4100, Client Eligibility Screening Process

Revision 24-2; Effective Oct. 15, 2024

Grantees 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
• FPP.

Eligibility screening criteria and processes are described below.

4110 Screening for Medicaid

Revision 24-2; Effective Oct. 15, 2024

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

• They will be issued a Your Texas Benefits card.
• They should show their Your Texas Benefits card at the point-of-service delivery.

Even with this card, providers must verify Medicaid eligibility by calling Texas Medicaid and 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 24-2; Effective Oct. 15, 2024

Healthy Texas Women (HTW) is a Medicaid waiver 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 15 through 44 years old, are U.S. citizens or qualified immigrants and live in Texas must be screened for HTW eligibility.

To screen for HTW, grantees may use the Prescreening Tool on the Your Texas Benefits website, 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 FPP can take place.

Rescreening for HTW

• If the applicant seeks services within 45 calendar days from the application submission date, and the person has undetermined HTW eligibility, then grantees 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 person’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 a person indicates 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 24-2; Effective Oct. 15, 2024

Grantees must determine and document FPP eligibility before services are rendered. To assess eligibility for services, grantees must use Form 1065, Eligibility Application, or an HHSC-approved eligibility screening form substitute, such as 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 person’s record and must show their FPL and the co-pay amount they may be charged. A person’s eligibility must be assessed annually. If eligibility is determined over the phone, the grantee is authorized to sign the form on the applicant’s behalf with a digital ID or handwritten signature.

Eligibility Requirements

A male or female is eligible for FPP if they:

• are 64 years old or younger.
• live in Texas. Residency is self-declared. Grantees may request residency verification but such verification should not jeopardize delivery of services.
• have countable income that does not exceed 250% of the federal poverty level (FPL). Review Definition of Income for the Family Planning Program in section 9000, Resources.

Grantees must require income verification. If the methods used for income verification jeopardize the person’s right to confidentiality or impose a barrier to receipt of services, the grantee must waive this requirement and approve full eligibility. Reasons for waiving verification of income must be noted in the person’s record. Review Calculation of Applicant’s Federal Poverty Level (FPL) Percentage in Section 4140.

Grantees determine eligibility at the point of service per program policy and procedures.

4140 Adjunctive Income Eligibility and Calculation of Applicant Income

Revision 24-2; Effective Oct. 15, 2024

An applicant is considered adjunctively, automatically, income eligible for services at an initial or renewal eligibility screening if they currently are enrolled in one of the following programs:

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

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

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

To verify eligibility for CHIP Perinatal, 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’s current enrollment status cannot be verified during the eligibility screening process, adjunctive income eligibility would not be granted. The grantee 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 U.S. 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. 
   
   To determine FPP eligibility, the household is defined as a person who lives alone or a group of two or more persons related by birth, marriage, common law marriage or adoption who live together and who are legally responsible for the support of the other person. Treat applicants who are 18 years old as adults. No one 18 years 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.
   
   To determine income eligibility, count the income of the following people if they are living together:
   • The people 18 through 64 years old applying for FPP;
     • the person’s spouse; and
     • the person’s children aged 18 and younger; or
   • The person 17 years or younger applying for FPP;
     • The person’s parent(s)
     • The person’s siblings 18 years and younger; and
     • The person’s children;
   • For an unmarried applicant who lives with a partner, only count the partner’s income and children as part of the household if the applicant and their 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 countable or exempt based on the source of the income per section 9000, Resources, Definition of Income. Grantees must have a written income verification policy.
   • Proof of income documentation may include:
     • copy(ies) of the most recent paycheck(s) or stub or monthly earning statement(s);
     • employer’s written verification of gross monthly income or Form 1065, Eligibility Application;
     • award letters;
     • domestic relation printouts of child support payments;
     • statement of support;
     • unemployment benefits statement or letter from the Texas Workforce Commission;
     • award letters, court orders or public decrees to verify support payments;
     • notes for cash contributions; and
     • other documents or proof of income determined valid by the grantee.
   • For unemancipated, unmarried people younger than18 years old, 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 to determine the charge for the service.
      
   • Income Deductions: Dependent care expenses must be deducted from total income to determine eligibility. Allowable deductions are actual expenses up to $200 per child per month for children younger than 2, $175 per child per month for each dependent 2 years old and older, and $175 per adult with disabilities per month. Legally obligated child support payments made by a member of the household group must also be deducted. Payments made weekly, every two weeks or twice a month must be converted to a monthly amount with 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% of the FPL for the household size.
    
4. Multiply by 100 to reach a percentage.

4150 Former Military Service Members

Revision 24-2; Effective Oct. 15, 2024

Women and men who served in any branch of the U.S. Armed Forces, including Army, Navy, Marines, Air Force, Space Force, Coast Guard, Reserves or National Guard, may be eligible for benefits and services under other HHSC programs. For more information, visit the Texas Veterans Portal.