4300, Procedures and Terminology When Determining PHC Eligibility

Revision 25-3; Effective Nov. 14, 2025

Potential Eligibility and Referral to Other Programs

The PHC program is the payor of last resort. Grantees must screen applicants for Medicaid, CHIP, Medicaid for Pregnant Women, CHIP Perinatal, and any other applicable benefit programs. Applicants must apply for any programs they appear eligible for. Grantees must document screening for other programs on Form 3029, Application for Program Benefits. Applicants who do not fully comply with applying for other benefit programs are not eligible for PHC. PHC will not reimburse for services provided to these people.

All Medicaid, CHIP, Medicaid for Pregnant Women, CHIP Perinatal, or other benefit program applications must be submitted promptly following PHC eligibility assessment. If a client was denied Medicaid or CHIP services, the denial letter must be included with the application. Grantees may use the HHSC Your Texas Benefits website to help screen for client eligibility. Call 2-1-1 for more information about HHSC benefits.

If a client appears eligible and applies for any of these other benefit programs, they must be granted Presumptive Eligibility for PHC while waiting benefit determination. The client is responsible for submitting proof of application or a denial letter before the presumptive eligibility period ends. If a client does not seem eligible for any other program, document this on the application.

Information for Former Military Service Members

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

Household

A 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.

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.

All children under 18 years must be counted as part of the household, including a pregnant client’s unborn children. Once a child turns 18, they must complete their own program application, listing themselves as the applicant and including any income they earn.

Documentation of Family Composition

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

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

Family members who receive other health care benefits must be included in the household. The grantee has discretion to document any special circumstances in the calculation of family composition.

Documentation of Residency

To be eligible for PHC services, a person must:

• be physically present within the geographic boundaries of Texas;
• have the intent to remain within the state, whether permanently or for an indefinite period; and
• not claim residency in any other state or country.

If a person is less than 18 years old, their parent or guardian must also be a resident of Texas and meet the criteria above.

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

Residency for PHC eligibility determination is self-declared, but a grantee must require documentation. If a grantee requires a client provide proof of residency, the type of proof provided by client must be documented on Form 3029, Application for Program Benefits. For documentation of residency, one of the following items may be provided:

• 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
• Other documents considered valid by the grantee

If none of the listed items are available, residency may be verified through one of the following:

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

If an applicant’s residency is unclear or questionable, explain and document concerns on Form 3029. If a family is otherwise eligible, but residency is in question, the household is entitled to services until residency information is verified.

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

Income

All income received must be included. If an unmarried applicant lives with a partner, count the partner’s income if the applicant and partner have mutual children that are born or unborn, together. Income is calculated before taxes (gross household income). Income is reviewed and determined either countable or exempt based on the source of the income, per Appendix I, Definition of Income. Grantees must have a written PHC income verification policy.

Documentation of income for PHC services must be provided to complete Form 3029. 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 60 days before the application processing date; or
• one month’s pay only if paid the same gross amount monthly, unless special circumstances are noted on the application.

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

• copy or copies of the most recent paycheck(s) 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 received;
• 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 safety or 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 time 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
• Income received twice monthly is multiplied by 2

Allowable 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 two;
• $175 per child per month for each dependent two or older; and
• $175 per adult with disabilities per month.

Legally required child support payments made by a member of the household must be deducted from gross household 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.

Gross household income less any allowable deductions is the Adjusted Gross Household Income.

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 near the start of each calendar year.

To calculate the household FPL percentage:

• determine the monthly adjusted gross household income;
• determine the household size;
• determine the current federal poverty level amount based on the household size;
• divide the household’s total monthly adjusted gross income by the corresponding poverty limit amount; and
• multiply by 100.

Documenting Special Circumstances

There may be special circumstances where an applicant cannot provide the required documentation for verification purposes. Appropriately document these types of special circumstances.

Client Fees and Copays

Grantees may assess a copay for services from PHC clients. Grantees who choose to collect copays must comply with the following guidelines:

• No PHC client shall be denied services based on an inability to pay.
• Clients with a household FPL at or below 100% will not be charged a copay.
• 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 are determined.
• Clients with an assessed copay must be given a billing statement at the time of service. A copy must be kept in the client’s record.
• Any outstanding balance shall not be turned over to a collection agency or reported delinquent to a credit reporting agency.
• Any outstanding balance shall not prohibit a client from receiving services.
• All policies and procedures about copay collection must be approved by the grantee’s board of directors.
• Copays must be reported as program income in the Monthly Reimbursement Packet (MRP). The grantee must complete B25 and E25.

Grantees may choose to use the optional copay table available in the Appendix II, Optional Co-Pay Table Based on Monthly Federal Poverty Level. This table is updated each calendar year after the new federal guidelines are published.

Other Fees

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

Grantees may bill clients for services outside the scope of PHC allowable services if the service is provided at the client’s request and the client is made aware of their 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 client is aware of the change:

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

The client may report changes in-person or by mail, email, phone, 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.

Continuation of Services

Once awarded grant funds are spent, grantees must continue serving their existing PHC clients through the end of their clients’ determined eligibility periods. Any funding sources other than PHC awarded program funds used to provide PHC services must be reported as non-HHSC funds on the Monthly Report Form and the quarterly Financial Status Report (FSR), also known as Form 269A.

Additionally, grantees do not have to screen potential new clients for program eligibility once awarded grant funds are exhausted. However, if screenings are completed and potential clients are determined eligible before funds are expended, the grantee must provide services to those clients.

Eligibility

Full program eligibility begins on the date the grantee determines a person or household is eligible for the program and all the 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

PHC emphasizes the importance of prevention and early intervention. The goal of PHC is for clients to be part of the health care system and not rely on episodic acute care. An applicant’s medical needs shall be met quickly and appropriately, using available resources in the community.

Presumptive eligibility provides short-term access to health care services when an applicant screens as potentially eligible for services and has an emergent medical need, but lacks the documentation required to achieve full eligibility. Grantees are only required to treat emergent medical needs during the presumptive eligibility period. Grantees must establish a presumptive eligibility period of a minimum of 30 days and up to a maximum of 90 days in their eligibility policy. During this time, clients are expected to produce the necessary verification documents. For clients who submit all required verification documents and are determined to be fully eligible during or at the end of their presumptive eligibility period, full eligibility will be granted, and the eligibility expiration date will be calculated 12 months from the day presumptive eligibility began.

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

The grantee may:

• waive the requirement to submit the eligibility documentation;
• approve full eligibility on a case-by-case basis, if the grantee determines submitting the documentation creates a barrier to care; and
• no other documentation is available.

These circumstances must be documented in the client record.

Clients are limited to one presumptive eligibility period per two calendar years.

Ineligibility

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

Potential Eligibility and Referral to Other Possible Qualifying Programs

Screening for other benefit programs must be documented in Form 3029, Application for Program Benefits.

In general, applicants are not eligible for the PHC program if they are enrolled in another third-party payer program, such as private health insurance, Medicaid or Medicare, TRICARE, Workers’ Compensation, Veterans Affairs Benefits, or other federal, state, or local public health care coverage that provides the same services.

The grantee must inform the applicant of their possible eligibility for any other program, suggest that they also apply for services from that program, and proceed with the eligibility determination process for PHC. The grantee must document in the applicant’s record that they were informed and referred to the other program.

Grantees may use the Your Texas Benefits website to help screen client eligibility. Get more information about HHSC benefits by calling 2-1-1.

Supplemental Benefits

Applicants receiving benefits from other sources, such as Children’s Medicaid or Medicaid for Pregnant Women, may also be eligible for partial PHC coverage. This supplemental or wraparound coverage is limited to services provided by PHC but not covered by other sources. Whenever federal, state, private or other benefits are available for payment of clients receiving PHC covered services, do not use any PHC funds for such care. An example of supplemental benefits is providing health education services to Medicaid-eligible clients since Medicaid does not provide health education services. The grantee must communicate to the client that supplemental services are of limited scope.

Adjunctive Eligibility

An applicant is considered adjunctively (automatically) eligible for PHC program services at an initial or renewal eligibility screening if the applicant is currently enrolled in one or more of the following:

• Children’s Medicaid;
• Medicaid for Pregnant Women;
• Special Supplemental Nutrition Program for Women, Infants and Children (WIC); or
• Supplemental Nutrition Assistance Program (SNAP).

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

*Note: Presentation of the Your Texas Benefits card does not completely verify current enrollment in the Children’s Medicaid or Medicaid for Pregnant Women program. To verify enrollment, grantees must call Texas Medicaid & Healthcare Partnership (TMHP) at 800-925-9126 or access TexMedConnect on the TMHP website. For a client's current enrollment status, grantees must enter two of the following four data elements:

• patient control number;
• date of birth;
• Social Security Number; or
• last name.

If the applicant’s current enrollment status cannot be verified during the eligibility screening process, adjunctive eligibility must not be granted. The grantee then determines eligibility per usual protocols.

Insurance

Annual Recertification

Annual eligibility determination and recertification is required for all clients who receive PHC services. Client eligibility must be redetermined every 12 months, using the most recent version of Form 3029, Application for Program Benefits. Grantees must have a system in place to track client eligibility and renewal status on an annual basis.