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Understanding Medicare Special Needs Plans

Texas Medicaid operates with the goal to provide health care to Texans who would otherwise not be able to afford it. If you qualify for TX Medicaid, you should take advantage of the services available to you!

• What does Medicaid cover in Texas?
• Texas Medicaid Providers
• Texas Medicaid Eligibility Income Chart 2018
• Medically Needy Medicaid Texas
• TX Medicaid Resources
• Take Time Texas and Caregiver Support
• The Texas Medicaid Application
• Dual Eligible Medicare and Medicaid plans 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

The Texas Medicaid prescription drug coverage formulary (list of covered drugs) is released every January and again in July.

Click here for the Texas Medicaid Prescription Drug List from July 2018.

The Texas Medicaid Wellness Program is exclusively for those who have Medicaid and suffer from long-lasting and serious health conditions. In most cases, if you are eligible for the Texas Medicaid Wellness Program, you will receive a letter and phone call notifying you of your eligibility. Some people within the Texas Medicaid Wellness Program can join Weight Watchers for free. Everyone in the program has access to special nurses who can help with care management, learning about health conditions and medications, and selecting the best medical care. These nurses are available at any time (toll-free) at 1-800-777-1178 (TTY 1-800-735-2989).  

Texas Medicaid Dental Coverage for Adults is provided by Dentaquest. It includes cleanings, fillings, crowns, and root canals and is available statewide. Adults and children can also get Texas Medicaid dental coverage through MCNA Dental. MCNA covers cleanings, exams, X-rays, fluoride, sealants, fillings, extractions, root canals, and dental emergencies.

Texas Medicaid Mental Health services include:

• Primary care physician mental health treatment
• Psychiatric diagnostics
• Psychotherapy
• Psychological and neuropsychological testing
• Inpatient psychiatric care in general acute hospitals
• Inpatient psychiatric care in psychiatric hospitals for those under 21 or over 65
• Psychotripic medications
• Rehabilitative case management

Medicaid in Texas provides free transportation to and from medical appointments for most Medicaid beneficiaries who have no other means of transportation. Children using this service must have an adult with them.

Medicaid beneficiaries in the Houston/Beaumont Service Area should call Medical Transportation Management at 1-855-687-4786 to arrange a ride. Medicaid beneficiaries in the Dallas/Fort Worth Service Area should call LogistiCare at 1-855-678-3255.

Houston/Beaumont includes the following counties: Austin, Brazoria, Chambers, Fort Bend, Galveston, Hardin, Harris, Jasper, Jefferson, Liberty, Matagorda, Montgomery, Newton, Orange, Polk, San Jacinto, Tyler, Walker, Waller, Wharton.

Dallas/Fort Worth includes the following counties: Dallas, Denton, Ellis, Erath, Hood, Hunt, Johnson, Kaufman, Navarro, Palo Pinto, Parker, Rockwall, Somervell, Tarrant.

One free and easy way to find Texas Medicaid Providers in your area is to call 2-1-1. Choose your language, then select option 1 to learn about food pantries, housing, child care, senior services, and more.

If you are in the STAR managed care system, your individual plan will have a network of doctors, pharmacists, and other providers that you can go to. You should use your health plan provider list or website for this information. If you are not in managed care, you can use this website to search for Texas Medicaid providers in your area that accept your plan.

The only way to truly determine your Texas Medicaid eligibility is to apply. There are four main eligibility groups: pregnant women, people recieving SSI (Supplemental Security Income), those receiving adoptive assistance, and households with kids under the age of 19. If you fit into one of those categories, you may qualify based on your household income. On the most basic level, your income (2019) should be below the following: 

STAR Medicaid is the managed Care Texas Medicaid program. If you have STAR, you will pick a medical plan from an approved list (which you will receive in the mail after you apply) and a primary doctor. Each plan has a group of specialists and hospitals that you can go to. STAR is available statewide. With STAR, there is no limit on hospital days or prescriptions. Health education classes are also provided.

You can enroll in STAR if you have Medicaid and are pregnant, you and your child(ren) have low income, or if you get cash assistance. If you have a newborn baby at home, you should enroll your baby in STAR.

STAR + Plus is the TX Medicaid program for those who are over 65 or disabled, meaning that those within the STAR+PLUS program will likely have both Medicare and Medicaid. Aside from other Medicaid benefits, STAR+PLUS adds home health coverage as well as assistance in making changes to your home so that things are more accessible to you. It can also provide short-term care when your caregiver can’t be there and can help you complete household tasks.

Those who have both Medicare and Texas STAR+PLUS will get most care covered through Medicare. Only long-term services and support will fall under STAR+PLUS.

To be eligible for STAR+PLUS, you can be:

• Age 21+ and eligible for Medicaid
• Age 21+ and getting Medicaid through a Social Security Exclusion program
• Age 21+ and living in a nursing home
• In the Medicaid Breast and Cervical Cancer program

You cannot get STAR+PLUS if you:

• Age 21+, get Medicaid 915 waiver services or live in a home for intellectual disabilities, and get Medicare.
• Are not eligible for full Medicaid
• Are a child in Texas foster care
• Are younger than 20 and not in the Medicaid Breast and Cervical Cancer Program.

The STAR Health slogan is, “Embracing Every Child.” STAR Health is available statewide for children in Texas foster care. STAR Health members have access to primary care doctors, behavioral health providers, dentists, eye doctors, and other specialists. The program also provides training to caregivers, caseworkers, and families of foster children as well as care coordination services to help you find transportation, schedule appointments, and understand the STAR Health benefits.

You can meet Texas Medicaid eligibility requirements if you are on social security. There are two types of Social Security disability benefits: Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). SSI beneficiaries are not automatically eligible for Medicare (unless they are over 65), but can receive Medicaid. Those qualified for SSDI will automatically be enrolled in Medicare after 24 months.

If you don’t 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.

Medicaid is not the only state financial assistance program offered in Texas. If you qualify for Medicaid but need more financial assistance, you may qualify for one of these programs:

The TANF Benefits Program supplies monthly cash payments that can be used for food, clothing, housing, utilities, transportation, home supplies, etc. - basically any necessity. Families with children under the age of 18 who have little to no income are eligible to apply. Those receiving TANF benefits may be asked to:

• Look for work
• Avoid drugs and/or alcohol
• Adhere to certain child support rules
• Take parenting classes
• Get vaccines for their kid(s)
• Keep their kid(s) in school

You may qualify for TANF if you and your family earn less than the following:

You can receive up to this much in support:

The WIC Program in Texas provides support to pregnant women and their newborn babies up until the child’s fifth birthday. The program includes special breastfeeding assistance and nutritional classes (available online). To be eligible, you must be considered “at risk” by a healthcare professional.

The WIC Program is similar to the SNAP program, which is the food stamp program for those in need. If you are eligible for SNAP, you can get your SNAP benefits installed right on your Lone Star Card, which you can then use like a credit card at stores that accept SNAP. SNAP is only for Texans with low income. It cannot be used to purchase tobacco, alcohol, or anything that you can’t eat or drink. Most people can only receive SNAP benefits for three months every three years. If you work for at least 20 hours a week or are in job training, or if you are unable to work for any reason, you may be able to receive an extension.

These are the amounts of SNAP you can qualify for:

Taking care of another person can mean a lot of hard work - and hard-earned money. That’s why Texas Health and Human Services provides respite for Texas caregivers. If you need a break from caring for someone, whether it’s to meet a friend or run an errand, you can find a respite provider to watch after your loved one.

Caregivers who don’t take time for themselves are more likely to develop chronic health conditions due to stress and lack of rest. It’s 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.

To apply for Texas Medicaid, go to yourtexasbenefits.com and click “apply for new benefits.” You’ll be asked to create an account to proceed. From there, you can apply for TX Medicaid, SNAP, TANF cash Help, WIC Food Benefits, and other support. You can also download the Texas Medicaid application online and send it to the HHSC (Health and Human Services or visit your local HHSC office.

If you need help completing your TX Medicaid application, visit your local HHSC office and ask for assistance. You can also complete your TX Medicaid application verbally by calling 877-541-7905, Monday through Friday from 8 AM to 6 PM.

Did you know that you can be eligible for both Medicare and Medicaid? If you meet the income limits for TX Medicaid eligibility but are also over the age of 65 (or are diagnosed with a qualifying disease), you can be eligible for both Medicaid and Texas Medicare.

At Medicare Plan Finder, we have Medicare benefits advisors all throughout the state of Texas that can help you figure out what benefits you are eligible for and what health plans work best for you. Medicare is confusing, but we can help! Click here or give us a call at 833-438-3676.