4100, Client Eligibility Screening Process

Revision 22-2; Effective April 1, 2022

HHSC FPP contracted agencies must screen all family planning applicants for eligibility in the following programs that provide family planning services in this order:

  • Medicaid; 
  • Healthy Texas Women (HTW); and
  • HHSC FPP. 

Eligibility screening criteria and processes are described below.

4110 Screening for Medicaid

Revision 22-2; Effective April 1, 2022

If the client has a Medicaid card, it can be used to document Medicaid eligibility.

How to know if a person is covered by Medicaid

  • He/she will be issued a “Your Texas Benefits” card.
  • He/she should show his/her “Your Texas Benefits” card at the point-of-service delivery.

Even with this card, providers must verify Medicaid eligibility by calling Texas Medicaid & Healthcare Partnership (TMHP) at 800-925-9126 or log on to TexMedConnect to check the member’s Medicaid ID number (PCN).     

4120 Screening for HTW

Revision 22-2; Effective April 1, 2022

Healthy Texas Women (HTW) is a Medicaid program administered by HHSC to provide eligible uninsured women with women’s health and family planning services, such as women’s health exams, health screenings and contraception. HTW providers must provide clinical services on a fee-for-service basis. They may also (but are not required to) contract with HHSC to provide support services that enhance clinical service delivery on a cost reimbursement basis.

Potential female clients who are ages 15 through 44, are U.S. citizens or legal immigrants and live in Texas, must be screened for HTW eligibility. 

To screen for HTW, contractors may use the Prescreening Tool on YourTexasBenefits.com, or the “Am I Eligible?” tool on the HTW website. Both tools are acceptable methods for screening for HTW eligibility.

If the applicant is determined to be ineligible for HTW, either by screening ineligible or by client presentation of the denial letter or reason for denial, then screening for HHSC FPP can take place.  

Rescreening for HTW

  • If the applicant seeks services within 45 days from the application submission date, and the person has undetermined HTW eligibility, then contractors are not required to rescreen for HTW.
  • If the applicant has screened eligible, but the application determination was deemed ineligible for HTW, a copy of the denial letter or reason for denial must be maintained in the individual’s record. If an applicant does not provide a copy of the denial letter or reason for denial, providers should discuss their application or advise them to contact 866-993-9972 to discuss the status of their application. 
  • If an individual indicates that they would not meet eligibility requirements for HTW and refuses to be screened for the program, documentation of the refusal and reason should be noted in the client’s record. This documentation should be reviewed annually, and eligibility screening and application offered if a change in circumstances would indicate a change in eligibility. Applicants who were initially screened ineligible for HTW because of their citizenship or immigration status must be rescreened annually or when the individual reports a change in their citizenship or immigration status.

4130 Screening for and Determining FPP Eligibility

Revision 22-2; Effective April 1, 2022

Contractors must determine and document HHSC FPP eligibility before services are rendered. To assess eligibility for HHSC FPP services, contractors must use either Form 1065, Eligibility Application, or an HHSC program-approved eligibility screening form substitute (for example, in-house form, electronic form or phone interview) that contains the required information for determining eligibility.

The eligibility assessment may be completed over the phone or in the office. The completed eligibility form must be kept in the individual’s record and must show the individual’s poverty level and the co-pay amount he or she may be charged. An individual’s eligibility must be assessed annually. If eligibility is determined over the phone, the contractor is authorized to sign the form on the applicant’s behalf using a digital ID or handwritten signature.

Eligibility Requirements

Eligible individuals must be:

  • Females and males age 64 years and younger;
  • Texas residents (residency is self-declared). Contractors may request residency verification, but such verification should not jeopardize delivery of services;
  • At/or under 250 percent of the federal poverty level. Contractors must require income verification. If the methods used for income verification jeopardize the individual’s right to confidentiality or impose a barrier to receipt of services, the contractor must waive this requirement and approve full eligibility. Reasons for waiving verification of income must be noted in the individual record. See “Calculation of Applicant’s Federal Poverty Level (FPL) Percentage” below in Section 4140.

4140 Adjunctive Income Eligibility and Calculation of Applicant Income

Revision 22-2; Effective April 1, 2022

An applicant is considered adjunctively income eligible for HHSC FPP services at an initial or renewal eligibility screening if she or he is currently enrolled in one of the following programs:

  • Children’s Health Insurance Program (CHIP)
  • Supplemental Nutrition Assistance Program (SNAP)
  • Temporary Assistance for Needy Families (TANF)
  • Special Supplemental Nutrition Program for Women, Infants and Children (WIC)

Applicants determined to be adjunctively income eligible have met the income requirements for HHSC FPP through their participation in other income-tested programs. Except for calculating the client’s income, contractors must follow all screening procedures outlined in Section 4100, Client Eligibility Screening Process, before enrolling applicants determined to be adjunctively income eligible in HHSC FPP.

The applicant must be able to provide proof of active enrollment in the adjunctively income eligible program. Acceptable eligibility verification documentation may include:

Program Documentation
CHIP Your Texas Benefits Medicaid card*
SNAP SNAP eligibility letter
TANF TANF verification of certification letter
WIC WIC verification of certification letter, printed WIC-approved shopping list or recent WIC purchase receipt with remaining balance

*Note: Presentation of the “Your Texas Benefits” card does not completely verify current eligibility in the CHIP program. To verify eligibility, providers must call TMHP at 800-925-9126 or log on to TexMedConnect to check the member’s Medicaid ID number (PCN).

If the applicant or the applicant’s child (must be considered part of the household) is enrolled in CHIP, they may be considered adjunctively income eligible.

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

Calculation of Applicant’s Federal Poverty Level (FPL) Percentage – The maximum monthly income amounts by household size are based on the 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:

  1. Determine the applicant’s household size. 

    For determining FPP eligibility, the “household” is defined as 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 who are legally responsible for the support of the other person. Treat applicants who are 18 years of age as adults. No children age 18 and older or other adults living in the home should be counted as part of the household group.

    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.
       
  2. Determine the applicant’s total monthly income amount.

    For determining FPP eligibility, income should be determined using the following guidance:
    • For an unmarried applicant living with a partner, only count the partner’s income and children as part of the household if the applicant and his or her partner have mutual children together. Unborn children should also be included. 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 Section 9000, Resources, Definition of Income. Contractors must have a written FPP income verification policy.
       
    • For unemancipated, unmarried individuals under 18 years of age, if parental consent is required for the receipt of services per Section 32 of the Texas Family Code, the family's income must be considered in determining the charge for the service.
       
    • Income Deductions: 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 Calculation: If income is 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.
         
  3. Divide the applicant’s total monthly income amount by the maximum monthly income amount at 100 percent of the FPL for the household size.
     
  4. Multiply by 100 percent.

See the example below for a family of three, with a monthly income amount of $2,093. The table is based on the 2021 percentage poverty tool, created by the Office of the Assistant Secretary for Planning and Evaluation (ASPE).

Total Monthly Income   Maximum Monthly Income
(Household Size of 3)
  Actual Household FPL%
$2,093 ÷ $1,830 = 1.14 X 100% = 114% FPL