Texas Women's Health Program Provider Announcements

Dec. 31: HHSC Set to Launch New Texas Women’s Health Program

On Dec. 31 a state district judge’s decision cleared the way for HHSC to launch the Texas Women’s Health Program Jan. 1 without Planned Parenthood clinics as providers. The judge denied Planned Parenthood’s request for a temporary restraining order that would have forced HHSC to include Planned Parenthood providers when the new state-funded program launched. A hearing on a similarly-worded temporary injunction is set for Jan. 11, but in the meantime, the new fully state-funded Texas Women’s Health Program will replace the Medicaid Women’s Health Program and continue to provide low-income women with family planning services and annual exams at no cost to the client.

While the new program features the same benefits, eligibility rules and administrative processes as the previous program, there are some things that have changed:

• New application:  The new application is similar to the previous Women’s Health Program application, but without references to Medicaid. The new application is available for download on the website www.TexasWomensHealth.org. Larger quantities can be ordered online on HHSC’s Women’s Health Program web page. Women applying for benefits can use either the new or previous program application.
• New ID cards: Women who enroll in the program will get Your Texas Benefits cards featuring “TWHP” in bold letters on the top right of the card. 

Providers will continue to submit claims and be reimbursed for services the same way they do now.

Providers that certified for the program between March and December 31, 2012, are certified for the full 2013 calendar year. Providers that have not certified can find information and the certification form online or can call TMHP Provider Enrollment at 1-800-925-9126, Option 2. 

Women who need help finding a certified Texas Women’s Health Program provider can search online at www.TexasWomensHealth.org.  

FQHC Billing for Women’s Health Program Services

FQHC WHP Claims Filing Requirements
Federally Qualified Health Centers (FQHCs) receive a per-visit encounter rate not to exceed three encounter rate payments per client per calendar year for family planning services under Medicaid, including WHP (Article II, Health and Human Services Commission, Rider 42, H.B. 1, 81st Legislature, Regular Session, 2009).

For FQHCs to receive an encounter rate payment for an annual family planning examination or a general family planning visit for WHP clients, FQHCs should use the most appropriate available procedure and diagnosis codes for the complexity of service provided.

To obtain the encounter rate payment for WHP-covered services, FQHCs must bill one of the following WHP-covered procedure codes along with an appropriate diagnosis code:

Procedure Codes

1-99201	1-99202	1-99203	1-99204	1-99205
1-99211	1-99212	1-99213	1-99214	1-99215
1-J7300	1-J7302	1-J7307

Diagnosis Codes

V2501	V2502	V2504	V2509	V251
V252	V2540	V2541	V2542	V2543
V2549	V255	V258	V259	V2651

The procedure codes listed above must be submitted in addition to the most appropriate informational procedure codes for services rendered. These include WHP-covered services that are not annual exams and visits during which only a contraceptive injection is provided. To bill a general family planning visit, the procedure code must be used with a family planning diagnosis code only (without modifier FP).

WHP-Covered Services
FQHCs cannot bill WHP clients for WHP-covered services, regardless of whether the three encounter rate payments per client per calendar year have already been paid to the FQHC. To learn more about allowable WHP-covered procedures and diagnosis codes see the Texas Medicaid Provider Procedures Manual.

Non-WHP-Covered Services
The Texas Administrative Code (TAC) prohibits FQHCs from billing WHP clients for any services rendered during a visit that results in the FQHC obtaining an encounter rate payment, regardless of whether the service is a WHP-covered service or not. However, FQHCs can bill a WHP client for services rendered during a new visit that requires treatment after the first visit that resulted in an encounter rate payment.

Title 1, Part 15, Chapter 355, Subchapter J, Division 14, Section §355.8261, Texas Administrative Code, defines an FQHC visit as follows:

A visit is a face-to-face encounter between an FQHC patient and a physician, physician assistant, nurse practitioner, nurse-midwife, visiting nurse, clinical psychologist, clinical social worker, other health professional for mental health services, dentist, dental hygienist or an optometrist. Encounters with more than one health professional and multiple encounters with the same health professional that take place on the same day and at a single location constitute a single visit, except where one of the following conditions exists:

1. after the first encounter, the patient suffers illness or injury requiring additional
   diagnosis or treatment; or
2. the FQHC patient has a medical visit and an “other” health visit.

A medical visit is a face-to-face encounter between an FQHC patient and a physician, physician assistant, nurse practitioner, nurse mid-wife, or visiting nurse. An “other” health visit includes, but is not limited to, a face-to-face encounter between an FQHC patient and a clinical psychologist, clinical social worker, other health professional for mental health services, a dentist, a dental hygienist, an optometrist, or a Texas Health Steps Medical Screen.

Change to When WHP Applications May be Submitted
If a WHP application is submitted during any month that a client is receiving Medicaid other than the last month of coverage, the woman's WHP application will be denied. Women with Medicaid for Pregnant Women can have coverage for up to two months postpartum. WHP applications may now be faxed during the final month of a woman’s Medicaid coverage. If determined eligible for WHP, the WHP coverage will begin the first day of the month following the termination of the women’s Medicaid coverage.