Revision 22-2; Effective April 1, 2022
Reproductive Life Plan
Providers should encourage all individuals to develop a reproductive life plan, which is an outline of each person’s plan for having children. Questions such as the following can be useful in helping individuals to 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 individual’s plan into account when counseling on contraceptive and family planning services. The provider can help the individual 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, individuals must receive patient-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 individuals a wide array of contraceptive options right for the person’s health status and reproductive plan. A six-step approach that engages the person in the decision-making process while addressing individual personal and cultural preferences will improve individual satisfaction and the likelihood that the selected method will be used correctly and consistently.
- Step One – Establish and maintain rapport with the person. Ways to do this include:
- Ask open-ended questions;
- Ensure confidentiality and privacy and explain how confidential information may be used;
- Listen to and observe the person; and
- Encourage questions and provide culturally sensitive answers that show knowledge of the subject matter in language the person understands.
- Step Two – Obtain social and clinical information from the person to include the following:
- Health history;
- Current reproductive life plan;
- Contraceptive experience and possible preferences; and
- Assessment of sexual health:
- Past and current contraceptive practices;
- Partner history (for example, number, gender and whether concurrently monogamous);
- Current and past STD and STI prevention (for example, limiting partners, use of condoms, barriers to condom use and consistency of use); and
- Prior treatment for, and possible exposure to, STDs and STIs.
- Step Three – Work interactively with the person to choose the most appropriate contraceptive method:
- Educate the person about all contraceptive methods that are safe and appropriate for that individual. Counsel individuals on the relative effectiveness of methods, correct use of methods, potential noncontraceptive-related benefits (for example, reduced risk of iron-deficiency anemia with combination hormonal contraceptives) and method side effects, working with the individual or couple to select the method that best meets their needs;
- Inform individuals that contraceptive methods other than condoms provide no protection from STDs and STIs, including HIV, and that condoms used correctly and consistently do reduce the risk of STDs and STIs, including HIV; and
- Help the person to identify barriers to correct contraceptive method use and develop solutions to overcome barriers.
- Step Four – Perform a physical evaluation appropriate to the method chosen, when warranted. In most cases, no physical examination or laboratory testing is necessary before starting to use a contraceptive method:
- Blood pressure should be recorded before starting combination hormonal contraception;
- Current pregnancy status should be determined at the time of service for any woman receiving contraceptive services, but routine pregnancy testing is not necessary if it is possible to be reasonably certain that she is not pregnant. A provider may be reasonably certain that a woman is not currently pregnant if she has no signs or symptoms of pregnancy (either intrauterine or ectopic) and meets at least one of the following criteria:
- Less than or equal to seven days since the start of normal menses;
- No sexual intercourse since the beginning of the last normal menses;
- Has been using a reliable method of contraception correctly and consistently;
- Less than or equal to seven days since a spontaneous or induced abortion;
- Less than or equal to four weeks postpartum; or
- Less than six months postpartum, amenorrhea since delivery, fully or nearly fully breastfeeding (exclusive, frequent breastfeeding with the time between feedings not longer than four hours during the day or six hours at night).
- Weight assessment is not necessary before starting a contraceptive method because obesity alone is not a contraindication to any method. However, a baseline weight measurement may aid in assessing the possible effect of a chosen method on weight change.
- Certain tests and components of the physical examination may provide logistical, economic or emotional barriers to contraceptive access or acceptance for some women. In most cases, these interventions can be safely delayed or avoided if delay is necessary to enable a healthy individual to start a suitable and preferred method (although there may be other health care-related indications for the interventions). The following tests and examinations are not necessary before starting a contraceptive method:
- Pelvic examination, except when fitting a diaphragm or inserting an IUD;
- Cervical, breast or other cancer screening;
- HIV screening;
- Laboratory testing for hemoglobin, glucose, lipid or liver enzyme levels, or for thrombogenic mutations; or
- Physical examination before dispensing condoms.
- Step Five – Once a method of contraception is selected, the provider should provide counseling on correct and consistent use, help the individual to develop a plan for correct use and follow-up, and confirm the individual’s understanding. Certain considerations may increase the likelihood of correct and consistent use:
- Ideally, the method should be dispensed on-site and started at the time of the visit (rather than waiting for the next menses), if the provider can be reasonably certain the woman is not pregnant (see Step Four above for criteria to determine with reasonable certainty that a woman is not currently pregnant);
- Multiple cycles (ideally a year’s supply) of oral contraceptive pills, the patch or the ring should be prescribed or provided to reduce the number of return visits necessary;
- Make condoms easily available. Note: All HHSC FPP contractors must make barrier methods and spermicides available on-site; and
- If the individual’s chosen method is not available immediately or on-site, provide another method on the day of the visit to be used until the chosen method can be started.
- Step Six – Help the person develop a plan for correct and consistent use of the chosen method and provide a plan for follow-up:
- Explore possible reasons for incorrect or inconsistent use and help develop strategies to deal with these. For example:
- Suggest a daily text message or a sign on the bathroom mirror to routinize daily pill taking;
- Discuss ways to ensure timely return for injections; and
- Discuss side effects, a common reason for method discontinuation and ways to deal with these.
- Create a follow-up plan with the person, considering the person’s individual needs and perceived risk of method lapse or discontinuation;
- Confirm the person’s understanding of the information given and document this in the medical record:
- The teach-back method, in which the individual shows understanding of the information by repeating back the messages received, is an effective way to confirm understanding and to increase retention of the information received.
- Provide counseling with teach-back of the following topics, at a minimum:
- Real-world method effectiveness;
- Correct method uses and common side effects;
- Back-up contraceptive methods, including issues related to discontinuation of the chosen method;
- Whether or not the method protects against STDs and STIs;
- Signs of rare, but serious, complications and what to do if any of these signs occur;
- How to find urgent or emergency care, including a 24-hour emergency telephone number; and
- When to return for follow-up.
- Explore possible reasons for incorrect or inconsistent use and help develop strategies to deal with these. For example:
Relative Method Effectiveness
Relative method for effectiveness (range of effectiveness for 100 women using the method for one year) for the following HHSC FPP-approved contraceptive methods is indicated in parentheses, if reported values are available. Actual effectiveness depends on correct and consistent use. Higher rates of effectiveness are seen with perfect use. Real-world effectiveness is generally reflected in the lower end of the effectiveness range.
- Completely effective (100%)
- Total sexual abstinence
- Extremely effective (approximately 99%)
- Contraceptive implant;
- Intrauterine device (IUD); and
- Male or female sterilization.
- Less effective (ranges of effectiveness are shown)
- Lactational amenorrhea (Less than six months postpartum, amenorrhea since delivery, fully or nearly fully breastfeeding (exclusive, frequent breastfeeding with the time between feedings not longer than four hours during the day or six hours at night);
- Progestin injection (Depo-Provera, 94%);
- Hormonal contraceptive pills (91%);
- Hormonal contraceptive patch (91%);
- Vaginal ring (91%);
- Diaphragm (88%);
- Male condom (82%);
- Female condom (79%);
- Cervical cap (77% - 83%);
- Sponge (76% - 88%)
- Fertility Awareness-Based Methods (76%); and
- Spermicide (72%)
For more information on implementing a program to provide Long-Acting Reversible Contraception (LARC), see the Texas LARC Toolkit.
Specific Method Access Requirements for Contractors
Contractors must ensure that the following requirements are met with respect to patient access to contraceptive methods:
- LARC methods must be available on-site or by referral. Providers who are delivering services under a contract with HHSC FPP must use the buy and bill method, which requires providers to order LARC devices directly from the manufacturer or a third-party distributor. The product manufacturer’s website provides information on how to order and pay for the device. These are available in different size lots and a discount may be available for purchasing multiple devices at a time;
- Male and female sterilization must be made available on-site or by referral;
- All contractors must make injectable hormonal contraceptive agents, male and female condoms, spermicides, diaphragms, contraceptive sponges, cervical caps, and counseling and education on sexual abstinence available on-site; and
- Contractors with a Class D pharmacy must also make oral and transdermal hormonal contraceptive agents or vaginal hormonal contraceptive rings available on-site, and contractors that have received an approved exemption to the Class D pharmacy requirement must ensure 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 HHSC FPP contractors:
|Contraceptive Method or Anti-infective Agent||On-site Availability Required|
|Class D Pharmacy||Class D Pharmacy Exempt|
|Anti-infective agents for treatment of STDs/STIs||X|
|Barrier methods and spermicides||X||X|
|Injectable hormonal contraceptives||X||X|
|Transdermal hormonal contraceptive (patch) and/or vaginal hormonal contraceptive (ring)||X|
|Sexual abstinence education and counseling||X||X|
Contraceptive Methods that May Be Provided by Referral
If the clinicians associated with an HHSC FPP contractor do not offer covered contraceptive services that require 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 individual. HHSC FPP contracted clinics that offer such services by referral must have a written agreement with the referral provider to offer the method or service under this condition.
Per Texas Administrative Code (TAC) Title 1, Part 15, Chapter 382, Subchapter B, §382.113(b), Non-Covered Services, services not provided through the HHSC FPP include:
- Counseling on and provision of abortion services;
- Counseling on and provision of emergency contraceptives; 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 costs (including overhead, rent, phones and utilities) of abortion procedures provided.
Contractors are responsible for implementing adequate controls to ensure claims submitted for HHSC FPP services do not seek HHSC FPP reimbursement for any benefit not covered by the HHSC FPP.
References and Resources
Centers for Disease Control and Prevention (2014). Provides quality family planning services. MMWR 63(4). Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6304a1.htm (web) http://www.cdc.gov/mmwr/pdf/rr/rr6304.pdf.
Centers for Disease Control and Prevention (2016). Update: Provides 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. U.S. selected practice recommendations for contraceptive use, 2016. MMWR 65(No. 4). Available at https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/summary.html (web) https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6504.pdf.
American College of Obstetricians and Gynecologists Long-Acting Reversible Contraception program webpage. Provides information, clinical guidance and educational materials on long-acting reversible contraceptives.
5610 Preconception Services
Revision 22-2; Effective April 1, 2022
The goal of preconception care is to establish a foundation for the best possible outcome of every pregnancy. Because almost half of all pregnancies in the United States are unplanned and most pregnancies occur in women who did not have a specific preconception care visit before becoming pregnant, providers should keep preconception care in mind at every encounter with a woman of childbearing potential.
Good preconception care incorporates all components of general health care as described elsewhere 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 ensure that they are euthyroid before and during pregnancy to reduce the risk of miscarriage and preterm birth; and
- 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 that immunizations are current;
- Medications (prescription and nonprescription) and potential radiation exposure in early pregnancy:
- In general, the lowest effective dose of necessary medications is preferred, but individuals should be cautioned against stopping or changing medications without first consulting their doctor, because an untreated or incompletely treated medical condition might pose greater risk to the fetus and mother than the medication prescribed; and
- Some known teratogenic medications include warfarin, valproic acid, carbamazepine, isotretinoin and angiotensin-converting enzyme inhibitors. Note: For more individual and provider information on risk associated with specific exposures to medications and other environmental factors, consult the website of the Organization of Teratology Information Specialists;
- Prevention of STDs and STIs;
- 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 homelessness; and
- Mental health.
References and Resources
American Academy of Pediatrics/American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care 7th Ed. (2012). Ch. 5, pp. 95-106.
American College of Obstetricians and Gynecologists. Committee opinion 762: Pre-pregnancy Counseling. Available at https://www.acog.org/-/media/project/acog/acogorg/clinical/files/committee-opinion/articles/2019/01/prepregnancy-counseling.pdf.
Centers for Disease Control and Prevention. Recommendations to improve preconception health and health care – United States. MMWR (2006). 55(RR06): 1-23. Available at http://www.cdc.gov/mmWR/PDF/rr/rr5506.pdf.
Centers for Disease Control and Prevention. Recommendations: Women and Folic Acid. Available at https://www.cdc.gov/ncbddd/folicacid/recommendations.html.
Organization of Teratology Information Specialists. Mother to Baby: Medications and more during pregnancy and breastfeeding. Available at http://mothertobaby.org/fact-sheets-parent/. (Provides information for patients and health care providers on teratogenic risk of drugs and other exposures in pregnancy.)
Resources for Patients and Providers
American Society for Reproductive Medicine. Available at http://www.reproductivefacts.org/. (Information for patients on a variety of topics related to fertility and infertility.)
Centers for Disease Control and Prevention. Preconception health and health care website. Contains links to resources for patients, providers and patient educators on planning for a healthy pregnancy. Available at http://www.cdc.gov/preconception/index.html.
5620 Sterilization Procedures, Consent, Billing and Reporting
Revision 22-2; Effective April 1, 2022
Conditions for Sterilization Procedures
Individuals who want to have a vasectomy or tubal ligation or occlusion sterilization procedure must:
- Be age 21 or older;
- Be mentally competent (individuals 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 in 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 an individual’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 individual’s EDD must be documented when there are less than 30 days between the date of the individual’s consent and date of surgery.
- Sterilization following emergency abdominal surgery – Circumstances must be described on the Sterilization Consent form. Operative report(s) detailing 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 individuals who choose sterilization, two consent forms must be signed by the person after counseling on method-specific risks and benefits is provided and all the person’s questions have been answered:
- The Sterilization Consent Form (English/Spanish) The contractor must ensure that the form is complete and correct before submitting it to TMHP. The Sterilization Consent Form is necessary for both abdominal and trans-cervical sterilization; and
- 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 is provided and all the patient’s questions are answered.
The individual 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 individual’s signature.
The consent form must be signed and dated by the:
- Individual 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 individual to be sterilized is:
- In labor or delivering an infant or infants; or
- Under the influence of alcohol or other substances that affect the individual’s state of awareness.
Sterilization Billing and Reporting
HHSC FPP contractors can receive reimbursement for vasectomy or tubal ligation/occlusion sterilization procedures through FPP Fee-for-Service. The individual may not be billed for any cost above the reimbursement rates. Individual co-pays for sterilizations must follow the contractor’s established, HHSC-approved co-pay policy and may not exceed the allowable amount.
Contractors must not expend more than 15 percent of their total award on female sterilizations. An exemption may be granted to this policy on a case-by-case basis. Contact email@example.com for more information.
Allowable sterilization codes and descriptions are presented in Section 9000, Resources, Reimbursable Codes for the Texas Health and Human Services Commission Family Planning Program.
Complications and Reimbursement
Contractors may request reimbursement through TMHP for costs associated with patient complications related to sterilizations, contraceptive implants or intrauterine devices (IUDs). Contractors may be reimbursed for approved charges up to $1,000 per occurrence. To request reimbursement, contractors should provide TMHP with the following information:
- A copy of the Remittance and Status (R&S) Report showing that a sterilization, contraceptive implant or IUD procedure was performed on the individual in question;
- A narrative summary detailing the procedure performed and related complications, if any;
- All surgical and progress notes for the individual 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 detailing the procedures for which the contractor is seeking reimbursement and date of occurrence. List all procedures related to the complication even if they are not typically reimbursable under the HHSC FPP.