We would like to thank Vanessa Lazar, Certified Medicaid Planner and owner of Texas Medicaid Experts, for contributing her knowledge of the Medicaid program in Texas for today’s article.
Medicaid and Medicare are two terms that sound similar and are easily confused. During a time when health insurance costs are rising and people are becoming more responsible for a greater portion of their healthcare costs, knowledge really is power.
If you’ve had questions about meeting the eligibility requirements for Medicaid and understanding how Medicaid and Medicare programs can work in tandem, you’ve come to the right place.
What is the Difference Between Medicare and Medicaid?
There are a few key things to understand about these government healthcare programs.
Medicare is a federal government program based on age for eligibility. Medicare helps seniors get healthcare coverage and consists of four main different parts: A & B are known as Original Medicare while Medicare Part C is known as Medicare Advantage. Medicare Part D is prescription drug coverage. Sounding familiar, right?
Medicaid is a joint federal and state program that is based on a combination of income and asset requirements. This program provides health insurance to millions of Americans, including children, pregnant women, parents, seniors, and people with disabilities. Because it is sponsored by each state, the requirements vary greatly and may not even have the same name.
Unlike Medicare, you must recertify for Medicaid each year. Medicaid typically covers pregnant women and children, elderly adults, and/or people with disabilities, as well as eligible low-income adults.
Can You have Medicare and Medicaid at the Same Time?
YES! It is possible to qualify for Medicare because of age (being 65 or older) and meeting the requirements within your state for Medicaid. If you’ve heard the term “dual eligible” that refers to qualifying for both government programs.
If you do meet the eligibility requirements for both programs, Medicare will pay first and Medicaid pays last.
Medicaid Programs for Seniors
Who should apply for a senior Medicaid program? Any senior (age 65 or older) or disabled Texan who requires assistance in paying for long-term care in a nursing home setting or at home through the STAR+PLUS waiver should consider applying for Medicaid.
The cost of paying for a nursing facility bed averages between $200 and $230 per day. Home health care costs $19 to $25 per hour. Medicare does not cover long-term care in a nursing home, at home, or at work on an ongoing basis.
Within Texas, there are typically two Medicaid programs senior clients can qualify for: institutional/nursing home facility Medicaid and/or the Star Plus waiver programs.
Nursing Home Medicaid Benefits Program
The Nursing Home Medicaid benefits are managed by Health and Human Services and must be applied for when the applicant is admitted to the nursing home. An applicant can apply for benefits at no cost using the yourtexasbenefits.com website. To receive benefits, applicants must be disabled or 65 or older, live in Texas, require nursing home care, and meet the eligibility requirements.
The income requirement is $2,742, and the asset requirement is $2,000. An asset is a bank account, stocks, bonds, CDs, a Roth, an IRA, or life insurance with more than $1,500 in cash value, a land, or property other than the applicant’s homestead. Anything that can be converted to cash within 20 days is considered an asset.
Once the benefits are approved, the applicant will be assigned a Medicaid ID number, which the nursing facility will use to bill Medicaid and doctors and hospitals will use to bill for provided care. Medicaid is the final payer, meaning if the applicant has Medicare, that will be billed first, then the secondary insurance, and Medicaid will be billed last.
The applicant will cover their monthly copayment, which is their income minus the personal needs allowance. Medicaid will pick up the remaining cost each month when the applicant meets the income and eligibility requirements. The clients are certified for a year and then will need to renew their benefits.
The nursing home Medicaid benefits cover nursing and related services, specialized rehab services as needed by the resident, social services, pharmaceutical services, assistance with generic prescriptions, emergency dental services, routine services covered by the state program, dietary services, and activities for each resident's well-being.
STAR+PLUS Program
STAR+PLUS is a Medicaid managed care program for adults with disabilities and those aged 65 and up and is managed by the Department of Aging. The waiting list for the star-plus waiver is currently a year to a year and a half long.
To add a loved one to the list, an applicant or their family must contact the Department of Aging at 1.855.937.2372. When the individual's name is called, they may apply for Medicaid benefits. STAR+PLUS | Texas Health and Human Services
The STAR+PLUS waiver Medicaid benefits cover medical and non-medical long-term care services delivered in the comfort of your own home. Personal care, adult day care, light home modification, and emergency response systems are all available.
You can also select your own caregiver under this program for non-medical long-term care services. This program also helps with service coordination and transportation to and from doctor's appointments.
Eligibility Requirements for Senior Medicaid Programs
Each Texas Medicaid programs have income and asset eligibility requirements. For both the nursing home Medicaid benefit and the Star Plus program, the income limit is $2,742 a month and the asset limit is $2,000 for a single applicant and $3,000 for a married couple.
Some assets, including your home, are not counted toward the asset limit if the applicant lived there prior to admission to the nursing home and the equity value is less than $688,000 as of 2023.
Don’t Go At It Alone!
Just as it is important to discuss your Medicare plan options with an expert, it is important to talk to a Certified Medicaid Planner if you need long-term care. The average monthly cost of nursing home care in Texas is well over $5,000.
Understanding the eligibility requirements for Medicaid programs can be difficult if you don’t have an expert to help guide you and find out if you qualify both financially and medically for Medicaid.
Hiring a Certified Medicaid Planner in Texas
Vanessa Lazar is a Certified Medicaid Planner and the owner of Texas Medicaid Experts. She does not offer assistance with regular Medicaid benefits, solely the senior programs.
Vanessa is passionate about helping seniors qualify for nursing facility Medicaid benefits by managing their application process, which takes between 45 and 60 days.
When clients exceed the eligibility limits, Vanessa and her team provide personalized Medicaid planning services in conjunction with local elder law attorneys.
The first step is scheduling an eligibility consultation to determine eligibility and discuss the application process. To learn more, visit www.texasmedicaidexperts.com.