Medicaid is the federally mandated, state-administered health plan for needy seniors, children and people with permanent disabilities. It covers doctor’s visits, inpatient and outpatient hospital services, X-rays, some blood tests and care in a nursing facility.
Some states also fund optional benefits, such as rehabilitation, vision and dental care, case management and personal care through state-specific Medicaid waivers. The Texas Medicaid program is administered through the Department of Health and Human Services using managed care organizations. There are at least two Medicaid plans available in every county, and in most cases, Medicaid enrollees can choose which plan they want to participate in.
Qualifying for Medicaid
Because Medicaid is for those who would otherwise be unable to afford basic health care, applicants must have a low income and few resources (countable assets). In Texas, seniors who are eligible for Supplemental Security Income benefits are automatically enrolled in basic Medicaid and only need to complete additional screening if requesting Medicaid-funded long-term care.
All other seniors must meet the following criteria:
- Earn no more than $2,313 per month or $4,626 per couple when both spouses require care, and
- Own no more than $2,000 in cash, investments and other countable assets or $3,000 together with a spouse who is also applying for Medicaid, and
- Be a U.S. citizen or have qualified immigration status, and
- Be a permanent resident of Texas, and
- Have a valid Social Security Number, and
- Have documentation from a licensed physician that verifies the need for 30 or more days of continuous care at the level normally provided in a nursing home setting
Some assets are exempt, including prepaid burial contracts, life insurance policies valued at $1,500 or less, one vehicle and a home in which the applicant and/or their spouse live worth $585,000 or less.
Income and Asset Exemptions for Non-Applicant Spouses When only one spouse requires long-term Medicaid services, special rules apply to the non-applicant, called the community spouse. The income of the community spouse is disregarded for Medicaid purposes.
In most cases the non-applicant spouse can keep up to half of the couple’s joint assets, up to a $126,420 limit, under the community spouse resource allowance. Higher limits may be granted through a court order or an appeal hearing, and this amount doesn’t include non-countable assets, such as the couple’s home.
If the community spouse is financially dependent on the applicant, the applicant may provide the community spouse with up to $3,160.50 per month to cover shelter costs. Any amount transferred under the minimum monthly maintenance needs allowance rule is deducted from the applicant’s countable income when assessing Medicaid eligibility.
STAR+PLUS Medicaid Nursing Home Diversion Program Medicaid-eligible seniors aged 65 and older who meet the criteria for placement in a nursing facility may qualify for enhanced home and community-based services through
STAR+PLUS, a Texas Medicaid managed care program.
STAR+PLUS provides long-term care services necessary to allow frail seniors to age in place in an assisted living facility. Services are assigned based on medical need as determined by the senior, their primary care provider, family members and a STAR+PLUS service coordinator.
Every STAR+PLUS plan must offer:
- All the mandatory Medicaid benefits
- Primary home care services
- Adult day health services
- Medical supplies and equipment
- Minor home modifications to improve safety and accessibility
- Rehabilitation therapies
- Skilled nursing
- Assisted living
- Access to a personal emergency response device
- Home delivered meals
- Emergency response services
- Respite care
- Transition support for seniors moving from a nursing facility into assisted living
Each STAR+PLUS plan also offers value-added services that aren’t covered under Medicaid, such as extra vision and dental coverage, wellness services, gift programs and podiatry services.
Dallas and Rockwall counties are in the STAR+PLUS service area. Participants here can choose to receive their STAR+PLUS services through either Molina Healthcare of Texas or Superior Health Plan. Upon receiving notice of approval for the STAR+PLUS program, seniors have 15 days to choose a plan provider, otherwise, they’re automatically assigned a plan and primary physician.
For more information about Medicaid and the STAR+PLUS program, contact the
Health and Human Services Commission office at (888) 337-6377.