PHC Manual

FISCAL YEAR 2012
DEPARTMENT OF STATE HEALTH SERVICES
PRIMARY HEALTH CARE PROGRAM
2012
POLICY MANUAL
SECTION ONE
GENERAL INFORMATION
SECTION ONE GENERAL INFORMATION
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Chapter 31, Health & Safety Code In the early 1980s, economic recession and cost containment measures on the part of employers and government agencies led to a decrease in the availability and accessibility of health care services for many Texans. A gubernatorial and legislative task force identified the provision of primary health care to the medically indigent as a major priority. The task force recommended the following: A range of primary health care services shall be made available to the medically indigent residing in Texas. The Department of State Health (DSHS) shall provide or contract to provide primary health care services to the medically indigent. These services should complement existing services and/or should be provided where there is a scarcity of services. Health education should be an integral component of all primary care services delivered to the medically indigent population. Preventive services should be marketed and made accessible to reduce the use of more expensive emergency room services.
These recommendations become the basis of the indigent health care legislative package enacted by the 69th Texas Legislature in 1985. The Primary Health Care Services Act, HB 1844, was part of this legislation and is the statutory authority for Primary Health Care Services (PHC) administered by DSHS. The Act delineates the specific target population, eligibility, reporting, and coordination requirements for PHC. Internet links to the relevant Health and Safety Code and Texas Administrative Code can be found in Appendix C of this manual. Support for the Primary Health Care Services Act is broad-based and includes local government associations, health professional organizations, religious organizations, citizen coalitions, and consumers. It is recognized that primary health care is of major importance in reducing the burden of unnecessary illness and premature death, as well as reducing overall health care expenditures incurred by expensive crisis-oriented care.
PHC Rules
The state rules for Primary Health Care Services in Texas can be found in the Texas Administrative Code (TAC), Title 25, Part 1, Chapter 39, Subchapter A. Section 39.2 of the Texas Administrative Code (TAC) states that PHC services include: Diagnosis and treatment Emergency services Family planning services Preventive health services, including immunizations Health education Laboratory, x-ray, nuclear medicine, or other appropriate diagnostic services
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PHC Rules (continued) Nutrition services Health screening Home health care Dental care Transportation Prescription drugs and devices, and durable supplies Environmental health services Podiatry services Social Services
TAC 39.3 and 39.4 state that, at a minimum, a PHC contractor must provide the following six priority primary health care services either directly or through agreements or subcontracts with other providers: Diagnosis and treatment Emergency services Family planning services Preventive health services, including immunizations Health education Laboratory, x-ray, nuclear medicine, or other appropriate diagnostic services
The Primary Health Care Services Act seeks to provide access to primary health care services for those individuals, at or below 150% of the Federal Poverty Level (FPL), who are unable to access the same care through other funding sources or programs. Contractors must assure that the services they provide either directly or indirectly (through a system of referrals and/or subcontracts) are accessible to clients in terms of cost, scheduling, distance, and cultural sensitivity.
Definitions
Below are some general definitions of terms or phrases that are used throughout this manual. Age For a child to be counted as part of the household, the child must be under 18 years of age and unmarried. The provider staff should terminate the childs eligibility at the end of the month the child become 18 unless the child: Is a full-time student (as defined by the school) in high school, attends an accredited GED class, or regularly attends vocational or technical training as an equivalent to high school attendance, and Is expected to graduate before or during the month of his/her 19th birthday. If the child does not meet the above criteria, he/she will be considered a separate household of one.
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Definitions (continued) Client An individual who has been screened, determined to be eligible for services, and has successfully completed the eligibility process. Community Assessment Tool used to identify factors that affect the health of a population and to determine the availability of resources within the community to impact these factors. Contractor The entity the Department of State Health Services has contracted with to provide services. The contractor is the responsible entity even if there is a subcontractor involved who actually provides the services. Co-Payment (co-pay) Monies collected directly from clients for services. The amount collected each month should be deducted from the Monthly Purchase Voucher (Form B -13) and is considered program income. Dental Services Periodic exams, fillings, prophylactic cleaning, etc. performed in a dental office or clinic. Department of State Health Services (DSHS) The agency responsible for administering physical and mental health-related prevention, treatment, and regulatory programs for the State of Texas. Diagnosis The recognition of disease status determined by evaluating the history of the client and the disease process, and the signs and symptoms present. (Determining the diagnosis may require microscopic (i.e. culture), chemical (i.e., blood tests), and/or radiological examinations (x-rays). Eligibility Date Date the individual submits a completed application to the provider. The eligibility expiration date will be twelve months from the eligibility date. Emergency Services Services provided to individuals when there is an unexpected health condition that requires immediate attention. Environmental Health The provision of treating a persons surroundings in regards to a health condition. Family Composition/Household A person living alone or a group of two or more persons related by birth, marriage (including common law) or adoption, who reside together and who are legally responsible for the support of the other person. Family Planning Services Assisting women and men in planning their families, whether it is to achieve, postpone, or prevent pregnancy. Family planning services include the following: pregnancy test (if indicated), health history, risk assessment, physical examinations, lab tests, counseling/education, and contraceptive supplies.
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Definitions (continued) 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, this level is determined by the Department of Health and Human Services. FPL varies according to family size. The number is adjusted for inflation and reported annually in the form of poverty guidelines. Public assistance programs, such as Medicaid in the U.S., define eligibility income limits as some percentage of FPL. Fiscal Year State fiscal year, September 1 August 31. Health and Human Services Commission (HHSC) State agency that has oversight responsibilities for designated Health and Human Services agencies, including DSHS, and administers certain health and human services programs including the Texas Medicaid Program, Childrens Health Insurance Program (CHIP), and Medicaid waste, fraud, and abuse investigations. Health Screening The provision of tests, i.e. blood glucose, serum cholesterol, fecal occult blood, as a means For determining the need for intervention and perhaps more comprehensive evaluation. Health Service Region For administrative purposes, DSHS has grouped counties within a specified geographic area into 11 Health Service Regions. Home Health Care Services include Registered Nurse (RN) visits for skilled nursing observation, assessment, evaluation, and treatment provided by a physician specifically requests the RN visit for this purpose. A home health aide to assist with administering medication is also covered. Laboratory, X-Ray, or other Appropriate Diagnostic Services Studies or tests ordered by the clients health care practitioner(s) to evaluate an individuals health status for diagnostic purposes. Medicaid Title XIX of the Social Security Act; reimburses for health care services delivered to low-income clients who meet eligibility guidelines. Minor A person who has not reached his/her 18th birthday and who has not had the classification of minor removed in court or who is not or never has been married or recognized as an adult by the State of Texas. Nutritional Services The provision of services to identify the nutritional status of an individual, and instruction which includes appropriate dietary information based on the clients needs, i.e. age, sex, health status, culture. Information may be provided on an individual, one- to-one basis, or to a group of individuals.
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Definitions (continued) Outreach Activities that are conducted with the purpose of informing and educating the community about services and increasing the number of participants. Podiatry Services The study and care of the foot, including its anatomy, pathology, and medical/surgical treatment. Prescription Drugs and Devices and Durable Supplies Medically necessary pharmaceuticals, medical supplies (capable of withstanding wear) which are needed for the treatment of a diagnosed condition. Presumptive Eligibility Short-term availability and access to health care services (90 days) when an immediate medical need exists as determined by a medical professional and the client screens potentially eligible for services. Preventive Health Care Services The major emphasis is placed on guarding or defending an individual or group against specific illness or injury. Included are immunizations, risk assessments, health histories, and baseline physicals for early detection of disease and restoration to a previous state of health, and prevention of further deterioration and/or disability. Program Income Monies collected directly by the contractor/provider for services provided under the grant award. Provider An individual clinician or group of clinicians who provide services. Re-certification The process of re-screening and determining eligibility for the next year. Resident Alien A person who is not an U.S. citizen, and has an immigration document. Service Any client encounter at a facility that results in the client having a medical or health-related need met. Social Services The provision of counseling and guidance; assistance to client and family in locating, accessing, and utilizing appropriate community resources. Texas Resident An individual who resides within the geographic boundaries of the state. Transportation Services provided to a client for the purpose of receiving a required health care service. Transportation could be provided via private vehicle, public transportation, project site vehicle, or emergency medical vehicle.
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Definitions (continued) Treatment Any specific procedure used for the cure or the improvement of a disease or pathological condition. Undocumented Alien A person who is not an U.S. citizen, and has no immigration documentation. Unduplicated Client Clients are counted only regardless of the number of services they receive. One client seen four times is counted as one unduplicated client and a family of three seen once is counted as three unduplicated clients.
Acronyms Acronym ADA BCCS CAM CDSB CFTR CHIP CIHCP CLIA CMB CPR DES DHHS DSHS EMR FPL FQHC FSR HIPPA HHSC HPV HSR IRB LEP MCH OTC PMU PHC PPCU QA QM QMB Term Americans with Disabilities Act Breast and Cervical Cancer Services Complementary and Alternative Medications Contract Development and Support Branch Cystic Fibrosis Transmembrane Conductance Regulator Childrens Health Insurance Program County Indigent Health Care Program Clinical Laboratory Improvement Amendments DSHS Contract Management Branch Cardiopulmonary Resuscitation Diethylstilbestrol U.S. Department of Health and Human Services Texas Department of State Health Services Electronic Medical Record Federal Poverty Level Federally Qualified Health Center Financial Status Report Health Insurance Portability and Accountability Act of 1996 Texas Health and Human Services Commission Human Papilloma Virus DSHS Health Service Region Institutional Review Board Limited English Proficiency Maternal and Child Health Services Over the Counter DSHS Performance Management Unit Primary Health Care DSHS Preventive and Primary Care Unit Quality Assurance Quality Management DSHS Quality Management Branch
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RFP RSDI SDO SSA SSDI SSI STI STL TAC TANF TMHP TMPPM WHL Request for Proposal Retirement Survivors Disability Income Standing Delegation Orders Social Security Administration Social Security Disability Income Supplemental Security Income Sexually Transmitted Infection South Texas Lab Texas Administrative Code Temporary Assistance for Needy Families Texas Medicaid Healthcare Partnership Texas Medicaid Provider Procedures Manual Womens Health Lab
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SECTION TWO
PROGRAM ADMINISTRATION
SECTION TWO PROGRAM ADMINISTRATION
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Client Access The contractor must ensure that clients are provided services in a timely and non-discriminatory manner. The contractor must: Have a policy in place that delineates the timely provision of services; Comply with all applicable civil rights laws and regulations including Title VI of the Civil Rights Act of 1964, the Americans with Disabilities Act of 1990, the Age Discrimination Act of 1975, and Section 504 of the Rehabilitation Act of 1973, and ensure services are accessible to persons with limited English proficiency (see: http: www.lep.gov/) and speech or sensory impairments; Have a system to prioritize clients needs; Have a triage system that utilities qualified staff; Screen clients in a way that is respectful and convenient; Provide referral resources for individuals that cannot be served or cannot receive a specific service; Continue to provide services to established clients once funds have been expended, and A contractor that is designated as a FQHC shall operate extended weekend and evening hours a minimum of one time per month.
Abuse Reporting
DSHS CHILD ABUSE COMPLIANCE AND MONITORING Chapter 261 of the Texas Family Code requires child abuse reporting. Contractors/providers are required to develop policies and procedures that comply with the child abuse reporting guidelines and requirements set forth in Chapter 261 and the DSHS Child Abuse, Screening, Documenting and Reporting Policy for Contractors/Providers. Contractors must adopt the DSHS Child Abuse Screening, Documenting and Reporting Policy for Contractors/Providers and develop an internal policy specific to how these reporting requirements will be implemented throughout their agency, how staff will be trained and how internal monitoring will be done to ensure timely reporting. The following outlines how the DSHS Quality Management Branch (QMB) staff will review for contractor compliance with these requirements. Policy Contractors/providers will be monitored to ensure compliance with screening for child abuse and reporting according to Chapter 261 of the Texas Family Code and the DSHS Child Abuse Screening, Documenting, and Reporting Policy for Contractors/Providers. Procedures During site monitoring of contractors by QMB the following procedures will be utilized to evaluate compliance: 1) The contractor's process used to ensure that staff is reporting according to Chapter 261 and the DSHS Child Abuse Screening, Documenting and
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Abuse Reporting (continued) Reporting Policy for Contractors will be reviewed as part of the Core Tool. To verify compliance with this item, monitors must review: a) that the contractor adopted the DSHS Policy; b) the contractor's internal policy which details how the contractor will determine, document, report, and track instances of abuse, sexual or non-sexual for all clients under the age of 17 in compliance with the Texas Family Code, Chapter 261 and the DSHS Policy; c) the contractor followed their internal policy and the DSHS Policy; and d) the contractor documentation of staff training on child abuse reporting requirements and procedures. 2) All records of clients under 14 years of age who are pregnant or have a confirmed diagnosis of an STD acquired in a manner other than through perinatal transmission or transfusion will be reviewed for appropriate screening and reporting documentation as required in the clinic or site being visited during a site monitoring visit. The review of the records will involve reviewing that the DSHS Child Abuse Reporting Form was utilized; a report was made; and the report was made in the proper timeframes required by law. 3) If during the record review process, noncompliance is identified, the staff person responsible will be notified and asked to make a report as required by law. The agency director will also be notified of the problem. Noncompliance will again be identified during the Exit Conference with the contractor. 4) If it is found during routine record review of other records for services that a report should have been made as evidenced by the age of the client and evidence of sexual activity, the failure to appropriately screen and report will be identified as lack of compliance with the DSHS Policy; and the QMB will identify the need for the contractor to train staff. Failure to report will be brought to the attention of the staff person who should have made the report or the appropriate supervisor with a request to immediately report. This failure to report will also be discussed with the agency director. 5) The report sent to the contractor will also indicate the number of applicable records reviewed in each clinic and the number of records that were found to be out of compliance. This report will be sent to the contractor 4 to 6 weeks from the date of the review, which is the usual process for Site Monitoring Reports. 6) The contractor will then be given 6 weeks to respond with written corrective actions to all findings. If the contractor has other findings that warrant technical assistance or accelerated monitoring review, either regional or central office staff will make the necessary contacts. Records and/or policies will again be reviewed to ensure compliance with Chapter 261 and the DSHS Policy requirements. If any subsequent finding of noncompliance is identified during a subsequent monitoring or technical assistance visit, the contractor will be referred for financial sanctioning.
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Abuse Reporting (continued) 7) If the contractor does not provide corrective actions during the required time period, the contractor will be sent a past due letter with a time period of 10 days to submit the corrective actions. If the corrective actions are not submitted during the time period given, failure to submit the corrective action is considered a subsequent finding of noncompliance and the contractor/provider will be referred for financial sanctioning due to noncompliance with Chapter 261 and the DSHS Policy. 8) If a contractor is found to have minimal findings overall but did have findings of noncompliance with Chapter 261 and the DSHS Policy, an additional sanction accelerated monitoring visit solely to review child abuse reporting will not be conducted. For agencies that receive technical assistance visits as a result of a quality assurance review, the agency will again be reviewed for compliance with child abuse reporting for the requirements with which the agency did not comply. In all cases, the corrective actions submitted by the contractor will be reviewed to ensure that the issues have been addressed. Agencies who do not receive a sanction or technical assistance visit will be required to complete the DSHS Progress Report, Compliance with Child Abuse Reporting within 3 months after the corrective actions are begun (no later than 6 months from the initial visit). Failure to submit a Progress Report within the required time period or submission of a report that is not adequate constitutes a subsequent finding of noncompliance with the DSHS Child Abuse Screening, Documenting, and Reporting Policy for Contractors/Providers and the contractor will be referred for financial sanctions. Information about this topic is available on the internet at: http://www.dshs.state.tx.us/childabusereporting/default.shtm. .
Confidentiality
All contracting agencies must be in compliance with the U.S. Health Insurance Portability and Accountability Act of 1996 (HIPPA) established standards for protection of client privacy. Information about HIPPA can be found at: http://www.dshs.gov/ocr/hipaa/. Employees and volunteers must be made aware during orientation that violation of the law in regard to confidentiality may result in civil damages and criminal penalties. The clients preferred method of follow-up to clinic services (cell phone, email, work phone) and preferred language must be documented in the clients record. (See Client Health Record Section Four, page 8). Each client must receive verbal assurance of confidentiality and an explanation of what confidentiality means (kept private and not shared without permission) and any applicable exceptions such as abuse reporting (See Abuse Reporting, Section Two, page 1).
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NonDiscrimination DSHS contractors must comply with state and federal anti-discrimination laws, including without limitation: 1. 2. 3. 4. 5. Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.); Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794); Americans with Disabilities Act of 1990 (42 U.S.C. 12101 et seq. Age Discrimination Act of 1975 (42 U.S.C. 6101-6107); Title IX of the Education Amendments of 1972 (20 U.S.C. 16811688); 6. Food Stamp Act of 2008 (7 U.S.C. 2011 et seq.); and 7. HHSCs administrative rules, as set forth in the Texas Administrative Code, to the extent applicable. To ensure compliance with DSHS non-discrimination policies DSHS contractors must: Have a written policy that states the agency does not discriminate on the basis of race, color, national origin including LEP, religion, disability, age, or sex; Sign a written assurance as to compliance with applicable federal and state civil rights laws and regulations; Have procedures for notifying the HHSC Civil Rights Office of any program or service-related discrimination allegation or complaint within ten (10) calendar days after receipt of the allegation or complaint. Notice provided pursuant to this section must be directed to: HHSC Civil Rights Office 701 W. 51st Street, Mail Code W206 Austin, Texas 78751 Phone Toll Free: (888) 388-6332 Phone: (512) 438-4313 TTY Toll Free: (877) 432-7232 Fax: (512) 438-5885 Notify all clients and applicants of the contractors nondiscrimination policies and complaint procedures; Ensure that all contractor staff is trained in the agencys nondiscrimination policies and complaint procedures; NonDiscrimination (continued) Take reasonable steps to ensure that LEP persons have meaningful access to its programs and services, and not require a client with LEP to use friends or family members as interpreters. However, a family member or friend may serve as their interpreter at the clients request, and the family member or friend does not compromise the effectiveness of the service or violate client confidentiality
The contractor must prominently display in client common areas, including lobbies and waiting rooms, front reception desks and locations where clients apply for services, the following three posters:
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Know Your Rights [English] [Spanish] Size: 8.5 x 11 (standard size sheet of paper) Posting Instructions: Post the English and Spanish versions of this poster next to each other Questions: Contact the HHSC Civil Rights Office Need an Interpreter [Language Translation] [American Sign Language] Size: 8.5 x 11 (standard size sheet of paper) Posting Instructions: Post the Language Translation version and American Sign Language version next to each other Questions: Contact the HHSC Civil Rights Office Americans with Disabilities Act [English A] [Spanish A] [English B] [Spanish B] Size: 8.5 x 11 or 8.5 x 14 Posting instructions: Post with other civil rights posters Questions: Contact the HHSC Civil Rights Office The contractor must have available, completed, and signed copies of the Non-Discrimination Policies and Procedures Survey, ADA/Section 504 Policies and Procedures, and Limited English Proficiency (LEP) Policies and Procedures Survey prior to any scheduled on-site review by the Quality Management (QMB) review team. More information about applicable laws and regulations can be found on HHSC Office of Civil Rights Office website at: http://www.hhs.state.tx.us/aboutHHS/CivilRights.shtml. The Non-Discrimination Policies and Procedures Survey, ADA/Section 504 Policies and Procedures Survey, and Limited English Proficiency (LEP) Policies and Procedures Survey and their instructions can be downloaded at the QMB Website at: http://www.dshs.states.tx.us/qmb/contact.shtm.
Termination of Services
Clients must never be denied services due to an inability to pay. Contractors have the right to terminate services to a client if the client is disruptive, unruly, threatening, or uncooperative to the extent that the client seriously impairs the contractors ability to provide services or if the clients behavior jeopardizes the safety of himself or herself, clinic staff, or other clients. Contractors have the right to terminate services to a client if the client is disruptive, unruly, threatening, or uncooperative to the extent that the client seriously impairs the contractors ability to provide services or if the clients behavior jeopardizes his or her own safety, clinic staff, or other clients. September 2011
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Any policy related to termination of services must be included in the contractors policy and procedures manual. Resolution of Complaints Contractors must ensure that clients have the opportunity to express concerns about care received and to further ensure that those complaints are handled in a consistent manner. Contractors policy and procedure manuals must explain the process clients will follow if they are not satisfied with the care received or feel they have been discriminated against or treated inappropriately or unfairly. In accordance with PHC rule, 25 TAC 39.10 (relating to Appeals), an applicant or client may appeal a decision according to the procedures outlined in 25 TAC 1.51 1.55 (relating to DSHS Fair Hearings Procedures). If an aggrieved client requests a hearing, contractors shall not terminate services to the client until a final decision is rendered. Any client complaint must be documented in the clients record. Client Records Management DSHS contractors must have an organized and secure client record system. The contractor must ensure that the record is organized, readily accessible, and available to the client upon request with a signed release of information. The records must be kept confidential and secure, as follows: Safeguarded against lost and used by unauthorized persons; Secured 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. The written consent of the client is required for the release of personally identifiable information, except as may be necessary to provide services to the client or as required by law, with appropriate safeguards for confidentiality. HIV information should be handled according to law. (See: http://www.dshs.state.tx.us/hivstd/policy/laws.shtm).
Client Records Management (continued)
When information is requested, contractors should release only the specific information requested. Information collected for reporting purposes may be disclosed only in summary, statistically, or in a form that does not identify particular individuals. Upon request, clients transferring to other providers must be provided with a copy or summary of their record to expedite continuity of care. Electronic records are acceptable as medical records. Contractors, providers, sub-recipients, and subcontractors must maintain for the time period specified by DSHS all records pertaining to client services, contracts, and payments. Record retention requirements are found in 15 TAC 354.1004 (relating to Time Limits for Submitted Medicaid Claims) and 22 TAC 165 (relating to Medical Records). Contractors must
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follow contract provisions and the DSHS Retention Schedule for Medical Records. All records relating to services must be accessible for examination at any reasonable time to representatives of DSHS and as required by law. DSHS guidelines for medical record retention are available at: http://www.dshs.state.tx.us/records/medicalrec.shtm All medical records and supporting documentation for Title XIX Medicaid services must be maintained in accordance with Medicaid rules as outlined in the 2010 Texas Medicaid Provider Procedures Manual, Section 1.4.3 (page 1-18). http://www.tmhp.com/TMPPM/2010/Vol1_01_Provider_Enrollment.pdf
Personnel Policy and Procedures
Contractors must develop and maintain personnel policies and procedures to ensure that clinical staff are hired, trained, and evaluated appropriately to their job position. Personnel policies and procedures must include job descriptions, a written orientation plan for new staff to include skills evaluation and/or competencies appropriate for the position, and performance evaluation process for all staff. Job descriptions, including those for contracted personnel, must specify required qualifications and licensure. All staff must be appropriately identified with a name badge. Contractors must show evidence that employees meet all required qualifications and are provided annual training. Job evaluations should include observation of staff/client interactions during clinical, counseling and educational services. Contractors shall establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of personal or organizational conflict of interest or personal gain. Contractors must provide medical care services under the supervision, direction, and responsibility of a qualified medical director. Contractors must have a documented plan of organized staff development based on an assessment of:
Training needs; Quality assurance indicators; and Changing regulations/requirements.
Contractors must also include orientation and in-service training for all personnel, including volunteers. There must be documentation of initial employee orientation and continuing education. Facilities and Equipment DSHS contractors are required to maintain a safe environment at all times. Contractors must have written policies and procedures that address hazardous waste, fire safety, and medical equipment.
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Hazardous Materials Contractors must have written policies and procedures that address: The handling, storage, and disposing of hazardous materials and waste according to applicable laws and regulations; The handling, storage, and disposing 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 Contractors 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 Contractors must have a written policy and maintain documentation of the maintenance, testing, and inspection of medical equipment. Documentation must include: Assessments of the clinical and physical risks of equipment through inspection, 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. Smoking Ban Contractors must have written policies that prohibit smoking in any portion of their indoor facilities. If a contractor subcontracts with another entity for the provision of health services, the subcontractor must also comply with this policy. Disaster Response Plan Written and oral plans that address how staffs are to respond to emergency situations (i.e., fires, flooding, power outage, bomb threats, etc.). A disaster response plan must be in writing, formally communicated to staff, and kept in the workplace available to employees for review. For an employer with 10 or fewer employees, the plan may be communicated orally to employees. For additional resources on facilities and equipment, you can visit: http://osha.gov/.
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Quality Management Organizations that embrace Quality Management (QM) concepts and methodologies and integrate them into the structure of the organization and day-to-day operations discover a very powerful management tool. Quality Management programs can vary in structure and organization and will be most effective if they are individualized to meet the needs of a specific agency, services and the populations served. Contractors are expected to develop quality processes based on the four core Quality Management principles of focusing on: the client, systems and processes, measurement and teamwork. Contractors must have a Quality Management program individualized to their organizational structure and based on the services provided. The goals of the quality program should ensure availability and accessibility of services, and quality and continuity of care. A Quality Management program must be developed and implemented that provides for ongoing evaluation of services. Contractors 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. Contractors 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. The Quality Management Committee, whose membership consists of key leadership of the organization, including the Executive Director/CEO and the Medical Director, where applicable, annually reviews and approves the quality work plan for the organization. The Quality Management 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 must be maintained. The quality work plan at a minimum must: Include clinical and administrative standards by which services will be monitored; Include process for credentialing and peer review of clinicians; Identify individuals responsible for implementing monitoring, evaluating and reporting; Establish timelines for quality monitoring activities; Identify tools/forms to be utilized; and Outline reporting to the Quality Management Committee.
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Quality Management (continued) Although each organizations quality program is unique, the following activities must be undertaken by all agencies providing client services: On-going eligibility, billing, and clinical record reviews to assure compliance with program requirements and clinical standards of care; Tracking and reporting of adverse outcomes; Client satisfaction surveys; Annual review of facilities to maintain a safe environment, including an emergency safety plan; and Annual review of policies, clinical protocols and standing delegation orders (SDOs) to ensure they are current. Data from these activities must be presented to the Quality Management Committee. Plans to improve quality should result from the data analysis and reports considered by the committee and should be documented. Information on the operating process of DSHSs Quality Management Branch as well as policies and review tools can be located at: http://www.dshs.state.tx.us/qmb/default.shtm.
Programmatic Contractor shall provide information and supporting documentation as Eligibility Desk requested by DSHS to conduct programmatic desk reviews to verify client eligibility for PHC Program. Failure to submit requested information in a Reviews timely manner may result in sanctions according to provisions of the contract. If contractors desk reviews results in a finding of misappropriation of DSHS PHC co-payment (co-pay) policy, contractor shall reimburse client(s).
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SECTION THREE
ELIGIBILITY CRITERIA & CLIENT SERVICES
SECTION THREE ELIGIBILITY CRITERIA
General Principles
For an individual to receive PHC services, three (3) criteria must be met: Not eligible for other programs/benefits providing the same services; Texas resident; and Gross family income at or below 150% of the adopted Federal Poverty Level (FPL).
Contractor Responsibilities The contractor must ensure the eligibility process is complete and includes documentation of the following: Individual/family name, present address, date of birth, and whether the individual/family members are currently eligible for Medicaid or other benefits; Health insurance policies, if applicable, providing coverage for the individual, spouse, and dependent(s); Monthly income of individual and spouse; and Other benefits available to the family or individual. Any specified or other supporting documentation necessary for the contractor to determine eligibility;
The contractor will: Use the DSHS Funding Source - Application For Health Care Assistance (Form EF05-13229); DSHS Funding Source Worksheet (Form EF05-13227); and verification/documentation procedures established by DSHS or completion of a comparable paper or electronic screening and eligibility tool that has the required DSHS information for determining eligibility; Assist the applicant with accurately completing the application for screening and eligibility determination purposes; Ensure that the verification the individual provides is sufficient to make an eligibility decision. Request for Information (Form 104) may be used to assist applicants with requested verification requirements; Document oral designations of any additional contacts; Determine eligibility for PHC services based on the three (3) eligibility criteria; Provide the eligible individual information regarding the services he/she is entitled to receive and his/her rights and responsibilities; Advise the client of his/her responsibility to report changes; and Determine the effect reported changes have on the clients eligibility by re-screening and completing the eligibility determination process.
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General Principles (continued) The contractor shall allow the individual an opportunity to resolve any discrepancy by providing documentary evidence or by designating a suitable contact to verify information. If the individual fails or refuses to do so, eligibility can be denied. Document this information on the DSHS Funding Source - Worksheet. Special circumstances may occur in the disclosure of information, documentation of pertinent facts, or events surrounding the clients application for services that make decisions and judgments by the contractor staff necessary. These circumstances should be documented in the case record on the DSHS Funding Source - Worksheet. Applicants Responsibility Complete the DSHS Funding Source - Application For Health Care Assistance (Form EF05-13229) or request assistance for completion; Provide requested verification by the contractor. Failure to provide all required information will result in denial of eligibility. If verification is not available or is insufficient to determine eligibility, contractor staff should ask the individual to designate a contact person to provide the information.
Clients Responsibility for Reporting Changes A client must report changes in the following area: income, family composition, residence, address, employment, types of medical insurance coverage, and receipt of Medicaid and/or third-party coverage benefits. The client may report changes by mail, telephone, in-person, or through someone acting on the individuals behalf. Changes must be reported no later than 14 days after the client is aware of the change. If changes result in the client no longer meeting eligibility criteria, the individual is denied continued services. By signing the required forms, the individual attests to the truth of the information provided. Screening & Eligibility Determination Clients Screened Potentially Eligible for Other Benefits Contractors must work to ensure that individuals seeking PHC covered services use other programs or benefits first. If individuals are determined potentially eligible for other benefits, contractors must refer them to the specific programs and assist them in completing the eligibility determination process. It is possible that a family will be referred to several programs as a result of the eligibility determination process. Programs/benefits that must be used first include: Private/Employer Insurance; Medicare; Medicaid; TRICARE; County Indigent Health Care; Children with Special Health Care Needs;
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Screening & Eligibility Determination (continued) CHIP (other than family planning services); CHIP Perinatal; Title V, Title X, Title XIX (including WHP), and Title XX Family Planning; Breast and Cervical Cancer Services; Womens Health Program; Workers Compensation; Veterans Administration Benefits; or Other comprehensive healthcare plans.
Individuals must be screened for potential Medicaid, CHIP, or other programs by using the DSHS Funding Source Application For Health Care Assistance (Form EF05-13229) or a comparable paper or electronic screening and eligibility tool that has the required DSHS information and applicants signature for determining eligibility. A copy of the Application For Health Care Assistance must be maintained in the medical record. For PHC purposes, contractors may use the Health and Human Services Commissions (HHSC) Your Texas Benefits website (www.yourtexasbenefits.com) to assist in the screening of client eligibility. The website offers access to information on HHSC benefits including Medicaid, Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), Childrens Health Insurance (CHIP), and nursing home care and other services for people who are elderly or have disabilities. The use of this system may replace the DSHS Funding Source Worksheet (Form EF05-13227), but can not replace the DSHS Funding Source Application (Form EF 05-13299). More information about HHSC benefits can also be obtained by calling 2-1-1. The applicant is responsible for completing page one of his/her own DSHS Funding Source Application For Health Care Assistance (Form EF0513229). If the applicant is incompetent, or incapacitated, someone acting responsibly for the client (a representative) may represent the applicant in the application and the review process, including signing and dating the Form EF05-13229 on the applicants behalf. This representative must be knowledgeable about the applicant and his household. A copy of this form and instructions can be found in the Forms Section of the Policy and Procedures Manual. If assistance is needed in completing the form, the contractor shall provide knowledgeable staff to assist. It is acceptable to fill out the form once and photocopy the form for the number of family members needed. The family member name listed under the family composition chart on question 1 can be (highlighted/circled) to indicate the intended client record in which it shall be filed. If the applicant is married and his/her spouse is a household member, the spouse must also sign and date the DSHS Funding Source Application For Health Care Assistance (Form EF0513229). If confidentiality of services is a concern, separate forms for spouses may be completed. The signature of anyone assisting in completion of the form is required as well. The form is filed in the client record.
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Screening & Eligibility Determination (continued) Family Composition/Household Establishing family composition/household is an important step in the eligibility process. Assessment of income eligibility relies on an accurate count of family members. A family is defined as a person living alone or a group of two or more persons related by birth, marriage (including commonlaw), or adoption, which reside together and are legally responsible for the support of the other person. Unborn children are also included in family size. Children and Family Composition A child must be under 18 years of age to be counted as part of a family. Eligibility will end on the last day of the month the child become 18 years of age unless the child is: A full-time high school student as defined by the school, attends an accredited GED class, or regularly attends vocational or technical training in place of high school, and Expected to graduate from one of the above before or during the month of his/her 19th birthday.
A child who is 18 years of age or older and resides with his/her parent(s)/guardian(s), but is not currently attending high school is considered a family of one. A child may be considered part of a family when living with relatives other than natural parents if documentation can be provided that verifies the relationship. Acceptable documents include birth certificates or other legal documents that demonstrate the relationship between the caretaker and the child. If no biological relationship exists between the caretaker or documentation is not provided to verify biological relationship: The child becomes a separate PHC household; The situation must be explained on the worksheet; and Caretaker may apply for PHC benefits on childs behalf.
Verification/Documentation of Family Composition To verify family relationships, one of the following items may be provided, if questionable: Birth certificate; Baptismal certificate; School records; or Other documents or proof of family relationship determined valid by the contractor to establish the dependency of the family member upon the client or head of household. Family members who receive other health care benefits are included in the family count. The contractor has discretion to document special circumstances in the calculation of family composition. Additionally, if a separate family group is established within the household based on the documentation gathered, document the basis used for determining separate households on the DSHS Worksheet (Form EF05-13227).
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Screening & Eligibility Determination (continued) Residency To be eligible for PHC, an individual must be physically present within the geographic boundaries of Texas and: Has the intent to remain within the state, whether permanently or for an indefinite period; Does not claim residency in any other state or country; and/or Is less than 18 years of age and his/her parent, managing conservator, or guardian is a resident of Texas. There is no requirement regarding the amount of time an individual must live in Texas to establish residency for the purpose of PHC eligibility. Although the following individuals may reside in Texas, they are not considered Texas residents for the purpose of receiving PHC services and are considered ineligible: Inmates of correctional facilities; Residents of state or federal schools; and Patients in federal institutions or state psychiatric hospitals. Verification/Documentation of Residency Document proof of residency provided by the client on the DSHS Funding Source Worksheet and explain why residency is questionable, if necessary. For verification of residency, one of the following items shall be provided: Valid Texas Drivers License; Current voter registration; Rent or utility receipts for one month prior to the month of application; Motor vehicle registration; School records; Medical cards or other similar benefit cards; Property tax receipt; Mail addressed to the applicant, his/her spouse, or children if they live together; or Other documents considered valid by the contractor.
If none of the listed items are available, residence may be verified through: Observance of personal effects and living arrangement, or Statement from landlords, neighbors, other reliable sources. Temporary Absences from State Individuals do not lose their residency status because of temporary absences from the state. For example, a migrant or seasonal worker may travel during certain times of the year but maintains a home in Texas and returns to that home after these temporary absences. If a family is otherwise eligible, but residence is in question/dispute, the household is entitled to services until factual information regarding residency change proves otherwise.
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Screening & Eligibility Determination (continued) Income To be eligible for PHC, clients must have a gross family income at or below 150% FPL. The table below details sources of income that contribute to the calculation of gross family income as well as income that is exempt from being counted.
Types of Income Adoption Payments Cash Gifts and Contributions* Child Support Payments* Child's Earned Income Crime Victim's Compensation * Disability Insurance Benefits/SSDI* Dividends, Interest, and Royalties* Educational Assistance Energy Assistance Foster Care Payment In-kind Income Job Training Loans (Non-educational)* Lump-Sum Payments* Military Pay* Mineral Rights* Pensions and Annuities* Reimbursements* RSDI /SSDI/Social Security Payments* Self-Employment Income* SSI Payments TANF Unemployment Compensation* Veteran's Administration* Wages and Salaries, Commissions* Worker's Compensation* Countable Exempt X X X X X X X X X X X X X X X X X X X X X
X X X X X X X
*Explanation of countable income provided below
Cash Gifts and Contributions Count unless they are made by a private, nonprofit organization on the basis of need; and total $300 or less per household in a federal fiscal quarter. The federal fiscal quarters are January March, April June, July September, and October December. If these contributions exceed $300 in a quarter, count the excess amount as income in the month received. Exempt any cash contribution for common household expenses, such as food, rent, utilities, and items for home maintenance, if it is received from a noncertified household member who:
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Screening & Eligibility Determination (continued)
Lives in the home with the certified household member, Shares household expenses with the certified household member, and No landlord/tenant relationship exists.
Child Support Payments Count income after deducting $75 from the total monthly child support payments the household receives. Disability Insurance Payments/SSDI Countable. Social Security Disability Insurance is a payroll tax-funded, federal insurance program of the Social Security Administration. Medical condition prohibits work for one year or results in death. Dividends, Interest and Royalties Countable. Exception: Exempt dividends from insurance policies as income. Count royalties, minus any amount deducted for production expenses and severance taxes. In-Kind Income Exempt. An in-kind contribution is any gain or benefit to a person that is not in the form of money/check payable directly to the household, such as clothing, public housing, or food. Loans (Non-educational) Count as income unless there is an understanding that the money will be repaid and the person can reasonably explain how he/she will repay it. Lump-Sum Payments Count as income in the month received if the person receives it or expects to receive it more often than once a year. Exempt lump sums received once a year or less, unless specifically listed as income.
Military Pay- Count military pay and allowances for housing, food, base pay, and flight pay, minus pay withheld to fund education under the G.I. Bill. Mineral Rights Countable. A payment received from the excavation of minerals such as oil, natural gas, coal, gold, copper, iron, limestone, gypsum, sand, gravel, etc. Pensions and Annuities Countable. A pension is any benefit derived from former employment, such as retirement benefits or disability pensions. Reimbursements Countable, minus the actual expenses. Exempt a reimbursement for future expenses only if the household plans to use it as intended. RSDI/SSDI/Social Security Payments Count the Retirement, Survivors, and Disability Insurance (RSDI) benefit amount including the deduction for the Medicare premium, minus any amount that is being recouped for a prior RSDI overpayment.
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Screening & Eligibility Determination (continued) Self-Employment Income Count total gross earned, minus the allowable costs of producing the self-employment income. SSI Payments Exempt Supplemental Security Income (SSI) benefits. Terminated Employment Count terminated income in the month received. Use actual income and do not use conversion factors if terminated income is less than a full months income. Income is terminated if it will not be received in the next usual payment cycle. Unemployment Compensation Payments Count the gross benefit less any amount being recouped for a UIB overpayment. VA Payments Count the gross Veterans Administration (VA) payment, minus any amount being recouped for a VA overpayment. Exempt VA special needs payments, such as annual clothing allowances or monthly payments for an attendant for disabled veterans. Wages, Salaries, Tips and Commissions Count the actual (not taxable) gross amount. Workers Compensation Count the gross payment, minus any amount being recouped for a prior workers compensation overpayment or paid for attorneys fees. NOTE: The Texas Workforce Commission (TWC) or a court sets the amount of the attorneys fee to be paid. Verification/Documentation of Income Verification and documentation of income must be provided to complete the DSHS Funding Source Worksheet. Declarations of unknown will not be accepted as representations of required facts and documentation. Incomplete or inadequately documented eligibility determination will result in limitations in the provision of funded services. To verify income, one of the following must be provided: a minimum of three (3) consecutive, current pay periods or one months pay only if paid same gross amount on a monthly basis, unless special circumstances are noted on the DSHS Funding Source - Worksheet: Copy(ies) of the most recent paycheck stub/monthly earning statement(s); Employers written verification of gross monthly income or the Employment Verification Form (Form 128); Award letters; Domestic relation printout of child support payments; Letter of support Unemployment benefits statement or letter from the Texas Workforce Commission; Award letters, court orders, or public decrees to verify support payments ; or Notes for cash contributions.
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Screening & Eligibility Determination (continued) If all attempts to verify income are unsuccessful because the employer/payer fails or refuses to provide information or threatens continued employment, and no other proof can be found, staff may determine an amount to use on the form based on the best available information and document the determined income on the DSHS Funding Source Worksheet. Income Determination Procedure Count income already received and any income the household expects to receive. When an individual has not yet received income for new employment, use the best estimate of the amount to be received. If telephone verification regarding new or terminated employment is made, it must be documented by the contractor on the DSHS Funding Source Worksheet (Form EF05-13227). Count terminated income in the month received. Use actual income and do not use conversion factors if terminated income is less than a full months income. Use at least three consecutive, current pay periods to calculate projected monthly income. If client is paid one time per month and receives the same gross pay each month, then one pay period will suffice. If actual or projected income is not received monthly, convert it to a monthly amount using one of the following methods: o o o Weekly income x 4.33; Every two weeks x 2.17; or Twice a month x 2.0.
Dependent childcare expenses shall be deducted from total income in determining eligibility. Allowable deductions are actual expenses up to $200 per child per month for children under age 2 and $175 per child per month for children age 2 to 12 or age 2 to 18 if child is disabled. Legally obligated child support payments made by a member of the household group shall also be deducted. Payments made weekly, every two weeks or twice a month must be converted to a monthly amount by using one of the above listed conversion factors.
Self-Employment Income If an applicant earns self-employment income, it must be added to any income received from other sources. Annualize self-employment income that is intended for an individual or familys annual support, regardless of how frequently the income is received.
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Screening & Eligibility Determination (continued) Determine the costs of producing self-employment income by accepting the deductions listed on the 1040 U.S. Individual Income Tax Return statement or by allowing the following deductions: o Capital asset improvements; o Capital asset purchases, such as real property, equipment, machinery and other durable goods, i.e., items expected to last at least 12 months; o Fuel; o Identifiable costs of seed and fertilizer; o Insurance premiums; o Interest from business loans on income-producing property; o Labor; o Linen service; o Payments of the principal of loans for income-producing property; o Property taxes; o Raw materials; o Rent; o Repairs that maintain income-producing property; o Sales tax; o Stock; o Supplies; o Transportation costs. The person may choose to use 50.0 cents per mile instead of keeping track of individual transportation expenses. Do not allow travel to and from the place of business, and o Utilities. NOTE: If the applicant conducts a self-employment business in his home, consider the cost of the home (rent, mortgage, utilities) as shelter costs, not business expenses, unless these costs can be identified as necessary for the business separately. If the self-employment income is only intended to support the individual or family for part of the year, average the income over the number of months it is intended to cover. If the individual has had self-employment income for the past year, use the income figures from the previous years business records or tax forms. If current income is substantially different from income the previous year, use more current information, such as updated business ledgers or daybooks. Remember to deduct predictable business expenses. If the individual or family has not had self-employment income for the past year, average the income over the period of time the business has been in operation and project the income for one year. September 2011
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Screening & Eligibility Determination (continued) If the business is newly established and there is insufficient information to make a reasonable projection, calculate the income based on the best available estimate and follow-up at a later date. A signed statement from individuals who are self-employed and have no documentation of their income will be accepted for a period of six months. PHC coverage cannot be extended on subsequent applications without formal verification and documentation of selfemployment income.
Seasonal Employment Include the total income for the months worked in the overall calculation of income. The total gross income for the year can be verified by a letter from the individuals employer, if possible. Statements of Support Unless the person providing the support to the individual is present during the interview and has acceptable documentation of identity, a statement of support will be required. The Statement of Support is used to document income when no supporting documentation is available or when income is irregular. If questionable, the contractor may document proof of identification such as a Texas Drivers License, Social Security card, or a birth certificate of the supporter. Eligibility Determination The contractor must consider the information provided by the client and document the basis for the eligibility decision on the DSHS Funding Source Worksheet (Form EF05-13227). The client must sign the Statement of Applicants Rights and Responsibilities (Form 101) to complete the eligibility determination. This form does not have to be signed again unless there is a break in services for two years or longer. It is required that after determining eligibility, the provider stating that either the family or individual is: Eligible o The individual/family is eligible for assistance; o The date eligibility begins and expires; and o The services the individual/family is entitled to receive. Ineligible o The individual/family is denied eligibility; o The reason the application was denied; o The effective date of denial; o The individuals right to appeal; and o The appropriate referrals to alternative agencies/programs for services.
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Screening & Eligibility Determination (continued) Appeal of Eligibility Determination Individuals and families can appeal to DSHS regarding the eligibility determination for PHC if they feel that information was incorrectly considered. Applicants may submit additional information to establish eligibility, or repeat the application process. Date Eligibility Begins An individual/family is entitled to services beginning with the date the completed application was submitted. Presumptive Eligibility Households, who have not had a final eligibility determination and a member in the household presents with an immediate medical need, may receive PHC funded services on a presumptive eligibility basis during the time that eligibility for services is pending. Presumptive eligibility is effective for 90 days from the date the member of the household is first seen by the medical provider. The household shall be enrolled on a presumptive eligibility basis only once in a 12-month period. If a medical condition makes eligibility determination impossible and the applicants spouse (if applicable) is not present to sign and date the DSHS Funding Source Application For Health Care Assistance (Form EF05-13229), provide immediate treatment and send a copy of the application with the client for spouses signature. The Presumptive Eligibility Form (102) is not to be used in lieu of the DSHS Funding Source Application For Health Care Assistance (Form EF05-13229). An appointment to complete the process should be made at the first possible opportunity. If the household has applied for another program, the contractor is responsible for updating the eligibility status on a timely basis. Documented proof of eligibility within the other funding sources is required. If emergency services are needed immediately and are not provided by another program, services shall be provided during this 90-day period. If a household member becomes Medicaid eligible, the services must be billed to Medicaid under the 90-days prior provision. PHC emphasizes the importance of prevention and early intervention. The goal of PHC is for clients to be part of the health care system and not rely on episodic, acute care. An applicants medical needs shall be met quickly and appropriately using whatever resources are available. Two exceptions to using other benefits in place of PHC include: If the benefits were created by the establishment of a city or county hospital, a joint city-county hospital, a county hospital authority, a hospital district, or by the facilities of a publicly supported medical school. Benefits created by any of these entities would not disqualify individuals from using PHC services. Contractors are not expected to refer clients to the County Indigent Health Care Program (CIHCP) if the county of residence is covered by a hospital district to provide CIHCP services, or the client does not meet the countys eligibility criteria for the program.
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Screening & Eligibility Determination (continued) Individuals potentially eligible for Medicaid or CHIP should be referred to the Your Texas Benefits website (www.yourtexasbenefits.com) or 2-1-1 for comprehensive Medicaid or CHIP eligibility determination. Clients who are determined eligible or potentially eligible for CHIP may also be eligible for PHC-funded services during the waiting period until CHIP coverage begins. Contractors are allowed to continue providing PHC-funded services after the initial 90-day period only if the client has applied for CHIP, is waiting on approval, and until the date CHIP enrollment is effective. A copy of the CHIP eligibility card showing when CHIP coverage will begin must be kept in the clients medical records. Individuals who are determined potentially eligible for another benefit by the DSHS Funding Source Application for Health Care Assistance (Form EF0513229), but fail to fully complete the required application process for the benefit, will not be eligible to receive PHC-funded services beyond those services delivered during the 90-day presumptive eligibility period. If within 90 days a client fails to complete the eligibility determination process for another benefit, the contractor may bill PHC for the services delivered during the 90-day period only. Contractors should make clients aware that failing or refusing to complete the appropriate eligibility determination processes may result in their determination as self-pay clients. Supplemental Benefits In some cases, individuals receiving benefits from other sources such as Medicaid, Medicare, CHIP, Title V, Title X, and Title XX may be eligible for partial PHC coverage. This coverage is limited to services provided by PHC but not covered by other sources. Whenever federal, state, private, or other benefits are available for payment of services for clients, no PHC funds shall be used to pay for such care. An example of a client receiving supplemental benefits would be a contractor providing health education services to a Medicaid eligible individual since Medicaid does not provide health education services. The contractor must communicate to the client that supplemental services are limited scope. Annual Re-certification The contractor will determine the system used to track clients status and renewal eligibility. Eligibility determination using the DSHS Funding Source Application for Health Care Assistance (Form EF05-13229) form is required for all clients. Eligibility services must be redetermined for each individual/family every 12 months. At least 30 days prior to the anniversary date of their original eligibility date, client should be notified that they must renew eligibility by the anniversary date or lose their benefits until they are re-certified by the program. If renewal has not been completed by the anniversary date, the individual/family record should be removed from active status and placed in the inactive files. The individual family should be notified of the status change. A client can be a new client only once. Regardless of the time lapse between the initial application and the renewal application, former clients will not be classified as new.
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Screening & Eligibility Determination (continued) Contractors should mail out notices, either postcards or letters, requesting that the individual or family representative come to the office for recertification. A contractor may include a new application in the letter and ask the individual to return with documentation. If an actual interview is chosen, appointment times may be given to prevent long waiting periods. For each record being renewed, whether in person or by mail, the eligibility provider staff shall complete a new DSHS Funding Source Application for Health Care Assistance (Form EF05-13229) using updated information provided by the client. Sending a Notice of Eligibility is required to inform the individual/family of continued eligibility. The contractor shall assist clients who request help in completing forms or providing documentation. Co-pay/Fees PHC contractors may assess a fee for services (co-pay) from PHC clients whose family income is at or below 150% FPL. Client co-pays may be the lesser of $40 or 25% of the Medicaid reimbursement rate. The contractor must waive the fee if a client self-declares an inability to pay. No PHC client shall be denied services based on an inability to pay. Client co-pays must be reported as program income on the monthly State Purchase Voucher (Form B-13) and the quarterly Financial Status Report (FSR or Form 269a). Example: CPT Code 99213 = $33.95 CPT Code 80053 = $14.53 CPT Code 80061 = $18.42 $66.90 x 25% = $16.72 (client co-pay/fee) Clients shall not be charged administrative fees for items such as processing and/or transfer of medical records, copies of immunization records, etc. Contractors are allowed to bill clients for services outside the scope of PHC allowable services, if the service is provided at the clients request, and the client is made aware of his/her responsibility for paying for the charges. Contractors who have expended their awarded PHC funds are required to continue to serve their existing PHC eligible clients. If other funding sources are used to provide PHC services, the funds must be reported as non-DSHS funds on the monthly State Purchase Voucher (Form B-13) and the quarterly Financial Status Report (FSR or Form 269a).
Other Fees
Continuation of Services
September 2011
SECTION FOUR
CLINICAL INFORMATION
SECTION FOUR CLINICAL INFORMATION
1
Clinical Informed Consent General Informed Consent Contractors must obtain the patients written, informed, voluntary general consent to receive services prior to receiving any clinical services. A general informed consent explains the types of services provided and how client/patient information may be shared with other entities for reimbursement or reporting purposes. If there is a period of time of three years or more during which a patient does not receive services a new general consent must be signed prior to reinitiating delivery of services. Consent information must be effectively communicated to every patient in a manner that is understandable by that patient and allows her/him to participate and make sound decisions regarding her/his own medical care in compliance with Limited English Proficiency regulations and addressing any disabilities that impair communication. Only the patient may consent. For situations when the patient is legally unable to consent (e.g., a minor or an individual with development disability), a parent, legal guardian or caregiver must consent. Consent must never be obtained in a manner that could be perceived as coercive. In addition, as described below, the contractor must obtain the informed consent of the patient for procedures as required by the Texas Medical Disclosure Panel. DSHS contractors should consult a qualified attorney to determine the appropriateness of the consent forms utilized by their health care agency. Method Specific Consent The method specific consent and/or the patient health record must document that the patient has received and understands information concerning the method effectiveness, appropriate use, benefits, potential side effects and complications, alternatives and discontinuation issues. Procedure Specific Consents Sterilization Procedures There are two consent forms required for sterilization procedures: the Sterilization Consent Form and the Texas Medical Disclosure Panel Consent. The Sterilization Consent Form This sterilization consent form is provided in the Texas Medicaid Provider Procedures Manual and is the only acceptable consent form for sterilizations funded by regular Medicaid (Title XIX), the Womens Health Program, Title V, Title X, or Title XX. An electronic copy may be found on the Texas Medicaid Healthcare Partnership website: http://www.tmhp.com/default.aspx. The federally mandated consent form is necessary for both abdominal and transcervical sterilization procedures in women and vasectomy in men.
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Clinical Informed Consent (continued) In brief, the individual to be sterilized must: Be at least 21 years old at the time the consent is obtained; Be mentally competent; Voluntarily give his or her informed consent; Sign the consent form at least 30 days but not more than 180* days prior to the sterilization procedure; and May choose a witness to be present when the consent is obtained. *An individual may consent to be sterilized at the time of premature delivery or emergency abdominal surgery, if at least 72 hours have passed after he or she gave informed consent to sterilization. In the case of premature delivery, the informed consent must have been given at least 30 days before the expected date of delivery. The consent form must be signed and dated by: The individual to be sterilized; The interpreter, if one is provided; The person who obtains the consent; The physician who will perform the sterilization procedure Informed consent may not be obtained while the individual to be sterilized is: In labor or childbirth; Seeking to obtain or obtaining an abortion; or Under the influence of alcohol or other substances that affect the individuals state of awareness. Texas Medical Disclosure Panel Consent The Texas Medical Disclosure Panel (TMDP) was established by the Texas Legislature to determine which risks and hazards related to medical care and surgical procedures must be disclosed by health care providers or physicians to their patients or persons authorized to consent for their patients, and to establish the general form and substance of such disclosure. TMDP has developed a List A (informed consent requiring full and specific disclosure) and a List B (informed consent not requiring specific disclosures) for certain procedures. More information about the TMDP can be found at: http://www.dshs.state.tx.us/hfp/tmdp.shtm List A procedures can be found at the following Texas Administrative Code link: http://info.sos.state.tx.us/pls/pub/readtac$ext.ViewTAC?tac_view=4&ti=25& pt=7&ch=601&rl=Y. With regard to Tubal Sterilization and Vasectomy, List A procedures, the TMDP required Disclosure and Consent Form for contractors who
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Clinical Informed Consent (continued) directly perform the procedure can be found at: http://info.sos.state.tx.us/fids/200504268-1.html This consent is in addition to the Sterilization Consent Form noted on the previous page. The required disclosures for Tubal Sterilization are: (A) Injury to the bowel and/or bladder; (B) Sterility; (C) Failure to obtain fertility (if applicable); (D) Failure to obtain sterility (if applicable); and (E) Loss of ovarian functions or hormone production from ovary(ies). The required disclosures for Vasectomy are: (A) Loss of testicle; and (B) Failure to produce permanent sterility. For all other procedures not listed on List A, the physician must disclose, through a procedure specific consent, all risks that a reasonable patient would want to know about. This includes all risks that are inherent to the procedure (one which exists in and is inseparable form the procedure itself) and that are material (could influence a reasonable person in making a decision whether or not to consent to the procedure). Parental Consent for Services Provided to Minors The general rule is that parents must consent for minors (Family Code 151.001). A minor is defined as a person less than 18 years of age who has never been married. However there are certain circumstances under which a minor may consent for her/his own treatment. Requirements for parental consent for provision of family planning services to minors vary according to the funding source subsidizing the services. The department and providers may provide family planning services, including prescription drugs, without the consent of the minors parent, managing conservator, or guardian only as authorized by Chapter 32 of the Texas Family Code or by federal law or regulations. Title X projects may not require consent of parents or guardians for the provision of services to minors. Nor can the project notify parents or guardians before or after a minor has requested and received Title X family planning services (see Table at end of Chapter). When parental consent is required, the parent must sign both the general consent for treatment and the method specific consent for prescription birth consent.
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Clinical Informed Consent (continued) There are instances in which a minor may consent to his/her own medical, dental, psychological and surgical treatment by a licensed physician or dentist if the minor: Is on active duty with the armed services; Is at least 16 years old, living apart from a parent or guardian and managing his or her own financial affairs. You do not have to provide the child is emancipated if the minor so declares in writing; Is consenting to diagnosis and treatment of an infectious, contagious, or communicable disease required to be reported to the local health officer or the Department of State Health Services; Consents to examination and treatment for drug or chemical addiction , dependency or any other condition directly related to drug or chemical use; Is unmarried and pregnant and seeking treatment related to the pregnancy, unless its an abortion; Has custody of his/her biological child and also consents to the childs medical, dental psychological or surgical treatment of the child; Is seeking a diagnosis or treatment for a sexually transmitted disease, including HIV; Is seeking counseling for chemical dependency or addiction, suicide prevention or sexual, physical or emotional abuse.
The Texas Family Code, Chapter 32, may be found at the following website: http://www.statutes.legis.state.tx.us/?link=FA. Consent for HIV Tests Texas Health and Safety Code 81.105 and 81.106 is as follows: 81.105. Informed Consent a) Except as otherwise provided by law, a person may not perform a test designed to identify HIV or its antigen or antibody without first obtaining the informed consent of the person to be test. b) Consent need not be written if there is documentation in the medical record that the test has been explained and the consent has been obtained. 81.106 General Consent a) A person who has signed a general consent form for the performance of medical tests or procedures is not required to also sign or be presented with a specific consent form relating to medical test or procedures to determine HIV infection, antibodies to HIV, or infection with any other probable causative agent of AIDS that will be performed on the person during the time in which the general consent form is in effect.
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Clinical Informed Consent (continued) b) Except as otherwise provided by the chapter, the result of a test or procedure to determine HIV infection, antibodies to HIV, or infection with any probable causative agent of AIDS performed under the authorization of a general consent form in accordance with this section may be used only for diagnostic or other purposes directly related to medical treatment. Texas Health and Safety Code may be found at the following website: http://www.statutes.legis.state.tx.us/?link=HS. Clinical Guidelines The PHC Clinical Guidelines gives providers guidance in providing direct patient care services. The guidelines are in a table format at the end of this chapter. Specific requirements for PHC are: Comprehensive medical and social history and updated as clinically indicated; Baseline and periodic physical exam (PE) initially and updated as clinically indicated; Health Risk Assessment (HRA) initially and updated as clinically indicated; and Patient education for health risks identified in the HRA. Services operating under specific DSHS guidelines/standards should be provided according to that particular programs requirements in addition to PHC requirements. Specific guidelines cover, but are not limited to, services such as family planning, child health, immunizations, maternity, diabetes management, and case management. Protocols, Standing Delegation Orders and Procedures Contractors that provide clinical services must develop and maintain written clinical protocols and standing delegation orders (SDOs) in compliance with statutes and rules governing medical and nursing practice and consistent with national evidence-based clinical guidelines. The written clinical protocols and/or SDOs must be signed by the Medical Director or supervising physician on an annual basis or more often if changes are required. When DSHS revises a policy, contractors need to incorporate the revised policy into their written procedures. Protocols Contractors that employ Advanced Practice Nurses or Physician Assistants must have written protocols to delegate authorization to initiate medical aspects of client care. The protocols must be agreed upon and signed by the supervising physician and the physician assistant and/or advanced practice nurse, reviewed and signed at least annually, and maintained on site. The protocols need not describe the exact steps that an advanced practice nurse or a physician assistant must take with respect to each specific condition, disease, or symptom.
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Clinical Guidelines (continued) Standing Delegation Orders Contractors that employ unlicensed and licensed personnel, other than advanced practice nurses or physician assistants, whose duties include actions or procedures for a patient population with specific diseases, disorders, health problems or sets of symptoms, must have written SDOs in place. SDOs are instructions, orders, rules, regulations or procedures that specify under what set of conditions and circumstances actions should be instituted. The SDOs delineate under what set of conditions and circumstances an RN, LVN, or non-delineate under what set of conditions and circumstance an RN, LVN, or non-licensed health care provider (NLHP) actions or tasks may be initiated in the clinical setting, and provide authority for use with patients when a physician or advance practice provider is not on the premises, and or prior to being examined or evaluated by a physician or advance practice provider. Example: SDO for assessment of Blood Pressure/Blood Sugar which includes an RN, LVN or NLHP that will perform the task, the steps to complete the task, the normal/abnormal range, and the process of reporting abnormal values. Other applicable SDOs when a physician is not present on-site may include, but are not limited to: Obtaining a personal and medical history; Performing an appropriate physical exam and the recording of physical findings; Initiating/performing laboratory procedures; Administering or providing drugs ordered by voice communication with the authorizing physician; Providing pre-signed prescriptions for: o Oral contraceptives; o Diaphragms; o Contraceptive creams and jellies; o Topical anti-infective for vaginal use; o Oral anti-parasitic drugs; or o Antibiotic drugs for treatment of venereal disease Handling medical emergencies to include on-site management as well as possible transfer of client; Giving immunizations; or Performing pregnancy testing. SDOs are distinct from specific orders written for a particular patient. The SDOs must be dated and signed by the physician who is responsible for the delivery of medical care covered by the orders. The SDOs must be reviewed and signed at least annually. Patient Education In addition to the above, contractors must have written plans for patient education that include goals and content outlines to ensure consistency and accuracy of information provided. Plans for patient education must be reviewed and signed by the Medical Director.
September 2011
7
Clinical Guidelines (continued) Resources Requirements addressing scope of practice and delegation of medical and nursing acts can be accessed at the following websites: http://www.tmb.state.tx.us/ (Texas Medical Board); and http://www.ben.state.tx.us/ (Board of Nurse Examiners for the State of Texas. Rules that are most pertinent to this topic are: Texas Administrative Code, Title 22, Part 9, Chapter 193; Texas Administrative Code, Title 22, Part 11, Chapters 221 and 224; and Texas Administrative Code, Title 22, Part 9, Chapter 185 (Physician Assistant Scope of Practice). Emergency Responsiveness Contractors must be adequately prepared to handle clinical emergency situations, as follows: There must be a written plan for the management of on-site medical emergencies, emergencies requiring ambulance services and hospital admission, and emergencies requiring evacuation of the premises. Each site where sterilization procedures are performed must have an arrangement with a licensed facility for emergency treatment of any surgical complication. If sterilization procedures are performed in a freestanding surgical care center or on an inpatient basis in a hospital, Medicare standards applicable to the facility and staff must be met. Each site must have staff trained in basic cardiopulmonary resuscitation (CPR) and emergency medical action. Staff trained in CPR must be present during all hours of clinic operation. There must be written protocols to address vaso-vagal reactions, anaphylaxis, syncope, cardiac arrest, shock, hemorrhage, and respiratory difficulties. Each site must maintain emergency resuscitative drugs, supplies, and equipment appropriate to the services provided at that site and appropriately trained staff when patients are present. Documentation must be maintained in personnel files that staff has been trained regarding these written plans or protocols.
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8
Patient Health Record (Medical Record) Clinical Guidelines (continued) Contractors must ensure that a patient health record (medical record) is established for every client who obtains services. These records must be maintained according to accepted medical standards and State laws, including those governing record retention. All client records must be: Complete, legible, and accurate documenting all clinical encounters, including those by telephone; Written in ink without erasures or deletions; or documented by Electronic Medical Record (EMR); Signed by the provider making the entry, including name of provider, provider title and date for each entry; o Electronic signatures are allowable to document provider review of care. However, stamped signatures are not allowable. Readily accessible to assure continuity of care and availability to client; Systematically organized to allow easy documentation and prompt retrieval of information; Maintained to safeguard against loss or unauthorized access and to assure confidentiality (complying with HIPAA regulations); and Secured by lock when not in use. The patient health record must include: Client identification and personal data; Completed Screening and Eligibility Determination Form for Medical Services Assistance; Completed Statement of Applicants Rights and Responsibilities signed by the client or responsible party; Copies of acceptable documentation establishing income, residency, and family composition; Copy of Medicaid and/or CHIP denial letter, if applicable; Preferred language/method of communication; Patient contact in formation with the best way to reach patient in such a manner that facilitates continuity of care, assures confidentiality, and adheres to HIPAA* regulations; Medical history, (in Medical History and Risk Assessment); Physical examination (in Physical Assessment); Laboratory and other diagnostic tests orders, results and follow-up; Assessment or clinical impression; Plan of care, including education/counseling, treatment, special instructions scheduled antenatal visits and referrals; Documentation on follow-up of missed appointments; Informed consent documentation; Refusal of services documentation; Medication and other allergic reactions recorded prominently in specific location; and September 2011
9
Clinical Guidelines (continued)
Problem list.
Preventive Services PHC providers may, but are not required to, use the current edition of the Guide to Clinical Preventive Services, developed by the U.S. Preventive Services Task Force, as guidelines for providing clinical preventive services such as health screening and client education. The guide can be accessed at: http://www.ahrg.gov/clinic/prevenix.htm. Vaccines PHC contractors are encouraged to become a Texas Vaccines for Children (TVFC) provider. The TVFC program supplies free vaccines to providers to vaccinate eligible patients from birth through age 18 years. All vaccines routinely recommended by the Advisory Committee on Immunization Practices (ACIP) and approved by the Centers for Disease Control and Prevention (CDC) are offered by the TVFC program. Additional information on provider enrollment can be found at: http://www.dshs.state.tx.us/immunize/tvfc/default.shtm or by calling 1-800252-9152. To be eligible to enroll in the TVFC, providers must be one of the following: Physician (Medical Doctor (MD) or Doctor of Osteopathy (DO)); Nurse Practitioner (NP); Certified Nurse Midwife (CNM); or Physician Assistant (PA). All other health care providers must enroll under the standing delegation orders of a physician including: Pharmacists (RPH); Nurses (Registered Nurses (RN) or Licensed Vocational Nurses (LVN); Medical Assistants (MA); Nurse Assistants (NA); or Emergency Medical Technicians (EMT). Medicaid and CHIP providers must enroll in the TVFC or use their privately purchased vaccines. They may not refer children to Local Health Departments (LHD) or other entities for routinely recommended vaccinations. A TVFC Provider Enrollment Form is included in the Medicaid provider enrollment packet. NOTE: Medicaid and CHIP programs do not reimburse providers for the cost of routinely recommended childhood vaccines but do reimburse an administration fee.
September 2011
10
Pharmaceuticals Clinical Guidelines (continued) Pharmaceuticals for the treatment of patients with gonorrhea, chlamydia, and syphilis may be obtained from the DSHS STD/HIV through participating Local Health Departments and DSHS regional offices. Contractors may use PHC funds for pharmaceuticals provided to patients receiving PHC services with the approval of PHC through the Request for Proposal (RFP) and contract processes. Contractors are encouraged to access Prescription Drug Patient Assistance Programs in order to obtain prescription medications at no cost or low cost to clients. Many programs are listed in the Pharmaceutical Research and Manufacturers of America (PhRMA) directory published online at: http://www.phrma.org and http://www.rxxassist.org. Medicare Prescription Drug Plan On January 1, 2006, the Medicare Prescription Drug Plan, Medicare Part D, was introduced to provide elderly and disabled Medicare beneficiaries access to prescription drug coverage. Texas beneficiaries pay monthly premiums, deductibles, and co-payments as part of program participation and can choose from a number of plans with distinct formularies. Medicare provides various premium and cost-sharing subsidies (extra help) to assist beneficiaries below 150% FPL with limited assets. The application process for extra help, coordinated by the Social Security Administration, is a separate process from enrolling in the drug plan. If beneficiaries do not enroll when they are first eligible, they may have to pay a higher premium amount if they join at a late date. If they have prescription drug coverage from other insurance that is the same or better than the Medicare plans, they can keep their current coverage and will not have to pay a higher premium if they decide to join Part D later. Enabling legislation mandates that PHC can only provide services that a client is not eligible for through another resource; therefore, Medicareeligible PHC clients must access their prescriptions through a Medicare Prescription Drug Plan. PHC contractors that provide supplemental prescription drug benefits may provide these benefits to client during the application process for Medicare Part D for a period up to 9-days, unless extenuating circumstances occur and clients would be harmed if access to medication ceased. Contractors must document such circumstances in the patient health record.
September 2011
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Clinical Guidelines (continued) Screening for Part D PHC rules mandate that all PHC contractors, regardless of whether or not they provide supplemental prescription drug benefits, must screen clients for Medicare Part D eligibility. Applicants and clients are eligible for Medicare Part D if they are eligible for Medicare. These individuals must be referred to the local health and human services agency, local Area Agencies on Aging, Medicare and/or the Social Security Administration to enroll in the Medicare Prescription Drug Plan and possible extra help in paying for out-of-pocket expenses associated with the plans. Resources are provided below. Out-of-Pocket Expenses The Medicare Prescription Drug Plan requires beneficiaries to pay out-of-pocket expenses such as premiums, deductibles, and co-payment. Beneficiaries that qualify for cost-sharing subsidies will receive assistance from Medicare in paying for these expenses. In addition, a catastrophic benefit is available when a certain threshold of out-of-pocket expenses is reached. In some cases, beneficiaries may pay more for their prescription under Medicare Part D PHC rules allow contractors to reimburse clients for cost of cost sharing incurred through participation in the Medicare Prescription Drug Plan upon the availability of funds. Contractors are responsible for establishing agreements with pharmacies participating in the Medicare plans and/or implementing a system in which clients are reimbursed their co-payments. Resources General information from Medicare for beneficiaries and service providers on Part D: Call 2-1-1 for local assistance in applying for Part D and the extra help. 1-800-MEDICARE / http://www.medicare.gov Information on Outreach and Partnerships from Medicare: http://www.cms.hhs.gov/partnerships/ Information on extra help from SSA: 1-800-772-1213 http://www.ssa.gov/prescriptionhelp/ Area Agencies on Aging: 1-800-252-9240 http://www.medicarerxoutreach.org General information and fact sheets on Medicare Part D: www.kff.org/rxdrugs/medicare.cfm
September 2011
12 Reserved for future use.
September 2011
13
CLINICAL GUIDELINES
STANDARD STATEMENT
HEALTH ASSESSMENT A. At sites providing medical care, a complete initial health history, signed and dated by the provider, is obtained and updated periodically, or at least annually, for all patients.
POLICIES & PROCEDURES

Policy: At sites providing medical care, the provider ensures a complete health history is obtained. Procedures: The health history includes a medical and social history. 1. The medical history includes the following: a. Current history b. Hospitalizations c. Allergies, sensitivities or reactions to medicines or other substances d. Family history e. Obstetric history and gynecologic history as indicated f. Sexual behavior history, including family planning practices g. Mental health history, to include depression and suicidal thoughts or gestures h. Nutritional history i. Developmental (pediatric) j. Immunization history k. Occupational hazards or environmental toxin exposure 2. The social history includes the following: a. Home environment, to include living arrangements b. Tobacco/alcohol/drugs use/abuse and exposure c. Family dynamics/problems; e.g., abuse
EVALUATION CRITERIA
Evidence of health history in the record
DSHS may distribute or provide appropriated funds only to patients who show good faith efforts to comply with all child abuse reporting guidelines and requirements set forth in Chapter 261 of the Texas Family Code. DSHS may distribute funds for medical, dental, psychological, or surgical treatment provided to a minor only if consent to treatment is obtained pursuant to Chapter 32 of the Texas Family Code.
Documentation of social history
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CLINICAL GUIDELINES
STANDARD STATEMENT
B. At sites providing medical care, a health risk assessment is completed for all patients.

Policy: Medical care providers assess health risk on all clients served. Procedures: Patients must have a health risk assessment according to the following: 1. Children ages birth through 20 years of age have health risk assessments done according to periodicity of visits, e.g., periodicity chart 2. People aged 21 years and older must have an initial health risk assessment, which is updated annually or with change in client status. Health Risk Assessment includes but is not limited to: a. Diabetes b. Heart disease c. High-risk sexual behavior d. Violence e. Injury f. Malignancy
EVALUATION CRITERIA
Health record Evidence of health assessment
C. At sites providing medical care, all patients shall receive preventive health education.
Policy: The providers of medical care shall provide preventive education based on health risk or patient need. Procedures: All patients must receive anticipatory guidance at each visit that covers the following appropriate areas: 1. Violence a. Family/domestic Documentation of education provided based on health risk assessment or patient need.
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CLINICAL GUIDELINES
STANDARD STATEMENT
2.

b. Gang c. Other types of violence Injury prevention a. Fire arms b. Car safety restraints c. Helmets d. Prevention of other types of injuries Behavior a. Substance abuse, e.g., tobacco, alcohol, chemicals and drugs b. Safe sex practices Nutrition a. Healthy diets b. Weight management c. Folic acid d. Calcium e. Other vitamins and minerals Health promotion a. Immunizations b. Dental care c. Physical activity d. Family planning e. Prenatal care f. Newborn care Other education based on specific problems or health risk Anticipatory guidance for teens in addition to above also includes: a. School performance b. Depression c. Suicide
EVALUATION CRITERIA
3.
4.
For infants: Pediatric Nutrition Handbook, 5th Edition from the American Academy of Pediatrics, 2003; Keep Kids Healthy at: http://www.keepkidshealthy.com/infant/infantnu trition.html For children: www.kidshealth.org/kid/stay_healthy/food/pyra mid.html For adults: www.lifeclinic.com/focus/nutrition/foodpyramid.asp and www.nal.usda.gov/fnic/Fpyr/pmap.htm
5.
6. 7.
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CLINICAL GUIDELINES
STANDARD STATEMENT
D. All patients or their guardians shall provide consent for services/treatment.

Policy: Providers shall ensure that all patients consent for services.
EVALUATION CRITERIA
Procedures: 1. Notification and consent of the parent/legal guardian for all services provided to a minor patient is required except for those patients for whom the minor may consent independently according to those stated in Family Code 32.003. 2. All patients and/or guardians must provide signed consent for immunizations.
Health record A signed and dated consent Texas Family Code, Chapter 32
E. At sites providing medical care, a baseline physical exam (PE) is conducted on all patients. Periodic physical exams are conducted based upon presenting symptoms, health risk factors, a review of systems, or according to the THSteps Periodicity Schedules for children.
Policy: At sites providing medical services, a baseline PE is conducted in conjunctions with the initial history, laboratory tests, and interventions. In addition, on subsequent visits a targeted PE, screening procedures, and interventions are conducted. Procedures: 1. As an integral part of the complete health assessment, the PE is based upon the patients presenting symptoms, review of systems (ROS), past history, and health risk factors. 2. Laboratory and interventions (general non-high risk population) a. Blood pressure
Reference for interventions: Guide to Clinical Preventive Services. This reference also contains interventions for high-risk individuals.
THSteps Periodicity Schedule can be found at: http://www.dshs.state.tx.us/thsteps.
September 2011
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CLINICAL GUIDELINES
STANDARD STATEMENT POLICIES & PROCEDURES
Health Risk Conditions Addressed: Coronary heart disease, congestive heart failure, cerebral vascular accident (stroke), ruptured aortic aneurysm, renal disease, and retinopathy. Recommended Practice: 1. At least once every two years for 140/85 2. Annually if diastolic blood pressure of 85-89 3. Higher blood pressure require more frequent measurements 4. Children and adolescents annually for ages 3-20 b. Height, weight and BMI or appropriate assessment for overweight/obesity. Health Risk Conditions Addressed: Overweight and obesity, which are associated with adult-onset diabetes, hypertension, et al. Recommended Practice: Initial visit, then periodically. c. Total blood cholesterol Recommended Practice: If no risk factors for coronary heart disease, routinely test men starting at 35 years old and women starting at age 45. If risk factors for coronary heart disease are present, routinely screen men and women starting at age 20. d. Cervical Cancer Screening for women U.S. Preventive Services Task Force http://www.ahrq.gov/clinic/uspstfix.htm
EVALUATION CRITERIA
Centers for Disease Control and Prevention http://www.cdc.gov/bloodpressure/about.htm
http://wonder.cdc.gov/wonder/prevguid/p0000109 /p0000109.asp#head008001000000000
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CLINICAL GUIDELINES
Health Risk Conditions Addressed: Cervical Cancer
EVALUATION CRITERIA
Recommended Practice: Cervical cancer screening test (i.e., Pap test) In 2009, ACOG updated their cervical cancer screening guidelines to include: Cervical cancer screening should begin at age 21 years. Cervical cytology screening is recommended every 2 years for women between the ages of 21 years and 29 years. Women aged 30 years and older who have three consecutive negative cervical cytology screening test results and who have no history of CIN 2 or 3, are not HIV infected, are not immunocompromised, and were not exposed to DES in utero, may extend the interval between cervical cytology examinations to every 3 years. Both liquid-based and conventional methods of cervical cytology are acceptable of screening.
http://www.acog.org/departments/dept_notice.cfm ?recno=20&bulletin=5021
http://www.acog.org/from_home/publications/press_ releases/nr11-20-09.cfm
Other organizational resources: http://www.cancer.org/docroot/NWS/content/NWS _1_1x_ACOG_Revises_Cervical_Cancer _Screening_Guidelines.asp http://www.ahrg.gov/clinic/uspstf/uspscerv.htm
American Cancer Society http://gantdaily.com/2010/08/03/whtf-newcervical-cancer-screening-guidelines-the-paptest/
Note: Regardless of the frequency of cervical cancer screening, annual gynecologic examinations are still recommended, including pelvic exams, when indicated.
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CLINICAL GUIDELINES
e. Colorectal Screening Health Risk Conditions Addressed: Colorectal Cancer. Recommended Practice: 1. Average risk screen men and women 50 years of age and older. 2. High risk screen prior to 50 years and/or more often if have any colorectal cancer risk factors. 3. Patient to visit with physician about which test is best. 4. Screening options are fecal occult blood testing (FOBT), flexible sigmoidoscopy, combination of FOBT and flexible sigmoid, colonoscopy, or double-contrast barium enema, or CT colonography. f. Mammography Health Risk Conditions Addressed: Breast cancer Recommended Practice: Every 1-2 years, with mammography and annual CBE, for women aged 50-69. g. Immunizations Health Risk Conditions Addressed: Tetanus (lock jaw), Rubella (measles), Influenza (including influenza pneumonia), and Pnuemococcal pneumonia.
http://www.dshs.state.tx.us/immunize/adult_sched.s htm
EVALUATION CRITERIA
American Cancer Society http://www.nccrt.org/Standards/STDDetail.aspx?a rticle_id=374
Center for Disease Control and Prevention http://www.cdc.gov/cancer/breast/fact_mammogr ams.htm America Cancer Society http://ww2.cancer.org/docroot/NWS/content/NWS _1_1x_Updated_Breast_Cancer_Screening_Guid elines_Released.asp
http://www.dshs.state.tx.us/immunize/schedule/d efault.shtm
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CLINICAL GUIDELINES
Recommended Practice: 1. Tetanus, diphtheria, pertussis (Td/Tdap) booster - Every 10 years 2. Rubella Based on a history of rubella vaccination or documented serology. Nonpregnant female patients of childbearing age with unknown or inadequate rubella immunity must be provided vaccination on-site or referred appropriately. 3. Influenza annually beginning at age 50 4. Pneumococcal once beginning at age 65, however a repeat may be indicated after five years. h. Vision and hearing screening Health Risk Conditions Addressed: Visual and hearing impairment. Recommended Practice: Periodically beginning at age 65 (optimal frequency not determined).
EVALUATION CRITERIA
http://www.dshs.state.tx.us/immunize/adult_sched
F. Episodic or Acute Care Visit
Policy: The physical assessment and laboratory tests/interventions must be based on the presenting complaints. Policy: Providers must refer patients to their provider network as necessary. Procedures: All patients who require a referral will be referred to the appropriate provider within their provider network. Health record Documentation of a referral
G. All clients shall be referred to other appropriate services as needed.
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Clinical Guidelines (continued) 1. For services determined to be necessary, but which are not provided by the contractor, patients must be referred to other resources for care. Contractors are expected to have established communications with Federally Qualified Health Centers (FQHCs) or DSHS funded organizations that provide primary care services or breast cancer and cervical cancer screening and diagnostic services for referral purposes if there are any such providers within their service area. Whenever possible, patients should be given a choice of referral resources from which to select. When a patient is referred to another resource because of an abnormal finding or for emergency clinical care, the contractor must: Make arrangements for the provision of pertinent patient information to the referral resource (obtaining required patient consent with appropriate safeguards to ensure confidentiality i.e., adhering to HIPPA* regulations); Advise patient about his/her responsibility in complying with the referral; Counsel patient on the importance of the referral and followup method; and Follow up to determine if the referral because of an abnormal finding was completed and document the outcome of the referral. *Health Insurance Portability and Accountability Act of 1996 Patients who have abnormal clinical breast exam (CBE) or cervical cytology findings may be scheduled to return for repeat exams if this is considered to be appropriate follow up by the clinician. For patients whose cervical cytology test or CBE results in an abnormal finding that requires referral for services beyond those available through primary health care, contractors are encouraged, whenever possible, to refer to a DSHS Breast and Cervical Cancer Services contractor. In order to promote the most effective use of limited resources, primary health care contractors clinicians should be familiar with nationally recognized guidelines and algorithms describing recommended practice regarding abnormal cervical cytology and CBE results (See Appendices).
September 2011
SECTION FIVE
REIMBURSEMENT, DATA COLLECTION & REPORTING
SECTION FIVE REIMBURSEMENT, DATA COLLECTION & REPORTING
1
Reimbursement
The Health and Safety Code and Texas Administrative Code require PHC activities to be evaluated on an annual basis. The evaluation process includes monthly, quarterly, and annual program and fiscal reporting as well as desk and/or site reviews by DSHS staff. Instructions for reimbursement and/or data collections are included in this section of the manual. Forms for reimbursement and data collection are located in the Forms section. Billing Primary Health Care services contract amounts are ceilings against which contractors may bill for providing primary health care services to PHC eligible clients. Once this dollar ceiling has been reached, no further funds will be available for reimbursement. Contractors may only bill for services provided to clients who have been screened for potential Medicaid, CHIP, Title V, Title X, and Title XX eligibility and been deemed as full-service, supplemental, or presumptive eligible. Categorical reimbursement for cost of providing services shall be billed on the State of Texas Purchase Voucher (Form B-13) and submitted simultaneously to the Contract Development & Support Branch (CDSB) (cdsb@dshs.state.tx.us) and the Accounting Section/Claims Processing Unit (CPU) (invoices@dshs.state.tx.us). See Form B-13 in the Forms Section for the PHC State of Texas Purchase Voucher and an example of a completed PHC Purchase Voucher. Reimbursement request for direct care services will be submitted on a monthly basis. Each request will cover services provided, or expenses incurred, in the preceding month as applicable to the contract attachment. Requests should be submitted within 30 days of the end of the preceding month and within 60 days of providing the service. Appropriate financial records must be maintained for review by DSHS through the quality assurance review process and/or fiscal monitoring and/or programmatic desk reviews. To be paid promptly, Purchase Vouchers must identify the Vendor Identification Number, DSHS document number and Attachment number, and the 10-digit Purchase Order Number. Incorrect identification numbers may delay payment. Failure to complete these sanctions will delay payment. The Purchase Voucher must also include the total number of unduplicated clients determined eligible and provided a primary care service for the month (bottom of box #20 on the voucher). The number of clients entered on the voucher must match the number of unduplicated clients served that is reported on the corresponding monthly PHC 200 Report. If a supplemental or amended voucher is submitted, an amended PHC200 Report must also be submitted to the PHC mailbox to reflect the changes in client numbers and/or dollar amounts. The PHC program
must approve the monthly PHC-200 Report before the corresponding September 2011
2
Reimburseme nt (continued)
monthly voucher may be processed for payment. Requests submitted without the required program reports will not be approved for payment. Vouchers and/or reports submitted with incorrect or missing information will be rejected and the contractor will be contacted to remedy the problem. Contractors must continue to submit a State Purchase Voucher and supporting monthly program reports even after they have reached contract ceilings. Any cost over the contract ceiling after deducting program income should be reflected under Non-DSHS Funding on the voucher and on the FSR. This submission is required to continue reporting expenditures on any program income collected monthly, and to provide DSHS with statistical information about the use of services. Non-Reimbursable Expenditures PHC will not reimburse services for individuals eligible for another program or clients who do not complete the respective eligibility process. Failure to fully comply with all requirements to apply for Medicaid or CHIP services does not deem a client eligible for PHC services. Services are often provided to clients whose screening results indicate they are potentially Medicaid or CHIP eligible, but the client has not yet completed or received notification of acceptance or rejection of an application. PHC may cover services delivered on the initial date of contact after the eligibility determination is complete and Medicaid and/or CHIP deny eligibility. Such a denial of eligibility must be documented in the clients file for the contractor to bill for the initial days services to PHC. Once the programs denial letter is received, with the exception of presumptive eligibility, the services provided on the initial day of service may be billed to PHC for reimbursement. Services delivered to PHC clients with supplemental service benefits may only be billed if a supplemental service was provided at the time of the visit. Submission of Vouchers Monthly reimbursement requests should be submitted within 30 days following the end of the month covered by the bill. All claims for reimbursement for services delivered must be submitted within 60 days of the end of the contract term. If contractors have services that occurred during the contract period left to bill after the August Purchase Voucher has been submitted, contractors can bill those services using a Purchase Voucher and a PHC-200 report marked FINAL and submit the forms on or before October 31. PHC contracts require closure of the contract attachment within 60 days of the end of the contract term. All requests for reimbursement must be submitted by email (preferred), or fax to CDSB.
The Purchase Voucher must be submitted by fax or email to CPU. Requests postmarked more than 60 days following the end of the Contract Attachment will not be paid. An original mailed Financial Status September 2011
3
Reimbursement
(continued)
Report (Form 269a) final report must be filed with the DSHS Accounting Section, Claims Processing Unit and by email (preferred) or fax to CDSB no later than 60 days after the contract term. The 269a must be marked as FINAL and include all reimbursements and adjustments in payments for the contract term. Altering of Forms Contractors are required to use the Excel format for ease of processing. None of the billing or the reporting forms may be altered in any manner. State Purchase vouchers should not be altered to itemize expenses for PHC services provided. Vouchers should be submitted for the total monthly reimbursement amount only. Please use at least 10 pt sized font when entering data. Illegible information will be questioned and/or returned.
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Data Collection & Reporting
PROGRAM INFORMATION Program Name: Primary Health Care Contract Type: Categorical Contract Term: September 1August 31 VOUCHER: Voucher 1 Voucher Name: State of Texas Purchase Voucher Form B-13 Submission Date: Within 30 days following the end of the month. Final due within 60 days after end of contract term. Submit Copy to: Name of Unit/Branch Original Accepted Method of # Required Submission Copies Yes No Contract Development & X Email (preferred), or Fax 1 Support Branch (CDSB) Claims Processing Unit X Email or Fax 1 (CPU) Instructions: Submit one Form B-13 voucher to CDSB and one Form B-13 voucher to CPU. Must submit to both.
REPORT: Report 1 Report Name: PHC 200 Monthly Report Form Submission Date: Within 5 working days following the end of each month. Submit Copy to: Name of Unit/Branch Original Accepted Method of Required Submission Yes No Primary Care Group X Email (preferred), or Fax (PCG)
# Copies 1
Instructions: Submit PHC 200 Monthly Report Form to PCG only. For CY 11, reports are due 1/7, 2/7, 3/7, 4/7, 5/6, 6/7, 7/8, 8/5, 9/8, 10/7, 11/7, 12/7 .For CY 12, reports are due 1/6.2/7,3/7,4/6,5/7,6/7,7/9, 8/7, 9/7, 10/5, 11/7, 12/7 NOTE: If you do not submit your PHC 200 by the due date, voucher payments may be held. REPORT: Report 2 Report Name: Financial Status Report 269A Submission Date: Quarterly, Sep 1-Nov 30, Dec 1-Feb 28, Mar 1-May 31, and Jun 1-Aug th 31. Submit 30 days after the end of each quarter. The 4 quarter is the final report and due th within 60 days after the end of the contract term. The 4 quarter report includes all final th charges and expenses associated with the program contract. Mark the 4 quarter report as Final. Name of Unit/Branch Original Accepted Method of # Required Submission Copies Yes No CDSB X Email (preferred), or Fax 1 CPU X Email scanned signed 1 document, fax or mail Instructions: Form 269A must have an original signature f(scanned email or fax)..
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Data Collection & Reporting (continued)
REPORT: Report 3 Report Name: PHC 300 Annual Report Submission Date: Within 60 days following the end of the contract period Submit Copy to: Original Accepted Method of Name of Unit/Branch Required Submission # Copies Yes No Primary Care Group (PCG) X Email (preferred), or Fax 1 Instructions: Submit PHC 300 Annual Report Form to PCG only.
Email Addresses: Fax Numbers:
CDSB CPU PCG CDSB CPU PCG
Mail Codes:
CDSB CPU PCG
Mailing Address for CPU: Last Updated Reviewed: 6/8/10
cdsb@dshs.state.tx.us invoices@dshs.state.tx.us PrimaryHealthCare@dshs.state.tx.us (512) 776-7521 (512) 776-7442 (512) 776-7713 Please use mail codes on all mail coming into DSHS to ensure accurate delivery. Mail code 1914 Mail code 1940 Mail code 2831 Claims Processing Unit, Mail Code 1940 Department of State Health Services P.O. Box 149347 Austin, TX 78714-9347
Quarterly Financial Status Report (FSR or Form 269a) must be submitted directly to the DSHS Accounting Section, Claims Processing Unit and the CDSB within 30 days of the completion of the quarter. This form requires an original signature for CPU. ** New For FY10: Scanned signed FSRs are acceptable. A scanned document may be emailed or faxed to CPU. The fourth quarter Financial Status Report should be marked as FINAL and submitted within 60 days of the completion of the contract year to the DSHS Accounting Section, Claims Processing Unit and to CDSB. This form requires an original signature for CPU.
Program Activity Reports
PHC-200 Monthly Report The following instructions are provided to help complete the monthly PHC-200. For the purposes of this report, the term unduplicated is defined as counting a client/individual only once during the reporting time specified. (See Form 200 reporting form)
Program
The purpose of the PHC-Form 200 Monthly report is to provide the following September 2011
6
Activity Reports (continued) information to DSHS: PHC caseload, and Contractors expenditure levels by PHC service PHC-200 Monthly report must be completed and submitted to DSHS Primary Care Group (PCG) within 5 working days of the month following the report month. Email Form 200 to PCG PrimaryHealthCare@dshs.state.tx.us (preferred), or fax to DSHS PCG at 512/776-7713. General Information: Contractor: Name of contractor on DSHS contract Report or Amended Report: Enter month and year the expenditures are spent/paid. Any amendments to a report should be marked as Amended and submitted on the Form 200. The amended item(s) should be circled, highlighted, bolded or identified in some way.
Sanctions
Sanctions Due to Non-Compliance With Reporting The Performance Management Unit will apply the following procedures when reports and/or vouchers are not received by the required deadlines: Fifteen (15) calendar days after any report or voucher is due DSHS notifies the contractor to request that the monthly report or voucher be submitted within five (5) business days. Note: Payments cannot be processed until correct and complete information is received. Five (5) business days after the written notice is sent The manager of the Contract Management Branch (CMB) will determine if technical assistance (TA) should be provided. If the contract has frequently been late in submitting reports and billing, contract sanctions may be imposed. Contract sanctions According to Article XIV of the DSHS Contract General Provisions (Core/Sub-recipient), the list of sanctions that may be imposed is not limited to the following: Require contactor to receive technical or managerial assistance; Temporary withhold cash payments; Permanently withhold cash payments; Disallow use of all or part of the funds allocated to the contract; Delay execution of a new contract or renewal; Reduce funding for the contract; Suspend all or part of the contract; Terminate the contract; or Deny additional or future contracts or renewals. September 2011
Sanctions
Reserved for future use.
September 2011
FORMS
DSHS FUNDING SOURCE Application for Health Care Assistance FUENTE DE FONDOS DEL DSHS Solicitud de asistencia mdica
Applicant Information / Informacin del solicitante
Name (Last, First, Middle) / Nombre (apellido y primer y segundo nombre) Home Telephone Number / Telfono de la casa
Email Address / Correo electrnico
Texas Residence Address (Street or P.O. Box) / Direccin residencial en Texas (calle o apartado postal)
City / Ciudad
County / Condado
State / Estado
ZIP / Cdigo postal
Household Information / Informacin de la unidad familiar

Fill in the first line with information about yourself. Fill in the remaining lines for everyone who lives in the house with you for which you are legally responsible. / Llene la primera lnea con informacin acerca de usted mismo. Llene las lneas restantes por todas las personas que viven con usted, y por las que es legalmente responsable. U.S. Citizen Name (Last, First, Middle) What Relation to Ciudadano SSN (optional) Date of Birth Age Sex Race Nombre (apellido y primer y segundo you? estadounidense Nm. del Seguro Social Fecha de Edad Sexo Raza nombre) Parentesco con usted Yes / S No (opcional) nacimiento 1. Self / Yo mismo
2. 3. 4. 5. 6.
List all of your households income below. Be sure to include the following: Government checks; money from work; money you collect from charging room and board; cash gifts, loans, or contributions from parents, relatives, friends, and others; sponsors income; school grants or loans; child support; and unemployment. / Haga una lista de los ingresos de su unidad familiar a continuacin. Asegrese de incluir: cheques del gobierno; dinero por trabajo; dinero que recibe por cobros de hospedaje y comida; regalos en efectivo, prstamos, o aportaciones de sus padres, familiares, amigos y otras personas; ingresos del patrocinador; becas o prstamos escolares; manutencin de nios o pagos por desempleo. Name of person receiving money Nombre de la persona que recibe el dinero Name of agency, person, or employer who provides the money Nombre de la agencia, persona o empleador que provee el dinero Amount received Cantidad recibida How often received? (daily, weekly, every two weeks, twice a month, monthly?) Con qu frecuencia lo recibe? (Diariamente, semanalmente, quincenalmente o mensualmente)
Do you have an immediate medical need? Tiene usted alguna necesidad mdica inmediata? Do you does any one in your household have health care coverage (Medicaid, Medicare, CHIP, health insurance, V.A., Tricare, etc.)? Tiene usted o alguien de su unidad familiar cobertura mdica (Medicaid, Medicare, CHIP, seguro medico, V.A., Tricare, etc.)? If yes, who? / Si contest que S, quin? Do you does any one in your household have any special circumstances? Tiene usted o alguien de su unidad familiar alguna circunstancia especial? If yes, who? Si contesta que S, quin?
Yes / S Yes / S
No No
Yes / S
No
The statement I have made, including my answers to all questions, are true and correct to the best of my knowledge and belief. I agree to give eligibility staff any information necessary to prove statements about my eligibility. I understand that giving false information could result in disqualification and repayment. A mi leal saber y entender, la declaracin que he hecho y mis respuestas a todas las preguntas son verdaderas y correctas. Me comprometo a dar al personal de verificacin de requisitos toda la informacin necesaria para comprobar mis declaraciones sobre dichos requisitos. Yo entiendo que dar informacin falsa podra causar que me descalifiquen y que tenga que devolver el pago al Programa. Signature Spouse (if applicable) / Firma Cnyuge (de ser aplicable) Signature Applicant / Firma Solicitante Date / Fecha Date / Fecha Signature Person Who Helped Complete this Application Firma Persona que ayud a completar esta solicitud Relationship to Client / Relacin con el cliente Date / Fecha
EF05-13229
DSHS FUNDING SOURCE Application for Health Care Assistance FUENTE DE FONDOS DEL DSHS Solicitud de asistencia mdica
APPLICATION FOR HEALTH CARE ASSISTANCE SOLICITUD DE ASISTENCIA MDICA
1. 2. 3.
Complete name and address; Applicant and spouse (if applicable) must sign and date the application; and Answer as many questions as possible on this application
1. 2. 3.
Nombre y direccin completos; El solicitante y el/la cnyuge (de ser aplicable) deben firmar y fechar la solicitud y Conteste tantas preguntas como pueda en esta solicitud
Turn in or mail back the application today even if all the questions are not answered. RESPONSIBILITIES Applicants are responsible for completing page one of the screening and eligibility form for medical services assistance. Applicants are responsible for providing documents requested by the contractor. Some examples of items that may be needed for proof and documents that can be used for proof are: Where Applicant Lives and Plans to Continue Living o Possible Proof: Valid Texas Drivers License o Current voter registration o Rent or utility receipts for one month prior to the month of application o Motor vehicle registration o School records o Medical cards or other similar benefit cards o Property tax receipt o Mail addressed to the applicant, his / her spouse, or children if they live together o Other documents considered valid by the contractor Applicant Income o Possible Proof: Pay check stubs o Pay checks o W-2 tax forms or income tax returns o Sales records o Statements from employers o Award letters o Legal documents o Statements from persons giving you money Other Health Care Coverage o Possible Proof: Award or claim letters o Insurance policies o Court documents o Other legal papers Information on social security numbers should be given if this information is available. Information on sex (Male / Female) is voluntary. These types of information will not affect your eligibility. Applicant must give information about health care insurance and any other third party financially liable for health care services.
Entregue su solicitud, o mndela por correo, hoy mismo aunque no conteste todas las preguntas. RESPONSABILIDADES Los solicitantes son responsables de completar la primera pgina del formulario de evaluacin y determinacin de requisitos de servicios de asistencia mdica. Los solicitantes son responsables de proporcionar los documentos solicitados por el contratista. Los siguientes son ejemplos de las cosas podran necesitar como comprobantes y los documentos que pueden usarse como comprobantes: Lugar donde vive y planea seguir viviendo el solicitante o Posibles comprobantes: licencia de conducir de Texas vlida o Inscripcin en el registro de votantes actual o Recibos de renta o servicios pblicos del mes anterior al mes de la solicitud o Registro de automvil o Registros escolares o Tarjetas mdicas o de otras prestaciones similares o Recibo de impuestos sobre la propiedad inmobiliaria o Correo dirigido al solicitante, su cnyuge o sus hijos si viven juntos o Otros documentos considerados vlidos por el contratista Ingresos de los solicitantes o Posibles comprobantes: talones de cheque de paga o Cheques de paga o Formularios W-2 de declaracin de impuestos o Registros de ventas o Declaraciones de empleadores o Cartas de asignacin de dinero o Documentos legales o Declaraciones de las personas que le dan dinero Otra cobertura mdica o Posibles comprobantes: cartas de asignacin de dinero o reclamacin o Plizas de seguro o Documentos de la corte o Otros documentos legales Debe darse la informacin sobre los nmeros del Seguro Social si la informacin est disponible. La informacin sobre su sexo (si es hombre o mujer) es voluntaria. Estos tipos de informacin no afectarn su derecho a participar. El solicitante debe dar informacin sobre seguros mdicos y cualquier tercera persona econmicamente responsable de los servicios mdicos.
DSHS FUNDING SOURCE - Worksheet

Todays Date Applicant Name Approved Client/Case # Case Record Action Presumptive Supplemental Denied Type of Determination New Re-certification Eligibility Effective Date
(MM-DD-YYYY)
Eligibility Items
Family Composition Legal Responsibility
Documentation (if applicable)

1.
2.
3.
4.
5.
.
6. Residency Must be physically present within the geographic boundaries of Texas. Type of Income Gross Earned Income Cash Gifts/Contributions Child Support Payments Dividends/Interest/Royalties Loans (Non-educational) Lawsuit/Lump-sum Pymts. Mineral Rights Pensions/Annuities Reimbursements Social Security Payments Unemployment Payments VA Payments Workers Compensation Total Countable Income Minus Dependent Care Net Countable Income Name of Member w/Income
Documentation of Residency (if applicable)
Documentation of Income (if applicable)

FPL Used: 185%
100% > 200%
133% 225%
150% 250%
Other Benefits Such as Medicaid, Medicare, CHIP, CIHCP, private health insurance, V.A., Tricare, etc.
Special Circumstances Document any special circumstances as needed and applicable to this application
Co-Pay Fees DOCUMENT CO-PAY BELOW:
Eligible Household Member(s): 1.

2.
3. BCCS PHC Title V/MCH DSHS FP 6.
BCCS PHC Title V/MCH 4.
DSHS FP 5.
BCCS PHC Title V/MCH BCCS PHC Title V/MCH
DSHS FP
BCCS PHC Title V/MCH
DSHS FP
BCCS PHC Title V/MCH
DSHS FP
DSHS FP
Provider-Staff Signature:
Date:
EF05-13227
DSHS FUNDING SOURCE Worksheet Instructions Eligibility and Benefits by 2012 Federal Poverty Level (FPL)
WIC MEDICAID F A M I L Y S I Z E CIHCP PHC M&CH Medically Needy Children under 1 / Pregnant Females 185% FPL
No Job W/Job
CHIP FP CSHCN BCCS
Children 1 thru 5 133% FPL
Children 6 thru 18 100% FPL
21% FPL Min. Income Standard

No Job W/Job
150% FPL
185% FPL
EPILEPSY 200% FPL
250% FPL
No Job
W/Job
No Job
W/Job
No Job
W/Job
N/A Statewide
1 2 3 4 5 6 7 8 9 10
For each additional Member
$104 216 275 308 357 392 440 475 532 567 57
$224 336 395 428 477 512 560 595 652 687
$1,723 2,333 2,944 3,544 4,165 4,775 5,386 5,996 6,607 7,217 611
$1,843 $1,239 $1,359 2,453 3,064 3,674 4,285 4,895 5,506 6,116 6,727 7,337 1,677 2,116 2,555 2,994 3,433 3,872 4,311 4,750 5,189 439 1,797 2,236 2,675 3,114 3,553 3,992 4,431 4,870 5,309
$931 1,261 1,591 1,921 2,251 2,581 2,911 3,241 3,571 3,901 330
$1,051 1,381 1,711 2,041 2,371 2,701 3,031 3,361 3,691 4,021
$196 265 335 404 473 542 612 681 750 820
$414 518 623 726 830 933 1,038 1,142 1,245 1,350
$1,397 1,892 2,387 2,882 3,377 3,872 4,367 4,862 5,357 5,852 495
$1,723 2,333 2,944 3,554 4,165 4,775 5,386 5,996 6,607 7,217 611
$1,862 2,522 3,182 3,842 4,502 5,162 5,822 6,482 7,142 7,802 660
$2,328 3,153 3,978 4,803 5,628 6,453 7,278 8,103 8,928 9,753 825
Effective March 1, 2012
o Family Composition Section Enter the total number of family members in each category listed.
Total should include a person living alone or a group of two or more persons related by birth, marriage (including common-law), or adoption, which reside together and are legally responsible for the support of the other person. For example: If an unmarried applicant lives with a partner, ONLY count the partners income and children as part of the budget group IF the applicant and his/her partner have mutual children together. Unborn children should also be included.
o Residency Section Must be physically present within the geographic boundaries of Texas. o Income Section - Income may be either earned or unearned. If actual or projected income is not received monthly, convert it to a monthly amount using one of the following methods: o Weekly income x 4.33 o Every two weeks x 2.17 o Twice a month x 2.0 Dependent childcare expenses and legally obligated child support payments shall be deducted from total income in determining eligibility. Allowable deductions are actual expenses up to $200 per child per month for children under age 2 and $175 per child per month for children age 2 to 12 or age 2 18 if child is disabled. The net countable income is used to determine eligibility based on the appropriate FPL percentage. o FPL Used Determine the appropriate FPL used for each individual program. o Other Benefits Section Provider staff shall document other benefits received by or denied to the applicant that are applicable to this application. An applicant or family member is eligible for the Medicare Prescription Drug Plan (Part D) if he/she is eligible and/or receives Medicare Part A and/or Part B benefits and shall be referred to this program for prescription drug benefits. o Special Circumstances Provider staff may document any special circumstances not already noted using this section of the application, if applicable. o Co-Pay/Fees Document co-pay/fees per program policies. o Eligible Household Members Identify each eligible household member and program (via number association listed on Family Composition). o Provider-Staff Signature/Date The provider staff that completes the eligibility determination process must sign and date this form.
EF05-13228
STATEMENT OF APPLICANTS RIGHTS AND RESPONSIBILITIES DECLARACIN DE LOS DERECHOS Y DEBERES DEL SOLICITANTE
By signing this application for assistance, I affirm the following: The information on the application and its attachments is true and correct. This application is a legal document. Deliberately omitting information or giving false information may cause the Provider to terminate services to a member of my household/family or me. If I omit information, fail or refuse to give information, or give false or misleading information about these matters, I may be required to reimburse the State for the services rendered if I am found to be ineligible for services. I will report changes in my household/family situation that affect eligibility during the certification period (changes in income, household/family members, and residency). I authorize release of all information, including but not limited to, income and medical information, by and to the Texas Department of State Health Services (DSHS) and Provider in order to determine eligibility, to bill, or to render services to my household/family or me. I understand I may be asked by Provider to provide proof of any of the information provided in this application. Health insurance coverage, including but not limited to individual or group health insurance, health maintenance organization membership, Medicaid, Medicare, Veterans Administration benefits, TRICARE, and Workers Compensation benefits, must be reported to Provider. Benefits from health insurance may be considered the primary source of payment for health care received. I hereby assign to Provider any such benefits. I also assign payment for benefits and services received from and through Provider directly to the service providers.
FORM 101
Al firmar esta solicitud para recibir asistencia, yo afirmo lo siguiente: La informacin escrita en la solicitud y en sus anexos es verdadera y correcta. Esta solicitud es un documento legal. El deliberadamente omitir informacin o el proporcionar informacin falsa podra dar lugar a que el Proveedor cancele los servicios a uno de los miembros de mi hogar, de mi familia o los mos propios. Si yo omito informacin, dejo de proporcionar o me niego a proporcionar informacin o; proporciono informacin falsa o engaosa acerca de estos asuntos, podra requerrseme que reembolse al Estado el costo de los servicios recibidos, si acaso se determina que no califico para los servicios. Yo reportar los cambios en la situacin de mi hogar, de mi familia, que afecten la elegibilidad durante el perodo de certificacin (cambios en el ingreso, en los miembros del hogar, en la familia y, cambios de residencia.) Yo autorizo la divulgacin de toda la informacin, incluyendo pero no limitada a, el ingreso y a la informacin mdica, de parte de y para, el Texas Department of State Health Services (DSHS) [Departamento Estatal de Servicios de Salud de Texas] y, al Proveedor para poder determinar la elegibilidad, para poder cobrar o, proporcionar servicios en mi hogar, a mi familia o, a m personalmente. Entiendo y acepto que podra pedirme el Proveedor que proporcione comprobantes de cualquiera de la informacin proporcionada en esta solicitud. La cobertura de seguro de salud, incluyendo pero no limitada a seguro para un individuo o seguro de salud para un grupo de personas; los de membresa proporcionados por organizaciones para el mantenimiento de la salud [como HMO], Medicaid, Medicare; beneficios de la Veterans Administration; de la TRICARE y Workers Compensation [beneficios de Compensacin Laboral], deben ser reportados al Proveedor. Los beneficios provenientes de esos seguros de salud pudieran ser considerados como la fuente principal de pago de la atencin de salud recibida. Por este medio yo, asigno al Proveedor cualquiera de dichos beneficios. Tambin asigno el pago de los beneficios y servicios recibidos de parte de y, a travs del Proveedor, directamente a los proveedores de servicios. Yo entiendo y acepto que, para mantener la elegibilidad para el programa, se me va a requerir que vuelva a solicitar para recibir asistencia, por lo menos cada doce meses. Soy residente legtimo de Texas o bien, dependiente del territorio. Yo vivo fsicamente en Texas, mantengo residencia en Texas y, no afirmo ser residente de otro estado o pas o bien, soy un dependiente de un residente legtimo de Texas. Algunos programas proporcionan atencin a travs de proveedores aprobados por los programas. Yo entiendo y acepto que, para recibir beneficios de dichos programas, el tratamiento debe ser recibido a travs de esos proveedores aprobados por el programa. Yo entiendo y acepto que el criterio para la participacin en el programa es el mismo para todos sin importar sexo, edad, discapacidad, raza o bien, origen de nacionalidad. Yo entiendo y acepto que tengo el derecho de registrar una queja con relacin al manejo de mi solicitud o con relacin a cualquier accin tomada por el programa con HHSC Civil Rights Office de 1-888-388-6332. Yo entiendo y acepto que recibir documentacin por escrito concerniente a los servicios para los cuales mi hogar, mi familia o yo calificamos o, potencialmente lleguemos a calificar. Tan solo por unas cuantas excepciones, usted tiene el derecho de solicitar y de ser informado sobre la informacin que el Estado de Texas rene sobre usted. A usted se le debe conceder el derecho de recibir y revisar la informacin al requerirla. Usted tambin tiene el derecho de pedir que la agencia estatal corrija cualquier informacin que se ha determinado sea incorrecta. Dirjase a http://www.dshs.state.tx.us para ms informacin sobre la Notificacin sobre privacidad. (Referencia: Government Code, seccin 552.021, 522.023 y 559.004) Entiendo y acepto que el programa no proporciona pago por la atencin de pacientes internos. Entiendo y acepto que yo debo hacer mis propios arreglos de atencin en el hospital y que yo soy responsable por el costo de la atencin.
Provider Staff Signature Date
I understand that, to maintain program eligibility, I will be required to reapply for assistance at least every twelve months. I am a bona fide resident of Texas or a dependent. I physically live in Texas, maintain living quarters in Texas, and do not claim to be a resident of another state or country, or am a dependent of a bona fide Texas resident. Some programs provide care through program-approved providers. I understand that, to receive benefits from such programs, treatment must be received through those programapproved providers. I understand that criteria for participation in the program are the same for everyone regardless of sex, age, disability, race, or national origin. I understand I have the right to file a complaint regarding the handling of my application or any action taken by the program with the HHSC Civil Rights Office at 1-888-388-6332. I understand that I will receive written documentation concerning the services for which my household/family or I is eligible or potentially eligible. With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See http://www.dshs.state.tx.us for more information on Privacy Notification. (Reference: Government Code, Section 552.021, 522.023 and 559.004) I understand and agree that the program does not provide payment for inpatient care. I understand that I must make my own arrangement for hospital care and that I am responsible for the cost of the care.
Signature Applicant / Firma Solicitante Date / Fecha
FORM 102
Presumptive Eligibility - Title V and Primary Health Care

Name/Nombre Home Telephone No./Telfono de la casa (If no phone, give number of person who can reach applicant/ de no tener telfono, proporcione el telfono de la persona que pueda ponerse en contacto con el solicitante)
Mailing Address (Street or P.O. Box)/Direccin Postal (Calle o Apdo.)
City/Ciudad
State/Estado
ZIP/Zona Postal
Home Address, if different from above. Domicillio particular, si es diferente a la direccin de arriba.
1. Are you or the person applying for services a resident of Texas? Son residents de Texas, usted o la persona que solicita servicios?...
Yes/S
No
2. How many family members live with you? (Count only applicant, spouse and children for whom applicant is legally responsible.)Cuntos miembros de la familia viven con usted? (Cuente nicamente al solicitante, esposo(a) y nios de los que el solicitante es legalmente responsable.) __________________________________ 3. How much money (before deductions) does your family receive each month? Cunto dinero (antes de las deducciones) recibe su familia por mes? __________________________________________________________
I am in need of immediate medical care. To the best of my knowledge, I have no other way to receive medical care and am applying for Presumptive Services. I understand that within 90 days following the delivery of services, I will submit a completed application for eligibility determination. The above information is true, correct, and complete to the best of my knowledge. Yo estoy necesitando atencin mdica inmediata. En lo que a m concierne carezco de cualquier otro medio para recibir atencin mdica y estoy solicitando Presumptive Services [Servicios Condicionales.] Yo entiendo y acepto que dentro de 90 das despus de recibir los servicios yo entregar una solicitud completamente llena, para que se lleve a cabo la determinacin de elegibilidad. La informacin arriba proporcionada es verdadera, correcta y completa segn mi leal saber y entender.
Signature Applicant / Firma Solicitante Date / Fecha
Signature Provider Staff / Firma Oficinista
Date / Fecha
I was not able to complete the eligibility determination process for the Program. My appointment for returning my complete application and interview is: No me fue posible completar el proceso de determinacin de elegibilidad para el Programa. La cita para devolver mi solicitud ya llenada y para la entrevista es
Date and Time/ Hora y Fecha Location and Phone/ Lugar y Telfono
I understand this is my obligation for the services received. Yo entiendo y acepto que esta es mi obligacin por los servicios recibidos.
EF21-11817 PHC 10-1 September 2010
FORM 102A INSTRUCTIONS
Presumptive Eligibility Form Instructions

PURPOSE 1. If applicant cannot fulfill application procedures AND applicant is in need of immediate medical services, the Presumptive Eligibility Form is to be completed. Additionally, a Statement of Applicants Rights and Responsibilities must be completed. 2. To establish if applicant appears to be eligible for Title V and/or Primary Health Care.
PROCEDURE When to Prepare Complete for persons in medical need who appear to be eligible for Title V and/or Primary Health Care but time or lack of materials prevent screening and eligibility determination. Number of Copies Complete an original and one copy. Transmittal Give a copy of the form to the applicant with an appointment time for application process. File original. Form Retention Keep the case record copy for three state fiscal years after services rendered.
DETAILED INSTRUCTIONS Complete the date, name of applicant, name of legally responsible adult if applicant is a minor, address and phone number where applicant (legally responsible adult) can be reached. Agency staff is responsible for ensuring appropriate completion of the Presumptive Eligibility Form and a Statement of Applicants Rights and Responsibilities. 1. Verify the residency of applicant and mark yes or no. Refer to the policy manual for definition of residency. 2. Enter the number of members in the immediate family. Refer to the policy manual for definition of family. 3. Enter the gross monthly income of the immediate family. Refer to the policy manual for definition of income if applicant falls within Program guidelines. The applicant appears to be potentially eligible for services on a Presumptive Eligibility basis if the applicant: 1. is a Texas resident, and 2. gross monthly family income (based on family size) falls at or below income guidelines.
NOTE: If the contractor renders services and the above two criteria were not met, Title V and/or PHC will not reimburse. If applicant does not meet these two criteria it is up to the Contractor to determine where and when services will be provided. Although Title V and PHC are under strict eligibility guidelines, it is encouraged that an applicant's medical needs be met quickly and appropriately using whatever resources are locally available.
FORM 103
Notice of Eligibility/Aviso de Elegibilidad - Title V and Primary Health Care

Date/Fecha Case No./ Nmero de caso Expiration Date/ Fecha de vencimiento
Office Address/ Direccin de la oficina
Office Telephone/Telfono de la oficina
Provider Staff Name/Nombre del trabajador
1. Your individual / family application for Title V / Primary Health Care is APPROVED / DENIED.
Su solicitud individual / familiar para el Ttulo V / Programa de Atencin Mdica Primaria ha sido APROBADA / NEGADA.
2. If approved, the following services will be provided beginning ______________________. (MM/DD/YYYY) Si tiene derecho, se ofrecern los siguientes servicios a partir del ______________________. (mes/da/ao)
Name/Nombre a. b. c. d. e. Date of Birth/ Fecha de nacimiento Services/Servicios
3. Your co-pay is $______________ for services and $______________ for prescriptions. Su copago es $______________ por servicios y $_______________ por recetas mdicas. 4. You must notify this office as soon as possible of any changes in your situation such as changes in income, property, health insurance, family members or address. Usted tiene que avisar a esta oficina tan pronto sea posible de cualquier cambio en su situacin como cambios de ingresos, propiedad, seguro medico, personas de la familia o direccin. 5. If a change occurs that makes you ineligible, and you fail to report the change as required, you may be responsible for payment of any medical services you receive after you become ineligible, or you may be subject to prosecution under the Texas Penal Code. Si ocurre un cambio que hace que pierda la elegibilidad y usted no informa del cambio como se exige, es posible que sea responsable de pagar cualquier servicio mdico que reciba despus de perder la elegibilidad, o puede ser que sea sujeto a enjuiciamiento bajo en Cdigo Penal de Texas. 6. You are responsible for renewing your eligibility prior to your certification expiration date. A DSHS Funding Source - Application for Health Care Assistance must be completed and submitted within thirty (30)-days of your anniversary eligibility date. Assistance will be provided if needed. Usted es responsable de renovar su elegibilidad antes de la fecha de vencimiento de la certificacin. Tiene que llenar y entregar un Screening and Eligibility Determination Form for Medical Services Assistance dentro de los treinta (30) das de la fecha de su aniversario. Recibir ayuda si es necesario. 7. If not eligible, your application for Title V/Primary Health Care benefits has been denied due to: Si no tiene derecho, su solicitud para beneficios del Programa de Atencin Mdica Primaria/Title V se ha negado porque:
If you believe this decision is not correct, you may request an appeal from this office. Si cree que esta decisin no est correcta, puede pedir una splica de esta officina. September 2011
FORM 103A INSTRUCTIONS
Notice of Eligibility Form Instructions PURPOSE 1. To notify Title V and/or Primary Health Care applicants that they are either eligible or not eligible for assistance. 2. To notify Title V and/or Primary Health Care clients of their responsibilities to report changes in their situation and their liability if they fail to report changes. PROCEDURE When to Prepare Complete form for individuals applying for Title V and Primary Health Care. Number of Copies Complete an original and one copy. Transmittal Face-to-face or mail form to the individual applying for assistance. File copy in the case record. Form Retention Keep the case record copy for three state fiscal years after eligibility begins. eligibility is valid for a maximum of twelve months. DETAILED INSTRUCTIONS Complete the information listed on the form.
However,
Form 104
PRIMARY HEALTH CARE PROGRAM REQUEST FOR INFORMATION PROGRAMA PRIMARIO de ASISTENCIA MEDICA SOLICITUD DE INFORMACIN
Date/Fecha Case Record No./Nm de Caso
Office Address and Telephone No./Oficina y Telfono
Your application for assistance is not complete. To determine your eligibility, we need the following additional information./Su solicitud de asistencia no est completa. Para determinar su elegibilidad, necesitamos la siguiente informacin.
ONLY THE CHECKED BOXES APPLY TO YOU./SOLAMENTE LAS CASILLAS MARCADAS SE APLICAN A SU CASO.
Mail Addressed to You or Another Household Member Correo Dirigido a Usted o a Otra Persona de su Casa Texas Drivers License or Other Official Identification Licencia de Manejar de Texas u Otra Identificacin Oficial Voter Registration Card Certificado de Registro Electoral Notice of TANF, SNAP/ Food Stamps, or Medicaid Benefits Aviso de Beneficios de TANF,Estampillas para Comida o Medicaid Paychecks or Paycheck Stubs Cheques de Paga o Talones de Cheques de Paga Earnings Statement from Employer Verificacin de Sueldo Preparada por el Empleador Workers Compensation Award Letter or Check Cheque del Seguro Obrero o Carta Diciendo que Van a Drselo Federal Income Tax Return Declaracin de los Impuestos Federales Sobre los Ingresos Self-Employment Bookkeeping, Sales, Expenditure Records Comprobantes de Cuentas, Ventas, Gastos de Trabajo Independiente Social Security Award Letter, Check, or Denial Notice Cheque de Seguro Socil o Carta Diciendo si se lo Van a Dar o No Disability Insurance Award Letter or Check Cheque de Seguro por Incapacidad or Carta Diciendo que Van a Drselo Unemployment Compensation Award Letter or Check Cheque de Compensacin de Desempleo o Carta Diciendo que Van a Drselo Veterans Administration Award Letter or Check Cheque de la Administracin de Veteranos o Carta Diciendo que Van a Drselo Other Items Otra
PLEASE RETURN THE ITEMS CHECKED ABOVE BY: HAGA EL FAVOR DE ENVIAR LOS DOCUMENTOS ENUMERADOS PARA EL: If we do not receive the information we need and you do not contact me, I will assume that you do not want assistance. Call me if you have any questions./ Si no recibimos la informacin que necesitamos y usted no se comunica conmigo, supondr que usted no quiere asistencia. Si tiene alguna pregunta, hbleme.
Signature/Firma:
Form 128 Page 1 of 2
PRIMARY HEALTH CARE PROGRAM EMPLOYMENT VERIFICATION
Date/Fecha
Case Record No./Nm de Caso
Office Address and Telephone No./Oficina y Telfono
Fax:
Employee Social Security Number
This individual is a member of a household applying for health care assistance from the Primary Health Care Program. To determine this households eligibility, it is necessary to verify all earnings. Since this individual is/was/will be your employee, your help is needed. Please completely and accurately provide the information requested on the back of this letter. If a question does not apply, mark it N/A. After you complete this form, give it to your employee, mail it in the envelope provided, or fax it to the number listed above. This information is needed by this date: ______________________. If you could send it before this date, it would be most appreciated. Thank you for helping. If you have questions, please feel free to call. I give my permission to release the information requested on this form. Yo doy mi permiso para que mi empleador d la informacin que se pide en esta forma.
Signature / Firma
Date / Fecha
Comments:
EMPLOYMENT VERIFICATION
Employee Name (as shown on your records)
Employee Address Street, City, State, ZIP (as shown on your records)
Is/was/will this person (be) employed by you?
Is FICA or FIT withheld?
Yes
Rate of Pay
No
If yes
Permanent
Temporary
Average Hours per Pay Period
Yes
No
How often is employee paid?
Per Hour
Per Day
Per Week
Per Month
Per Job
On the chart below, list all wages received by this employee during the months of: _______________________________________________________ Other Pay * Date Pay Period Ended Date Employee Received Paycheck Actual Hours Gross Pay
(Bonuses, Commissions, Overtime, Pension Plan, Profit Sharing, Tips)
* In Comments Section below, please explain when and how Other Pay is received. Date Hired Date First Paycheck Received If employee is/was on Leave Without Pay
Start Date:
If this person is no longer in your employ
End Date:
Date Final Paycheck Received:

Is health insurance available?
Gross Amount of Final Paycheck: $

Enrolled for Self Only Enrolled with Family Members
Yes
No
If Yes, employee is
Not Enrolled
Comments:
Signature and Title of Person Verifying This Information Company or Employer Address (Street, City, State, ZIP)
Date Telephone Number (Include area code.)
STATEMENT OF SELF-EMPLOYMENT INCOME DECLARACIN DE INGRESOS DEL NEGOCIO PROPIO

See Instructions on Page 2./Vea las Instrucciones en la pgina 2.
Case Record Name Case Record Number
1. Name of Person Having Self-Employment Income/Nombre de la persona que tiene ingresos de negocio propio.
2. Give the number of months covered by this income statement. D el nmero de meses que cubre esta declaracin de ingresos. ............................................................................. 3. Describe what you did to earn this money./Describa lo que hizo para ganarse este dinero.
4. List your business expenses and income. IMPORTANTE: Attach receipts, invoices, or other verifying papers. Anote los gastos y ingresos de su negocio. IMPORTANTE: Adjunte recibos, facturas, u otros comprobantes. Date Fecha EXPENSES GASTOS $ Amount Cantidad Date Fecha INCOME INGRESOS $ Amount Cantidad
Total Expenses Total de Gastos
SUBTOTAL Enter expenses here and subtract. Anote el total de gastos y reste.
NET SELF-EMPLOYMENT INCOME INGRESOS NETOS DEL NEGOCIO PROPIO $ The above information is true, correct, and complete to the best of my knowledge. I understand that giving false information to the provider could result in my being disqualified for fraud./Segn mi leal saber y entender, toda esta informacin es cierta, correcta y completa. Comprendo que si doy informacin falsa al proveedo puedo ser descalificado por fraude.
Signature of anyone helping you to prepare this form / Date Firma de la persona que le ayud a llenar la forma / Fecha Signature / Firma Date / Fecha
Form 149, Statement of Self-Employment Income Page 2 of 2

If you or any member of your household has any kind of selfemployment income, fill out this form and attach it to your application. You may attach a copy of the latest income tax forms in place of this form. If your accounting system is not the same as this form, you may substitute a copy of your accounting statement. You must answer all questions and sign and date at the bottom. Use additional sheets of paper if you need to. Sign and date each sheet. Remember, this is your sworn statement. You will need to bring with you to the interview: bills, receipts, checks or stubs, and any other business records you have. Your worker will need to see them. Your records will be returned to you. Self-employment Income. This is any money you earn working for yourself. It is not money you earn working for someone else. If you are in doubt, ask your caseworker. Questions 1, 2, and 3. These questions are self-explanatory. Question 4. List your business income and expenses. In the boxes on the left side of the form, list your business expenses (see the information below). Write in the dates you paid the expenses and the amount of each expense. Add the amounts, and enter your total in the box "total self-employment expenses." In the boxes on the right side of the form, list your income (see the information below). List the dates you received the income, your sources of income, and the amounts. Add the amounts, and enter your total in the box "total self-employment income." Subtract your expenses from your total self-employment income, and enter your "net self-employment income." Expenses are your costs of doing business. Examples of expenses are supplies, repairs, rent, utilities, seed, feed, business insurance, licenses, fees, payments on principal of loans for income-producing property, capital asset purchases (such as real property, equipment, machinery, and other durable goods and capital asset improvements), your social security contribution for people who worked for you, and labor (not salaries you pay yourself). If you claim labor costs, list each person and the amount you paid them. If you have any other kinds of business expenses, be sure to list them and the date they were paid. You may not claim: Rent, mortgage, taxes, or utilities on your business if it operates out of your home (unless these costs are separate from the costs of your home); Cost of goods you buy for the business but use yourself; Net business loss from a prior period and Depreciation. If you are in doubt, bring proof of the expense and ask your worker. Income includes money from sales, cash receipts, crops, commissions, leases, fees, or whatever you do or sell for money. If you have any other kind of income from your business, be sure to list it. Be sure to list the dates income was received. Who must sign. The form must be signed by the applicant, spouse, or authorized representative. Anyone may help you complete the form, but that person must also sign and date the form. Ask your worker if anyone else needs to sign the form. Si usted u otra persona de su casa tiene algn tipo de ingresos de negocio propio, llene esta forma y adjntela a su solicitud. En lugar de esta forma, puede adjuntar una copia de la declaracin de impuestos sobre ingresos ms reciente. Si el sistema de contabilidad que usa no es igual al de esta forma, puede substituir la forma con una copia de su registro de contabilidad. Tiene que contestar todas las preguntas y firmar y fechar la forma al final. Use hojas adicionales si las necesita. Firme y feche cada hoja. Recuerde que sta es una declaracin jurada. Tiene que llevar a la entrevista: cuentas, recibos, cheques o talones de cheques y cualquier otra documentacin que tenga del negocio. El trabajador tendr que verlos. Estos documentos le sern devueltos. Ingresos del Negocio Propio. Este trmino se refiere al dinero que gana cuando trabaja por su propia cuenta. No es el dinero que recibe cuando trabaja para otra persona. Si tiene alguna duda, consulte con su trabajador de casos. Preguntas 1, 2, y 3. Estas preguntas no necesitan ms explicacin. Pregunta 4. Apunte los ingresos y gastos de su negocio. En las cajas del lado izquierdo de la forma, enumere los gastos de su negocio (vea la informacin abajo). Ponga la fecha en que pag los gastos y la cantidad de cada gasto. Sume las cantidades y ponga el total en la caja que dice "total de gastos del negocio propio". En las cajas a la derecha de la forma, enumere los ingresos (vea la informacin abajo). Ponga la fecha en que recibi cada ingreso, la fuente del ingreso y la cantidad. Sume las cantidades y ponga el total en la caja que dice "total de ingresos del negocio propio". Reste los gastos del total de ingresos del negocio propio y anote sus "ingresos netos del negocio propio". Los gastos son los costos de un negocio. Algunos ejemplos de posibles gastos son: provisiones, reparaciones, renta, servicios pblicos, semilla, forraje, seguro del negocio, licencias, cuotas, pagos del capital de prstamos para propiedades que generan ingresos, compras de bienes de capital (como bienes races, equipo, maquinaria y otros bienes duraderos y mejoras de bienes de capital), su aportacin al seguro social de las personas que trabajan para usted y sueldos (pero no los que se paga a s mismo). Si declara el costo de sueldos, ponga el nombre de cada persona y la cantidad que le pag a cada quien. Si tiene cualquier otro tipo de gastos del negocio, asegrese de anotarlos y poner la fecha en que los pag. No puede declarar: El pago de la renta, la hipoteca, los impuestos o los servicios pblicos del negocio si lo opera de su casa (a no ser que estos costos son aparte de los costos de la casa); El costo de artculos que compra para el negocio pero que usa personalmente; La prdida neta del negocio de un periodo anterior; and La depreciacin. Si tiene alguna duda, lleve comprobantes del gasto y consulte con el trabajador. Los ingresos son, entre otros, el dinero de ventas, el ingreso de caja, las cosechas, las comisiones, las rentas, las cuotas o cualquier cosa que hace o que vende por dinero. Si usted tiene cualquier otro tipo de ingresos del negocio, asegrese de anotarlo. No olvide poner las fechas en que recibi el ingreso. Quin debe firmar. El solicitante, su cnyuge o su representante autorizado para firmar la forma. Cualquier persona puede ayudarle a llenar la forma, pero esa persona tambin tiene que firmar y poner le fecha en la forma. Consulte con el trabajador para saber si alguien ms tiene que firmar.
With a few exceptions, you have the right to request and be informed about the information that the county obtains about you. You are entitled to receive and review the information upon request. You also have the right to ask the county to correct information that is determined to be incorrect (Government Code, Sections 552.021, 552.023, 559.004). To find out about your information and your right to request correction, please contact your local county office. / Con algunas excepciones, usted tiene el derecho de saber qu informacin obtiene sobre usted el condado de pedir dicha informacin. Si desea recibir y estudiar la informacin, tiene el derecho de solicitarla. Tambin tiene el derecho de pedir que el condad corrija cualquier informacin incorrecta (Cdigo Gubernamental, Secciones 552.021, 552.023, 559.004). Para enterarse sobre la informacin y el derecho de pedir que la corrijan, favor de ponerse en contacto con la oficina local del condado.
FORM 200
PHC - 200 MONTHLY REPORTING FORM
Report or Amended Contractor: ____________________________________ Location: ____________________________________ Report for (Month/Year) ______
Phone number: _________________________________ I. TOTAL NUMBER OF UNDUPLICATED CLIENTS DETERMINED ELIGIBLE AND PROVIDED A PRIMARY CARE SERVICE: _______________(must match # in Box #20 of voucher)
TOTAL NUMBER OF INELIGIBLE APPLICANTS:_______________
II. COSTS OF PHC FUNDED SERVICES DURING THIS REPORTING MONTH Diagnostic and Treatment Emergency Services Family Planning Services Preventive Health Services Health Education Services Laboratory/X-Ray Services Nutrition Health Screening Dental Transportation Prescription Drugs Social Services Other Optional Services Administrative Costs Total (1 - 14= 15) (Amount of Requested Reimbursement)
1 2 3 4 5 6 7 8 9 10 11 12 13 14
15
Signature of Person Submitting Form
Date PHC 08-2 September 2008
FORM 200A Monthly Report INSTRUCTIONS PURPOSE Use to provide information to DSHS about: PHC caseload and Contractors expenditure levels by PHC service. PROCEDURE Form 200 must be completed and submitted to DSHS PCG in Austin within 5 working days of the month following the report month. Fax or email Form 200 to DSHS PCG at 512/458-7713 / (FY11PHCReports@dshs.state.tx.us) DETAILED INSTRUCTIONS General Information: Contractor: Name of contractor on DSHS contract Report or Amended Report: Enter month and year the expenditures are spent/paid. Any amendments to a report should be marked Amended and submitted on the Form 200. The amended item(s) should be circled. I. Caseload Data. Total number of unduplicated clients served. Enter the total number of all eligible individuals that were provided any of the six priority and/or optional services (i.e. presumptive, full-service, supplemental). Regardless of the number of PHC services or visits, only count the individual once. DO NOT count that individual again during the report month or in any other month the remainder of the fiscal year. If an eligibility determination was made, but no PHC service was given, do not count until a PHC service is provided. This number must match number reported on voucher. Total number of ineligible applicants: Enter the total number of individuals were determined ineligible for PHC services. II. Cost of Services During Month: Enter the dollar amount spent/paid in the calendar report month for each of the categories in Items 1-14. List only expenditures that are applicable to DSHS PHC funds and services. Item 1-13 enter costs for providing the services associated with providing direct patient care; costs may include salaries of individuals providing healthcare services, medical supplies and equipment, contractor costs, etc. Item 2 enter costs associated with providing emergency services, however, DO NOT count costs associated with hospital emergency room costs. Item 3 enter costs associated with pregnancy tests, physicals, contraceptive, etc. Item 4 enter costs associated with immunizations, annual Pap smears, routine eye exams, etc. Item 5 enter associated with any other costs such as, education materials, etc. Item 6 same as noted in item 1. Item 7-13 enter the costs associated with each service. Item 14 administrative costs may include costs not associated with direct patient care, such as salaries for non-healthcare individuals, administrative supplies, screening and eligibility and other costs not listed in Items 1-13. Item 15 enter the total of 1-14. The Total costs listed in Item 15 should equal the total requested reimbursement amount on the monthly voucher. (See PHC State of Texas Purchase Voucher {FORM B-13}.)
PHC 11-1 February 2011
FORM 300
PRIMARY CARE ANNUAL REPORT

Contractor Name: Contact Name Contact Phone: Fiscal Year 1. Total number of unduplicated DSHS PHC clients served this fiscal year: _______ 2. Number of unduplicated DSHS PHC clients served by age and gender: Age 0 to 17 years 18 64 years 65 years + TOTAL Number of Males Number of Females
3. Number of unduplicated DSHS PHC clients served by race/ethnicity: Race White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Pacific Islander Unknown TOTAL Ethnicity Hispanic or Latino Not Hispanic or Latino TOTAL 4. Number of unduplicated DSHS PHC clients served by citizenship: Citizenship US Citizens or legal Residents Non-citizens TOTAL Number Served Number Served
0 Number Served
September 2011
FORM 300
5. Number of unduplicated DSHS PHC clients served according to income levels based on Federal Poverty Level (FPL): Percent of FPL 150 - 101% 100 - 51% 50 - 22% 21 - 0% TOTAL 6. Number of unduplilcated DSHS PHC clients by type of service: Services Full-services Presumptive services only Supplemental services TOTAL 7. a. Number of counties in DSHS PHC service area: 7. b. Number of unduplicated DSHS PHC eligible clients served by county of residence: County Name Number of Clients Number Served Number Served
8. List the top five diagnoses of unduplicated DSHS PHC clients: 1 2 3 4 5
September 2011
FORM 300
9. List the number of unduplicated clients to be served on the FY 12 Contract Performance Measure ____________. If the FY 12 Performance Measure was not met, provide an explanation.
10. Program accomplishments: In narrative form, highlight accomplishments of your DSHS PHC project in providing primary health care sevices to unduplicated PHC clients during this fiscal year.
September 2011
FORM 300A PHC-300 Annual Report INSTRUCTIONS PURPOSE Use to provide information to TDSHS about: PHC demographic information PROCEDURE Form 300 must be completed and submitted to th TDSHS PHC in Austin by the 60 day of the following fiscal year. Fax the Form 300 to PCG at 512/776-7713 or email PrimaryHealthCare@dshs.state.tx.us DETAILED INSTRUCTION Item 1: Enter the total number of unduplicated PHC clients who received a PHC service this year. Do not count individuals more than once regardless of the number visits or services. Item 2: Enter the total unduplicated client count served by age and gender. Item 3. List the total unduplicated client count served by race and by ethnicity. The unknown category is for those clients who did not specify or no information is available. The total for race should equal the total for ethnicity. Item 4. List the total unduplicated client count served by citizenship status. U.S. citizens or Legal Residents are born in the U.S. or have documentation for legal residency at the time services are provided. Non-citizens are those individuals not born in the U.S. and have no documentation of legal residency. ( Accept self declaration as listed on the Screening and Eligibility Application.) Item 5. List the total unduplicated client count by poverty level. Item 6. List the total unduplicated client count by PHC eligibility status. Full-service = PHC Clients with no other payment source; Supplemental = clients that have another source of payment; and Presumptive = Individuals receiving immediate PHC services but are potentially eligible for another payment source such as Medicaid, Medicare, etc. Only count these individuals in one of the above eligible categories. NOTE: The number listed under TOTAL in 1, 2, 3, 4, 5, and 6 should be the same number. Each total should equal the unduplicated client count as listed in Item 1. Item 7: List the counties that are in your projects service area. Next to county name, list the number of PHC clients served according their county of residence. The total number of clients served for all counties should equal the unduplicated client count in Item 1. Item 8: List the top five health care problems most frequently encountered, with number one being the most frequent.
Item 9. Provide the number of unduplicated DSHS clients that were listed for FY 12 contract performance measure. If you were unable to serve the number listed, please provide an explanation. Item 10: Write a summary of PHC program objectives or accomplishments achieved in the fiscal year.
September 2011
DSHS Form B-13

STATE OF TEXAS PURCHASE VOUCHER Page
WP5.1 (9/93)
of
1. Archive reference number
2. Agency No.
3. Agency Name
4. Current document number
537
5. Effective date 6. DOC date
TEXAS DEPARTMENT OF STATE HEALTH SERVICES

7. Due date 8. Doc Agency
537
9.Payee identification number
10. PDT
11. PCC
12. Requisition number
PO #
13. Document amount
14. Payee name/address
15. GSC order number
17. AGENCY USE FUND BUDGET or Program CAT. SERV DATE
16. Lease number
General
Activity Code
18. SFX 001
Ref Doc APPN
SFX Fund
M NACUBO Sub-Fund
TC Grant number Description
Index Grant year/phase
PCA Project number
AY Project phase AGENCY USE
COBJ
AOBJ
Amount Multipurpose code
Contract number
Invoice number 18. SFX 002 Ref Doc APPN SFX Fund M NACUBO Sub-Fund
PCA Project number
COBJ
AOBJ
Contract number
PCA Project number
COBJ
AOBJ
Contract number
Invoice number
19. SER/DEL DATE
20. DESCRIPTION OF GOODS OR SERVICES
21. QUANTITY
22. UNIT PRICE
23. AMOUNT
Reimbursement for services as specified in the contract between the Texas Department of State Health Services and
Monthly Expenses Less Program Income Less Advance Repayment Less Non DSHS Funding Total Reimbursement
Program: CHS/PHC Contract Term: 9/1/08 thru 8/31/09 DSHS Doc #2009Type of Entity:
Total number of unduplicated clients determined eligible and provided a primary care service for this month: _____________ (This number must match the number reported on corresponding PHC-200 Report.)
24. Contact name
Phone (Area code and number)
25. Entered by
26. I approve this voucher for payment. The above goods or services correspond in every particular with the contract under which they were purchased. The invoice for the goods or services is correct. This payment complies with the General Appropriations Act. Approved sign here < Phone (Area code and number) Date
DSHS Form B-13

STATE OF TEXAS PURCHASE VOUCHER Page
WP5.1 (9/93)
EXAMPLE ONLY
of
1. Archive reference number
2. Agency No.
3. Agency Name
4. Current document number
537
5. Effective date 6. DOC date
TEXAS DEPARTMENT OF STATE HEALTH SERVICES

7. Due date 8. Doc Agency
Submit Date
9.Payee identification number
537 12. Requisition number
10. PDT
11. PCC
12345678901234
14. Payee name/address 15. GSC order number
PO #0000123456
13. Document amount
$12,345.67
17. AGENCY USE FUND BUDGET or Program CAT. SERV DATE
Contractor Agency Name Street/P.O. Box Address as set up with Comptroller City, State 12345-1234
16. Lease number
General
Activity Code
18. SFX 001
Ref Doc APPN
SFX Fund
M NACUBO Sub-Fund
PCA Project number
COBJ
AOBJ
Contract number
PCA Project number
COBJ
AOBJ
Contract number
PCA Project number
COBJ
AOBJ
Contract number
Invoice number
19. SER/DEL DATE
20. DESCRIPTION OF GOODS OR SERVICES
21. QUANTITY
22. UNIT PRICE
23. AMOUNT
Month & Year of services
Reimbursement for services as specified in the contract between the Texas Department of State Health Services and (Contractor Agency Name).
Monthly Expenses Less Program Income Less Advance Repayment Less Non DSHS Funding Total Reimbursement
$12,895.67
300.00
Program: CHS/PHC Contract Term: 9/1/08 thru 8/31/09 DSHS Doc #2009-123456-123 Type of Entity: University, Gov, Non-Profit, etc
0.00
250.00
Total number of unduplicated clients determined eligible and provided a primary care service for this month . (This number must match the number reported on corresponding PHC-200 Report.)
$12,345.67
24. Contact name
Phone (Area code and number)
25. Entered by
Person to be contacted when questions arise
Contact persons phone and extension
26. I approve this voucher for payment. The above goods or services correspond in every particular with the contract under which they were purchased. The invoice for the goods or services is correct. This payment complies with the General Appropriations Act. Approved sign here < Phone (Area code and number) Date
4:43 PM
Page 1
B 1 2 3 4 5 1100 West 49th Street 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
DEPARTMENT OF STATE HEALTH SERVICES

FINANCIAL STATUS REPORT
Form 269A Austin, Texas 78756-3199 DSHS Program: DSHS Document # Year Attachment # Contractor Name: Payee Name: Address: Address: City, ST, Zip: Payee Vendor ID No.: Final Report? PO Number: Contract Term: ( Month / Day / Year ): from:
Cash
to:
Accrual
Period Covered by this Report:
BUDGET CATEGORIES SALARIES FRINGE BENEFITS TRAVEL EQUIPMENT SUPPLIES CONTRACTUAL OTHER
APPROVED BUDGET
CURRENT PERIOD Col 1
CUMULATIVE Col 2
BUDGET BALANCE Col 3
SUB-TOTAL
INDIRECT
$ $
$ $
$ $
TOTAL $ LESS:
PROGRAM INCOME NON-DSHS FUNDING
SUBTOTAL:
DSHS SHARE
ADVANCE: Received (Col1) - Repaid (Col 2) = Balance Owed (Col 3)
$ $
REIMBURSEMENTS (net of advances) Prepared by:
33 34 35 36 37
Title: Telephone #: CERTIFICATION: I certify to the best of my knowledge and belief that this report is correct and complete and that all outlays and unliquidated obligations are for the purposes set forth in the award documents. Name of Authorized Certifying Official: Telephone #: Fax #: Title of Certifying Official: Date Submitted: FSR Receipt Date:
9/2/2010
33-Financial Status Report 269a
APPENDICES
The Primary Health Care Program may be contacted at: Texas Department of State Health Services Community Health Services Primary Care Group 1100 West 49th Street Austin, Texas 78756-3168 Phone: (512) 776-7111 Fax: (512) 776-7713 www.dshs.state.tx.us/phc
Jan Maberry, Group Manager (All aspects of the Program) Ext: 7728 E-mail: jan.maberry@dshs.state.tx.us Carolyn Wachel, Program Specialist (Policy, Desk Reviews and Reports)) Ext: 2141 E-mail: caroly.wachel@dshs.state.tx.us Sheila Rhodes, RN (Region 1 Contract Coordinator) Phone: (806) 783-6485 / Fax: (806)783-6435 E-mail: sheila.rhodes@dshs.state.tx.us Jamie Moore, RN (Region 1 Contract Coordinator) Phone: (806) 655-7151 X1113 / Fax: (806) 655-7159 E-mail: jamie.moore@dshs.state.tx.us Laticcia Riggins (Region 2/3 Contract Coordinator) Phone: (817) 264-4658 / Fax: (817)264-4555 E-mail : laticcia.riggins@dshs.state.tx.us Della Mendez (Region 4/5N Contract Coordinator) Phone: (903) 533-5334 / Fax: (903) 533-5367 E-mail: della.mendez@dshs.state.tx.us Gina Baber, Program Specialist (Program Lead ) Ext: 2023 E-mail: gina.baber@dshs.state.tx.us Karen Gray, Program Specialist (PHC Eligibility Training) Ext: 2752 E-mail: karen.gray@dshs.state.tx.us Jim Conditt, Program Specilaist (Policy and Desk Reviews) Ext: 3529 E-mail: jim.conditt@dshs.state.tx.us Chrysanne Randal, RN (Region 2/3 Contract Coordinator) Phone: (940) 888-8019 / Fax: (940) 888-3364 E-mail: chrysanne.randal@dshs.state.tx.us Lucille Coggins, RN (Region 2/3 Contract Coordinator) Phone: (817) 573-8186 / Fax: (817) 578-3310 E-mail: lucille.coggins@dshs.state.tx.us Waseem Ahmed (Region 6/5S Contract Coordinator) Phone: (713) 767-3011 / Fax: (713)767-3408 E-mail: waseem.ahmed@dshs.state.tx.us
Ngozi Adimora, RN (Region 6/5S Contract Coordinator) Phone: (713) 767-3014 / Fax: (713) 767-3408 E-mail: ngozi.adimora@dshs.state.tx.us
Chesca Thurman (Region 7 Contract Coordinator) Phone: (254) 771-6764 / Fax: (254) 778-6819 E-mail: chesca.thurman@dshs.state.tx.us
September 2011
APPENDIX B RESOURCES
DSHS Standards and Policy More information on department-wide standards and policy for contractors may be found on the Quality Management Branch website: http://www.dshs.state.tx.us/qmb/default.shtm
Enabling Legislation Enabling PHC legislation and Texas Administrative Code Rules may be found at the following web site locations: Texas Administrative Code:
http://info.sos.state.tx.us/pls/pub/plsql/readtac$ext.ViewTAC?tac_view=4&ti=25&pt=1&ch=39
Texas Health and Safety Code: http://www.capitol.state.tx.us/statutes/hs.toc.htm

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PHC Manual

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FISCAL YEAR 2012

DEPARTMENT OF STATE HEALTH SERVICES

PRIMARY HEALTH CARE PROGRAM

SECTION ONE GENERAL INFORMATION

SECTION ONE GENERAL INFORMATION

SECTION ONE GENERAL INFORMATION

SECTION ONE GENERAL INFORMATION

SECTION ONE GENERAL INFORMATION

SECTION ONE GENERAL INFORMATION

SECTION ONE GENERAL INFORMATION

SECTION TWO PROGRAM ADMINISTRATION

SECTION TWO PROGRAM ADMINISTRATION

SECTION TWO PROGRAM ADMINISTRATION

SECTION TWO PROGRAM ADMINISTRATION

SECTION TWO PROGRAM ADMINISTRATION

SECTION TWO PROGRAM ADMINISTRATION

Client Records Management (continued)

SECTION TWO PROGRAM ADMINISTRATION

Personnel Policy and Procedures

Training needs; Quality assurance indicators; and Changing regulations/requirements.

SECTION TWO PROGRAM ADMINISTRATION

SECTION TWO PROGRAM ADMINISTRATION

SECTION TWO PROGRAM ADMINISTRATION

ELIGIBILITY CRITERIA & CLIENT SERVICES

SECTION THREE ELIGIBILITY CRITERIA

PHC 10-1 September 2010

SECTION THREE ELIGIBILITY CRITERIA

SECTION THREE ELIGIBILITY CRITERIA

SECTION THREE ELIGIBILITY CRITERIA

SECTION THREE ELIGIBILITY CRITERIA

SECTION THREE ELIGIBILITY CRITERIA

*Explanation of countable income provided below

SECTION THREE ELIGIBILITY CRITERIA

SECTION THREE ELIGIBILITY CRITERIA

SECTION THREE ELIGIBILITY CRITERIA

SECTION THREE ELIGIBILITY CRITERIA

SECTION THREE ELIGIBILITY CRITERIA

SECTION THREE ELIGIBILITY CRITERIA

SECTION THREE ELIGIBILITY CRITERIA

SECTION THREE ELIGIBILITY CRITERIA

SECTION FOUR CLINICAL INFORMATION

SECTION FOUR CLINICAL INFORMATION

SECTION FOUR CLINICAL INFORMATION

SECTION FOUR CLINICAL INFORMATION

SECTION FOUR CLINICAL INFORMATION

SECTION FOUR CLINICAL INFORMATION

SECTION FOUR CLINICAL INFORMATION

SECTION FOUR CLINICAL INFORMATION

SECTION FOUR CLINICAL INFORMATION

SECTION FOUR CLINICAL INFORMATION

SECTION FOUR CLINICAL INFORMATION

SECTION FOUR CLINICAL INFORMATION

12 Reserved for future use.

SECTION FOUR CLINICAL INFORMATION

POLICIES & PROCEDURES

Documentation of social history

SECTION FOUR CLINICAL INFORMATION

POLICIES & PROCEDURES

SECTION FOUR CLINICAL INFORMATION

POLICIES & PROCEDURES

SECTION FOUR CLINICAL INFORMATION

POLICIES & PROCEDURES