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.
(2) Authorized representative--A person or organization
whom an applicant authorizes to apply for Medicaid benefits on behalf
of the applicant.
(3) CFR--Code of Federal Regulations.
(4) Change in circumstance--A change in circumstance
that may affect eligibility including:
(A) a change in household composition; or
(B) a change in categorical eligibility (e.g., aging
out, eligibility conferred through the receipt of other program benefits).
(5) Child--An adoptive, step, or natural child who
is under 19 years of age.
(6) Continuous coverage--Uninterrupted eligibility
for the extent of the certification period regardless of any changes
in circumstances, unless:
(A) the recipient dies;
(B) the recipient disenrolls voluntarily;
(C) the recipient changes state residence;
(D) the state has erred in the eligibility determination;
or
(E) the recipient or recipient's authorized representative
has committed fraud, perjury, or abuse.
(7) Eligible group--A category of people who are eligible
for Pregnant Women's Medicaid.
(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 CFR §435.603(f)
as "household."
(11) Medicaid--A state and federal cooperative program,
authorized under Title XIX of the Social Security Act (42 U.S.C. §1396
et seq.) and Texas Human Resources Code Chapter 32, that pays for
certain medical and health care costs for people who qualify. Also
known as the medical assistance program.
(12) Person acting responsibly--A person, other than
a provider, who may apply for Medicaid on behalf of an applicant who
is incompetent or incapacitated if the person is determined by HHSC
to be acting responsibly on behalf of the applicant.
(13) Recipient--A person receiving Pregnant Women's
Medicaid services.
(14) Retroactive coverage--Payment for Medicaid-reimbursable
medical services received up to three months before the month of application.
(15) 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 https://www.hhs.texas.gov/handbooks/texas-works-handbook.
(16) Third-party resource--A person or organization,
other than HHSC or a person living with the applicant or recipient,
who may be liable as a source of payment of the applicant's or recipient's
medical expenses (for example, a health insurance company).
(17) U.S.C.--United States Code.
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Source Note: The provisions of this §366.303 adopted to be effective January 1, 2014, 38 TexReg 9467; amended to be effective June 1, 2014, 39 TexReg 3981; amended to be effective June 2, 2024, 49 TexReg 3795 |