3200, Client Eligibility

Revision 24-2; Effective Sept. 20, 2024

3210 Eligibility Guidelines

Revision 24-2; Effective Sept. 20, 2024

For an applicant to receive BCCS services, three general criteria must be met. The person must:

• have gross household income at or below 200% of the adopted Federal Poverty Level (FPL);
• be a Texas resident; and
• be without access to programs or benefits that provide the same services.

Other Eligibility Factors

Other eligibility factors include:

• Undocumented applicants who meet the general eligibility criteria are program eligible.
• Applicant must meet age-specific eligibility criteria for screening and diagnostic services.
• Applicants with a primary need of cancer screening should be enrolled in BCCS.
• Applicants whose health insurance does not fully cover screening and diagnostic services are considered underinsured and may be enrolled for services.

Grantee Responsibilities for Eligibility Determination

Grantees must develop an agency policy to determine BCCS eligibility. The policy must outline the grantee’s procedures to determine program eligibility and who is responsible for eligibility screening. The policy must also be available during monitoring visits and must address:

• Acceptable documents to verify household income at or below 200% FPL. Income must be recorded in the client record and Med-IT®.
• Use of Form 1065, Eligibility Application (PDF).
• Use of a comparable paper or electronic screening and eligibility tool with required information. Note: If a grantee desires to use a comparable eligibility screening tool, HHSC staff must review and approve before use. Grantees must use Form 1065 until they receive approval to use a comparable form. The grantee must maintain and retain proof of approval and must make the approval available during QA visits.
• Applicants who served in any branch of the U.S. Armed Forces, Reserves or National Guard may be eligible for more benefits and services. For more information, visit the Texas Veterans Portal.

Grantee eligibility policy must also make sure:

• Client insurance status is assessed before service delivery.
• General BCCS eligibility is determined before enrollment and annually thereafter.
• Clients 65 and over do not meet eligibility unless the client is ineligible for or unable to pay premiums for Medicare Part B.

A woman who is eligible to receive Medicare benefits and is not enrolled in Medicare should be encouraged to enroll. Women enrolled in Medicare Part B are not eligible to receive services. Women who are not eligible to receive Medicare Part B and Medicare-eligible women who cannot pay the premium to enroll in Medicare Part B are eligible to receive services. If a client cannot afford Medicare Part B premiums, Medicaid-sponsored Medical Savings Programs may pay Medicare premiums, deductibles and coinsurance amounts for eligible Medicare beneficiaries. The Qualified Medicare Beneficiary (QMB) program, the Specified Low-Income Medicare Beneficiary (SLMB) program, the Qualified Individuals (QI-1) and the Qualified Disabled Working Individuals (QDWI) program are all called Medicare Savings Programs. More information about Medicare Savings Programs is at Medicare.gov.

3220 Applying for Services

Revision 24-2; Effective Sept. 20, 2024

Screening and Eligibility Determination

Grantees must use Form 1065, Eligibility Application (PDF). Another eligibility screening form substitute, such as in-house form, electronic or automated form and phone interview, that contains the required information to determine eligibility may be used if first approved by HHSC staff.

The applicant is responsible for completing Form 1065. If the applicant needs help completing the form, the grantee must provide knowledgeable staff to assist.

Client eligibility determination may be conducted by phone. Applicants may print the form, add a handwritten signature and scan, email or fax the form to a grantee. Client and grantee digital signatures are allowable. If needed, a grantee may sign on behalf of an applicant. If eligibility is determined over the phone, the grantee must read and obtain the applicant’s verbal authorization to sign or initial, where applicable, the application on the applicant’s behalf with a digital ID or handwritten signature. Anyone who helps the applicant complete the form is also required to sign and date the form.

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 on Form 1065. Special circumstances must also be documented in the Med-IT® Data System in the notes section of the enrollment screen.

Household

Establishing household size is an important step in the eligibility process. Assessment of income eligibility relies on an accurate count of household members. The household consists of a person who lives 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. Unborn children should also be included. Treat applicants who are 18 years old as adults.

A BCCS-eligible applicant who is a legal adult is required to complete Form 1065.

The grantee has discretion to document special circumstances in the calculation of household composition.

Residency

To be eligible for BCCS, a person must be physically present within the geographic boundaries of Texas. There is no requirement about the amount of time a person must live in Texas to establish residency for BCCS eligibility. The person must have the intent to remain within the state permanently or for an indefinite period.

Income

To be eligible for BCCS services, applicants must provide verification of countable household income at or below 200% of the Federal Poverty Level (FPL). If the applicant is unable to provide verification, they may self-declare income. The reasons an applicant self-declares income must be documented in the client record and in the Med-IT® Data System. Both actual income amounts, which is income that was already received, and projected income amounts, which is income that has not been received but expected for the current month must be used to determine eligibility.

Note: Applicants who seek Medicaid for Breast and Cervical Cancer (MBCC) may not self-declare income. This includes women who have been diagnosed with a qualifying cancer by BCCS grantees or other health care providers. Applicants who received help from a BCCS grantee to apply for MBCC must have verification of income documented in their client record and on the eligibility screen in Med-IT®.

Calculation of Applicant’s FPL Percentage

1. Determine the applicant’s household size.
2. Determine the applicant’s total monthly income amount.
3. Divide the applicant’s total monthly income amount by the maximum monthly income amount at 100% FPL, for the appropriate household size.
4. Multiply by 100%.

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 near the beginning of each calendar year. However, grantees should not use updated guidelines until the BCCS program makes the necessary changes in Med-IT and a notification is sent to grantees on the updated guidelines’ effective date. The current FPL information is in Appendix V.

Income Deductions

Dependent care expenses and payments made by a member of the household group must be deducted up to the allowable amount as follows:

• legally obligated child support payments paid to the household;
• $200 per child per month for children under 2;
• $175 per child per month for children 2 – 17; and
• $175 per dependent adult with disabilities per month who is 18 and older.

Monthly Income Calculation

List the applicant’s household income in the table in Section IV of Form 1065. Include:

• income from work;
• income the applicant collects from charging room and board;
• the spouse’s income; and
• unemployment benefits.

For more countable and exempt income sources, refer to the Texas Works Handbook.

Calculate the Total Countable Monthly Income. Subtract the deductions to figure Net Countable Monthly Income.

When income is received in lump sums at irregular intervals or at longer intervals than monthly, such as contract labor, seasonal employment and lump sums, the total amount received is divided over the period for which the income is expected to cover household expenses to find a monthly income. Convert the amount with one of the following methods:

• Weekly income is multiplied by 4.33
• Income received every two weeks is multiplied by 2.17
• Income received twice a month is multiplied by 2.0
• Income received annually is divided by 12

For seasonal income, count the total income for the months worked in the overall calculation of income.

3230 Adjunctive Eligibility

Revision 24-2; Effective Sept. 20, 2024

An applicant is considered adjunctively, which is automatically eligible for BCCS services at an initial or renewal eligibility screening if the applicant or a member of the applicant’s household is currently enrolled in one of the programs listed below. An applicant must provide proof of active enrollment in the adjunctively eligible program. Acceptable eligibility verification documentation may include the following.

Note: Presentation of the Your Texas Benefits card does not completely verify current eligibility. Grantees must verify current eligibility as outlined below. If the applicant’s child, who must be considered part of the household, is enrolled in CHIP, the applicant may be considered adjunctively eligible in BCCS. If the applicant currently receives CHIP, BCCS services may not be provided until the applicant is no longer eligible for CHIP.

To verify eligibility, providers must call Texas Medicaid and Healthcare Partnership (TMHP) at 800-925-9126 or log on to TexMedConnect on the TMHP website. For a person's current eligibility status, providers must enter two of the following four data elements for the client:

• Patient Control Number
• Date of Birth
• Social Security Number
• Last Name

If the applicant’s current enrollment status cannot be verified during the eligibility screening process, adjunctive eligibility would not be granted. The grantee would then find eligibility according to usual protocols.

A copy of the accepted documentation must be kept in the client’s record and available during QA reviews.

3240 Date Eligibility Begins

Revision 24-2; Effective Sept. 20, 2024

Applicants are eligible to receive services the date an application is completed and the applicant is determined eligible. Services rendered before the date the applicant is determined eligible will not be reimbursed.

3250 Fees

Revision 23-2; Effective Sept. 29, 2023

Clients must not be charged administrative fees for items such as processing or transfer of medical records, or both, copies of immunization records and similar documents.

Grantees may bill clients for services outside the scope of BCCS allowable services if the service is provided at the client’s request and the client is made aware of their responsibility for paying the charges before services are rendered.

3260 Continuation of Services

Revision 23-2; Effective Sept. 29, 2023

Grantees who expend their awarded funds must continue to serve their existing eligible clients currently in the process of a care plan. It is allowable to obtain other funding to pay for these services. Dependent on the funding source, such funds may be counted toward the match requirement.

Grantees who expend their awarded funds are not required to enroll new clients. However, it is allowable to offer services at full pay or on a sliding scale basis.

3270 Med-IT® Data and Billing Services

Revision 24-2; Effective Sept. 20, 2024

Med-IT® users should verify a person is eligible for BCCS before adding a client to the database. Before entering a client’s information into the Med-IT® database, grantees must do a client search to find out if she has:

• ever received services funded by BCCS; and
• an existing Med-IT® identification number, which is a unique number assigned to each BCCS client.

This process can be completed by entering client identifiers, which may include name, date of birth, Social Security number or all three. A client’s address and ZIP Code may also be used to search for an existing Med-IT® identification number. If a client has an existing Med-IT® identification number and received services in a different region, the grantee should submit a region change request to Med-IT@hhs.texas.gov.

Minimum PC Requirements for Med-IT® are:

• Any internet connection – For optimum performance and response time, grantee locations should have access to a broadband connection with a minimum of 1 MB upload speed and 2 MB download speed.
• Google Chrome and Microsoft Edge.

Med-IT® users must have access to the database and BCCS service providers must be listed in the database. New users may request access by completing Form 5200, Med-IT New User Request (PDF). New providers must complete Form 5201, Med-IT New Provider Request (PDF). Each of these forms must be submitted to Med-ITHelpdesk@hhs.texas.gov.