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).
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”
Review of Revisions


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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
Review of Revisions


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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.”
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.
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.
Review of Revisions

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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.
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.”
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.
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.
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.”
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)
http://www.dshs.state.tx.us/ephc/Expanded-Primary-Health-Care.aspx
Expanded Primary Health Care Program
&
Traditional Primary Health Care Program
Email Address
PrimaryHealthCare@dshs.state.tx.us