How Medicaid Covers Long-Term Care in Texas

STAR+PLUS: how Texas actually delivers Medicaid long-term care

STAR+PLUS is the managed care program through which Texas delivers Medicaid to adults who are 65 or older and to adults with disabilities. Enrollment is mandatory across most of the state. A member picks a health plan, the plan assigns a service coordinator, and that coordinator authorizes the long-term care services a person actually receives, with no state caseworker standing behind them to appeal to first.

Section 1915(c) waivers let a state pay for long-term services in the home or community instead of an institution, limited to populations who would otherwise need an institutional level of care 1Ref 1Centers for Medicare & Medicaid Services (2025).Home & Community-Based Services 1915(c).That Section 1915(c) HCBS waivers let states provide long-term services and supports in the home or community instead of an institution, targeted to specific populations who would otherwise need an institutional level of care.. Texas operates several of them, but the ones most people have heard of target intellectual and developmental disabilities or deaf-blindness rather than aging. For an older adult in Texas, the community door is the STAR+PLUS Home and Community Based Services program — worth learning precisely, because it is the thing with the queue attached.

A service coordinator is the health plan's employee who authorizes hours and services. In Texas this person, not a state office, is the first place to escalate when the authorized care does not match the need.

What a Texas interest list is, and why it is not quite a waiting list

An interest list is Texas's name for the queue to enter a waiver program or STAR+PLUS HCBS. It is not a waiting list in the ordinary sense, because position is set by the date a name went on it, not by how sick that person is. Someone in crisis does not move up. Someone who signed on years ago and no longer needs anything still holds their place.

This produces the advice Texas elder law attorneys give more often than any other, and that families almost always hear too late: put the name on the list before there is a need, because the list does not measure need. There is no cost to being on it and no obligation to accept services when the name comes up. Lists are kept by program, and one person can sit on several.

The interest list rewards the date you signed up and nothing else. Adding a name costs nothing and commits you to nothing.

Nursing facility care works the other way, and that asymmetry drives more Texas outcomes than any rule does. A person who meets both the level-of-care standard and the financial test can enter a Medicaid-funded nursing facility without waiting for any list. The institutional door stands open. The community door has a queue in front of it.

Does STAR+PLUS pay for assisted living in Texas?

Yes, once a person is actually enrolled in STAR+PLUS HCBS. The program can pay for assisted living as a service setting, covering personal care, medication oversight and the supervision the residence provides. It does not pay room and board. The resident puts their own income toward that and keeps a personal needs allowance, and the residence has to hold a contract with that member's specific health plan.

Texas licences assisted living facilities by type, and the type is a safety fact rather than a marketing one. A Type A licence covers residences whose residents can evacuate the building without staff help. A Type B licence covers residences permitted to serve people who need staff assistance to evacuate, who cannot follow directions in an emergency, or who need overnight attendance. A parent whose mobility is quietly declining may be living somewhere that is not licensed for the person they are becoming.

So two blunt questions belong on any Texas tour: which licence type do you hold, and which STAR+PLUS plans do you contract with. A residence can take Medicaid through one plan and not another, so "we accept Medicaid" resolves neither.

The CareScout Cost of Care Survey publishes state-level medians alongside national ones, and the Texas figures are their own numbers 2Ref 2CareScout (Genworth) (2024).Cost of Care Survey 2024.That the 2024 Cost of Care Survey reports state median costs for assisted living, nursing homes and home care alongside national medians, so a state's own figure differs from the national one.. Reading your state's median before touring sets a realistic expectation of the room-and-board share a family carries every month.

The Texas pathway that has no interest list

Texas runs a personal attendant benefit outside the waiver structure, and it does not use an interest list. Community Attendant Services provides in-home help with bathing, dressing, meal preparation and household tasks for people who meet a functional-need standard and an income test. It is narrower than STAR+PLUS HCBS and it will not fund assisted living. It is also available now rather than in several years.

That matters most to the family whose parent needs help today and whose name went onto an interest list last week. Attendant care is not the full package, but for many households it is the difference between a parent staying home another two years and not.

The structural distinction predicts how any Texas program will behave. Waiver services are capped in number, which is why a queue forms in front of them. State plan services such as attendant care are an entitlement for people who qualify, which is why they are not queued and also why they are drawn more narrowly. Ask which category a program sits in and you will know what to expect.

Programs of All-Inclusive Care for the Elderly are a third possibility in some counties. PACE covers everything Medicare and Medicaid cover plus whatever the interdisciplinary team judges necessary, and Medicaid enrollees generally pay no premium and no cost-sharing for PACE-approved care 3Ref 3Centers for Medicare & Medicaid Services (2025).Programs of All-Inclusive Care for the Elderly Benefits.That PACE provides all Medicare- and Medicaid-covered services plus anything the interdisciplinary care team deems necessary, and that enrollees with Medicaid generally pay no monthly premium and no cost-sharing for PACE-approved care.. It operates only inside defined service areas, so the question is whether a program reaches your county.

Texas has an income cap and no Medicaid expansion, and both bite

Texas sets a hard monthly income cap for long-term care eligibility instead of allowing a spend-down. Income one dollar over the cap disqualifies a person outright, regardless of the bill in front of them. The fix is a Qualified Income Trust, known in Texas as a Miller trust, which routes the excess through a trust account each month so the eligibility formula stops counting it.

The trust is plumbing, not shelter. The money still goes to the cost of care; only its treatment on the application changes. It must be drafted correctly and funded every month, and a lapse can undo the eligibility it was created to establish.

Texas is also among the states that did not adopt the Medicaid expansion, and the absence has a specific consequence: no adult coverage group sits underneath the long-term care rules to catch someone who falls short of them. In an expansion state across the border, an older adult with low income who does not qualify for long-term care may still have Medicaid for ordinary medical care. In Texas they frequently have nothing until they are frail enough to clear the long-term care standard. That is one reason medicaid waivers by state cannot be reasoned about by analogy from a neighbour.

The cap figure, the asset limit and the transfer look-back each change on their own schedule. Those numbers belong on a Texas Health and Human Services page, not in an article.

What Medicare pays for, and for exactly how long

Original Medicare covers medically necessary skilled care in a certified skilled nursing facility. It does not cover long-term custodial care, meaning help with bathing, dressing, eating and moving, when that is the only care a person needs 4Ref 4Centers for Medicare & Medicaid Services (2026).Nursing home care.That Original Medicare covers only medically necessary skilled care in a certified skilled nursing facility, and not long-term custodial care when that is the only care a person needs.. The distinction turns on whether a skilled professional is required, and it can flip inside a single week.

Families in Texas find this out at the same moment families everywhere do: partway through a rehabilitation stay, when the skilled need ends and the bill converts to private pay. Nothing about the parent changed that morning. The billing category did.

That is usually when the STAR+PLUS question gets asked for the first time, and by then it is late. If the person is heading into a facility, the Medicaid nursing facility route has no interest list. If the plan is to bring them home, the interest list clock should have started years earlier. Nobody is penalised for planning early and not needing it. Joining the list costs nothing and obliges nothing.

Spousal protections, and what Texas recovers afterward

Federal spousal-impoverishment rules apply in Texas. When one spouse needs institutional or waiver long-term care expected to last at least 30 days, a share of the couple's combined income and assets is protected for the spouse staying in the community, through the Community Spouse Resource Allowance and the Minimum Monthly Maintenance Needs Allowance 5Ref 5Centers for Medicare & Medicaid Services (2025).Spousal Impoverishment.That spousal-impoverishment rules protect a portion of a couple's income and assets for the community spouse through the Community Spouse Resource Allowance and the Minimum Monthly Maintenance Needs Allowance, when the other spouse needs institutional or waiver long-term care lasting at least 30 days.. The asset figure rests on a snapshot taken at the start of the care episode, so the date of a hospital admission can matter as much as the balances.

Two Texas notes sit alongside the federal rule.

• Estate recovery here has a start date. The Texas Medicaid Estate Recovery Program reaches people who began receiving long-term care services on or after March 1, 2005 — worth confirming against current program material if the timing is close to your situation. It carries exemptions and hardship waivers, and its interaction with Texas homestead protections is intricate — an elder law attorney's question, not an internet answer.
• The ombudsman is free, and does not work for the facility. Every state operates a Long-Term Care Ombudsman program advocating for residents of nursing homes, assisted living and board-and-care homes, and resolving complaints about their health, safety, welfare and rights 6Ref 6Administration for Community Living (HHS) (2025).Long-Term Care Ombudsman Program.That a State Long-Term Care Ombudsman program operates in every state, advocating for residents of nursing homes, board-and-care and assisted living facilities and resolving complaints about their health, safety, welfare and rights.. It covers assisted living too — useful, because that oversight is thinner.