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.
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