reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 363 - TEXAS HEALTH STEPS COMPREHENSIVE CARE PROGRAM › Subchapter C - PRIVATE DUTY NURSING SERVICES › Section 363.309 - Benefits and Limitations

Current through Reg. 49, No. 28; July 12, 2024
(a) PDN
				  services are a benefit of the Texas Medicaid Program in accordance with the
				  Code of Federal Regulations, Title 42, §440.80, relating to PDN services,
				  and §440.40(b), relating to EPSDT services.
(b) EPSDT recipients are eligible for all PDN
				  services that are medically necessary to correct or ameliorate the recipient's
				  disability and physical and mental illnesses and conditions.
(c) The provider requesting PDN services must
				  supply documentation to support the medical need for a private duty nurse. The
				  documentation must also support the number of PDN hours that are medically
				  necessary to correct or ameliorate the recipient's disability and physical and
				  mental illnesses and conditions.
(d) EPSDT recipients are eligible for all
				  medically necessary PDN services that are required to meet the recipient's
				  documented PDN needs over the span of time the needs arise, as the needs occur
				  over the course of a 24-hour day.
(e) PDN services must be:
(1) prescribed by and provided under the
				  direction of a treating physician;
(2) included in a plan of care, as described
				  in §
											RSA 363.313 of this
				  subchapter (relating to Plan of Care);
(3) delivered by a Texas Medicaid
				  Program-enrolled PDN services provider; and
(4) provided in compliance with all
				  applicable state and federal laws and regulations.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 363 - TEXAS HEALTH STEPS COMPREHENSIVE CARE PROGRAM › Subchapter C - PRIVATE DUTY NURSING SERVICES › Section 363.311 - Prior Authorization Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) PDN services must be prior authorized.
				  Prior authorization is a condition of reimbursement but is not a guarantee of
				  payment.
(b) HHSC will publish in
				  the
Texas Medicaid Provider Procedures Manual
and websites all
				  processes, tools, and scales used to prior authorize PDN services. HHSC may use
				  only these processes, tools, and scales to prior authorize PDN
				  services.
(c) The provider must
				  submit a complete request for prior authorization in order to be considered by
				  HHSC for reimbursement. The authorization request must include the
				  authorization form approved by HHSC, signed and dated by the recipient's
				  treating physician. The provider must use the documents, tools, or processes
				  published in the
Texas Medicaid Provider Procedures Manual
or
				  any updates made available through bulletins, banners, or other means to
				  request prior authorization.
(d)
				  Documentation supporting the prior authorization request must clearly and
				  consistently describe the recipient's:
(1)
				  current diagnosis;
(2) functional
				  status and condition;
(3) history
				  and treatment; and
(4) frequency
				  and complexity of skilled nursing needs, as those needs arise over the span of
				  a 24-hour day.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 363 - TEXAS HEALTH STEPS COMPREHENSIVE CARE PROGRAM › Subchapter C - PRIVATE DUTY NURSING SERVICES › Section 363.313 - Plan of Care

Current through Reg. 49, No. 28; July 12, 2024
(a) A plan of care
				  is developed by an RN and represents the treating physician's orders.
(b) The plan of care must be established and
				  periodically reviewed by the treating physician in consultation with the
				  provider and the recipient or responsible adult.
(c) The plan of care developed by the RN must
				  be:
(1) submitted with a request for prior
				  authorization of PDN services;
(2)
				  recommended, signed, and dated by the treating physician no more than 30 days
				  before the start of care or 30 days before the end of the prior authorization
				  period; and
(3) reviewed and
				  revised by the treating physician with each prior authorization, or more
				  frequently as the treating physician or the PDN services provider deems
				  necessary.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 363 - TEXAS HEALTH STEPS COMPREHENSIVE CARE PROGRAM › Subchapter D - DENTAL SERVICES › Section 363.401 - Eligibility for TH Steps Dental Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Persons are eligible for dental services
				  if they have a current Texas Medicaid identification or Medicaid verification
				  letter that indicates Medicaid and Texas Health Steps eligibility for the time
				  period during which services are delivered, and are under age 21. Providers may
				  also verify eligibility for clients who do not have a Medicaid identification
				  or Medicaid verification letter by contacting the department's claims
				  processing agent.
(b) Dental
				  services can be continued through the month in which the recipient reaches 21.
				  A recipient becomes ineligible for THSteps-Comprehensive Care Program (CCP)
				  services on his or her 21st birthday.
(c) Persons one year of age and older who are
				  eligible for Medicaid and Texas Health Steps services may receive periodic,
				  preventive dental services as defined in § 33.303 of this title (relating
				  to Preventive Dental Services) every six months.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 363 - TEXAS HEALTH STEPS COMPREHENSIVE CARE PROGRAM › Subchapter E - EPSDT EYEGLASS PROGRAM › Section 363.501 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
					 subchapter, have the following meanings, unless the context clearly indicates
					 otherwise.
(1) EPSDT--The federally
				  mandated Early and Periodic Screening, Diagnosis, and Treatment program defined
				  in 25 TAC Chapter 33 (relating to Early and Periodic Screening, Diagnosis, and
				  Treatment).
(2) Eyeglass
				  supplier--A person, firm, or institution that has a written agreement with HHSC
				  as an eyeglass supplier and is an eligible provider under the program. The
				  fitting, adjustment, and repairs of the eyewear must be performed by an
				  appropriate and qualified provider under Texas Medicaid. Suppliers accept the
				  payments stipulated by HHSC as payment in full for the service and supplies
				  involved, unless otherwise provided.
(3) Eyeglasses--Lenses and frames, dispensed
				  and delivered, that: are medically necessary; are prescribed by an appropriate
				  and qualified provider; are professionally determined to be necessary and
				  appropriate for the lens, age, and sex of the recipient; and significantly
				  improve visual acuity or impede progression of visual problems. The term
				  eyeglasses does not include artificial eyes or any item of eyewear that is not
				  covered under the EPSDT Eyeglass Program.
(4) HHSC--The Texas Health and Human Services
				  Commission, a Texas Medicaid managed care organization, or another
				  designee.
(5) Prosthetic
				  eyewear--Eyewear that is medically necessary and prescribed by an appropriate
				  and qualified provider under Texas Medicaid for post cataract surgery,
				  congenital absence of the eye lens, or loss of an eye lens because of trauma.
				  Prosthetic eyewear includes contact lenses and eyeglasses that meet state and
				  federal specifications.
(6)
				  Prosthetic eyewear supplier--A person, firm, or institution that has a written
				  agreement with HHSC as an eyewear supplier. The fitting, adjustment, and repair
				  of the eyewear must be performed by an appropriate and qualified provider. The
				  eyewear supplier accepts the payment stipulated by HHSC as payment in full for
				  the services and supplies, unless otherwise provided in this chapter.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 363 - TEXAS HEALTH STEPS COMPREHENSIVE CARE PROGRAM › Subchapter E - EPSDT EYEGLASS PROGRAM › Section 363.502 - Benefits and Limitations

Current through Reg. 49, No. 28; July 12, 2024
In addition to the services specified in §
										RSA
					 354.1023 of this title (relating to
					 Optometric Services Provider), the benefits and limitations applicable to
					 vision services available through the Medicaid EPSDT Program are as
					 follows.
(1) Recipient eligibility.
				  All Medicaid recipients under the age of 21 are eligible for EPSDT vision
				  services. Services may be continued through the month the eligible recipient
				  becomes 21.
(2) Provider
				  eligibility. All vision services reimbursable by the program must be provided
				  to eligible recipients by an appropriate provider who is enrolled in the
				  Medicaid Program at the time the service is provided.
(3) Reimbursable services.
(A) Examination. One examination of the eyes
				  by refraction may be provided to each eligible recipient:
(i) once every twelve months;
(ii) if there is a significant change in
				  visual acuity measured in diopter or axis changes, as defined by HHSC;
				  or
(iii) if the exam is otherwise
				  medically necessary.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 363 - TEXAS HEALTH STEPS COMPREHENSIVE CARE PROGRAM › Subchapter E - EPSDT EYEGLASS PROGRAM › Section 363.503 - Specifications for Eyewear

Current through Reg. 49, No. 28; July 12, 2024
The provider must ensure that eyewear provided through this
					 program meets the following specifications.
(1) Lenses must meet federal and state
				  specifications and all standards of the American standard prescription
				  requirements for first quality lenses and dress eyewear.
(2) Standard sizes of frames for individuals
				  ages 6 months to 21 years are dispensed at no cost to the eligible
				  recipient.
(3) An eyeglass supplier
				  must show the recipient a minimum selection of frame styles and colors as
				  required by HHSC policy.
(4) Frames
				  are manufactured in the United States of America, unless foreign-made frames
				  are comparable in quality and less expensive than American-made
				  frames.
(5) Frames are serviceable
				  and meet prescription quality standards.
(6) Lens and frame materials are
				  new.
(7) Supplies are at least
				  equivalent in quality to program eyeglasses provided under this category at no
				  cost to the eligible recipient.
(8)
				  Repair materials, if claimed for reimbursement, are new, are at least
				  equivalent to the original item, and meet the specifications for eyewear cited
				  in these provisions.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 363 - TEXAS HEALTH STEPS COMPREHENSIVE CARE PROGRAM › Subchapter E - EPSDT EYEGLASS PROGRAM › Section 363.504 - Claims Information Requirements

Current through Reg. 49, No. 28; July 12, 2024
Providers must meet the criteria established in this
					 subchapter for vision services and the provisions for participation in the
					 Medicaid Program established under Chapter 354, Subchapter A, Division 1, of
					 this title (relating to Medicaid Procedures for Providers), and Chapter 354,
					 Subchapter A, Division 11, of this title (relating to General Administration).
					 In addition to the claims information requirements established in §
										RSA
					 354.1001 of this title (relating to Claim
					 Information Requirements), the following information is required for claims for
					 vision services:
(1) name, address,
				  and Medicaid provider identification number of the ordering provider, as
				  appropriate;
(2) description of
				  lenses and frames provided;
(3)
				  provider's signature on the claim verifying the diopter change required for the
				  dispensing of eyeglasses;
(4)
				  certification by the provider that the dispensed materials used for repairs
				  meet the specifications for eyewear in §
										RSA
				  363.503 of this subchapter (relating to
				  Specifications for Eyewear);
(5)
				  claims for eyewear with special features, signed by the recipient,
				  acknowledging selection of eyewear that is beyond the specifications for
				  eyewear in §
										RSA
				  363.503 of this subchapter. A signed patient
				  certification satisfies this requirement for claims the provider submitted
				  electronically;
(6) a copy of the
				  invoice for supplies dispensed, attached to a claim for repairs or kept the
				  provider, as authorized by HHSC;
(7) if the claim is for replacement of
				  prosthetic eyewear or of nonprosthetic eyewear when the records of HHSC show
				  that less than 24 months have elapsed since the date of the original
				  nonprosthetic eyewear service, then:
(A)
				  submission of a statement justifying the need for the replacement eyewear
				  (reimbursement is made only if the eyewear was lost or damaged beyond repair or
				  if the recipient's visual acuity has changed significantly, as specified in
				  §
											RSA
				  363.502(3)(B)(i) or
				  (ii)(II) of this subchapter (relating
				  to Benefits and Limitations)). If the original eyewear has been lost or damaged
				  beyond repair, the recipient must sign the claim form or a patient
				  certification if the provider submits claims electronically; and
(B) claim form signed by the recipient if the
				  original eyewear was lost or damaged beyond repair.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 363 - TEXAS HEALTH STEPS COMPREHENSIVE CARE PROGRAM › Subchapter F - PERSONAL CARE SERVICES › Section 363.601 - Purpose

Current through Reg. 49, No. 28; July 12, 2024
(a) The purpose of this subchapter is to
				  define the personal care services (PCS) benefit that is available through the
				  Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)-Comprehensive
				  Care Program, which in Texas is known as the Texas Health Steps-Comprehensive
				  Care Program.
(b) PCS may be
				  provided to individuals who are under 21 years of age and eligible for EPSDT
				  through the medical assistance program.
(c) PCS are authorized for recipients who
				  require assistance with activities of daily living (ADLs), instrumental
				  activities of daily living (IADLs), or health maintenance activities (HMAs)
				  because of a physical, cognitive or behavioral limitation that is related to
				  the recipient's disability or chronic health condition.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 363 - TEXAS HEALTH STEPS COMPREHENSIVE CARE PROGRAM › Subchapter F - PERSONAL CARE SERVICES › Section 363.603 - Provider Participation Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) Personal care services (PCS) must be
				  provided by an individual who:
(1) is 18
				  years of age or older;
(2) is an
				  attendant who:
(A) is an employee of a
				  provider organization licensed as a home and community support services agency
				  (HCSSA) per 40 TAC Chapter 97 (relating to Licensing Standards for Home and
				  Community Support Services Agencies); or
(B) if the recipient is receiving PCS through
				  the consumer directed services (CDS) option described in 40 TAC Chapter 41
				  (relating to Consumer Directed Services Option), is an employee of:
(i) the recipient; or
(ii) the recipient's responsible adult or
				  legally authorized representative (LAR);
(3) has demonstrated the competence
				  necessary, when competence cannot be demonstrated through education and
				  experience, to perform the personal assistance tasks assigned by the provider
				  organization supervisor or by the recipient or the recipient's responsible
				  adult or LAR acting as employer through the CDS option described in 40 TAC
				  Chapter 41;
(4) is not the
				  responsible adult of the recipient if the recipient is under the age of 18;
				  and
(5) is not the legal spouse of
				  the recipient.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 363 - TEXAS HEALTH STEPS COMPREHENSIVE CARE PROGRAM › Subchapter F - PERSONAL CARE SERVICES › Section 363.605 - Benefits and Limitations

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Personal care services (PCS) include:
(1)
				  Assistance with Activities of Daily Living (ADLs) and Instrumental Activities
				  of Daily Living (IADLs);
(2)
				  Nurse-delegated tasks and Health Maintenance Activities (HMAs) as permitted by
				  program policy and 22 TAC Chapter 225 (relating to RN Delegation to Unlicensed
				  Personnel and Tasks not Requiring Delegation in Independent Living Environments
				  for Client's with Stable and Predictable Conditions); and
(3) Hands-on assistance, cueing, redirecting,
				  or intervening, to accomplish the approved PCS task.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 363 - TEXAS HEALTH STEPS COMPREHENSIVE CARE PROGRAM › Subchapter F - PERSONAL CARE SERVICES › Section 363.607 - Place of Service

Current through Reg. 49, No. 28; July 12, 2024
(a) Personal care
				  services (PCS) may be provided in an individual or group setting.
(b) PCS may be authorized for the following
				  place(s) of service:
(1) The recipient's
				  home;
(2) The home of the primary
				  or alternate care giver;
(3) The
				  recipient's school;
(4) The
				  recipient's day care facility; or
(5) Any community setting in which the
				  recipient is located.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter B - PRESUMPTIVE MEDICAID FOR PREGNANT WOMEN PROGRAM › Division 1 - GENERAL › Section 366.201 - Purpose and Scope

Current through Reg. 49, No. 28; July 12, 2024
(a) This subchapter
					 establishes the criteria:
(1) for a pregnant
					 woman, a child under the age of 19, a parent or caretaker relative, or a former
					 foster care child to receive medical care under the Presumptive Medicaid
					 Program; and
(2) for a qualified
					 hospital or qualified entity as defined in §366.203 of this division
					 (relating to Definitions) to provide services under the Presumptive Medicaid
					 Program.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter B - PRESUMPTIVE MEDICAID FOR PREGNANT WOMEN PROGRAM › Division 1 - GENERAL › Section 366.203 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
In this subchapter, the following words and terms have
						the following meanings, unless the context clearly indicates otherwise.
(1) Applicant--An individual seeking
					 assistance under the Presumptive Medicaid Program who:
(A) has never received Medicaid and is not
					 currently receiving Medicaid; or
(B) previously received Medicaid but
					 subsequently was denied and reapplies for Medicaid.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter B - PRESUMPTIVE MEDICAID FOR PREGNANT WOMEN PROGRAM › Division 2 - ELIGIBILITY REQUIREMENTS › Section 366.211 - General Eligibility Requirements

Current through Reg. 49, No. 28; July 12, 2024
To be eligible for benefits under the Presumptive
						Medicaid Program, an individual must be determined presumptively eligible by a
						qualified hospital or qualified entity as defined in §
											RSA 366.203 of this
						subchapter (relating to Definitions) to:
(1) meet the criteria for an eligible group
					 as described in §366.213 of this division (relating to Eligible Groups);
					 and
(2) meet all other eligibility
					 and participation requirements in this subchapter.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter B - PRESUMPTIVE MEDICAID FOR PREGNANT WOMEN PROGRAM › Division 2 - ELIGIBILITY REQUIREMENTS › Section 366.213 - Eligible Groups

Current through Reg. 49, No. 28; July 12, 2024
To qualify for the Presumptive Medicaid Program, an
						applicant must:
(1) be--
(A) a pregnant woman with household income
					 less than or equal to the limit for Pregnant Women's Medicaid as stated in
					 §
												RSA 366.307 of
					 this chapter (relating to Eligible Group);
(B) a newborn with household income less than
					 or equal to the limited stated in §
												RSA
					 366.507(1) of
					 this chapter (relating to Eligible Groups);
(C) a child age one through 18 years of age
					 with household income less than or equal to the limit stated in §
												RSA
					 366.507(2) of
					 this chapter;
(D) a parent or
					 caretaker relative of a dependent child who receives Medicaid and meets the
					 income eligibility criteria stated in §
												RSA 366.723 of
					 this chapter (relating to Income Eligibility); or
(E) an individual who was under the
					 conservatorship of this State upon attaining age 18, received Medicaid at the
					 time he or she left foster care, and is 18 through 25 years of age as stated in
					 §
												RSA 366.1011 of
					 this chapter (relating to Eligible Group);
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter B - PRESUMPTIVE MEDICAID FOR PREGNANT WOMEN PROGRAM › Division 2 - ELIGIBILITY REQUIREMENTS › Section 366.215 - Application Requirements and Processing

Current through Reg. 49, No. 28; July 12, 2024
(a) An applicant, authorized representative,
					 or someone acting responsibly for the applicant applies for presumptive
					 eligibility at a qualified hospital or qualified entity site.
(b) The qualified hospital or qualified
					 entity electronically submits the presumptive eligibility determination to
					 HHSC.
(c) The qualified hospital or
					 qualified entity must assist the individual in submitting an electronic
					 Medicaid application to HHSC if the individual wishes to apply for regular
					 Medicaid.
(d) For individuals
					 determined to be presumptively eligible, the qualified hospital or qualified
					 entity must notify the individual in writing and orally if appropriate that if
					 a Medicaid application:
(1) is not filed by
					 the last day of the month following the presumptive eligibility determination,
					 then presumptive eligibility will end on that last day; and
(2) is filed by the last day of the month
					 following the presumptive eligibility determination, then presumptive
					 eligibility will end on the day that a decision is made on the Medicaid
					 application.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter B - PRESUMPTIVE MEDICAID FOR PREGNANT WOMEN PROGRAM › Division 2 - ELIGIBILITY REQUIREMENTS › Section 366.217 - Citizenship

Current through Reg. 49, No. 28; July 12, 2024
(a) An applicant for the Presumptive Medicaid
					 Program must attest to being a citizen or national of the United States or to
					 having an eligible immigration status. Verification of citizenship or
					 immigration status is not required.
(b) In accordance with
					 RSA
					 435.406, to be eligible for the Presumptive
					 Medicaid Program, an individual must be:
(1)
					 a citizen or national of the United States ;
(2) an alien who legally entered the United
					 States before August 22, 1996, and who meets the eligibility criteria in
					 RSA
					 1641 (b) or (c);
(3) an alien who legally entered the United
					 States on or after August 22, 1996, and who meets the eligibility criteria in
					 RSA
					 1612 (b) and §1613, except that a legal
					 permanent resident alien is eligible after residing in the United States for
					 five years only if the alien meets one of the following eligibility
					 requirements:
(A) the alien is an honorably
					 discharged veteran or active duty military personnel;
(B) the alien is a spouse, unmarried
					 surviving spouse, or minor unmarried child of an honorably discharged veteran
					 or active duty military personnel (if a surviving spouse of a deceased veteran
					 or active duty military individual , the surviving spouse must not have
					 remarried);
(C) the alien entered
					 the United States before August 22, 1996, and remained continuously present in
					 the United States (a single absence from the United States of more than 30 days
					 or a combined absence of more than 90 days interrupts the "continuous
					 presence") since at least August 21, 1996, until obtaining qualifying immigrant
					 status (an alien who entered the United States without proper documents or
					 overstayed his or her visa, is treated the same as an alien who entered and
					 remained in the United States with valid immigration documents);
(D) the alien entered the United States with
					 a status described in the
Texas Works Handbook,
Item A-342,
					 Chart C or Chart D and meets those eligibility criteria, or meets the criteria
					 in the
Texas Works Handbook,
Item A-343, How to Determine
					 Eligibility for Battered Aliens; or
(E) the alien meets the 40 qualifying
					 quarters requirements in the
Texas Works Handbook,
Item A-354,
					 Verifying 40 "Qualifying Quarters," and five years have passed since the
					 alien's legal date of entry; or
(4) an alien child 18 years of age or under
					 who meets the definition of a qualified alien at
					 RSA
					 1641 (b).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter B - PRESUMPTIVE MEDICAID FOR PREGNANT WOMEN PROGRAM › Division 2 - ELIGIBILITY REQUIREMENTS › Section 366.219 - Social Security Number

Current through Reg. 49, No. 28; July 12, 2024
An applicant may provide a social security number (SSN),
						but verification of SSN is not required.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter B - PRESUMPTIVE MEDICAID FOR PREGNANT WOMEN PROGRAM › Division 2 - ELIGIBILITY REQUIREMENTS › Section 366.221 - Residence

Current through Reg. 49, No. 28; July 12, 2024
(a) An applicant must be a resident of Texas.
					 HHSC follows
					 RSA 435.403 in
					 determining an individual's state residence.
(b) An applicant must attest to being a
					 resident of Texas. Verification of residence is not required.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter B - PRESUMPTIVE MEDICAID FOR PREGNANT WOMEN PROGRAM › Division 2 - ELIGIBILITY REQUIREMENTS › Section 366.223 - Income Limits

Current through Reg. 49, No. 28; July 12, 2024
To be eligible for benefits under the Presumptive
						Medicaid Program, an applicant must meet the household income requirements
						established in §366.213 of this division (relating to Eligible
						Groups).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter B - PRESUMPTIVE MEDICAID FOR PREGNANT WOMEN PROGRAM › Division 2 - ELIGIBILITY REQUIREMENTS › Section 366.225 - Determination of Household Composition

Current through Reg. 49, No. 28; July 12, 2024
To determine income eligibility for the Presumptive
						Medicaid Program, HHSC counts the income of the following individuals, if
						living together:
(1) the individual;
(2) the individual's spouse;
(3) the individual's children
					 under 19 years of age; and
(4) the
					 individual's parents and siblings under the age of 19 if the individual is a
					 child under the age of 19.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter B - PRESUMPTIVE MEDICAID FOR PREGNANT WOMEN PROGRAM › Division 2 - ELIGIBILITY REQUIREMENTS › Section 366.227 - Calculation of Household Income

Current through Reg. 49, No. 28; July 12, 2024
(a) For
					 each applicant, the household income is:
(1)
					 the sum of individual income (as calculated under §
												RSA
					 366.1109 of this chapter (relating to
					 Calculation of Individual Income)) for each individual in the applicant's
					 household composition (as determined under §
												RSA
					 366.225 of this subchapter (relating to
					 Determination of Household Composition));
(2) less a standard income disregard equal to
					 five percentage points of the Federal Poverty Level for the applicable
					 household size, as permitted by
					 RSA
					 435.603 (d)(4).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter B - PRESUMPTIVE MEDICAID FOR PREGNANT WOMEN PROGRAM › Division 2 - ELIGIBILITY REQUIREMENTS › Section 366.229 - Third-Party Resources

Current through Reg. 49, No. 28; July 12, 2024
Medicaid is considered the payor of last resort for an
						individual's medical expenses. As a condition of eligibility, in accordance
						with
						RSA
						433.138 -
						RSA
						433.148, an applicant or recipient must:
(1) assign to HHSC the applicant's or
					 recipient's right to recover any third-party resources available for payment of
					 medical expenses covered under the Texas State Plan for Medical Assistance; and
(2) report to HHSC any third-party
					 resource within 60 days after learning about the third-party
					 resource.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter B - PRESUMPTIVE MEDICAID FOR PREGNANT WOMEN PROGRAM › Division 2 - ELIGIBILITY REQUIREMENTS › Section 366.231 - Medicaid Eligibility Effective Date

Current through Reg. 49, No. 28; July 12, 2024
(a) The Medicaid eligibility effective date
					 is the date the qualified hospital or qualified entity makes the presumptive
					 eligibility determination.
(b) In
					 accordance with
					 RSA
					 435.1102 (b)(2)(iv), eligibility for the
					 Presumptive Medicaid Program ends with (and includes) the earlier of:
(1) the date HHSC makes an eligibility
					 determination for regular Medicaid if a Medicaid application is filed by the
					 last day of the following month; or
(2) the last day of the month after the month
					 the qualified hospital or qualified entity made the presumptive eligibility
					 determination if a Medicaid application is not filed by the last day of the
					 following month.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter B - PRESUMPTIVE MEDICAID FOR PREGNANT WOMEN PROGRAM › Division 2 - ELIGIBILITY REQUIREMENTS › Section 366.233 - Resident of an Institution for Mental Diseases

Current through Reg. 49, No. 28; July 12, 2024
An individual who lives in an institution for mental
						diseases, as defined in
						RSA
						435.1010, is eligible for the Presumptive
						Medicaid Program only to the extent allowed by federal law.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter B - PRESUMPTIVE MEDICAID FOR PREGNANT WOMEN PROGRAM › Division 2 - ELIGIBILITY REQUIREMENTS › Section 366.235 - Inmates of Public Institutions

Current through Reg. 49, No. 28; July 12, 2024
An inmate of a public institution, including a jail,
						prison, reformatory, or other correctional or holding facility, as defined in
						RSA
						435.1009 and §
											RSA
						435.1010, is not eligible for Medicaid
						payment for Medicaid-covered services received while residing in the public
						institution.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter B - PRESUMPTIVE MEDICAID FOR PREGNANT WOMEN PROGRAM › Division 2 - ELIGIBILITY REQUIREMENTS › Section 366.237 - Right to Appeal

Current through Reg. 49, No. 28; July 12, 2024
According to
						RSA
						435.1102 (e), fair hearing regulations do not
						apply to Presumptive Medicaid decisions.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter B - PRESUMPTIVE MEDICAID FOR PREGNANT WOMEN PROGRAM › Division 3 - PROVIDER REQUIREMENTS › Section 366.251 - Qualified Hospital and Qualified Entity Eligibility Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) A Medicaid provider that wishes to
					 provide services as a qualified hospital or qualified entity under the
					 Presumptive Medicaid Program must provide notification in the format prescribed
					 by HHSC.
(b) As defined in
					 RSA
					 435.1101, a qualified entity applicant must:
(1) furnish health care items and services
					 covered under the approved plan and be eligible to receive payments under the
					 Texas State Plan for Medical Assistance;
(2) be authorized to determine a child's
					 eligibility to participate in a Head Start program under the Head Start Act;
(3) be authorized to determine a
					 child's eligibility to receive child care services for which financial
					 assistance is provided under the Child Care and Development Block Grant Act of
					 1990;
(4) be authorized to
					 determine an infant's or child's eligibility to receive assistance under the
					 special nutrition program for women, infants, and children (WIC) under section
					 17 of the Child Nutrition Act of 1966;
(5) be authorized to determine a child's
					 eligibility for medical assistance under the Medicaid State plan, or
					 eligibility of a child for child health assistance under that State Children's
					 Health Insurance Program;
(6) be
					 an elementary or secondary school, as defined in section 14101 of the
					 Elementary and Secondary Act of 1965 (RSA 8801);
(7) be an elementary or secondary
					 school operated or supported by the Bureau of Indian Affairs;
(8) be a State or Tribal child support
					 enforcement agency;
(9) be an
					 organization that:
(A) provides emergency
					 food and shelter under a grant under the Stewart B. McKinney Homeless
					 Assistance Act;
(B) is a State or
					 Tribal office or entity involved in enrollment in the program under the
					 following provisions of the Social Security Act: Title XIX; Part A of Title IV;
					 or Title XXI; or
(C) determines
					 eligibility for any assistance or benefits provided under any program of public
					 or assisted housing that receives federal funds, including the program under
					 section 8 or any other section of the United States Housing Act of 1937
					 (RSA
					 1437) or under the Native American Housing
					 Assistance and Self Determination Act of 1996 (RSA
					 4101 et seq.); and
(10) Any other entity HHSC so deems, as
					 approved by the Centers for Medicare and Medicaid Services.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter B - PRESUMPTIVE MEDICAID FOR PREGNANT WOMEN PROGRAM › Division 4 - OVERSIGHT › Section 366.261 - Oversight of Qualified Hospitals and Qualified Entities

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC establishes, in accordance with
					 RSA
					 435.1102 (b)(3), oversight mechanisms to
					 ensure that qualified hospitals and qualified entities are making presumptive
					 eligibility determinations consistent with statute and regulations.
(b) HHSC establishes, in accordance with
					 RSA
					 435.1110 (d)(1), standards for qualified
					 hospitals making presumptive Medicaid eligibility determinations related to the
					 proportion of individuals determined presumptively eligible for Medicaid by the
					 hospital who:
(1) Submit a regular
					 application, as described in
					 RSA
					 435.907, before the end of the presumptive
					 eligibility period and in accordance with HHSC timeliness standards; and/or
(2) Are determined eligible for
					 Medicaid by HHSC based on such application.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter B - PRESUMPTIVE MEDICAID FOR PREGNANT WOMEN PROGRAM › Division 4 - OVERSIGHT › Section 366.263 - HHSC Responsibilities to Qualified Hospitals and Qualified Entities

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC provides Medicaid during a
					 presumptive eligibility period to individuals who are determined by a qualified
					 hospital or qualified entity on the basis of preliminary information to be
					 presumptively eligible for Medicaid.
(b) HHSC provides the qualified hospital or
					 qualified entity with application forms for Medicaid and information on how to
					 assist individuals in completing and filing such forms.
(c) HHSC establishes procedures to ensure
					 that qualified hospitals and qualified entities adhere to the requirements in
					 RSA
					 435.1102 (b)(2) relating to:
(1) notifying an individual determined
					 presumptively eligible orally and in writing of the presumptive eligibility
					 determination and the effective dates of the presumptive eligibility period;
(2) providing the individual with
					 a Medicaid application form;
(3)
					 notifying HHSC of the presumptive eligibility determination;
(4) notifying an individual determined not
					 presumptively eligible orally and in writing of the reason for the
					 determination and that he or she can file an application for Medicaid with
					 HHSC; and
(5) not delegating
					 authority to determine presumptive eligibility to another entity.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter C - PREGNANT WOMEN'S MEDICAID › Section 366.301 - Purpose and Scope

Current through Reg. 49, No. 28; July 12, 2024
(a) This subchapter
				  establishes the eligibility criteria and participation requirements for
				  Pregnant Women's Medicaid, in accordance with
				  RSA
				  1396d(a).
(b) Nothing in these rules shall be construed
				  to violate the maintenance of eligibility requirements of §5001 of the
				  American Recovery and Reinvestment Act of 2009 (Public Law 111-5)
				  and make eligibility standards, methodologies, or procedures under the Texas
				  State Plan for Medical Assistance (or any waiver under §1115 of the Social
				  Security Act (RSA 1315))
				  more restrictive than the eligibility standards, methodologies, or procedures,
				  respectively, under such plan (or waiver) that were in effect on July 1,
				  2008.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter C - PREGNANT WOMEN'S MEDICAID › Section 366.303 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
					 subchapter, have the following meanings, unless the context clearly indicates
					 otherwise:
(1) Applicant--A person
				  seeking assistance under Pregnant Women's Medicaid who:
(A) has never received Medicaid and is not
				  currently receiving Medicaid; or
(B) previously received Medicaid but
				  subsequently was denied and reapplies for Medicaid.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter C - PREGNANT WOMEN'S MEDICAID › Section 366.305 - General Eligibility Requirements

Current through Reg. 49, No. 28; July 12, 2024
To be eligible for Pregnant Women's Medicaid, a person
					 must:
(1) meet the criteria for an
				  eligible group as described in §
										RSA 366.307 of
				  this subchapter (relating to Eligible Group) and the provisions of Subchapter K
				  of this chapter (relating to Modified Adjusted Gross Income
				  Methodology);
(2) comply with
				  HHSC's application requirements in this subchapter; and
(3) meet all other eligibility and
				  participation requirements in this subchapter.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter C - PREGNANT WOMEN'S MEDICAID › Section 366.307 - Eligible Group

Current through Reg. 49, No. 28; July 12, 2024
To be eligible for Pregnant Women's Medicaid, an applicant
					 must be a pregnant woman with household income equal to or less than 185% of
					 the Federal Poverty Level after application of the methodology in Subchapter K
					 of this chapter (relating to Modified Adjusted Gross Income
					 Methodology).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter C - PREGNANT WOMEN'S MEDICAID › Section 366.309 - Application Requirements

Current through Reg. 49, No. 28; July 12, 2024
(a) To apply
				  for Pregnant Women's Medicaid benefits, an applicant, authorized
				  representative, or person acting responsibly must:
(1) use the application prescribed by HHSC
				  and complete it according to HHSC instructions:
(A) in writing, using a paper application
				  obtained via telephone, Internet request, or other means;
(B) online, using the application process
				  available over the Internet;
(C)
				  over the telephone, through the State's toll-free telephone number;
				  or
(D) in person, by visiting an
				  HHSC benefits office;
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter C - PREGNANT WOMEN'S MEDICAID › Section 366.311 - Application Processing

Current through Reg. 49, No. 28; July 12, 2024
(a) HHSC processes
				  Pregnant Women's Medicaid applications received electronically, by paper, or by
				  telephone.
(b) HHSC allows any
				  office of a state health and human services agency to accept an initial
				  application.
(c) HHSC contracts
				  with third parties to accept applications from hospital districts (including
				  state-owned teaching hospitals), federally qualified health centers, and county
				  health departments.
(d) HHSC may
				  conduct an interview with an initial applicant.
(e) HHSC reopens a denied initial
				  application, so long as the applicant complies with the missed requirements
				  within 60 days after the date the application was submitted. HHSC otherwise
				  requires the applicant to file a new application.
(f) HHSC may reopen an application for three
				  months prior coverage if:
(1) within two
				  years after the application was filed, the applicant requests that the
				  application be reopened; and
(2) a
				  Medicaid eligibility determination was not previously made for the three-month
				  prior period.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter C - PREGNANT WOMEN'S MEDICAID › Section 366.313 - Citizenship

Current through Reg. 49, No. 28; July 12, 2024
To be eligible for Pregnant Women's Medicaid, an applicant
					 must be:
(1) a citizen or national of
				  the United States;
(2) an alien who
				  legally entered the United States before August 22, 1996, and who meets the
				  eligibility criteria in
				  RSA
				  1641(b) or
				  (c);
(3) an alien who legally entered the United
				  States on or after August 22, 1996, and who meets the eligibility criteria in
				  RSA
				  1612(b) and
				  §
										RSA
				  1613, except that a legal permanent resident
				  alien is eligible after residing in the United States for five years only if
				  the alien meets one of the following eligibility requirements:
(A) the alien is an honorably discharged
				  veteran or active duty military personnel;
(B) the alien is a spouse, unmarried
				  surviving spouse, or minor unmarried child of an honorably discharged veteran
				  or active duty military personnel (if a surviving spouse of a deceased veteran
				  or active duty military person, the surviving spouse must not have
				  remarried);
(C) the alien entered
				  the United States before August 22, 1996, and remained continuously present in
				  the United States (a single absence from the United States of more than 30 days
				  or a combined absence of more than 90 days interrupts the "continuous
				  presence") since at least August 21, 1996, until obtaining qualifying immigrant
				  status (an alien who entered the United States without proper documents or
				  overstayed his or her visa, is treated the same as an alien who entered and
				  remained in the United States with valid immigration documents);
(D) the alien entered the United States with
				  a status described in the
Texas Works Handbook,
Item A-342,
				  Chart C and meets those eligibility criteria, or meets the criteria in the
Texas Works Handbook,
Item A-343, How to Determine Eligibility
				  for Battered Aliens; or
(E) the
				  alien meets the 40 qualifying quarters requirements in the
Texas Works
				  Handbook,
Item A-354, Verifying 40 "Qualifying Quarters," and five
				  years have passed since the alien's legal date of entry; or
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter C - PREGNANT WOMEN'S MEDICAID › Section 366.315 - Social Security Number

Current through Reg. 49, No. 28; July 12, 2024
An applicant or recipient must provide or apply for her
					 social security number. Prior to denying eligibility, HHSC allows a period of
					 reasonable opportunity for an applicant or recipient to provide or apply for a
					 social security number.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 366 - MEDICAID ELIGIBILITY FOR WOMEN, CHILDREN, YOUTH, AND NEEDY FAMILIES › Subchapter C - PREGNANT WOMEN'S MEDICAID › Section 366.317 - Residence

Current through Reg. 49, No. 28; July 12, 2024
An applicant or recipient must be a resident of Texas. HHSC
					 follows
					 RSA 435.403 in
					 determining a person's state residence.