| (a) A medical provider that wishes to contract with the Texas Health and Human Services Commission (HHSC) to provide services under the Presumptive Medicaid for Pregnant Women Program must apply on the form prescribed by HHSC. The form is available from HHSC, Attn: Texas Works Policy, MC 2039, P.O. Box 12668, Austin, TX 78711-2668. (b) A medical provider applicant must: (1) be an eligible Medicaid provider; (2) offer services provided by outpatient hospitals, rural health clinics, or clinics, either provided or directed by physicians (clinics may be administered by someone who is not a physician), as further described in §1905(a)(2)(A) or (B) of the Social Security Act (42 U.S.C. §1396d(a)(2)(A) or (B)), or §1905(a)(9) of the Social Security Act (42 U.S.C. §1396d(a)(9)), or both; and (3) receive funds from, or participate in, one of the following programs: (A) health centers for medically underserved populations providing primary health services, including migrant health centers, under 42 U.S.C. §254b; (B) rural health outreach networks, under 42 U.S.C. §254c; (C) maternal and child health services block grant programs, under (42 U.S.C. §701 et seq.); (D) the Indian Health Care Improvement Act, Public Law 94-437, as amended (25 U.S.C. §1651 et seq.); (E) Special Supplemental Food Program for Women, Infants, and Children (WIC), under 42 U.S.C. §1786; (F) Commodity Supplemental Food Program of the Agriculture and Consumer Protection Act of 1973, Public Law 93-86, as amended (7 U.S.C. §612c note); (G) a state perinatal program; or (H) the Indian Health Service or a health program or facility operated by a tribe or tribal organization under the Indian Self-Determination Act, Public Law 93-638, as amended (25 U.S.C. §450f et seq.). (c) A medical provider applicant must demonstrate the capability to make presumptive eligibility determinations and receive: (1) preliminary HHSC approval of the criteria in subsection (b) of this section; and (2) final HHSC approval, based on an operating plan as described in subsection (d) of this section, which is developed with the HHSC regional director responsible for Medicaid programs for pregnant women. (d) The operating plan contains the details of the operating procedures between the local HHSC office and the medical provider. The operating plan must specify how the medical provider will: (1) meet the basic intent of the Presumptive Medicaid for Pregnant Women Program; (2) provide access to prenatal care services as a part of the facility's ongoing service package, with the following stipulations: (A) a provider not offering prenatal care services must, through a referral and tracking system, coordinate access to prenatal care services; and (B) a provider must ensure that services include a case management approach, which assists pregnant women during the Medicaid application process and prenatal care visits; (3) provide or assure verification of pregnancy; (4) ensure that prenatal care appointments are scheduled within 10 working days after a presumptive eligibility decision, unless HHSC gives an exception, in which case a provider must report quarterly on the provider's progress toward meeting the requirement; (5) provide enough trained staff to interview and process the budget of each pregnant woman; (6) monitor the accuracy of presumptive eligibility determinations; (7) ensure that presumptive eligibility application packets are delivered to an HHSC service site within one working day after eligibility decisions; (8) ensure that medical provider staff are trained by HHSC on how to determine presumptive eligibility; (9) maintain a record of each presumptive eligibility application decision, both certified and denied, for three years after the decision date; (10) submit required reports to the HHSC regional director responsible for Medicaid for pregnant women; (11) prepare an applicant for her HHSC interview, if needed, by providing her with a list of HHSC-required documents and informing her as to what information HHSC must verify; (12) keep the financial information of applicants and recipients confidential; and (13) provide services without discrimination on the grounds of race, color, national origin, age, sex, or disability. (e) HHSC may verify with a third-party agency that a medical provider applicant meets the criteria specified in subsections (b) - (d) of this section. (f) HHSC notifies a medical provider applicant of HHSC's approval or disapproval of qualified provider status for the provider. |
