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, which is different from regular Medicaid. Medicaid will help pay for long term care for Texas residents in a nursing home, in their home and in other residential settings 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 / Regular Medicaid.

 

Texas Medicaid Long Term Care Programs

Nursing Home / Institutional Medicaid

Medicaid will cover the cost of long term care in a nursing home for eligible Texas residents through its Nursing Home / Institutional Medicaid. This 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 Activities of Daily Living (eating, bathing, moving, dressing and using the bathroom).

Some of the things that 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.

Any Texas Medicaid beneficiary who receives Nursing Home Medicaid 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. This can be spent on any personal item – clothes, snacks, books, haircuts, cell phones, etc. It cannot be spent on any item that Medicaid covers, including hygiene basics like toothbrush, soap, deodorant, razors and incontinence supplies, unless the Medicaid beneficiary wants a specific brand that is not covered by Medicaid. In this case, they could spend their personal needs allowance on the item.

 

Home and Community Based Service (HCBS) Waivers

Home and Community Based Service (HCBS) Waivers will pay for goods and services 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. Living “in the community” can mean living in their home, the home of a loved one, an adult foster care home or an assisted living residence. The goods and services provided by HCBS Waivers can be medical (skilled nursing care, physical therapy, durable medical equipment or prescription medication) or non-medical (like adult day care, transportation, housekeeping, and personal care assistance with Activities of Daily Living such as getting out of bed, dressing, eating, bathing and toileting). While HCBS Waiver benefits can include nursing home care, the program’s primary purpose is to delay nursing home placement by providing care in the community.

Texas Medicaid currently offers two HCBS programs relevant to the elderly and those requiring long term care.

STAR+PLUS HCBS Program
Many Texas residents will receive their long term care Medicaid benefits through the STAR+PLUS Program, which is also known as the STAR+PLUS Waiver, and the STAR+PLUS Home and Community-Bases suite of services. STAR+PLUS benefits can be provided to Medicaid beneficiaries who live at home, the home of a loved one, an adult foster care home or an assisted living residence. However, STAR+PLUS will not cover the cost of room and board at any of these places.

STAR+PLUS members 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 within the STAR+PLUS program. There are also some STAR+PLUS benefits that can be consumer directed. This means the beneficiary can choose a caregiver from outside the MCO network, including some family members. STAR+PLUS benefits that can be consumer directed are nursing services, personal care services, respite services and various therapies (physical, cognitive, occupational, speech and rehabilitation). Other STAR+PLUS benefits include adaptive aids, adult day care, financial management, home modifications and personal emergency response services.

Not all STAR+PLUS benefits are available to everyone who qualifies for the program. Instead, each STAR+PLUS applicant will be evaluated to help determine which benefits are needed and how often they are needed. Texas uses its Medical Necessity and Level of Care Assessment, which is completed by the MCO and signed by a physician, to help make these determinations.

STAR+PLUS, like all HCBS Waivers, is not an entitlement. This means that even if an applicant is eligible for the program, they are not guaranteed to receive the benefits. The STAR+PLUS Program has approximately 24,000 enrollment spots, and once all of those are full, eligible applicants are placed on a waiting list until there is an open enrollment slot for them.

Day Activity and Health Services (DAHS)
The Day Activity and Health Services (DAHS) Waiver covers adult day care services at facilities certified through the Texas Health and Human Services Commission. These facilities are open at least 10 hours per day on weekdays during daytime hours, except for holidays. In addition to supervision, these facilities provide nursing and personal care services, physical rehabilitation, nutrition counseling, mental health services, social activities and transportation to and from the facility.

The DAHS Waiver, like all HCBS Waivers, is not an entitlement, which means there are a limited number of enrollment spots. If a DAHS Waiver applicant is accepted into the program but all of the spots are full, they will be placed on a waiting list.

 

Medicaid for the Elderly and People with Disabilities / Regular Medicaid

Texas’ Medicaid for the Elderly and People with Disabilities (MEPD), also known as Regular Medicaid, provides healthcare and personal service benefits to low-income Texas residents who are aged (65 and older) or disabled and live “in the community.” Living “in the community” can mean living in their home, the home of a loved one, an adult foster care home or an assisted living residence. While MEPD will cover services in all of those settings, it will not cover room and board costs.

MEPD is an entitlement, which means that anyone who meets the requirements is guaranteed by law to receive the benefits without any wait. This includes a variety of long term care benefits such as adult day care, doctor’s visits, skilled nursing care, in-home personal care, prescription assistance and transportation. 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. Instead, MEPD recipients will be evaluated by the state to determine what kind of long-term care benefits they need and will receive.

MEPD beneficiaries receive their non-medical long term care services through two programs:
• Community First Choice (CFC) – for individuals who require a Nursing Facility Level of Care and need help with Activities of Daily Living
• Primary Home Care (PHC) – for individuals with health issues that create a need for help with Activities of Daily Living

Benefits of both the CFC and PHC programs include help with Activities of Daily Living – mobility, bathing, dressing, eating and toileting – as well as housekeeping, shopping and transportation.

Program of All-Inclusive Care for the Elderly (PACE)
Elderly (age 65 and up) Texas residents who have Medicaid for the Elderly and People with Disabilities (MEPD) 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 is intended to help Texas residents who need a Nursing Facility Level of Care but want to keep residing and receiving care in their home or somewhere else in the community. This program can be used by people who are “dual eligible” for Medicaid and Medicare and will help them coordinate the care from those two programs.

 

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 / Regular Medicaid.

 The easiest way to find the most current Texas Medicaid eligibility criteria for one’s specific situation is to use our Medicaid Eligibility Requirements Finder tool.

 

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 2022, 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 2022 income limit for a single applicant is $2,523 / 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 2022 asset limit for Nursing Home Medicaid through Texas Medicaid is $3,000 combined between the two applicants/spouses and the income limit is $5,046 / month combined. For a married applicant with just one spouse applying, the 2022 asset limit is $2,000 for the applicant spouse and $137,400 for the non-applicant spouse, and the income limit is $2,523 / month for the applicant. The income of the non-applicant spouse is not counted.

Texas 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. This is determined through a state assessment and reports from the applicant’s doctors and other relevant healthcare professionals.

 

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 2022, 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 2022 income limit for a single applicant is $2,523 / 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 2022 asset limit for HCBS Waivers in Texas is $3,000 combined between the two applicants/spouses, and the income limit is a combined $5,046 / 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 $2,523 / month income limit for 2022, and the non-applicant spouse has a $137,400 asset limit and no income limit.

Texas 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 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 the applicant needs this level of care, Texas uses its Medical Necessity and Level of Care Assessment.

 

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 2022, 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 2022 income limit for a single applicant is $841 / 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 2022 asset limit for Texas MEPD is $3,000 combined between the two applicants/spouses, and the income limit is a combined $1,261 / month. These limits are used for both married couples with both spouses applying for MEPD and married couples with only one spouse applying.

Texas 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 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 services the beneficiary needs and the state will cover.

 How Texas Medicaid Counts the Home
One’s home is often their most valuable asset, and if counted towards Texas Medicaid’s asset limit, it would likely cause them to be over the limit for eligibility. However, in some situations the home is not counted against the asset limit. If the applicant lives in their home and the home equity interest is less than $636,000 (as of 2022), then the home is exempt from the asset limit. Home equity interest is portion of the home’s equity value that the applicant owns, and the home’s equity value is the current value of the home minus any outstanding mortgage / debt against the home. If the applicant’s spouse, minor child, or blind or disabled child of any age lives there, the home is exempt regardless of the applicant’s home equity interest, and regardless of where the applicant lives. If none of the above-mentioned people live in the home, the home can be exempt if the applicant/beneficiary files an “intent to return” home and the home equity interest is at or below $636,000. These rules apply to all three types of Medicaid.

 

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 / Regular Medicaid.

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.