Presumptive Eligibility

Steps to Complete Presumptive Eligibility Determinations

Step 1 The qualified hospital/entity staff member logs in to the Presumptive Eligibility Portal with the staff person's unique login. Look up the following eligibility requirements:

• Does the individual currently receive Medicaid or CHIP?
• Has the individual received presumptive eligibility within any of the past two calendar years of this application or within the same period of pregnancy if applying for a pregnant woman?
• If the individual is currently receiving Medicaid or CHIP or has received presumptive eligibility within the time periods listed above, the individual is ineligible. If the individual is not ineligible, proceed to the next step.

Step 2

• Collect information related to an individual’s citizenship/immigration status, residency, household composition, and income using Form H1265, Presumptive Eligibility Worksheet. Ask applicants to attest to their citizenship/immigration status and residency. Verification is not required for any eligibility criteria when making a presumptive eligibility determination.

Step 3

• If eligible, issue the form H1266, Short-term Medicaid Notice - Approval to the individual.
• Enter into the Presumptive Eligibility Portal the individual’s demographic information and the program for which the individual qualifies. There are presumptive eligibility programs for pregnant women, children, parents and caretaker relatives, and former foster care children.
• When a presumptive eligibility determination is submitted, the confirmation page displays a PE submission ID. Save this number because it will be needed later.
• If ineligible based on non-financial or financial eligibility criteria, follow the process under Denials.

Step 4

• Help the individual complete the application for regular Medicaid. To do this, go to YourTexasBenefits.com with the individual and log in at the QH/QE login. If the individual does not already have an account with YourTexasBenefits.com, help them create one. Once the individual has an account and is logged in, help them complete the application for regular Medicaid, Form H1205, Texas Streamlined Application through YourTexasBenefits.com. Before submitting the application, a question will appear requesting the PE submission ID. Enter the PE submission ID that was provided when the presumptive eligibility determination was submitted. This number links the presumptive eligibility determination to the individual’s application for regular Medicaid.
• Once the application has been submitted, explain to the individual what documents may be required to be sent to the state to verify eligibility for a regular Medicaid determination.

Note: If an individual chooses not to submit a regular Medicaid application, do not delay in entering the individual’s presumptive eligibility determination into the portal. Denials

• If the individual is ineligible for Short-term Medicaid based on either financial or non-financial eligibility requirements, indicate the reason for ineligibility in the Form H1265. Give the individual the Form H1267, Short-term Medicaid Notice: Not Approved and information about how to apply for regular Medicaid or CHIP.

Linking Determinations and Medicaid Applications

Presumptive eligibility determinations must be linked to the application for regular Medicaid. This is accomplished with the PE submission ID. When a presumptive eligibility determination is submitted through the portal, a PE submission ID is generated. There are two ways the PE submission ID can be used to link the determination with the application for regular Medicaid:

1. When helping the individual complete an application for regular Medicaid, sign into YourTexasBenefits.com before the individual gets to the end of the application and gets a prompt to enter the PE submission ID. This prompt appears directly above the individual's signature.
2. You may also use the Presumptive Eligibility Portal to search for determinations submitted by your qualified hospital/entity and link the determination and application through the search functionality.