Revision 19-0; Effective September 1, 2019

 

 

1100 Purpose and Program Background

Revision 19-0; Effective September 1, 2019

 

This manual is a guide for contractors who deliver women’s health and family planning services in Texas through the Healthy Texas Women (HTW) Program. It has been structured to provide contractor staff with information needed to comply with program requirements and only applies to HTW cost reimbursement contractors. Federal and state laws related to reporting abuse, operation of health facilities, professional practice, insurance coverage and similar topics also impact women’s health and family planning services. Contractors are required to be aware of, and comply with, current laws. In

December 2014, the Sunset Commission directed Texas Health and Human Services Commission (HHSC) and Texas Department of State Health Services (DSHS) to consolidate the Texas Women’s Health and Expanded Primary Care Programs at HHSC, while leaving the Family Planning Program unchanged. The Sunset Commission also directed the agencies to move funding for all women’s health programs under a single budget strategy, allowing for implementation of a consolidated women’s health program. On July 1, 2016, a new and consolidated program launched as the Healthy Texas Women Program under the direction of HHSC. The new HTW Program is a successor program to the Texas Women’s Health Program and the former Medicaid Women’s Health Program, and is therefore subject to Texas Human Resources Code §32.024(c-1).

 

1200 Reimbursement

Revision 19-0; Effective September 1, 2019

 

The HTW Program includes a fee-for-service component as well as a cost reimbursement component. The HTW fee-for-service component is patterned after the previous Texas Women’s Health Program. Clients can apply online or by mailing or faxing a paper copy of their application. Fee-for-service claims are processed by the Texas Medicaid & Healthcare Partnership (TMHP). Benefits for the HTW Fee-for-Service Program include, but are not limited to:

  • Pelvic examinations;
  • Contraceptive services (pregnancy prevention and birth spacing);
  • Pregnancy testing and counseling;
  • Sexually transmitted infection (STI) services;
  • Breast and cervical cancer screenings and diagnostic services;
  • Immunizations; • Cervical dysplasia treatment; and
  • Other preventive services.

The HTW Cost Reimbursement Program provides funds to agencies that support the overall outcomes of clients served through the HTW Fee-for-Service Program. These funds may be used for support services that enhance HTW fee-for-service client service delivery. Activities must include:

  • Assisting clients with enrollment into the HTW Program;
  • Client and community-based educational activities related to HTW;
  • Staff development and training related to HTW service delivery;
  • Direct clinical care for clients deemed presumptively eligible for the HTW Program; or
  • Upon approval by HHSC, other activities that will enhance HTW service delivery including the purchase of equipment and supplies to support the project.

 

1300 Rules

Revision 19-0; Effective September 1, 2019

 

State rules for HTW services are found in Texas Administrative Code (TAC), Title 1, Part 15, Chapter 382, Subchapter A.

 

1400 Definitions

Revision 19-0; Effective September 1, 2019

 

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

Applicant – A female applying to receive services under HTW, including a current client who is renewing her application.

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

Case Management – An individualized approach for each person. Case management is a broad category that fits within the larger field of human services. Generally, case management involves coordination of care, advocacy and discharge planning. Case management aims to assist clients to navigate social service systems and attain the highest quality of care; however, counseling and therapeutic support may also be offered.

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

Community Assessment – Tool used to identify factors that affect the health of a population and to determine the availability of resources within the community to impact these factors.

Community Health Worker (CHW) – A person who, with or without compensation, is a liaison and provides cultural mediation between health care and social services and the community. A CHW is a trusted member of the community who:

  • understands the ethnicity, language, socio-economic status and life experiences of the community served;
  • assists people with gaining access to needed services;
  • increases health knowledge and self-sufficiency through a range of activities such as outreach, client navigation and follow-up to community health education and information, informal counseling, social support, advocacy and participation in clinical research; and
  • is a person with current certification as a community health worker issued by DSHS.

Contraceptive Methods – A broad range of birth control options, approved by the United States Food and Drug Administration, except for emergency contraception.

Contractor – An entity that HHSC 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 (Co-pay) – Monies collected directly from clients for services.

Core Tool – A standardized instrument used to review contractors to ensure compliance with basic requirements for operating a clinic providing health services, as reflected in DSHS Standards for Public Health Clinic Services.

DSHS – Texas Department of State Health Services oversees public health services; funds local health departments; operates the state’s center for infectious disease and public health laboratory; provides services for persons with infectious diseases and specific health conditions; and regulates consumer services and products.

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 (i.e., x-rays).

Diagnostic Services – Activities related to the diagnosis made by a physician, advanced practice nurse or physician assistant, 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 a client’s health status for diagnostic purposes.

Documented Immigrant – A non-U.S. citizen with a valid immigration document.

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

Eligible Immigrant – A qualified alien of the U.S. with 40 countable qualifying quarters or earnings, if five years have passed since the legal date of entry as outlined in the Texas Administrative Code (TAC) Title 1, Part 15, Chapter 382, Subchapter A. The applicant must meet the residency standards defined in 1 TAC §366.513.

Expanded Primary Health Care (EPHC) – A state-funded health care program that provided primary, preventive and screening services to women, age 18 and older, who were at or below 200 percent of the federal poverty level (FPL) and were unable to access the same care through other programs. These services were made available at participating clinic sites throughout the state and were intended to increase the number of women receiving primary and preventive care services; increase early detection of breast and cervical cancers; avert unintended Medicaid births; reduce the number of preterm births; and reduce the number of cases of potentially preventable hospitalizations related to hypertension and diabetes. This program ended August 31, 2016, and transitioned to the HTW Program.

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 Program (FPP) – A non-Medicaid program used to provide family planning services to low-income women and men who are Texas residents.

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

Federal Poverty Level (FPL) – The household income guidelines issued annually and published in the Federal Register by the United States Department of Health and Human Services.

Fee-for-Service – Payment mechanism for services that are reimbursed on a set rate per unit of service (also known as unit rate). Fiscal Year (FY) – State fiscal year, September 1 through August 31.

HHSC – Texas Health and Human Services Commission provides oversight and support for the Health and Human Services agencies; administers the state’s Medicaid and other client service programs; sets policies; defines covered benefits; and determines client eligibility for major programs.

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

Health Service Region (HSR) – Counties grouped within a specified geographic area throughout the state.

Healthy Texas Women (HTW) – HTW is a state-funded program administered by HHSC to provide uninsured women with women’s health and family planning services such as women’s health exams, health screenings and birth control. HTW providers must provide client services on a fee-for-service basis and may also, but are not required to, contract with HHSC to provide support services that enhance the HTW fee-for-service client delivery on a cost reimbursement basis.

HTW Cost Reimbursement – The funding mechanism for qualified agencies that support the overall outcomes of client provided services through the HTW fee-for-service program. These funds may be used for support services that enhance HTW fee-for-service client service delivery.

HTW Fee-for-Service – Women’s health and family planning client services provided through the HTW Program on a fee-for-service basis through the TMHP system.

HTW Provider – A health care provider that performs covered HTW services. An HTW provider’s agency may be contracted with HHSC to receive additional funding to support the HTW Fee-for-Service Program.

Informed Consent – The process by which a health care provider ensures that the benefits and risks of a diagnostic or treatment plan, the benefits and risks of other appropriate options, and the benefits and risks of taking no action are explained to a patient in a manner that is understandable to that patient and allows the patient to participate and make sound decisions regarding his or her own medical care.

Laboratory (Lab) – Facility that measures or examines materials derived from the human body for providing information on diagnosis, monitoring, prevention or treatment of disease.

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

Medicaid – The Texas Medical Assistance Program, a joint federal and state program provided in Texas Human Resources Code Chapter 32 and subject to Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq.

Minor – In accordance with the Texas Family Code, a person under 18 years of age who has never been married and never been declared an adult by a court (emancipated).

Nutritional Services – The provision of services to identify the client’s nutritional status, and instruction which includes appropriate dietary information based on the client’s needs (i.e., age, sex, health status, culture). Information may be provided on a one-on-one basis or to a group.

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

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

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

Presumptive Eligibility – Temporary eligibility that grants access to health care services (up to 90 days) when the client screens potentially eligible for services but the client’s application has not been processed and approved yet by HHSC.

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 or provider for services provided under the categorical contract award and revenue from HTW fee-for-service.

Readiness – Respondent has the specified attributes to support a given service, the ability to meet program and contractual requirements, and the capacity to achieve service levels based on awarded funds.

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.

Referral Agency – An agency that will provide a service for the client that the contractor or one of its subcontractors does not provide.

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

Service – Any client encounter at a facility that results in the client having a medical or health-related need met.

Social Services – The provision of counseling and guidance, assistance to the client and family in locating, accessing and utilizing appropriate community resources.

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

Texas Resident – A person who resides within the geographic boundaries of the state for at least one year.

Unduplicated Individual – Clients enrolled in the HTW Program are counted only one time during the program’s fiscal year, regardless of the number of visits, encounters or services they receive (e.g., one person seen four times during the year is counted as one unduplicated client).

 

1500 Acronyms

Revision 19-0; Effective September 1, 2019

 

Acronym Full Name
ADA Americans with Disabilities Act
BCCS Breast and Cervical Cancer Services
CAD Computer Aided Detection
CAM Complementary and Alternative Medications
CAP Corrective Action Plan
CBE Clinical Breast Exam
CD Cervical Dysplasia
CDC Centers for Disease Control and Prevention
CDSB Contract Development and Support Branch
CHIP Children’s Health Insurance Program
CHW Community Health Worker
CIHCP County Indigent Health Care Program
CLIA Clinical Laboratory Improvement Amendments
CMS Centers for Medicare and Medicaid Services
CPR Cardiopulmonary Resuscitation
CPT Current Procedure Terminology
DES Diethylstilbestrol
DHHS U.S. Department of Health and Human Services
DSHS Texas Department of State Health Services
ECC Endocervical Curettage
EDI Electronic Data Interchange
EHR Electronic Health Record
E/M Evaluation and Management Services
EMR Electronic Medical Record
EOB Explanation of Benefits
EPHC Expanded Primary Health Care
EPT Expedited Partner Therapy
FDA Federal Drug Administration
FFS Fee-for-Service
FP Family Planning
FPL Federal Poverty Level
FQHC Federally Qualified Health Center
FSR Financial Status Report
HIPAA Health Insurance Portability and Accountability Act of 1996
HHSC Texas Health and Human Services Commission
HPV Human Papillomavirus
HSR Health Service Region
HSV Herpes Simplex Virus
HTW Healthy Texas Women
IPV Intimate Partner Violence
IRB Institutional Review Board
IUC Intrauterine Contraception
IUD Intrauterine Device
LARC Long-Acting Reversible Contraceptive
LEP Limited English Proficiency
MBCC Medicaid for Breast and Cervical Cancer
MCH Maternal and Child Health Services
MRI Magnetic Resonance Imaging
NBCCEDP National Breast and Cervical Cancer Early Detection Program
NPI National Provider Identifier
NIPPES National Plan and Provider Numeration System
OTC Over the Counter
PHC Primary Health Care
QA Quality Assurance
QM Quality Management
RFP Request for Proposal
RSDI Retirement, Survivors, and Disability Insurance
SDO Standing Delegation Orders
SSA Social Security Administration
SSDI Social Security Disability Income
SSI Supplemental Security Income
STI Sexually Transmitted Infection
TAC Texas Administrative Code
TANF Temporary Assistance for Needy Families
TMHP Texas Medicaid & Healthcare Partnership
TMPPM Texas Medicaid Provider Procedures Manual
TPI Texas Provider Identifier
TWHP Texas Women’s Health Program
USPSTF United States Preventive Services Task Force
WIC Special Supplemental Nutrition Program for Women, Infants and Children
VDP &Vendor Drug Program