How to Qualify for Medicaid Assisted Living in Texas: STAR+PLUS Waivers, Income Caps, and Facility Types

For Texas families facing the reality of aging parents who can no longer live safely alone, the cost of private-pay assisted living—averaging between $4,200 and $5,800 per month in major Texas metros like Houston, Dallas-Fort Worth, and Austin—can rapidly deplete life savings. While many assume Medicaid only pays for skilled nursing facilities, Texas does offer a pathway for assisted living through the STAR+PLUS Home and Community Based Services (HCBS) Waiver.

The Core Distinction: Clinical Care vs. Room and Board

By federal regulation, Medicaid cannot pay for food and housing in an assisted living setting. In Texas, assisted living funding is divided into two parts:

1. STAR+PLUS Waiver Care Package: Medicaid pays the facility directly for personal care services (help with bathing, dressing, transferring, and eating), 24-hour on-site response, medication administration, and nursing oversight.
2. Resident Room and Board: The resident pays the monthly room and board rate directly to the community using their Social Security, pension, or family contributions. Many contracted communities set this rate close to the resident's net monthly Social Security check, allowing the senior to retain a small Personal Needs Allowance.

Clinical Eligibility: The Nursing Facility Level of Care (NFLOC)

To qualify for the STAR+PLUS waiver, an applicant must be certified as meeting the state's Medical Necessity (MN) criteria, equivalent to the care level provided in a licensed nursing home:

• Requires ongoing skilled nursing care or substantial assistance with at least two Activities of Daily Living (ADLs).
• Has a physician-certified diagnosis of Alzheimer's disease or related dementia causing severe disorientation and safety risks.
• An in-person Texas Medical Necessity and Level of Care (MN/LOC) assessment is conducted by the state or the participating managed care organization (MCO).

Financial Rules: The Texas Income Cap & Miller Trusts

Texas is one of approximately 23 "income-cap states." Understanding how financial eligibility is evaluated is critical to avoiding immediate disqualification:

• Monthly Income Limit: The gross monthly income cap for an individual is $2,901 (300% of the Federal Benefit Rate). Because Texas does not have a traditional spend-down program, income even $1 over this limit triggers denial unless a Miller Trust (Qualified Income Trust / QIT) is established.
• The Miller Trust Solution: An elder law attorney drafts an irrevocable trust into which excess pension and Social Security checks are deposited each month, legally lowering countable income to meet Medicaid criteria.
• Asset Limit: Countable assets cannot exceed $2,000 for an individual. The primary home (equity up to $713,000), one vehicle, and pre-paid burial policies are exempt.
• Spousal Protections: Under federal spousal impoverishment rules, a healthy spouse living at home (the community spouse) can protect up to $154,140 in assets and retain up to $3,853.50/month in income.

Texas Facility Licensing: Type A vs. Type B

When searching for a Texas assisted living facility that accepts Medicaid, families must verify the license type issued by the Texas Health and Human Services Commission (HHSC):

• Type A Communities: Appropriate for independent seniors who can evacuate within 3 minutes without staff assistance during fire alarms.
• Type B Communities: Required for any resident with mobility impairments, nighttime confusion, or Alzheimer's/dementia requiring secured memory care units.

Because STAR+PLUS waiver slots have an interest list (waitlist), families should place their loved one on the Texas HHS interest list as early as possible.