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Effective Date: 
11/2019

Documents

 

Instructions

Updated: 11/2019

 

Purpose

Form 3029 is used by applicants to apply for the Primary Health Care (PHC) Services Program, the Title V Maternal and Child Health Fee-For-Service Program and the Epilepsy Program.

 

Transmittal

The applicant will finalize or complete Form 3029 in the clinic they choose to go to for services.

 

Form Retention

The contractor completes the form in partnership with the applicant, and it becomes a part of the client’s medical record and is retained according to the rules for medical record retention.

 

Detailed Instructions

Section I, Primary Applicant Information — Complete all fields, unless otherwise specified.

Are you a veteran? — Check yes or no.

Communication Preferences — This section is optional and will not affect eligibility. OPSH keeps email addresses in strict confidentiality and does not share or sell with other third parties.

Section II, Household Information — Fill in the number of people in the household. Complete the other lines for everyone who lives with you for whom you are legally responsible. How to determine your household number:

  • If you are married (including common-law marriage), include yourself, your spouse and any mutual or non-mutual children (including unborn children).
  • If you are not married, include yourself and your children, if any (including unborn children).
  • If you are not married and you live with a partner with whom you have mutual children, count yourself, your partner, your children and any mutual children (including unborn children).

Note: Applicants age 18 and older are adults. Do not include children age 18 and older or other adults living in the house as part of the household. Minors should include their parent(s) or legal guardian(s) living in the house.

Section III, Health Care Information — Select yes or no to indicate whether you have an immediate medical need. Select yes or no if you have comprehensive health care coverage. If yes, check the boxes that apply:

  • Children’s Health Insurance Program (CHIP) Perinatal
  • Supplemental Nutrition Assistance Program (SNAP)
  • Women, Infants and Children (WIC) Program
  • Medicaid for Pregnant Women
  • Texas Women’s Health Program (TWHP)
  • None of these

If you select one of these benefits or health care coverage programs and you are able to provide proof of current enrollment, you may be adjunctively (automatically) eligible for a state health program administered by OPSH. If so, you can skip Section III of the form if you do not collect a copay. Exception: Adjunctive eligibility does not apply to applicants seeking Title V Fee-For-Service benefits.

Select yes or no if you or anyone in your household has any special circumstances. If yes, provide the name.

Section IV, Acknowledgment – The applicant reads, initials, signs and dates the form. If a person helps the applicant complete the form, that person should sign, state his/her relationship to the applicant, and date the form.

For Office Use Only – This section is completed by staff only.

Section V, Household Income Information – List all of your household’s income. Include:

  • government checks;
  • money from work;
  • money you collect from charging room and board;
  • cash gifts, loans or contributions from parents, relatives, friends and others;
  • a sponsor’s income;
  • school grants or loans;
  • child support; and
  • unemployment benefits.

In the first column, list the name of the household member who receives the money. In the second column, enter the name of the agency, person or employer who provides the money. In the third column, enter the type of income received per month. In the fourth column, enter the amount of money received. In the fifth column, enter the frequency or how often the person receives the money. In the sixth column, enter the total monthly amount of income the person receives, using the data from the fourth and fifth columns.

Calculate the Total Countable Monthly Income.

Subtract the Deductions to determine Net Countable Monthly Income, which may include:

  • child support payments;
  • dependent child care, up to $200 per child per month for children under age 2;
  • dependent child care, up to $175 per child per month for children age 2 and older; or
  • adults with disabilities, up to $175 per adult per month.

Enter any notes in the Verification of income box.

Section VI, Program Eligibility

Determine program eligibility for each household member, using the corresponding names from Section II, Household Information.

  • PHC = Primary Home Care
  • Title V/MCH = Title V Maternal and Child Health
  • Epilepsy = Epilepsy Program

Section VII, Contractor Eligibility Certification

This section is completed, signed and dated by the provider.

Enter the Eligibility Effective Date. Enter the date the applicant is eligible.

Complete the following numbered items:

1. Select yes or no for all household members eligible as Texas residents.

2. Total the amount received per month to fill in the box for Total Monthly Household Income.

3. Calculate the individual’s household Federal Poverty Level (FPL), using the applicable policy (include applicable deductions) and fill in the FPL. Refer to the table below to determine the FPL and enter the correct percentage in the Household FPL box.

Program Eligibility by 2019 Federal Poverty Level (FPL) Effective April 1, 2019
Persons in Household 185% FPL 200% FPL 250% FPL
1 $1,925.54 $2,081.66 $2,602.08
2 $2,606.95 $2,818.33 $3,522.91
3 $3,288.37 $3,555.00 $4,445.75
4 $3,969.79 $4,291.66 $5,364.58
5 $4,651.21 $5,028.33 $6,285.42
6 $5,332.63 $5,765.00 $7,206.25
7 $6,014.05 $6,501.66 $8,127.08
8 $6,695.46 $7,238.33 $9,047.92
Each Additional
Person in Household
$681.45 $736.66 $920.83

4a. Check yes or waived for the proof of income.

4b. Enter reason for waiver for the proof of income.

5. Check yes, no or N/A for verification of adjunctive eligibility.

6. Check the appropriate program(s) for which the applicant has been screened for eligibility: Medicare, Medicaid, CHIP, CHIP Perinatal, Private insurance, Veterans Affairs (VA) benefits, TRICARE, Healthy Texas Women (HTW), Family Planning (FP) or Breast and Cervical Cancer Services (BCCS).

7a. Check yes, no or N/A for presumptively eligible.

7b. Once the applicant completes the requirements for full eligibility, check yes. If the applicant does not complete the requirements for full eligibility, check no or N/A.

7c. Enter the full eligibility met date.

8. Check yes, no or N/A regarding the applicant’s eligibility. If yes is checked, enter the copayment amount for the program, based on the applicant’s household and income information.

Notes: Document other appropriate information concerning eligibility and screening.

Name of Agency, Agency/Staff Member Signature and Date – The agency staff member enters the agency name, signs and dates the form.