A-124.6 Medical Effective Date

Revision 15-4; Effective October 1, 2015

The medical effective date for PE is the date that the QH or QE determines the individual is presumptively eligible for Medicaid.

Note : An individual is not eligible for PE coverage if the individual is currently certified for Medicaid, CHIP or CHIP perinatal.

If the individual does not apply for regular Medicaid, PE coverage ends the last day of the month after the month of the PE determination (see scenario 1 below).

If the individual submits Form H1205, Texas Streamlined Application , or Form H1010, Texas Works Application for Assistance — Your Texas Benefits , HHSC determines whether the individual is eligible for regular Medicaid. If the person is not eligible for regular Medicaid, the individual's PE coverage ends the date that HHSC determines the individual is ineligible (see scenario 2 below). If the person is eligible for regular Medicaid, the person’s PE coverage ends when HHSC makes the Medicaid eligibility determination, following cutoff rules.

If an individual is Medicaid-eligible during the application month, the individual receives Medicaid from the first of that month through the PE MED. Regular Medicaid coverage for the ongoing period starts once the PE period ends (see scenarios 3 and 4 below). Exception : Since PE for pregnant women provides only limited prenatal services, ongoing Medicaid coverage overlays the PE coverage (see scenario 5 below).

Examples :

PE Scenarios Individual does not apply for regular Medicaid A child is determined eligible for MA-Children 6–18 Presumptive on February 2. Her mother does not submit an application for regular Medicaid. The child’s PE coverage ends on March 31. Individual is ineligible for regular Medicaid A child is determined eligible for MA-Children Under 1 Presumptive on April 4. Her father submits an application for regular Medicaid on the same date. HHSC determines on April 20 that the child is not eligible for regular Medicaid. Her PE coverage ends on April 20. Individual is eligible for regular Medicaid (HHSC makes eligibility determination before cutoff) A child is determined eligible for MA-Children 1–5 Presumptive on March 6. His mother submits an application for regular Medicaid on the same date. HHSC determines on March 15 (before cutoff) that the child is eligible for regular Medicaid. His PE coverage ends March 31. He is certified for regular Medicaid effective March 1 to March 5 and April 1 through ongoing. Individual is eligible for regular Medicaid (HHSC makes eligibility determination after cutoff) A former foster care child is determined eligible for MA-FFCC Presumptive on May 9. He submits an application for regular Medicaid on the same date. HHSC determines on May 22 (after cutoff) that the individual is eligible for regular Medicaid. His PE coverage ends June 30. He is certified for regular Medicaid effective May 1 to May 8 and July 1 through ongoing. Pregnant woman is eligible for regular Medicaid A woman is determined eligible for MA-Pregnant Women Presumptive on June 4. She submits an application for regular Medicaid on the same date. HHSC determines on June 10 that the woman is eligible for regular Medicaid. Her PE coverage ends on June 30. Regular Medicaid overlays her PE coverage with an effective date of June 1.