Revision 23-2; Effective Sept. 8, 2023

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

4100 Eligibility and Assessment of Co-pay and Fees

Revision 23-2; Effective Sept. 8, 2023

Grantees must develop a policy to show how staff will determine Title V MCH FFS program client eligibility. The policy must outline the grantee’s procedures for determining program eligibility and who is responsible for eligibility screening. 

Grantees 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 grantee may be used in place of Form 3029 with prior written approval by Title V MCH FFS program. To apply for approval, the grantee must send a request for an Application for Alternate Eligibility Tool to the program mailbox at titlevffs@hhs.texas.gov. The alternate eligibility tool must contain, at minimum, all required elements of the Form 3029. 

Once a grantee obtains approval for the use of an alternate eligibility screening tool, the following requirements will apply: 

• Grantees must request approval from Title V MCH FFS 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 grantee is awarded funding under a subsequent contract, the grantee 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 HHSC program must be incorporated into the grantee-developed alternate screening tool. Grantees will need to submit their grantee-developed alternate screening tool with the incorporated changes within 60 calendar days for re-review and approval.   
• The Title V MCH FFS program reserves the right to request more edits or withdraw its approval of the use of an alternate eligibility tool. Title V MCH FFS program will notify the grantee of the decision in writing and include the date that the alternate tool must be discontinued.  

The following forms are optional, but may be used to aid in completing the PHC eligibility process: 

• Form 3056, Request for Information; 
• Form 3049, Employment Verification; and 
• Form 3051, Statement of Self-Employment Income. 

If an applicant is determined to be ineligible for services after the screening process is complete, the applicant's must be given the Notice of Ineligibility, Form 3047. The applicant must also be informed of their right to appeal the eligibility decision using the process described on the Notice of Ineligibility.

Client Eligibility Screening Process

For a person to receive Title V MCH FFS services, three criteria must be met:

• gross family income at or below 185% of the Federal Poverty Level (FPL);
• Texas resident; and
• not eligible for other programs or benefits providing the same services.

The Title V Child Health and Child Dental program serves persons from birth until their 22nd birthday and the Title V Prenatal Medical and Prenatal Dental programs serve pregnant women of any age through three months postpartum, including following pregnancy loss.

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

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's affirmation and the eligibility staff person’s signature. The client must sign the document at the time of their next visit to the clinic. 

If documentation is not available or is insufficient to determine eligibility, grantees staff should ask the individual to designate a contact person to provide the information.

Upon award expenditure, grantees are not required to screen new clients for Title V MCH FFS eligibility. However, if a screening is completed, the grantee must provide services to eligible clients.

Procedures and Terminology When Determining Title V MCH FFS Eligibility

Potential Eligibility and Referral to Other Programs Screening for other benefit programs must be documented on the Application for Program Benefits form. 

The Title V MCH FFS Program is the payor of last resort. Applicants must be screened for Medicaid, CHIP, CHIP Perinatal, and any other benefit programs. Title V MCH FFS will not reimburse for services provided to people potentially eligible for another funding source and who do not complete the respective eligibility application process. Applicants who do not fully comply with applying for other benefit programs for which they appear eligible are not eligible for Title V MCH FFS, and grantees will not be reimbursed for services provided.

If a client appears eligible for any of these other benefit programs, they must be granted Presumptive Eligibility for Title V while awaiting benefit determination.  

The grantee must notify the client they must apply for any program for which they appear eligible. The client is responsible for submitting proof of application or a denial letter before the presumptive eligibility period ends. If a client does not appear eligible for any other program, this must be documented on the application. 
   
All Medicaid, CHIP, Medicaid for Pregnant Women, CHIP Perinatal, or other benefit program applications must be submitted promptly following Title V MCH FFS eligibility assessment. If a client was denied Medicaid or CHIP services, the denial letter must be included with the application. 

All pregnant women served by Title V MCH FFS must apply for the CHIP Perinatal program to receive health benefits for the unborn child and newborn. Providers are required to inform, encourage, and assist pregnant women in the CHIP Perinatal and Medicaid for Pregnant Women application process. A maximum of two (2) clinical prenatal care visits will be allowed for women who are in the process of applying for and enrolling in the CHIP Perinatal and Medicaid for Pregnant Women programs.  

Grantees may use the HHSC Your Texas Benefits website to assist in the screening of client eligibility. More information about HHSC benefits can also be obtained by calling 2-1-1. 

Household

The household consists of a person living alone, or a group of two or more people related by birth, marriage (including common law) or adoption, 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 his or her partner have mutual children together. Unborn children should also be included. 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:

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

Documentation of Date of Birth

Documentation of date of birth must be provided for clients applying for the Child Health or Child Dental programs. One of the following should be provided and a copy should be kept with the client’s application:  

• birth certificate;
• baptismal certificate;
• school records; or
• other documents or proof of date of birth determined valid by the grantee.

Documentation of Family Composition

If family relationships are unclear, request one of the following items:

• birth certificate;
• baptismal certificate;
• school records; or
• other documents or proof of family relationship determined valid by the grantee to establish the dependency of the family member with the client or head of household.

Family members who receive other health care benefits are included in the family count. The grantee 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 Title V MCH FFS services, a person must be physically present within the state 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 about the amount of time a person must live in Texas to establish residency for the purposes of Title V MCH FFS 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, provide one of the following items:

• 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, their spouse, or children if they live together; or
• other documents considered valid by the grantee.

If none of the listed items are available, verify residency 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 residency information is verified. 

People 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.

Documentation of Income

All income received must be included. Income is calculated before taxes (gross). Income is reviewed and determined either countable or exempt (based on the source of the income), as defined in Appendix I, Definition of Income. Grantees must have a written Title V MCH FFS income verification policy.

Documentation of income for Title V MCH FFS services must be provided to complete Form 3029, Application for Program Benefits. Declarations of “unknown” will not be accepted as documentation.

Provide the following documentation:

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

The pay periods must accurately reflect the person’s usual and customary earnings. Proof may include, but is not limited to:

• copy(ies) of the most recent paycheck(s) or stub or monthly earning statement(s);
• employer’s written verification of gross monthly income or Form 3049, Employment Verification; 
• award letters;
• domestic relation printouts of child support payments;
• statement of support;
• unemployment benefits statement or letter from the Texas Workforce Commission;
• court orders or public decrees to verify support payments;
• notes for cash contributions; and
• other documents or proof of income determined valid by the grantee.

Grantees must require income verification for countable income. In cases when submitting the income verification jeopardizes the client's right to confidentiality or imposes a barrier to receipt of services, the grantee must waive this requirement and document the reason.  

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.

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

The grantee must determine the household FPL percentage.

The maximum monthly income amounts by household size are based on the U.S 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 household FPL percentage are:

• determine the household's total monthly income amount;
• determine the household size;
• divide the household’s total monthly poverty guideline based on the household size; and
• multiply by 100.

There may be special circumstances where an applicant is unable to provide required documentation for verification purposes. These types of special circumstances should be appropriately documented.

Income Deductions

Dependent care expenses may be deducted from total income. This expense must be both necessary for employment and incurred by an employed person. Documentation must be provided. Allowable deductions are actual expenses up to:

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

Legally required child support payments made by a member of the household group may be deducted from total income. Documentation of payments must be provided. Convert payments made weekly, every two weeks or twice a month by using one of the conversion factors listed above. 

Documenting Special Circumstances

There may be special circumstances where an applicant is unable to provide required documentation for verification purposes. These types of special circumstances should be appropriately documented.

Client Fees and Copayments

Grantees may assess a copay for services from Title V MCH FFS clients. Grantees who choose to collect copays must have a copay policy using the following guidelines:

• No Title V MCH FFS 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 copay, as calculated using the U.S. HHS Poverty Guidelines.
• Clients with a household FPL above 100% may be charged a copay of no greater than $30 per visit. 
• Grantees must have a written copay policy which clearly defines how copay amounts will be determined.
• Clients who are assessed a copay must be presented a statement at the time of service and a copy should be kept in the client’s record.
• Clients who declare an inability to pay a copay shall not be denied services. Any outstanding balance may not be turned over to a collection agency or reported delinquent to a credit reporting agency.
• All policies and procedures regarding copay collection must be approved by the grantee’s board of directors.
• Copays must be reported as program income on the Monthly Reimbursement Packet (MRP). The grantee must complete B25 and E25.

Grantees may use the optional copay table available in Appendix II, Optional Co-Pay Table Based on Monthly Federal Poverty Level (FPL).

Other Fees

Do not charge clients administrative fees for items such as processing or transfer of medical records and copies of immunization records.

Grantees can bill clients for services outside the scope of Title V MCH FFS allowable services if the service is provided at the client’s request and the client is made aware of financial responsibility for the charges before services are provided.

Client’s Responsibility for Reporting Changes

A client must report the following changes no later than 30 days after the change:

•    income;  
•    family composition;  
•    residence;  
•    current address;  
•    employment;  
•    medical insurance coverage; or 
•    receipt of Medicaid, CHIP, CHIP-P, or other third-party coverage benefits. 

The client may report changes by mail, phone, in person or through someone acting on the client's behalf. If changes result in the client no longer meeting eligibility criteria, the client’s eligibility will terminate. Upon termination, the grantee must issue Form 3047, Notice of Ineligibility, to the client, including the date of termination.

Date Eligibility Begins

An individual or household is eligible for services beginning with the date the grantee determines they are eligible for the program and signs the completed application. To notify an applicant of eligibility, the grantee must issue the following forms to the client:

• Form 3048, Notice of Eligibility
• Form 3046, Applicant’s Rights and Responsibilities

Presumptive Eligibility

Presumptive eligibility provides short-term access to healthcare services for up to 90 days when an applicant screens as eligible and has a medical or dental need but lacks the required documentation or verification. For clients who submit all required application documentation during their presumptive eligibility period, the eligibility expiration date will be calculated from the first day that presumptive eligibility began. The expiration date is 365 days from the first day of presumptive eligibility except for Perinatal benefits which expire at 3 months postpartum. 

Clients without final eligibility for services determined who present with a medical or dental need may receive Title V MCH FFS funded services on a presumptive eligibility basis during the time that eligibility determination is pending. If a medical condition makes eligibility determination impossible, make an appointment to complete the process at the first possible opportunity.

If eligibility cannot be determined because of missing eligibility criteria components, the grantee may issue Form 3056, Request for Information.

To notify an applicant of Presumptive Eligibility, the grantee must issue the following forms to the client:

• Form 3045, Presumptive Eligibility Notice
• Form 3046, Applicant’s Rights and Responsibilities 

If the client enrolls in Medicaid or CHIP during the presumptive eligibility period, bill the services to Medicaid.

Annual Recertification

Annual eligibility determination is required for all clients who receive Title V MCH FFS services. Client eligibility must be redetermined every 12 months, using the most recent version of Form 3029, Application for Program Benefits. Perinatal benefits expire at 3 months postpartum.

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