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:

  • 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 and/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.

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:

  • Have a policy in place that delineates the timely provision of services;
  • Have policies in place to identify and eliminate possible barriers to client care;
  • Comply with all applicable civil rights laws and regulations, including Title VI of the Civil Rights Act of 1964, the Americans with Disabilities Act (ADA) of 1990, the Age Discrimination Act of 1975 and Section 504 of the Rehabilitation Act of 1973, and ensure services are accessible to persons with Limited English Proficiency (LEP) and speech or sensory impairments;
  • Have a policy in place that requires qualified staff to assess and prioritize client needs;
  • Provide referral resources for individuals that cannot be served or cannot receive a specific needed service;
  • Manage funds to ensure that established clients continue to receive services throughout the budget year, even after allocated funds are expended;
  • Ensure that family planning services are provided to clients in a timely manner, preferably within 30 days of the request for services. Clients who request contraception but cannot be immediately provided a clinical appointment must be offered a nonprescription method; and
  • Ensure clinic/reception room wait times are reasonable so as not to represent a barrier to care.

 

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:

  • How child abuse reporting requirements will be implemented throughout their agency;
  • How staff will be trained; and
  • How internal monitoring will be done to ensure timely reporting.

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

  • The contractor's process to ensure that staff is reporting child abuse, as required by Chapter 261. To verify compliance, contract monitors will review that the contractor:
    • has an internal policy which details how the contractor will determine, document, report and track instances of abuse, sexual or nonsexual, for all individuals under the age of 17 in compliance with the Texas Family Code, Chapter 261; 
    • followed their internal policy; and
    • documented staff training on child abuse reporting requirements and procedures.
  • The contractor’s internal policy must clearly describe the reporting process for child abuse.

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:

  • Sign a written assurance to comply with applicable federal and state nondiscrimination laws and regulations;
  • Have a written policy that states the agency does not discriminate on race, color, national origin, including limited English proficiency (LEP), sex, age, religion, disability or sexual orientation;
  • Have a policy that addresses individual rights and responsibilities that is applicable to all individuals requesting family planning services;
  • Have procedures for notifying the HHSC Civil Rights Office of any program or service-related discrimination allegation or complaint no more than 10 calendar days of the allegation or complaint;
  • Ensure that all contractor staff is trained in the contractor’s nondiscrimination policies, including policies for serving individuals with LEP and individuals with disabilities, and HHSC complaint procedures;
  • Notify all individuals who are applying for family planning services of the contractor’s nondiscrimination policies and complaint procedures; and
  • Prominently display civil rights posters in common areas, including lobbies and waiting rooms, front reception desk and locations where individuals apply for services. Posters can be found on the Civil Rights Office website.

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.