Texas Medicaid Program: Eligibility, Coverage, and Administration

Texas Medicaid is a joint federal-state health coverage program serving low-income individuals and families across Texas. Administered at the state level by the Texas Health and Human Services Commission (HHSC), the program operates under federal Medicaid statute (42 U.S.C. § 1396 et seq.) and delivers medical, behavioral, and long-term care services to eligible residents. The program's eligibility structures, covered services, and administrative processes are governed by a combination of federal Centers for Medicare & Medicaid Services (CMS) requirements and state-specific rules codified in the Texas Administrative Code. Understanding these structures is essential for providers, policy researchers, and applicants navigating coverage determinations in Texas.

Definition and scope

Texas Medicaid is a means-tested public health insurance program jointly financed by the federal government and the State of Texas. The federal share, known as the Federal Medical Assistance Percentage (FMAP), varied for Texas at approximately 61.82% for federal fiscal year 2024 (CMS FMAP Data), with the state funding the remaining share through general revenue and other sources.

The program is administered through the Texas Health and Human Services system, with HHSC serving as the single state agency responsible for program integrity, eligibility determination, and managed care contracting. Day-to-day service delivery is largely delegated to managed care organizations (MCOs) under contracts overseen by HHSC.

Scope and geographic coverage: Texas Medicaid applies exclusively to residents of Texas meeting state-defined eligibility criteria. This page addresses Texas-specific program rules only. Federal Medicare, the Children's Health Insurance Program (CHIP) as a standalone program, and Medicaid rules in other states are outside this page's coverage. Coordination between Texas Medicaid and Medicare for dual-eligible beneficiaries is governed by separate federal requirements and is not addressed in full here.

How it works

Texas Medicaid operates primarily through a managed care delivery model. Eligible enrollees are assigned to or select an MCO, which then coordinates and authorizes covered services through a contracted provider network. Fee-for-service (FFS) Medicaid remains available for specific populations, including certain individuals with complex needs or those in rural areas with limited MCO access.

Eligibility determination follows a structured sequence:

  1. Application submission — Applications are submitted through YourTexasBenefits.com, by mail, or in person at a local HHSC benefits office.
  2. Identity and residency verification — Applicants must document Texas residency and U.S. citizenship or qualifying immigration status per (8 U.S.C. § 1611 and related federal Medicaid rules).
  3. Income assessment — Income is measured against the Federal Poverty Level (FPL). Children under age 1 may qualify at up to 198% FPL; pregnant women at up to 198% FPL; parents and caretaker relatives at a significantly lower threshold dependent on household size (Texas HHSC Medicaid eligibility tables).
  4. Category assignment — Approved applicants are enrolled into the appropriate eligibility category (e.g., STAR, STAR+PLUS, STAR Health, or STAR Kids), each corresponding to a specific population and service set.
  5. MCO enrollment — Enrollees in managed care regions select or are auto-assigned to an MCO within 30 days of eligibility approval.

Covered services under Texas Medicaid include physician visits, inpatient and outpatient hospital care, prescription drugs, laboratory services, mental health and substance use disorder treatment, personal attendant services, and long-term services and supports (LTSS) for qualifying individuals. Dental and vision services are covered for children enrolled in STAR and STAR Health.

Common scenarios

Children and families represent the largest enrollment category in Texas Medicaid. Children qualify under STAR managed care when household income falls within program thresholds. Pregnant women who do not qualify for full Medicaid may qualify for Emergency Medicaid or limited prenatal coverage.

Individuals with disabilities and long-term care needs are typically enrolled in STAR+PLUS, which integrates acute care with LTSS including home and community-based services (HCBS). STAR Kids specifically serves individuals under age 21 with complex medical needs or disabilities, coordinating with the Texas Department of Family and Protective Services (DFPS) for children in foster care under STAR Health.

Dual-eligible individuals — those qualifying for both Medicare and Medicaid — receive Medicare as the primary payer. Texas Medicaid covers Medicare cost-sharing and certain supplemental services not covered by Medicare. This population often receives coordination through STAR+PLUS or standalone Medicare Savings Programs (MSPs).

Undocumented residents do not qualify for full Texas Medicaid benefits. Federal law restricts full Medicaid to qualified immigrants; Emergency Medicaid covers only treatment of emergency medical conditions for otherwise ineligible individuals (42 C.F.R. § 440.255).

Decision boundaries

The most consequential determination in Texas Medicaid is the distinction between categorical eligibility groups, as each group carries different income thresholds, covered benefits, and managed care program assignments.

STAR vs. STAR+PLUS: STAR serves children and low-income adults primarily requiring acute and primary care. STAR+PLUS serves adults with disabilities or complex chronic conditions requiring integrated LTSS. An individual aging out of STAR or developing a qualifying disability may transition between programs; HHSC conducts functional assessments to determine LTSS eligibility.

CHIP vs. Medicaid: Children whose household income exceeds full Medicaid thresholds but falls below 200% FPL may qualify for CHIP rather than Medicaid. CHIP carries cost-sharing requirements absent in full Medicaid. This boundary is income-driven and determined at application.

Continuous coverage and redetermination: Texas Medicaid eligibility is not permanent. HHSC conducts annual redeterminations; failure to return required documentation within the notice period results in disenrollment. The Texas Comptroller of Public Accounts provides appropriations data relevant to program funding cycles, which directly affect managed care capitation rates set by HHSC each state fiscal year.

For a broader orientation to state agency structures governing programs like Medicaid, see the Texas Government Authority site index.

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