Overview of the STAR+PLUS HCBS Program
Texas’ STAR+PLUS is a statewide Medicaid managed care program for elderly and disabled residents through which medical care and long-term care services and supports are provided. While nursing home care is available via STAR+PLUS, the STAR+PLUS Home and Community-Based Services (HCBS) suite of services, called the STAR+PLUS HCBS Program, provides benefits specifically intended to prevent and delay nursing home admissions for persons who require a nursing home level of care. Services and supports may include in-home personal care assistance, personal emergency response systems, adult day care, and respite care, allowing seniors and disabled individuals to live at home, the home of a loved one, an adult foster care home, or an assisted living residence rather than a nursing home.
STAR+PLUS HCBS’ program participants receive their healthcare and long-term care benefits via a single Medicaid plan provided by a managed care organization (MCO), essentially a private healthcare company. The MCO has a network of care providers and program participants receive services via these providers. With STAR+PLUS HCBS, there are several healthcare plans from which a program participant can choose. Persons who are “dual eligible”, meaning they are eligible for Medicare and Medicaid, are able to participate in this program. However, they will continue to receive their medical care via Medicare. Texas does offer a Dual Demonstration Program, a managed care program in which persons can receive both their Medicaid and Medicare benefits. Persons enrolled int the Dual Demonstration Program are still able to access long-term care benefits via the STAR+PLUS HCBS Program.
There is some flexibility of providers for persons receiving home and community based services via STAR+PLUS, as select care services may be consumer directed. This means that rather than receive services by the MCO’s network of licensed care providers, a program participant can hire their own caregiver. While spouses cannot be hired, other family members, such as one’s adult child or grandchild, can be hired. A financial management services agency handles the financial aspects of employment responsibilities such as background checks, tax withholding, and caregiver payments.
STAR+PLUS HCBS is not an entitlement, which means meeting eligibility requirements does not equate to immediate receipt of program benefits. Instead, the program has a limited number of participant enrollment slots, and when these slots are full, an interest list (waitlist) for program participation forms.
Texas previously had a Medicaid Waiver called Community Based Alternatives (CBA). HCBS available via this waiver were absorbed into the STAR+PLUS HCBS Program. The STAR+PLUS HCBS Program may also informally be called the STAR+PLUS Waiver. STAR+PLUS operates through a 1115(a) Demonstration Waiver called the Texas Healthcare Transformation and Quality Improvement Program (THTQIP).
Benefits of the STAR+PLUS HCBS Program
Program participants receive Medicaid healthcare services in addition to long-term services and supports. Follows is a list of potential home and community based services available. An individualized service plan will determine which benefits a program participant will receive. This means meeting waiver requirements does not guarantee receipt of all benefits.
Some care services can be participant-directed, meaning the beneficiary is able to choose their care provider. These are indicated by an asterisk (*) below.
– Adaptive Aids – specialized medical equipment to assist persons in communicating or completing daily living activities
– Adult Day Health Care – formally called Day Activities and Health Services (DAHS) – provides daytime personal care assistance and supervision in a group setting
– Adult Foster Care Services – personal care assistance and homemaker services in an adult foster care home
– Assisted Living Services – assistance with personal care, homemaker tasks, and medication management
– Financial Management Services – for persons who self-direct their care services
– Home Delivered Meals
– Home Modifications – adding grab bars, wheelchair ramps, etc. for safety and accessibility purposes
– Medical Supplies
– Nursing Services*
– Personal Assistance Services* – non-medical in-home assistance with personal hygiene, dressing, toileting, eating, etc.
– Personal Emergency Response Services
– Primary Home Care (PHC) – personal care assistance for persons with health issues
– Respite Care* – short-term care to alleviate a primary caregiver
– Service Coordination
– Therapies* – cognitive rehabilitation, occupational, speech-language, and physical
– Transitional Assistance Services – covers security deposits, utility set-up fees, moving expenses, etc. for persons transitioning from a nursing home to a home
While services and supports can be provided in adult foster care homes and assisted living residences, the cost of room and board in these settings is not covered by Texas Medicaid.
Eligibility Requirements for STAR+PLUS Program
The STAR+PLUS HCBS Program is for Texas residents who are elderly (65+) or a minimum of 21 years old and disabled who are at risk of nursing home placement. Additional eligibility criteria are listed below. Reading these criteria can be confusing. An as alternative, one can take a Texas Medicaid eligibility test here.
Financial Criteria: Income, Assets & Home Ownership
The applicant income limit is equivalent to 300% of the Federal Benefit Rate (FBR), which increases on an annual basis in January. In 2021, an applicant, regardless of marital status, can have a monthly income up to $2,382. When both spouses are applicants, each spouse is considered individually, with each spouse allowed income up to $2,382 / month. When only one spouse is an applicant, the income of the non-applicant spouse is not counted towards the income eligibility of his/her spouse. Furthermore, monthly income from the applicant spouse can be transferred to the non-applicant spouse as a spousal income allowance, also called a monthly maintenance needs allowance. The maximum amount that can be transferred is $3,259.50 / month and is intended to ensure the non-applicant spouse has a minimum monthly income of this amount. Non-applicant spouses who have their own monthly income equal to or greater than $3,259.50 are not entitled to a spousal income allowance.
In 2021, the asset limit is $2,000 for a single applicant. For married couples, with both spouses as applicants, the asset limit is $3,000. When only one spouse is an applicant, the assets of both the applicant and non-applicant spouse are limited, though the non-applicant spouse is allocated a larger portion of the assets to prevent spousal impoverishment. (Unlike with income, Medicaid considers the assets of a married couple to be jointly owned). In this case, the applicant spouse can retain up to $2,000 in assets and the non-applicant spouse can keep up to $130,380. This larger allocation of assets to the non-applicant spouse is called a community spouse resource allowance.
Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.
Assets should not be given away or sold under fair market value within 60-months of long-term care Medicaid application. This is because Medicaid has a look back rule and violating it results in a penalty period of Medicaid ineligibility.
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take their home. Fortunately, for eligibility purposes, Texas Medicaid considers the home exempt (non-countable) in the following circumstances.
– The applicant lives in the home or has “intent” to return to the home and his / her home equity interest is no greater than $603,000 (in 2021). Home equity interest is the current value of the home minus any outstanding mortgage.
– A non-applicant spouse lives in the home.
– The applicant has a dependent relative living in the home.
To learn more about the potential of Medicaid taking the home, click here.
Medical Criteria: Functional Need
An applicant must require a nursing facility level of care (NFLOC) to be eligible for the STAR+PLUS HCBS Program. A Medical Necessity and Level of Care (MN/LOC) Assessment is completed by the managed care organization and signed by a physician. It is then electronically submitted to the Texas Medicaid & Healthcare Partnership (TMHP), who determines if this level of care need is met. One area considered is one’s ability / inability to independently complete the activities of daily living (i.e., transferring from the bed to a chair, mobility, eating, toileting, eating). Relevant to some persons with Alzheimer’s disease or a related dementia, behavioral problems, such as regular attempts to leave the facility or removal of one’s clothes, are also considered. A diagnosis of dementia in and of itself does not mean one will meet a NFLOC.
Qualifying When Over the Limits
Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for Medicaid. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.
When persons have income over the limits, Miller Trusts, also called a qualified income trust can help. “Excess” income is deposited into the trust, no longer counting as income.
When persons have assets over the limits, one option is to “spend down” assets. Examples include paying off debt, making home modifications for accessibility and safety purposes, and purchasing pre-paid funeral and burial expense trusts called Irrevocable Funeral Trusts. Another option are annuities that turn countable assets into a stream of income. There are many other options when the applicant has assets exceeding the limit.
Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid planners are educated in the planning strategies available in the state of Texas to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Furthermore, there are additional planning strategies that not only help one meet Medicaid’s financial criteria but can also protect assets for family as inheritance. These strategies often violate Medicaid’s 60-month look back rule, and therefore, should be implemented well in advance of the need for long-term care. However, there are some workarounds, and Medicaid planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid planner.
How to Apply for the STAR+PLUS Program
Before You Apply
Prior to applying for the STAR+PLUS HCBS Program, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid eligibility test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid eligibility test.
As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, bank statements up to 60-months prior to application, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are held up is required documentation is missing or not submitted in a timely manner.
Since the STAR+PLUS HCBS Program is not an entitlement program, there may be a waitlist for program participation. Currently, approximately 24,000 persons per year can be served via this program. In the case of a waitlist, an applicant’s access to a participant slot is based on the date of Medicaid application. One exception exists; Persons who enroll via Money Follows the Person are put at the top of the waitlist.
To apply for the STAR+PLUS HCBS Program, applicants must be eligible for Texas Medicaid. State residents may apply online at Your Texas Benefits or by calling 2-1-1. Alternatively, persons can request an application for Medicaid for the Elderly and People with Disabilities (Form H1200) be mailed or downloaded here. Applicants who are eligible for STAR+PLUS will receive a packet in the mail that includes information about the program and enrolling in a managed care health plan. Persons have 15 days to enroll in a health plan or one will automatically be assigned. Within 30 days of program enrollment, a service coordinator will conduct an in-home visit and an individualized service plan will be developed.
For additional information about the STAR+PLUS HCBS Program, click here. Persons can also call 2-1-1 or 877-541-7905 for information and / or assistance.
The Texas Health and Human Services Commission (HHSC), an agency within Texas Health and Human Services (HHS), administers the STAR+PLUS HCBS Program. It was previously administered by the Department of Aging and Disability Services (DADS). However, in 2017, DADS was abolished.
Approval Process & Timing
The Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed even further. In most cases, it takes between 45 and 90 days for the Medicaid agency to review and approve or deny one’s application. Based on law, Medicaid offices have up to 45 days to complete this process (up to 90 days for disability applications). However, despite the law, applications are sometimes delayed even further. Furthermore, as an interest list may exist, approved applicants may spend many months waiting to receive benefits.