In Texas, long-term care is expensive, whether in a nursing home, assisted living facility, or home health care. Medicare coverage for long-term care is very limited, private health insurance policies generally do not cover long-term care, and few people have purchased private long-term care insurance policies. For Texans needing long-term care, Medicaid is the most common source of funding.
Medicaid is funded by both federal and state funds, and it provides health insurance to about 14% of Texans. There are many different ways to become eligible for Medicaid in Texas, and Texas has specific eligibility rules for long-term care services like nursing homes, assisted living facilities, and home health care services.
Nursing home costs averaged approximately $4,000 per month in Texas in 2010, so most people cannot afford to pay their own nursing home expenses. Nursing homes are residential facilities that offer 24-hour skilled nursing care in addition to other supportive services.
If you already qualify for Texas Medicaid, then your Medicaid coverage includes nursing home care if you need it.Groups of people who can automatically, qualify for Medicaid include SSI recipients, participants in the TANF (Texas’ Temporary Assistance to Needy Families) program, and children in its foster care system. In addition, people who are sixty-five (65) or older, disabled, or blind can qualify for Medicaid if they also meet income and resource limits.
To be able to get Texas's Medicaid program to pay for long-term care in 2014, a single person’s monthly income cannot be higher than $2,163. If both spouses of a married couple need nursing home care, the couple’s monthly income cannot be higher than $4,326. The income and asset limits change every 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 that would let 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.
To qualify for Medicaid, you must have few resources. Resources are assets, like money in the bank, retirement accounts, land, and personal property like cars.
The resource limit for a single person to qualify for Medicaid is $2,000, and for a married couple who both want to qualify for Medicaid, it is $3,000.
Some property does not count toward the resource limit. In Texas, the home you live in (or intend to return to, if you are in a nursing home) is excluded from the resource calculation as long as it is worth less than $543,000. There are other excluded resources, including one car.
Most Medicaid recipients in Texas get services through a managed care system. The most common system is called the State of Texas Access Reform (STAR) Managed Care. In managed care, Medicaid recipients pick a medical plan from a list of plans available in their area and choose a primary physician who works under that plan. The plans are operated by private companies that contract with Texas to provide Medicaid services.
STAR-PLUS is Texas’ Medicaid managed care program for people with disabilities or people who are 65 and over. STAR PLUS has been limited to elderly and disabled individuals who do not need nursing home care, but STAR PLUS plans will be required to cover nursing home care by late 2014.
If you have a problem getting your managed care plan to pay for services that you need, make sure to appeal the written denial notice that you get. In addition, you can follow the separate complaint procedure for your plan. If you have a problem with your Medicaid managed care program, you can also file a complaint with Texas’ Health and Human Services Commission Ombudsman at 877-787-8999.
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 only need custodial care (someone to watch over you), for instance, because you fall often or because you have dementia and tend to wander, then Medicaid will find that a nursing home stay is not medically necessary because you do not need a nurse.
Assisted living facilities provide food, personal care services like help with bathing or dressing, and medication administration. Historically, Medicaid did not pay for assisted living facilities. However, Texas has two programs that offer Medicaid payment for assisted living facilities, if you meet specific criteria.
If you are otherwise eligible for Medicaid and if you can show that a nursing home is medically necessary for you (also called “meeting the nursing home level of care”), then you may qualify for Community Based Alternative (CBA) Medicaid or for STAR PLUS Medicaid Waiver services. Both programs pay for home and community based services, including assisted living facilities, for people who would otherwise have to be institutionalized in a nursing home. CBA and STAR PLUS have limited enrollment and are not available in all parts of the state. For more information, contact your local Texas Department of Aging and Disability Services office.
Texas has a particular kind of assisted living facility called a continuing care facility (CCF). CCFs provide custodial care through round-the-clock supervision, but not round-the-clock nursing care. CCFs are not covered by Medicaid.
Texas covers home health services under its Medicaid program. If your doctor prescribes home health services like nursing or therapy services in your plan of care for a particular medical condition, Medicaid will cover those. Medicaid reviews your need for home health care every 60 days. You do not need to meet the nursing home level of care to qualify for home health services. However, because these Medicaid-funded home health services are related to a doctor’s plan of care for a particular medical condition, they are generally offered on a short-term basis.
If you otherwise qualify for Medicaid, and if your doctor says that you have a medical condition that causes you to need assistance with one or more activities of daily living, then you may qualify for Primary Home Care (PHC), a Texas program providing long-term care services at home. Activities of daily living are bathing, getting dressed, doing routine hair and skin care, preparing meals and eating, getting exercise, using the toilet, walking, and getting in or out of a bed, chair, or wheelchair.
If you apply for PHC, the state will send an assessor to meet with you and ask you about your ability to do all of the activities of daily living. Based on your answers, the state will rank your need and approve you for certain types and amounts of PHC services. PHC services include things like assistance with bathing, dressing, cooking, shopping, and escorting to medical appointments. PHC does not have a waitlist and is available statewide. To apply for PHC, contact your local Texas Department of Aging and Disability Services office.