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. Qualified hospitals can make presumptive eligibility determinations for pregnant women, children, former foster care children, and parents and other caretakers. Qualified entities can make presumptive eligibility determinations only for pregnant women. A presumptive eligibility determination provides full Medicaid coverage for children, former foster care children, and parents and other caretakers, and coverage for pre-natal ambulatory services only for pregnant women.

A qualified hospital:

• Is a Medicaid provider.
• Notifies HHSC of its intent to make presumptive eligibility determinations.
• Agrees to make presumptive eligibility determinations following HHSC policies and procedures.
• Can make presumptive eligibility determinations for pregnant women, children, former foster care children, and parents and other caretakers.
• Help individuals complete and submit online applications for regular Medicaid.
• Helps individuals understand what documents to send to the state to see if they qualify for regular Medicaid.
• Has not been disqualified.

A qualified entity meets the same criteria as a qualified hospital with the following exceptions.
A qualified entity:

• Can be a hospital, clinic, school, etc.
• May make presumptive eligibility determinations only for pregnant women.

Learn More

• To learn more about becoming a qualified hospital or entity, click the Become a QH/QE link at the top of this page.
  If you have questions, email OSS_QHQE_PE@hhsc.state.tx.us.