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Medicaid offers health care services to persons in need.

Understanding Texas Medicaid

A Guide to Better Health Care: Understanding Texas Medicaid

Reprinted with permission by Office of Attorney General, Texas


A guide to get services and stay healthy and getting the care you need for your family. Depending on your income, the county you live in, and other factors, you or your children may qualify for Medicaid programs.


Prepare Yourself:

  • Have an identification (ID) card for yourself and legal resident papers for all family members who are applying for benefits.
  • Have proof of all family members’ monthly income and resources (for example:  money you have in the bank, paycheck stubs, and the make, model, and year of your cars, trucks, vans, or other vehicles).
  • Have the Social Security numbers for all persons applying for benefits. Social Security numbers are not required of parents applying for their children.

Remember to:

  • Ask questions and get answers that make sense to you! Ask for a supervisor, if needed.
  • Get the names and telephone numbers of every person with whom you speak.
  • Get rules, decisions, and answers in writing. Keep a copy for your records.

What is Medicaid?


Medicaid is a program that offers health care services to persons who have limited income, are pregnant, and/or persons with disabilities.


To qualify for Medicaid:

  • Be a Texas resident
  • Be a U.S. citizen or a legal resident
  • Meet certain resource and income limits

Fit into one of these groups:

  • Families and children with limited income
  • Children
  • Pregnant women
  • Non-U.S. citizen needing emergency medical services
  • Children or pregnant women who are medically needy due to high medical bills
  • People who get Supplemental Security Income (SSI) from Social Security Administration
  • Persons having low-income and needing long-term services and supports or help with daily activities
  • Once you are enrolled in Medicaid, the state will send you a Medicaid ID form (Form H3087).
  • Keep this form in a safe place! You have to show this every time you see your doctor or fill a prescription using Medicaid.


How to Apply for Medicaid
 

  • If you are a person with a disability or a person over 65 years of age with limited income and receive Supplemental Security Income (SSI), you do not have to apply for Medicaid. You will receive Medicaid automatically when you receive SSI. Go to your local Social Security Administration office to apply for SSI.
  • Applications for children (age 18 and younger) for CHIP or Children’s Medicaid can be done over the phone, by mail, or by fax. You can get an application from the CHIP/Children’s
  • Medicaid website at www.chipmedicaid.org, or by calling 1-877-543-7669.
    All other persons must apply for Medicaid through the local HHSC office or a HHSC caseworker in a hospital or clinic.

When you apply for services, you will need to take or mail (if available) the following documents:

  • Pay stubs or other papers to show all family members’ monthly income.
  • Social Security numbers for all individuals who want Medicaid (not required for
    children under 6 months of age).
  • Papers that show your resources for all individuals who want Medicaid (for example: bank records, make, model, and year of your vehicles). This is not needed if you are applying because you are pregnant or if you are applying only for children (age 18 or younger).
  • Legal resident papers if you are not a U.S. citizen and you want Medicaid for yourself.
  • Proof of residence (for example: gas, electric, or water bill, letter from your landlord). This is not needed if you are applying only for children (age 18 and younger).

NOTE: You may ask a friend or other person you choose to be your “authorized representative” to apply for you. You may also ask for a language or a sign interpreter to help you apply. Ask for an interpreter when you call to set up an

appointment.

 

Medicaid gives you many services that will help you stay healthy. Below is a listing of some, but not all, Medicaid services:
 

  • Ambulance services
  • Attendant/personal assistance services
  • Behavioral (mental) health services
  • Case management for persons with chronic mental illness; persons with mental retardation/related conditions; women with high-risk pregnancies and infants; children with health risks or health conditions
  • Chemical dependency treatment for children (under 21 years of age)
  • Chiropractic services
  • Clinic visits
  • Day activity and health services
  • Dental care for children (under 21 years of age)
  • Dialysis
  • Doctor visits (including psychiatrists)
  • Emergency medical services
  • Family planning services
  • Glasses and contact lenses
  • Hearing aid services
  • Home and community-based services
  • Home health services, including durable medical equipment, such as wheelchairs
  • Hospice care
  • Hospital services: inpatient and outpatient
  • Medicines prescribed by your doctor
  • Nursing home services
  • Optometry
  • Physical, occupational, and speech therapy
  • Podiatry
  • Pregnancy and birthing services
  • Prenatal care
  • Psychiatric inpatient hospital services for children (under 21 years of age)
  • Rehabilitative services for mental illness, psychiatrist’s services, and inpatient medical stabilization for chemical dependency in a general acute hospital
  • Rehabilitative services for people with severe mental illness
  • Services in intermediate care facilities for persons with mental retardation (ICF-MR)
  • Transportation
  • X-rays
  • The state of Texas may limit some of these services.

Medicaid Buy-In
 

Effective September 1, 2006, HHSC implemented the Medicaid Buy-In program, which allows people of any age who have a disability and are working to receive Medicaid by paying a monthly premium. The monthly premium is based on earned and unearned income.
 

To be eligible:


A person’s earnings and FICA contributions must be enough in a calendar quarter to count as a Social Security Administration “qualifying quarter.” For 2006, this amount is $970 a quarter. A person must meet the disability criteria for Social Security’s Supplemental Security Income without consideration of earned income.


A person’s countable resources must be equal to or less than the Supplemental Security Income resource limit, currently, $2,000. A person’s countable earned income must be less than 250 percent of the federal poverty level. For 2006, this amount is $2,042 a month. Monthly premium amounts are determined by examining both unearned and earned income. The unearned income premium amount is all unearned income over the Supplemental Security Income federal benefit rate, which is currently $603 a month.


Individuals whose gross earned income minus mandatory payroll deductions exceeds 150 percent of the federal poverty limit are required to pay an amount between $20 and $40 a month.

Eligibility is not established until the first premium is paid. The applicant will receive a notice containing the amount of the premium and the premium due date. Ongoing monthly premium payments are due by the 20th of each month.


Transportation


The Medical Transportation Program (MTP) is a free service provided to you through Medicaid when you or your children have no other way to get to appointments with Medicaid-enrolled doctors, dentists, or other health care services (including pharmacies) covered by Medicaid.


MTP offers free rides by bus, van, taxi, or airplane to appointments and back home. You can also receive a ride in a private vehicle driven by an Individual

Driver Registrant (IDR).


MTP can provide free transportation only to persons who have a scheduled health care appointment or to a responsible adult who is traveling with a child who is under 15 years of age who has a scheduled health care appointment.
 

Adult clients may request an attendant to travel with them if there is a medical need or a need for language translation or sign language interpretation. A friend, neighbor, or relative can take you and your family to a medical appointment and

be reimbursed for travel, when pre-approved.


How to Get a Ride          


Call at least two working days or more before you need a ride. If you are traveling out of town or a long distance, call at least five working days or more before you need a ride. If you need same or next day service, call MTP. They

will try to help but cannot guarantee a ride.


When you call, you must give MTP:
 

The nine-digit Medicaid ID number or Social Security number of the person needing the ride.
The address where you want to be picked up and a phone number, if any, where you can be reached.
The name, address, and phone number of the doctor, dentist, hospital, or pharmacy where you or your children need a ride.
The date and time of your health care appointment and any special services you will need.
Be sure to tell them if you or your children have any special needs (for example: wheel chair access, a car seat, or if you are diabetic).
Long-Term Services and Supports in Medicaid

The Medicaid program also offers long-term services and supports if you need help with day-to-day living activities. These services are offered either in a facility or in your home. Some of these services include:


Community care services for older adults and persons with disabilities, including

personal attendant services, meals, and day activity and health services.


Long-term care waiver services (listed below) may not be available in all areas of

the state. They provide community-based care as an alternative to institutions: 

  • Community Based Alternatives (CBA) – serves adults who require nursing home level of care in the home.
  • Consolidated Waiver Program (CWP) – serves people with physical or developmental disabilities; operates only in Bexar County.
  • Community Living Assistance and Support Services (CLASS) – serves people with developmental disabilities like cerebral palsy, spina bifida, etc.
  • Home and Community Services (HCS) – serves people with mental retardation.
  • Medically Dependent Children’s Program (MDCP) – serves children who require nursing home level of care in the home.
  • Deaf Blind Multiple Disabilities (DBMD) Services – serves adults who are deaf, blind and have a third disability.
  • Nursing home care, including dental care.
  • State schools and intermediate care facilities for persons with mental retardation, including dental care.
  • Program of All-Inclusive Care for the
  • Elderly (PACE) – serves adults age 55 and older who need nursing home level of care. This program is available in El Paso and is under development in Amarillo.
  • Prescription Benefits

In Medicaid, the prescription benefit is different for adults and children. For all Medicaid recipients, your doctor may need to get prescriptions pre-approved for certain drugs or medicine before you can pick them up at the pharmacy.


If you are not sure if your pharmacy accepts Medicaid, ask them before you get your prescriptions filled. If you are required to participate in the Limited Program, you may be assigned one pharmacy to fill all of your prescriptions


For Adults:

Most adults are limited to three prescriptions per month. This applies to prescriptions your doctor orders for you. Adults who receive their care through a Medicaid HMO are not limited to three prescriptions a month. Adults get unlimited prescriptions while living in a hospital or nursing home. Adults enrolled in home and community-based waivers get unlimited prescriptions.

Adults may receive unlimited prescriptions or their family planning needs.


Medicaid and Medicare are Different Programs


Some people get both Medicaid and Medicare. Medicare is a health insurance program paid for by the federal government, not by the state of Texas. If you receive both Medicaid and Medicare, show your Medicare card and your Medicaid ID form for medical visits, so your doctor will have the right billing information. 

  • You may be receiving Medicare if any of the following apply to you:
  • You are 65 years or older.
  • You have a disability and are under 65 years of age and receive Social Security Disability Income (SSDI)
  • You have end-stage renal disease
  • If you have limited income and you are receiving Medicare, HHSC may assist in paying your Medicare premiums, coinsurance, and deductibles through Medicaid.

 Qualified Medicare Beneficiary (QMB)
 

Deductibles: Both Medicare Part A and Part B have deductibles that you must meet before Medicare pays its part of the bill. Medicaid can pay the amount applied to your deductible

Coinsurance: After Medicare pays, there is often a “coinsurance” amount left that is usually your responsibility to pay. If you are a Medicare client, Medicaid may pay your coinsurance if the services are a benefit of Medicare.


Copays: Medicaid now pays for some copay expenses that you are required to pay. Your providers should bill Medicaid directly for these services.


NOTE: Not all copayments are reimbursed by Medicaid. Medicaid Qualified Medicare Beneficiary (MQMB) Deductibles: Both Medicare Part A and Part B

have deductibles that you must meet before Medicare pays its part of the bill.


Medicaid can pay the amount applied to your deductible. Coinsurance: Medicaid may pay the coinsurance amount even for services not usually covered by Medicaid if you have QMB or MQMB coverage.


Copays: Medicaid now pays for some copay expenses that you are required to pay. Your providers should bill Medicaid directly for these services.


NOTE: Not all copayments are reimbursed by Medicaid.


Additional Services: If you have MQMB, there are some services that Medicaid pays for that are not covered by Medicare, like routine eye exams. Your providers should bill Medicaid directly for these services.


Medicare Prescription Drug Plans (Medicare Part D)


Prescription drug benefits are covered under Medicare. Medicaid clients that also have Medicare must enroll in one of the Medicare drug plans before they can get medicines that their doctor prescribes for them. Medicaid no longer pays for medications for clients enrolled in both Medicare and Medicaid.

For more information about Medicare, visit www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227 [toll- free]). For people with hearing or speech impairments, call the TDD number at 1-877-486-2048 (toll-free).
 
Medicaid and Private Insurance
 

As a condition of Medicaid eligibility, you must report all other medical insurance information to the program, including prescription insurance. If your private health insurance is canceled, if you have obtained new insurance coverage, or if you have general questions regarding third party insurance you should call the Medicaid Third Party Resources (TPR) hotline so that you can update your records and answer your questions. You can call the TPR hotline at 1-800-846-7307 (toll-free).
 

Having other insurance does not affect whether or not you qualify for Medicaid.
 

Medicaid Health Insurance Premium Payment Program
 

The Health Insurance Premium Payment Program (HIPP) is a program that enrolls Medicaid clients in a group health plan offered by the client’s employer. When you have access to private health insurance through your employer or can

get medical coverage for a family member through your employer, Medicaid may be able to reimburse you for the premiums deducted from your paycheck. You can call the HIPP line at 1-800-440-0493 (toll-free) for more information.
 

Emergency Care
 

What is Emergency Care? A medical need is an Emergency if you think you or your child’s condition is life-threatening; if you or your child has serious pain; or if serious harm could come to you or your child without immediate medical attention.
 

Some examples of emergency medical needs are:

  • Bad chest pains
  • Unable to breathe
  • Choking
  • A seizure
  • Poisoning or a drug overdose
  • A broken bone
  • Severe bleeding
  • Physical attack (raped, stabbed, shot, beaten)
  • Labor and delivery
  • Serious injury to the arm, leg, hand, foot, mouth, or head
  • Severe burn
  • Severe allergic reaction
  • An animal bite
  • Uncontrollable behavior that without treatment is dangerous to self or others
  • Infant with a fever

Go to the nearest hospital if you think you have any of these problems. You may call 9-1-1 for assistance in getting to the hospital emergency room.

REMEMBER: If you are in Medicaid Managed Care your health plan has a nurse hotline staffed by nurses who are available 24 hours a day, 7 days a week to help you. Call them to get help.