Section 3000, Eligibility, Client Services, Community Activities and Clinical

Revision 20-1; Effective July 31, 2020

 

Section 3000 provides policy requirements for eligibility, client services, community activities and clinical guidelines.

 

3100 Client Eligibility

Revision 19-0; Effective September 1, 2019

 

 

 

3110 Eligibility Guidelines

Revision 19-0; Effective September 1, 2019

 

A female is eligible to receive services through HTW if she meets the following qualifications:

 

3120 Other Benefits

Revision 19-0; Effective September 1, 2019

 

In general, people are not eligible for HTW services if they are enrolled in another third-party payor such as private health insurance, Medicaid or Medicare, or other federal, state or local public health care coverage that provides the same services. People with third-party insurance may be eligible for services provided by HTW if client confidentiality is a concern.

 

3130 Applying for HTW

Revision 19-0; Effective September 1, 2019

 

A client may apply for HTW services by completing an application form and providing documentation as required by HHSC. A female age 15 to 17 must have a parent or legal guardian apply on her behalf.

An applicant may obtain an application in the following ways:

HHSC accepts and processes every application received through the following means:

Forms can be submitted by mail or by fax to:

Healthy Texas Women
P.O. Box 149021
Austin, TX 78714-9021
Fax (toll-free) 866-993-9971

HHSC processes an HTW application within 45 days of receiving the application. Program coverage begins on the first day of the month in which HHSC receives a valid application. A client is deemed eligible to receive covered services for 12 continuous months after her application is approved. Providers and community-based organizations can help women fill out and fax their applications to HHSC for processing.

Renewal – A female, or parent or legal guardian acting on the client’s behalf if she is age 15 through 17, inclusive, may renew HTW services by completing a renewal form and providing documentation as required by HHSC. An HTW client will be sent a renewal packet during the 10th month of her 12-month certification period for HTW.

HHSC accepts and processes every renewal form received through the following means:

Forms can be submitted by mail or by fax to:

Healthy Texas Women
P.O. Box 149021
Austin, TX 78714-9021
Fax (toll-free) 866-993-9971

 

Verifying HTW Eligibility

To verify that a woman is enrolled in HTW:

 

Referral to Other Programs

A female who is determined ineligible for HTW may be eligible for Medicaid or Family Planning Program services. If a female is determined ineligible for HTW, the contractor should refer her to other state programs that she might be eligible for.

 

3140 Determining HTW Presumptive Eligibility

Revision 19-0; Effective September 1, 2019

 

HTW emphasizes the importance of proper family planning and women’s health preventative care. The goal of HTW is for women to have access to women’s health services and not rely upon episodic acute care.

HTW cost reimbursement contractors must use a portion of their cost reimbursement funds to provide services for a limited time to a person who is determined to be presumptively eligible for HTW and has submitted an HTW application, but a final eligibility determination has not been made yet by HHSC. Presumptive eligibility is effective for 90 days from the date the client is first seen by the medical provider. The client shall be enrolled on a presumptive eligibility basis only once in a 12-month period.

Clients seen on presumptive eligibility will be captured in the contractor’s total client count only after a claim is paid. Clients seen on a presumptive basis and later determined ineligible for HTW will not be counted toward the contractor’s overall client count. These claims will deny and are subject to categorical fund reimbursement as requested on your monthly voucher. Contractors should be diligent when screening clients and providing presumptive services.

HHSC has developed a screening tool and an income worksheet to help providers screen for eligibility and identify acceptable forms of proof of citizenship, identity and income.

To verify citizenship:

To verify identity:

Documentation is not required for:

Documentation is not required during the presumptive eligibility screening process; however, documentation will be required once the client submits an HTW application.

Verification of household composition is self-declared. Household budget group is determined as follows:

 

3150 Adjunctive Eligibility

Revision 19-0; Effective September 1, 2019

 

An applicant is considered adjunctively (automatically) eligible for HTW Program services at a presumptive eligibility screening, if:

Acceptable eligibility verification documentation may include:

Program Documentation
WIC WIC verification of certification letter, printed WIC-approved shopping list or recent WIC purchase receipt with remaining balance
SNAP SNAP eligibility letter
TANF TANF verification certification letter

A woman may also prove income eligibility if someone in her household (such as a child) has Medicaid. Providers can verify Medicaid eligibility using TexMed Connect on the TMHP website.

 

3160 Calculation of Applicant’s Federal Poverty Level (FPL) Percentage

Revision 20-1; Effective July 31, 2020

 

The steps to determine the FPL percentage are:

  1. Determine the applicant’s household size;
  2. Determine the applicant’s total monthly income amount;
  3. Divide the applicant’s total monthly income amount by the maximum monthly income amount at 100 percent FPL for the appropriate household size; and
  4. Multiply by 100 percent.

The maximum monthly income amounts by household size are based on the U.S. 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

 

Monthly Income Limits for Healthy Texas Women

(Based on FY 2020 FPL Guideline)

Household Size Monthly Income
1 $2,127
2 $2,874
3 $3,620
4 $4,367
5 $5,114
6 $5,860
7 $6,607

 

3170 Date Eligibility Begins

Revision 19-0; Effective September 1, 2019

 

Program coverage begins on the first day of the month in which HHSC receives a valid application. For applicants age 18 through 44, inclusive, a valid application has, at a minimum, the applicant’s name, address and signature. For applicants age 15 through 17, inclusive, a valid application has, at a minimum, the applicant’s name, address and signature of a parent or legal guardian.

 

3180 Client Fees/Co-payments and Other Fees

Revision 19-0; Effective September 1, 2019

 

HTW contractors may not assess a co-payment (co-pay) for HTW services from HTW clients. No HTW client shall be denied services based on an inability to pay.

Clients shall not be charged administrative fees for items such as processing and/or transfer of medical records, copies of immunization records, etc. Contractors can bill clients for services outside the scope of HTW allowable services, if the service is provided at the client’s request, and the client is made aware of her responsibility for paying for the charges.

 

3190 Continuation of Services

Revision 19-0; Effective September 1, 2019

 

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

If other funding sources are used to provide HTW services, the funds must be reported as non-HHSC funds on the monthly internal Form 1811, Healthy Texas Women Supporting Schedule for Reimbursement Vouchers (previously Form B13-H), submitted with Form 4116, State of Texas Purchase Voucher, and the quarterly Financial Status Report (FSR or Form 269a).

 

3200 Consent

Revision 19-0; Effective September 1, 2019

 

 

 

3210 General Consent

Revision 19-0; Effective September 1, 2019

 

Contractors must obtain the client’s written, informed and voluntary general consent to receive services prior to receiving any clinical services. A general consent explains the types of services provided and how client 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 client 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 client in a manner that is understandable. This communication must allow the client to participate, make sound decisions regarding her own medical care, and address any disabilities that impair communication (in compliance with Limited English Proficiency (LEP) regulations). Only the client may give consent, except when the client is legally unable to consent, in which case a parent (i.e., in the case of an unemancipated minor) or court-appointed legal guardian must consent. Consent must never be obtained in a manner that could be perceived as coercive. A minor may only provide consent to medical treatment in specific situations outlined in the Texas Family Code, Chapter 32.   

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

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

 

3220 Procedure-Specific Informed Consent

Revision 19-0; Effective September 1, 2019

 

Sterilization Procedures

There are two consent forms required for sterilization procedures:

 

Sterilization Consent Form

The Sterilization Consent Form is a federally mandated consent form and is necessary for both abdominal and trans cervical sterilization procedures in women. It is provided in the Texas Medicaid Provider Procedures Manual (TMPPM) and is the only acceptable consent form for sterilizations funded by the HTW Program and Family Planning Program. Electronic copies of the Sterilization Consent Form (in English and Spanish) may be found on the TMHP website. In brief, the person to be sterilized must:

The Sterilization Consent Form must be signed and dated by the:

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

 

3230 Texas Medical Disclosure Panel Consent

Revision 19-0; Effective September 1, 2019

 

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

TMDP has developed a “List A” (informed consent requiring full and specific disclosure) for certain procedures, which can be found in the Texas Administrative Code (TAC).

Contractors that directly perform tubal sterilization (a “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 3220, Procedure-Specific Informed Consent.

The required disclosures for tubal sterilization are:

For all other procedures not listed on “List A,” the physician must disclose, through a procedure specific consent, all risks that a reasonable client would want to know. 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 whether to consent to the procedure).

 

3240 Consent for Services to Minors

Revision 19-0; Effective September 1, 2019

 

A parent or legal guardian must apply on the behalf of a minor age 15-17 for HTW services and provide documentation as required by HHSC. Minors age 15-17 are required to obtain consent from a parent, managing conservator or court appointed guardian before receiving HTW services as required by Texas Family Code, Chapter 151, and may consent to their own services only as authorized by Texas Family Code, Chapter 32, or by federal law or regulations. Proof of consent must be included in the minor client’s medical record.

Parental consent is not required for minors to receive pregnancy testing, HIV/STD testing, or treatment for an STD.

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:

 

3250 Consent for HIV Tests

Revision 19-0; Effective September 1, 2019

 

Texas Health and Safety Code, §81.105 and §81.106 are as follows:

§81.105, Informed Consent

§81.106, General Consent

 

3300 Clinical Policy

Revision 19-0; Effective September 1, 2019

 

This section describes the requirements and recommendations for HTW 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:

 

3310 Covered Services

Revision 19-0; Effective September 1, 2019

 

HTW seeks to promote the general and reproductive health of Texas women by providing safe and effective family planning and certain primary care services to women age 15 through 44 who meet program eligibility requirements.

The following services are covered under the HTW Program:

 

3311 Requirement for Documentation of Reproductive Health Services

Revision 19-0; Effective September 1, 2019

 

All patients must receive services related to reproductive health at least annually for covered services to remain reimbursable under the HTW Program. Patients 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 HTW Program is to improve the reproductive health of women to ensure that every pregnancy and every baby are healthy. At each patient encounter, including encounters for treatment of other conditions (e.g., diabetes, follow up of 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. Providers are encouraged to take the opportunity provided by each subsequent encounter to reinforce or build on the counseling provided in previous encounters.

Examples: The following are provided for illustration purposes only:

For a patient who has undergone sterilization, this counseling and documentation are not required when receiving covered services.  

 

3312 Client Health Record and Documentation of Patient Encounters

Revision 19-0; Effective September 1, 2019

 

Providers must ensure that a patient health record (medical record) is created for every client who obtains clinical services (also see Section 2400, Client Record Management).

All patient health records must be:

The client health record must include:

 

3313 Initial Clinical Visit

Revision 19-0; Effective September 1, 2019

 

At the initial clinical visit or an early subsequent visit, a comprehensive health history must be taken, to include the following (in addition to the elements required for the client health record in Section 3312, Client Health Record and Documentation of Patient Encounters):

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.

 

3314 Annual Comprehensive Family Planning Visit, Physical Examination and Testing

Revision 19-0; Effective September 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 Section 3312, Client Health Record and Documentation of Patient Encounters, as well as appropriate screening, assessment, counseling and immunizations based on the person’s age, risk factors, preferences and concerns.

All clients must undergo a physical examination annually as part of the family planning visit. This can be deferred to a later date if the patient’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 client record. Any breast or pelvic examination should be performed only with the consent of the patient. Clients 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 person declines any or all components of the examination.

It is recommended that the family planning visit include all of 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 patient notification, should be documented in the medical record as well as patient refusal or other reason for not testing or performing a specified part of the examination):

*Health care providers can voluntarily participate in DSHS Adult Safety Net (ASN) vaccine program, which provides vaccines at no cost.

 

3315 Counseling and Education

Revision 19-0; Effective September 1, 2019

 

All clients must receive accurate patient-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 patient education is to enable the client 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 age 17 and younger, to include the following, at a minimum:

Details of appropriate educational interventions are included in each subsection of Section 3300, Clinical Policy. In addition, links are provided to information of use to patients and educators at the end of most sections.

 

3316 Requirements for Policies to Ensure Appropriate Follow-up and Continuity of Care

Revision 19-0; Effective September 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 patient is considered lost to follow-up, the contractor must make at least three documented separate attempts to contact the patient, using an accelerated protocol, where subsequent attempts involve a more intensive effort to contact the patient. An example might be 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 circumstances of the population they serve and adapt their usual processes, as needed, based on their knowledge of the circumstances and preferences of the person they are attempting to contact.

 

3317 Problem Visits

Revision 19-0; Effective September 1, 2019

 

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

 

3318 Referrals

Revision 19-0; Effective September 1, 2019

 

When a client 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 patient regarding the purpose of the referral and answering any questions the patient has about the referral. Pertinent patient information and appropriate portions of the medical record must be provided to the referral clinician, and this 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.

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

 

3320 Prescriptive Authority Agreements

Revision 19-0; Effective September 1, 2019

 

When services are provided by advanced practice registered nurse(s) and/or physician assistant(s), it is the responsibility of the contractor to ensure that a properly executed prescriptive authority agreement (PAA), as required by Texas Administrative Code, Title 22, Part 9, Chapter 193, is in place for each such provider.  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 advanced practice registered nurse 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 advanced practice registered nurse or physician assistant provides care.

 

3321 Standing Delegation Orders

Revision 19-0; Effective September 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 a particular provider. 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 patients 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: SDO for assessment of blood pressure/blood sugar which includes an RN, LVN or NLHP who 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.

 

3322 References

Revision 19-0; Effective September 1, 2019

 

 

3330 Family Planning and Contraceptive Services

Revision 19-0; Effective September 1, 2019

 

Reproductive Life Plan

Providers should encourage all clients to develop a reproductive life plan, which is an outline of each person’s immediate and future plans for having children. Questions such as the following can be useful in helping clients to develop the plan:

Providers and clients should understand that such plans can change with time. Providers should take the client’s stated plan into account in counseling on contraceptive and family planning services.

 

Contraceptive Counseling and Education

At each encounter for services, clients 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 clients 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 client in the decision-making process, while addressing personal and cultural preferences, will improve client satisfaction and the likelihood that the selected method will be used correctly and consistently.

Step 1: Establish and maintain rapport with the client. Some ways to do this include:

 

Step 2: Obtain social and clinical information from the client to include the following:

Health history

 
Step 3: Work interactively with the client to choose the most appropriate contraceptive method.

 

Step 4: Perform a physical evaluation appropriate to the method chosen, when warranted. In most cases, no physical examination or laboratory testing is necessary prior to initiating a contraceptive method.

 
Step 5: Once a method of contraception is selected, the provider should provide counseling on correct and consistent use, assist the client to develop a plan for correct use and follow-up, and confirm the client’s understanding. Certain considerations may increase the likelihood of correct and consistent use.

 

Step 6: Finally, help the client develop a plan for correct and consistent use of the chosen method and provide a plan for follow-up.

 

Relative Method Effectiveness

The following contraceptive methods and services necessary to provide them are approved for reimbursement under HTW. Providers must make each method available either on-site or by referral. 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.  

 

Long-Acting Reversible Contraceptive (LARC) Methods  

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 clients who are candidates for their use. See the Long-Acting Reversible Contraception Program webpage 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.

 

Consent for Sterilization

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

Notes:  

 

References

 

Resource for Patients and Educators

 

Resource for Providers

 

3331 Preconception Services

Revision 19-0; Effective September 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 U.S. 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:

References

 

Resources for Patients and Providers

 

3340 Cervical Cancer Screening

Revision 19-0; Effective September 1, 2019

 

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

In this summary, guidelines from a variety of medical specialty organizations and U.S. government agencies were reviewed. Where 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 percent 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

 

Screening Frequency and Response to Abnormal Findings

 

Discontinuation of Screening

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

References

 

3341 Breast Cancer Screening

Revision 19-0; Effective September 1, 2019

 

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

 

Risk Screening and Patient Counseling

All patients must have an assessment of their risk for breast cancer, updated periodically, to include the patient’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 for identifying a patient’s five-year risk of developing breast cancer for women age 35 and older is available from the National Cancer Institute.

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

 

Screening Frequency

The following considerations* apply to women age 40 years and older who do not have a preexisting breast cancer or other high-risk breast lesion and who do not have a known underlying genetic mutation (such as a BRCA 1 or 2 mutations or other familial breast cancer syndrome) or a history of chest radiation at an early age.  

Note that the age ranges included in the statements below reflect the age ranges covered by HTW and may not include the full age ranges included in the guideline statements used as reference.  

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 (Sui, 2016). 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 the References section immediately below.

 

Follow-up and Referral for Treatment

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

For patients who require referral for services beyond those available through the contracted provider, contractors are encouraged whenever possible to refer to an HHSC Breast and Cervical Cancer Services 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 patients 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/services/health/medicaid-chip/programs-services/medicaid-breast-cervical-cancer-program-managed-care-expansion

References

 

Additional Reading

 

Information for Patients

 

Online Provider Resource

 

3342 Sexually Transmitted Disease/Infection (STD/STI) Screening and Treatment

Revision 19-0; Effective September 1, 2019

 

Screening and treatment of STD/STI 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 clients to determine what testing is indicated and documented in the medical record as well. The following is a brief overview of STD/STI screening recommendations (for more detailed information, go to the CDC screening link above).

 

HIV Screening

 

Chlamydia and Gonorrhea Testing

 

Herpes Simplex Virus (HSV) Screening

 

Syphilis Screening (non-pregnant women)

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

 

3343 Patient-Delivered Partner Therapy

Revision 19-0; Effective September 1, 2019

 

Patient-delivered partner therapy (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). An amendment to the Texas Administrative Code, Chapter 22, Section 190.8, [Texas Secretary of State], adopted in June 2009 by the Texas Medical Board, expressly allows PDPT. The exception created by this amendment acknowledges the serious impact of sexually transmitted diseases and the contribution of untreated partners to the reinfection of treated patients and exposure of others to infection. Providers are encouraged to implement PDPT by providing patients 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.

References

 

Resources for Patients and Providers:

 

3350 Healthy Lifestyle Intervention

Revision 19-0; Effective September 1, 2019

 

All clients 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

 

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 U.S. No single diet has been shown to be the best and providers should counsel clients on a variety of healthy eating patterns tailored to their health condition 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, and increased fiber, vegetables, fruits, fish, oils and nuts, while allowing wide freedom of food choices to accommodate eating preferences and cultural differences among people.

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 a client 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 patients 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 people, regardless of age, gender and ethnicity, including those with mild untreated hypertension.

 

Salt Intake

There is strong evidence that reducing sodium (salt) intake reduces blood pressure in people with normal blood pressure, as well as those with mild to moderate hypertension regardless of gender, ethnicity and age. This holds true even if no other dietary changes are made. Therefore, some people 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 clients should receive advice to limit their salt intake and 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 clients on dietary cholesterol intake specifically.

 

Physical Activity

Regular aerobic physical activity (e.g., walking, jogging, dancing, swimming, water-walking, gardening, climbing stairs, even housecleaning) 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. Clients 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 a setting and more sessions per week), for those whose health status permits, offer more benefit.

Reference

 

Information for Patients and Educators

 

3360 Diabetes Mellitus Screening, Prevention and Treatment

Revision 19-0; Effective September 1, 2019

 

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

 

Who Should be Screened for Diabetes

The screening criteria below apply to nonpregnant patients only.  

 

Risk Factors for diabetes

 

Diagnostic Criteria

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):

The following table summarizes the diagnostic criteria for diabetes mellitus.

Test Criteria to Diagnose Diabetes Mellitus Comments
Fasting plasma glucose >/= 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 >/= 200 mg/dL (11.1. mmol/L)  
Hemoglobin A1C >/= 6.5% (48 mmol/mol) For diagnosis of type I diabetes in patients with acute hyperglycemic symptoms, blood glucose testing is preferred.
Random plasma glucose >/= 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. Unless stated otherwise, all initial results should be confirmed with repeat testing.

 

Treatment Considerations

A thorough review of the management of Type 1 and Type 2 diabetes mellitus is beyond the scope of this manual. The reader is referred to the references at the end of this section and relevant textbooks for a more detailed discussion.

Diabetes care should be patient-centered, team-oriented and individualized, and should take the patient’s social and cultural background and preferences into account. The foundations of diabetes care include:

 

Evaluation of the Diabetic Patient

A comprehensive evaluation of the patient with diabetes should include a thorough medical and psychosocial history, updated as appropriate at periodic intervals and when changes occur in the patient’s health.  

A comprehensive physical examination should include all the following items:

Laboratory evaluation at the time of comprehensive workup should include:

 

Diabetes Self-Management Education (DSME) and Diabetes Self-Management Support (DSMS)

DSME and DSMS are essential components of diabetes care. All patients with diabetes should receive DSME aimed at developing and maintaining the knowledge and skills necessary for optimal self-care and self-management. Four critical time points for delivery of DSME and DSMS have been identified:

 

Medical Nutrition Therapy

All patients with diabetes should receive individualized medial nutrition therapy (MNT), developed in a collaborative process involving the patient and the health care team, preferably guided by a registered dietitian, and tailored to the patient’s needs, preferences and cultural background. MNT should promote healthy eating habits, preserve the enjoyment of food and provide the practical tools necessary to maintain a healthy eating pattern throughout life.

Nutrition counselors and educators should become aware of and consider issues that may influence or impair a patient’s ability to understand or comply with MNT, such as food insecurity, low educational level, poor literacy (and/or poor numeracy – inability to work with numbers) and homelessness. Where needs are identified, clients should be referred to appropriate resources in the community for assistance.

For people who are overweight or obese, modest weight loss (sustained loss of five to seven percent of body weight) may improve blood glucose control and reduce the need for medication in those with Type 2 diabetes and may delay the progression to Type 2 diabetes in those with prediabetes.

 

Physical Activity

Regular exercise has been shown to improve blood glucose control, support weight loss, reduce the risk of cardiovascular disease and improve well-being in persons with diabetes. Furthermore, it may help to prevent or delay the development of Type 2 diabetes in people who are high risk. All people with diabetes should be advised to engage in at least 150 minutes per week of moderate-intensity physical activity, divided over at least three days each week, with no more than two consecutive days without exercise. If no contraindications exist, those with Type 2 diabetes should engage in resistance training (e.g., working with light hand or leg weights) at least twice weekly.

 

Tobacco Use Cessation

All patients should have a thorough assessment of tobacco use and exposure, including the use of cigarettes, other tobacco products and e-cigarettes, and exposure to second-hand smoke updated at periodic intervals. Users should be assessed regularly for their readiness to quit and receive cessation counseling and information on other forms of cessation treatment.

 

Immunization

 

Psychosocial Issues

Because psychosocial issues can substantially impair a person’s ability to optimally self-manage diabetes and adversely affect outcomes, providers should routinely address each person’s psychological and social situation, including such things as:

Patients should receive periodic routine screening for psychosocial problems such as depression, diabetes-related distress, anxiety, eating disorders and cognitive impairment. A team approach to care is encouraged, with consideration of referral to a mental health specialist as indicated.

 

Glucose Monitoring and Glycemic Targets

Self-monitoring of blood glucose (SMBG) is appropriate for some patients, especially those on intensive insulin therapy (multiple-dose or insulin pump) and may be useful in patients on less intensive insulin therapy and non-insulin therapies, to help guide treatment. For patients with Type 2 diabetes on non-insulin regimens, SMBG may not be clinically beneficial or cost-effective, and the decision should be individualized based on whether the information obtained will influence patient management. A detailed review of SMBG and its use in management of diabetes is out of scope for this manual. Refer to the Standards of Medical Care in Diabetes by the American Diabetes Association (see Reference section below) for a more detailed discussion.

All patients with diabetes should undergo periodic testing of hemoglobin A1C according to the following schedule:

 

Hypoglycemia

A thorough review of the treatment and prevention of hypoglycemia in diabetic patients is out of scope for this manual. Refer to the Standards of Medical Care in Diabetes by the American Diabetes Association (see Reference section below) for a more detailed discussion.

All patients should be evaluated for their risk of hypoglycemia and questioned for any history of hypoglycemic episodes, severe hypoglycemia and hypoglycemia unawareness. Patients with increased risk or a positive history of hypoglycemia may benefit from SMBG to guide treatment to reduce hypoglycemia risk. Patients should be counseled on situations of increased risk (e.g., fasting for laboratory tests or procedures, during or after intense exercise, while sleeping, when unable to eat normally due to illness or with changes in diet as with calorie restriction for weight loss). They should be advised on measures to take, such as ingesting glucose-containing foods, when they experience or suspect hypoglycemia.

Consideration should be given to referral of patients at increased risk of hypoglycemia to a diabetes specialist for their care.

 

Management of Obesity in Prediabetes and Type 2 Diabetes

There is clear evidence that management of obesity can delay the progression to Type 2 diabetes in people with prediabetes and can be beneficial in persons with Type 2 diabetes.

Sustained weight loss can be achieved with dietary calorie restriction and regular moderate-intensity physical activity and requires the commitment of the patient and the support and encouragement of the health care team. Patient education is an essential element of a program aimed at bringing about the lifestyle changes necessary to achieve and maintain a healthier body weight.

Following is a list of recommended practices for providers who care for patients with Type 2 diabetes to promote weight management:

 

Medical Therapy

A thorough treatment of the pharmaceutical management of Type 1 and Type 2 diabetes is out of scope for this manual. Refer to the Standards of Medical Care in Diabetes by the American Diabetes Association and relevant textbooks for further information. For patients with multiple comorbid conditions, those who present with marked symptomatology or markedly elevated laboratory values, those who fail initial therapy and those whose diabetes proves difficult to manage, consideration may be given to referring the patient to a specialist in the treatment of diabetes.

 

Type 1 Diabetes

Most persons with Type 1 diabetes will require multiple-dose insulin injections or continuous subcutaneous insulin infusion. Refer to the Standards of Medical Care in Diabetes by the American Diabetes Association and relevant textbooks for further information. Consideration may be given to referring the patient to a specialist in the treatment of diabetes.

 

Type 2 Diabetes

For a more detailed discussion of pharmaceutical therapy in patients with Type 2 diabetes, refer to the section “Approaches to Glycemic Treatment” in the Standards of Medical Care in Diabetes by the American Diabetes Association and relevant textbooks.

References

 

Resources for Patients and Educators

 

3370 Hypertension Screening and Treatment

Revision 19-0; Effective September 1, 2019

 

This section is intended to serve as a guide for the diagnosis and management of hypertension by primary care providers. A detailed treatment of the management of hypertension, particularly in patients with multiple coexisting health conditions and those whose blood pressure is difficult to control, is out of scope for this manual. Refer to the References and Resources for Providers sections below as well as relevant textbooks for a more thorough discussion of the topic. Providers are encouraged to seek consultation from a specialist in the relevant area of medicine for management of complex patients and those whose blood pressure is difficult to control.

The summary of cited guideline recommendations provided in this section reflects the ages of eligibility for HTW and does not reflect guideline recommendations for patients outside this eligibility range.

 

Classification of BP and Diagnosis of Hypertension

In the U.S., 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 and management 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 Category (mm Hg) Management

Normal BP

<120/80

Optimize healthy lifestyle habits, reevaluate BP in one year.

Elevated BP

120-129/<80

Offer nonpharmacologic therapy (healthy lifestyle intervention), reevaluate BP in three to six months.

Stage 1 Hypertension

130-139/80-89

Assess 10-year cardiovascular disease risk.

  • If less than 10 percent, offer nonpharmacologic therapy and reevaluate BP in three to six months.
  • If greater than or equal to 10 percent, offer nonpharmacologic therapy and antihypertensive medication; reevaluate BP in one month.
    • If BP at target goal, reevaluate in three to six months.
    • If BP above target goal, ensure optimal adherence to therapy and consider more intensive therapy.

Stage 2 Hypertension

>/=140/90

Offer nonpharmacologic therapy and antihypertensive medication; reevaluate BP in one month.

  • If BP at target goal, reevaluate in three to six months.
  • If BP above target goal, ensure optimal adherence to therapy and consider more intensive therapy.

 

Measurement of Blood Pressure

 

Instructions for Home BP Monitoring

 

Nonpharmacologic Intervention

All patients, regardless of BP category or treatment, should receive instruction in healthy lifestyle habits with regular reinforcement of teaching. For those who are unable to maintain BP in the normal range despite such nonpharmacologic intervention, BP-lowering medications should be considered.

 

Thresholds for Initiating BP-lowering Medication

While treatment based on BP alone is cost-effective, treatment based on cardiovascular disease risk, which incorporates both BP and other risk factors, is more efficient and cost-effective. Therefore, the patient’s 10-year arteriosclerotic cardiovascular disease (ACSVD) risk should be calculated using the cardiovascular disease risk estimator, developed by the American College of Cardiology and American Heart Association, prior to initiating therapy and periodically to assess evolving risk estimates. The 10-year ASCVD risk is defined as the estimated risk of a first nonfatal myocardial infarction, fatal or nonfatal stroke, or death due to coronary heart disease within 10 years. This calculator incorporates multiple risk factors, as well as various types of therapy, allowing providers to evaluate both existing risk and what effect certain changes in therapy might have on risk estimates.

 

BP Targets for Hypertension Treatment

Treat adults with confirmed hypertension with a goal of systolic BP less than 130 mm Hg and diastolic BP less than 80 mm Hg.

 

Choice of BP Lowering Medication

References

 

Resources for Patients and Educators

 

Resources for Providers

 

3380 High Cholesterol Screening and Treatment

Revision 19-0; Effective September 1, 2019

 

The summary of cited guideline recommendations provided in this section address only women and reflect the ages of eligibility for HTW, and do not include guideline recommendations for men or for women 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 the reference section below 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

 

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.

 

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.

 

Evaluation of Screening Results

Results of the lipid profile should be interpreted in the context of the patient’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 patients with the following risk profiles:

 

Treatment Considerations

Consider statin therapy for patients whose risk profile and screening results suggest a possible benefit as described above. See the References section below for links to guidelines for treatment of cholesterol to reduce cardiovascular risk.

References

 

Further Reading

 

Resources for Providers

 

3390 Postpartum Depression Screening and Treatment

Revision 19-0; Effective September 1, 2019

 

Prevalence and Risk Factors for Postpartum Depression

As many as 80 percent of new mothers experience a brief episode of the “baby blues” which may last up to two weeks. Approximately five to 25 percent 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 all 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

Because postpartum depression can be a serious and sometimes life-threatening condition, all new mothers must 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 on-line, 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:

 

Screening for Suicide Risk

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

 

Nonpharmacologic Treatment

Milder degrees of postpartum depression may respond well to cognitive behavioral interventions (e.g., stress management, problem solving, goal setting), provided in individual or group settings. The provider might work with the patient to develop a Postpartum Depression Action Plan and see her again in a week to assess response to the intervention. Response can be assessed by repeating the screening tool to see if the score improves over time. If no improvement is seen, or if symptoms worsen, consideration should be given to initiating pharmaceutical therapy.

 

Pharmacologic Treatment

For patients with more severe symptoms and those who do not respond to nonpharmacologic therapy, selective serotonin reuptake inhibitors are commonly used to treat postpartum depression. There is no evidence that one agent is superior to any other. If the patient has taken an antidepressant in the past with good result, that agent would be a logical choice to initiate therapy.  

It is generally prudent to start with a low dose and increase as needed, since the side effects of antidepressants can be a barrier to compliance and because the lowest effective dose is preferred in the breastfeeding mother. The response to treatment can be assessed by repeating the screening tool used to diagnose postpartum depression. When remission of symptoms is achieved, treatment is generally continued for a period of time (e.g., six to nine months) and then discontinued. To minimize the side effects of suddenly discontinuing therapy, the dose can be tapered over a period of two weeks.

 

Referral for Additional Treatment

Patients in need of more intensive treatment for postpartum depression should be referred to a provider of behavioral health services. Providers must have arrangements in place for appropriate referral of patients to behavioral health providers in their area. For information on local behavioral health care providers, refer to the Texas Health and Human Services website Office of Mental Health Coordination or call 2-1-1.

 

Coding for Postpartum Depression Services

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

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

 

Texas Clinician’s Postpartum Depression Toolkit

The Texas Clinician’s Postpartum Depression Toolkit, a resource for screening, diagnosis and treatment of postpartum depression published by HHSC is available at: https://hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/providers/health/women/tx-clinicians-ppd-toolkit.pdf.

References

 

Resources for Patients and Providers

 

3400 Program Promotion and Outreach

Revision 19-0; Effective September 1, 2019

 

Contractors must develop and implement an annual plan to provide community education and program promotion to:

The plan should be based on an assessment of the needs of the community and contain an evaluation strategy. Contractors should consider a variety of program promotion and client 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 client outreach activities, contractors must:

Contractors must submit a one-page Healthy Texas Women Promotion Plan for the contract period within 45 days of the contract start date. The plan should describe the agency’s outreach and marketing strategy and include a description of planned activities to reach potential Healthy Texas Women clients. Contractors must submit Form 1810, Healthy Texas Women Promotion Outreach Annual Report to: HTWContracts@hhsc.state.tx.us.