State of Texas
Health and Human Services Commission
PO Box 13247, Austin, TX 78711
[Entity Name]
[Entity Address]

This Memorandum of Understanding is effective as of _____ (date signed by HHSC) between the State of Texas Health and Human Services Commission (“HHSC”) and [Entity name] (“Entity”). It shall remain in effect unless terminated in accordance with the policies and procedures outlined in Section IV.

I. Introduction and Purpose

Under Federal regulations at 42 CFR 435.1103, qualified entities may determine certain individuals presumptively eligible (“PE”) for Medicaid, subject to federal and state requirements. By conducting PE determinations in accordance with this MOU, the Entity can assist individuals in securing temporary Medicaid coverage on a timely basis and facilitating enrollment in regular Medicaid coverage.

When conducting PE determinations, the Entity will evaluate an individual's eligibility only for the Medicaid for Pregnant Women program using financial and non-financial eligibility criteria established by HHSC.

The purpose of this MOU is to set forth the roles, responsibilities, and other terms for the Entity to conduct Medicaid PE determinations and facilitate enrollment in ongoing coverage, as well as HHSC’s roles and responsibilities in supporting and overseeing these activities.

II. HHSC Responsibilities

In general, HHSC will support the Entity in conducting PE determinations by providing training, oversight, and approving corrective action measures where relevant. HHSC will provide PE Medicaid coverage to individuals based on the Entity’s proper determinations of presumptive eligibility as long as they were conducted in accordance with HHSC policies and procedures. HHSC will not hold the entity financially responsible if an individual is found ineligible for Medicaid based on a full eligibility determination.


HHSC will provide initial and ongoing training and technical assistance to the Entity, including responding to the Entity’s questions regarding the appropriate policies and procedures to use when conducting PE determinations.


In accordance with federal regulations at 42 C.F.R. §435.1102(b)(3) and in conjunction with 42 C.F.R. §435.1110(d)(1), HHSC may cancel the qualified provider status of qualified entities if they are determined not capable of making determinations of presumptive eligibility as defined under 42 C.F.R. § 435.1101(2). If the Entity fails to meet HHSC’s performance standards, HHSC may, prior to cancelling the qualified provider status:

  • notify the Entity;
  • provide the Entity additional training;
  • provide technical assistance to the Entity in developing and implementing a corrective action plan, and provide approval of the corrective action plan; or
  • Identify the timeline within which the Entity must achieve improved results that meet HHSC’s performance standards.

HHSC will evaluate Entity compliance with HHSC’s performance standards using automated reports at regular intervals. Entities will be notified if they are not complying with HHSC’s performance standards.


HHSC will provide:

  • the Entity with the forms and access to IT systems required to conduct PE determinations;
  • the Entity with the policy and process for submitting PE determinations and applications for health care coverage to HHSC;
  • an HHSC staff member that will serve as the point of contact for the Entity and update the Entity if the staff member changes.

III. Entity Responsibilities

The Entity will conduct PE determinations for Medicaid in accordance with all HHSC policies and procedures provided by HHSC and in accordance with all applicable laws, rules, and regulations. All PE determinations are the responsibility of the Entity, including any assistance provided by contractors or vendors of the Entity.

  • The Entity must have sufficient technology available to support staff completion of training, the electronic submission of PE determinations, and the electronic submission of associated applications for regular Medicaid.
  • The Entity will not delegate the authority to make PE determinations to another entity.
  • The Entity will provide services without discrimination on the grounds of race, color, national origin, age, sex, religion, or disability.
  • The Entity will make PE determinations in accordance with all HHSC policies and procedures.
  • The Entity will keep current with changes affecting PE through provider bulletins, notices, and/or further training.
  • The Entity will provide a point of contact and update the HHSC designated staff member if the point of contact changes.

The Entity will require all staff that conduct Medicaid PE determinations to successfully complete HHSC-provided training. It will keep a record of this training for HHSC to review as requested. Upon HHSC request, the Entity will provide HHSC with the name, title, and contact information for staff that complete the training.


When conducting PE determinations, the Entity will take all measures necessary to safeguard client and HHSC confidential information and will comply with all state, federal, and HHSC rules and regulations regarding data privacy and security, including, without limitation, the Health Insurance Portability and Accountability Act (HIPAA) and Medicaid confidentiality standards.


All Entity staff must avoid conflict of interests or the appearance of impropriety. Staff is not allowed to make presumptive eligibility determinations if the individual is a relative (by blood or marriage), roommate, dating companion, co-worker, supervisor, friend, acquaintance, or volunteer or staff at the Entity.

In cases with a potential conflict of interest, staff may provide the patient with a paper application and information about other options on how and where to apply for benefits.

IV. Termination of this Memorandum of Understanding

The Entity may withdraw from conducting PE determinations and terminate this MOU upon 30 days written notice to HHSC.

HHSC may terminate this MOU with 30 days written notice if, in its reasonable determination, the Entity is intentionally misrepresenting program eligibility requirements; is negligent in determining eligibility; remains unable to meet the performance standards established by HHSC in section II(B) of this MOU; or is fraudulently submitting PE determinations for the Entity’s own financial gain or other purpose.

V. Signatures

The terms of this MOU are not intended to alter, amend, or rescind any provisions of federal or state law. Any provision of this MOU that conflicts with Federal and state law will be null and void.

By entering your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.

This page is a sample only.

Please provide an electronic signature on this document and submit. When HHSC has signed the MOU, a pdf version will be emailed for your records.

If you have questions about this Memorandum of Understanding, please contact