5600, Family Planning and Contraceptive Services

Revision 24-2; Effective Oct. 15, 2024

Reproductive Life Plan

Providers should encourage all clients to develop a reproductive life plan, which includes an outline of each person’s plan for having children. The following questions can be useful to help clients develop the plan:

• Do you have children?
• Do you want to have children?
• If yes, how many children would you like to have?
• When would you like to start having children?
• If you want more than one child, at what intervals would you like to have them?
• If you have children, do you want to have more children?

Plans for having a family can change with time. Providers must take the person’s plan into account when counseling on contraceptive and family planning services. The provider can help the person by providing the following:

• Contraceptive services if the person is sexually active and does not want pregnancy.
• Pregnancy testing and counseling to any female who may be pregnant or who requests such testing. Initiate or provide referral for prenatal services if the test is positive.
• Services to help the female and her partner achieve a healthy pregnancy if pregnancy is desired and the female is not pregnant.

Contraceptive Counseling and Education

At each encounter for services, clients must receive client-centered counseling and education to make informed decisions about family planning, including information on preventing STDs, STIs and HIV, the results of the physical examination and other testing, method-specific counseling as described below, and other counseling as suggested by the history and clinical evaluation.

Providers must offer clients a wide array of contraceptive options right for the person’s health status and reproductive plan. Review the Texas LARC Toolkit (PDF) for more information on implementing a program to provide long-acting reversible contraception (LARC).

Specific Method Access Requirements for Grantees

Grantees must make sure the following requirements are met for client access to contraceptive methods:

• LARC methods must be available on-site or by referral. Providers typically purchase LARC devices directly from the manufacturer or a third-party distributor.  Providers may get LARC products through the existing buy and bill process. This requires providers to purchase LARCs from wholesalers or other sources before being reimbursed upon insertion of the device and opting to receive reimbursement for LARC products as a clinician-administered drug. Buy and bill is the preferred option as it allows for same day insertion. Grantees can also order a device from a specialty pharmacy for the client to pick up and bring in for insertion. Grantees are expected to maximize any discount available for purchasing multiple devices at a time.
• Male and female sterilization must be made available on-site or by referral.
• All grantees must make injectable hormonal contraceptive agents, male and female condoms, spermicides, diaphragms, cervical caps, and counseling and education on sexual abstinence available on-site.
• Grantees with a Class D pharmacy must also make oral and transdermal hormonal contraceptive agents or vaginal hormonal contraceptive rings available on-site. Grantees that have received an approved exemption to the Class D pharmacy requirement must make sure these methods are readily accessible to clients through a referral pharmacy.

The table below outlines the requirements for on-site availability of contraceptive methods and anti-infective agents for grantees:

Contraceptive Methods that May Be Provided by Referral

If a clinician associated with a grantee does not offer covered contraceptive services requiring a special level of training or expertise (for example, sterilization, intrauterine device, hormonal implant and diaphragm fitting), these services may be offered by referral to another provider at no added cost to the client. Grantees offering such services by referral must have a written agreement with the referral provider to offer the method or service under this condition.

Non-Covered Services

Per Texas Administrative Code (TAC) Title 1, Part 15, Chapter 382, Subchapter B, Section 382.113(b), Non-Covered Services, services not provided through FPP include:

• counseling on and provision of abortion services; and
• other services that cannot be appropriately billed with a permissible procedure code.

No state funds appropriated to Texas Health and Human Services may be used to pay the direct or indirect abortion procedures costs including overhead, rent, phones and utilities.

Grantees must implement adequate controls to make sure claims submitted for FPP services do not seek reimbursement for any benefit not covered by the program.

Distinguishing Federal Title X Family Planning Program Funds

The Title X Family Planning Program is a funding program established by Congress in 1970 to provide comprehensive family planning and related preventative services to low income and uninsured people. This program is administered by the Office of Population of Affairs (OPA) under the U.S. Department of Health and Human Services.

The Title X Family Planning Program is federally funded and operates nationwide. FPP is a state-specific initiative designed to provide similar services but within the framework and regulations set by the State of Texas.

HHSC recognizes grantees may be recipients of funds from both Title X and FPP. As allowable services differ between the programs, grantees are strongly encouraged to use the following language in their clinical operations policy to make sure a clear delineation of service delivery, claims and billing covered by FPP:

Clients may be dual eligible for both the HHSC FPP and Federal Title X programs. Allowable billing codes that are approved through HHSC FPP must match the services rendered. Upon request, an FPP grantee must provide HHSC with all information HHSC requires to determine the provider's compliance with this section.

References and Resources

American College of Obstetricians and Gynecologists Clinical Information

5610 Preconception Services

Revision 24-2; Effective Oct. 15, 2024

The goal of preconception care is to establish a foundation for the best possible outcome of every pregnancy. Quality preconception care incorporates all components of general health care included in this manual. Attention should be paid to the following components:

• Awareness and treatment of chronic medical conditions, such as diabetes, hypertension, thyroid disease, epilepsy and asthma:
  • Well-controlled blood sugar, as indicated by normal hemoglobin A1C before and early in pregnancy can substantially reduce the risk of birth defects in the babies of mothers with Type 1 and Type 2 diabetes.
  • Women with hyperthyroidism or hypothyroidism should be treated as necessary to make sure they are euthyroid before and during pregnancy to reduce the risk of miscarriage and preterm birth.
  • Women with a history of phenylketonuria should be counseled on the need to follow a low-phenylalanine diet before and during pregnancy to reduce the risk of birth defects and serious developmental delay.
• Screening, as indicated, for conditions that may be undiagnosed.
• Confirming immunizations are current.
• Medications, both prescription and non-prescription, and potential radiation exposure in early pregnancy.  In general, the lowest effective dose of necessary medications is preferred, but clients should be cautioned against stopping or changing medications without first consulting their doctor. An untreated or incompletely treated medical condition might pose greater risk to the fetus and mother than the medication prescribed.
• Prevention of STDs, STIs and HIV.
• Nutrition and food insecurity.
• Occupational and environmental exposures to health risks and teratogens.
• Tobacco and substance use and other high-risk behaviors.
• Family medical history and genetic risk.
• Domestic, intimate and partner violence.
• Social issues, such as non-medical drivers of health.
• Mental health.

References and Resources

American College of Obstetricians and Gynecologists Clinical Information

5620 Sterilization Procedures, Consent, Billing and Reporting

Revision 24-2; Effective Oct. 15, 2024

Conditions for Sterilization Procedures

Clients who want to have a vasectomy or tubal ligation or occlusion sterilization procedure must:

• be 21 years or older;
• be mentally competent (clients are presumed mentally competent unless adjudicated incompetent for sterilization);
• not be institutionalized in a correctional facility, mental hospital or other rehabilitative facility;
• not give consent during labor or childbirth; and
• not give consent if under the influence of alcohol or drugs.

Date of Sterilization

There is a required waiting period of at least 30 days, but no more than 180 days, between a person’s documented consent for sterilization and the date of service for the sterilization procedure.

Exceptions to the required waiting period are allowed in the following situations:

• Sterilization following premature delivery. There must be at least 72 hours between the date of consent and the date of surgery. The informed consent must have been given at least 30 days before the expected date of delivery (EDD). The client’s EDD must be documented when there are less than 30 days between the date of the client’s consent and date of surgery.
• Sterilization following emergency abdominal surgery. Circumstances must be described on the Sterilization Consent form. Operative report(s) that detail the need for emergency abdominal surgery are required. There must be at least 72 hours between the date of consent and the date of surgery.

Consent for Sterilization Required Forms

For  client who choose sterilization, two consent forms must be signed by the person after the provision of counseling on method-specific risks and benefits and all the person’s questions have been answered:

• The Sterilization Consent Form in English or Spanish: The grantee must make sure the form is complete and correct before submitting it to TMHP. The Sterilization Consent Form is necessary for both abdominal and trans-cervical sterilization.
• A Texas Medical Disclosure Panel Consent for the surgical procedure by which sterilization will be performed must be signed by the person after full disclosure of the possible risks and benefits and all the client’s questions are answered.

The client may choose a witness to be present when consent is obtained. The consent for sterilization is valid for 180 days from the date of the client’s signature.  

The consent form must be signed and dated by the:

• person to be sterilized;
• interpreter, if one is provided;
• person who obtains the consent; and
• physician who will perform the sterilization procedure.

Consent is not considered to be informed consent if the person to be sterilized is:

• in labor or delivering an infant or infants; or
• under the influence of alcohol or other substances affecting the person’s state of awareness.

Sterilization Billing and Reporting

Grantees can receive reimbursement for vasectomy or tubal ligation or occlusion sterilization procedures through FPP Fee-for-Service. The client may not be billed for any cost above the reimbursement rates. Client co-pays for sterilizations must follow the grantee’s established, HHSC-approved co-pay policy and may not exceed the allowable amount.

Complications and Reimbursement

Grantees may request reimbursement through TMHP for costs associated with client complications related to sterilizations, contraceptive implants or intrauterine devices (IUDs). Grantees may be reimbursed for approved charges up to $1,000 per occurrence. To request reimbursement, grantees should provide TMHP with the following information:

• a copy of the Remittance and Status (R&S) Report that shows a sterilization, contraceptive implant or IUD procedure was performed on the client in question;
• a narrative summary that details the procedure performed and related complications, if any;
• all surgical and progress notes for the client related to the complications of the sterilization procedure;
• the initial operative report for the sterilization surgery; and
• a completed paper 2017 Claim Form or CMS-1500 professional claim form that details the procedures for which the grantee seeks reimbursement and date of occurrence. List all procedures related to the complication even if they are not typically reimbursable under FPP.

References

American College of Obstetricians and Gynecologists Clinical Information

Texas Administrative Code Title 25, Part 7, Chapter 601, Section 601.4