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Revision 24-2; Effective Sept. 20, 2024
2310 Confidentiality
Revision 25-3; Effective Sept. 1, 2025
Grantees must comply with the U.S Health Insurance Portability and Accountability Act of 1996 (HIPAA) established standards for privacy protection. The HIPAA Privacy Rule requires grantees to develop and distribute a notice that provides a clear explanation of privacy rights and practices. This Notice of Privacy Practices must be given to clients, at the first appointment, upon request, and at a minimum, every three years. The notice must be posted in a clear and easy to find location for clients to review. It also must be posted on the organization’s website. More information on health information privacy is on the U.S. Department of Health and Human Services Notice of Privacy Practices website and Notice of Privacy Practices for Protected Health Information website.
Grantees must make sure all employees and volunteers receive training about client confidentiality during orientation and be made aware that violation of the law about confidentiality may result in civil damages and criminal penalties. A health care provider’s staff, paid and unpaid, must be informed during orientation of the importance of keeping client information confidential. All employees, volunteers, subrecipient, board members and advisory board members must sign a confidentiality statement during orientation.
A grantee must document the client’s preferred method of communication, such as cell phone, email, work phone or text, and preferred language in the client’s record. Each client must receive verbal assurance of confidentiality. Clients must be told that confidentiality means information is kept private and not shared without permission. They also must be told about any applicable exceptions such as abuse reporting. Grantees are required to provide clients with a copy of the signed confidentiality policy or agreement and maintain a copy in the client's record. Grantees must not require consent for services from the spouse of a married client.
2320 Nondiscrimination and Limited English Proficiency
Revision 25-3; Effective Sept. 1, 2025
HHSC contracts require grantees to comply with state and federal antidiscrimination laws including state rules in Texas Administrative Code (TAC) Title 1, Part 15, Chapter 395, Subchapter B, Section 395.11.
Find more information about nondiscrimination laws and regulations on the HHSC Civil Rights Office website and the Requirements for Contractors website.
Contract Terms and Conditions
To ensure compliance with nondiscrimination laws, regulations and policies, grantees must:
- sign a written assurance to comply with applicable federal and state nondiscrimination laws and regulations;
- have a written policy that states the agency does not discriminate based on:
- race;
- color;
- national origin including limited English proficiency (LEP);
- sex;
- age;
- religion; or
- disability;
- have a policy that addresses client rights and responsibilities that is applicable to all people who request services;
- have procedures to notify the HHSC Civil Rights Office of any program- or service-related discrimination allegation or complaint no more than 10 calendar days after the allegation or complaint;
- make sure all grantee staff are trained in the grantee's nondiscrimination policies, including policies for serving people with LEP and people with disabilities, and HHSC complaint procedures;
- notify all people who apply for services of the grantee's nondiscrimination policies and complaint procedures; and
- prominently display civil rights posters in common areas, including lobbies and waiting rooms, front reception desks and locations where clients apply for services. Posters are on the Civil Rights Office website.
Direct questions about this section and civil rights matters to the HHSC Civil Rights Office.
LEP
To comply with civil rights requirements related to LEP, grantees must:
- take reasonable steps to make sure people with LEP have meaningful access to its programs and services;
- not require a person with LEP to use friends or family members as interpreters;
- a family member or friend may serve as a person’s interpreter if the person requests it; and
- the family member or friend does not compromise the effectiveness of the service or violate client confidentiality; and
- make people with language service needs, including people with LEP and disabilities, aware that the grantee will provide an interpreter free of charge.
2330 Termination of Services
Revision 24-2; Effective Sept. 20, 2024
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:
- they are disruptive, unruly, threatening or uncooperative to the extent the client seriously impairs the grantee’s ability to effectively and safely provide services; or
- their behavior jeopardizes their own safety, or the safety of clinic staff or others.
A client has the right to appeal the denial, modification, suspension or termination of services. See 2340, Resolution of Complaints.
Grantees must have a written policy related to termination of services. For more information, see the Fair and Fraud Hearings website.
2340 Resolution of Complaints
Revision 24-2; Effective Sept. 20, 2024
Grantees must make sure clients can express concerns about care received and that those concerns are handled in a consistent manner. A grantee’s policy must explain the process to follow if the client is not satisfied with the care received. This process must include:
- Grantees must investigate and resolve a concern within 30 business days after the grantee receives the concern.
- Clients may contact a grantee’s clinic to see if the clinic can explain the decision or correct the problem.
- If a client remains unsatisfied with how the concern was handled, grantee may encourage the client to send an email to BCCSProgam@hhs.texas.gov.
- Grantees must provide the client with contact information to the HHS Office of the Ombudsman.
- All concerns must be documented in the client’s record.
2350 Reserved for Future Use
Revision 24-2; Effective Sept. 20, 2024
2360 Freedom of Choice
Revision 22-0; Effective August 15, 2022
Clients have the right to choose health care providers, without coercion or intimidation. Acceptance of health care services does not preclude eligibility for, or receipt of, any other service or assistance.
2370 Research (Human Subject Clearance)
Revision 23-2; Effective Sept. 29, 2023
To participate in proposed research that would involve the use of BCCS clients as subjects, the use of BCCS clients’ records or any data collected from BCCS clients, BCCS grantees must get prior approval from their own internal Institutional Review Board (IRB) and from HHSC. For information about the process, grantees should visit the Institutional Review Board Home.
The grantee must have a policy in place that indicates that prior approval will be obtained from HHSC before instituting any research activities. The grantee must also ensure that all staff are made aware of this policy through staff training. Documentation of training on this topic must be maintained. Federal BCCS funds may not be used for research.