Texas Medicaid Long Term Care Programs, Benefits & Eligibility Requirements

Summary
Medicaid is a joint federal and state program, so its rules, coverage plans and even its name all vary by state. This article focuses on Texas Medicaid Long Term Care for seniors. This is different from regular Medicaid, which is for low-income people of all ages. In Texas, Medicaid is administered by Texas Health and Human Services. Department of Community Health. Medicaid will help pay for long term care for Texas residents in a nursing home, their home, the home of a loved one, an adult foster care home or an assisted living residence through one of three programs – Nursing Home / Institutional Medicaid, Home and Community Based Service (HCBS) Waivers and Medicaid for the Elderly and People with Disabilities (MEPD).

Texas Medicaid Long Term Care Programs

Nursing Home / Institutional Medicaid

Texas Medicaid will cover the cost of long term care in a nursing home for eligible Texas residents who require a Nursing Facility Level of Care. Nursing home coverage includes payment for room and board, as well as all necessary medical and non-medical goods and services. These can include skilled nursing care, physician’s visits, prescription medication, medication management, mental health counseling, social activities and assistance with the Activities of Daily Living (eating, bathing, moving, dressing, toileting).

Some of the things Texas Medicaid won’t cover in a nursing home are a private room, specialized food, comfort items not considered routine (tobacco, sweets and cosmetics, for example), personal reading items, plants, flowers, and any care services not considered medically necessary.

Nursing Home Medicaid is an entitlement. This means that eligible Texas residents who apply are guaranteed by law, aka “entitled,” to receive Nursing Home Medicaid benefits once their application has been approved.

Any Texas Medicaid beneficiary who receives nursing home coverage must give most of their income to the state to help pay for the cost of the nursing home. They are only allowed to keep a “personal needs allowance” of $60 / month, as of 2023. This can be spent on personal items such as clothes, snacks, books, etc.

Home and Community Based Service (HCBS) Waivers

Home and Community Based Service (HCBS) Waivers will pay for long term care services and supports goods that help Texas Medicaid recipients who require a Nursing Facility Level of Care remain living in the community instead of moving to a nursing home. The word “waiver” means something like voucher in this instance. Think of it as a voucher that will pay for long term care services for Texas residents who live in their home, the home of a loved one, an adult foster care home or an assisted living residence. While Texas’ HCBS Waiver will cover some long term care services and supports in those settings, it will not cover room and board costs.

Unlike Nursing Home Medicaid, Texas HCBS Waivers are not an entitlement. Remember, entitlement means guaranteed by law. So, even if an applicant is eligible for an HCBS Waiver program in Texas, they are not guaranteed by law to receive the benefits. Instead, there are a limited number of enrollment spots. Once those spots are full, additional eligible applicants will be placed on a waiting list.

Texas residents can receive HCBS Waiver long term care benefits through the STAR+PLUS Waiver.

STAR+PLUS Waiver
Texas’ STAR+PLUS Waiver provides long term care services and supports to eligible Texas residents who require a Nursing Facility Level of Care but live in the community instead. To determine if applicants meet that level of care requirement, Texas uses a Medical Necessity and Level of Care (MN/LOC) Assessment. This tool takes into account an applicant’s ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting), as well as behavioral and cognitive issues.

STAR+PLUS Waiver benefits can include nursing services, adult day care, home modifications, meal delivery, Personal Emergency Response Services (PERS) and personal care assistance with the Activities of Daily Living. Benefits will be made available depending on the needs and circumstances of each individual.

STAR+PLUS Waiver program participants receive their benefits through a single Medicaid plan provided by a managed care organization (MCO), which has a network of healthcare providers. Beneficiaries can choose from several plans. STAR+PLUS program participants also have the option to self-direct some of their benefits (like personal care assitance and homemaker services) by choosing caregivers from outside the MCO network. These caregivers can include family member like adult children or siblings, but they can not be spouses.

STAR+PLUS Waiver beneficiaries must live in their own home, the home of a loved one, an adult foster care home or an assisted living residence. As mentioned above, the waiver will pay services and supports in those settings, but it will not cover room and board costs.

There are a limited number of enrollment spots for the STAR+PLUS waiver (approximately 24,000 as of 2022). Once those spots are full, additional eligible applicants will be placed on a waiting list.

Medicaid for the Elderly and People with Disabilities

Texas’ Medicaid for the Elderly and People with Disabilities (MEPD) provides healthcare and personal service benefits to low-income Texas residents who are aged (65 and older) or disabled and live in their home, the home of a loved one or an adult foster care home. While MEPD will cover services in all of those settings, it will not cover room and board costs. MEPD can sometimes be referred to as regular Medicaid for seniors, but it should not be confused with the regular Medicaid that is available for low-income people of all ages.

MEPD is an entitlement, which means that anyone who meets the requirements is guaranteed by law to receive the benefits without any wait. In addition to medical care, MEPD benefits can include non-medical services and supports. MEPD beneficiaries qualify for these benefits and services one at a time, which is different from Nursing Home Medicaid, which makes all of its services immediately available for anyone who qualifies.

MEPD beneficiaries can receive long term care benefits through four programs:

1) Community First Choice – provides in-home personal care services for MEPD recipients who require a Nursing Facility Level of Care (NFLOC)
2) Primary Home Care – provides in-home personal care services to MEPD recipients who show a need for the services but do not require a NFLOC
3) Day Activity and Health Services – provides weekday daytime supervision and care at health centers around the state for MEPD beneficiaries with chronic health problems
4) Program for All-Inclusive Care for the Elderly – coordinates all medical and personal care services for dual-eligible MEPD beneficiaries

1) Community First Choice
Texas’ Community First Choice (CFC) program provides long term care benefits to MEPD recipients who live in their own home or the home of a loved one but require a Nursing Facility Level of Care. To determine if applicants meet that level of care requirement, Texas uses a Medical Necessity and Level of Care (MN/LOC) Assessment. This tool takes into account an applicant’s ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting), as well as behavioral and cognitive issues.

CFC benefits can include light housecleaning, Personal Emergency Response Services (PERS), companion services (to appointments and activities), assistance in developing and maintaining independent living skills, and personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting). These benefits will be made available depending on the needs and circumstances of each individual.

Texas Medicaid will provide licensed agency workers to deliver CFC benefits, but program participants can also self-direct some of their care through the Consumer Directed Services option. This allows CFC beneficiaries to hire workers of their choice to provide their personal care assistance. This includes friends and family members, although spouses can not be hired as CFC caregivers.

2) Primary Home Care
Texas’ Primary Home Care (PHC) program provides long term care services and supports to MEPD recipients who live in their own home and the home of a loved one and show a medical need for PHC benefits. Applicants must need help with at least one of the Activities of Daily Living (mobility, bathing, dressing, eating, toileting), undergo a functional assessment by the state and have a physician’s statement confirming their need for the benefits to be eligible for the PHC program.

Program beneficiaries can receive up to 50 hours of care per week through the PHC program. This care can include housekeeping, laundry, shopping, cooking, companion services to appointments and personal care assistance with the Activities of Daily Living. The total number of hours and available benefits will depend on the needs and circumstances of each individual.

PHC benefits can be delivered through a provider agency, but program participants also have the option to hire their own caregiver. This includes friends and family members, like adult children, but spouses can not be hired as PHC caregivers.

3) Day Activity and Health Services
Texas’ Day Activities and Health Services (DAHS) program provides daytime supervision and health services to MEPD recipients who have a chronic medical condition. This can include conditions like Alzheimer’s disease, arthritis, diabetes, vascular disease, etc. DAHS applicants must have a physician’s order stating their condition and their need for DAHS services, but they are not required to need a Nursing Facility Level of Care.

DAHS program participants can reside in their own home, the home of a loved one or adult foster care. DAHS care facilities are located throughout the state. They will provide DAHS beneficiaries with supervision, nursing services, meals, therapies and personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting). This Texas Health and Human Services webpage has a list of DHAS facilities.

Although DHAS is an entitlement, which means all eligible applicants are guaranteed by law to receive benefits, some DHAS facilities may be at full capacity and not have room for any new members. In these cases, applicants can go on a waiting list for the next available spot, or try another facility in their area.

4) Program of All-Inclusive Care for the Elderly (PACE)
Texas residents who are age 55 or older and have Aged Blind and Disabled Medicaid can coordinate their medical, social service and non-medical personal needs into one comprehensive plan and delivery system using the Program of All-Inclusive Care for the Elderly (PACE). PACE program participants are required to need a Nursing Facility Level of Care, but they must live in the community. Texas’ PACE programs can be used by people who are “dual eligible” for Medicaid and Medicare, and it will coordinate the care and benefits from those two programs into one plan. PACE also administers vision and dental care, and PACE day centers provide meals, social activities, exercise programs and regular health checkups and services to program participants. Texas’ PACE programs are located in El Paso (Bienvivir Senior Health Services), Lubbock (Silver Star PACE) and Amarillo (The Basics at Jan Werner). More.

Eligibility Criteria For Texas Medicaid’s Long Term Care Programs

To be eligible for Texas Medicaid, a person has to meet certain financial requirements and functional (medical) requirements. The financial requirements vary by the applicant’s marital status, if their spouse is also applying for Medicaid, and what program they are applying for – Nursing Home / Institutional Medicaid, Home and Community Based Service (HCBS) Waivers and Medicaid for the Elderly and People with Disabilities (MEPD).

Texas Medicaid Nursing Home Medicaid Eligibility Criteria

Financial Requirements
Texas residents have to meet an asset limit and an income limit in order to be financially eligible for Nursing Home Medicaid. For a single applicant in 2023, the asset limit is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities. The 2023 income limit for a single applicant is $2,742 / month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income. However, Nursing Home Medicaid recipients are only allowed to keep a $60 / month of their income as a “personal needs allowance” and must give the state the rest to help offset nursing home costs.

For married applicants with both spouses applying, the 2023 asset limit for Nursing Home Medicaid through Texas Medicaid is $4,000 combined between the two applicants/spouses and the income limit is $5,484 / month combined. For a married applicant with just one spouse applying, the 2023 asset limit is $2,000 for the applicant spouse and $148,620 for the non-applicant spouse, and the income limit is $2,742 / month for the applicant. The income of the non-applicant spouse is not counted.

Texas Nursing Home Medicaid applicants are not allowed to give away their assets in order to get under the asset limit. To make sure they don’t, Texas Medicaid has a “look-back” period of five years. This means the state will look back into the previous five years of the applicant’s financial records to make sure they have not given away assets.

Functional Requirements
The functional, or medical, criteria for Texas Medicaid’s Nursing Home Medicaid is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that can only be provided in a nursing home. To determine if applicants meet that level of care requirement, Texas uses a Medical Necessity and Level of Care (MN/LOC) Assessment. This tool takes into account an applicant’s ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting), as well as behavioral and cognitive issues.

Texas Home and Community Based Service (HCBS) Waivers Eligibility Criteria

Financial Requirements
Texas residents have to meet an asset limit and an income limit and in order to be financially eligible for Home and Community Based Service (HCBS) Waivers. For a single applicant in 2023, the asset limit is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities. The 2023 income limit for a single applicant is $2,742 / month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income.

For married applicants with both spouses applying, the 2023 asset limit for HCBS Waivers in Texas is $4,000 combined between the two applicants/spouses, and the income limit is a combined $5,484 / month. For a married applicant with just one spouse applying for HCBS Waivers in Texas, the applicant spouse has a $2,000 asset limit and a $2,742 / month income limit for 2023, and the non-applicant spouse has a $148,620 asset limit and no income limit.

Texas HCBS Waiver applicants are not allowed to give away their assets in order to get under the asset limit. To make sure they don’t, Texas Medicaid has a “look-back” period of five years. This means the state will look back into the previous five years of the applicant’s financial records to make sure they have not given away assets.

Functional Requirements
The functional, or medical, criteria for Home and Community Based Service (HCBS) Waivers in Texas is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that can only be provided in a nursing home. To determine if applicants meet that level of care requirement, Texas uses a Medical Necessity and Level of Care (MN/LOC) Assessment. This tool takes into account an applicant’s ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting), as well as behavioral and cognitive issues.

Texas Medicaid for the Elderly and People with Disabilities (MEPD) Eligibility Criteria

Financial Requirements
Texas residents have to meet an asset limit and an income limit in order to be financially eligible for Medicaid for the Elderly and People with Disabilities (MEPD) / Regular Medicaid. For a single applicant in 2023, the asset limit is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities. The 2023 income limit for a single applicant is $914 / month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income.

For married applicants, the 2023 asset limit for Texas MEPD is $3,000 combined between the two applicants/spouses, and the income limit is a combined $1,371 / month. These limits are used for both married couples with both spouses applying for MEPD and married couples with only one spouse applying.

While Texas has a “look-back” period of five years for Nursing Home Medicaid and Home and Community Based Service Waivers applicants to make sure they don’t give away their assets to get under the limit, there is no “look-back” period for MEPD applicants. However, MEPD applicants should be cautious about giving away their assets. They might eventually need Nursing Home Medicaid, or an HCBS Waiver, and those programs will deny or penalize the applicant for giving away assets.

Functional Requirements
The functional requirements for Texas Medicaid for the Elderly and People with Disabilities (MEPD) are being disabled or aged (65 or over) and needing help with Activities of Daily Living (mobility, bathing, dressing, eating, toileting). Texas Medicaid will conduct an assessment of MEPD applicants and their ability to perform Activities of Daily Living to determine the kind of long term care services and supports the beneficiary needs and the state will cover.

Applying For Texas Medicaid Long Term Care Programs

The first step in applying for a Texas Medicaid Long Term Care program is deciding which of the three programs discussed above you or your loved one want to apply for – Nursing Home / Institutional Medicaid, Home and Community Based Service (HCBS) Waivers and Medicaid for the Elderly and People with Disabilities (MEPD).

The second step is determining if the applicant meets the financial and functional criteria, also discussed above, for that Long Term Care program. Applying for Texas Medicaid when not financially eligible will result in the application, and benefits, being denied.

During the process of determining financial eligibility, it’s important to start gathering documentation that clearly details the financial situation for the Texas Medicaid applicant. These documents will be needed for the official Texas Medicaid application. Necessary documents include five years of quarterly bank statements from all accounts; the most recent monthly or quarterly statements from all investments, IRAs, 401Ks, annuities and any other financial accounts; a letter from the Social Security Administration showing the applicant’s gross Social security income and deductions; tax forms to verify income streams including wages, pensions, royalties and interest; lists of items of any trusts; proof life insurance (if the applicant has any) and a list of beneficiaries; Power of Attorney documentation.

After financial eligibility requirements are checked and double checked, documentation is gathered, and functional eligibility is clarified, individuals can apply online at Your Texas Benefits, by calling 2-1-1, or with a paper application.

Choosing a Texas Medicaid Nursing Home

After an applicant has been approved for Nursing Home Medicaid through Texas Medicaid, they need to choose which Medicaid-approved nursing home they will live in. Even though Nursing Home Medicaid is an entitlement, Texas Medicaid will only cover stays and care in approved nursing homes. Texas residents can find and compare nursing homes in the state using this search tool provided by Texas Health and Human Services. Nursing Home Compare is a federal government website that has information about more than 15,000 nursing homes across the country. All of the nursing homes on this site are either Medicaid- or Medicare-approved.