What Does Medicaid Cover In Texas
The Medicaid program in Texas places an emphasis on preventative care, continuity of care, and high-quality services. There are four different types of Texas Medicaid coverage that cover most of your healthcare needs:
- STAR: For most Texas Medicaid eligibles
- STAR+PLUS: For those over 65 and/or disabled
- STAR Kids: For low-income and/or disabled children
- STAR Health: For low-income and/or disabled foster children
When A Nursing Home Is Medically Necessary
Medicaid will pay for a nursing home only when it is medically necessary. In Texas, for a nursing home to be considered medically necessary, you must have a medical condition that is so serious that you need the level of nursing care that is only available in an institution. Your doctor must document your medical condition and must prescribe skilled nursing services to be provided to you on a regular basis in an institutional setting. Nursing care includes things like giving shots, inserting a feeding tube or catheter, treating bed sores, and changing wound dressings.
For Medicaid to keep paying for your nursing home stay, a doctor has to certify at least every six months that you meet the standard for medical necessity.
If you need only custodial care , for instance, because you fall often or because you have dementia and tend to wander, then Medicaid may find that a nursing home stay is not medically necessary because you do not need a skilled nurse.
What Is Defined As Income
When you are applying for Medicare and Medicaid benefits, one of the most important components that will be reviewed is your income. Income level is what qualifies or disqualifies a person, usually, for these benefits.
When it comes to applying for Medicaid, any income a person receives from any source is counted as income for this type of benefit. This included employment wages, alimony payments, pension payments, social security income or even investment dividend income.
If only one spouse in a couple is applying for these benefits then only that spouses income will be counted for the application. The spouse that is not applying may be able to get an allowance that will prevent spousal impoverishment from happening.
There are income limits in Texas on the non-applicant spouse, though. In order to determine if you are eligible for non-applicant spousal benefits or allowance, you will need to contact your Medicaid center to talk about your specific situation.
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Nutrition & Services For Seniors
Meals on Wheels operates through Nutrition & Services for Seniors in Jefferson and Hardin counties, bringing home-delivered meals to individuals and pets. This organization also provides valuable services, such as congregate dining, free transportation, and emergency communication systems.
Find them online at www.SeniorMeals.org. Visit Nutrition & Services for Seniors at 4590 Concord, Beaumont, TX 77703, or call 892-4455.
Assisted Living Admission Requirements
An assisted living facility cannot accommodate residents whose medical needs exceed the capabilities of staff unless a resident is covered by a licensed home health agency. Home health agencies can be hired by residents with greater care needs, although there are limitations on residency in an ALF for more fully disabled individuals. The state of Texas determines the extent of care available at ALFs by designating two levels of assistance, Type A and Type B, with Type A residents not requiring the added assistance of a home health agency.
Residents cannot be admitted to an ALF if they are permanently bedridden, or if their medical needs cannot be met by the facility or by a contracting home health agency.
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What Medicaid Covers For Medicare Enrollees
Medicare has four basic forms of coverage:
- Part A: Pays for hospitalization costs
- Part B: Pays for physician services, lab and x-ray services, durable medical equipment, and outpatient and other services
- Part C: Medicare Advantage Plan offered by private companies approved by Medicare
- Part D: Assists with the cost of prescription drugs
Medicare enrollees who have limited income and resources may get help paying for their premiums and out-of-pocket medical expenses from Medicaid . Medicaid also covers additional services beyond those provided under Medicare, including nursing facility care beyond the 100-day limit or skilled nursing facility care that Medicare covers, prescription drugs, eyeglasses, and hearing aids. Services covered by both programs are first paid by Medicare with Medicaid filling in the difference up to the state’s payment limit.
Where To Submit Your Medicaid Application
You can submit your application in the following ways.
- Mail The PO Box is found on the 1st page of the Medicaid application.
- Fax You can also find the fax number on the 1st page of the application.
- In-person Refer to the section below to find a Houston Medicaid office, call 211 or visit Your Texas Benefits.
- Online If you change your mind and want to complete the Medicaid application online, visit Your Texas Benefits.
- Phone You also call 877.541.7905 to apply for Medicaid.
Note: If you do not feel safe visiting a Medicaid office due to COVID 19, consider applying by mail or online.
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How To Apply For Medicaid In Texas For The Elderly
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Approximately 3.7 million or 13% of the population in Texas is at least 65 years of age, and that number is only growing every day. The projected growth of an aging population means that there is going to be an increase in the need for healthcare services and long-term care for the people of Texas.
One of the services that Texans will likely rely on will be Medicaid. This is a program that is different from Medicare , and it will help seniors to pay for their healthcare needs to make sure they get the services as they need them.
Do you automatically get Medicaid? Do you need to apply for it? There are some differences between this program and Medicare, and heres what you need to know about it.
Benefits Of A Qualified Income Trust
- It allows you to become eligible for Medicaid, even if your income is above Medicaid caps.
- It provides a means to cover the gap between your income and the actual cost of long-term care.
- Allows you to contribute a monthly allowance to a healthy spouse: If your spouse is still living at home you can contribute enough to bring their monthly income to $3,216.
- Removes the out-of-pocket burden from your family and loved ones.
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What Is Assisted Living
Its a supportive living option that includes housing, assistance with personal care needs, dining and a variety of convenient services and amenities. For individuals who value their independence but can benefit from help with personal care, dressing and taking medications assisted living can provide an ideal option.
Medically Needy Medicaid Texas
If you dont meet Texas Medicaid eligibility requirements based on your income level, you can still qualify based on spend down. This means that if you spend enough money on health care to put you below the qualifying limit, you can still qualify. However, that money that puts you below the line has to be going towards your healthcare costs.
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Assisted Living In Texas
At the Assisted Living Research Institute, we have analyzed the senior living landscape across the United States, compiling data on over 20,000 assisted living facilities. In the state of Texas, which hosts over 1,000 facilities, the average cost is $3,795 per month $200 less than the national average.
Being the second largest state in America, Texas encompasses a diverse range of climates and landscapes. From the semi-arid marshes of the coast to the spring-fed hills farther north, this expansive state is likely to appeal to retirees from many different regions. For senior citizens, most of whom live on fixed incomes, finding such atmospheric variety in a state that does not have a state income tax is exceptional.
How Mepd Services Are Provided
If you’re an adult with a disability and qualify for MEPD, these services are typically provided by STAR+PLUS. You will choose a STAR+PLUS health plan from the ones available in your service area.
If you have a child with a disability who qualifies for MEPD, these services are typically provided by STAR Kids. You will choose a STAR Kids health plan from the ones available in your service area.
You might also be enrolled into traditional Medicaid. Traditional Medicaid just means the state pays your doctors, nurses and other caregivers directly.
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Eligibility Criteria For Texas Medicaids Long Term Care Programs
To be eligible for Texas Medicaid, a person has to meet certain financial requirements and functional requirements. The financial requirements vary by the applicants 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 Waivers and Medicaid for the Elderly and People with Disabilities / Regular Medicaid.
Texas Medicaid Nursing Home Medicaid Eligibility Criteria
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 dont, Texas Medicaid has a look-back period of five years. This means the state will look back into the previous five years of the applicants financial records to make sure they have not given away assets.
Texas Home and Community Based Service Waivers Eligibility Criteria
How Texas Medicaid Counts the Home
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, physicians visits, prescription medication, medication management, mental health counseling, social activities and assistance with Activities of Daily Living .
Some of the things that Texas Medicaid wont cover in a nursing home are a private room, specialized food, comfort items not considered routine , 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 Waivers
Medicaid for the Elderly and People with Disabilities / Regular Medicaid
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Assisted Living Laws And Regulations In Texas
Assisted living communities in Texas must adhere to strict regulations and rules set by Texas Health and Human Services Commission . These regulations set out minimum requirements regarding staffing, care and amenities to ensure high standards of senior care.
Assisted Living Admission Requirements
There are two licensing types in Texas for assisted living communities: A and B. The license types are largely based on a residents physical and mental ability to evacuate the premises in an emergency situation. Residents must be appropriate for the license type when admitted. If a residents situation later changes and is not in accordance with the license, the community is not obliged to retain them. A community cannot admit anyone whose physical and mental needs cannot be met by the facility. A community can, however, secure services through third-party providers to meet resident needs, with written agreement of the resident, their physician or their legal representative.
Assisted Living Facility Requirements
Assisted Living Medicaid Policy
Texass Medicaid program covers assisted living services under the STAR+PLUS waiver. Assisted living facilities must have a contract with a residents managed care organization .
Assisted Living Scope of Care
Assisted Living Service Plan Requirements
Background Checks for Assisted Living
Medication Management Regulations
Which Services Will Medicaid Cover
The restrictions will differ depending on the state you live in, which is why it is critical to check with your local Medicaid reps to ensure what is covered.
Medicaid will, in general, cover:
- Personal Care Assistance Entails a variety of personal tasks such as dressing, eating, and bathing. However, it also includes a variety of other tasks.
- Homemaker services Entail tasks around the house that the elderly may find difficult to complete, such as shopping, washing, food preparation, and so on.
- Management of Cases
- Personal Emergency Response Systems
Remember that Medicaid will NOT pay the room and board portion of the charges. However, there are various methods to compensate for this, lowering the overall cost.
Given that the average monthly cost of Assisted Living is $4.300, any financial support and assistance are greatly appreciated.
With that in mind, you should be aware that most states will also provide Medicaid Waivers for Home and Community-Based Services. These Waivers can assist persons in receiving the assistance they require while remaining in the comfort of their own homes.
Furthermore, the income restrictions for the Waivers are often significantly higher, however, as is customary, each state sets its regulations and there are waiting lists included.
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Income Limits For Long
To be able to get Texas’s Medicaid program to pay for long-term care in 2019, a single person’s monthly income cannot be higher than $2,313. If both spouses of a married couple need nursing home care, the couple’s monthly income cannot be higher than $4,326. The applicable income and resource limits, discussed below, may change each year.
Texas does not allow individuals to qualify for Medicaid by “spending down” their income on qualifying medical expenses until they reach Medicaid income limits. Texas does, however, allow individuals to place some extra monthly income in a trust to allow a person qualify financially for Medicaid. These trusts are called “Medicaid Trusts” or “Miller Trusts” you can read more about them in Nolo’s article on Medicaid income trusts. If you meet the non-financial criteria for Medicaid but have been told that you are over-income for the program, you should consult an attorney to see whether a trust can help you qualify.
Memory Care Made Personal
The Monarch at Richardson embraces a unique, more innovative approach to life for those with dementia, Alzheimers, and other memory impairments. The Valeo signature programs empower each individual to build on their personal strengths and life experiences, enabling true moments of joy and purpose.
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The Aging & Disability Resource Center
This center was opened by the HHS as part of the national No Wrong Door initiative, and it is intended to streamline public access to resources and information concerning long-term services and supports. The Aging & Disability Resource Center helps to reduce confusion and facilitate access to care for long-term care recipients in all 254 counties of Texas.
Contact them by calling YES-ADRC, or 937-2372. Find out more online by visiting hhs.texas.gov.
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Take Time Texas And Caregiver Support
Taking care of another person can mean a lot of hard work and hard-earned money. Thats why Texas Health and Human Services provides respite for Texas caregivers. If you need a break from caring for someone, whether its to meet a friend or run an errand, you can find a respite provider to watch after your loved one.
Caregivers who dont take time for themselves are more likely to develop chronic health conditions due to stress and lack of rest. Its also more likely that a primary caregiver does not have a job of his or her own. If you or someone you love is a caregiver, he or she should apply for Medicaid or another state program that can help cover the costs of that care. To find out if you qualify, call 1-855-937-2372.
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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 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, its 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 applicants 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 and a list of beneficiaries Power of Attorney documentation.
Choosing a Texas Medicaid Nursing Home
