4000, Eligibility and Fees
Revision 22-4; Effective Sept. 16, 2022
This section provides policy requirements for eligibility determinations, client fees, and continuity of client services.
4100, Eligibility and Assessment of Co-pay/Fees
Revision 22-4; Effective Sept. 16, 2022
Contractors must develop a policy indicating how staff will determine PHC program client eligibility. The policy must outline the contractor’s procedures for determining program eligibility and who is responsible for eligibility screening.
Contractors must perform an eligibility screening assessment on all clients who present for services using the most recent version of Form 3029.
An alternate eligibility tool created by the contractor may be used in place of Form 3029 with prior written approval by the PHC program. The tool must contain, at minimum, all required elements of the Form 3029 for eligibility determination as well as the applicant or applicant’s legal representative’s signature.
Once a contractor obtains approval for the use of an alternate eligibility screening tool, the following requirements will apply:
- Contractors must request approval from the PHC program for any revisions to their eligibility screening tool and include a copy of the revised tool.
- The eligibility screening tool is only approved for the life of the current contract cycle. If a contractor is awarded funding under a subsequent contract, the contractor must resubmit their eligibility screening tool for review and written approval, even if no changes have been made to the tool since the last written approval.
- Any required changes made to Form 3029 by the PHC program must be incorporated into the contractor-developed alternate screening tool. Contractors will need to submit their contractor-developed alternate screening tool with the incorporated changes within 60 calendar days for re-review and approval.
- The PHC program reserves the right to request additional edits or withdraw its approval of the use of an alternate eligibility tool. HHSC program will notify the contractor of the decision in writing and include the date the use of the alternate tool must be discontinued.
The following forms are optional, but may be used to aid in completing the PHC eligibility process:
- Form 3056, Office of Primary and Specialty Health Request for Information;
- Form 3049, Office of Primary and Specialty Health (OPSH) Employment Verification; and
- Form 3051, Office of Primary and Specialty Health Statement of Self-Employment Income.
If it is determined that an applicant is ineligible for services after the screening process is complete, give the applicant the OPSH Notice of Ineligibility, Form 3047. Inform the applicant of their right to appeal the eligibility decision. These steps must be taken. Do this by using the process described on the Notice of Ineligibility.
4200, Client Eligibility Screening Process
Revision 22-4; Effective Sept. 16, 2022
For a person to receive PHC program services, three criteria must be met:
- Gross family income at or below 200% of the Federal Poverty Level (FPL)
- Texas resident
- Not eligible for other programs or benefits providing the same services
Residency is self-declared. Contractors may require residency verification, but such verification should not jeopardize delivery of services. Contractors must require income verification for countable income. In cases when submitting the income verification jeopardizes the client's right to confidentiality or imposes a barrier to receipt of services, the contractor must waive this requirement. Reasons for waiving verification of income must be noted in the client record.
Eligibility determinations for PHC can be made by conducting interviews over the phone for both new applicants and to re-certify current clients. Phone interviews for eligibility determinations must comply with all eligibility guidelines outlined in program policy.
In lieu of a client’s signature on the application in the Acknowledgment section of the Application for Program Benefits or on the Statement of Applicant’s Rights and Responsibilities, the eligibility staff person must read the statements to the applicant and document that the applicant affirms the statements. The documentation must include the date and time of the applicant affirmation and the eligibility staff person’s signature. The client must sign the document at the time of their next visit to the clinic.
4300, Procedures and Terminology When Determining PHC Eligibility
Revision 22-4; Effective Sept. 16, 2022
Household – The household consists of 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 are legally responsible for the support of the other person. If an unmarried applicant lives with a partner, only count the partner’s income and children as part of the household group if the applicant and their partner have mutual children together. Also include unborn children.
A child must be under 18 years old to be counted as part of a larger family. Eligibility will end on the last day of the month the child becomes 18 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 or her 19th birthday.
- legal responsibility for support exists between:
- people who are legally married including common-law marriage;
- a legal parent and a minor child, including unborn children; or
- a managing conservator and a minor child. A managing conservator is a person designated by a court to have daily legal responsibility for a child.
Documentation of Family Composition
If family relationships seem questionable, request one of the following items:
- Birth certificate
- Baptismal certificate
- School records
- 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.
Documentation of Residency
To be eligible for PHC services, a person must be physically present within the geographic boundaries of Texas and:
- have the intent to remain within the state, whether permanently or for an indefinite period; and
- does not claim residency in any other state or country; or
- if a person is less than 18 years old, parent, managing conservator, caretaker, or guardian is a resident of Texas as defined above.
There is no requirement for the amount of time a person must live in Texas to establish residency for the purposes of PHC eligibility.
Document proof of residency provided by the client on the HHSC Office of Primary and Specialty Health Application for Program Benefits, Form 3029. Explain why residency is questionable, if necessary. For documentation of residency, one of the following items may be provided:
- Valid Texas Driver 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, their spouse, or children if they live together
- Other documents considered valid by the contractor
If none of the listed items are available, residence may be verified through one of the following:
- Observance of personal effects and living arrangement
- Statements from landlords, neighbors, or other reliable sources
- If a family is otherwise eligible, but residence is in question, the household is entitled to services until information about residency change proves otherwise.
Individuals do not lose their residency status because of temporary absences from the state. For example, a migrant or seasonal worker who may travel during certain times but maintains a home in Texas and returns to that home after these temporary absences.
Income – All income received must be included. Income is calculated before taxes (gross). Income is reviewed and determined either countable or exempt (based on the source of the income), as defined in Appendix I, Definition of Income. Contractors must have a written PHC income verification policy.
Documentation of income for PHC services must be provided to complete the HHSC OPSH Application for Program Benefits, Form 3029.Declarations of “unknown” will not be accepted as representations of required facts and documentation.
The following are examples of documentation that could be included in the contractors’ verification of income policy:
- at least two pay periods that accurately represent their earnings dated within the 60 days before the application processing date; or
- one month’s pay (only if paid same gross amount monthly), unless special circumstances are noted on the application.
The pay periods must accurately reflect the individual’s usual and customary earnings. Proof may include, but is not limited to:
- Copy(is) of the most recent paycheck(s) or stub/monthly earning statement(s)
- Employer’s written verification of gross monthly income or the Employment Verification, Form 3049
- Award letters
- Domestic relation printouts of child support payments
- Statement of support
- Unemployment benefits statement or letter from the Texas Workforce Commission
- Award letters, court orders, or public decrees to verify support payments
- Notes for cash contributions
- Other documents or proof of income determined valid by the contractor
Income Deductions – Dependent care 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 2, $175 per child per month for each dependent 2 and older, and $175 per adult with disabilities per month.
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 conversion factors listed below.
Monthly Income Conversions – If income payments are received in lump sums or at longer intervals than monthly, such as seasonal employment, the income is prorated over the time the income is expected to cover. Income received weekly, every two weeks or twice a month must be converted as follows:
- Weekly income is multiplied by 4.33
- Income received every two weeks is multiplied by 2.17
- Income received twice monthly is multiplied by 2
Presumptive Eligibility – 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 applicant’s medical needs shall be met quickly and appropriately, using available resources in the community.
Presumptive eligibility is the short-term availability and access to health care services (up to 90 days) when the client screens potentially eligible for services but lacks verification to achieve full eligibility. For clients who are determined to be fully eligible during the presumptive period, the eligibility expiration date will include the days of presumptive eligibility (expiration date is 365 days beginning the first date of eligibility determination).
When full eligibility is granted during or at the end of the 90 days, the eligibility period end date is 12 months from the presumptive eligibility. The contractor may waive the requirement to submit the eligibility documentation and approve full eligibility on a case-by-case basis, if the contractor determines submitting the documentation will create a barrier to care and no other documentation is available.
Adjunctive Eligibility – An applicant is considered adjunctively (automatically) eligible for PHC program services at an initial or renewal eligibility screening, if the person is currently enrolled in one or more of the following:
- Children’s Health Insurance Program (CHIP) Perinatal;
- Medicaid for Pregnant Women;
- Special Supplemental Nutrition Program for Women, Infants and Children (WIC);
- Supplemental Nutrition Assistance Program (SNAP); or
- Healthy Texas Women (HTW) Program.
The applicant must be able to provide proof of active enrollment in the adjunctively eligible program. Acceptable eligibility verification documentation may include:
|CHIP Perinatal||CHIP Perinatal benefits card|
|Medicaid for Pregnant Women||Your Texas Benefits card (Medicaid card)*|
|WIC||WIC verification of certification letter, printed WIC-approved shopping list or recent WIC purchase receipt with remaining balance|
|SNAP||SNAP eligibility letter|
|HTW||Your Texas Benefits card with "Healthy Texas Women" printed in the upper right corner|
|*Note: Presentation of the Your Texas Benefits card does not completely verify current eligibility in the HTW program or the Medicaid for Pregnant Women program. To verify eligibility, contractors must call Texas Medicaid & Healthcare Partnership (TMHP) at 800-925-9126 or access TexMedConnect on the TMHP website at www.tmhp.com. For a client's current eligibility status, contractors must enter two of the following four data elements for the client:
If the applicant’s current enrollment status cannot be verified during the eligibility screening process, adjunctive eligibility is not granted. The contractor would then determine eligibility according to usual protocols.
Potential Eligibility and Referral to Other Possible Qualifying Programs – In general, individuals are not eligible for the PHC program if they are enrolled in another third-party payer, such as private health insurance, Medicaid or Medicare, TRICARE, Workers’ Compensation, Veterans Affairs Benefits or other federal, state or local public health care coverage that provides the same services. A person may still be eligible for the PHC program even if they are also eligible for another program that covers the same services provided by the PHC program. The contractor should proceed with the eligibility process for the PHC program but inform the person of their possible eligibility for the other program and suggest that they also apply for services for that program. The contractor must document in the person’s case record that they were informed and were referred to the other program.
Supplemental Benefits – In some cases, people receiving benefits from other sources, such as Medicaid or Medicare, may be eligible for partial PHC coverage. This supplemental or wraparound 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 clients receiving PHC covered services, no PHC funds shall be used to pay for such care. An example of supplemental benefits would be providing health education services to Medicaid-eligible people, since Medicaid does not provide health education services. The contractor must communicate to the client that supplemental services are of limited scope.
Insurance – People with insurance may be eligible for services provided by PHC when the applicant’s confidentiality is a concern or if the applicant’s insurance deductible is 5% or greater than their income. Most insurance deductibles are given as an annual amount. PHC household incomes are figured as a monthly amount. To compare an annual deductible with a monthly income, multiply the monthly income by 12 and then determine 5% of that amount. See the example below for a monthly household income of $1,000:
- Determine the total household’s monthly income.
- Determine the total household’s annual income by multiplying the monthly income by 12 (months).
- Determine 5% of the total annual income by multiplying it by 0.05 (5%).
|Total Monthly Household Income||Total Annual Household Income||5% of Total Annual Household Income|
|$1,000 x 12 (months) =||$12,000 x 0.05||= $600|
|If the applicant's annual insurance deductible is any amount over $600, they are eligible under this criterion for PHC.|
Another way to make the comparison is to divide the annual insurance deductible into a monthly amount. See the example below for an annual insurance deductible of $6,000 and a monthly household income of $1,000:
- Determine the household’s monthly insurance deductible by dividing the annual deductible by 12 (months).
- Determine 5% of the total monthly household income by multiplying it by 0.05 (5%).
|Household Annual Insurance Deductible||Household Monthly Insurance Deductible||Total Monthly Household Income||5% of Total Monthly Household Income|
|$6,000 ÷ 12||= $500||$1,000 x 0.05||= $50|
|If the applicant's monthly insurance deductible is any amount over $50, they are eligible under this criterion for PHC.|
The completed eligibility form must be maintained in the client medical record, indicating the client's poverty level and the co-pay amount the person will be charged.
Payor of Last Resort – As previously mentioned, people seeking PHC-covered services may be dually eligible for other HHSC funded programs within an agency that provides the same services, such as HHSC Family Planning, Breast and Cervical Cancer Screening Services, or the Title V Prenatal, Child or Dental Program(s). In such cases, it is up to the contractor to determine the best use of funds within their agency.
PHC is the payor of last resort for a client who is enrolled in any other non-HHSC program that provides payment for the cost of the same primary care services at the time the client presents for those services.
Calculation of Applicant's Federal Poverty Level (FPL) Percentage – If a contractor collects a co-payment (co-pay), the contractor must determine the applicant's exact household FPL percentage. The contractor must not charge a co-pay for PHC clients whose household income is at or below 100% of the FPL. The maximum monthly income amounts by household size are based on the Department of Health and Human Services federal poverty guidelines.
The guidelines are subject to change around the beginning of each calendar year. The steps to determine the applicant's actual household FPL percentage are:
- Determine the applicant's total monthly income amount.
- Determine the applicant's household size.
- Divide the applicant's total monthly income amount by the maximum monthly income amount at 100% FPL for the appropriate household size.
- Multiply by 100. See the example below for a family of three, with a monthly income amount of $2,093:
See the example below for a family of three, with a monthly income amount of $2,093:
|Total Monthly Income||Maximum Monthly Income (Household Size of 3)||Actual Household FPL %|
|$2,093 ÷||$1,778 = 1.18 x 100||= 118% FPL|
Client Fees and Co-Pays – PHC contractors may (but are not required to) assess a co-pay for services from PHC clients. The co-pay guidelines are:
- No PHC client shall be denied services based on an inability to pay.
- Clients with a household FPL at or below 100% should not be charged a co-pay.
- Contractors may charge a co-pay amount ranging from $10 up to a maximum of $30 per encounter for clients above 100% of the FPL.
- People who are assessed a co-pay should be presented with the bill at the time of service.
- Clients who declare an inability to pay a co-pay shall not be denied services, have an account with an outstanding balance turned over to a collection agency or reported delinquent to a credit reporting agency.
- The client co-pay for a single visit must cover all the priority services provided or ordered at that visit.
- Contractors may charge an additional co-pay for all optional services provided during one visit. The optional co-pay amount may not exceed the co-pay amount for priority services. The co-pay for optional services may be assessed in addition to the co-pay for priority services.
- Client co-pays must be reported as program income on the Monthly Report Form and the quarterly Financial Status Report (FSR) or Form 269a.
- The OPSH Monthly Federal Poverty Guidelines is for contractor use to determine a PHC household’s federal poverty level and is updated annually when the revised Federal Poverty Income Guidelines become available.
- Contractors must have policies and procedures regarding fee collection, which must be approved by the contractor’s Board of Directors.
- Client co-pays collected by the contractor are considered program income and must be used to support the delivery of HHSC PHC services.
Other Fees – Clients shall not be charged administrative fees for items such as processing or transfer of medical records or copies of immunization records. Contractors can bill clients for services outside the scope of PHC allowable services if the service is provided at the client’s request and the client is made aware of their responsibility for paying for the charges.
Client’s Responsibility for Reporting Changes
A client must report changes in the following areas no later than 30 days after the client is aware of the change: income, family composition, residence, current address, employment, types of medical insurance coverage, and receipt of Medicaid CHIP, or other third-party coverage benefits. The client may report changes by mail, phone, in-person, or through someone acting on the person’s behalf. If changes result in the client no longer meeting eligibility criteria, they are denied continued services. By signing the required forms, the person attests to the truth of the information provided.
Continuation of Services – Contractors who have expended their awarded PHC funds are required to continue to serve their existing PHC clients through the end of the client’s eligibility. If other funding sources are used to provide PHC services, the funds must be reported as non-HHSC funds on the Monthly Report Form and the quarterly Financial Status Report (FSR) or Form 269A.
Date Eligibility Begins – A person or household is eligible for services beginning with the date the contractor determines they are eligible for the program and signs the completed application. This includes the date a person or household is determined eligible for Presumptive Eligibility. Contractors have the option to notify PHC applicants of their eligibility status using the optional letters provided by the PHC program:
- Form 3045, Office of Primary and Specialty Health Presumptive Eligibility Notice
- Form 3048, Office of Primary and Specialty Health Notice of Eligibility
Annual Recertification – Annual eligibility determination and recertification is required for all clients who receive PHC services. Client eligibility must be redetermined every 12 months, using the appropriate form for individuals or households. Contractors must have a system in place to track client eligibility and renewal status on an annual basis.