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What is Medicaid?

When looking for health insurance in Texas, you want to purchase the best insurance for your family. You would shop the Marketplace within the Affordable Care Act if you could, and perhaps you even tried, but when you began to shop, you could only see the premiums. You were saddened that those policies were out of your price range, even on the low end. You need to follow the mandate and you only wished your small employer offered you a health insurance benefit. But did you know there is an option with Texas Medicaid?

What is Medicaid Insurance for Texas? 

When you live within the state of Texas, you have the option to obtain health insurance and adhere to the ACA guidelines. Texas Medicaid is a program that helps low-income families obtain health insurance that would not be able to find affordable coverage otherwise. You can qualify for health insurance coverage through the program if you fall within certain criteria like household income, family size, or disability.

How Do I Qualify for Texas Medicaid Insurance?

The first thing that must be understood is that Medicaid was originally designed with children being the focus. Seeing a high number of low-income adults without coverage, the federal government expanded the program by lowering the threshold for enrollment. Adults can now also obtain health insurance coverage. We will get into how in a moment. Second, two different types of programs are available: Medicaid and CHIP. CHIP is the Children’s Health Insurance Program. It behaves just as it sounds—health insurance for children alone. This is designed for those who earn too much to qualify for the Medicaid program. CHIP will cover pregnant women and their children up to their 19th birthday. It acts the same as medical coverage, the only difference is the income criteria.

As for Texas Medicaid, there are certain conditions that must be met. It is unlike traditional ACA health insurance, where you simply apply, and you’re covered. While there are no significant questions about health condition, the primary criteria for Texas Medicaid are your financial status and residency. 

It is also important to understand to obtain Medicaid insurance in Texas, you need to meet one of the following stipulations:

  • You must be pregnant.
  • Responsible for a child under the age of twenty
  • You need to be blind
  • You or a member of your immediate household must have a disability
  • A member of the immediate household must be sixty-five or older
  • The household must meet annual income levels for the maximum household size

If you do not meet one of the above conditions, you will most likely not qualify for Medicaid. As mentioned, this will include residential status. One must be a permanent resident of Texas with proof of legal status in the United States. 

NOTE: There is another restriction on Medicaid. At the beginning of the new year, they do not automatically assume your status is unchanged. You must reapply every year, even if your home situation remains the same. This can be tedious, but if you fail to reapply or forget, come January 1, you will not have coverage.

What does Medicaid Cover?

Like all Affordable Care Act Marketplace insurance plans, Medicaid plans will cover your medical insurance needs. It is comprehensive in its coverage.

Medicaid at the federal level is mandated to cover these 16 benefits:

  • Hospital services for inpatients
  • Hospital services for outpatients
  • Health screenings for individuals and children under age 21
  • Nursing facility care
  • Home healthcare
  • Physician checkups and other services
  • Rural health clinic visits
  • Visits to federally qualified health centers
  • Laboratory tests and X-rays
  • Family planning
  • Nurse midwife care
  • Maternity and newborn care
  • Visits to pediatric and family nurse practitioners
  • Visits to licensed freestanding birth centers
  • Emergency and non-emergency medical transportation
  • Tobacco cessation programs for pregnant women

Within the state of Texas, Medicaid has additional features. These can include:

  • Dental Care
  • Optometrists/Eyeglasses
  • Oral Care
  • Hearing Aids
  • Psychologists
  • Inpatient Psychiatric care for under twenty-one
  • Hospice care
  • Home Medical Equipment
  • Occupational Therapy
  • Speech/Language Therapy

These are just some of the features Texas Medicaid makes available to recipients. There may be other services available that vary by the medical plan you have. These can include substance abuse and mental health services. You can check with your insurance company and healthcare provider to see which services would be available to you. 

As you can see, this list is comprehensive. One of the benefits of having a Medicaid insurance plan is that you, as the insured party, often do not pay for services. Most coverage with Medicaid in Texas is cost-free. However, there may be instances where a co-pay may be involved. 

How Do I Apply for Texas Medicaid?

You first need to know that you do not have to wait for Open Enrollment. You can apply for Medicaid or CHIP at any time. Visit the Health Insurance Marketplace website to begin your application for Medicaid there. 

You begin by first applying for Health Insurance through the Marketplace. The ACA Marketplace platform itself will assist you in letting you know if you qualify for Texas Medicaid. There are a couple of ways to go about this:

  • If you currently do not have health insurance. You simply apply for coverage with your information. If you are eligible, the Marketplace will pass on your information to the Texas Medicaid agency, and you will be contacted about continuing the enrollment process. 
  • If you currently have health insurance. There are a few extra steps you will need to follow if you choose to switch to a Medicaid policy from your current Marketplace insurance policy. First, it is okay to have both. However, if you are receiving subsidies, you need to report the change. Understand you will lose any premium tax credit you are receiving for the child with the Medicaid benefits, and you will now need to pay full price for the Marketplace plan for the child. You also have the option to unenroll from the Marketplace plan. 

When you click submit, you will be notified your application is under consideration. They do not tell you how long the wait is, but you will be notified by a email about your options should you qualify. When you submit your application, you will also be given options on which Marketplace insurance plans you qualify for and if you meet the requirement to receive premium tax credits to help you save on your monthly payments if they are available.

What if I Don’t Qualify for Texas Medicaid Insurance?

If you don’t qualify for Medicaid, you always have the option to sign up for one of the many Affordable Care Act Marketplace plans. They do not have age or income restrictions on their insurance policies. Many policies can be more affordable than one may think. 

There are certain situations where some do not qualify for an ACA Marketplace plan. While this is rare, it does happen. In these instances, there are policies that are called Catastrophic health plans. These cover emergencies such as homelessness, you were to have filed for bankruptcy, you experienced a flood or fire, cared for an ill family member, or you suffered from domestic violence. There are also insurance policy reasons, like a state that had yet to expand eligibility for Medicaid under the Affordability Act.

The Expansion of Texas Medicaid Insurance

Texas is among the twelve states that have yet to opt in to the Medicaid expansion. This has left many who could be insured, uninsured. One of the biggest advantages of the expansion is that it would allow adults without children to be covered and those within the coverage gap to find their application approved. 

Speaking of allowance, the expansion for Medicaid would increase from 14 percent of the poverty level to 137 percent of the poverty level. This would amount to a payment from about $300 per month to near $3000 per month for a family of four for each needy Texan and their family. 

Final Thoughts

Finding health insurance coverage can be a stressful ordeal, especially for those who may not be able to purchase ACA policies. Medicaid is in place to provide children and their families with a means to receive adequate medical care. Cover Mile is here to assist you. We aim to find the best health insurance plan in Texas that will fit your budget and meets Affordability Care Act mandates providing you with quality health insurance.