Breast and Cervical Cancer Services Policy Manual

1100, Program Contact Information

Revision 23-2; Effective Sept. 29, 2023

Mailing Address

Breast and Cervical Cancer Services (BCCS) Program
North Austin Complex, Mail Code 0224
4601 W. Guadalupe Street, Suite #4.507
Austin, TX 78751-2920

Helpline

8 a.m. to 5 p.m. Central Time
Monday through Friday
Austin Phone No. 512-776-7796

Provider questions: 800-925-9126 
(TMHP contact center, pick option 5)

Email

Fax

512-776-7203

Website(s):

1200, Program Authorization

Revision 23-2; Effective Sept. 29, 2023

The Breast and Cervical Cancer Services (BCCS) Policy Manual is a guide for grantees who deliver BCCS services in Texas. The manual has been structured to provide grantees with information needed to comply with program requirements.

BCCS is authorized by federal law 42 USC Section 300k--300n-5 through the Centers for Disease Control and Prevention (CDC) by the National Breast and Cervical Cancer Early Detection Program (NBCCEDP).

Federal Medicaid law gives states the option to provide Medicaid assistance to women who were screened through the Centers for Disease Control and Prevention’s (CDC) NBCCEDP and found to have breast or cervical cancer. [See 42 United States Code Section1396a(aa).]

We acknowledge the Centers for Disease Control and Prevention, for its support of the Texas staff, and the printing and distribution of the monograph under cooperative agreement NU58DP007140 awarded to Texas. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC.

Texas provides Medicaid coverage to eligible women diagnosed with breast or cervical cancer by a BCCS program grantee. In 2007, the 80th Texas Legislature adopted Human Resources Code Section 32.024 (y-1) authorizing any health care provider to refer eligible women in need of treatment for breast or cervical cancer to Medicaid. Effective Sept. 1, 2007, any woman diagnosed with breast or cervical cancer that meets all eligibility requirements, as determined by BCCS policy for Medicaid for Breast and Cervical Cancer (MBCC), may receive Medicaid services.

1210 Compliance

Revision 23-2; Effective Sept. 29, 2023

Federal and state laws about reporting abuse, operation of health facilities, professional practice, insurance coverage and similar topics also impact women’s health services. Grantees are required to be aware of, and comply with, current laws.

Title XIX – Medicaid (Title XIX of the Social Security Act) was created by Congress in 1965. All organizations that receive BCCS funding are required to be enrolled providers of services to Medicaid-eligible women and men. (Federal regulation: Title XIX, Social Security Act, [42 USC Section1396-1396v et. seq.] Grants to States for Medical Assistance Programs).

Texas Human Resources Code Section32.024(c-1)

1220 Program Description, Rules and Funding

Revision 22-0; Effective August 15, 2022

BCCS provides access to quality breast and cervical cancer screening and diagnostic services to women with low incomes.

The state rules for program services can be found at the following link:

Funding

BCCS services are funded by a federal CDC cooperative agreement, federal Temporary Assistance for Needy Families (TANF) to Title XX funds and State General Revenue.

1230 Definitions

Revision 23-2; Effective Sept. 29, 2023

The following words and terms are used in this manual according to these definitions.

Applicant – A person applying to receive services, including a current client who is applying to renew.

Barrier to Care – A factor that hinders a person from receiving health care. For example, distance, lack of transportation, documentation requirements and copayment amount.

Breast and Cervical Cancer Services (BCCS) – A program administered by HHSC that provides breast and cervical cancer screening services to low-income, uninsured and underinsured women.

Centers for Disease Control and Prevention (CDC) – Federal agency responsible for protecting the health and safety of all Americans and for providing essential human services.

Cervical Dysplasia Management and Treatment Services – Management and treatment services provided to women with biopsy-confirmed cervical dysplasia (CD).

Client – A person who has been screened and determined to be eligible for the program.

Confidentiality – The state of keeping information private and not sharing it without permission.

Consultation – A type of service provided by a health care provider with expertise in a medical or surgical specialty. Who, upon request of another appropriate health care provider, assists with the evaluation, management, or both of a patient.

Covered Service – A medical procedure for which the program will reimburse a health care provider.

Diagnosis – The recognition of disease status determined by evaluating the history of the client and the disease process, and the signs and symptoms present. Determining the diagnosis may require some or all the following:

  • Microscopic (culture)
  • Chemical (blood tests)
  • Radiological examinations (X-rays)

Diagnostic Services – Activities related to the diagnosis made by a physician or other health professional.

Diagnostic Studies or Diagnostic Tests – Tests ordered by the client’s health care practitioners to evaluate a client’s health status for diagnostic purposes.

Disease Surveillance – Periodic monitoring for disease progression to quickly identify and treat pre-cancerous and cancerous conditions.

Dual-Eligible – Eligible for programs providing the same or similar services.

Eligibility Date – Date the grantee or program administrator determines a person becomes eligible for the program.

Eligible Immigrant – A qualified immigrant living in the United States with 40 qualifying quarters, if five years have passed since the legal date of entry, as outlined in Texas Administrative Code (TAC) Title 1, Part 15, Chapter 366, Subchapter D. The applicant must meet the residency standards defined in TAC Section 366.407.

Household – A person living alone or a group of two or more persons related by birth, marriage (including common law) or adoption, who reside together and who are legally responsible for the support of the other person. Unborn children should also be included. Treat applicants who are 18 years old as adults. No children 18 and older or other adults living in the home should be counted as part of the household group.

Federal Poverty Level (FPL) – The set minimum amount of income that a family needs for food, clothing, transportation, shelter and other necessities. In the United States, this level is determined by the Department of Health and Human Services. FPL varies according to family size. The number is adjusted for inflation and reported annually in the Federal Poverty Guidelines. Public assistance programs, such as Medicaid, define eligibility income limits in terms of a percentage of FPL.

Fee-for-Service – Payment mechanism for services that are reimbursed on a set rate per unit of service (also known as unit rate).

Fiscal Year (FY) – The state fiscal year is from Sept. 1 through Aug. 31.

Good Faith Effort – Making at least three documented attempts to obtain treatment or navigate clients with a pre-cancerous or cancerous breast or cervical diagnosis who do not meet the eligibility criteria for either BCCS Cervical Dysplasia, Medicaid for Breast and Cervical Cancer (MBCC) or both.

Grantee – A non-state or non-federal entity that is awarded a grant agreement for the purpose of carrying out a state or federal grant program.

Health and Human Services Commission (HHSC) – The Texas administrative agency established under Chapter 531, Texas Government Code, or its designee. HHSC manages programs that help families with food, health care, safety and disaster services.

Health Care Provider – A physician, physician assistant, nurse practitioner, clinical nurse specialist, certified nurse midwife, federally qualified health center, family planning agency, health clinic, ambulatory surgical center, hospital ambulatory surgical center, laboratory or rural health center.

Health Service Region (HSR) – Counties grouped within specified geographic service areas throughout the state. See the Texas Department of State Health Services (DSHS) website, Texas Public Health Regions at www.dshs.texas.gov/regions/state.shtm.

Informed Consent – A health care provider ensures the benefits and risks of a diagnostic or treatment plan, the benefits and risks of other appropriate options, and the benefits and risks of taking no action are explained to a patient in a manner that is understandable to that patient and allows the patient to participate and make sound decisions regarding their own medical care. 

In-reach – Activities that are conducted with the purpose of informing and educating existing clients within an organization about services they are not receiving but may be eligible to receive.

Medicaid – The Texas Medical Assistance Program, a joint federal and state program provided in Texas Human Resources Code Chapter 32 subject to Title XIX of the Social Security Act, 42 U.S.C. Section 1396, et seq. Reimburses for health care services delivered to low-income clients who meet eligibility guidelines.

Medicaid for Breast and Cervical Cancer (MBCC) – Medicaid program that provides access to cancer treatment services for qualified women.

Med-IT® – Medical Information Tracking System.

Minimum Data Elements (MDE) – A set of standardized data elements used to collect demographic and clinical information on women screened with NBCCEDP funds.

Minor – In accordance with the Texas Family Code, a person under 18 years old who is not and has not been married or who has not had the disabilities of minority removed for general purposes (i.e., emancipated). In this policy manual, “minor” and “child” may be used interchangeably.

National Breast and Cervical Cancer Early Detection Program (NBCCEDP) – A federal program administered by the CDC that awards funds to Texas BCCS and other state and tribal grantees to help women who are low-income, uninsured and underserved gain access to screening for early detection of breast and cervical cancer.

Outreach – Activities that are conducted with the purpose of informing and educating the community about services and increasing the number of individuals served.

Patient Navigation – Individualized assistance provided to women to help overcome barriers and facilitate timely access to quality screening and diagnostic services, as well as to initiate timely treatment for those diagnosed with cancer.

Point of Service – The location where a person can receive services.

Quality Assessment (QA) – The measurement of the level of quality at a given point in time.

Quality Improvement (QI) – The commitment and approach used to improve the process continuously with the intent of meeting and exceeding set expectations and outcomes. 

Quality Monitoring – The planned, systematic, and ongoing collection, compilation and organization of data about the quality or appropriateness of an important aspect of care, as well as the comparison of those data to an established level of performance.

Referral – The process of directing or redirecting (as a medical case or a person) to an appropriate specialist or agency for information, help or treatment.

Subgrantee – A non-state entity that receives a subaward from a pass-through entity to carry out part of a state program; but does not include an individual that is a beneficiary of such a program. A subgrantee may also be a grantee of other state awards directly from a state awarding agency. A subgrantee may also be referred to as a subrecipient. 

Texas Resident – An individual who resides within the geographic boundaries of the state of Texas.

Underinsured – A person whose health insurance does not fully cover screening and diagnostic services.

Unduplicated Client – Clients enrolled in BCCS are counted only one time during the program’s fiscal year, regardless of the number of visits, encounters or services they receive. For example, one person seen four times during the year is counted as one unduplicated client.

1240 Acronyms

Revision 22-0; Effective August 15, 2022

AcronymFull Name
ADAAmericans with Disabilities Act
AEDAutomated External Defibrillator
AGCAtypical Glandular Cells
AMAAmerican Medical Association
ASC-USAtypical Squamous Cells of Undetermined Significance
BCCSBreast and Cervical Cancer Services
CADComputer Aided-Detection
CBEClinical Breast Exam
CDCervical Dysplasia
CDCCenters for Disease Control and Prevention
CHIPChildren’s Health Insurance Program
CHWCommunity Health Worker
CINCervical Intraepithelial Neoplasia
CLIAClinical Laboratory Improvement Amendments
CMSCenters for Medicare and Medicaid Services
CPRCardiopulmonary Resuscitation
CPTCurrent Procedure Terminology
DESDiethylstilbestrol
DHHSU.S. Department of Health and Human Services
DSHSDepartment of State Health Services
ECEndocervical
ECCEndocervical Curettage
EHRElectronic Health Record
E&MEvaluation and Management Services
EMRElectronic Medical Record
FDAFederal Drug Administration
FFSFee-for-Service
FPLFederal Poverty Level
FQHCFederally Qualified Health Center
FRRFinancial Reconciliation Report
FSRFinancial Status Report
HHSCTexas Health and Human Services Commission
HIPAAHealth Insurance Portability and Accountability Act
HPVHuman Papillomavirus
HSILHigh-grade Squamous Intraepithelial Lesion
HSRHealth Service Region
IPVIntimate Partner Violence
IRBInstitutional Review Board
LEPLimited English Proficiency
LSILLow-grade Squamous Intraepithelial Lesion
MBCCMedicaid for Breast and Cervical Cancer
MDEMinimum Data Elements
Med-IT®Medical Information Tracking
MRIMagnetic Resonance Imaging
NBCCEDPNational Breast & Cervical Cancer Early Detection Program
NILMNegative for Intraepithelial Lesion or Malignancy
NPINational Provider Identifier
PAAPrescriptive Authority Agreement
QAQuality Assurance
QIQuality Improvement
QMQuality Management
RSDIRetirement, Survivors and Disability Insurance
SDOStanding Delegation Order
SSDISocial Security Disability Income
SSISupplemental Security Income
TACTexas Administrative Code
TANFTemporary Assistance for Needy Families
USPSTFUnited States Preventive Services Task Force
WICSpecial Supplemental Nutrition Program for Women, Infants and Children

2100, Client Access

Revision 23-2; Effective Sept. 29, 2023

The grantee must ensure clients are provided services in a timely and nondiscriminatory manner. The grantee must adhere to the following guidelines:

  • have a policy in place that delineates the timely provision of services;
  • provide services to people deemed eligible as soon as possible and no later than 30 days from the initial request;
  • maintain reasonable clinic and reception room wait times that do not present a barrier to care;
  • comply with all applicable civil rights laws and regulations outlined in 2320, Nondiscrimination;
  • have a policy in place that requires qualified staff to assess and prioritize a client’s needs;
  • provide referrals for people that cannot be served, or cannot receive a specific service;
  • manage funds to ensure established clients continue to receive services throughout the budget year, including after allocated funds are expended;
  • inform people of program services and encourage them to bring required documentation to the initial visit for eligibility processing; and
  • have policies to identify and eliminate possible barriers to care.

2200, Abuse and Neglect Reporting

Revision 23-2; Effective Sept. 29, 2023

Grantees must comply with state laws governing the reporting of suspected abuse and neglect of children, adults with disabilities, or people 65 years or older. Grantees and providers must develop policies and procedures that follow the reporting guidelines and requirement in Human Resources Code, Chapter 48 which requires suspected abuse, neglect or exploitation of an elderly person, a person with a disability or a person receiving services from certain home and community-based providers to be reported.

Reporting an Abuse Emergency

To report an emergency that involves the abuse or neglect of children, adults with disabilities, people 65 years or older, or a person receiving services from certain home and community-based providers, call the Texas Abuse Hotline at 800-252-5400. For cases that pose an imminent threat or danger to the individual, call 9-1-1 or any local or state law enforcement agency.  

Reporting a Suspicion of Abuse

For situations that do not require immediate investigation and to report suspicions of abuse, neglect and exploitation of children, adults with disabilities, people 65 years or older, or a person receiving services from certain home and community-based providers, use the Department of Family and Protective Services Texas Abuse Hotline.

2210 Human Trafficking

Revision 23-2; Effective Sept. 29, 2023

Grantees must obey state laws governing the reporting of abuse and neglect. Additionally, as part of the requirement that grantees obey all applicable federal laws, grantees must follow the federal anti-trafficking laws, including the Trafficking Victims Protection Act of 2000. (22 USC Section 7101, et seq.)

Grantees must have a written policy on human trafficking which includes the provision of annual staff training.

Resources for Human Trafficking Policy Development

2220 Domestic and Intimate Partner Violence (IPV)

Revision 23-2; Effective Sept. 29, 2023

Intimate partner violence (IPV) describes physical, sexual or psychological harm by a current or former partner or spouse. IPV may also be referred to as domestic violence or family violence. Per Texas Human Resources Code, Chapter 51, family violence may also include emotional harm and a threat of harm. This type of violence can occur among heterosexual or same-sex couples. Intimate partner violence can occur whether sexual intimacy is part of the relationship.

Grantees must have a written policy related to assessment and prevention of domestic and intimate partner violence, including the provision of annual staff training.

2300, Client Rights

Revision 22-0; Effective August 15, 2022

2310 Confidentiality

Revision 23-2; Effective Sept. 29, 2023

Grantees must comply with the U.S. Health Insurance Portability and Accountability Act of 1996 (HIPAA) established standards for protection of privacy.

Grantees must ensure that all employees and volunteers receive training about client confidentiality during orientation and be made aware that violation of the law regarding confidentiality may result in civil damages and criminal penalties. A health care provider’s staff (paid and unpaid) must be informed during orientation of the importance of keeping client information confidential. All employees, volunteers, sub-grantees, board members and advisory board members must sign a confidentiality statement during orientation.

The client’s preferred method of follow-up to clinic services (cell phone, email, work phone or text) and preferred language must be documented in the client’s record. Clients must receive verbal assurance of confidentiality, an explanation of what confidentiality means (kept private and not shared without permission) and any applicable exceptions, such as abuse reporting. A health care provider must not require consent for services from the spouse of a married client.

2320 Nondiscrimination and Limited English Proficiency

Revision 23-2; Effective Sept. 29, 2023

Grantees must comply with state and federal antidiscrimination laws. These laws are contained in the Health and Human Services Commission (HHSC) HHSC Uniform Terms and Conditions – Grant Version 2.16.1 (PDF), which includes the following laws:

Additionally, grantees must comply with Article IX, Section 9.21 (a-f) Civil Rights, the HHSC Special Conditions Version 1.1, Article V, Section 5.06 Services, and Information for Persons with Limited English Proficiency. These are part of a grantee's contract with the state.

It is highly recommended that grantees comply with Texas Government Code, Section 2054.457, Access to Electronic and Information Resources.

Find more information about nondiscrimination laws and regulations on the HHSC Civil Rights website and the HHSC Civil Right Office, Requirements for Grantees website.

Contract Terms and Conditions

To ensure compliance with nondiscrimination laws, regulations and policies, grantees must:

  • sign a written assurance to comply with applicable federal and state nondiscrimination laws and regulations;
  • have a written policy that states the agency does not discriminate based on race, color, national origin (including LEP), sex, age, religion, disability or sexual orientation;
  • have a policy that addresses individual rights and responsibilities that is applicable to all people requesting services;
  • have procedures for notifying the HHSC Civil Rights Office of any program or service-related discrimination allegation or complaint no more than 10 calendar days of the allegation or complaint;
  • ensure all grantee staff are trained in the grantee's nondiscrimination policies, including policies for serving people with LEP and people with disabilities, and HHSC complaint procedures;
  • notify all people who are applying for services of the grantee's nondiscrimination policies and complaint procedures; and
  • prominently display civil rights posters in common areas, including lobbies and waiting rooms, front reception desk and locations where individuals apply for services. Posters can be found on the Civil Rights Office website.

Direct questions concerning this section and civil rights matters to the HHSC Civil Rights Office.

Limited English Proficiency (LEP)

To ensure compliance with civil rights requirements related to LEP, grantees must:

  • take reasonable steps to ensure people with LEP have meaningful access to its programs and services, and not require a person with LEP to use friends or family members as interpreters;
    • a family member or friend may serve as a person’s interpreter, if the person requests it and if the family member or friend does not compromise the effectiveness of the service or violate client confidentiality; and
  • make people with language service needs, including people with LEP and disabilities, aware that the grantee will provide an interpreter free of charge.

2330 Former Military Service Members

Revision 23-2; Effective Sept. 29, 2023

Women and men who served in any branch of the U.S. Armed Forces, including Army, Navy, Marines, Air Force, Space Force, Coast Guard, Reserves or National Guard, may be eligible for benefits and services under other HHSC programs. For more information, visit the Texas Veterans Portal.

2340 Termination of Services

Revision 23-2; Effective Sept. 29, 2023

Grantees have the right to terminate services to a person if the client is disruptive, unruly, threatening or uncooperative to the extent the client seriously impairs the grantee’s ability to provide services effectively and safely, or if the client’s behavior jeopardizes their own safety, clinic staff or others. A client has the right to appeal the denial, suspension or termination of services.

Grantees must have a written policy related to termination of services.

2350 Resolution of Complaints

Revision 23-2; Effective Sept. 29, 2023

Grantees must ensure clients can express concerns about care received and further ensure those complaints are handled in a consistent manner. A grantee’s policy must explain the process clients may follow if they are not satisfied with the care received. If an aggrieved client requests a hearing, a grantee shall not terminate services to the client until a final decision is rendered by HHSC. All complaints must be documented in the client’s record.

2360 Freedom of Choice

Revision 22-0; Effective August 15, 2022

Clients have the right to choose health care providers, without coercion or intimidation. Acceptance of health care services does not preclude eligibility for, or receipt of, any other service or assistance.

2370 Research (Human Subject Clearance)

Revision 23-2; Effective Sept. 29, 2023

To participate in proposed research that would involve the use of BCCS clients as subjects, the use of BCCS clients’ records or any data collected from BCCS clients, BCCS grantees must get prior approval from their own internal Institutional Review Board (IRB) and from HHSC. For information about the process, grantees should visit the Institutional Review Board Home.

The grantee must have a policy in place that indicates that prior approval will be obtained from HHSC before instituting any research activities. The grantee must also ensure that all staff are made aware of this policy through staff training. Documentation of training on this topic must be maintained. Federal BCCS funds may not be used for research.

2400, Consent

Revision 23-2; Effective Sept. 29, 2023

Grantees must obtain the client’s written, informed and voluntary general consent to receive services before receiving any clinical services pursuant to applicable state and federal law. A general informed consent explains the types of services provided and how client information may be shared with other entities for reimbursement or reporting purposes. If there is a period of three years or more during which a person does not receive services, a new general consent must be signed before reinitiating delivery of services.

Consent information must be effectively communicated to every client in a manner that is understandable. This communication must allow the client to participate, make sound decisions regarding their own medical care, and address any disabilities that impair communication (in compliance with LEP regulations). Only the client receiving services may give consent. When the client is legally unable to consent, a parent (that is, in the case of an unemancipated minor) or court-appointed legal guardian must consent on the client’s behalf. Consent must never be obtained in a manner that could be perceived as coercive.

In addition, as described below, the contractor must obtain informed consent of the client for procedures as required by the Texas Medical Disclosure Panel.

Clients entering BCCS for services must also sign consent authorizing the grantee to enter or view client protected health information in the statewide Med-IT® database. If this statement is not included in the general consent, an additional consent must be developed for the client to sign and included with the general consent in the patient health record. 

HHSC grantees should consult a qualified attorney to determine the appropriateness of all consent forms used by their health care agency.

2410 Texas Medical Disclosure Panel Consent

Revision 23-2; Effective Sept. 29, 2023

Grantees must obtain the client’s informed consent for procedures as required by the Texas Medical Disclosure Panel. The Texas Medical Disclosure Panel (TMDP) was established by the Texas Legislature to:

  • determine which risks and hazards related to medical care and surgical procedures must be disclosed by health care providers or physicians to their patients or persons authorized to consent for their patients; and
  • establish the general form and substance of such disclosure. TMDP has developed a list of procedures that require full and specific disclosure (List A) for certain procedures. More information about TMDP can be found in the TMDP or the Civil Practice and Remedies Code, Chapter 74.102.

For all other procedures not on List A, the physician must disclose, through a procedure-specific consent, all risks that a reasonable patient would want to know. This includes all risks that are inherent to the procedure (one which exists in, and is inseparable from, the procedure itself) and that could influence a reasonable person deciding whether to consent to the procedure.

2500, Client Record Management

Revision 23-2; Effective Sept. 29, 2023

Grantees must have an organized and secure client record system. The grantee must ensure the record is organized, readily accessible and available to the client upon request with a signed release of information. Records must be kept confidential and secure, as follows:

  • safeguarded against loss or use by unauthorized persons;
  • secured by lock when not in use and inaccessible to unauthorized persons; and
  • maintained in a secure environment in the facility, as well as during transfer between clinics and between home and office visits.

Written consent of the client is required for the release of personally identifiable information, except as may be necessary to provide services to the client or as required by law, with appropriate safeguards for confidentiality. HIV information must be handled according to law. See the DSHS HIV/STD Program webpage titled Laws, Rules, and Authorization for more information.

When information is requested, grantees should release only the specific information requested. Information collected for reporting purposes may be disclosed only in summary, statistical or other form that does not identify clients. Upon request, clients transferring to other providers must be provided with a copy or summary of their record to expedite continuity of care. Electronic records are acceptable as medical records.

Grantees, providers and subgrantees must maintain for the period specified by HHSC all records pertaining to client services, contracts and payments. Requirements are found in Title 1, Part 15 TAC Section 354.1003, relating to time limits for submitted claims, and in Title 22, Part 9 TAC Section 165, relating to maintenance of medical records. Grantees must follow contract provisions, maintain medical records for at least seven years after the close of the contract, and follow the retention standards of the appropriate licensing entity. All records relating to services must be accessible for examination at any reasonable time to representatives of HHSC and as required by law.

2510 Personnel Policy and Procedures

Revision 23-2; Effective Sept. 29, 2023

Grantees must develop and maintain personnel policies and procedures to ensure all staff are hired, trained, and evaluated appropriately for their job position. Personnel policies and procedures must include:

  • job descriptions;
  • a written orientation plan for new staff to include skills evaluation and competencies appropriate for the position; and
  • a performance evaluation process for all staff.

Job descriptions, including those for contracted personnel, must specify required qualifications and licensure. All staff must be appropriately identified with a name badge.

Grantees must show evidence employees meet all required qualifications and receive required annual training. Job evaluations should include observation of staff and client interactions during clinical, counseling and educational services.

Grantees must establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of personal or organizational conflict of interest or personal gain. All employees and board members must complete a conflict-of-interest statement during orientation. All medical care must be provided under the supervision, direction and responsibility of a qualified medical director. The medical director must be a licensed Texas physician.

Grantees must have a documented plan for organized staff development. There must be an assessment of:

  • training needs;
  • quality assurance indicators; and
  • changing regulations and requirements.

Staff development must include orientation and in-service training for all personnel and volunteers. Nonprofit entities must provide orientation for board members and government entities must provide orientation for their advisory committees. Employee orientation and continuing education must be documented in agency personnel files.

2600, Facilities

Revision 22-0; Effective August 15, 2022

2610 Facilities and Equipment

Revision 23-2; Effective Sept. 29, 2023

Grantees must maintain a safe environment. Grantees must provide clean and well-maintained facilities where services can be delivered with space for exam rooms, client intake, waiting areas, and space for clinical and administrative staff. Grantees must have written policies and procedures addressing the handling of hazardous materials, fire safety and medical equipment.

Hazardous Materials

Grantees must have written policies and procedures addressing:

  • the handling, storing and disposing of hazardous materials and waste, according to applicable laws and regulations;
  • the handling, storing and disposing of chemical and infectious waste, including sharps; and
  • an orientation and education program for personnel who manage or have contact with hazardous materials and waste.

Fire Safety

Grantees must have a written fire safety policy including a schedule for testing and maintenance of fire safety equipment. Evacuation plans for the premises must be clearly posted and visible to all staff and clients.

Medical Equipment

Grantees must have a written policy and maintain documentation of the maintenance, testing and inspection of medical equipment, including an automated external defibrillator (AED). Documentation must include:

  • assessments of the clinical and physical risks of equipment through inspection, testing and maintenance;
  • reports of any equipment management problems, failures and use errors;
  • an orientation and education program for personnel who use medical equipment; and
  • manufacturer recommendations for the care and use of medical equipment.

Radiology Equipment and Standards

All facilities providing radiology services must:

See the Texas Department of State Health Services, Radiation Control Program for information on X-ray machine registration.

Smoking and Vaping Ban

Grantees must have a written policy prohibiting smoking and vaping in any portion of their indoor facilities. If a grantee subcontracts with another entity for the provision of health services, the subgrantee must comply with this policy.

Disaster Response Plan

Grantees must have written and oral plans addressing how staff are to respond to emergency situations (that is, fires, flooding, power outages and bomb threats). The disaster plan must identify the procedures and processes to be initiated during a disaster and the staff position responsible for each activity. A disaster response plan must be in writing, formally communicated to staff and kept in the workplace available to employees for review. For an employer with 10 or fewer employees, the plan may be communicated orally to employees.

See the Occupational Safety and Health Administration website for more resources on facilities and equipment.

Clinical Emergencies

Grantees must be adequately prepared to handle clinical emergency situations, as follows:

  • There must be a written plan for the management of on-site medical emergencies, emergencies requiring ambulance services and hospital admission.
  • Each site must have staff trained in basic cardiopulmonary resuscitation (CPR) and emergency medical action. Staff trained in CPR must be present during all hours of clinic operations.
  • There must be written protocols to address vasovagal reactions, anaphylaxis, syncope, cardiac arrest, shock, hemorrhage and respiratory difficulties.
  • Each site must maintain emergency resuscitative drugs, supplies, and equipment appropriate to the services provided at that site and appropriately trained staff when clients are present.
  • Documentation must be maintained in personnel files that staff have been trained regarding these written plans or protocols.

2700, Quality Management

Revision 23-2; Effective Sept. 29, 2023 

Quality assurance and quality improvement (QA/QI) support the quality of clinical service delivery. Grantees must use internal QA/QI systems and processes to monitor services. Grantees must have the ability to meet the management standards prescribed in 2 Code of Federal Regulations Part 200.

QA/QI processes are intended to:

  • improve screening and diagnostic services;
  • link structure and process and include standards, measurement, and actions;
  • identify and remedy root causes of quality problems;
  • meet client needs; and
  • focus on high-volume, costly, high-risk, or problem-prone aspects of care.

These aims are achieved by assessing performance, making changes based on the assessment, and monitoring improvement. Steps to QA/QI include:

  • Quality monitoring – The BCCS performance indicators are designed specifically for this purpose and represent aspects of care that align with the purpose of the NBCCEDP.
  • Quality assessment – Assessing quality provides organizations with an opportunity to measure performance against standards (targets or benchmarks). Quality assessment creates a bridge between monitoring and improvement by establishing a common understanding of the quality of services provided and identifying opportunities for improvement.
  • Quality improvement – QI strives to find strategies that will institute a change and continuously improve quality.

A Quality Management (QM) program must be developed and implemented that provides for ongoing evaluation of services. Grantees should have a comprehensive plan for the internal review, measurement and evaluation of services, the analysis of monitoring data, and the development of strategies for improvement and sustainability.

Grantees who subcontract for the provision of services must also address how quality will be evaluated and how compliance with HHSC policies and basic standards will be assessed with the subgrantees.

The QM Committee, whose membership consists of key leadership of the organization, including the executive director, chief executive officer, or both; the medical director; and other appropriate staff where applicable, annually reviews and approves the quality work plan for the organization.

2710 Quality Management (QM) Committee

Revision 23-2; Effective Sept. 29, 2023

The QM Committee must meet at least quarterly to:

  • receive reports of monitoring activities;
  • make decisions based on the analysis of data collected;
  • determine quality improvement actions to be implemented; and
  • reassess outcomes and goal achievement.

Meeting dates, minutes of the discussion and actions taken by the QM Committee and a list of the attendees must be maintained.

2720 Comprehensive Quality Work Plan

Revision 22-0; Effective August 15, 2022 

The comprehensive quality work plan, at a minimum, must:

  • include clinical and administrative standards by which services will be monitored;
  • include a process for credentialing and peer review of clinicians;
  • identify those responsible for implementing, monitoring, evaluating and reporting;
  • establish timelines for quality monitoring activities;
  • identify tools and forms to be used; and
  • outline reporting to the QM Committee.

2730 Quality Assurance Activities

Revision 23-2; Effective Sept. 29, 2023

Although each organization’s quality assurance program is unique, the following activities must be undertaken by all agencies providing client services:

  • ongoing eligibility, billing and clinical record reviews to ensure compliance with program requirements and clinical standards of care;
  • utilization review;
  • tracking and reporting of adverse outcomes;
  • client satisfaction surveys;
  • annual review of facilities to maintain a safe environment, including an emergency safety plan;
  • annual review and update of all prescriptive authority agreements (PAAs) for mid-level providers;
  • annual review of all standing delegation orders and clinical protocols used;
  • annual review of all policies and forms;
  • up-to-date performance evaluations that include primary license verification, Drug Enforcement Administration, and immunization status; and
  • clearly noted review or revision date on each policy, form, agreement, order, etc. used.

2740 Subrecipient Quality and Compliance

Revision 23-2; Effective Sept. 29, 2023

Grantees who subcontract with subgrantee for the provision of services must also address how quality will be evaluated and how compliance with policies and basic standards will be assessed with the subgrantee, to include at a minimum:

  • annual license and certification verification (primary source verification);
  • clinical record review;
  • billing and eligibility review;
  • utilization review;
  • facility on-site review;
  • annual client satisfaction evaluation process; and
  • child abuse training and reporting.

Data from these activities must be presented to the QM Committee. Plans to improve quality should result from the data analysis and reports considered by the committee and should be documented.

2750 Clinical Quality Assurance

Revision 23-2; Effective Sept. 29, 2023

Ambulatory Surgical Centers

Ambulatory surgical centers providing  services must be Centers for Medicare and Medicaid Services (CMS) certified, state-licensed and Joint Commission-accredited, as applicable. See the HHS website, Ambulatory Surgical Centers for more information.

Mammography Quality Assurance

All grantees and subgrantees providing mammography services must:

  • possess a current Certification of Mammography Systems from DSHS Regulatory Licensing Unit, Mammography Certification Program (each mammography unit must be fully accredited or undergoing accreditation); and
  • possess a current mammography facility certificate from the appropriate agency certifying compliance with the U.S. Food and Drug Administration Mammography Quality Standards, at 21 CFR Part 900.

The Mammography Radiation Control Program may be contacted for certification questions and information on inspection results, escalated enforcement or "cease and desist" status.

Cytology Quality Assurance

Grantees and subgrantees providing screening and diagnostic cytology services must have current documentation showing the agency meets all quality assurance standards required by the BCCS program as established under state and federal laws.

All cytology laboratories providing services to grantees and subgrantees must:

  • possess a current, unrevoked, and unsuspended registration certificate issued by the U.S. Department of Health and Human Services under the terms of the Clinical Laboratory Improvement Amendments of 1988 (CLIA 88) (42 U.S.C. Section 263a); and
  • have a mechanism for expedited notification of Pap tests which are CIN III or greater, such that the clinic is notified by the next business day after the case is signed out.

Human Papillomavirus (HPV) Quality Assurance

Grantees must assure all HPV tests are:

  • for high-risk oncogenic types; and
  • FDA approved and clinically validated.

Utilization Review

To ensure clients receive high quality care and funds are expended according to program policies, BCCS performs utilization review of billed services. Grantees not in compliance with billing guidelines may be required to refund the BCCS program for services inappropriately billed.

2800, Reimbursement

Revision 23-2; Effective Sept. 29, 2023

2810 Reimbursement for Services

Revision 23-2; Effective Sept. 29, 2023

Grantees may be reimbursed using the fee-for-service reimbursement method by submitting claims to Med-IT® for services rendered.

2820 Fee-for-Service Reimbursement

Revision 23-2; Effective Sept. 29, 2023

The fee-for-service component of funding pays for direct medical services on a fee-for-service basis. Each grantee is responsible for determining a person’s eligibility for clinical services. BCCS reimburses grantees on a fee-for-service basis for services that have been provided to eligible people. Grantees must continue to provide services to established people and to submit claims for individual services even after the grant funding limit has been met.

Grantees are required to file claims electronically through the Med-IT® system.

Grantee claims must be filed within certain time frames, as follows:

  • Initial claims submission: Submitted within 45 days of the date of service on the claim. If the 45th day falls on a weekend or holiday, the filing deadline is extended until the next business day.
  • All claims must be submitted and processed within 60 days after the end of the grant period.
  • All claims must continue to be billed even after the grant funding limit has been met.

Grantees may contact Med-IT® Helpdesk at med-ithelpdesk@hhs.texas.gov for questions about claims and payment status.

Reimbursable Codes

Fee-for-service reimbursement is limited to a prescribed set of procedure codes approved by BCCS. The approved list of reimbursable codes may be found in Med-IT® and referenced in the BCCS Billing Guideline, available in Appendix VI.

Grantees may submit claims for a person’s office visits that reflect different levels of service for new and established people. A new person is defined as one who has not received clinical services at the grantee’s clinics during the previous three years. The level of services, which determines the procedure code to be billed for that individual visit, is indicated by a combination of factors, such as the complexity of the problem addressed, and the time spent with the individual by clinic providers. The American Medical Association (AMA) publishes materials related to Current Procedural Terminology (CPT) coding that includes guidance on office visit codes (Evaluation and Management Services).

3100, Grantee Responsibilities

Revision 23-2; Effective Sept. 29, 2023

Grantees must provide or assure the provision of breast cancer screening, cervical cancer screening, or both; and diagnostic and support services, including tracking, follow-up, patient navigation and individual client education. Although BCCS allows the provision of diagnostic services, grantees must ensure program focus supports cancer screening consistent with funding intent.

Collectively, these grantee required components will ensure the achievement of performance measures. Grantee requirements also include:

  • program management;
  • eligibility determination;
  • initiation of, or referral to, treatment if clinically indicated; 
  • quality management;
  • professional development;
  • recruitment, including public education and outreach; and
  • data collection, including tracking and follow-up.

Grantees are responsible for the coordination of a client’s services from screening through diagnosis, if clinically warranted. Grantees who have expended their awarded funds must continue to serve their existing BCCS eligible clients currently in the process of an approved care plan. Grantees must ensure existing clients receive services from qualified breast and cervical cancer providers to continue client care.

All grantees must have an established referral relationship and subcontract with a qualified provider of each service the grantee does not provide.

Note: Duplication of BCCS services by multiple grantees will not be reimbursed. Before services may be rendered, grantees must have procedures to verify clients are not receiving services with another BCCS grantee. NBCCEDP funds cannot be used to cover services covered by another public health program or private coverage (42 U.S.C. Section 300m(d)).

Data Collection – Grantees are required to comply with and use the web-based system Med-IT® to collect and process breast and cervical cancer data, including reports and billing in accordance with the business requirements of the program.

Eligibility – Grantees are required to determine BCCS program eligibility of every client at enrollment and annually thereafter. Insurance status should be reassessed at each client visit.

Partnerships – Grantees must establish and maintain partnerships with coalitions, community-based organizations and other health and human services agencies that further the goal of providing BCCS in the proposed service area.

Program Management – The process of leading, facilitating and ensuring the strategic planning, implementation, coordination, integration and evaluation of programmatic activities and administrative systems to ensure efficiency and effectiveness.

Professional Development – Grantees are responsible for ensuring health care professionals provide BCCS services competently and with sensitivity to diverse patient cultures.

Quality Management – Grantees are expected to ensure the quality of services by monitoring performance and identifying opportunities for improvement. Grantees must have policies and procedures to ensure health care providers follow evidence-based clinical guidelines and provide clinical services consistent with current nationally recognized standards of care.

Recruitment – Grantees must establish and maintain outreach and inreach methods to recruit priority populations.

3200, Client Eligibility

Revision 22-0; Effective August 15, 2022

3210 Eligibility Guidelines

Revision 23-2; Effective Sept. 29, 2023

For a person to receive BCCS services, three general criteria must be met. The person must:

  • have gross household income at or below 200 percent of the adopted Federal Poverty Level (FPL);
  • be a Texas resident; and
  • be without access to programs or benefits providing the same services.

Other Eligibility Factors

Other eligibility factors include the following:

  • Undocumented applicants who meet the general eligibility criteria are program eligible.
  • Applicant must meet age-specific eligibility criteria for screening and diagnostic services.
  • Clients with a primary need of cancer screening should be enrolled in BCCS.
  • Applicants whose health insurance does not fully cover screening and diagnostic services are considered underinsured and may be enrolled for services.

Grantee Responsibilities for Eligibility Determination

Grantees must develop an agency policy to determine BCCS eligibility. The policy must outline the grantee’s procedures for determining program eligibility and who is responsible for eligibility screening. The policy must also be available during monitoring visits and must address the following:

  • Acceptable documents for verifying household income at or below 200 percent FPL (income must be recorded in the client record and Med-IT®).
  • Use of Form 1065, Eligibility Application.
  • Use of a comparable paper or electronic screening and eligibility tool with required information. Note: If a grantee desires to use a comparable eligibility screening tool, HHSC staff must review and approve before use. Grantees must use Form 1065 until approval to use a comparable form is received. The grantee must maintain and retain proof of approval and must make the approval available during QA visits.

Grantee eligibility policy must also ensure:

  • Client insurance status is assessed before service delivery.
  • General BCCS eligibility is determined before enrollment and annually thereafter.
  • Clients 65 and over do not meet eligibility unless the client is ineligible for, or unable to pay, premiums for Medicare Part B.

If a woman is eligible to receive Medicare benefits and is not enrolled in Medicare, she should be encouraged to enroll. Women enrolled in Medicare Part B are not eligible to receive services. Women who are not eligible to receive Medicare Part B, and Medicare-eligible women who cannot pay the premium to enroll in Medicare Part B, are eligible to receive services. If a client cannot afford the expense of Medicare Part B premiums, Medicaid-sponsored Medical Savings Programs may pay Medicare premiums, deductibles and coinsurance amounts for eligible Medicare beneficiaries. The Qualified Medicare Beneficiary (QMB) program, the Specified Low-Income Medicare Beneficiary (SLMB) program, the Qualified Individuals (QI-1) and the Qualified Disabled Working Individuals (QDWI) program are all called Medicare Savings Programs. Find more information about Medicare Savings Programs at Medicare.gov.

3220 Applying for Services

Revision 23-2; Effective Sept. 29, 2023

Screening and Eligibility Determination

Grantees must use Form 1065, Eligibility Application. Another eligibility screening form substitute (for example, in-house form, electronic or automated form and phone interview) containing the required information for determining eligibility may be used if first approved by HHSC staff.

The applicant is responsible for completing Form 1065. If assistance is needed to complete the form, the grantee must provide knowledgeable staff to assist.

Client eligibility determination may be conducted by phone. Applicants may print the form, add a handwritten signature, and scan, email, or fax the form to a grantee. Client and grantee digital signatures are allowable. If needed, a grantee may sign on behalf of an applicant.

Documenting Special Circumstances 

There may be special circumstances where an applicant is unable to provide required documentation for verification purposes. These types of special circumstances should be appropriately documented on Form 1065. Special circumstances must also be documented in the Med-IT® Data System in the notes section of the enrollment screen.

Household

Establishing household size is an important step in the eligibility process. Assessment of income eligibility relies on an accurate count of household members. The household consists of a person living alone or a group of two or more persons related by birth, marriage (including common law) or adoption, who reside together and are legally responsible for the support of the other person. Unborn children should also be included. Treat applicants who are 18 years old as adults. No children 18 and older or other adults living in the home should be counted as part of the household group.

A BCCS-eligible applicant who is a legal adult is required to complete Form 1065.

The grantee has discretion to document special circumstances in the calculation of household composition. 

Residency

To be eligible for BCCS, a person must be physically present within the geographic boundaries of Texas. There is no requirement regarding the amount of time a person must live in Texas to establish residency for the purposes of BCCS eligibility. The person must have the intent to remain within the state permanently or for an indefinite period.

Income

To be eligible for BCCS services, applicants must provide verification of countable household income at or below 200 percent of the Federal Poverty Level (FPL). If the applicant is unable to provide verification, income may be self-declared by the applicant. The reasons for an applicant self-declaring income must be documented in the client record and in the Med-IT® Data System.

Note: Applicants seeking Medicaid for Breast and Cervical Cancer (MBCC) may not self-declare income. This includes women who have been diagnosed with a qualifying cancer by BCCS grantees or other health care providers. Applicants assisted by a BCCS grantee to apply for MBCC must have verification of income documented in their client record and on the eligibility screen in Med-IT®.

Calculation of Applicant’s FPL Percentage

  1. Determine the applicant’s household size.
  2. Determine the applicant’s total monthly income amount.
  3. Divide the applicant’s total monthly income amount by the maximum monthly income amount at 100 percent FPL, for the appropriate household size.
  4. Multiply by 100 percent.

The maximum monthly income amounts by household size are based on the United States Department of Health and Human Services federal poverty guidelines. The guidelines are subject to change near the beginning of each calendar year. Once the changes are reviewed by the BCCS program, the income amounts are updated in Med-IT. The current FPL information may be found in Appendix V.

Income Deductions

Dependent care expenses and payments made by a member of the household group must be deducted up to the allowable amount, as follows:

  • legally obligated child support payments paid to the household;
  • $200 per child per month for children under 2;
  • $175 per child per month for children 2 – 17; and
  • $175 per dependent adult with disabilities per month who is 18 and over.

Monthly Income Calculation

When income is received in lump sums, at irregular intervals or at longer intervals than monthly (that is, contract labor, seasonal employment and lump sums), the total amount received is divided over the period for which the income is expected to cover household expenses to determine a monthly income. Convert the amount using one of the following methods:

  • Weekly income is multiplied by 4.33
  • Income received every two weeks is multiplied by 2.17
  • Income received twice a month is multiplied by 2.0
  • Income received annually is divided by 12

For seasonal income, count the total income for the months worked in the overall calculation of income.

3230 Adjunctive Eligibility

Revision 23-2; Effective Sept. 29, 2023

An applicant is considered adjunctively (automatically) eligible for BCCS services at an initial or renewal eligibility screening, if the applicant or a member of the applicant’s household is currently enrolled in one of the programs listed below. An applicant must provide proof of active enrollment in the adjunctively eligible program. Acceptable eligibility verification documentation may include:

ProgramAccepted Documentation
Children’s Health Insurance Program (CHIP) PerinatalCHIP Perinatal benefits card
Medicaid for Pregnant WomenYour Texas Benefits card (Medicaid card)*
Special Supplemental Nutrition Program for Women, Infants and Children (WIC)WIC verification of certification letter, printed WIC-approved shopping list or recent WIC purchase receipt with remaining balance
Supplemental Nutrition Assistance Program (SNAP)SNAP eligibility letter
Temporary Assistance for Needy Families (TANF)TANF verification of certification letter

Note: Presentation of the Your Texas Benefits card does not completely verify current eligibility in the Medicaid for Pregnant Women (MPW) program. Grantees must verify current eligibility as outlined below. However, BCCS services may not be provided until such time as the applicant is no longer eligible for MPW.

To verify eligibility, providers must call Texas Medicaid & Healthcare Partnership (TMHP) at 800-925-9126 or log on to TexMedConnect on the TMHP website. For a person's current eligibility status, providers must enter two of the following four data elements for the client:

  • Patient Control Number
  • Date of Birth
  • Social Security Number
  • Last Name

If the applicant or the applicant’s child (must be considered part of the household) is enrolled in CHIP, she may be considered adjunctively eligible.

If the applicant’s current enrollment status cannot be verified during the eligibility screening process, adjunctive eligibility would not be granted. The grantee would then determine eligibility according to usual protocols.

A copy of the accepted documentation must be kept in the client’s record and available during QA reviews.

3240 Date Eligibility Begins

Revision 22-0; Effective August 15, 2022

Clients are eligible to start receiving services beginning with the date an application is completed and the client is determined eligible. Services rendered before the date that the client is determined eligible will not be reimbursed.

3250 Fees

Revision 23-2; Effective Sept. 29, 2023

Clients must not be charged administrative fees for items such as processing or transfer of medical records, or both, copies of immunization records and similar documents.

Grantees may bill clients for services outside the scope of BCCS allowable services if the service is provided at the client’s request and the client is made aware of their responsibility for paying the charges before services are rendered.

3260 Continuation of Services

Revision 23-2; Effective Sept. 29, 2023

Grantees who expend their awarded funds must continue to serve their existing eligible clients currently in the process of a care plan. It is allowable to obtain other funding to pay for these services. Dependent on the funding source, such funds may be counted toward the match requirement.

Grantees who expend their awarded funds are not required to enroll new clients. However, it is allowable to offer services at full pay or on a sliding scale basis.

3270 Med-IT® Data and Billing Services

Revision 23-2; Effective Sept. 29, 2023

Med-IT® users should verify a person is eligible for BCCS prior to adding a client to the database. Before entering a client’s information into the Med-IT® database, grantees must do a client search to determine whether she:

  • has ever received services funded by BCCS; and
  • has an existing Med-IT® identification number (a unique number assigned to each BCCS client).

This process can be completed by entering patient identifiers, which may include name, date of birth, social security number, or all three. A client’s address and ZIP code may also be used to search for an existing Med-IT® identification number. If a client has an existing Med-IT® identification number and received services in a different region, the grantee should submit a region change request to Med-IT@hhs.texas.gov.

Minimum PC Requirements for Med-IT® are:

  • Any internet connection – For optimum performance and response time, grantee locations should have access to a broadband connection with a minimum of 1 MB upload speed and 2 MB download speed.
  • Google Chrome and Microsoft Edge.

Med-IT® users must have access to the database and BCCS service providers must be listed in the database. New users may request access by completing Form 5200, Med-IT New User Request. New providers must complete Form 5201, Med-IT New Provider Request. Each of these forms must be submitted to Med-ITHelpdesk@hhs.texas.gov.

3300, Clinical Policy

Revision 23-2; Effective Sept. 29, 2023

3310 BCCS Grantee Clinical Responsibilities

Revision 23-2; Effective Sept. 29, 2023

Grantees must:

  • administer pelvic examinations in compliance with Chapter 167A of the Health and Safety Code;
  • accept referrals for Breast and Cervical Cancer Services (BCCS), funds permitting;
  • assess all clients for their need of patient navigation services and provide such services accordingly;
  • assist eligible clients in applying for Medicaid for Breast and Cervical Cancer (MBCC), including eligible clients diagnosed outside the BCCS program;
  • make a good faith effort to obtain treatment for clients with a precancerous or cancerous breast or cervical diagnosis who do not meet the eligibility criteria for BCCS cervical dysplasia, MBCC or both;
  • communicate with team members within your organization regarding program requirements of the BCCS program; and
  • provide and document monitoring and oversight of subgrantees and subcontracted services to ensure compliance with BCCS policies and standards.

3311 Covered Services

Revision 23-2; Effective Sept. 29, 2023

Breast and Cervical Cancer Services (BCCS) program services include:

  • clinical breast examination;
  • mammogram;
  • pelvic examination and Pap test;
  • diagnostic services;
  • cervical dysplasia management and treatment; and
  • assistance in completing the Medicaid for Breast and Cervical Cancer (MBCC) application.

Detailed information on available BCCS services is in the BCCS Billing Guideline.

3320 Client Health Record and Documentation of Patient Encounters

Revision 23-2; Effective Sept. 29, 2023

Individual Health Records and Documentation

Grantees must ensure a patient health record (medical record) is established for every client who obtains BCCS services.

All patient health records must be:

  • complete, legible, written in ink or documented within an Electronic Medical Record (EMR). No erasures or deletions should occur within a health record;
  • accurate documentation of all clinical encounters, including those by phone;
  • signed by the provider making the entry, including name of the provider, provider title and date for each entry. 
    • Note: Electronic signatures are acceptable to document provider review of care; however, stamped signatures are not acceptable;
  • readily accessible to assure continuity of care and availability to patients; and
  • systematically organized to allow easy documentation and prompt retrieval of information.

All patient health records must include the following documentation:

  • client identification, personal data, and eligibility assessment (including an insurance assessment);
  • preferred language, method of communication, or both;
  • patient contact information with the best way to reach the patient in such a manner that facilitates continuity of care, assures confidentiality, and adheres to Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations;
  • a problem list, updated as needed at each encounter, indicating significant illnesses and medical conditions;
  • a complete medication list, including prescription and nonprescription medications, as well as dietary supplements, updated at each encounter;
  • a complete listing of all medication allergies and adverse reactions, and other allergic reactions, displayed in a prominent place and confirmed or updated at each encounter. If the person has no known allergies, this should be properly noted;
  • the person’s past medical history to include all serious illnesses, hospitalizations, surgical procedures, pertinent biopsies, accidents, exposures to blood products and mental health history;
  • a person’s health risk survey and assessment, including past and current tobacco, alcohol and substance use or misuse; domestic or intimate partner violence or abuse, or both (for any positive result, the person must be offered referral to a family violence shelter in compliance with Texas Family Code, Chapter 91); occupational and environmental hazard exposure; environmental safety (for example, seat belt use, car seat use and bicycle helmets); nutritional and physical activity assessment; and living arrangements updated, as appropriate, at each encounter;
  • at each encounter, an encounter-relevant history and physical examination pertinent to the person’s reason for presentation;
  • assessment or clinical impression;
  • a plan of care, consistent with diagnoses and assessments which in turn are consistent with clinical findings, including education, counseling, treatment, special instructions, scheduled visits and referrals;
  • appropriate laboratory and other diagnostic test orders, results and follow-up, as indicated;
  • recommended follow-up care, scheduled return visit dates and follow-up for missed appointments;
  • informed consent or refusal of services, to include at a minimum:
    • general consent for care;
    • informed consent for any surgical or invasive procedures, as indicated; and
    • for required or recommended services refused or declined by the person, documentation of the service offered, counseling provided and the person’s decision to decline; and
  • client counseling and education, with attention to risks identified in the health risk assessment.

Note: At every clinic visit, the record must be updated as appropriate, and the reason for the visit, assessments made, if any, and the service that was provided must be documented.

A comprehensive patient health record, as described above, does not have to be established for clients referred only for Medicaid for Breast and Cervical Cancer (MBCC) assistance. For these clients, the BCCS grantee shall establish a Patient Navigation Record.

3321 Counseling and Education

Revision 23-2; Effective Sept. 29, 2023

For every woman who receives breast or cervical cancer screening, or both, or diagnostic services through BCCS, the service provider must effectively communicate and document the following information during the initial visit and update it during follow-up visits, as indicated by the client’s risk assessment:

  • Risk factors for breast and cervical cancer
  • Signs and symptoms of breast and cervical cancer
  • The importance of cancer screening at regular intervals
  • Limitations of screening, including limitations of imaging in women with dense breast tissue
  • Information on human papilloma virus (HPV) and safe sex practices
  • Information on the HPV vaccine
  • An advisory that BCCS services and eligibility may change from year to year
  • Information about tobacco cessation and a quit line referral, if appropriate

Tobacco Use Assessment and Texas Tobacco Quitline Referral

All women receiving BCCS services must be assessed for tobacco use consistently through standardized screening and referral procedures at every encounter. The assessment should be performed by agency staff and documented in the clinical record. Cessation rates improve when healthcare providers spend at least three minutes counseling their patients. Screening, counseling and referral to treatment do not need to be performed by the same healthcare provider.

Women who use any type of tobacco product, including electronic nicotine delivery systems, should be referred to the Texas Tobacco Quitline via one of the following:

The Texas Tobacco Quitline provides confidential, free and convenient cessation services to Texas residents ages 13 and older, including quit coaching and nicotine replacement therapy. Services can be accessed by phone at 1-877-YES-QUIT (1-877-937-7848) or online at YesQuit.org.

3330 Requirements for Policies to Ensure Appropriate Follow-up and Continuity of Care

Revision 23-2; Effective Sept. 29, 2023

Follow-up of Breast and Cervical Screening Results

The clinician must notify a woman of findings, reinforce the need for continued routine screening examination and provide the expected interval for her next routine screening examination. Grantees must attempt to remind each woman of her regular screening due date.

Rescreening Eligibility

Rescreening is the process of returning for a breast cancer screening or cervical cancer screening (or both) at a pre-determined interval (as per program guidelines) when no symptoms are present.

Women may return for rescreening if they continue to meet BCCS financial and clinical eligibility requirements. Women with a history of cancer may return for screening when they conclude their cancer treatment if they continue to meet BCCS financial and clinical eligibility requirements.

Exceptions to Rescreening

Grantees are not required to rescreen a client if the grantee has documented that she:

  • cannot be located or has moved from the contractor’s service area;
  • no longer meets the BCCS financial or clinical eligibility;
  • has Medicare Part B or other adequate health insurance which provides coverage for breast and cervical cancer screening and diagnostic testing; or
  • refuses, in writing or verbally, to return for services.

3331 Prescriptive Authority Agreements

Revision 23-2; Effective Sept. 29, 2023

When services are provided by an advanced practice registered nurse (APRN) or physician assistant (PA), it is the responsibility of the grantee to ensure that a properly executed prescriptive authority agreement (PAA) is in place for each mid-level provider. The PAA must meet all the requirements delineated in Texas Occupations Code, Chapter 157, including, but not limited to, the following criteria: 

  • be in writing and signed and dated by the parties to the agreement; 
  • be reviewed at least annually (including amendments);  
  • be kept on-site where the APRN or PA provides care;  
  • include the name, address and all professional license numbers of all parties to the agreement; 
  • state the nature of the practice, practice locations or practice settings; 
  • identify the types or categories of drugs or devices that may be prescribed, or the types or categories of drugs or devices that may not be prescribed; 
  • provide a general plan for addressing consultation and referral; 
  • provide a plan for addressing patient emergencies; 
  • describe the general process for communication and sharing of information between the physician and the APRN or PA to whom the physician has delegated prescriptive authority related to the care and treatment of individuals; 
  • if alternate physician supervision will be used, appoint one or more alternate physicians who may: 
    • provide appropriate temporary supervision following the requirements established by the PAA and the requirements of this section; and 
    • participate in the prescriptive authority quality assurance and improvement plan meetings required under this section; 
  • describe a prescriptive authority quality assurance and improvement plan and specify methods for documenting the implementation of the plan that includes: 
    • chart review, with the number of charts to be reviewed determined by the physician and APRN or PA; and 
    •  periodic meetings between the APRN or PA and the physician at a location determined by the physician, APRN or physician assistant. 

References 

3340 Standing Delegation Orders

Revision 23-2; Effective Sept. 29, 2023 

Per TAC Title 22, Part 9, Chapter 193, when services are provided by unlicensed and licensed personnel other than an APRN or PA whose duties include actions or procedures for a population with specific diseases, disorders, health problems or sets of symptoms, the clinic must have written standing delegation orders (SDOs) in place. SDOs are distinct from specific orders written for an individual. SDOs are instructions, orders, rules, regulations, or procedures that specify under what set of conditions and circumstances certain actions may be taken.  

The grantee must have SDOs in place for unlicensed and licensed personnel (not APRNs or PAs) that include the following: 

  • actions or procedures for a population with specific diseases, disorders, health problems or sets of symptoms;  
  • delineate under what circumstances an RN, LVN or non-licensed health care provider (NLHP) may initiate actions or tasks in the clinical setting; and  
  • provide authority for use with a patient:  
    • when a physician or advance practice provider is not on the premises; and  
    • before a patient is examined or evaluated by a physician or advanced practice provider.  

Example: An SDO for assessment of blood pressure and blood-sugar level would name the RN, LVN or NLHP that will perform the task, the steps to complete the task, the ranges for normal and abnormal and the process of reporting abnormal values.  
Other applicable SDOs when a physician is not present on-site may include, but are not limited to: 

  • obtaining a personal and medical history; 
  • performing an appropriate physical exam and the recording of physical findings; 
  • initiating and performing laboratory procedures; 
  • administering or providing drugs ordered by voice communication with the authorizing physician; 
  • handling medical emergencies to include on-site management, as well as possible transfer of the individual; 
  • giving immunizations; or
  • performing pregnancy testing.

The grantee must have a process in place to ensure that SDOs are reviewed, signed, and dated at least annually by the supervising physician responsible for the delivery of the medical care covered by the orders and by other appropriate staff. SDOs must be kept on-site.

References

3341 Breast Clinical Policy

Revision 23-2; Effective Sept. 29, 2023

Breast Cancer Screening Eligibility

Breast screening refers to procedures including clinical breast examination (CBE), screening mammogram and MRI for women who present without symptoms suspicious for breast cancer. For breast cancer screening to be most effective, the screening must be conducted at regular intervals.

Risk Screening and Individual Counseling

All women should undergo a risk assessment to determine if they are at high risk for breast cancer. Women considered high risk include: 

  • those who have a known genetic mutation such as BRCA 1 or 2; 
  • have first-degree relatives with premenopausal breast cancer or known genetic mutation;
  • with a history of radiation treatment to the chest area before the age of 30 (typically for Hodgkin’s lymphoma);
  • have a lifetime risk of 20 percent or more for development of breast cancer based on risk assessment models largely dependent on family history; or
  • have Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or have first-degree relatives with one of these syndromes.

Providers can choose whichever risk assessment method they prefer to determine if a woman is at high risk for breast cancer. Women at high risk for breast cancer should be screened with both an annual mammogram and an annual breast MRI.

All people should be counseled on breast awareness and advised to be familiar with their breasts and to report promptly any changes such as a mass, lump, thickening, or nipple discharge.

All people should be counseled on the benefits and risks of mammography. If a person has the option of having a 3-D mammogram, she should be counseled on the benefits and risks of 3-D mammograms versus 2-D mammograms to make an informed decision. 

Screening Frequency

Women 40 and older may receive breast screening services every 1 to 2 years based on the woman’s history and clinical presentation. Note: Grantees must document high-risk assessment in Med-IT®.

Transgender Clients

Transgender women (male-to-female), who have taken or are taking hormones and meet all program eligibility requirements, are eligible to receive breast cancer screening and diagnostic services. The Center of Excellence for Transgender Health and the World Professional Association for Transgender Health have developed consensus recommendations on preventive care services for the transgender population. Those recommendations include transwomen with past or current hormone use and breast-screening mammography in patients over 50 with additional risk factors (for example, estrogen and progestin use more than five years, positive family history and BMI more than 35). Find the preventive care recommendations at https://transcare.ucsf.edu/guidelines/breast-cancer-women.

Transgender men (female-to-male), who have not undergone a bilateral mastectomy and meet all program eligibility requirements, are also eligible to receive breast cancer screening and diagnostic services. Find guidance on breast cancer screening for transgender men from the Center of Excellence for Transgender Health

BCCS recommends grantees and providers counsel all eligible persons, including transgender men and women, about the benefits, potential harms, and limitations of screening, and discuss individual risk factors to determine if screening is medically indicated.

3342 Components of Breast Cancer Screening

Revision 23-2; Effective Sept. 29, 2023

The grantee must provide a complete breast cancer screening, which includes a mammogram, individualized client education, tobacco use assessment and Quit Line referral, if indicated, and may include a clinical breast examination (CBE). The grantee must document the breast cancer screening components in the client’s record and Med-IT®.

A breast health history must be included as part of the breast cancer screening. The health history includes:

  • Date and time intervals of previous mammograms
  • Results of previous mammograms
  • Date and results of the last CBE
  • Date and results of any previous breast surgery
  • Date of last menstrual period
  • Medication history, including current or previous use of hormones (for example, hormone replacement therapy and oral contraceptives
  • Other risk factors for breast cancer (personal history of breast cancer or family history of first-degree relatives with breast cancer)
  • Description of breast symptoms, if any

Clinical Breast Examination

A CBE is not a prerequisite for reimbursement for a screening mammogram by the BCCS program. Grantees should document if a CBE is not indicated for Minimum Data Element (MDE) records. CBEs must be performed by a physician, physician’s assistant, nurse practitioner, certified nurse midwife or additionally a qualified registered nurse with specialized training as required under standing delegation orders (SDOs). The specialized RN CBE training must be documented in the personnel record (for example, an educational certificate, a degree, or continuing education credits). Complete documentation of the CBE must be included in the patient health record and Med-IT ®.

Screening Mammogram Special Circumstances

Additional views, as used with a diagnostic mammogram (four to six specified diagnostic views), can be used to screen women with the following special circumstances:

  • Cosmetic or reconstructive breast implants
  • A history of breast cancer and lumpectomy (partial mastectomy)

Screening Magnetic Resonance Imaging (MRI)

Breast MRI may be reimbursed by BCCS in conjunction with a screening mammogram after program approval. Grantees must request approval using Form 5203, Breast MRI Pre-Authorization Request Form. Once reviewed by HHSC clinical staff, Form 5203 will be returned to the grantee within 10 business days.

Breast MRI can also be reimbursed when used to better assess areas of concern on a mammogram or for evaluation of a client with a history of breast cancer after completing treatment.

MRI Restrictions:

  • Breast MRI must never be performed alone as a breast cancer screening tool.
  • Breast MRI cannot be reimbursed to assess the extent of disease for staging in women already diagnosed with breast cancer.
  • All breast MRI procedures require pre-authorization.
  • MRI procedures must be performed in facilities with dedicated breast MRI equipment able to perform MRI-guided breast biopsies.

Imaging Reports – Screening Mammogram and MRI

Radiology facilities must prepare a written report of the results of each radiologic examination, including screening mammography and MRI. This report must include the following:

  • Name of the client and an additional client identifier
  • Name of the physician who interpreted the mammogram
  • An overall final assessment of findings using the Breast Imaging Reporting and Data System (BIRADS) classification

3343 Breast Cancer Diagnostic Services

Revision 23-2; Effective Sept. 29, 2023

Breast Cancer Diagnostic Eligibility

Applicants 18 to 64 may be eligible for breast cancer diagnostic services if they have an abnormal breast cancer screening result and meet program eligibility requirements.

Managing Women with Abnormal Breast Cancer Screening Results

The management of women whose mammogram, clinical breast examination (CBE), or both, are abnormal relies on a body of scientific literature that is constantly growing and changing. Providers should follow standards established by organizations such as the National Comprehensive Cancer Network and the American College of Radiology.

Reimbursement for Complications of Breast Procedures

Grantees may request reimbursement for treatment costs associated with patient complications related to breast biopsy procedures that occur in the immediate post-procedure or post-operative period, excluding inpatient hospital services. Grantees may be reimbursed through a voucher system for approved charges up to $3,000 per occurrence from awarded contract funds. To request reimbursement, grantees must email the Breast and Cervical Diagnostic Procedure Complication Reimbursement Request Form 5205 and supporting documents to BCCS program staff at BCCSprogram@hhs.texas.gov.

Supporting documents include the following:

  • The client’s Med-IT® ID and date of service when treatment procedures were performed on the client in question.
  • A narrative summary detailing the breast biopsy procedure performed and any related complications which have been documented in the Navigation or Cycle Note section of the client’s Med-IT® record.
  • All emergency room, surgical and office progress notes, and similar notes related to complications of the procedure.
  • The procedure notes, operative report or both, and similar documentation for the initial procedure.
  • A completed paper Health Insurance Claim Form (CMS-1500) detailing the procedures for which the grantee is seeking reimbursement.
    • List all procedures related to the complication even if they are not typically reimbursable under the BCCS Program.

3350 Cervical Clinical Policy

Revision 23-2; Effective Sept. 29, 2023

3351 Cervical Cancer Screening Services

Revision 23-2; Effective Sept. 29, 2023

The cervical cancer priority population includes women who have never been screened for cervical cancer or not been screened within the past 10 years. Recruitment efforts should be concentrated on the priority population. For cervical cancer screening to be most effective, the screening must be conducted at regular intervals.

Cervical Cancer Screening Management

Cervical cancer screening is primarily performed using the Pap test and the HPV DNA test. BCCS uses United States Preventive Services Task Force (USPSTF) cervical cancer screening recommendations.

Clinical and reimbursement guidelines for cervical screening are as follows:

  • 21 – 29: Cervical cytology (Pap smear) alone every three years, with reflex HPV testing when cytology reveals atypical squamous cells of undetermined significance (ASCUS).
  • 30 – 64: Cervical cytology (Pap smear) alone every three years, with reflex HPV testing for ASCUS or cervical cytology and HPV co-testing every five years (preferred).
  • Under 21: Not eligible for cervical cancer screening.

Special circumstances may warrant alterations in screening intervals, as determined by a clinician. Special circumstances must always be documented in Med-IT® cycle notes. These may include:

  • Clients considered high-risk (for example, HIV positive, immunosuppressed, exposed to diethylstilbestrol (DES) in utero or history of cervical cancer).
  • Clients who had a hysterectomy for cervical intraepithelial neoplasia (CIN) disease. These clients may continue screening for 20 years.
  • Clients who have had cervical cancer. These clients may be screened indefinitely if they are in good health.
  • Clients who have had a hysterectomy for benign disease and the cervix is still present. These people may be eligible for cervical cancer screening services. Funds can be used to pay for an initial examination to determine whether the cervix is still present.

Transgender Clients

Transgender men (female-to-male) who have a cervix may receive BCCS cervical cancer screening services if other eligibility criteria are met. Transgender women (male-to-female) are not eligible for cervical services.

Components of Cervical Cancer Screening

The clinical components of cervical cancer screening are pelvic examination, Pap test, HPV test (if indicated), clinical breast examination (CBE) (if indicated), client education, tobacco assessment and Quitline referral (if indicated). The grantee must document the CBE and cervical cancer screening components in the client’s record and Med-IT®.

A cervical health history must be included as part of the cervical cancer screening. The health history includes the:

  • Date and results of the last pelvic examination and Pap test.
  • Date and results of any past diagnostic procedures and treatments for cervical disease.
  • Date of last menstrual period and pregnancy history.
  • Medication history, including current or previous use of hormones (for example, hormone replacement therapy and oral contraceptives).
  • Risk factors for cervical cancer.
  • Description of present pelvic symptoms.

Clinical components of cervical cancer screening must be performed by a physician, physician’s assistant, nurse practitioner, certified nurse midwife or a qualified registered nurse with specialized training as required under standing delegation orders (SDOs). The RN’s specialized training for cervical cancer screening must be documented in the personnel record (for example, an educational certificate, a degree, or continuing education credits).

Grantees must have policies and procedures to ensure health care providers follow evidence-based clinical guidelines and provide clinical services consistent with current nationally recognized standards of care.

HPV Testing

HPV DNA testing is a reimbursable procedure when used for screening with Pap testing (that is, co-testing) and for follow-up of abnormal Pap results, as per the American Society for Colposcopy and Cervical Pathology (ASCCP) algorithms. Reimbursement for low-risk HPV DNA panel is not permitted.

HPV tests must be approved by the Federal Drug Administration (FDA) and clinically validated.

3352 Cervical Cancer Diagnostics

Revision 23-2; Effective Sept. 29, 2023

Cervical Cancer Diagnostic Eligibility

Applicants 18-64 years old who meet BCCS general requirements may receive diagnostic services. BCCS funded diagnostics services must be delivered according to the ASCCP guidelines.

Follow-up for Abnormal Cervical Screening

When the results of the pelvic exam, cervical cancer screening test (Pap test), or both are abnormal, further diagnostic follow-up is required. A normal Pap test does not rule out cancer if a woman has a cervical lesion on pelvic examination. A colposcopy or cervical biopsy, or both, are allowed if determined appropriate by the clinician after an abnormal pelvic exam.

BCCS grantees must follow the algorithms for the management of the specific type of abnormal result and in consideration of special populations (for example, pregnant women and clients 20 years and younger or at high risk).

Diagnostic Procedures

Tests performed to confirm or rule out cancer when screening tests yield abnormal results include colposcopy, cervical biopsy, endocervical curettage (ECC) and diagnostic excisional procedures. A clinical breast exam (CBE) is not required when a client is referred to BCCS after an abnormal pelvic exam or abnormal Pap test. Diagnostic procedures must be performed by qualified clinicians with specialized training (physicians, physician's assistants, nurse practitioners or certified nurse midwives).

Clinical Utilization Restrictions for Diagnostic Procedures

Diagnostic loop electrosurgical excision procedure (LEEP) conization, laser conization and cold knife conization cannot be performed on the following clients:

  • Any age in the absence of high-grade squamous intraepithelial lesion (HSIL), ASC-H or higher abnormality.
  • Any age with histology cervical intraepithelial neoplasia (CIN) I or lesser abnormality for a duration of less than two years and in the absence of HSIL or atypical glandular cells (AGC) on Pap tests.

Other Restrictions

The BCCS program will monitor the use of facility and anesthesia services for cold knife conization as well as for use with LEEP.

Grantees are encouraged to develop subcontracts with practitioners having specialized training in the management of cervical disease, including LEEP, as an office-based procedure.

Consultations

Consultations for follow-up of abnormal cervical results must be performed by health care providers with specialized training in the management of cervical disease, including skill performing invasive diagnostic procedures.  

A consultation may be performed only by a health care provider who did not perform the original screening examination. If that health care provider is not a licensed physician, appropriate protocols must be established and documented for that provider. Consultations must involve direct examination of the client and are billed using office visit codes.

Access to Treatment

The following treatment options may be available for eligible clients with a qualifying diagnosis:

  • General revenue funds for cervical dysplasia management and treatment of clients who have qualifying diagnoses and are not eligible for Medicaid for Breast and Cervical Cancer (MBCC). For a description of qualifying diagnoses, see 3353, Cervical Dysplasia Management and Treatment.
  • MBCC for applicants who have qualifying breast or cervical cancer diagnoses and meet all other MBCC eligibility criteria. See 3354, Medicaid for Breast and Cervical Cancer, and the MBCC Guidelines for Determination of Qualifying Diagnosis for guidance.

Office-based Procedures Performed in an Ambulatory Surgical Center

Special circumstances may arise that necessitate an office-based diagnostic procedure being performed in an ambulatory surgical center. These services require pre-authorization before the client receives services in an ambulatory surgical center or other outpatient facility. Grantees must submit the Office-based Procedures Performed in an Ambulatory Surgical Center Pre-authorization Form 5204, along with all supporting documentation to BCCSprogram@hhs.texas.gov. Once reviewed by BCCS clinical staff, Form 5204 will be returned to the grantee within 10 business days. BCCS will not reimburse for any office-based procedures performed in an ambulatory surgical center that have not received pre-authorization. Evidence of pre-authorization approval must be made available to BCCS review staff during monitoring on-site visits.

Note: Special circumstances may include clients with a history of cervical cancer, obesity, cervical stenosis, vaginal stenosis or atrophy.

Reimbursement Following Complications of LEEP and LEEP Conization Procedures

Grantees may request reimbursement for treatment costs associated with patient complications related to LEEP and conization procedures that occur in the immediate post-procedure or post-operative period, excluding inpatient hospital services. Grantees may be reimbursed through a voucher system for approved charges up to $3,000 per occurrence from awarded contract funds. To request reimbursement, grantees must email the Breast and Cervical Diagnostic Procedure Complication Reimbursement Request Form 5205 and supporting documents to BCCS program staff at the email box designated by the program.

Supporting documents include the following:

  • The client’s Med-IT® ID number and date of service when the treatment procedure was performed on the client in question.
  • A narrative summary detailing the LEEP or conization procedure performed and related complications which have been documented in the Case Management or Cycle Note section of the client’s Med-IT® record.
  • All emergency room, surgical and office progress notes for the client related to complications of the procedure.
  • The procedure notes and operative report, or both for the initial procedure.
  • A completed Health Insurance Claim Form (CMS-1500) detailing the procedures for which the grantee is seeking reimbursement. List all procedures related to the complication even if they are not typically reimbursable under the BCCS program.

3353 Cervical Dysplasia Management and Treatment

Revision 23-2; Effective Sept. 29, 2023

The Centers for Disease Control and Prevention (CDC) strictly prohibits reimbursement of treatment services. However, grantees may receive limited state funding for management and treatment of cervical dysplasia (CD). CD procedures are reimbursed from non-federal funding, as the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) prohibits use of CDC grant funds for treatment. Cervical dysplasia funds may not be used to reimburse for BCCS cervical screening or diagnostic services.

Cervical Dysplasia Eligibility

Applicants must meet BCCS general eligibility criteria and have a definitive, biopsy-confirmed diagnosis of one of the following:

  • CIN I, CIN II, CIN II-III; or
  • High-grade dysplasia (severe dysplasia or CIN III) or CIS.

Grantees must assess clients with severe dysplasia, CIN III or CIS for MBCC eligibility before using CD funds to pay for treatment services. Undocumented applicants are eligible for CD services.

Components of Cervical Dysplasia Services

Cervical dysplasia management and treatment may include the following services:

  • Follow-up testing and observation without treatment, for example, cytology (Pap tests), HPV testing and colposcopy.  
  • Treatment using excision or ablation, for example, cryotherapy and cervical conization.
  • Patient Navigation (see 3360, Patient Navigation Services).

Reimbursement for Cervical Dysplasia Management and Treatment Services

Reimbursement for cervical dysplasia services is limited to the codes which begin with “CD,” "FCX” and “FCD" listed separately in the BCCS Billing Guidelines. These codes must be billed in the Med-IT® system. Grantees should bill CD services throughout the dysplasia plan of care and return clients to BCCS services once released to routine screening intervals by the provider.

BCCS grantees must submit specimens for program covered laboratory testing to a U.S. Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory and adhere to all quality management requirements for cytology quality assurance.

Office-based Procedures Performed in an Ambulatory Surgical Center

Special circumstances may arise that necessitate an office-based diagnostic procedure being performed in an ambulatory surgical center. These services require pre-authorization before the client receives services in an ambulatory surgical center or other outpatient facility. Grantees must submit the Office-based Procedures Performed in an Ambulatory Surgical Center Pre-Authorization Form 5204, along with all supporting documentation to BCCSprogram@hhs.texas.gov. Once reviewed by BCCS clinical staff, Form 5204 will be returned to the grantee within 10 business days. BCCS will not reimburse for any office-based procedures performed in an ambulatory surgical center that have not received pre-authorization. Evidence of pre-authorization approval must be made available to BCCS review staff during monitoring on-site visits.

Note: A special circumstance may be an abnormal pelvic exam, a client with a history of cervical cancer, obesity, cervical stenosis, vaginal stenosis or atrophy.

3354 Medicaid for Breast and Cervical Cancer

Revision 23-2; Effective Sept. 29, 2023 

The Texas Health and Human Services Commission (HHSC) administers the Medicaid for Breast and Cervical Cancer (MBCC) Program, a special Medicaid program authorized by federal and state laws to provide access to cancer treatment services through full Medicaid benefits to qualified women. See 42 Code of Federal Regulations Section 435.213, Human Resources Code Section 32.024(y) and (y-1) and Title 1 Texas Administrative Code, Chapter 366, Subchapter D.

MBCC Eligibility

Applicants who need treatment must meet each of the following criteria:

  • Be diagnosed by a BCCS grantee or diagnosed by any physician and referred to a BCCS grantee for the application process.
  • Have a diagnosis considered to be a qualifying diagnosis for the program.
  • Be at or below 200 percent of the federal poverty level.
  • Be uninsured. That is, she must not otherwise have creditable coverage. Creditable coverage is health care coverage that covers treatment for breast and cervical cancer, including current enrollment in Medicaid or Medicare Part A, Part B, or Part A and B. Note: If the woman is enrolled in the Healthy Texas Women (HTW) Program at the time of diagnosis, she will be disenrolled from HTW to be enrolled in MBCC by Medicaid eligibility staff.
  • Be under 65 years old.
  • Provide their social security number or proof that they have applied for one.
  • Be a U.S. citizen or eligible immigrant.
  • Be a Texas resident.

MBCC eligibility guidelines and verification requirements may be found in Part X- Medicaid for Breast and Cervical Cancer of the Texas Works Handbook.

Need Treatment

A person is considered to need treatment for breast or cervical cancer if after the initial screen under BCCS or the initial period of eligibility, their treating health professional determines that:

  • Definitive treatment for breast or cervical cancer is needed, including treatment of a precancerous condition or an early-stage cancer, and including diagnostic services as necessary to determine the extent and proper course of treatment.
  • More than routine diagnostic services or monitoring services for a precancerous breast or cervical condition are needed.

Clients receiving hormonal treatment or breast reconstruction are considered to be receiving treatment and may remain eligible for MBCC benefits if the client had initial treatment paid for by Medicaid. Clients with triple negative receptor breast cancer (TNRBC) receiving active disease surveillance are also considered to be receiving treatment and may remain eligible for MBCC benefits if active treatment was paid for by MBCC.

Active disease surveillance (for the purposes of determining eligibility for MBCC) is periodically monitoring disease progression to quickly treat cancerous and precancerous conditions arising from the presence of a previously diagnosed breast or cervical cancer. Disease surveillance is not considered to be active treatment for new applicants.

Verification of Citizenship and Identity

As part of Public Law 109-171, Deficit Reduction Act of 2005, individuals declaring to be a U.S. citizen or nationals of the U.S. must provide evidence of citizenship when applying for, or receiving, Medicaid benefits. The documented verification must establish both citizenship and identity. The Medicaid citizenship and qualified immigrant rules apply to MBCC. To be eligible for Medicaid, a person must either be a U.S. citizen or a qualified immigrant.

Citizenship guidelines and verification requirements may be found in the Texas Works Handbook: A-300, Citizenship.

If an applicant states that she is a citizen or legal immigrant, the BCCS grantee indicates on the last page of Form H1034, Medicaid for Breast and Cervical Cancer, that she is presumptively eligible. If the BCCS grantee (or health provider) is uncertain whether a woman meets citizenship and eligible immigrant requirements, the completed Form H1034 should be submitted for processing and determination, along with any citizenship or immigration documents the woman provides. If an applicant states that she does not meet citizenship requirements, an MBCC application should not be submitted.

Grantee may call 2-1-1 or 877-541-7905 for help with client eligibility and citizenship determination.

Presumptive Eligibility

Presumptive eligibility is a Medicaid option that allows states to enroll women in Medicaid for a limited period before a full citizenship or legal immigrant eligibility determination is complete. Presumptive eligibility facilitates the prompt enrollment and immediate access to services for women who need treatment for breast or cervical cancer. The earliest date presumptive eligibility may begin is the day after the client received a biopsy-confirmed qualifying diagnosis.

Coverage

The earliest date a woman may be enrolled in full Medicaid coverage through MBCC is the day after a biopsy-confirmed qualifying diagnosis. Coverage may continue through the duration of her cancer treatment. MBCC services include the full range of Medicaid benefits in addition to the treatment of breast or cervical cancer. If a client has a question about her Medicaid benefits or wants to locate a Medicaid provider in their area, she can call the TMHP Medicaid Client Help Line at 800-335-8957.

A client can continue to receive MBCC benefits if she meets the eligibility criteria and provides proof from her treating physician that she is receiving active treatment for breast or cervical cancer. The client must return Form H1551, Treatment Verification, along with Form H2340, Medicaid for Breast and Cervical Cancer Renewal, to HHSC before the end of the six-month coverage renewal period.

If the client’s cancer is in remission and the physician determines that the client requires only routine health screenings (for example, annual breast examinations, mammograms or Pap tests as recommended by the American Cancer Society and the U.S. Preventative Services Task Force), the client is not considered to be receiving treatment and MBCC coverage would not be renewed. If a client is later diagnosed with a new breast or cervical cancer, recurrence of breast or cervical cancer, or metastasis related to the primary qualifying diagnosis, she may reapply for MBCC.

BCCS State Office Responsibilities

BCCS program staff have the responsibility of reviewing the client’s application, required clinical documents, and other required documentation, along with submitting the information to HHSC Centralized Benefits Services (CBS) within five business days of receipt of the complete application package.

Note: Once submitted for consideration to HHSC CBS, BCCS staff cannot review the application status and do not assist with, or collect documents for, pended MBCC applications.

HHSC MBCC Eligibility Staff Responsibilities

HHSC CBS staff verify receipt of the Form H1034 application within 48 hours and process the application within two business days of receipt. If additional information is required, clients are placed on MBCC Presumptive status and allowed 10 days to provide the required information. Eligibility for all applications will be determined within 45 calendar days of receipt of the application packet.

Eligibility Determination Group (EDG) disposition is the result of processing the request for assistance and making an eligibility determination. The Texas Integrated Eligibility Redesign System (TIERS) generates Form TF0001, Notice of Case Action when the EDG is disposed. Form TF0001 is sent the same day eligibility is determined. This notice informs clients of their Medicaid status with an effective date of coverage and notifies the client of their EDG number. Clients may contact 2-1-1 to request the status of their application and Medicaid number.

MBCC inquiries from BCCS grantees on client reinstatements, approvals, denials, and final application status should be sent to CBS_MBCC@hhsc.state.tx.us.

BCCS Grantee Responsibilities

BCCS grantees are responsible for assisting women with the completion of Form H1034, determining presumptive eligibility for qualified women, and assessing patient navigation needs. In situations where a BCCS grantee or subgrantee is unsure about a cancer diagnosis, the first steps should be to:

  • review the guidelines for determination of qualifying diagnosis; and
  • if the diagnosis is unclear, consult with their medical director or physician and provider staff regarding the diagnosis.  

BCCS grantees should not submit a diagnosis to the BCCS clinical team or BCCS staff for evaluation prior to submitting an MBCC application. Initial BCCS grantee and subgrantee responsibilities include:

  • collection and review of documents to ensure eligible income, age, insurance, citizenship and biopsy-confirmed qualifying diagnosis;
    • Do not send bills, tax forms or other financial statements or information to BCCS. Grantees shall retain proof of income in the client record and document financial eligibility in Med-IT®.
    • Verify that analysis of all biopsies has been performed by a U.S. CLIA-certified laboratory.
    • Verify the date of specimen collection is documented (specimen collection date is typically found on the pathology report, operative record or procedure note).
  • assistance with the completion of the medical assistance application, Form H1034;
    • The name on Form H1034 must match the name on the client’s Social Security card or legal identification. If the names differ, grantees must provide clarification.
    • The driver’s license and immigrant ID numbers must be written on the copy of the identification cards.
  • Complete the Med-IT® data entry and billing before submitting the completed MBCC application to BCCS, including the Final Diagnosis and Treatment screen for clients diagnosed with BCCS funds. BCCS grantees must submit the MBCC application and other required documents no later than two working days from the date presumptive eligibility determination is made (certification date at the bottom of Page 6 of the application).

Submitted MBCC application documents include:

  • Form H1034;
  • final biopsy confirmed report for the qualifying diagnosis. Preliminary or temporary reports of qualifying diagnoses will not be accepted;
  • any other supportive documents that may be necessary to verify the date of specimen collection and need for cancer treatment (for example, operative record, procedure note or progress notes);
  • if the diagnosis is more than six months old submit both of the following:
    • physician letter or office visit note(s) or other documentation specifying the need for active treatment; and
    • recent medical tests supporting the need for active treatment;
  • To support a metastatic or recurrent cancer diagnosis, send:
    • final biopsy-confirmed report of the original breast or cervical cancer diagnosis; and
    • diagnostic reports (for example, CT scan and biopsy report) which indicate the disease is “compatible with” or “consistent with” an original qualifying breast or cervical cancer diagnosis. For example, a diagnosis such as “metastatic adenocarcinoma consistent with the prior breast primary” would be acceptable. Many metastatic or recurrent cancers may look the same; the primary does not need to be explicitly diagnosed.

Following MBCC application submission, grantees may locate the application status in the client’s Med-IT® record. BCCS program staff will document in the client’s Med-IT® record under enrollment notes when an application has been received and when it was sent to CBS for final eligibility determination. If grantees do not see notes in the client’s enrollment record after three business days, they may email the client’s Med-IT® ID number to MBCCApps@hhs.texas.gov to confirm receipt of the application.

Medicaid Reinstatement

A client enrolled in Medicaid under MBCC within the past 12 months, and who is no longer on Medicaid but is still in active treatment or in need of active treatment for the original cancer, may reapply for MBCC. Reinstatements are handled directly by HHSC. The BCCS grantee may assist  the client by:

  • requesting Form H1551 and Form H2340 by calling 2-1-1 or 877-541-7905;
  • assisting with completing the required documents; and
  • faxing the following documents to HHSC:
    • Form H1551 and Form H2340; and
    • citizenship and identity verification.

State-to-State Transfers

State-to-state transfers are handled directly by HHSC by doing the following:

Pathology Specimens

Pathology specimens (original slides) collected and evaluated outside the U.S must be reviewed by a U.S. CLIA-certified lab to determine a qualifying diagnosis. The BCCS program and the client cannot be billed for the reading and interpretation of the specimen submitted to a U.S. CLIA lab.

A specimen may be transported either by the client or by a lab to another lab.

3360 Patient Navigation Services

Revision 23-2; Effective Sept. 29, 2023

Clients often face significant barriers to accessing and completing cancer screening and diagnostics. Patient navigation is a strategy aimed to reduce disparities by helping women overcome those barriers. Patient navigation is defined as individualized assistance provided to women to help facilitate timely access to quality screening and diagnostic services, as well as initiation of timely treatment services for those diagnosed with cancer.

Patient Navigation Activities

Although patient navigation services vary based on a client’s needs, at a minimum, patient navigation for women served by the BCCS program must include the following:

  • An assessment of the client’s barriers to cancer screening, diagnostic services, and initiation of cancer treatment.
  • Client education and support.
  • Resolution of client barriers (for example, transportation and translation services).
  • Client tracking and follow-up to monitor progress in completing screening, diagnostic testing and initiating cancer treatment.
  • A minimum of two, but preferably more, contacts with the client.
  • Collection of data to evaluate the primary outcomes of patient navigation, such as client adherence to cancer screening, diagnostic testing, and treatment initiation.
  • Tracking of clients lost to follow-up.

Assessment is a cooperative effort between the client and patient navigator to examine and document the client’s needs (diagnostic, treatment, and essential support services) through a process of gathering critical information from the client.

Planning uses short- and long-term needs identified in the assessment to establish services planned, time frames and follow-up. As applicable, time frames must be consistent with BCCS required screening and diagnostic intervals. Services must be completed no later than 30 days from the date of the planned activity or before initiation of treatment, whichever is sooner.

Coordination is the implementation of the service plan, including the appropriate use of available resources to meet the needs of the client. Coordination of services may include scheduling appointments, making referrals, and obtaining and disseminating appropriate reports.

Monitoring is the ongoing assessment of the client’s service plan to ensure that the client’s needs are met. In addition to monitoring clients who are receiving patient navigation services, grantees must establish a system to monitor abnormal screening or diagnostic results for identifying clients who need to have patient navigation initiated.

Resource Development

Patient navigators are responsible for identifying resources to meet client needs, including dysplasia and cancer treatment services, regardless of client ability to pay. Documentation must be maintained in a resource directory developed specifically for detailing services that support BCCS-enrolled women with unmet needs.

Grantee Requirements

All women enrolled in BCCS must be assessed for their need of patient navigation services and provided with such services accordingly. Grantees are required to provide patient navigation services to:

  • BCCS-enrolled clients with abnormal screening or diagnostic results;
  • clients referred to BCCS with qualifying breast or cervical cancer diagnoses that are presumptively eligible for MBCC; and
  • clients referred to BCCS for cervical dysplasia management and treatment. Cervical dysplasia recipients must not be eligible for MBCC.

Patient navigation does not include eligibility determination or navigation of MBCC applicants whose presumptive eligibility determination was inaccurate.

Terminating Patient Navigation

Depending on screening and diagnostic outcomes, patient navigation services are terminated when a client:

  • completes screening and has a normal result;
  • completes diagnostic testing and has normal results;
  • has attended a referral appointment for treatment;
  • is documented as lost to follow-up or refused services;
  • has had a good faith effort made according to BCCS policy; or
  • initiates cancer treatment or refuses treatment.

When a client concludes her cancer treatment and has been released by her treating physician to return to a routine screening schedule, she may return to the program and receive all services, including patient navigation, if she continues to meet BCCS eligibility requirements.

Requirements for Patient Navigation Compliance

Navigation of patients must meet the following requirements:

  • Patient navigation must include an assessment for needs and care coordination planning.  
  • The assessment is to be conducted within 30 days from the date of referral for diagnostic procedures or before the initiation of the first diagnostic service, whichever is sooner.
  • The assessment should be conducted in person, via phone, or using virtual telehealth software in a face-to-face interview format, if possible. 
  • The service plan must be documented in the Med-IT® Data System Navigation screen and the client’s office progress notes.
  • The grantee must ensure that monitoring of abnormal results is conducted and documented at the grantee level.
  • The grantee must contact clients with abnormal screening and noncancerous diagnostic results no later than 30 days following receipt of an abnormal result. All screening and diagnostic services must be documented, including procedure specific consent, if applicable.
  • The grantee must contact clients with cancer diagnoses no later than two weeks following the receipt of a cancer diagnostic result. All screening and diagnostic services must be documented, including procedure specific consent, if applicable.
  • Within one month after completion of the patient navigation plan for a diagnosis of cancer or cervical dysplasia, the patient navigator must follow-up and document that the service was implemented.
  • As additional needs are identified, they are recorded on the plan and the accompanying services and time frames are indicated.
  • Grantees must develop and maintain a resource directory containing information on services that could support women with unmet needs who are eligible for BCCS, which may include Healthcare.gov referral material.
  • Grantees must document client refusal, client lost to follow-up, and good faith effort, as appropriate.

Navigation of MBCC Referrals

Referred MBCC applicants must be provided a needs assessment and MBCC application assistance if determined to meet presumptive eligibility. BCCS grantees may choose to provide patient navigation for MBCC referrals that were determined to be ineligible. If patient navigation is initiated for a client found to be ineligible for MBCC, BCCS grantees shall follow the client until treatment is initiated but may not bill BCCS for the patient navigation services provided. If patient navigation will not be initiated, the client should be provided with information about available local resources and referred to the diagnosing health professional.

Good Faith Effort

A good faith effort is defined as at least three documented attempts to obtain treatment or to navigate clients with a precancerous or cancerous breast or cervical diagnoses who do not meet the eligibility criteria for cervical dysplasia or MBCC enrollment. Examples include, but are not limited to, seeking service(s) for clients through the American Cancer Society, Susan G. Komen for the Cure, Livestrong, other health care providers and facilities through pro bono, sliding fee scale, reduced payment plan or sponsorship assistance.

3361 Client Refusal of Services

Revision 23-2; Effective Sept. 29, 2023

The grantee must attempt to obtain, in writing, and document in the client record informed refusal from the client if the client fails to keep appointments or refuses recommended procedures. If the client cannot, or will not, sign an informed refusal, the grantee must document verbal refusal. Before closing the client record as a refusal, a thorough review of the client’s plan, recommendations and navigator's actions must be conducted to ensure proper closure.

Lost to Follow-up

Before a grantee can consider a client as lost to follow-up, the grantee must have at least three documented attempts to contact the client, with the last attempt sent by certified mail. The grantee must allow enough time between contact attempts for the client to reply or respond to the grantee.

Client contact attempts can be made by:

  • office visit;
  • phone;
  • home visit;
  • mail; or
  • a combination of these methods.

Attempts to contact the client must be written or presented verbally (when appropriate) in the client’s primary language (if the client has limited English proficiency) and must include appropriate provisions for the visually and hearing impaired.

3400, Reimbursement

Revision 22-0; Effective August 15, 2022

3410 Billing Procedures

Revision 23-2; Effective Sept. 29, 2023

Grantees must accept fee-for-service (FFS) payment rates for screening, diagnostic and patient navigation services specified in Med-IT®.

BCCS client data shall be entered in Med-IT® no later than 45 days after the provision of each service. BCCS services and procedures that have been met will be marked approved to pay and submitted electronically to HHSC for processing through the state comptroller. Paid claims will be deposited into the grantee’s direct deposit account. Grantees may be reimbursed only for services listed in the BCCS Billing Guideline.

Completed MBCC applications shall not be submitted to HHSC until all client data and patient navigation billing have been entered in Med-IT®.

The BCCS Billing Guideline is available in Appendix VI

3420 Funding for Screening Mammograms and MRI

Revision 22-0; Effective August 15, 2022

Reimbursement for screening mammograms and MRI for high-risk asymptomatic women 40 – 49 must initially be billed using the B codes listed in the BCCS Billing Guideline.

Note: BCCS funds may not be used for breast cancer screening in clients under 40.

3430 Funds for Cervical Dysplasia (CD) Management and Treatment

Revision 22-0; Effective August 15, 2022

Federal funds may never be applied to treatment services. CD funds should be used for CD management and treatment services for women who meet BCCS eligibility criteria and have a definitive diagnosis (biopsy confirmed) of:

  • CIN I, CIN II and CIN II-III; or
  • CIN III or CIS if the client does not meet eligibility criteria for Medicaid for Breast and Cervical Cancer (MBCC). CIN III and CIS results should always be screened for MBCC eligibility before CD treatment enrollment.

3500, Data Collection, Reporting and Performance

Revision 22-0; Effective August 15, 2022

3510 Financial Reconciliation Report (FRR)

Revision 23-2; Effective Sept. 29, 2023

The FRR is the annual reconciliation report submitted to HHSC. Each grantee must report final financial results as part of the closeout process on each contract. This report is due no later than 60 days after the end of the applicable contract term or 30 days after the last pay file is run, whichever is later. The grantee sends the completed form to PSPS_Finance@hhs.texas.gov.

3520 Match Report

Revision 23-2; Effective Sept. 29, 2023

Matching funds refer to non-federal resources such as money and in-kind contributions. The Centers for Disease Control and Prevention (CDC) requires the BCCS program to provide $1 in match for every $3 of CDC funding awarded. Grantees must secure, budget, expend and report the non-federal match. Match reports are submitted to HHSC 30 days after the end of each quarter to PSPS_Contracts@hhs.texas.gov.

3530 Clinical Performance Measures

Revision 23-2; Effective Sept. 29, 2023

Grantees are required to meet National Breast and Cervical Cancer Early Detection Program (NBCCEDP) performance measures. The following performance measures are used to assess, in part, the grantee’s effectiveness in providing BCCS services. Screening indicators are as follows:

PI No.ServiceDescription
1CervicalPercentage of initial program pap tests provided to women 30 and older who have never or rarely been screened (Goal: >=35%)
2Cervical Percentage of pap test records with planned and completed diagnostic follow-up (Goal: >= 90%)
3CervicalPercentage of pap test records where time between screening and final diagnosis was <= 60 days (Goal: >= 75%)
4BreastPercentage of pap test records with a diagnosis of HSIL, CIN2, CIN3/CIS or invasive cervical carcinoma where treatment has been started (Goal: >=90)
5BreastPercentage of pap test records with a diagnosis of HSIL, CIN2 or CIN3/CIS where time between diagnosis and treatment is <= 60 days (Goal: >= 80%)
6BreastPercentage of mammogram screening records with abnormal results and completed diagnostic follow-up (Goal: >= 90%)
7BreastPercentage of mammogram screening records with completed follow-up and time between screening and final diagnosis was <= 60 days (Goal: >= 75%)
8BreastPercentage of breast cancer records with a diagnosis of CIS, other; DCIS; or invasive breast cancer that have treatment started (Goal: >= 90%)
9BreastPercentage of breast cancer records with a diagnosis of CIS, other; DCIS; or invasive breast cancer where time between diagnosis and treatment is <= 60 days (Goal: >= 80%)
  • A minimum of 35 percent of all NBCCEDP-reimbursed cervical cancer screenings should be provided to program-eligible women 30 and over who have never been screened or not screen within the last 10 years through the program. Grantees may use either conventional or liquid-based cytology.

Cervical cancer diagnostic indicators are as follows:

  • A minimum of 90 percent of cervical screening records with planned and complete diagnostic follow-up.
  • The interval between screening and final diagnosis of cervical cancer screenings should be 60 days or less for a minimum of 75 percent of the women.
  • A minimum of 90 percent of cervical cancer records with final diagnosis of HSIL, CIN2, CIN 3, CIS, or invasive cervical cancer must have started treatment.
  • The interval between final diagnosis and initiation of treatment for HSIL, CIN2, CIN3, CIS, or invasive cervical cancer should be 60 days or less for a minimum of 80 percent of the women.

Breast cancer diagnostic indicators are as follows:

  • A minimum of 90 percent of mammogram screening records with abnormal results must have a completed diagnostic follow-up.
  • The interval between completed follow-up and time between abnormal screening and final diagnosis should be 60 days or less for a minimum of 75 percent of women.
  • A minimum of 90 percent of breast cancer records with a final diagnosis of ‘CIS, other’, or DCIS, or invasive breast cancer must have started treatment.
  • The interval between final diagnosis and initiation of treatment for breast cancer records with a final diagnosis of ‘CIS, other’, or DCIS, or invasive breast cancer should be 60 days or less for a minimum of 80 percent of women.

Administrative indicators are as follows:

  • Grantees must serve a minimum of 85 percent of proposed unduplicated clients.
  • Grantees must expend a minimum of 95 percent of the awarded funds.
  • Grantees must submit quarterly match reports 30 days after the end of each quarter.

Grantees must comply with and use Med-IT®, an online database system, to collect and process breast and cervical data, reports and billing in accordance with the business requirements of the program, including Med-IT® data entry, within 45 days of services provided.

Note, these performance measures are subject to change.

3600, Program Promotion, Outreach and Inreach

Revision 23-2; Effective Sept. 29, 2023

The purpose of program promotion, outreach and inreach is to:

  • inform the public of the purpose of the program and available services;
  • enhance community understanding of program objectives;
  • disseminate breast and cervical cancer screening knowledge;
  • enlist community support; and
  • enroll clients for BCCS.

BCCS grantees are required to develop an annual promotion and outreach plan within 45 days of the start of each fiscal year. Grantees are expected to follow the plan and make the plan available for monitoring purposes.

The plan should be based on an assessment of the needs of the community and contain an evaluation strategy. Grantees should consider a variety of program promotion and client outreach strategies in accordance with organizational capacity, availability of existing resources and materials, and the needs and culture of the local community.

To gauge the efficacy of program promotion and client outreach activities, BCCS grantees are required to complete an HHSC-distributed survey twice annually to report on promotion and outreach efforts. Surveys must be completed within 30 days of receipt and will be emailed to grantees via BCCSProgram@hhs.texas.gov. Questions related to the plan and surveys should be sent to BCCSprogram@hhs.texas.gov.

Survey SentReporting PeriodSurvey Due Date
Mid-month FebruarySept. 1 – Feb. 28 (Q1 & Q2)Mid-month March
Mid-month AugustMarch 1– Aug. 30 (Q3 & Q4)Mid-month September

Guidance for Promotion and Outreach Plans 

The plan should include the determination of the priority population, a recruitment work plan and in-reach and outreach methods.

Grantees should have an array of materials and resources to aid in community awareness. Grantees must develop and maintain relationships with local partners and collaborators that can assist in the recruitment of the priority population. Grantees must provide HHSC with current clinic location information. The information provided will be entered into the Healthy Texas Women Find a Doctor function and may be shared with other BCCS grantees.

Grantees must include in their outreach plan how they plan to implement strategies to enroll clients in BCCS and raise community awareness of BCCS and MBCC, including the following activities:

  • identify priority populations in the community to receive information;
  • identify the populations at highest risk for developing breast and cervical cancer;
  • provide culturally competent health education and social support;
  • help reduce participants’ barriers to accessing clinical services; 
  • establish relationships with internal and external partners to reach eligible clients in the priority populations;
  • establish relationships with clinic sites offering other HHSC programs (e.g. the Family Planning Program, Primary Health Care Program, and Healthy Texas Women) to increase cross-program referrals, coordination, and service provision;
  • link and connect participants to partner clinics for breast and cervical cancer screening;
  • educate partners, such as subgrantees, other health care providers, community organizations, coalitions and local advocacy groups about MBCC and how to refer a non-BCCS diagnosed client for MBCC screening appropriately;
  • track participants from community through screening completion;
  • educate clients diagnosed with breast or cervical cancer about MBCC eligibility requirements and how to apply for services;
  • provide information to each eligible woman in her primary language;
  • provide access to information that is culturally sensitive, linguistically appropriate and available to the visually and hearing impaired;
  • conduct outreach activities specifically for program-eligible women 30 and over who have never been screened or not screened within the last 10 years through the program; and
  • collect information that describes how clients learned about BCCS and entering data into Med-IT® using the “Learned of Program” function on the enrollment screen.

Appendix I, Medicaid for Breast and Cervical Cancer (MBCC) Application Checklist

Revision 23-2; Effective Sept. 29, 2023

Note: Incomplete MBCC applications must not be submitted to BCCS.

MBCC Application (H-1034)

Answer all questions and fill in every blank on the H-1034, as follows:

  • Verify the client’s legal name, date of birth and social security number are correct.
  • Verify presumptive eligibility has been met.
  • Verify the client has a biopsy-confirmed and qualifying diagnosis. (See MBCC Guidelines for Determination of Qualifying Diagnosis.)
  • Verify the date of the diagnosis matches the collection date on the biopsy pathology report.
  • Check for unpaid medical bills — Indicate yes or no, and months in which they occurred, if applicable.
  • Do not mark in the For DSHS Agency Use Only section.

Attach copies of the following supporting documents:

  • The final pathology report with the biopsy-confirmed, qualifying diagnosis (no highlighting)
  • Verification of identity, U.S. citizenship or legal immigrant status

Email the HHSC—MBCC Eligibility Specialist at Centralized Benefits Services (CBS) for additional information regarding citizenship and immigrant status.

If the client’s insurance is expired, terminated or does not cover cancer treatment, check for both of the following:

  • Copy of insurance card
  • Letter or explanation of benefits from insurance company

If the client’s reinstatement or qualifying diagnosis was more than one year ago, check for the following:

  • Physician letter specifying active treatment needed or Form H-1551
  • Recent medical documentation supporting a need for active treatment

Note: Do not fax tax forms, pay stubs or any other financial documents. Clients may not self-declare income. Financial documents must be kept with the client chart.

Med-IT

Enter client details and patient navigation in Med-IT as follows:

  • Ensure that enrollment status is correct:
    • Active — client received BCCS services before the cancer diagnosis.
    • MBCC Referred-In — client never received BCCS services, was diagnosed by a non-BCCS provider and was referred in for MBCC application only.
  • Ensure that the navigation module is complete.
  • Bill using the appropriate patient navigation code.

Processing the H-1034

Fax or securely email the H-1034 to BCCS at 512-776-7203 or MBCCApps@hhs.texas.gov

When the application is received, BCCS:

  • staff requests additional information if needed; and
  • nurse consultants review and send the H-1034 to HHSC CBS.

Note: BCCS does not assist with or collect documents for MBCC applications following submission to CBS.

  • Confirm receipt with BCCS staff and note the following:
    • Status of MBCC application will be noted in client’s Med-IT record
    • Email MBCCApps@hhs.texas.gov if there are no notes in the client’s enrollment record after three business days
    • Use Med-IT ID as patient identifier, excluding protected health information

MBCC Application Status and Medicaid Number

Let clients know to call 2-1-1 for their application status and Medicaid number.

Appendix II, Medicaid for Breast and Cervical Cancer (MBCC) Guidelines

Revision 23-2; Effective Sept. 29, 2023

Guidelines for Determination of Qualifying Diagnosis

Texas Breast and Cervical Cancer Services (BCCS) is providing the following guidance to health care providers and grantees to facilitate their determination of qualifying diagnoses for Medicaid for Breast and Cervical Cancer (MBCC). Analysis of all biopsies must be performed by a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory.

Cervical Cancer Qualifying Diagnoses

Qualifying precancerous cervical diagnoses must be biopsy-confirmed*:

  • High-grade dysplasia or cervical intraepithelial neoplasia (CIN 2/3 or CIN 3)
  • Carcinoma or adenocarcinoma in situ

Qualifying malignancies of the cervix must be biopsy-confirmed*:

  • Adenocarcinoma
  • Adenoid cystic carcinoma
  • Adenosquamous carcinoma
  • Glassy cell carcinoma
  • Invasive cervical cancer
  • Invasive endocervical adenocarcinoma
  • Invasive neoplasm
  • Malignant neoplasia
  • Melanoma
  • Sarcoma
  • Small cell carcinoma
  • Squamous cell carcinoma

* Cervical biopsy or endocervical sampling that have a qualifying pre- cancerous diagnosis or cervical malignancy qualify as biopsy confirmed.

Breast Cancer Qualifying Diagnoses

Qualifying breast cancer diagnoses must be biopsy-confirmed. On the pathology report, the diagnosis or the description of the specimen, or both, may include at least one of the following phrases: “breast cancer,” “breast carcinoma” or “breast malignancy.”

Examples of the majority of breast cancer types are as follows:

Ductal Carcinomas

  • Comedo
  • Cribriform
  • Ductal carcinoma in situ (DCIS)
  • Infiltrating
  • Inflammatory
  • Invasive
  • Medullary
  • Mucinous (colloid)
  • Papillary or Micropapillary
  • Scirrhous
  • Tubular

Lobular Carcinoma*

  • Invasive
  • Infiltrating

Nipple Carcinoma

  • Paget’s disease

Other Carcinomas

  • Adenoid cystic carcinoma
  • All Phyllodes tumors
  • Any biopsy-proven malignancy identified in a biopsy of either breast
  • Apocrine
  • Carcinoma, NOS (not otherwise specified)
  • Carcinoma with endocrine differentiation
  • Metaplastic
  • Primary lymphoma
  • Sarcoma
  • Secretory
  • Undifferentiated carcinoma

* A diagnosis of lobular carcinoma in situ (LCIS) is not considered a qualifying pre-cancerous or breast cancer diagnosis for referral to MBCC.
 
For a medical condition to qualify as a breast cancer, the medical record documentation (for example, the operative report or procedure note) must state that a biopsy was taken from at least one breast, and a pathology report for that biopsy must confirm the diagnosis of a qualifying malignant lesion. It is not necessary for the pathology report to describe the malignancy as definitively representing a breast primary, but that a malignancy was identified on at least one biopsy of the breast must be clear from the medical record documentation.

Metastatic Breast and Cervical Cancers

For patients who present with cancers believed to be metastatic from the breast or cervix, if a diagnosis is made based only on the metastatic tumor, a Medicaid application may be considered if:

  • no further diagnostic workup is planned before treatment is initiated; and
  • treatment will proceed on the assumption that the primary source is breast or cervix, regardless of whether a primary tumor has been identified.

The medical record documentation must clearly state that the primary source is believed to be breast or cervix and that treatment will be initiated based on that assumption. Terms such as “compatible with” and “consistent with” a breast or cervical cancer are acceptable. For example, a diagnosis such as “metastatic adenocarcinoma consistent with a breast primary” would be acceptable.

For patients who present with cancers metastatic to the breast or cervix, malignancy diagnosed in a biopsy taken from a breast or from the cervix constitutes a qualifying diagnosis.

Appendix III, Program Resource Guide

Revision 23-2; Effective Sept. 29, 2023

Patient Education, Advocacy and Support

Program NamePhone NumberWebsiteServices
American Cancer Society800-277-2345www.cancer.org/
  • Guide to Quitting Smoking
  • Prescription Questions
  • Cancer education classes
  • Access to health care
  • Clinical trials
  • Stories of hope
  • Financial issues
  • Finding support groups
Know Your LemonsNot applicablewww.knowyourlemons.org
  • Patient education materials
  • Volunteer education training
Beyond the Brochure: Alternative Approaches to Effective Health CommunicationNot applicablewww.cdc.gov/cancer/nbccedp/pdf/amcbeyon.pdf
  • CDC manual that provides guidance to more effective health communication
  • Techniques
  • Strategies
  • Healthcare messaging
Health Equity Guiding Principles for Inclusive CommunicationNot applicablewww.cdc.gov/healthcommunication/Health_Equity.html
  • Inclusive Communication Principles
Susan G. Komen Breast Cancer Foundation

877-465-6636
Education Helpline

Or email Helpline@komen.org

www.komen.org/
  • Breast health and breast cancer information
  • Emotional support services
  • Finding breast cancer services via an affiliate
National Cancer Institute Cancer Information Service800-422-6237
TTY: 800-332-8615
www.cancer.gov/
  • What is cancer?
  • Understanding treatment
  • Prevention of cancer
  • Free booklets on cancer
  • Information and website in Spanish
Cancer Prevention and Control- English800-CDC-INFO (232-4636)www.cdc.gov/cancer/
  • Cancer information
  • Survivorship information
Cancer Prevention and Control-Spanish800-CDC-INFO (232-4636)
TTY: 888-232-6348
www.cdc.gov/Spanish/cancer/
  • Cancer information
  • Information in Spanish
Livestrong Foundation

Call:

855-220-7777 for cancer support

877-236-8820 for general inquiries

www.livestrong.org/
  • Patient navigation
  • Survivorship
  • Clinical trial information
  • One-on-one support
  • Information for family members

Clinic Information

Program NamePhone NumberWebsiteServices
Susan G. Komen Breast Cancer Foundation877-465-6636www.komen.org/
  • Grants for providers
National Cancer Institute Cancer Information Service800-422-6237
TTY: 800-332-8615
www.cancer.gov/contact
  • Clinical trials
  • Research and funding
  • Cancer statistics
  • Cancer information
  • Drug dictionary
  • News releases
  • Grants
  • Provider training
The Community Guide404-498-1827www.thecommunityguide.org/
  • Strategies for providers to improve care
  • What Works Fact Sheets
  • Reminder systems
  • Incentives for patients
  • Funding and grants
  • Research
  • Education program development
  • Publications for patients
Cochrane Collaboration+44-207-183-7503
(London, UK)
www.cochrane.org/

Objective evidence-based strategies to improve healthcare delivery

  • Case management
  • Provider reminder systems
  • Provider feedback
Texas Department of State Health Services Community Health Worker or Promotor(a) Training and Certification Program

CHW Certification 
512-776-2570 or 512-776-2624

Instructor or Training Program Certification
512-776-2777 or 512-776-2208

Email: chw@dshs.texas.gov

Fax: 512-776-7555

www.dshs.texas.gov/mch/chw/Community-Health-Workers_Program.aspx
  • CHW training and certification
  • CHW resources, including training manuals
  • Advisory Committee
  • Training locations

Evidenced-Based Interventions and Strategies

Program NameWebsiteServices
The Community Guidewww.thecommunityguide.org/
  • Strategies for providers to improve care
  • What Works Fact Sheets
  • Reminder systems
  • Incentives for patients
  • Funding and grants
  • Research
  • Education program development
National Cancer Instituteebccp.cancercontrol.cancer.gov/index.doEvidence-Based Cancer Control Programs (EBCCP)
National Association of Community Health Workers (NACHW)nachw.org/
  • Community Health worker resources
  • Guidance for policy development
  • Learning collaboratives

Appendix IV, Resources and Contacts

Revision 23-2; Effective Sept. 29, 2023

BCCS Program Information

ContactInformation
Fax512-776-7203
Help Line512-776-7796
Med-IT® AssistanceMed-ITHelpdesk@hhs.texas.gov
Program AssistanceBCCSProgram@hhs.texas.gov
Contract SupportPSPS_Finance@hhs.texas.gov
PSPS_Contracts@hhs.texas.gov
BCCS Websitewww.healthytexaswomen.org/healthcare-programs/breast-cervical-cancer-services
Clinic Locator — BCCS and MBCC Serviceswww.healthytexaswomen.org/healthcare-programs/breast-cervical-cancer-services

Medicaid for Breast and Cervical Cancer (MBCC) Information

ContactInformation
Fax512-776-7203
Application Statuswww.med-itweb.com
MBCC AssistanceMBCCApps@hhs.texas.gov
Renewal Paperwork2-1-1
Medicaid Provider Line800-925-9126
Medicaid Covered Services800-335-8957
TMHPwww.TMHP.com
Health and Human Services Commission — Centralized Benefit ServicesCBS_MBCC@hhs.texas.gov
Transportation Assistance877-MED-TRIP (877-633-8747)
Texas Medicaid Wellness Program800-777-1178

Additional Cancer Resources

ContactInformation
Livestrong Foundationwww.livestrong.org
855-220-7777
American Cancer Societywww.cancer.org
800-227-2345
Patient Advocate Foundation (Access, Job Retention, Financial Assistance and Debt)www.patientadvocate.org
800-532-5274
Clinical Trialshttps://clinicaltrials.gov/
CancerCarewww.cancercare.org

Forms

ES = Spanish version available.

Form Title
1060 Health and Developmental Services (HDS) Promotion and Outreach Quarterly Report  
1065 Eligibility Application ES
1080 Health and Developmental Services (HDS) Promotion and Outreach Annual Plan  
5200 Med-IT New User Request  
5201 Med-IT New Provider Request  
5202 Patient Navigation Consent ES
5203 Breast MRI Pre-Authorization Request  
5204 Office-based Procedures Performed in an Ambulatory Surgical Center Pre-Authorization Request  
5205 Breast and Cervical Diagnostic Procedure Complication Reimbursement Request  

24-1, Updates Appendix V

Revision 24-1; Effective May 1, 2024

RevisedTitleChange
Appendix VMonthly Income Standard Based on 2024 Federal Poverty Level (FPL)Updates Appendix V, Monthly Income Standard Based on 2024 Federal Poverty Level (FPL).

23-2, Miscellaneous Revisions

Revision 23-2; Effective Sept. 29, 2023

RevisedTitleChange
1100Program Contact InformationUpdates language. Removes physical address for courier service.
1200Program AuthorizationUpdates language.
1210ComplianceUpdates language.
1230DefinitionsUpdates definitions throughout.
2100Client AccessUpdates language.
2200Abuse and Neglect ReportingUpdates language. Adds abuse report, compliance and monitoring requirements [from previous 2210 section].
2210Abuse Reporting, Compliance and MonitoringMoves existing information to 2200 and changes title to Human Trafficking. Incorporates information previously in 2220. Updates language.
2220Human TraffickingMoves human trafficking information to 2210. Changes title to Domestic and Intimate Partner Violence (IPV) and incorporates information previously in 2230. Updates language. 
 
2230Domestic and Intimate Partner Violence (IPV)Moves information to 2220 and deletes section.
2310ConfidentialityUpdates language.
2320Nondiscrimination Changes title to Nondiscrimination and Limited English Proficiency. Updates language.
2330Former Military Service MembersUpdates language.
2340Termination of ServicesUpdates language.
2350Resolution of ComplaintsUpdates language.
2370Research (Human Subject Clearance)Updates language.
2400ConsentUpdates language.
2410Texas Medical Disclosure Panel ConsentUpdates language.
2500Client Record ManagementUpdates language. Adds references to Texas Administrative Code requirements.
2510PersonnelChanges title to Personnel Policy and Procedures. Updates language.
2610Facilities and EquipmentUpdates language. Revises facility and equipment requirements.
2700Quality ManagementUpdates language.
2710Quality Management (QM) CommitteeUpdates language.
2730Quality Assurance ActivitiesRevises QA requirements.
2740Subrecipient Quality and ComplianceUpdates language.
2750Clinical Quality AssuranceUpdates language.
2810Reimbursement for ServicesUpdates language.
2820Fee-for-Service ReimbursementUpdates language.
3100Grantee ResponsibilitiesRevises title of section. Updates language.
3210Eligibility GuidelinesUpdates language. Revises eligibility factors. Revises requirements for eligibility policy and procedures.
3220Applying for ServicesUpdates language. Adds process to establish an alternate eligibility tool and revises residency requirements.
3230Adjunctive EligibilityUpdates language. Clarifies requirements for adjunctive eligibility with Medicaid for Pregnant Women.
3250FeesUpdates language.
3260Continuation of ServicesUpdates language.
3270Med-IT Data and Billing ServicesUpdates language.
3310BCCS Contractor Clinical ResponsibilitiesChanges title to BCCS Grantee Clinical Responsibilities. Updates language.
3320Client Health Record and Documentation of Patient EncountersUpdates language.
3321Counseling and EducationUpdates language. Revises tobacco use assessment and Quitline referral requirements.
3330Requirements for Policies to Ensure Appropriate Follow-up and Continuity of CareUpdates language.
3331Prescriptive Authority AgreementsUpdates language. Revises PAA requirements.
3340Standing Delegation OrdersUpdates language. Revises SDO requirements.
3341Breast and Clinical PolicyUpdates language.
3342Components of Breast Cancer ScreeningUpdates language.
3343Breast Cancer Diagnostic ServicesUpdates language.
3351Cervical Cancer Screening ServicesUpdates language.
3352Cervical Cancer DiagnosticsUpdates language. Revises priority population.
3353Cervical Dysplasia Management and TreatmentUpdates language.
3354Medicaid for Breast and Cervical CancerUpdates language.
3360Patient Navigation ServicesUpdates language.
3361Client refusal of servicesUpdates language.
3410Billing ProceduresUpdates language. Renamed section. Added link to Appendix VI.
3510Financial Reconciliation Report (FRR)Updates email address.
3520Match ReportUpdates language and email address.
3530Clinical Performance MeasuresUpdates language. Revised screening indicators.
3600Program Promotion, Outreach and InreachUpdates language. Revised promotion and outreach plan and report requirements.
Appendix IMedicaid for Breast and Cervical Cancer (MBCC) Application ChecklistUpdates language.
Appendix IIMedicaid for Breast and Cervical Cancer (MBCC) GuidelinesUpdates language and revises guidelines.
Appendix IIIProgram Resource GuideUpdates resources throughout.
Appendix IVResources and ContactsUpdates language and contacts throughout.
Appendix VIBCCS Billing GuidelineAdds new appendix on billing guidelines. Updated billing guidelines throughout.

23-1, Appendices Revised

Revision 23-1; Effective Mar. 31, 2023

RevisedTitleChange
Appendix VMonthly Income Standard Based on 2023 Federal Poverty LevelAdds Appendix V, Monthly Income Standard Based on 2023 Federal Poverty Level

22-0, BCCS Handbook Changes

Revision Notice 22-0; Effective August 15, 2022

Revision 22-0 updates the Breast and Cervical Cancer Services Policy Manual and replaces the PDF version. The handbook contains standards and policies for eligibility, screening, patient navigation, education, client documentation, reimbursement and evaluation. Updates to text have been made throughout the handbook.