Revision 23-2; Effective Sept. 8, 2023

This section provides policy requirements for eligibility determinations, client fees, and the continuity of client services.

4100 Eligibility and Assessment of Co-pay and Fees

Revision 24-2; Effective Sept. 30, 2024

Grantees must:

  • Develop a policy to show how staff will determine TVFFS program client eligibility. The policy must outline the grantee’s procedures to determine program eligibility and responsible party for eligibility screening. 
  • Use the most recent version of Form 3029, Application for Benefits to screen applicants for program eligibility, or an HHSC-approved alternate eligibility screening tool. 

Alternate Eligibility Screening Tools

An alternate eligibility screening tool created by the grantee may be used in place of Form 3029 with prior written approval by TVFFS program. To apply for approval, the grantee must send a request for an Application for Alternate Eligibility Tool to the TVFFS program mailbox. The alternate eligibility 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 apply: 

  • Grantees must request approval from TVFFS 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 contract cycle. If a grantee is awarded funding under a later contract, 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 HHSC 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 TVFFS program reserves the right to request more edits or withdraw its approval of the use of an alternate eligibility tool. TVFFS program will notify the grantee of the decision in writing and include the date that the alternate tool must be discontinued.   

Information for Former Military Service Members

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

Client Eligibility Screening Process

For a person to receive TVFFS services, three criteria must be met:

  • gross family income at or below 185% of the Federal Poverty Level (FPL);
  • Texas resident; and
  • not eligible for other programs or benefits providing the same services.

The TVFFS Child Health and Dental program serves people from birth until their 22nd birthday. The TVFFS Prenatal Medical and Dental program serve pregnant women of any age through three months postpartum, including following pregnancy loss.

Eligibility determinations for TVFFS can be made by conducting interviews in-person or over the phone for both new applicants and to re-certify current clients. Phone interviews for eligibility determinations must comply with all eligibility guidelines outlined in program policy. 

Instead of a client’s signature on the application in the Acknowledgment section of the Application for Program Benefits or on the Statement of Applicant’s Rights and Responsibilities, the eligibility staff person must read the statements to the applicant and document that the applicant affirms the statements. The documentation must include the date and time of the applicant's affirmation and the eligibility staff person’s signature. The client must sign the document at the time of their next visit to the clinic. 

If an applicant is unable to provide the information required to determine eligibility, eligibility staff should ask the applicant to designate a contact person to provide the information.

Upon award expenditure, grantees are not required to screen new clients for TVFFS eligibility. However, if a screening is completed, the grantee must provide services to eligible clients.

Potential Eligibility and Referral to Other Programs 

Screening for other benefit programs must be documented on the Application for Program Benefits form. 

The TVFFS Program is the payor of last resort. Applicants must be screened for Medicaid, CHIP, CHIP Perinatal, and any other benefit programs. TVFFS will not reimburse for services provided to people potentially eligible for another funding source and who do not complete the respective eligibility application process. Applicants who do not fully comply with applying for other benefit programs for which they appear eligible are not eligible for TVFFS, and grantees will not be reimbursed for services provided.

If a client appears eligible for any of these other benefit programs, they must be granted Presumptive Eligibility for TVFFS while awaiting benefit determination.  

The grantee must notify the client they must apply for any program for which they appear eligible. The client is responsible for submitting proof of application or a denial letter before the presumptive eligibility period ends. If a client does not appear eligible for any other program, this must be documented on the application.  
    
All Medicaid, CHIP, Medicaid for Pregnant Women, CHIP Perinatal, or other benefit program applications must be submitted promptly following TVFFS eligibility assessment. If a client was denied Medicaid or CHIP services, the denial letter must be included with the application. 

All pregnant women served by TVFFS must apply for Medicaid or CHIP Perinatal programs. 

Providers are required to inform, encourage, and assist pregnant women in the CHIP Perinatal and Medicaid for Pregnant Women application process. A maximum of two clinical prenatal care visits are allowed for women in the process of applying for and enrolling in the CHIP Perinatal and Medicaid for Pregnant Women programs.   

Grantees may use the HHSC Your Texas Benefits website to assist in the screening of client eligibility. More information about HHSC benefits can also be obtained by calling 2-1-1. 

TVFFS clients who enroll in a Managed Care Organization (MCO) that does not provide any dental benefits will remain eligible for TVFFS Prenatal Dental benefits. These clients must provide documentation that their MCO does not provide dental benefits to continue receiving TVFFS dental benefits. This documentation must be maintained in the client record.   

Household

The household includes a person living alone, or a group of two or more people related by birth, marriage which includes common law, or adoption, who live 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 or her partner have mutual children together. Unborn children should also be included. A child must be under 18 years old to be counted as part of a larger family. Once a child turns 18, they should complete their own program application, listing themselves as the applicant.

Legal responsibility for support exists between:

  • people 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.

Documentation of Date of Birth

Documentation of date of birth must be provided for clients applying for the Child Health or Child Dental programs. One of the following should be provided and a copy should be kept with the client’s application:  

  • birth certificate;
  • baptismal certificate;
  • school records; or
  • other documents or proof of date of birth determined valid by the grantee.

Documentation of Family Composition

If family relationships are unclear, request one of the following items:

  • birth certificate;
  • baptismal certificate;
  • school records; or
  • other documents or proof of family relationship determined valid by the grantee to establish the dependency of the family member with the client or head of household.

Family members who receive other health care benefits are included in the family count. The grantee has discretion to document special circumstances in the calculation of family composition. Additionally, if a separate family group is established within the household based on the documentation gathered, document the basis used for determining separate households, if applicable.

Documentation of Residency

To be eligible for TVFFS services, a person must be physically present within the state of Texas and:

  • have the intent to remain within the state, whether permanently or for an indefinite period;
  • not claim residency in any other state or country; or
  • if a person is less than 18 years old, a parent, managing conservator, caretaker or guardian is a resident of Texas as defined above.

There is no requirement about the amount of time a person must live in Texas to establish residency for the purposes of TVFFS eligibility.

Document proof of residency provided by the client on Form 3029, Application for Program Benefits. Explain why residency is questionable, if necessary. For documentation of residency, provide one of the following items:

  • valid Texas driver license;
  • current voter registration;
  • rent or utility receipts for one month before the month of application;
  • motor vehicle registration;
  • school records;
  • medical cards or other similar benefit cards;
  • property tax receipt;
  • mail addressed to the applicant, their spouse, or children if they live together; or
  • other documents considered valid by the grantee.

If none of the listed items are available, verify residency through:

  • observance of personal effects and living arrangement; or
  • statements from landlords, neighbors or other reliable sources.

If a family is otherwise eligible, but residency is in question or dispute, the household is entitled to services until residency information is verified. 

People do not lose their residency status because of temporary absences from the state. For example, a migrant or seasonal worker who may travel during certain times but maintains a home in Texas and returns to that home after these temporary absences.

Documentation of Income

Include all income. Income is calculated before taxes (gross). Income is reviewed and determined either countable or exempt  and is based on the source of the income, as defined in Appendix I, Definition of Income. Grantees must have a written TVFFS  income verification policy.

Documentation of income for TVFFS services must be provided to complete Form 3029, Application for Program Benefits. Declarations of unknown will not be accepted as documentation.

Provide the following documentation:

  • at least two pay periods that accurately represent their gross earnings dated within the 60 days before the application processing date; or
  • one month’s pay only if paid same gross amount monthly, unless special circumstances are noted on the application.

The pay periods must accurately reflect the person’s usual and customary earnings. Proof may include, but is not limited to:

  • 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 3049, Employment Verification; 
  • award letters;
  • domestic relation printouts of child support payments;
  • statement of support;
  • unemployment benefits statement or letter from the Texas Workforce Commission;
  • 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.

Grantees 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 grantee must waive this requirement and document the reason.  

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 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.

Calculation of Applicant’s Federal Poverty Level (FPL) Percentage

The grantee must determine the household FPL percentage, using current 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 household FPL percentage are:

  • determine the household's total monthly income amount;
  • determine the household size;
  • divide the household’s total monthly poverty guideline based on the household size; and
  • multiply by 100.

There may be special circumstances where an applicant cannot provide required documentation for verification purposes. Document these types of special circumstances appropriately.

Income Deductions

Dependent care expenses may be deducted from total income. This expense must be both necessary for employment and incurred by an employed person. Documentation must be provided. Allowable deductions are actual expenses up to:

  • $200 per child per month for children under 2; 
  • $175 per child per month for each dependent 2 or older; and 
  • $175 per adult with disabilities per month. 

Legally required child support payments made by a member of the household group may be deducted from total income. Documentation of payments must be provided. Convert payments made weekly, every two weeks or twice a month by using one of the conversion factors listed above. 

Documenting Special Circumstances

There may be special circumstances where an applicant cannot provide required documentation for verification purposes. Document these types of special circumstances appropriately.

Copayments

Grantees may assess a copay for services from TVFFS clients. Grantees who choose to collect copays must have a copay policy using the following guidelines:

  • No TVFFS 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 copay, as calculated using the U.S. HHS Poverty Guidelines.
  • Clients with a household FPL above 100% may be charged a copay of no more than $30 per visit. 
  • Grantees must have a written copay policy which clearly defines how copay amounts will be determined.
  • Clients who are assessed a copay must be presented a statement at the time of service and a copy should be kept in the client’s record.
  • Clients who declare an inability to pay a copay shall not be denied services. Any outstanding balance may not be turned over to a collection agency or reported delinquent to a credit reporting agency.
  • All policies and procedures regarding copay collection must be approved by the grantee’s board of directors.
  • Copays must be reported as program income on the Monthly Reimbursement Packet (MRP). The grantee must complete B25 and E25.

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

Other Fees

Do not charge clients administrative fees for items such as processing or transfer of medical records and copies of immunization records.

Grantees can bill clients for services outside the scope of TVFFS allowable services if the service is provided at the client’s request and the client is made aware of financial responsibility for the charges before services are provided.

Client’s Responsibility for Reporting Changes

A client must report the following changes no later than 30 days after the change:

•    income;  
•    family composition;   
•    residence;   
•    current address;   
•    employment;   
•    medical insurance coverage; or  
•    receipt of Medicaid, CHIP, CHIP-P, or other third-party coverage benefits. 

The client may report changes by mail, phone, in person or through someone acting on the client's behalf. If changes result in the client no longer meeting eligibility criteria, the client’s eligibility will terminate. Upon termination, the grantee must issue Form 3047, Notice of Ineligibility, to the client, including the date of termination.

Eligibility

Full program eligibility begins on the date the grantee determines a person or household is eligible for the program and all following requirements are met:

  • all program eligibility requirements are met;
  • program application is completed and signed; and
  • all verification documents are submitted.

To notify an applicant of eligibility, the grantee must issue Form 3012,  Verification of Eligibility, to the client.

Presumptive Eligibility

Presumptive eligibility provides short-term access to healthcare services for up to 90 days when an applicant completes an application and screens as eligible and has a medical or dental need but lacks the required verification documentation. For clients who submit all required verification documentation during their presumptive eligibility period, full eligibility is given and the eligibility expiration date is calculated from the first day that presumptive eligibility began. The expiration date is 365 days from the first day of presumptive eligibility except for Perinatal benefits which expire at 3 months postpartum. 

If a medical condition makes eligibility determination impossible, make an appointment to complete the process at the first possible opportunity.

To notify an applicant of Presumptive Eligibility, the grantee must issue Form 3045, Presumptive Eligibility Notice to the client.

If the client enrolls in Medicaid or CHIP during the presumptive eligibility period, bill the services to Medicaid. 

Ineligibility

If an applicant is determined to be ineligible for program services after the screening process is complete, the applicant must be given the Notice of Ineligibility, Form 3047. The applicant must also be informed of their right to appeal the eligibility decision using the process described on the Notice of Ineligibility. 

Optional Forms

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

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

Annual Recertification

Annual eligibility determination is required for all clients who receive TVFFS services. Client eligibility must be determined every 12 months, using the most recent version of Form 3029, Application for Program Benefits. Perinatal benefits expire at three months postpartum.

Grantees must have a system in place to track client eligibility and renewal status on an annual basis.