Medicaid is a program that provides free or very low-cost health insurance to people who need it. If you cannot afford private health insurance, Medicaid is designed to help you get the medical care you need without going into debt.
However, Medicaid rules are not the same in every state. The federal government sets the basic rules, which you can read about at medicaid.gov, but each state gets to make its own specific choices. The rules in Texas are some of the strictest in the country.
This guide will explain exactly how Texas Medicaid works. We will cover who can get it, what it pays for, the different programs Texas uses, and how you can apply. We have written this in plain, clear language so you know exactly what your choices are and what steps to take next.
Medicaid is paid for by both the federal government and the state of Texas. In Texas, the program is run by a state agency called the Texas Health and Human Services Commission (HHSC).
When you get Medicaid in Texas, the state usually does not pay your doctor directly. Instead, Texas uses a system called “Managed Care.” This means the state hires private health insurance companies to manage your care. If you are approved for Medicaid, you will be asked to pick a health plan from a real insurance company that operates in your part of Texas.
Your Medicaid card will have the name of that health plan on it. When you need to see a doctor, you must go to a doctor who works with that specific health plan. This group of doctors is called a “network.”
The most important thing to know about Texas Medicaid is that Texas chose not to “expand” its program.
In many other states, any adult who has a low income can get Medicaid. In Texas, this is not true. Having a low income is only the first step. To get Texas Medicaid, you must have a low income and you must fit into a specific category.
If you are a healthy adult between the ages of 19 and 64, you do not have children under 18, and you are not pregnant, you cannot get Medicaid in Texas, even if you make zero dollars a year. This is a hard rule, and it surprises many people who move to Texas from other states.
To get regular Texas Medicaid, you must be able to check all of the boxes below that apply to your situation.
| Group | Who This Means |
|---|---|
| Children | Kids and teens up to age 18. This group has the highest income limits. |
| Pregnant Women | Women who are currently pregnant. The baby is covered too. |
| Seniors | Adults who are 65 years old or older. |
| Disabilities | People of any age who have a serious, long-term disability. |
| Parents/Caretakers | Parents who have children under 18. The income limit for this group is extremely low. |
Because you must fit into a specific group to get Texas Medicaid, it helps to look at each group one by one. The income limits change slightly every year based on the Federal Poverty Level. The state will look at how many people live in your house and how much money everyone makes combined.
Texas is very committed to making sure children have health insurance. Children up to age 18 have the easiest time qualifying for Medicaid.
Children’s Medicaid is completely free. There are no monthly bills (called premiums) and no extra fees when you visit the doctor (called copays). It covers almost everything a growing child needs, including checkups, shots, dental work, and glasses.
If you apply for your child and the state says you make too much money for regular Medicaid, your child will likely be moved over to CHIP.
What is CHIP? CHIP stands for the Children’s Health Insurance Program. It is designed for working families who make too much money for Medicaid but still cannot afford to buy private health insurance for their kids. CHIP is not completely free, but it is very cheap.
Depending on your income, you might have to pay an enrollment fee of up to $50 once a year. When you take your child to the doctor or pick up medicine, you might have to pay a small copay, usually between $3 and $5. CHIP covers the same great benefits as Children’s Medicaid.
If you are pregnant, you have a much better chance of getting Medicaid. The income limits for pregnant women are higher than they are for regular adults.
Medicaid for pregnant women covers all of your doctor visits during your pregnancy, your vitamins, the hospital stay when you have the baby, and care for you and the baby after the birth.
Texas recently changed the rules to give mothers more help. If you get Medicaid while you are pregnant, that coverage will now last for a full 12 months after the baby is born. This gives you a full year of health insurance to make sure you heal well and stay healthy. After that year is up, your coverage will end unless you qualify under a different rule, but your baby will stay on Children’s Medicaid.
What is CHIP Perinatal? Some pregnant women in Texas do not qualify for regular Medicaid. Most often, this is because of their immigration status. If you are an undocumented immigrant or a legal resident who has not been in the country for 5 years yet, you cannot get regular Medicaid.
However, Texas has a special program called CHIP Perinatal. This program covers the unborn baby. It will pay for your prenatal doctor visits and the birth of the child. It does not cover your own health problems if they are not related to the pregnancy. Once the baby is born in Texas, the baby is a U.S. citizen and can get regular Children’s Medicaid.
If you are a healthy adult under age 65, the only way you can get regular Medicaid is if you have children under 18 living with you. Even then, it is extremely hard to get.
The income limits for parents in Texas are very, very low. A single parent with two children must make a very small amount of money per month to qualify. For most working parents, even working a part-time minimum-wage job will put them over the income limit. Because this rule is so strict, most parents in Texas do not get Medicaid. Their children will get Medicaid or CHIP, but the parents will not have coverage.
If you are 65 or older, or if you have a serious disability, you fall into a different group. Texas has special Medicaid programs for you.
Many people in this group already have Medicare. Medicare is a different program run entirely by the federal government for seniors. But Medicare does not pay for everything. It has monthly bills, and it only pays for part of your doctor visits.
If you are a senior with a low income, you can get Medicaid at the same time as Medicare. This is often called having “dual coverage.” When you have both, Medicaid steps in and pays the bills that Medicare leaves behind. Medicaid can pay your monthly Medicare premium, and it can pay your doctor copays.
Texas Medicaid also pays for things that Medicare never pays for, like long-term care in a nursing home or hiring a nurse to come to your house to help you bathe and get dressed.
If you are approved for Medicaid, you do not just get a generic card. You will be put into a specific program based on your age and health needs. In Texas, these programs all use the word “STAR.”
| Program Name | Who It Is For | How It Works |
|---|---|---|
| STAR | Children, pregnant women, and parents. | This is the standard Medicaid program. You pick a health plan and a main doctor who coordinates all your care. |
| STAR+PLUS | Adults 65 or older, and adults with disabilities. | This covers regular medical care, but also adds long-term care, like nursing homes or at-home helpers. |
| STAR Kids | Children age 20 and younger with serious disabilities. | Specialized care for kids with complex medical needs. It provides extra help coordinating care between many doctors. |
| STAR Health | Children in the Texas foster care system. | A single statewide plan managed by Superior HealthPlan to ensure foster kids get care no matter where they move in Texas. |
When you get your approval letter in the mail, it will tell you which STAR program you are in. You will then get a packet in the mail asking you to pick a health insurance company. You might see names like UnitedHealthcare, Blue Cross Blue Shield, Molina, or Superior.
You must pick one of these companies. If you do not pick one, the state will pick one for you. You will also be asked to pick a “Primary Care Provider” (PCP). This is your main doctor. Any time you are sick, you must go to this doctor first. If you need a special doctor, like a heart doctor or a skin doctor, your main doctor must write a note giving you permission to go. This note is called a referral.
Texas Medicaid provides very good, comprehensive health coverage. For the most part, if a medical treatment is required to keep you healthy, Medicaid will pay for it.
Here is a list of the main things Texas Medicaid covers:
If your doctor says you need medicine, they will send a prescription to a pharmacy. You cannot go to just any pharmacy. You must go to a pharmacy that accepts Texas Medicaid. Most large pharmacies, like CVS, Walgreens, and Walmart, accept it.
When you go to the pharmacy, you show them your Medicaid card. The pharmacist will check to see if your medicine is on the “formulary.” This is a list of drugs that Medicaid agrees to pay for. If your medicine is on the list, Medicaid pays for it. If it is not on the list, your doctor will either have to change your medicine to one that is on the list, or the doctor must call Medicaid and explain why you absolutely need this specific drug.
For most people on Medicaid, prescriptions are completely free. If you are on CHIP, you might pay a very small fee, like $3.
This is where the rules are very different for children and adults.
For Children: Medicaid and CHIP are excellent for kids’ teeth and eyes. Children get free dental checkups, cleanings, x-rays, and fillings every six months. If a dentist says a child medically needs braces, Medicaid will pay for them. Children also get free eye exams and free glasses if they need them.
For Adults: Once you turn 21, the dental and vision benefits almost completely stop. Adult Medicaid does not pay for routine teeth cleanings or regular fillings. It only pays for emergency dental work, like if you have a terrible infection and need a tooth pulled to stop the pain. Adult Medicaid also does not usually pay for glasses, though it will pay for an eye doctor if you have a medical disease in your eye, like glaucoma.
Applying for Medicaid can seem scary, but it is actually a straight path if you take it one step at a time. Do not pay anyone to help you apply. Applying is always free.
Before you start, you need to collect papers that prove who you are and how much money you make. The state will ask for proof of everything you write on the application. You will need:
There are a few different ways to give your application to the state of Texas.
After you apply, you have to wait. By law, the state has up to 45 days to make a decision on your application. If you are pregnant, the state tries to move faster and usually makes a decision within 15 days. If you are applying for a disability program, it can take up to 90 days because doctors have to review your medical records.
While you are waiting, the state might mail you a letter asking for more information. For example, they might say, “We need a copy of your last pay stub.” If you get a letter like this, send the proof back immediately. If you do not send it by the deadline, they will deny your application.
If you are approved, you will get a big envelope in the mail. This is your welcome packet. It will tell you which program you are in (like STAR or STAR+PLUS). It will give you a yellow form. You must use this yellow form to pick your health insurance company and your main doctor.
Shortly after that, you will get a plastic card in the mail. It is called the “Your Texas Benefits” card. You must keep this card safe and bring it with you every time you go to the doctor or the pharmacy.
Medicaid is not forever. Texas will check your income and your living situation every single year to see if you still qualify. This yearly check is called a “renewal.”
About two months before your coverage is scheduled to end, the state will mail you a renewal packet. The packet will ask if anything has changed. Do you have a new job? Did you get a raise? Did someone move into or out of your house?
You must fill this packet out and send it back, along with new proof of your income. If you do not send it back, your Medicaid will be canceled, even if you still qualify.
You also have a rule you must follow all year long: you must report big changes. If you get a new job, if you move to a new address, or if you get married, you are required to tell the Texas Health and Human Services Commission within 10 days. If you move and do not tell them, they will mail your renewal packet to your old house, you will not see it, and you will lose your health insurance.
Sometimes, people get a letter saying they were denied Medicaid. This can happen for a few reasons. Maybe your income was too high. Maybe you forgot to send in a piece of paper. Maybe the state made a mistake.
If you are denied, you have two choices.
Choice 1: File an Appeal. If you believe the state made a mistake, you have the right to ask them to look at your case again. This is called an appeal. The denial letter will have instructions on how to ask for a “Fair Hearing.” You must ask for this hearing quickly, usually within 90 days of getting the letter. A judge who works for the state will listen to your side of the story, look at your papers, and decide if the denial was right or wrong.
Choice 2: Look at the ACA Marketplace. If your income truly is too high for Medicaid, or if you are an adult without children and Texas rules block you, you need another option. Your best choice is the Affordable Care Act (ACA) Marketplace. This is a system where the federal government helps pay for regular private health insurance. If your income is close to the poverty level, the government might pay almost the entire cost of the monthly bill. You can learn more about how this works on our state guide for Texas.
There is a specific rule that applies to seniors on Medicaid. It is called the Medicaid Estate Recovery Program (MERP).
If you are 55 or older, and Medicaid pays for you to live in a nursing home or pays for special care in your house, the state keeps a record of how much money they spent on you. After you pass away, Texas law says the state can try to get that money back from your “estate.” Your estate is the property you leave behind, which is usually your house.
The state will not take your house while you are alive, and they will not take it if your husband or wife is still living in it. They also will not take it if you have a child under 21 or a child with a disability. But if none of those exceptions apply, the state might force your family to sell the house to pay back the Medicaid bills. If you are a senior going into a nursing home, it is very wise to speak to a lawyer about how MERP works.
When you have a private health plan through Medicaid (like Blue Cross or Superior), there are rules about what they will pay for without asking questions. If you go to your regular doctor for a cold, the plan just pays the bill.
But if your doctor says you need something expensive—like an MRI scan, a special surgery, or a brand-name drug—your doctor must ask the health plan for permission first. This is called a “Prior Authorization.” The insurance company’s doctors will look at your chart and decide if they agree that you really need this test or treatment. If they say no, your doctor cannot do it, or you will have to pay for it yourself. Your doctor can appeal this decision if they think the insurance company is wrong.
Understanding Texas Medicaid takes time. The rules are strict, and the paperwork can be frustrating. But for millions of Texans, this program is the only way to see a doctor when they are sick, get medicine when they need it, and keep their children healthy.
Your first step is to figure out if you fit into one of the main groups: a child, a pregnant woman, a senior, a person with a disability, or a parent with a very low income. If you do, gather your pay stubs, your ID, and your birth certificates. Go to the Texas Health and Human Services Commission website and begin your application. Take your time, read every question carefully, and make sure you answer honestly.
If you do not fit into those groups, do not give up on getting health insurance. The ACA Marketplace has helped millions of Texans get coverage when Medicaid was not an option.