Family Planning Program Policy Manual

 

Section 1000, Program Authorization and Services

Revision 19-0; Effective July 1, 2019

 

 

1100 Purpose and Program Background

Revision 19-0; Effective July 1, 2019

 

The Texas Health and Human Services Commission (HHSC) Family Planning Program (FPP) provides comprehensive family planning and related health services statewide to reduce unintended pregnancies, positively affect future pregnancies and improve the health status of low-income women and men.

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

FPP services are funded by state general revenue and federal Temporary Assistance for Needy Families (TANF) to XX funds.

The state rules that apply most specifically to FPP services in Texas are found in the Texas Administrative Code (TAC), Title 1, Part 15, Chapter 382, Subchapter B.

 

1110 Purpose of FPP Policy Manual

Revision 19-0; Effective July 1, 2019

 

The Family Planning Program Policy Manual is a guide for contractors who deliver HHSC FPP services in Texas. FPP providers must also follow policies and procedures as established by the Texas Medicaid Program in the Texas Medicaid Provider Procedures Manual (TMPPM).

Federal and state laws related to reporting of child abuse, operation of health facilities, professional practice, insurance coverage and similar topics also impact family planning services. Contractors are required to be aware of, and comply with, existing laws. 

Family planning contractors also must be in compliance with the DSHS Standards for Public Health Clinic Services. For additional information about HHSC FPP services, access the HHSC Family Planning Program website.

 

1200 Definitions

Revision 19-0; Effective July 1, 2019

 

The following words and terms, when used in this manual, have the following meanings:

Class D Pharmacy License – A pharmacy license issued to a pharmacy to dispense a limited type of drug or devices under a prescription drug order (e.g., XYZ Health Clinic). Information to apply for a Class D Pharmacy License may be found at: http://www.tsbp.state.tx.us/files_pdf/INSTRUCTIONS_CLASS_D_PHY.pdf.

Client – An individual who has been screened and been determined to be eligible for the program.

Compass 21 – Texas Medicaid & Healthcare Partnership’s automated claims processing system used to process claims for services delivered to HHSC FPP and Medicaid.

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 and who, upon request of another appropriate health care provider, assists with the evaluation and/or management of a patient.

Contraception – The means of pregnancy prevention, including permanent and temporary methods.

Contraceptive Method – Any birth control option approved by the United States Food and Drug Administration, except for emergency contraception.

Contractor Any entity that HHSC has contracted with to provide services. The contractor is the responsible entity even if there is a subcontractor involved who implements the services.

Co-pay or Co-payment – Money collected directly from clients for services.

Cost Reimbursement – Funding used to develop and maintain contractor infrastructure for the provision of family planning services.

Elective Abortion – The intentional termination of a pregnancy by an attending physician who knows that the female is pregnant, using any means that is reasonably likely to cause the death of the fetus. The term does not include the use of any such means to terminate a pregnancy that resulted from an act of rape or incest; in a case which a female suffers from a physical disorder, physical disability or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy, that would, as certified by a physician, place the female in danger of death or risk of substantial impairment of a major bodily function unless an abortion is performed; or in a case in which a fetus has a life-threatening physical condition that, in reasonable medical judgement, regardless of the provision of life-saving treatment, is incompatible with life outside the womb.

Eligibility Date – The date the contractor determines an individual eligible for the program. The eligibility expiration date will be twelve months after the eligibility date.

Family Planning Services – Educational or comprehensive medical services that assist women and men to plan their families, whether it is to achieve, postpone or prevent pregnancy. If a woman chooses to become pregnant, Family Planning Services can enable the individual to determine freely the number and spacing of her children and how this may be achieved. Services include, but are not limited to, contraceptive and preconception health services (e.g., health screening for obesity, smoking and mental health), counseling/education, pregnancy testing (if indicated), and health history, physical examinations, lab tests, STI/STD screening and services (including HIV/AIDS).

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 form of poverty guidelines. Public assistance programs, such as Medicaid, define eligibility income limits as some 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 – State fiscal year from September 1 through August 31.

Health and Human Services Commission (HHSC) – State agency with administration and oversight responsibilities for designated HHSC agencies.

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.

Healthy Texas Women (HTW) – A state-funded program administered by HHSC to provide uninsured women with women’s health and family planning services such as women’s health exams, health screenings and birth control.

Household – For the purpose of eligibility determination, 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. If an unmarried applicant lives with a partner, only count the partner’s income and children as part of the household group if the applicant and his or her partner have mutual children together. Unborn children should also be included. Treat individuals who are 18 years of age as adults. No children aged 18 and older or other adults living in the home should be counted as part of the household group.

Informed Consent – The process by which a health care provider ensures that the benefits and risks of a diagnostic or treatment plan, the benefits and risks of other 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 person to participate and make sound decisions regarding her or his own medical care.

Intended Pregnancy – Pregnancy a woman reports as timed well or desired at the time of conception.

Intimate Partner Violence (IPV) – 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.

Long-Acting Reversible Contraceptives (LARCs) – Methods of birth control that provide effective contraception for an extended period without requiring user action. LARCs include intrauterine devices (IUDs) and subdermal contraceptive implants.

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

Minor – In Texas, a minor is a person under 18 years of age who has never been married and never been declared an adult by a court (emancipated). (See Texas Family Code Section 101.003.)

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

Program Income – Monies collected directly by the contractor or provider for services provided under the contract award (i.e., reimbursements from the fee-for-service contract, patient co-pay fees and donations).

Provider – An individual clinician or group of clinicians who provide services.

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.

Reproductive Life Plan – A plan that outlines an individual’s personal goals regarding whether to have children, the desired number of children, and the optimal timing and spacing of children. Counseling should include the importance of developing a reproductive life plan and information about reproductive health, family planning methods and services, and obtaining preconception health services, as appropriate.

Texas Medicaid & Healthcare Partnership (TMHP) The Texas Medicaid Claims and Primary Care Case Management (PCCM) administrator. HHSC contracts with TMHP to process claims for providers.

 

1300 Acronyms

Revision 19-0; Effective July 1, 2019

 

ADA Americans with Disabilities Act
AMA American Medical Association
A/R Accounts Receivable
BCCS Breast and Cervical Cancer Services
CBE Clinical Breast Exam
CDC Centers for Disease Control and Prevention
CHIP Children’s Health Insurance Program
CPT Current Procedural Terminology
DES Diethylstilbestrol
EOB Explanation of Benefit
EDI Electronic Data Interchange
FPP Family Planning Program
FPL Federal Poverty Level
FRR Financial Reconciliation Report
FSR Financial Status Report
HHSC Texas Health and Human Services Commission
HIPAA Health Insurance Portability and Accountability Act
HIV Human Immunodeficiency Virus
HPV Human Papilloma Virus
HSV Herpes Simplex Virus
HTW Healthy Texas Women
IRB Institutional Review Board
IUD Intrauterine Device
LARC Long-Acting Reversible Contraceptive
LEP Limited English Proficiency
NPI National Provider Identifier
NPPES National Plan and Provider Numeration System
PDPT Patient-Delivered Partner Therapy
QA Quality Assurance
QM Quality Management
PAA Prescriptive Authority Agreement
SDO Standing Delegation Orders
STD Sexually Transmitted Disease
STI Sexually Transmitted Infection
TAC Texas Administrative Code
TANF Temporary Assistance for Needy Families
TMHP Texas Medicaid & Healthcare Partnership
TMPPM Texas Medicaid Provider Procedures Manual
TPI Texas Provider Identifier
WIC Special Supplemental Nutrition Program for Women, Infants and Children

Section 2000, Client Access

Revision 19-0; Effective July 1, 2019

 

 

The contractor must ensure that individuals are provided services in a timely and nondiscriminatory manner. The contractor must:

A qualifying individual seeking family planning services must not be denied services due to an inability to pay.

Contractors have the right to terminate services for an individual if the individual is disruptive, unruly, threatening or uncooperative to the extent that the individual seriously impairs the contractor’s ability to effectively and safely provide services, or if the individual’s behavior jeopardizes his or her own safety, clinic staff or others. An individual has the right to appeal the denial, suspension or termination of services. See appeal rights: Denial, Suspension or Termination of Services and Client Appeals (1 TAC §382.111).

Any policy related to termination of services must be included in the contractor’s policy manual.

Section 3000, Abuse and Neglect Reporting

Revision 19-0; Effective July 1, 2019

 

 

HHSC contractors must comply with state laws governing the reporting of suspected abuse and neglect of children, adults with disabilities, or individuals 65 years of age or older. Contractors must have an agency policy regarding abuse and neglect.

To report abuse or neglect, call the Texas Abuse Hotline at 800-252-5400, use the secure website, or call any local or state law enforcement agency for cases that pose an imminent threat or danger to an individual.

 

3100 Child Abuse Reporting, Compliance and Monitoring

Revision 19-0; Effective July 1, 2019

 

Family Code, Chapter 261, requires suspected abuse or neglect of a child to be reported. Human Resources, Chapter 48, requires suspected abuse, neglect or exploitation of an elderly person, a person with a disability or an individual receiving services from certain home and community-based providers to be reported.

Contractors and providers are required to develop policies and procedures that comply with the reporting guidelines and requirements set forth in Chapter 261 of the Texas Family Code.

Policy – Contractors must develop an internal policy specific to:

Procedures – During Quality Assurance (QA) monitoring, the following procedures will be utilized to evaluate compliance:

References for child abuse reporting policy development – Child Abuse Reporting Requirements for DSHS Contractors and Providers; includes links to policies, child abuse reporting form and statutory references, available at http://www.dshs.texas.gov/childabusereporting/default.shtm.

 

3200 Human Trafficking

Revision 19-0; Effective July 1, 2019

 

HHSC mandates that contractors comply with state laws governing the reporting of abuse and neglect. Additionally, as part of the requirement that contractors comply with all applicable federal laws, family planning contractors must comply with the federal anti-trafficking laws, including the Trafficking Victims Protection Act of 2000. (22 USC §7101, et seq.)

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

References for Human Trafficking Policy Development  

Human trafficking into and within the United States: A review of the literature on human trafficking in the U.S. for the U.S. Department of Health and Human Services.

Polaris Project website: Contains links to victim and survivor support and other resources for health care providers and victims.

Polaris Project: Recognize the signs. Provides lists of common identifiable features of human trafficking victims in multiple settings.

Rescue and Restore Campaign by the U.S. Department of Health and Human Services. Contains multiple resources for health care providers, social service personnel, and law enforcement for identifying and aiding trafficking victims. Includes PowerPoint presentations for training purposes.

 

3300 Domestic and Intimate Partner Violence

Revision 19-0; Effective July 1, 2019

 

Intimate partner violence (IPV) describes physical, sexual, or psychological harm by a current or former partner or spouse. This type of violence can occur among heterosexual or same-sex couples and does not require sexual intimacy.

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

Section 4000, Client Rights

Revision 19-0; Effective July 1, 2019

 

4100 Confidentiality

Revision 19-0; Effective July 1, 2019

 

All contracting agencies must be in compliance with the U.S. Health Insurance Portability and Accountability Act of 1996 (HIPAA) established standards for protection of privacy.

A contractor must document the individual’s preferred method of follow-up for clinic services (cell phone, email, work phone) and the individual’s preferred language. Contractor must verbally assure everyone the right to confidentiality. Contractors must comply with adult and child abuse and neglect reporting laws in Texas. An FPP health care provider may not require consent for family planning services from the spouse of a married client. (1 TAC §382.125)

Contractors 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. An FPP health care provider’s staff (paid and unpaid) must be informed during orientation of the importance of keeping client information confidential. (1 TAC §382.125(c)). All employees, volunteers, subcontractors, board members and/or advisory board members must sign a confidentiality statement during orientation.

 

4110 Minors and Confidentiality

Revision 19-0; Effective July 1, 2019

 

A provider is required to maintain the confidentiality of care provided to a minor and may not disclose confidential information without the documented consent of the minor’s legally authorized representative, or the minor when allowed by law. A provider may only disclose confidential information without consent as required by law, such as to report abuse, and with appropriate safeguards for confidentiality.

The HIPAA privacy rule requires a covered entity to treat a “personal representative” the same as the individual with respect to uses and disclosures of the individual’s protected health information. [45 Code of Federal Regulations (CFR) §164.502(g)(1)] In most cases, parents are legally considered to be the personal representatives for their minor children, and they can exercise individual rights, such as access to medical records, on behalf of their minor children. [45 CFR §164.502(g)(2) and (3)]

 

4200 Nondiscrimination and Limited English Proficiency

Revision 19-0; Effective July 1, 2019

 

HHSC contractors must comply with state and federal anti-discrimination laws. These laws are contained in the HHSC Uniform Terms and Conditions – Grant Version 2.15, 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, which are part of a contractor’s contract with the state.

Information about nondiscrimination laws and regulations can be found on the HHS Civil Rights website.

 

4210 Contract Terms and Conditions

Revision 19-0; Effective July 1, 2019

 

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

Questions concerning this section and civil rights matters can be directed to the HHSC Civil Rights Office.

 

4300 Important Information for Former Military Service Members

Revision 19-0; Effective July 1, 2019

 

Women and men who served in any branch of the United States Armed Forces, including Army, Navy, Marines, Air 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.

 

4400 Termination of Services

Revision 19-0; Effective July 1, 2019

 

A qualifying individual seeking family planning services must not be denied services due to an inability to pay. Contractors have the right to terminate services for an individual if the individual is disruptive, unruly, threatening or uncooperative to the extent that the individual seriously impairs the contractor’s ability to effectively and safely provide services, or if the individual’s behavior jeopardizes his or her own safety, clinic staff or others. An individual has the right to appeal the denial, suspension or termination of services. See appeal rights: Denial, Suspension, or Termination of Services and Client Appeals (1 TAC §382.111).

Any policy related to termination of services must be included in the contractor’s policy manual.

 

4500 Resolution of Complaints

Revision 19-0; Effective July 1, 2019

 

Contractors must ensure that individuals can express concerns about care received and to further ensure that those complaints are handled in a consistent manner. Contractors’ policy manuals must explain the process when individuals request a hearing. A contractor shall not terminate services to the individual until a final decision is rendered by HHSC (1 TAC §357.13). Any complaint must be documented in the individual’s record.

 

4600 Freedom of Choice

Revision 19-0; Effective July 1, 2019

 

HHSC FPP clients are guaranteed the right to voluntarily choose qualified family planning providers and methods without coercion or intimidation. Acceptance of family planning services must not be a prerequisite to eligibility for, or receipt of, any other service or assistance from the entity or individual that provided the service or assistance.

 

4700 Research (Human Subject Clearance)

Revision 19-0; Effective July 1, 2019

 

An HHSC FPP contractor that wishes to participate in any proposed research that would involve the use of HHSC FPP clients as subjects, the use of HHSC FPP clients’ records or any data collection from FPP clients, must obtain prior approval from their own internal Institutional Review Board (IRB) and HHSC. For information about the process, contractors should contact the Department of State Health Services IRB at InstitutionalReviewBoard@dshs.texas.gov. The IRB will review the materials and approve or deny the application.

The contractor must have a policy in place that indicates that prior approval will be obtained from HHSC, prior to instituting any research activities. The contractor must also ensure that all staff are made aware of this policy through staff training. Documentation of training on this topic must be maintained.

Section 5000, Client Records Management

Revision 19-0; Effective July 1, 2019

 

 

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

The written consent of the individual is required for the release of personally identifiable information, except as may be necessary to provide services to the individual, or as required by law, with appropriate safeguards for confidentiality. If the individual is 17 years of age or younger, the individual’s parent, managing conservator or guardian, as authorized by Chapter 32 of the Texas Family Code or by federal law or regulations, must authorize the release. HIV information should be handled according to law.

When information is requested, contractors 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 particular individuals. Upon request, individuals 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.

Contractors, providers, subrecipients and subcontractors must maintain for the time period specified by HHSC all records pertaining to client services, contracts and payments. Record retention requirements are found in Title 1, Part 15 TAC §354.1003 (relating to time limits for submitted claims) and Title 22, Part 9 TAC §165 (relating to medical records). Contractors 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. 

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

Job descriptions, including those for contracted personnel, must specify required qualifications and licensure.

Contractors must show evidence that employees meet all required qualifications and are provided annual training. Job evaluations should include observation of staff/client interactions during clinical, counseling and educational services.

Contractors shall 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 FPP medical director must be a licensed Texas physician.

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

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.

Section 6000, Personnel Policy and Procedures

Revision 19-0; Effective July 1, 2019

 

 

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

Job descriptions, including those for contracted personnel, must specify required qualifications and licensure.

Contractors must show evidence that employees meet all required qualifications and are provided annual training. Job evaluations should include observation of staff/client interactions during clinical, counseling and educational services.

Contractors shall 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 FPP medical director must be a licensed Texas physician.

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

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.

Section 7000, Facilities and Equipment

Revision 19-0; Effective July 1, 2019

 

 

HHSC contractors are required to always maintain a safe environment. Contractors must have written policies and procedures that address the handling of hazardous materials, fire safety and medical equipment.

Hazardous Materials – Contractors must have written policies and procedures that address:

Fire Safety – Contractors must have a written fire safety policy that includes 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 – Contractors must have a written policy and maintain documentation of the maintenance, testing and inspection of medical equipment, including automated external defibrillators (AEDs). Documentation must include:

Radiology Equipment and Standards – All facilities providing radiology services must:

For information on x-ray machine registration, see the Texas Department of State Health Services, Radiation Control Program.

Smoking Ban – Contractors must have written policies that prohibit smoking in any portion of their indoor facilities. If a contractor subcontracts with another entity for the provision of health services, the subcontractor must comply with this policy.

Disaster Response Plan – Contractors must have written and oral plans that address how staff are to respond to emergency situations (i.e., fires, flooding, power outage, bomb threats, etc.). The disaster plan must identify the procedures and processes that will be initiated during a disaster and the staff [position(s)] 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 ten or fewer employees, the plan may be communicated orally to employees.

For additional resources on facilities and equipment, see the Occupational Safety and Health Administration website.

Section 8000, Quality Management

Revision 19-0; Effective July 1, 2019

 

 

Contractors must use internal quality assurance/quality improvement (QA/QI) systems and processes to monitor FPP services. Contractors must have the ability to meet the management standards prescribed in 45 CFR Part 75.

Contractors should integrate quality management (QM) concepts and methodologies into the structure of the organization and day-to-day operations. QM programs can vary in structure and organization and will be most effective if they are individualized to meet the needs of a specific agency, services and the populations served.

Contractors are expected to develop quality processes based on four core QM principles that focus on:

Contractors must have a QM program individualized to their organizational structure and based on the services provided. The goals of the quality program should ensure availability and accessibility of services, quality and continuity of care.

A QM program must be developed and implemented that provides for ongoing evaluation of services. Contractors 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.

Contractors 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 subcontracting entities.

The QM committee, whose membership consists of key leadership of the organization, including the executive director/chief executive officer, medical director and other appropriate staff, where applicable, annually reviews and approves the quality work plan for the organization. Note: The medical director must be a licensed Texas physician.

The QM committee must meet at least quarterly to:

Minutes of the discussion, actions taken by the committee, and a list of the attendees must be maintained and made available during QA/QI reviews.

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

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

HHSC contractors who subcontract 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 subcontracting entities including:

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.

Section 9000, Pharmacy

Revision 19-0; Effective July 1, 2019

 

 

To facilitate immediate client access to, and compliance with, contraceptive methods and related medications, contractors must be capable of providing limited pharmaceutical services (including contraceptive methods and related medications) to family planning clients at each clinic site that is funded by the HHSC FPP.

Contractors are required to have at least a Class D pharmacy on-site at each HHSC Title X clinic, have applied for a Class D pharmacy license through the Texas Pharmacy Licensing Board or have obtained approval for a Class D Pharmacy exemption from HHSC. HHSC staff will verify the license application date and status prior to reviewing a contractor’s exemption request.

It is the contractor’s responsibility to ensure that all contraceptive methods and related medications approved for reimbursement by the FPP are made available at no additional charge to the individual.

Pharmacies must be operated in accordance with federal and state laws relating to security and record keeping for drugs and devices. The inventory, supply and provision of pharmaceuticals must be conducted in accordance with state pharmacy laws and professional practice regulations. It is essential that each facility maintain an adequate supply and variety of drugs and devices on-site to effectively manage the contraceptive needs of its patients.

Class D Pharmacy Exemption

If extenuating circumstances prohibit a license from being granted, or if having an exemption would facilitate client access to contraceptive methods and related medications, a contractor may request an exemption to the requirement to have an on-site pharmacy.

A request for an exemption must be made in writing to the HHSC FPP and will be considered on a case-by-case basis. A request for an exemption is the first step in the process and must:

The following criteria must be met to potentially qualify for an exemption:

An exemption request will be reviewed by FPP staff and, depending on the justification and circumstances specific to each clinic site, may or may not be granted. The FPP reserves the right to approve or disapprove an exemption request based upon the merit of the justification.

The pharmacy exemption process is not complete until the contractor receives either an approval or a denial from the program.

A pharmacy exemption does not exclude a contractor from providing the following contraceptive methods on-site:

Section 10000, Eligibility and Assessment of Co-pay and Fees

Revision 20-1; Effective July 20, 2020

 

10100 Client Eligibility Screening Process

Revision 19-0; Effective July 1, 2019

 

HHSC FPP contracted agencies must screen all family planning applicants for eligibility in the following programs that provide family planning services in this order: Medicaid, Healthy Texas Women (HTW) and then the HHSC FPP. Eligibility screening criteria and processes are described below.

 

10110 Screening for Medicaid

Revision 19-0; Effective July 1, 2019

 

If the individual has a Your Texas Benefits Medicaid card, it can be used to document Medicaid eligibility.

Providers can call TMHP at 800-925-9126 or log on to TexMedConnect to check the member’s Medicaid ID number (PCN).

 

10120 Screening for HTW

Revision 19-0; Effective July 1, 2019

 

All women 15 to 44 years of age who are not eligible for full Medicaid services must be screened for HTW. HTW is a state-funded program administered by HHSC to provide eligible uninsured women with women’s health and family planning services such as woman’s health exams, health screenings and birth control. HTW providers must provide clinical services on a fee-for-service basis, and may also, but are not required to, contract with HHSC to provide support services that enhance clinical service delivery on a cost reimbursement basis.

HTW is for women who meet the following qualifications:

How to Know if a Person is Covered by HTW

If the individual has a Your Texas Benefits Medicaid card, it can be used to document Medicaid eligibility.

Providers can call TMHP at 800-925-9126 or log on to TexMedConnect to check the member’s Medicaid ID number (PCN).

Contractors must assist individuals who screen eligible for HTW to complete Form H1867, Healthy Texas Women Application Form, and verify the person’s income, identity and citizenship in accordance with HTW policies. An applicant may qualify as adjunctively eligible if she, or a member of her family, participates in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) or Children’s Medicaid. For more information on documents that are acceptable as proof of adjunctive eligibility see the HTW website.

Form H1867 is used to apply for HTW if the screening form indicates that a woman is likely to be determined eligible.

Note: An HTW Screening Tool or Form H1867 must be maintained in the client record for all potentially eligible HTW individuals.

After ensuring that the application is completed and signed, the contractor must fax the application to the toll-free number included on the application to HHSC for processing. Verification of income, expenses, adjunctive eligibility, identity and citizenship must also be faxed with the application. Contractors must fax the application to the eligibility office even if all required documentation is not provided by the individual. The eligibility office will contact the person for any missing information. To minimize paperwork and the chance that verification will be lost, the documents should be photocopied to fit on one sheet, if possible. A woman’s enrollment in HTW will be effective from the first day of the month HHSC receives her application for the program. For example, if a woman applies for HTW on January 20 and she is certified, her enrollment will be effective starting January 1.

 

10130 Screening for and Determining FPP Eligibility

Revision 19-0; Effective July 1, 2019

 

Contractors must determine FPP eligibility. To assess eligibility for FPP services, contractors must use either the Family and Social Services (FSS) Section eligibility form or an FSS Section-approved eligibility screening form substitute (e.g., in-house form, electronic/automated form, phone interview, etc.), that contains the required information for determining eligibility.

The eligibility assessment may be completed over the phone or in the office. The completed eligibility form must be maintained in the individual record, indicating the individual’s poverty level and the co-pay amount he or she may be charged. An individual’s eligibility must be assessed on an annual basis.

Eligibility Requirements

Eligible individuals must be:

If a barrier to receiving FPP services exists, the contractor may waive the requirement and approve full eligibility.

For determining FPP eligibility, the following definitions will be used:

Monthly Income Calculation

Rescreening for HTW

 

10200 Adjunctive Eligibility

Revision 19-0; Effective July 1, 2019

 

An applicant is considered adjunctively (automatically) eligible for HHSC FPP services at an initial or renewal eligibility screening, if she or he is currently enrolled in one of the following programs:

The applicant must be able to provide proof of active enrollment in the adjunctively eligible program. Acceptable eligibility verification documentation may include:

Program Documentation
CHIP Your Texas Benefits Medicaid card*
SNAP SNAP eligibility letter
TANF TANF verification of certification letter
WIC WIC verification of certification letter, printed WIC-approved shopping list, or recent WIC purchase receipt with remaining balance

*Note: If the individual has a Your Texas Benefits Medicaid card, it can be used to document Medicaid eligibility.

To verify eligibility, providers must call TMHP at 800-925-9126 or log on to TexMedConnect to check the member’s Medicaid ID number (PCN).

If the applicant or the applicant’s child (must be considered part of the household) is enrolled in CHIP, they 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 contractor would then determine eligibility according to usual protocols.

 

10300 Calculation of Applicant’s Federal Poverty Level Percentage

Revision 20-1; Effective July 20, 2020

 

Household FPL Calculation

If a contractor collects a co-payment, the contractor must determine the applicant’s exact household Federal Poverty Level (FPL) percentage at federal poverty guidelines. The steps to do so include:

The maximum monthly income amounts by household size are based on the Department of Health and Human Services federal poverty guidelines. The guidelines are subject to change around the beginning of each calendar year.

Example:

Applicant has a total monthly income of $2,093 and counts three family members in the household.

Total Monthly Income   Maximum Monthly Income
(Household Size of 3)
          Actual Household FPL%
$2,093 ÷ $1,810 = 1.16 x 100% = 116% FPL

Date Eligibility Begins

An individual is eligible for services beginning the date the contractor determines the individual eligible for the program and signs the completed application.

 

10400 Client Fees, Co-pays and Guidelines

Revision 20-1; Effective July 20, 2020

 

All FPP services provided at an HHSC FPP funded clinic, including nonreimbursable services, must be offered on a sliding fee scale.

Notes:

Co-pay Guidelines

If a contractor opts to charge a co-pay for services, a co-pay schedule must be developed and implemented with sufficient proportional increments so that inability to pay is never a barrier to service. Individuals whose household income is at or below 100% of the FPL must not be charged a co-pay. Individuals whose household income is between 101% and 250% of FPL may be charged a co-pay, but it is not required.

Other Fees

Individuals shall not be charged administrative fees for items such as processing and/or transfer of medical records, copies of immunization records, etc.

Contractors are allowed to bill individuals for services outside the scope of FPP reimbursable services, if the service is provided at the individual’s request, and the person is made aware of his or her responsibility for paying the charges.

 

10500 Continuation of Services

Revision 19-0; Effective July 1, 2019

 

Contractors who have expended their awarded FPP funds are required to continue to serve their existing FPP clients.

If other funding sources are used to provide FPP services, the funds must be reported as non-HHSC funds on the monthly Form 4116, State of Texas Purchase Voucher, and the quarterly Financial Status Report (FSR) (Form 269A).

Section 11000, Consent

Revision 19-0; Effective July 1, 2019

 

 

11100 General Consent

Revision 19-0; Effective July 1, 2019

 

Contractors must obtain the individual’s written, informed, voluntary general consent to receive services prior to receiving any clinical services. A general consent explains the types of services provided and how an individual’s 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 prior to reinitiating delivery of services.

Consent information must be effectively communicated to every individual in a manner that is understandable. This communication must allow the person to participate, make sound decisions regarding her or his own medical care and address any disabilities that impair communication (in compliance with Limited English Proficiency regulations). Only the person receiving services may give consent. For situations when the person is legally unable to consent, a parent (in case of an unemancipated minor) or legal guardian must consent on his or her behalf. Consent must never be obtained in a manner that could be perceived as coercive.

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

HHSC contractors should consult a qualified attorney to determine the appropriateness of the consent forms utilized by their health care agency.

 

11200 Procedure Specific Informed Consent

Revision 19-0; Effective July 1, 2019

 

11210 Sterilization Procedures and Sterilization Consent Form

Revision 19-0; Effective July 1, 2019

 

There are two consent forms required for sterilization procedures:

The Sterilization Consent Form is necessary for both abdominal and trans-cervical sterilization procedures in women and vasectomy in men. It is published in the Texas Medicaid Provider Procedures Manual (TMPPM) and is the only acceptable consent form for sterilizations funded by regular Medicaid (Title XIX), HTW or the HHSC FPP.

An electronic copy of the Sterilization Consent Form (in English and Spanish) may be found on the TMHP website. It is important that contractors use the most recent Sterilization Consent Form available. Additionally, it is the contractor’s responsibility to ensure that the form is complete and accurate prior to submission to TMHP.

In brief, the individual to be sterilized must:

*An individual may consent to be sterilized at the time of premature delivery or emergency abdominal surgery, if at least 72 hours have passed after the individual gave informed consent to sterilization. In the case of premature delivery, the informed consent must have been given at least 30 days before the expected date of delivery.

The consent form must be signed and dated by the:

Informed consent may not be obtained while the individual to be sterilized is:

 

11220 Texas Medical Disclosure Panel Consent

Revision 19-0; Effective July 1, 2019

 

The Texas Medical Disclosure Panel (TMDP) was established by the Texas Legislature to:

Contractors that directly perform tubal sterilization and/or vasectomy (both List A procedures), must also complete the TMDP Disclosure and Consent Form. This consent is in addition to the Sterilization Consent Form noted in Section 11210 above.

The required disclosures for tubal sterilization are:

The required disclosures for vasectomy are:

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

 

11300 Consent for Services to Minors

Revision 19-0; Effective July 1, 2019

 

Minors age 17 and younger are required to obtain consent from a parent or guardian before receiving certain medical services. HHSC FPP contractors must have proof of a parent’s or guardian’s consent prior to providing FPP services to a minor. Proof of consent must be included in the minor’s medical record.

Minors may consent to HIV/STD testing and treatment for an STD. Minors may consent to other medical treatment services in certain circumstances, pursuant to Texas Family Code Chapter 32 as outlined below.

For information on health services and consent requirements for minors, see: Adolescent Health – A Guide for Providers and The Texas Family Code, Chapter 32, part of which is outlined below.

Texas Family Code, Chapter 32, Sec. 32.003, Consent to Treatment by Child: There are instances in which a child may consent to medical, dental, psychological, and surgical treatment for the child by a licensed physician or dentist if the child:

 

11400 Consent for HIV Tests

Revision 19-0; Effective July 1, 2019

 

Contractors must comply with Texas Health and Safety Code §81.105 and §81.106 as follows:

§81.105. Informed Consent

§81.106. General Consent

Section 12000, Clinical Policy

Revision 19-0; Effective July 1, 2019

 

 

This section describes the requirements and recommendations for FPP contractors pertaining to the delivery of direct clinical services to patients. In addition to the requirements and recommendations found within this section, contractors should develop protocols consistent with national evidence-based guidelines appropriate to the target population.

All providers must offer the following core family planning services:

 

12100 Covered Services

Revision 19-0; Effective July 1, 2019

 

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

The following services are covered under the FPP:

 

12110 Requirement for Documentation of Reproductive Health Services

Revision 19-0; Effective July 1, 2019

 

All individuals should receive services related to reproductive health and/or contraception at least annually Individuals using long-acting reversible contraception (intrauterine device, implantable hormonal contraceptive agent) and patients who have undergone permanent sterilization may continue to receive services under the program if they meet eligibility requirements. 

The guiding principle of the FPP is to improve the reproductive health of women and men to ensure that every pregnancy and every baby are healthy. At each patient encounter, including encounters for treatment of other conditions (e.g., follow up of an abnormal Pap smear), the provider must educate the patient on how the service being provided relates to reproductive health or contraception, and this must be documented in the patient record.

For individuals who have undergone sterilization, and women who are post-menopausal or have had a hysterectomy, this counseling and documentation are not required when receiving covered services. This must be documented in the medical record at least annually.

 

12111 Individual Health Records and Documentation of Encounters

Revision 19-0; Effective July 1, 2019

 

Providers must ensure that a patient health record (medical record) is created for every individual who obtains clinical services (also see Section 5000, Client Records Management).

All patient health records must be:

The individual health record must include:

 

12120 Initial Clinical Visit

Revision 19-0; Effective July 1, 2019

 

At the initial clinical visit or an early subsequent visit, a comprehensive health history must be taken to include, in addition to the elements required for the individual health record in Section 12110 above (adapt, as appropriate, to the gender of the person):

At every subsequent 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.

 

12121 Annual Comprehensive Family Planning Visit, Physical Examination and Testing

Revision 19-0; Effective July 1, 2019

 

The annual family planning visit offers an excellent opportunity for providers to address issues of wellness and health risk reduction, as well as addressing any current 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 12110 above, as well as 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. This can be deferred to a later date if the person’s current history and health status do not suggest issues requiring more urgent examination. However, the annual physical examination should not be deferred longer than six months, unless the clinician identifies a compelling reason for extended deferral. Such reason must be documented in the individual’s record. Any breast or pelvic examination should be performed only with the consent of the person. Individuals must be offered a suitable method of contraception, such as oral contraceptives, without delay even if the physical examination is put off temporarily or an otherwise asymptomatic individual declines any or all components of the examination.

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

 

12122 Counseling and Education

Revision 19-0; Effective July 1, 2019

 

All individuals must receive accurate person-centered education and counseling in their preferred language, presented in a way they are able to understand and to demonstrate their understanding, and 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 to address counseling and other services provided to adolescents 17 years of age and younger, to include the following at a minimum:

Details of appropriate educational interventions are included in this manual. In addition, links are provided to information of use to individuals and educators at the end of most sections.

 

12130 Requirements for Policies to Ensure Appropriate Follow-up and Continuity of Care

Revision 19-0; Effective July 1, 2019

 

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

Before a person is considered lost to follow-up, the contractor must make at least three documented separate attempts to contact the person, using an accelerated protocol where subsequent attempts involve a more intensive effort to contact the person. Examples: 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 adapted to the circumstances of the population they serve, and adapt their usual processes based on their knowledge of the circumstances and preferences of the individual they are attempting to contact. 

 

12131 Problem Visits

Revision 19-0; Effective July 1, 2019

 

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

 

12132 Referrals

Revision 19-0; Effective July 1, 2019

 

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, counseling of the person regarding the purpose of the referral and answering any questions the person has about the referral. Pertinent individual information and appropriate portions of the medical record must be provided to the referral clinician and must also be documented in the medical record. The results of the consultation or referral must be followed up on and documented in the medical record.

When services covered under the FPP are to be provided by referral, the contractor must establish a written agreement with a referral resource for the provision of services and 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.

 

12133 Prescriptive Authority Agreements

Revision 19-0; Effective July 1, 2019

 

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 the Texas Occupations Code, Chapter 157, including but not limited to, the following minimum criteria:

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 any amendments must be reviewed at least annually, dated and signed by the parties to the agreement. A copy of the current PAA must be maintained on-site where the APRN or physician assistant provides care.

 

12134 Standing Delegation Orders

Revision 19-0; Effective July 1, 2019

 

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 actions should be instituted. The SDOs delineate under what set of conditions and 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 individuals when a physician or advance practice provider is not on the premises, and/or prior to being examined or evaluated by a physician or advanced practice provider. Example: An SDO for assessment of blood pressure/blood sugar which includes an RN, LVN or NLHP that will perform the task, the steps to complete the task, the normal/abnormal range 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:

The SDOs must be reviewed, signed and dated by the supervising physician who is responsible for the delivery of medical care covered by the orders and other appropriate staff at least annually, and maintained on-site.

 

12140 References

Revision 19-0; Effective July 1, 2019

 

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 534: Well-woman visit. Obstet Gynecol 120: 421-424. Available at http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Gynecologic_Practice/Well-Woman_Visit.

Centers for Disease Control and Prevention. Content of care for women website. Available at http://www.cdc.gov/preconception/careforwomen/index.html.

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

 

12200 Family Planning and Contraceptive Services

Revision 19-0; Effective July 1, 2019

 

12210 Reproductive Life Plan

Revision 19-0; Effective July 1, 2019

 

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:

Of course, providers and individuals should understand that such plans can change with time. Providers should take the individual’s stated plan into account in counseling on contraceptive and family planning services.

 

12220 Contraceptive Counseling and Education

Revision 19-0; Effective July 1, 2019

 

At each encounter for services, individuals must receive patient-centered counseling and education to enable them 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 indicated by the history and clinical evaluation.

Providers must offer individuals a wide array of contraceptive options appropriate for the person’s health status and reproductive plan. A six-step approach that seeks to engage 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.

 

12221 Relative Method Effectiveness

Revision 19-0; Effective July 1, 2019

 

The following contraceptive methods are approved for reimbursement under the FPP. (see pharmacy requirements for FPP contractors in Section 9000, Pharmacy, and Section 12222.2, Specific Method Access Requirements for Contractors). 
It is the contractor’s responsibility to ensure that all contraceptive methods approved for reimbursement by the FPP are made available at no additional charge to the individual.

Relative method effectiveness (range of effectiveness for 100 women using the method for one year) is indicated in parentheses, if reported values are available.  Actual effectiveness depends on correctness and consistency of use. Higher rates of effectiveness are seen with perfect use. Real-world effectiveness is generally reflected in the lower end of the effectiveness range.

*Long-acting reversible contraceptive methods.

 

12222 Long-Acting Reversible Contraceptive (LARC) Methods

Revision 19-0; Effective July 1, 2019

 

Because of their safety, reversibility, ease of use and very high real-world effectiveness, providers are encouraged to make LARC agents and devices (i.e., the intrauterine device and the subdermal contraceptive implant) available to all who are candidates for their use. See Long-Acting Reversible Contraception Program from the American Congress of Obstetricians and Gynecologists for information and resources on the use of LARCs.

For more information on implementing a program to provide LARCs, see the Texas LARC Toolkit on the Healthy Texas Women website.

 

12222.1 Consent for Sterilization

Revision 19-0; Effective July 1, 2019

 

For individuals who choose male or female sterilization, two consent forms are required to be signed by the person after counseling on method-specific risks and benefits is provided and all the person’s questions have been answered:

 

12222.2 Specific Method Access Requirements for Contractors

Revision 19-0; Effective July 1, 2019

 

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

Injectable hormonal contraceptives

Oral contraceptives

 

Transdermal hormonal contraceptive (patch) and/or vaginal hormonal contraceptive (ring)

 

Sexual abstinence education and counseling

 

12223 Contraceptive Methods that May Be Provided by Referral

Revision 19-0; Effective July 1, 2019

 

If the clinicians associated with an FPP contractor do not provide covered contraceptive services that require a special level of training or expertise (e.g., sterilization, intrauterine device, hormonal implant and diaphragm fitting), these services may be offered by referral to another provider at no additional cost to the individual. FPP contract 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.

Notes:

 

12224 References and Resources

Revision 19-0; Effective July 1, 2019

 

References

Centers for Disease Control and Prevention (2014). Providing 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 (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. 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.

Resource for Patients and Educators

Association of Reproductive Health Professionals. Method Match. Online decision support tool to help patients compare and select from different methods of contraception. Includes information on relative effectiveness of methods. Available at http://www.arhp.org/methodmatch/.

Resource for Providers

American Congress of Obstetricians and Gynecologists. Long-acting reversible contraception program web page. Provides information, clinical guidance and educational materials on long-acting reversible contraceptives. Available at https://www.acog.org/About_ACOG/ACOG_Departments/Long_Acting_Reversible_Contraception

 

12230 Preconception Services

Revision 19-0; Effective July 1, 2019

 

The goal of preconception care is optimizing the health of every woman to lay the 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 prior to 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:

 

12231 References and Resources

Revision 19-0; Effective July 1, 2019

References

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 313: The importance of preconception care in the continuum of women’s health care.  Obstet Gynecol (2005). 106: 665-666. Available at http://www.acog.org/Resources_And_Publications/~/link.aspx?_id=75AD1BF47A76489F8E719EA5E3F22797&_z=z.

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.

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. Content of care for women website. Available at http://www.cdc.gov/preconception/careforwomen/index.html.

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

Centers for Disease Control and Prevention. Preconception health and health care web site. 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.

 

12300 Screenings

Revision 19-0; Effective July 1, 2019

 

 

12310 Cervical Cancer Screening

Revision 19-0; Effective July 1, 2019

 

The summary of cited guideline recommendations provided in this section reflects the ages of eligibility for the FPP and does not include guideline recommendations for individuals outside this range.

Guidelines were reviewed from a variety of medical specialty organizations and U.S. government agencies. Where a slight divergence was found among guidelines from different organizations, an attempt was made to synthesize the recommendations so that all recommendations are represented cohesively in the summary below. 

Most cases of cervical cancer occur in women who have never had screening or have had inadequate screening. It is estimated that half of women who receive a diagnosis of cervical cancer have never had cervical cytology testing and an additional 10% have not had screening in the five years prior to the diagnosis of cancer. Providers are encouraged to implement and participate in programs aimed at increasing the percentage of women in their communities who receive indicated cervical cancer screening.

General Considerations

 

12311 Screening Frequency and Response to Abnormal Findings

Revision 19-0; Effective July 1, 2019

 

Discontinuation of Screening

For women in the FPP age group, screening should be discontinued after a hysterectomy with removal of the cervix in individuals with no prior history of CIN 2 or greater.

 

12312 References

Revision 19-0; Effective July 1, 2019

 


American Society for Colposcopy and Cervical Pathology (2013). Consensus guidelines for managing abnormal cervical cancer screens and CIN/AIS. Available at http://www.asccp.org/asccp-guidelines.
Huh, W. K., Ault, K. A., Chelmow, D., Davey, D. D., Goulart, R. A., Garcia, F. A., Einstein, M. H. (2015). Use of primary high-risk human papillomavirus testing for cervical cancer screening: Interim clinical guidance. Gynecol Oncol, 136(2), 178-182.

Practice Bulletin No. 168: Cervical cancer screening and prevention. (2016). Obstet Gynecol, 128(4), e111-e130.

U.S. Department of Health and Human Services Panel on opportunistic infections in HIV-infected adults and adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. Recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health and the HIV Medicine Association of the Infectious Diseases Society of America. Available at https://aidsinfo.nih.gov/guidelines/html/4/adult-and-adolescent-opportunistic-infection/0.

U.S. Preventive Services Task Force, Curry, S. J., Krist, A. H., Owens, D. K., Barry, M. J., Caughey, A. B., Wong, J. B. (2018). Screening for cervical cancer: US Preventive Services Task Force Recommendation Statement. JAMA, 320(7), 674-686.

 

12320 Breast Cancer Screening

Revision 19-0; Effective July 1, 2019

 

The summary of cited guideline recommendations provided in this section reflect the ages of eligibility for the FPP and do not include guideline recommendations for individuals outside this range.

Risk Screening and Individual Counseling

All females should have an assessment of their risk for breast cancer, updated periodically, to include the individual’s age and ethnicity, personal and family history of breast cancer, other relevant genetic predisposition to breast cancer and any history of chest radiation (particularly before age 30). A risk calculator is available from the National Cancer Institute for an individual’s five-year risk of developing breast cancer (for women age 35 and older).

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

 

12321 Screening Frequency

Revision 19-0; Effective July 1, 2019

 

The following considerations* apply to women age 40 and older who do not have preexisting breast cancer or other high-risk breast lesion and who do not have a known underlying genetic mutation (such as a BRCA1 or 2 mutations, or other familial breast cancer syndrome) or a history of chest radiation at an early age. 

More frequent or earlier screening mammography may be considered in women with increased or uncertain individual breast cancer risk and in other circumstances where the balance of potential benefits and harms of screening is felt to justify it.

*Note: The recommendations for frequency of mammography screening described above come from the U.S. Preventive Services Task Force Recommendation Statement on Screening for Breast Cancer. The National Comprehensive Cancer Network recommends annual screening mammography be offered to all asymptomatic women age 40 and older. Links to both guidelines are provided in Section 12323, References and Resources.

 

12322 Follow-up and Referral for Treatment

Revision 19-0; Effective July 1, 2019

 

Any individual with an abnormality identified on screening or a specific breast complaint (including, but not limited to a mass, lump, thickening or nipple discharge) should be evaluated, as indicated, in a timely manner. Providers should have procedures in place to ensure appropriate individual education and counseling, referral for further evaluation (including additional testing and biopsy) when indicated, communication and coordination with the person and other providers, and proper follow-up through the conclusion of the case.

For persons who require referral for services beyond those available through the contracted provider, contractors are encouraged, whenever possible, to refer those persons to an HHSC Breast and Cervical Cancer Services (BCCS) contractor.  Information is available at https://hhs.texas.gov/Doing-Business-HHS/Provider-Portals/Health-Services-Providers/Womens-Health-Services/Breast-Cervical-Cancer-Services.

Eligible individuals in need of treatment for biopsy-proven breast cancer may apply for coverage under the Medicaid for Breast and Cervical Cancer Program. Information is available at https://hhs.texas.gov/doing-business-hhs/provider-portals/health-services-providers/womens-health-services/breast-cervical-cancer-services/breast-cervical-cancer-treatment-information.

 

12323 References and Resources

Revision 19-0; Effective July 1, 2019

 

References

Siu, AL. Screening for breast cancer: U.S. Preventive Services Task Force Recommendation Statement.Ann Intern Med. 2016;164(4):279-296. Available at http://annals.org/article.aspx?articleid=2480757

National Comprehensive Cancer Network (2018). NCCN clinical practice guidelines in oncology: Breast cancer screening and diagnosis. Version 2.2018. Available at https://www.nccn.org/professionals/physician_gls/f_guidelines.asp#breast_screening.

Additional Reading

National Comprehensive Cancer Network (2018). NCCN clinical practice guidelines in oncology: Breast cancer risk reduction. Version 2.2018. Available at https://www.nccn.org/professionals/physician_gls/f_guidelines.asp#breast_risk.

National Comprehensive Cancer Network (2017). NCCN clinical practice guidelines in oncology: Genetic/familial high-risk assessment: Breast and ovarian. Version 1.2018. Available at https://www.nccn.org/professionals/physician_gls/f_guidelines.asp#breast_risk.

Information for Patients

National Cancer Institute. Mammograms patient information. Available at http://www.cancer.gov/types/breast/mammograms-fact-sheet.

National Cancer Institute. Breast Cancer – Patient Version. Available at http://www.cancer.gov/types/breast.

Online Provider Resources

National Cancer Institute. Breast Cancer Risk Assessment Tool. Available at http://www.cancer.gov/bcrisktool/Default.aspx.

 

12330 Sexually Transmitted Disease/Infection (STD/STI) Screening and Treatment

Revision 19-0; Effective July 1, 2019

 

The summary of cited guideline recommendations provided in this section reflect the ages of eligibility for the FPP and do not include guideline recommendations for individuals outside this range.

Screening and treatment of STDs/STIs must follow the current guidelines for screening and treatment from the Centers for Disease Control and Prevention (CDC). A risk assessment should be done for all individuals to determine what testing is indicated and documented in the medical record. Following is a brief overview of STD/STI screening recommendations (for more detailed information, go to the CDC screening links above).

 

12331 HIV Screening

Revision 19-0; Effective July 1, 2019

 

 

12332 Chlamydia and Gonorrhea Testing

Revision 19-0; Effective July 1, 2019

 

 

12333 Herpes Simplex Virus (HSV) Screening

Revision 19-0; Effective July 1, 2019

 

 

12334 Syphilis Screening (Men and Nonpregnant Women)

Revision 19-0; Effective July 1, 2019

 

 

12335 Other Screening and Pregnant Women

Revision 19-0; Effective July 1, 2019

 

Screening for other infections and more frequent screening should be considered as appropriate based on the person’s condition, risk factors and concerns.

Pregnant Women

 

12336 Patient-Delivered Partner Therapy (PDPT)

Revision 19-0; Effective July 1, 2019

 

PDPT is the practice of providing therapy to the sexual partner(s) of a person being treated for chlamydia or gonorrhea without first developing a patient-clinician relationship with the partner(s). Untreated partners can reinfect treated individuals and expose others to infection.

Providers are encouraged to implement PDPT by providing individuals who are being treated for either chlamydia or gonorrhea with medications or prescriptions the partner(s) can use to be treated as well. 

Providers may not receive reimbursement for providing partner treatment under this policy to persons who have not been patients.

 

12337 References

Revision 19-0; Effective July 1, 2019

 

American College of Obstetricians and Gynecologists. Committee Opinion No. 598: The initial reproductive health visit. Obstet Gynecol (2014) 123: 1143-1147. Available at http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Adolescent_Health_Care/The_Initial_Reproductive_Health_Visit.

Branson, BM., et al. Revised recommendations for HIV testing of adults, adolescents and pregnant women in health care settings. MMWR (2006) 55(RR14): 1-17.  Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm.

Centers for Disease Control and Prevention. Genital herpes. Available at http://www.cdc.gov/std/Herpes/default.htm.

Centers for Disease Control and Prevention. Pregnant women, infants and children: An opt-out approach to HIV screening. Available at http://www.cdc.gov/hiv/group/l/pregnantwomen/opt-out.html.

Centers for Disease Control and Prevention. Sexually transmitted diseases:
Treatment. Available at http://www.cdc.gov/std/treatment/default.htm.

Centers for Disease Control and Prevention. STD and HIV Screening Recommendations. Available at http://www.cdc.gov/std/prevention/screeningreccs.htm.

U.S. Preventive Services Task Force. Screening for syphilis infection in nonpregnant adults and adolescents: U.S. Preventive Services Task Force recommendation statement. JAMA (2016) 315(21): 2321-2327. Available at http://jamanetwork.com/journals/jama/fullarticle/2526645.

Expedited (Patient-Delivered) Partner Therapy (information for patients and providers):

Centers for Disease Control and Prevention. Expedited partner therapy website. Available at http://www.cdc.gov/std/ept/.

Texas Dept. of State Health Services. Expedited partner therapy website. Available at http://www.dshs.state.tx.us/hivstd/ept/default.shtm.

 

12340 Diabetes Mellitus Screening

Revision 19-0; Effective July 1, 2019

 

Who Should Be Screened for Diabetes

The criteria below apply to nonpregnant patients only.

Risk Factors for Diabetes

 

12341 Diagnostic Criteria

Revision 19-0; Effective July 1, 2019

 

Any one or more of the following results, confirmed on repeat testing, meets the criteria for a diagnosis of diabetes (repeat testing for confirmation is not required in the presence of unequivocal clinical hyperglycemia):

Test Criteria to Diagnose Diabetes Mellitus Comments
Fasting plasma glucose Greater than or equal to 126 mg/dL (7.0 mmol/L) After no caloric intake for a minimum of eight hours.
Oral glucose tolerance test (with a 75-g glucose load) Two-hour glucose greater than or equal to 200 mg/dL (11.1. mmol/L)  
Hemoglobin A1C Greater than or equal to 6.5% (48 mmol/mol) For diagnosis of type I diabetes in individuals with acute hyperglycemic symptoms, blood glucose testing is preferred.
Random plasma glucose Greater than or equal to 200 mg/dL (11.1. mmol/L) If this occurs in the setting of a hyperglycemic crisis or classic symptoms of hyperglycemia, confirmation by repeat testing is not required.

Table: Diagnostic Criteria for Diabetes Mellitus. All initial results should be confirmed with repeat testing.

 

12342 References and Resources

Revision 19-0; Effective July 1, 2019

 

References

American College of Obstetricians and Gynecologists (2013). Practice Bulletin No. 137: Gestational diabetes mellitus. Obstet Gynecol. 122 406-416.

American Diabetes Association. Standards of medical care in diabetes – 2018. Diabetes Care (2018); 41(Suppl. 1). Available at  http://care.diabetesjournals.org/content/41/Supplement_1.

Resources for Patients and Educators

American Diabetes Association at http://www.diabetes.org.

American Diabetes Association Diabetes Pro website (information for providers of care) at http://professional.diabetes.org.

American Diabetes Association Diabetes Educators (information and resources for both patients and educators) at http://professional.diabetes.org/diabetes-education.

Centers for Disease Control and Prevention. Adult BMI calculator. Available at http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.html.

Centers for Disease Control and Prevention. BMI calculator for child and teen. Available at http://nccd.cdc.gov/dnpabmi/Calculator.aspx.

Centers for Disease Control and Prevention. Defining childhood obesity (provides definition of overweight and obesity in children and adolescents age 2 to 19, and link to BMI calculator for children and teens). Available at http://www.cdc.gov/obesity/childhood/defining.html.

National Diabetes Education Initiative (patient education handouts and links to professional resources) at http://www.ndei.org

National Institute of Diabetes and Digestive Diseases. National Diabetes Education Program (resources for patients and educators). Available at http://www.niddk.nih.gov/health-information/health-communication-programs/ndep/pages/index.aspx.

National Heart, Lung and Blood Institute Aim for a Healthy Weight at https://www.nhlbi.nih.gov/health/educational/lose_wt.

 

12350 Hypertension Screening

Revision 19-0; Effective July 1, 2019

 

All individuals, including those with hypertension, should be advised to adhere to a healthy lifestyle as described in Section 12400, Healthy Lifestyle Intervention.

Classification of BP and Diagnosis of Hypertension

In the United States, high blood pressure (BP) is the second leading cause of preventable death after cigarette smoking and is the most important modifiable risk factor for death due to cardiovascular disease. Because hypertension is generally asymptomatic, it is important that all persons be screened at least annually for elevated BP.

The following table provides guidance on diagnosis of hypertension in adults. Recent guidelines emphasize greater reliance on home BP monitoring to aid in the diagnosis of hypertension when clinic readings are high normal, borderline high or elevated. It is generally agreed that clinic BP measurements are often higher than home BP measurements, particularly in the higher ranges of BP.

BP (mm Hg) Category
Less than 120/80 Normal
120-129/Less than 80 Elevated
130-139/80-89 Stage 1 hypertension
Greater than or equal to 140/90 Stage 2 hypertension

Measurement of BP

Instructions for Home BP Monitoring

Nonpharmacologic Intervention

All patients, regardless of BP category should receive instruction in healthy lifestyle habits, with regular reinforcement of teaching. 

 

12351 References and Resources

Revision 19-0; Effective July 1, 2019

 

References

Carey, R. M., Whelton, P. K. (2018). Prevention, detection, evaluation and management of high blood pressure in adults: Synopsis of the 2017 American College of Cardiology/American Heart Association hypertension guideline. Ann Intern Med, 168(5), 351-358. Available at http://annals.org/aim/fullarticle/2670318/prevention-detection-evaluation-management-high-blood-pressure-adults-synopsis-2017.

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Himmelfarb, C. D., Wright, J. T. (2017). ACC/AHA/AAPA/ABC/ACPM/AGS/APha/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation and management of high blood pressure in adults. Hypertension, 71(6), e13-e115. Available at http://hyper.ahajournals.org/content/71/6/e13.long.

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Himmelfarb, C. D., Wright, J. T. (2017). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APha/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation and management of high blood pressure in adults. Executive Summary: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. J Am Coll Cardiol, 71(19), 2199-2269. Available at https://www.sciencedirect.com/science/article/pii/S073510971741518X?via%3Dihub.

Resources for Patients and Educators

American Heart Association. High blood pressure. Provides information on the meaning and importance of high blood pressure, risks for, and prevention of, high blood pressure, blood pressure monitoring and treatment of high blood pressure. Available at http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/High-Blood-Pressure_UCM_002020_SubHomePage.jsp.

National Heart, Lung and Blood Institute. Description of high blood pressure. Provides a plain language discussion of the prevention, diagnosis and treatment high blood pressure. Available at http://www.nhlbi.nih.gov/health/health-topics/topics/hbp.

Resources for Providers

American Society of Hypertension. Hypertension Guidelines at http://www.ash-us.org/About-Hypertension/Hypertension-Guidelines.aspx.

 

12360 High Cholesterol Screening

Revision 19-0; Effective July 1, 2019

 

The summary of cited guideline recommendations provided in this section reflect the ages of eligibility for the FPP and do not include guideline recommendations for individuals outside this eligibility range.

The diagnosis and treatment of elevated blood cholesterol is a complex subject and a complete discussion is beyond the scope of this manual. For more information, providers are referred to Section 12362, References and Resources, and relevant textbooks.

Rationale for Cholesterol Screening

Evidence shows that a healthy lifestyle (following a heart healthy diet, maintaining a healthy weight, regular exercise and avoidance of tobacco products) reduces the risk of cardiovascular disease. In certain persons with specific risk factors, cholesterol-lowering medications (i.e., statins) can further reduce the risk of an adverse health event. Measurement of blood cholesterol is a component of the individual risk assessment in some patients.

Who Should Be Screened for High Cholesterol

No recommendation is made regarding routine screening in men age 20 through 35 or in women age 20 or older without increased risk of CHD.

Risk Factors

Increased risk of CHD is defined by the presence of any one of the risk factors below.  Greater risk results from the presence of multiple risk factors.

Screening Frequency

The optimal interval for screening is uncertain. Reasonable options include every five years, shorter intervals for people who have lipid levels close to those warranting therapy, and longer intervals for those not at increased risk who have had repeatedly normal lipid levels.

An age at which to stop screening has not been established.

Screening Method

The preferred screening test for elevated cholesterol is the serum lipid panel (total cholesterol, high-density lipoprotein [HDL] cholesterol, and low-density lipoprotein [LDL] cholesterol) in the fasting or non-fasting state. If non-fasting results are used, only the total cholesterol and HDL cholesterol are reliable. Abnormal screening results should be confirmed by a repeat sample on a separate occasion, and the average of both results should be used for risk assessment.

 

12361 Evaluation of Screening Results

Revision 19-0; Effective July 1, 2019

 

Results of the lipid profile should be interpreted in the context of the individual’s risk factors and 10-year estimated risk of atherosclerotic cardiovascular disease (ASCVD), defined as acute coronary syndrome, myocardial infarction, stable or unstable angina, stroke, transient ischemic attack, coronary or other arterial revascularization procedure, or atherosclerotic peripheral arterial disease. A risk calculator for 10-year ASCVD risk is available from the American College of Cardiology and American Heart Association.

Studies have shown a benefit of statin therapy in individuals with the following risk profiles:

 

12362 References and Resources

Revision 19-0; Effective July 1, 2019

 

Stone N.J., et al. 2013 ACC/AHA Guidelines on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation (2014). 129 (25 Suppl. 2): S1-S45 Available at https://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a.full.

National Heart, Lung and Blood Institute. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Cholesterol in Adults (Adult Treatment Panel III). NIH Publication No. 01-3670, May 2001. Available at http://www.nhlbi.nih.gov/files/docs/guidelines/atp3xsum.pdf.

U.S. Preventive Services Task Force. The Guide to Clinical Preventive Services, Lipid Disorders in Adults (2014), Page 45. Available at http://www.ahrq.gov/sites/default/files/publications/files/cpsguide.pdf.

Further Reading

Pursnani A, et al. Guideline-based statin eligibility, coronary artery calcification and
cardiovascular events. JAMA (2015) 314:134-141. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4754085/.

Resources for Providers

ASCVD Risk Estimator from the American College of Cardiology. Provides an estimate of the 10-year risk of developing ASCVD. Available at http://tools.acc.org/ASCVD-Risk-Estimator/.

 

12370 Postpartum Depressing Screening

Revision 19-0; Effective July 1, 2019

 

Prevalence and Risk Factors for Postpartum Depression

As many as 80% of new mothers experience a brief episode of the “baby blues” which may last up to two weeks. Approximately 5-25% of new mothers will experience postpartum depression that warrants intervention. It typically begins in the first four to six weeks after birth of the infant but may develop any time in the first year. 

Risk factors for postpartum depression include the following:

Common signs and symptoms of postpartum depression include the following (some or none of these symptoms may be apparent):

Screening for Postpartum Depression

Providers are encouraged to review The Texas Clinician’s Postpartum Depression Toolkit for a more detailed review of screening for postpartum depression.

Because postpartum depression can be a serious and sometimes life-threatening condition, all new mothers should have screening for postpartum depression at the postpartum visit. For those who screen negative, repeat screening should be considered at a later visit or when the mother takes her baby in for a checkup.

A standardized self-administered screening tool with review and follow-up questions in a face-to-face interview with the provider will ensure consistency and efficiency in the screening process. The following postpartum depression screening tools are available online and have been validated for use in postpartum patients:

To ensure that all patients are screened without undue interruption of clinic workflow, a convenient approach to screening is the following:

 

12371 Referral for Treatment

Revision 19-0; Effective July 1, 2019

 

Individuals in need of treatment for postpartum depression should be referred to a provider of behavioral health services. Providers must have arrangements in place for appropriate referral of individuals to behavioral health providers in their area. For information on local behavioral health care providers, refer to the website of the Office of Mental Health Coordination, Texas Health and Human Services, or call 211.

Coding for Postpartum Depression Services

The following Current Procedural Terminology (CPT) codes are covered under the FPP:

99201 99202 99203 99204 99205
99211 99212 99213 99214 99215
90791 90792      



12372 References and Resources

Revision 19-0; Effective July 1, 2019

 

American College of Obstetricians and Gynecologists Committee Opinion No. 630. Screening for perinatal depression. Obstet Gynecol (2015). 125: 1268-1271.  Available at http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Screening-for-Perinatal-Depression.

Hirst K.P. and Moutier C.Y. Postpartum major depression. American Family Physician (2010). 82: 926-933. Available at http://www.aafp.org/afp/2010/1015/p926.html.

Norhayati M.N., et al. Magnitude and risk factors for postpartum symptoms: A literature review. J. Affect Disord. (2015). 175: 34-52.

O’Connor E, et al. Primary care screening for and treatment of depression in pregnant and postpartum women: Evidence report and systematic review for the U.S. Preventive Services Task Force. JAMA (2016). 315: 388-406.

Resources for Patients and Providers

American Academy of Family Physicians. Postpartum Depression webpage, information for patients and providers on postpartum depression. Available at http://familydoctor.org/familydoctor/en/diseases-conditions/postpartum-depression.html.

American Academy of Family Physicians. Postpartum Depression Action Plan. Available at http://familydoctor.org/familydoctor/en/diseases-conditions/postpartum-depression/treatment/postpartum-depression-action-plan.html.

Office of Mental Health Coordination website, Texas Health and Human Services, provides links to information for providers and patients in Texas on a variety of behavioral health topics, and a link to the Substance Abuse and Mental Health Services Administration (SAMHSA) behavioral health treatment services locator.  Available at http://mentalhealthtx.org/.

STEP-PPD Support and training to enhance primary care for postpartum depression website. Provides links to resources, including postpartum depression screening tools, online training, case studies, classroom materials, Clinician’s Pocket Guide and other materials. Available at  https://step-ppd.com/.

Texas Health and Human Services, the Texas Clinician’s Postpartum Depression Toolkit. Contains a review of the diagnosis and treatment of postpartum depression for the primary care provider, including a section on covered services, coding and billing for services provided under Texas state health care programs. Available at  https://www.healthytexaswomen.org/provider-resources#family-planning-program.

 

12380 Suicide Risk Screening

Revision 19-0; Effective July 1, 2019

 

Any individual with a positive screen based on responses to questions related to suicide risk, and any individual who expresses suicidal thoughts or ideation, must be evaluated immediately for suicide risk. If the individual is felt to be acutely at risk of suicide, she must be referred for emergent evaluation and/or hospitalization, as indicated.

 

12400 Healthy Lifestyle Intervention

Revision 19-0; Effective July 1, 2019

 

All individuals should receive a health risk survey, at least annually, to determine areas where lifestyle modifications might reduce the risk of future disease and improve health outcomes and quality of life.

Counseling on Healthy Lifestyle Choices

The following provides details for why and how to achieve some of these goals.

Diet and Nutrition

There is strong evidence that nutrition plays an important role in our risk of disease. Dietary patterns that emphasize a lower percentage of total calories from fat, reduced amounts of saturated fats, and reduced sodium intake while achieving and maintaining a healthy body weight have been shown to reduce the risk of cardiovascular disease, the most common cause of death in both men and women in the United States. No single diet has been shown to be the best and providers should counsel individuals on a variety of healthy eating patterns tailored to their health and cultural background, while preserving the pleasure of meals and eating.

Healthy Dietary Patterns

Two dietary patterns that have been shown to improve some measures of cardiovascular risk are the Dietary Approaches to Stop Hypertension (DASH) and Mediterranean (MED) diets. Both dietary patterns emphasize reduced saturated fat and red meat, increased fiber, vegetables, fruits, fish, oils and nuts, while allowing wide freedom of food choices to accommodate eating preferences and cultural differences among individuals.

The MED diet emphasizes:

The DASH diet is:

Dietary counseling on healthy eating patterns, such as those described above, provided as a routine part of an individual encounter has been shown to reduce blood pressure in those with type 2 diabetes or risk factors for cardiovascular disease, including those with mild untreated hypertension. For individuals with normal or modestly elevated cholesterol, regardless of gender or ethnicity, following a DASH dietary pattern can reduce low-density lipoprotein cholesterol (LDL cholesterol) and high-density lipoprotein cholesterol (HDL cholesterol). Following a DASH dietary pattern can reduce blood pressure in all individuals, regardless of age, sex and ethnicity, including those with mild untreated hypertension.

Salt Intake

There is strong evidence that reducing sodium (salt) intake reduces blood pressure in individuals with normal blood pressure, as well as those with mild to moderate hypertension, regardless of sex, ethnicity and age. This holds true even if no other dietary changes are made. Therefore, some individuals who consider the dietary patterns described above too drastic a change can reduce their blood pressure just by lowering their salt intake. Those who adopt a DASH dietary pattern and reduce their salt intake can lower their blood pressure even more. All individuals should receive advice to limit their salt intake and be counseled on ways to do so.

Cholesterol

Despite much public attention given to cholesterol in the diet as a cause of poor health, there has been very little research on the effect of reducing dietary cholesterol on the risk of future disease. Therefore, no recommendation can be made to counsel individuals specifically on dietary cholesterol intake.

Physical Activity

Regular aerobic physical activity (e.g., walking, jogging, dancing, swimming, water-walking, gardening, climbing stairs and even house cleaning) and resistance training (e.g., working with light weights or elastic bands) can reduce the risk of serious disease by lowering LDL cholesterol and blood pressure. Individuals should be encouraged to engage in at least 30 minutes of an activity they enjoy, suitable to their current health status and risk, at least three times a week with no more than two consecutive inactive days. More intensive physical activity (e.g., up to 60 minutes at a setting, more sessions per week), for those whose health status permits, offer more benefit.

 

12410 References and Information

Revision 19-0; Effective July 1, 2019

 

Reference

National Heart, Lung and Blood Institute. Lifestyle interventions to reduce cardiovascular risk: Systematic Evidence Review from the Lifestyle Work Group (2013). Available at http://www.nhlbi.nih.gov/health-pro/guidelines/in-develop/cardiovascular-risk-reduction/lifestyle.

Information for Patients and Educators

American Heart Association, Healthy Eating. Provides information on food choices, recipes, how to eat healthy when dining out and how to shop for groceries with a focus on healthy eating. Available at http://www.heart.org/HEARTORG/HealthyLiving/HealthyEating/Healthy-Eating_UCM_001188_SubHomePage.jsp.

American Heart Association, Get moving! Easy tips to get active. Provides information on physical activity and fitness. Available at http://www.heart.org/HEARTORG/HealthyLiving/PhysicalActivity/Physical-Activity_UCM_001080_SubHomePage.jsp.

American Heart Association, Sodium and Salt. Provides information on ways to reduce dietary salt intake. Available at http://www.heart.org/HEARTORG/HealthyLiving/HealthyEating/Nutrition/Sodium-and-Salt_UCM_303290_Article.jsp#.WThZ4-v1DRY.

Mayo Clinic, Healthy diets. Available at http://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/basics/healthy-diets/hlv-20049477.

Mayo Clinic, DASH diet: Healthy eating to lower your blood pressure. Available at http://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/dash-diet/art-20048456.

Mayo Clinic, DASH diet recipes. Available at http://www.mayoclinic.org/healthy-lifestyle/recipes/dash-diet-recipes/rcs-20077146.

Mayo Clinic, Mediterranean diet recipes. Available at http://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/mediterranean-diet-recipes/art-20046682.

 

12500 Perinatal Clinical Policy

Revision 19-0; Effective July 1, 2019

 

Prenatal services should be provided based on American College of Obstetricians and Gynecologists (ACOG) guidelines.

Components of Initial Prenatal Interventions/Screening

Prenatal Visit – The initial encounter with a pregnant woman includes a complete history, physical examination, assessment, planning, treatment, counseling and education (referral as indicated), routine prenatal laboratory tests and additional laboratory tests as indicated by history, physical exam and/or assessment.

Components of Return Visit Interventions/Screening

Return Prenatal Visit – The follow-up prenatal visit includes interval history, physical examination, risk assessment, medical services, nutritional counseling, psychosocial counseling, family planning counseling and client education regarding maternal and child health topics. Hemoglobin and/or hematocrit, and urinalysis for protein and glucose are also included.

 

12510 Perinatal Histories

Revision 19-0; Effective July 1, 2019

 

Prenatal Visit

The comprehensive medical history documented at the initial prenatal visit must
at least address the following:

Return Prenatal Visits

The interval history includes:

 

12520 Physical Assessments

Revision 19-0; Effective July 1, 2019

 

All initial and routine prenatal visits must include an appropriate physical exam according to the purpose of visit and week of gestation. For any portion of the examination that is deferred, the reason(s) for deferral must be documented in the client health record.

Initial Prenatal Visit

Return Prenatal Visits

 

12530 Laboratory and Diagnostic Tests

Revision 19-0; Effective July 1, 2019

 

All initial and return prenatal visits must include appropriate laboratory and diagnostic tests, as indicated by weeks of gestation and clinical assessment. Contractors must have written plans to address laboratory and other diagnostic test orders, results and follow-up to include:

Initial Prenatal Visit Laboratory and Diagnostic Tests

Review CDC’s revised recommendations for HIV testing for adults and pregnant women:

 

12531 ACOG/ACS/ASCCP/ASCP Cervical Cancer Screening Guidelines 

Revision 19-0; Effective July 1, 2019

 

Women with special circumstances, who are considered high-risk [e.g. HIV positive, immunosuppressed or were exposed to Diethylstilbestrol (DES) in utero] may be screened more frequently as determined by the clinician.

Individuals already following a plan of care/algorithm may continue with that plan of care/algorithm until completed and they return to routine screening. Once the person returns to routine screening, follow the guidelines above.

 

12532 Return Prenatal Visits Laboratory and Diagnostic Tests

Revision 19-0; Effective July 1, 2019

 

 

12533 Ultrasounds

Revision 19-0; Effective July 1, 2019

 

Obstetrical ultrasounds will be reimbursed when clinically indicated, including the
following:

Complete ultrasound – A complete evaluation of the pregnant uterus, to include fetal number, viability, presentation, dating measurements, complete anatomical survey, placental localization characterizations and amniotic fluid assessment.

Complete ultrasound for confirmed multiple gestation – A complete evaluation of the pregnant uterus that includes viability, presentation, dating measurements, complete anatomical survey, placental localization characterizations and amniotic fluid assessment.

Follow-up or limited ultrasound – A brief, more limited evaluation of the pregnant uterus that may follow a previous complete exam, be it an initial exam prior to 12 weeks or an initial exam at 12 weeks which is limited in scope. It includes fetal number, viability, presentation, dating measurements, limited anatomic assessment, placental localization and characterization, and amniotic fluid assessment.

 

12534 Repeat D Antibody Test

Revision 19-0; Effective July 1, 2019

 

For all unsensitized D-negative women at 24 through 28 weeks of gestation, followed by the administration of a full dose of D immunoglobulin if they are antibody negative. If the father is known with certainty to be Rh D-negative, this may be deferred.

 

12535 Special Procedures

Revision 19-0; Effective July 1, 2019

 

Nonstress test (NST) – Fetal well-being assessment to be performed in the presence of identified risk factors, as indicated, once a viable gestational age has been reached. It may be billed as often as the provider deems the procedure to be medically necessary.

Biophysical Profile (BPP)/Fetal Biophysical Profile (FBPP) – Fetal well-being
assessment to be performed in the presence of identified risk factors, as indicated, once a viable gestational age has been reached. It may be billed as often as the provider deems the procedure to be medically necessary.

 

12540 Education and Counseling Services

Revision 19-0; Effective July 1, 2019

 

Contractors must have written plans for individual education that ensure consistency and accuracy of information provided, and that identify mechanisms used to ensure client understanding of the information.

Education and counseling must be:

Education and counseling during the initial prenatal visit, based on health history, risk assessment and physical exam, must cover the following:

Education and counseling during the return prenatal visits, should be appropriate to weeks’ gestation and be based on health history, risk assessment and physical exam, including but not limited to:

Tobacco Assessment and Quit Line Referral – All women receiving prenatal services should be assessed for tobacco use. Women who use tobacco should be referred to tobacco quit lines. The Texas American Cancer Society Quit Line is 877-YES-QUIT or 866-228-4327 (hearing impaired). The assessment and referral should be performed by agency staff and documented in the clinical record.

Information for Parents of Newborns Requirement Chapter 161, Health and Safety Code, Subchapter T, requires hospitals, birthing centers, physicians, nurse-midwives and midwives who provide prenatal care to pregnant women during gestation or at delivery, to provide the woman and the father of the infant, or other adult caregiver for the infant, with a resource pamphlet that includes information on postpartum depression, shaken baby syndrome, immunizations, newborn screening, pertussis and sudden infant death syndrome. In addition, it must be documented in the person's chart that she received this information and the documentation must be retained for a minimum of five years. It is recommended that the information be given twice, once at the first prenatal visit and again after delivery.

Information for Parents of Children Chapter 161, Health and Safety Code,
Subchapter T, also requires hospitals, birthing centers, physicians, nurse-midwives and midwives who provide prenatal care during gestation or at delivery to pregnant women on Medicaid, to provide the woman and the father of the infant, or other adult caregiver for the infant, with a resource guide that includes information relating to the development, health and safety of a child from birth until age five. The resource guide must provide information about medical home, dental care, effective parenting, child safety, importance of reading to a child, expected developmental milestones, health care and other resources available in the state, and selecting appropriate child care.

Provision of Information about Umbilical Cord Blood Donation Requirement Chapter 162, Health and Safety Code, Subtitle H, requires that a physician, or other person permitted by law to attend a pregnant woman during gestation or at delivery of an infant, shall provide the woman with an informational brochure before the third trimester of the woman’s pregnancy or as soon as reasonably feasible, that includes information about the uses, risks and benefits of cord blood stem cells for a potential recipient, options for future use or storage of cord blood, the medical process used to collect cord blood, any costs that may be incurred by a pregnant woman who chooses to donate or store cord blood after delivery and average cost of public and private storage. The brochure is available on the DSHS website or can be ordered from the DSHS literature warehouse. https://www.dshs.state.tx.us/pdf/umbilical_brochure_(2).pdf

Education and counseling during postpartum visits should include, but not be limited to:

 

12541 Referral and Follow-up

Revision 19-0; Effective July 1, 2019

 

Agencies must have written policies and procedures for follow-up on referrals that are made because of abnormal physical examination or laboratory test findings. These policies must be sensitive to patients’ concerns for confidentiality and privacy and must follow state or federal requirements for transfer of health information.

For services determined to be necessary, but which are beyond the scope of the agency, patients must be referred to other providers for care. (Whenever possible, patients should be given a choice of providers from which to select.) When a patient is referred to another provider, or for emergency clinical care, the agency must:

Section 13000, Program Promotion and Outreach

Revision 19-0; Effective July 1, 2019

 

 

Contractors must promote their FPP and provide outreach within the community to:

To help facilitate community awareness of and access to FPP services, contractors should establish and implement planned community activities to promote their programs.

Contractors should consider a variety of program promotion and 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 outreach activities, contractors must:

Within 45 days after the end of the contract period, contractors must submit an FPP Promotion/Outreach Annual Report to famplan@hhsc.state.tx.us.

Section 14000, Medicaid Provider Enrollment

Revision 19-0; Effective July 1, 2019

 

 

HHSC FPP contractors are required to enroll as Medicaid (Title XIX) providers with TMHP. The contractor must complete the required Medicaid provider enrollment application forms and enter into a written provider agreement with HHSC, the single state Medicaid agency. TMHP Provider Enrollment supplies these forms.

Family planning agencies are not required to enroll as a physician group, which includes an application for performing provider number. To enroll as a family planning agency, all that is required is a supervisory practitioner. The supervisory practitioner may be a physician or nurse practitioner and may be the same person for all clinic sites. Changes in supervisory practitioner must be reported in writing to TMHP. An application must be submitted for the new supervisory practitioner.

When enrolling as a Title XIX provider, Clinical Laboratory Improvement Amendments (CLIA) information must be provided. For public health agencies that provide limited numbers of tests, one CLIA certificate is all that is required for all clinics. 

 

14100 Provider Identifiers 

Revision 19-0; Effective July 1, 2019

 

When a contractor’s Medicaid application is approved, TMHP assigns the contractor a nine-digit Texas Provider Identifier (TPI). Contractors must have a unique TPI for each clinical service site.

Contractors must submit claims to TMHP using the billing TPI where clinical services are rendered. Contractors must not provide FPP services at one clinic site and bill those services to TMHP using the TPI of a different clinic site. If an additional TPI clinic site is required, providers must contact TMHP and complete the enrollment process.   

The TPI is used in conjunction with a National Provider Identifier (NPI) to identify the provider for claims processing. An NPI is a 10-digit number assigned randomly by the National Plan and Provider Numeration System (NPPES). Contractors may apply for an NPI at the NPPES website.

When a provider obtains their NPI, they are required to attest to NPI data for each of their current TPI. For more information on NPI and the attestation process, visit the TMHP website.

Texas Medicaid & Healthcare Partnership and Compass 21

HHSC FPP claims are submitted to TMHP. TMHP processes claims using Compass 21, an automated claims processing and reporting system. Claims are subject to the following procedures:

The Texas Medicaid Provider & Procedure Manual (TMPPM) includes information related to HHSC FPP claims submission such as:

In addition, Medicaid bulletins and R&S banner messages provide up-to-date claims filing and payment information. The R&S banner messages and the TMPPM are available on the TMHP website.

 

14200 Reimbursement for Family Planning Services

Revision 19-0; Effective July 1, 2019

 

Family planning contractors may seek reimbursement for project costs using one or two methods.

Contractors may designate up to 50% of their total award on a categorical cost reimbursement basis. The remaining portion of their award will be paid on a fee-for-service basis. Contractors may designate up to 100% of their total award on a fee-for-services basis.

 

14210 Categorical Reimbursement

Revision 19-0; Effective July 1, 2019

 

The categorical portion of the HHSC FPP funding is used to develop and maintain contractor infrastructure for the provision of family planning services. The funding can be used to support clinic facilities, staff salaries, utilities, medical and office supplies, equipment and travel, as well as direct medical services. Costs may be assessed against any of the following categories the contractor identifies during their budget development process:

Up to 50% of the HHSC FPP funds may be disbursed to contractors through a voucher system as expenses are incurred during the contract period. Program income must be expended before categorical funds are requested through the voucher process. Contractors must still submit vouchers monthly, even if program income equals or exceeds program expenses, or if the contract reimbursement limit has been met. When program expenses exceed program income, the monthly voucher will result in a payment. Program income includes all fees paid by the individuals and HHSC FPP fee-for-service reimbursements. 

To request reimbursement for the categorical contract, the following forms must be submitted by the last business day of the following month in which expenses were incurred or services provided:

The following forms must be submitted within 45 days following the end of the contract term:

 

14220 Fee-for-Service Reimbursement

Revision 19-0; Effective July 1, 2019

 

The fee-for-service component of the HHSC FPP funding pays for direct medical services on a fee-for-services basis. Up to 100% of HHSC FPP funds may be reimbursed on a fee-for-service basis. Each contracting agency is responsible for determining an individual’s eligibility for clinical services. The HHSC FPP reimburses contractors on a fee-for-service basis for services and supplies that have been provided to eligible individuals. HHSC FPP contractors must continue to provide services to established individuals and to submit and appeal claims for individual services even after the contract funding limit has been met.

All contractors are required to submit claims for all HHSC FPP services to TMHP, using the 2017 Claim form found on the TMHP website. The Texas Medicaid Provider Procedures Manual (TMPPM) provides detailed instructions of how to complete the form, including required and optional fields.

Effective May 1, 2017, FPP providers can submit professional claims electronically using a modified CMS-1500 electronic claim form.

HHSC FPP claims or appeals must be filed within certain time frames:

HHSC FPP contractors may contact the TMHP Contact Center from 7 a.m. to 7 p.m. (CST), Monday through Friday at 800-925-9126 for questions about claims and payment status.

 

14300 HHSC FPP Reimbursable Codes

Revision 19-0; Effective July 1, 2019

 

HHSC FPP reimbursement is limited to a prescribed set of procedure codes approved by HHSC. For a complete list of valid HHSC FPP procedures, see Appendix I, Reimbursable Codes.

HHSC FPP contractors may submit claims for individuals’ office visits that reflect different levels of service for new and established individuals. A new individual is defined as one who has not received clinical services at the contractor’s clinic(s) 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 (E/M)].

 

14310 Medroxyprogesterone Acetate Injection

Revision 19-0; Effective July 1, 2019

 

Providers may not bill a lower complexity office visit code (99211/99212) when the primary purpose is for the individual to receive an injection of Medroxyprogesterone acetate (Depo-Provera/DMPA/depo) injection. Rather, contractors should bill the injection fee (96372) with the Depo-Provera contraceptive method (J1050).

 

14400 Electronic Claims Submission

Revision 19-0; Effective July 1, 2019

 

All HHSC FPP contractors are strongly encouraged to submit claims electronically. TMHP offers specifications for electronic claims formats. These specifications are available from the TMHP Provider Portal and relate the paper claim instruction to the electronic format. Contractors may use their own claims filing system, vendor software or TexMedConnect (a free web-based claims submission tool available through the TMHP website) for submission of electronic claims. For more information concerning electronic claims submission, contractors may contact the TMHP Electronic Data Interchange (EDI) Help Desk at 512-514-4150 or 888-863-3638. Additional information may be found on the TMHP website.

 

14410 HTW Claims Pending Eligibility Determination

Revision 19-0; Effective July 1, 2019

 

To verify an applicant’s Healthy Texas Women (HTW) eligibility:

Contractors must hold claims up to 45 calendar days for individuals who have applied to HTW. If an individual’s HTW eligibility has not been determined after 45 calendar days, the contractor may bill the service to the HHSC FPP if the individual has a current HHSC FPP eligibility form on file. The contractor can file an HHSC FPP claim before the 45-day waiting period if a copy of the HTW program denial letter is in the individual’s record before filing the claim. 

 

14500 Sterilization Billing and Reporting

Revision 19-0; Effective July 1, 2019

 

HHSC FPP contractors can receive reimbursement for vasectomy or tubal ligation/occlusion sterilization procedures as part of their family planning services. The individual may not be billed for any cost above the reimbursement rates. Individual co-pays for sterilizations must follow the contractor’s established co-pay policy and may not exceed the allowable amount.

Contractors shall expend no more than 15% of their combined HHSC fee-for-service and HHSC categorical contract amounts on female sterilizations. An exemption may be granted to this policy on a case-by-case basis. Contact famplan@hhsc.state.tx.us for more information.

Allowable sterilization codes and descriptions are presented in Appendix I, Reimbursable Codes.

Conditions for Sterilization Procedures

Individuals receiving a vasectomy or tubal ligation/occlusion sterilization procedure must:

Waiting Period

The consent for sterilization is valid for 180 days from the date of the individual’s signature. 

 

14510 Sterilization Consent Form                                                         

Revision 19-0; Effective July 1, 2019

 

The Texas Medicaid Provider Procedures Manual (TMPPM) provides both an English and Spanish version of the Sterilization Consent form to be used by HHSC FPP contractors. The form may be copied for use and contractors are encouraged to frequently re-copy the original form to ensure legible copies and to expedite consent validation. The TMPPM also includes detailed instructions for the completion of the Sterilization Consent form. It is important that contractors use the most recent Sterilization Consent form available. Additionally, it is the contractor’s responsibility to ensure that the form is complete and accurate prior to submission to TMHP. For more information regarding the Sterilization Consent form and instructions, see Section 11210, Sterilization Procedures and Consent Form.

 

14520 Sterilization Complications

Revision 19-0; Effective July 1, 2019

 

Contractors may request reimbursement for costs associated with patient complications related to sterilization procedures. Contractors may be reimbursed for approved charges up to $1,000 per occurrence. To request reimbursement, contractors should provide the HHSC FPP with the following information:

 

14600 IUD and Contraceptive Implant Complications

Revision 19-0; Effective July 1, 2019

 

Contractors may request reimbursement for costs associated with patient complications related to IUD or contraceptive implant insertions or removals. Contractors may be reimbursed for approved charges up to $1,000 per occurrence. To request reimbursement, contractors should provide the HHSC FPP with the following information:

 

14700 Retroactive Eligibility

Revision 19-0; Effective July 1, 2019

 

Title XIX Retroactive Eligibility

Retroactive eligibility occurs when an individual has applied for Medicaid coverage but has not yet been assigned a Medicaid individual number at the time of service. Individuals who are eligible for Title XIX (Medicaid) medical assistance receive three months prior eligibility to cover any medical expenses incurred during that period. 

HHSC FPP Retroactive Eligibility

Any co-pay collected from an individual found to be eligible retroactively for Medicaid must be refunded to the individual. If a claim has been paid and later the individual receives retroactive Title XIX (Medicaid) eligibility, TMHP recoups/adjusts the funds paid from the HHSC FPP and processes the claim as Title XIX. An HHSC FPP accounts receivable (A/R) is then established for the adjusted claim. 

Note: Contractors are responsible for paying HHSC back the amount of any HHSC FPP A/R balance that may remain at the end of a state fiscal year.

The contractor’s HHSC FPP R&S Report(s) will reflect the retroactive Title XIX adjustment with EOB message “Recoupment is due to Title XIX retro eligibility.”

Assistance on reconciling R&S reports may be provided through the TMHP Contact Center from 7 a.m. to 7 p.m. CST, Monday through Friday at 800-925-9126. A TMHP Provider Relations representative is also available for these specific questions, as a representative can be located by region on the TMHP website.

Performing Provider Number and Retroactive Eligibility

HHSC family planning claims do not require a performing provider number for reimbursement. However, if a Title XIX retroactive eligibility claim does not have a performing provider number in a TPI format, TMHP will deny the services. A common EOB message for this specific denial is “EOB 00118: Service(s) require performing provider name/number for payment.” A request for reconsideration of claim reimbursement may be sent to TMHP through the appeal methods.

Note: The performing provider number requirement applies to all Title XIX submissions.

 

14800 Claims Submitted with Laboratory Services

Revision 19-0; Effective July 1, 2019

 

If a Title XIX retroactive eligibility claim includes laboratory services and the HHSC FPP contractor is not CLIA certified for the date of service on the claim, TMHP will deny the laboratory services. The Title XIX R&S report will reflect EOB 00488 message: “Our records indicate that there is not a CLIA number on file for this provider number or the CLIA is not valid for the dates of services on the claim.” 

When this occurs, the laboratory that performed the procedure(s) is responsible for refiling laboratory charges with TMHP to receive Title XIX reimbursement. For claims past the 95-day filing deadline, the laboratory will be required to follow their Medicaid appeals process. Contractors must make arrangements with their contracted laboratory to recoup any funds paid to the laboratory for lab services for HHSC FPP individuals prior to Title XIX retro eligibility determination.

 

14810 Patient Co-pays

Revision 19-0; Effective July 1, 2019

 

Title XIX does not allow providers to collect co-pays. HHSC FPP contractors must refund any co-pay collected if the individual services were billed to Title XIX.

Also see Section 10400, Client Fees, Co-pays and Guidelines.

Note: Contractors who have expended their awarded funds must continue to serve their existing eligible individuals and submit fee-for-service claims for services provided. It is allowable to obtain other funding to pay for these services, as well as continue to charge co-pay, per policy. This funding should be recorded as program income for the FPP contract. 

 

14900 Donations

Revision 19-0; Effective July 1, 2019

 

Voluntary donations from individuals are permissible. However, individuals must not be pressured to make donations and donations must not be a prerequisite to the provision of services or supplies. Donations are considered program income per specification of contract general provisions. All donations must be documented by source, amount and date they were received by the contractor. Contractors must have a written policy on the collection of donations. Individual donations collected by the contractor must be utilized to support the delivery of family planning services.

Section 15000, Required Reports

Revision 19-0; Effective July 1, 2019

 

 

Financial Reporting

Voucher and Report Submission – Categorical

Program Information:

Program Name: HHSC FPP

Contract Type: Categorical

Contract Term: July 1 thru August 31

Voucher:

Voucher Name: Form 4116, State of Texas Purchase Voucher.

Submission Date: By the last business day of the month following the month in which expenses were incurred or services provided. Final voucher due within 45 days after end of the contract term.

Submit Copy to:

Name of Area Original Signature Required Accepted Method of Submission No. of Copies
  Yes No  

Women’s Health & Educational Services Mailbox:

X Email 1

WHSFinance@hhsc.state.tx.us

 

Instructions: Attach B-13X to Voucher Form 4116.

Note: Vouchers must be submitted each month even if there are zero expenditures. Vouchers must still be submitted each month for actual expenditures of the program even if the contract limit has been reached. 

Voucher Supporting Document:

Report Name: Supporting Schedule for Family Planning Reimbursement Vouchers Form B-13X in Excel format.

Submission Date: By the last business day of the month following the month in which expenses were incurred or services provided. Final B-13X due within 45 days after end of the contract term.

Submit Copy to:

Name of Area Original Signature Required Accepted Method of Submission No. of Copies
  Yes No  

Women’s Health & Educational Services Mailbox:

X Email 1

WHSFinance@hhsc.state.tx.us

 

Instructions: Attach B-13X to Form 4116.

Financial Report:  Financial Status Quarterly Report

Report Name: Financial Status Report Form 269A

Submission Date: Reports are due as follows: Quarter 1: September through November; Quarter 2: December through February; Quarter 3: March through May; Quarter 4: June through August. Submit 30 days after the end of each quarter. The final quarterly FSR is due 45 days after the end of the contract term. The final quarter report includes all final charges and expenses associated with the program contract. Mark it as "Final."

Submit Copy to:

Name of Area Original Signature Required Accepted Method of Submission No. of Copies
  Yes No  

Women’s Health & Educational Services Mailbox:

X   Email 1

WHSFinance@hhsc.state.tx.us

 

Instructions: Form 269A must have an original signature (scanned email or fax accepted).   

Financial Report:  Fee-for-Service Report        

Program Information:

Program Name: HHSC FPP

Contract Type: Fee-for-Service (File Furnished Voucher through TMHP TexMed Connect/Compass 21)

Contract Term: September 1 through August 31

Fee-For-Service Claims Submission Information:

2017 Claim Form: File Furnished Voucher through TMHP TexMed Connect/Compass 21

Claims Filing Deadline: Within 95 days from date of service or date of third-party insurance EOB form. Within 45 days after the end of the contract term.

Claims Submission Entity: Texas Medicaid Healthcare Partnership/Compass 21

Notes: Claims must continue to be submitted to TMHP TexMed Connect/Compass 21 even if the contract limit has been reached.

Appeals must be submitted within 120 days of rejection during the contract term.

All appeals must be submitted and finalized within 45 days after the end of the contract term.

Report Name: Financial Reconciliation Report (FRR)

Submission Date: No later than 60 days after the end of the contract term.

Submit Copy to:

Name of Area Original Signature Required Accepted Method of Submission No. of Copies
  Yes No  

Women’s Health & Educational Services Mailbox:

X   Email, scan, or fax 1

WHSFinance@hhsc.state.tx.us

 

Instructions: FRR form does require a signature (scanned or fax accepted).  FRR only necessary if contractor only has fee for service component without cost reimbursement component. 

Financial Status Reports (FSRs) for Categorical Family Planning Contracts

The HHSC FPP operates using the FFS award, categorical award and anticipated co-pays to be collected as the total budget. All revenue directly generated by, or earned because of, the project (co-pays), along with FFS reimbursement is considered program income on the quarterly FSRs. FPP contractors with categorical funding are required to identify and report receipt and expenditure of co-pays and FFS payments quarterly and annually on the FSR Form 269A. See quarters for categorical FSR submission below. Program income (co-pays and FFS payments), must be expended prior to receiving reimbursement for program costs. 

The quarterly reports are due by the last business day of the month following the end of each quarter of the contract term. The final FSR, Form 269A, is due within 45 days after the end of the contract term, unless stipulated differently in the contract attachment following the end of the contract term. HHSC reserves the right to base funding levels, in part, upon the contractor’s proficiency in identifying, billing, collecting and reporting income, and in utilizing it for the delivery of family planning services.

Quarters for Categorical FSR submission:

Quarter 1: September through November
Quarter 2: December through February
Quarter 3: March through May
Quarter 4: June through August

FPP Categorical Budget Revisions

Contractors are not required to obtain approval from HHSC for cumulative budget transfers up to 10% of their total FPP categorical direct budget, except for the equipment category. Transfer to or from the equipment category requires prior approval from HHSC.

Contractors must obtain prior approval from HHSC for cumulative budget transfers that exceed 10% of their total FPP categorical direct budget.

Contractors are required to submit a revised budget to HHSC for review anytime a budget revision is made.

Programmatic Reporting

The FPP Promotion/Outreach Annual Report must be sent to: famplan@hhsc.state.tx.us. The report is due within 45 days after the end of the contract period (October 15).

Appendices

Appendix I, Reimbursable Codes

Revision 19-0; Effective July 1, 2019

 

 

Evaluation and Management  
99201 Office Visit. New Individual. Problem focused history/exam. Straightforward decision-making.
99202 Office Visit. New Individual. Expanded problem focused history/exam. Straightforward medical decision-making.
99203 Office Visit. New Individual. Detailed history/exam. Low complexity decision-making.
99204 Office Visit. New Individual. Comprehensive history/exam. Moderate complexity decision-making.
99205 Office Visit. New Individual. Comprehensive history/exam. High complexity decision-making.
99211 Office Visit. Established Individual. Minor problem focus. Straightforward decision-making.
99212 Office Visit. Established Individual. Problem focused history/exam. Straightforward decision-making.
99213 Office Visit. Established Individual. Expanded problem focused history/exam. Low complexity decision-making.
99214 Office Visit. Established Individual. Detailed history/exam. Moderate complexity decision-making.
99215 Office Visit. Established Individual. Comprehensive history/exam. High complexity decision-making.
99241 Office Consultation. New or Established Individual. Problem focused history/exam. Straightforward decision-making.
99242 Office Consultation. New or Established Individual. Expanded problem focused history/exam. Straightforward decision-making.
99243 Office Consultation. New or Established Individual. Detailed history/exam. Low complexity decision-making.
99244 Office Consultation. New or Established Individual. Comprehensive history/exam. Moderate complexity decision-making.
99384 Preventive Visit. New Individual. Age 12 – 17.
99385 Preventive Visit. New Individual. Age 18 – 39.
99386 Preventive Visit. New Individual. Age 40 – 64.
99394 Preventive Visit. Established Individual. Age 12 – 17.
99395 Preventive Visit. Established Individual. Age 18 – 39.
99396 Preventive Visit. Established Individual. Age 40 – 64.
59430 Postpartum visit
Radiology  
71010 Chest x-ray one view frontal
71020 Chest x-ray two view frontal and lateral
73060 Radiologic examination x-ray, humerus, minimum of two views
74000 X-ray, abdomen, single a/p view
74010 X-ray, abdomen, a/p and additional views
74740 Hysterosalpingogram
76098 Radiological exam, surgical specimen
76641 Ultrasound, complete examination of breast including axilla, unilateral
76642 Ultrasound, limited examination of the breast including axilla, unilateral
76700 US exam, abdominal, complete
76705 US exam, abdominal, limited
76770 US exam abdominal back wall, comp
76801 OB US less than 14 weeks, single fetus
76802 OB US less than 14 weeks, additional fetus
76805 Ultrasound pregnant uterus, greater than or equal to 14 weeks’ gestation, single or first gestation
76810 US exam, pregnant uterus, multiple gestation
76811 OB US, detailed, single fetus
76813 OB US, nuchal measure, one gestation
76815 Ultrasound of pregnant uterus, limited
76816 Ultrasound of pregnant uterus as follow-up of abnormal previous scan
76817 Transvaginal US, obstetric
76818 Fetal biophysical profile with W/NST
76819 Fetal biophysical profile with/out NST
76820 Umbilical artery echo
59025 Fetal non-stress test
76830 Ultrasound, transvaginal
76856 Ultrasound, pelvic, non-obstetric
76857 Ultrasound, pelvic, non-obstetric, limited or follow-up
76881 Ultrasound, extremity, nonvascular, real-time with image documentation, complete
76882 Ultrasound, extremity, nonvascular, real-time with image documentation, limited, anatomic specific
76942 Echo guide for biopsy
76998 Ultrasound guidance, intraoperative
77051 Computer dx mammogram add-on
77053 Mammary ductogram or galactogram, single duct, global fee
77065 Mammogram, one breast
77066 Mammogram, both breasts
77067 Mammogram, screening, appropriate for male and female
77058 Magnetic resonance imaging, breast, with and/or without contrast, unilateral, global fee
77059 Magnetic resonance imaging, breast, with and/or without contrast, bilateral, global fee
G0202 Screening Mammography digital
G0204 Diagnostic mammography, (producing direct 2-d digital image, bilateral, all views)
G0206 Diagnostic mammography, (producing direct 2-d digital image, unilateral, all views)
Medications, Immunizations and Vaccines  
90460 IM admin first/only component
90471 Immunization admin
90472 Immunization admin, any route, each additional vaccine (single or combination)
90632 Hep A vaccine, adult, IM
90633 Hep A vaccine, ped/adol, 2 dose, IM
90636 Hep A/Hep B vaccine, adult, IM
90649 HPV vaccine 4 valent, IM
90650 HPV vaccine 2 valent, IM
90651 HPV vaccine 9 valent, IM
90654 Flu vaccine, split virus, preservative-free, for intradermal use
90656 Flu vaccine no preservative 3 years and older
90658 Flu vaccine 3 years and older, IM
90660 Flu vaccine, live, no preservative, trivalent, IM
90670 Pneumococcal vaccine, 13 Val IM
90673 Flu vaccine, no preservative, trivalent, IM
90686 Flu vaccine, no preservative, quadrivalent, 3 years and older
90688 Flu vaccine, quadrivalent, split virus
90707 MMR vaccine, live, SC
90710 MMRV vaccine, live, SC
90714 Td vaccine, no preservative, age 7 and older, IM
90715 Tdap vaccine, age 7 and older, IM
90716 Chicken pox vaccine, IM
90723 Diphtheria, pertussis, tetanus, Hepatitis B, IMPV
90732 Pneumococcal vaccine, SC or IM
90733 Meningococcal vaccine, SC
90734 Meningococcal vaccine, IM
90736 Zoster vaccine, SC
90743 Hep B vaccine, adolescent, 2 dose, IM
90744 Hep B vaccine, birth – 19 years, 3 dose, IM
90746 Hep B vaccine, 20+ years, 3 dose, IM
96372 Non-neoplastic hormonal therapy injection
A9150 Non-Rx drugs
J0558 Penicillin G benzathine/procaine injection
J0561 Penicillin G benzathine injection
J0690 Cefazolin sodium injection
J0696 Ceftriaxone sodium injection
J0702 Betamethasone sodium phosphate and acetate
J1100 Dexamethasone sodium phosphate
J1725 Hydroxyprogesterone caproate injection
J2010 Lincomycin injection
J2790 Rho D immune globulin injection
J3490 Injection Medication for STD or G/U infection
S5000 Oral prescription medication, generic
Contraceptive Method  
H1010 Instruction, NFP
A4261 Cervical cap
A4266 Diaphragm
A4267 Condom, male, each
A4268 Condom, female, each
A4269 Spermicide (e.g., foam, gel) each, six suppositories or film are quantity of one
S4993 Oral contraceptive pills, one cycle
J7297 Lilleta IUD (52mg levonorgestrel-releasing intrauterine contraceptive)
J7298 Mirena IUD (52mg levonorgestrel-releasing intrauterine contraceptive)
Q9984 Kyleena IUD (19.5 mg levonorgestrel -releasing intrauterine contraceptive)
J7300 Copper intrauterine contraceptive
J7301 Skyla IUD (13.5 mg levonorgestrol intrauterine contraceptive)
J7303 Vaginal ring, each
J7304 Contraceptive patch, each
J7307 Implantable contraceptive capsule
Contraceptive Method-Related Services  
57170 Diaphragm or cervical cap fitting with instructions
58300 Insertion of intrauterine device
58301 Removal of intrauterine device
11982 Removal nonbiodegradable drug delivery implant
11983 Removal with reinsertion, nonbiodegradable drug delivery implant
58562 Hysteroscopy, surgical; with removal of impacted foreign body
J1050 Medroxyprogesterone acetate for contraceptive use, injection
96372 Injection fee, Medroxyprogesterone acetate
11976 Removal, implantable contraceptive
11981 Nonbiodegradable drug delivery implant insertion
Counseling and Education  
90791 Psychiatric diagnostic interview without medical services
90792 Psychiatric diagnostic interview for provider of medical services
97802 Medical nutrition therapy, initial assessment, individual, face to face, every 15 minutes
97803 Medical nutrition therapy, reassessment, individual, face to face, every 15 minutes
97804 Medical nutrition therapy, group (two or more), every 30 minutes
99078 Group health education
99406 Behavior change, smoking 3-10 minutes
99407 Behavior change, smoking greater than 10 minutes
Pathology and Laboratory  
80061 Lipid profile with cholesterol
80300 Drug screen, qualitative/multiple
80301 Drug screen, single
81000 Urinalysis, by dipstick or tablet, nonautomated, with microscopy
81001 Urinalysis, by dipstick or tablet, automated, with microscopy
81002 Urinalysis, dipstick or tablet, nonautomated, without microscopy
81003 Urinalysis, by dipstick or tablet, automated, without microscopy
81005 Urinalysis, qualitative or semiquantitative
81015 Urinalysis, microscopic only
81025 Urine pregnancy test, visual comparison methods
82947 Glucose, blood, except reagent strip
82948 Glucose, blood, reagent strip
83036 Hemoglobin A1c
84443 Thyroid stimulating hormone
84702 Chorionic gonadotropin, quantitative (pregnancy test)
84703 Chorionic gonadotropin, qualitative (pregnancy test)
85013 Microhematocrit, spun
85014 Hematocrit
85018 Hemoglobin
85025 CBC with differential, automated
85027 CBC, automated
86318 Immunoassay, infection agent
86580 Tb skin test, intradermal
86592 Syphilis
86689 HTLV/HIV confirmatory test
86695 Herpes simplex, type 1
86696 Herpes simplex, type 2
86701 HIV-1 antibody
86702 HIV-2 antibody
86703 HIV-1 and HIV-2, single assay
86762 Rubella antibody
86803 Hepatitis C antibody
86900 Blood typing, ABO
86901 Blood typing, Rh
87070 Culture, bacterial; any source other than blood or stool; with presumptive identification of isolates
87086 Urine culture, bacterial, quantitative
87088 Urine culture, bacterial, with presumptive identification of isolates
87102 Culture, fungi, with presumptive identification of isolates, source other than blood, skin, hair or nail
87110 Chlamydia culture
87205 Smear with interpretation, routine stain for bacteria, fungi or cell types
87210 Wet mount for infectious agents (e.g., saline, India ink, KOH preps)
87220 Tissue examination by KOH slide of samples from skin, hair or nails for fungi, ectoparasite ova, mites
87252 Virus isolation, tissue culture inoculation and presumptive identification (herpes)
87389 HIV-1 AG w/ HIV-1 & HIV 2 AB
87480 Candida species, direct probe technique
87490 Chlamydia, direct probe technique
87491 Chlamydia, amplified probe technique
87510 Gardnerella vaginalis, direct probe technique
87535 HIV-1 probe and reverse transcription
87590 Gonorrhea, direct probe technique
87591 Gonorrhea, amplified probe technique
87624 HPV, high-risk types
87625 HPV, types 16 and 18 only
87660 Trichomonas vaginalis, direct probe technique
87797 Infectious agent, NOS, direct probe
87800 Infectious agent, multiple organisms, direct probe technique
87801 Infectious agent, multiple organisms, amplified probe technique
87810 Chlamydia, immunoassay with direct optical observation
87850 Gonorrhea, immunoassay with direct optical observation
88142 Cytopathology, cervical/vaginal, liquid based, automated
88150 Cytopathology, cervical/vaginal, slides, manual
88164 Cytopathology, cervical/vaginal, slides, manual, the Bethesda System
88175 Cytopathology, cervical/vaginal, any reporting system, fluid based, automated screening with manual rescreening or review.
80048 Basic metabolic panel
80053 Comprehensive metabolic panel
85730 Thromboplastin time, partial
88305 Tissue exam by pathologist
88307 Tissue exam by pathologist
93000 Electrocardiogram, complete
88141 Cytopath, cervical or vaginal (C/V), interpret
88143 Cytopath, C/V thin layer, redo
88173 Cytopath evaluation, FNA, report
88174 Cytopath, C/V auto, in fluid
80050 General health panel
80051 Electrolyte panel
80053 Comprehensive metabolic panel
80069 Renal function panel
80074 Acute hepatitis panel
80076 Hepatic function panel
82270 Occult blood, feces
82465 Total cholesterol
82950 Glucose test
83020 Hemoglobin electrophoresis
83021 Hemoglobin chromatography
83036 Glycosylated hemoglobin test
84450 Transferase (AST) (SGOT)
84460 Alanine amino (ALT) (SGPT)
84478 Assay of Triglycerides
84479 Assay of thyroid (T3 or T4)
85007 Differential WBC count
85610 Prothrombin time (PT)
85660 RBC sickle cell test
85730 Thromboplastin time, partial (PTT)
86631 Chlamydia trachomatis, immunofluorescent technique
86677 Helicobacter pylori antibody
86704 Hepatitis B core antibody, total
86706 Hepatitis B surface antibody
86780 Treponema pallidum
86885 Coombs test, indirect, qualitative
87270 Chlamydia trachomatis, immunofluorescent technique
87512 Gardnerella vaginalis, quantification
87529 HSV, DNA, amplified probe
87530 HSV, DNA, quantitative
87661 Trichomonas vaginalis, amplified
88155 Cytopath, C/V, index add-on
88160 Cytopath smear, other source
88161 Cytopath smear, other source
88165 Cyopath, bethesda system, w/manual screen/rescreen
88167 Cytopathology, Bethesda system, cervical/vaginal, select
88172 Cytopathology, evaluation of fine needle aspirate
80055 Obstetric panel
80300 Drug screen, single
82105 Alpha-fetoprotein, serum
82677 Estriol (UE3)
82951 Glucose tolerance test (GTT)
84436 T4
84479 Assay of thyroid (T3 or T4)
85384 Fibrinogen
85610 Prothrombin time
86336 Inhibin A
86777 Toxoplasmosis, IgG IFA
86778 Toxoplasmosis, IgM
86850 Blood, antibody screen
86900 Blood group type
86901 Rh type
87081 GBS culture
87184 Susceptibility test
87340 Hepatitis B surface antigen, by enzyme immunoassay
94760 Non-invasive pulse oximetry for oxygen saturation
99000 Specimen handling or conveyance
Anesthesia  
00851 Anesthesia for sterilization, lower abdomen
00400 Anesthesia for procedures on the integumentary system, anterior trunk
00940 Anesthesia for vaginal procedures (including biopsy of cervix), NOS
Surgical Procedures  
55250 Male sterilization, vasectomy
58340 Catheter for hysterography
58565 Female sterilization, hysteroscopy with bilateral fallopian tube cannulation and placement of permanent implants to occlude the fallopian tubes
58600 Female sterilization, fallopian tube transection, blocking or other procedure
58611 Female sterilization, fallopian tube transection performed at time of cesarean delivery
58615 Female sterilization, occlusion of fallopian tubes by device, vaginal approach
58670 Female sterilization, laparoscopy with fulguration of oviducts
58671 Female sterilization, laparoscopy with occlusion of oviducts by device
10022 FNA with image
19000 Drainage of breast lesion
19081 Breast biopsy first lesion, includes stereotactic guidance
19082 Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous, stereotactic guidance, each additional lesion
19083 Breast biopsy, first lesion, US imaging
19084 Breast biopsy, with placement of localization device and imaging of biopsy specimen, percutaneous, US guidance, each additional lesion
19100 Breast biopsy, percutaneous, needle core, not using imaging guidance, one or more lesion
19101 Incisional breast biopsy, one or more lesions
19120 Removal of breast lesion
19125 Excision of abnormal breast tissue, duct, nipple or areolar lesion, single lesion; identified by preoperative placement of radiological marker (physician in facility)
19126 Excision of abnormal breast tissue, duct, nipple or areolar lesion, each additional lesion (physician in facility)
19281 Preoperative placement of breast localization device, percutaneous: mammographic guidance, first lesion (physician in office)
19282 Preoperative placement of breast localization device, percutaneous: mammographic guidance, each additional lesion (physician in office)
19283 Preoperative placement of breast localization device, percutaneous: stereotactic guidance, first lesion (physician in office)
19284 Preoperative placement of breast localization device, percutaneous: stereotactic guidance, each additional lesion (physician in office)
19285 Preoperative placement of breast localization device, percutaneous: ultrasound guidance, first lesion (physician in office)
19286 Preoperative placement of breast localization device, percutaneous: ultrasound guidance, each additional lesion (physician in office)
56405 I & D of vulva/perineum
56420 Drainage of gland abscess
56501 Destroy, vulva lesions, simple
56515 Destroy vulva lesions, complex
56605 Biopsy of vulva/perineum
56606 Biopsy of vulva/perineum
56820 Exam of vulva w/scope
57023 I & D vaginal hematoma, non-ob
57061 Destroy vaginal lesions, simple
57100 Biopsy of vagina
57421 Exam/biopsy of vagina w/scope
57511 Cryocautery of cervix
58100 Biopsy of uterine lining
Cervical Cancer Screening Services  
57452 Examination of vagina – colposcopy
57454 Vagina examination and biopsy
57455 Biopsy of cervix with scope
57456 Endocervical curettage with scope
57460 Cervix excision
57461 Conization of cervix with scope, leep
57500 Biopsy of cervix
57505 Endocervical curettage
57520 Conization of cervix, cold knife or laser
57522 Conization of cervix, leep
58110 Biopsy done w/colposcopy add-on
Supplies  
A4253 Blood glucose/reagent strips
A4258 Springload device for lancet
A4259 Lancets per box (100 count)
A4264 Intratubal occlusion device

Appendix II, Definition of Income

Revision 19-0; Effective July 1, 2019

 

 

Types of Income Countable Exempt
  Adoption Payments  
Cash Gifts and Contributions            
Child Support Payments  
Child's Earned Income  
Crime Victim's Compensation  
Disability Insurance Benefits  
Dividends, Interest and Royalties  
Educational Assistance  
Energy Assistance  
Foster Care Payment  
In-kind Income  
Job Training  
Loans (Noneducational)  
Lump-Sum Payments
Military Pay  
Mineral Rights  
Pensions and Annuities  
Reimbursements  
RSDI/Social Security Payments  
Self-Employment Income  
SSDI  
SSI Payments  
TANF  
Unemployment Compensation  
Veteran's Administration
Wages and Salaries, Commissions  
Workers’ Compensation  

A description of all types of countable income is provided below.

Cash Gifts and Contributions – Count unless they are made by a private, nonprofit organization based on need, and total $300 or less per household in a federal fiscal quarter. The federal fiscal quarters are January through March, April through June, July through September and October through December. If these contributions exceed $300 in a quarter, count the excess amount as income in the month received.

Exempt any cash contribution for common household expenses, such as food, rent, utilities and items for home maintenance, if it is received from a noncertified household member who:

  • lives in the home with the certified household member;
  • shares household expenses with the certified household member; and
  • does not have a landlord/tenant relationship.

Child Support Payments – Count income after deducting $75 from the total monthly child support payments the household receives.

Disability Insurance Payments/SSDI – Social Security Disability Insurance is a payroll tax-funded, federal insurance program of the Social Security Administration.

Dividends, Interest and Royalties – This income is countable with an exception:  Exempt dividends from insurance policies as income. Count royalties minus any amount deducted for production expenses and severance taxes.

Loans (Noneducational) – Count as income unless there is an understanding that the money will be repaid, and the person can reasonably explain how he or she will repay it.

Lump-Sum Payments – Count as income in the month received if the person receives it, or expects to receive it, more often than once a year. Exempt lump sums received once a year or less, unless specifically listed as income.

Military Pay – Count military pay and allowances for housing, food, base pay and flight pay, minus pay withheld to fund education under the G.I. Bill.

Mineral Rights – A payment received from the excavation of minerals such as oil, natural gas, coal, gold, copper, iron, limestone, gypsum, sand and gravel.

Pensions and Annuities – A pension is any benefit derived from former employment, such as retirement benefits or disability pensions.

Reimbursements – Countable, minus the actual expenses. Exempt a reimbursement for future expenses only if the household plans to use it as intended.

RSDI/Social Security Payments – Count the Retirement, Survivors and Disability Insurance (RSDI) benefit amount including the deduction for the Medicare premium, minus any amount that is being recouped for a prior RSDI overpayment.

Self-Employment Income – Count total gross earned, minus the allowable costs of producing the self-employment income.

Terminated Employment – Count terminated income in the month received. Use actual income and do not use conversion factors if terminated income is less than the income received in a full month. Income is terminated if it will not be received in the next usual payment cycle.

Unemployment Compensation Payments – Count the gross benefit less any amount being recouped for an Unemployment Insurance Benefit overpayment.

VA Payments – Count the gross Veterans Administration (VA) payment, minus any amount being recouped for a VA overpayment. Exempt VA special needs payments, such as annual clothing allowances or monthly payments for an attendant for disabled veterans.

Wages, Salaries, Tips and Commissions – Count the actual (not taxable) gross amount. 

Workers’ Compensation – Count the gross payment, minus any amount being recouped for a prior workers’ compensation overpayment or paid for attorney’s fees.  Note: The Texas Workforce Commission (TWC) or a court sets the amount of the attorney’s fee to be paid.

Forms

ES = Spanish version available.

Form Title  
4116 State of Texas Purchase Voucher  
H1867 Healthy Texas Women Program Application Form ES

Policy Revisions

20-1, Changes to Sections 10300 and 10400

Revision 20-1; Effective July 20, 2020

 

The following changes(s) were made:

Revised Title Change
10300 Calculation of Applicant’s Federal Poverty Level Percentage Updates links to federal poverty guidelines and information in the table.
10400 Client Fees, Co-pays and Guidelines Updates links to federal poverty guidelines.

 

19-0, Handbook Has New Format

Effective July 1, 2019

 

The Family Planning Program Policy Manual has a new improved format to guide contractors who deliver women’s health and family planning program services in Texas.

Contact Us

For questions about the Family Planning Program Policy Manual, email: famplan@hhsc.state.tx.us

For technical or accessibility issues with this handbook, email: Editorial_Services@hhsc.state.tx.us