5500, Covered Services

Revision 22-2; Effective April 1, 2022

HHSC FPP seeks to promote the general and reproductive health of Texas residents by providing safe and effective family planning services to people through 64 years of age who live in Texas and meet program eligibility requirements.

The following services are covered under FPP:

• Annual family planning and preventive health care visit;
• Pregnancy testing and counseling;
• Contraceptive services, all methods except emergency contraception, including necessary follow-up and surveillance;
• Certain health screening and diagnostic services, as indicated:
  • Screening, diagnosis and treatment of cervical intraepithelial neoplasia;
  • Cervical cancer screening and diagnosis;
  • Breast cancer screening and diagnosis;
  • Screening and outpatient treatment for sexually transmitted diseases and infections (STDs and STIs);
  • HIV screening;
  • Limited prenatal care services;
  • Recommended immunizations;
  • Screening for postpartum depression;
  • Diabetes screening;
  • Hypertension screening;
  • Screening for elevated cholesterol; and
  • Preconception health (for example, screening for nutrition and obesity, tobacco and substance use, other high-risk behaviors, social issues and mental health).

Initial Clinical Visit

At the first clinical visit or an early follow-up visit, a comprehensive health history must be taken to include, in addition to the elements required for the individual health record in Section 5400, Client Health Records and Documentation of Encounters, adapt as appropriate to the gender of the person:

• The reason for the visit and current health status;
• A review of systems with documentation of pertinent positives and negatives;
• A reproductive health history, as follows:
  • For women, this includes menstrual history, complete obstetrical history, sexual activity history (including contraceptive practices, number and gender of partners, sexually transmitted infection or sexually transmitted disease (STI or STD) and HIV history and risk factors, whether currently sexually active) and reproductive life plan;
  • For men, this includes sexual activity history (including contraceptive practices, number and gender of partners, STI or STD and HIV history and risk factors, whether currently sexually active) and reproductive life plan;
• For women, cervical and breast cancer screening history, noting any abnormal results and treatment, and dates of the most recent testing;
• For women, other history of gynecological conditions;
• Other history of genital and/or urological conditions; and
• Family health and genetic history.

At every later visit, including the annual primary health care and problem visits, the record must be updated, as appropriate, and the reason for the visit and current health status documented.

Annual Comprehensive Family Planning Visit, Physical Examination and Testing

The annual family planning visit offers an excellent opportunity for providers to address issues of wellness and health risk reduction, as well as findings or patient concerns. The annual visit must include an update of the person’s health record, as described in the individual health record in Section 5400, as well as documentation of appropriate screening, assessment, counseling and immunizations based on the individual’s age, risk factors, preferences and concerns.

All individuals must undergo a physical examination annually as part of the family planning visit.  The physical examination may be postponed if the individual’s history and current health status do not indicate issues requiring urgent examination. However, unless the clinician finds a compelling reason for continued postponement, the annual physical examination should not be postponed more than six months and the reason for the postponement must be documented in the individual’s record. 

A breast or pelvic examination may be performed only with the consent of the individual. Individuals must be offered a suitable method of contraception, such as oral contraceptives without delay, even if the physical examination is postponed or an otherwise asymptomatic individual declines any or all components of the examination.

Pelvic examinations must be administered in compliance with Chapter 167A of the Health and Safety Code.

It is recommended that the family planning visit include all the following components at least annually, in addition to other components as suggested by history and presenting signs and symptoms. Note: All findings, including tests, results and the individual’s notification of results as well as an individual’s refusal or other reason for not testing or performing a specified part of the examination, should be documented in the medical record:

• Measurement of height, weight and blood pressure (BP) screening for hypertension.
• Calculation of body mass index (BMI) with assessment for underweight, overweight or obesity, with counseling (if indicated), on achieving and maintaining a healthful body weight (a BMI calculator for adults and a BMI calculator for children and teens are available from the Centers for Disease Control and Prevention).

Recommended components for examinations for females:

• Clinical breast examination, breast cancer risk assessment and breast cancer screening, as appropriate, based on person’s age, risk and preferences:
  • Counseling on breast awareness and advice to report any symptom or sign that is of concern to the individual; 
  • Screening for cervical cancer beginning at 21 years of age regardless of sexual history, and continuing as indicated based on the individual’s age, previous test results and treatment history; and
  • Pelvic examination, in compliance with Chapter 167A of the Health and Safety Code, (for all consenting individuals 21 years and older, but for consenting individuals less than 21 years of age, only if indicated by the medical history), to include the following elements:
    • Visual examination of the external genitalia, vaginal introitus, urethral meatus and perianal area;
    • Speculum examination of the cervix and vagina; and
    • Bimanual examination of the cervix, uterus and adnexa, and when indicated, rectovaginal examination;
  • Pregnancy testing, available on-site (if the pregnancy test is positive, the person must be given information on good health practices during pregnancy and given or referred for appropriate physical evaluation and initiation of prenatal care, within 15 days); and
  • Rubella immunity testing in women of reproductive age if the status cannot be determined by history or previous testing.

Recommended components for examinations for males:

• Visual and manual examination of the external genitalia (scrotum, penis and testicles) and visual inspection of the perianal area;
• Assessment for hernia;
• Palpation of the prostate as indicated by history and person’s age; and
• Advice on testicular awareness and recommendation to report any symptom or sign that is of concern to the person.

Recommended components for examinations for all individuals regardless of sex:

• Other examinations as indicated by history, signs and symptoms, and the individual’s concerns, as follows (for example, thyroid, heart, lungs, abdomen, and similar concerns):
  • Diabetes screening as appropriate for age and risk factors;
  • Sexually transmitted infections;
  • Cholesterol and/or serum lipid testing;
  • Thyroid stimulating hormone;
  • Immunizations as indicated (health care providers can voluntarily participate in the Texas Department of State Health Services (DSHS) Adult Safety Net (ASN) vaccine program, which provides vaccines at no cost); and
  • Other testing, if indicated;
• Appropriate family planning counseling and treatment; and
• Healthful lifestyle interventions and counseling, as indicated based on age, risk factors, and client interest and receptiveness.

Counseling and Education

All individuals must receive accurate person-centered education and counseling in their preferred language, presented in such a way that they can understand and demonstrate their understanding. The education must be documented in the medical record. The intent of individual education is to enable the person to understand the range of available services and how to access them, to make informed decisions about family planning, to reduce personal health risk and to understand the importance of recommended tests, health promotion and disease prevention strategies.

Specific clinical policies must be in place for counseling and other services provided to minors under 18 years of age, to include the following at a minimum:

• Counseling of minors, including:
  • All medically approved methods of contraception, including abstinence;
  • Prevention of STDs, STIs and HIV;
  • Domestic, partner, dating and family violence, and the offer of assistance as needed; and
  • Recognition and avoidance of sexual coercion.
• Counseling and clinical services to minors must be expedited so that appointments are made available as soon as possible.
• Minors must be assured that their privacy and confidentiality will be protected within the parameters of applicable law, including the Health Insurance Portability and Accountability Act (HIPAA), Texas Family Code, Chapter 32, and Section 5100, Minors, Consent and Confidentiality.

5510 Requirements for Policies to Ensure Appropriate Follow-up and Continuity of Care

Revision 22-2; Effective April 1, 2022

Providers must develop and maintain policies and procedures to ensure timely follow-up and continuity of care, to include at a minimum:

• Tracking pending tests until results are reviewed by the provider and the individual is notified of their results and recommended follow-up;
• Documentation of all tests and results in the individual’s health record;
• A mechanism to inform individuals promptly of test results that protects the person’s privacy and confidentiality while supporting and promoting timely, appropriate follow-up;
• A mechanism to track individual compliance with recommended follow-up care, schedule return visits and follow-up on missed appointments; and
• A process to ensure compliance with all applicable state and local laws for disease reporting.

Before a person is considered lost to follow-up, the contractor must make at least three documented attempts to contact the person, using a protocol in which subsequent attempts involve a more intensive effort to contact the person. Example: A telephone call on the first attempt, a letter by regular mail on the second attempt and a certified letter on the third attempt. 

Providers should develop processes that are suitable for the population they serve and adapt their usual processes to the known circumstances and preferences of the person whom they are trying to contact. 

5520 Visits Regarding a Particular Medical Concern (Problem Visits)

Revision 22-2; Effective April 1, 2022

For all problem visits, the following elements must be documented in the medical record:

• Reason for the visit;
• Appropriate interval medical history and focused history relevant to the problem reported; and
• Relevant physical examination and testing, as indicated, as well as an assessment and prescribed treatment.

5530 Referrals

Revision 22-2; Effective April 1, 2022

When a person is referred to another provider of services for consultation or continuation of care, the chart must reflect a record of the purpose for the referral, the name of the provider consulted or referred to, the counseling that the person received about the purpose of the referral and about questions the person had about the referral. Pertinent information about the individual and relevant parts of the medical record must be provided to the referral clinician, and this provision of information must also be documented in the medical record. The results of the consultation or referral must be documented in the medical record.

When services covered under the HHSC FPP are to be provided only by referral, the contractor must establish a written agreement with a referral resource for the provision of services and for the reimbursement of costs and ensure that the patient is not charged by the referral resource for these services.

Contractors must maintain a written policy reflecting these requirements for referral activities.

5540 Prescriptive Authority Agreements

Revision 22-2; Effective April 1, 2022

When services are provided by an advanced practice registered nurse (APRN) and/or physician assistant, it is the responsibility of the contractor to ensure that a properly executed prescriptive authority agreement (PAA) is in place for each provider, as required by Texas Administrative Code, Title 22, Part 9, Chapter 193. This is true whether the provider is employed by the contractor or is providing services by subcontract with, or referral by, the contractor. 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;
• 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 physician assistant 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 physician assistant; and
  • Periodic face-to-face meetings between the APRN or physician assistant and the physician at a location determined by the physician, APRN or physician assistant.

The PAA need not describe the exact steps that an APRN or physician assistant must take with respect to each specific condition, disease or symptom. The PAA and amendments, if any, must be reviewed at least annually, dated and signed by the parties to the agreement. A copy of the current PAA must be kept on-site where the APRN or physician assistant provides care.

5550 Standing Delegation Orders

Revision 22-2; Effective April 1, 2022

When services are provided by unlicensed and licensed personnel other than advanced practice nurses or physician assistants 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. SDOs:

• 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/or 
  • 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;
• Providing pre-signed prescriptions for:
  • Oral contraceptives;
  • Diaphragms;
  • Contraceptive creams and jellies;
  • Topical anti-infective for vaginal use; or
  • Antibiotic drugs for treatment of STIs and STDs;
• Handling medical emergencies to include on-site management, as well as possible transfer of the individual;
• Giving immunizations; or
• Performing pregnancy testing.

At least annually, SDOs must be reviewed, signed and dated 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

American Academy of Family Physicians (2017). Summary of recommendations for clinical preventive services. AAFP Policy Action Order No. 1968. Available at http://www.aafp.org/dam/AAFP/documents/patient_care/clinical_recommendations/cps-recommendations.pdf.

American College of Obstetricians and Gynecologists (2012). Committee opinion 755: Well-woman visit. Obstet Gynecol 132: 181-186. Available at https://journals.lww.com/greenjournal/Fulltext/2018/10000/ACOG_Committee_Opinion_No__755__Well_Woman_Visit.61.aspx.

Centers for Disease Control and Prevention. Content of care for women website. Available at CDC Planning for Pregnancy. 

Centers for Disease Control and Prevention. Clinical content of care for men website. Available at https://www.cdc.gov/preconception/men.html.

Centers for Disease Control and Prevention (2014). Providing quality family planning services. MMWR 63(4). Available at http://www.cdc.gov/mmwr/pdf/rr/rr6304.pdf.

Centers for Disease Control and Prevention (2016). Update: Providing quality family planning services. Recommendations from CDC and the U.S. Office of Population Affairs, 2015. MMWR 65(9); 231-234. Available at https://www.cdc.gov/mmwr/volumes/65/wr/mm6509a3.htm.

Centers for Disease Control and Prevention. Immunization schedules website. Available at http://www.cdc.gov/vaccines/schedules/.