Texas Medicaid: Eligibility, Benefits, and How to Apply

Texas Medicaid is a crucial state and federal program that gives free or low-cost health coverage to millions of eligible Texans. It acts as a safety net, ensuring that children, pregnant women, adults with disabilities, and seniors can access the medical care they need. The program is designed to help you and your family stay healthy by covering services from routine doctor visits to hospital stays and prescription drugs.

How Managed Care Works

Most people in Texas receive their Medicaid benefits through a managed care system. Once you are approved, you will enroll in a health plan, similar to an HMO or PPO, that will coordinate all of your healthcare services. This approach helps ensure you receive quality, consistent care from a network of doctors and specialists.

Understanding the Different Programs

To meet the diverse needs of Texans, the program is divided into several key components. Understanding which one applies to you is the first step toward getting the right coverage.

• STAR: The most common program, serving children, newborns, pregnant women, and some low-income families.
• STAR+PLUS: A program for adults aged 65 or older and adults with disabilities, which includes long-term care services to help them live independently.
• STAR Kids: A specialized program designed for the unique needs of children and young adults up to age 20 who have disabilities.
• Children's Health Insurance Program (CHIP): A low-cost health plan for children in families who earn too much for traditional Medicaid but cannot afford private insurance.

Navigating the application process can feel complex. The following sections break down the requirements into simple, clear steps, giving you the information you need on eligibility, covered services, and how to apply.

Who Qualifies for Texas Medicaid? A Detailed Eligibility Breakdown

Qualifying for Texas Medicaid is not based on a single rule but on specific requirements for your age, income, family size, and health status. This complexity is a common source of confusion for applicants.

The income limits for a parent are significantly stricter than those for their child or for a pregnant woman. This is because Texas has not expanded Medicaid coverage under the Affordable Care Act (ACA), which would have created more uniform income rules for most low-income adults.

The Texas "Coverage Gap"

This policy decision has created a "coverage gap" where many low-income adults are ineligible for assistance, no matter how low their income is, unless they are pregnant, disabled, or caring for a dependent child.

The state operates a patchwork system with different standards for different groups. More generous rules apply to children and pregnant women, while much stricter rules apply to parents. This can result in a parent qualifying for coverage only during pregnancy and for a year after, while their child remains covered.

A. Foundational Requirements for All Applicants

Before looking at specific programs, every applicant must meet two basic criteria:

• Texas Residency: You must live in Texas. Proof can include a utility bill, lease agreement, or a valid Texas ID.
• Citizenship or Immigration Status: You must be a U.S. citizen or a qualified non-citizen (such as a legal permanent resident, refugee, or asylee). You will need to provide documents like a U.S. birth certificate, passport, or immigration papers. You do not need to prove your own status for an eligible child to receive coverage.

B. Coverage for Children and Teenagers (Children's Medicaid & CHIP)

Texas provides health coverage for children through two main programs. The state automatically determines which program your child qualifies for based on family income.

Children's Medicaid

This program offers free, comprehensive health coverage for children and teens 18 and younger in low-income families. There are no monthly premiums or co-pays.

• Monthly Income Limits (Children's Medicaid):
  • Family of 2: up to $2,345
  • Family of 3: up to $2,954
  • Family of 4: up to $3,564
  • Add $610 for each additional person.

Children's Health Insurance Program (CHIP)

CHIP is a low-cost health plan for children whose families earn too much for Medicaid but can't afford private insurance. Families may pay a small annual enrollment fee ($50 or less per family) and low co-pays for doctor visits and prescriptions.

• Monthly Income Limits (CHIP):
  • Family of 2: up to $3,543
  • Family of 3: up to $4,464
  • Family of 4: up to $5,386
  • Add $922 for each additional person.

C. Coverage for Pregnant Women

Texas offers strong health coverage options to ensure pregnant women receive vital care for their health and their baby's.

Medicaid for Pregnant Women

This program provides free, full Medicaid benefits during pregnancy and for 12 months after the baby is born.

• Monthly Income Limits (Medicaid for Pregnant Women):
  • Family of 1 (yourself): up to $2,583
  • Family of 2: up to $3,490
  • Family of 3: up to $4,398
  • Add $908 for each additional person.

CHIP Perinatal

This program is for pregnant women who don't qualify for Medicaid due to income or immigration status and lack other insurance. It covers prenatal care, labor and delivery, and two postpartum checkups. The newborn is typically enrolled in Medicaid or CHIP after birth.

D. Coverage for Parents and Caretaker Relatives

This is the most restrictive category, with some of the lowest income limits in the nation due to Texas not expanding Medicaid. To qualify, you must be the parent or caretaker relative of a child 17 or younger who lives with you and receives Texas Medicaid.

The monthly income limits are exceptionally low:

• One-Parent Household: up to $196 (family of 2) or $230 (family of 3).
• Two-Parent Household: up to $161 (family of 2) or $251 (family of 3).
• For each additional person, add $52.

E. Coverage for Adults Age 65+ and People with Disabilities (MEPD)

Medicaid for the Elderly and People with Disabilities (MEPD) is for individuals who meet specific age or disability criteria, along with financial limits on both income and assets.

Who is Eligible?

You must meet one of these criteria:

• Be age 65 or older.
• Be blind.
• Have a disability as defined by the Social Security Administration (SSA).

Financial Requirements

MEPD considers both your income and your "countable assets."

• Income Limit: The monthly income limit for an individual is approximately $2,901.
• Asset Limit: An individual cannot have more than $2,000 in countable assets, like cash or bank accounts.
• Exempt Assets: Many important assets do not count toward this limit, including your primary home, one vehicle, personal belongings, and burial plots.

If you are applying for a program with long-term care, like STAR+PLUS, you must also have a medical need for that level of care.

What Services and Benefits Are Covered by Texas Medicaid?

Your benefits are delivered through the managed care health plan you choose. While all plans must cover a core set of essential services, they also compete by offering "value-added services"—extra benefits at no cost to you. Comparing these extra benefits is an important step in selecting the right plan for your family.

A. Essential Health and Medical Services

All Texas Medicaid plans provide comprehensive coverage for medically necessary services with little to no cost. Core benefits include:

• Doctor Visits: Regular checkups with a primary care provider (PCP) and visits to specialists.
• Hospital Care: Coverage for both inpatient hospital stays and outpatient procedures.
• Emergency Services: Care received in a hospital emergency room.
• Diagnostic Services: Lab work, X-rays, and other imaging tests.
• Maternity and Newborn Care: Full coverage for prenatal appointments, labor and delivery, and postpartum checkups.
• Mental and Behavioral Health: Access to mental health care and substance use disorder treatment.
• Preventive Care: Immunizations and routine screenings to keep your family healthy.
• Texas Health Steps: A program for members up to age 20 that provides regular medical and dental checkups to detect and treat health problems early.

B. Prescription Drug Coverage

Your Medicaid plan covers a wide range of prescription medications.

How It Works

Your doctor can prescribe any medically necessary drug, which you can fill at a pharmacy in your health plan's network.

Formulary and Preferred Drugs

Texas Medicaid uses a statewide list of covered drugs, known as the formulary. Some drugs are "preferred" and are easily filled. Others are "non-preferred" and may require special approval from your doctor, called a prior authorization. Sometimes, you may need to try a preferred drug first before a non-preferred one is approved ("step therapy").

Emergency Prescriptions

If you urgently need a medication that requires prior authorization, your pharmacist may be able to provide a 72-hour emergency supply.

C. Dental Care Benefits

Dental coverage under Texas Medicaid varies significantly based on age.

For Children (up to age 20)

Children receive comprehensive dental benefits through a separate managed dental plan. These plans cover a full range of services at no cost, including:

• Exams and cleanings every six months.
• X-rays.
• Fluoride treatments and sealants.
• Fillings, crowns, root canals, and extractions.

For Adults

Standard Medicaid for adults generally only covers emergency dental services, such as treating an injury or severe infection. Routine care like cleanings and fillings is typically not covered. Some STAR+PLUS plans may offer limited routine dental care as a value-added service.

D. Vision Care Benefits

Most Texas Medicaid plans provide vision benefits to help with eye care and corrective eyewear.

Covered Services

Benefits typically include routine eye exams and an allowance for eyeglasses or contact lenses. The specifics, such as how often you can get an exam or the dollar amount for glasses, vary by age and the health plan you choose.

The Main Texas Medicaid Programs Explained

Texas Medicaid is divided into distinct managed care programs, each tailored to a specific group. The main difference between the STAR program and the others is the inclusion of Long-Term Services and Supports (LTSS), which help people with significant health needs live in the community.

A. STAR Program: Core Coverage for Families and Children

• Who It's For: STAR is the most common Medicaid program, serving the majority of recipients, including low-income children, newborns, pregnant women, and eligible parents.
• What It Provides: The STAR program delivers essential medical services like doctor visits, hospital care, and prescription drugs through a health plan you choose in your area.

B. STAR+PLUS Program: Health and Long-Term Support for Adults

• Who It's For: STAR+PLUS is for adults age 65 or older and adults 21 and over who have a disability.
• What It Provides: STAR+PLUS combines standard medical care with Long-Term Services and Supports (LTSS). The goal of LTSS is to help members live safely and independently in their homes or communities instead of a nursing facility.
• Key LTSS Benefits Include:
  • Personal Assistance Services (PAS): Help with daily activities like bathing, dressing, and meal preparation.
  • Respite Care: Temporary relief for a family caregiver.
  • Minor Home Modifications: Safety improvements like wheelchair ramps or grab bars.
  • Adaptive Aids: Walkers, hospital beds, and other medical equipment.
  • Assisted Living or Adult Foster Care: Coverage in an approved residential facility if living at home is not possible.
• Your Service Coordinator: Every STAR+PLUS member has a service coordinator from their health plan. This person is your dedicated guide who assesses your needs, develops a service plan, and helps arrange all your care.

C. STAR Kids Program: Specialized Care for Children with Disabilities

• Who It's For: STAR Kids is a specialized program for children and young adults aged 20 and younger who have disabilities.
• What It Provides: Like STAR+PLUS, STAR Kids combines medical benefits with LTSS to provide well-coordinated care for children with complex health needs.
• Key Services Include:
  • Private Duty Nursing (PDN): Skilled nursing care at home.
  • Therapies: Physical, occupational, and speech therapies.
  • Personal Care Services (PCS): Assistance with daily activities.
  • Respite Care: In-home support to give family caregivers a break.
• Assessment and Service Planning: A service coordinator conducts a comprehensive assessment to understand your child's needs and create an Individual Service Plan (ISP) that outlines all the services they will receive.

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

The application process requires a lot of information, but breaking it into steps makes it manageable. Be aware that due to a high volume of applications and the "unwinding" of pandemic-era policies, processing times can be long. Patience and follow-through are essential.

Step 1: Gather Your Information and Documents

Having your documents ready will save time and help prevent delays. You will need the following for everyone in your household who is applying:

• Proof of Identity: Driver's license, Texas ID, or U.S. birth certificate.
• Social Security Numbers: For every person applying.
• Proof of Citizenship or Immigration Status: U.S. passport, birth certificate, or permanent resident card.
• Proof of Texas Residency: A recent utility bill, lease agreement, or rent receipt.
• Proof of Income: Pay stubs from the last 30-60 days or a letter from an employer.
• Proof of Resources (for MEPD applicants): Recent bank statements for all accounts.
• Proof of Expenses: Information about your rent, mortgage, or child care costs may be needed.

Step 2: Choose Your Application Method

Texas offers several ways to apply.

• Online (Recommended): The fastest way is through the official portal: https://www.yourtexasbenefits.com/. Creating an account lets you save your application, upload documents, and check your status.
• By Phone: Call 2-1-1 and select the option for state benefits to apply over the phone.
• By Mail or Fax: Download Form H1010 from the Your Texas Benefits website. You can mail the completed form or fax it to 1-877-447-2839.
• In Person: Visit a local Texas Health and Human Services (HHSC) benefits office or a certified community partner for help. Call 2-1-1 to find a location near you.

Step 3: After You Apply – What to Expect

Once your application is submitted, the review process begins.

• The Interview: HHSC may need to call you for an interview to verify your information. The call will come from (737) 867-7700. Be sure to answer.
• Processing Time: HHSC has up to 45 days to process most applications (15 days for pregnant women), but wait times are often longer due to high volume.
• Checking Your Status: You can check your application's progress by logging into your account at YourTexasBenefits.com or by calling 2-1-1.
• Approval and Next Steps: If approved, you will get an official approval letter. Soon after, you will receive a large enrollment packet in the mail. This packet is very important, as it contains the information you need to choose your health plan.

You're Approved for Medicaid: Choosing Your Health Plan and Doctor

After you are approved, you must choose a health plan to manage your care. This decision affects which doctors you can see and what extra benefits you receive. If you don't choose one, the state will assign one to you.

A. Understanding the Enrollment Packet

• Look for a Yellow Envelope: Your enrollment packet will arrive in a large, yellow envelope marked "Action Required". It contains a comparison of the health plans available in your area.
• Meet Your Deadline: The packet will have a deadline for choosing a plan. Make your choice before this date to avoid being automatically assigned one.

B. How to Compare Health Plans

Review your options carefully to find the best fit for your family.

• Check the Provider Network: The most important factor is often keeping your current doctors. Use the "Find a Doctor" tool on each plan's website to see if your doctors, specialists, and preferred hospitals are in their network. You can find links to the plans on the official HHSC website.
• Compare Value-Added Services (VAS): These are the extra benefits plans offer. Look for ones that are most helpful to you, such as:
  • An allowance for eyeglasses.
  • Expanded dental coverage for adults.
  • Gift card rewards for completing healthy activities.
  • A 24/7 nurse advice line.
  • Help with gym memberships or youth sports fees.
• Review Health Plan Report Cards: The state publishes report cards that rate each plan's performance on customer service and quality of care.

C. Making Your Choice Official

Once you decide, you must formally enroll.

• Call the Enrollment Broker: You must call the Texas Enrollment Broker to make your choice. The phone number will be in your packet. For STAR and CHIP, the number is usually 1-800-964-2777.
• Select a Primary Care Provider (PCP): When you call, be ready to select a main doctor (PCP) for each family member. Your PCP will be your home base for medical care.
• Receive Your ID Card: Your new health plan will mail you a welcome packet and a member ID card. You must show this card at every doctor, hospital, or pharmacy visit.

Frequently Asked Questions