Revision 23-2; Effective Sept. 15, 2023

Primary Health Care Services Program Background

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:

• A range of primary health care services shall be made available to the medically indigent residing in Texas.
• The Texas Health and Human Services Commission (HHSC) shall provide or contract to provide primary health care services to the medically indigent.
• These services should complement existing services or should be provided where there is a scarcity of services.
• Health education should be an integral component of all primary care services delivered to the medically indigent population.
• Preventive services should be marketed and made accessible to reduce the use of more expensive emergency room services.

Statute

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 Program administered by HHSC. The Act delineates the specific target population, eligibility, reporting and coordination requirements for PHC.

Rules

The state rules for PHC services in Texas can be found in the Texas Administrative Code (TAC), Title 26, Part 1, Chapter 364, Subchapter A. PHC program rules require that, at a minimum, a grantee 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
6. Laboratory, x-ray, nuclear medicine or other appropriate diagnostic services

PHC provides services through contracted providers (grantees) 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. Grantees 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.

Funding Sources

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 nonprofit 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 program services. 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.

Revision 23-2; Effective Sept. 15, 2023

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, copayment amount, etc.).

Client – A person who has been screened and determined to be eligible for the program. The term client and patient may be used interchangeably in other sources.

Confidentiality – The state of keeping information private and not sharing it without permission.

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

Consultation – A type of service provided by a health care provider with expertise in a medical or surgical specialty and who, upon request of another appropriate health care provider, assists with the evaluation or management of a patient.

Copayment or Copay – Money collected directly from clients for services.

Dental Services – Diagnostic, preventive, and therapeutic dental services that are provided to eligible individuals and are performed in a dental office or clinic. In the context of the Primary Health Care program, dental services are optional and are not included in the six required priority health services. 

Department of State Health Services (DSHS) – The agency responsible for administering physical and mental health-related prevention, treatment and regulatory programs for the state of Texas. 

Dependent Care Deduction – The expense of providing care for a dependent. This expense must be both necessary for employment and incurred by an employed person. Allowable deductions are actual expenses, up to $200 per month for each child under age 2 and $175 per month for each child age 2 or older.  

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 some or all the following:  Microscopic (culture), Chemical (blood tests), 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 other health professional.

Diagnostic Studies or Diagnostic Tests – Tests ordered by a health care practitioner to evaluate a client's health status for diagnostic purposes.

Eligibility Date – Date the grantee or program administrator determines a person becomes eligible for the program.

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 – Educational or comprehensive medical activities that enable clients to freely determine the number and spacing of their children and select how this may be achieved.

Federal Poverty Level (FPL) – The set minimum amount of income that a family needs for food, clothing, transportation, shelter and other necessities. In the United States, this level is determined by the Department of Health and Human Services. FPL varies according to family size. The number is adjusted for inflation and reported annually in the Federal Poverty Guidelines . Public assistance programs, such as Medicaid, define eligibility income limits in terms of a percentage of FPL.

Fiscal Year – The state fiscal year is from Sept. 1 through Aug. 31. The federal fiscal year is from Oct. 1 through Sept. 30.

Grantee – A non-state entity that receives an award directly from the state awarding agency to carry out an activity under a state program. The term grantee does not include subgrantees. 

Health and Human Services Commission (HHSC) – The Texas administrative agency established under Chapter 531, Texas Government Code, or its designee. HHSC manages programs that help families with food, health care, safety and disaster services.

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

Minor – In accordance with the Texas Family Code, a person under 18 years old who is not and has not been married or who has not had the disabilities of minority removed for general purposes (i.e., emancipated). 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.

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

Preventive Health Care – Services include, but are not limited to the following: 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 or disability. 

Program Income – Money collected directly by the grantee, subgrantee or provider for services provided under the grant award (i.e., third-party reimbursements, such as Title XIX, private insurance and patient copay 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 person) to an appropriate specialist or agency for information, help or treatment.

Subgrantee— A non-state entity that receives a subaward from a pass-through entity to carry out part of a state program; but does not include an individual that is a beneficiary of such a program. A subgrantee may also be a grantee of other state awards directly from a state awarding agency. A subgrantee may also be referred to as a subrecipient.

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).