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Medicaid Explained

Authored By: Partnership for Legal Access



What is Medicaid?

Medicaid is a type of health insurance for low-income families, children, and people who are elderly or have a disability. The Texas Health and Human Services Commission (TxHHSC) runs the Medicaid program in Texas. In most cases, Medicaid pays for doctors' services, laboratory and X-ray charges, medicines, nursing facility and hospital services, family planning, eyeglasses, hearing aids, ambulance, podiatry, chiropractic, maternity, nurse midwife, and other health care services. Medicaid covers more services for children. Medicaid pays for most services, but not for everything. Medicaid pays for regular medical checkups for children. Medicaid also covers children's dental care. Your Medicaid ID card gives limited information about services that you can get. It also shows when children are due for routine medical and dental services. Look for the toll free numbers to call if you have questions. People who are elderly or have a disability who need help with daily activities may be able to receive services in their homes. The state also offers some non-Medicaid community care services.

How does Medicaid work?

The Texas Health and Human Services Center issues a Medicaid ID card each month. The card needs to be shown each time you visit the doctor or get a prescription filled. Medicaid payments are made directly to service providers, such as the doctor, hospital, pharmacy, or lab. Medicaid will not pay you directly for health care visits. Not all medical providers accept Medicaid. Make sure to ask if a doctor takes Medicaid before your appointment. If a medical provider accepts Medicaid, the medical provider cannot bill you for the covered services.


Who is eligible for Medicaid?  

Medicaid is available to qualifying Texans of all ages and abilities. There are separate programs for families and children and for people who are elderly or have a disability.  In most cases, to be eligible for Medicaid in Texas you must: 1) Be a Texas resident, 2) Have evidence that you are a citizen of the United States or a non-citizen in certain recognized categories and 3) Meet certain resource and income limits, which vary by eligibility group. 



Other people who may qualify for Medicaid depending on their income and resources include:


1) Pregnant women;

2) Youths aging out of foster care; and

3) Many nursing home residents.

How is financial eligibility decided? 

For the Health and Human Services Commission to decide if you are income eligible for Medicaid, you will be required to provide financial information for everyone in your household. This decision will be made by looking at both your income and your financial resources. If you own the home you live in, this homestead will not be considered a resource that affects your financial eligibility for Medicaid. The same goes for the value of your family car if you only have one. If you have more than one car, each extra car can be worth up to $4,650 without affecting your Medicaid eligibility. Remember, you are responsible for reporting any changes in your income, resources, job, address and household members to the Health and Human Services Commission within 10 days of the change.

Is Medicaid like TANF?

Family income limits are much higher for Medicaid than for TANF. Additionaly, unlike TANF, there are no time limits on Medicaid eligibility. If a family reaches it's TANF time limit, the family will not automatically lose Medicaid at the same time. If a family's income becomes too high to receive TANF, the family may still get transitional medicaid for 12 more months.

How do I apply for Medicaid? 

To apply for Medicaid, visit your local medicaid office. You can call 211 for help locating the office nearest you. Parents that are new to Medicaid must also attend an orientation to learn how to use Medicaid and learn about the checkups and immunizations that are described in the Texas Health Steps program. This orientation may be provided over the phone. Remember that you must reapply/ recertify to make sure that you do not lose your coverage.

If you have questions, you can call the toll-free Medicaid Hotline at 1-800-252-8263 between 7:30 a.m. and 5:30 p.m., Monday through Friday.


What is Medicaid Managed Care?

In most counties in Texas, you will be required to enroll in "managed care" if you get Medicaid. You should receive an information packet in the mail about managed care after you are determined eligible for Medicaid. In managed care, each patient has a "primarey care provider" or PCP. Your PCP should provide basic healthcare for you, and refer you to specialists when needed. You can choose your PCP from the list that is in your packet. If you already have a doctor that you like, chose a managed care program where that doctor is enrolled.


What are my rights in the Medicaid Process?

1. The Texas Health and Human Services Commission must give you a written decision on your Medicaid application within 45 days of application submission.


2. If your application is determined to be incomplete, you have the right to receive written notice of what information is missing and a deadline for providing the missing information. This deadline must be at least 10 days after you received notice.


3. You have the right to receive written notice about why your application was denied or why your benefits were reduced or terminated. This notice must also include instructions on how to request an appeal of the decision.


4. You have the right to challenge the denial or termination of your benefits.


5. You have the right to have a legal representative assist you in your appeal. This representative does not have to be an attorney, but can be one. Attorneys will not be provided by the court. You can contact your local legal aid organization for possible legal representation or assistance through their program.


6. You have the right to written notice of the outcome of your appeal.


How do I appeal the denial or termination of Medicaid Benefits?

To appeal the denail or termination of Medicaid benefits, you must request a Fair Hearing. Fair Hearing meetings are conducted by a regional hearing officer, together with the applicant or client who disagrees with the agency's decision. The Texas Health and Human Services Commission accepts requests for Fair Hearings by mail, fax and phone.

You must request a fair hearing by filing your appeal within 90 days of the letter denying your Medicaid application. If your Medicaid is being reduced or terminated, you can request that your benefits continue while you wait for your appeal decision. You have 10 days to ask in writing that your benefits continue during this time. If you lose your appeal you will have to pay this money that was paid during your appeal, back to the agency. You should receive written notice of when and where your hearing will be held. 


At the Fair Hearing:

ØYou will have a chance to explain why the decision is wrong.

ØThe case worker gets to explain why the decision is correct.

ØYou can question the case worker and witnesses.

ØYou should bring your own witnesses with you, if you have any.

ØIf your appeal involves a medical issue, you should take a letter from your doctor with you to the hearing.

ØThe hearing officer (judge) can question you and witnesses.

Ø You have the right to an interpreter during the hearing.


The Health Information, Counseling and Advocacy Program (HICAP) helps older Texans and people with disabilities by providing them information about healthcare coverage and public benefits. If you need help with issues related to Medicare, Medicaid, guardianship, social service programs and insurance fraud against seniors, consider talking to a benefits counselor through the Health Information Counseling and Advocacy Program (HICAP).

Counselors can also help you by

  • providing information about Medicare and Medicaid eligibility, program benefits, and appeal rights
  • explaining your options for receiving Medicare benefits
  • helping you use online plan finders and other tools on the Medicare website
  • explaining Medicare supplement insurance policy benefits, exclusions, and coverages
  • providing information about Medicare Advantage plans and Medicare prescription drug plans
  • providing information about long-term care planning and payment options
  • making referrals to community agencies and services.

All HICAP services are free. Benefits counselors may not recommend any insurance policy or plan. Their role is to provide factual, unbiased information and assistance and to act as advocates when needed.


Click here for more information about local resources that help with legal questions about medical related, public benefits