Payor of Last Resort/Fee for Service Screening Tool

Client Number: Date Completed: Completed By:

PAYOR OF LAST RESORT/FEE FOR SERVICE SCREENING TOOL

PART 1: IDENTIFYING BILLABLE SOURCES * Case Managers must support and assist clients in applying for ALL potential sources of assistance

Third Party Payors for Medical Services: Client Potentially Why or Has: Payor Eligible? Why Not? Applied? Approved? Notes Employer-Based Yes Yes Yes Insurance No No No

Yes Yes Yes Medicare* No No No

Yes Yes Yes Medicaid* No No No

County Indigent Yes Yes Yes Health Care No No No

Yes Yes Yes CHIP No No No

Yes Yes Yes VA Benefits No No No Other: Yes Yes Yes No No No Other: Yes Yes Yes No No No

Other assistance programs: Client Potentially Why or Enrolled: Program: Eligible? Why Not? Applied? Approved? Notes Yes Yes Yes THMP/ADAP No No No

Yes Yes Yes WIC No No No

Medicare Yes Yes Yes Part D No No No

Yes Yes Yes Food Stamps* No No No

Pharmaceutical Yes Yes Yes Assistance No No No Other: Yes Yes Yes No No No Other: Yes Yes Yes No No No * Eligibility for programs marked with an asterisk above can be identified through www.yourtexasbenefits.com PART 2: FINANCIAL SCREENING

Income determination for Individual or Family (family size: )

Income Source: Gross Amount Per Year: Paid To (Name): Documentation:

Total Gross Annual Income: $

PART 3: FEE DETERMINATION

Client’s FPL Calculation Total Allowable Individual/Family Annual Gross Income Income Is: (for family size of ) Annual Charges No charges Equal to or below the official poverty line permitted 5% or less of gross 101 to 200 percent of the official poverty line income 7% or less of gross 201 to 300 percent of the official poverty line income More than 300 percent of the official poverty 10% or less of gross line income

Client’s Maximum Allowable Annual Charge: $

NO FEE WILL BE CHARGED Client has a billable source for medical services OR client’s individual/family gross income is equal to or below the official poverty line

CLIENT WILL BE CHARGED A FEE OF $ Client has no billable source for medical services AND client’s individual/family gross income is 101% or greater of the official poverty line