Texas Medicaid: Check Your Eligibility and Apply for Health Coverage

Texas Medicaid offers vital health coverage to millions of Texans, acting as a key support system for low-income individuals and families. This program, a joint effort between Texas and the federal government, assists with costs for doctor visits, dental care, hospital stays, and prescription medications.

To secure these benefits, it's essential to understand the eligibility criteria, the various programs available, and the application process. The system is specifically designed to help children, pregnant women, parents, seniors, and people with disabilities, ensuring access to necessary medical care for the state's most vulnerable populations.

The scope of Texas Medicaid is substantial, highlighting its role as a pillar of the state's public health system. It provides medical coverage to over 4 million low-income Texans, including half of all children in the state and two-thirds of all residents in Texas nursing homes.

For most members, services are delivered through managed care health plans. These are private insurance companies contracted by the state to provide all Medicaid services, manage provider networks, and coordinate member care. This means that after approval, most individuals will select a health plan available in their local area.

Are You Eligible for Texas Medicaid?

Eligibility is the most critical and often the most complex aspect of the Medicaid process. Requirements differ based on whether the applicant is a child, a pregnant woman, a senior, a person with a disability, or a parent. Eligibility is determined by both general requirements and specific financial rules for each group.

General Requirements for All Applicants

Every person applying for Texas Medicaid must first meet two basic criteria before financial qualifications are considered.

• Texas Residency: Applicants must be residents of Texas. This can be verified with documents like a utility bill, rent receipt, or a valid Texas ID.
• Citizenship or Immigration Status: Applicants must be U.S. citizens or qualified legal aliens. This includes Green Card holders, refugees, asylees, and certain other immigrants. Proof such as a U.S. birth certificate, passport, or immigration documents is required.

Eligibility for Children and Families

Texas Medicaid offers extensive health coverage for children from low-income families, with more generous financial limits compared to adults. However, the income rules for parents are among the strictest in the country.

Children's Medicaid

Eligibility for children is based on family income and the child's age, measured against the Federal Poverty Level (FPL).

• Infants (age 0-1): Household income up to 198% of the FPL.
• Children (age 1-5): Household income up to 144% of the FPL.
• Children (age 6-18): Household income up to 133% of the FPL.

For a family of three, the monthly income limit for Children's Medicaid is about $2,954. For a family of four, the limit is approximately $3,564 per month.

Medicaid for Parents and Caretakers

Parents and caretaker relatives face much lower income limits. To qualify, an adult must be the primary caregiver for a child under 18 on Medicaid, and the household income must be extremely low.

For a single parent with two children (a family of three), the total monthly household income cannot exceed $230. For a two-parent household with two children (a family of four), the income limit is just $285 per month. This creates a significant coverage gap where children may qualify but their parents do not.

Eligibility for Pregnant Women

Texas provides dedicated Medicaid coverage for pregnant women to support the health of both mother and child. The income limits for this group are higher than for other adults.

To qualify, a pregnant woman's household income can be up to 198% of the FPL. This coverage lasts through the pregnancy and for a period after birth. For those with slightly higher incomes, the CHIP Perinatal program offers similar coverage for the unborn child.

Eligibility for Seniors (Age 65+) and People with Disabilities

This category of Medicaid is for Texans who are aged, blind, or disabled. Unlike other programs, eligibility here involves both an income test and a strict asset test.

Non-Financial Requirements

An applicant must be either 65 or older or have a disability that meets the Social Security Administration's definition. Individuals already receiving SSI or SSDI automatically meet this requirement. Otherwise, the Texas Health and Human Services Commission (HHSC) will conduct a disability determination.

Financial Requirements: Income

For many programs in this category, including those for long-term care, there is a "special income limit."

• Individual Applicant: Monthly income cannot exceed $2,901.
• Married Couple (both applying): Combined monthly income cannot exceed $5,802.

If an individual's income is slightly above this limit, a Qualified Income Trust (QIT), or Miller Trust, can be used. This legal tool allows excess income to be placed into a trust each month, making the person income-eligible for Medicaid.

Financial Requirements: Assets

The asset, or resource, limit is very strict.

• Individual Applicant: Cannot have more than $2,000 in countable assets.
• Married Couple (both applying): Cannot have more than $3,000 in countable assets.

Countable assets include cash, bank accounts, stocks, bonds, and property other than a primary home.

Spousal Impoverishment Protections

When only one spouse in a marriage needs long-term care, special rules protect the other spouse (the "community spouse") from financial hardship.

• Community Spouse Resource Allowance (CSRA): The community spouse can keep a portion of the couple's assets, up to a maximum of $157,920.
• Monthly Maintenance Needs Allowance (MMNA): The community spouse is guaranteed a minimum monthly income of $3,948. If their own income is lower, they can receive a portion of the applicant spouse's income to reach this amount.

The Texas Coverage Gap: Why Many Low-Income Adults Don't Qualify

A key factor in Texas Medicaid eligibility is the state's decision not to expand its program under the Affordable Care Act (ACA). The ACA intended for states to cover nearly all adults with incomes up to 138% of the FPL, but a Supreme Court ruling made this optional.

Because Texas has not expanded Medicaid, a significant "coverage gap" exists. This gap affects adults who earn too much for traditional Medicaid but not enough to get financial help for private insurance on the HealthCare.gov marketplace.

As a result, non-disabled adults under 65 without dependent children are not eligible for Texas Medicaid, no matter how low their income is. This policy contributes to Texas having the highest rate of uninsured residents in the nation. In 2020, an estimated 45% of Texas adults with incomes below the poverty level were uninsured due to this gap.

Texas Medicaid Programs: STAR, STAR+PLUS, STAR Kids, and CHIP

Once approved for Medicaid in Texas, individuals are typically enrolled in a managed care program tailored to their specific needs.

• STAR: This is the most common program, serving the majority of low-income children, pregnant women, and some families. Members select a local health plan to receive their standard Medicaid benefits.
• STAR+PLUS: This program is for adults aged 65 or older and adults with disabilities. It covers basic medical care and long-term services and supports (LTSS), such as in-home personal care and home modifications.
• STAR Kids: This is a specialized program for children and young adults up to age 20 with disabilities or complex medical needs. It provides coordinated care management. At age 21, members must transition to STAR+PLUS to continue services.
• CHIP (Children's Health Insurance Program): CHIP provides low-cost health coverage for children in families who earn too much for Medicaid but cannot afford private insurance. It covers a full range of benefits, though it may require a small enrollment fee and co-pays.

What Health Services Are Covered?

Texas Medicaid offers a comprehensive set of health benefits. While core services are consistent, the specific health plan a member chooses may offer additional perks.

Core Medical and Hospital Benefits

All Texas Medicaid programs cover a wide range of essential medical services.

• Doctor Visits: Includes regular checkups and specialist visits.
• Hospital Care: Covers inpatient and outpatient services, including surgery and emergency care.
• Prescription Drugs: A broad range of medications are covered. There is no limit on prescriptions for children.
• Preventive Care: Services like immunizations and wellness checkups, including the Texas Health Steps program for children, which provides regular medical and dental screenings.
• Lab and X-ray Services: Diagnostic tests ordered by a doctor are covered.

Dental, Vision, and Hearing Services

Medicaid provides strong coverage for these services, especially for younger members.

• Dental Care: Children and young adults up to age 20 receive comprehensive dental services through separate dental plans like DentaQuest or MCNA Dental. Adult dental care is not a standard benefit, but some STAR+PLUS plans may offer it as an extra service.
• Vision Care: All members are typically eligible for routine eye exams and prescription glasses.
• Hearing Services: Hearing tests and hearing aids are covered, particularly for members under 21 through the Texas Health Steps program.

Mental Health and Substance Use Services

Texas Medicaid covers a wide array of services for mental health and substance use disorders.

• Individual, group, and family therapy, including Cognitive Behavioral Therapy (CBT).
• Medication management and psychiatric evaluations.
• Crisis intervention services.
• Peer support services.
• Inpatient and outpatient treatment for substance use disorders.

Long-Term Services and Supports (LTSS)

For individuals in the STAR+PLUS program, Medicaid covers services to help them live in the community and avoid nursing homes. These are often provided through Home and Community-Based Services (HCBS) waiver programs.

• Personal Attendant Services: Help with daily activities like bathing and dressing.
• Respite Care: Short-term relief for caregivers.
• Adult Day Care: Supervised care in a group setting.
• Home Modifications: Minor changes to a home, like installing a wheelchair ramp.
• Assisted Living and Adult Foster Care Support: Services in a residential setting.

Transportation and Other Support

Non-Emergency Medical Transportation (NEMT) is a crucial benefit. This service provides rides at no cost to and from medical appointments and the pharmacy, ensuring transportation is not a barrier to care.

Value-Added Services: The Importance of Choosing Your Health Plan

Managed care organizations (MCOs) offer extra, non-medical benefits called "value-added services" (VAS) to attract members. These services vary significantly between plans and regions.

This makes choosing a health plan a critical decision. Examples of value-added services can include:

• Allowances for over-the-counter items.
• Gift card rewards for healthy activities.
• Expanded adult dental or vision benefits.
• Gym memberships or programs like the Boys & Girls Club.
• Cell phones or extra minutes.

It is essential for new members to review the comparison charts provided by HHSC for their service area before selecting a health plan.

How to Apply for Texas Medicaid: A Step-by-Step Process

Being prepared can make the Medicaid application process smoother. It is helpful to gather all necessary information and documents before you begin.

Gathering Your Information and Documents

Collect the following paperwork for everyone in the household who is applying.

Personal Identification

• Social Security numbers for all applicants.
• Proof of identity (e.g., driver's license).
• Proof of U.S. citizenship or legal immigration status.

Proof of Income

• Recent pay stubs.
• A letter from an employer detailing wages.
• Self-employment records or the most recent tax return.
• Award letters for other income like Social Security or unemployment.

Proof of Assets (for aged or disabled applicants)

• Current bank statements.
• Vehicle titles.
• Copies of life insurance policies, stocks, or bonds.

Proof of Expenses

• Rent receipts or mortgage statements.
• Recent utility bills.
• Receipts for dependent care expenses.
• Court orders for child support paid.
• Records of medical bills.

Submitting Your Application

Texas offers several ways to apply for Medicaid benefits.

• Online (Recommended): The fastest way is through the Your Texas Benefits website at YourTexasBenefits.com. You can start, save, and return to your application, and later use the account to upload documents and check your status.
• By Phone: Call 2-1-1 and select option 2 to apply over the phone.
• By Mail: Download an application from the website or call 2-1-1 to have one mailed to you. Mail the completed form to HHSC, P.O. Box 149024, Austin, TX 78714-9968.
• In-Person: Visit a local HHSC benefits office or a community partner organization for assistance.

After You Apply: What to Expect

HHSC will review your application, which can take up to 45 days. They may contact you for an interview from the number (737) 867-7700. You can check your application status online at YourTexasBenefits.com or by calling 2-1-1.

Avoiding Common Application Mistakes

Simple misunderstandings can lead to application denials. Being aware of these common issues can help prevent problems.

• Report Gross Income, Not Net Pay: Always report your income before taxes and deductions are taken out.
• Disclose All Assets: For programs with an asset test, you must disclose all resources, including the cash value of life insurance policies and recently closed bank accounts.
• State an "Intent to Return Home": For an applicant in a nursing facility, their primary home is usually not a countable asset. To protect this, the application should state an "intent to return home," even if it seems unlikely.
• Understand the Rules on Gifting Assets: Giving away money or property within five years of applying for long-term care Medicaid can result in a penalty period of ineligibility. This is different from federal gift tax law.

Managing Your Coverage After Approval

After your Medicaid application is approved, take these steps to activate your coverage.

Choosing Your Health Plan

You will receive an enrollment packet from the Texas Enrollment Broker with information about the managed care health plans (MCOs) in your area. You must choose one to manage your healthcare.

To make an informed choice, you should:

• Review the Comparison Charts: HHSC provides detailed charts comparing the value-added services offered by each plan in your service area.
• Check for Your Doctors: If you have doctors you want to keep, check which health plans they accept by calling their office or checking the plan's website.
• Call for Help: If you need assistance, call the Enrollment Broker helpline at 800-964-2777.

If you do not choose a plan by the deadline, one will be chosen for you.

Finding a Doctor Who Accepts Medicaid

Once enrolled in a health plan, you must select a Primary Care Provider (PCP). Here are several ways to find doctors in your plan's network:

• Use the Official State Lookup Tool: The Texas Medicaid & Healthcare Partnership (TMHP) has an Online Provider Lookup tool to search for participating providers.
• Check Your Health Plan's Website: Every MCO, such as Wellpoint, Superior HealthPlan, or UnitedHealthcare, has its own online provider directory.
• Call Member Services: The phone number for your health plan is on your insurance card. They can help you find a provider and schedule an appointment.

Renewing Your Texas Medicaid Benefits

Medicaid coverage must be renewed every year. Failing to complete the renewal process on time is a common reason people lose their health benefits.

HHSC redetermines eligibility for all members every 12 months. You will receive a renewal notice by mail, often in a yellow envelope marked "ACTION REQUIRED," or by email or text if you have opted for paperless notifications.

To complete your renewal, follow these steps:

1. Log in to YourTexasBenefits.com: The easiest way to renew is online.
2. Complete the Renewal Form: Provide updated information about your household's income, assets, and expenses.
3. Submit Promptly: Return the form and any requested documents as soon as possible to avoid a gap in coverage.

It is crucial to keep your contact information updated with HHSC. If you move, report it immediately through YourTexasBenefits.com or by calling 2-1-1. If HHSC cannot reach you, your coverage will likely be terminated. Recently, over 1.3 million children in Texas were disenrolled from Medicaid, many for procedural reasons like a failure to return a renewal packet.

If Your Application is Denied or Coverage is Terminated

If your application is denied or your coverage is terminated, you have the legal right to challenge the decision through a formal appeals process. It is important to act quickly due to strict deadlines.

Understanding the Appeals Process

The process begins with an internal appeal to your managed care organization (MCO) before moving to a state-level hearing.

Step 1: File an Internal Appeal with Your Health Plan

If your health plan denies or reduces a service, you must first appeal to them.

• Timeline: You must file the appeal within 60 calendar days from the date on the denial letter.
• How to File: You can file by phone, mail, or fax. The contact information will be in the denial letter.
• Continuing Benefits: To keep receiving a service during the appeal, you must file within 10 calendar days of the notice date. If you lose the appeal, you may have to pay for those services.

Your health plan has 30 days to review your appeal and send a written decision.

Requesting a State Fair Hearing

If your health plan upholds its denial, or if you are appealing an eligibility denial from HHSC, your next step is a State Fair Hearing.

Step 2: Request a Fair Hearing

An impartial hearings officer from HHSC will review your case.

• Timeline: You must request a hearing within 120 days of your health plan's appeal decision letter. For eligibility denials from HHSC, the deadline is 90 days.
• How to Request: You can request a hearing in writing, by calling 2-1-1, or by visiting an HHSC office.
• The Hearing Process: Most hearings are held by phone. You will have the opportunity to testify, present evidence, and question the agency representative.

The hearings officer will issue a final decision in writing within 90 days. For assistance with the appeals process, you can contact the HHSC Ombudsman's office at 877-787-8999.

Frequently Asked Questions