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Revision 26-2; Effective Sept. 1, 2026
This section provides policy requirements for client eligibility determinations, client fees and the continuity of client services.
4100 Eligibility and Assessment of Co-pay and Fees
Revision 26-2; Effective Sept. 1, 2026
Grantees must determine and document TVFFS eligibility before rendering services. Grantees must have a policy outlining the procedures to determine program eligibility and the staff member(s) responsible for eligibility screening.
To assess eligibility for TVFFS, grantees must use the most recent version of Form 3029, Application for Program Benefits, 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.
Alternate Eligibility Screening Tool
An Alternate Eligibility Screening Tool (AEST) created by the grantee may be used in place of Form 3029 with prior written approval by the TVFFS program.
To apply for approval, grantees must send a request to TVFFS program mailbox with AEST Request in the subject line.
The HHSC program contact will send grantees an AEST Request Form to complete. Grantees must complete the form and return it to the program mailbox with the proposed AEST.
The AEST must contain all required elements of Form 3029.
HHSC must review and approve before use. Grantees must use Form 3029 until they have received written approval of the proposed AEST from HHSC. The grantee must maintain and retain proof of approval and must make the approval available during Quality Assurance visits.
Once a grantee receives approval for the use of the AEST, the following requirements apply.
- Grantees must request approval from the TVFFS program for any revisions to their eligibility screening tool and include a copy of the revised tool.
- The AEST is only approved for use during the current grant term. If a grantee is awarded funding under a subsequent grant, the grantee must resubmit the AEST for review and written approval, even if no changes have been made to the tool since the last written approval.
- Any changes made to Form 3029 that are considered requirements for eligibility by HHSC must be incorporated into the grantee-developed AEST. Grantees must submit their AEST with the incorporated changes within 60 calendar days after notification of a change to Form 3029 for rereview and approval.
- The TVFFS program reserves the right to request edits or withdraw its approval of the use of an alternate eligibility tool. The TVFFS program will notify the grantee of the decision in writing and include the date the AEST must be discontinued.
4200 Client Eligibility Screening Process
Revision 26-2; Effective Sept. 1, 2026
For a person to receive TVFFS 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 TVFFS Child Health and Dental program serves people from birth until their 22nd birthday. The TVFFS Prenatal Medical and Dental program serves pregnant women of any age through three months postpartum, and through three months following a pregnancy loss.
Application and eligibility determinations for TVFFS can be made by conducting interviews in person or over the phone. Phone interviews for eligibility determinations must comply with all eligibility guidelines outlined in this manual.
If a client is unable to sign the Acknowledgment section of Form 3029, Application for Program Benefits, the eligibility staff may read the statements to the applicant over the phone and document that the applicant affirms the statements. The documentation must include the date and time of the applicant's affirmation and the eligibility staff person’s signature. The client must sign the document at the time of their next visit to the clinic.
4300 Procedures and Terminology When Determining TVFFS Eligibility
Revision 26-2; Effective Sept. 1, 2026
Potential Eligibility and Referral to Other Programs
The TVFFS program is the payor of last resort. Grantees must screen applicants for Children’s Medicaid, CHIP, Medicaid for Pregnant Women, CHIP Perinatal, and any other applicable benefit programs. Applicants must apply for any programs for which they appear eligible. Applicants who do not fully comply with applying for other benefit programs are not eligible for TVFFS. TVFFS will not reimburse services provided to these applicants.
The grantee must notify the client that they must apply for any program for which they appear eligible. If a client does not screen as eligible for any other program, this must be documented on the application form.
All Children’s Medicaid, CHIP, Medicaid for Pregnant Women, CHIP Perinatal or other benefit program applications must be submitted promptly following TVFFS eligibility assessment. If a client was denied Medicaid or CHIP services, the denial letter must be included with their application.
All pregnant women served by TVFFS must apply for Medicaid or CHIP Perinatal programs.
Providers are required to inform, encourage and assist pregnant women in the CHIP Perinatal and Medicaid for Pregnant Women application process. A maximum of two clinical prenatal care visits are allowed for women in the process of applying for and enrolling in the CHIP Perinatal and Medicaid for Pregnant Women programs.
Grantees may use the HHSC Your Texas Benefits website to help screen for client eligibility. More information about HHSC benefits can also be obtained by calling 2-1-1.
TVFFS prenatal clients who enroll in a managed care organization (MCO) that does not provide dental benefits will remain eligible for TVFFS Prenatal Dental benefits. These clients must provide documentation that their MCO does not provide dental benefits to continue receiving TVFFS dental benefits. This documentation must be maintained in the client’s record.
If a client appears eligible and applies for any of these other benefit programs, they must be granted Presumptive Eligibility for TVFFS while awaiting benefit determination. The client is responsible for submitting proof of application or a denial letter before the presumptive eligibility period ends.
Information for Former Military Service Members
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.
Household
A household consists of a person living alone or a group of two or more people related by birth, marriage, common-law marriage 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 their 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 younger than 18 are 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 Date of Birth
Documentation of date of birth must be provided for clients who apply for the Child Health or Child Dental programs. One of the following should be provided and a copy should be kept with the client’s application:
- birth certificate,
- baptismal certificate,
- school records, or
- other documents or proof of date of birth determined valid by the grantee.
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 familial relationship determined valid by the grantee to establish the dependency of the family member with 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 TVFFS services, a person must:
- be physically present within the state 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 younger 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 TVFFS eligibility.
Document proof of residency provided by the client 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, or
- 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, or
- statements from landlords, neighbors or other reliable sources.
If an applicant’s residency is unclear or questionable, explain and document concerns if necessary. 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 seasonal worker who travels during certain times, but maintains a home in Texas and returns to that home after temporary absences is considered a Texas resident.
Documentation of Income
All income received must be included. If an unmarried applicant lives with a partner, count the partner’s income only if the applicant and partner have mutual children together, including unborn children. Income is calculated before taxes – gross household income. Income is reviewed and determined either countable or exempt based on the source of the income, as defined in Appendix I, Definition of Income. Grantees must have a written TVFFS income verification policy.
Documentation of income for TVFFS services must be provided to complete Form 3029. Declarations of unknown income will not be accepted as 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 the 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:
- copy(ies) of the most recent paycheck(s) or stub or monthly earning statement(s)
- employer’s written verification of gross monthly income,
- optional Form 3049, Employment Verification,
- optional Form 3051, Statement of Self-Employment Income,
- 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.
Optional Forms
The following forms are optional. They may be used to help complete the income and employment verification process:
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.
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 younger than 2,
- $175 per child per month for each dependent 2 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 Percentage
The grantee must determine the household Federal Poverty Level (FPL) percentage by using current U.S. Department of Health and Human Services federal poverty guidelines. The guidelines are subject to change around the beginning 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
Special circumstances may prevent an applicant from providing the required documentation for verification purposes. Document these types of circumstances appropriately on Form 3029.
Client Fees and Co-pays
Grantees may assess a co-pay for services from TVFFS clients. Grantees who choose to collect co-pays must comply with these guidelines:
- No TVFFS client will be denied services based on an inability to pay.
- Clients with a household FPL at or below 100% will not be charged a co-pay.
- Clients with a household FPL above 100% may be charged a co-pay of no more than $30 per visit.
- Grantees must have a written co-pay policy which clearly defines how co-pay amounts will be determined.
- Clients who are assessed a co-pay must be given a billing statement at the time of service and a copy must be kept in the client’s record.
- Any outstanding balance may not be turned over to a collection agency or reported delinquent to a credit reporting agency. An outstanding balance will not prohibit a client from receiving services.
- All policies and procedures regarding co-pay collection must be approved by the grantee’s board of directors.
- Co-pays must be reported as program income on the Monthly Reimbursement Packet (MRP). The grantee must complete B25 and E25.
Grantees may choose to use the optional co-pay table in Appendix II, Optional Co-Pay Table Based on Monthly Federal Poverty Level (FPL). This table is updated each calendar year after the new federal poverty guidelines are published.
Other Fees
Grantees must not charge clients administrative fees for items such as processing or transfer of medical records and copies of immunization records.
Grantees may bill clients for services outside the scope of TVFFS 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 Responsibility for Reporting Changes
A client must report changes to the following no later than 30 calendar days after the client is made aware of any changes:
- Income,
- family composition,
- residence,
- current address,
- employment,
- medical insurance coverage, and
- 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 be terminated. The grantee must issue Form 3047, Notice of Ineligibility to the client upon termination and include the date of termination.
Continuation of Services
Once awarded grant funds are spent, grantees must continue serving their existing TVFFS clients through the end of their clients’ determined eligibility periods.
Grantees do not have to screen potential new clients for TVFFS 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 client is eligible for the program and all the following requirements are met:
- all program eligibility requirements,
- program application is completed and signed, and
- all verification documents are submitted.
The grantee must issue Form 3012, Verification of Eligibility to notify an applicant of eligibility.
Presumptive Eligibility
Presumptive eligibility provides short-term access to health care services for up to 90 days when an applicant:
- screens as potentially eligible for services,
- has a medical or dental need, and
- lacks the documents required to achieve full eligibility.
Grantees must establish a presumptive eligibility period of 90 days in their eligibility policy. During this period, clients are expected to produce the necessary documents or be enrolled in other applicable programs, such as Medicaid or CHIP.
For clients who submit all required documents and are determined to be fully eligible before the end of their presumptive eligibility period, full eligibility will be granted. The eligibility expiration date will be calculated 12 months from the first day presumptive eligibility began. For Perinatal benefits, the eligibility expiration date is at three months postpartum or at three months after a pregnancy loss.
Child Health and Dental (CHD) clients are limited to one presumptive eligibility period per two calendar years.
Prenatal Medical and Dental (PMD) clients are limited to one presumptive eligibility period per pregnancy.
If the client enrolls in a Medicaid or CHIP program during the presumptive eligibility period, TVFFS enrollment will end on the date Medicaid or CHIP program eligibility begins.
The grantee must issue Form 3045, Presumptive Eligibility Notice to notify an applicant of Presumptive Eligibility.
Ineligibility
An applicant must be given Form 3047, Notice of Ineligibility if they are determined to be ineligible for program services after the screening process is complete. The applicant must also be informed of their right to appeal the eligibility decision. The applicant must use the process described on the Notice of Ineligibility.
Annual Eligibility Determination
Annual eligibility determination is required for all TVFFS clients. Client eligibility must be redetermined every 12 months, using the most recent version of Form 3029, Application for Program Benefits.
Perinatal benefits expire at three months postpartum or at three months following a pregnancy loss. Grantees must have a system in place to track client eligibility expiration dates to determine when a new application is needed.