4000, Eligibility and Fees

Revision 22-4; Effective Dec. 12, 2022

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

4100 Eligibility and Assessment of Co-pay/Fees

Revision 22-4; Effective Dec. 12, 2022

Contractors must develop a policy to show how staff will determine Title V MCH FFS program client eligibility. The policy must outline the contractor’s procedures for determining program eligibility and who is responsible for eligibility screening. 

Contractors must perform an eligibility screening assessment on all clients who present for services using the most recent version of Form 3029.

An alternate eligibility tool created by the contractor may be used in place of Form 3029 with prior written approval by Title V MCH FFS program. The tool must contain, at minimum, all required elements of the Form 3029 for eligibility determination and the signature of the applicant or applicant’s legal representative. 

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

  • Contractors must request approval from Title V MCH FFS 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 contractor is awarded funding under a subsequent contract, the contractor 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 contractor-developed alternate screening tool. Contractors will need to submit their contractor-developed alternate screening tool with the incorporated changes within 60 calendar days for re-review and approval.   
  • The Title V MCH FFS program reserves the right to request more edits or withdraw its approval of the use of an alternate eligibility tool. Title V MCH FFS program will notify the contractor of the decision in writing and include the date that the alternate tool must be discontinued.  

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. 

If an applicant is determined to be ineligible for services after the screening process is complete, the applicant must be given the OPSH 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.

Client Eligibility Screening Process

For a person 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 or benefits providing the same services.

The Title V MCH FFS program serves persons from birth until their 22nd birthday and pregnant women of any age.

Eligibility determinations for Title V can be made by conducting interviews 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 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 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 people related by birth, marriage (including 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. Eligibility will end on the last day of the month the child becomes 18 years old 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:

  • 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

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, provide one of the following items:

  • 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 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 contractor 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 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, 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 Title V MCH FFS eligibility.

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, 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, his or her spouse, or children if they live together; or
  • other documents considered valid by the contractor.

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 information about residency change proves otherwise.

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

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, OPSH Definition of Income. 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.

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 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 are deducted from total income to determine eligibility. 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. 

Deduct legally obligated child support payments made by a member of the household group. Convert payments made weekly, every two weeks or twice a month 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.

Presumptive Eligibility

People without final eligibility for services determined but present with a medical or 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, make an appointment to complete the process at the first possible opportunity.

If eligibility cannot be determined because of missing eligibility criteria components, the contractor may issue Form 3056, Office of Primary and Specialty Health Request for Information.

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 determined to be fully eligible during the presumptive period, the eligibility expiration date includes the days of presumptive eligibility. The 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 is12 months from the presumptive eligibility.

If the client becomes Medicaid eligible, bill the services to Medicaid.

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:

  • determine the applicant’s total monthly income amount;
  • determine the applicant’s household size;
  • divide the applicant’s total monthly income amount by the maximum monthly income amount at 100% FPL for the appropriate household size; and
  • 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 three)   Actual Household FPL %
$2,093 ÷ $1,778 = 1.18 x 100 = 118% FPL

Special Circumstances For 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 and 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.
  • Present a bill to people who are assessed a co-pay 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. It 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 Packet (MRP). The contractor must complete B25 and E25.

Other Fees

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

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 or 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 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 is denied continued services. By signing the required forms, the client attests to the truth of the information provided.

Date Eligibility Begins

An individual or household is eligible for services beginning with the date the contractor determines they are eligible for the program and signs the completed application. This includes the date an individual or 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 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.

Potential Eligibility and Referral to Other Possible Qualifying Programs

The Title V MCH FFS Program is the payor of last resort. Individuals must be screened for potential Medicaid, CHIP and all other potential benefit programs. Document this screening on the application for program benefits.

All Medicaid or other potential benefit program applications must be submitted promptly following Title V MCH FFS eligibility assessment. If a client was denied Medicaid services, this letter must be filed with the application.

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. 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.