Paul Sanchez
Texas has some of the strictest Medicaid eligibility requirements in the US, and the state has repeatedly refused to expand its Medicaid program under the Affordable Care Act (ACA). As a result, Texas has missed out on billions in federal funding that would have provided medical care for low-income residents. Despite this, Texas residents who meet the state's eligibility criteria can apply for Medicaid through the Health Insurance Marketplace or directly through the Texas Medicaid agency. If approved, Medicaid may cover the costs of certain medical services and prescriptions, as well as long-term care and nursing home care.
| Characteristics | Values |
|---|---|
| Who is eligible for Medicaid in Texas? | Low-income people, families and children, pregnant women, the elderly, and people with disabilities |
| How to apply for Medicaid in Texas | Apply through HealthCare.gov, either online or by phone at 1-800-318-2596 |
| Apply through the Texas Medicaid website maintained by the Texas Health and Human Services Commission | |
| Download and print a paper application from the Texas Medicaid website or request one by mail | |
| Create an account with the Health Insurance Marketplace and fill out an application | |
| Your state Medicaid agency may ask for information about any existing insurance plans | |
| Your state may review your information each year to decide if you are eligible for Medicaid | |
| How does Medicaid work with other insurance? | Medicaid may be used as secondary insurance for those with Medicare |
| If you have Medicare and qualify for full Medicaid coverage, your state will pay your Medicare Part B monthly premiums | |
| Your state might pay for your share of Medicare costs, like deductibles, coinsurance, and copayments | |
| Medicaid may pay for other drugs and services that Medicare doesn't cover | |
| If approved, Medicaid may pay the private health insurance costs for the entire family and not just for the family members who get Medicaid | |
| If you have a Marketplace health plan, you may be able to lower your costs with a premium tax credit |
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What You'll Learn
Texas Medicaid eligibility criteria
Income and Resources:
Medicaid is designed to help individuals and families with limited incomes and resources. The specific income limits vary by program and the number of people in a household. Texas uses gross income for eligibility determination, and deductions withheld from income may be included. Additionally, some states, including Texas, have a "spend-down" option. This allows individuals with income above the Medicaid limit to qualify by paying non-covered medical expenses until their income is lowered to the qualifying level.
Age:
Texas Medicaid offers coverage for various age groups, including children, young adults, adults, and the elderly. For children, the Children's Health Insurance Program (CHIP) provides coverage for those up to age 19. Texas also offers Medicaid coverage for youth transitioning out of foster care up to age 21. For adults, Medicaid coverage is available for those with disabilities or aged 65 and older through the STAR+PLUS program.
Residency:
To be eligible for Texas Medicaid, individuals must be residents of the state. This requirement applies to all applicants, regardless of age or income level.
Institutionalization:
Texas Medicaid provides coverage for individuals residing in specific types of institutions. This includes nursing homes, state-supported living centers, and community-based Intermediate Care Facilities for Individuals with Intellectual Disabilities or Related Conditions (ICF/IID). To receive Medicaid assistance for institutional care, individuals must stay in a facility with a Medicaid contract for 30 consecutive days.
Medicare and Other Insurance:
Medicaid can serve as secondary insurance for individuals who have Medicare or other types of insurance but still need assistance with out-of-pocket costs. In some cases, Medicaid may help pay for Medicare premiums, deductibles, and coinsurance. Additionally, the Health Insurance Premium Payment program (HIPP) helps families pay for private health insurance if the cost of that insurance is less than the cost of care with Medicaid.
To determine specific eligibility for Texas Medicaid, individuals can use the search tools provided by Texas Health and Human Services to find doctors, drug stores, and programs that accept Medicaid. They can also contact the Texas State Medical Assistance (Medicaid) office and create an account with the Health Insurance Marketplace to apply for coverage.
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Applying for Texas Medicaid
Texas Medicaid is a federal and state-funded program that helps cover medical costs for certain low-income people, families, and children, pregnant women, the elderly, and people with disabilities. The program also covers other adults. Texas Medicaid is also offered to children in DFPS conservatorship (under 18), children in the foster care program, and youth with voluntary extended foster care placement agreements.
To apply for Texas Medicaid, you must be a resident of Texas and meet the state's rules for income and resources. You can check your eligibility through the Your Texas Benefits' Medicaid Client Portal, which provides access to your available Medicaid health information. Here, legally authorized representatives can also view their children's available Medicaid health information.
Texas Health and Human Services (HHS) provides a broad range of services to qualifying Texans to ensure their direct health needs are met and to improve the overall health of all Texans. The Health Insurance Premium Payment Program (HIPP) is a Texas Medicaid program that helps families pay for private health insurance. If approved, Medicaid may pay for the entire family's private health insurance, not just for family members who receive Medicaid.
To apply for Texas Medicaid, you can contact your State Medical Assistance (Medicaid) office and ask about help for people with limited resources. You can also use the search tools provided by Texas Health and Human Services to find a doctor or drug store that accepts Medicaid or CHIP.
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Using the Health Insurance Marketplace
The Health Insurance Marketplace is a platform where individuals can purchase health insurance plans. It is important to note that Texas has not expanded Medicaid under the Affordable Care Act (ACA), resulting in a coverage gap in the state. However, individuals can still explore the following options through the Marketplace:
Premium Subsidies and Cost-Sharing Reductions
The ACA offers premium subsidies and cost-sharing reductions that can make health insurance more affordable. These subsidies are determined by income level and are generally available to those who do not have access to affordable employer-provided health coverage. Texas requires higher premiums for Silver-level plans due to the loss of federal CSR funding, which has resulted in Gold plans often being priced lower than Silver plans. Individuals eligible for CSR should carefully consider Silver plans to avoid forfeiting their CSR benefit.
Medicaid and CHIP
Medicaid is a federal-state program that assists specific low-income individuals, families, children, pregnant women, the elderly, and people with disabilities. Texas offers the Health Insurance Premium Payment program (HIPP), which helps families pay for private health insurance if the cost is lower than Medicaid coverage. Additionally, children in the state's foster care program can receive dental services through the STAR Health program. Texas also has the STAR+PLUS program, providing Medicaid healthcare and long-term services for adults with disabilities or those aged 65 and older.
Alternative Health Plans
Alternative health plans can help save money but may offer limited coverage. These plans can be explored through the Marketplace to find options that suit an individual's needs.
Community Health Centers
For those without health insurance, Texas offers the option of contacting local community health centers. These centers provide low-cost, high-quality healthcare on a sliding fee scale, regardless of age, health, insurance, or immigration status.
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Medicaid as secondary insurance
In Texas, Medicaid is a managed care program that is provided in partnership with the Texas Department of Family and Protective Services (DFPS). The program offers benefits like nursing home care and personal care services, which are not typically covered by Medicare. Texas has strict eligibility requirements for Medicaid, and the state has refused to expand its Medicaid program under the ACA, which has resulted in billions in lost federal funding.
To get Texas Medicaid as secondary insurance, you must first meet the state's eligibility criteria. You can start the process by creating an account with the Health Insurance Marketplace and filling out an application. If it appears that you qualify for Medicaid, your information will be sent to the Texas Medicaid agency, and they will contact you about enrollment. You can also apply through the Texas Medicaid website, where you can download and print a paper application or request one by mail.
If you have Medicare and qualify for full Medicaid coverage, Texas will pay your Medicare Part B monthly premiums. Depending on the level of Medicaid coverage you qualify for, the state may also pay for other costs like deductibles, coinsurance, and copayments. If you have private insurance and qualify for Medicaid, the Health Insurance Premium Payment program (HIPP) may be able to help your family pay for it.
To access your Texas Medicaid information, you can use the Medicaid Client Portal. This allows you to view your available health information, and authorized representatives can access their children's Medicaid information. You can also use the search tools on the Texas Health and Human Services website to find Medicaid-accepting drug stores and doctors.
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Medicaid drug coverage
Texas offers Medicaid as a health insurance option for certain low-income people, families and children, pregnant women, the elderly, and people with disabilities. Medicaid is a joint federal and state program, and the rules around eligibility differ from state to state. In Texas, Medicaid offers benefits not normally covered by Medicare, like nursing home care and personal care services.
If you are unsure whether your medication is covered, you can contact your State Medical Assistance (Medicaid) office, or Aetna Better Health of Texas, and they will be able to check for you. You will need to have a list of your prescription and over-the-counter medications ready.
Medicaid may also pay for other drugs and services that Medicare does not cover. If you have both Medicare and full Medicaid coverage, you are considered "dually eligible". Your state will pay your Medicare Part B (Medical Insurance) monthly premiums, and may also pay for your share of Medicare costs, like deductibles, coinsurance, and copayments.
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Frequently asked questions
You can apply for Texas Medicaid through HealthCare.gov, either online or by phone at 1-800-318-2596. You can also apply through the Texas Medicaid website, where you can download and print a paper application or request to have one mailed to you.
The eligibility requirements for Texas Medicaid vary based on age, income, and resources. Generally, you must be a Texas resident with limited resources and meet the state's income rules.
Yes, you can have Medicaid as secondary insurance if you meet the eligibility requirements. If you have Medicare and qualify for full Medicaid coverage, your state will pay your Medicare Part B monthly premiums and may cover other costs.
Texas Medicaid covers a range of medical costs, including nursing home care, personal care services, prescription drugs, and dental services for children in the state's foster care program. It also covers vitamin and mineral products with a written doctor's order.
You can use the search tools on the Texas Health and Human Services website to find doctors and drug stores that accept Texas Medicaid. These tools allow you to search based on various criteria, such as language, weekend availability, and age specialization.
