3200, Client Eligibility

Revision 24-2; Effective Sept. 20, 2024

3210 Eligibility Guidelines

Revision 26-3; Effective Sept. 1, 2026

For an applicant to receive BCCS services, they must meet three general criteria. The person must:

• have a gross household income at or below 200% of the Federal Poverty Level (FPL)
• be a Texas resident
• be without access to programs or benefits that provide the same services

BCCS is the payor of last resort. When a grantee is awarded multiple HHSC program grants, consult this manual for times when limited dual certification grantee billing is allowed. Grantee must seek HHSC approval for any times not clearly defined in this manual.

Other Eligibility Factors

Other eligibility factors include:

• Applicants must meet age-specific eligibility criteria for screening and diagnostic services.
• Applicants with a primary need for cancer screening should be enrolled in BCCS.
• Applicants whose health insurance does not fully cover screening and diagnostic services are considered underinsured and may be enrolled for services. Note: Applicants eligible for Emergency Medicaid coverage through pregnancy and 12-month postpartum period only receive treatment of emergency medical conditions. These applicants are considered underinsured and may be enrolled for BCCS services if they meet all other eligibility requirements. BCCS does not provide any emergency services.

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.

Grantee Responsibilities for Eligibility Determination

Grantees must develop policy and procedures to determine BCCS eligibility and identify people responsible for eligibility screening.  The policy must be available during monitoring visits and must address:

• acceptable documents that verify household income at or below 200% FPL. Income must be recorded in the client record and Med-IT^®.
• use of Form 1065, 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. Refer to Alternative Eligibility Screening Tool below.

Grantees eligibility policy must also make sure:

• client insurance status is assessed before service delivery.
• general BCCS eligibility is determined before enrollment, then annually.
• clients 65 and older are only eligible if they are unable to pay or are ineligible for Medicare Part B.

A woman who is eligible to receive Medicare benefits and is not enrolled in Medicare should be encouraged to enroll.

Women enrolled in Medicare Part B are not eligible to receive services. Women who are not eligible to receive Medicare Part B and Medicare-eligible women who cannot pay the premium to enroll in Medicare Part B are eligible to receive services. 

If a client cannot afford Medicare Part B premiums, Medicaid-sponsored Medical Savings Programs may pay Medicare premiums, deductibles and coinsurance amounts for eligible Medicare beneficiaries. The Qualified Medicare Beneficiary (QMB) program, the Specified Low-Income Medicare Beneficiary (SLMB) program, the Qualified Individuals (QI-1) and the Qualified Disabled Working Individuals (QDWI) program are all called Medicare Savings Programs. More information about Medicare Savings Programs is at Medicare Savings Programs.

3220 Applying for Services

Revision 26-3; Effective Sept. 1, 2026

Screening and Eligibility Determination

Grantees must use Form 1065, 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. Refer to Alternative Eligibility Screening Tool below.

The applicant must complete Form 1065. If the applicant needs help completing the form, grantees must provide knowledgeable staff to assist.

Client eligibility determination may be conducted by phone. Applicants may print the form, add a handwritten signature, scan it and email or fax the form to a grantee. Client and grantee digital signatures are allowed. A grantee may sign on behalf of an applicant if needed. If eligibility is determined over the phone, grantees must read and get the applicant’s verbal authorization to sign or initial the form on the applicant’s behalf with a digital ID or handwritten signature. Anyone who helps the applicant complete the form must also sign and date it.

Documenting Special Circumstances

Special circumstances may prevent an applicant from providing required documentation for verification purposes. Document these types of special circumstances on Form 1065. Special circumstances must also be documented in the Med-IT^® Data System in the notes section of the enrollment screen.

Former Military Service Members

Grantees must collect and report service member data for clients served by the BCCS program. Grantees will collect and report the service member data through Med-IT^®.

Applicants who served in any branch of the U.S. Armed Forces, Reserves or National Guard may be eligible for more benefits and services. Grantees must 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.

Residency

A person must be physically present within the geographic boundaries of Texas to be eligible for BCCS. There is no required amount of time a person must live in Texas to establish residency for BCCS eligibility. The person must have the intent to remain within the state permanently or for an indefinite period.

Household

Establishing household size is an important step in the eligibility process. Assessment of income eligibility relies on an accurate count of household members. The household consists of a person who lives 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 younger than 18 years must be counted as part of the household, including a pregnant client’s unborn children. A BCCS-eligible applicant who is a legal adult must complete Form 1065.

Grantees have discretion to document special circumstances in the calculation of household composition.

Income

To be eligible for BCCS services, applicants must provide verification of countable household income at or below 200% of the FPL. If the applicant cannot provide verification, they may self-declare income. The reasons an applicant self-declares income must be documented in the client record and in the Med-IT^® Data System. Both actual income amounts, which is income that was already received, and projected income amounts, which is income that has not been received but expected for the current month, must be used to determine eligibility.

Note: Applicants who seek Medicaid for Breast and Cervical Cancer (MBCC) may not self-declare income. This includes women who have been diagnosed with a qualifying cancer by BCCS grantees or other health care providers. Applicants who received help from a BCCS grantee to apply for MBCC must have verification of income documented in their client record and on the eligibility screen in Med-IT^®.

Income Deductions

Dependent care expenses and payments made by a member of the household group must be deducted up to the allowable amount as follows:

• legally obligated child support payments paid to the household;
• $200 per child per month for children younger than 2;
• $175 per child per month for children 2 – 17; and
• $175 per dependent adult with disabilities per month who is 18 and older.

Monthly Income Calculation

List the applicant’s household income in the table in Section 4 of Form 1065. Include:

• income from work;
• income the applicant collects from charging room and board;
• the spouse’s income; and
• unemployment benefits.

Refer to the Texas Works Handbook for more countable and exempt income sources.

Calculate the Total Countable Monthly Income. Subtract the deductions to figure the applicant’s total monthly adjusted gross household income if deductions are included.

To find a monthly income when income is received in lump sums at irregular intervals or at intervals longer than monthly, such as contract labor and seasonal employment, divide the total amount received over the period it is expected to cover household expenses. Convert the amount by:

• multiplying weekly income by 4.33
• multiplying income received every two weeks by 2.17
• multiplying income received twice a month by 2.0
• dividing income received annually by 12

Count the total income for the months worked in the overall calculation of income for seasonal income.

Calculation of Applicant’s FPL Percentage

• 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 U.S. Department of Health and Human Services federal poverty guidelines. The guidelines are subject to change near the beginning of each calendar year. However, grantees should not use updated federal guidelines until the BCCS program makes the necessary changes in Med-IT^® and a notification is sent to grantees on the updated guidelines’ effective date. The current FPL information is in Appendix V.

Alternative Eligibility Screening Tool – AEST

An AEST, created by the grantee may be used in place of Form 1065 with prior written approval by the BCCS program.

To apply for approval, grantees must send a request to the BCCS program mailbox. Put AEST Request in the subject line.

The HHSC BCCS 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. 

At a minimum, the AEST must contain all required elements of Form 1065.

HHSC must review and approve before use. Grantees must use Form 1065 until they have received written approval of the proposed AEST from HHSC. The grantee must maintain and retain proof of approval. The grantee 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 BCCS 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. This is required even if no changes have been made to the tool since the last written approval.
• Any changes made to Form 1065 that HHSC considers requirements for eligibility 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 1065 for re-review and approval.

The BCCS program reserves the right to request edits or withdraw its approval of the use of an alternate eligibility tool. The BCCS program will notify the grantee of the decision in writing and include the date the AEST must be discontinued.

3230 Adjunctive Eligibility

Revision 25-3; Effective Sept.1, 2025

An applicant is considered adjunctively eligible, which is automatically eligible for BCCS services at an initial or renewal eligibility screening, if the applicant or a member of the applicant’s household is currently enrolled in one of the programs listed below. An applicant must provide proof of active enrollment in the adjunctively eligible program. Acceptable eligibility verification documentation may include the following.

3240 Date Eligibility Begins

Revision 24-2; Effective Sept. 20, 2024

Applicants are eligible to receive services the date an application is completed and the applicant is determined eligible. Services rendered before the date the applicant is determined eligible will not be reimbursed.

3250 Fees

Revision 26-3; Effective Sept. 1, 2026

Clients must not be charged copays for BCCS allowable services or administrative fees for items such as processing or transfer of medical records, or both, copies of immunization records and similar documents.

Grantees may bill clients for services outside the scope of BCCS allowable services if:

• the service is provided at the client’s request and
• the client is made aware of their responsibility for paying the charges before services are rendered.

3260 Continuation of Services

Revision 23-2; Effective Sept. 29, 2023

Grantees who expend their awarded funds must continue to serve their existing eligible clients currently in the process of a care plan. It is allowable to obtain other funding to pay for these services. Dependent on the funding source, such funds may be counted toward the match requirement.

Grantees who expend their awarded funds are not required to enroll new clients. However, it is allowable to offer services at full pay or on a sliding scale basis.

3270 Med-IT^® Data and Billing Services

Revision 26-3; Effective Sept. 1, 2026

Med-IT^® users should verify if a person is eligible for BCCS before adding a client to the database. Before entering a client’s information into the Med-IT^® database, grantees must do a client search to find out if she has:

• ever received services funded by BCCS; and
• an existing Med-IT^® identification number, which is a unique number assigned to each BCCS client.

This process can be completed by entering client identifiers, which may include name, date of birth, Social Security number or all three. A client’s address and ZIP Code may also be used to search for an existing Med-IT^® identification number. If a client has an existing Med-IT^® identification number and received services in a different region, the grantee should submit a region change request to Med-ITHelpDesk@hhs.texas.gov.

Minimum PC Requirements for Med-IT^® are:

• Any internet connection. For optimum performance and response time, grantee locations should have access to a broadband connection with a minimum of 1 MB upload speed and 2 MB download speed.
• Google Chrome or Microsoft Edge.

Med-IT^® users must have access to the database and BCCS service providers must be listed in the database. New users may request access by completing Form 5200, Med-IT New User Request. New providers must complete Form 5201, Med-IT New Provider Request. Each of these forms must be submitted to Med-ITHelpdesk@hhs.texas.gov.