Presumptive Eligibility

Case Example

On June 17, Rebecca Fowler brings her 3-year-old daughter Chloe to the hospital. Chloe has a broken arm. Rebecca reports she is four months pregnant. Rebecca indicates that she is not able to pay the bill for Chloe and that she would like to have coverage for her pregnancy. Rebecca says that neither she nor Chloe has Medicaid and have not received Short-term Medicaid. Rebecca says both she and Chloe are U.S. citizens, Texas residents and intend to remain in Texas. Rebecca works at Home Care Inc. and earns $300 per week. Her husband, Joe, is unemployed and receives $250 unemployment bi-weekly. They have no allowable expenses. Step 1
Complete a Form 1265, Presumptive Eligibility Worksheet for the household. Complete Section 1 to determine the household composition and if Chloe and Rebecca meet the non-financial eligibility for Short-term Medicaid. Both Rebecca and Chloe meet non-financial eligibility criteria.

Continue to Section 2 to determine their financial eligibility. Determine the household size for Chloe and Rebecca using Rebecca’s statement. Rebecca’s household consists of Rebecca, Joe, Chloe, and the unborn child, totaling four. Chloe’s household consists of Chloe, Rebecca, Joe, and the unborn child also totaling four people.

Convert the household’s income to a monthly amount. Rebecca is paid weekly. Convert her income to a monthly amount by multiplying the $300 by 4.33 (conversion factor). $300 x 4.33 = $1299

Joe is paid bi-weekly. Convert his income to a monthly amount by multiplying the $250 x 2.17 (conversion factor). $250 x 2.17 = $542.50

To determine the net household income, add Rebecca and Joe’s income and subtract the 5 percent income disregard. For a household size of four in 2014, the standard disregard is $99.40. $1299 + $542.50 - $99.40 = $1,742.10

The total net income for both Rebecca and Chloe is $1,742.10. The 2014 Income limit for pregnant women with a household size of four is $3,936. The income limit for children ages 1 -5 is $2,862. As the household income for both Chloe and Rebecca is $1742.10, they both fall below the income limits for Medicaid. Step 2
Log in to the Presumptive Eligibility Portal and perform inquiry for both Rebecca and Chloe. Inquiry confirms that Rebecca and Chloe do not receive Medicaid and have not had a period of presumptive eligibility within the past two calendar years for Chloe or current pregnancy for Rebecca.

Based on inquiry, income and information provided, both Rebecca and Chloe are eligible for Short-term Medicaid effective June 17, the same day the presumptive eligibility determination is made. Enter the determination of eligibility into the Presumptive Eligibility Portal. Provide Rebecca with Forms H1266, Short-term Medicaid Notice: Approved for both Rebecca and Chloe. Step 3
Rebecca chooses to apply for regular Medicaid for herself and Chloe. Go to the Presumptive Eligibility state page on YourTexasBenefits.com and login using your unique staff login. Help Rebecca create an account at www.YourTexasBenefits.com. Once an account is created, help Rebecca complete and submit an application for regular Medicaid. Rebecca has a copy of a check stub and her driver’s license with her. Scan these documents and upload them to Rebecca’s account. Explain to Rebecca that electronic verifications will be explored first for any required verification. If electronic verification is not available, HHSC will request paper verification. Also explain any additional documents the state may need from her using form H1858, Items we might need from anyone on your case.

Rebecca and Chloe will have Short-term Medicaid beginning June 17 through the last day of the month HHSC makes the regular Medicaid determination, if HHSC finds both individuals eligible for regular Medicaid. If HHSC finds either ineligible for regular Medicaid, Short-term Medicaid ends the date that HHSC made the eligibility determination.