SECTION 366.251. Qualified Hospital and Qualified Entity Eligibility Requirements

(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 42 C.F.R. §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 (20 U.S.C. §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 (42 U.S.C. §1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. §4101 et seq.); and

(10) Any other entity HHSC so deems, as approved by the Centers for Medicare and Medicaid Services.

(c) Based on 42 C.F.R. §435.1110(b), a qualified hospital is a hospital that:

(1) is a Medicaid provider;

(2) assists individuals in completing and submitting an application for ongoing Medicaid and understanding any documentation requirements; and

(3) has not been disqualified by HHSC.

(d) A qualified entity or qualified hospital must demonstrate the capability to make presumptive eligibility determinations and:

(1) receive HHSC approval of the criteria in subsections (b) and (c) of this section;

(2) complete training as prescribed by HHSC; and

(3) enter into a Memorandum of Understanding as prescribed by HHSC.

(e) HHSC may verify with a third-party agency that the qualified hospital or qualified entity applicant meets the criteria specified in subsections (b) and (c) of this section.

(f) HHSC notifies the qualified hospital or qualified entity applicant of HHSC's approval or disapproval to make presumptive eligibility determinations.

(g) The qualified hospital or qualified entity must adhere to the standards as set forth in §366.261 of this subchapter (relating to Oversight of Qualified Hospitals and Qualified Entities).

(h) The qualified hospital or qualified entity may not delegate to another entity the authority to determine presumptive eligibility.

Source Note: The provisions of this §366.251 adopted to be effective June 9, 2010, 35 TexReg 4661; amended to be effective January 18, 2015, 40 TexReg 31