Medicaid Home Care Programs in Texas: What Caregivers Should Know

What Medicaid home care may cover in Texas

Medicaid home care means long-term services and supports that help a person stay at home or in a community setting. It is not the same as short home health care after a hospital stay. It is also not a promise of full-time care.

Texas may cover different services through different routes. Some are state plan services. Some are waiver services. Some are handled through a STAR+PLUS managed care plan. A managed care plan is a health plan that manages Medicaid services for the member.

Services may include:

• Personal care: hands-on help or reminders for daily tasks.
• Bathing help: help getting in and out of the bath or shower, washing, drying, and safety support.
• Dressing help: help with clothes, socks, shoes, braces, or special garments.
• Homemaker help: light cleaning, laundry, or tasks tied to safe care at home when approved in the service plan.
• Meals: meal preparation or home-delivered meals when covered by the person’s plan or local program.
• Transportation: rides to covered health care services through Texas Medicaid nonemergency medical transportation.
• Emergency response: a call device or service for people who need a way to get help in an emergency.
• Respite: short-term relief for an unpaid caregiver when the person qualifies for a route that covers it.
• Adult day care: Texas often calls this Day Activity and Health Services, or DAHS. It can include nursing, personal care, nutrition, transportation, and other support in a licensed setting.

Not every person gets every service. The service must be allowed by the program, medically or functionally needed, approved in the service plan, and available through the person’s route.

Programs to check first

Who may qualify

Texas Medicaid home care rules depend on the route. The person may need to meet financial rules, medical rules, functional rules, residency rules, and program-specific rules.

In plain English, the state usually looks at these questions:

• Does the person live in Texas?
• Does the person qualify for Medicaid, or do they need to apply?
• Is the person age 65 or older, disabled, or in another covered group?
• Does the person need help with daily living tasks?
• Does the person need a nursing facility level of care for STAR+PLUS HCBS?
• Can the needed care be provided safely at home or in a community setting?
• Is the service allowed under the person’s program and health plan?

Do not rely on old income or asset numbers from a blog or forum. Texas Medicaid financial rules can change and can be different for regular Medicaid, Medicaid for the Elderly and People with Disabilities, waiver services, and a married couple. If income or assets are close to the limit, ask Texas HHS or an elder law attorney before giving up.

For more on common Medicaid money issues, see Medicaid spend-down and Medicaid look-back period.

How the assessment works

The assessment is where Texas or the managed care plan decides what the person needs. For STAR+PLUS HCBS, the process can include a Medical Necessity and Level of Care assessment. For Community First Choice, Texas uses assessment tools to look at personal assistance, habilitation, emergency response, activities of daily living, and unmet needs.

Activities of daily living are basic tasks such as bathing, dressing, eating, toileting, transferring from bed to chair, and moving around. Instrumental activities of daily living are tasks such as meals, laundry, shopping, housework, and using the phone.

Before the assessment, write down what happens on a bad day, not just a good day. Be honest and specific. Do not say, “She is fine,” if she is only fine because you are there all day.

How to apply

If the person is not on Medicaid, start the Medicaid application. Texas HHS says applications for Medicaid for the Elderly and People with Disabilities can be submitted online through YourTexasBenefits.com, at a local office, by mail, by fax, or by phone. Texas also uses Form H1200 for Medicaid for the Elderly and People with Disabilities and the Medicare Savings Program.

If the person already has Medicaid, the next step may be a plan call, not a new Medicaid application. Call the STAR+PLUS health plan and ask for the service coordinator.

What to do while waiting

Waiting is common. It can happen because Medicaid is still being processed, proof is missing, an assessment is pending, a plan has not approved services, or an interest list applies.

While you wait:

• Call the Area Agency on Aging. Ask about respite, meals, transportation, caregiver support, and local programs for people age 60 or older.
• Ask about nonemergency medical transportation. If the person has Medicaid, rides to covered health care services may be available.
• Ask the doctor for records. A short letter that explains the need for help with daily tasks may support the assessment.
• Track safety risks. Write down falls, missed medications, unsafe cooking, wandering, bathing problems, and ER visits.
• Check VA benefits if the person is a veteran or surviving spouse. VA Aid and Attendance may help some households. Learn more at VA Aid and Attendance.
• Price private backup care carefully. Use the care cost calculator before signing a long private-pay plan.

If you need a short break from care, see respite care for caregivers. If you need help making calls, see phone scripts for caregivers.

If services are denied or cut

A denial can mean several things. Medicaid may be denied. A waiver slot may not be open. The plan may deny a service. Hours may be reduced. The person may be found not to meet nursing facility level of care. Or a document may be missing.

Do not stop at a short phone answer. Ask for the written notice. The notice should explain the action, the reason, and appeal rights.

Texas HHS materials for STAR+PLUS HCBS describe appeal and state fair hearing procedures. One Texas HHS page states that a STAR+PLUS HCBS applicant, member, or authorized representative can request an appeal within 90 days from the effective date of an HHSC action. Still, always follow the exact deadline on your notice because the route and facts can matter.

If current services are being cut, ask right away whether services can continue during the appeal. Do this before the effective date in the notice if possible.