4100, Client Eligibility Screening Process

Revision 25-3; Effective Oct. 29, 2025

Grantees must perform an eligibility screening assessment on everyone who present for services.

Applicants must be screened in this order:

• Medicaid;
• Healthy Texas Women (HTW);
• Family Planning Program (FPP); and
• Any other HHSC-funded health program for which the grantee holds a grant agreement.

If a person is eligible for:

• Medicaid, HTW, or FPP, they are not eligible for BCCS.
• Any other HHSC-funded health program for which the grantee holds a Grant Agreement, enroll the person in the program that best matches their primary need.

For Clients with Emergency Medicaid

Clients eligible for Emergency Medicaid coverage through pregnancy and 12-month postpartum period only receive treatment of emergency medical conditions. These clients are considered underinsured and may be enrolled for FPP services if they meet all other eligibility requirements. FPP does not provide any emergency services.

Eligibility screening criteria and processes are described below.

4110 Screening for Medicaid

Revision 24-2; Effective Oct. 15, 2024

If the client has a Medicaid card, it can be used to document Medicaid eligibility.

How to know if a person is covered by Medicaid

• They will be issued a Your Texas Benefits card.
• They should show their Your Texas Benefits card at the point-of-service delivery.

Even with this card, providers must verify Medicaid eligibility by calling Texas Medicaid and Healthcare Partnership (TMHP) at 800-925-9126 or log on to TexMedConnect to check the member’s Medicaid ID number (PCN).

4120 Screening for HTW

Revision 25-3; Effective Oct. 29, 2025

Healthy Texas Women (HTW) is a Medicaid waiver program administered by HHSC to provide eligible uninsured women with women’s health and family planning services, such as women’s health exams, health screenings and contraception. HTW providers must provide clinical services on a fee-for-service basis. They 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 female clients who are 15 through 44 years old, are U.S. citizens or qualified immigrants and live in Texas must be screened for HTW eligibility.

To screen for HTW, grantees may use the Prescreening Tool on the Your Texas Benefits website, or the Am I Eligible? tool on the HTW website. Both tools are acceptable methods for screening for HTW eligibility.

If the applicant is determined to be ineligible for HTW, either by screening as ineligible or by client's presentation of the denial letter or reason for denial, then screening for FPP can take place.

Rescreening for HTW

• If the applicant seeks services within 45 calendar days from the application submission date, and the person has undetermined HTW eligibility, then grantees are not required to rescreen for HTW.
• If the applicant has been screened eligible but the application determination was deemed ineligible for HTW, a copy of the denial letter or reason for denial must be maintained in the person’s record. If an applicant does not provide a copy of the denial letter or reason for denial, providers should discuss their application or advise them to contact 866-993-9972 to discuss the status of their application.
• If a person indicates they would not meet eligibility requirements for HTW and refuses to be screened for the program, document the refusal and reason in the client’s record. This documentation should be reviewed annually, and eligibility screening and application offered if a change in circumstances would indicate a change in eligibility. Applicants who were initially screened ineligible for HTW because of their citizenship or immigration status must be rescreened annually or when the the person reports a change in their citizenship or immigration status.

4130 Screening for and Determining FPP Eligibility

Revision 25-3; Effective Oct. 29, 2025

Grantees must determine and document FPP eligibility before rendering services. To assess eligibility for services, grantees must use Form 1065, Breast and Cervical Cancer Services (BCCS) Program or Family Planning Program (FPP) Eligibility Application, or an HHSC-approved eligibility screening form substitute, such as in-house form, electronic form or phone interview that contains the required information for determining eligibility.

If a grantee wants to use an Alternate Eligibility Screening Tool (AEST), the grantee must send a request to famplan@hhs.texas.gov with AEST Request in the subject line. HHSC staff must review and approve before use. Grantees must use Form 1065 until they receive approval to use an AEST. The grantee must maintain and retain proof of approval and must make the approval available during Quality Assurance visits.

The eligibility assessment may be completed over the phone or in the office. The completed eligibility form must be kept in the person’s record and must show their FPL and the co-pay amount they may be charged. A person’s eligibility must be assessed annually. If eligibility is determined over the phone, the grantee is authorized to sign the form on the applicant’s behalf with a digital ID or handwritten signature.

Eligibility Requirements

A male or female is eligible for FPP if they:

• are 64 years old or younger.
• live in Texas. Grantees must verify and document residency but such verification should not jeopardize delivery of services.
• have countable income that does not exceed 250% of the federal poverty level (FPL). Review Definition of Income for the Family Planning Program in 9000, Resources.

Grantees must require income verification. If the methods used for income verification jeopardize the person’s right to confidentiality or impose a barrier to receipt of services, the grantee must waive this requirement and approve full eligibility. Reasons for waiving verification of income must be noted in the person’s record. Review Calculation of Applicant’s Federal Poverty Level (FPL) Percentage in 4140, Adjunctive Income Eligibility and Calculation of Applicant Income.

Grantees determine eligibility at the point of service per program policy and procedures.

4140 Adjunctive Income Eligibility and Calculation of Applicant Income

Revision 25-3; Effective Oct. 29, 2025

An applicant is considered adjunctively, automatically, income eligible for services at an initial or renewal eligibility screening if they currently are enrolled in one of the following programs:

• Children’s Health Insurance Program (CHIP) Perinatal
• Supplemental Nutrition Assistance Program (SNAP)
• Special Supplemental Nutrition Program for Women, Infants and Children (WIC)

Applicants determined to be adjunctively income eligible have met the income requirements through their participation in other income-tested programs. Except for calculating the client’s income, grantees must follow all screening procedures outlined in 4100, Client Eligibility Screening Process, before enrolling applicants determined adjunctively income eligible in FPP.

The applicant must be able to provide proof of active enrollment in the adjunctively income eligible program. Acceptable eligibility verification documentation may include:

To verify eligibility for CHIP Perinatal, 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’s current enrollment status cannot be verified during the eligibility screening process, adjunctive income eligibility would not be granted. The grantee would then determine income eligibility according to usual protocols.

Calculation of Applicant’s Federal Poverty Level (FPL) Percentage – The maximum monthly income amounts by household size are based on the 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 applicant’s actual household FPL percentage are the following below.

Step 1

To determine FPP eligibility, the household is defined as a person who lives alone or a group of two or more persons related by birth, marriage, common-law marriage or adoption who live together and who are legally responsible for the support of the other person. Treat applicants who are 18 years old as adults. No one 18 years 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.

Step 2

Determine the applicant’s total monthly income amount.

To determine income eligibility, count the income of the following people if they are living together:

• The people 18 through 64 years old applying for FPP;
  • the person’s spouse; and
  • the person’s children 18 and younger; or
• The person 17 years or younger applying for FPP;
  • the person’s parent(s);
  • the person’s siblings 18 years and younger; and
  • the person’s children.
• For an unmarried applicant who lives with a partner, only count the partner’s income and children as part of the household if the applicant and their partner have mutual children together. Unborn children should also be included.
• All income received must be included. Income is calculated before taxes – gross. Income is reviewed and determined countable or exempt based on the source of the income per 9000, Resources, Definition of Income. Grantees must have a written income verification policy.
• Proof of income documentation may include:
  • copy(ies) of the most recent paycheck(s), pay stub or monthly earning statement(s);
  • employer’s written verification of gross monthly income;
  • 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 the grantee determines valid.
• For unemancipated, unmarried people younger than 18 years, 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 to determine the charge for the service.
• Income Deductions: Dependent care expenses must be deducted from total income to determine eligibility. Allowable deductions are actual expenses up to $200 per child per month for children younger than 2, $175 per child per month for each dependent 2 years and older, and $175 per adult with disabilities per month. Legally obligated child support payments made by a member of the household group must also be deducted. Payments made weekly, every two weeks or twice a month must be converted to a monthly amount with 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 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.

Step 3

Divide the applicant’s total monthly income amount by the maximum monthly income amount at 100% of the FPL for the household size.

Step 4

Multiply by 100 to reach a percentage.

4150 Former Military Service Members

Revision 25-3; Effective Oct. 29, 2025

Applicants who served in any branch of the U.S. Armed Forces, Reserves or National Guard may be eligible for more benefits and services and must be referred to the Texas Veterans Portal for more information. Former female military service members must also be referred to the Texas Veterans Commission’s Women Veterans Program.

4160 Client Travel

Revision 25-3; Effective Oct. 29, 2025

If awarded funding for client travel, grantees must establish a policy for providing financial travel support to and from clinic or mobile location(s). Grantees must make sure clients who receive travel assistance live within the HHSC-approved service delivery area. Criteria for client travel support must be income based and include a justification of need. Grantee may include other factors.

Grantees may provide travel services through options such as bus passes, vouchers and rideshare apps like Uber or Lyft.

4170 Patient Navigation Services

Revision 25-3; Effective Oct. 29, 2025

If grantee is using cost reimbursement funds for a dedicated patient navigator, a policy must be in place to make sure the following services and activities are provided:

1. Application assistance to clients screening eligible for the following preventive and primary health programs:
   1. HTW;
   2. FPP;
   3. BCCS; and
   4. Primary Health Care (PHC).
2. Nonmedical service needs assessment provided by HHSC that identifies barriers to transportation, childcare, housing, food and employment. Grantee may use a comparable, alternative tool with prior written approval by HHSC. Grantee must administer these assessments during initial visit. All clients must be screened annually.
3. Education, appropriate referrals and follow-ups to show any resolution of barriers. Grantee must document these activities and support services in the client record including:
   1. Information about covered program benefits
   2. Attempt to resolve client barriers such as application assistance for SNAP benefits, referrals to local resources and client travel.
4. Document person’s refusal, lost to follow-up and good faith effort, as appropriate.
   1. Good faith effort is defined as at least three documented attempts to assist with applications or to navigate a person to services via phone, email, text or other preferred method of communicating with the person.
   2. Personal contact attempts can be made by office visit, phone, home visit, mail or a combination of these methods. Attempts to contact the person must be written or presented verbally. When appropriate, contact the client in their primary language if the client has limited English proficiency. The grantee must include appropriate provisions for the visually and hearing impaired.   
   3. Before closing a person’s record as a refusal, a thorough review of the person’s plan, recommendations and the following navigator's actions must be conducted to ensure proper closure.
5. Document informed refusal from the person if they fail to keep appointments, complete the Non-Medical Service needs assessment or refuse recommended procedures. If the person cannot, or will not, sign an informed refusal, the grantee must document verbal refusal.