Frew Agreement - The Texas Legislature approved $150 million for the 2008-2009
biennium to finance various strategic initiatives to expand children's access to Medicaid
services. The funding is part of a $1.8 billion plan in response to the Frew v. Hawkins
lawsuit over utilization of preventive services in children's Medicaid. As of September
2008, HHSC has requested and received expenditure authority from the Legislative
Budget Board and the Governor’s Office for five strategic initiatives for an estimated $40
million general revenue for the 2008-2009 biennium. These five initiatives will have a
key role in improving access to care and participation of children under the age of 21
enrolled in Medicaid. Below is a brief summary of each project and its current status:
First Dental Home
HHSC implemented the First Dental Home initiative in March 2008 for pediatric dentists
and in May 2008 for general dentists. The First Dental Home provides an oral
evaluation, dental caries risk assessment, dental cleaning, parental education on
children’s oral health topics, and application of fluoride varnish for Medicaid-enrolled
children starting at six months of age. As of July 1, 2008, a total of 6,119 unduplicated
children, all under the age of three, had received First Dental Home services. HHSC
projects the First Dental Home will provide dental care to an estimated 130,000 children
during state fiscal years (SFYs) 2008-2009.
As of September 1, 2008, a total of 391 dentists have been trained and are eligible to bill
Texas Medicaid for providing the First Dental Home services to Medicaid-enrolled
children. Since March 11, 2008, six pediatric dental trainings have been completed with
172 pediatric dentists. Since May 3, 2008, nine general dentist trainings have been
completed with 219 general dentists trained. Training for pediatric and general dentists is
ongoing. Training for senior dental students as well as pediatric and general dentistry
residents is being coordinated through the Texas Dental Association, Texas Academy of
Pediatric Dentistry, and the Texas Academy of General Dentistry to be offered during the
organizations’ annual meetings.
Oral Evaluation and Fluoride Varnish in the Medical Home
HHSC implemented the Oral Evaluation and Fluoride Varnish (OEFV) in the Medical
Home in September 2008. This project intentionally was scheduled for implementation
after the First Dental Home project in order to allow the state to recruit and train enough
pediatric and general dentists to accept referrals from physicians for a permanent dental
home. HHSC projects OEFV will provide care to an estimated 63,272 children.
Training of medical professionals has been initiated for pediatric and family practice
faculty and/or staff at the University of Texas Medical School in Houston, Cook’s
Children’s Hospital in Fort Worth, and Driscoll Children’s Health Plan in Corpus Christi.
OEFV trainings through computer-based webinars are being coordinated through a
collaborative effort between the state, the Texas Medical Association, the Texas Pediatric
Society, and the Texas Association of Family Practitioners. The initial webinars will be
offered during October and November 2008. Training will also be offered during the
rescheduled Texas Pediatric Society annual meeting at the Woodlands, Texas, on
November 2, 2008. Other trainings are being coordinated through several Texas medical
schools and group medical practices.
Mobile Dental Unit in the Valley
HHSC finalized negotiations with the University of Texas Health Science Center in San
Antonio (UTHSC-SA) Dental School (Dental School) to operate a mobile dental unit
(MDU) in the Valley. HHSC has provided funding for SFY 2008 to the Dental School to
purchase the MDU and dental equipment, and to cover staffing costs and expenses
incurred for developing a dental home in the UTHSC-SA Pediatric Dental resident clinic
at the City of Laredo Health Department for Medicaid children and young adults without
a dental home.
The Dental School’s MDU will provide dental services to Medicaid-enrolled children in
three counties in Texas, which may include Zapata, Starr, Duval or Webb counties.
Those children with a dental home will be connected to their regular source of care;
children without a dental home will be directed for follow-up care to the dental home
being developed by the City of Laredo Health Department and UTHSC-SA.
The Dental School’s pediatric dental team on the MDU is expected to provide 3,500
patient visits in the MDU and follow-up care in the 15 dental clinics in the City of Laredo
per year, assuming a complete full year of operations with the MDU.
Integrated Pediatric and Mental Health Proposal
This proposal has been re-named Services Uniting Pediatrics and Psychiatry Outreaching
to Texas (SUPPORT). This project addresses mental health needs of Medicaid-enrolled
children in pediatric primary care clinics. HHSC contracted with the University of Texas
Health Science Center in San Antonio (UTHSC-SA) School of Psychiatry to initiate and
manage pilots throughout the state. Through these pilots, licensed practitioners of the
healing arts (LPHAs) are placed in pediatric practices to conduct mental health
assessments and primarily brief solution-focused interventions. More in-depth
interventions are available as needed. Child and adolescent psychiatrists consult both
with the LPHA and the pediatrician, providing medication counsel or advice on when to
refer select cases for more appropriate intensive care.
Six pilot areas were selected, including the following:
1) Fort Worth/Arlington
 Cook Children’s Physician Network
2) Dallas
 Parkland Hospital District
3) Rio Grande Valley
 Brownsville Community Health Center
 Harlingen Pediatric Associates
 Mid Valley Pediatric and Allergy Clinic
4) Lubbock
 Texas Tech University Health Science Center
5) El Paso
 Texas Tech Medical Center
6) San Antonio
 South Texas Center for Pediatric Care (Medical Center and Southeast
locations)
 The Children’s Health Center
 Texas Diabetes Institute & Christus Santa Rosa Endocrinology Clinic
 VIVA Pediatrics
SUPPORT plans to serve 200 Medicaid children per LPHA per year. The total number
served per full state fiscal year is anticipated to be 6,000 children. SUPPORT began
providing services in September 2008.
Increased Access to Pediatric Subspecialty Care

Telephone Consultations for Pediatric Subspecialists: HHSC is revising its benefit
policy and programming the necessary changes to the Medicaid claims payment
system to allow reimbursement of telephone consults between specialists and primary
care providers who are providing clinician-directed care coordination.
Implementation for this new benefit is expected in January or February 2009 after
system changes have been complete.

Referral Guidelines for Primary Care Providers Referring to Pediatric Subspecialists:
DSHS and HHSC are developing referral guidelines for up to ten health conditions.
The guidelines will be distributed to all health care providers through continuing
education modules, presented, at no cost, both online and in-person. The goals of the
continuing education modules are to:
1) Eliminate unnecessary or inappropriate referrals to sub-specialists.
2) Decrease the number of missed subspecialty patient appointments.
3) Assist primary care providers to determine which diagnostic testing, if any,
may be performed prior to the appointment with the sub-specialist, so as to
maximize the client’s and sub- specialist’s time by eliminating the need for
additional follow-up appointments to obtain and review test results.
A workgroup of subject matter experts will provide medical expertise and guidance
on the objectives and content of these modules. The initial workgroup planning
meeting will be held on October 14. At this meeting, the workgroup will identify
objectives for the first module: “When to Refer to a Pediatric Sub-specialist.” It is
anticipated that this module will be completed in Spring 2009.