4200, Client Fees, Co-pays and Guidelines

Revision 22-2; Effective April 1, 2022

Co-pays 

If an HHSC FPP contractor opts to charge a co-pay for services, a co-pay schedule must be developed and implemented with enough proportional increments so that inability to pay is never a barrier to service. The co-pay guidelines are:

  • No FPP client shall be denied services based on an inability to pay;
  • Clients with a household federal poverty level (FPL) at or below 100% shall not be charged a co-pay;
  • Individuals may not be charged an added co-pay for services that are provided by referral;
  • Individuals who are assessed a co-pay shall be presented with the bill at the time of service;
  • Contractors must keep records of individual co-pays paid and any balance owed;
  • Contractors must have a system for aging accounts receivable, which must be documented in the contractor’s policy and procedures and must clearly indicate a period for removing balances from an individual’s account due to inability to pay;
  • Contractors must maintain a co-pay schedule, approved by HHSC in advance, which must have proportional FPL increments and co-pay amounts (Note: An example of a co-pay schedule is provided by HHSC to contractors annually, following release of the Federal Poverty Guidelines. Contractors may opt to use the pre-approved PSPS Optional Co-Pay Table Based on Monthly Federal Poverty Level (FPL), which can be found in Section 9000, Resources);
  • The maximum co-pay amount must not exceed $30;
  • The co-pay schedule must be updated when the revised Federal Poverty Guidelines are released annually;
  • The co-pay must include all prescriptions;
  • Co-pays collected by the contractor are considered program income and must be used to support the delivery of HHSC FPP services;
  • Contractors must have policies and procedures regarding co-pay collection, which must be approved by the contractor’s governing body; and
  • Signs indicating this policy must be visibly posted at contractor clinic sites.

Other Fees

Clients shall not be charged administrative fees for items such as processing and/or transfer of medical records, copies of immunization records, etc. Contractors can bill clients for services outside the scope of HHSC FPP allowable services if the service is provided at the individual’s request and the client is made aware of their responsibility for paying for the charges.

Insurance 

Services may be provided to individuals with third-party insurance if the confidentiality of the person is a concern or if the person’s insurance deductible is 5% or more of their monthly income. Most insurance deductibles are given as an annual amount. FPP 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:

  1. Determine the total household’s monthly income.
  2. Determine the total household’s annual income by multiplying the monthly income by 12 (months).
  3. Determine 5% of the total annual income by multiplying it by 0.05 (5%).
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
If the applicant’s annual insurance deductible is any amount over $600, they are eligible under this criterion for HHSC FPP.

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:

  1. Determine the household’s monthly insurance deductible by dividing the annual deductible by 12 (months).
  2. Determine 5% of the total monthly household income by multiplying it by 0.05 (5%).
Household Annual Insurance Deductible Household Monthly Insurance Deductible Total Monthly Household Income 5% of Total Monthly Household Income
$6,000 ÷ 12 = $500 $1,000 x 0.05 = $50
If the applicant’s monthly insurance deductible is any amount over $50, they are eligible under this criterion for HHSC FPP.

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. 

Annual Recertification 

Annual eligibility determination and recertification is required for all clients who receive HHSC FPP services. Client eligibility must be redetermined every 12 months. Contractors must have a system in place to track client eligibility and renewal status on an annual basis.