C-1110, Medical Information

C—1111 State Medicaid Agencies

Revision 13-3; Effective July 1, 2013

Medical Programs

For links to all State Medicaid Agencies, go to https://www.medicaid.gov/medicaid/by-state/by-state.html.

C—1112 Services Under the Texas Medical Assistance Program

Revision 19-3; Effective July 1, 2019

Medical Programs

Benefits provided through health insuring agent:

• In-patient hospital services*
• Out-patient hospital services*
• Laboratory and x-ray services
• Physician's services
• Podiatrist's services
• Optometric services*
• Ambulance services*
• Family planning services*
• Home health services limited to nurse and home health aide visits*
• Medicare Part A deductible and coinsurance when benefits would otherwise be payable under Medical Assistance and Medicare Part B deductible and coinsurance for assigned claims only
• Chiropractic treatment — limited to Medicare Part B deductible and coinsurance for assigned claims only
• Eyeglasses*
• Rural health clinics*

Services provided through contract or by direct vendor payments from the Health and Human Services Commission (HHSC):

• Nursing care skilled and intermediate care. Skilled care is limited to recipients age 21 and over. Medicare SNF coinsurance.*
• Active treatment for recipients or patients of any age in licensed and approved section of institutions for persons with intellectual disabilities.*
• In-patient hospital care for recipients or patients age 65 and older in contracted mental hospitals and state (tuberculosis) hospitals.*
• Texas Health Steps screening program and limited dental treatment for eligible persons under age 21.
• Prescriptions limited to no more than three covered per month if over 18. Unlimited if 18 and under.
• Prior authorized hearing aid services.*
• Primary home care for recipients age 18 and over.*
• Other medical transportation.

*With limitations — see appropriate provider manuals for details.

The benefits of this program do not extend to:

• Inmates in a public institution. (Recipients in approved medical units in certain contracted institutions are eligible for vendor payments made by HHSC.)
• Special shoes or other supportive devices for the feet or walking aids.
• Services in military medical facilities, Veteran's Administration (VA) facilities, or United States Public Health Service Hospitals.
• Care and treatment related to any condition for which benefits are provided or are available under Workman's Compensation laws.
• Dental care and services except certain oral surgery or that provided under Texas Health Steps.
• Any services or supplies provided in connection with a routine physical examination except family planning services.
• Any care or services payable under Title XVIII (Medicare).
• Any service provided by an immediate relative of the recipient or member of the recipient's household.
• Any services or supplies not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of the malformed body member.
• Custodial care.
• Any services provided to the recipient after a utilization review or medical review finding that such services are not medically necessary.
• Any services or supplies that are payable through a third party.
• Any service or supplies not specifically provided by the Texas Medical Assistance Program.

Disclaimer: This list is for convenient reference and does not have the effect of law, regulation or policy. If there is a conflict between this list and law, regulations, and policy, the latter will prevail. If there is a question, use the appropriate provider manuals or filed releases for clarification.

C—1113 Qualified Hospital/Qualified Entity Policy and Procedures for Presumptive Eligibility Determinations

Revision 15-3; Effective July 1, 2015

TA 66, TA 74, TA 75, TA 76, TA 83, TA 86 and TP 42

Presumptive eligibility (PE)provides short-term medical coverage to pregnant women, Medicaid for Breast and Cervical Cancer (MBCC) applicants, children under age 19, parents and caretaker relatives of dependent children under age 19, and former foster care children. PE provides full fee-for-service Medicaid with the exception of pregnant women. Pregnant women receive ambulatory prenatal care only.

Qualified hospitals (QHs)determine PE for all groups except MBCC.

Qualified entities (QEs)determine PE for pregnant women and MBCC applicants. For MBCC applicants, only QEs that are also Texas Department of State Health Services (DSHS) Breast and Cervical Cancer Services contractors can make MBCC PE determinations, following the process outlined in X-100, Application Processing.

C—1113.1 Eligible Groups

Revision 15-3; Effective July 1, 2015

The following groups can receive presumptive eligibility coverage:

• Children:
  1. MA-Children Under 1 Presumptive — TA 74
  2. MA-Children 1–5 Presumptive — TA 75
  3. MA-Children 6–18 Presumptive — TA 76
• Former Foster Care Children (MA-FFCC Presumptive —TA 83)
• Pregnant Women (MA-Pregnant Women Presumptive — TP 42)
• Parents and Other Caretaker Relatives (MA-Parents and Caretaker Relatives Presumptive — TA 86)

C—1113.2 Household Composition

Revision 15-3; Effective July 1, 2015

The QH/QE uses the non-taxpayer/non-tax dependent rules to determine the household composition.

C—1113.3 Modified Adjusted Gross Income (MAGI) Methodology

Revision 15-4; Effective October 1, 2015

The QH/QE uses a simplified MAGI methodology to determine if an individual meets the income requirements for PE. The income limits for each PE type of assistance are the same as the income limits for the associated regular Medicaid type of assistance. For example, MA-Children Under 1 Presumptive has the same income limit as MA-Children Under 1.

C—1113.4 Verifications

Revision 15-3; Effective July 1, 2015

The individual must attest to being:

• a Texas resident, and
• a United States citizen or an eligible immigrant.

For all other PE criteria, the individual's statement is acceptable verification. Additional forms of verification beyond an individual's statement are not required.

C—1113.5 Medical Effective Dates

Revision 15-4; Effective October 1, 2015

The medical effective date (MED) is the date the QH or QE determines the individual is presumptively eligible for Medicaid. If the individual is presumptively eligible, QH/QE staff give the individual Form H1266, Short-term Medicaid Notice: Approved. It informs the individual when the PE coverage begins and when the PE coverage ends, based on whether the individual applies for regular Medicaid.

Note: An individual is not eligible for PE if they are currently receiving Medicaid, Children's Health Insurance Program (CHIP) or CHIP perinatal.

If the individual does not apply for regular Medicaid, the PE coverage ends the last day of the month after the month of the PE determination (see scenario 1 below).

If the individual submits Form H1205, Texas Streamlined Application, or Form H1010, Texas Works Application for Assistance — Your Texas Benefits, HHSC staff determine whether the individual is eligible for regular Medicaid. If the individual is not eligible for regular Medicaid, the individual's PE coverage ends the date that HHSC determines the individual is ineligible (see scenario 2 below). If the individual is eligible for regular Medicaid, the individual's PE coverage ends when HHSC makes the Medicaid eligibility determination, following cutoff rules.

If an individual is Medicaid-eligible during the application month, the individual receives Medicaid from the first of that month through the PE MED. Regular Medicaid coverage for the ongoing period begins once the PE period ends (see scenarios 3 and 4 below). Exception: Since PE for pregnant women provides only limited prenatal services, ongoing Medicaid coverage overlays the PE coverage (see scenario 5 below).

Examples:

C—1113.6 Periods of Presumptive Eligibility

Revision 15-3; Effective July 1, 2015

Pregnant women are allowed one PE period per pregnancy.

For all other PE groups, an individual is allowed no more than one period of PE per two calendar years. Example: An individual receives MA-Children 6–18 Presumptive in June 2015. He cannot receive another period of PE until January 2017.

C—1113.7 Three Months Prior Coverage

Revision 15-3; Effective July 1, 2015

Three months prior coverage does not apply to presumptive eligibility. Eligibility for three months prior Medicaid coverage is determined when HHSC eligibility staff make a regular Medicaid determination, if requested.

C—1113.8 Application Processing

Revision 15-4; Effective October 1, 2015

QH/QE staff first must perform a PE portal inquiry to find out if an individual is currently receiving Medicaid, CHIP or CHIP perinatal or if the applicant has received a period of PE within the PE period limit.

QH/QE staff make the PE determination based on information the individual provides about citizenship/immigration status, Texas residency, income and household composition. To determine whether the individual is presumptively eligible, QH/QE staff fill out Form H1265, Presumptive Eligibility (PE) Worksheet, using the information the individual provides.

If the individual is presumptively eligible, QH/QE staff do the following:

• Enter the individual's demographic information and the PE type of assistance for which the individual is eligible into the PE portal. QH/QE staff use the PE portal to conduct limited inquiries and submit PE determinations.
• Give the individual Form H1266, Short-term Medicaid Notice: Approved. QH/QE staff also help the individual complete and submit the regular Medicaid application via YourTexasBenefits.com if the individual wants to apply. Note: An individual is not required to submit a regular Medicaid application to receive PE Medicaid.

If the individual is not eligible for PE, QH/QE staff issue Form H1267, Short-term Medicaid Notice: Not Approved, to the individual and tell the individual about the right to apply for regular Medicaid.

C—1113.9 Due Dates and Processing Time Frames

Revision 15-3; Effective July 1, 2015

Within one business day of the PE determination, the QH/QE must submit the PE determination to HHSC through the PE portal.

C—1113.10 How to Become a Qualified Hospital or Qualified Entity

Revision 15-3; Effective July 1, 2015

Hospitals or entities that want to become qualified to make PE determinations must (1) submit to HHSC a notice of intent, (2) sign a Memorandum of Understanding, and (3) complete online training at the PE website at www.TexasPresumptiveEligibility.com.

C—1113.11 Presumptive Eligibility Forms

Revision 15-3; Effective July 1, 2015

Qualified hospital/qualified entity staff use the following forms in the presumptive eligibility process:

• Form H1265, Presumptive Eligibility (PE) Worksheet—Completed by the QH/QE and used to determine if an applicant is presumptively eligible.
• Form H1266, Short-term Medicaid Notice: Approved-Completed by the QH/QE and given to an individual determined presumptively eligible. This form notifies the individual about PE coverage and lists the eligibility start date and end date, which is based on whether the individual submits an application for regular Medicaid. If an individual needs proof of Medicaid coverage before receiving their Medicaid identification card, the individual can present this form in an HHSC local eligibility determination office, and HHSC staff will provide the individual with Form H1027-A, Medicaid Eligibility Determination.
• Form H1267, Short-term Medicaid Notice: Not Approved— Completed by the QH/QE and given to an individual determined ineligible for PE coverage. This form explains the reason for ineligibility and how to apply for regular Medicaid.

Related Policy

Processing Presumptive Eligibility Applications, A-124

C—1114 Guidelines for Providing Retroactive Coverage for Children and Medical Programs

Revision 23-2; Effective April 1, 2023

Medical Programs

When determining retroactive eligibility for children and pregnant women, use the applicable income, standard MAGI income disregard, and IRS monthly income thresholds charts.

Five Percentage Points of FPL

IRS Monthly Income Thresholds

Five Percentage Points of FPL

C—1115 Immunization Terms

Revision 13-3; Effective July 1, 2013

TANF and Medical Programs

Immunization by inoculation or vaccination protects against childhood diseases. Except for tetanus, these diseases are contagious. Encourage individuals to follow the Texas Department of Health's recommended schedule found on Form H1012, Immunization Record. If a child is on an alternate schedule refer to A-2125, Immunizations.

The following are descriptions of the diseases and symptoms associated with immunizations.

• Diphtheria — An acute, bacterial illness that causes a sore throat and a fever and sometimes causes more serious or even fatal complications.
• Haemophilus Influenza Type b (HIB) — A bacterium that can cause meningitis and pneumonia and infect other body systems such as blood, joints, bones and soft tissue under the skin, throat, and the covering of the heart.
• Hepatitis A — An infection of the liver caused by the Hepatitis A virus.
• Hepatitis B — An infection of the liver caused by the Hepatitis B virus.
• Measles — An acute, highly contagious viral disease involving the respiratory tract that causes a characteristic rash, fever, runny nose, sore eyes, and cough.
• Mumps — An acute viral disease mainly of childhood. It is characterized by a swelling of the parotid (salivary) glands on one or both sides and may cause fever, headache, and difficulty swallowing may develop.
• Pertussis (Whooping Cough) — An acute highly contagious respiratory disease characterized by a severe attack of coughing that ends in a characteristic "whoop" as breath is drawn in.
• Poliomyelitis (Polio – once known as "infantile paralysis") — An infectious disease that may lead to extensive paralysis of the muscles.
• Rubella (German Measles) — A viral infection characterized by a mild fever, swollen glands in the neck and a rash that lasts up to three days.
• Tetanus (Lockjaw) — A very serious disease of the central nervous system caused by an infection of a wound that makes an individual unable to open his/her mouth or swallow and causes muscle spasms in the jaw, neck, leg or other muscles.
• Varicella (Chickenpox) — A highly contagious viral infection which presents as a generalized, itchy, vesicular rash. The rash begins as smooth, red spots which develop into blisters that last three to four days before forming crusty scabs.

C—1116 Managed Care Plans

Revision 19-1; Effective January 1, 2019

Information concerning the medical and dental managed care plans with contact information for each plan is located at https://www.hhs.texas.gov/services/health/medicaid-chip/about-medicaid-chip/medicaid-medical-dental-policies.

Related Policy

Managed Care, A-821.2 
Releasable Information for Medicaid Providers and Their Contractors, B-1230 
Office of the Ombudsman,B-1420

C—1118 Health Care Orientation Quick Reference Guide

Revision 23-3; Effective July 1, 2023

Medical Transportation Service (MTS)

• The Medical Transportation Service provides non-emergency medical transportation (NEMT) services.
• Explain the Medical Transportation Service is available for all Medicaid-covered health care services to those with full Medicaid (not Qualified Medicare Beneficiary [QMB] or Specified Low-Income Medicare Beneficiary [SLMB]), Children with Special Health Care Needs (CSHCN), and Transportation for Indigent Cancer Patients (TICP), who do not have any other means of transportation.
• "Call at least two business days before the appointment in the same county or adjacent county and five business days before an appointment outside the county adjacent to your residence and be prepared to provide your:
  • name;
  • Medicaid ID number;
  • address;
  • phone number;
  • doctor's name and address;
  • doctor's phone number;
  • date; and
  • time of appointment."

Ways to Travel:

• If you don't have a car and you don't have anyone else to drive you, the Medical Transportation Service will help. This may be by bus tickets or by van.
• If you have a car or know someone who can drive you to the appointment, the Medical Transportation Service can pay you or your driver gas reimbursement by the mile.

How do I get a ride? First, set up an appointment with your doctor or provider.

To request a ride, call at least two workdays before your appointment, or five days before the appointment if it is outside your county. Phones are answered Monday through Friday, 8 a.m.-5 p.m. local time.

You may be able to be approved for same day rides when:

• Your doctor or dentist must see you on the same day.
• You are released from a hospital, clinic, or other health care facility.
• You need a ride to a drugstore.

If you or your child have a Medicaid health plan:

• Call your health plan’s medical transportation contact number.

If you or your child do not have a health plan:

• Call 877-633-8747 (877-MED- TRIP).

Children 14 and younger may not travel without a parent or guardian. Children 15 through 17 may travel without a parent, but the parent must provide written permission before the trip is scheduled.
 

Children's Health Insurance Program (CHIP)

• If anyone in the household is under 19 and does not have health insurance, explain they may be eligible for some type of state-funded health insurance. They may call 2-1-1 Option 2 to apply for CHIP and Children's Medicaid.

WIC (Women, Infant, and Children's Program)

• Explain WIC is a supplemental nutrition and education program to provide nutritious foods to help women, infants and children improve on their nutrition. "If you are receiving Medicaid, you are income-eligible for the program, but you will have to complete a nutritional screening to receive benefits."
• If pregnant or a postpartum woman or a child under 5 years lives in the household, give the parent the 800-942-3678 number to locate their nearest WIC office.

Summary

• "Any questions about Texas Health Steps or Medicaid?"
• Inform the person that they have received a "Health Care Orientation."
• Verify the person's information, phone number, migrant status, and if any other children are in the household.
• If enrolled, recap enrollment information including the names of the primary care provider and main dentist, if known, and the name of the health plan.
• Provide toll free number for future assistance (see chart below). Thank the person for their time.
• If in person, provide literature and any numbers needed from the Resource Directory (see chart below).

Resource Directory