Revision 21-1; Effective April 15, 2021

 

10100 Client Eligibility Screening Process

Revision 19-0; Effective July 1, 2019

 

HHSC FPP contracted agencies must screen all family planning applicants for eligibility in the following programs that provide family planning services in this order: Medicaid, Healthy Texas Women (HTW) and then the HHSC FPP. Eligibility screening criteria and processes are described below.

 

10110 Screening for Medicaid

Revision 19-0; Effective July 1, 2019

 

If the individual has a Your Texas Benefits Medicaid card, it can be used to document Medicaid eligibility.

Providers can call TMHP at 800-925-9126 or log on to TexMedConnect to check the member’s Medicaid ID number (PCN).

 

10120 Screening for HTW

Revision 21-1; Effective April 15, 2021

 

All women 15 to 44 years of age who are not eligible for full Medicaid services must be screened for eligibility for Healthy Texas Women (HTW). HTW is a Medicaid program administered by HHSC to provide eligible uninsured women with women’s health and family planning services such as woman’s health exams, health screenings and birth control. HTW providers must provide clinical services on a fee-for-service basis and may also, but are not required to, contract with HHSC to provide support services that enhance clinical service delivery on a cost reimbursement basis.

Potential clients who are between the ages of 15 to 44, are U.S. citizens or legal immigrants and reside in Texas must be screened for HTW eligibility. If they are determined to be ineligible for HTW, then screening for FPP can take place. To screen for HTW, visit Your Texas Benefits and use the Prescreening Tool at the bottom of the page.

 

10130 Screening for and Determining FPP Eligibility

Revision 19-0; Effective July 1, 2019

 

Contractors must determine FPP eligibility. To assess eligibility for FPP services, contractors must use either the Family and Social Services (FSS) Section eligibility form or an FSS Section-approved eligibility screening form substitute (e.g., in-house form, electronic/automated form, phone interview, etc.), that contains the required information for determining eligibility.

The eligibility assessment may be completed over the phone or in the office. The completed eligibility form must be maintained in the individual record, indicating the individual’s poverty level and the co-pay amount he or she may be charged. An individual’s eligibility must be assessed on an annual basis.

Eligibility Requirements

Eligible individuals must be:

  • Females and males age 64 years and younger;
  • Texas residents (residency is self-declared). Contractors may require residency verification, but such verification should not jeopardize delivery of services;
  • At or under 250% of the federal poverty level (FPL). Contractors must require income verification. If the methods used for income verification jeopardize the individual’s right to confidentiality or impose a barrier to receipt of services, the contractor must waive this requirement. Reasons for waiving verification of income must be noted in the individual record.
  • For unemancipated, unmarried individuals under 18 years of age, if parental consent is required for the receipt of services per Section 32 of the Texas Family Code, the family's income must be considered in determining the charge for the service.
  • If parental consent is not required to provide services to an individual under 18 years of age, per Section 32 of the Texas Family Code, only the individual's income is used to assess eligibility, not the income of other family members. In this case, the minor's own income is applied, and the size of the family should be recorded as one.

If a barrier to receiving FPP services exists, the contractor may waive the requirement and approve full eligibility.

For determining FPP eligibility, the following definitions will be used:

  • 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. Household is self-declared. Example: If an unmarried applicant lives with a partner, only count the partner’s income and children as part of the household if the applicant and his or 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 household should be counted as part of the household group.
  • Income – All income received must be included. Income is calculated before taxes (gross). Include sources of income as defined in Appendix II, Definition of Income.
    • For individuals who are married or who are 18 years of age or older, the income of all family members must be used.
    • For unemancipated, unmarried individuals under 18 years of age, if parental consent is required for the receipt of services per Section 32 of the Texas Family Code, the family's income must be considered in determining the charge for the service.  
    • If parental consent is not required to provide services to an individual under 18 years of age, per Section 32 of the Texas Family Code, only the individual's income is used to assess eligibility, not the income of other family members. In this case, the minor's own income is applied, and the size of the family should be recorded as one.
  • 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 and $175 per child per month for each dependent age 2 or older.

    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 Calculation

  • If income is received in lump sums or at longer intervals than monthly, such as seasonal employment, the income is prorated over the time period the income is expected to cover.
  • Weekly income is multiplied by 4.33.
  • Income received every two weeks is multiplied by 2.17.
  • Income received twice monthly is multiplied by 2.

Rescreening for HTW

  • An applicant must be rescreened at subsequent visits if her eligibility for HTW has not been determined after 45 calendar days from the application submission date. If the applicant seeks services within 45 days from the application submission date, and the person has undetermined HTW eligibility, then contractors are not required to rescreen for HTW.
  • Applicants who were initially screened ineligible for HTW because of their citizenship or immigration status must be rescreened annually or when the individual reports a change in their citizenship or immigration status.
  • If the applicant has been deemed ineligible for HTW, a copy of the denial letter must be maintained in the individual’s record. Applicants who do not provide a copy of denial letter must be rescreened at subsequent visits.
  • Individuals who refuse to apply for HTW must be rescreened at subsequent visits.

 

10200 Adjunctive Eligibility

Revision 19-0; Effective July 1, 2019

 

An applicant is considered adjunctively (automatically) eligible for HHSC FPP services at an initial or renewal eligibility screening, if she or he is currently enrolled in one of the following programs:

  • Children’s Health Insurance Program (CHIP);
  • Supplement Nutrition Assistance Program (SNAP);
  • Temporary Assistance for Needy Families (TANF); and/or
  • Special Supplemental Nutrition Program for Women, Infants and Children (WIC).

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 Your Texas Benefits Medicaid card*
SNAP SNAP eligibility letter
TANF TANF verification of certification letter
WIC WIC verification of certification letter, printed WIC-approved shopping list, or recent WIC purchase receipt with remaining balance

*Note: If the individual has a Your Texas Benefits Medicaid card, it can be used to document Medicaid eligibility.

To verify eligibility, providers must call TMHP at 800-925-9126 or log on to TexMedConnect to check the member’s Medicaid ID number (PCN).

If the applicant or the applicant’s child (must be considered part of the household) is enrolled in CHIP, they may be considered adjunctively eligible.

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.

 

10300 Calculation of Applicant’s Federal Poverty Level Percentage

Revision 20-1; Effective July 20, 2020

 

Household FPL Calculation

If a contractor collects a co-payment, the contractor must determine the applicant’s exact household Federal Poverty Level (FPL) percentage at federal poverty guidelines. The steps to do so include:

  • Determine the applicant’s household size.
  • Determine the applicant’s total monthly income amount.
  • Divide the applicant’s total monthly income amount by the maximum monthly income amount at 100% FPL, for the appropriate household size.
  • Multiply by 100%.

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.

Example:

Applicant has a total monthly income of $2,093 and counts three family members in the household.

Total Monthly Income   Maximum Monthly Income
(Household Size of 3)
          Actual Household FPL%
$2,093 ÷ $1,810 = 1.16 x 100% = 116% FPL

Date Eligibility Begins

An individual is eligible for services beginning the date the contractor determines the individual eligible for the program and signs the completed application.

 

10400 Client Fees, Co-pays and Guidelines

Revision 20-1; Effective July 20, 2020

 

All FPP services provided at an HHSC FPP funded clinic, including nonreimbursable services, must be offered on a sliding fee scale.

Notes:

  • Medicaid-eligible individuals must never be charged a fee for services covered by Medicaid.
  • HTW-eligible individuals must never be charged a fee for services covered by HTW.
  • HHSC FPP-eligible individuals at or under 100% FPL must never be charged a fee for services covered by the program.
  • Individuals must never be denied services because of the inability to pay current fees or any fees owed. Signs indicating this policy should be visibly posted at contractor clinic sites.

Co-pay Guidelines

  • Individuals between 101% and 250% FPL may be assessed a co-pay for FPP services. If an individual is charged a co-pay, the co-pay amount must be reflected on the individual’s account.
  • Individuals may not be charged an additional co-pay for services that are provided by referral.
  • Individuals who are assessed a co-pay should be presented with the bill at the time of service.
  • Contractors must maintain records regarding individual co-pays paid and any balance owed. Contractors must also have a system for aging accounts receivable. This system must be documented in the contractor’s policy and procedures and must clearly indicate a time frame for removing balances from an individual’s account due to inability to pay.

If a contractor opts to charge a co-pay for services, a co-pay schedule must be developed and implemented with sufficient proportional increments so that inability to pay is never a barrier to service. Individuals whose household income is at or below 100% of the FPL must not be charged a co-pay. Individuals whose household income is between 101% and 250% of FPL may be charged a co-pay, but it is not required.

  • An example of a co-pay schedule is sent to contractors annually, following release of the federal poverty guidelines. Contractors can adopt the example or develop their own. The co-pay schedule must have proportional FPL increments and co-pay amounts. The maximum co-pay amount must not exceed $30. The co-pay includes all prescriptions. If a contractor does not use the HHSC FPP example, the scale must be submitted to, and approved by, HHSC FPP staff.
  • The co-pay schedule must be updated when the revised Federal Poverty Income Guidelines are released.
  • Contractors must have policies and procedures regarding co-pay collection, which must be approved by the contractor’s Board of Directors.
  • Services may be provided to individuals with third-party insurance if the confidentiality of the person is a concern or if the person’s insurance deductible is 5% or greater of their monthly income.
  • Co-pays collected by the contractor are considered program income and must be used to support the delivery of HHSC FPP services.

Other Fees

Individuals shall not be charged administrative fees for items such as processing and/or transfer of medical records, copies of immunization records, etc.

Contractors are allowed to bill individuals for services outside the scope of FPP reimbursable services, if the service is provided at the individual’s request, and the person is made aware of his or her responsibility for paying the charges.

 

10500 Continuation of Services

Revision 19-0; Effective July 1, 2019

 

Contractors who have expended their awarded FPP funds are required to continue to serve their existing FPP clients.

If other funding sources are used to provide FPP 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) (Form 269A).