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Texas Women's Health Program Information for Providers

Provider Announcements

The program  provides low-income women with family planning exams, treatment of certain sexually transmitted diseases, health screenings, and contraception.

For more detailed information about provider enrollment, claims filing and billing procedures, services, benefits, limitations, and prior authorization, see the Texas Medicaid Provider Procedures Manual, Gynecological and Reproductive Health, Obstetrics, and Family Planning Services Handbook, Section 3, “Texas Women’s Health Program.”

Common Questions for Providers and Other Stakeholders:

Who can provide Texas Women's Health Program services?

Providers who meet the following criteria can provide services:

  • Deliver the type of services available through the program.
  • Have completed the Medicaid-enrollment process through the Texas Medicaid & Healthcare Partnership (TMHP).
  • Do not perform abortions or affiliate with an entity that performs or promotes elective abortions, in accordance with TAC Title 25 §39.31 - 39.45. This prohibition only applies to providers delivering services to Texas Women’s Health Program clients. The prohibition does not affect services delivered to clients not enrolled in the program.

    Notes:
    • Visit the TMHP website for more information about the requirement and links to the certification documents.
    • A complete copy of the new rules is available on this website.   
    • “Elective abortion” means the use of any means to terminate the pregnancy of a female whom the attending physician knows to be pregnant with the intention that the termination of the pregnancy by those means is reasonably likely to cause the death of the fetus, except that the term does not include an abortion: (1) to terminate a pregnancy that resulted from an act of rape or incest; or (2) in the case where a woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a physician, place a woman in danger of death unless an abortion is performed.
    • An affiliate is an individual or entity that has a legal relationship with another entity. The legal relationship between the entities is created by at least one document, and that document shows that the two entities have common ownership, common management, or common control, or that they share a licensed trademark or other registered identification mark.

How do I know if an applicant I have treated is enrolled in the Texas Women's Health Program and her claim will be paid?

To verify that a woman is enrolled in the program:

  • Call the TMHP Contact Center at 1-800-925-9126. 
  • Check online in the Texas Medicaid Provider section of www.tmhp.com (Look for the “Go to TexMed Connect” button in the upper right corner of the screen).
  • Check online at www.YourTexasBenefitsCard.com.

Note:  Providers should verify that a woman is enrolled in the program before billing. Claims received before enrollment will be denied, but providers can resubmit claims once a woman is enrolled. Providers have 95 calendar days from service delivery to bill the program.

How does a client get contraception through the Texas Women's Health Program?

Contraception, except emergency contraception, is provided through a family planning clinic or by prescription at a pharmacy that participates in the Medicaid Vendor Drug Program.

Do clients have any cost sharing responsibility?

No. Benefits are available at no cost to the woman, though she might incur some cost for services or treatment the Women’s Health Program doesn’t cover.

Can providers charge co-payments to women covered by the Texas Women's Health Program?

No.

Am I required to bill private health insurance first?

No. Prior insurance billing is not permitted for women getting services through the Women’s Health Program. Family planning client information is confidential under federal and state regulations. Asking for information from third-party insurance resources may jeopardize confidentiality.

How do I make referrals to other providers and programs?

Primary care referrals

  • If a woman covered by the Women’s Health Program does not want to pay out-of-pocket for services not covered by the program, providers must refer the woman to another physician or clinic. This referral should occur when health issues are identified and necessary services related to those health issues are not covered under the program.
  • HHSC prefers referrals to local indigent care services; however, 2-1-1 can assist with locating other primary care providers, if needed.

Breast and cervical cancer screening

Patients diagnosed with breast and/or cervical cancer

Who is eligible for the Texas Women's Health Program?

The program is for women who:

  • Are ages 18 to 44. Women can apply the month of their 18th birthday through the month of their 45th birthday.
  • Are U.S. citizens or qualified immigrants.
  • Live in Texas.
  • Do not currently get full Medicaid benefits, CHIP, or Medicare Part A or B.
  • Are not pregnant.
  • Have not been sterilized, are infertile, or are unable to get pregnant due to medical reasons. If a woman has received a sterilization procedure (such as Essure), but has not had the sterilization confirmed, she may still qualify for the program, which covers the confirmation of a sterilization procedure. However, no other Women’s Health Program services are covered for women that have received a sterilization procedure.
  • Do not have private health insurance that covers family planning services (unless filing a claim on the health insurance would cause physical, emotional, or other harm from a spouse, parent, or other person).
  • Have a countable household income at or below 185 percent of the federal poverty level (FPL).
Monthly Income Limits for Texas Women's Health Program Coverage
Family Size Monthly Income
1 $1,800
2 $2,426
3 $3,051
4 $3,677
5 $4,303
6 $4,929
For each additional person add: $626

Do all women have to prove income eligibility?

No. If a woman or one of her family members receives Temporary Assistance for Needy Families (TANF), SNAP food benefits, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), or children’s Medicaid, she has already proven income eligibility for the Women’s Health Program. She does not have to fill out the income section of the Women’s Health Program application. This is sometimes referred to as “adjunctive eligibility.” Women can provide proof of participation in one of these programs as proof of income eligibility.
Any of the following documents serve as proof of participation:

  • Active WIC Verification of Certification
  • Active WIC Voucher
  • Active WIC/ Electronic Benefit Transfer (EBT) Shopping Card

A woman may also prove income eligibility if someone in her household (such as a child) has Medicaid. Providers can verify Medicaid eligibility using TexMed Connect on the TMHP website. 

Are women who have been sterilized eligible?

No. However, if a woman has received a sterilization procedure (such as Essure), but has not had the sterilization confirmed, she may still qualify for the program for confirmation of the sterilization only. No other program services are covered for women that have received a sterilization procedure.

Can pregnant women enroll?  

No. Providers may refer pregnant women to HHSC to determine their eligibility for Medicaid for Pregnant Women or CHIP perinatal coverage. If a woman becomes pregnant while she is covered by the Women’s Health Program, she may apply for Medicaid for Pregnant Women or CHIP perinatal. Once enrolled in one of those two programs, she will be automatically disenrolled from the Women’s Health Program.

Can women who have Medicaid for Pregnant Women (MPW) transition to the Texas Women's Health Program to avoid a gap in coverage?

A woman cannot be enrolled in the Women’s Health Program and either Medicaid for Pregnant Women or CHIP perinatal at the same time. To transition from Medicaid or CHIP perinatal to the Women’s Health Program, she may apply for the program in the last month eligibility for her other pregnancy coverage. If she meets the eligibility criteria, her Women’s Health Program coverage will begin the first day of the month following the end of her Medicaid or CHIP perinatal coverage.

Can women with health insurance coverage enroll?

Women enrolled in Medicaid, CHIP, or Medicare Parts A or B are not eligible for the Women’s Health Program. A woman who has private health insurance is not eligible for the program unless:

  • Her private coverage does not cover family planning services (physician office visits and procedures, as well as contraceptive drug and devices), or
  • Filing a claim on her health insurance would cause physical, emotional, or other harm from her spouse, parents, or other person.

How do women apply for the program?

Women can apply by faxing a completed application and required documents to 1-866-993-9971 (toll-free).
Applications are available:

To order large quantities of the one-page application, use the online order form.

Notes:

  • Providers and community-based organizations can help women fill out and fax their applications to HHSC for processing.
  • If a woman fills out an application at the clinic or doctor’s office and HHSC gets it that same month, the services she receives that day will be covered if she meets program eligibility requirements.
  • HHSC has developed a screening tool [Spanish screening tool] and an income worksheet to help providers screen for eligibility and identify acceptable forms of proof of citizenship, identity, and income.  Please do not fax the screening tool with the application.

What name should the woman use on her application?

The name printed on her current Social Security card.

What information and documents are required to be submitted with an application?

Documentation is required for:

  • Household income:
  • Paycheck stub issued in the last 60 days
  • Letter from employer
  • Proof of self-employment income (i.e., recent tax statements), unemployment benefits, child support, Supplemental Security Income (SSI), or other contributions)
  • Proof of educational assistance

If an applicant has no countable household income, she should write that on the income section of the application. She does not need to show proof of income. HHSC eligibility staff may contact her for more information.

Applicants may provide a letter to confirm income or expenses. For example, a letter from an employer or from someone providing financial support is acceptable for verifying income. A letter from a provider confirming child care payments is an example of a document that can verify expenses. A letter must be from the person providing income or being paid expenses, not the applicant.  Letters must indicate the amount and frequency of the payment or expense, as well as the author’s phone number and address. All letters must be signed and dated by the author.

Note: The letter does not need to state that the information is being requested for determining eligibility for the Texas Women's Health Program.

Citizenship and identity:

  • U.S. passport
  • Certificate of naturalization
  • Certificate of U.S. citizenship

Women who are covered by the Women’s Health Program do not have to resubmit proof of citizenship or identification if they renew or reapply in the future.

Applicants that don’t have any of the documents listed above must provide two documents—one from each side of the list below:

Verification Methods
To Verify Citizenship To Verify Identity
U.S. birth certificate Current driver’s license with photo
U.S. citizen ID card DPS ID with photo (Texas ID card)
Hospital record of birth Work or school ID card with photo.
Northern Mariana ID card  
American Indian card with classification code KIC  
Religious record of birth with date and place of birth, such as baptism record  
Affidavit from two adults establishing the date and place of birth in the United States  

Documentation is not required for:

  • Address
  • Residency status
  • Household information
  • Social Security number
  • Household expenses

Note: Documentation of household expenses is not required, but HHSC recommends that women send the following, if available:

  • Expenses for dependent care (statement or current bill from provider, current receipts, income tax return, etc.).
  • Expenses for child support paid by the household (Attorney General collection and distribution records, county clerk records, cancelled checks, wage withholding statements, withholding statements from unemployment compensation, statement from the custodial parent regarding direct payments or third-party payments paid on their behalf).

How long does it take for applications to be processed?

It usually takes 45 days to process applications. Times may vary depending on the number of applications received.

How does HHSC protect a woman’s confidentiality?

  • The application allows women to list a separate mailing address where all correspondence can be sent. Note: The applicant must list her home street address on the application, but she can list a post office box as a mailing address.
  • If the woman has private health insurance coverage, providers do not bill the private insurance first, as this could jeopardize her confidentiality.

How often do women need to reapply for the program?

Women have continuous coverage for 12 months. HHSC sends a renewal packet two months before coverage expires. Women must mail back the renewal forms by the deadline indicated in the renewal letter. Clients that miss the deadline will need to reapply for coverage.
Notes:

  • Renewal packets include a postage-paid return envelope. If the envelope is lost, clients can mail their renewals to: HHSC, P.O. Box 149021, Austin, TX 78714-9021.
  • Clients can call 1-866-993-9972 if they lose the renewal packet and need a replacement.
  • HHSC does not accept renewals by fax.

What if a client needs to report a change to her case?

Report changes on Form H1019 – Report of Change  [Form H1019-Spanish]
Note:

  • Applicants do not have to submit a copy of their Social Security cards, and the card cannot be used as proof of citizenship or identity.
  • If the woman changed her name legally (due to marriage, divorce, or some other reason) but did not report the change to the Social Security Administration, she can go to Social Security Online to find out how to change or correct the name on her card.

When does coverage start?

The enrollment effective date is the first day of the month HHSC receives the application. For example, if HHSC receives a woman’s application on January 20 and she is determined eligible for the program, her coverage begins January 1. Call 1-866-993-9972 if you have questions about the enrollment effective date, or think there may be an error.

Does enrollment in the Texas Women's Health Program affect other HHSC benefits?

A woman’s enrollment in the Women’s Health Program does not make a household ineligible for other program benefits such as Medicaid, TANF, or SNAP food benefits. However, information reported when applying for the Women’s Health Program, may affect the household’s other benefits if it’s different than what was previously reported for other programs.

Who can we call for help?

  • Verify client eligibility: 1-800-993-9972
  • Provider inquiries:  1-800-925-9126 (TMHP contact center)
  • Client questions or to find a provider: 1-800-335-8957 (pick a language, then pick option 5)