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Effective Date: 



Updated: 2/2015


Qualified entity/qualified hospital staff use this form as a tool to determine eligibility for the following types of PE assistance:

  • Children Under 1
  • Children 1-5
  • Children 6-18
  • Pregnant Women
  • Parents and Other Caretaker Relatives
  • Former Foster Care Children (FFCC)


When to Prepare

Complete Form H1265 for each household applying for PE.


Head of Household — Enter the head of household’s name.

Phone Number — Enter the household’s phone number, if available.

Home Address — Enter the household’s home address.

Mailing Address — Enter the household’s mailing address, if different from the home address.

Section 1 — Non-Financial

For all immediate family members living together in the applicant’s household, complete the following sections:

  • Name (first, middle, last) — Self-explanatory.
  • Date of Birth — Self-explanatory.
  • Social Security Number (optional) — Self-explanatory.
  • Relationship to Applicant — Self-explanatory.
  • Applying for PE Medicaid? — Self-explanatory.

For all family members applying for PE, complete the following sections:

  • Already Has Medicaid or CHIP? — Self-explanatory.
  • U.S. Citizen, U.S. National or Eligible Immigrant? — Self-explanatory.
  • Resident of Texas and Plans to Stay in Texas? — Self-explanatory.

Question 1 — Check inquiry to determine if any of the applying individuals have received PE during any of the last 2 calendar years, or if the individual is pregnant, whether she has received PE for this pregnancy. Check Yes or No. If yes, list the name of the individual.

Note: A calendar year is the period of time from Jan. 1 through Dec. 31. For example, an individual is applying for PE for her 6-year-old daughter in March 2017. Inquiry shows that the daughter was certified for PE in December 2015. The daughter meets the criteria of not having received PE in the last 2 calendar years.

Question 2 — Indicate if any of the applying individuals meet one of the following criteria by checking Yes or No:

  • Children under age 19:
    • Children Under 1
    • Children 1-5
    • Children 6-8
  • Pregnant — If yes, state who, the pregnancy start and due dates (optional), and how many babies are expected.
  • Main caretaker of a child under age 19 who gets Medicaid and lives with the main caretaker — If yes, state who.
  • Under age 26, was in foster care or Voluntary Agency (VolAg) conservatorship at age 18 or older, and was getting Medicaid when they aged out of foster care — If yes, state who.

Question 3 — Determine if any of the applying members meet the non-financial criteria for PE. Check Yes or No. If the answer to question 3 is:

  • Yes, complete both Sections 2 and 3.
  • No, skip Section 2 and complete Section 3.

Section 2 — Financial

Total Number in Household — List the total number of people in the household. To determine the number of people in the household, include the following if living together:

  • Applicant
  • Applicant’s spouse
  • Applicant’s children under age 19
  • If the applicant is a child under age 19, the individual’s parents and siblings under age 19


  • If the applicant is a pregnant woman, include the number of unborn children.
  • If the applicant is under age 26 and was in foster care or VolAg conservatorship at age 18 or older, before testing eligibility for FFCC, first test the individual’s eligibility for one of the other types of PE assistance.

Household Income

Step 1 — Total the household income (earned and unearned) using the proper conversion factor and enter the amount on line 1.

Step 2 — Total the household expenses using the proper conversion factor and enter the amount on line 2.

Step 3 — Subtract the total household expenses on line 2 from the total household income on line 1 and enter the difference on line 3.

Step 4 — Find the standard income disregard from the Standard Income Disregard table on the provider website and enter the amount on line 4.

Step 5 — Calculate the total net income by subtracting the amount on line 4 from the amount on line 3 and enter the difference on line 5.

Step 6 — For each type of PE assistance being determined: (1) enter the type of assistance, and (2) see the Income Limit table on the provider website for the household size and enter the amount on line 6.

If the amount on line 5 is less than or equal to the amount on line 6 a., b., c. or d., the applicant is financially eligible for PE.

Section 3

PE Eligible? — Check Yes or No to indicate eligibility or non-eligibility for PE.

  • If presumptively eligible, list the individuals eligible for PE, the presumptive eligibility date and the type(s) of PE assistance.
  • If not presumptively eligible, indicate the reason.

Qualified Hospital/Qualified Entity (QH/QE) Employee Printed Name — Print the name of the QH/QE staff making the PE determination.

QH/QE Employee Signature — Provide a written signature and enter the date the PE determination is made.

Name of QH/QE — Enter the name of the QH/QE.