Revision 21-1; Effective March 1, 2021

 

Introduction

Assistance is available to help pay for medical care and supportive services for people with limited income and resources. 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 need to file an application. Depending on your income, you will file an 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, eligibility staff are responsible for determining the financial eligibility for Medicaid. This Medicaid assistance is available for those who do not have SSI and need care:

Depending on your income, assistance is also available to help pay for your Medicare premiums (Part A, Part B or both), deductibles and coinsurance costs through a Medicare Savings Programs, Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB) or Qualifying Individuals-1 (QI-1).

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 the information you provide on the application, documents you send in, and information that you orally explain.

By federal law, HHSC must also use your Social Security number to compare information 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. 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.

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

 

Non-Financial Eligibility

  • Age and Disability — You must be at least 65 or older or, if under 65, you must get Social Security or Railroad Retirement 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 or dependent children of veterans), certain refugees or 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 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, deductions that are withheld from your income before you get it may be included.

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 you receive quarterly.

Certain types of income may be exempt or excluded for the eligibility determination. An example of exempt income is a refund of federal income taxes relating to the earned income tax credit a person receives from the Internal Revenue Service (IRS).

 

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 or dividend payments, rent receipts (tax, insurance, and repair expense receipts), and copies of checks.

It may take some time to gather all the needed proof and more proof may be needed to verify your eligibility. Any of the above items that you send in with an application may speed up the eligibility decision.

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 owned by your or your spouse individually or together. 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.

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 of the home is not counted. Absence from a homestead may result in loss of its homestead status and exclusion unless you have an intent to return. If you have 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 a certain amount, you may not qualify for payment of nursing facility or waiver services.
  • Vehicle — One vehicle is excluded, 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 —All burial spaces are excluded, unless you purchased them as an investment, in which case the equity value is counted.
  • Burial Funds —Up to $1,500 of the funds identified for burial may be excluded, if kept separate from other resources. This exclusion is only for you and your spouse. This amount is reduced by the face value of any excluded life insurance and the value of any irrevocable arrangements for the individual's burial.

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

  • Checking accounts, savings accounts, certificates of deposit, money market accounts, individual retirements accounts (IRAs), stocks, bonds, land, lots or houses (other than homestead), and oil, gas, and mineral rights.
  • Prepaid Burial Contracts — Prepaid burial contracts may or may not be excluded depending on the terms of the contract, how the contract is paid, ownership of life insurance, and the value of 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 still living at home to keep additional income and resources so they can continue to live independently.

If you apply for Medicaid in a nursing facility, ICF/IID, IMD or for a waiver program and have a spouse living in the community, a Spousal Protected Resource Allowance (SPRA) is determined for your spouse. The SPRA is determined as of the month you are admitted to a facility or the month you apply for waiver services.

The value of all resources owned by you and your spouse 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.  Your spouse who continues to live in the community is allowed to keep up to half of the total countable resources subject to the minimum and maximum allowable amounts, which change annually.

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

The SPRA exclusion ends at the first annual redetermination of your circumstances. At that time, all resources that remain in your name are considered in determining eligibility. Your total 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 include bank statements, copies of notes, stocks, bonds, property deeds, loans, mortgages, insurance policies, prepaid burial contracts, annuities, letters from appraisers, and trust instruments.

It may take some time to gather all the needed proof and additional proof may be needed to determine the resource amount for specific months. Any of the above items that you send in with your application may help to speed up the eligibility decision. Proof of your resources will also be needed whenever there is a change in the ownership or the value of items you own 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 is up to 60 months before you apply for institutionalization or waiver services.

 

Cost of Care 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, you are allowed to keep 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 and your case manager or your service provider of the amount. The arrangement for your portion of the payment is between you, your case manager 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 information is a general overview about Medicaid financial eligibility determinations and may not specifically cover your situation. The information is dated because the eligibility policies may be changed by federal, state, and agency rules. If you have questions about your situation, please contact 211.

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.