SECTION 366.203. Definitions

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.

(2) Authorized representative--An individual or organization whom an applicant authorizes to apply for Medicaid benefits on behalf of the applicant.

(3) Caretaker--An individual who supervises and cares for a child, and who meets relationship requirements of §366.519(b) and §366.719(c) of this chapter (relating to Relationship and Domicile).

(4) C.F.R.--Code of Federal Regulations.

(5) Child--An adoptive, step, or natural child who is under 19 years of age.

(6) Dependent child--A child who is--

(A) either:

(i) under the age of 18; or

(ii) 18 and a full-time student in secondary school or equivalent vocational or technical training, if before attaining age 19 the child may reasonably be expected to complete such school or training; and

(B) deprived of parental support by reason of death, absence from the home, physical or mental incapacity, or unemployment of at least one parent.

(7) Eligible group--A category of individuals who are eligible for the Presumptive Medicaid Program.

(8) Federal Poverty Level (FPL)--The household income guidelines issued annually and published in the Federal Register by the United States Department of Health and Human Services.

(9) HHSC--The Texas Health and Human Services Commission or its designee.

(10) Household composition--The group of individuals who are considered in determining eligibility for an applicant or recipient for certain medical programs based on tax status, tax relationships, living arrangements, and family relationships referenced in 42 C.F.R. §435.603(f) as "household."

(11) Household income--The sum of individual incomes of every individual within an applicant's or recipient's household composition, from which is subtracted the standard income disregard.

(12) Household size--The number of individuals in an applicant's or recipient's household composition, plus the number of unborn children, if applicable, referenced in 42 C.F.R. §435.603(b) as "family size."

(13) Individual income--The sum of income received by the individuals in a household composition, from which is subtracted expenses, in compliance with 42 C.F.R. §435.603(e), referenced as "MAGI-based income."

(14) MAGI--Modified adjusted gross income.

(15) Medicaid--A state and federal cooperative program, authorized under Title XIX of the Social Security Act (42 U.S.C. Chapter 7, Title XIX) and Texas Human Resources Code Chapter 32, that pays for certain medical and health care costs for individuals who qualify.

(16) Medicaid provider--A health care practitioner, institution, or other entity enrolled in the Medicaid program and authorized to submit claims for payment or reimbursement of Medicaid services.

(17) Newborn--A child from birth through 12 months of age.

(18) Parent--An individual who is the adoptive, step, or natural parent of a child.

(19) Person acting responsibly--An individual, other than a provider, who may apply for Medicaid on behalf of an applicant who is incompetent or incapacitated if HHSC determines the individual is acting responsibly on behalf of the applicant.

(20) Presumptive Medicaid--A period of temporary Medicaid for pregnant women, children under age 19, parents and caretaker relatives, and former foster care children for whom eligibility is determined by a qualified hospital or a qualified entity.

(21) Presumptive eligibility segment--A period of Medicaid coverage that begins with the date a qualified hospital or qualified entity determines an individual eligible for Presumptive Medicaid and ends:

(A) the date that HHSC determines the individual's eligibility for ongoing Medicaid, if the individual submits an application for ongoing Medicaid; or

(B) the last day of the month following the month the Presumptive Medicaid determination is made, if the individual does not submit an application for ongoing Medicaid.

(22) Qualified entity--A Medicaid provider that notifies HHSC of its election to make presumptive eligibility determinations and agrees to make presumptive eligibility determinations for pregnant women only according to HHSC policies and procedures.

(23) Qualified hospital--A hospital that is a Medicaid provider, notifies HHSC of its election to make presumptive eligibility determinations, and agrees to make presumptive eligibility determinations for children under age 19, pregnant women, parents and caretaker relatives, and former foster care children according to HHSC policies and procedures.

(24) Recipient--An individual receiving Presumptive Medicaid Program services.

(25) Sibling--An individual under age 19 who is an adoptive, step, or natural sibling of a child.

(26) Standard income disregard--An income disregard equal to five percentage points of FPL fr the applicable household size.

(27) Texas Health Steps--Federally mandated Medicaid services that provide medical and dental check-ups, diagnosis, and treatment to eligible clients from birth through age 20. Federally, this program is known as the Early Periodic, Screening, Diagnostic and Treatment (EPSDT) Program.

(28) Texas Works Handbook --An HHSC manual containing policies and procedures used to determine eligibility for Supplemental Nutrition Assistance Program (SNAP) food benefits, Temporary Assistance for Needy Families (TANF), the Children's Health Insurance Program (CHIP), and Medicaid programs for children and families. The Texas Works Handbook is found on the Internet at www.dads.state.tx.us/handbooks/TexasWorks.

(29) Third-party resource--An individual or organization, other than HHSC or an individual living with the applicant, who may be liable as a source of payment of the applicant's medical expenses (for example, a health insurance company).

(30) U.S.C.--United States Code.

Source Note: The provisions of this §366.203 adopted to be effective June 9, 2010, 35 TexReg 4661; amended to be effective January 18, 2015, 40 TexReg 31