4100, Eligibility and Assessment of Copay and Fees

Revision 24-1; Effective Jan. 8, 2024

Contractors must develop a policy indicating how staff will determine Epilepsy Program client eligibility. The policy must outline the contractor’s procedures to determine 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 3094.

An alternate eligibility tool created by the contractor may be used in place of Form 3094 with prior written approval by the Epilepsy Program. The tool must contain, at minimum, all required elements of Form 3094 for eligibility determination as well as the signature of the applicant or applicant’s legal representative.

Once a contractor gets approval for the use of an alternate eligibility screening tool, the following requirements 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 3094 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 notifies the contractor of the decision in writing and includes the date when the alternate tool must be discontinued. 

The following forms are optional, but may be used to help complete the epilepsy eligibility process:

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