4000, Eligibility and Fees

Body

Revision 20-0; Effective December 18, 2020

 

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

 

4100 Eligibility and Assessment of Co-pay/Fees

Revision 20-0; Effective December 18, 2020

 

Contractors must develop a policy to determine Title V MCH FFS 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; or
  • A comparable paper or electronic eligibility tool, previously approved by the Title V MCH FFS Program may be used, if 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 Title V MCH FFS eligibility process:

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

Client Eligibility Screening Process

For an individual to receive Title V MCH FFS 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/benefits providing the same services.

If documentation is not available or is insufficient to determine eligibility, contractor staff should ask the individual to designate a contact person to provide the information.

Procedures and Terminology When Determining Title V MCH FFS Eligibility

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. A child must be under 18 years of age to be counted as part of a larger family. Eligibility will end on the last day of the month the child becomes 18 years of age unless the child is:

  • A full-time high school student as defined by the school, attends an accredited GED class or regularly attends vocational or technical training in place of high school; and
  • Expected to graduate from one of the above before or during the month of his or her 19th birthday.

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.

Documentation of Date of Birth

Document proof of a client’s birth provided by the client on Form 3029, Office of Primary and Specialty Health Application for Program Benefits. For documentation of a client’s date of birth, one of the following items shall be provided:

  • Birth certificate;
  • Baptismal certificate;
  • School records; or
  • Other documents or proof of date of birth determined valid by the contractor.

Documentation of Family Composition

If family relationships appear questionable, one of the following items shall be requested:

  • Birth certificate;
  • Baptismal certificate;
  • School records; or
  • Other documents or proof of family relationship determined valid by the contractor to establish the dependency of the family member upon the client or head of household.

Family members who receive other health care benefits are included in the family count. The contractor 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 Title V MCH FFS services, an individual must be physically present within the geographic boundaries 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 an individual is less than 18 years of age, a parent, managing conservator, care taker or guardian is a resident of Texas as defined above.

There is no requirement regarding the amount of time an individual must live in Texas to establish residency for the purposes of Title V MCH FFS eligibility.

Individuals described below are not eligible to receive Title V MCH FFS services:

  • Inmates of correctional facilities;
  • Residents of state schools or federal schools; and
  • Patients in federal institutions or state psychiatric hospitals.

Document proof of residency provided by the client on Form 3029, Office of Primary and Specialty Health Application for Program Benefits. Explain why residency is questionable, if necessary. For documentation of residency, one of the following items shall be provided:

  • Valid Texas driver license;
  • Current voter registration;
  • Rent or utility receipts for one month prior to the month of application;
  • Motor vehicle registration;
  • School records;
  • Medical cards or other similar benefit cards;
  • Property tax receipt;
  • Mail addressed to the applicant, his/her spouse, or children if they live together; or
  • Other documents considered valid by the contractor.

If none of the listed items are available, residence may be verified through:

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

If a family is otherwise eligible, but residence is in question/dispute, the household is entitled to services until information regarding residency change proves otherwise.

Individuals 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.

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 OPSH Definition of Income (available via the Provider Portal on the HHS website). Contractors must have a written Title V MCH FFS income verification policy.

Documentation of income for Title V MCH FFS services must be provided to complete Form 3029, Office of Primary and Specialty Health Application for Program Benefits. Declarations of “unknown” will not be accepted as representations of required facts and documentation.

The following documentation shall be provided:

  • At least two pay periods that accurately represent their earnings dated within the 60 days prior to 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 individual’s usual and customary earnings. Proof may include, but is not limited to:

  • Copy(ies) of the most recent paycheck(s) or stub/monthly earning statement(s);
  • Employer’s written verification of gross monthly income or Form 3029, Office of Primary and Specialty Health Application for Program Benefits;
  • 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 contractor.

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 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.

Disability

The individual must submit a statement from his/her physician verifying the approximate length of disability or a letter from the company/program providing eligibility dates.

Statements of Support

Unless the person providing the support to the individual is present during the interview and has acceptable documentation of identity, a statement of support will be required. The statement of support is used to document income when no supporting documentation is available or when income is irregular. If questionable, the contractor may document proof of identification such as a Texas driver license, Social Security card, or a birth certificate of the supporter.

Decision Pended

If eligibility cannot be determined because components that pertain to the eligibility criteria are missing, the contractor may issue Form 3056, Office of Primary and Specialty Health Request for Information. List all information that needs to be provided by the applicant, as well as the due date by which the information should be submitted. If the requested information is not provided by the due date, contractor may issue Form 3047, Office of Primary and Specialty Health Notice of Ineligibility.

When the requested information is the result of a referral to another program and is dependent on another program making an eligibility determination, the due date should be a best estimate. Inform the applicant of their responsibility to contact the contractor by this date to provide the status of their application for the other benefits. If the requested information is provided by the due date, proceed with processing the application.

Presumptive Eligibility

Individuals, who have not had final eligibility for services determined but present with a medical/dental need, may receive Title V MCH FFS funded services on a presumptive eligibility basis during the time that eligibility for services is pending. If a medical condition makes eligibility determination impossible, an appointment to complete the process should be made at the first possible opportunity.

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.

If the client becomes Medicaid eligible, the services must be billed to Medicaid under the “90-days prior provision.”

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

The contractor must determine the applicant’s actual household FPL percentage.

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; and
  4. Multiply by 100.

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

Special Circumstances Regarding Documentation

There may be special circumstances where an applicant is unable to provide required documentation for verification purposes. These types of special circumstances should be appropriately documented.

Client Fees/Co-Payments

Title V MCH FFS contractors may (but are not required to) assess a co-pay for services from Title V MCH FFS clients. Contractors must have a co-pay policy using the following guidelines:

  • No Title V MCH FFS 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 OPSH Monthly Federal Poverty Guidelines (available via the Provider Portal on the HHS website) is for contractor use to determine a Title V MCH FFS household’s FPL and is updated annually when the revised Federal Poverty Income Guidelines are released.
  • Contractors must have policies and procedures regarding fee collection, which must be approved by the contractor’s board of directors.
  • The co-pay must be reported as program income on the Monthly Reimbursement Request (MRR) and fiscal reporting Form 270, if applicable, and utilize the HHSC Data and Document Management System when it is available.

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 Title V MCH FFS allowable services if the service is provided at the client’s request and the client is made aware of his/her responsibility for paying for the charges.

Client’s Responsibility for Reporting Changes

A client must report changes in the following areas no later than 30 days after the client is aware of the change: income, family composition, residence, current address, employment, types of medical insurance coverage, receipt of Medicaid CHIP and/or other third-party coverage benefits. The client may report changes by mail, telephone, in person or through someone acting on the individual’s behalf. If changes result in the client no longer meeting eligibility criteria, the individual is denied continued services. By signing the required forms, the individual attests to the truth of the information provided.

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 Title V MCH FFS applicants of their eligibility status using the optional letters provided by the Office of Primary and Specialty Health:

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

Annual Recertification

Annual eligibility determination and recertification is required for all clients who receive Title V MCH FFS services. Client eligibility must be redetermined every 12 months, using the most recent version of Form 3029, Office of Primary and Specialty Health Application for Program Benefits.

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

Appeal Eligibility Determination

Individuals and families can appeal to the HHSC Title V MCH FFS contractor regarding the eligibility determination for Title V MCH FFS, if they disagree with the determination. Applicants may submit additional information to establish eligibility or repeat the application process.

If the client feels that the repeated eligibility determination is still incorrect, then the individual may appeal to the HHSC Title V MCH FFS Office at titlevffs@hhsc.state.tx.us.

Potential Eligibility and Referral to Other Possible Qualifying Programs

Individuals must be screened for potential Medicaid, CHIP or other programs. Document this completion on the application for program benefits.

All pregnant women currently served by Title V MCH FFS are eligible for the CHIP Perinatal Program to receive health benefits for the unborn child and newborn. There is a 12-month continuous eligibility period for the unborn child, including pre- and post-delivery. More information is available here.

Contractors 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.