Revision 23-4; Effective Nov. 17, 2023
If a grantee opts to charge a copay for services, a copay schedule must be developed and implemented with enough proportional increments so that inability to pay is never a barrier to service. The following copay guidelines apply:
- no FPP client shall be denied services based on an inability to pay;
- clients with a household federal poverty level (FPL) at or below 100% shall not be charged a copay;
- clients may not be charged an added copay for services provided by referral;
- clients assessed a copay shall be presented with the bill at the time of service;
- grantees must keep records of individual copays paid and any balance owed;
- grantees must have a system for aging accounts receivable, which must be documented in the grantee’s policy and procedures and must clearly indicate a period for removing balances from a person’s account due to inability to pay;
- grantees must maintain a copay schedule, approved by HHSC in advance, which must have proportional FPL increments and copay amounts (Note: An example of a copay schedule is provided by HHSC to grantees annually, following release of the Federal Poverty Guidelines. Grantees may opt to use the pre-approved Optional Co-Pay Table Based on Monthly Federal Poverty Level (FPL), which can be found in Section 9000, Resources);
- the maximum copay amount must not exceed $30;
- the copay schedule must be updated when the revised Federal Poverty Guidelines are released annually;
- the copay must include all prescriptions;
- copays collected by the grantee are considered program income and must be used to support the delivery of FPP services;
- grantees must have policies and procedures regarding copay collection, which must be approved by the grantee’s governing body; and
- signs indicating this policy must be visibly posted at contractor clinic sites.
Clients shall not be charged administrative fees for items such as processing or transfer of medical records, copies of immunization records, etc. Grantees can bill clients for services outside the scope of 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.
Services may be provided to clients with third-party insurance if the confidentiality of the person is a concern or if the person’s insurance deductible is 5% or more of their monthly income. Most insurance deductibles are given as an annual amount. FPP 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
|If the applicant’s annual insurance deductible is any amount over $600, they are eligible under this criterion for FPP.
Another way to make the comparison is to divide the annual insurance deductible into a monthly amount. See the example below for an annual insurance deductible of $6,000 and a monthly household income of $1,000:
- Determine the household’s monthly insurance deductible by dividing the annual deductible by 12 (months).
- Determine 5% of the total monthly household income by multiplying it by 0.05 (5%).
|Household Annual Insurance Deductible
|Household Monthly Insurance Deductible
|Total Monthly Household Income
|5% of Total Monthly Household Income
|$6,000 ÷ 12
|$1,000 x 0.05
|If the applicant’s monthly insurance deductible is any amount over $50, they are eligible under this criterion for FPP.
Date Eligibility Begins
A person or household is eligible for services beginning with the date the grantee determines the person or household is eligible for the program and signs the completed application.
Annual eligibility determination and recertification is required for all clients who receive services. Client eligibility must be redetermined every 12 months. Grantees must have a system in place to track client eligibility and renewal status on an annual basis.
Client 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, household composition, residence, current address, employment, types of medical insurance coverage, and receipt of Medicaid, CHIP or other third-party coverage benefits. The client may report changes by mail, phone, in person or through someone acting on the client's behalf. If changes result in the client no longer meeting eligibility criteria, the client is denied continued services. By signing Form 1065, the client attests to the truth of the information provided.