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Medicaid and You - The Short Version
gekko two
So I've been saying I'd do an informational entry in a continuing effort to offer up options for those who want to receive government benefits in the state of Texas--I think the last time I covered any ground was during Katrina, so today, a little more.

This is all about Medicaid and You.

This is a brief version to give an overview only. To actually find out if you qualify, you will need to turn in an application. For actaul detailed info, you will need to see a caseworker. My specialization and training was in Food Stamps, Medicaid for Families, and TANF, not the long-term cares for the aged and disabled, so my information is pretty basic.

Again, cannot emphasize enough: INFORMATIONAL. This cannot and will not take the place of a trained caseworker or social worker making an assessment.

Medicaid and You: Women and Children

Pregnancy--Texas has two different programs for women who are pregnant. One is TP-40, or Medicaid for pregnancy, the second is CHIP perinatal, put into effect this month. The first is for citizen women and certain groups of legal aliens, at or below the 185% FPIL, or Federal Poverty Income Limit. The second is for undocumented aliens. I can't find offhand the income limit charts--suffice to say, if you know a pregnant undocumented alien that needs assistance, send them to their nearest HHSC office or the closest pregnancy crisis center.

Children--there are several separate programs, four Medicaid, one state-funded, with varying income limits. The highest limit is CHIP with a top limit of 200% FPIL; TP-45, children born to mother with Medicaid, no limit; TP-43, children under one year old, income limit 185%; TP-48, children one to five, income limit 133%; and TP-44, children six to eighteen, income limit 100%. These programs do not include foster children, children who have been adopted, or children on SSI.

Undocumented Aliens--see above under pregnancy for Medicaid for women who are pregnant. For everyone else, including children, program TP-30, which exclusively covers emergency medical condition--labor and delivery, car accident, etc.

For adults needing Medicaid--well, good luck. Not so easy unless you a.) have kids and b.) can prove on or around 25% of FPIL (not exact percentage). However, for those with ovarian cancer, there are special programs under the adult Medicaid program TP-55. There is also the new Women's Health Program, which I'll try and get a full circular about later this week. Suffice to say, if you have no insurance, ask your doctor or the clinic you visit for details. As far as we know, most clinics now have information on the subject and should be able to either give you an application or tell you where to go to get one and apply.

Medicaid and You: You and Your Parents/Grandparents/Siblings

So, you have an elderly relative that needs to be moved into a nursing home. You ask yourself, can we afford this? And let's face it, unless you're fairly independently wealthy or that relative has some money in the background somewhere, you probably can't. For those who can, this isn't for you.

For those looking for options, here you go.

TP-14 - Nursing Home Care or Alternatives to Nursing Home Care - pays the cost of long-term care faclities for individuals residing in Title XiX facilites who meet SSI eligibility criteria except those for income. An individual must live in one or more Title XIX long-term care facility at least 30 consecutive days to be eligible. Applies to persons residing in Title XIX nursing facilities as well as Title XIX-apporved sections of state schools and private facilities for the mentally retarded.

Okay, what does that mean?

Your elderly relative/friend needs to be in a nursing home for thirty days to be able to qualify. These have waiting lists. These have *long* waiting lists, this is done in block-type grants, so when they run out of money, they simply can't add anyone else. The second you know Relative will need more intensive care than you can provide--and I would suggest that if you can figure this out a few years ahead of time? Good idea--apply. There are amazing restrictions, income limits, interviews, resource limits.

If you have the means to consult a lawyer or someone who has casework experience before applying, *DO SO*. If you don't, read all the literature they can provide at the office before you go in. There is a reason it's a *three month intensive course* before someone becomes a caseworker for the aged and disabled. It is *that complex*. I had to overview it during my training and almost lost some important brain cells just getting the *idea* of it.

When in doubt? Call your local Medicaid Eligibility office--this is in the phone book--and ask. I cannot emphasize enough--most people do not know what they need or can get until they ask. Tell them your situation, pick up an application. There are more programs here than I can cover and most are confusing. Agency for Aging is also a good source. Most nursing homes take Medicaid. Ask them. Their reason for existing is to help. Use it. That is why they collect paychecks.

Medicaid and You: The Medicare Cost Sharing Plans

You, your elderly relative, etc receive Medicare. Great! But you're paying the 93.50 premium every month. You or your relative are low income. Very low income. You think, I need help.

QMB - Qualified Medicare Beneficiary - Provides payment of Medicare premiums (Part A and B), deductibles and copays. Income limit is 100% FPIL, and there are resource limits.

What does this mean? Your income is at or less than 100% FPIL, and if you qualify, this pays for your premium and the 20% on doctor's visits.

SLMB - Specified Low Income Beneficiary - Pays Mediare Part A and B premiums. Income limit somewhere around 120% FPIL.

QI-1 - Qualified Individual-1 - I have no idea what the acronym means. Pays Medicare Part A premiums, slightly higher income limits.

ETA: Added Medicare Part A to SLMB and clarified QI-1 thanks to stop in commments.

What do these mean? They pay only the 93.50 Medicare premium per month.

Medicaid and You: Final Words

WHEN IN DOUBT? APPLY. I cannot emphasize enough the sheer importance of going to the local office and ASKING QUESTIONS. This is their job. They know this stuff. And most caseworkers like giving benefits, because we don't like it when clients cry in the office or threaten to kill us and stuff. And because you know, most of us entered the job anticipating assisting others. We are here for you. But God, please don't tell us how your taxes pay for our jobs. WE KNOW THAT. It is very annoying.

Now, you still want information? 211. Yes. No, that's all you dial, really. 2-1-1. Just those three numbers. Hit option one, tell them your city/county in Texas? They will help you find services and organizations to help. Still not sure?

http://hhsc.state.tx.us One stop shopping for all your state needs.

Other Useful Places

PPARx - go here for assistance with prescriptions.

Helpful Numbers with DADS (Department of Aged and Disabled Services - useful for a lot of things, not least of which is the awesomness of finding out how nursing homes rate in the state. This site is chock-full of informational goodness. When in doubt? Call. Nag if you have to.

Your Texas Benefits. Unless you are in Austin or San Marcos, DO NOT SUBMIT AN APPLICATION THROUGH THE WEB INTERFACE. VERY BAD IDEA. But wander through and read.

Annnnd we're done today. Questions, thoughtful murmurs, intersting insights? Go at it.

ETA: For more information, read this commment by nat_am_drachen

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This is amazing. I'm a lawyer, with a Texas law license, and I can't get my head around most Medicare/Medicaid stuff. I have several elderly relatives who probably qualify for some of this, and it is so great to have a basic outline and resources.

Thank you so much for outlining this!


For any relative who needs care, contact DADS. They have a lot of programs, some of which allow staying at home, in-home care, etc. It's kind of a song and dance to get it, but usually the caseworkers can guide people through.

It is interesting how things are the same from state to state, but yet so different. I did eligibility casework (TANF, Medicaid, FS, and some Childcare) at Dept of Family and Children Services for 6 years *shudders* before saying so long. Here in GA the state is getting ready to put a cap on PeachCare for Kids. It is a type of Low Income Medicaid. If you fall below 200% of the FPL and are not employees of the state or Board of Regents, you could apply. You pay so much per child, up to a set limit. It was $15 when I was working for DFCS, but that could have changed. The sad thing is that most state employees (this includes all full and part-time school employees) could qualify for the program. Many of my clients on the free program wanted to go on PeachCare but were told they had to be on the 'free' program. No wonder our health care programs are going broke. We have people that want to pay a small fee, however small, but we won't allow them. Then we have people who don't need the system and defraud it for over $2 mill. *grrr* So, if you don't mind me asking, where do you stand on universal health care? You don't have to answer. It does not make sense to me, never has. I applaud you for continuing to help those that need it (and those that maybe don't). Keep up the good work! I know it is a daunting task.

I have attached a couple of links for you to check out. I did not know if you were aware of them or not. I always had clients asking me where they could go to get affordable health care, especially for adults. I found that is hard to get health care unless you have insurance or go to the emergency room. I found that after I lost my health care (I work P/T right now), I could not even get an appointment with my PCP. My neurologist that I see was helping me get my medicine through the companies. Who knew anti-seizure and migraine medication could cost so much? But she is 4 1/2 hours away. I was able to find out that there is a free clinic around that would see me even though I am not a resident of their county. It was a surprise to me. Working for DFCS, we always here about , the health clinic, but not the free clinic. Let me preface what I am about to say, this is where I live, every clinic is different, and this is just a reference. The free clinic actually sees people 7 days a week on a sliding scale fee basis. The have medical, dental, x-ray, lab, and pharmacy facilitates. If necessary, they will refer you out to a participating physician if they are unable to handle the problem. The facility I go to is wonderful. It is clean, has a guard (because it is downtown and near the homeless shelter), the staff is nice and competent, and you don't have to wait for hours (like you do at a doctor's office). Again, this is where I live. This is not all clinics.


I hope the difference in acronyms did not throw you off too much. I remember QMB and QI-1 (not exactly what QI-1 was), but SLMB was something else for us. SLMB was a spenddown. Is it a spenddown for Texas, too. I can't remember what the FPL was.

Just so you know, I work for Medicare, and QI-1 stands for "Qualified Individual 1" and the difference between QI1 and SLMB is that SLMB will pay Part A premiums AND Part B premiums for those who are required to pay part A premiums (i.e. did not work greater than ten years in US) and QI1 pays only Part B premiums.

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