Revision 19-1; Effective March 1, 2019

 

Introduction

Assistance is available to help pay for medical care and supportive services for people who have limited income and assets. The following information explains some of the requirements used to determine if you are eligible for help and what must be done to get help.

If you are interested in getting Medicaid to pay for medical and supportive services, you will need to file an application. Depending on how much income you have, you will file the application with either the Social Security Administration for Supplemental Security Income (SSI) or with the Texas Health and Human Services Commission (HHSC). If the Social Security Administration determines you are eligible for SSI, you will also be eligible for Medicaid without having to file a separate application with HHSC.

At HHSC, Medicaid for the Elderly and People with Disabilities (MEPD) staff are responsible for the financial eligibility for Medicaid. This Medicaid assistance is available for those who do not have SSI and need care:

  • in a nursing facility;
  • in an intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID);
  • in an institution for mental diseases (IMD); or
  • through waiver programs in the community (these programs offer services and supports to help you live in the community).

There is also help to pay for Medicare premiums (Part A, Part B or both), deductibles and coinsurance costs through the Qualified Medicare Beneficiary (QMB) program, and for Medicare Part B premium costs through the Specified Low-Income Medicare Beneficiary (SLMB) or Qualifying Individuals-1 (QI-1) programs.

You or your representative must complete an application for Medicaid and furnish the proof needed to make an eligibility determination. HHSC will determine your eligibility for Medicaid based on an analysis of the information on the application, documents you send in and information that you orally explain.

If you meet all eligibility requirements, HHSC is required to completely review your circumstances at least once a year to make sure you are still eligible for help. By federal law, HHSC must also use your Social Security number to compare its records with other state and federal agencies, such as the Internal Revenue Service, Social Security Administration, Texas Workforce Commission, and any others to ensure that your benefits are correctly determined.

You have the responsibility to let HHSC know, within 10 days, of any changes in your circumstances. These changes include changes in your address and living arrangements, your income and assets, and your private health insurance premium amounts.

Non-Financial Eligibility

  • Age/Disability — You must be at least age 65 or older or, if under age 65, you must get Social Security, Railroad Retirement, or SSI disability benefits. If you are not getting a disability benefit, HHSC will complete a disability determination using your medical, education, and work history information.
  • Citizenship — You must be a U.S. citizen or a qualified legal alien. Qualified legal aliens include those who have been lawfully admitted for permanent residence, active-duty military or honorably discharged veterans (or the spouses and dependent children of veterans), certain refugees/asylees, and certain people for whom deportation has been deferred. Unless you already have Medicaid or Medicare, a U.S. public birth certificate showing birth in one of the 50 states, the District of Columbia, Puerto Rico (if born on or after Jan. 13, 1941), Guam (on or after April 10, 1899), the Virgin Islands of the U.S. (on or after Jan. 17, 1917), American Samoa, Swain’s Island or the Northern Mariana Islands (after Nov. 4, 1986) may be necessary to prove your citizenship. You may also need proof of earning 40 quarters of Social Security credit or proof of 10 years of verifiable work credit to prove your alien status.
  • Residence — You must be a resident of the U.S. and Texas.
  • Medicare Savings Programs — You must be entitled to Medicare Part A for QMB, SLMB and QI-1. You will need a Medicare card, award letter, or some other document from the Social Security Administration as proof of your Medicare Part A entitlement.
  • Medical Necessity/Level of Care for Nursing Facility, ICF/IID and Waiver Programs — Your need for medical care available in a Medicaid facility or a Medicaid waiver program will need to be determined.
  • 30 Consecutive Days in an Institution — This applies after admission to a nursing facility, ICF/IID or IMD (if age 65 or older). If you want help paying for care in a facility, you must stay in a facility that has a Medicaid contract for 30 consecutive days. If you must go to the hospital before the end of 30 days, but return directly to a Medicaid facility, the hospital stay counts toward the 30 days. If you meet all other eligibility criteria from the day you are first admitted to a facility, Medicaid can pay for care beginning the day of admission, once 30 days has passed.

Income

HHSC must consider your income from all sources. Gross income is usually used for the eligibility determination. Therefore, when comparing your income to the income limit for a program, HHSC includes deductions that are withheld from your income before you get it.

If you get your income less frequently than monthly, it may or may not be countable. An example of income that may not be countable is a small amount of interest that is paid quarterly.

If you live in someone else's home or get help with food, clothing and shelter costs, a dollar value of the help you get may be considered for an eligibility determination (except in waiver programs).

There are certain income exemptions and exclusions that may be allowed for specific types of income. An example of an exemption is a refund of federal income taxes relating to the earned income tax credit a person receives from the Internal Revenue Service (IRS).

If you have a spouse who is living in the same household, HHSC may count your spouse's income. If minor children are in the household, certain deductions from your spouse's income may be allowed. HHSC also considers the income of the parent(s) living with a minor child disability may also be considered. The income of spouses and parents is not considered for waiver programs

Proof of Income

HHSC requires proof of income and deductions from income, such as award letters; check stubs from pension checks; check stubs from mineral rights payments; amortization schedules; bank statements listing interest/dividend payments; rent receipts (tax, insurance, and repair expense receipts); and copies of checks.

It sometimes takes a long time to gather all the needed proof. Any of the above items that you send in with an application may help to speed up the eligibility decision. HHSC may need additional proof, depending on your individual circumstances as determined by the information on the application form, collateral contacts, and documents used to verify your eligibility.

If you are determined to be eligible, proof of your income may also be needed whenever there is a change in the amounts and at least once a year when your circumstances must be completely reviewed.

Resources

Resources are things that you own or are buying. The resources of both you and your spouse must be reported, regardless if the resources are community or separate property. The total value of resources that must be counted cannot exceed certain resource limits. Resource values are determined as of 12:01 a.m. on the first day of the month(s) that eligibility is determined. Some resources may not be counted.

For a waiver program, resources of a parent(s) are not considered; however, resources of a spouse are considered.

Examples of Excluded Resources — The following are examples of some resources that HHSC does not count when determining eligibility:

  • Homestead — If you, your spouse, or a dependent relative live in the home, the value is not counted. Absence from a homestead may result in loss of its homestead status and exclusion unless you declare an intent to return. If you declare an intent to return to a homestead in another state, you do not meet the Texas residency requirement. If the value of your home exceeds $585,000, it may disqualify you for payment of nursing facility or waiver services in the community.
  • Vehicle — HHSC excludes one vehicle, regardless of value. If your household has more than one person and the additional member of the household requires an additional vehicle for transportation to and from work, the additional vehicle is excluded for that member for work transportation. If your household has more than one person and there is an additional member of the household who requires disability accessible transportation, an additional vehicle is excluded if the vehicle is specially equipped for that additional member of the household. For all other vehicles, HHSC counts the current market value or, if you still owe on the vehicle, the current equity value as a resource.
  • Life Insurance — Life insurance policies that you own with a total face value of $1,500 or less per insured person are excluded. If the face value of all policies per person exceeds $1,500, the cash value is counted as a resource. Term insurance is excluded.
  • Burial Spaces —HHSC excludes all burial spaces, unless you have purchased them as an investment, in which case HHSC counts the equity value.
  • Burial Funds — HHSC may exclude up to $1,500 of the funds you separate from other resources. This exclusion is only for you and your spouse. The $1,500 amount is reduced by the face value of any excluded life insurance and any irrevocable arrangements for the individual's burial.

Examples of Countable Resources — The following are examples of resources you may own that HHSC counts when determining eligibility:

  • Checking accounts, savings accounts, certificates of deposit, money market accounts, individual retirements accounts (IRAs), stocks, bonds, land/lots/houses (other than homestead), and oil/gas/mineral rights.
  • Prepaid Burial Contracts — All or part of a prepaid burial contract may be excluded depending on the terms of the contract, how the contract is paid, and ownership of life insurance, and any other burial arrangements you own or another person owns that is for you.
  • Other resources may or may not be countable depending on ownership and the use of items. Examples are antiques, jewelry, livestock, promissory notes, loans, property agreements, annuities, and trusts.

Spousal Impoverishment

The term "spousal impoverishment" is used to identify a federal law that allows a spouse who remains in the community to keep more of the couple's resources and income, thereby not becoming impoverished.

A Spousal Protected Resource Allowance (SPRA) is determined for your spouse who remains in the community when you apply for Medicaid in a nursing facility, ICF/IID, IMD or for a waiver program. The SPRA is determined as of the month you are admitted to a facility or the month you select or choose to apply for waiver services.

The value of you and your spouse's total resources is combined and divided in half. The value of a homestead, one vehicle, personal goods, and certain burial funds for both you and your spouse is not included in the resource total. A minimum of $25,284, effective January 2019, may be protected for the community spouse. If half the combined resources exceeds the minimum amount, that is the amount protected for the community spouse, up to a maximum of $126,420, effective January 2019.

The amount of resources that is not included in the SPRA is your countable resource amount. Your countable resources cannot exceed the $2,000 resource limit to be eligible for medical assistance.

Example: If the value of you and your spouse’s resources is $50,000, the spousal protected resource amount will be $25,000 for your spouse at home. The remaining $25,000 is your countable resource amount and must be spent down to $2,000 before you are eligible for Medicaid.

At the first annual redetermination of your circumstances, the SPRA exclusion ends. All resources that remain in your name are considered in determining eligibility. Countable resources cannot exceed the $2,000 resource limit for you to stay eligible for medical assistance.

Proof of Resources

Proof of the ownership and value of resources is required. Examples of proof are bank statements, copies of notes, stocks, bonds, property deeds, loans, mortgages, insurance policies, prepaid burial contracts, annuities, letters from appraisers, and trust instruments.

It sometimes takes a long time to gather all the needed proof. Any of the above items that you send in with an application may help to speed up the eligibility decision. Additional proof may be needed to determine the resource amount for specific months, depending on your individual circumstances as determined by analysis of the application and verification documents. If you are determined to be eligible, proof of your resources may also be needed whenever there is a change in the ownership or values and at least once a year when your circumstances must be completely reviewed.

Transfer of Assets

Giving away things you own for no compensation or refusing to accept income or reducing income you could receive may result in a penalty of non-payment for nursing facility services, ICF/IID facility services, or ineligibility for waiver program services or state supported living center services.

For income and resources that you transfer, the look-back time may be up to 60 months before you apply for institutionalization or waiver services, depending on the type of resource.

Care Cost Responsibility

If you are eligible for Medicaid in a nursing facility, ICF/IID facility, IMD (if 65 or older) or for waiver program services, you may have to pay toward the cost of your care. This is referred to as your copayment. From your total income, there is a deduction for a standard personal needs allowance. The amount of this allowance is different for different programs. Certain medical expenses you may pay, such as general health insurance premiums, Medicare premiums/deductibles and coinsurance, certain dental fees or prescription drug costs, may also be deducted. HHSC staff will calculate your copayment and notify you, your case manager and/or your service provider of the amount. The arrangement for your portion of the payment is between you, your case manager and/or the service provider. Medicaid payments for your care will be made directly to the service provider.

To access the Medicaid eligibility rules on the Internet, follow the steps below:

  • Go to www.sos.state.tx.us/tac.
  • Under Points of Interest, select View the current Texas Administrative Code.
  • A menu will appear entitled Texas Administrative Code: Titles. Select Title 1, Administration.
  • Select Part 15, Texas Health and Human Services Commission.
  • Select Chapter 358, Medicaid Eligibility for the Elderly and People with Disabilities.
  • Select the subchapter you desire.

This recorded information is a general overview about Medicaid eligibility financial determinations and may not specifically cover your situation. The information is dated because the eligibility limits and policies may be changed by federal, state, and agency rules. If you have questions about your situation, please contact an HHSC eligibility specialist.

Current Income and Resource Limits

Current budget limits are available in Appendix XXXI, Budget Reference Chart, of the Medicaid for the Elderly and People with Disabilities Handbook.

To access Appendix XXXI on the Internet, follow the steps below:

  • Go to www.hhsc.state.tx.us/.
  • On the top menu, select Rules and Statutes.
  • Scroll down to Handbooks and Forms.
  • The Medicaid for the Elderly and People with Disabilities Handbook is listed alphabetically.
  • Select Medicaid for the Elderly and People with Disabilities Handbook.
  • Select Appendices from the menu on the left.
  • Scroll down to Appendix XXXI, Budget Reference Chart, and click on the appendix number or title to view the appendix.
  • Open the file by clicking Appendix XXXI.