Table of Contents Previous Next

December 2016 Texas Medicaid Provider Procedures Manual

Section 4: Client Eligibility : 4.4 Restricted Medicaid Coverage : 4.4.4 Presumptive Eligibility : Services
Presumptive eligibility provides full coverage for all PE types of assistance with the exception of pregnant women. Pregnant women only receive ambulatory care services. Labor, delivery, inpatient services, and THSteps medical are not covered during the PE period for pregnant women. If the woman is determined to be eligible for regular Medicaid for the same period of time, regular Medicaid coverage overlays the PE period and provides a full range of services. Client eligibility for PE coverage must be determined by a qualified hospital or qualified entity. Once eligibility has been determined, services may be obtained from any enrolled Medicaid provider. The claims filing procedures for clients who have PE are the same as those for all other Medicaid clients.
There are five client type programs that provide full Medicaid coverage through presumptive eligibility. Services reimbursed under the presumptive eligibility process are fee-for-service only.
The following client type programs are eligible for presumptive eligibility:
The length of coverage depends on several factors:

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.