County Indigent Health Care Program Handbook

1100, Handbook Purpose and Contact Information

1100 Handbook Purpose and Contact Information

Revision 23-4; Effective Sept. 22, 2023

The purpose of the County Indigent Health Care Program (CIHCP) Handbook is to:

  • establish the eligibility standards and application, documentation and verification procedures for counties;
  • define basic and department established optional health care services;
  • establish the payment standards for basic and department established optional health care services; and
  • outline the procedures for administering the state assistance fund.

Contact Information

Mailing Address

County Indigent Health Care Program

North Austin Complex, Mail Code 0224

4601 W. Guadalupe Street, Suite #4.507

Austin, TX 78751-2920

Phone: 512-438-2350

Fax number: 512-776-7417

Email: CIHCP@hhs.texas.gov

Website: https://hhs.texas.gov/services/health/county-indigent-health-care-program

 

1110 Rules

Revision 22-1; Effective April 8, 2022

The Texas Administrative Code (TAC) is the compilation of all state agency rules in Texas.

The County Indigent Health Care Program (CIHCP) rules are in TAC, Title 26 (Health Services), Part 1 (HHSC), Chapter 363 (CIHCP), and the following Subchapters:

  • Program Administration
  • Determining Eligibility
  • Providing Services

The CIHCP rules may be accessed at https://texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_view=4&ti=26&pt=1&ch=363.

 

1120 Health and Safety Code

Revision 20-0; Effective November 2019

A law was passed by the First Called Special Session of the 69th Texas Legislature in 1985 that:

  • Defines who is indigent;
  • Assigns responsibilities for indigent health care;
  • Identifies health care services eligible people can receive; and
  • Establishes a state assistance fund to match expenditures for counties that exceed certain spending levels and meet state requirements.

Chapter 61, Health and Safety Code, is intended to ensure that needy Texas residents, who do not qualify for other state or federal health care assistance programs, receive health care services.

Chapter 61, Health and Safety Code, may be accessed at: https://statutes.capitol.texas.gov/Docs/HS/htm/HS.61.htm.

 

1130 County Responsibility

Revision 23-4; Effective Sept. 22, 2023

A county not fully served by a public facility must:

  • administer a County Indigent Health Care Program;
  • provide basic health care services to eligible county residents who do not live in a county area served by a public facility;
  • follow either the policies and procedures described in this handbook or less restrictive policies and procedures;
  • establish procedures for administrative hearings that provide for appropriate due process, including procedures for appeals requested by households that are denied;
  • adopt reasonable procedures for:
    • minimizing the opportunity for fraud;
    • establishing and maintaining methods for detecting and identifying situations in which a question of fraud may exist, and
    • administrative hearings to be conducted on disqualifying persons in cases where fraud appears to exist; and
  • maintain the records relating to an application at least until the end of the third complete state fiscal year following the date on which the application is submitted.

Public Notice. Not later than the beginning of the state fiscal year (Sept. 1), a county not covered by a public facility shall specify the procedure it will use during that fiscal year to verify eligibility and the documentation required to support a request for assistance and make reasonable effort to notify the public of the application procedure.

Maintaining Program Information on 2-1-1

Programs must maintain current and correct program information on 211Texas.org for all locations providing services. Program coordinators or administrators will use the Add or Edit Your 2-1-1 Listing link found at the top of the webpage to make any changes to their program location information listing. The information that the program coordinator or administrator shall maintain in their 2-1-1 listing includes, but is not limited to, program phone number, location, hours and services provided.

1140 Public Hospital and Hospital District

Revision 20-0; Effective November 2019

Public Notice. Not later than the beginning of a public hospital’s or hospital district’s operating year, the hospital or district shall specify the procedure it will use during the operating year to determine eligibility and the documentation required to support a request for assistance and shall make a reasonable effort to notify the public of the procedure.

 

1150 Options

Revision 23-4; Effective Sept. 22, 2023

A county not fully served by a public facility may file for Texas Medicaid reimbursement through the local provider or through Texas Health and Human Services Commission (HHSC) for eligible Supplemental Security Income (SSI) appellant CIHCP recipients who become eligible for retroactive Medicaid. For instructions regarding the filing process through HHSC, request the CIHCP Medicaid Reimbursement Manual.

An entity that chooses to establish an optional work registration procedure may contact its local Texas Workforce Commission (TWC) office to determine how to establish the county’s procedure and to negotiate what type of information can be provided. In addition, a county must follow the guidelines below.

  1. Notify all eligible residents and those with pending applications of the program requirements at least 30 days before the program begins.
  2. Allow an exemption from work registration if applicants or eligible residents meet one of the following criteria:
    • receive SNAP benefits;
    • receive unemployment insurance benefits or have applied but not yet been notified of eligibility;
    • physically or mentally unfit for employment;
    • undocumented alien;
    • distance prohibits walking or transportation is not available;
    • commuting time (not including taking a child to and from a child care facility) is greater than two hours a day;
    • age 15 or younger;
    • age 16 or 17 and not the head of household;
    • age 16, 17 or 18 and attending school, including home school, or on an employment training program on at least a half-time basis;
    • age 60 or older;
    • parent or other household member who personally provides care for a child under age 6 or a disabled person of any age living with the household;
    • employed or self-employed at least 30 hours per week;
    • receive earnings equal to 30 hours per week multiplied by the federal minimum wage;
    • migrant in the mainstream;
    • a regular participant or outpatient in a drug addiction or alcoholic treatment and rehabilitation program; or
    • three to nine months pregnant.
  3. If a nonexempt applicant or CIHCP eligible resident fails without good cause to comply with work registration requirements, disqualify them from CIHCP benefits as follows:
    • for one month or until they agree to comply, whichever is later, for the first noncompliance;
    • for three consecutive months or until they agree to comply, whichever is later, for the second noncompliance; or
    • for six consecutive months or until they agree to comply, whichever is later, for the third or subsequent noncompliance.

1200, Definitions

Revision 23-4; Effective Sept. 22, 2023

The following words and terms, when used in this manual, have the following meanings:

Accessible Resources – Resources legally available to the household.

Adult – A person at least age 18 or a younger person who is or has been married or had the disabilities of minority removed for general purposes.

Aged Person – Someone age 60 or older as of the last day of the month for which benefits are being requested.

Alien Sponsor – A person who signed an affidavit of support (namely, INS Form I-864 or I-864-A) on or after Dec. 19, 1997, agreeing to support an alien as a condition of the alien’s entry into the United States.

Approval Date – The date Form 3077, Notice of Eligibility, is issued to the household.

Assets – All items of monetary value owned by an individual.

Budgeting – The method used to determine eligibility by calculating income and deductions using the best estimate of the household’s current and future circumstances and income.

Claim – CMS-1500, UB-04 or pharmacy statement.

Claim Pay Date – The date the county writes a check to pay a claim.

Client—A person who has been screened and determined to be eligible for the program. The term client and patient may be used interchangeably in other sources.

Common Law Marriage – A relationship in which the parties age 18 or older are free to marry, live together and hold out to the public that they are spouses. A minor child in Texas is not legally allowed to enter a common law marriage unless the claim of common law marriage began before Sept. 1, 1997.

Complete Application – Includes Form 3064, Application for Health Care Assistance, and:

  • applicant’s full name and address;
  • applicant’s county of residence;
  • names of everyone who lives in the house with the applicant and their relationship to the applicant;
  • type and value of the CIHCP household’s resources;
  • CIHCP household’s monthly gross income;
  • information about any health care assistance that household members may receive;
  • applicant’s Social Security number, if available;
  • applicant’s and spouse’s signatures with the date Form 3064 is signed; and
  • all needed information, such as verifications.

The date that Form 3064 and all information necessary to make an eligibility determination is received is the application completion date.

Confidentiality—The state of keeping information private and not sharing it without permission.

County – A county not fully served by a public facility, namely a public hospital or hospital district; or a county that provides indigent health care services to its eligible residents through a hospital established by a board of managers jointly approved by a county and a municipality.

Days – All calendar days, except as specifically identified as workdays.

Denial Date – The date Form 3082, Notice of Ineligibility, is issued to the household.

Disqualified Member – A person receiving, or categorically eligible to receive, Medicaid.

Earned Income – Income a person receives for a certain degree of activity or work. Earned income is related to employment and, therefore, entitles the person to work-related deductions not allowed for unearned income.

Eligibility Date—Date the program administrator determines a person becomes eligible for the program.

Emancipated Minor – A person under age 18 who has been married. The marriage must not have been annulled.

Equity – The amount of money that would be available to the owner after the sale of a resource. Determine this amount by subtracting from the fair market value any money owed on the item and the costs normally associated with the sale and transfer of the item.

Family Planning Services—Educational or comprehensive medical activities that enable clients to freely determine the number and spacing of their children and select how this may be achieved.

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 Federal Poverty Guidelines. Public assistance programs, such as Medicaid, define eligibility income limits in terms of a percentage of FPL.

Fiscal Year— The state fiscal year is from Sept. 1 through Aug. 31.

Expenditure – Funds spent on basic or department-established optional health care services.

Expenditure Tracking – A county should track monthly basic and department-established optional health care expenditures.

Fair Market Value – The amount a resource would bring if sold on the current local market.

General Revenue Tax Levy (GRTL) – Used by the county to determine eligibility for state assistance funds. For information on determining and reporting the GRTL, contact the Property Tax Division of the Texas State Comptroller of Public Accounts at 512-475-1826.

Governmental Entity – A county, municipality or other political subdivision of the state, excluding a hospital authority.

Gross Income – Income before deductions.

Health and Human Services Commission – The Texas administrative agency established under Chapter 531, Texas Government Code, or its designee. HHSC manages programs that help families with food, health care, safety and disaster services.

Hospital Authority – Created under Article 4437E, Section 3, City Created Hospital Authorities or Article 4494R, Section 3, County Created Hospital Authorities, a hospital authority has no obligation under Chapter 61, Health and Safety Code, to provide indigent health care assistance.

Hospital District – Created under the authority of the Texas Constitution, Article IX, Sections 4 – 11.

Identifiable Application – An application is identifiable if it includes the applicant’s name, applicant’s address, applicant’s signature and the date the applicant signed the application.

Inaccessible Resources – Resources not legally available to the household. Examples include, but are not limited to irrevocable trust funds, property in probate, security deposits on rental property and utilities.

Managing Conservator – A person designated by a court to have daily responsibility for a child.

Mandated Provider – A health care provider, selected by the county, who agrees to provide health care services to eligible residents.

Married Minor – An individual, age 14-17, who is married. These individuals must have parental consent or court permission. An individual under age 18 may not be a party to an informal (common law) marriage.

Medicaid – The Texas Medical Assistance Program, a joint federal and state program provided in Texas Human Resources Code Chapter 32 subject to Title XIX of the Social Security Act, 42 U.S.C. Section 1396, et seq. Reimburses for health care services delivered to low-income clients who meet eligibility guidelines. 

Minor— In accordance with the Texas Family Code, a person under 18 years old who is not and has not been married or who has not had the disabilities of minority removed for general purposes (i.e., emancipated). In this policy manual, “minor” and “child” may be used interchangeably.

Minor Child – A person under age 18 who is not, or has not been, married and has not had the disabilities of minority removed for general purposes.

Net Income – Gross income minus allowable deductions.

Optional Services – Department-established optional health care services that a county may choose to provide.

Person with Disabilities – Someone who is physically or mentally unfit for employment.

Personal Possessions – Appliances, clothing, farm equipment, furniture, jewelry, livestock and other items if the household uses them to meet personal needs essential for daily living.

Public Facility – A public hospital or a hospital owned, operated or leased by a hospital district.

Public Hospital – A hospital owned, operated or leased by a county, city, town or other political subdivision of the state, excluding a hospital district and a hospital authority. For additional information, refer to Chapter 61, Health and Safety Code, Subchapter C.

Real Property – Land and any improvements on it.

Reimbursement – Repayment for a specific item or service.

Referral – The process of directing or redirecting (as a medical case or a person) to an appropriate specialist or agency for information, help or treatment.

Reimbursement Expenditure – A health care expenditure that may be applied to state assistance funds eligibility/reimbursement and that is for a service provided to a person who is eligible under a monthly net income standard that is at least 21% of the Federal Poverty Level (FPL) or up to 50% of the FPL. For additional information, refer to Section 5, State Assistance Funds.

Relative – A person who has one of the following relationships biologically or by adoption:

  • mother or father;
  • child, grandchild or stepchild;
  • grandmother or grandfather;
  • sister or brother;
  • aunt or uncle;
  • niece or nephew;
  • first cousin;
  • first cousin once removed; and
  • stepmother or stepfather.

Relationship also extends to:

  • the spouse of the relatives listed above, even after the marriage is terminated by death or divorce;
  • the degree of great-great aunt or uncle, and niece or nephew; and
  • the degree of great-great-great grandmother or grandfather.

Resident – An individual who resides within the geographic boundaries of the state of Texas.

Resources – Both liquid and non-liquid assets a person can convert to meet their needs. Examples include, but are not limited to bank accounts, boats, bonds, campers, cash, certificates of deposit, gas rights, livestock (unless the livestock is used to meet personal needs essential for daily living), mineral rights, notes, oil rights, real estate (including buildings and land, other than a homestead), stocks and vehicles.

Service Area – The geographic region in which a governmental entity, public hospital or hospital district has a legal obligation to provide health care services.

Sponsored Alien – A person who has been lawfully admitted to the United States for permanent residence under the Immigration and Nationality Act (8 U.S.C. Section 1101 et seq.) and who, as a condition of admission, was sponsored by a person who executed an affidavit of support on behalf of the person.

Tip Income – Income earned in addition to wages that is paid by patrons to people employed in service-related occupations, such as beauticians, waiters, valets, pizza delivery staff, etc.

Unearned Income – Payments received without performing work-related activities.

2100, Residence

Revision 20-0; Effective November 2019

2110 General Principles

Revision 23-4; Effective Sept. 22, 2023

A person must live in the Texas county in which they apply. There is no durational requirement for residency.

An inmate in a county correctional facility, who is a resident of another Texas county, would not be required to apply for assistance from the county they live in. They can apply for assistance in the county where they are incarcerated.

A person is a county resident if the person’s home or fixed place of habitation is in the county where they are applying for assistance and the person intends to return to the county after any temporary absences.

A person with no fixed residence, or a new resident in the county who states their intent to remain in the county, is also considered a county resident.

A person does not lose residency status because of a temporary absence from the county. No time limits are placed on a person’s absence from the county.

A person cannot qualify for CIHCP from more than one county simultaneously.

Persons Not Considered Residents:

  • an inmate or resident of a state supported living center or institution operated by any state agency;
  • an inmate, patient or resident of a school or institution operated by a federal agency;
  • a minor student primarily supported by their parents whose home residence is in another county or state; and
  • a person who moved into the county solely to obtain health care assistance.

Presumptive Eligibility

CIHCP emphasizes the importance of clients receiving primary and preventive care services. The goal of CIHCP is to ensure that Texas residents in need who do not qualify for other state or federal health care assistance programs receive health care services.  
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 appears to potentially be 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 start date. The program coordinator or administrator may waive the requirement to submit the eligibility documentation and approve full eligibility on a case-by-case basis, if the CIHCP determines submitting the documentation will create a barrier to care and no other documentation is available. 
 

2120 Verifying Residence

Revision 20-0; Effective November 2019

Residency may be verified, if it is questionable. Proof may include, but is not limited to:

  • Mail addressed to the applicant, spouse or children;
  • Texas driver license or other official identification;
  • Rent, mortgage payment or utility receipt;
  • Property tax receipt;
  • Voting record;
  • School enrollment records; and
  • Statement from a landlord, neighbor or other reliable source.

 

2130 Documenting Residence

Revision 20-0; Effective November 2019

On Form 3065, Worksheet, document why information regarding residence is questionable and how questionable residence is verified.

2200, Household

Revision 20-0; Effective November 2019

 

2210 General Principles

Revision 20-0; Effective November 2019

A County Indigent Health Care Program (CIHCP) household is a person living alone, or two or more persons living together, where legal responsibility for support exists, excluding disqualified persons.

Legal responsibility for support exists between:

  • Persons 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.

Medicaid is the only program that disqualifies a person from CIHCP.

2220 CIHCP Household

Revision 23-4; Effective Sept. 22, 2023

Disqualified Persons

  • A person who receives or is categorically eligible to receive Medicaid.
  • A person who receives SSI benefits.
  • A person who receives Qualified Medicare Beneficiary (QMB), Medicaid Qualified Medicare Beneficiary (MQMB), Specified Low-Income Medicare Beneficiary (SLMB), Qualified Individual-1 (QI-1), or Qualified Disabled and Working Individual (QDWI) and a Medicaid recipient who partially exhausts some component of their Medicaid benefits.

A disqualified person is not a CIHCP household member regardless of their legal responsibility for support.

CIHCP One-Person Household

  • A person living alone
  • An adult living with others who are not legally responsible for the adult’s support
  • A minor child living alone or with others who are not legally responsible for the child’s support
  • A Medicaid ineligible spouse
  • A Medicaid ineligible parent whose spouse or minor children are Medicaid eligible
  • A Medicaid ineligible foster child
  • An inmate in a county jail

CIHCP Group Households

Two or more persons who are living together and meet one of the following descriptions:

  • Two persons legally married to each other
  • One or both legal parents and their legal minor children
  • A managing conservator and a minor child and the conservator’s spouse and other legal minor children, if any
  • Minor children, including unborn children, who are siblings
  • Both Medicaid ineligible parents of Medicaid eligible children

 

2230 Screening Tools

Revision 23-4; Effective Sept. 22, 2023

Your Texas Benefits at http://www.yourtexasbenefits.com screens for potential eligibility for Medicaid and other programs provided by Texas state agencies.

The Benefit Eligibility Screening Tool (BEST) at http://www.ssabest.benefits.gov screens for potential eligibility for benefits from any of the programs that Social Security administers.  

 

2240 Verifying Household

Revision 23-4; Effective Sept. 22, 2023

Verify household, if questionable. Proof may include, but is not limited to:

  • lease agreement; or
  • statement from a landlord, neighbor or other reliable source.

 

2250 Documenting Household

Revision 23-4; Effective Sept. 22, 2023

On Form 3065, Worksheet, document why information regarding household is questionable and how questionable household is verified.

2300, Resources

Revision 20-0; Effective November 2019

 

2310 General Principles

Revision 20-0; Effective November 2019

A household must pursue all resources to which the household is legally entitled unless it is unreasonable to pursue the resource. Reasonable time (at least three months) must be allowed for the household to pursue the resource, which is not considered accessible during this time.

  • The resources of all CIHCP household members are considered.
  • Resources are either countable or exempt.
  • Resources from disqualified and non-household members are excluded but may be included if processing an application for a sponsored alien.
  • A household is not eligible if the total countable household resources exceed $3,000 when a person living in the home is aged or has disabilities and they meet relationship requirements or $2,000 for all other households.
  • A household is not eligible if their total countable resources exceed the limit on or after the first interview date or the process date for cases processed without an interview.
  • In determining eligibility for a prior month, the household is not eligible if their total countable resources exceed the limit any time during the prior month.
  • Consider a joint bank account with a nonmember as inaccessible if the money in the account is used solely for the nonmember's benefit. The CIHCP household must provide verification that the bank account is used solely for the nonmember's benefit and that no CIHCP household member uses the money in the account for their benefit. If a household member uses any of the money for their benefit or if any household member’s money is also in the account, consider the bank account accessible to the household.

2320 Countable Resources and Exemptions

Revision 23-2; Effective Sept. 22, 2023

Alien Sponsor’s Resources – If an entity chooses to include the resources of a person who executed an affidavit of support on behalf of a sponsored alien and the resources of the person’s spouse, the entity shall adopt written procedures for processing the resources of the sponsor and the sponsor’s spouse.

Bank Accounts – Count the cash value of checking and savings accounts unless exempt for another reason.

Burial Insurance (Prepaid) – Exempt up to $7,500 cash value of a prepaid burial insurance policy, funeral plan or funeral agreement for each certified household member. Count the cash value exceeding $7,500 as a liquid resource.

Burial Plots – Exempt all burial plots.

Crime Victim’s Compensation – Exempt.

Energy Assistance Payments – Exempt payments or allowances made under any federal law for energy assistance.

Exemption: Resources and Income Payments – If a payment or benefit counts as income for a particular month, do not count it as a resource in the same month. If you prorate a payment as income over several months, do not count any portion of the payment as a resource during that time. If the client combines this money with countable funds, such as a bank account, exempt the prorated amounts for the time you prorate it.

Homestead – Exempt the household’s usual residence and surrounding property not separated by property owned by others. The exemption remains in effect if public rights of way, such as roads, separate the surrounding property from the home. The homestead exemption applies to any structure the person uses as a primary residence, including additional buildings on contiguous land, a houseboat or a motor home, if the household lives in it. If the household does not live in the structure, count it as a resource.

  • Houseboats and Motor Homes – Count houseboats and motor homes according to vehicle policy, if not considered the household’s primary residence or otherwise exempt.
  • Own or Purchasing a Lot – For households that currently do not own a home, but own or are purchasing a lot on which they intend to build, exempt the lot and partially completed home.
  • Real Property Outside of Texas – Households cannot claim real property outside of Texas as a homestead, except for migrant and itinerant workers who meet the residence requirements.
  • Homestead Temporarily Unoccupied – Exempt a homestead temporarily unoccupied because of employment, training for future employment, illness (including health care treatment), casualty (fire, flood, state of disrepair, etc.) or natural disaster, if the household intends to return.
  • Sale of a Homestead – Count money remaining from the sale of a homestead as a resource.

Income-Producing Property – Exempt property that:

  • is essential to a household member’s employment or self-employment (for example, tools of a trade, farm machinery, stock and inventory). Continue to exempt this property during temporary periods of unemployment if the household member expects to return to work;
  • annually produces income consistent with its fair market value, even if used only on a seasonal basis;
  • is necessary for the maintenance or use of a vehicle that is exempt as income-producing or as necessary for transporting a physically disabled household member. Exempt the portion of the property used for this purpose; or
  • for farmers or fishermen, the value of the land or equipment for one year from the date that the self-employment ceases.

Insurance Settlement – Count, minus any amount spent or intended to be spent for the household's bills for burial, health care or damaged or lost possessions.

Lawsuit Settlement – Count, minus any amount spent or intended to be spent for the household's bills for burial, legal expenses, health care expenses or damaged or lost possessions.

Life Insurance – Exempt the cash value of life insurance policies.

Liquid Resources – Count, if readily available. Examples include, but are not limited to cash, checking accounts, savings accounts, certificates of deposit (CDs), notes, bonds and stocks.

Loans (Non-educational) – Exempt these loans from resources. Consider financial assistance as a loan if there is an understanding that the loan will be repaid and the person can reasonably explain how they will repay it. Count assistance not considered a loan as unearned income (contribution).

Lump-Sum Payments – Count lump-sum payments received once a year or less frequently as resources in the month received, unless specifically exempt. Countable lump-sum payments include, but are not limited to, retroactive lump-sum Retirement, Survivors and Disability Insurance (RSDI), public assistance, retirement benefits, lump-sum insurance settlements, refunds of security deposits on rental property or utilities, and lump-sum payments on child support. Exempt federal tax refunds permanently as income and resources for 12 months after receipt. Count lump-sum payments received or anticipated to be received more often than once a year as unearned income in the month received. Exception: Count contributions, gifts and prizes as unearned income in the month received, regardless of the frequency of receipt.

Personal Possessions – Exempt.

Real Property – Count the equity value of real property unless it is otherwise exempt. Exempt any portion of real property directly related to the maintenance or use of a vehicle necessary for employment or to transport a physically disabled household member. Count the equity value of any remaining portion unless it is otherwise exempt.

  • Good Faith Effort to Sell – Exempt real property if the household is making a good effort to sell it.
  • Jointly Owned Property – Exempt property jointly owned by the household and other individuals not applying for or receiving benefits if the household provides proof that they cannot sell or divide the property without consent of the other owners, and the other owners will not sell or divide the property.

Reimbursement – Exempt a reimbursement in the month received. Count as a resource in the month after receipt. Exempt a reimbursement earmarked and used for replacing and repairing an exempt resource. Exempt the reimbursement indefinitely.

Retirement Accounts – An account in which an employee or their employer contribute money for retirement. There are several types of retirement plans. Some of the most common plans authorized under Section 401(a) of the Internal Revenue Services (IRS) Code are the 401(k) plan, Keogh, Roth Individual Retirement Account (IRA) and a pension or traditional benefit plan. Common plans under Section 408 of the IRS Code are the IRA, Simple IRA and Simplified Employer Plan. A pension or traditional defined benefit plan is employed based and promises a certain benefit upon retirement regardless or investment performance.

Exclude all retirement accounts or plans established under:

  • Internal Revenue Code of 1986, Sections 401(a), 403(a), 403(b),408, 408A, 457(b), 501(c)(18);
  • Federal Thrift Savings Plan, Section 8439, Title 5, United States Code; and
  • Other retirement accounts determined to be tax exempt under the Internal Revenue Code of 1986.

Count any other retirement accounts not established under plans or codes listed above.

Trust Fund – Exempt a trust fund if all the following conditions are met:

  • the trust arrangement is unlikely to end during the certification period; and
  • no household member can revoke the trust agreement or change the name of the beneficiary during the certification period; and
  • the trustee of the fund is either a:
    • court, institution, corporation or organization not under the direction or ownership of a household member; or
    • court-appointed individual who has court-imposed limitations placed on the use of the funds; and
  • the trust investments do not directly involve or help any business or corporation under the control, direction or influence of a household member. Exempt trust funds established from the household’s own funds if the trustee uses the funds:
    • only to make investments on behalf of the trust; or
    • to pay the education or health care expenses of the beneficiary.

Vehicles – Exempt a vehicle necessary to transport physically disabled household members, even if disqualified and regardless of the purpose of the trip. Exempt no more than one vehicle for each disabled member. There is no requirement that the vehicle be used primarily for the disabled person. Exempt vehicles if the equity value is less than $4,650, regardless of the number of vehicles owned by the household. Count the value in excess of $4,650 toward the household’s resource limit.

Examples:

$15,000Fair Market Value
- 12,450Amount Still Owed
$2,550Equity Value
- 4,650 
$0Countable Resource
$9,000Fair Market Value
- 0Amount Still Owed
$9,000Equity Value
- 4,650 
$4,350Countable Resource
  • Income-producing Vehicles – Exempt the total value of all licensed vehicles used for income-producing purposes. This exemption remains in effect when the vehicle is temporarily not in use. A vehicle is considered income-producing if it:
    • is used as a taxi, farm truck or fishing boat;
    • is used to make deliveries as part of the person’s employment;
    • is used to make calls on clients or customers;
    • is required by the terms of employment; or
    • produces income consistent with its fair market value.
  • Solely Owned Vehicles – A vehicle whose title is solely in one person’s name, is considered an accessible resource for that person. This includes the following situations:
    • Vehicles involved in community property issues that belong to the person whose name is on the title.
    • If a vehicle is solely in the household member’s name and the household member claims they purchased it for someone else, the vehicle is considered accessible to the household member.   

      Exceptions: The vehicle is inaccessible if the title holder verifies:   
       
    • That they sold the vehicle but have not transferred the title. In this situation, the vehicle belongs to the buyer. Note: Count any payments made by the buyer to the household member or the household member’s creditors (directly) as self-employment income.
    • That they sold the vehicle but the buyer has not transferred the title into the buyer’s name.
    • That the vehicle was repossessed.
    • That the vehicle was stolen.
    • That they filed for bankruptcy (Title 7, 11, or 13) and that the household member is not claiming the vehicle as exempt from the bankruptcy. Note: In most bankruptcy petitions, the court will allow each adult individual to keep one vehicle as exempt for the bankruptcy estate. This vehicle is a countable resource.   

      A vehicle is accessible to a household member even though the title is not in the household member’s name if the household member purchases, or is purchasing, the vehicle from the person who is the title holder, or if the household member is legally entitled to the vehicle through an inheritance or divorce settlement.   
       
  • Jointly Owned Vehicles – Consider vehicles jointly owned with another person not applying for or receiving benefits as inaccessible if the other owner is not willing to sell the vehicle.
  • Leased Vehicles – When a person leases a vehicle, they are not generally considered the owner of the vehicle because the:
    • vehicle does not have any equity value;
    • person cannot sell the vehicle; and
    • title remains in the leasing company’s name.   

      Exempt a leased vehicle until the person exercises their option to purchase the vehicle. Once the person becomes the owner of the vehicle, count it as a resource. The person is the owner of the vehicle if the title is in their name, even if the person and the dealer refer to the vehicle as leased. Count the vehicle as a resource.   
       
  • How to Determine Fair Market Value of Vehicles
    • Determine the current fair market value of licensed vehicles using the average trade-in or wholesale value listed on a reputable automotive buying resource website (i.e., National Automobile Dealers Association (NADA), Edmunds or Kelley Blue Book). Note: If the household claims that the listed value does not apply because the vehicle is in less than average condition, allow the household to provide proof of the true value from a reliable source, such as a bank loan officer or a local licensed car dealer.
    • Do not increase the basic value because of low mileage, optional equipment or special equipment for the handicapped.
    • Accept the household’s estimate of the value of a vehicle no longer listed on an automotive buying resource website unless it is questionable and would affect the household’s eligibility. In this case, the household must provide an appraisal from a licensed car dealer or other evidence of the vehicle’s value, such as a tax assessment or a newspaper advertisement indicating the sale value of similar vehicles.
    • Determine the value of new vehicles not listed on an automotive buying resource website by asking the household to provide an estimate of the average trade-in or wholesale value from a new car dealer or a bank loan officer. If this cannot be done, accept the household’s estimate unless it is questionable and would affect eligibility. Use the loan value only if other sources are unavailable. Request proof of the value of licensed antique, custom made or classic vehicles from the household.

 

2330 Penalty for Transferring

Revision 23-4; Effective Sept. 22, 2023

A household is ineligible if, within three months before application or any time after certification, they transfer a countable resource for less than its fair market value to qualify for county health care assistance. This penalty applies if the total of the transferred resource added to other resources affects eligibility.

Base the length of denial on the amount by which the transferred resource exceeds the resource maximum when added to other countable resources. Use the chart below to determine the length of denial.

Amount in Excess of Resource LimitDenial Period
$.01 to $249.991 month
$250.00 to $999.993 months
$1,000.00 to $2,999.996 months
$3,000.00 to $4,999.999 months
$5,000.00 to $5,000.00 and more12 months

If spouses separate and one spouse transfers their property, it does not affect the eligibility of the other spouse.

 

2340 Verifying Resources

Revision 23-4; Effective Sept. 22, 2023

Verify countable resources. Proof may include, but is not limited to:

  • bank account statements; and
  • award letters.

 

2350 Documenting Resources

Revision 23-4; Effective Sept. 22, 2023

On Form 3065, Worksheet, document whether a resource is countable or exempt and why resources are verified.

2400, Income

Revision 20-0; Effective November 2019

 

2410 General Principles

Revision 23-4; Effective Sept. 22, 2023

A household must pursue and accept all income to which the household is legally entitled  unless it is unreasonable to pursue the income. At least three months should be allowed for the household to pursue the income, which is not considered accessible during this time.

  • The income of all CIHCP household members is considered.
  • Income is either countable or exempt.
  • If attempts to verify income are unsuccessful because the payer fails or refuses to provide information and other proof is not available, the household’s statement is used as best available information.
  • Income of disqualified and non-household members is excluded but may be included if processing an application for a sponsored alien.

2420 Countable Income and Exemptions

Revision 23-4; Effective Sept. 22, 2023

Adoption Payments Adoption Payments– Exempt.

Alien Sponsor’s Income – If an entity chooses to include the income of a person who executed an affidavit of support on behalf of a sponsored alien and the income of the person’s spouse, the entity shall adopt written procedures for processing the income of the sponsor and the sponsor’s spouse.

Cash Gifts and Contributions – Count as unearned income unless they are made by a private, nonprofit organization based on 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 non-certified household member who:

  • lives in the home with the certified household member;
  • shares household expenses with the certified household member; and
  • no landlord or tenant relationship exists.

If a noncertified household member makes additional payments for use by a certified member, it is a contribution.

Child’s Earned Income – Exempt a child’s earned income if the child, who is under 18 and not an emancipated minor, is a full-time student (including a home-schooled child) or a part-time student employed less than 30 hours a week.

Child Support Payments – Count as unearned income after deducting up to $75 from the total monthly child support payments the household receives. Count payments as child support if a court ordered the support or the child’s caretaker or the person making the payment states the purpose of the payment is to support the child. Count ongoing child support income as income to the child even if someone else living in the home receives it. Count child support arrears as income to the caretaker. Exempt child support payments as income if the child support is intended for a child who receives Medicaid, even though the parent receives the child support.

  • Child Support Received for a Nonmember – If a caretaker receives ongoing child support for a nonmember (or a member who is no longer in the home) but uses the money for personal or household needs, count it as unearned income. Do not count the amount used for or provided to the nonmember for whom it is intended to cover.
  • Lump-Sum Child Support Payments – Count lump-sum child support payments (on child support arrears or on current child support) received or anticipated to be received more often than once a year, as unearned income in the month received. Consider lump-sum child support payments received once a year or less frequently as a resource in the month received.
  • Returning Parent – If an absent parent is making child support payments but moves back into the home of the caretaker and child, process the household change.

Crime Victim’s Compensation Payments – Exempt. These are payments from the funds authorized by state legislation to assist a person who has been a victim of a violent crime; was the spouse, parent, sibling or adult child of a victim who died as a result of a violent crime; or is the guardian of a victim of a violent crime. The payments are distributed by the Office of the Attorney General in monthly payments or in a lump sum.

Disability Insurance Payments – Count disability payments as unearned income, including Social Security Disability Insurance (SSDI) payments and disability insurance payments issued for non-medical expenses. Exception: Exempt Supplemental Security Income (SSI) payments.

Dividends and Royalties – Count dividends as unearned income. Exception: Exempt dividends from insurance policies as income. Count royalties as unearned income, minus any amount deducted for production expenses and severance taxes.

Educational Assistance – Exempt educational assistance, including educational loans, regardless of source.  Educational assistance also includes college work study.

Energy Assistance – Exempt the following types of energy assistance payments:

  • assistance from federally funded, state or locally administered programs, including HEAP, weatherization, Energy Crisis, and one-time emergency repairs of a heating or cooling device (down payment and final payment);
  • energy assistance received through Housing and Urban Development (HUD), United States Department of Agriculture’s Rural Housing Service (RHS) or Farmer’s Home Administration (FmHA); and
  • assistance from private, nonprofit or governmental agencies based on need.

If an energy assistance payment is combined with other payments of assistance, exempt only the energy assistance portion from income (if applicable).

Foster Care Payments – Exempt.

Government Disaster Payments – Exempt federal disaster payments and comparable disaster assistance provided by states, local governments and disaster assistance organizations if the household is subject to legal penalties when the funds are not used as intended. Examples: Payments by the Individual and Family Grant Program, Small Business Administration or Federal Emergency Management Agency (FEMA).

In-Kind Income – Exempt. An in-kind contribution is any gain or benefit to a person that is not in the form of money or check, payable directly to the household, such as clothing, public housing or food.

Interest – Count as unearned income.

Job Training – Exempt all payments made under the Workforce Innovation and Opportunity Act (WIOA). Exempt portions of non-WIOA job training payments earmarked as reimbursements for training-related expenses. Count any excess as earned income. Exempt on-the-job training (OJT) payments received by a child who is under age 19 and under parental control of another household member.

Loans (Non-educational) – Count as unearned income unless there is an understanding that the money will be repaid and the person can reasonably explain how he 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. Consider retroactive or restored payments to be lump-sum payments and count as a resource. Separate any portion that is ongoing income from a lump-sum amount and count it as income. Exempt lump sums received once a year or less, unless specifically listed as income. Count them as a resource in the month received. Exempt federal tax refunds permanently as income and resources for 12 months after receipt. If a lump sum reimburses a household for burial, legal or health care bills, or damaged or lost possessions, reduce the countable amount of the lump sum by the amount earmarked for these items.

Military Pay – Count military pay and allowances for housing, food, base pay and flight pay as earned income, minus pay withheld to fund education under the G.I. Bill.

Mineral Rights – Count payments for mineral rights as unearned income.

Pensions – Count as unearned income. A pension is any benefit derived from former employment, such as retirement benefits or disability pensions.

Reimbursement – Exempt a reimbursement (not to exceed the individual's expense) provided specifically for a past or future expense. If the reimbursement exceeds the individual's expenses, count any excess as unearned income. Do not consider a reimbursement to exceed the individual's expenses unless the individual or provider indicates the amount is excessive. Exempt a reimbursement for future expenses only if the household plans to use it as intended.

Retirement, Survivors and Disability Insurance (RSDI) Payments – Count as unearned income the benefit amount including the deduction for the Medicare premium, minus any amount that is being recouped for a prior RSDI overpayment. If a person receives an RSDI check and a Supplemental Security Income (SSI) check, exempt both checks since the person is a disqualified household member. If an adult receives a Social Security survivor's benefit check for a child, this check is considered the child's income.

Self-Employment Income – Count as earned income, minus the allowable costs of producing the self- employment income. Self-employment income is earned or unearned income available from one’s own business, trade or profession rather than from an employer. However, some individuals may have an employer and receive a regular salary. If an employer does not withhold Federal Insurance Contributions Act (FICA) or income taxes, even if required to do so by law, the person is considered self-employed.

Types of self-employment include:

  • odd jobs, such as mowing lawns, babysitting and cleaning houses;
  • owning a private business, such as a beauty salon or auto mechanic shop;
  • farm income; and
  • income from property, which may be from renting, leasing or selling property on an installment plan. Property includes equipment, vehicles and real property.

If the person sells the property on an installment plan, count the payments as income. Exempt the balance of the note as an inaccessible resource.

Supplemental Security Income (SSI) Payments – Exempt. A person receiving any amount of SSI benefits also receives Medicaid and is, therefore, a disqualified household member.

Temporary Assistance for Needy Families (TANF) Benefits – Exempt.

Terminated Income – Count terminated income in the month received. Use actual income and do not use conversion factors if terminated income is less than a full month’s income. Income is terminated if it will not be received in the next usual payment cycle.

Income is not terminated if:

  • someone changes jobs while working for the same employer;
  • an employee of a temporary agency is temporarily not assigned;
  • a self-employed person changes contracts or has different customers without having a break in normal income cycle; or
  • someone received regular contributions, but the contributions are from different sources.

Third-Party Payments – Exempt the money received that is intended and used for the maintenance of a person who is not a member of the household. If a single payment is received for more than one beneficiary, exclude the amount used for the nonmember up to the nonmember's identifiable portion or prorated portion, if the portion is not identifiable.

Tip Income – Count the actual (not taxable) gross amount of tips as earned income. Add tip income to wages before applying conversion factors. Tip income is income earned in addition to wages paid by patrons to people employed in service-related occupations, such as beauticians, waiters, valets, pizza delivery staff, etc. Do not consider tips as self-employment income unless related to a self-employment enterprise.

Trust Fund – Count as unearned income trust fund withdrawals or dividends that the household can receive from a trust fund that is exempt from resources.

Unemployment Compensation Payments – Count as unearned income the gross benefit less any amount being recouped for an Unemployment Insurance Benefits (UIB) overpayment. Count the cash value of UIB in a UIB debit account, less amounts deposited in the current month, as a resource. Account inquiry is accessible to a UIB recipient online at www.chase.com or at any Chase Bank automated teller machine free of charge. Exception: Count the gross amount if the household agreed to repay a SNAP overpayment through voluntary garnishment.

Veterans Affairs (VA) Payments – Count the gross VA payment as unearned income, 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.

Vacation Pay – If an individual receives vacation pay:

  • During or before termination of employment, consider it earned income.
  • After termination of employment in one lump sum, consider it a liquid resource in the month received.
  • After termination of employment in multiple checks, consider it unearned income.

Vendor Payments – Exempt vendor payments if made by a person or organization outside the household directly to the household's creditor or person providing the service. Exception: Count as income money that is legally obligated to the household, but which the payer makes to a third party for a household expense.

Wages, Salaries, Commissions – Count the actual (not taxable) gross amount as earned income. If a person asks their employer to hold their wages or the person’s wages are garnished, count this money as income in the month the person would otherwise have been paid. If, however, an employer holds his employee’s wages as a general practice, count this money as income in the month it is paid. Count an advance in the month the person receives it.

Workers’ Compensation Payments – Count the gross payment as unearned income, minus any amount being recouped for a prior worker’s compensation overpayment or paid for attorney’s fees. Note: The Texas Workforce Commission (TWC) or a court sets the amount of the attorney’s fee to be paid. Do not allow a deduction from the gross benefit for court-ordered child support payments. Exception: Exclude workers’ compensation benefits paid to the household for out-of-pocket health care expenses. Consider these payments as reimbursements.

Other Types of Benefits and Payments – Exempt benefits and payments from the following programs:

  • AmeriCorps;
  • Child Nutrition Act of 1966;
  • Supplemental Nutrition Assistance Program (SNAP);
  • Foster Grandparents;
  • funds distributed or held in trust by the Indian Claims Commission for Indian tribe members under Public Laws 92-254 or 93-135;
  • Learn and Serve;
  • National School Lunch Act;
  • National Senior Service Corps (Senior Corps);
  • Nutrition Program for the Elderly (Title III, Older American Act of 1965);
  • Retired and Senior Volunteer Program (RSVP);
  • Senior Companion Program;
  • Special Supplemental Nutrition Program for Women, Infants and children (WIC);
  • Tax-exempt portions of payments made under the Alaska Native Claims Settlement Act;
  • Uniform Relocation Assistance and Real Property Acquisitions Act (Title II); and
  • Volunteers in Service to America (VISTA).

 

2430 Verifying Income

Revision 23-4; Effective Sept. 22, 2023

Verify countable income, including recently terminated income, at initial application and when changes are reported. Proof may include, but is not limited to:

  • pay stubs;
  • statements from employers;
  • W-2 forms;
  • notes for cash contributions;
  • business records;
  • award letters;
  • court orders or public decrees (support documents);
  • sales records;
  • income tax returns; and
  • statements completed, signed and dated by the self-employed person.

 

2440 Documenting Income

Revision 23-4; Effective Sept. 22, 2023

On Form 3065, Worksheet, document exempt income and the reason it is exempt, and unearned income, including the following items:

  • date income is verified;
  • type of income;
  • check or document seen;
  • amount recorded on check or document;
  • frequency of receipt; and
  • calculations used.

For self-employment income, include the following items:

  • the allowable costs for producing the self-employment income; and
  • other factors used to determine the income amount;

For earned income, include the following items:

  • payer’s name and address;
  • dates of each wage statement or pay stub used;
  • date paycheck is received;
  • gross income amount;
  • frequency of receipt;
  • calculations used; and
  • allowable deductions.

2500, Budgeting Income

Revision 21-1; Effective March 1, 2021

2510 General Principles

Revision 20-0; Effective November 2019

Count income already received and any income the household expects to receive. If the household is not sure about the amount expected or when the income will be received, use the best estimate.

  • Income, whether earned or unearned, is counted in the month that it is received.
  • Count terminated income in the month received. Use actual income and do not use conversion factors if terminated income is less than a full month’s income.
  • View at least two pay amounts in the time beginning 45 days before the interview date or the process date for cases processed without an interview. However, do not require the household to provide verification of any pay amount that is older than two months before the interview date or the process date for cases processed without an interview.
  • When determining the amount of self-employment income received, verify four recent pay amounts that accurately represent their pay. Verify one month’s pay amount that accurately represent their pay for self-employed income received monthly. Do not require the household to provide verification of self-employment income and expenses for more than two calendar months before the interview date or the case process date if not interviewed, for income received monthly or more often.
  • Accept the applicant's statement as proof if there is a reasonable explanation of why documentary evidence or a collateral source is not available, and the applicant's statement does not contradict other individual statements or other information received by the entity.
  • The self-employment income projection, usually 12 months, is the time that the household expects the income to support the family.
  • There are deductions for earned income that are not allowed for unearned income.
  • The earned income deductions are not allowed if the income is gained from illegal activities, such as prostitution and selling illegal drugs.

2520 Steps for Budgeting Income

Revision 23-2; Effective Sept. 22, 2023

There are 10 steps:

  • Determine countable income, using CIHCP guidelines.
  • Determine how often countable income is received, such as yearly, monthly, twice a month, every other week or weekly.
  • Convert countable income to monthly amounts if income is not received monthly.
  • Convert self-employment allowable costs to monthly amounts.
  • Determine if countable income is earned or unearned.
  • Subtract converted monthly self-employment allowable costs, if any, from converted monthly self-employment income.
  • Subtract earned income deductions, if any.
  • Subtract the deduction for Medicaid individuals, if applicable.
  • Subtract the deduction for child support, alimony and other payments to dependents outside the home, if applicable.
  • Compare the household’s monthly net income to the 21% Federal Poverty Level (FPL) minimum income standard, using the CIHCP monthly income standard.

Step 1: Determine countable income, using CIHCP guidelines.

  • Evaluate the household's current and future circumstances and income.
  • Decide if changes are likely during the current or future months.
  • If changes are likely, then determine how the change will affect eligibility.

Step 2: Determine how often countable income is received, such as yearly, monthly, twice a month, every other week or weekly.

  • All income, excluding self-employment – Based on verifications or the person’s statement as best available information, determine how often income is received. If the income is based hourly or for piecework, determine the amount of income expected for one week of work.
  • Self-employment Income – Compute self-employment income, using one of these three methods:
    • Annual. Use this method if the person has been self-employed for at least the past 12 months.
    • Monthly. Use this method if the person has at least one full representative calendar month of self-employment income.
    • Daily. Use this method when there is less than one full representative calendar month of self-employment income, and the source or frequency of the income is unknown or inconsistent. 

      Determine if the self-employment income is annual or seasonal, since that will determine the length of the projection period. 
       
    • The projection period is annual if the self-employment is intended to support the household for at least the next 12 months. The projection period is 12 months whether the income is received monthly or less often.
    • The projection period is seasonal if the self-employment income is intended to support the household for less than 12 months since it is available only during certain months of the year. The projection period is the number of months the self-employment is intended to provide support. 

      Determine the costs of producing self-employment income by accepting the deductions listed on the 1040 U.S. Individual Income Tax Return or by allowing the following deductions: 
       
    • capital asset improvements;
    • capital asset purchases, such as real property, equipment, machinery and other durable goods, i.e., items expected to last at least 12 months;
    • fuel;
    • identifiable costs of seed and fertilizer;
    • insurance premiums;
    • interest from business loans on income producing property;
    • labor;
    • linen service;
    • payments of the principal of loans for income-producing property;
    • property tax;
    • raw materials;
    • rent;
    • repairs that maintain income-producing property;
    • sales tax;
    • supplies;
    • transportation costs. The person may choose to use 50 cents per mile instead of keeping track of individual transportation expenses. Do not allow travel to and from the place of business; and
    • utilities. 

      Note: If the applicant conducts a self-employment business in their 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. 

      The following are not allowable costs of producing self-employment income: 
       
    • costs not related to self-employment;
    • costs related to producing income gained from illegal activities, such as prostitution and the sale of illegal drugs;
    • depreciation;
    • net loss which occurred in a previous period; and
    • work-related expenses, such as federal, state and local income taxes, and retirement contributions.

Step 3:  Convert countable income to monthly amounts if income is not received monthly.

When converting countable income to monthly amounts, use the following conversion factors:

  • Multiply weekly amounts by 4.33.
  • Multiply amounts received every other week by 2.17.
  • Add amounts received twice a month (semi-monthly).
  • Divide yearly amounts by 12.

Step 4: Convert self-employment allowable costs to monthly amounts.

When converting the allowable costs for producing self-employment to monthly amounts, use the conversion factors in Step 3 above.

Step 5: Determine if countable income is earned or unearned.

For earned income, proceed with Step 6. For unearned income, skip to Step 8.

Step 6: Subtract converted monthly self-employment allowable costs, if any, from converted monthly self-employment income.

Step 7: Subtract earned income deductions, if any.

Subtract these deductions, if applicable, from the household’s monthly gross income, including monthly self-employment income after allowable costs are subtracted:

  • Deduct $120 per employed household member for work-related expenses.
  • Deduct one-third of the remaining earned income per employed household member.
  • Dependent child care or adult with disabilities care expenses shall be deducted from the total income when determining eligibility, if paying for the care is necessary for the employment of a member in the CIHCP household. This deduction is allowed even when the child or adult with disabilities is not included in the CIHCP household. Deduct the actual expenses up to:
    • $200 per month for each child under age 2;
    • $175 per month for each child age 2 or older; and
    • $175 per month for each adult with disabilities.

Exception: For self-employment income from property, when a person spends an average of less than 20 hours per week in management or maintenance activities, count the income as unearned and only allow deductions for allowable costs of producing self-employment income.

Step 8: Subtract the deduction for Medicaid individuals, if applicable.

This deduction applies when the household has a member who receives Medicaid and, therefore, is disqualified from the CIHCP household. Using the chart below, deduct an amount for the support of the Medicaid member(s) as follows: Subtract an amount equal to the deduction for the number of Medicaid-eligible individuals.

Deduction for Medicaid-Eligible Individuals

Number of Medicaid-Eligible IndividualsSingle Adult or Adult with ChildrenMinor Children Only
1$78$64
2$163$92
3$188$130
4$226$154
5$251$198
6$288$214
7$313$267
8$356$293

Step 9: Subtract the deduction for child support, alimony and other payments to dependents outside the home, if applicable.

Allow the following deductions from members of the household group, including disqualified members:

  • The actual amount of child support and alimony a household member pays to persons outside the home.
  • The actual amount of a household member's payments to persons outside the home that a household member can claim as tax dependents or is legally obligated to support.

Consider the remaining income as the monthly net income for the CIHCP household.

Step 10: Compare the household’s monthly net income to the 21% Federal Poverty Level (FPL) minimum income standard, using the CIHCP monthly income standard.

A household is eligible if its monthly net income, after rounding down cents, does not exceed the monthly income standard for the CIHCP household’s size.

3100, General Principles

Revision 23-4; Effective Sept. 22, 2023

Use the application, documentation and verification procedures established by HHSC or a less restrictive application, documentation or verification procedure.

  • A program shall use the application Form 3064, Application for Health Care Assistance, documentation, and verification procedures established by HHSC. A country may use a less restrictive application, documentation, or verification procedure after review and approval by HHSC to ensure it captures all necessary information included in the HHSC established processes. The county should have a written policy that outlines the procedure they will use for eligibility documentation and verification no later than the beginning of a state fiscal year. 
  • The program shall provide an application for assistance to the applicant or their representative on the same date that the request is received and accept an identifiable application.
  • The program shall assist the applicant with accurately completing Form 3064 and getting all needed verifications and information if the applicant requests help in completing the application process. Anyone who helps fill out the Form 3064 must sign and date it.
  • If the applicant lacks the ability to complete the application, is incapacitated or deceased, someone acting responsibly for the client (a representative) may represent the applicant in the application and the review process, including signing and dating the application on the applicant’s behalf. This representative must be knowledgeable about the applicant and their household. Document the specific reason for designating this representative.

The Program shall determine eligibility based on residence, household, resources and income.

  • The program shall allow at least 14 days for requested information to be provided from an applicant or household, unless the applicant or household agrees to a shorter time frame, when issuing Form 3068, Request for Information, or similar document.
  • Use any information received from the provider of service when making the eligibility determination, but counties, public hospitals and hospital districts may require further eligibility information from the potentially eligible resident, if necessary.
  • The date that a complete application is received is the application completion date, which counts as Day 0.
  • Determine eligibility no later than the 14th day after the application completion date. If eligibility is not determined within this 14-day period, the applicant is considered eligible and the provider must be notified.
  • Issue written notice of the program’s decision on Form 3077, Notice of Eligibility, or Form 3082, Notice of Ineligibility. If the county denies health care assistance, the written notice shall include the reason for the denial and an explanation of the procedure for appealing the denial.
  • Review each eligible case record at least once every six months.
  • Use the “Prudent Person Principle” in situations where there are unusual circumstances in which an applicant’s statement must be accepted as proof if there is a reasonable explanation why documentary evidence or a collateral contact is not available, and the applicant’s statement does not contradict other client statements or other information received by staff.
  • Current eligibility continues until a change resulting in ineligibility occurs and Form 3082 is issued to the household.
  • Consult the county’s legal counsel to develop procedures regarding disclosure of information.
  • The applicant has the right to:
    • have their application assessed in a non-discriminatory manner;
    • request a review of the decision made on their application or recertification for health care assistance; and
    • request, orally or in writing, a fair hearing about actions affecting receipt or termination of health care assistance.
  • The applicant is responsible for:
    • completing Form 3064 accurately;
    • signing and dating Form 3064;
    • providing all needed information requested by staff.  If information is not available or is not sufficient, the applicant may designate a collateral contact for the information. A collateral contact could be any objective third party who can provide reliable information. A collateral contact does not need to be separately and specifically designated if that source is named either on Form 3064 or during the interview; and
    • reporting changes, which affect eligibility, within 14 days after the date that the change occurred.

3200, Processing an Application

Revision 23-4; Effective Sept. 22, 2023

There are eight steps for processing an application:

  • Accept the identifiable application.
  • Determine if an interview is needed.
  • Interview the applicant or their representative face-to-face or by phone if an interview is necessary.
  • Check that all information is complete, consistent and sufficient to make an eligibility determination.
  • Request needed information pertaining to the four eligibility criteria: residence, household, resources and income.
  • Repeat Steps 4 and 5 as necessary
  • Determine eligibility based on the four eligibility criteria.
  • Issue the appropriate form, either Form 3082 or Form 3077.

Step 1: Accept the identifiable application.

On Form 3064, Application for Health Care Assistance or other HHSC-approved application, document the date that the identifiable application is received. This is the application file date.

Step 2: Determine if an interview is needed.

Eligibility may be determined without interviewing the applicant if all questions on the application are answered and all additional information has been provided.

Step 3: Interview the applicant or their representative face-to-face or by phone if an interview is necessary.

If an interview appointment is scheduled, issue Form 3067, Appointment Notice, including the date, time and place of the interview. If the applicant fails to keep the appointment, reschedule the appointment, if requested, or follow the Denial Decision procedure in Step 8.

Step 4: Check that all information is complete, consistent and sufficient to make an eligibility determination.

Step 5: Request needed information pertaining to the four eligibility criteria: residence, household, resources and income.

  • Decision Pended – If eligibility cannot be determined because components that pertain to the eligibility criteria are missing, issue Form 3068, Request for Information, listing the due date and additional information that needs to be provided. If the requested information is not provided by the due date, follow the Denial Decision procedure in Step 8. If the requested information is provided by the due date, proceed with Step 6.
  • Decision Pended for a Supplemental Security Income (SSI) Applicant – If eligibility cannot be determined because the person is also an SSI applicant, issue Form 3068, listing the due date and additional information that needs to be provided, including the SSI decision. If the SSI application is denied for eligibility requirements, proceed with Step 6 whether or not the SSI denial is appealed. 

Step 6: Repeat Steps 4 and 5 as necessary.

Step 7: Determine eligibility based on the four eligibility criteria.

Document information in the case record to support the decision.

Step 8: Issue the appropriate form, either Form 3082 or Form 3077.

  • Denial Decision – If any one of the eligibility criteria is not met, the applicant is ineligible. Issue Form 3082, Notice of Ineligibility, including the reason for denial, effective date of the denial, if applicable, and an explanation of the procedure for appealing the denial. Reasons for denial include, but are not limited to:
    • not a resident of the county;
    • a recipient of Medicaid;
    • resources exceed the resource limit;
    • income exceeds the income limit;
    • failed to keep an appointment;
    • failed to provide information requested;
    • failed to return the review application;
    • failed to comply with requirements to obtain other assistance; or
    • voluntarily withdrew.
  • Eligible Decision. If all eligibility criteria are met, the applicant is eligible. Determine the applicant’s eligibility effective date. Current eligibility begins on the first calendar day in the month that an identifiable application is filed or the earliest, subsequent month in which all eligibility criteria are met. Exception: The eligibility effective date for a new county resident begins the date the applicant is considered a county resident. For example, if the applicant meets all four eligibility criteria, but doesn’t move to the county until the 15th of the month, the eligibility effective date will be the 15th of the month, not the first calendar day in the month that an identifiable application is filed.
    • The applicant may be retroactively eligible in any of the three calendar months before the month the identifiable application is received if all eligibility criteria are met.
    • Issue Form 3077, Notice of Eligibility, including the eligibility effective date.

3210, Reporting Changes

Revision 23-4; Effective Sept. 22, 2023

Changes are situations that occur in a household that may affect the eligibility of the household. An applicant must report changes which affect eligibility within 14 days of becoming aware of the changes.

Follow the steps in Section 3200, beginning with Step 4, Check that all information is complete, consistent and sufficient to make an eligibility determination, to determine the effect of the change on the household’s eligibility. 
If a change results in the household’s ineligibility, the eligibility end date is the date that Form 3082 is issued to the household.

3300, Denial Decision Disputes

Revision 23-4; Effective Sept. 22, 2023

Responses Regarding a Denial Decision

If a denial decision is disputed by the household, the following may occur:

  • the household may submit another application to have their eligibility redetermined;
  • the household may appeal the denial; or
  • the county may choose to reopen a denied application.

Eligibility Dispute

If a provider of assistance and a governmental entity or hospital district cannot agree on a household’s eligibility for assistance, the provider or the governmental entity or hospital district may submit Form 3073, Eligibility Dispute Resolution Request, within 90 days of the date the eligibility determination is issued.

HHSC initiates the resolution process by notifying the appropriate entities and requesting any necessary information. HHSC will decide within 45 days. An appeal may be submitted in writing within 30 days. HHSC shall issue a final decision within 45 days after the date on which the appeal is filed.

Employment Services Program

Reference 1000, Program Administration.

3400, Case Record Maintenance

Revision 23-4; Effective Sept. 22, 2023

Case Record Review

Issue the household Form 3064, Application for Health Care Assistance or other HHSC-approved application. Follow the steps in 3200, Processing an Application, beginning with Step 2, Determine if an interview is needed.

Case Filing Record

Documents relating to eligibility and claim payments may be kept in the same case record or in separate case records. Case record documents may be kept in the order of the chart below.

Left Side of Case Record or Claim Payment RecordRight Side of Case Record or Eligibility Record

From top to bottom: 
 

  • Form 3069, Health Care Services Record, for current state fiscal year
  • Claims for current fiscal year
  • Divider
  • Form 3081, Appellant – Provider Assignment, if applicable
  • Divider
  • Form 3069 for previous state fiscal years
  • Claims for previous state fiscal years

From top to bottom: 
 

  • Current Form 3077, Notice of Eligibility, or Form 3082 , Notice of Ineligibility
  • Current Form 3064, Application for Health Care Assistance
  • Current Form 3065, Worksheet
  • Current Form 3067, Appointment Notice, if applicable
  • Current Form 3068, Request for Information
  • Current verifications
  • Current miscellaneous documents

4100, General Principles

Revision 23-4; Effective Sept. 22, 2023

A program shall provide the basic health care services established by HHSC in this handbook or less restrictive health care services. The basic health care services are:

  • Physician services
  • Annual physical examinations
  • Immunizations
  • Medical screening services
    • Blood pressure
    • Blood sugar
    • Cholesterol screening
  • Laboratory and X-ray services
  • Family planning services
  • Skilled nursing facility services
  • Prescription drugs
  • Rural health clinic services
  • Inpatient hospital services
  • Outpatient hospital services

In addition to providing basic health care services, a program may provide other department-established optional health care services that the county determines to be cost effective. The department-established optional health care services are:

  • Advanced practice nurse services provided by:
    • Nurse practitioner services
    • Clinical nurse specialist
    • Certified nurse midwife (CNM)
    • Certified registered nurse anesthetist
  • Ambulatory surgical center (freestanding) services
  • Colostomy medical supplies and equipment
  • Counseling services provided by:
    • Licensed clinical social worker (LCSW)
    • Licensed marriage family therapist (LMFT)
    • Licensed professional counselor (LPC)
    • Ph.D. psychologist
  • Dental Care
  • Diabetic medical supplies and equipment
  • Durable medical equipment (DME)
  • Emergency medical services
  • Home and community health care services
  • Physician assistant services
  • Vision care, including eyeglasses
  • Federally qualified health center services
  • Occupational therapy services
  • Physical therapy services
  • Other medically necessary services or supplies that the local governmental municipality or entity determines to be cost effective

Services or supplies must be reasonable and medically necessary for diagnosis and treatment.

For a listing of services, supplies and expenses that may not be CIHCP benefits, refer to the Texas Provider Procedures Medicaid Manual at Section 1 Provider Enrollment and Responsibilities, Texas Medicaid Limitations and Exclusions.

Chapter 61, Health and Safety Code, Section 61.035, states, “The maximum county liability for each state fiscal year for health care services provided by all assistance providers, including hospital and skilled nursing facility, to each eligible county resident is:

  • $30,000; or
  • the payment of 30 days of hospitalization or treatment in a skilled nursing facility, or both, or $30,000, whichever occurs first, if the county provides hospital or skilled nursing facility services to the resident.”

Thirty days of hospitalization refers to inpatient hospitalization. Use the client’s actual dates-of-service when determining which fiscal year to apply the maximum county liability.

For the claim payment to be considered, a claim should be received:

  • within 95 days from the approval date for services provided before the household was approved;
  • within 95 days from the date of service for services provided after the approval date; or
  • within the agreed upon time frame in a legal contract between the providers and the local indigent program.

The payment standard is determined by the date the claim is paid.

For additional information on claim payment, see 4400, User’s Guide to Fee Schedules.

4200, Basic Health Care Services

Revision 23-1; Effective Jan. 5, 2023

HHSC-established Basic Health Care Services Payment Method

4210, Physician Services – Physician Fee Schedule 
4211, Annual Physical Examinations – Physician Fee Schedule 
4212, Immunizations – Physician Fee Schedule 
4213, Medical Screening Services – Physician Fee Schedule 
4214, Laboratory and X-Ray Services – Physician Fee Schedule 
4215, Family Planning Services – Physician Fee Schedule 
4216, Skilled Nursing Facility Services – Daily Rate 
4217, Prescription Drugs – Formula 
4218, Rural Health Clinic (RHC) Services – Rate per Visit 
4219, Inpatient Hospital Services – Diagnosis Related Group (DRG) or Inpatient Percent Rate 
4220, Outpatient Hospital Services – Outpatient Percent Rate or ASC Rate

Negotiate rates with providers for basic service procedure codes not listed in the Fee Schedules. For additional information on claim payment, see 4400, User’s Guide to Fee Schedules.

4210 Physician Services

Revision 23-1; Effective Jan. 5, 2023

Physician services include services ordered and performed by a physician that are within the scope of practice of their profession as defined by state law. Physician services must be provided in the doctor's office, patient’s home, a hospital, a skilled nursing facility or elsewhere.

Payment Standard for Physicians. Use the Fee Schedule for Texas Medicaid Physician at www.tmhp.com and proceed as follows:

  1. Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
  2. If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

Payment Standard for Anesthesia Services. Using the Fee Schedule for Texas Medicaid Physician at www.tmhp.com, use the number of Relative Value Units (RVUs) listed in the Total RVUs column, the conversion factor listed in the Conversion Factor column and the calculation instructions below.

  1. Calculate the anesthesia units of time by using the following formula. 

    Total anesthesia time in minutes divided by 15 = Anesthesia units of time. 
     
  2. Calculate the reimbursement for anesthesia services by using the following formula. 

    Anesthesia units of time plus RVUs multiplied by conversion factor = Reimbursement amount.

Payment Standard for Podiatrists. Use the Fee Schedule for Texas Medicaid Podiatrist at www.tmhp.com and proceed using the instructions for Payment Standard for Physicians.

Payment Standard for Injections. Use the Fee Schedule for Texas Medicaid Physician at www.tmhp.com.

For additional information on claim payment, see 4400, User’s Guide to Fee Schedules.

4211 Annual Physical Examinations

Revision 23-4; Effective Sept. 22, 2023

Annual physicals are examinations provided once per calendar year by a physician, physician assistant (PA) or an advance practice nurse (APN).

Associated testing, such as mammograms, can be covered with a physician’s referral.

These services may be provided by an APN if they are within the scope of practice of the APN in accordance with the standards established by the Board of Nursing and published in 22 Texas Administrative Code Rule 221.13.

Payment Standard for a Physician. Use the Fee Schedule for Texas Medicaid Physician at www.tmhp.com and proceed as follows:

  1. Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
  2. If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

For additional information on claim payment, see 4400, User’s Guide to Fee Schedules.

4212 Immunizations

Revision 23-1; Effective Jan. 5, 2023

Immunizations are given when appropriate.

Payment Standard. Use the Fee Schedule for Texas Medicaid Physician at www.tmhp.com and proceed as follows:

  1. Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
  2. If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

For additional information on claim payment, see 4400, User’s Guide to Fee Schedules.

4213 Medical Screenings

Revision 23-1; Effective Jan. 5, 2023

Medical screenings include blood pressure, blood sugar and cholesterol screening.

Payment Standard. Use the Fee Schedule for Texas Medicaid Physician at www.tmhp.com and proceed as follows:

  1. Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
  2. If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

For additional information on claim payment, see 4400, User’s Guide to Fee Schedules.

4214 Laboratory and X-ray Services

Revision 23-1; Effective Jan. 5, 2023

Laboratory and X-ray services are professional and technical services ordered by a physician and provided under the personal supervision of a physician in a setting other than a hospital (inpatient or outpatient).

Payment Standard. Use the Fee Schedule for Texas Medicaid Physician at www.tmhp.com and proceed as follows:

  1. Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
  2. If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

For additional information on claim payment, see 4400, User’s Guide to Fee Schedules.

4215 Family Planning Services

Revision 23-1; Effective Jan. 5, 2023

Family planning services are preventive health care services that assist an individual in controlling fertility and achieving optimal reproductive and general health.

Payment Standard. Use the Fee Schedule for Texas Medicaid Physician Fee Schedule at www.tmhp.com and proceed as follows:

  1. Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
  2. If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

For additional information on claim payment, see 4400, User’s Guide to Fee Schedules.

4216 Skilled Nursing Facility Services

Revision 23-4; Effective Sept. 22, 2023

Skilled nursing facility services must be:

  • medically necessary;
  • ordered by a physician; and
  • provided in a skilled nursing facility that provides daily services on an inpatient basis.

Payment Standard

1. Payment Standard with a Resource Utilization Grouping (RUG)-III System

The skilled nursing facility rate should be reimbursed at Medicaid rate when appropriate.

The RUG-III system groups skilled nursing facility residents into 36 rates for a day of service, based on an assessment at admission and every 90 days. The most recent Base Rate for a day of service can be found here:  Texas Nursing Facility (NF) Medicaid Rate Sets Effective (PDF)

Rates are also listed below for convenience.

Base Rate – No Liability Insurance

RUGDirect Care StaffOther Resident CareDietaryGeneral and Admin.Fixed CapitalTotal
RAD$109.87$36.79$12.62$27.25$6.83$193.36
RAC$92.97$31.12$12.62$27.25$6.83$170.79
RAB$85.18$28.52$12.62$27.25$6.83$160.40
RAA$70.70$23.67$12.62$27.25$6.83$141.07
SE3$138.02$46.21$12.62$27.25$6.83$230.93
SE2$111.90$37.47$12.62$27.25$6.83$196.07
SE1$92.56$30.99$12.62$27.25$6.83$170.25
SSC$89.58$29.99$12.62$27.25$6.83$166.27
SSB$82.78$27.71$12.62$27.25$6.83$157.19
SSA$82.51$27.62$12.62$27.25$6.83$156.83
CC2$66.76$22.36$12.62$27.25$6.83$135.82
CC1$61.40$20.55$12.62$27.25$6.83$128.65
CB2$58.35$19.54$12.62$27.25$6.83$124.59
CB1$54.13$18.13$12.62$27.25$6.83$118.96
CA2$49.62$16.62$12.62$27.25$6.83$112.94
CA1$44.55$14.91$12.62$27.25$6.83$106.16
IB2$49.76$16.65$12.62$27.25$6.83$113.11
IB1$44.02$14.73$12.62$27.25$6.83$105.45
IA2$37.16$12.44$12.62$27.25$6.83$96.30
IA1$33.43$11.19$12.62$27.25$6.83$91.32
BB2$48.22$16.14$12.62$27.25$6.83$111.06
BB1$40.31$13.50$12.62$27.25$6.83$100.51
BA2$35.81$11.99$12.62$27.25$6.83$94.50
BA1$29.07$9.74$12.62$27.25$6.83$85.51
PE2$54.62$18.29$12.62$27.25$6.83$119.61
PE1$49.72$16.64$12.62$27.25$6.83$113.06
PD2$50.91$17.04$12.62$27.25$6.83$114.65
PD1$45.85$15.35$12.62$27.25$6.83$107.90
PC2$43.70$14.63$12.62$27.25$6.83$105.03
PC1$40.47$13.55$12.62$27.25$6.83$100.72
PB2$38.48$12.88$12.62$27.25$6.83$98.06
PB1$34.92$11.69$12.62$27.25$6.83$93.31
PA2$30.57$10.23$12.62$27.25$6.83$87.50
PA1$26.86$9.00$12.62$27.25$6.83$82.56
BC1$26.86$9.00$12.62$27.25$6.83$82.56
PCE$26.86$9.00$12.62$27.25$6.83$82.56
       
Vent. - Cont.$96.81$31.81   $128.62
Vent. - < Cont.$38.72$12.73   $51.45
Pediatric Trach.$58.09$19.08   $77.17

2. Payment Standard Without a RUG-III System

The base rate is $118.35 per day.

This $118.35 daily rate does not include physician services or three prescription drugs per month. These additional services must be billed separately.

4217 Prescription Drugs

Revision 23-1; Effective Jan. 5, 2023

This service includes up to three prescription drugs per month. New and refilled prescriptions count equally toward the three prescription drugs per month total. Drugs must be prescribed by a physician or other practitioner within the scope of practice under law.

The quantity of each prescription depends on the prescribing practice of the physician and the needs of the patient.

Payment Standard. Use the following information and formula.

Payment standards align with HHSC Vendor Drug Program (VDP) guidelines. The most up to date Vendor Drug Program Formulary guidance is on HHSC webpage at https://www.txvendordrug.com

To search the formulary for pricing, follow the steps below:

  1. Go to https://www.txvendordrug.com/ and go to the pull-down menu, select Formulary, and Formulary Search.
  2. Under Formulary Search, Drug search, type in the information of a drug and click on Search.
  3. From the Search Results: Formulary Drugs screen, select the correct Brand Name/Generic Name/Package Size.
  4. From the Drug Details screen, obtain the package size and the retail pharmacy cost. (The package size can be found from the line named Package size under the section General. The retail pharmacy cost can be found from the line named Retail Pharmacy Cost under the section Drug Pricing.
  5. Go to webpage Professional Dispensing Fees by clicking the link: https://www.txvendordrug.com/about/manuals/pharmacy-provider-procedure-manual/p-12-pricing-and-reimbursement/professional-dispensing-fees
  6. Follow the instructions under Professional Dispensing Fees to calculate the reimbursed amount. At the bottom of this webpage, there is an example on how to calculate the total reimbursement amount.

4218 Rural Health Clinic (RHC) Services

Revision 23-1; Effective Sept. 22, 2023

RHC services must be provided in a freestanding or hospital based RHC and provided by a physician, physician assistant, advanced practice nurse (including a nurse practitioner, clinical nurse specialist and certified nurse midwife) or visiting nurse.

Payment Standard: Use the Rate per Visit at Rural Health Clinics.

4219 Inpatient Hospital Services

Revision 23-1; Effective Jan. 5, 2023

Inpatient hospital services must be medically necessary and provided:

  • in an acute care hospital;
  • to hospital inpatients;
  • by or under the direction of a physician; and
  • for the care and treatment of patients.

Payment Standard. For the hospital in which the inpatient services were provided, use the Hospital Inpatient Payment lists that are located at https://pfd.hhs.texas.gov/hospitals-clinic/hospital-services/inpatient-services. These lists will be used to calculate the payment rate using either the Percent Standard or the Diagnosis Related Group (DRG) Standard.

Note: If you are unable to locate payment information for a facility, complete Form 3079, Facility Payment Rate Request.

  • Inpatient RCC Rates List – Hospitals on this list are paid using the Percent Standard. The percent listed in the Inpatient Rate column reflects all applicable rate reductions.
  • Hospital Prospective Standard Dollar Amount (SDA) List – Hospitals on this list are paid using the DRG Standard. The SDA listed in the Final Add-on SDA column reflects all applicable rate reductions.
  • Texas APR-DRG Grouper List – This list provides the DRG Code, All Patient Refined (APR)- DRG Title, Relative Weights, Mean Length of Stay (LOS), and Day Threshold needed when using the DRG Standard.

Percent Standard. This standard reimburses hospitals based on a percent of the hospital’s total billed amount.

  • From the total billed amount, subtract the cost of services that are not a CIHCP benefit.
  • Use the Inpatient Rate listed on the Inpatient RCC Rates List.
  • Multiply the remaining billed amount by the Inpatient Rate listed.

DRG Standard. This standard reimburses hospitals at a predetermined rate for services based on the patient’s diagnosis. In some cases, the reimbursement will be more than the actual cost of providing services for that stay. In other cases, the reimbursement will be less than the hospital’s actual cost. In either case, use the calculated DRG payment.

The DRG Standard incorporates the DRG code that is assigned to the hospital stay, the Relative Weight (Rel. Wt.) and the Mean Length of Stay that are assigned to the DRG code, and the SDA, which is the blended average dollar amount a hospital recovers for any given patient account.

To calculate a full or partial DRG payment, use the APR-DRG Version 29 of the Core Grouping Software along with the DRG Code, Relative Weight, Mean Length of Stay, and the SDA, which are located at Inpatient Services

Determine the type of DRG Payment based on the following information:

  • When one hospital provided the patient care, or one hospital provided most of the days of care, calculate a full DRG payment.
  • When one hospital provided fewer days of care, or when two hospitals provided equal days of care, calculate a partial DRG payment.
  • If the patient was CIHCP-eligible for any part of the hospital stay, calculate the full DRG payment.
  • If the patient was Medicaid-eligible for any part of the hospital stay, there is no CIHCP payment.

Full DRG Payment. To calculate, proceed as follows:

  • Assign the DRG code using Core Grouping Software.
  • Refer to the assigned DRG code’s Relative Weight.
  • Refer to the hospital’s SDA.
  • Multiply the SDA by the Relative Weight.

Partial DRG Payment. To calculate, proceed as follows:

  • Calculate the full DRG payment.
  • Refer to the assigned DRG code’s Mean Length of Stay.
  • Divide the full DRG payment by the Mean Length of Stay.
  • Multiply the result by the CIHCP-allowed number of days of care.

DRG Software. 3M Health Information Systems Division is the supplier of the APR-DRG Version 29 Core Grouping Software, which is used to assign a three-digit group or code based on the diagnosis code(s). For more information, contact: www.3mhis.com.

Gerry Tracy, Sales, 3M Health Information Systems Telephone: 800-367-2447 
Email: gwtracy@mmm.com

Gregg Perfetto, Manager, 3M Health Information Systems Telephone: 800-367-2447 
Email: gmperfetto@mmm.com

4220 Outpatient Hospital Services

Revision 23-4; Effective Sept. 22, 2023

Outpatient hospital services must be medically necessary and be:

  • provided in an acute care hospital or hospital-based ambulatory surgical center (HASC);
  • provided to hospital outpatients;
  • provided by or under the direction of a physician; and
  • diagnostic, therapeutic or rehabilitative.

Payment Standard. For the hospital in which the outpatient services were provided, use the Outpatient RCC Rates list that is located on the Texas Health and Human Services website at Outpatient Services. This list will be used to calculate the payment rate using the Percent Standard.

Outpatient RCC Rates List – Hospitals on this list are paid using the Percent Standard. The percentage listed in the Outpatient Rate column reflects all applicable rate reductions.

  • Use the Outpatient Rate listed on the Outpatient RCC Rates List.
  • Multiply the billed amount by the Outpatient Rate listed.

Exception: If the outpatient service is for a scheduled surgery, the program may use the Fee Schedule for Texas Medicaid HASC Group Rate Amounts and HASC Group number at www.tmhp.com.

A hospital-based ambulatory surgical center (ASC) service should be billed as one inclusive charge on a UB-04.

4300, Optional Health Care

4310 HHSC-Established Optional Health Care Services

Revision 23-1; Effective Jan. 5, 2023

ServiceFee Schedule
Advanced Practice Nurse (APN) ServicesNurse Practitioner/Clinical Nurse Specialist Fee Schedule, Certified Nurse Midwife (CNM), and Certified Registered Nurse Anesthetist (CRNA)/Anesthesiologist Assistant (AA)
Ambulatory Surgical Center (ASC) Freestanding ServicesAmbulatory Surgical Center (ASC)/Hospital – Based Ambulatory Surgical Center (HASC) Fee Schedule
Colostomy Medical Supplies or EquipmentDMEPOS – TOS 9, E, J, L, And R Fee Schedule
Counseling (Psychotherapy) ServicesOutpatient Behavioral Health - Psychologist Fee Schedule
Dental CareDental and Orthodontist Fee Schedule
Diabetic Supplies or EquipmentDMEPOS – TOS 9, E, J, L, And R Fee Schedule
Durable Medical Equipment (DME)DMEPOS – TOS 9, E, J, L, And R Fee Schedule
Emergency Medical ServicesAmbulance Fee Schedule
Federally Qualified Health Center (FQHC) ServicesRate Per Visit
Home and Community Health Care ServicesRate Per Visit
Occupational Therapy ServicesOccupational Therapist Fee Schedule
Physical Therapy ServicesPhysical Therapist Fee Schedule
Physician Assistant (PA) ServicesPhysician Assistant Fee Schedule
Vision Care, including EyeglassesOptometrist and Miscellaneous Other Professionals - Optician Fee Schedule
Other Medically Necessary Services or SuppliesFee Schedule or Negotiable Rate

Note: For all but APN Services, negotiate rates with providers for optional service procedure codes not listed in the Fee Schedules. For additional information on claim payment, see 4400, User’s Guide to Fee Schedules.

4311 Advanced Practice Nurse (APN) Services

Revision 23-4; Effective Sept. 22, 2023

An APN must be licensed as a registered nurse (RN) within the categories of practice, specifically a nurse practitioner (NP), clinical nurse specialist (CNS), certified nurse midwife (CNM) and a certified registered nurse anesthetist (CRNA), as determined by the Board of Nursing. APN services must be medically necessary and provided within the scope of practice of the APN.

The Medicaid rate for NPs or CNSs reflect 92% of the rate paid to a physician for the same service and 100% of the rate paid to physicians for laboratory, X-ray and injections.

Payment Standard for an NP, CNS and CNM. Use the Fee Schedule for Texas Medicaid Nurse Practitioner/Clinical Nurse Specialist Fee Schedule and Certified Nurse Midwife (CNM), at www.tmhp.com and proceed as follows:

  • Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
  • If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

Payment Standard for a CRNA. Use the Fee Schedule for Texas Medicaid Certified Registered Nurse Anesthetist (CRNA)/Anesthesiologist Assistant (AA) at www.tmhp.com.

Anesthesia. Use the number of Relative Value Units (RVUs) listed in the Total RVUs column, the conversion factor listed in the Conversion Factor column, and the calculation instructions below.

  • Calculate the anesthesia units of time by using the following formula:

    Total anesthesia time in minutes divided by 15 = anesthesia units of time.
     
  • Calculate the reimbursement for anesthesia services by using the following formula:

    Anesthesia units of time plus RVUs multiplied by Conversion Factor = reimbursement amount.
     
  • Use 92% of this physician amount to reimburse CRNA services.

Medical, Surgery and Laboratory Services. Proceed as follows:

  • Use the amount listed in the age-appropriate Adjusted Fee for Report Date Column.
  • If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

For additional information on claim payment, see 4400, User’s Guide to Fee Schedules.

4312 Ambulatory Surgical Center (ASC) Services

Revision 23-1; Effective Jan. 5, 2023

ASC services must be provided in a freestanding ASC and are limited to items and services provided in reference to an ambulatory surgical procedure. A freestanding ASC service should be billed as one inclusive charge on Form CMS-1500. If more than one procedure code is listed, only the code with the highest HHSC payable amount should be paid.

Payment Standard. Use the Fee Schedule for Texas Medicaid Ambulatory Surgical Center (ASC)/Hospital – Based Ambulatory Surgical Center (HASC)  at www.tmhp.com.

4313 Colostomy Medical Supplies and Equipment

Revision 23-4; Effective Sept. 22, 2023

Colostomy medical supplies and equipment must be medically necessary and prescribed by a physician or advanced practice nurse (APN) within the scope of their practice in accordance with the standards established by the Board of Nursing and published in 22 Texas Administrative Code Rule 221.13. The county may require the supplier to receive prior authorization.

Items covered are cleansing irrigation kits, colostomy bags or pouches, paste or powder, and skin barriers with flange (wafers).

Payment Standard. For covered items listed above, use the Fee Schedule for Texas Medicaid DMEPOS – TOS 9, E, J, L, And R at www.tmhp.com and proceed as follows:

  • Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
  • If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

For additional information on claim payment, see 4400, User’s Guide to Fee Schedules.

4314 Counseling Services

Revision 23-4; Effective Sept. 22, 2023

Behavioral health services must be medically necessary, based on a physician referral and provided by a licensed clinical social worker (LCSW, previously known as LMSW-ACP), licensed marriage family therapist (LMFT), licensed professional counselor (LPC) or licensed psychologist with a Ph.D. These services may also be provided based on an advanced practice nurse (APN) referral if the referral is within the scope of their practice in accordance with the standards established by the Board of Nursing and published in 22 Texas Administrative Code Rule 221.13.

Payment Standard for LCSW, LMFT and LPC. The following procedure codes are covered for Type of Service (TOS) 1 counseling services provided by these providers: 90806, 90847 and 90853 (Current Procedures Terminology (CPT) codes only. The HHSC payable amounts may be accessed in the Texas Medicaid Physician Fee Schedule.

Payment Standard for Ph.D. Psychologist. Use the appropriate Texas Medicaid Outpatient Behavioral Health - Psychologist Fee Schedule at www.tmhp.com and proceed as follows:

  • Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
  • If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

For additional information on claim payment, see 4400, User’s Guide to Fee Schedules.

4315 Dental Care

Revision 23-1; Effective Jan. 5, 2023

Dental services must be medically necessary and provided by a Doctor of Dental Surgery (DDS), Doctor of Dental Medicine (DMD) or Doctor of Dental Medicine (DDM). The county may require prior authorization.

Items covered are an annual routine dental exam, annual routine cleaning, one set of annual X-rays and the least-costly service for emergency dental conditions for the removal or filling of a tooth due to abscess, infection or extreme pain.

Payment Standard. For covered items listed above, use the Fee Schedule for Texas Medicaid Dental and Orthodontist at www.tmhp.com and proceed as follows:

  • Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
  • If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

For additional information on claim payment, see 4400, User’s Guide to Fee Schedules.

4316 Diabetic Medical Supplies and Equipment

Revision 23-4; Effective Sept. 22, 2023

Diabetic medical supplies and equipment must be medically necessary and prescribed by a physician. These supplies and equipment may also be prescribed by an advance practice nurse (APN) if this is within the scope of their practice in accordance with the standards established by the Board of Nursing and published in 22 Texas Administrative Code Rule 221.13. The county may require the supplier to receive prior authorization.

Items covered are test strips, alcohol prep pads, lancets, glucometers, insulin syringes, humulin pens and needles required for the humulin pens.

Insulin syringes, humulin pens, and the needles required for humulin pens are dispensed with a National Dispensing Code (NDC) number and are paid as prescription drugs. They do not count toward the three prescription drugs per month limitation. Insulin and humulin pen refills are prescription drugs (not optional services) and count toward the three prescription drugs per month limitation.

Payment Standard. For covered items listed above, use the Fee Schedule for Texas Medicaid Durable Medical DMEPOS – TOS 9, E, J, L, And R at www.tmhp.com and proceed as follows:

  • Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
  • If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

For additional information on claim payment, see 4400, User’s Guide to Fee Schedules.

4317 Durable Medical Equipment (DME)

Revision 23-4; Effective Sept. 22, 2023

DME must be medically necessary, meet the Medicare and Texas Title XIX Medicaid requirements and be provided under a physician’s prescription. These supplies and equipment may also be prescribed by an advanced practice nurse (APN) if this is within the scope of their practice in accordance with the standards established by the Board of Nursing and published in 22 Texas Administrative Code Rule 221.13. Items can be rented or purchased, whichever is the least costly. The county may require the supplier to receive prior authorization.

Items covered are appliances for measuring blood pressure that are reasonable and appropriate, canes, crutches, home oxygen equipment (including masks, oxygen hose and nebulizers), hospital beds, standard wheelchairs and walkers.

Payment Standard. For covered items listed above, use the Fee Schedule for Texas Medicaid DMEPOS – TOS 9, E, J, L, And R Fee Schedule at www.tmhp.com and proceed as follows:

  • Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
  • If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

For additional information on claim payment, see 4400, User’s Guide to Fee Schedules.

4318 Emergency Medical Services

Revision 23-1; Effective Jan. 5, 2023

Emergency Medical Services (EMS) are ground ambulance transport services. When the person’s condition is life-threatening and requires the use of special equipment, life support systems and close monitoring by trained attendants while enroute to the nearest appropriate facility, ground transport is an emergency service.

Payment Standard. Use the Fee Schedule for Texas Medicaid Ambulance at www.tmhp.com and proceed as follows:

  • Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
  • If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

4319 Home and Community Health Care Services

Revision 23-1; Effective Jan. 5, 2023

These services must be medically necessary, meet the Medicare and Medicaid requirements and are provided by a certified home health agency.

A plan of care must be recommended, signed and dated by the recipient’s attending physician prior to care being provided.

The county may require prior authorization.

Items covered are registered nurse (RN) visits for skilled nursing observation, assessment, evaluation and treatment, provided that a physician specifically requests the RN visit for this purpose. A home health aide to assist with administering medication is also covered.

Visits made for performing household services are not covered.

The skilled nurse visit is also called an SNV, RN or LVN visit. The Current Procedural Terminology (CPT) code G0154 below includes $10 maximum for incidental supplies used during the visit.

The home health aide visit is also called an HHA visit. The CPT code G0156 below includes incidental supplies used during the visit.

Payment Standard. Use the HHSC Payable below.

Type of Service (TOS)Procedure Code
CG0154/Visit
CG0156/Visit

4320 Physician Assistant (PA) Services

Revision 23-1; Effective Jan. 5, 2023

PA services must be medically necessary and provided by a PA under the supervision of a physician and billed by and paid to the supervising physician.

Payment Standard. Use the Fee Schedules for Texas Medicaid Nurse Practitioner, Clinical Nurse Specialist and Physician Assistant at www.tmhp.com.

The Medicaid rate for PAs reflects 92% of the rate paid to a physician for the same service and 100% of the rate paid to physicians for laboratory, X-rays and injections.

4321 Vision Care, Including Eyeglasses

Revision 23-1; Effective Jan. 5, 2023

Every 24 months, one examination of the eyes by refraction and one pair of prescribed eyeglasses may be covered. The county may require prior authorization.

Payment Standard for Examination of the Eyes by Refraction. Use the Fee Schedule for Texas Medicaid Optometrist at www.tmhp.com and proceed as follows:

  • Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
  • If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

Payment Standard for Prescribed Eyeglasses. Use the Fee Schedule for Texas Medicaid Miscellaneous Other Professionals – Optician at www.tmhp.com and proceed as follows:

  • Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.
  • If the Adjusted Fee for Report Date Column is blank and the Note Code is 5 or blank, HHSC does not have a payable amount; however, a payment amount may be negotiated with the provider.

For additional information on claim payment, see 4400, User’s Guide to Fee Schedules.

4322 Federally Qualified Health Center (FQHC)

Revision 23-1; Effective Jan. 5, 2023

FQHC services must be provided in an approved FQHC by a physician, physician assistant, advanced practice nurse, clinical psychologist or clinical social worker.

Payment Standard. Use the Rate per Visit at Federally Qualified Health Centers.

4323 Occupational Therapy Services

Revision 23-1; Effective Jan. 5, 2023

These services must be medically necessary and may be covered if provided in a physician’s office, therapist’s office, an outpatient rehabilitation or free-standing rehabilitation facility, or in a licensed hospital. Services must be within the provider’s scope of practice, as defined by Occupations Code, Chapter 454.

Payment Standard. Use the Fee Schedule for Texas Medicaid Occupational Therapist at www.tmhp.com. Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.

4324 Physical Therapy Services

Revision 23-1; Effective Jan. 5, 2023

These services must be medically necessary and may be covered if provided in a physician’s office, therapist’s office, an outpatient rehabilitation or free-standing rehabilitation facility, or in a licensed hospital. Services must be within the provider’s scope of practice, as defined by Occupations Code, Chapter 453.

Payment Standard. Use the Fee Schedule for Texas Medicaid Physical Therapist at www.tmhp.com. Use the amount listed in the age-appropriate Facility or Non-Facility Adjusted Fee for Report Date Column.

4400, User’s Guide to Fee Schedules

Revision 23-1; Effective Jan. 5, 2023

4410 Fee Schedules

Revision 23-1; Effective Jan. 5, 2023

All Texas Medicaid Fee Schedules are available at www.tmhp.com.

The Texas Medicaid Fee Schedule is categorized by field descriptions. Type of Service (TOS) codes are listed in the first field. The TOS identifies the specific field or specialty of services provided. The TOS descriptions are listed below. The most current information can be found in the Texas Medicaid Providers Procedures Manual, Section 6, Claims Filing.

Type of Service (TOS) Table TOS

Type of Service Description
0 Blood
1 Medical Services
2 Surgery
3 Consultations
4 Radiology (total component)
5 Laboratory (total component)
6 Radiation Therapy (total component)
7 Anesthesia
8 Assistant surgery
9 Other medical items or services
C Home health services
D TB clinic
E Eyeglasses
F Ambulatory surgical center (ASC)/hospital-based ambulatory surgical center (HASC)
G Genetics
I Professional component for radiology, laboratory, or radiation therapy
J DME purchase new
L DME rental
R Hearing aid
S THSteps medical
T Technical component for radiology, laboratory, or radiation therapy
W THSteps dental

Procedure Code. The third field lists the current procedure codes. The Texas Medicaid physician, advanced practice nurse (APN), and certified registered nurse anesthetists (CRNA) fee schedules each contain a list of payment rates for Current Procedural Terminology (CPT) codes, including the TOS 7 American Society of Anesthesiologists (ASA) procedure codes. The five-character alphanumeric procedure codes follow the numeric procedure codes.

Modifier. The modifier is placed after the five-digit procedure code, if applicable. A modifier describes and qualifies services that are provided. However, not all procedures require a modifier. Modifiers may affect the CIHCP payment amount. A list of frequently used modifiers is located in the Texas Medicaid Providers Procedures Manual in Section 6, Claims Filing.

Child Age. The sixth and seventh fields list the age range for pricing determination.

Resource-Based Units. Texas Medicaid Reimbursement Methodology (TMRM). The eighth field lists the payable amount for the TOS and procedure code.

Total RVUs. The ninth field lists the relative value units (RVUs) for the procedure code.

Conv Factor. The tenth field lists the conversion factor used in the calculation formula for anesthesia services in determining the TMRM payable amount.

PPS Fee. The eleventh field lists the prospective payment system (PPS) fee. Not applicable for CIHCP.

Access-Based or Max Fee. The twelfth field lists the access-based fee amount or maximum fee.

Effective Date. The thirteenth field lists the effective date for total RVUs for Resource-Based Fees (RBFs). For fees other than RBFs, the effective date for the PPS, access-based, or max fee.

Note Code. The fourteenth field lists the note code indicator. For CIHCP, a payment amount may be negotiated with the provider when the Note Code is 5.

TOS. The CPT codes are divided into sections based on the type of service codes. The one-digit TOS code identifies the specific field or specialty of services provided. TOS 0 and TOS 9 are not basic health care services.

See 4420, Type of Services – Definition and Payment Information, below.

4420 Type of Services – Definition and Payment Information

Revision 23-1; Effective Jan. 5, 2023

1 Medical Services – Includes office, inpatient hospital and emergency room visits; allergy treatment; chemotherapy; injections; physical therapy; dialysis; psychotherapy; ophthalmology; dermatology; ventilation; etc. Excludes anesthesia, radiological interpretations and laboratory interpretations.

2 Surgery – Includes invasive diagnostic procedures.

  • Single Surgical Procedure. Unless the description for a surgical procedure clearly states otherwise, a single surgical procedure code represents the full scope of activities performed to complete the surgical procedure.
  • Multiple Surgical Procedures. Some surgical services involve multiple surgical procedures that may be payable as separate procedures but only if they are not a component of a more comprehensive procedure. Determine if the multiple surgical procedure codes are:
    • components of one comprehensive procedure; or
    • a primary procedure and secondary procedure(s).

If you are unable to make this determination, contact the provider for further clarification. The payment standard for paying multiple surgical procedures that are not components of one comprehensive procedure is to allow the full HHSC physician payment standard for the primary procedure and half of the HHSC physician payment standard for the other procedure(s).

3 Consultations – Used when the attending physician consults with another physician concerning some non-surgical aspect of the patient’s treatment.

4 Radiology (total component, i.e., technical and interpretation) – Includes radiological exams (X-rays), computerized axial tomography (CAT) scans, magnetic resonance imaging (MRI), mammography, echography (ultrasound), and other types of internal organ and vascular X-rays. Procedure codes with a type of service (TOS) 4 include radiology services that are both the technical component and the interpretation (professional) component of X-ray services.

  • Use the following information for processing bills for TOS 4 (Radiology), TOS T (Technical), and TOS I (Interpretation).
  • Providers who perform both the technical and the interpretation service may be paid for the total component (TOS 4).
  • Providers who perform only the technical service may be paid only for the technical component (TOS T).
  • Providers who perform only the interpretation service may be paid only for the interpretation component (TOS I).
  • TOS 4 = Total Component (Technical + Interpretation)
  • TOS 4 = TOS T + TOS I

In summary:

  • If a TOS 4 is paid first, then the total component has been met.
  • If a TOS T is paid first, then a TOS I may be payable.
  • If a TOS I is paid first, then a TOS T may be payable.

5 Laboratory (total component, i.e., technical and interpretation) – Includes most types of blood, urine, feces, and sputum tests and tests on other bodily fluids or by-products; tissue studies and analysis; various hearing and speech tests; electrocardiograms (EKGs) and cardiovascular stress tests; respiratory (pulmonary) function tests; electroencephalograms (EEGs) and other brain activity tests. Procedure codes with a TOS 5 include laboratory services that are both the technical component and the interpretation (professional) component of laboratory services.

Use the following information for processing bills for TOS 5 (Laboratory), TOS T (Technical) and TOS I (Interpretation).

  • Providers who perform both the technical and the interpretation service may be paid for the total component (TOS 5).
  • Providers who perform only the technical service may be paid only for the technical component (TOS T).
  • Providers who perform only the interpretation service may be paid only for the interpretation component (TOS I).
  • TOS 5 = Total Component (Technical + Interpretation)
  • TOS 5 = TOS T + TOS I

In summary:

  • If a TOS 5 is paid first, then the total component has been met.
  • If a TOS T is paid first, then a TOS I may be payable.
  • If a TOS I is paid first, then a TOS T may be payable.

6 Radiation Therapy (total component, i.e., technical and interpretation) – Includes radiology treatment planning, radiological dosimetry, teletherapy, megavoltage treatment and radioelement application. Procedure codes with a TOS 6 include radiation therapy services that are both the technical component and the interpretation (professional) component of radiology treatment planning, radiological dosimetry, teletherapy, megavoltage treatment and radioelement application services.

Use the following information for processing bills for TOS 6 (Radiation Therapy), TOS T (Technical), and TOS I (Interpretation).

  • Providers who perform both the technical and the interpretation service may be paid for the total component (TOS 6).
  • Providers who perform only the technical service may be paid only for the technical component (TOS T).
  • Providers who perform only the interpretation service may be paid only for the interpretation component (TOS I).
  • TOS 6 = Total Component (Technical + Interpretation)
  • TOS 6 = TOS T + TOS I

In summary:

  • If a TOS 6 is paid first, then the total component has been met.
  • If a TOS T is paid first, then a TOS I may be payable.
  • If a TOS I is paid first, then a TOS T may be payable.

7 Anesthesia – Usually provided by or under the supervision of a physician in a hospital setting.

8 Assistant Surgery – A surgical procedure that requires the assistance of another surgeon. Procedure codes with a TOS 8 include assistant surgical services and are reimbursed at 16% of the reimbursement rate for TOS 2. In addition, use of a modifier code of 80, 81 and 82 with a surgical procedure code results in TOS 8 being assigned to the procedure.

Although certain surgical procedures require the service of an assistant surgeon, not all surgical procedures require this service.

  • Single Surgical Procedure. Unless the description for a surgical procedure clearly states otherwise, a single surgical procedure code represents the full scope of activities performed to complete the surgical procedure.
  • Multiple Surgical Procedures. Some surgical services involve multiple surgical procedures that may be payable as separate procedures but only if they are not a component of a more comprehensive procedure. Determine if the multiple surgical procedure codes are:
    • components of one comprehensive procedure; or
    • a primary procedure and secondary procedure(s).

If you are unable to make this determination, contact the provider for further clarification. The payment standard for paying multiple surgical procedures that are not components of one comprehensive procedure is to allow the full HHSC physician payment standard for the primary procedure and pay half of the HHSC physician payment standard for the other procedure(s).

I Interpretation – Professional component for radiology, laboratory or radiation therapy services. Only one provider is entitled to reimbursement for interpreting a radiology, laboratory or radiation therapy procedure.

  • Providers who perform both the technical and the interpretation service may be paid for the total component (TOS 4, 5 or 6).
  • Providers who perform only the technical service may be paid only for the technical component (TOS T).
  • Providers who perform only the interpretation service may be paid only for the interpretation component (TOS I).
  • TOS 4, 5 or 6 = Total Component (Technical and Interpretation)
  • TOS 4, 5 or 6 = TOS T + TOS I

In summary:

  • If a TOS 4, 5 or 6 is paid first, then the total component has been met.
  • If a TOS T is paid first, then a TOS I may be payable.
  • If a TOS I is paid first, then a TOS T may be payable.

T Technical – Technical component for radiology, laboratory or radiation therapy services.

Only one provider is entitled to reimbursement for performing the technical component of a radiology, laboratory or radiation therapy procedure.

  • Providers who perform both the technical and the interpretation service may be paid for the total component (TOS 4, 5, or 6).
  • Providers who perform only the technical service may be paid only for the technical component (TOS T).
  • Providers who perform only the interpretation service may be paid only for the interpretation component (TOS I).
  • TOS 4, 5 or 6 = Total Component (Technical + Interpretation)
  • TOS 4, 5, or 6 = TOS T + TOS I

In summary:

  • If a TOS 4, 5 or 6 is paid first, then the total component has been met.
  • If a TOS T is paid first, then a TOS I may be payable.
  • If a TOS I is paid first, then a TOS T may be payable.

5100, General Principles

Revision 20-0; Effective November 2019

Based on an annual allocation, subject to funding, HHSC distributes state assistance funds to counties not fully served by a public hospital or hospital district. To receive state assistance funds, a county must comply with the HHSC-established standards and procedures contained in this handbook.

Expenditures are reimbursable if they are paid:

  • for CIHCP eligible county residents;
  • for CIHCP basic or department-approved optional health care services; and
  • according to the CIHCP payment standards.

Reimbursable expenditures must be paid in the state fiscal year for which state assistance funds are being requested.

The county is eligible for state assistance funds when it exceeds the 8% General Revenue Tax Levy (GRTL) expenditure level.

5200, Steps for Applying

Revision 20-0; Effective November 2019

 

5210 Steps for Applying for State Assistance Funds

Revision 23-4; Effective Sept. 22, 2023

Step 1 – Submit Form 3072, Monthly Financial Report, to be received by the HHSC County Indigent Health Care Program (CIHCP) by the 10th day of the month following the report month. Form 3072 must have been submitted for each of the 12 months prior to the month state assistance funds are requested. Submit Form 3086, End of Year Report, to HHSC CIHCP in Austin by Sept. 30.

Step 2 – Submit the county’s General Revenue Tax Levy (GRTL) to the Texas State Comptroller of Public Accounts.

Step 3 – Notify HHSC CIHCP by email within seven days after the date that the county will expend 6% of its General Revenue Tax Levy (GRTL) and follow up with a written notification.

6% Program Review. Upon receiving written notification that a county has expended 6% of its General Revenue Tax Levy (GRTL), HHSC may complete a review of the county's eligibility system and billing and provide the county with a written report on the findings of the review. If inadequacies are identified, the county must correct them within five workdays from the date the inadequacies are identified. The county must subtract any uncorrectable inadequacies from reimbursable expenditures.

Step 4 – Request state assistance funds when the county exceeds the 8% General Revenue Tax Levy (GRTL) expenditure level. Calculate the dollar amount that will be paid when the court authorizes payment. Request 90% of that amount from HHSC.

Contact HHSC by telephone or email to request state assistance funds prior to the Commissioner’s Court authorizing payment of the health care claims. HHSC will provide the county with a State Assistance Request number. Complete and submit to HHSC Form 3088, Request for State Assistance Funds (90 Percent), and supporting documentation within 30 days after the request.

6100, General Principles

Revision 23-4; Effective Sept. 22, 2023

To receive retroactive Medicaid reimbursement for Supplemental Security Income (SSI) appellants, a county must comply with the HHSC-established standards and procedures contained in this handbook.

HHSC can only file Medicaid claims for reimbursement if they are:

  • paid for CIHCP-eligible county residents;
  • received within 95 days from the "SSI add date" and within 365 days from the date of service.

In addition, all Medicaid claims processed through HHSC must meet the 365-day federal filing deadline.

6200, Steps for Applying

Revision 20-0; Effective November 2019

6210 Steps for Requesting Medicaid Reimbursement for SSI Appellants

Revision 23-3; Effective Apr. 6, 2023

Step 1 – County staff must sign and submit Form 3087, TMHP Confidentiality Agreement, to HHSC.

Step 2 – County staff must have a potential Supplemental Security Income (SSI) appellant sign Form 3081, Appellant – Provider Assignment. The form must also be signed by the provider. Note: Claims paid before signatures are obtained will not be eligible for reimbursement.

Step 3 – Submit Form 3080, SSI Appellant Notification, with the requested reimbursement costs and Medicaid approved claim forms (Form CMS-1500, UB-04 or pharmacy statement).

The full Medicaid Reimbursement Manual may be accessed at Medicaid Reimbursement Manual (PDF).

Forms

ES = Spanish version available.

FormTitle 
3064Application for Health Care AssistanceES
3065Worksheet 
3066Report of Changes 
3067Appointment NoticeES
3068Request for InformationES
3069Health Care Services Record 
3072Monthly Financial Report 
3073Eligibility Dispute Resolution Request 
3076Case Record Information ReleaseES 
3077Notice of EligibilityES 
3078Claim Processing Notification 
3079Facility Payment Rate Request 
3080SSI Appellant Notification 
3081Appellant – Provider AssignmentES 
3082Notice of IneligibilityES 
3083Optional Health Care Services Notification 
3084Employment VerificationES 
3085Statement of Self-Employment IncomeES
3086End of Year Report 
3087TMHP Confidentiality Agreement 
3088Request for State Assistance Funds (90 Percent) 

23-4, Miscellaneous Revisions

Revision 23-4; Effective Sept. 22, 2023

RevisedTitleChange
1100Contact InformationRemoves physical address for courier service and helpline information.
1130County ResponsibilityAdds requirement to maintain current program information on Texas 2-1-1.
1150OptionsAdds link to Texas Workforce Commission.
1200DefinitionsUpdates definitions throughout and merges previous definitions in previously numbered sections 2200, 2320, 2420.
2110General PrinciplesUpdates language. Adds presumptive eligibility requirements.
2220DefinitionsChanges title to CIHCP Household and moves information from 2230. Deletes definitions. Updates language.
2230CIHCP HouseholdChanges title to Screening Tools and moves information from 2240.
2240Screening ToolsChanges title to Verifying Household and moves information from 2250.
2250Verifying HouseholdChanges title to Documenting Household and moves information from 2260.
2260Documenting HouseholdDeletes section.
2320DefinitionsChanges title to Countable Resources and Exemptions and moves information up from 2330. Deletes definitions. Updates language.
2330Countable Resources and ExemptionsChanges title to Penalty for Transferring and moves information up from 2340. Updates language.
2340Penalty for TransferringChanges title to Verifying Resources and moves information up from 2350.
2350Verifying ResourcesChanges title to Documenting Resources and moves information up from 2360.
2360Documenting ResourcesDeletes section.
2410General PrinciplesUpdates language.
2420DefinitionsChanges title to Countable Income and Exemptions and moves information up from 2430. Deletes definitions. Updates language.
2430Countable Income and ExemptionsChanges title to Verifying Income and moves information up from 2340. Updates language.
2440Verifying IncomeChanges title to Documenting Income and moves information up from 2450.
2450Documenting IncomeDeletes section.
2520Steps for Budgeting IncomeUpdates language.
3100General PrinciplesUpdates language. Revises application requirements.
3200Processing an ApplicationUpdates language.
3210Reporting ChangesAdds new section on requirements for reporting household changes.
3300Denial Decision DisputesUpdates language.
3400Case Record MaintenanceUpdates language.
4100General PrinciplesUpdates language.
4211Annual Physical ExaminationsUpdates language.
4216Skilled Nursing Facility ServicesUpdates language. Updated link.
4218Rural Health Clinic (RHC) ServicesUpdates language.
4220Outpatient Hospital ServicesUpdates language.
4311Advanced Practice Nurse (APN) ServicesUpdates language.
4313Colostomy Medical Supplies and EquipmentUpdates language.
4314Counseling ServicesUpdates language.
4316Diabetic Medical Supplies and EquipmentUpdates language.
4317Durable Medical Equipment (DME)Updates language.
5210Step for Applying for State Assistance FundsUpdates language.
6100General PrinciplesUpdates language.

23-3, Section 6210 Revised

Revision 23-3; Effective Apr. 6, 2023

RevisedTitleChange
6210Steps for Requesting Medicaid Reimbursement for SSI AppellantsUpdates the link in Step 3 to the updated Medicaid Reimbursement Manual.

23-1, Section 4000 Changes

Revision 23-1; Effective Jan. 5, 2023

The following change(s) were made:

Revised Title Change
4100 General Principles Edits text.
4200 Basic Health Care Services Edits text.
4210 Physician Services Removes information about reducing reimbursement amount for services rendered on or after Feb. 1, 2011.
4211 Annual Physical Examinations Edits text.
4212 Immunizations Edits text.
4213 Medical Screenings Edits text.
4214 Laboratory and X-ray Services Edits text.
4215 Family Planning Services Edits text.
4216 Skilled Nursing Facility Services Adds information on payment rates.
4217 Prescription Drugs Adds new instructions for formulary pricing. Deletes prior pricing instructions.
4218 Rural Health Clinic (RHC) Services Updates link for payment standards.
4219 Inpatient Hospital Services Updates link for payment standards.
4220 Outpatient Hospital Services Updates link for payment standards.
4310 HHSC-Established Optional Health Care Services Updates service list and fee schedules.
4311 Advanced Practice Nurse (APN) Services Updates terminology.
4312 Ambulatory Surgical Center (ASC) Services Updates terminology.
4313 Colostomy Medical Supplies and Equipment Updates terminology.
4314 Counseling Services Updates terminology.
4315 Dental Care Updates terminology.
4316 Diabetic Medical Supplies and Equipment Updates terminology.
4317 Durable Medical Equipment Updates terminology.
4318 Emergency Medical Services Edits text.
4319 Home and Community Health Care Services Edits text.
4320 Physician Assistant (PA) Services Edits text.
4321 Vision Care, Including Eyeglasses Updates terminology.
4322 Federally Qualified Health Center (FQHC) Updates link for payment rates.
4323 Occupational Therapy Services Edits text.
4324 Physical Therapy Services Edits text.
4410 Fee Schedules Updates service table.
4420 Type of Services – Definition and Payment Information Clarifies reimbursement rate for assistant surgical services.

22-1, Federal Poverty Guidelines 2022 Income and Miscellaneous Changes

Revision 22-1; Effective April 8, 2022

The following change(s) were made:

Revised Title Change
1100 Handbook Purpose and Contact Information Updates the mailing address, physical address for courier service, helpline, fax number and email address.
1110 Rules Updates the Texas Administrative Code information and link.
2520 Steps for Budgeting Income Updates the table in Step 10 for CIHCP Monthly Income Standard Based on the 2022 Federal Poverty Guidelines.

21-1, Federal Poverty Guidelines 2021 Income Changes

Revision 21-1; Effective March 1, 2021

The following change(s) were made:

Revised Title Change
2520 Steps for Budgeting Income Updates the table in Step 10 for CIHCP Monthly Income Standard Based on the 2021 Federal Poverty Guidelines.

 

20-1, Monthly Income Standard Changes

Revision 20-1; Effective April 27, 2020

The following change(s) were made:

Revised Title Change
2520 Steps for Budgeting Income Updates the table in Step 10 for CIHCP Monthly Income Standard Based on the 2020 Federal Poverty Guideline.