X-910, Screening and Active Treatment

Revision 12-3; Effective July 1, 2012

To qualify for Medicaid for Breast and Cervical Cancer (MBCC)-Presumptive or MBCC, applicants must have been screened and found to need active treatment for either breast or cervical cancer.

Related Policy

Screening, X-911

At each periodic review, MBCC recipients must provide verification that they continue to receive treatment for breast or cervical cancer.

Related Policy

Active Treatment, X-912


X—911 Screening

Revision 15-4; Effective October 1, 2015

A woman must be screened for breast and cervical cancer under the Centers for Disease Control and Prevention’s (CDC’s) National Breast and Cervical Cancer Early Detection Program (NBCCEDP). The Breast and Cervical Cancer Services (BCCS) contractor or provider, through the Texas Department of State Health Services (DSHS), is responsible for providing the Texas Health and Human Services Commission (HHSC) with verification that a woman has been screened and diagnosed using the NBCCEDP criteria.

A woman is considered screened under the NBCCEDP if:

  • CDC Title XV funds paid for all or part of the cost of her screening services; or
  • her particular clinical service has not been paid for by CDC NBCCEDP Title XV funds, but the:
    • service was provided by a provider and/or an entity funded at least in part by CDC Title XV funds;
    • service was within the scope of a grant, sub-grant or contract under that state program; and
    • state CDC Title XV grantee has elected to include such screening activities provided by the provider as screening activities pursuant to CDC Title XV.

The 80th Texas Legislature passed Senate Bill 10, the Medicaid Reform Act, which authorized any health care provider to refer eligible women in need of treatment for breast or cervical cancer to Medicaid. Beginning September 1, 2007, any woman diagnosed with breast or cervical cancer may receive MBCC if they meet all eligibility requirements. The diagnosing provider refers the woman to a BCCS contractor who assists the woman in applying for MBCC.

If Form H1034, Medicaid for Breast and Cervical Cancer, is received and the woman does not have a qualifying medical diagnosis, deny the application due to the woman not having a diagnosis for breast or cervical cancer.


X—912 Active Treatment

Revision 15-4; Effective October 1, 2015

At reapplication and at each redetermination, the MBCC applicant or recipient must provide Form H1551, Treatment Verification, completed by her treating health professional verifying that she needs active treatment services for breast or cervical cancer. Active cancer treatment includes services related to the individual's condition as documented in her plan of care, such as:

  • surgery,
  • chemotherapy,
  • radiation,
  • reconstructive surgery, and
  • medication (ongoing hormonal treatment).

These services also may include diagnostic services that are necessary to determine the extent and proper course of treatment and active disease surveillance for triple negative receptor breast cancer.

Women who are determined to require only routine health screening services for a breast or cervical condition (for example, annual clinical breast examinations, mammograms and pap tests as recommended by the American Cancer Society and the U.S. Preventative Services Task Force) are not considered to need treatment and are not eligible for MBCC. A woman may reapply for MBCC if she is later diagnosed with a new breast or cervical cancer, pre-cancerous condition or a metastatic or recurrent breast or cervical cancer.

If the woman’s treating health professional indicates on Form H1551 that she is not actively receiving treatment, deny the MBCC Eligibility Determination Group (EDG) due to the woman not actively receiving treatment.