4000, Eligibility and Fees

Revision 20-2; Effective October 15, 2020

This section provides policy requirements for eligibility, client services, community activities and clinical guidelines.

4100 Eligibility and Assessment of Co-pay/Fees

Revision 20-2; Effective October 15, 2020

Contractors must develop a policy to determine Primary Health Care (PHC) eligibility. The contractor must ensure documentation provides a clear understanding of the eligibility screening process. Contractors must perform an eligibility screening assessment on all clients who present for services using the most recent version of one of following eligibility tools:

  • Form 3029, Office of Primary and Specialty Health Application for Program Benefits.
  • A comparable paper or electronic eligibility tool, previously approved by the PHC program may be used, as long as it contains the required HHSC information for eligibility determination and the applicant's signature.

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

  • Form 3056, Office of Primary and Specialty Health Request for Information;
  • Form 3049, Office of Primary and Specialty Health (OPSH) Employment Verification; and
  • Form 3051, Office of Primary and Specialty Health Statement of Self-Employment Income.

4200 Client Eligibility Screening Process

Revision 20-2; Effective October 15, 2020

For an individual to receive PHC program services, three criteria must be met:

  • Gross family income at or below 200% of the Federal Poverty Level (FPL);
  • Texas resident; and
  • Not eligible for other programs/benefits providing the same services.

Residency is self-declared. Contractors may require residency verification, but such verification should not jeopardize delivery of services. Contractors must require income verification for countable income. In cases when submitting the income verification jeopardizes the client's right to confidentiality or imposes a barrier to receipt of services, the contractor must waive this requirement. Reasons for waiving verification of income must be noted in the client record.

4300 Procedures and Terminology When Determining PHC Eligibility

Revision 20-2; Effective October 15, 2020

Household – The household consists of 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 are legally responsible for the support of the other person. If an unmarried applicant lives with a partner, only count the partner's income and children as part of the household group if the applicant and his/her partner have mutual children together. Unborn children should also be included. 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.

Income – 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 Appendix I, Definition of Income. Contractors must have a written PHC income verification policy.

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 Conversions – If income payments are received in lump sums or at longer intervals than monthly, such as seasonal employment, the income is prorated over the time 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.

Presumptive Eligibility – PHC emphasizes the importance of prevention and early intervention. The goal of PHC is for clients to be part of the health care system and not rely on episodic acute care. An applicant's medical needs shall be met quickly and appropriately, using available resources in the community. Presumptive eligibility is the short-term availability and access to health care services (up to 90 days) when the client screens potentially eligible for services but lacks verification to achieve full eligibility. For clients who are determined to be fully eligible during the presumptive period, the eligibility expiration date will include the days of presumptive eligibility (expiration date is 365 days beginning the first date of eligibility determination). When full eligibility is granted during or at the end of the 90 days, the eligibility period end date is 12 months from the presumptive eligibility. On a case-by-case basis, the contractor may waive the requirement to submit the eligibility documentation and approve full eligibility, if the contractor determines submitting the documentation will create a barrier to care and no other documentation is available.

Adjunctive Eligibility – An applicant is considered adjunctively (automatically) eligible for PHC program services at an initial or renewal eligibility screening, if the individual is currently enrolled in the Children's Health Insurance Program (CHIP) Perinatal, Medicaid for Pregnant Women, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Supplemental Nutrition Assistance Program (SNAP) and/or Healthy Texas Women (HTW) Program. The applicant must be able to provide proof of active enrollment in the adjunctively eligible program. Acceptable eligibility verification documentation may include:

Program Documentation
CHIP Perinatal CHIP Perinatal benefits card
Medicaid for Pregnant Women Your Texas Benefits card (Medicaid card)*
WIC WIC verification of certification letter, printed WIC-approved shopping list or recent WIC purchase receipt with remaining balance
SNAP SNAP eligibility letter
HTW Your Texas Benefits card with "Healthy Texas Women" printed in the upper right corner
*Note: Presentation of the Your Texas Benefits card does not completely verify current eligibility in the HTW program or the Medicaid for Pregnant Women program. To verify eligibility, contractors must call Texas Medicaid & Healthcare Partnership (TMHP) at 1-800-925-9126 or access TexMedConnect on the TMHP website at www.tmhp.com. For a client's current eligibility status, contractors must enter two of the following four data elements for the client:
  • Patient Control Number;
  • Date of Birth;
  • Social Security Number; or
  • Last Name.

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

Potential Eligibility and Referral to Other Possible Qualifying Programs – In general, individuals are not eligible for the PHC program if they are enrolled in another third-party payer, such as private health insurance, Medicaid or Medicare, TRICARE, Workers' Compensation, Veterans Affairs Benefits or other federal, state or local public health care coverage that provides the same services. An individual may still be potentially eligible for the PHC program even if they are also eligible for another program that covers the same services that are provided by the PHC program. The contractor should proceed with the eligibility process for the PHC program but inform the individual of their possible eligibility for the other program and suggest that they also apply for services for that program. The contractor must document in the individual's case record that they were informed and were referred to the other program.

Supplemental Benefits – In some cases, individuals receiving benefits from other sources, such as Medicaid or Medicare, may be eligible for partial PHC coverage. This supplemental or wraparound coverage is limited to services provided by PHC but not covered by other sources. Whenever federal, state, private or other benefits are available for payment of clients receiving PHC covered services, no PHC funds shall be used to pay for such care. An example of supplemental benefits would be providing health education services to a Medicaid-eligible individual, since Medicaid does not provide health education services. The contractor must communicate to the client that supplemental services are of limited scope.

Insurance – Individuals with insurance may be eligible for services provided by PHC when the applicant's confidentiality is a concern or if the applicant's insurance deductible is 5% or greater than their income. Most insurance deductibles are given as an annual amount. PHC 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 PHC.

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 PHC.

The completed eligibility form must be maintained in the client medical record, indicating the client's poverty level and the co-pay amount the person will be charged.

Payer of Last Resort – As previously mentioned, individuals seeking PHC-covered services may be dually eligible for other HHSC funded programs within an agency that provides the same services, such as HHSC Family Planning, Breast and Cervical Cancer Screening Services, or the Title V Prenatal, Child or Dental Program(s). In such cases, it is up to the contractor to determine the best use of funds within their agency.

PHC is the payer of last resort for a client who is enrolled in any other non-HHSC program that provides payment for the cost of the same primary care services at the time the client presents for those services.

Calculation of Applicant's Federal Poverty Level (FPL) Percentage – If a contractor collects a co-payment (co-pay), the contractor must determine the applicant's exact household FPL percentage. The contractor must not charge a co-pay for PHC clients whose household income is at or below 100% of the FPL. The maximum monthly income amounts by household size are based 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 total monthly income amount.
  2. Determine the applicant's household size.
  3. Divide the applicant's total monthly income amount by the maximum monthly income amount at 100% FPL for the appropriate household size.
  4. Multiply by 100. See the example below for a family of three, with a monthly income amount of $2,093:

See the example below for a family of three, with a monthly income amount of $2,093:

Total Monthly Income Maximum Monthly Income (Household Size of 3) Actual Household FPL %
$2,093 ÷ $1,778 = 1.18 x 100 = 118% FPL

Client Fees/Co-Pays – PHC contractors may (but are not required to) assess a co-pay for services from PHC clients. The co-pay guidelines are:

  • No PHC client shall be denied services based on an inability to pay.
  • Clients with a household FPL at or below 100% should not be charged a co-pay.
  • Contractors may charge a co-pay amount ranging from $10 up to a maximum of $30 per encounter for clients above 100% of the FPL.
  • Individuals who are assessed a co-pay should be presented with the bill at the time of service.
  • Clients who declare an inability to pay a co-pay shall not be denied services, have an account with an outstanding balance turned over to a collection agency or reported delinquent to a credit reporting agency.
  • The client co-pay for a single visit must cover all the priority services provided or ordered at that visit.
  • Contractors may charge an additional co-pay for all optional services provided during one visit. The optional co-pay amount may not exceed 50% of the amount for priority services. The co-pay for optional services may be assessed in addition to the co-pay for priority services.
  • Client co-pays must be reported as program income on the monthly Form 4116, Authorization for Expenditures, and the quarterly Financial Status Report (FSR) or Form 269a.
  • The OPSH Monthly Federal Poverty Guidelines is for contractor use to determine a PHC household's federal poverty level and is updated annually when the revised Federal Poverty Income Guidelines become available.
  • Contractors must have policies and procedures regarding fee collection, which must be approved by the contractor's Board of Directors.
  • Client co-pays collected by the contractor are considered program income and must be used to support the delivery of HHSC PHC services.

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 PHC allowable services if the service is provided at the client's request and the client is made aware of their responsibility for paying for the charges.

Continuation of Services – Contractors who have expanded their awarded PHC funds are required to continue to serve their existing PHC clients through the end of the client's eligibility. If other funding sources are used to provide PHC services, the funds must be reported as non-HHSC funds on the monthly Form 4116, Authorization for Expenditures, and the quarterly Financial Status Report (FSR) or Form 269a.

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. This includes the date an individual/household is determined eligible for Presumptive Eligibility. Contractors have the option to notify PHC applicants of their eligibility status using the optional letters provided by the PHC program:

  • Form 3045, Office of Primary and Specialty Health Presumptive Eligibility Notice
  • Form 3048, Office of Primary and Specialty Health Notice of Eligibility
  • Form 3047, Office of Primary and Specialty Health Notice of Ineligibility

Annual Recertification – Annual eligibility determination and recertification is required for all clients who receive PHC services. Client eligibility must be redetermined every 12 months, using the appropriate form for individuals or households. Contractors must have a system in place to track client eligibility and renewal status on an annual basis.