Revision 21-1; Effective January 6, 2021
This section provides policy requirements for eligibility, client services community activities and clinical guidelines.
4100 Eligibility and Assessment of Co-pay/Fees
Revision 21-1; Effective January 6, 2021
Contractors must develop a policy to determine epilepsy eligibility. The contractor must ensure documentation provides a clear understanding of the eligibility screening process. Contractors must perform an eligibility screening assessment on all clients who present for services using the most recent version of one of following eligibility tools:
- Form 3029, Office of Primary and Specialty Health Application for Program Benefits; or
- A comparable paper or electronic eligibility tool, previously approved by the Epilepsy Program may be used, if it contains the required HHSC information for eligibility determination and the applicant’s signature.
The following forms are optional, but may be used to aid in completing the epilepsy eligibility process:
- Form 3056, Office of Primary and Specialty Health Request for Information;
- Form 3049, Office of Primary and Specialty Health Employment Verification; and
- Form 3051, Office of Primary and Specialty Health Statement of Self-Employment Income.
Client Eligibility Screening Process
For an individual 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 age 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.
Procedures and Terminology When Determining Epilepsy Eligibility
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/her partner have mutual children together. Unborn children should also be included. Treat applicants who are 18 years of age 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 of age to be counted as part of a larger family. Eligibility will end on the last day of the month the child becomes 18 years of age 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/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), as defined in Office of Primary and Specialty Health (OPSH) Definition of Income (see the Provider Portal on the HHS website). Contractors must have a written epilepsy income verification policy.
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 under age 2; $175 per child per month for each dependent age 2; 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 period of time 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:
|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:
|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.
- Individuals 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 OPSH Optional Co-Pay Table Based on Monthly Federal Poverty Level is for contractor use to determine an Epilepsy Program household’s FPL 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 and/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 are required to 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).
Date Eligibility Begins
An individual/household is eligible for services beginning with the date the contractor determines the individual/household is eligible for the program and signs the completed application. Contractors have the option to notify epilepsy applicants of their eligibility status using the optional letters provided by the Epilepsy Program:
- Form 3047, Office of Primary and Specialty Health Notice of Ineligibility; or
- Form 3048, Office of Primary and Specialty Health 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, Office of Primary and Specialty Health Application for Program Benefits.
Contractors must have a system in place to track client eligibility and renewal status on an annual basis.