Epilepsy Program Policy Manual

1200, Purpose of Manual

Revision 20-0; Effective December 18, 2020

The Texas Health and Human Services Commission (HHSC) Epilepsy Program Policy Manual is a guide for contractors who deliver epilepsy services in Texas. The policy manual has been structured to provide contractor staff with information needed to comply with program legislation and rules.

Federal and state laws related to reporting abuse, operation of health facilities, professional practice, insurance coverage and similar topics also impact epilepsy services. Contractors are required to be aware of and comply with existing laws.

2100, Program Authorization and Services

Revision 22-1; Effective April 8, 2022

Purpose of the Program

The Epilepsy Program provides comprehensive outpatient care (diagnosis and treatment of epilepsy; management for continuity of care; integration of personal, social and vocational support services into the treatment plan; and epilepsy education) to eligible persons who have epilepsy and/or seizure-like symptoms through subrecipient providers in selected service areas in Texas.

Legislative and Statutory Authorization

The enacting legislation for the Epilepsy Program is House Bill 1685, 67th Regular Session, 1981. The Texas Health and Safety Code, Chapter 40, is the statutory authority for the Epilepsy Program administered by Texas Health and Human Services Commission (HHSC).

Rules

The state rules for epilepsy services in Texas can be found in the Texas Administrative Code (TAC), Title 26, Part 1, Chapter 355.

Funding Sources

Epilepsy Program services are funded by State General Revenue. HHSC epilepsy funds are allocated through a competitive application process, after which selected applicants negotiate contracts with HHSC to provide services. A variety of types of organizations provide Epilepsy Program services, such as medical schools, hospital districts, private nonprofit agencies and community-based clinics. Providers must enroll with the Texas Medicaid & Healthcare Partnership (TMHP) to provide the HHSC Epilepsy Program.

​​​​​​​2200, Definitions

Revision 22-3; Effective Nov. 8, 2022

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

Barrier to Care – A factor that hinders a person from receiving health care (e.g., proximity or distance, lack of transportation, documentation requirements, co-payment amount, etc.)

Caretaker – An adult who is present in the home and supervises and cares for a child.

Client – A person  who has been screened, determined to be eligible for services and has successfully completed the eligibility process. “Client” and “patient” may be used interchangeably throughout this policy manual.

Contractor – Any entity that Texas Health and Human Services Commission has contracted with to provide services. The contractor is the responsible entity even if there is a subcontractor involved who provides the services.

Co-Payment (Co-pay) – Monies collected directly from clients for services. The amount collected each month should be deducted from the Monthly Report Form and is considered program income.

Diagnosis – The practitioner’s main tool in diagnosing epilepsy is a careful medical history with as much information as possible about what the seizures looked like and what happened just before they began. The practitioner will also perform a thorough physical exam and may require microscopic (i.e., culture), chemical (i.e., blood tests), EEG and/or radiological examinations (CAT, MRI, etc.).

Eligibility Date – Date the contractor determines an individual to be eligible for the program. The eligibility expiration date will be 12 months after the eligibility date.

Family Composition/Household – A person living alone or a group of two or more persons related by birth, marriage (including common law) or adoption, who reside together and who are legally responsible for the support of the other person.

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 form of poverty guidelines. Public assistance programs, such as Medicaid, define eligibility income limits as some percentage of FPL.

Fiscal Year (FY) – State fiscal year from September 1 through August 31 of each year.

Health and Human Services Commission (HHSC) – State agency with administration and oversight responsibilities for designated Health and Human Services agencies.

Laboratory (Lab) – Facility that measures or examines materials derived from the human body for the purpose of providing information on diagnosis, monitoring prevention or treatment of disease.

Laboratory, X-Ray or other Appropriate Diagnostic Services – Studies or tests ordered by the client’s health care practitioner(s) (e.g., physicians and mid-level providers) to evaluate an individual’s health status for diagnostic purposes.

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

Medicaid – Title XIX of the Social Security Act; reimburses for health care services delivered to low-income clients who meet eligibility guidelines.

Minor – In Texas, a person under 18 years old who has never been married and never been declared an adult by a court (emancipated). See Texas Family Code Sections 101.003, 31.001-31.007, 32.003-004, 32.202. In this manual, “minor” and “child” may be used interchangeably.

Outreach – Activities conducted with the purpose of informing and educating the community about services and increasing the number of program participants.

Patient – A person who is eligible to receive medical care, treatment or services. “Client” and “patient” may be used interchangeably in this manual.

Payer Source – Programs, benefits or insurance that pays for the service provided.

Program Income – Monies collected directly by the contractor, subcontractor, or provider for services provided under the contract award (i.e., third-party reimbursements, such as Title XIX, private insurance and patient co-pay fees). Program income also includes client donations.

Provider – An individual clinician or group of clinicians who provide services.

Recertification – The process of rescreening and determining eligibility for the next year.

Referral – The process of directing or redirecting (as a medical case or a patient) to an appropriate specialist or agency for definitive treatment; or direct to a source for help or information.

Service – Any client encounter at a facility that results in the client having a medical or health-related need met.

Telehealth – Health care services delivered by a health professional to a patient at a different physical location than the health professional, using telecommunications or information technology.

Telemedicine Medical Service – A health care service delivered to a patient at a different physical location than the physician or health professional using telecommunications or information technology by a physician licensed in this state, or a health professional acting under the delegation and supervision of a physician licensed in this state and acting within the scope of the physician’s or health professional’s license.

Texas Resident –A person who resides within the geographic boundaries of the state.

Treatment – Any specific procedure used for the cure or the improvement of a disease or pathological condition.

Unduplicated Client – Clients are counted only one time during the program’s fiscal year, regardless of the number of visits, encounters or services they receive (e.g., one client seen four times during the year is counted as one unduplicated client.)

3000, Administrative Policy

Revision 22-3; Effective Nov. 8, 2022

This section assists the contractor in conducting administrative activities such as assuring client access to services and managing client records.

3100, Administrative Policies

Revision 22-3; Effective Nov. 8, 2022

3110 Maintaining Clinic Information on 2-1-1

Revision 22-3; Effective Nov. 8, 2022

Contractors must maintain current and correct clinic information on 211Texas.org for all locations providing services. Contractors 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 clinic location and information listings. The information that contractors shall maintain in their 2-1-1 listings includes, but is not limited to, clinic phone number, location, hours, and services provided.  

3120 Client Access

Revision 22-3; Effective Nov. 8, 2022

The contractor must ensure that clients are provided services in a timely and nondiscriminatory manner. The contractor must:

  • Have a policy in place that delineates the timely provision of services.
  • Have policies in place to identify and eliminate possible barriers to client care.
  • Comply with all applicable civil rights laws and regulations including Title VI of the Civil Rights Act of 1964, the Americans with Disabilities Act (ADA) of 1990, the Age Discrimination Act of 1975 and Section 504 of the Rehabilitation Act of 1973, and ensure services are accessible to persons with Limited English Proficiency (LEP) and speech or sensory impairments.
  • Have a policy in place that requires qualified staff to assess and prioritize client needs.
  • Provide referral resources for individuals that cannot be served or cannot receive a specific needed service.
  • Manage funds to ensure that established clients continue to receive services throughout the budget year, even after allocated funds are expended.
  • Ensure clinic and reception room wait times are reasonable so as not to represent a barrier to care.

3130 Important Information for Former Military Service Members

Revision 22-3; Effective Nov. 8, 2022

Women and men who served in any branch of the United States Armed Forces, including Army, Navy, Marines, Air Force, Coast Guard, Reserves or National Guard, may be eligible for additional benefits and services. For more information, visit the Texas Veterans Portal at https://veterans.portal.texas.gov.

3200, Abuse and Neglect Reporting

Revision 22-3; Effective Nov. 8, 2022

Texas Health and Human Services agencies may only provide funds to contractors and providers who show good faith efforts to comply with all child abuse reporting guidelines and requirements set forth in Chapter 261 of the Texas Family Code.

To report abuse or neglect, call the Texas Abuse Hotline at 800-252-5400, or use the secure Texas Abuse Hotline Website. For cases that pose an imminent threat or danger to an individual, call 9-1-1, or any local or state law enforcement agency.

3210 Child Abuse Reporting, Compliance and Monitoring

Revision 22-3; Effective Nov. 8, 2022

Contractors are required to develop policies and procedures that comply with the child abuse reporting guidelines and requirements set forth in Chapter 261 of the Texas Family Code.

Contractors must develop an internal policy specific to:

  • how child abuse reporting requirements will be implemented throughout their agency;
  • how staff will be trained; and
  • how internal monitoring will be done to ensure timely reporting.

During Quality Assurance (QA) monitoring, the following procedures will be utilized to evaluate compliance:

  • The contractor's process to ensure that staff is reporting child abuse as required by Chapter 261. To verify compliance, contract monitors will review that the contractor:
    • has an internal policy which details how the contractor will determine, document, report and track instances of abuse, sexual or non-sexual, for all individuals under 17 in compliance with Chapter 261;
    • follows their internal policy; and
    • has documented staff training on child abuse reporting requirements and procedures.
  • The contractor’s internal policy must clearly describe the reporting process for child abuse.

Additional information for abuse reporting: Texas Department of Family and Protective Services.

3220 Human Trafficking

Revision 22-3; Effective Nov. 8, 2022

HHSC mandates that contractors comply with state laws governing the reporting of abuse and neglect. Additionally, as part of the requirement that contractors comply with all applicable federal laws, contractors must comply with the federal anti-trafficking laws, including the Trafficking Victims Protection Act of 2000 (22 USC Section 7101, et seq.).

Contractors must have a written policy on human trafficking which includes the provision of annual staff training.

References for human trafficking policy development:

3230 Domestic and Intimate Partner Violence

Revision 22-3; Effective Nov. 8, 2022

Intimate partner violence (IPV) describes physical, sexual or psychological harm by a current or former partner or spouse. This type of violence can occur among heterosexual or same sex couples and does not require sexual intimacy.

Contractors must have a written policy related to assessment and prevention of domestic and IPV, including the provision of annual staff training.

Additional information on IPV can be found on the CDC website.

3300, Confidentiality

Revision 22-3; Effective Nov. 8, 2022

All contracting agencies must comply with the U.S. Health Insurance Portability and Accountability Act of 1996 (HIPPA) established standards for protection of client privacy.

Contractors must ensure that all employees and volunteers receive training about client confidentiality during orientation and be made aware that violation of the law regarding confidentiality may result in civil damages and criminal penalties. All employees, volunteers, sub-contractors, and board members or advisory board members must sign a confidentiality statement during orientation.

The client’s preferred method of follow-up to clinic services (cell phone, email, work phone, or text) and preferred language must be documented in the client’s record.

Each client must receive verbal assurance of confidentiality and an explanation of what confidentiality means (kept private and not shared without permission) and any applicable exceptions such as abuse reporting.

3310 Minors and Confidentiality

Revision 22-3; Effective Nov. 8, 2022

Except as permitted by law, a provider is legally required to maintain the confidentiality of care provided to a minor. Confidential care does not apply when the law requires parental notification or consent, or when the law requires the provider to report health information such as in the cases of contagious disease or abuse. The definition of privacy is the ability of the individual to maintain information in a protected way. Confidentiality in health care is the obligation of the health care provider not to disclose protected information. While confidentiality is implicit in maintaining a patient's privacy, confidentiality between provider and patient is not an absolute right.

The HIPAA privacy rule requires a covered entity to treat a “personal representative” the same as the individual with respect to uses and disclosures of the individual’s protected health information. In most cases, parents are the personal representatives for their minor children and they can exercise individual rights, such as access to medical records, on behalf of their minor children (Code of Federal Regulations - 45 CFR Section 164.502(g)).

For more information, see Adolescent Health – A Guide for Providers.

Nondiscrimination and Limited English Proficiency (LEP)

As outlined in the HHSC Uniform Terms and Conditions – Grant Version 2.16, HHSC contractors must comply with state and federal antidiscrimination laws, including but not limited to:

More information about nondiscrimination laws and regulations can be found at HHSC Civil Rights Office.

3320 Termination of Services

Revision 22-3; Effective Nov. 8, 2022

A qualifying individual must never be denied services due to an inability to pay. Contractors have the right to terminate services to a client if the client is disruptive, unruly, threatening or uncooperative to the extent that the client seriously impairs the contractor’s ability to effectively and safely provide services, or if the client’s behavior jeopardizes his or her own safety, clinic staff or others. An individual has the right to appeal the denial, modification, suspension or termination of services. (See Fair Hearings, in the Epilepsy rules at Title 26, Part 1, Chapter 355). Any policy related to termination of services must be included in the contractor’s policy manual.

3330 Resolution of Complaints

Revision 22-3; Effective Nov. 8, 2022

Contractors must ensure that clients can express concerns about care received and that complaints are handled in a consistent manner. Contractors’ policy and procedure manuals must explain the process clients may follow if they are not satisfied with the care received.

If a client remains unsatisfied with how the complaint was handled, they can appeal to the HHSC Epilepsy Program Office at Epilepsy@hhs.texas.gov, call 512-438-3769, or mail PO Box 149030, Austin TX 78714-9947. Additional information may be needed.

Any client complaint must be documented in the client’s record.

3340 Research (Human Subject Clearance)

Revision 22-3; Effective Nov. 8, 2022

Contractors considering clinical or sociological research using Epilepsy Program-funded clients as subjects must obtain prior approval from their own internal Institutional Review Board (IRB) and HHSC. Contractors should first contact the HHSC Epilepsy Program (Epilepsy@hhs.texas.gov) to initiate a research request. Next, the Epilepsy Program will assist contractors to find the most current version of the appropriate IRB application to complete and submit. The IRB will review the materials and approve or deny the application.

The contractor must have a policy in place that indicates approval will be obtained from the HHSC Epilepsy Program, as well as the IRB, prior to instituting any research activities. The contractor must also ensure that all staff is made aware of this policy through staff training. Documentation of training on this topic must be maintained.

3400, Client Records Management

Revision 20-0; Effective December 18, 2020

HHSC contractors must have an organized and secure client record system. The contractor must ensure that the record is organized, readily accessible, and available to the client upon request with a signed release of information. The records must be kept confidential and secure, as follows:

  • Safeguarded against loss and used by unauthorized persons;
  • Secured by lock when not in use or inaccessible to unauthorized persons; and
  • Maintained in a secure environment in the facility, as well as during transfer between clinics and in between home and office visits.

The written consent of the client is required for the release of personally identifiable information, except as it may be necessary to provide services to the client or as required by law, with appropriate safeguards for confidentiality. If the client is 17 years of age or younger, the client’s parent, managing conservator or guardian, as authorized by Chapter 32 of the Texas Family Code or by federal law or regulations, must authorize the release. HIV information should be handled according to law.

When information is requested, contractors should release only the specific information requested. Information collected for reporting purposes may be disclosed only in summary, statistically or in a form that does not identify individuals. Upon request, clients transferring to other providers must be provided with a copy or a summary of their record to expedite continuity of care. Electronic records are acceptable as medical records.

Contractors, providers, subrecipients and subcontractors must maintain for the time specified by HHSC all records pertaining to client services, contracts and payments. Contractors must follow contract provisions, maintain medical records for at least seven years after the close of the contract and follow the retention standards of the appropriate licensing entity. All records relating to services must be accessible for examination at any reasonable time to representatives of HHSC and as required by law.

3500, Personnel Policies and Procedures

Revision 22-3; Effective Nov. 8, 2022

Contractors must develop and maintain personnel policies and procedures to ensure that clinical staff are hired, trained and evaluated appropriately for their job position. Contracted staff must also be trained and evaluated according to their responsibilities. Job descriptions, including those for contracted personnel, must specify required qualifications and licensure. All staff must be appropriately identified with a name badge. Personnel policies and procedures must include:

  • job descriptions, including those for contracted personnel;
  • a written orientation plan for new staff to include skills evaluation and/or competencies appropriate for the position; and
  • a performance evaluation process for all staff.

Contractors must show evidence that employees meet all required qualifications and are provided annual training. Job evaluations should include observation of staff and client interactions during clinical, counseling and educational services.

Contractors shall establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of personal or organizational conflict of interest or personal gain. All employees and board members must complete a conflict of interest statement during orientation. All medical care must be provided under the supervision, direction and responsibility of a qualified medical director.

The epilepsy medical director for the clinic must be a licensed Texas physician. Contractors must have a documented plan for organized staff development. There must be an assessment of:

  • training needs;
  • quality assurance indicators; and
  • changing regulations and requirements.

Staff development must include orientation and in-service training for all personnel and volunteers (nonprofit entities must provide orientation for board members and government entities must provide orientation for advisory committees). Employee orientation and continuing education must be documented in agency personnel files.

3600, Facilities and Equipment

Revision 22-3; Effective Nov. 8, 2022

HHSC contractors are required to always maintain a safe environment. Contractors must have written policies and procedures that address hazardous waste, fire safety and medical equipment.

3610 Hazardous Materials

Revision 22-3; Effective Nov. 8, 2022

Contractors must have written policies and procedures that address:

  • handling, storage and disposing of hazardous materials and waste according to applicable laws and regulations;
  • handling, storage and disposing of chemical and infectious waste including sharp objects; and
  • an orientation and education program for personnel who manage or have contact with hazardous materials and waste.

3620 Fire Safety

Revision 22-3; Effective Nov. 8, 2022

Contractors must have a written fire safety policy that includes a schedule for testing and maintenance of fire safety equipment. Evacuation plans for the premises must be clearly posted and visible to all staff and clients.

3630 Medical Equipment

Revision 22-3; Effective Nov. 8, 2022

Contractors must have a written policy and maintain documentation of the maintenance, testing and inspection of medical equipment, including an Automated External Defibrillator (AED). Documentation must include:

  • assessments of the clinical and physical risks of equipment through inspection, testing and maintenance;
  • reports of any equipment management problems, failures and use errors;
  • an orientation and education program for personnel who use medical equipment; and
  • manufacturer recommendations for care and use of medical equipment.

3640 Radiology Equipment and Standards

Revision 22-3; Effective Nov. 8, 2022

All facilities providing radiology services, including dental X-rays, must:

For information on X-ray machine registration, see the Texas Department of State Health Services, Radiation Control Program.

3650 Smoking Ban

Revision 22-3; Effective Nov. 8, 2022

Contractors must have written policies that prohibit smoking in any portion of their indoor facilities. If a contractor subcontracts with another entity for the provision of health services, the subcontractor must also comply with this policy.

3660 Disaster Response Plan

Revision 22-3; Effective Nov. 8, 2022

Contractors must have written and oral plans that address how staff must respond to emergency situations (e.g., fires, flooding, power outage, bomb threats, etc.). The disaster plan must identify the procedures and processes that will be initiated during a disaster and the staff position(s) responsible for each activity. A disaster response plan must be in writing, formally communicated to staff and kept in the workplace available to employees for review. For an employer with ten or fewer employees, the plan may be communicated orally to employees.

For additional resources on facilities and equipment, see the Occupational Safety and Health Administration website.

3700, Emergency Responsiveness

Revision 20-0; Effective December 18, 2020

Clinical Emergencies

Contractors must be adequately prepared to handle clinical emergency situations, as follows:

  • There must be a written plan for the management of on-site medical emergencies, emergencies requiring ambulance services and hospital admission.
  • Each site must have staff trained in basic cardiopulmonary resuscitation (CPR) and emergency medical action. Staff trained in CPR must be present during all hours of clinic operations.
  • There must be written protocols to address vaso-vagal reactions, anaphylaxis, syncope, cardiac arrest, shock, hemorrhage and respiratory difficulties.
  • Each site must maintain emergency resuscitative drugs, supplies and equipment appropriate to the services provided at that site, and appropriately trained staff when clients are present.
  • Documentation must be maintained in personnel files that staff has been trained regarding these written plans or protocols.

Emergency Preparedness

There must be a written safety plan that includes maintenance of fire safety equipment, an emergency evacuation plan and a disaster response plan.

3800, Quality Management

Revision 20-0; Effective December 18, 2020

Contractors must use internal Quality Assurance/Quality Improvement (QA/QI) systems and processes to monitor epilepsy services. Contractors must have a Quality Management (QM) program individualized to their organizational structure and based on the services provided. The goals of the quality program should ensure availability and accessibility of services, quality and continuity of care.

Contractors should integrate QM concepts and methodologies into the structure of the organization and day-to-day operations.

Contractors are expected to develop quality processes based on four core QM principles that focus on:

  • The client;
  • Systems and processes;
  • Measurement; and
  • Teamwork.

The QM program must be developed and implemented in such a way that provides for ongoing evaluation of services. Contractors should have a comprehensive plan for the internal review, measurement and evaluation of services, the analysis of monitoring data, and the development of strategies for improvement and sustainability.

Contractors who subcontract for the provision of services must also address how quality will be evaluated and how compliance with HHSC policies and basic standards will be assessed with the subcontracting entities.

The QM Committee, whose membership consists of key leadership of the organization, including the executive director/CEO and the medical and dental director and other appropriate staff where applicable, annually reviews and approves the quality work plan for the organization.

The QM Committee must meet at least quarterly to:

  • Receive reports of monitoring activities;
  • Make decisions based on the analysis of data collected;
  • Determine quality improvement actions to be implemented; and
  • Reassess outcomes and goal achievement.

Minutes of the discussion and actions taken by the QM Committee and a list of the attendees must be maintained.

The comprehensive quality work plan, at a minimum, must:

  • Include clinical and administrative standards by which services will be monitored;
  • Include a process for credentialing and peer review of clinicians;
  • Identify individuals responsible for implementing monitoring, evaluating and reporting;
  • Establish timelines for quality monitoring activities;
  • Identify tools/forms to be utilized; and
  • Outline reporting to the QM Committee.

Although each organization’s QA program is unique, the following activities must be undertaken by all agencies providing client services:

  • Ongoing eligibility, billing and clinical record reviews to assure compliance with program requirements and clinical standards of care;
  • Tracking and reporting of adverse outcomes;
  • Client satisfaction surveys;
  • Annual review of facilities to maintain a safe environment, including an emergency safety plan;
  • Annual review of prescriptive authority agreements (PAAs), policies, clinical protocols and standing delegation orders (SDOs) to ensure they are current; and
  • Performance evaluations to include primary license verification, valid Drug Enforcement Agency (DEA) number and immunization status to ensure they are current.

HHSC contractors who subcontract for the provision of services must also address how quality will be evaluated and how compliance with policies and basic standards will be assessed with the subcontracting entities including:

  • Annual license verification (primary source verification);
  • Clinical record review;
  • Eligibility and billing review;
  • On-site facility review;
  • Annual client satisfaction evaluation process; and
  • Child abuse training and reporting – subcontractor staff.

Data from these activities must be presented to the QM Committee. Plans to improve quality should result from the data analysis and reports considered by the QM Committee and should be documented.

4000, Eligibility and Fees

Revision 22-3; Effective Nov. 8, 2022

This section provides policy requirements for eligibility determinations, client fees, and continuity of client services.

4100, Eligibility and Assessment of Copay and Fees

Revision 24-1; Effective Jan. 8, 2024

Contractors must develop a policy indicating how staff will determine Epilepsy Program client eligibility. The policy must outline the contractor’s procedures to determine program eligibility and who is responsible for eligibility screening.

Contractors must perform an eligibility screening assessment on all clients who present for services using the most recent version of Form 3094.

An alternate eligibility tool created by the contractor may be used in place of Form 3094 with prior written approval by the Epilepsy Program. The tool must contain, at minimum, all required elements of Form 3094 for eligibility determination as well as the signature of the applicant or applicant’s legal representative.

Once a contractor gets approval for the use of an alternate eligibility screening tool, the following requirements apply:

  • Contractors must request approval from the Epilepsy Program for any revisions to their eligibility screening tool and include a copy of the revised tool.
  • The eligibility screening tool is only approved for the life of the current contract cycle. If a contractor is awarded funding under a subsequent contract, the contractor must resubmit their eligibility screening tool for review and written approval, even if no changes have been made to the tool since the last written approval.
  • Any required changes made to Form 3094 by the Epilepsy Program must be incorporated into the contractor-developed alternate screening tool. Contractors will need to submit their contractor-developed alternate screening tool with the incorporated changes within 60 calendar days for re-review and approval. 
  • The Epilepsy Program reserves the right to request additional edits or to withdraw its approval of the use of an alternate eligibility tool. The Epilepsy Program notifies the contractor of the decision in writing and includes the date when the alternate tool must be discontinued. 

The following forms are optional, but may be used to help complete the epilepsy eligibility process:

4200, Client Eligibility Screening Process

Revision 24-1; Effective Jan. 8, 2024

For a person to receive epilepsy services with HHSC funds, four criteria must be met:

  • diagnosis of epilepsy certified by a licensed physician, or a statement that the applicant is suspected of having epilepsy;
  • gross household income is at or below 200% of Federal Poverty Level (FPL);
  • applicant is a Texas resident; and
  • applicant is not eligible for other programs or benefits providing the same services, such as Medicaid, Medicare or Children with Special Health Care Needs (CSHCN).

If a person is under 21 and on a waiting list for CSHCN, they can receive epilepsy services until removed from the waiting list. If an applicant meets all eligibility requirements except for the financial criteria, the applicant is eligible only for support services.

Eligibility determinations for the Epilepsy Program can be made by conducting interviews over the phone for new applicants and to re-certify current clients. Phone interviews for eligibility determinations must comply with all eligibility guidelines outlined in program policy.

Instead of a client’s signature on the application in the Acknowledgment section of the Application for Program Benefits or on the Statement of Applicant’s Rights and Responsibilities (PDF), the eligibility staff person must read the statements to the applicant and document that the applicant affirms the statements. The documentation must include the date and time of the applicant affirmation and the eligibility staff person’s signature. The client must sign the document at their next visit to the clinic.

4300, Procedures and Terminology When Determining Epilepsy Eligibility

Revision 24-3; Effective May 1, 2024

Documentation of Date of Birth

Document proof of the client’s birthdate provided by the client on Form 3094, Application for Program Benefits. Provide one of the following items for documentation of a client’s date of birth:

  • Birth certificate
  • Baptismal certificate
  • School records
  • Other documents or proof of date of birth determined valid by the contractor.

Documentation of Family Composition

Request one of the following items if family relationships are unclear:

  • Birth certificate
  • Baptismal certificate
  • School records
  • Other documents or proof of family relationship determined valid by the contractor to establish the dependency of the family member on the client or head of household

Family members who receive other health care benefits are included in the family count. The contractor has discretion to document special circumstances in the calculation of family composition. Additionally, if a separate family group is established within the household based on the documentation gathered, document the basis used to determine separate households.

Documentation of Residency

To be eligible for the Epilepsy Program, a person must be physically present within the geographic boundaries of Texas and:

  • intend to remain in the state either permanently or for an indefinite period;
  • not claim residency in any other state or country; or
  • if a person is younger than 18 years old, then a parent, managing conservator, caretaker or guardian must be a resident of Texas as defined above.

A person is not required to live in Texas a certain amount of time to establish residency for the purposes of Epilepsy Program eligibility.

Document proof of residency provided by the client on Form 3094, Application for Program Benefits. Explain why residency is questionable, if necessary. For documentation of residency, one of the following items must be provided:

  • Valid Texas driver license
  • Current voter registration
  • Rent or utility receipts for one month before the month of application
  • Motor vehicle registration
  • School records
  • Medical cards or other similar benefit cards
  • Property tax receipt
  • Mail addressed to the applicant, his or her spouse, or children if they live together
  • Other documents considered valid by the contractor

If none of the listed items are available, residency may be verified through:

  • observance of personal effects and living arrangement; or
  • statements from landlords, neighbors or other reliable sources.

If a family is otherwise eligible, but residency is in question or dispute, the household is entitled to services until information about residency change proves otherwise.

People do not lose their residency status because of temporary absences from the state. An example is a migrant or seasonal worker who travels during certain times but maintains a home in Texas and returns to that home after these temporary absences.

Household

The household consists of a person living alone, or a group of two or more people related by birth including adoption, or marriage including common law, who live together and are legally responsible for the support of the other person. If an unmarried applicant lives with a partner, only count the partner’s income and children as part of the household group if the applicant and their partner have mutual children together. Unborn children should also be included. Treat applicants who are 18 years old as adults. No children 18 or older or other adults living in the home should be counted as part of the household group. A child must be under 18 years old to be counted as part of a larger family. Eligibility will end on the last day of the month the child becomes 18 years old unless the child is: 

  • a full-time high school student as defined by the school, attends an accredited GED class, or regularly attends vocational or technical training in place of high school; and
  • expected to graduate from one of the above before or during the month of their 19th birthday.

Legal responsibility for support exists between:

  • people who are legally married including common-law marriage;
  • a legal parent and a minor child including unborn children; or
  • a managing conservator and a minor child. A managing conservator is a person designated by a court to have daily legal responsibility for a child.

Income

All income received must be included. Gross income is calculated before taxes. Income is reviewed and determined either countable or exempt based on the source of the income in  the Epilepsy Program Definition of Income. Contractors must have a written epilepsy income verification policy.

Documentation of income for Epilepsy Program services must be provided to complete Form 3094, Application for Program Benefits. Declarations of unknown will not be accepted.

Provide one of the following:

  • At least two pay periods that accurately represent their earnings dated within the 60 days before the application processing date.
  • One month’s pay, only if paid same gross amount monthly, unless special circumstances are noted on the application.

The pay periods must accurately reflect the person’s usual and customary earnings. Proof may include:

  • copy(ies) of the most recent paycheck(s), stub or monthly earning statement(s);
  • employer’s written verification of gross monthly income or Form 3094, Application for Program Benefits;
  • award letters;
  • domestic relation printouts of child support payments;
  • statement of support;
  • unemployment benefits statement or letter from the Texas Workforce Commission;
  • award letters, court orders or public decrees to verify support payments;
  • notes for cash contributions; and
  • other documents or proof of income determined valid by the contractor.

Income Deductions

Deduct dependent care expenses from total income to determine eligibility. Allowable deductions are actual expenses up to:

  • $200 per child per month for children under 2 years old;
  • $175 per child per month for each dependent 2 years and older; and  
  • $175 per adult with disabilities per month.

Deduct legally obligated child support payments made by a member of the household group. Payments made weekly, every two weeks, or twice a month must be converted to a monthly amount by using one of the conversion factors listed below.

Monthly Income Conversions

If income payments are received in lump sums or at longer intervals than monthly, such as seasonal employment, the income is prorated over the period the income is expected to cover. Income received weekly, every two weeks, or twice a month must be converted as follows:

  • weekly income is multiplied by 4.33;
  • income received every two weeks is multiplied by 2.17; and
  • income received twice monthly is multiplied by 2.

Potential Eligibility and Referral to Other Possible Qualifying Programs

In general, a person is not eligible for the Epilepsy Program if they are enrolled in another third-party payer such as private health insurance, Medicaid or Medicare, TRICARE, workers’ compensation, Veterans Affairs Benefits, or other federal, state, or local public health care coverage that provides the same services.

A person may still be potentially eligible for the Epilepsy Program even if they are also possibly eligible for another program that covers the same services provided by the Epilepsy Program. The contractor should proceed with the eligibility process for the Epilepsy Program but inform the person of their possible eligibility for the other program and suggest they also apply for services for that program. The contractor must document in the person’s case record that they were informed and were referred to the other program.

Insurance

People with insurance may be eligible for services provided by the Epilepsy Program when the applicant’s confidentiality is a concern or if the applicant’s insurance deductible is 5% or greater than their income.

Most insurance deductibles are given as an annual amount. Epilepsy household incomes are figured as a monthly amount. To compare an annual deductible with a monthly income, multiply the monthly income by 12 and then determine 5% of that amount. See the example below for a monthly household income of $1,000:

  1. Determine the total household’s monthly income.
  2. Determine the total household’s annual income by multiplying the monthly income by 12 (months).
  3. Determine 5% of the total annual income by multiplying it by 0.05 (5%).
Total Monthly Household IncomeTotal Annual Household Income5% of Total Annual Household Income
$1,000 x 12 (months)= $12,000X 0.05 = $600
In this case, if the applicant’s annual insurance deductible is any amount over $600, then they are eligible under this criterion for the Epilepsy Program.

Another way to make the comparison is to divide the annual insurance deductible into a monthly amount. 

Review the example below for an annual insurance deductible of $6,000 and a monthly household income of $1,000:

  1. Determine the household’s monthly insurance deductible by dividing the annual deductible by 12 (months).
  2. Determine 5% of the total monthly household income by multiplying it by 0.05 (5%).
Household Annual Insurance DeductibleHousehold Monthly Insurance DeductibleTotal Monthly Household IncomeTotal Monthly Household Income
$6,000÷ 12 = $500$1,000X 0.05 = $50
In this case, if the applicant’s monthly insurance deductible is any amount over $50, then they are eligible under this criterion for the Epilepsy Program.

The completed eligibility form must be maintained in the client medical record, indicating the client’s poverty level and the co-pay amount the person will be charged.

Payer of Last Resort

The Epilepsy Program is the payer of last resort for a client who is enrolled in any other program that provides payment for the cost of the same epilepsy services at the time the client presents for those services.

Calculation of Applicant’s Federal Poverty Level (FPL) Percentage

If a contractor collects a co-pay, they must determine the applicant’s exact household FPL percentage. The contractor must not charge a co-pay for epilepsy clients whose household income is at or below 100% FPL.

The maximum monthly income amounts by household size are based on the Department of Health and Human Services federal poverty guidelines. The guidelines are subject to change near the beginning of each calendar year.

The steps to determine the applicant’s actual household FPL percentage are:

  1. determine the applicant’s total monthly income amount;
  2. determine the applicant’s household size;
  3. divide the applicant’s total monthly income amount by the maximum monthly income amount at 100% FPL for the appropriate household size; and
  4. multiply by 100.

Review the example below for a family of three, with a monthly income amount of $2,593:

Total Monthly IncomeMaximum Monthly Income Household Size of ThreeActual Household FPL %
$2,593÷ $2,152 = 1.20 X 100= 120% FPL

Client Fees and Co-Pays

Epilepsy contractors may, but are not required, to assess a co-pay for services from epilepsy clients. The co-pay guidelines are as follows:

  • No epilepsy client shall be denied services based on an inability to pay.
  • Clients with a household FPL at or below 100%, should not be charged a co-pay.
  • Contractors may charge a co-pay amount ranging from $10 up to a maximum of $30 per encounter for clients above 100% of the FPL.
  • People who are assessed a co-pay should be presented with the bill at the time of service.
  • Clients who declare an inability to pay a co-pay shall not be denied services, have an account with an outstanding balance turned over to a collection agency or reported delinquent to a credit reporting agency.
  • Client co-pays must be reported as program income on the monthly Form 4116, Authorization for Expenditures, and the quarterly Financial Status Report (FSR or Form 269a).
  • The Optional Co-Pay Table based on Monthly Federal Poverty Level may be used by the contractor to determine an allowable co-pay and is updated annually when the revised Federal Poverty Income Guidelines becomes available.
  • Contractors must have policies and procedures regarding fee collection, which must be approved by the contractor’s board of directors.
  • Client co-pays collected by the contractor are considered program income and must be used to support the delivery of HHSC epilepsy services.

Other Fees

Clients shall not be charged administrative fees for items such as processing or transfer of medical records, copies of immunization records.

Contractors are allowed to bill clients for services outside the scope of Epilepsy Program allowable services if the service is provided at the client’s request and the client is made aware of their responsibility for paying for the charges.

Continuation of Services

Contractors who have expended their awarded Epilepsy Program funds must continue to serve their existing epilepsy clients through the end of the client’s eligibility. If other funding sources are used to provide epilepsy services, the funds must be reported as non-HHSC funds on the monthly Form 4116 and the quarterly Financial Status Report (FSR or Form 269a).

Client’s Responsibility for Reporting Changes

A client must report changes in the following areas no later than 30 days after the client is aware of the change:

  • Income
  • Family composition
  • Residence
  • Current address
  • Employment
  • Types of medical insurance coverage
  • Receipt of Medicaid CHIP or other third-party coverage benefits.

The client may report changes by mail, phone, in person or through someone acting on their behalf. If changes result in the client no longer meeting eligibility criteria, they are denied continued services. By signing the required forms, they attest to the truth of the information provided.

Date Eligibility Begins

A person or household is eligible for services beginning with the date the contractor determines the person or household is eligible for the program and signs the completed application. Contractors have the option to notify applicants of their eligibility status using the optional letter provided by the Epilepsy Program:

Annual Recertification

Annual eligibility determination and recertification is required for all clients who receive Epilepsy Program services. Client eligibility must be redetermined every 12 months, using the most recent version of Form 3094, Application for Program Benefits.

Contractors must have a system in place to track client eligibility and renewal status on an annual basis.

5000, Clinical Guidelines

Revision 22-3; Effective Nov. 8, 2022

This section describes the requirements and recommendations for contractors pertaining to the delivery of direct clinical services to clients. In addition to the requirements and recommendations found within this section, contractors should develop protocols consistent with national evidence-based guidelines appropriate to the target population.

5100, General Consent

Revision 22-3; Effective Nov. 8, 2022

Contractors must obtain the client’s written, informed, voluntary, and general consent prior to performing any clinical services. The general consent form explains the types of services provided and how client information may be shared with other entities for reimbursement or reporting purposes. If there is a period of three years or more during which a client does not receive services, a new general consent must be signed prior to reinitiating delivery of services.

For the Epilepsy Program, a client’s verbal consent for general treatment may be obtained by phone. This type of consent is adequate for routine treatment, provided through telemedicine. 

To record a client’s verbal consent, the staff person obtaining the consent must read the consent form to the applicant and document that the applicant affirms by giving their verbal consent for treatment. The documentation must include the date and time of the applicant’s consent and the signature of the staff person obtaining consent. The client must sign the consent at the time of their next visit to the clinic.

Consent information must be effectively communicated to every client in a manner that is understandable. This communication must allow the client to participate, make sound decisions regarding their own medical care and address any disabilities that impair communication in compliance with Limited English Proficiency regulations. Only the client may consent, except when the client is legally unable to consent (i.e., a minor or an individual with development disability), to which a parent, legal guardian or caregiver must consent on his or her behalf. Consent must never be obtained in a manner that could be perceived as coercive.

HHSC contractors should consult a qualified attorney to determine the appropriateness of the consent forms used by their health care agency. In addition, as described below, the contractor must obtain informed consent of the client for procedures as required by the Texas Medical Disclosure Panel (TMDP).

5110 Texas Medical Disclosure Panel Consent

Revision 22-3; Effective Nov. 8, 2022

The Texas Medical Disclosure Panel (TMDP) was established by the Texas Legislature to:

  • determine which risks and hazards related to medical care and surgical procedures must be disclosed by health care providers or physicians to their patients or persons authorized to consent for their patients; and
  • establish the general form and substance of such disclosure.

TMDP has developed List A (informed consent requiring full and specific disclosure) for certain procedures, which can be found in 25 Texas Administrative Code Section 601.2.

For all other procedures not included on List A, the physician must disclose, through a procedure specific consent, all risks that a reasonable client would need to know. This includes all risks that are inherent to the procedure (one which exists in and is inseparable from the procedure itself) and that are material (could influence a reasonable person in deciding whether to consent to the procedure).

5120 Consent for Services Provided to Minors

Revision 22-3; Effective Nov. 8, 2022

Generally, a parent must consent to treatment for minors. A minor is defined as a person under 18 years of age who has never been married and has never been declared an adult by a court (emancipated). However, there are certain circumstances under which a minor may consent for their own treatment. Requirements for parental consent for the provision of family planning services to minors vary according to the funding source subsidizing the services. The department and providers may provide family planning services, including prescription drugs, without the consent of the minor’s parent, managing conservator or guardian only as authorized by Chapter 32 of the Texas Family Code or by federal law or regulations.

5130 Resources and References

Revision 22-3; Effective Nov. 8, 2022

5200, Clinical Policy

Revision 22-3; Effective Nov. 8, 2022

Clinical guidelines are intended to establish minimal expectations of contractor agencies that receive funds to support epilepsy services. In general, specific decisions about tests for diagnostic evaluation, treatment modalities and ongoing follow-up are at the discretion of the clinician in consultation with the client or the client’s family, with the understanding that these decisions will be in line with nationally recognized standards of credible organizations.

Clinical visits to Epilepsy Program providers will be for epilepsy diagnosis and treatment, case management for ongoing care and assistance with integration of personal, social and vocational support services. Therefore, preventive care physical exams and risk assessments are not a requirement in the clinical record for epilepsy clients.

It is an expectation of the Epilepsy Program that epilepsy services providers will encourage each client to receive regular preventive care and health care for any needs other than epilepsy services from an appropriate provider.

5210 Telehealth and Telemedicine

Revision 22-3; Effective Nov. 8, 2022

Epilepsy Program providers may provide services via telehealth, if appropriate. Telehealth services are defined as health care services delivered by a health professional to a patient at a different physical location than the health professional, using telecommunications or information technology.

Providers who offer telehealth and telemedicine medical services must have written policies and procedures that include:

  • clinical oversight by the medical director or designated physician responsible for medical leadership;
  • contraindication considerations for telemedicine use;
  • qualified staff members to ensure the safety of the individual being served by telemedicine at the remote site;
  • safeguards to ensure confidentiality and privacy in accordance with state and federal laws;
  • services are provided by credentialed, licensed clinicians providing clinical care within the scope of their licenses;
  • demonstrated competency by all staff members who are involved in the operation of the system and provision of the services prior to initiating the protocol;
  • quality oversight and monitoring of satisfaction of the individuals served; and
  • management of information and documentation for telemedicine services that ensures timely access to accurate information between the two sites.

5220 Client Health Records and Documentation of Encounters

Revision 22-3; Effective Nov. 8, 2022

Providers must ensure that a patient health record is established for every individual who receives clinical services.

All patient health records must be:

  • complete, legible and accurate documentation of all client encounters, including those by phone, email or text message;
  • written in ink without erasures or deletions, or documented in the electronic medical record (EMR) or electronic health record (EHR);
  • signed by the provider making the entry, including the name of the provider, the provider’s title and the date for each entry;
    • Electronic signatures are allowable to document the encounter or provider review of care.
    • Stamped signatures are not allowable.
  • readily accessible to assure continuity of care and availability to clients; and
  • systematically organized to allow easy documentation and prompt retrieval of information.

All client health records must include:

  • client identification and personal data, including financial eligibility;
  • client’s preferred language and method of communication;
  • client contact information, including the best way and alternate ways to reach the client to ensure continuity of care, confidentiality and compliance with HIPAA regulations;
  • a complete medication list, including prescription, nonprescription medications and dietary supplements, updated at each encounter;
  • a complete listing of all allergies and adverse reactions to medications, food and environmental substances (e.g., latex). If the patient has no known allergies, this should be listed. Note: This information should be prominently displayed in the patient’s record and updated at each encounter;
  • a plan of care, updated as appropriate, that is consistent with diagnoses and assessments, which in turn are consistent with clinical findings;
  • documentation of recommended follow-up care, scheduled return visit dates and follow-up for missed appointments;
  • documentation of informed consent or refusal of services;
  • documentation of client education and counseling with attention to risks identified through the health risk assessment; and
  • at every visit, the record must be updated as appropriate, documenting the reason for the visit, relevant history, physical exam findings, and pertinent screening and diagnostic tests with results and treatment plan.

5230 Initial Medical History and Risk Assessment

Revision 22-3; Effective Nov. 8, 2022

In addition to the elements required for the client health record listed above, a comprehensive medical history must be obtained during the initial or early subsequent clinical visit (appropriately adapted to the age and gender of the client):

  • reason for the visit and current health status;
  • history of present illness, if indicated;
  • past medical history to include all serious illnesses, hospitalizations, surgical procedures, pertinent biopsies, accidents, exposures to blood and blood products, and mental health history;
  • review of systems with pertinent positives and negatives documented in the chart;
  • current and past tobacco, alcohol and substance use or abuse;
  • occupational and environmental hazard exposure;
  • nutritional and physical activity assessment;
  • assessment for sexual and intimate partner violence (IPV); and
  • pertinent family history.

Note: The comprehensive medical history can be obtained from another provider’s clinical record with the client’s consent.

5240 Laboratory Tests

Revision 22-3; Effective Nov. 8, 2022

All initial and routine follow-up clients must be provided appropriate laboratory and diagnostic tests or interventions, as indicated by contractor policy or procedure or clinician judgment.

Agencies must have written plans to address laboratory and other diagnostic tests orders, results,  and follow-up to include:

  • tracking and documentation of tests ordered and performed for each client;
  • tracking test results and documentation in the client’s records; and
  • mechanism to notify clients of results in a manner to ensure confidentiality, privacy and prompt, appropriate follow-up.

5250 Resources

Revision 22-3; Effective Nov. 8, 2022

5260 Treatment

Revision 22-3; Effective Nov. 8, 2022

Treatment decisions must be made individually with each client. Before initiating anti-epileptic drugs (AEDs) as therapy, factors to discuss with the client and family are the likelihood of further seizures without drug treatment, the efficacy of the drug, adverse effectsand client and family preferences. Non-AED treatment may include implantation of a vagus nerve stimulator (VNS) or surgical intervention in selected clients (surgical interventions performed in an inpatient setting are not a benefit for the Epilepsy Program).

5270 Client Education

Revision 22-3; Effective Nov. 8, 2022

Contractors must have written plans for client education that include goals and content outlines to ensure consistency and accuracy of information provided. The medical director must sign client education plans.

All clients must be provided counseling and health education by a person who:

  • is knowledgeable, objective, nonjudgmental, and sensitive to the rights and differences of individual clients;
  • provides accurate, current information;
  • documents the session in the client record;
  • provides information appropriate to client’s age, level of knowledge and socio-cultural background; and
  • presents information in an unbiased manner.

As relevant to each individual Epilepsy Program client, educational counseling sessions should provide the following minimum content:

  • Types of seizure disorders
  • Possible symptoms
  • Common first aid procedures for seizures
  • Emergency contact numbers
  • Presence and absence of auras
  • Medication, dosages, side effects and interactions, as appropriate
  • Drug level monitoring
  • Signs of toxicity
  • Diagnostic tests
  • Treatment options
  • Frequency of follow-up visits
  • After-hour assistance

Epilepsy and women’s health:

  • Pre-conception counseling
  • Birth control and antiepileptic drugs (AEDs)
  • Pregnancy and AEDs
  • Bone health
  • Menopause

Epilepsy and men’s health:

  • Self-image
  • Mental health

General:

  • Employment
  • Driving restrictions
  • Safety (school, sports and jobs)
  • Financial assistance
  • Community resources, support group, legal aid and social services
  • Sexuality
  • Mental health
  • Personal violence

5280 Referral and Follow-Up

Revision 22-3; Effective Nov. 8, 2022

Contractors should assist clients to meet all identified health care needs either directly or by referral. Contractors must have written policies and procedures for follow-up on referrals that are made because of abnormal physical examination or laboratory test findings. These policies must be sensitive to clients’ concerns for confidentiality and privacy and must follow state or federal requirements for transfer of health information. For services determined to be necessary, but are not provided by the contractor, clients must be referred to other resources for care. Whenever possible, clients should be given a choice of referral resources.

When a client is referred to another resource because of an abnormal finding, or for emergency clinical care, the contractor must:

  • plan for the provision of pertinent client information to the referral resource (obtaining required client consent with appropriate safeguards to ensure confidentiality, i.e., adhering to HIPAA regulations);
  • advise the client about their responsibility in complying with the referral;
  • follow up to determine if the referral was completed; and
  • document the outcome of the referral.

5300, Prescriptive Authority Agreements, Clinical Protocols and Standing Delegation Orders

Revision 22-3; Effective Nov. 8, 2022

Contractors that provide clinical services must develop and maintain written clinical prescriptive authority agreements (PAAs), protocols and standing delegation orders (SDOs) in compliance with statutes and rules governing medical and nursing practice and consistent with national evidence-based clinical guidelines. When HHSC revises a policy, contractors need to incorporate the revised policy into their written procedures.

5310 Prescriptive Authority Agreements (PAAs)

Revision 22-3; Effective Nov. 8, 2022

Contractors who delegate the act of prescribing or ordering a drug or device to advanced practice registered nurse(s) and/or physician assistant(s) must have in place a prescriptive authority agreement (PAA), as required by Texas Administrative Code Title 22, Part 9, Chapter 193.

The PAA must meet all the requirements delineated in the Texas Medical Practice Act, Chapter 157 including, but not limited to, the following minimum criteria:

  • Be in writing, signed and dated by the parties to the agreement.
  • Include the name, address and professional license numbers of all parties to the agreement.
  • State the nature of the practice, practice locations or practice settings.
  • Identify the types or categories of drugs or devices that may be prescribed, or the types or categories of drugs or devices that may not be prescribed.
  • Provide a general plan for addressing consultation and referral.
  • Provide a plan for addressing patient emergencies.
  • Describe the general process for communication and sharing of information between the physician and the advanced practice registered nurse or physician assistant to whom the physician has delegated prescriptive authority related to the care and treatment of patients.

If alternate physician supervision is used, designate one or more alternate physicians who may:

  • provide appropriate supervision on a temporary basis in accordance with the requirements established by the prescriptive authority agreement and the requirements of this section;
  • participate in the prescriptive authority quality assurance and improvement plan meetings required under this section; and
  • describe a prescriptive authority quality assurance and improvement plan and specify methods for documenting the implementation of the plan that includes the following:
    • chart review, with the number of charts to be reviewed determined by the physician and advanced practice registered nurse or physician assistant; and
    • periodic face-to-face meetings between the advanced practice registered nurse or physician assistant and the physician at a location determined by the physician and the advanced practice registered nurse or physician assistant.

5320 Protocols

Revision 22-3; Effective Nov. 8, 2022

Contractors that employ advanced practice nurses or physician assistants must have written protocols to delegate authorization to initiate medical aspects of client care. Historically, this delegation has occurred through a protocol or other written authorization. Rather than have two documents, this delegation can now be included in a prescriptive authority agreement (PAA) if both parties agree. The PAA and protocols need not describe the exact steps that an advanced practice nurse or a physician assistant must take with respect to each specific condition, disease or symptom.

The protocols must be reviewed, agreed upon, signed, and dated by the supervising physician and the physician assistant or advanced practice nurse at least annually and maintained on-site.

5330 Standing Delegation Orders (SDOs)

Revision 22-3; Effective Nov. 8, 2022

When services are provided by unlicensed and licensed personnel, other than advanced practice nurses or physician assistants, whose duties include actions or procedures for a population with specific diseases, disorders, health problems or sets of symptoms, the clinic must have written SDOs in place. SDOs are distinct from specific orders written for a particular individual. SDOs are instructions, orders, rules, regulations, or procedures that specify under what set of conditions and circumstances actions should be instituted. The SDOs delineate under what set of conditions and circumstances an RN, LVN or non-licensed health care provider (NLHP) may initiate actions or tasks in the clinical setting and provide authority for use with individuals when a physician or advanced practice provider is not on the premises, or prior to being examined or evaluated by a physician or advanced practice provider.

Example: SDO for assessment of blood pressure or blood sugar which includes an RN, LVN or NLHP who will perform the task, the steps to complete the task, the normal and abnormal range, and the process of reporting abnormal values.

Other applicable SDOs when a physician is not present on-site may include, but are not limited to:

  • obtaining a personal and medical history;
  • performing an appropriate physical assessment and the recording of physical findings;
  • initiating or performing laboratory procedures;
  • administering or providing drugs ordered by voice communication with the authorizing physician;
  • providing pre-signed prescriptions for:
    • oral contraceptives;
    • diaphragms;
    • contraceptive creams and jellies;
    • topical anti-infective for vaginal use;
    • oral antiparasitic drugs for treatment of pinworms;
    • topical antiparasitic drugs; or
    • antibiotic drugs for treatment of STIs;
  • handling medical emergencies, to include on-site management as well as possible transfer of the client;
  • giving immunizations; or
  • performing pregnancy testing.

The SDOs must be reviewed, signed and dated by the supervising physician who is responsible for the delivery of medical care covered by the orders and other appropriate staff at least annually and maintained on site.

5340 Resources

Revision 22-3; Effective Nov. 8, 2022

Requirements addressing scope of practice and delegation of medical and nursing acts can be accessed at the following websites:

Rules that are most pertinent to this topic are:

  • Texas Administrative Code, Title 22, Part 9, Chapter 193
  • Texas Administrative Code, Title 22, Part 11, Chapters 221 and 224
  • Texas Administrative Code, Title 22, Part 9, Chapter 185 (Physician Assistant Scope of Practice)

5400, Community Education, Outreach and Participation

Revision 22-3; Effective Nov. 8, 2022

Epilepsy Program contractors must develop and implement an annual plan to provide community education to inform the public of their purpose and services, to disseminate knowledge of epilepsy, to enlist community support and to educate potential clients. The plan should be based on an assessment of the needs of the community and contain an evaluation strategy. Promotional activities should be reviewed annually.

5410 Informational Brochure

Revision 22-3; Effective Nov. 8, 2022

Contractors shall have an informational brochure with the following minimum content:

  • Mission statement
  • Hours of operation
  • Location
  • Services offered
  • Eligibility requirements
  • Phone number of each community clinic site
  • Toll free number or web address

5420 Duplication of Services

Revision 22-3; Effective Nov. 8, 2022

To prevent the duplication of services, contractors shall coordinate activities with, but not limited to, the following types of related agencies, organizations, and health and social service agencies in the area:

  • Area hospital physicians
  • School personnel
  • Local epilepsy association and support groups

5430 Professional Education

Revision 22-3; Effective Nov. 8, 2022

Contractors shall provide the opportunity for community-wide professional educational events for primary care providers, nurses, emergency workers and social workers, etc.

6100, Reimbursement, Data Collection and Reports

Revision 22-3; Effective Nov. 8, 2022

Epilepsy services contract amounts are ceilings against which contractors may bill for services provided to Epilepsy Program eligible clients. Once this ceiling has been reached, no further funds will be available for reimbursement.   Upon award expenditure, contractors are not required to screen new clients for program eligibility; however, if a screening is completed, the contractor is required to provide services to eligible clients. No client can be denied services for the inability to pay.

Contractors may only bill for services provided to clients who have been screened for potential Medicaid eligibility and other benefit programs and who have been determined eligible for the Epilepsy Program.

Categorical Reimbursement

Epilepsy categorical funding (cost reimbursement) is used to develop and maintain contractor infrastructure for the provision of epilepsy and related health services. The funding can be used to support clinic facilities, staff salaries, utilities, medical and office supplies, equipment,  travel, and direct medical services. All services will be reimbursed on a cost reimbursement basis. Payments will be made for costs incurred and will be supported by reporting services provided and limited client-level data. Costs may be assessed against any of the following categories the contractor identifies during their budget development process:

  • Personnel
  • Fringe Benefits
  • Travel
  • Equipment and Supplies
  • Contractual
  • Other
  • Indirect Costs

Epilepsy funds are disbursed to contractors through an invoicing system as expenses are incurred during the contract period. Program income must be expended before categorical funds are requested through the reimbursement  process. Contractors must submit a Monthly Reimbursement Packet (MRP) even if the contract reimbursement limit has been met. When program expenses exceed program income, the invoice will result in a payment. Program income includes all fees paid by Epilepsy Program clients (client co-pay) and other non-HHSC funding.

Accurate financial records must be maintained for quality assurance, fiscal monitoring, and programmatic evaluation by HHSC.

Monthly Reporting Packet (MRP)

At the start of each contract year, contractors will access their organization’s personalized MRP from the SharePoint Contractor Portal.

When the MRP is accessed at the start of the contract year, contractors should download and save the invoice and MRP by double clicking on the file to open, selecting  “file” at the top of the MRP and selecting “save as.” When done this way, the template (xltx) file saves a new file with an .xlsx extension. This process leaves the template intact for later use.

Each MRP will cover services provided or expenses incurred in a preceding month as applicable to the contract. The MRP has five  tabs:

  1. Monthly Report Form
  2. Data Collection
  3. Narrative
  4. Monthly Report Form Instructions
  5. Data Instructions & Definitions

Monthly Submission Requirements

  • Monthly Report Form (MRF)
  • Data Collection Form – section A

The MRP is required to be completed and submitted monthly no later than 30 days after the last day of the preceding month to the contact(s) identified in the MRP instructions.

Note: The tabs in the MRP are interconnected and must not be moved or altered in any way. These tabs must remain intact for the formulas to work and for data to be accurately transferred from one tab to another.

Contractors should note that indirect charges (or indirect costs) in excess of the contracted amount will not be allowed.

Quarterly Submission Requirements

In addition to the monthly submission requirements, the following are required to be submitted quarterly:

  • Data Collection Form – sections B, C, and D
  • Quarterly Narrative
  • Signed Financial Status Report (Form 269A)

Quarterly requirements are due by the last business day of the month following the end of each quarter except the final quarter, which is due 45 days after the end of the contract period (Oct 15th). When October 15th falls on a weekend or holiday, the report is due on the previous Friday.

Reconciling Errors on Previously Submitted MRPs

If expenses are overstated on one month’s invoice, the following month’s expenses should be reduced accordingly.

Submission and Reporting after Entire Contract Award is Expended

Contractors must continue to submit the MRP even after contract ceilings have been reached. Any cost over the contract ceiling after deducting program income should be reflected under “Non-HHSC Funding.” This submission is required to continue reporting expenditures on any program income collected monthly and to provide HHSC with statistical information about the use of services.

Submission of Final MRP

Contractors may have claims after the submission of their August billing. Any additional invoices must be received by October 15th. Mark this as FINAL.

All claims for reimbursement for services delivered must be submitted within 45 days of the end of the contract.

Reimbursement requests submitted more than 45 days following the end of the contract term will not be paid.

Reimbursable Expenditures

Services may be provided to clients whose screening  indicates they are potentially Medicaid eligible, but the client has not yet completed the application process. Services provided on the initial day of service may be billed to the Epilepsy Program for reimbursement with proper documentation of client’s eligibility status.

Altering of Forms

Contractors are required to use the most current version of their organization’s personalized MRP  for ease of processing. No billing or  reporting forms may be altered in any manner. Invoices  should not be altered to itemize expenses for epilepsy services provided. Invoices  should be submitted for the total monthly reimbursement amount only.

Appendix I, Epilepsy Program Definition of Income

Revision 23-1; Effective March 31, 2023

Types of IncomeCountableExempt
Adoption Payments X
Cash Gifts and Contributions*X 
Child Support Payments*X 
Child's Earned Income X
Crime Victim's Compensation X
Disability Insurance Benefits*X 
Dividends, Interest and Royalties*X  X
Educational Assistance X
Energy Assistance X
Foster Care Payment X
In-Kind Income* X
Job Training X
Loans (Noneducational)*X 
Lump-Sum Payments*XX
Military Pay*X 
Mineral Rights*X 
Pensions and Annuities*X 
Reimbursements*X 
Retirement, Survivors and Disability(RSDI)/Social Security Payments*X 
Self-Employment Income*X 
Social Security Disability Income (SSDI)*X 
Supplemental Security Income (SSI) Payments X
Temporary Assistance for Needy Families (TANF) X
Terminated Employment*X 
Unemployment Compensation*X 
Veterans Affairs (VA)*XX
Wages and Salaries, Commissions*X 
Workers’ Compensation*X 

*Explanation of countable income and definitions of certain exemptions provided below.

Cash Gifts and Contributions – Count unless they are made by a private, nonprofit organization on the basis of need and total $300 or less per household in a federal fiscal quarter. The federal fiscal quarters are January through March, April through June, July through September and October through 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 noncertified household member who:

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

Child Support Payments – Count as income after deducting $75 from the total monthly child support payments the household receives.

Disability Insurance Benefits – Countable. Disability Insurance Benefits are part of a payroll tax-funded, federal insurance program of the Social Security Administration.

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

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

Loans (Noneducational) – Count as income unless there is an understanding that the money will be repaid and the person can reasonably explain how they 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. Exempt lump sums received once a year or less, unless specifically listed as income.

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

Mineral Rights – Countable. A payment received from the excavation of minerals, such as oil, natural gas, coal, gold, copper, iron, limestone, gypsum, sand, gravel, etc.

Pensions and Annuities – Countable. A pension is any benefit derived from former employment, such as retirement benefits or disability pensions.

Reimbursements – Countable, minus the actual expenses. Exempt a reimbursement for future expenses only if the household plans to use it as intended.

RSDI/Social Security Payments – Count the RSDI benefit amount, including the deduction for the Medicare premium, minus any amount that is being recouped for a prior RSDI overpayment.

Self-Employment Income – Count the total gross earned, minus the allowable costs of producing the self-employment income.

Social Security Disability Income (SSDI) – SSDI is a payroll tax-funded, federal insurance program of the Social Security Administration.

Terminated Employment – 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.

Unemployment Compensation Payments – Count the gross benefit less any amount being recouped for an Unemployment Insurance Benefit (UIB) overpayment.

VA Payments – Count the gross VA payment, 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.

Wages, Salaries, Tips and Commissions – Count the actual (not taxable) gross amount.

Workers’ Compensation – Count the gross payment, minus any amount being recouped for a prior workers’ compensation overpayment or paid for attorney’s fees. Note: Texas Workforce Commission (TWC) or a court sets the amount of the attorney’s fee to be paid.

Appendix II, Optional Copay Table Based on Monthly Federal Poverty Level (FPL)

Revision 24-2; Effective March 1, 2024

Fiscal Year 2024 Worksheet

Persons in Family/Household100% FPL Monthly $0 Copay133% FPL Monthly
Up to $10 Copay
150% FPL Monthly
Up to $20 Copay
185% FPL Monthly
Up to $25 Copay
200% FPL Monthly
Up to $30 Copay
1$1,255$1,670$1,883$2,322$2,510
2$1,704$2,266$2,555$3,152$3,407
3$2,152$2,862$3,228$3,981$4,304
4$2,600$3,458$3,900$4,810$5,200
5$3,049$4,055$4,573$5,640$6,097
6$3,497$4,651$5,245$6,469$6,994
7$3,945$5,247$5,918$7,299$7,890
8$4,394$5,844$6,590$8,128$8,787
9$4,842$6,440$7,263$8,958$9,684
10$5,290$7,036$7,935$9,787$10,580
11$5,739$7,632$8,608$10,616$11,477
12$6,187$8,229$9,280$11,446$12,374
Extra*$449$597$673$830$897

*For families and households with more than 12 persons, add Extra for each additional person.

Note: No copay can be charged for a household below 100% FPL.

The contractor must waive the fee if a client self-declares an inability to pay. No client shall be denied services based on an inability to pay. If a copay is charged, it may not exceed $30 or the cost of the visit or encounter, whichever is less. The FPL is calculated and published annually each calendar year at HHS FPL Guidelines.

Forms

ES = Spanish version available.

FormTitle
3046Statement of Applicant’s Rights and ResponsibilitiesES
3047Notice of IneligibilityES
3048Notice of EligibilityES
3049Employment VerificationES
3051Self-Employment IncomeES
3056Request for InformationES
3094Application for Program BenefitsES
4116Authorization for Expenditures 

24-3, Updates Section 4300

Revision 24-3; Effective May 1, 2024

The following changes(s) were made:

RevisedTitleChange
4300Procedures and Terminology When Determining Epilepsy EligibilityUpdates Documentation of Residency and Calculation of Applicant’s Federal Poverty Level (FPL) Percentage tables with Fiscal Year 2024 changes.

24-2, Appendix II Revised

Revision 24-2; Effective March 1 2024

The following changes(s) were made:

RevisedTitleChange
Appendix IIOptional Copay Table Based on Monthly Federal Poverty Level (FPL)Updates appendix with fiscal year 2024 Federal Poverty Level for program eligibility.

24-1, Miscellaneous Changes

Revision 24-1; Effective Jan. 8, 2024

The following change(s) were made:

RevisedTitleChange
4100Eligibility and Assessment of Copay  and FeesUpdates form numbers.
4200Eligibility and Fees Updates form numbers.
4300Procedures and Terminology When Determining Epilepsy EligibilityUpdates form numbers.

23-1, Miscellaneous Changes

Revision 23-1; Effective March 31, 2023 

The following change(s) were made:

RevisedTitleChange
4100Eligibility and Assessment of Copay  and FeesUpdates form names.
4300Procedures and Terminology When Determining Epilepsy EligibilityUpdates form names.
AppendicesAppendicesUpdates Appendix I title.
Appendix IAppendix I, Epilepsy Program Definition of IncomeRevises appendix title.
Appendix IIAppendix II, Optional Copay Table Based on Monthly Federal Poverty Level (FPL)Revises appendix title and updates Fiscal Year 2023 Worksheet to reflect FPL changes.
FormsFormsUpdates forms. Replaces Form 3029 with Form 3094.
EEPM Contact UsEPPM Contact UsUpdates program email.