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<br />" <br /> <br />ELIGIBILITY <br /> <br />All individuals considered for Title V eligibility must be screened and determined <br />eligible using a DSHS or Title V program approved screening tool as updated in the <br />spring of each year when federal poverty levels and eligibility determination forms are <br />revised. <br /> <br />CO-PAY <br /> <br />PERFORMING AGENCY may assess a co-pay from clients provided services by <br />RECEIVING AGENCY under this Attachment. A co-pay shall not be assessed from <br />such clients if their family income is at or below 100% of the most recently defined <br />federal poverty level. A co~pay assessment may not exceed 25% of the amount <br />RECEIVING AGENCY pays PERFORMING AGENCY for the provision of a given <br />service. A client shall not be denied services due to inability to pay. Local Health <br />Departments shall comply with RECEIVING AGENCY fee collection policies detailed <br />in 25 TAC § 1.91. <br /> <br />General Provisions, Program Income Article, is revised to include: <br /> <br />All revenues directly generated by a Contract Attachment(s) supported activity or earned <br />only as a result of the Attachment(s) during the term of the Attachment(s) are considered <br />program income. PERFORMING AGENCY shall identify and report all program <br />income monthly. <br /> <br />Program Income may be retained by PERFORMING AGENCY so long as it is used to <br />provide services specified in the scope of work detailed in this Attachment. This shall be <br />demonstrated only by submission of acceptable billing vouchers for services provided to <br />Title V eligible clients which exceeds PERFORMING AGENCY'S Attachment amount <br />by the total program income amount. <br /> <br />General Provisions, Reports Article, is revised to include: <br /> <br />PERFORMING AGENCY shall submit: <br /> <br />. Title V MCH Monthly Aggregate Activity Report, in conjunction with each <br />monthly billing request. Each report shall detail the total unduplicated number of <br />clients seen for the first time within a service category type during the contract <br />period by age, and race/ethnicity. Billing requests will not be processed for <br />payment by RECEIVING AGENCY unless accompanied by a complete <br />corresponding aggregate report; <br />. A Request for Advance or Reimbursement Form 270 (Form GC-I0), no later than <br />ninety (90) days after the end of the attachment term; and, <br />. Other reports as deemed necessary by RECEIVING AGENCY upon reasonable <br />notice to PERFORMING AGENCY. <br /> <br />A IT ACHMENT - Page 4 <br /> <br />T <br /> <br />I <br />