Health Coverage in Texas After an SSI or SSDI Approval

Do Texas SSI recipients get Medicaid automatically?

Yes. The Texas Health and Human Services Commission (HHSC) states in its Medicaid handbook that people found eligible for SSI cash payments are automatically eligible for Medicaid. Social Security reports the approval to the state through a data exchange, and HHSC certifies Medicaid and sends a Your Texas Benefits Medicaid card.

Texas is one of the states where Social Security makes the Medicaid decision for SSI recipients. Social Security's manual, POMS SI 01730.005, explains that in states with a section 1634 agreement an SSI application is also an application for Medicaid. A companion section, POMS SI 01715.010, names the states that use other arrangements, and Texas is not on either list.

So the real work sits in the SSI claim itself. In Texas an SSI approval is a health coverage decision as much as a cash decision, which is why it is worth checking whether you qualify for SSI as well as SSDI before you file. Our national guide to Medicaid with SSI covers the federal rules that sit underneath the Texas ones.

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How Texas Medicaid works for adults on SSI through STAR+PLUS

Texas delivers Medicaid to many adults on SSI through a health plan. HHSC describes STAR+PLUS as a Medicaid managed care program for adults with disabilities and adults 65 and older, and it lists adults 21 or older who receive SSI and qualify for Medicaid on low income among the people who can be in the program.

Members choose a health plan, and a service coordinator helps set goals and build a service plan. Beyond medical care, HHSC lists long-term services and supports such as help with daily activities at home, home modifications, short-term caregiver breaks and emergency response services. Members approved for STAR+PLUS home and community-based services can also receive therapies, medical supplies and home-delivered meals.

Choosing among health plans is outside what we handle as Social Security lawyers, but the timing is not. Medicaid in Texas follows the SSI approval, so a delayed or denied SSI claim delays the coverage that comes with it. That is one more reason an SSI appeal deserves the same attention as an SSDI appeal.

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Keeping Texas Medicaid when Social Security benefits end SSI

Some people lose SSI because another Social Security benefit starts or rises, and Texas keeps Medicaid open for several of those groups. HHSC's handbook lists them among its mandatory coverage groups:

• The Pickle group: people who lost SSI for any reason since April 1977, were once eligible for and entitled to both SSI and Social Security in the same month, and would still qualify for SSI if the Social Security cost-of-living increases received since that month were left out of their income.
• Disabled adult children: people 18 or older who became disabled before 22 and were denied SSI because disabled adult child benefits on a parent's record started or increased.
• Disabled widows and widowers: people age 50 to 60 who are not eligible for Medicare and were denied SSI because of disabled widow's or widower's benefits.

These groups do not cover the case where SSDI on your own work record is large enough to end SSI. Pickle leaves out only the Social Security cost-of-living increases received since you were eligible for and entitled to both SSI and Social Security in the same month, and the other two groups cover benefits paid on a parent's or a spouse's record. Whether Medicaid continues when SSI ends depends on which group, if any, fits the history, and that is worth settling before the SSI stops, not after the Medicaid card is canceled.

None of these groups is automatic in the way SSI Medicaid is. Each has its own conditions in the HHSC handbook, and the dates and benefit types in your Social Security record are the evidence that places you in one.

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Health coverage during the SSDI Medicare waiting period in Texas

Medicare for SSDI beneficiaries begins with the 25th month of entitlement to disability benefits, under Social Security's manual at POMS HI 00801.146. The same section explains that federal law waives that wait for amyotrophic lateral sclerosis (ALS). Entitlement itself usually starts only after SSDI's own five-month waiting period, which our SSDI waiting period guide explains, so the two waits usually stack.

SSDI by itself does not bring Texas Medicaid. Three Medicaid routes are worth checking for a Texan waiting on Medicare, and the first is the one we handle:

• SSI, if your income and resources are low enough, since a Texas SSI approval brings Medicaid automatically.
• The Texas Medicaid Buy-In for adults, which treats anyone already receiving Social Security disability benefits as meeting its disability rule and requires that you be working.
• STAR+PLUS home and community-based services, which HHSC opens to adults 21 or older who have full Medicaid financial eligibility, an approved medical necessity for a nursing facility level of care and a service plan within the program's cost limit.

The Medicaid Buy-In has its own earnings and asset limits and a monthly fee for some members, and HHSC publishes the current figures on its Buy-In page, which is the place to check them, since printed numbers here would go out of date. The Buy-In application goes to HHSC, not to Social Security.

Two features of the Buy-In surprise people on SSDI. HHSC says it does not apply Social Security's guidelines about limits on working or the amount you earn from a job, so the program is built for exactly the person who is working despite a disability. You must also live in Texas and not live full time in a state institution or nursing home. The application is HHSC form H1200, available by calling 2-1-1, at an HHSC benefits office or as a download from HHSC, and HHSC aims to decide within 45 days, or up to 90 when it needs more information about the disability.

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Texas Medicare Savings Programs once SSDI Medicare starts

Once Medicare begins, the question becomes what it costs you. HHSC manages the four Medicare Savings Programs, and each pays a different share:

• Qualified Medicare Beneficiary (QMB): Medicare premiums, deductibles and coinsurance.
• Specified Low-Income Medicare Beneficiary (SLMB): the Medicare Part B premium.
• Qualifying Individual (QI): the Medicare Part B premium.
• Qualified Disabled and Working Individual (QDWI): the Medicare Part A premium, for certain working people with disabilities who pay one.

The income limits for QMB, SLMB and QI are based on the federal poverty level, which is adjusted each year, and the resource limits for every program except QDWI are updated each year, so HHSC's handbook is the place to check them for the current year. QI and QDWI cannot be combined with regular Medicaid.

You apply through HHSC. Applying for Extra Help with Medicare drug costs through Social Security also starts one, because Social Security sends HHSC a list of Extra Help applicants and HHSC treats the date it receives that list as your Medicare Savings Program application date. The timing is worth planning. QMB coverage starts the month after HHSC finds you eligible, and no Medicare Savings Program can start before your Medicare Part A does, so apply as soon as your first Medicare month is known. If your SSDI award was retroactive, that month may already have passed.

Our Texas disability page covers the rest of a Texas claim, from the state division that makes the medical decision to the hearing offices that hear Texas appeals.

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