1100 Grant Information

Revision 25-3; Effective Sept. 1, 2025

Mailing Address

Title V MCH Fee-For-Service Program
North Austin Complex
4601 W. Guadalupe St., Mail Code 0224
Austin TX 78751-2920

Email

titlevffs@hhs.texas.gov

Websites

Title V Maternal and Child Health Fee for Service Program

1200 Purpose of Manual

Revision 25-3; Effective Sept. 1, 2025

The Texas Health and Human Services Commission (HHSC) Title V Maternal and Child Health Fee-for-Service (TVFFS) Program Policy Manual is a guide for grantees who deliver TVFFS in Texas. The program policy manual provides program requirements and is subject to change with advance notice from HHSC. Grantees are required to comply with all updates made to the policy manual.

Federal and state laws about reporting abuse, operation of health facilities, professional practice, insurance coverage and similar topics also impact TVFFS health care services. Grantees are required to be aware of and comply with existing laws.

2100 Program Authorization and Services

Revision 24-2; Effective Sept. 30, 2024

Title V Maternal and Child Health Fee-for-Services (TVFFS) Program Background

The purpose of the Maternal and Child Health (MCH) Services Title V Block Grant is to create federal and state partnerships. These partnerships provide direct services to low-income women and children not eligible for Medicaid, Children’s Health Insurance Program (CHIP), CHIP Perinatal, or another payor source that covers these same services. TVFFS grantees provide services:

• significantly reducing infant mortality;
• including comprehensive care for women before, during, and after pregnancy and childbirth; and
• including preventive and primary care services for infants, children and adolescents.

Legal Authority

Through Title V of the Social Security Act (SSA) of 1935, the federal government pledged to support state efforts to improve the health of all mothers and children. The MCH Block Grant Program under Title V of the SSA was created in 1981 to consolidate multiple programs. These programs support a more comprehensive, coordinated approach to meeting states’ individual needs consistent with the applicable health status goals and national health objectives now identified in Healthy People 2030.

Within Texas, TVFFS operates within a framework articulated by the Texas Legislature and Texas Health and Human Services Commission (HHSC).

States are required to use awarded federal funds as follows:

• 30% for preventive or primary care services for children
• 30% for services for children with Special Health Care Needs
• Up to 10% on administrative costs
• Remaining funds to support other MCH populations, such as pregnant women and mothers

Funding Sources

TVFFS program services are funded both by state general revenue and federal funds through the Title V MCH Block Grant. HHSC TVFFS funds are allocated through a competitive application process. After the funds are allocated, selected applicants negotiate contracts with HHSC to provide services.

2200 Definitions

Revision 25-3; Effective Sept. 1, 2025

The following terms, when used in this manual, mean the following:

Adjusted Gross Household Income – The gross household income – before taxes – minus any allowable deductions. The adjusted gross household income is used to calculate the Federal Poverty Level (FPL) percentage.

Barriers to Care – A factor that hinders a person from receiving health care. For example, distance, lack of transportation, documentation requirements and copayment amounts.

Case Management – Relating to pregnant women, this means services to assure access to quality prenatal, delivery and postpartum care. With respect to infants, children and adolescents, it means services to assure access to quality preventive and primary care services.

Children’s Health Insurance Program (CHIP) – A health insurance program for non-Medicaid eligible children with a family income up to 198% Federal Poverty Level (FPL).

CHIP Perinatal Program – An HHSC program that provides medical coverage for perinatal care of unborn children of non-Medicaid eligible women with an income up to 202% FPL.

Children and Adolescents – People from their first birthday through the 21st year of age.

Client – A person who has been screened and determined to be eligible for the program.

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

Consultation – A type of service provided by a health care provider with expertise in a medical or surgical specialty. These providers help with the evaluation or management of a patient when requested by another appropriate health care provider.

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

Dental Services – Diagnostic, preventive and therapeutic dental services provided to clients and performed in a dental office or clinic.

Department of State Health Services (DSHS) – The agency responsible for public health in the state of Texas.

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

Diagnosis – The recognition of disease status determined by evaluating the history of the client and the disease process, and the signs and symptoms present. Determining the diagnosis may require some or all the following:

• microscopic – culture
• chemical – blood tests
• radiological examinations – X-rays

Diagnostic Services – Activities related to the diagnosis made by a physician or other health professional.

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

Federal Poverty Level (FPL) – The set minimum amount of income that a family needs for food, clothing, transportation, shelter and other necessities. In the United States, the Department of Health and Human Services determines this level. FPL varies per 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.

Fee-for-Service (FFS) – Payment mechanism for services that are reimbursed on a set rate per unit of service, also known as unit rate.

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

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

Gross Household Income – The total countable income of the household before taxes. Refer to Appendix I, Definition of Income.

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

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

Minor – Per Texas Family Code, Section 101.003, a person younger than 18 who is not and has not been married, or who has not had the disabilities of minority removed for general purposes such as emancipated.

Nutritional Services – The provision of services to identify the nutritional status of a person and offer instruction. Instruction includes appropriate dietary information based on the client’s needs such as age, sex and health status. This may be provided to a person on a one-to-one basis or to a group of people.

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

Prescription Drugs, Devices and Durable Supplies – Medically necessary pharmaceuticals and medical supplies that are capable of withstanding wear, which are needed for the treatment of a diagnosed condition.

Preventive Health Care – Services include immunizations, risk assessments, health histories and baseline physicals for early detection of disease and restoration to a previous state of health, and prevention of further deterioration or disability.

Program Income – Money collected directly by the grantee or provider for services provided under the grant award.

Promotores or Community Health Worker (CHW) – A person who, with or without compensation, helps connect people in their community with health care and social services. A certified CHW is someone with current certification issued by DSHS.

Provider – A clinician or group of clinicians who provide services.

Recertification – The process of rescreening and determining eligibility for the next state fiscal year.

Referral – The process of directing or redirecting, as a medical case or a person, to an appropriate specialist or agency for information, help or treatment.

Referral Agency – An agency that provides a service for a TVFFS client that the TVFFS grantee does not provide and is not a reimbursable TVFFS service.

Subrecipient  – A non-state entity that receives a subaward from a pass-through entity to carry out part of a state program. It does not include a person that is a beneficiary of such a program. A subrecipient may also be a grantee of other state awards directly from a state awarding agency. A subgrantee may also be referred to as a subrecipient. Refer to Texas Grant Management Standards – Version 2.0, Appendix 2, Page 57.

Teledentistry – A health service delivered by a dentist or by a health professional acting under the delegation and supervision of a dentist. The providers act within the scope of the dentist's or health professional's license or certification to provide dental care to a patient at a different physical location than the dentist or health professional using telecommunications or information technology.  

Telehealth – A health service, other than a telemedicine medical service or a teledentistry dental service, delivered by a health professional licensed, certified or otherwise entitled to practice in this state and acting within the scope of their license, certification or entitlement to a patient at a different physical location than the health professional using telecommunications or information technology.

Telemedicine – A health care service delivered 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 to a patient at a different physical location than the physician or health professional using telecommunications or information technology.

Texas Resident  – A person who lives within the geographic boundaries of the state of Texas.

Transportation  – Services that may be provided to transport a client to receive required health care services. Transportation could be provided by private vehicle, public transportation, project site vehicle or emergency medical vehicle.

Unduplicated Client  – A client who is counted only one time during the program’s fiscal year for each Title V program they participate in, which includes: Prenatal Medical, Prenatal Dental, Child Health and Child Dental. If a client participates in more than one Title V program, only their first visit of the fiscal year will be counted as an unduplicated client for each program they participate in.

Revision 23-2; Effective Sept. 8, 2023

This section assists the grantee in conducting administrative activities such as assuring client access to services and managing client records.

3100 Accessibility

Revision 25-3; Effective Sept. 1, 2025

Maintaining Clinic Information on 2-1-1

Grantees must maintain current and correct information on  211Texas.org for all clinic locations that provide TVFFS services. Grantees may use the Add or Edit Your 2-1-1 Listing link at the top of the webpage or contact their local 2-1-1 Resource Manager to make any changes to their clinic location information listings. Grantees must accurately maintain the following information in their 2-1-1 listings or add a new listing.

At a minimum, grantees must maintain up-to-date information on each clinic’s:

• phone number,
• physical location,
• hours of operation, and
• services provided.

Client Access

The grantee must:

• have a policy in place:
  • to identify and eliminate possible barriers to client care, including making sure clinic or reception room wait times do not present a barrier to care.
  • that delineates the timely provision of services, including:
    • applicants deemed eligible for TVFFS should be given an appointment as soon as possible and no later than 30 days from the initial request, and
    • clients who request a contraceptive method but cannot be given a clinical appointment immediately must be offered a non-prescription contraception method.
  • that requires qualified staff to assess and prioritize client needs.
• provide referral resources for services outside of the scope of TVFFS.
• manage funds to make sure established clients continue to receive services throughout the budget year, even after allocated funds are expended.
• display appropriate exterior signage that identifies the entity as a health care facility.
• comply with all applicable laws, regulations and contract terms in conditions as outlined in 3310, Civil Rights.

3200 Abuse and Neglect Reporting

Revision 25-4; Effective Dec. 15, 2025

Grantees must obey state laws that govern the reporting of suspected abuse and neglect.

Call the Texas Abuse Hotline at 800-252-5400 or use the secure Texas Abuse Hotline website to report abuse or neglect. For cases that pose an imminent threat or danger to a person, call 911 or the appropriate local law enforcement agency.

Grantees must have written policies and procedures in place for the detection and appropriate reporting of abuse, neglect and exploitation of:

• the elderly and adults with disabilities per Texas Human Resources Code, Chapter 48; and
• child abuse and neglect per Texas Family Code, Chapter 261.

Grantees also must have written policies and procedures in place to identify and respond to:

• human trafficking, and
• domestic and intimate partner violence per Texas Family Code, Chapter 91.

Grantees must provide annual staff training on each separate policy and procedure listed in this section.

Child Abuse and Neglect

Child abuse and neglect policies must include:

• the requirement that medical professionals make a report no later the 24th hour after they first suspect a child has been abused or neglected or is a victim of an offense.
• how to determine, document, report and track instances of sexual or non-sexual abuse or neglect for all people 17 years old and younger per Texas Family Code, Chapter 261.

More information on abuse reporting is at the Texas Department of Family and Protective Services website.

Human Trafficking

Grantees must comply with all state and federal anti-trafficking laws, including the Trafficking Victims Protection Act of 2000, 22 USC Section 7101, et seq., and Texas Occupations Code, Chapter 116 and 301, which require health practitioners to complete a Health and Human Services Commission (HHSC)-Approved Human Trafficking Course for every licensure renewal period.

Grantees must have a written policy on human trafficking that includes:

• the definition of human trafficking,
• how to identify possible situations of human trafficking,
• the screening tool used to identify possible situations of human trafficking,
• what to do and who to report to if human trafficking is suspected,
• mandatory reporting of suspected child human trafficking, and
• victim support resources.

References for human trafficking policy development:

• HHS Texas Human Trafficking Resource Center 
• HHS Health Care Practitioner Human Trafficking Training Page
• Governor’s Child Sex Trafficking Team
• National Human Trafficking Hotline, 888-373-7888
• Rescue and Restore Campaign by the U.S. Department of Health and Human Services. Contains multiple resources for health care providers, social service personnel and law enforcement to identify and aid trafficking victims. Includes slide presentations for training purposes.

Domestic and Intimate Partner Violence (IPV)

Intimate partner violence (IPV) describes physical, sexual or psychological harm by a current or former partner or spouse. Per Texas Human Resources Code, Chapter 51, family violence may also include emotional harm and threat of harm. This type of violence does not require sexual intimacy.

Grantees must comply with all requirements listed in Texas Family Code, Chapter 91 and have a written policy about assessment and prevention of domestic violence and IPV. Clients who experience IPV are not required to submit information to verify income eligibility if doing so jeopardizes the client's safety or imposes a barrier to receipt of services.

More information on IPV is on the Centers for Disease Control and Prevention website. The National Domestic Violence Hotline operates 24 hours, seven days a week and provides interpretation services in over 200 languages at 800-799-7233.

3300 Confidentiality

Revision 25-3; Effective Sept. 1, 2025

All grantees must comply with the U.S. Health Insurance Portability and Accountability Act of 1996 (HIPAA) established standards for protection of privacy.

A TVFFS provider must maintain all health care information as confidential to the extent required by law.

HIPAA requires grantees to develop and distribute a notice that provides a clear explanation of privacy rights and practices. Grantees must give this Notice of Privacy Practices to clients at the first appointment, upon request and every three years at minimum. Grantees also must post the notice in a clear and easy-to-find location for clients to view. The notice also must be on the organization’s website.

Grantees must make sure all employees and volunteers receive training about client confidentiality during orientation. Employees and volunteers must be made aware that violation of privacy laws may result in civil damages and criminal penalties. A health care provider’s staff, both paid and unpaid, must be informed during orientation of the importance of keeping client information confidential. Grantees must maintain a written confidentiality policy that requires staff to be informed during orientation of the importance of keeping client information confidential. All employees, volunteers, subrecipients, board members and advisory board members must sign a confidentiality statement during orientation.

Grantees must monitor client records to make sure only appropriate staff and HHSC may access the records. A grantee must document a client’s preferred language and method of communication, including phone, email or text, in the client’s record. Each client must receive verbal assurance of confidentiality, an explanation of what confidentiality means, and any applicable exceptions, such as abuse reporting. Grantees are required to provide clients with a copy of their confidentiality policy or agreement. Clients must sign this policy or agreement. The grantee must maintain a signed copy in client's record.

A health care provider must not require consent for services from the spouse of a married client. 

More information on confidentiality and required postings is available on these HHSC and U.S. Department of Health and Human Services (HHS) webpages:

• HIPAA and Privacy Laws – HHSC
• Notice of Privacy Practices for Protected Health Information – HHS.gov
• Your Rights Under HIPAA – HHS.gov, information for individuals
• HIPAA Guidance Materials – HHS.gov, information for providers

Minors and Confidentiality

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 cases of contagious disease or abuse. The definition of privacy is the person’s ability to maintain information in a protected way. Confidentiality in health care is the health care provider’s obligation not to disclose protected information. While confidentiality is generally understood to be part of maintaining a patient’s privacy, confidentiality between provider and patient is not an absolute right.

The HIPAA privacy rule requires a covered entity to treat a personal representative the same as the person with respect to uses and disclosures of the person’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. Review Code of Federal Regulations - 45 CFR Section 164.502(g).

Review Adolescent Health – A Guide for Providers (PDF) for more information.

3310 Civil Rights

Revision 25-3; Effective Sept. 1, 2025

Grantees must comply with state and federal anti-discrimination laws per grantee contracts with HHSC.

Find more information about nondiscrimination laws and regulations on the HHSC Civil Rights website.

3320 Required Signage

Revision 25-3; Effective Sept. 1, 2025

Grantees that provide direct services to clients must display certain HHS posters related to civil rights. The posters must be displayed in areas where clients and the public can easily view them, such as lobbies, waiting rooms, front reception desks, and locations where people apply for and receive HHS services. The following posters are required:  

• Americans with Disabilities Act (English PDF)
• Americans with Disabilities Act (Spanish PDF)
• Know Your Rights - Clients and Applicants (English PDF)
• Know Your Rights - Clients and Applicants (Spanish PDF)
• Need a Sign Language Interpreter? (PDF)
• Need an Interpreter? (PDF)

Grantees are encouraged to display signage about human trafficking and suicide prevention, including the 988 Suicide and Crisis Lifeline. If a grantee elects to display such signage, it must be displayed in areas where it is easily viewed by clients and the public, such as lobbies, waiting rooms, front reception desks, and locations where people apply for and receive services. Examples of a suitable flyers are available on the following Office of the Attorney General (OAG) and Substance Abuse and Mental Health Services Administration (SAMHSA) webpages: 

• Signs for Commercial Establishments – OAG
• 988 Suicide & Crisis Lifeline Poster, English – SAMHSA 
• 988 Suicide & Crisis Lifeline Poster, Spanish – SAMHSA 
• Suicide Warning Signs for Youth Poster – SAMHSA 
• Texting 988 Poster 1, Spanish – SAMHSA 
• Texting 988 Poster 2, English – SAMHSA 

More mental health and suicide prevention resources are available here:  

• Behavioral Health Provider Resources
• Suicide Prevention
• 988 Partner Toolkit – SAMHSA 
• Mental Health and Substance Use

3330 Complaints and Termination of Services

Revision 25-3; Effective Sept. 1, 2025

Termination of Services

A grantee must never deny services to an eligible client because of an inability to pay.

Grantees 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 grantee’s ability to effectively and safely provide services, or
• the client’s behavior jeopardizes their own safety, the safety of clinic staff or others.

A termination of services policy must be included in the grantee’s policy manual.

If a grantee denies, modifies, suspends or terminates services to a client, an explanation must be documented in the client’s record. A client has the right to appeal the denial, modification, suspension or termination of services by following the Resolution of Complaints process.

Resolution of Complaints

Grantees must make sure clients can express concerns about care received and further ensure those complaints are handled in a consistent manner. Grantees’ policy and procedure manuals must explain the process clients may follow if they are not satisfied with the care received.

1. Grantees must investigate and resolve a complaint or concern within 30 business days, beginning on the day they are notified by the aggrieved client.
2. Clients may contact the grantee during and after the resolution of an investigation to receive more information on the grantee's decision or help to correct the issue.
3. Grantees must provide the client with contact information to the HHS Office of the Ombudsman. If a client has requested more assistance from the ombudsman, a grantee must not terminate services to that client until a final decision is rendered by HHSC, unless there is a viable risk to the safety of the aggrieved client, clinic staff or others.
4. All complaints and concerns must be documented in the client's record.

3340 Research, Human Subjects Clearance

Revision 25-3; Effective Sept. 1, 2025

Grantees considering clinical or sociological research using TVFFS-funded clients as subjects must get prior approval from their own internal institutional review board (IRB) and HHSC.

The grantee must have a policy in place that indicates prior approval will be obtained from the HHSC TVFFS program, as well as the IRB, before beginning any research activities. The grantee must also make sure all staff are made aware of this policy through staff training. Documentation of training on this topic must be maintained.

3400 Records Management

Revision 25-3; Effective Sept. 1, 2025

Grantees must have an organized and secure client record system. The grantee must make sure records are organized, readily accessible and available to clients upon request with a signed release of information. Records must be kept confidential, secure and:

• safeguarded against loss and use by unauthorized persons,
• protected by lock when not in use or inaccessible to unauthorized persons, and
• maintained in a secure environment in the facility, as well as during transfer between clinics and in between home and office visits.

Written consent is required for the release of personally identifiable information. Written consent is not required when personally identifiable information is necessary to provide services to the client or as required by law, with appropriate safeguards for confidentiality. If the client is 17 years or younger, the client’s parent, managing conservator or guardian, as authorized by Chapter 32 of the Texas Family Code or by federal law or regulations, must authorize the release of information. HIV information should be handled per federal and state law.

When information is requested, grantees should release only the specific information requested. Information collected for reporting purposes may be only disclosed in summary, statistically or in a format that does not identify anyone. Upon request, clients transferring to other providers must be given a copy or summary of their record to facilitate continuity of care.

Grantees, providers and subrecipients must maintain all records that pertain to client services, contracts and payments for the time specified by HHSC. Grantees must follow contract provisions, maintain medical records for at least seven years after the close of the contract and follow the retention standards of the appropriate licensing entity. All records related to services must be accessible for examination at any reasonable time to representatives of HHSC and as required by law. 

3500 Personnel Policies and Procedures

Revision 25-3; Effective Sept. 1, 2025

Grantees must develop and maintain personnel policies and procedures to make sure clinical staff are hired, trained and evaluated appropriately for their position. Contracted staff must also be trained and evaluated per their responsibilities. Job descriptions, including those for contracted personnel, must specify required qualifications and licensure. It is the responsibility of the grantee to verify that all staff who provide services to TVFFS clients have the appropriate licenses and certifications required by applicable law. All licenses and certifications must be current, valid and in good standing, and must remain so for the term of the grant. Grantees must offer appropriate immunizations to health care staff, following Advisory Committee on Immunization Practices (ACIP) All staff must be appropriately identified with a name badge. Personnel policies and procedures must include:

• job descriptions, including those for contracted personnel;
• a written orientation plan for new staff, which includes skills evaluation or competencies appropriate for the position; and
• a performance evaluation process for all staff.

Grantees must show evidence that employees meet all required qualifications and receive annual training. All staff must have appropriate clinical and administrative background to serve TVFFS populations. Job evaluations should include observation of staff and client interactions during clinical, counseling and educational services. Grantees must have at least one provider in network who has an active medical or dental license in Texas with a minimum of five years of medical or dental practice experience, respective to the program services they intend to provide.

Grantees must establish safeguards to prohibit employees from using their positions in ways that constitutes or presents the appearance of personal or organizational conflict of interest or personal gain. All employees and board members must complete a conflict-of-interest statement during orientation. All medical care must be provided under the supervision, direction and responsibility of a qualified medical director. All dental services must be provided under the supervision, direction and responsibility of a qualified licensed dentist.

The TVFFS medical director for the clinic must be a licensed Texas physician. The TVFFS dental director for the clinic must be a licensed Texas dentist.

Grantees must have a documented plan for organized staff development. There must be an assessment of:

• training needs;
• quality assurance indicators; and
• changing regulations or requirements.

Staff development must include orientation and in-service training for all personnel and volunteers. Nonprofit entities must provide orientation for board members. Government entities must provide orientation for their advisory committees. Employee orientation and continuing education must be documented in agency personnel files.

Grantees must establish, annually review and train staff on TVFFS program requirements and policies. This includes any updates to the program policy manual and required forms that occur during the grant term.

Grantees must have at least one representative participate in all HHSC-scheduled meetings. Additionally, one representative who is responsible for training staff must participate in two TVFFS mandatory training sessions per state fiscal year, at the discretion of HHSC.

Grantees must make sure at least one representative from their organization has access to the SharePoint site to view and upload program and contract information. Each staff person who has access to this site must sign and submit an extranet and data security agreement form to HHSC. This form must be signed by the user and their supervisor. If only one representative has access to the SharePoint site, that person must be responsible for disseminating necessary information to administrative and clinic staff. All users must have an Outlook or Microsoft 365 account.

Designated representatives may be the same person or different people. Grantees must notify their contract manager when a designated representative changes and provide updated contact information, including name, email address and phone number.

3600 Facilities and Equipment

Revision 25-3; Effective Sept. 1, 2025

Grantees must always maintain a safe environment and provide clean and well-maintained facilities where services are delivered. Appropriate space must be provided for:

• exam rooms,
• client intake,
• waiting areas, and
• clinical and administrative staff attendance and functions.

Clinic sites must be geographically close to the target population(s) the grantee intends to serve.

Hazardous Materials

Grantees must have written policies and procedures that address:

• the handling, storage and disposal of hazardous materials and waste per applicable laws and regulations,
• the handling, storage and disposal of chemical and infectious waste, including sharps, and
• an orientation and education program for personnel who manage or have contact with hazardous materials and waste.

Fire Safety

Grantees must have a written fire safety policy that includes a schedule for testing and maintenance of fire safety equipment. Evacuation plans for the premises must be clearly posted and visible to all staff and clients.

Medical Equipment

Medications and medical supplies must be kept in locked storage. Grantees must have a written policy and maintain documents of the maintenance, testing and inspection of medical equipment, including an automated external defibrillator (AED). Documentation must include:

• equipment testing and maintenance,
• reports of any equipment management problems, failures and use errors,
• an orientation and education program for personnel who use medical equipment, and
• manufacturer recommendations for care and use of medical equipment.

Radiology Equipment and Standards

All facilities that provide radiology services, including dental X-rays, must:

• have a current Certificate of Registration from the Texas Department of State Health Services (DSHS) Radiation Control Program,
• have operating and safety procedures as required by Texas Administrative Code Title 25, Part 1, Chapter 289, Radiation Control, and
• post Notice to Employees, Texas Regulations for Control of Radiation.

For information on X-ray machine registration and online license search, see the DSHS Radiation Control Program.

Laboratory Standards 

All facilities that provide laboratory services must possess a current Clinical Laboratory Improvement Amendments (CLIA) Certificate of Waiver.  CLIA requires that any facility examining human specimens for diagnosis, prevention, treatment of a disease, or for assessment of health must register with the federal Centers for Medicare & Medicaid Services (CMS) and obtain CLIA certification.  

Smoking Ban

Grantees must have written policies that prohibit smoking in any portion of their indoor facilities. If a grantee subcontracts with another entity for the provision of health services, the subcontractor must also comply with this policy. 

3700 Emergency Responsiveness

Revision 25-3; Effective Sept. 1, 2025

Clinical Emergencies

Grantees must adequately prepare to handle clinical emergency situations. Each site must:

• have a written plan for the management of on-site medical emergencies, and emergencies that require ambulance services or hospital admission.
• have staff trained in basic cardiopulmonary resuscitation (CPR) and emergency medical action. Staff trained in CPR must be present during all hours of clinic operations.
• maintain emergency resuscitative drugs, supplies and equipment appropriate to the services provided at that site. Have appropriately trained staff when clients are present.
• maintain documentation that staff are trained in the clinical emergencies plans or protocols.

Dental Emergencies

The dental office or clinic must have a written emergency plan that includes criteria for management of emergencies. The plan must be reviewed annually and as needed. Requirements for emergencies are at the Texas State Board of Dental Examiners website and in the Texas Administrative Code, Title 22, Part 5, Chapter 108, under Section 108.7, Minimum Standard of Care, General.

Disaster Response Plan

Grantees must have a written disaster response plan that addresses how staff must respond to emergency situations such as:

• fires,
• flooding,
• power outage, and
• bomb threats.

The disaster plan must identify the procedures that will be initiated during a disaster and the staff position(s) responsible for each activity. A disaster response plan must be in writing, formally communicated to staff and kept in the workplace available to employees for review. An employer with 10 or fewer employees may communicate the plan to them verbally. 

Review the  Occupational Safety and Health Administration website for more resources on facilities and equipment.  

3800 Quality Management

Revision 25-3; Effective Sept. 1, 2025

Grantees must use internal Quality Assurance/Quality Improvement (QA/QI) systems and processes to monitor TVFFS services. Grantees must have a Quality Management (QM) program individualized to their organizational structure and based on the services provided. The goals of the quality management program should ensure availability and accessibility of services; and quality and continuity of care.

Grantees should integrate QM concepts and methodologies into the structure of the organization and day-to-day operations.

Grantees are expected to develop quality processes based on four core QM principles that focus on:

• the client,
• systems and processes,
• measurement, and
• teamwork.

The QM program must be developed and implemented in a way that provides for ongoing evaluation of services. Grantees should have a comprehensive plan for the internal review, measurement and evaluation of services, the analysis of monitoring data, and the development of strategies for improvement and sustainability.

Grantees who subcontract for the provision of services must also address how quality will be evaluated and how compliance with HHSC policies and basic standards will be assessed with the subcontracting entities.

The QM Committee, whose membership consists of key leadership of the organization, including the executive director or CEO, the medical director and dental director, and other appropriate staff where applicable, annually reviews and approves the quality work plan for the organization.

The QM Committee must meet at least quarterly to:

• receive reports of monitoring activities,
• make decisions based on the analysis of data collected,
• determine quality improvement actions to be implemented, and
• reassess outcomes and goal achievement.

Minutes of the discussion and actions taken by the committee and a list of the attendees must be maintained.

The comprehensive quality work plan must, at minimum:

• be reviewed annually,
• include clinical and administrative standards by which services will be monitored,
• include a process for credentialing and peer review of clinicians,
• identify people responsible for implementing monitoring, evaluation and reporting,
• establish timelines for quality monitoring activities,
• identify tools and forms to be used, and
• outline reporting to the QM Committee.

Although each organization’s QA program is unique, the following activities are required by all agencies that provide client services:

• ongoing eligibility, billing and clinical record reviews to assure compliance with program requirements and clinical standards of care,
• utilization review,
• client satisfaction surveys,
• defining, reporting, tracking and follow-up of adverse outcomes,
• annual performance evaluations to include primary license verification, verification of Drug Enforcement Agency (DEA) number, as applicable, and other required licenses or certifications,
• annual review of facilities to maintain a safe environment, including an emergency safety plan,
• annual review and update of all prescriptive authority agreements (PAAs), including protocols, for mid-level providers,
• annual review of all standing delegation orders (SDOs) and clinical protocols, and
• annual review of all policies and forms. 

The review or revision date must be clearly noted on each policy, form, agreement and order that is in use. 

Grantees who subcontract for the provision of services must also address how quality will be evaluated and how compliance with policies and basic standards will be assessed with the subcontracting entities, including:

• annual license verification, primary source verification,
• clinical record review,
• eligibility and billing review,
• utilization review,
• on-site facility review,
• annual client satisfaction evaluation process, and
• compliance with all abuse and neglect, and civil rights requirements.

Data from these activities must be presented to the QM Committee. Plans to improve quality should result from the data analysis and reports considered by the QM Committee and should be documented.

3900 Fiscal Policies and Requirements

Revision 25-3; Effective Sept. 1, 2025

Grantee must have written policies and procedures in compliance with state and federal guidelines to address financial management systems and secure data storage.

Revision 23-2; Effective Sept. 8, 2023

This section provides policy requirements for eligibility determinations, client fees, and the continuity of client services.

4100 Eligibility and Assessment of Co-pay and Fees

Revision 25-3; Effective Sept. 1, 2025

Grantees must:

• Develop a policy to show how staff will determine TVFFS program client eligibility. The policy must outline the grantee’s procedures to determine program eligibility and the responsible party for eligibility screening.
• Use the most recent version of Form 3029, Application for Benefits, to screen applicants for program eligibility.

Alternate Eligibility Screening Tools

An alternate eligibility screening tool created by the grantee may be used in place of Form 3029 with prior written approval by TVFFS program. To apply for approval, the grantee must contact program staff by email to request an Alternate Eligibility Screening Tool Request form. Grantees will send the request form and a copy of their proposed alternate screening tool to the program mailbox at titlevffs@hhs.texas.gov. The alternate eligibility tool must contain, at minimum, all required elements of Form 3029.

Once a grantee gets approval for the use of an alternate eligibility screening tool, the following requirements apply.

• Grantees must request approval from TVFFS program for any revisions to their eligibility screening tool and include a copy of the revised tool.
• The eligibility screening tool is only approved for the life of the current five-year grant term. If a grantee is awarded funding under a subsequent grant, the grantee must resubmit their eligibility screening tool for review and written approval, even if no changes have been made to the tool since the last written approval.
• Any required changes made to Form 3029 by HHSC must be incorporated into the grantee-developed alternate screening tool. Grantees will need to submit their grantee-developed alternate screening tool with the incorporated changes within 60 calendar days after notification of a change to Form 3029 for re-review and approval.   
• The TVFFS program reserves the right to request edits or withdraw its approval of the use of an alternate eligibility tool. TVFFS program will notify the grantee of the decision in writing and include the date the alternate tool must be discontinued.   

Client Eligibility Screening Process

For a person to receive TVFFS services, three criteria must be met:

• gross family income at or below 185% of the Federal Poverty Level (FPL),
• Texas resident, and
• not eligible for other programs or benefits providing the same services.

The TVFFS Child Health and Dental program serves people from birth until their 22nd birthday. The TVFFS Prenatal Medical and Dental program serve pregnant women of any age through three months postpartum, including following pregnancy loss.

Eligibility determinations for TVFFS can be made by conducting interviews in person or over the phone for both new applicants and to re-certify current clients. Phone interviews for eligibility determinations must comply with all eligibility guidelines outlined in program policy.

If a client is unable to sign the Acknowledgment section of Form 3029, Application for Program Benefits, the eligibility staff person may read the statements to the applicant over the phone and document that the applicant affirms the statements. The documentation must include the date and time of the applicant's affirmation and the eligibility staff person’s signature. The client must sign the document at the time of their next visit to the clinic.

Upon award expenditure, grantees are not required to screen new clients for TVFFS eligibility. However, if a screening is completed, the grantee must provide services to eligible clients.

Potential Eligibility and Referral to Other Programs

The TVFFS program is the payor of last resort. Grantees must screen applicants for Children’s Medicaid, CHIP, Medicaid for Pregnant Women, CHIP Perinatal and any other applicable benefit programs, and document screening using Form 3029, Application for Program Benefits. Applicants must apply for any programs for which they appear eligible. Applicants who do not fully comply with applying for other benefit programs are not eligible for TVFFS, and TVFFS will not reimburse for services provided to these people.

The grantee must notify the client they must apply for any program for which they appear eligible. If a client does not screen as eligible for any other program, this must be documented on the application.

All Children’s Medicaid, CHIP, Medicaid for Pregnant Women, CHIP Perinatal or other benefit program applications must be submitted promptly following TVFFS eligibility assessment. If a client was denied Medicaid or CHIP services, the denial letter must be included with the application.

All pregnant women served by TVFFS must apply for Medicaid or CHIP Perinatal programs. Providers are required to inform, encourage and assist pregnant women in the CHIP Perinatal and Medicaid for Pregnant Women application process. A maximum of two clinical prenatal care visits are allowed for women in the process of applying for and enrolling in the CHIP Perinatal and Medicaid for Pregnant Women programs.   

Grantees may use the HHSC Your Texas Benefits website to help screen for client eligibility. More information about HHSC benefits can also be obtained by calling 2-1-1.

TVFFS prenatal clients who enroll in a managed care organization (MCO) that does not provide dental benefits will remain eligible for TVFFS Prenatal Dental benefits. These clients must provide documentation that their MCO does not provide dental benefits to continue receiving TVFFS dental benefits. This documentation must be maintained in the client record.

If a client appears eligible and applies for any of these other benefit programs, they must be granted Presumptive Eligibility for TVFFS while awaiting benefit determination. The client is responsible for submitting proof of application or a denial letter before the presumptive eligibility period ends.

Information for Former Military Service Members

Applicants who served in any branch of the U.S. Armed Forces, Reserves or National Guard, may be eligible for more benefits and services and must be referred to the Texas Veterans Portal for more information. Former female military service members must also be referred to the Texas Veterans Commission’s Women Veterans Program.

Household

A household consists of a person living alone or a group of two or more people related by birth, marriage, common-law marriage or adoption who live together and are legally responsible for the support of the other person.

Legal responsibility for support exists between:

• people who are legally married, including common-law marriage,
• a legal parent and their 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.

Once a child turns 18, they must complete their own program application, listing themselves as the applicant and including any income they earn.

Documentation of Date of Birth

Documentation of date of birth must be provided for clients who apply for the Child Health or Child Dental programs. One of the following should be provided and a copy should be kept with the client’s application:  

• birth certificate,
• baptismal certificate,
• school records, or
• other documents or proof of date of birth determined valid by the grantee.

Documentation of Family Composition

If family relationships are unclear, request one of the following items:

• birth certificate,
• baptismal certificate,
• school records, or
• other documents or proof of family relationship determined valid by the grantee to establish the dependency of the family member with the client or head of household.

Family members who receive other health care benefits must be included in the household. The grantee has discretion to document any special circumstances in the calculation of family composition.

Documentation of Residency

To be eligible for TVFFS services, a person must:

• be physically present within the state of Texas,
• have the intent to remain within the state permanently or for an indefinite period, and
• not claim residency in any other state or country.

If a person is younger than 18 years old, their parent or guardian must also be a resident of Texas and meet the criteria above.

There is no requirement about the length of time a person must live in Texas to establish residency for the purposes of TVFFS eligibility.

Document proof of residency provided by the client on Form 3029, Application for Program Benefits. Explain why residency is questionable if necessary. For documentation of residency, provide one of the following:

• valid Texas driver license,
• current voter registration,
• rent or utility receipts for one month before the month of application,
• motor vehicle registration,
• school records,
• medical cards or other similar benefit cards,
• property tax receipt,
• mail addressed to the applicant, their spouse or children if they live together, or
• other documents considered valid by the grantee.

If none of the listed items are available, verify residency through:

• observance of personal effects and living arrangement, or
• statements from landlords, neighbors or other reliable sources.

If a family is otherwise eligible, but residency is in question or dispute, the household is entitled to services until residency information is verified.

Applicants do not lose their residency status because of temporary absences from the state. For example, someone who travels during certain times but maintains a home in Texas and returns to that home after these temporary absences a resident.

Documentation of Income

All income received must be included. If an unmarried applicant lives with a partner, count the partner’s income if the applicant and partner have mutual children, born or unborn, together. Income is calculated before taxes – gross household income. Income is reviewed and determined either countable or exempt based on the source of the income, as defined in Appendix I, Definition of Income. Grantees must have a written TVFFS income verification policy.

Documentation of income for TVFFS services must be provided to complete Form 3029, Application for Program Benefits. Declarations of unknown will not be accepted as documentation.

Provide the following documentation:

• at least two pay periods that accurately represent their gross earnings dated within the 60 days before the application processing date, or
• one month’s pay only if paid the same gross amount monthly, unless special circumstances are noted on the application.

The pay periods must accurately reflect the person’s usual and customary earnings. Proof may include:

• copy(ies) of the most recent paycheck(s) or stub or monthly earning statement(s),
• employer’s written verification of gross monthly income or Form 3049, Employment Verification,
• award letters,
• domestic relation printouts of child support payments,
• statement of support,
• unemployment benefits statement or letter from the Texas Workforce Commission,
• court orders or public decrees to verify support payments,
• notes for cash contributions, and
• other documents or proof of income determined valid by the grantee.

Grantees must require income verification for countable income. In cases when submitting the income verification jeopardizes the client's safety or confidentiality, or imposes a barrier to receipt of services, the grantee must waive this requirement and document the reason.  

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 period 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.

Allowable Income Deductions

Dependent care expenses may be deducted from total income. This expense must be both necessary for employment and incurred by an employed person. Documentation must be provided. Allowable deductions are actual expenses up to:

• $200 per child per month for children younger than 2,
• $175 per child per month for each dependent 2 or older, and
• $175 per adult with disabilities per month.

Legally required child support payments made by a member of the household must be deducted from gross household income. Documentation of payments must be provided. Convert payments made weekly, every two weeks or twice a month, by using one of the conversion factors listed above.

Gross household income less any allowable deductions is the Adjusted Gross Household Income.

Calculation of Applicant’s Federal Poverty Level Percentage

The grantee must determine the household Federal Poverty Level (FPL) percentage by using current U.S. Department of Health and Human Services federal poverty guidelines. The guidelines are subject to change around the beginning of each calendar year.

To calculate the household FPL percentage:

• determine the monthly adjusted gross household income,
• determine the household size,
• determine the current federal poverty level amount based on the household size,
• divide the household’s total monthly adjusted gross income by the corresponding poverty limit amount, and
• multiply by 100.

Documenting Special Circumstances

There may be special circumstances where an applicant cannot provide required documentation for verification purposes. Document these types of special circumstances appropriately.

Copays

Grantees may assess a copay for services from TVFFS clients. Grantees who choose to collect copays must comply with the following guidelines:

• No TVFFS client will be denied services based on an inability to pay.
• Clients with a household FPL at or below 100% will not be charged a copay.
• Clients with a household FPL above 100% may be charged a copay of no more than $30 per visit.
• Grantees must have a written copay policy which clearly defines how copay amounts will be determined.
• Clients who are assessed a copay must be given a billing statement at the time of service and a copy must be kept in the client’s record.
• Any outstanding balance may not be turned over to a collection agency or reported delinquent to a credit reporting agency. An outstanding balance will not prohibit a client from receiving services.
• All policies and procedures regarding copay collection must be approved by the grantee’s board of directors.
• Copays must be reported as program income on the Monthly Reimbursement Packet (MRP). The grantee must complete B25 and E25.

Grantees may choose to use the optional copay table in Appendix II, Optional Co-Pay Table Based on Monthly Federal Poverty Level (FPL). This table is updated each calendar year after the new federal guidelines are published.

Fees

Grantees must not charge clients administrative fees for items such as processing or transfer of medical records and copies of immunization records.

Grantees may bill clients for services outside the scope of TVFFS allowable services if the service is provided at the client’s request and the client is made aware of their financial responsibility for the charges before services are provided.

Client’s Responsibility for Reporting Changes

A client must report the following changes no later than 30 days after the change:

• income,
• family composition,
• residence,
• current address,
• employment,
• medical insurance coverage, or
• receipt of Medicaid, CHIP, CHIP-P or other third-party coverage benefits.

The client may report changes in person or by mail, email, phone or through someone acting on the client's behalf. If changes result in the client no longer meeting eligibility criteria, the client’s eligibility will terminate. Upon termination, the grantee must issue Form 3047, Notice of Ineligibility to the client, and include the date of termination.

Eligibility

Full program eligibility begins on the date the grantee determines a person or household is eligible for the program and all the following requirements are met:

• all program eligibility requirements are met,
• program application is completed and signed, and
• all verification documents are submitted.

To notify an applicant of eligibility the grantee must issue Form 3012, Verification of Eligibility to the client.

Presumptive Eligibility

Presumptive eligibility provides short-term access to health care services for up to 90 days when an applicant screens as potentially eligible for services and has a medical or dental need, but lacks the documents required to achieve full eligibility. Grantees must establish a presumptive eligibility period of 90 days in their eligibility policy. During this time, clients are expected to produce the necessary documents or be enrolled in other applicable programs, such as Medicaid or CHIP. For clients who submit all required documents and are determined to be fully eligible during or at the end of their presumptive eligibility period, full eligibility will be granted. The expiration date is 12 months from the first day of presumptive eligibility, except for Perinatal benefits, which expire at three months postpartum.

Child Health and Dental (CHD) clients are limited to one presumptive eligibility period per two calendar years.

Prenatal Medical and Dental (PMD) clients are limited to one presumptive eligibility period per pregnancy.

To notify an applicant of Presumptive Eligibility, the grantee must issue Form 3045, Presumptive Eligibility Notice to the client.

If the client enrolls in a Medicaid or CHIP program during the presumptive eligibility period, TVFFS enrollment will end on the date Medicaid or CHIP program eligibility begins.

Ineligibility

If an applicant is determined to be ineligible for program services after the screening process is complete, the applicant must be given the Notice of Ineligibility, Form 3047. The applicant must also be informed of their right to appeal the eligibility decision using the process described on the Notice of Ineligibility.

Optional Forms

The following forms are optional, but may be used to aid in completing the eligibility screening process:

• Form 3049, Employment Verification; and
• Form 3051, Statement of Self-Employment Income. 

Annual Recertification

Annual eligibility determination and recertification is required for all clients who receive TVFFS services. Client eligibility must be determined every 12 months, using the most recent version of Form 3029, Application for Program Benefits. Perinatal benefits expire at three months postpartum.

Grantees must have a system in place to track client eligibility and renewal status on an annual basis.

Revision 23-2; Effective Sept. 8, 2023

This section describes the requirements and recommendations for grantees pertaining to the delivery of direct clinical services to clients. In addition to the requirements and recommendations found within this section, grantees should develop protocols consistent with national evidence-based guidelines appropriate to the target population.

5100 General Consent

Revision 25-3; Effective Sept. 1, 2025

Grantees must get the client’s written, informed, voluntary general consent to receive services before 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 a client does not receive services for a period of three years or more, a new general consent must be signed before reinitiating delivery of services.

A client’s verbal consent for general treatment may be obtained by phone. This type of consent is enough for routine treatment provided through telemedicine. To record a client’s verbal consent, the staff person who obtains the consent must read the consent form to the applicant and document that the applicant affirms by giving their verbal consent for treatment. The document must include the date and time of the applicant’s consent and the signature of the staff person who obtained consent. The client must sign the consent at the time of their next visit to the clinic.

Consent information must be effectively communicated to every client in an understandable manner. This communication must allow the client to participate, make sound decisions about their own medical care, and address any disabilities that impair communication in compliance with Limited English Proficiency regulations. Only the client may consent, unless legally incapable of doing so, such as a minor or a person with a development disability. In such cases, a parent, legal guardian or caregiver must consent on their behalf. Consent must never be obtained in a manner that could be perceived as coercive.

Grantees should consult a qualified attorney to determine the appropriateness of the consent forms used by their health care agency.

Consent for Dental Procedures

Written informed consent for dental procedures must be obtained and must comply with the Texas Administrative Code, State Board of Dental Examiners, Section 108.7, Minimum Standards of Care.

Texas Medical Disclosure Panel Consent

The Texas Medical Disclosure Panel (TMDP) was established by the Texas Legislature to:

• determine which medical care and surgical procedure risks and hazards must be disclosed by health care providers or physicians to their patients or people authorized to consent for their patients; and
• establish the general form and substance of such disclosure.

The grantee is responsible for assuring that informed consent is obtained from the client for procedures per TMDP. TMDP has developed List A, which is informed consent that requires full and specific disclosure for certain procedures.

For all other procedures not listed on List A, the physician must disclose, through a specific consent procedure, all risks that a reasonable client would want to know. These risks include all that:

• are inherent to the procedure, which means one that exists in and is inseparable from the procedure itself; and
• are material that could influence a reasonable person to decide if they should consent to the procedure.

Consent for Services Provided to Minors

Generally, a parent must consent to treatment for minors. A minor is defined as a person younger than 18 years old who has never been married and never been declared an adult by a court – emancipated. However, there are certain circumstances when a minor may consent for their own treatment. Requirements for parental consent for provision of family planning services to minors vary per the funding source that subsidizes the services. The department and providers may provide pregnancy testing, HIV testing, sexually transmitted infection (STI) testing and treatment for an STI, 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.

Resources and References

• Adolescent Health - A Guide for Providers (PDF)
• Chapter 151 of the Texas Family Code: Rights and Duties in Parent-Child Relationship
• Chapter 32 of the Texas Family Code: Consent to Treatment or Child by Non-Parent or Child
• Pelvic Examinations – Chapter 167A of the Health and Safety Code

Consent for Human Immunodeficiency Virus (HIV) Tests

For HIV testing, grantees must comply with Texas Health and Safety Code:

• Section 81.105, about Informed Consent; and
• Section 81.106, about General Consent.

5200 Clinical Policy

Revision 25-3; Effective Sept. 1, 2025

Telemedicine

Providers may provide services by telemedicine if appropriate.

Providers that offer telemedicine services must follow all rules of the Texas Occupations Code, Chapter 111 and must have written policies and procedures for:

• obtaining informed consent,
• maintaining confidentiality of the client’s clinical information,
• ensuring appropriate, quality care,
• preventing abuse and fraud in the use of telemedicine services,
• ensuring adequate supervision of health professionals who are not physicians and who providing telemedicine care, and
• establishing the maximum number of health professionals that a physician may supervise through telemedicine services.

Client Health Records and Documentation of Encounters

Providers must ensure that a client health record is established for every person who receives clinical services and must meet the requirements of the TAC, Texas Medical Board, General Documentation Provisions Rule.

All client 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 and title of the provider, and the date for each entry.
• Electronic signatures are allowable to document the encounter or provider review of care.  
• Stamped signatures are not allowable.
• Readily accessible to assure continuity of care and availability to clients.
• 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 list of all allergies and adverse reactions to medications, food and environmental substances such as latex, including specifying when a client has no known allergies,
• this information should be prominently displayed in the client’s record and updated at each encounter,
• a plan of care, updated as appropriate, consistent with diagnoses and assessments, which 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 to document the reason for the visit, relevant history, physical exam findings, and pertinent screening and diagnostic tests with results and a treatment plan.

Case Management

Grantees must provide case management services on an as-needed basis to clients who require help accessing community resources.

Grantees must refer clients to other resources for assistance with community services they determine necessary but don’t provide. Referrals and case management services must be documented in the clinical record.

Referral and Follow-Up

Grantees 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 follow state or federal requirements for transfer of health information.

Clients should be given a choice of referral resources to choose from whenever possible. When a client is referred to another resource because of an abnormal finding or for emergency clinical care, the grantee must:

• transmit client’s information — with client’s consent — to the referral resource while maintaining confidentiality and adhering to HIPAA regulations,
• advise the client about her or his responsibility to comply with the referral,
• follow up to determine if the referral was completed, and
• document the outcome of the referral.

Before a grantee can consider a client as lost to follow-up, the grantee must have at least three documented attempts to contact the client.

The provider must comply with state and local sexually transmitted infection (STI) reporting requirements.

5300 Perinatal Clinical Guidelines

Revision 25-3; Effective Sept. 1, 2025

Perinatal Services

Provide prenatal and postpartum services based on American College of Obstetricians and Gynecologists (ACOG) guidelines. Perinatal visits include medical history, physical examination, laboratory and diagnostic testing, and education and counseling.  

Grantees may bill TVFFS for allowable services provided in clinical prenatal care visits for women during the CHIP-Perinatal or Medicaid for Pregnant Women enrollment process. Review Monthly Reporting Packet (MRP) for reimbursable procedure codes.

Medically necessary postpartum visits are reimbursable and include interval history, physical examination, assessment, family planning, counseling, education and referrals as indicated.

Perinatal Laboratory and Other Diagnostic Tests

Include appropriate laboratory and diagnostic tests, as indicated by weeks of gestation and clinical assessment, in all prenatal visits. Grantees must have written plans to address laboratory and other diagnostic test orders, results and follow-up to include:

• tracking and documenting tests ordered and performed for each client,
• tracking and documenting test results in client records, and
• a mechanism to address abnormal results, facilitate continuity of care and assure confidentiality that adheres to HIPAA regulations by making results and interventions accessible to the delivering hospital, facility or provider.

Ultrasounds

Obstetrical ultrasounds will be reimbursed as recommended by ACOG guidelines.

• Complete ultrasound – A complete evaluation of the pregnant uterus, performed between 18 and 22 weeks’ gestation, to include fetal number, viability, presentation, dating measurements, complete anatomical survey, placental localization and characterizations, and amniotic fluid assessment.
• Limited ultrasound – A brief, more limited evaluation to determine the number of fetuses, viability, presentation, dating measurements, limited anatomic assessment, placental location and characterization, and amniotic fluid assessment.

Non-Stress Test (NST)

Perform fetal assessment as medically necessary and may be billed as often as the provider deems the procedure to be medically necessary.

Biophysical Profile (BPP)/Fetal Biophysical Profile (FBPP)

The test combines fetal heart rate monitoring – nonstress test –  and fetal ultrasound to evaluate a baby's heart rate, breathing, movements, muscle tone and amniotic fluid level. It may be done when results of other tests are non-reassuring.

Perinatal Education and Counseling Services

Grantees must have written plans for client education that include goals and content outlines to ensure consistency and accuracy of information provided. Education must be appropriate to client’s age, level of knowledge and background, and be presented in an unbiased manner.

Depression and Anxiety Screening

ACOG recommends all perinatal clients be screened for depression and anxiety symptoms with a standardized, validated tool at the first obstetric visit, at 24-28 weeks gestation, and at the comprehensive postpartum visit. For ease of administration in obstetric practices, Lifeline for Moms created a composite screener, with separate screeners for both the Edinburgh Postnatal Depression Scale (EPDS) and Patient Health Questionnaire (PHQ-9). Both screeners include the Mood Disorder Questionnaire (MDQ), General Anxiety Disorder (GAD-7), and Primary Care PTSD Screen for DSM-5 (PC-PTSD-5). Another safety screener is available to assess suicide risk.

• Combined EDPS Screener and Scoring Sheet
• Combined PHQ-9 Screener and Scoring Sheet
• Patient Safety Screener

Tobacco Assessment and Quit Line Referral

All women who receive prenatal services should be assessed for tobacco use. Refer women who use tobacco to tobacco quit lines. The Texas Tobacco Quitline provides confidential, free and convenient smoking cessation services to Texas residents 13 years and older, including quit coaching and nicotine replacement therapy. Services can be accessed by phone at 877-937-7848 (877-YES-QUIT) or online at YesQuit.org. The assessment and referral should be performed by agency staff and documented in the clinical record.

Substance Use Disorder Screening, Brief Intervention and Referral to Treatment

All women who receive prenatal services should be screened for substance use disorder through screening, brief intervention, and referral to treatment (SBIRT). Routine screening should be done at the first comprehensive prenatal visit and should use a validated screening tool such as 4Ps, 5Ps, NIDA Quick Screen, CRAFFT, T-ACE, ASSIST and TWEAK.

SBIRT and mental health resources:

• Screening, Brief Intervention, and Referral to Treatment (SBIRT)
• Find Your Local Mental Health or Behavioral Health Authority

Nutrition Counseling

Nutritional counseling by a licensed dietitian is not billable to TVFFS. Clients may be referred to Women, Infants and Children (WIC) for nutritional counseling.

5310 State-Mandated Education

Revision 25-3; Effective Sept. 1, 2025

Information for Parents of Newborns

Health and Safety Code, Subchapter Section T, 161.501 requires hospitals, birthing centers, physicians, nurse-midwives and midwives who provide prenatal care to pregnant women during gestation or at delivery to give the woman and the infant's father or other adult caregiver Information for Parents of Newborns (PDF). This guide includes information about immunization, newborn screening, postpartum depression and shaken baby syndrome.

Grantees must document in the client’s chart that they received this information. 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.

A Parent’s Guide to Raising Healthy, Happy Children

A Parent’s Guide to Raising Healthy, Happy Children (PDF) is designed for parents and adult caregivers of children. The guide provides information about the development, health and safety of children from birth to 5 years.

Provision of Information about Umbilical Cord Blood Donation Requirement

Health and Safety Code, Subtitle H, Section 162.018 requires a physician or other person permitted by law to attend a pregnant woman during gestation or at delivery of an infant to give the woman an informational brochure:

• before the third trimester of the woman’s pregnancy, or
• as soon as possible.

The brochure should include information about:

• the uses, risks and benefits of cord blood stem cells for a potential recipient,
• options for future use or storage of cord blood,
• the medical process used to collect cord blood,
• any costs that may be incurred by a pregnant woman who chooses to donate or store cord blood after delivery, and
• average cost of public and private storage.

An Umbilical Cord Blood Banking and Donation Brochure is available through DSHS.

Resources

• Maternal and Child Health Publications
• American College of Obstetricians and Gynecologists (ACOG).
• Pelvic Examinations – Chapter 167A of the Health and Safety Code.
• The Texas Clinician’s Postpartum Depression Toolkit (PDF)

5320 Initial Prenatal Visit Requirements

Revision 25-3; Effective Sept. 1, 2025

Comprehensive Medical History – Initial Visit

A comprehensive medical history documented at the initial prenatal visit must address at least:

• current health status, including:
  • symptoms of pregnancy; and
  • acute and chronic medical conditions;
• significant history, including:
  • hospitalizations;
  • surgeries;
  • biopsies; and
  • blood transfusions and other exposure to blood products;
• current medications, including prescription, over the counter, and complementary and alternative medications;
• allergies, sensitivities or reactions to medicines or other substance(s);
• immunization status or assessment, including Rubella status;
• mental health history including current and past mental health conditions;
• pertinent history of immediate family, including genetic conditions;
• pertinent partner history, including:
  • injectable drug use;
  • number of partners STI and HIV history; and
  • other risk factors;
• reproductive health history must include:
  • menstrual history, including last normal menstrual period;
  • sexual activity history, including:
    • family planning practices;
    • number of partners;
    • sex of  partners; and
    • sexual abuse, as indicated;
  • detailed obstetrical history;
  • gynecological and urologic conditions;
  • STIs, including hepatitis B and C, and HIV risks and exposure;
  • cervical cancer screening history:
    • date and results of last Pap test or other cervical cancer screening test; and
    • note of any abnormal results and treatment;
• social history and health risk assessment:
  • home environment, including living arrangements;
  • family dynamics with assessment for family violence including safety assessment, when indicated which is mandated by Texas Family Code, Chapter 261;
  • human trafficking;
  • tobacco, alcohol, medications, recreational drug use or abuse and exposure, drug dependency including type, duration, frequency and route;
  • nutritional history;
  • occupational hazards or environmental toxin exposure;
  • ability to perform activities of daily living (ADL);
  • risk assessment, including:
    • diabetes;
    • heart disease;
    • intimate partner violence; and
    • injury or malignancy; and
• systems review documenting pertinent positives and negatives in the health record.

Physical Examination – Initial Visit

For any part of the examination that is deferred, document the reason(s) for deferral in the client health record.

• height measurement;
• weight measurement, with documentation of pre-pregnancy weight and assessment for underweight, overweight and obesity;
• blood pressure evaluation;
• cardiovascular assessment;
• visual inspection of external genitalia and anus;
• pelvic exam, including estimate of uterine size per Chapter 167A of the Health and Safety Code;
• fetal heart rate for gestational age more than 12 weeks; and
• other systems, as indicated by history and the health risk assessment.

Laboratory and Diagnostic Tests – Initial Visit

Perform lab tests as recommended by accepted standards of care for client’s weeks of gestation or as indicated by risk assessment, history or physical exam. Review Monthly Reporting Packet (MRP) for covered lab tests.

The following tests are state-mandated:

• Hepatitis B Antigen (HbsAg), mandated by Health and Safety Code 81.090.
• HIV, unless declined by client, who must then be referred to anonymous testing, mandated by Health and Safety Code 81.090.
• Syphilis serology, mandated by Health and Safety Code 81.090.

Education – Initial Visit

Base client education on history, risk assessment and physical exam. It must cover:

• nutrition and weight gain;
• physical activity and exercise;
• sexual activity;
• environmental or work hazards;
• travel;
• alcohol use and substance abuse;
• when and where to get emergency care;
• anticipated course of prenatal care, including prenatal testing;
• injury prevention, including seat belt use;
• cocooning infants and children against pertussis including immunization of family members and potential caregivers of the infant;
• toxoplasmosis precautions;
• referral to WIC;
• use of medications; and
• other education and counseling as indicated by state mandate, risk assessment, history and physical exam. 

5330 Return Prenatal Visits Requirements

Revision 25-3; Effective Sept. 1, 2025

Interval Medical History – Return Visit

Interval history, including:

• symptoms of infections;
• symptoms of preterm labor;
• headaches or visual changes;
• fetal movement at more than18 weeks;
• family violence screening when client is more than 28 weeks; and
• intimate partner violence assessment at least once each trimester;

Physical Exam – Return Visit

For any portion of the examination that is deferred, document the reason(s) for deferral in the client health record.

• weight measurement;
• blood pressure evaluation;
• uterine size and fundal height;
• fetal heart rate at more than 12 weeks;
• fetal lie or position at more than 30 weeks; and
• other systems, as shown by history or other findings.

Laboratory and Diagnostic Tests – Return Visit

Perform lab tests as recommended by accepted standards of care for client’s weeks of gestation, those mandated by law, and indicated by risk assessment, history or exam. Review Monthly Reporting Packet (MRP) for covered lab tests. 

Return Prenatal Visit Education

Education should be appropriate to weeks of gestation and based on history, risk assessment and physical exam, including but not limited to:

• signs and symptoms of preterm labor beginning in the second trimester;
• warning signs and symptoms of pregnancy induced hypertension (PIH);
• breastfeeding;
• selecting a provider for the infant; and
• postpartum family planning.

5340 Postpartum Visits Requirements

Revision 25-3; Effective Sept. 1, 2025

Interval Medical History – Postpartum Visit

Interval history, including:

• labor and delivery history, noting maternal and neonatal complications;
• infant bonding;
• breastfeeding and infant feeding issues;
• symptoms of infections;
• symptoms of excessive or abnormal vaginal bleeding;
• assessment for postpartum depression, The Texas Clinician’s Postpartum Depression Toolkit (PDF);
• intimate partner violence assessment; and
• family planning and contraception including current method or future plans;

Postpartum Visit Physical Exam

Document the reason(s) for deferral in the client health record, for any portion of the examination that is deferred.

• weight;
• blood pressure evaluation;
• breast and axilla exam;
• abdomen exam;
• pelvic exam, including uterine size per Chapter 167A of the Health and Safety Code; and
• systems indicated by history or risk profile and other findings.

Laboratory and Diagnostic Tests – Postpartum Visit

Perform lab tests as recommended by accepted standards of care for client’s weeks of gestation, those mandated by law, and indicated by risk assessment, history or exam. Review Monthly Reporting Packet (MRP) for covered lab tests.

Education - Postpartum Visit 

Client education should include:

• physiologic changes;
• signs and symptoms of common complications;
• care of the breast;
• care of perineum and abdominal incision, if indicated;
• physical activity and exercise;
• breastfeeding and infant feeding;
• resumption of sexual activity;
• family planning and contraception; and
• depression and post-partum depression.

5350 Perinatal Dental Services

Revision 25-3; Effective Sept. 1, 2025

Providers are expected to follow rules and regulations established by the Dental Practice Act.

Review Monthly Reporting Packet (MRP) for reimbursable procedure codes.

Perinatal dental services are provided to pregnant women through three months post-partum. These include:

• comprehensive and periodic oral evaluations;
• radiographs; and
• preventive and therapeutic dental services.

Procedure Code Limitations

Space maintainers are designed to prevent tooth movement and may help after premature loss of a deciduous primary first or second molar(s) in the following situations:

• TID: A, B, I and J- for clients who are 1 through 12 years old using procedure codes D1510 and D1516.
• TID: K, L, S and T - for clients who are 1 through 12 years old using procedure codes D1510 and D1517. 

The following procedure codes have age restrictions and limitations:

• D2950 Not allowed on primary teeth; restricted to ages 4 and older
• D2952 Not allowed on primary teeth; restricted to ages 13 and older and not payable with D2950
• D3310, D3320 and D3330 Restricted to 6 and older, reimbursement for a root canal includes all appointments necessary to complete the treatment
• D2933 and D2934 are benefits for anterior primary teeth only (TID C- H and M R
• Direct restoration of a primary tooth with the use of a prefabricated crown is a once in a lifetime restoration, same TID, any provider. Exceptions may be considered when pre-treatment X-ray images, intra-oral photos, and narrative documentation clearly support the medical necessity for the replacement of the prefabricated crown (D2930, D2933, D2934).

Perinatal Dental Visit History

Document a medical and dental history at the initial dental visit. Update a history and reason for the visit at each visit. Dental history must include:

• history of the present problem;
• relevant past medical history, including reproductive history and pregnancy status;
• allergies, sensitivities or reactions to medicines or other substances;
• current medications, prescriptions, over the counter and complementary and alternative medicines; 
• use of tobacco and alcohol, including type, duration, frequency and route; and
• screening and reporting, if indicated, for abuse and neglect per Texas Family Code, Chapter 261.

Perinatal Dental Examination

All dental visits must include an oral examination. Initial and return dental visit must include:

• limited head and neck examination for the initial visit and as indicated for return visits;
• blood pressure and pulse, as indicated;
• radiographs and photographs, as indicated;
• prescription(s), if indicated;
• treatment plan of care; and
• procedure(s) and treatment provided.

Perinatal Dental Education and Counseling

Dental education and counseling is provided by dentists or dental hygienists as it relates to prevention of dental disease and achieving oral health. Education should include:

• oral hygiene instruction;
• healthier eating and drinking habits to reduce the risk of tooth decay;
• safety of dental treatment while pregnant;
• impact of the mother’s oral health on the pregnancy and infant;
• oral hygiene for infants and children; and
• individualized education based on history, exam, procedures or risks.

Resource

• DSHS Oral Health Improvement Program
• DSHS Information for Pregnant Moms

5400 Child and Adolescent Clinical Guidelines

Revision 25-3; Effective Sept. 1, 2025

Child and Adolescent Services

Provide services based on recommendations of the American Academy of Pediatrics (AAP), Texas Health Steps Checkup Components (PDF) and the Texas Health Steps Periodicity Schedule. All staff who perform child health exams must have completed the online Texas Health Steps module Texas Health Steps: Overview.

Review Monthly Reporting Packet (MRP) for reimbursable procedure codes. Grantees may not bill for a Texas Health Steps medical checkup until all required components are completed. Only one visit may be billed per day, per client. If a client returns on a different day to complete required components of a Texas Health Steps exam, an additional visit may not be charged.

Well Child and Adolescent History and Risk Assessment

A new client initial health history must be retained in the medical record for reference at future checkups and does not need to be repeated at subsequent checkups. It must include the following:

• If less than five years old, history related to pregnancy, delivery and neonatal conditions
• Family medical history
• Personal medical history

Established client interval health history must include:

• reason for visit,
• current health status, including any changes in personal health history,
• current medications, including prescription, over-the-counter, and complementary and alternative medicines,
• allergies, sensitivities or reactions to medicines or other substance(s),
• exposure to or use of tobacco, alcohol and illicit drugs, including type, duration, frequency and route,
• review of systems,
• assessment for family violence including a safety assessment when indicated,
• reproductive health history, when appropriate, must include:
  • menstrual history, including last normal menstrual period,
  • sexual behavior history, including:
    • family planning practices,
    • sexual abuse,
  • gynecological and urologic conditions,
  • STIs and HIV risks and exposure, and
  • cervical cancer screening beginning at 21 years. 

Comprehensive Child and Adolescent Physical Examination

For well child and adolescent visits, a complete physical exam is required at each visit. A comprehensive unclothed physical exam includes all the components listed below. For any portion of the exam that is deferred, document the reason(s) for deferral.

• Comprehensive unclothed exam including secondary sex characteristics.
• Measurements and percentiles, as appropriate, should document:
  • length, height and weight measurements,
  • frontal-occipital head circumference for 2 years and younger,
  • body mass index (BMI) beginning at 2 years, and
  • blood pressure beginning at 3 years.
• Screening, as appropriate, should document:
  • Complete developmental screening at checkups from birth through 6 years. Providers should follow the Texas Health Steps Periodicity Schedule (PDF) and must use one of the following validated, standardized tools at Developmental and Autism Screening Tools.
  • Conduct mental health screening at each checkup using one of the following tools. Providers should follow the Texas Health Steps Periodicity Schedule (PDF) and must use one of the following validated, standardized tools at Mental Health Screening Tools.
  • Perform screening for maternal postpartum depression at infant checkups up to 12 months. Find screening tools in The Texas Clinician’s Postpartum Depression Toolkit (PDF). 
  • Sensory screening should include vision acuity and audiometric hearing screening at various ages following the Texas Health Steps Periodicity Schedule.
  • Documentation of test results from a school vision or hearing screening program may replace the required screening if conducted within 12 months of the checkup.
  • Limited oral screening for caries and general health of the teeth and oral mucosa is part of the physical examination. Refer to a dentist at 6 months and every six months after.
  • Nutritional screening or counseling by a licensed dietitian is completed for children with a high-risk condition and for children 3 years and older with an abnormal BMI. Nutritional screening must be performed at every visit.
  • Risk screening, including family violence, lead, tuberculosis and adolescent lifestyle.
• Age-appropriate immunizations
  • Vaccines must be administered per the American Academy of Pediatrics (AAP) recommendations.
  • HHSC recommends TVFFS grantees become a Texas Vaccines for Children (TVFC) provider. Providers may get vaccines free of charge from the Texas Vaccines for Children (TVFC) Program for clients birth through 18 years. Providers must not charge the client for the vaccines.
• Age-appropriate laboratory tests
  • Well child and adolescent laboratory tests should follow the Texas Health Steps Periodicity Schedule. Tests should be appropriate to age and risk. Review TVFFS MRP for covered lab tests.
  • Documented laboratory results within the past month are acceptable for use for children 2 years and younger and up to 90 days for those 3 years and older.

Sick Child Visit

Other sources of funding should be used to provide medications for the treatment of acute and minor illness at little or no cost to the client. A sick child visit includes problem-oriented history, physical exam and lab tests as indicated by condition.

Resources

• World Health Organization (WHO) growth charts for infants and children birth to 2 years.
• Centers for Disease Control and Prevention (CDC) growth charts for children who are 2 years or older.
• Pelvic Examinations – Chapter 167A of the Health and Safety Code.
• The Texas Clinician’s Postpartum Depression Toolkit (PDF)

Child and Adolescent Laboratory and Other Diagnostic Tests

Grantees can submit all TVFFS laboratory testing to the laboratory of their choice, with the exception of Newborn Screening (NBS) Tests. NBS Tests must be submitted to the Texas Department of State Health Services (DSHS) laboratory.

Grantees and subrecipients must have a DSHS laboratory submitter number to submit specimens to the laboratory.

Laboratory specimens sent to the DSHS laboratory will be charged at the DSHS laboratory’s published fee schedule rate.

Agencies must have written plans to address laboratory and other diagnostic tests orders, results and follow-up to include:

• Tracking and documentation of tests ordered and performed for each client.
• Tracking test results and documentation in client’s records.
• A mechanism to notify clients of results in a manner to ensure confidentiality, privacy and prompt, appropriate follow-up.

Resources

• DSHS Laboratory
• DSHS Lab Reporting for Results
• Texas Newborn Screening Program
• DSHS TB Control Standards

Child and Adolescent Education and Counseling

• Health education and counseling must be provided at each checkup and documentation must include the time period recommended before the next appointment. 
• Base education and counseling on health history, risk assessment and physical exam, and must cover the following:
  • age-appropriate anticipatory guidance including injury prevention, behavior, health promotion and nutrition.
  • the recommended Anticipatory Guidance: A Guide for Providers (PDF) offers age-appropriate guidance for children, birth through 20 years, and mirrors anticipatory guidance topics included on the THSteps Child Health Clinical Record Forms.
  • child development.
  • immunizations.
  • when and where to get emergency care.
  • risk factors identified during the visit.
  • referral to WIC.
  • information on parenting and postpartum counseling, as indicated and mandated by Health and Safety Code, Chapter 161, Subchapter T.
  • other education and counseling as indicated. 

5410 Child and Adolescent Dental Services

Revision 25-3; Effective Sept. 1, 2025

Providers must follow rules and regulations established by the Dental Practice Act, provided to children from birth through 21 years. These include:

• diagnostic services including comprehensive and periodic oral evaluations and radiographs,
• preventive services including fluoride treatment and placement of dental sealants to any tooth at risk of dental decay, and
• therapeutic services including restorative treatment.

Review Monthly Reporting Packet (MRP) for reimbursable procedure codes.

For children younger than 6 months, medically necessary dental services may be provided because of oral trauma, early childhood caries or both.

Procedure Code Limitations

Space maintainers are designed to prevent tooth movement. They may help in the following situations:

• After premature loss of a deciduous primary first or second molar(s), TID: A, B, I and J, for clients who are 1 through 12 years old using procedure codes D1510 and D1516.
• After premature loss of a deciduous primary first or second molar(s), TID: K, L, S and T, for clients who are 1 through 12 years old using procedure codes D1510 and D1517.

The following procedure codes have age restrictions and limitations:

• D2950 is not allowed on primary teeth. Is restricted to 4 and older.
• D2952 is not allowed on primary teeth. Is restricted to 13 and older and is not payable with D2950.
• D3310, D3320 and D3330 is restricted to 6 and older. Reimbursement for a root canal includes all appointments necessary to complete the treatment.
• D2933 and D2934 are benefits for anterior primary teeth only (TID C-H, M-R).
• Direct restoration of a primary tooth with a prefabricated crown is a once in a lifetime restoration, same TID, any provider. Exceptions may be considered when pre-treatment X-ray images, intra-oral photos and narrative documentation clearly support the medical necessity for the replacement of the prefabricated crown (D2930, D2933, D2934).

Child and Adolescent History

Document medical and dental history at the first dental visit. History and reason for the visit must be updated at each visit. Dental history must include:

• history of the present problem,
• relevant past medical history, including pregnancy status, as applicable,
• allergies, sensitivities or reactions to medicines or other substances,
• current medications, prescriptions and over the counter, complementary and alternative medicines,
• use of tobacco and alcohol including type, duration, frequency and route, and
• screening for abuse and neglect and reporting, if indicated as mandated by Texas Family Code, Chapter 261.

Child and Adolescent Dental Examination

All dental visits must include an oral exam. The initial or return dental visit must include:

• limited head and neck exam for the initial visit and as indicated for return visits,
• blood pressure and pulse, as indicated,
• radiographs and photographs, as indicated,
• prescription(s), if indicated,
• treatment plan of care, and
• procedure(s) and treatment provided.

Child and Adolescent Dental Education and Counseling

Dental education and counseling is provided by dentists or dental hygienists for the prevention of dental disease and achieving oral health. Education should include: 

• oral hygiene instruction,
• healthier eating and drinking habits to reduce the risk of tooth decay, and
• individual education based on history, exam, procedures or risks.

Resources

• DSHS Oral Health Improvement Program
• THSteps Dental Provider Guidance

5500 Prescriptive Authority Agreements, Clinical Protocols and Standing Delegation Orders

Revision 25-3; Effective Sept. 1, 2025

Grantees that provide clinical services must develop and maintain written clinical prescriptive authority agreements, protocols and standing delegation orders to comply with statutes and rules governing medical, dental and nursing practice, and consistent with national evidence-based clinical guidelines. When HHSC revises a policy, grantees need to incorporate the revised policy into their written procedures.

Prescriptive Authority Agreements (PAAs)

When services are provided by an advanced practice registered nurse (APRN) or physician assistant (PA), the grantee must make sure a properly executed PAA is in place for each mid-level provider. The PAA must meet all the requirements delineated in Texas Occupations Code, Chapter 157, including the following criteria:

• be in writing and signed and dated by the parties to the agreement,
• be reviewed at least annually, including amendments,
• kept on-site where the APRN or PA provides care,
• include the name, address and all professional license numbers of all parties to the agreement,
• state the nature of the practice, locations or settings,
• identify the types or categories of drugs or devices that may or may not be prescribed,
• provide a general plan to address consultation and referral,
• provide a plan to address client emergencies,
• describe the general process for communication and information sharing between the physician and the APRN or PA the physician has delegated prescriptive authority related to the care and treatment of people,
• if alternate physician supervision will be used, appoint one or more alternate physicians who may:
  • provide appropriate temporary supervision that follows the requirements established by the PAA and of this section, and
  • participate in the prescriptive authority quality assurance and improvement plan meetings required under this section,
• describe a prescriptive authority quality assurance and improvement plan and specify methods for documenting the implementation of the plan that includes:
  • chart review, with the number of charts to be reviewed determined by the physician and APRN or PA, and
  • periodic meetings between the APRN or PA and the physician at a location determined by the physician, APRN or PA.

References

• Texas Occupations Code Title 3, Subtitle B, Chapter 157 about Authority of Physicians to Delegate Certain Medical Acts
• TAC, Texas Board of Nursing Rules
• TAC, Texas Medical Board, Physician Assistant Rules

Protocols

Grantees that employ APRNs or PAs 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 be included in a PAA if both parties agree to it. The protocols do not need to describe the exact steps an APRN or a PA must take for each specific condition, disease or symptom.

The supervising physician and the PA or APRN must review, agree on, sign and date the protocol at least annually. They must be maintained on-site per Texas Administrative Code, Title 22, Part 9, Chapter 169, Subchapter A

Standing Delegation Orders (SDOs)

SDOs are written instructions, orders, rules or procedures designed for a patient population with specific diseases, disorders, health problems or sets of symptoms. This type of order provides a general set of conditions and circumstances when action can be instituted before being examined or evaluated by a physician. Clinics must have written SDOs in place as outlined in TAC Title 22, Part 9, Chapter 169, Subchapter A.

Standing delegation orders may permit the administration or provision of the following types of drugs if specifically ordered by or using a pre-signed prescription from the delegating physician:

• oral contraceptives,
• diaphragms and contraceptive creams and jellies,
• topical anti-infectives for vaginal use,
• oral anti-parasitic drugs for treatment of pinworms,
• topical anti-parasitic drugs,
• antibiotic drugs for treatment of venereal disease, or
• immunizations.

General standards for Standing Delegation Orders, Standing Medical Orders and Protocols require:

• development and approval by the delegating physician or following facility bylaws and policies,
• the order or protocol must be in writing and signed by the delegating physician,
• a description of the specific instructions, orders, protocols or procedures to be followed,
• a notation of the level of supervision required, unless specified by other law,
• plans to address patient emergencies,
• annual review signed by the delegating physician, and
• maintenance at the facility or practice site.

Dental Delegation

Grantees must abide by delegation rules set forth by the Dental Practice Act and Texas State Board of Dental Examiners Rules. A licensed dentist may delegate verbally or in writing a service, task or procedure to a dental hygienist under the supervision and responsibility of the dentist, per the Dental Practice Act. A dentist is not required to be on the premises when the dental hygienist performs a delegated act. A licensed dentist may delegate to a qualified and trained dental assistant acting under the dentist’s general or direct supervision any dental act that is reasonable, and a prudent dentist would find is within the scope of sound dental judgment to delegate specified by the Dental Practice Act. Physical presence does not require the supervising dentist be in the treatment room when the dental assistant performs the service if the dentist is in the dental office or clinic. A delegating dentist is responsible for a dental act performed by the person the dentist delegates the act.

References

• Texas Board of Nursing Position Statement 15.5 Nurses with Responsibility for Initiating Physician Standing Orders
• Delegation of Nursing Tasks by Registered Professional Nurses
• Texas State Board of Dental Examiners
• Texas Medical Board

Revision 23-2; Effective Sept. 8, 2023

This section provides policy requirements for submitting for reimbursement, data collection and required reports.

6100 Reimbursement, Data Collection and Reports

Revision 24-2; Effective Sept. 30, 2024

Submission of the Monthly Invoice and Monthly Reporting Packet (MRP)

The reimbursement officer sends the MRP for both programs by email at the start of each state fiscal year. Each MRP submission should only include services provided in the preceding month as applicable to the grant. Late or absent submissions can impact HHSC midyear utilization determination, which is decided during the second quarter of the state fiscal year. The September MRP for both programs must be submitted and reimbursed by Dec.1. Submissions that do not meet the above requirement will not be processed.

Send monthly submissions to HDS.ADS@hhs.texas.gov. They are due within 30 business days after the end of the preceding service month. Billing or reporting forms may not be altered in any manner.  

Grantees need to:

• complete the date and contact information on the Monthly Reimbursement Request (MRR);
• supply supporting documentation (billing strip);
• complete the service quantities on the 185 and 186 tabs; and
• complete demographic data and unduplicated number of clients on the Monthly Activity tab.

Appropriate Supporting Documentation

Grantees must maintain a monthly billing log, also known as billing strips, either automated or manual, to support their Monthly Reporting Packet (MRP) submissions. The log should contain a unique client number, client’s age at time of service, date of service, and procedure code for each service billed.

Reconciling Discrepancies on Previously Submitted Monthly Reporting Packets (MRP)

Incorrect or missing information that requires clarification or follow-up by HHSC staff may delay payment. A response is required within five business days of the initial outreach to the grantee. Discrepancies can occur that result in a grantee receiving payment for services not billed appropriately during a service month. This can be corrected by subtracting the amount from the next month, adjusting all information. 

If an MRP requires a correction, grantees should resubmit a corrected MRP with supporting documentation as a new email submission to HDS.ADS@hhs.texas.gov.

Grantees must maintain records that document the necessary information for services provided and billed for reimbursement. 

Supplemental Invoices

Instances can occur that result in missed reporting of a prior month’s services that have not yet been billed TVFFS. Any services performed before the current service month must be submitted as a supplemental invoice, with a separate invoice for each service month applicable. Use your MRP to submit the supplemental invoice to HDS.ADS@hhs.texas.gov. Include supplemental in the message’s subject line. 

Submission and Reporting After Entire Contract Award is Expended

Grantees must continue to submit the MRP even after the contract award has been expended. Grantees bill for allowable services provided to eligible clients and will receive reimbursement up to their grant award amount. Once all award funds have been expended, no other funds will be available for reimbursement. Grantees who have exhausted their awarded funds must continue to serve their existing clients. 

An MRP must be submitted even if the reimbursement requested amount is zero. Any cost over the contract award after deducting program income should be reflected under Non-HHSC Funding. This submission must continue reporting expenditures on any program income collected monthly and to provide HHSC with statistical information about the use of services.

Submission of Final Invoice and MRP

Grantees may have claims after the submission of their August billing. Additional services must be submitted within 45 calendar days after the end of the contract term. Mark this as final. Submit the final invoice and MRP before this date if the 45-day deadline falls on a weekend. Reimbursement requests submitted over 45 days after the contract term end will not be paid.

Submission of Financial Reconciliation Report (FRR)

The FRR must include all reimbursements and adjustments in payment for the contract term and must submit them to HDS.ADS@hhs.texas.gov 60 calendar days from the end of the contract year, which is Oct. 31. 

For technical or accessibility issues with this handbook, please email the HHS Form & Handbook Request mailbox.

For questions about the Title V Maternal and Child Health Fee-for-Service Program Policy Manual, email the Titlevffs@hhs.texas.gov mailbox.