Medicaid is a needs-based program which was created by Congress to help pay for medical care for those aged and disabled persons, as well as poor children and their caretaker relatives, who meet the very strict eligibility criteria. Medicaid policies can be complex. They change frequently, and at the present time, many changes to the Medicaid program are being debated on both the federal and state levels. This information about the eligibility rules and benefits provided through the Medicaid program for people who live in their own homes is accurate as of January 2006. Information regarding Medicaid eligibility for nursing home care and long-term home care is also available from the Center for Medicare Advocacy.
Medicaid is jointly financed by the federal and state governments, and is administered in Texas by the Department of Social Services. Texas is required to adhere to the basic eligibility and benefits requirements contained in the federal statute and regulations. The Department of Social Services has developed its own regulations and policies interpreting the federal rules.
While Medicaid, like Medicare, affords access to health care services, it is very different from Medicare in a number of key areas. Persons are only eligible for Medicaid if they satisfy both the financial and non-financial eligibility rules. In general, Medicaid is only available for individuals who do not have sufficient income and assets to pay for their own medical treatment. However, Medicaid is not available to all such individuals. Only certain people; those who are 65 years of age or older, disabled as defined by the rules governing Social Security disability benefits, young children or their caretaker relatives may qualify for Medicaid. Unlike Medicaid, often called Title 19 in Texas, eligibility for Medicare is not predicated upon the income or assets of the beneficiary.
Medicaid covers far more nursing home care than Medicare, since it pays for custodial as well as skilled long-term care and has no limits as to how long a period of care is covered for an eligible individual. Significantly both programs can be a source of funding for long-term home care. Medicare only covers home health care if the individual is homebound and needs some skilled nursing or therapy services. Medicaid does not require that a person be homebound to get home health benefits, nor does Medicaid require that the person need a skilled service to qualify for home care services
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The Medicaid financial eligibility rules differ depending upon the living arrangement of the applicant. The rules for establishing eligibility for Medicaid for a person living in her own home are very different from the rules governing eligibility for those residing permanently in nursing homes. A special home care program, called level 3 of the Texas Home Care Program for Elders, uses the more liberal long-term care (i.e. nursing home) eligibility rules.
For a person living at home, income must be very limited to meet the Medicaid eligibility rules. In most of the state of Texas, an individual's income may be no more than $476.00 per month, including the standard unearned income disregard of $207.00 per month. The exact amount depends upon where in the state the applicant resides. A chart at the end of this section provides the specific amount of income permitted for each region. There are a number of deductions which may be made from income. All aged, disabled and blind persons are entitled to a deduction from unearned income, such as Social Security check, of $207.00 per month. In addition, the amount of the Medicare Part B Premium may also be deducted from gross income except in establishing eligibility for the qualified Medicare beneficiary (QMB) and specified low income Medicare beneficiary (SLMB) programs. (See the section on those programs.) There are also deductions from earned income. The eligibility of individuals on T19 residing in nursing homes or receiving home health care through the Texas Home Care Program for Elders are very different. (See the section on long-term care Medicaid eligibility.)
Persons who meet all of the other Medicaid eligibility rules, but whose incomes are too high are permitted to "spend down" their income to establish Medicaid eligibility for 6 month periods of time. The "spend down" is similar in concept to a deductible amount in health insurance. "Spending down" is done by incurring or paying medical bills in an amount equal to six times the amount by which income exceeds the Medicaid allowable limit. Proof of the bills incurred or paid must be submitted to the Department of Social Services. After the person's "spend down" has been accomplished, Medicaid will cover the individual's Medicaid-coverable medical care for the rest of the 6 month period.
The Qualified Medicare Beneficiary and Specified Low Income Medicare Beneficiary Programs provide additional ways to establish eligibility for some Medicaid coverage while living at home. (See the section describing those programs for eligibility and coverage information.)
In Texas, the resources (or accumulated wealth) that one may maintain without affecting eligibility for Medicaid (Title 19) benefits while living at home are: