What are the basic eligibility requirements for long-term care Medicaid in Texas?

There are five basic requirements that must be satisfied in order to receive nursing home Medicaid services. The requirements are as follows:

1. Nationality and Residency. The Medicaid applicant must be either a U.S. citizen or an alien with qualified alien status. Additionally, the applicant must be a resident of Texas. There is no length of residence requirement. The applicant merely needs to reside in Texas and intend to remain or return to Texas.

2. Medicaid Facility, Medicaid Bed. To receive long-term care Medicaid, the applicant must be in a Medicaid certified facility and in a Medicaid bed for at least 30 consecutive days.

3. Medical Necessity. The Medicaid applicant must have “medical necessity” for nursing home care. The individual’s medical condition must be sufficiently serious that it requires the services of licensed nurses in an institutional setting. The medical services must be ordered by a physician and the conditions requiring regular skilled nursing care must be documented.

4. Income. The Medicaid income limit for an unmarried Medicaid applicant is $2,163 per month (in 2014). The income cap for a married applicant with an ineligible spouse is also $2,163 per month (in 2014). Importantly, this income cap is only applied to the income apportioned to the Medicaid eligible spouse using “the name on the check rule.” In other words, income received in the name of the ineligible spouse is not counted as income to the Medicaid eligible spouse. If both spouses live in the nursing home and apply for Medicaid, the income limit is doubled. The Medicaid income cap for a married couple, both of whom apply for or are receiving Medicaid is $4,326 per month (in 2014). If the above income caps are exceeded, a Qualified Income Trust (also known as a QIT or Miller Trust) can be used to overcome the income barrier to Medicaid eligibility.

5. Resources. Resources are categorized as “countable” and “excluded” for eligibility purposes. The resource eligibility limits, like the income limits, depend on whether the Medicaid applicant is married, married with an ineligible spouse, or has a spouse who is also applying for Medicaid benefits. Countable resources are counted as of 12:01 a.m. on the first day of the month.

The countable resources limit for an unmarried applicant is $2,000.
The countable resource limit for a married applicant with an ineligible spouse is one half of the couple’s combined countable resources as of 12:01 a.m. of the first day of the month in which the eligible spouse began a period of continuous institutional care (i.e. first day of the month in which the eligible spouse was admitted to the nursing home or hospital, known as the “snapshot date”), subject to a minimum of $23,448 and a maximum of $117,240 (in 2014), known as the “spousal protected resource amount” or SPRA. The SPRA can be “expanded” if the married couple’s combined income is less than $2,931 per month (in 2014).
The countable resource limit for a married couple, both of whom are applying for Medicaid nursing home benefits is $3,000.
If both spouses live in the nursing home and only one spouse is applying for Medicaid, the countable resource limit for the applying spouse is $2,000. The countable resource limit for the spouse that is not applying for Medicaid is unlimited.

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