Financial Eligibility

Click here to see this page in full context

Financial Eligibility

The CMBHS Financial Eligibility assessment is the process by which financial responsibility for services and the client’s eligibility to receive financial assistance from Texas Health and Human Services is determined and documented. Documenting the client’s financial situation — income, expenses, and family size — is important to determine financial eligibility for HHSC funding and how much the client will be expected to share the costs for services.

Clinical Management for Behavioral Health Services (CMBHS) gives HHSC providers a place to document financial information obtained during the client screening. Providers also receive an automated determination of the client’s financial eligibility status according to provider type. CMBHS allows the user to attach digital scans of supporting paper documents to the client’s electronic health record. This makes the record easily available for future reference and oversight purposes.

Not all HHSC contracts require that providers determine or document financial eligibility in CMBHS. Be sure to check your contract to determine if this is required for your program.

The CMBHS financial eligibility questions are not a script to be read word for word to the client. The questions should be asked using words the client will understand to ensure the financial eligibility assessment results are accurate.

NOTE: The Client's Financial Eligibility is valid for 180 days and must be updated prior to the expiration date, or when there is a change in the client's residency, income, Medicaid status, or insurance coverage. This document cannot be edited if it has expired. Also, this document cannot be back-dated more than 180 days.

Financial Eligibility Headings

The Financial Eligibility Document is organized under six headings. The first five sections are for documentation about the client. The last, Eligibility Determination Results, displays system-generated information.
Documentation of financial eligibility begins with a pre-filled General Information section that has today’s date for the Financial Eligibility Date and your name in the Performed By space. You may change the date with the calendar icon, or select someone else’s name if you are entering financial eligibility data that was gathered by someone else.
Next are questions about the financially responsible party (client or other party), including name, marital status, and address. Third Party Resource Information is next, addressing the client’s participation in programs such as Medicaid, Medicare, and Veteran’s benefits programs.
In the next two sections, Resource Information and Income, you can click on New Income or New Expense to insert insurance and income information, which includes the client’s family size and any Extraordinary Expenses.
When the user selects the Calculate button, CMBHS determines the client’s financial eligibility to receive services, and/or the amount the client or other financially responsible party may need to pay.

Before You Start Documenting Financial Eligibility Information

The organization and the service location you have logged into must provide substance use treatment or other services where a financial eligibility assessment is required for clients.
The user must be assigned a CMBHS role that permits documentation of a financial eligibility assessment. Click here for a list of Page Rights according to Role, either Read-Only or Read-Write.
The client must have a Client Profile in CMBHS before a Financial Eligibility Assessment can be created. The user must be in the client’s CMBHS health record, at the Client Workspace.
Check to make sure that you are at the correct location where the client is being served. Check the location by looking in the top left corner of the page, under the CMBHS logo. The Provider’s name is listed first, and underneath it is the CMBHS location you are currently logged into. If this is not the correct location for the client, go to Administrative Toolbar > Account Management > Change Location. If the location you need is not in the list, contact your Local CMBHS Security Administrator for assistance.
Before you begin documenting, always verify that you have the correct client’s record by checking the client’s name and at least one other identifier at the top of the page.

Business Rules for Documenting Financial Eligibility

Some fields in the document are required, others are optional. Required fields are designated by a red * asterisk. An answer must be documented for each required question in Financial Eligibility.
Before you can save a Financial Eligibility, a Medicaid Eligibility Verification (MEV) must be submitted and results received. This can be done within the Financial Eligibility document.
When all information has been entered and a Financial Eligibility determination can be calculated by CMBHS, the determination will be displayed.
CMBHS does not require that a financial eligibility assessment be completed before providing services to all clients. Users should review their applicable HHSC contract to determine the requirements for Financial Eligibility determination for various services types and client groups.
If you select Pending as the Documentation Status – Proof of Income, CMBHS will display the following message on the page immediately beneath the Documentation Status – Proof of Income field: Services for client cannot be billed to HHSC while status is set to Pending.
When Documentation Status-Proof of Income is Refused to Provide, CMBHS will display a pop-up message that says: Not Eligible for HHSC funded services because of refusal to provide documentation.
When documenting client information about Veteran’s Administration Benefits (VA), evaluate not only the client’s benefit status but the client’s ability to access the VA services. If a veteran has benefits but cannot use them or access the services he or she needs, he/she may be eligible for HHSC funded services.
If the client's eligibility for HHSC funded services is ever in question, please contact your HHSC Contract Manager.

How to Complete a Financial Eligibility Document

Navigating from the Clinician's Workspace

If you are in the Clinician's Workspace, select a client from your Client List by CLICKING anywhere in the row so that the client's name is highlighted. Then, CLICK on the button to the bottom right of the list that says Client Workspace. This will take you to the selected client's workspace.

To create a Financial Eligibility for a client, from the Client Workspace, go to the Client Services Toolbar on the left side of the screen. Move your mouse pointer over Intake and select Financial Eligibility. The Financial Eligibility determination page will display.

Fill in all the required fields

Financial Eligibility Data Fields

Financial Eligibility Date (Required)

This field is used to record the date that information was obtained from the client to determine financial eligibility.
The date will pre-fill with today’s date. To change the date, click the calendar icon next to the field, or enter the date in mm/dd/yyyy format. You can enter the eight numbers and CMBHS will arrange the numbers into the correct date format (e.g., 02/04/2019 represents February 4, 2019; 02042019 will be formatted as 02/04/2019). Or you can TYPE the numbers with the forward slashes between the month and day, and the day and year (mm/dd/yyy).

Performed By (Required)

This field is used to document the name of the staff who performed the financial eligibility assessment. Performed means the person who actually met with the client and collected and approved the documentation.
Select the name of the person who performed the financial eligibility assessment from the dropdown list. The dropdown list includes only staff who have access at this Location.

Responsible Party Section

Client is the Responsible Party for Payment (Required).
This field is used to document whether the client is responsible for paying for services.
If Yes is selected, certain other fields that follow will be filled in automatically.
If No is selected, the system user (staff) must manually enter the Responsible Party information.

Responsible Party First Name (Required)

This field is used to record the First Name of the party who is financially responsible for service delivery.
If the selected response to Client is the Responsible Party for Payment is Yes, this field will be populated automatically with the client’s first name.

Responsible Party Last Name (Required)

This field is used to record the Last Name of the party who is financially responsible for service delivery.
If the selected response to Client is the Responsible Party for Payment is Yes, this field will be populated automatically with the client’s last name.

Responsible Party Marital Status (Required)

This field is used to record the marital status of the person determined to be financially responsible for services.

If the selected response to Client is the Responsible Party for Payment was Yes, this field will be populated automatically with the client’s marital status.

The answer choices are:

Divorced – The client identifies him/herself as being divorced.
Married – The client is currently married. Include common-law marriages only if the client identifies him/herself as being in a common-law marriage.
Separated – Although not officially recognized as a marital status in Texas, select this answer choice if the client is married and is not living with his/her spouse.
Single – The client is not married.
Widowed – The client was married and his/her spouse is deceased.
Never married – The client has never been married.
Now married – The client is currently married. Include common-law marriages only if the client identifies him/herself as being in a common-law marriage.
Other – The client identifies him or herself as a marital status not listed above.

Same as Client Address

If this check box is selected, the address information is immediately populated with the client’s address information. If the check box is unselected, any address information is automatically removed and address information for the responsbile party can be entered.

Mailing Address 1 (Required)

This field is used to record information about the address of the financially responsible party for service delivery.
If the check box Same as Client Address is selected, the address information is immediately populated with the client’s address information. If the check box is unselected, address information is automatically removed.
If the field is blank, enter the first line of the mailing address for the party determined to be financially responsible for the services (e.g., 1234 Penny Lane).

Mailing Address 2 (Not required)

This field is used to record information about the address of the party financially responsible for service delivery.
If the check box Same as Client Address is selected, the address information is immediately populated with the client’s address information. If the check box is deselected, address information is automatically removed.
Enter the second line of the mailing address for the financial party (e.g., Apartment #123).

ZIP Code (Required)

This field is used to record the zip code of the party financially responsible for service delivery.
If the check box Same as Client Address is selected, the address information is immediately populated with the client’s address information. If the check box is unselected, address information is automatically removed.
If the field is blank, enter the primary ZIP Code of the financially responsible party.
Then CLICK outside of the text box and CMBHS will automatically update the CITY field based on the Zip Code you entered.
If available, provide the +4 code. This is NOT automatically populated and this part of the ZIP code is optional.

City (Required)

This field is used to record the city of the party financially responsible for service delivery.
If the check box Same as Client Address is selected, the address information is immediately populated with the client’s address information. If the check box is deselected, address information is automatically removed.
This field is automatically limited based on the entry in the ZIP code field. Once a ZIP code is TYPED in, only cities using the specific ZIP code are displayed. The user should select the appropriate city for the financially responsible party. If the ZIP code is entirely within one city, no user action is needed.

County (Optional)

This field is used to record the county of the party financially responsible for service delivery.
Although for CMBHS this is an optional field, your organization may require it.
If the check box Same as Client Address is selected, the address information is immediately populated with the client’s address information. If the check box is unselected, address information is automatically removed.
This field is automatically limited based on the entry in the ZIP code field. Once a ZIP code is provided, only counties using the specific ZIP code are displayed. If None Selected is displayed, the user should select the appropriate county for the financially responsible party from the dropdown list. If the ZIP code is entirely within one county, no user action is required.

State (Required)

This field is used to record information about the address of the party financially responsible for service delivery.
If the check box Same as Client Address is selected, the address information is immediately populated with the client’s address information. If the check box is deselected, address information is automatically removed.
This field is automatically limited based on the entry in the ZIP code field. Due to residency requirements, only Texas will be displayed.

Home Telephone (Optional)

This field is used to record the home phone number of the party financially responsible for services. If the party indicates he/she does not have a home phone number, you may enter a cell phone number or other number where he/she can be reached.
Although for CMBHS this is an Optional field, your organization may require that it be completed.
TYPE in the area code and phone number for the financially responsible party in one of the following formats: 123-456-7890 or 1234567890.

Work Telephone (Optional)

This field is used to record the work phone number of the party financially responsible for services.
Although for CMBHS this is an optional field, your organization may require it.
TYPE in the area code and phone number for the financially responsible party in one of the following formats: 123-456-7890 or 1234567890 (the system will format the number automatically).

Third Party Resource Information (Required)

This section of the CMBHS Financial Eligibility assessment is used to record information about what programs/benefits currently cover the client.

Is the client covered by any of the following programs? (Required)

Medicaid

Is the client currently covered by Medicaid? (Required)
The answer choices for this question are Yes or No. The default answer is No.
If Yes is selected, a field appears to enter the client’s Medicaid number. The Medicaid number is required.

Medicare

Is the client currently covered by Medicare? (Required)
If Yes is selected, fields appear for the user to enter the client’s Medicare Number Format, Medicare Number, and Medicare Type.
If the provider selected Yes on any of the above, will the provider seek reimbursement from the eligible source? (The provider must seek reimbursement for the client to be eligible for state funding.)

Veterans Administration (VA) Benefits

Is the client covered by Veteran’s Administration (VA) benefits and/or do they have access to the VA benefits? (Required)
This single question has two parts, and it is very important that you determine both parts before you document an answer to this question.
Does the client have VA benefits? If the client indicates they have VA benefits, answer Yes for this part of the question.
Does the client have access to VA benefits? You must determine if the client can actually use the benefits and access the services they need through the VA. Answer Yes or No as to whether the client can access VA services.
If both parts of the question are answered Yes, and Yes is documented in the available radio button, a message will display stating that the client is not eligible for HHSC-funded services and should be referred to the Veterans Administration.
If the answer to either question is No, document No in the radio button for the entire question. CMBHS will display the eligibility status based on additional information provided by the user.

Resource Information

If the client has coverage from another source or other insurance, click on the New Resource button and complete the details about the client’s insurance policy. Specify at the end of the list whether the benefits include chemical dependency counseling.

If the benefits include chemical dependency counseling, the question “Have all chemical dependency benefits been exhausted?” will be displayed. If the answer is No, then the question “What, if any, is the amount of the deductible?” will be displayed. Also displayed is the question "What, if any, is the amount of the co-pay?"

If the client has insurance and the client meets residency and financial eligibility for HHSC funded services, the deductible can be billed to HHSC. Once the deductible amount has been reached, subsequent claims will be denied.

The final question in this section is related to insurance co-pay; however, HHSC does not cover co-pays. This field is for informational purposes only.

If the client does not have any other resources, click on No and continue to the next section.

Income

If the client has income, select the Yes button. Click on the New Income button.

In the fields that display, select the kind of income from the Income Type dropdown list. Next, fill in the Income Description and the Dollar Amount (required) in those text boxes. Select Income Frequency from the dropdown list. Click Add to add the income to the form.

Family Size (Required)

Enter the number of regular family/household members, including the client.
Regular family/household members are those that live together the majority or most of the time and share any income and/or expenses.
If a person is included in Family Size, you must also include his or her income in the Dollar Amount above.
If a person has just joined the household and is expected to live there for the next six months, he or she should be included.
CLICK in the box and TYPE the number.

Proof of Income (Required)

HHSC policy requires that one of the following documents be obtained from the client to establish the client's income.

One of these Proof on Income Types must be in a file that the provider maintains for the client. Or the Proof of Income must be digitally scanned, uploaded into CMBHS, and attached to the Financial Eligibility assessment.

Last pay stub
W-2 form or last year's Income Tax Return if the applicant's income is unchanged
Income verification letter from employer
Statement of no income (This statement must be signed and dated by the client/applicant for services and by the staff member who witnessed the client signing the statement.)
Statement of inability to obtain income information
This statement must be signed and dated by the client/applicant for services and by the staff member who witnessed the client signing the statement.

Documentation Status — Proof of Income (Required)

Using the dropdown list, document how the client provided proof of income and the status of the proof.
The client is not eligible for HHSC funded services until all required documentation is submitted.
Select one of the following that corresponds with the status of the client’s proof of income.

— In File

Select In File if all the required documentation of the client's income is on file in the provider’s office and/or has been electronically scanned and loaded into CMBHS.

— Pending

Select this option if the client has submitted part of or none of the documentation to support the income reported by the client, but indicates they have and will bring in the required documentation.
If Pending is selected, services for client cannot be billed to HHSC. A message to this effect is displayed beneath the Documentation Status – Proof of Income field. The client is not eligible for HHSC funded services until all the required documentation is submitted.
If Pending is selected, an additional field, Proof of Income Documentation Due Date field is displayed.

— Proof of Income Documentation Due Date

This is the date by which the applicant must submit proper financial and residency documentation to the provider.
This field is required if you select Pending in the prior field.
You cannot enter a date in the past.
TYPE in the eight numbers of the date and CMBHS will change them into the proper date format. For example, if you type 02192019, the system will format it as 02/19/2019. However, if you wish, you may type in the slash marks yourself.

— Refused to Provide

Select this status if the client refuses to submit the documentation needed to support the income he/she reports.
If the client is an adult, the client is not eligible for HHSC funded services until all the required documentation is submitted. This is noted in a message.

— Unavailable

If the client's income is based on activities or work that cannot be proven, such as day laborer, recycling scrap for money, etc., then the client can explain his or her income by providing an attestation statement.
Select Unavailable if the client is physically unable to respond to the request for financial and other eligibility information due to intoxication or other behavioral or health issue.
Under these circumstances, the financial assessment may be delayed, but it must be completed within three days of admission.

NOTE: Only statuses of In File and Unavailable will permit billing to HHSC.

Documentation Status — Proof of Address

The CMBHS user must document how the client provided Proof of Address and the status of the proof.

The client is not eligible for HHSC funded services until all the required documentation is submitted.

From the dropdown list, select the type of address proof that the client submits:

Select In File if all the required documentation of the client's address is on file in the provider’s office and/or has been electronically scanned and uploaded into CMBHS.
Pending – select this option if the client has submitted part of or none of the documentation needed to establish proof of address, but indicates he or she has and will bring in the required documentation.
If Pending is selected, services for client cannot be billed to HHSC. A message to this effect is displayed beneath this field. The client is not eligible for HHSC funded services until all the required documentation is submitted.
If Pending is selected, an additional field, Proof of Address Documentation Due Date, is displayed. This field is required if you select Pending in the prior field. This is the date by which the applicant must submit proper documentation to the provider. You cannot enter a date in the past.
Refused to Provide – Select this status if the client refuses to submit the documentation needed to support the address he/she reports.
If the client is an adult, the client is not eligible for HHSC funded services until all the required documentation is submitted. A message appears stating that the client is not eligible because of refusal to submit documentation.
The eligibility determination for the client will also reflect that the client is not eligible for HHSC services.
Unavailable – If the client's residency cannot be easily proven, such as the client is staying with family, then the client can explain residency by providing an attestation statement.
Select Unavailable if the client is physically unable to respond to the request for financial and other eligibility information due to intoxication or other behavioral health issue. Under these circumstances, the financial assessment may be delayed, but it must be completed within three days of admission.
The provider must document the reason for the delay in the Comments text box below the Document Status at the bottom of the form.
When the client is able to complete an attestation or provide documentation, a new financial eligibility must be completed.

Extraordinary Expenses

If the client has no Extraordinary Expenses, CLICK the No button and move to the next section.

Document Extraordinary Expenses reported by the client by clicking the New Expense button.

The CMBHS user must document the type and Dollar Amount of Extraordinary Expenses.

The types and definitions for Extraordinary Expenses are:

Care of a Disabled Person – This is the amount of extraordinary expenses used to support a disabled person in the household. Based on IRS and state rules, expenses may include medical expenses or work-related expenses for purposes of taking care of a dependent disabled person.
Child Care – This is the amount of extraordinary expenses to provide child care for a child or children in the household.
Major Casualty – This is the amount of extraordinary expenses due to major casualty loss(es). A Major Casualty Loss is a household disaster that results from a fire, flood, hurricane, tornado, accident, or a similar event — affecting only that household or any number of households. Damage or destruction resulting from household neglect, such as damage caused by pets or children, is not considered a disaster for the purpose of calculating Extraordinary Expenses.
Major Medical – This is the amount of extraordinary expenses due to catastrophic medical expenses for serious illness or hospitalization.

NOTE: For Substance Use Disorder, consider only extraordinary expenses paid in the last 12 months. For Mental Health Services, extraordinary expenses incurred in the last 12 months OR the expenses projected for the next 12 months may be considered and documented here.

Documenting Extraordinary Expenses

When you have finished entering documentation for an Extraordinary Expense, use the mouse to CLICK the Add button on the right hand side of the screen. Do not forget this step. The page cannot be saved if you have not CLICKED the Add button.
The screen will refresh and the expense will be documented in the table. Additional entries can be made until there are no additional extraordinary expenses.
To edit a previously entered answer, select the appropriate row and use the mouse to select Edit. The screen will refresh and display the previously recorded information. You may change answers. After you have made the changes, CLICK on the Add button.
To remove a previously entered answer, select the appropriate row and CLICK on Remove. The screen will refresh and the answer will be struck out with a line.
To restore a removed answer, select a struck-out row and use the mouse to select Restore. The screen will refresh and all answers will be recalculated.
If an Extraordinary Expense has been entered, this question will display: "Have the documentation requirements for extraordinary expenses been met?" A selection of a Yes or No radio button is required. In addition, there must be a comment added to the "Describe Circumstances of the Extraordinary Expenses" text box to explain the extraordinary expenses.
Calculate – This button is displayed when the Financial Eligibility document is in edit mode. CLICK this button to calculate the client's eligibility determination.
The Federal Poverty Guidelines Sliding Fee Scale has been included in the functionality of the Financial Eligibility screen. HHSC updates this scale when it is released from the Federal government.

Eligibility Determination Results

Annual Income – This field displays the client's annual income less any documented extraordinary expenses. The default answer is blank. When you click Calculate or Save, CMBHS calculates the answer and displays it as view-only.
If Total Extraordinary Expenses exceeds the Annual Income, CMBHS displays a message stating Total Extraordinary Expenses cannot exceed the Annual Income. You must make the appropriate adjustment before the document can be saved.
Less Documented Extraordinary Expenses – This field displays the amount of Total Extraordinary Expenses. The default answer is blank. When you click Calculate or Save, CMBHS displays the Total Extraordinary Expenses from the Extraordinary Expenses sections. This field is view-only.

NOTE: The amount defaults to zero if you select No to the question, Has documentation of extraordinary expense been submitted? Only documented income and documented extraordinary expenses are used when determining financial eligibility.

Client Fee (Maximum monthly dollar amount)

This is the percentage of all fees the client is expected to pay. This field is calculated using the Adjusted Annual Income and the category in which the applicant’s income falls on the sliding fee scale.
Select the Document Status from the dropdown list, and enter Comments about the client’s Financial Eligibility in the text box.
If possible, use a digital scanner to scan the client's paper documents. Keep the paper documents in a file.
Set the document Status to Ready for Review and Save.