Presumptive Eligibility

Thank you for your interest in becoming a qualified hospital (QH) or qualified entity (QE) and making presumptive eligibility determinations for Medicaid. To become a QH or QE:

• Submit a Qualified Hospital/Qualified Entity Presumptive Eligibility Notice of Intent to the Texas Health and Human Services Commission (HHSC).
• HHSC will verify the provider is enrolled in Medicaid.
• Sign the Memorandum of Understanding (MOU), which will also be signed by HHSC.
• Access training provided by HHSC.

Once your organization has successfully completed training, HHSC will provide systems logins so you can submit presumptive eligibility determinations.

Who Can Submit a Notice of Intent?

The Notice of Intent must be submitted by someone with decision making authority for the hospital/entity. If the intention is to participate as a QH the person completing the Notice of Intent must be able to speak for your hospital or if relevant, hospital system.

Selecting Qualified Hospital vs. Qualified Entity

Hospitals/entities must designate whether the intent is to participate as a QH or a QE:

• Qualified Hospital – a hospital that is a Medicaid provider and is able to make presumptive eligibility determinations for children, pregnant women, parents and caretaker relatives, and former foster care children.
• Qualified Entity – an organization that is able to make presumptive eligibility determinations for pregnant women only.

Name of Hospital/Entity

Provide the name of the primary hospital, hospital system, or entity. The hospital/entity named will be responsible for signing the MOU. This may be a primary hospital or a hospital system.

Texas Provider Identifier (TPI) Number

Any hospital and most entities participating as a QH/QE must be a Medicaid provider. Provide the Texas Provider Identifier (TPI) so HHSC can verify Medicaid provider status. Hospital systems may not have a TPI, but any hospital/entity within the system that will be submitting PE determinations must have a TPI and must provide the TPI in the Notice of Intent.

Contact Person

The person listed will be the primary contact for the presumptive eligibility process within the hospital/entity. This person is the system administrator, will designate site administrators, and may add and remove your staff and locations that can participate in the presumptive eligibility process. Contractors (QHQE Resource/Third-Party Entity) have very limited roles in the PE process and cannot be designated as Staff, System Administrator, or Site Administrator for a QH/QE. Contractors may access the PE Portal, perform benefit inquiries, search for PE determinations, assist applicants in submitting a full Medicaid application, and link applications that have been submitted by the Qualified Hospital through YourTexasBenefits.com. If it is found that a contractor is submitting PE determinations on behalf of QH/QE, this could result in disciplinary action, up to and include disqualification of the QH/QE from the Presumptive Eligibility program. The Role of Staff, System Administrator, or Site Administrator can only be assigned to an employee of the QH/QE.

Clinics

Any Medicaid provider clinic owned by a QH may make presumptive eligibility determinations. Details for all clinics that will be making determinations must be provided along with their respective TPI numbers.

Clinics Contact Person

This person is the site administrator for the specific clinic. This person will be the primary contact person for the location and will be able to add and remove staff who can participate in the presumptive eligibility process.

MOU Details

The MOU must be signed by the hospital/entity CFO, CEO, or similar role. Enter the name, title, telephone number, and email address for the person who will be signing the MOU. Submitting the Notice of Intent will prompt an email to be sent to the person listed with a link asking that the MOU be signed.

Signature

The system administrator must e-sign and submit the Notice of Intent for the qualification process to begin.