Summary
Medicaid’s rules, benefits and name can all vary by state. This article focuses on Texas Medicaid Long Term Care for seniors, which is administered by Texas Health and Human Services and will pay for care in a nursing home, a beneficiary’s home and other settings through one of three programs – Nursing Home Medicaid, HCBS Waivers or Medicaid for the Elderly and People with Disabilities. This is different from regular Medicaid, which is for financially limited people of all ages.
Texas Nursing Home Medicaid will cover the cost of long-term care in a nursing home for financially limited Texas seniors who require a Nursing Facility Level of Care. Coverage includes payment for room and board, as well as all necessary medical and non-medical goods and services, such as:
Items not covered include a private room, specialized food, comfort items not considered routine (tobacco, sweets and cosmetics, for example) and any care services not considered medically necessary.
Texas Nursing Home Medicaid beneficiaries are required to give most of their income to the state to help cover care expenses. They are only allowed to keep a “personal needs allowance” (PNA) of $75/month, which can be spent on personal items such as clothes, snacks, books, haircuts, flowers, etc. They can also keep enough of their income to make Medicare premium payments if they are “dual eligible,” and enough to make any Medicaid-approved spousal income allowance payments to financially needy spouses who are not Medicaid applicants or recipients.
Texas Nursing Home Medicaid is an entitlement. This means all qualified applicants are guaranteed by law, aka “entitled,” to receive benefits without wait. However, not all nursing homes accept Medicaid, and those that do may not have any available spaces when you or your loved one needs care. So, eligible applicants are guaranteed nursing home coverage without wait, but they are not guaranteed coverage in any facility they choose.
A Nursing Home Alternative – Texas Nursing Home Medicaid beneficiaries who want to leave their nursing home and return to living “in the community” can receive financial and functional help with that transition through Texas’ Money Follows the Person (MFP) program. This help can include paying for moving expenses, as well as long-term care services and supports in the new residence. MFP beneficiaries must be moving from a Medicaid-approved facility and into their own home, the home of a relative or a small group home with a maximum of four unrelated residents.
Texas 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 Waivers will cover some long-term care services and supports in those settings, it will not cover room and board costs such as mortgage payments, rent, utility bills and food expenses.
The HCBS Waiver relevant to Texas seniors is 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 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.
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 (mobility, bathing, dressing, eating, toileting). These 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 members like adult children or siblings, but they can not be spouses.
Unlike Nursing Home Medicaid, the STAR+PLUS Waiver is not an entitlement. Instead, it has a large but limited number of enrollment spots (roughly 24,000 as of 2022), and once those spots are full additional applicants are placed on a waitlist.
Texas’ Medicaid for the Elderly and People with Disabilities (MEPD) provides healthcare and long-term care benefits to Texas residents who are aged (65 and older) or disabled and live in the community. 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 healthcare coverage without wait. Access to long-term care benefits via MEPD depends on the availability of funds, programs and caregivers in the area where the beneficiary lives. MEPD is similar to ABD Medicaid in other states.
MEPD beneficiaries who show a medical need for long-term care services and supports can receive those benefits through the following programs:
1. Community First Choice
Texas’ Community First Choice (CFC) program offers 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 self-direct their care by hiring 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 Medicaid for the Elderly and People with Disabilities can cover their medical, social service and non-medical long-term care needs with 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 they 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). To learn more about PACE, click here.
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 Medicaid, Home and Community Based Services (HCBS) Waivers and Medicaid for the Elderly and People with Disabilities (MEPD).
Just For You: The easiest way to find the most current Texas Medicaid eligibility criteria for your specific situation is to use our Medicaid Eligibility Requirements Finder tool.
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 2024, 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 How Medicaid Treats the Home section below for more details), and there are other non-countable assets, like Irrevocable Funeral Trusts and Medicaid Compliant Annuities.
The 2024 income limit for a single applicant is $2,829/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, Texas Medicaid beneficiaries who reside in nursing homes must give most of their income to the state to help pay for the cost of care. They are only allowed to keep $75/month of their income as a “personal needs allowance,” and they are allowed to make Medicare premium payments if they are “dual eligible,” and they can make any allowable spousal income allowance payments to financially needy, non-applicant spouses.
For married applicants with both spouses applying, the 2024 asset limit for Texas Nursing Home Medicaid is a combined $3,000, and the income limit is a combined $5,658/month. For a married applicant with just one spouse applying, the 2024 asset limit is $2,000 for the applicant spouse and $154,140 for the non-applicant spouse, thanks to the Community Spouse Resource Allowance. The income limit is $2,829/month for the applicant, and the income of the non-applicant spouse is not counted.
There are alternative pathways to eligibility for Texas Nursing Home Medicaid applicants who don’t meet their financial limits, such as Medicaid Planning. However, applicants are not allowed to simply give away their assets in order to get under the asset limit. To make sure they don’t, Texas has a Look-Back Period of five years. This means the state will look back into the previous five years of the Nursing Home Medicaid 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 is normally associated with 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.
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 How Medicaid Treats the Home section below for more details), and there are other non-countable assets, like Irrevocable Funeral Trusts and Medicaid Compliant Annuities.
The 2024 income limit for Texas HCBS Waivers for a single applicant is $2,829/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 2024 asset limit for HCBS Waivers in Texas is a combined $3,000, and the income limit is a combined $5,658/month. For a married applicant with just one spouse applying, the 2024 asset limit is $2,000 for the applicant spouse and $154,140 for the non-applicant spouse, thanks to the Community Spouse Resource Allowance. The 2024 income limit is $2,829/month for the applicant, and the income of the non-applicant spouse is not counted.
Plan Ahead: There are alternative pathways to eligibility for Texas HCBS Waivers applicants who don’t meet their financial limits, such as Medicaid Planning. However, applicants are not allowed to simply give away their assets in order to get under the asset limit. To make sure they don’t, Texas has a Look-Back Period of five years. This means the state will look back into the previous five years of the Nursing Home Medicaid 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 Services (HCBS) Waivers in Texas is needing a Nursing Facility Level of Care, which means the applicant requires the kind of full-time care that is usually associated with a nursing home. To determine if applicants meet that level of care requirement, Texas uses a Medical Necessity and Level of Care 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.
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). For a single applicant in 2024, 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 How Medicaid Treats the Home section below for more details), and there are other non-countable assets, like Irrevocable Funeral Trusts and Medicaid Compliant Annuities.
The 2024 income limit for MEPD for a single applicant is $943/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 2024 asset limit for Texas’s MEPD is a combined $3,000, and the income limit is a combined $1,415/month. These limits are used for both married couples with both spouses applying for MEPD and married couples with only one spouse applying.
Plan Ahead: There are alternative pathways to eligibility for MEPD applicants who are over the asset limit and/or the income limit, such as Medicaid Planning. While Texas has a Look-Back Period of five years for Nursing Home Medicaid and HCBS Waivers applicants to make sure they don’t give away their assets to get under the limit, the Look-Back Period does not apply to MEPD applicants. However, MEPD applicants should be cautious about giving away their assets. They might eventually need Nursing Home Medicaid or HCBS Waivers, and those programs will deny or penalize the applicant for giving away assets.
Functional Requirements
The only functional requirements for receiving basic healthcare coverage through Texas’s Medicaid for the Elderly and People with Disabilities (MEPD) are being aged (65 or over) or disabled. For MEPD applicants/recipients who want long-term care services and supports, the state will conduct an assessment of their ability to perform Activities of Daily Living to determine the kind of long-term care benefits they require and the state will cover.
One’s home is often their most valuable asset, and if counted toward Medicaid’s asset limit, it would likely cause them to be over the limit. However, in many situations the home is not counted against the asset limit:
These rules apply to all three types of Medicaid, with one important exception – Medicaid for the Elderly and People with Disabilities (MEPD) applicants can disregard the home equity limit. Value does not matter regarding their home’s exempt status. To learn more about the impact of home ownership on Medicaid eligibility, click here.
Texas Medicaid applicants and recipients may also want to consider protecting their home (and other assets) from estate recovery. States are required by law to try and collect reimbursement for long-term care after the death of Medicaid recipients. They do this through their Medicaid Estate Recovery Programs (MERPs). The rules and regulations regarding estate recovery can vary greatly by state, but all states have a MERP. To learn more about the MERP in Texas and how you can protect your home from it, click here.
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 Medicaid, Home and Community Based Services (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 may include tax forms, Social Security benefits letters, deeds to the home, proof of life insurance and quarterly statements for all bank accounts, retirement accounts and investments. For a complete list of documents you might need to submit with your Medicaid Long Term Care application, go to our Medicaid Application Documents Checklist.
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.
For step-by-step guides to applying for each of the 3 types of Medicaid Long Term Care, just click on the name: 1) Nursing Home Medicaid 2) HCBS Waivers 3) ABD Medicaid.
Professional Help: Many seniors need support when it comes to Medicaid Long Term Care’s rules, benefits and application process. These are all complicated, constantly changing and vary by state. The best place to get help with Medicaid Long Term Care is through a professional like a Certified Medicaid Planner or an Elder Law Attorney.
After getting approved for Nursing Home Medicaid through Texas Medicaid, you or your loved one needs to choose which Medicaid-accepting nursing home best meets your needs. Even though Nursing Home Medicaid is an entitlement, not all nursing homes take Medicaid, and those that do may not have available spaces. Finding a residence that meets your needs can be difficult or time-consuming, especially if you want to be in a specific geographic area.
There are approximately 1,200 nursing facilities in Texas, with the majority of them clustered around the state’s biggest cities. There are roughly 100 facilities in and around Dallas that accept Medicaid, and about another 75 in the Forth Worth area. There are 115 nursing facilities in the Houston area, and about 50 in and around San Antonio. The choices get narrower in the others parts of the state, but the majority of facilities remain clustered around cities. There are 20 nursing facilities in El Paso, 15 in Lubbock, 14 in Corpus Christi, 12 in Amarillo and six in Odessa.
TOOLS: Texas residents can find and compare nursing homes in the state using this LTC Provider Search tool from Texas Health and Human Services. They can also use Nursing Home Compare, a search tool administered by the Centers for Medicare & Medicaid Services (CMS) that has information about more than 15,000 nursing homes across the country.
Once you’ve found nursing homes in your area that accept Medicaid, you can start comparing them, if you have multiple options. The Texas LTC Provider Search tool has information on inspections, enforcement actions and quality measures for every facility. The search on Nursing Home Compare can be filtered by overall rating, health inspections, staffing and quality measures. You can also get information on nursing homes by contacting your local Area Agency on Aging.
After doing your research, you or someone you trust should also visit any nursing homes you’re considering before making a final decision. Call first to make an appointment for the visit, and arrive prepared with a list of questions. Some things you might ask are: Does the residence coordinate social activities? Does it provide transportation? Who are the staff doctors? What are the meals like? How will the residence provide access to oral and eye care? CMS has a thorough “Nursing home checklist” you can use to evaluate a nursing home while visiting.
According to data collected by CMS, Texas nursing homes averaged 20 health citations from 2019-2022, which is below the national average of 25.7. And they reported 9.1 fire safety citations, which is also below the national average of 13.5.
If you need Medicaid long term care but do not meet the financial eligibility criteria, consider working with a Medicaid Planning professional. These fee-based experts help families structure their finances to become eligible, while streamlining the application process and preserving assets for spouses and family members.
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