SECTION 366.261. Oversight of Qualified Hospitals and Qualified Entities

(a) HHSC establishes, in accordance with 42 C.F.R. §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 42 C.F.R. §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 42 C.F.R. §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.

(c) HHSC monitors qualified hospitals to determine if the hospitals are meeting the standards set by HHSC and approved in the Texas State Plan for Medical Assistance.

(d) HHSC takes action, including disqualification of a hospital from the Presumptive Medicaid Program if HHSC determines that the hospital is not:

(1) Making or capable of making presumptive eligibility determinations in accordance with HHSC policies and procedures; or

(2) Meeting the standards established by HHSC.

(e) Prior to disqualifying a hospital, HHSC provides additional training or takes other reasonable corrective action measures to address the issue.

(f) HHSC cancels the qualified provider status of qualified entities, in accordance with 42 C.F.R. §435.1102(b)(3), or qualified hospitals, in accordance with 42 C.F.R. §1110(d)(2), that intentionally misrepresent program eligibility requirements or are negligent in determining eligibility.

Source Note: The provisions of this §366.261 adopted to be effective January 18, 2015, 40 TexReg 31