Medicaid Costs and Coverage in Texas

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“How much is Medicaid in Texas?” is a common question from Texas Medicaid applicants. Medicaid cost estimates will vary, depending on the coverage that the applicant qualifies to receive. The types of Medicaid insurance available will vary depending on the applicant’s life situation. It is also important to look at what services are covered by Medicaid and understand what does Medicaid not cover in order to know which services an applicant will have to pay out-of-pocket, since the Texas Medicaid program does not cover the entire cost of all medical services for all patients. Sometimes, Medicaid recipients have to pay copayments and deductibles to receive care. For answers to questions such as “How much does Medicaid cost in TX?” and more about what services Medicaid covers, read the following sections.

What services does Medicaid cover in Texas?

Texas Medicaid coverage receives funding from both the federal and the state governments. All states must offer mandatory Medicaid benefits coverage in compliance with required federal guidelines. The state government decides what services Medicaid covers beyond the required services, and this depends on the funding available in the state. Although this is not a complete list of mandatory benefits covered by Medicaid in TX, it will include the following services:

  • Laboratory services and x-rays
  • Inpatient and outpatient hospital services
  • Services at nursing facilities
  • Early screening, diagnostic and treatment services for certain conditions
  • Physician services
  • Family planning services

To obtain a comprehensive list of services covered by Medicaid, you can download our complimentary Medicaid guide.

What are the types of Medicaid insurance in Texas?

Texas Medicaid coverage is categorized into various classes, all of which depend on an applicant’s life situation when applying for Medicaid benefits. The following are the types of Medicaid insurance currently available in Texas.

Traditional Medicaid coverage in Texas is for those ineligible for benefits under the state’s STAR Health, STAR Kids, STAR+PLUS or STAR programs. Services that are covered by Medicaid in addition to mandated benefits under the traditional program vary by a patient’s needs, but some of the services traditional Medicaid insurance coverage includes are the following:

  • Emergency care
  • Medications
  • Care during pregnancy and childbirth
  • Mental health treatment
  • Glasses
  • Speech, physical, and occupational therapy

STAR, managed care Medicaid, is how most Texas Medicaid recipients receive coverage. Like all the special types of TX Medicaid benefits plans available in Texas, STAR requires that a recipient choose a plan from several plans, most of which come from regular insurance companies. A recipient of this type of Medicaid insurance must also choose a primary care doctor from the plan’s list. All plans also include specialists, hospitals, clinics and therapists that provide Medicaid services.

TAR KidsS provides Medicaid coverage in Texas to children and young adults (20 years of age and younger) who have disabilities. Like STAR, STAR Kids is a managed care program that offers various plans to its clients.

STAR+PLUS provides managed TX Medicaid care coverage to people 65 years of age or older or who have disabilities. Like the other STAR Medicaid coverage programs, recipients choose from various plans. In addition to the mandated federal and state benefits, STAR+PLUS will cover long-term support needs such as assistance with daily living, modification to the home environment, short-term care and help with household tasks.

Combined Medicaid and Medicare coverage plans are available for Texans who qualify. Clients may choose from plans available in their service areas. Services included in the combined Medicaid program varies by area.

What services does Medicaid not cover in Texas?

Services not covered by Medicaid in Texas include, but are not limited to, the following:

Home-based telehealth services for mental health patients: It is important to know what Medicaid does not cover for Medicaid recipients with mental health issues. TX Medicaid coverage will not extend to telehealth services for mental health conditions, unless the patient is inside an established health care site, a state-run mental health facility or a state-run supported living center

Elective cosmetic surgery (with a few exceptions): In general, Texas Medicaid coverage will not extend to cover cosmetic procedures. Medicaid will only cover elective cosmetic surgery if the procedure repairs or restores the function of the patient’s malformed body part, repairs damage due to an accidental injury or reconstructs a breast removed due to breast cancer.

To learn about other services that Medicaid does not cover, download our comprehensive Medicaid guide today.

How much does Medicaid cost in Texas?

“How much is Medicaid in Texas?” is one of the most important questions Texas Medicaid applicants ask. For Texans who meet eligibility guidelines for Medicaid coverage, enrollment itself is free. Some Texas residents who may not qualify for Medicaid can, however, buy into the coverage if they meet certain requirements.

The Medicaid Buy-In program provides low-cost Medicaid coverage for Texans with disabilities who work. TX Medicaid cost estimates for this program will vary, since the state bases the amount an individual must pay on the money the person earns from work and the amount he or she receives from rental property, Social Security benefits or other income.

The Medicaid Buy-In program for children offers Medicaid benefits coverage to children with disabilities whose families earn too much money to receive traditional Medicaid benefits.

Though enrollment in Medicaid is free for Texans, patients often have to pay certain out-of-pocket costs. Texas Medicaid costs vary, but they may include coinsurance, deductibles and copayments. There are, though, some federal limits to what out-of-pocket costs can include. Providers may not impose out-of-pocket costs for certain services, including emergency services, pregnancy-related care and family planning services. Furthermore, certain groups, including children, people with a terminal illness and people who reside in an institution are exempt from any out-of-pocket Medicaid costs.