Policy and Process
When can a qualified hospital begin submitting presumptive eligibility determinations?
Qualified hospitals may submit presumptive eligibility determinations beginning
February 1, 2015.
What is Presumptive Eligibility?
Presumptive eligibility is a process that allows qualified hospitals and qualified
entities to determine if an individual can get short-term Medicaid. It provides
individuals with Medicaid coverage while HHSC processes their application for regular
Medicaid.
How long does short-term Medicaid last?
The length of coverage depends on several factors:
- If the individual submits an application for regular Medicaid, the short-term Medicaid
coverage ends the date the state makes a determination for regular Medicaid.
- If the individual does not submit an application for regular Medicaid, the short-term
coverage ends the last day of the month following the presumptive eligibility determination.
What is the difference between a qualified hospital and a qualified entity?
- A qualified hospital can make presumptive eligibility determinations for children,
pregnant women, parents and caretaker relatives, and former foster care children.
A qualified entity can make determinations only for pregnant women. The requirements
and processes for qualifying and making presumptive eligibility determinations are
the same. For a list of organizations that may be a qualified entity, see
the policy.
- Qualified entities that make presumptive eligibility determinations for Medicaid
for Breast and Cervical Cancer (MBCC) follow different processes and have additional
requirements. These Frequently Asked Questions do not apply to the MBCC program.
Can hospitals be disqualified?
Hospitals that do not meet HHSC standards or comply with policies and procedures
may be disqualified after a period of corrective action. Once a participating hospital
has been found to not be meeting standards or complying with policies and procedures,
it must submit a corrective action plan. The hospital must meet the established
standards as part of the corrective action plan.
Can entities be disqualified?
Qualified entities are held to accuracy and timeliness standards but may not be
disqualified. If an entity does not meet the established standards, HHSC will work
with it to address any issues.
Is the presumptive eligibility process limited to certain individuals?
- A qualified hospital can make presumptive eligibility determinations for children
under age 19, pregnant women, parents and caretaker relatives, and former foster
care children.
- A qualified entity can make presumptive eligibility determinations for pregnant
women only.
Is there a limit to the number of presumptive eligibility periods an individual can receive?
Yes, an individual is limited to one presumptive eligibility period per two calendar
years (24 months from January to December) or per pregnancy if applying for coverage
as a pregnant woman.
What types of services does short-term Medicaid cover?
- Children, former foster care children, and parents and caretaker relatives receive
full Medicaid benefits. Pregnant women receive Medicaid coverage for ambulatory,
prenatal services only.
- Short-term Medicaid services are provided on a fee-for-service basis.
How will an applicant know the outcome of their application for regular Medicaid?
HHSC will send the applicant a letter telling them whether or not they are eligible
for regular Medicaid. The individual can also get this information by logging onto
their account on YourTexasBenefits.com. After logging in, they can go to "View my
case" on the website and click on the "Case facts" tab near the top of the page.
Will short-term Medicaid recipients get a Medicaid identification card?
Yes. They may also print a card from YourTexasBenefits.com 24 to 48 hours after
submission of the presumptive eligibility determination, request one through 2-1-1,
or present their Notice of Eligibility at an HHSC eligibility office.
Is the Qualified Hospital/Entity required to retain the Presumptive Eligibility Worksheet and a copy of the notice after the determination has been entered into the portal?
Yes, qualified hospitals and entities must retain the documents for three years.
Roles and Permissions for Contractor (QHQE Resource/Third-Party Entity) Staff
Can contractors make presumptive eligibility determinations?
- No. Contractors may help make presumptive eligibility determinations, but
only the qualified hospital or entity can make the actual determination. If this process is performed by contractor staff, the qualified hospital
or entity may be immediately dismissed from Presumptive Eligibility.
- Contractors may be granted access to the Presumptive Eligibility Portal,
but cannot submit determinations.
- Contractors may help staff welcome desks and meet with individuals as long
as the qualified hospital or entity takes responsibility for the presumptive eligibility
determination. Contractors may also help individuals complete and submit
applications for regular Medicaid.
Can contractors assist a client in submitting an ongoing Medicaid application in YourTexasBenefits.com?
Yes. Contractors may assist clients with the completion and submission
of their ongoing (regular) Medicaid applications in YourTexasBenefits.com
Can contractors submit a Notice of Intent form for participation in Presumptive Eligibility?
Yes. Contractors can perform the administrative function of submitting
a Notice of Intent form. However, the form must list an internal qualified hospital
or entity staff member as the System Administrator (Contact Person) and the person
signing the Memorandum of Understanding.
Can contractors sign or submit a Memorandum of Understanding?
No. Contractors are prohibited from signing or submitting a Memorandum
of Understanding to HHSC for participation in Presumptive Eligibility. This document
must be signed and submitted by the organization's Chief Financial Officer, Chief
Executive Officer, President, etc.
What actions are permitted for contractors in Presumptive Eligibility?
Systems
What if I forget my Qualified Hospital/Entity website user ID or password?
Your user ID is the email address that you used to register. If you forget your
password, click on the link "I forgot/change your password" on the login page. Enter
your email address and click "Submit." A temporary password will be sent to you.
What if I forget my Presumptive Eligibility Portal user ID or password?
Contact the Help Desk at 1-800-214-4175, and select option 1. Explain that you
are calling about presumptive eligibility.
What if I'm having problems with the portal?
Contact the Help Desk at 1-800-214-4175, and select option 1. Explain that you
are calling with a Presumptive Eligibility Portal issue.
In what languages is YourTexasBenefits.com available?
YourTexasBenefits.com and the online application are available in Spanish and
English. The language setting can be changed by clicking “Spanish” or “English”
on the top-right corner of the home page.
What benefits can an individual apply for on YourTexasBenefits.com?
Texans can use YourTexasBenefits.com to apply for:
- SNAP food benefits
- Medicaid
- CHIP (Children's Health Insurance Program)
- Long-term care services
- Medicare Savings Programs
- TANF cash help for families
Qualified hospitals and entities are only required to help the individual submit
an application for Medicaid.
Can someone create a YourTexasBenefits.com account without a Social Security number?
Yes. There are two options:
- The person can create an Application Account (do not select the option to view all
case facts and actions). Once they have submitted an application and have a case
number, they can create a Case Access Account to view case information.
- The person can call 2-1-1 (pick a language then pick option 2) and authenticate
over the phone to create a Case Access Account immediately.
How are supporting documents submitted when using YourTexasBenefits.com?
An individual can upload documents directly into their online application before
or after they have sent their application.
- Completed but not submitted: When the individual has completed the online
application, they will be taken to the upload page. The system will provide step-by-step
instructions on how to upload their files on the page. They can send up to 30MB.
- After sending application:
- The individual must log into their account.
- Go to "View my case" on the website.
- Click on the "Actions" tab near the top of the page.
- Go to "Applications actions."
- Go to the row that has the number that matches the application they want to work
on.
- Click on "Upload."
- Follow the steps on the upload page.
Eligibility
Can a qualified hospital or entity make a presumptive eligibility determination for an individual who has health insurance?
Yes, individuals can have health insurance and qualify for short-term Medicaid.
Health insurance is the primary payor and Medicaid is the secondary payor.
Does pregnancy have to be verified?
No, verification of pregnancy is not required.
What if the individual does not have verification of their income, residence or citizenship/immigration status with them?
You may accept the client’s statement for these eligibility factors. Verification
is not required.
What is meant by the individual attesting that they are a Texas resident and a U.S. citizen, U.S. national, or immigrant with an eligible status?
This means the person states that they live in Texas, are a U.S. citizen or national,
or an immigrant with an eligible status.
Can someone visiting Texas from another state get short-term Medicaid?
No. The person must live in Texas.
What if the individual meets presumptive eligibility requirements but does not want to apply for regular Medicaid?
The individual is not required to apply for regular Medicaid as a condition of
eligibility for short-term Medicaid. However, qualified hospitals are required to
assist an individual who wants to apply for regular Medicaid to submit an application
online.
When is the unborn child counted in the household composition?
Include the unborn children in the household composition number when making a
determination for a pregnant woman or for a child if a pregnant woman is included
in the household.
How are supporting documents submitted when using YourTexasBenefits.com?
An individual can also use the Your Texas Benefits app to check
their case, upload files and more. The app is available in the iOS App Store for
iPhone and the Google Play Store for Android users. For more information, see the
Your Texas Benefits App Overview and Quick Tips.