Primary Health Care Services Program Policy Manual

1000, Purpose and Contact Information

Revision 20-1; Effective May 8, 2020

 

The Texas Health and Human Services Commission (HHSC) Primary Health Care Services Program Policy Manual is a guide for contractors who deliver primary health care services in Texas. The policy manual is structured to provide contractor staff with information needed to comply with program legislation and rules.

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

Primary Health Care Services program contractors must also follow the DSHS Standards for Public Health Clinic Services.

 

Contact Information

Mailing Address

Primary Health Care Services Program
P.O. Box 149347, Mail Code 1938
Austin, TX 78714-9347

Physical Address for Courier Service

Primary Health Care Services Program
Office of Primary and Specialty Health, Mail Code 1938
Texas Health and Human Services Commission
Moreton Building
1100 W. 49th Street
Austin, TX 78756

Helpline

800-222-3986 Ext. 5922
8 a.m. to 5 p.m. Central Time
Monday through Friday

Austin Phone No. 512-776-5922
Austin Fax No. 512-776-7417

Email

PrimaryHealthCare@hhsc.state.tx.us

Website

https://hhs.texas.gov/services/health/primary-health-care-services-program

SharePoint Contractor Portal

2000, Program Authorization and Services

Revision 20-1; Effective May 8, 2020

 

 

2100 Background, Statute and Rules

Revision 20-0; Effective November 2019

 

In the early 1980s, economic recession and cost containment measures on the part of employers and government agencies led to a decrease in the availability and accessibility of health care services for many Texans. A legislative task force identified the provision of primary health care to the medically indigent as a major priority. The task force recommended the following:

These recommendations become the basis of the indigent health care legislative package enacted by the 69th Texas Legislature in 1985. The Primary Health Care Services Act, House Bill 1844, was part of this legislation and is the statutory authority for Primary Health Care (PHC) Services administered by HHSC. The Act delineates the specific target population, eligibility, reporting and coordination requirements for PHC.

The state rules for PHC services in Texas can be found in the Texas Administrative Code (TAC), Title 25, Part 1, Chapter 39, Subchapter A. PHC program rules require that, at a minimum, a contractor must provide the following six priority PHC services:

  1. Diagnosis and treatment;
  2. Emergency medical services;
  3. Family planning services;
  4. Preventive health services;
  5. Health education; and
  6. Laboratory, x-ray, nuclear medicine or other appropriate diagnostic services.

PHC provides services for individuals who are at or below 200% of the Federal Poverty Level (FPL) and are unable to access the same care through other funding sources or programs. Contractors must assure that services provided to clients are accessible in terms of cost, scheduling and distance, and are provided in a way that is sensitive to the individual’s culture.

 

2200 Funding Sources

Revision 20-0; Effective November 2019

 

PHC program services are funded by State General Revenue. HHSC PHC funds are allocated through a competitive application process, after which selected applicants negotiate contracts with HHSC to provide services. A variety of types of organizations provide PHC program services, such as local health departments, medical schools, hospitals, private non-profit agencies, community-based clinics, federally qualified health centers (FQHCs) and rural health clinics. Providers must enroll with the Texas Medicaid & Healthcare Partnership (TMHP) to provide the HHSC PHC Services program. State and federal law prohibits the use of contracted funds awarded by HHSC to pay the direct or indirect costs (including overhead, rent, phones and utilities) of abortion procedures.

 

2300 Definitions

Revision 20-1; Effective May 8, 2020

 

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

Barrier to Care – A factor that hinders a person from receiving care (i.e., proximity or distance, lack of transportation, documentation requirements, co-payment amount, etc.).

Client – An individual who has been screened, determined to be eligible for services, and has successfully completed the eligibility process. “Client” and “patient” may be used interchangeably throughout this policy manual.

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

Contractor – The entity Texas Health and Human Services Commission has contracted with to provide services. The contractor is the responsible entity even if there is a subcontractor involved who provides the services.

Co-payment or Co-pay – Monies collected directly from clients for services. The amount collected each month should be deducted from the monthly Form 4116, State of Texas Purchase Voucher, and is considered program income.

Dental Services – Diagnostic, preventive, and therapeutic dental services that are provided to eligible individuals and are performed in a dental office or clinic.

Diagnosis – The recognition of disease status determined by evaluating the history of the client and the disease process, and the signs and symptoms present. Determining the diagnosis may require microscopic (i.e., culture), chemical (i.e., blood tests), and/or radiological examinations (x-rays).

Diagnosis and Treatment – This includes common acute and chronic disease that affect the general health of the client. Services include the first contact with a client for an undiagnosed health concern, as well as continuing care of varied medical conditions not limited by cause or organ system. Services must not be limited to only one service (i.e., family planning, breast and cervical cancer screening or podiatry).

Diagnostic Services – Activities related to the diagnosis made by a physician or nurse practitioner, which may also be performed by nurses or other health professionals.

Diagnostic Studies or Diagnostic Tests – Tests ordered by the client’s health care practitioner(s) to evaluate an individual’s health status for diagnostic purposes.

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

Emergency Services – Urgent care services provided for an unexpected health condition requiring immediate attention. Clinical emergency situations include conditions such as anaphylaxis, syncope, cardiac arrest, shock, hemorrhage, and respiratory difficulties and in response to environmental emergencies (including natural and man-made disaster situations).

Family Composition/Household – 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 who are legally responsible for the support of the other person.

Family Planning Services – Services that assist women and men in planning their families, whether it is to achieve, postpone or prevent pregnancy. Family planning services should include the following: pregnancy test (if indicated), health history, physical examinations, basic infertility services, lab tests, sexually transmitted disease (STD) services (including HIV/AIDS), and other preconception health services (e.g., screening for obesity, smoking and mental health), counseling/education and contraceptive supplies.

Federal Poverty Level (FPL) – The set minimum amount of income that a family needs for food, clothing, transportation, shelter and other necessities. In the U.S., 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.

Fiscal Year – The state fiscal year is September 1 through August 31 of the next year.

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

Health Education – The process of educating or teaching individuals about lifestyles and daily activities that promote physical, mental and social well-being. This process may be provided to an individual or to a group of individuals.

Health Screening – The provision of tests (e.g., blood glucose, serum cholesterol and fecal occult blood) as a means of determining the need for intervention and perhaps a more comprehensive evaluation.

Laboratory (informally, Lab) – A facility that measures or examines materials derived from the human body to provide information on diagnosis, monitoring prevention or treatment of disease.

Laboratory, X-ray or other Appropriate Diagnostic Services – Studies or tests ordered by the client’s health care practitioner(s) (e.g., physicians, dentists and mid-level providers) to evaluate an individual’s health status for diagnostic purposes.

Managing Conservator – A person designated by a court to have daily legal responsibility for a child.

Medicaid – Title XIX of the Social Security Act; reimburses for health care services delivered to low-income clients who meet eligibility guidelines.

Minor – In Texas, a person under age 18 who has never been married and never been declared an adult by a court (emancipated). See Texas Family Code Sections 101.003, 31.001-31.007, 32.003-004, 32.202. In this policy manual, “minor” and “child” may be used interchangeably.

Patient – An individual who is eligible to receive medical care, treatment or services. “Client” and “patient” may be used interchangeably in this policy manual.

Payer Source – Programs, benefits or insurance that pays for the service provided.

Preventive Health Care Services – Medical care that focuses on disease prevention and health maintenance, including early diagnosis of disease, discovery and identification of people at risk of development of specific problems, counseling and other necessary intervention to avert a health problem. Included are screening tests, immunizations, risk assessments, health histories and baseline physicals for early detection of disease and restoration to a previous state of health, and prevention of further deterioration and/or disability.

Program Income – Monies collected directly by the contractor/subcontractor/provider for services provided under the contract award (i.e., third-party reimbursements, such as Title XIX, private insurance and patient co-pay fees). Program income also includes client donations.

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

Recertification – The process of rescreening and determining eligibility for the next year.

Referral – The process of directing or redirecting (as a medical case or a patient) to an appropriate specialist or agency for definitive treatment, or direct to a source for help or information.

Telehealth Service – A health service, other than a telemedicine medical service, delivered by a health professional licensed, certified or otherwise entitled to practice in this state and acting within the scope of the health professional’s license, certification or entitlement to a patient at a different physical location than the health professional using telecommunications or information technology.

Telemedicine Medical Service – A health care service delivered to a patient at a different physical location than the physician or health professional using telecommunications or information technology by a physician licensed in this state, or a health professional acting under the delegation and supervision of a physician licensed in this state and acting within the scope of the physician’s or health professional’s license.

Texas Resident – An individual who resides within the geographic boundaries of the state of Texas.

Treatment – Any specific procedure used for the cure, or the improvement, of a disease or pathological condition.

Unduplicated Client – An individual counted only one time during the program’s fiscal year, regardless of the number of visits, encounters or services they receive (e.g., one client seen four times during the year is counted as one unduplicated client).

 

2400 Administrative Policies

Revision 20-0; Effective November 2019

 

This section assists the contractor in conducting administrative activities, such as assuring client access to services and managing client records.

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

 

2500 Important Information for Former Military Service Members

Revision 20-0; Effective November 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 additional benefits and services. For more information, visit the Texas Veterans Portal at https://veterans.portal.texas.gov.

 

2600 Abuse and Neglect Reporting

Revision 20-1; Effective May 8, 2020

 

Texas Health and Human Services agencies may only provide funds to contractors/providers who show good faith efforts to comply with all child abuse reporting guidelines and requirements set forth in Chapter 261 of the Texas Family Code.

HHSC contractors must comply with state laws governing reporting of abuse and neglect and have an agency policy regarding abuse and neglect. It is mandatory to be familiar with, and comply with, adult and child abuse and neglect reporting laws in Texas.

To report abuse or neglect, call the Texas Abuse Hotline at 800-252-5400, or use the secure Texas Abuse Hotline website. For cases that pose an imminent threat or danger to an individual, call 9-1-1, or any local or state law enforcement agency.

 

2610 Child Abuse Reporting, Compliance and Monitoring

Revision 20-0; Effective November 2019

 

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

Contractors must develop an internal policy specific to:

During quality assurance (QA) monitoring, the following procedures will be utilized to evaluate compliance:

References for child abuse reporting requirements for HHSC contractors and providers are available at https://hhs.texas.gov/doing-business-hhs/provider-portals/wic-providers/child-abuse-reporting. This site includes links to policies, the child abuse reporting form and statutory references.

 

2620 Human Trafficking

Revision 20-0; Effective November 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, 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:

 

2630 Domestic and Intimate Partner Violence

Revision 20-0; Effective November 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.

Additional information on intimate partner violence can be found on the CDC website.

 

2700 Confidentiality

Revision 20-0; Effective November 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 client privacy.

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. All employees, volunteers, subcontractors, and board members and/or advisory board members must sign a confidentiality statement during orientation.

The client’s preferred method of follow-up to clinic services (cell phone, email, work phone, and/or text) and preferred language must be documented in the client’s record. See Section 4320, Client Health Records and Documentation of Encounters.

Each client must receive verbal assurance of confidentiality and an explanation of what confidentiality means (kept private and not shared without permission) and any applicable exceptions such as abuse reporting. See Section 2600, Abuse and Neglect Reporting.

 

2710 Minors and Confidentiality

Revision 20-0; Effective November 2019

 

Except as permitted by law, a provider is legally required to maintain the confidentiality of care provided to a minor. Confidential care does not apply when the law requires parental notification or consent, or when the law requires the provider to report health information, such as in the cases of contagious disease or abuse. The definition of privacy is the ability of the individual to maintain information in a protected way. Confidentiality in health care is the obligation of the health care provider not to disclose protected information. While confidentiality is implicit in maintaining a patient's privacy, confidentiality between provider and patient is not an absolute right.

The Health Insurance Portability and Accountability Act (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. In most cases, parents are 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 (Code of Federal Regulations - 45 CFR§164.502(g)).

For more information, see Adolescent Health – A Guide for Providers.

 

2720 Nondiscrimination and Limited English Proficiency (LEP)

Revision 20-0; Effective November 2019

 

As outlined in the HHSC Uniform Terms and Conditions – Grant Version 2.16, HHSC contractors must comply with state and federal anti-discrimination laws, including but not limited to:

More information about non-discrimination laws and regulations can be found on the HHSC Civil Rights website.

 

2730 Contract Terms and Conditions

Revision 20-0; Effective November 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.

 

2740 Termination of Services

Revision 20-0; Effective November 2019

 

A qualifying individual must never be denied services due to an inability to pay. Contractors have the right to terminate services to a client if the client is disruptive, unruly, threatening or uncooperative to the extent that the client seriously impairs the contractor’s ability to effectively and safely provide services, or if the client’s behavior jeopardizes his or her own safety, clinic staff or others. An individual has the right to appeal the denial, modification, suspension or termination of services. See Appeals, in the PHC rules at Title 25, Part 1, Chapter 39.10, Subchapter A.

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

 

2750 Resolution of Complaints

Revision 20-0; Effective November 2019

 

Contractors must ensure that clients 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 clients may follow if they are not satisfied with the care received. If an aggrieved client requests a hearing, a contractor shall not terminate services to the client until a final decision is rendered by HHSC. Any client complaint must be documented in the client’s record.

 

2760 Research (Human Subject Clearance)

Revision 20-0; Effective November 2019

 

Any HHSC PHC contractor that wishes to participate in any proposed research that would involve the use of HHSC PHC clients as subjects, the use of HHSC PHC clients’ records or any data collection from HHSC PHC clients, must obtain prior approval from the HHSC PHC program and be approved by the Institutional Review Board (IRB). 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 the HHSC PHC program, as well as the IRB, prior to instituting any research activities. The contractor must also ensure that all staff is made aware of this policy through staff training. Documentation of training on this topic must be maintained by the contractor.

3000, Client Records, Personnel, Facilities and Quality Management

Revision 20-1; Effective May 8, 2020

 

3100 Client Records Management

Revision 20-0; Effective November 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 records must be kept confidential and secure, as follows:

The written consent of the client is required for the release of personally identifiable information, except as may be necessary to provide services to the client or as required by law, with appropriate safeguards for confidentiality. If the client is 17 years of age or younger, the client’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, statistically or in a form that does not identify individuals. Upon request, clients 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 specified by HHSC all records pertaining to client services, contracts and payments. 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.

 

3200 Personnel Policy and Procedures

Revision 20-0; Effective November 2019

 

Contractors must develop and maintain personnel policies and procedures to ensure that clinical staff are hired, trained and evaluated appropriately to their job position. Contracted staff must also be trained and evaluated according to their responsibilities. Job descriptions, including those for contracted personnel, must specify required qualifications and licensure. All staff must be appropriately identified with a name badge. Personnel policies and procedures must include:

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. All dental services must be provided under the supervision, direction and responsibility of a qualified licensed dentist.

The PHC medical director for the clinic must be a licensed Texas physician and the PHC dental director for the clinic must be a U.S. licensed dentist.

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.

 

3300 Facilities and Equipment

Revision 20-0; Effective November 2019

 

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

 

3310 Hazardous Materials

Revision 20-0; Effective November 2019

 

Contractors must have written policies and procedures that address:

 

3320 Fire Safety

Revision 20-0; Effective November 2019

 

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.

 

3330 Medical Equipment

Revision 20-0; Effective November 2019

 

Contractors must have a written policy and maintain documentation of the maintenance, testing and inspection of medical equipment, including an Automated External Defibrillator (AED). Documentation must include:

 

3340 Radiology Equipment and Standards

Revision 20-0; Effective November 2019

 

All facilities providing radiology services, including dental x-rays, must:

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

 

3350 Smoking Ban

Revision 20-0; Effective November 2019

 

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 also comply with this policy.

 

3360 Disaster Response Plan

Revision 20-0; Effective November 2019

 

Written and oral plans address how staff must 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 10 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.

 

3400 Emergency Responsiveness

Revision 20-1; Effective May 8, 2020

 

HHSC contractors are required to have an emergency preparedness plan. Contractors must have written policies and procedures that address emergency situations.

 

3410 Clinical Emergencies

Revision 20-1; Effective May 8, 2020

 

Contractors must be adequately prepared to handle clinical emergency situations, as follows:

 

3420 Emergency Preparedness

Revision 20-1; Effective May 8, 2020

 

There must be a written safety plan that includes maintenance of fire safety equipment, an emergency evacuation plan and a disaster response plan.

 

3500 Quality Management

Revision 20-1; Effective May 8, 2020

 

Contractors must use internal Quality Assurance/Quality Improvement (QA/QI) systems and processes to monitor PHC services. Contractors must have a Quality Management (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.

Contractors should integrate QM concepts and methodologies into the structure of the organization and day-to-day operations.

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

The QM program must be developed and implemented in such a way 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/CEO, medical director, dental director and other appropriate staff, where applicable, annually reviews and approves the quality work plan for the organization.

The QM Committee must meet at least quarterly to:

Minutes of the discussion and actions taken by the committee and a list of the attendees must be maintained.

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

Although each organization’s quality assurance 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.

 

 

4000, Eligibility and Assessment of Co-pay and Fees

Revision 20-1; Effective May 8, 2020

 

This section provides policy requirements for eligibility, client services, community activities and clinical guidelines. Contractors must develop a policy to determine Primary Health Care (PHC) eligibility. The contractor must ensure documentation provides a clear understanding of the eligibility screening process. Contractors must perform an eligibility screening assessment on all clients who present for services using the most recent version of one of following eligibility tools.

HHSC PHC contractors must perform an eligibility screening assessment on all clients who present for PHC services, using Form 3029, Office of Primary and Specialty Health Application for Program Benefits.

A comparable paper or electronic eligibility tool may be used that contains the required HHSC information for eligibility determination, the applicant’s signature and be approved by the PHC program.

The following forms are optional, but may be used to aid in completing the PHC eligibility process:

 

4100 Client Eligibility Screening Process

Revision 20-1; Effective May 8, 2020

 

For an individual to receive PHC program services, three criteria must be met:

Residency is self-declared. Contractors may require residency verification, but such verification should not jeopardize delivery of services. Contractors must require income verification for countable income. In cases when submitting the income verification jeopardizes the client’s right to confidentiality or imposes a barrier to receipt of services, the contractor must waive this requirement. Reasons for waiving verification of income must be noted in the client record.

 

4110 Procedures and Terminology When Determining PHC Eligibility

Revision 20-1; Effective May 8, 2020

 

Household – 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/her partner have mutual children together. Unborn children should also be included. Treat applicants who are 18 years of age as adults. No children age 18 and older or other adults living in the home should be counted as part of the household group. Legal responsibility for support exists between:

Income – All income received must be included. Income is calculated before taxes (gross). Income is reviewed and determined either countable or exempt (based on the source of the income), as defined in Appendix I, Definition of Income. Contractors must have a written PHC income verification policy.

Income Deductions – Dependent care expenses shall be deducted from total income in determining eligibility. Allowable deductions are actual expenses up to $200 per child per month for children under age 2, $175 per child per month for each dependent age 2, and $175 per adult with disabilities per month. Legally obligated child support payments made by a member of the household group shall also be deducted. Payments made weekly, every two weeks or twice a month must be converted to a monthly amount by using one of the conversion factors listed below.

Monthly Income Conversions – If income payments are received in lump sums or at longer intervals than monthly, such as seasonal employment, the income is prorated over the time the income is expected to cover. Income received weekly, every two weeks or twice a month must be converted as follows:

Presumptive Eligibility – PHC emphasizes the importance of prevention and early intervention. The goal of PHC is for clients to be part of the health care system and not rely on episodic acute care. An applicant’s medical needs shall be met quickly and appropriately, using available resources in the community. Presumptive eligibility is the short-term availability and access to health care services (up to 90 days) when the client screens potentially eligible for services but lacks verification to achieve full eligibility. For clients who are determined to be fully eligible during the presumptive period, the eligibility expiration date will include the days of presumptive eligibility (expiration date is 365 days beginning the first date of eligibility determination). When full eligibility is granted during or at the end of the 90 days, the eligibility period end date is 12 months from the presumptive eligibility. On a case-by-case basis, the contractor may waive the requirement to submit the eligibility documentation and approve full eligibility, if the contractor determines submitting the documentation will create a barrier to care and no other documentation is available.

Adjunctive Eligibility – An applicant is considered adjunctively (automatically) eligible for PHC program services at an initial or renewal eligibility screening, if the individual is currently enrolled in the Children’s Health Insurance Program (CHIP) Perinatal, Medicaid for Pregnant Women, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Supplemental Nutrition Assistance Program (SNAP) and/or Healthy Texas Women (HTW) Program. 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 Perinatal CHIP Perinatal benefits card
Medicaid for Pregnant Women Your Texas Benefits card (Medicaid card)*
WIC WIC verification of certification letter, printed WIC-approved shopping list or recent WIC purchase receipt with remaining balance
SNAP SNAP eligibility letter
HTW Your Texas Benefits card with “Healthy Texas Women” printed in the upper right corner
*Note: Presentation of the Your Texas Benefits card does not completely verify current eligibility in the HTW program or the Medicaid for Pregnant Women program. To verify eligibility, contractors must call Texas Medicaid & Healthcare Partnership (TMHP) at 1-800-925-9126 or access TexMedConnect on the TMHP website at www.tmhp.com. For a client’s current eligibility status, contractors must enter two of the following four data elements for the client:
  • Patient Control Number;
  • Date of Birth;
  • Social Security Number; or
  • Last Name.

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.

Potential Eligibility and Referral to Other Possible Qualifying Programs – In general, individuals are not eligible for the PHC program if they are enrolled in another third-party payer, such as private health insurance, Medicaid or Medicare, TRICARE, Workers’ Compensation, Veterans Affairs Benefits or other federal, state or local public health care coverage that provides the same services. An individual may still be potentially eligible for the PHC program even if they are also eligible for another program that covers the same services that are provided by the PHC program. The contractor should proceed with the eligibility process for the PHC program but inform the individual of their possible eligibility for the other program and suggest that they also apply for services for that program. The contractor must document in the individual’s case record that they were informed and were referred to the other program.

Supplemental Benefits – In some cases, individuals receiving benefits from other sources, such as Medicaid or Medicare, may be eligible for partial PHC coverage. This supplemental or wraparound coverage is limited to services provided by PHC but not covered by other sources. Whenever federal, state, private or other benefits are available for payment of clients receiving PHC covered services, no PHC funds shall be used to pay for such care. An example of supplemental benefits would be providing health education services to a Medicaid-eligible individual, since Medicaid does not provide health education services. The contractor must communicate to the client that supplemental services are of limited scope.

Insurance – Individuals with insurance may be eligible for services provided by PHC when the applicant’s confidentiality is a concern or if the applicant’s insurance deductible is 5% or greater than their income. Most insurance deductibles are given as an annual amount. PHC household incomes are figured as a monthly amount. To compare an annual deductible with a monthly income, multiply the monthly income by 12 and then determine 5% of that amount. See the example below for a monthly household income of $1,000:

  1. Determine the total household’s monthly income.
  2. Determine the total household’s annual income by multiplying the monthly income by 12 (months).
  3. Determine 5% of the total annual income by multiplying it by 0.05 (5%).
Total Monthly Household Income Total Annual Household Income 5% of Total Annual Household Income
$1,000 x 12 (months) = $12,000 x 0.05 = $600
If the applicant’s annual insurance deductible is any amount over $600, they are eligible under this criterion for PHC.

 

Another way to make the comparison is to divide the annual insurance deductible into a monthly amount. See the example below for an annual insurance deductible of $6,000 and a monthly household income of $1,000:

  1. Determine the household’s monthly insurance deductible by dividing the annual deductible by 12 (months).
  2. Determine 5% of the total monthly household income by multiplying it by 0.05 (5%).
Household Annual Insurance Deductible Household Monthly Insurance Deductible Total Monthly Household Income 5% of Total Monthly Household Income
$6,000 ÷ 12 = $500 $1,000 x 0.05 = $50
If the applicant’s monthly insurance deductible is any amount over $50, they are eligible under this criterion for PHC.

 

The completed eligibility form must be maintained in the client medical record, indicating the client’s poverty level and the co-pay amount the person will be charged.

Payer of Last Resort – As previously mentioned, individuals seeking PHC-covered services may be dually eligible for other HHSC funded programs within an agency that provides the same services, such as HHSC Family Planning, Breast and Cervical Cancer Screening Services, or the Title V Prenatal, Child or Dental Program(s). In such cases, it is up to the contractor to determine the best use of funds within their agency.

PHC is the payer of last resort for a client who is enrolled in any other non-HHSC program that provides payment for the cost of the same primary care services at the time the client presents for those services.

Calculation of Applicant’s Federal Poverty Level (FPL) Percentage – If a contractor collects a co-payment (co-pay), the contractor must determine the applicant’s exact household FPL percentage. The contractor must not charge a co-pay for PHC clients whose household income is at or below 100% of the FPL. 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. The steps to determine the applicant’s actual household FPL percentage are:

  1. Determine the applicant’s total monthly income amount.
  2. Determine the applicant’s household size.
  3. Divide the applicant’s total monthly income amount by the maximum monthly income amount at 100% FPL for the appropriate household size.
  4. Multiply by 100. See the example below for a family of three, with a monthly income amount of $2,093:

See the example below for a family of three, with a monthly income amount of $2,093:

Total Monthly Income Maximum Monthly Income (Household Size of 3) Actual Household FPL %
$2,093 ÷ $1,778 = 1.18 x 100 = 118% FPL

 

Client Fees/Co-Pays – PHC contractors may (but are not required to) assess a co-pay for services from PHC clients. The co-pay guidelines are:

Other Fees – 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 PHC allowable services if the service is provided at the client’s request and the client is made aware of their responsibility for paying for the charges.

Continuation of Services – Contractors who have expanded their awarded PHC funds are required to continue to serve their existing PHC clients through the end of the client’s eligibility. If other funding sources are used to provide PHC 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) or Form 269a.

Date Eligibility Begins – An individual/household is eligible for services beginning with the date the contractor determines the individual/household is eligible for the program and signs the completed application. This includes the date an individual/household is determined eligible for Presumptive Eligibility. Contractors have the option to notify PHC applicants of their eligibility status using the optional letters provided by the PHC program:

Annual Recertification – Annual eligibility determination and recertification is required for all clients who receive PHC services. Client eligibility must be redetermined every 12 months, using the appropriate form for individuals or households. Contractors must have a system in place to track client eligibility and renewal status on an annual basis.

 

4200 General Consent

Revision 20-0; Effective November 2019

 

Contractors must obtain the client’s written, informed, voluntary general consent to receive services prior to the client 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 their own medical care and address any disabilities that impair communication, in compliance with Limited English Proficiency regulations. Only the client may consent, except when the client is legally unable to consent (e.g., a minor or an individual with a development disability). If the client is legally unable to consent, a parent, legal guardian or caregiver must consent on the client’s behalf. Consent must never be obtained in a manner that could be perceived as coercive.

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

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

 

4210 Procedure Specific Informed Consent

Revision 20-0; Effective November 2019

 

Sterilization

There are two consent forms required for sterilization procedures:

The Sterilization Consent Form (English, Spanish, Instructions); and The Texas Medical Disclosure Panel Consent Form.

 

4220 Texas Medical Disclosure Panel Consent

Revision 20-0; Effective November 2019

 

The Texas Medical Disclosure Panel (TMDP) was established by the Texas Legislature to determine which risks and hazards related to medical care and surgical procedures must be disclosed by health care providers or physicians to their patients or persons authorized to consent for their patients, and establish the general form and substance of such disclosure.

TMDP has developed List A (informed consent requiring full and specific disclosure) for certain procedures, which can be found in 25 TAC §601.2. Contractors that directly perform tubal sterilization and/or vasectomy (both List A procedures), must also complete the TMDP Disclosure and Consent Form. 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 deciding to consent to the procedure).

 

4230 Dental Procedures

Revision 20-0; Effective November 2019

 

Written informed consent for dental procedures must be obtained in compliance with 22 TAC §108.7, regarding minimum standards of care for dentists.

 

4240 Consent for Services Provided to Minors

Revision 20-0; Effective November 2019

 

Generally, a parent must consent to treatment for minors. A minor is defined as a person under 18 years of age who has never been married and never been declared an adult by a court (emancipated). However, there are certain circumstances under which a minor may consent for their own treatment. Requirements for parental consent for provision of family planning services to minors vary according to the funding source subsidizing the services. The department and providers may provide family planning services, including prescription drugs, without the consent of the minor’s parent, managing conservator or guardian only as authorized by Chapter 32 of the Texas Family Code, or by federal law or regulations.

 

4250 Resources and References

Revision 20-0; Effective November 2019

 

 

4260 Consent for HIV Tests

Revision 20-0; Effective November 2019

 

For HIV testing, contractors must comply with Texas Health and Safety Code:

 

4300 Clinical Policy

Revision 20-0; Effective November 2019

 

This section describes the requirements and recommendations for contractors pertaining to the delivery of direct clinical services to clients. 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.

 

4310 Scope of Services – Six Priority Primary Health Care Services

Revision 20-0; Effective November 2019

 

1. Diagnosis and Treatment

 

This includes diagnosis and treatment of common acute and chronic disease that affect the general health of the client. Services include first contact with a client for an undiagnosed health concern, as well as continuing care of varied medical conditions not limited by cause or organ system. Services must not be limited to only one service (i.e., family planning, breast and cervical cancer screening or podiatry).

 

2. Emergency Medical Services

Services must be for urgent care for an unexpected health condition requiring immediate attention as determined by the appropriate medical staff and must be services that can be treated in a primary care clinic or setting.

 

3. Family Planning Services

These are preventive health and medical services that assist an individual in controlling fertility and achieving optimal reproductive and general health. Services include:

4. Preventive Health Services

Services that may be included are:

 

5. Health Education

Planned learning experiences based on sound theories that provide individuals, groups and communities the opportunity to increase knowledge, and skills needed to make healthy decisions.

 

6. Diagnostic Laboratory and Radiological Services  

These services must be medically necessary and are technical laboratory and radiological services ordered and provided by, or under the direction of, a physician in an office or a facility other than a hospital inpatient setting.

Contractors are strongly encouraged to visit the U.S. Preventive Services Task Force website for additional guidance on preventive services.

 

4320 Client Health Records and Documentation of Encounters

Revision 20-0; Effective November 2019

 

Providers must ensure that a patient health record is established for every individual who has clinical services. See Section 3100, Client Records Management.
 
All patient health records must be:

All client health records must include:

 

4321 Initial Medical History and Risk Assessment

Revision 20-0; Effective November 2019

 

At the initial clinical visit, or an early subsequent visit, a comprehensive medical history must be obtained to include, in addition to the elements required for the Client Health Record in Section 4320 above (adapt as appropriate to the gender and age of the client), the following:

Reproductive health history in female clients of reproductive age must include:

Reproductive health history in male clients of reproductive age must include:

 

4322 Physical Assessment

Revision 20-0; Effective November 2019

 

A periodic preventive health care visit offers an excellent opportunity for clinicians to address issues of wellness and health risk reduction and to address current findings and client concerns. The periodic preventive health care visit must include an update of the person’s health record, as described in Section 4320, Client Health Records and Documentation of Encounters, as well as appropriate screening, assessment, health education and counseling, and immunizations based on the client’s age, risk factors, preferences and concerns.

All clients must be provided an appropriate physical assessment, as indicated by health history and a health risk assessment. A physical examination is not essential prior to the provision of most contraceptive methods and should not be a barrier to the client receiving a method of contraception.

The initial physical exam may be deferred if the client history and presentation do not reveal potential problems requiring immediate evaluation. The comprehensive physical exam should be performed within six months of the initial visit unless the clinician identifies a compelling reason for extended deferral. Such reason must be documented in the client record.

Program protocols should be developed, accordingly, and must be consistent with national evidence-based guidelines.

 

4323 Initial Primary Health Physical Examination

Revision 20-0; Effective November 2019

 

The new client baseline physical examination must include the following components for clients age 21 years and older:

A periodic primary health visit physical examination for clients age 21 years and older must include:

Clients age birth through 20 years must have the following age-appropriate baseline and periodic health assessment components (see Texas Health Steps Provider Information Periodicity Schedules):

An episodic or acute care visit must include:

 

4324 Resources

Revision 20-0; Effective November 2019

 

 

4330 Healthy Lifestyle Intervention

Revision 20-0; Effective November 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.

 

4331 Counseling on Healthy Lifestyle Choices

Revision 20-0; Effective November 2019

 

All clients should be advised not to smoke or to use tobacco products, and to avoid exposure to second-hand smoke as much as possible. Those who use tobacco products should be advised to quit and be assessed for their readiness to do so at each encounter.

Clients should be counseled on healthy eating patterns and offered access to relevant information.

Clients should be advised to engage in physical activity or resistance training, tailored to their individual health condition and risks.

 

4332 Diet and Nutrition

Revision 20-0; Effective November 2019

 

There is strong evidence that nutrition plays an important role in the risk of disease. 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.

 

4333 Laboratory Tests

Revision 20-0; Effective November 2019

 

All clients presenting for an initial, annual, routine follow-up or problem-related visit must be provided appropriate laboratory and diagnostic tests, as indicated by history, health risk assessment (HRA), physical examination and/or clinical assessment.

The following tests or procedures must be provided:

Note: Initial tests may be deferred until the initial physical exam is provided.

Agencies must have written plans to address laboratory and other diagnostic test orders, results and follow-up to include:

*HPV screening is only reimbursable for female clients who are 21 years or older after an initial abnormal squamous cells-undetermined significance (ASC-US) pap result. See the current information about HPV and HPV testing. For the management of abnormal Pap tests, see the ASCCP Cervical Cytology Consensus Guideline Algorithms.

**HIV screening must be provided on-site. Providers should follow the Centers for Disease Control and Prevention (CDC) recommendations that all clients age 13-64 years be screened at least once for HIV infection and that all persons likely to be at high risk for HIV be rescreened at least annually. CDC further recommends that screening be provided after the patient is notified that testing will be performed as part of general medical consent, unless the patient declines (opt-out screening). The provision of negative test results by telephone must follow procedures that address patient confidentiality, identification of the client and prevention counseling. Contractors must always provide positive HIV test results to patients in a face-to-face encounter with an immediate opportunity for counseling and referral to community support services. Test results must be provided by staff knowledgeable about HIV prevention and HIV testing. Clients whose risk screenings assessment reveals high risk behaviors should be provided directly, or referred for, more extensive risk reduction counseling by a DSHS HIV/STD program trained risk reduction specialist. To find a DSHS HIV/STD program contractor, visit the DSHS HIV/STD website.

 

4334 Resources

Revision 20-0; Effective November 2019

 

 

4340 Expedited Partner Therapy

Revision 20-0; Effective November 2019

 

Expedited Partner Therapy (EPT) is the clinical practice of treating the sex partners of clients diagnosed with chlamydia or gonorrhea by providing prescriptions or medications to the client to take to their partner without the health care provider first examining the partner.

The Texas Administrative Code, Title 22, §190.8(1)(L)(ii) allows the use of EPT for sexually transmitted infection (STI) treatment. HHSC endorses the CDC recommendations for EPT. Clinic sites implementing EPT should develop necessary policies, procedures and standing delegation orders (SDOs) to reflect the CDC guidelines. For more information on implementing EPT, see the DSHS HIV/STD website.

 

4350 Radiology Procedures

Revision 20-0; Effective November 2019

 

PHC clients must be provided appropriate radiologic tests, to include the technical procedure and the interpretation of the x-ray, as indicated by history and clinical assessment related to the current reason for a visit. If a provider is unable to provide radiological services on-site, the provider must have a Memorandum of Understanding (MOU) with another provider and make the services available through referral.

 

4400 Family Planning Services

Revision 20-0; Effective November 2019

 

 

 

4410 Contraceptive Method Counseling

Revision 20-0; Effective November 2019

 

Clients being provided contraceptive method specific information must receive individualized dialogue that covers:

Providers are encouraged to present the most effective methods of contraception first, before presenting information on less effective methods. This information should state that long-acting reversible contraception (LARC) methods are safe and effective for most women, including those who have never given birth. A visual depiction of contraceptive methods arranged in order of typical effectiveness can be found on the CDC website.

LARCs, i.e., intrauterine devices (IUDs) and implants, have definite benefits related to client contraceptive effectiveness, client convenience and long-term costs. Contractors should discuss and offer these methods for consideration to all women, as medically appropriate. As with all methods, the client’s preference after receiving unbiased, factual, nondirective education should be respected.

A specific contraceptive method that requires additional clinical expertise outside the training of the PHC contractor clinicians (i.e., sterilization) may be provided by referral.

If a contractor provides a method or service by referral, the method or service must be provided to clients at the referral site at no fee or at the same discounted client fee that would be charged if the method or service were provided on-site. The referring site must have a written agreement with the referral site to provide the method or service to clients under this condition.

Sterilization procedures, when performed or arranged for by the contractor, must comply with consent requirements for sterilization of persons in federally assisted family planning projects. The federally mandated consent form is necessary for both abdominal and transcervical sterilization procedures in women and vasectomy in men (see Section 4210, Procedure Specific Informed Consent).

Note: Abortion is not considered a method of family planning and no state funds appropriated to the department shall be used to pay the direct or indirect costs (including overhead, rent, phones and utilities) of abortion procedures provided by contractors.

Personnel at contractors’ clinics must be informed that they may be subject to prosecution under federal law if they coerce, or endeavor to coerce, any person to undergo an abortion or sterilization procedure (Section 205 of Public Law 94-63).

 

4420 Counseling Adolescents

Revision 20-0; Effective November 2019

 

Adolescents age 17 and younger must be provided individualized family planning counseling and medical services that meet their specific needs. Appointments should be available to them for counseling and medical services as soon as possible. Contractors must address these issues in counseling adolescents:

 

4430 Referral and Follow-Up

Revision 20-0; Effective November 2019

 

Contractors should assist clients to meet identified primary health care needs, either directly or by referral. When services required as part of the HHSC PHC contract 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 assure that the client is charged no more than the appropriately assessed co-pay fee.

Contractors 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 clients’ concerns for confidentiality and privacy and must comply with state or federal requirements for the transfer of health information.

Before a contractor can consider a client as “lost to follow-up,” the contractor must have at least three documented separate attempts to contact the client. The provider must comply with state and local sexually transmitted infection (STI) reporting requirements.

For services determined to be necessary, but which are not provided by the contractor, clients must be referred to other resources for care. Contractors are expected to have established communications with Federally Qualified Health Centers (FQHCs) or HHSC funded organizations that provide breast cancer and cervical cancer services for referral purposes, if there are any such providers within their service area. Whenever possible, clients should be given a choice of referral resources from which to select.

When a client is referred to another resource because of an abnormal finding or for emergency clinical care, the contractor must:

Health services available through HHSC Office of Primary and Specialty Health (OPSH) can be found by searching the OPSH Service Locator.

Clients who have abnormal clinical breast exam (CBE) or cervical cytology findings may be scheduled to return for repeat exams if this is considered appropriate follow-up by the clinician. For clients whose cervical cytology test or CBE result in an abnormal finding that requires referral for services beyond those available through primary health care, contractors are encouraged, whenever possible, to refer the client to an HHSC Breast and Cervical Cancer Services (BCCS) contractor. In order to promote the most effective use of limited resources, PHC contractors’ clinicians should be familiar with nationally recognized guidelines and algorithms describing recommended practice regarding abnormal cervical cytology and CBE results.

 

4440 Perinatal Clinical Policy

Revision 20-0; Effective November 2019

 

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

 

4450 State Requirements for Health Care Professionals Regarding Information that Must Be Provided to Parents

Revision 20-0; Effective November 2019

 

 

 

4451 Information for Parents of Newborns Requirement

Revision 20-0; Effective November 2019

 

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 client'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 Newborns
English (Revised Jan. 2016)
Spanish (Revised Feb 2016)

 

4452 Information for Parents of Children

Revision 20-0; Effective November 2019

 

Chapter 161, Health and Safety Code, Subchapter T 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.

A Parent’s Guide to Raising Healthy, Happy Children is available through Texans Care for Children.

 

4460 Dental Clinical Policy

Revision 20-0; Effective November 2019

 

Dental services should be provided based on American Dental Association (ADA) guidelines.

 

4500 Prescriptive Authority Agreements, Clinical Protocols, Standing Delegation Orders and Client Education

Revision 20-0; Effective November 2019

 

Contractors that provide clinical services must develop and maintain written clinical prescriptive authority agreements (PAAs), protocols and standing delegation orders (SDOs) in compliance with statutes and rules governing medical, dental and nursing practice, and consistent with national evidence-based clinical guidelines. When HHSC revises a policy, contractors need to incorporate the revised policy into their written procedures.

 

4510 Prescriptive Authority Agreements

Revision 20-0; Effective November 2019

 

Contractors who delegate the act of prescribing or ordering a drug or device to an advanced practice registered nurse(s) and/or physician assistant(s) must have in place a prescriptive authority agreement (PAA), as required by Texas Administrative Code Title 22, Part 9, Chapter 193. The PAA must meet all the requirements delineated in the Texas Medical Practice Act, Chapter 157, including, but not limited to, the following minimum criteria:

 

4520 Protocols

Revision 20-0; Effective November 2019

 

Contractors that employ advanced practice registered nurses or physician assistants must have written protocols to delegate authorization to initiate medical aspects of client care. Historically, this delegation has occurred through a protocol or other written authorization. Rather than have two documents, this delegation can now be included in a prescriptive authority agreement (PAA) if both parties agree to do so. The PAA and/or protocols need not describe the exact steps that an advanced practice registered nurse or a physician assistant must take with respect to each specific condition, disease or symptom.

The protocols must be reviewed, agreed upon, signed and dated by the supervising physician and the physician assistant and/or advanced practice registered nurse at least annually and maintained on-site.

 

4530 Standing Delegation Orders

Revision 20-0; Effective November 2019

 

When services are provided by unlicensed and licensed personnel, other than advanced practice registered 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 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: 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.

 

4540 Client Education

Revision 20-0; Effective November 2019

 

In addition to the above, contractors must have written plans for client education that includes goals and content outlines to ensure consistency and accuracy of the information provided. Contractors’ plans for client education must be reviewed and signed by the clinic medical director.

 

4550 Resources

Revision 20-0; Effective November 2019

 

Requirements addressing the scope of practice and delegation of medical and nursing acts can be accessed at the following websites:

Rules that are most pertinent to this topic are:

5000, Reimbursement, Data Collection and Reporting

Revision 20-1; Effective May 8, 2020

 

PHC services contract amounts are ceilings against which contractors may bill for services provided to PHC eligible clients. Once this ceiling has been reached, no further funds will be available for reimbursement. Contractors may only bill for services provided to clients who have been screened for potential Medicaid and other benefit programs and been determined PHC eligible.

 

5100 Categorical Reimbursement

Revision 20-0; Effective November 2019

 

PHC categorical funding (cost reimbursement) is used to develop and maintain contractor infrastructure for the provision of primary health 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. All services will be reimbursed on a cost reimbursement basis. Payments will be made for costs incurred and will be supported by reporting to show services provided and limited client-level data. Costs may be assessed against any of the following categories the contractor identifies during their budget development process:

PHC funds are 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 clients (client co-pay).

 

5110 Monthly Billing and Reporting

Revision 20-0; Effective November 2019

 

Categorical reimbursement for the cost of providing services shall be billed monthly on Form 4116, State of Texas Purchase Voucher, and submitted to the contact(s) outlined in the instructions for the form. Each request will cover services provided, or expenses incurred, in the preceding month, as applicable to the contract attachment. Requests should be submitted within 30 days of the end of the preceding month and within 60 days of providing the service. Appropriate financial records must be maintained for review by HHSC through the quality assurance review process and/or fiscal monitoring and/or programmatic desk reviews.

A monthly PHC Reporting Form 225 must be submitted with the monthly voucher, within 30 days following the end of the month covered by the bill. Reimbursement requests submitted without the required program reports will not be approved for payment. Vouchers and/or reports submitted with incorrect or missing information will be rejected and the contractor will be contacted to remedy the problem.

 

5120 Submission of Vouchers

Revision 20-1; Effective May 8, 2020

 

If expenses are overstated on one month’s voucher, the following month’s expenses should be reduced accordingly. All claims for reimbursement for services delivered must be submitted within 45 days of the end of the contract term. If contractors have services that occurred during the contract period left to bill after the August Form 4116, State of Texas Purchase Voucher, has been submitted, contractors can bill those services using Form 4116 and a PHC Reporting Form 225, marked “Supplemental” and “Final,” and submit the forms on or before October 15. PHC contracts require closure of the contract attachment within 45 days of the end of the contract term. All requests for reimbursement must be submitted by email to HDS.ADS@hhsc.state.tx.us and PHCReports@hhsc.state.tx.us.

Form 4116 must be submitted via email to the email address provided on the form. Requests received more than 45 days following the end of the Contract Attachment will not be paid. A signed final Financial Status Report (Form 269A) must be submitted by email to the email address on the form no later than 45 days after the contract term. Form 269A must be marked as “Final” and include all reimbursements and adjustments in payments for the contract term.

 

5130 Voucher Submission and Reporting after Entire Contract Award is Expended

Revision 20-0; Effective November 2019

 

Contractors must continue to submit Form 4116, State of Texas Purchase Voucher, and supporting monthly program reports even after contract ceilings have been reached. Any cost over the contract ceiling after deducting program income should be reflected under “Non-HHSC Funding” on Form 4116 and on the Financial Status Report (Form 269A). This submission is required to continue reporting expenditures on any program income collected monthly and to provide HHSC with statistical information about the use of services.

 

5140 Non-Reimbursable Expenditures

Revision 20-0; Effective November 2019

 

PHC will not reimburse services for individuals enrolled in another program or clients who do not complete the respective eligibility process, except for clients who meet the presumptive eligibility criteria. Payment for clients who were treated under presumptive eligibility may be eligible for services only during the 90-day time period. If clients fail to fully comply with all requirements to apply for Medicaid services, they will not be considered eligible for PHC services after the presumptive time period expires.

 

5150 Reimbursable Expenditures

Revision 20-0; Effective November 2019

 

Services may be provided to clients whose screening results indicate they are potentially Medicaid eligible, but the client has not yet completed the application process. Except for presumptive eligibility, services provided on the initial day of service may be billed to PHC for reimbursement with proper documentation of the client’s eligibility status.

 

5160 Altering of Forms

Revision 20-0; Effective November 2019

 

Contractors are required to use the most current version of their organization’s personalized Form 4116, State of Texas Purchase Voucher, for ease of processing. None of the billing or the reporting forms may be altered in any manner. The vouchers should not be altered to itemize expenses for PHC services provided. Vouchers should be submitted for the total monthly reimbursement amount only.

 

5200 Data Collection and Reporting

Revision 20-0; Effective November 2019

 

The table below outlines the data collection and reporting requirements for HHSC PHC Services Program Contractors.

Program Information
Program Name: Primary Health Care (PHC)
Contract Type: Categorical
Contract Term: September 1 through August 31
Required Form Type: Voucher 1
Name: Form 4116, State of Texas Purchase Voucher
Submission Date: By the last business day of the following month. Final voucher due within 45 days after the end of the contract term.
Submit Copy To: HDS.ADS@hhsc.state.tx.us
PHCReports@hhsc.state.tx.us
Original Signature Required: No
Accepted Method of Submission: Email
No. of Copies: 1
Instructions: Submit Form 4116 to Health and Developmental Services (HDS)
Note: Form 4116 and PHC Reporting Form 225 must be submitted at the same time to the HDS email box. Form 4116 will not be processed unless the PHC Reporting Form 225 is received with Form 4116. All forms must be submitted in their original format in the same email. No exceptions.

 

Program Information
Program Name: Primary Health Care (PHC)
Contract Type: Categorical
Contract Term: September 1 through August 31
Required Form Type: Report 1 - Supporting
Name: PHC Reporting Form 225 Monthly Report
Submission Date: By the last business day of the following month. Final report due within 45 days after the end of the contract term.
Submit Copy To: HDS.ADS@hhsc.state.tx.us
PHCReports@hhsc.state.tx.us
Original Signature Required: No
Accepted Method of Submission: Email
No. of Copies: 1
Instructions: Submit Form 4116 to Health and Developmental Services (HDS)
Note: Form 4116 and PHC Reporting Form 225 must be submitted at the same time to the HDS email box. Form 4116 will not be processed unless the PHC Reporting Form 225 is received within Form 4116. All forms must be submitted in their original format in the same email. No exceptions.

 

Program Information
Program Name: Primary Health Care (PHC)
Contract Type: Categorical
Contract Term: September 1 through August 31
Required Form Type: Report 1
Name: Financial Status Report 269A
Submission Date: Quarterly, Sept. 1-Nov. 30, Dec. 1-Feb. 28, March 1-May 31, June 1-Aug. 31. Submit 30 days after the end of each quarter. The final quarterly Financial Status Report 269A 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: HDS.ADS@hhsc.state.tx.us
PHCReports@hhsc.state.tx.us
Original Signature Required: Yes
Accepted Method of Submission: Email scanned document
No. of Copies: 1
Instructions: Submit one Financial Status Report 269A with an original signature (signed and scanned in email accepted).

 

Program Information
Program Name: Primary Health Care (PHC)
Contract Type: Categorical
Contract Term: September 1 through August 31
Required Form Type: Report 2
Name: PHC Annual Report
Submission Date: Within 60 days following the end of the contract period.
Submit Copy To: HDS.ADS@hhsc.state.tx.us
PHCReports@hhsc.state.tx.us
Original Signature Required: No
Accepted Method of Submission: Email
Instructions: Submit PHC Annual Report to Health and Developmental Services (HDS).

Appendices

Appendix I, Definition of Income

11-2019

 

For information about document accessibility, contact accessibility@hhsc.state.tx.us.

Definition of Income

Appendix II, Optional Co-Pay Table Based on Monthly Federal Poverty Level (FPL)

Revision 20-1; Effective May 8, 2020

 

For information about document accessibility, contact accessibility@hhsc.state.tx.us.

Optional Co-Pay Table Based on Monthly Federal Poverty Level (FPL)

Forms

ES = Spanish version available.

 

Form Title  
3029 Office of Primary and Specialty Health Application for Program Benefits ES
3045 Office of Primary and Specialty Health Presumptive Eligibility Notice ES
3046 Office of Primary and Specialty Health Statement of Applicant’s Rights and Responsibilities ES
3047 Office of Primary and Specialty Health Notice of Ineligibility ES
3048 Office of Primary and Specialty Health Notice of Eligibility ES
3049 Office of Primary and Specialty Health Employment Verification ES
3051 Office of Primary and Specialty Health Statement of Self-Employment Income ES
3056 Office of Primary and Specialty Health Request for Information ES
4116 State of Texas Purchase Voucher ES

Policy Revisions

20-1, Miscellaneous Changes

Revision 20-1; Effective May 8, 2020

 

The following change(s) were made:

Revised Title Change
1000 Purpose and Contact Information Adds a reference to the SharePoint Contractor Portal.
2300 Definitions Updates the definition for Fiscal Year, changes Payor to Payer, and adds Telehealth Service and Telemedicine Medical Service.
2600 Abuse and Neglect Reporting Adds Texas Health and Human Services agencies may only provide funds to contractors/providers who show good faith efforts to comply with all child abuse reporting guidelines and requirements set forth in Chapter 261 of the Texas Family Code.
3400 Emergency Responsiveness Moves the information previously in Section 4600 explaining HHSC contractors are required to have an emergency preparedness plan with written policies and procedures that address emergency situations.
3410 Clinical Emergencies Moves the information previously in Section 4610 citing how contractors must be adequately prepared to handle clinical emergency situations.
3420 Emergency Preparedness Moves the information previously in Section 4620 that there must be a written safety plan that includes maintenance of fire safety equipment, an emergency evacuation plan and a disaster response plan.
3500 Quality Management Moves the information previously in Section 3400.
4000 Eligibility and Assessment of Co-pay and Fees Adds contractors must develop a policy to determine Primary Health Care (PHC) eligibility. The contractor must ensure documentation provides a clear understanding of the eligibility screening process and must perform an eligibility screening assessment on all clients who present for services. Adds forms used in completing the PHC eligibility process.
4100 Client Eligibility Screening Process Clarifies the criteria that must be met for an individual to receive PHC program services.
4110 Procedures and Terminology When Determining PHC Eligibility Changes the section title and clarifies for a client’s current eligibility status, contractors must enter two of the four data elements (Patient Control Number, Date of Birth, Social Security Number or Last Name).
4600 Emergency Responsiveness Deletes section as information is now in Section 3400.
4610 Clinical Emergencies Deletes section as information is now in Section 3410.
4620 Emergency Preparedness Deletes section as information is now in Section 3420.
5120 Submission of Vouchers Adds all requests for reimbursement must be submitted by email to HDS.ADS@hhsc.state.tx.us and PHCReports@hhsc.state.tx.us.
Appendix II Optional Co-Pay Table Based on Monthly Federal Poverty Level (FPL) Changes the title and updates the amounts.

 

20-0, Handbook Revised with New Format

Effective November 2019

 

The Primary Health Care Services Program Policy Manual is revised with a new format to guide contractors who deliver primary health care services in Texas.

Contact Us

For questions about the Primary Health Care Services Program Policy Manual, email PrimaryHealthCare@hhsc.state.tx.us.

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