4100, Eligibility and Assessment of Co-pay and Fees

Revision 24-2; Effective Sept. 16, 2024

Grantees must develop a policy showing how staff determine PHC program client eligibility. The policy must outline the grantee’s procedures for determining program eligibility and who is responsible for eligibility screening.

Grantees must  use the most recent version of  Form 3029, Application for Program Benefits (PDF), when screening applicants for program eligibility.

An alternate eligibility screening tool created by the grantee may be used in place of Form 3029 with prior written approval by the PHC program. To apply for approval, the grantee must contact program staff by email to request an Alternate Eligibility Screening Tool Request form. Grantees will send the request form and a copy of their proposed alternate screening tool to the program mailbox at primaryhealthcare@hhs.texas.gov once completed. The tool must contain, at minimum, all required elements of the Form 3029.

Once a grantee gets approval for the use of an alternate eligibility screening tool, the following requirements will apply:

• Grantees must request approval from the PHC 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 grant term. If a grantee is awarded funding under a subsequent grant, the grantee 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 3029 by the PHC program must be incorporated into the grantee-developed alternate screening tool. Grantees will need to submit their grantee-developed alternate screening tool with the incorporated changes within 60 calendar days for re-review and approval.
• The PHC program reserves the right to request additional edits or withdraw its approval of the use of an alternate eligibility screening tool. HHSC program will notify the grantee of the decision in writing and include the date the use of the alternate tool must be discontinued.

The following forms are optional, but may be used to aid in completing the eligibility screening process:

• Form 3049, Employment Verification; and
• Form 3051, Statement of Self-Employment Income.

Grantee may use the optional copay table available in Appendix II, Optional Co-Pay Table Based on Monthly Federal Poverty Level (FPL).

Applicants who served in any branch of the United States Armed Forces, Reserves, or National Guard may be eligible for additional benefits and services and must be referred to the Texas Veterans Portal for more information.