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 23-1; Effective March 31, 2023
Contractors must develop a policy indicating how staff will determine Epilepsy Program client eligibility. The policy must outline the contractor’s procedures for determining program eligibility and who is responsible for eligibility screening.
Contractors must perform an eligibility screening assessment on all clients who present for services using the most recent version of Form 3029.
An alternate eligibility tool created by the contractor may be used in place of Form 3029 with prior written approval by the Epilepsy Program. The tool must contain, at minimum, all required elements of Form 3029 for eligibility determination as well as the signature of the applicant or applicant’s legal representative.
Once a contractor obtains approval for the use of an alternate eligibility screening tool, the following requirements will apply:
- Contractors must request approval from the 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 3029 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 will notify the contractor of the decision in writing and include the date by which use of the alternate tool must be discontinued.
The following forms are optional, but may be used to aid in completing the epilepsy eligibility process:
4200, Client Eligibility Screening Process
Revision 22-3; Effective Nov. 8, 2022
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 under 21 is on a waiting list for CSHCN, he or she 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, the eligibility staff person must read the statements to the applicant and document that the applicant affirms the statements. The documentation must include the date and time of the applicant affirmation and the eligibility staff person’s signature. The client must sign the document at the time of their next visit to the clinic.
4300, Procedures and Terminology When Determining Epilepsy Eligibility
Revision 23-1; Effective March 31, 2023
Documentation of Date of Birth
Document proof of a client’s birth provided by the client on Form 3029, Application for Program Benefits. For documentation of a client’s date of birth, one of the following items may be provided:
- Birth certificate
- Baptismal certificate
- School records
- Other documents or proof of date of birth determined valid by the contractor.
Documentation of Family Composition
If family relationships are unclear, one of the following items may be requested:
- Birth certificate
- Baptismal certificate
- School records
- Other documents or proof of family relationship determined valid by the contractor to establish the dependency of the family member upon the client or head of household
Family members who receive other health care benefits are included in the family count. 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 for determining separate households, if applicable.
Documentation of Residency
To be eligible for the Epilepsy Program, a person must be physically present within the geographic boundaries of Texas and:
- have the intent to remain within the state, whether permanently or for an indefinite period;
- not claim residency in any other state or country; or
- if a person is less than 18 years old, a parent, managing conservator, caretaker or guardian is a resident of Texas as defined above.
There is no requirement regarding the amount of time a person must live in Texas to establish residency for the purposes of Epilepsy Program eligibility.
Document proof of residency provided by the client on Form 3029, Application for Program Benefits. Explain why residency is questionable, if necessary. For documentation of residency, one of the following items shall be provided:
- Valid Texas driver license
- Current voter registration
- Rent or utility receipts for one month prior to the month of application
- Motor vehicle registration
- School records
- Medical cards or other similar benefit cards
- Property tax receipt
- Mail addressed to the applicant, 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 regarding residency change proves otherwise.
Individuals do not lose their residency status because of temporary absences from the state. For example, a migrant or seasonal worker who may travel during certain times but maintains a home in Texas and returns to that home after these temporary absences.
The household consists of a person living alone, or a group of two or more persons related by birth, marriage (including common law) or adoption, who reside together and are legally responsible for the support of the other person. If an unmarried applicant lives with a partner, only count the partner’s income and children as part of the household group if the applicant and his or her partner have mutual children together. Unborn children should also be included. Treat applicants who are 18 years old as adults. No children aged 18 and 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 his or her 19th birthday.
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. A managing conservator is a person designated by a court to have daily legal responsibility for a child.
All income received must be included. Income is calculated before taxes (gross). Income is reviewed and determined either countable or exempt (based on the source of the income), 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 3029, Application for Program Benefits. Declarations of “unknown” will not be accepted as representations of required facts and documentation.
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 individual’s usual and customary earnings. Proof may include, but is not limited to:
- copy(ies) of the most recent paycheck(s) or stub/monthly earning statement(s);
- employer’s written verification of gross monthly income or Form 3029, 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.
Dependent care expenses shall be deducted from total income in determining eligibility. Allowable deductions are actual expenses up to $200 per child per month for children less than two years old; $175 per child per month for each dependent two years and older; and $175 per adult with disabilities per month.
Legally obligated child support payments made by a member of the household group shall also be deducted. Payments made weekly, every two weeks or twice a month must be converted to a monthly amount by using one of the conversion factors listed below.
Monthly Income Conversions
If income payments are received in lump sums or at longer intervals than monthly, such as seasonal employment, the income is prorated over the time 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, individuals are 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.
An individual may still be potentially eligible for the Epilepsy Program even if they are also possibly eligible for another program that covers the same services that are provided by the Epilepsy Program. The contractor should proceed with the eligibility process for the Epilepsy Program but inform the individual of their possible eligibility for the other program and suggest that they also apply for services for that program. The contractor must document in the individual’s case record that they were informed and were referred to the other program.
Individuals 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:
- Determine the total household’s monthly income.
- Determine the total household’s annual income by multiplying the monthly income by 12 (months).
- Determine 5% of the total annual income by multiplying it by 0.05 (5%).
|Total Monthly Household Income||Total Annual Household Income||5% of Total Annual Household Income|
|$1,000 x 12 (months)||= $12,000||X 0.05 = $600|
|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. See the example below for an annual insurance deductible of $6,000 and a monthly household income of $1,000:
- Determine the household’s monthly insurance deductible by dividing the annual deductible by 12 (months).
- Determine 5% of the total monthly household income by multiplying it by 0.05 (5%).
|Household Annual Insurance Deductible||Household Monthly Insurance Deductible||Total Monthly Household Income||Total Monthly Household Income|
|$6,000||÷ 12 = $500||$1,000||X 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, the contractor 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% of the FPL.
The maximum monthly income amounts by household size are based on the Department of Health and Human Services federal poverty guidelines. The guidelines are subject to change around the beginning of each calendar year.
The steps to determine the applicant’s actual household FPL percentage are:
- determine the applicant’s total monthly income amount;
- determine the applicant’s household size;
- divide the applicant’s total monthly income amount by the maximum monthly income amount at 100% FPL for the appropriate household size; and
- multiply by 100.
See the example below for a family of three, with a monthly income amount of $2,093:
|Total Monthly Income||Maximum Monthly Income (Household Size of 3)||Actual Household FPL %|
|$2,093||÷ $1,778 = 1.18 X 100||= 118% FPL|
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.
Clients shall not be charged administrative fees for items such as processing or transfer of medical records, copies of immunization records, etc.
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:
- Family composition
- Current address
- 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 the individual’s 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
An individual or household is eligible for services beginning with the date the contractor determines the individual 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:
- Form 3048, Notice of Eligibility.
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 3029, Application for Program Benefits.
Contractors must have a system in place to track client eligibility and renewal status on an annual basis.