Revision 20-2; Effective October 15, 2020

 

2100 Program Authorization and Services

Revision 20-2; Effective October 15, 2020

 

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 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.

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 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 through contracted providers 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.

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.

 

2200 Definitions

Revision 20-2; Effective October 15, 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 12 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).