Petition for Expansion of Medicaid Long-Term Care Eligibility
Petition for Expansion of Medicaid Long-Term Care Eligibility
The Issue
In the State of Texas, Medicaid can be used to cover long-term care expenses for those that meet certain requirements, including income and asset limitations, as well as “medical necessity”. These requirements are established by state and federal policies and qualifications are determined by the Texas Medicaid and Healthcare Partnership (TMHP). Unfortunately, the criteria for medical has the potential to exclude many Texans who require assistance in taking care of themselves, but do not have a qualifying medical diagnosis.
Current requirements of medical necessity to qualify for long-term care Medicaid coverage stipulate that a person must have a medical condition that necessitates assistance beyond what an untrained person is able to provide in the home, and requires the regular assistance of a registered or licensed nurse in an institutional setting (Texas Medicaid and Healthcare Partnership, 2019).
In 2022, it was estimated that approximately 3.9 million Texans live with a disability. It was also estimated that 36.8% of the elderly population in Texas live with a disability (Health and Human Services Commission, 2025). This can significantly impact their quality of life and the ability to complete their Activities of Daily Living (ADLs), including cooking, cleaning, bathing, toileting, medication management, and ambulation (Health and Human Services Commission, 2025).
For many elderly Texans, their inability to complete their ADLs independently does not meet the medical necessity requirement for long-term care Medicaid, as they do not require a registered or licensed nurse to assist them (Texas Medicaid and Healthcare Partnership, 2019). It is suggested that these people who do not meet the criteria set forth by TMHP receive assistance in the community, through provider service agencies. Provider service agencies provide limited support in a person’s home, for anywhere from 30 minutes, one day per week, to 8 hours per day, 7 days per week (Health and Human Services Commission, 2017).
While this may be sufficient for many elderly people in Texas that struggle with providing self-care, it can be woefully insufficient for many others. Provider agencies often struggle with staffing, particularly in rural areas, and may only be able to provide limited services once per week. These paid caregivers provide assistance with toileting, meal preparation, housecleaning, bathing, medication reminders, and grocery shopping (ASPE, 2019). Those receiving daily assistance are often without any assistance at all overnight. A lack of sufficient assistance with ADLs can lead to the inability to escape the home in case of an emergency, as well as increased risk of hospitalization (Xu et al., 2012).
The average cost of long-term care in Dallas, for a semi-private room, is estimated to range from $70,810 to $104,025 per year (American Council on Aging, n.d.). On average, people on Social Security receive $1976 per month (Social Security Administration, 2025). Currently, it is estimated that only 12% of long-term care in the State of Texas is covered by Medicaid (Werner et al., 2025). The rest must be paid by individuals in care, or their families (Genworth Financial, 2024). It is estimated that only 17% of Medicare recipients also qualify for Medicaid assistance (Health and Human Services Commission, 2025).
Recent changes in legislation will likely make qualifying for Medicaid assistance more difficult, including recertification for eligibility being required every 6 months, as opposed to the previous once per year (Woody, 2025). In addition, retroactive payments for healthcare have been reduced from 90 days to 30 days, meaning a person who is hospitalized or in an institution for an extended period of time will be responsible for any cost incurred outside of that time frame (Woody, 2025). The average length of time required to process Medicaid eligibility is 45 to 90 days (Eldercare Resource Planning, 2025), meaning those that apply for Medicaid assistance while in a facility could possibly necessitate discharge before the application process can even be completed and approved.
This petition calls for an expansion of criteria for the long-term care Medicaid qualifications to include Texans with limited mobility that does not necessarily require licensed medical care on a regular basis. This would allow those who cannot otherwise afford long-term care to have access to 24-hour assistance with activities of daily living and potentially improve quality of life while reducing risks of hospitalization and unattended death.
References
American Council on Aging. (n.d.). Medicaid Planning Assistance. Medicaid Planning
Assistance.org. https://www.medicaidplanningassitance.org/
Genworth releases cost of Care Survey Results for 2023: Twenty years of tracking long-term
care costs. Genworth Financial, Inc. (2024, March 12).
https://investor.genworth.com/news-events/press-releases/detail/972/genworth-releases
cost-of-care-survey-results-for-2023
Medicaid approval process and timing. Eldercare Resource Planning. (2025, January 11).
https://www.eldercareresourceplanning.org/medicaid-faq/applying/timing/
Medical Necessity and Level of Care Assessment. Texas Medicaid & Healthcare Partnership.
Primary Home Care and Community Attendant Services. Texas Health and Human Services.
The Texas State Plan on Aging 2026–2028. Texas Health and Human Services Commission.
Werner, R. M., Hoffman, A. K., & Konetzka, R. T. (2025). The evolution of long-term care and
health policy in the United States. Journal of Health Politics, Policy and Law.
https://doi.org/10.1215/03616878-11995144
What is the lifetime risk of needing and receiving long-term services and supports? ASPE (2019)
https://aspe.hhs.gov/reports/what-lifetime-risk-needing-receiving-long-term-services-supports-0
Woody, M. (2025, July 1). Major changes to Medicaid qualification under the “One big
beautiful bill”: What families need to know. McIntyre Elder Law. https://mcelderlaw.com/medicaid-bbb/
Xu, H., Covinsky, K. E., Stallard, E., Thomas, J., & Sands, L. P. (2012). Insufficient help for
activity of daily living disabilities and risk of all‐cause hospitalization. Journal of the
American Geriatrics Society, 60(5), 927–933. https://doi.org/10.1111/j.1532-5415.2012.03926.x
92
The Issue
In the State of Texas, Medicaid can be used to cover long-term care expenses for those that meet certain requirements, including income and asset limitations, as well as “medical necessity”. These requirements are established by state and federal policies and qualifications are determined by the Texas Medicaid and Healthcare Partnership (TMHP). Unfortunately, the criteria for medical has the potential to exclude many Texans who require assistance in taking care of themselves, but do not have a qualifying medical diagnosis.
Current requirements of medical necessity to qualify for long-term care Medicaid coverage stipulate that a person must have a medical condition that necessitates assistance beyond what an untrained person is able to provide in the home, and requires the regular assistance of a registered or licensed nurse in an institutional setting (Texas Medicaid and Healthcare Partnership, 2019).
In 2022, it was estimated that approximately 3.9 million Texans live with a disability. It was also estimated that 36.8% of the elderly population in Texas live with a disability (Health and Human Services Commission, 2025). This can significantly impact their quality of life and the ability to complete their Activities of Daily Living (ADLs), including cooking, cleaning, bathing, toileting, medication management, and ambulation (Health and Human Services Commission, 2025).
For many elderly Texans, their inability to complete their ADLs independently does not meet the medical necessity requirement for long-term care Medicaid, as they do not require a registered or licensed nurse to assist them (Texas Medicaid and Healthcare Partnership, 2019). It is suggested that these people who do not meet the criteria set forth by TMHP receive assistance in the community, through provider service agencies. Provider service agencies provide limited support in a person’s home, for anywhere from 30 minutes, one day per week, to 8 hours per day, 7 days per week (Health and Human Services Commission, 2017).
While this may be sufficient for many elderly people in Texas that struggle with providing self-care, it can be woefully insufficient for many others. Provider agencies often struggle with staffing, particularly in rural areas, and may only be able to provide limited services once per week. These paid caregivers provide assistance with toileting, meal preparation, housecleaning, bathing, medication reminders, and grocery shopping (ASPE, 2019). Those receiving daily assistance are often without any assistance at all overnight. A lack of sufficient assistance with ADLs can lead to the inability to escape the home in case of an emergency, as well as increased risk of hospitalization (Xu et al., 2012).
The average cost of long-term care in Dallas, for a semi-private room, is estimated to range from $70,810 to $104,025 per year (American Council on Aging, n.d.). On average, people on Social Security receive $1976 per month (Social Security Administration, 2025). Currently, it is estimated that only 12% of long-term care in the State of Texas is covered by Medicaid (Werner et al., 2025). The rest must be paid by individuals in care, or their families (Genworth Financial, 2024). It is estimated that only 17% of Medicare recipients also qualify for Medicaid assistance (Health and Human Services Commission, 2025).
Recent changes in legislation will likely make qualifying for Medicaid assistance more difficult, including recertification for eligibility being required every 6 months, as opposed to the previous once per year (Woody, 2025). In addition, retroactive payments for healthcare have been reduced from 90 days to 30 days, meaning a person who is hospitalized or in an institution for an extended period of time will be responsible for any cost incurred outside of that time frame (Woody, 2025). The average length of time required to process Medicaid eligibility is 45 to 90 days (Eldercare Resource Planning, 2025), meaning those that apply for Medicaid assistance while in a facility could possibly necessitate discharge before the application process can even be completed and approved.
This petition calls for an expansion of criteria for the long-term care Medicaid qualifications to include Texans with limited mobility that does not necessarily require licensed medical care on a regular basis. This would allow those who cannot otherwise afford long-term care to have access to 24-hour assistance with activities of daily living and potentially improve quality of life while reducing risks of hospitalization and unattended death.
References
American Council on Aging. (n.d.). Medicaid Planning Assistance. Medicaid Planning
Assistance.org. https://www.medicaidplanningassitance.org/
Genworth releases cost of Care Survey Results for 2023: Twenty years of tracking long-term
care costs. Genworth Financial, Inc. (2024, March 12).
https://investor.genworth.com/news-events/press-releases/detail/972/genworth-releases
cost-of-care-survey-results-for-2023
Medicaid approval process and timing. Eldercare Resource Planning. (2025, January 11).
https://www.eldercareresourceplanning.org/medicaid-faq/applying/timing/
Medical Necessity and Level of Care Assessment. Texas Medicaid & Healthcare Partnership.
Primary Home Care and Community Attendant Services. Texas Health and Human Services.
The Texas State Plan on Aging 2026–2028. Texas Health and Human Services Commission.
Werner, R. M., Hoffman, A. K., & Konetzka, R. T. (2025). The evolution of long-term care and
health policy in the United States. Journal of Health Politics, Policy and Law.
https://doi.org/10.1215/03616878-11995144
What is the lifetime risk of needing and receiving long-term services and supports? ASPE (2019)
https://aspe.hhs.gov/reports/what-lifetime-risk-needing-receiving-long-term-services-supports-0
Woody, M. (2025, July 1). Major changes to Medicaid qualification under the “One big
beautiful bill”: What families need to know. McIntyre Elder Law. https://mcelderlaw.com/medicaid-bbb/
Xu, H., Covinsky, K. E., Stallard, E., Thomas, J., & Sands, L. P. (2012). Insufficient help for
activity of daily living disabilities and risk of all‐cause hospitalization. Journal of the
American Geriatrics Society, 60(5), 927–933. https://doi.org/10.1111/j.1532-5415.2012.03926.x
92
The Decision Makers
Petition created on July 12, 2025