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:

  • Form 3056, Office of Primary and Specialty Health Request for Information;
  • Form 3049, Office of Primary and Specialty Health (OPSH) Employment Verification; and
  • Form 3051, Office of Primary and Specialty Health Statement of Self-Employment Income.

 

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:

  • Gross family income at or below 200% of the Federal Poverty Level (FPL);
  • Texas resident; and
  • Not eligible for other programs/benefits providing the same services.

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:

  • Persons who are legally married (including common-law marriage);
  • A legal parent and a minor child (including unborn children); or
  • A managing conservator and a minor child. A managing conservator is a person designated by a court to have daily legal responsibility for a child.

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:

  • Weekly income is multiplied by 4.33;
  • Income received every two weeks is multiplied by 2.17; and
  • Income received twice monthly is multiplied by 2.

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:

  • No PHC client shall be denied services based on an inability to pay.
  • Clients with a household FPL at or below 100% should not be charged a co-pay.
  • Contractors may charge a co-pay amount ranging from $10 up to a maximum of $30 per encounter for clients above 100% of the FPL.
  • Individuals who are assessed a co-pay should be presented with the bill at the time of service.
  • If attempts to collect a co-pay creates a barrier to care, or if a client self-declares an inability to pay, the contractor must waive the fee(s) owed.
  • Client co-pays must be reported as program income on the monthly Form 4116, State of Texas Purchase Voucher, and the quarterly Financial Status Report (FSR) or Form 269a.
  • Appendix II, Optional Co-Pay Table Based on Monthly Federal Poverty Level (FPL), is for contractor use to determine a PHC household’s FPL and is updated annually when the revised Federal Poverty Income Guidelines are released.
  • Contractors must have policies and procedures regarding fee collection, which must be approved by the contractor’s Board of Directors.
  • Client co-pays collected by the contractor are considered program income and must be used to support the delivery of HHSC PHC services.

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:

  • Form 3045, Office of Primary and Specialty Health Presumptive Eligibility Notice
  • Form 3048, Office of Primary and Specialty Health Notice of Eligibility
  • Form 3047, Office of Primary and Specialty Health Notice of Ineligibility

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:

  • §81.105, regarding Informed Consent; and
  • §81.106, regarding General Consent.

 

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).

  • Physician Services – Services must be medically necessary and provided by a physician in the doctor's office, clinic or facility other than a hospital setting.
  • Physician Assistant (PA) Services – These services must be medically necessary and provided by a PA under the direction of a physician and may be billed by, and paid to, the supervising physician.
  • Advanced Practice Nurse (APN) Services – An APN must be licensed as a registered nurse (RN) within the categories of practice, specifically a nurse practitioner, a clinical nurse specialist, a certified nurse midwife (CNM) and a certified registered nurse anesthetist (CRNA), as determined by the Board of Nurse Examiners. APN services must be medically necessary, provided within the scope of practice of an APN, and covered in the Texas Medicaid Program and under the direction of a physician.

 

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:

  • Health check-up and physical exam
  • Birth control methods (pills, IUD, condoms, shot, ring, etc.)
  • Natural family planning
  • Lab tests for:
    • Sexually transmitted infections (STIs)
    • Pregnancy testing
  • Counseling regarding:
    • Abstinence
    • Preconception counseling (planning for a healthy pregnancy)
    • Nutrition
    • Infertility

4. Preventive Health Services

Services that may be included are:

  • Immunizations – These services are provided in an appropriate setting for diseases that are preventable by vaccines.
  • Cancer screening services – These must be medically necessary and by clinical recommendation and include:
    • Clinical breast examinations;
    • Mammograms;
    • Pelvic examinations; and
    • Cervical cancer screening.
  • Screenings for chronic conditions – These may include screenings for hypertension, diabetes and other chronic conditions, as indicated.
  • Health screening – This is to determine the need for intervention and possibly a more comprehensive evaluation. Health screenings may include taking a personal and family health history and performing a physical examination, laboratory tests or radiological examination, and may be followed by counseling, education, referral or further testing. Examples of these services include blood pressure, blood sugar and cholesterol screening.

 

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:

  • Complete, legible and accurate documentation of all client encounters, including those by phone, email or text message;
  • Written in ink without erasures or deletions, or documented in the electronic medical record (EMR) or electronic health record (EHR);
  • Signed by the provider making the entry, including the name of the provider, the provider’s title and the date for each entry;
    • Electronic signatures are allowable to document the encounter and/or provider review of care.  
    • Stamped signatures are not allowable.
  • Readily accessible to assure continuity of care and availability to clients; and
  • Systematically organized to allow easy documentation and prompt retrieval of information.

All client health records must include:

  • Client identification and personal data, including financial eligibility;
  • The client’s preferred language and method of communication;
  • Client contact information, including the best way and alternate ways to reach the client to ensure continuity of care, confidentiality and compliance with HIPAA regulations;
  • A complete medication list, including prescription and nonprescription medications, as well as dietary supplements, updated at each encounter;
  • A complete listing of all medication allergies and adverse reactions, displayed prominently in the record and updated at each encounter, and if the patient has no known allergies, this should be properly noted;
  • Allergies and sensitivities to foods and environmental substances (e.g., latex, seafood, etc.) displayed prominently in the record and updated at each encounter;
  • A plan of care, updated as appropriate, consistent with diagnoses and assessments, which in turn are consistent with clinical findings;
  • Documentation of recommended follow-up care, scheduled return visit dates and follow-up for missed appointments;
  • Documentation of informed consent or refusal of services;
  • Documentation of client education and counseling with attention to risks identified through the health risk assessment; and
  • At every visit, the record must be updated, as appropriate, documenting the reason for the visit, relevant history, physical exam findings, and pertinent screening and diagnostic tests with results and a treatment plan.

 

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:

  • Reason for the visit and current health status;
  • History of present illness, if indicated;
  • Past medical history to include all serious illnesses, hospitalizations, surgical procedures, pertinent biopsies, accidents, exposures to blood and blood products, and mental health history;
  • Immunization status/assessment [see Centers for Disease Control and Prevention (CDC) immunization schedules by age];
  • Rubella status (based on a history of rubella vaccination or documented rubella serology, nonpregnant female clients of childbearing age with unknown or inadequate rubella immunity must be provided vaccination on-site or referred appropriately). PHC contractors can voluntarily participate in the DSHS Adult Safety Net (ASN) Program or the Texas Vaccines for Children (TVFC). Both programs provide vaccines at no cost;
  • Review of systems with pertinent positives and negatives documented in the chart;
  • Current and past tobacco, alcohol and substance use/abuse;
  • Occupational and environmental hazard exposure;
  • Environmental safety (e.g., seat belt use, car seat use, bicycle helmets, etc.); nutritional and physical activity assessment and living arrangement;
  • Assessment for sexual and intimate partner violence (IPV) [Mandated by Texas Family Code, Chapter 261 and Rider 19] (for any positive result, the client should be offered referral to a family violence shelter in compliance with Texas Family Code, Chapter 91);
  • Pertinent family history;
  • Pertinent partner history, including injectable drug use, number of partners, STIs and HIV history, risk factors and gender of sexual partners;
  • Cervical and breast cancer screening history, noting any abnormal results and treatment, and dates of the most recent testing; and
  • A reproductive health history, as detailed below.

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

  • Menstrual history, including last normal menstrual period;
  • Pertinent sexual behavior history, including family planning practices (i.e., past and current contraceptive use), number of partners, gender of sexual partners, last sexual encounter and sexual abuse;
  • Obstetrical history;
  • Gynecological and urological conditions; and
  • STIs/STDs and HIV history, risks and exposure.

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

  • Pertinent sexual behavior history, including family planning practices (e.g., past and current contraceptive use), number of partners, gender of sexual partners, last sexual encounter and sexual abuse;
  • Genital and urologic conditions, as indicated; and
  • STIs/STDs and HIV history, risks and exposure.

 

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:

  • Height measurement;
  • Body mass index (BMI), waist measurement and/or other measurement to assess for underweight, overweight and obesity;
  • Blood pressure evaluation;
  • Cardiovascular assessment; and
  • Other systems, as indicated by history and health risk assessment (e.g., evaluation of thyroid, lungs and abdomen).

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

  • Height measurement annually until five years post menarche for females or annually until 20 years of age for males;
  • Weight measurement annually (to assess for underweight, overweight and obesity);
  • Blood pressure evaluation; and
  • Other systems, as indicated by history (e.g., evaluation of thyroid, heart, lungs and abdomen).

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):

  • Health history;
  • Health risk assessment;
  • Preventive health education to include anticipatory guidance, provided to parent(s) or the child, as appropriate;
  • Physical exam; and
  • Immunizations.

An episodic or acute care visit must include:

  • History of present illness;
  • Physical assessment focused on the presenting problem;
  • Laboratory tests based on the presenting problem; and
  • Interventions appropriate to current findings.

 

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:

  • Colorectal cancer screening, in individuals 50 years of age and older;
  • Cervical cancer screening for females age 21 years and older;
  • Human Papillomavirus (HPV) screening for female patients who are 21 years or older after an initial ASC-US Pap result*;
  • HIV screening**;
  • Sexually transmitted infection (STI) screening, per CDC guidelines;
  • Pregnancy test that must be provided on-site;
  • Rubella serology, if status is not previously established by client history and documented in the chart, either on-site or by referral; and
  • Other labs, such as blood glucose, lipid panel, thyroid stimulating hormone, etc., as indicated by the HRA, history and physical, either on-site or by referral.

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:

  • Tracking and documentation of tests ordered and performed for each client;
  • Tracking test results and documentation in each client’s record;
  • A mechanism to notify clients of results in a manner that ensures confidentiality, privacy and prompt, appropriate follow-up; and
  • The provider must comply with state and local STI reporting requirements.

*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:

  • Results of the physical exam and assessments;
  • Correct use of the contraceptive method(s) selected for personal use by the client, as well as possible side effects and complications;
  • Back up methods, including information about emergency contraception and discontinuation issues;
  • Scheduled revisits;
  • Access for urgent and emergency care, including a 24-hour emergency telephone number; and
  • Appropriate referral for additional services, as needed.

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:

  • All methods of contraception, including abstinence;
  • Discussion about contraceptive options and safer sex practices that reduce the risk of STI/HIV and pregnancy;
  • Identifying and resisting sexual coercion; and
  • Discussion about partner, dating, and/or family violence, as well as available resources and/or assistance.

 

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:

  • Plan for the provision of pertinent client information to the referral resource (obtaining required client consent with appropriate safeguards to ensure confidentiality – i.e., adhering to HIPAA regulations);
  • Advise the client about their responsibility in complying with the referral;
  • Follow up to determine if the referral was completed; and
  • Document the outcome of the referral.

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:

  • Be in writing and signed and dated by the parties to the agreement;
  • Include the name, address and all professional license numbers of all parties to the agreement;
  • State the nature of the practice, practice locations or practice settings;
  • Identify the types or categories of drugs or devices that may be prescribed, or the types or categories of drugs or devices that may not be prescribed;
  • Provide a general plan for addressing consultation and referral;
  • Provide a plan for addressing patient emergencies;
  • Describe the general process for communication and sharing of information between the physician and the advanced practice registered nurse or physician assistant to whom the physician has delegated prescriptive authority related to the care and treatment of patients;
  • If alternate physician supervision is to be utilized, designate one or more alternate physicians who may:
    • Provide appropriate supervision on a temporary basis, in accordance with the requirements established by the PAA and the requirements of this section; and
    • Participate in the prescriptive authority quality assurance and improvement plan meetings required under this section; and
  • Describe a prescriptive authority quality assurance and improvement plan and specify methods for documenting the implementation of the plan that includes the following:
    • Chart review, with the number of charts to be reviewed determined by the physician and advanced practice registered nurse or physician assistant; and
    • Periodic face-to-face meetings between the advanced practice registered nurse or physician assistant and the physician at a location determined by the physician and the advanced practice registered nurse or physician assistant.

 

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:

  • Obtaining a personal and medical history;
  • Performing an appropriate physical assessment and the recording of physical findings;
  • Initiating/performing laboratory procedures;
  • Administering or providing drugs ordered by voice communication with the authorizing physician;
  • Providing pre-signed prescriptions for:
    • Oral contraceptives;
    • Diaphragms;
    • Contraceptive creams and jellies;
    • Topical anti-infective for vaginal use;
    • Oral anti-parasitic drugs for treatment of pinworms;
    • Topical anti-parasitic drugs; or
    • Antibiotic drugs for treatment of STIs.
  • Handling medical emergencies, to include on-site management as well as possible transfer of the client;
  • Giving immunizations; or
  • Performing pregnancy testing.

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:

  • Texas Administrative Code, Title 22, Part 9, Chapter 193;
  • Texas Administrative Code, Title 22, Part 11, Chapters 221 and 224; and
  • Texas Administrative Code, Title 22, Part 9, Chapter 185 (Physician Assistant Scope of Practice).