Expanded Primary Health Care Program Contractor Eligibility Webinar Training

1. Expanded Primary Health Care ProgramContractor Eligibility Webinar Training

2. Training Goal The goal of this training is to educate and familiarize contractors with the FY14 Revised Client Eligibility Process & Policies for the Expanded Primary Health Care Program (EPHC).

3. Section Three - Client Eligibility

4. Client Eligibility Review of Revisions • Renamed - “General Principles” to “Eligibility Guidelines” • Removed – “Contractor’s Responsibilities” • Removed – “Applicant’s Responsibilities” • Re-ordered - Client’s Responsibilities for Reporting Changes is now located after “Verification/Documentation of Income”

5. Client Eligibility Review of Revisions • Condensed & revised – “Screening & Eligibility Determination; Clients Screened Potentially Eligible for Other Benefits” is now “Other Benefits” • Added language – “Supplemental Benefits” is also identified as “Wrap-around” coverage • Re-ordered – “Payor of Last Resort” is now located near the end of Section 3

6. Client Eligibility Review of Revisions • New addition– “Medicare, Medicaid, and TWHP Eligibility” adds information about Texas Women’s Health Program (TWHP) • New addition– “Screening for TWHP” provides instruction and requirements for screening • New addition – “Screening for EPHC Program Eligibility” provides instruction for using the new Individual Eligibility Form and the revised Household Eligibility Form • Revised/Removed – “Family Composition/Household” is now identified as “Household” and is self-declared. Also removed “Special Family Composition/Household” and “Verification/Documentation of Composition/Household.”

7. Client Eligibility Review of Revisions • Revised/Removed –“Verification/Documentation of Residency” policy is now revised to self-declared “Residency.” • Revised – “Income” policy explains that verification of income is required but must be waived if the methods used for income verification jeopardize the client’s right to confidentiality or impose a barrier to receipt of services; reasons for waiving must be noted in the client record; if not waived, must be documented on DSHS FCHS Individual or Household Eligibility Form/Worksheet. NOTE: Contractor must have a written “Verification/Documentation of Income” policy that must be available to DSHS upon request.

8. Client Eligibility Review of Revisions • Re-ordered– “Income Deductions/Monthly Income Calculation” have been relocated but still remain in the “Income” policy. • Removed – The “Self-Employment Income”; “Seasonal Employment”; and “Statement of Support” policies have all been removed. • Removed – The “Case Processing” policy has been removed.

9. Client Eligibility Review of Revisions • New addition – “Adjunctive Eligibility” policy explains the process and the criteria for allowing “adjunctive” (or “automatic”) eligibility. • Revised – “Eligibility Determination Date” has been revised to allow the eligibility determination start and end dates to more closely align with contractors’ electronic practice management systems.” • Revised – The “Presumptive Eligibility” criteria has been revised to remove “immediate medical need” and broadens the description to an “individual” who has not had a final eligibility determination. • Revised – “Annual Recertification”  Revised – simplifies process.

10. forms

11. Client Eligibility Review of Forms “INDIVIDUAL Eligibility” Form(Form # EF05-14215) – this is a new form. It can be used for an applicant who is applying for the EPHC program individually (no other household members are applying at the same time). There is no separate worksheet for this form. After the applicant completes Parts I – IV (, the eligibility worker completes Part V. Part V is “the worksheet.”

13. Client Eligibility Review of Forms “HOUSEHOLD Eligibility” Form(Form # EF05-14214) – this updated form is used if two or more members of a household apply together for EPHC services. The applicant completes this form (eligibility worker may assist the applicant if needed). The eligibility worker completes the HOUSEHOLD Eligibility Worksheet.

15. Client Eligibility Review of Forms “HOUSEHOLD Eligibility Worksheet”(Form # EF05-13227) – this updated form must be completed by the eligibility worker and is used in conjunction with the HOUSEHOLD Eligibility Form.

17. Client Eligibility Review of Forms “Notice of Presumptive Eligibility”(Form # 102) – this form is used for an “individual” who has met the criteria for presumptive and will be granted EPHC coverage under “Presumptive Eligibility.”

19. Client Eligibility Review of Forms Optional Forms • Notice of Eligibility Form – (Form # 103) • Notice of Ineligibility Form – (Form # 117) • Request for Information Form – (Form # 104) • Statement Self-Employment Form – (Form # 149) • Employment Verification Form – (Form # 128)

20. EPHC WEBSITEhttp://www.dshs.state.tx.us/ephc/Expanded-Primary-Health-Care.aspx

21. EPHC questions Expanded Primary Health Care Program & Traditional Primary Health Care Program Email Address PrimaryHealthCare@dshs.state.tx.us