Revision 20-1; Effective May 8, 2020

 

PHC services contract amounts are ceilings against which contractors may bill for services provided to PHC eligible clients. Once this ceiling has been reached, no further funds will be available for reimbursement. Contractors may only bill for services provided to clients who have been screened for potential Medicaid and other benefit programs and been determined PHC eligible.

 

5100 Categorical Reimbursement

Revision 20-0; Effective November 2019

 

PHC categorical funding (cost reimbursement) is used to develop and maintain contractor infrastructure for the provision of primary health services. The funding can be used to support clinic facilities, staff salaries, utilities, medical and office supplies, equipment and travel, as well as direct medical services. All services will be reimbursed on a cost reimbursement basis. Payments will be made for costs incurred and will be supported by reporting to show services provided and limited client-level data. Costs may be assessed against any of the following categories the contractor identifies during their budget development process:

  • Personnel;
  • Fringe Benefits;
  • Travel;
  • Equipment and Supplies;
  • Contractual;
  • Other; and
  • Indirect Costs.

PHC funds are disbursed to contractors through a voucher system as expenses are incurred during the contract period. Program income must be expended before categorical funds are requested through the voucher process. Contractors must still submit vouchers monthly even if program income equals or exceeds program expenses, or if the contract reimbursement limit has been met. When program expenses exceed program income, the monthly voucher will result in a payment. Program income includes all fees paid by the clients (client co-pay).

 

5110 Monthly Billing and Reporting

Revision 20-0; Effective November 2019

 

Categorical reimbursement for the cost of providing services shall be billed monthly on Form 4116, State of Texas Purchase Voucher, and submitted to the contact(s) outlined in the instructions for the form. Each request will cover services provided, or expenses incurred, in the preceding month, as applicable to the contract attachment. Requests should be submitted within 30 days of the end of the preceding month and within 60 days of providing the service. Appropriate financial records must be maintained for review by HHSC through the quality assurance review process and/or fiscal monitoring and/or programmatic desk reviews.

A monthly PHC Reporting Form 225 must be submitted with the monthly voucher, within 30 days following the end of the month covered by the bill. Reimbursement requests submitted without the required program reports will not be approved for payment. Vouchers and/or reports submitted with incorrect or missing information will be rejected and the contractor will be contacted to remedy the problem.

 

5120 Submission of Vouchers

Revision 20-1; Effective May 8, 2020

 

If expenses are overstated on one month’s voucher, the following month’s expenses should be reduced accordingly. All claims for reimbursement for services delivered must be submitted within 45 days of the end of the contract term. If contractors have services that occurred during the contract period left to bill after the August Form 4116, State of Texas Purchase Voucher, has been submitted, contractors can bill those services using Form 4116 and a PHC Reporting Form 225, marked “Supplemental” and “Final,” and submit the forms on or before October 15. PHC contracts require closure of the contract attachment within 45 days of the end of the contract term. All requests for reimbursement must be submitted by email to HDS.ADS@hhsc.state.tx.us and PHCReports@hhsc.state.tx.us.

Form 4116 must be submitted via email to the email address provided on the form. Requests received more than 45 days following the end of the Contract Attachment will not be paid. A signed final Financial Status Report (Form 269A) must be submitted by email to the email address on the form no later than 45 days after the contract term. Form 269A must be marked as “Final” and include all reimbursements and adjustments in payments for the contract term.

 

5130 Voucher Submission and Reporting after Entire Contract Award is Expended

Revision 20-0; Effective November 2019

 

Contractors must continue to submit Form 4116, State of Texas Purchase Voucher, and supporting monthly program reports even after contract ceilings have been reached. Any cost over the contract ceiling after deducting program income should be reflected under “Non-HHSC Funding” on Form 4116 and on the Financial Status Report (Form 269A). This submission is required to continue reporting expenditures on any program income collected monthly and to provide HHSC with statistical information about the use of services.

 

5140 Non-Reimbursable Expenditures

Revision 20-0; Effective November 2019

 

PHC will not reimburse services for individuals enrolled in another program or clients who do not complete the respective eligibility process, except for clients who meet the presumptive eligibility criteria. Payment for clients who were treated under presumptive eligibility may be eligible for services only during the 90-day time period. If clients fail to fully comply with all requirements to apply for Medicaid services, they will not be considered eligible for PHC services after the presumptive time period expires.

 

5150 Reimbursable Expenditures

Revision 20-0; Effective November 2019

 

Services may be provided to clients whose screening results indicate they are potentially Medicaid eligible, but the client has not yet completed the application process. Except for presumptive eligibility, services provided on the initial day of service may be billed to PHC for reimbursement with proper documentation of the client’s eligibility status.

 

5160 Altering of Forms

Revision 20-0; Effective November 2019

 

Contractors are required to use the most current version of their organization’s personalized Form 4116, State of Texas Purchase Voucher, for ease of processing. None of the billing or the reporting forms may be altered in any manner. The vouchers should not be altered to itemize expenses for PHC services provided. Vouchers should be submitted for the total monthly reimbursement amount only.

 

5200 Data Collection and Reporting

Revision 20-0; Effective November 2019

 

The table below outlines the data collection and reporting requirements for HHSC PHC Services Program Contractors.

Program Information
Program Name: Primary Health Care (PHC)
Contract Type: Categorical
Contract Term: September 1 through August 31
Required Form Type: Voucher 1
Name: Form 4116, State of Texas Purchase Voucher
Submission Date: By the last business day of the following month. Final voucher due within 45 days after the end of the contract term.
Submit Copy To: HDS.ADS@hhsc.state.tx.us
PHCReports@hhsc.state.tx.us
Original Signature Required: No
Accepted Method of Submission: Email
No. of Copies: 1
Instructions: Submit Form 4116 to Health and Developmental Services (HDS)
Note: Form 4116 and PHC Reporting Form 225 must be submitted at the same time to the HDS email box. Form 4116 will not be processed unless the PHC Reporting Form 225 is received with Form 4116. All forms must be submitted in their original format in the same email. No exceptions.

 

Program Information
Program Name: Primary Health Care (PHC)
Contract Type: Categorical
Contract Term: September 1 through August 31
Required Form Type: Report 1 - Supporting
Name: PHC Reporting Form 225 Monthly Report
Submission Date: By the last business day of the following month. Final report due within 45 days after the end of the contract term.
Submit Copy To: HDS.ADS@hhsc.state.tx.us
PHCReports@hhsc.state.tx.us
Original Signature Required: No
Accepted Method of Submission: Email
No. of Copies: 1
Instructions: Submit Form 4116 to Health and Developmental Services (HDS)
Note: Form 4116 and PHC Reporting Form 225 must be submitted at the same time to the HDS email box. Form 4116 will not be processed unless the PHC Reporting Form 225 is received within Form 4116. All forms must be submitted in their original format in the same email. No exceptions.

 

Program Information
Program Name: Primary Health Care (PHC)
Contract Type: Categorical
Contract Term: September 1 through August 31
Required Form Type: Report 1
Name: Financial Status Report 269A
Submission Date: Quarterly, Sept. 1-Nov. 30, Dec. 1-Feb. 28, March 1-May 31, June 1-Aug. 31. Submit 30 days after the end of each quarter. The final quarterly Financial Status Report 269A is due 45 days after the end of the contract term. The final quarter report includes all final charges and expenses associated with the program contract. Mark it as “Final.”
Submit Copy To: HDS.ADS@hhsc.state.tx.us
PHCReports@hhsc.state.tx.us
Original Signature Required: Yes
Accepted Method of Submission: Email scanned document
No. of Copies: 1
Instructions: Submit one Financial Status Report 269A with an original signature (signed and scanned in email accepted).

 

Program Information
Program Name: Primary Health Care (PHC)
Contract Type: Categorical
Contract Term: September 1 through August 31
Required Form Type: Report 2
Name: PHC Annual Report
Submission Date: Within 60 days following the end of the contract period.
Submit Copy To: HDS.ADS@hhsc.state.tx.us
PHCReports@hhsc.state.tx.us
Original Signature Required: No
Accepted Method of Submission: Email
Instructions: Submit PHC Annual Report to Health and Developmental Services (HDS).