Texas Medicaid Long-Term Care Application Packet (MEPD / STAR+PLUS / Nursing Facility)

TEXAS MEDICAID LONG-TERM CARE APPLICATION PACKET

TABLE OF CONTENTS

1. Cover Letter to HHSC
2. Applicant Identification
3. Program(s) Sought
4. Texas Eligibility Snapshot — 2026 Figures
5. Income Worksheet and QIT (Miller Trust) Determination
6. Resource (Asset) Inventory
7. Spousal Impoverishment / CSRA Calculation
8. Homestead and Real Property
9. Transfer-of-Assets Disclosure (60-Month Look-Back)
10. Functional / Medical Necessity
11. Authorized Representative and HIPAA
12. Document Index
13. Verification and Signatures
14. Texas Practice Notes
15. Sources and References

1. COVER LETTER TO HHSC

Texas Health and Human Services Commission

Medicaid for the Elderly and People with Disabilities (MEPD)

[HHSC LOCAL OFFICE ADDRESS]

Date: [__/__/____]

Re: Application for Medicaid Long-Term Care Benefits

Applicant: [APPLICANT FULL LEGAL NAME]

Social Security No.: [XXX-XX-____]

Date of Birth: [__/__/____]

Medicaid ID (if any): [________________________________]

To Whom It May Concern:

Enclosed please find the completed Form H1200 (Application for Assistance) and supporting documentation for the above-named applicant, who is seeking Medicaid long-term services and supports under the program(s) identified in Section 3 of this packet. The applicant is medically and financially eligible based on the worksheets enclosed herein, and (where applicable) a Qualified Income Trust has been established under 1 Tex. Admin. Code § 358.339 with effective date [__/__/____].

Please direct all correspondence to the Authorized Representative listed in Section 11.

Respectfully,

[________________________________]

[AUTHORIZED REPRESENTATIVE / ATTORNEY NAME]

2. APPLICANT IDENTIFICATION

3. PROGRAM(S) SOUGHT

Check all that apply:

• ☐ Nursing Facility Medicaid (institutional Medicaid; Form H1200 + Form 3618 admission/discharge from facility)
• ☐ STAR+PLUS managed-care LTSS (community-based managed long-term services and supports for adults age 21+; 1 TAC Chapter 353)
• ☐ STAR+PLUS Home and Community-Based Services (HCBS) Waiver
• ☐ Community First Choice (CFC) (state-plan attendant services and supports under 42 U.S.C. § 1396n(k); 1 TAC Chapter 354)
• ☐ Program of All-Inclusive Care for the Elderly (PACE)
• ☐ Day Activity and Health Services (DAHS)
• ☐ Medicaid Buy-In for Children / Workers with Disabilities (where applicable)

Effective coverage date requested: [__/__/____] (HHSC may make eligibility retroactive up to three months prior to the month of application per 42 U.S.C. § 1396a(a)(34)).

4. TEXAS ELIGIBILITY SNAPSHOT — 2026 FIGURES

5. INCOME WORKSHEET AND QIT (MILLER TRUST) DETERMINATION

5.1 Gross Monthly Countable Income

5.2 QIT Determination

Texas is an income-cap state under 42 U.S.C. § 1396a(a)(10)(A)(ii)(V). If gross monthly countable income exceeds $2,982 (2026), the applicant is ineligible unless all income above the cap (or, in practice, all income from the over-cap source(s)) is deposited into a Qualified Income Trust ("QIT" or Miller Trust) that conforms to 42 U.S.C. § 1396p(d)(4)(B) and 1 Tex. Admin. Code § 358.339.

• ☐ Total gross monthly income is at or below $2,982 — no QIT required.
• ☐ Total gross monthly income exceeds $2,982 — QIT required and is in place.

5.3 QIT Mechanics (if applicable)

• QIT effective date: [__/__/____]
• QIT trustee: [________________________________]
• Dedicated QIT bank account (separate from personal funds): [BANK / ACCOUNT NUMBER LAST 4]
• Income source(s) deposited monthly into QIT: [________________________________]
• QIT residual (Medicaid-payback) beneficiary: State of Texas, up to total medical assistance paid, per 42 U.S.C. § 1396p(d)(4)(B) and 1 TAC § 358.339(c)(2).
• Confirmation that the QIT is funded EVERY MONTH the applicant requires Medicaid eligibility (failure to fund the QIT in a given month destroys eligibility for that month — HHSC MEPD Handbook Appendix XXXVI).

5.4 Co-Payment / Applied Income to Facility (Nursing Facility cases)

After deducting the $75 personal needs allowance, Medicare and supplemental health-insurance premiums, court-ordered guardian fees, and (where applicable) MMMNA diversion to the community spouse, the balance of QIT-deposited income is paid as the resident's "applied income" co-payment to the nursing facility each month.

6. RESOURCE (ASSET) INVENTORY

6.1 Countable Resources (must be ≤ $2,000 individual / $3,000 couple)

6.2 Exempt / Non-Countable Resources

• ☐ Primary residence (homestead) — see Section 8
• ☐ One vehicle (any value, used for transportation of the applicant or household)
• ☐ Household goods and personal effects
• ☐ Burial plots, prepaid irrevocable funeral contracts (IFCs), and burial space items
• ☐ Burial fund up to $1,500 (offset by face-value life insurance)
• ☐ Term life insurance with no cash value
• ☐ Property essential to self-support (limited)
• ☐ Special Needs Trusts under 42 U.S.C. § 1396p(d)(4)(A) or (C)
• ☐ Other (specify): [________________________________]

7. SPOUSAL IMPOVERISHMENT / CSRA CALCULATION

If the applicant is married and the non-applicant spouse ("community spouse") is not seeking Medicaid, the spousal-impoverishment rules of 42 U.S.C. § 1396r-5 protect the community spouse:

8. HOMESTEAD AND REAL PROPERTY

8.1 Homestead Status

• ☐ Applicant maintains intent to return home (express written intent recommended; see HHSC MEPD §§ F-3220, F-3231)
• ☐ Community spouse, minor child, or disabled child resides in the home (homestead exempt without equity cap per 42 U.S.C. § 1396p(f)(2))
• ☐ Applicant is single / no qualifying resident — equity ≤ $752,000 limit (2026; verify)
• Property address: [________________________________]
• Tax-appraisal value: $[____]
• Mortgage balance: $[____]
• Equity: $[____]

8.2 Texas Homestead Constitutional Protection — Medicaid Context

The Texas Constitution provides one of the strongest homestead protections in the country (Tex. Const. art. XVI, § 50; Tex. Prop. Code Chapter 41), shielding the homestead from forced sale by most creditors during the homeowner's life. HOWEVER, federal law mandates the Medicaid Estate Recovery Program (MERP) under 42 U.S.C. § 1396p(b), implemented in Texas at 1 TAC Chapter 360. MERP can recover from the probate estate of a deceased Medicaid recipient age 55+ who received LTSS — including the homestead if it passes through probate. Counsel should evaluate non-probate transfer alternatives (Lady Bird / enhanced life-estate deed; transfer-on-death deed under Tex. Est. Code Chapter 114; revocable trust planning) before applicant's death to minimize MERP exposure. MERP claim will be waived/reduced for undue hardship under 1 TAC § 360.601 and where a surviving spouse, minor child, or disabled child exists.

8.3 Other Real Property

9. TRANSFER-OF-ASSETS DISCLOSURE (60-MONTH LOOK-BACK)

Per 42 U.S.C. § 1396p(c) and 1 TAC §§ 358.401–358.471, all transfers for less than fair market value within 60 months prior to the application month must be disclosed.

Total uncompensated transfer amount: $[____]

Estimated penalty period: [____] days, beginning [__/__/____] (otherwise-eligible institutionalization date), per 1 TAC § 358.413 and HHSC MEPD I-5200.

Exception(s) claimed (caregiver child, disabled child, sibling with equity interest, transfer to spouse, etc.): [________________________________]

10. FUNCTIONAL / MEDICAL NECESSITY

• ☐ Form 3071 (Texas Medicaid Nursing Facility Specifications) on file
• ☐ Form 3618 (Resident Transaction Notice) submitted by NF
• ☐ MDS 3.0 assessment of record establishing required level of care
• ☐ Physician's certification of medical necessity (Form 3071/3074) signed and dated [__/__/____]
• ☐ STAR+PLUS HCBS waiver functional assessment completed by managed-care organization (MCO): [MCO NAME]

11. AUTHORIZED REPRESENTATIVE AND HIPAA

12. DOCUMENT INDEX

Please find enclosed the following documents (☐ = enclosed):

• ☐ Form H1200 — Application for Assistance — Your Texas Benefits
• ☐ Form H1200-A (supplemental long-term care section)
• ☐ Form H1003 — Appointment of an Authorized Representative
• ☐ Photo identification and Social Security card
• ☐ Proof of citizenship / lawful presence
• ☐ Marriage certificate (if married)
• ☐ Death certificate of prior spouse (if widowed)
• ☐ Divorce decree (if divorced)
• ☐ All bank statements, 60 months
• ☐ All brokerage / IRA / 401(k) statements, 60 months
• ☐ Pension / annuity statements
• ☐ Social Security award letter and Medicare card(s)
• ☐ Life insurance policies (declarations and cash-value statements)
• ☐ Burial contract / IFC documentation
• ☐ Deeds and mortgage statements for all real property
• ☐ Vehicle titles and registrations
• ☐ Tax returns, prior 5 years
• ☐ QIT trust instrument and bank statements (if applicable)
• ☐ Form 3618 / 3619 (NF transactions)
• ☐ Physician medical-necessity certification
• ☐ Powers of attorney / guardianship orders

13. VERIFICATION AND SIGNATURES

I, [APPLICANT NAME] (or Authorized Representative on applicant's behalf), declare under penalty of perjury under the laws of the State of Texas that the foregoing application and all enclosures are true and correct to the best of my knowledge. I understand that knowingly making a false statement to obtain Medicaid benefits is a criminal offense under 42 U.S.C. § 1320a-7b and Tex. Penal Code Chapter 35A.

Signature: [________________________________]

Print Name: [________________________________]

Date: [__/__/____]

Authorized Representative / Attorney signature:

[________________________________]

Print Name and Bar No.: [________________________________]

Date: [__/__/____]

14. TEXAS PRACTICE NOTES

• Income-cap state — no medically needy spend-down for LTC. Texas does not extend a "medically needy" eligibility track to nursing-facility or HCBS waiver applicants. The QIT under 1 TAC § 358.339 is the exclusive mechanism for over-income applicants. Funding the QIT each month is mandatory; a missed deposit destroys eligibility for that month.
• QIT formalities. The QIT must be irrevocable; must be funded with the applicant's income (not principal); must name the State of Texas as the residual beneficiary up to total Medicaid expenditures; and the trustee must maintain a dedicated bank account. HHSC publishes a model QIT in MEPD Appendix XXXVI; many practitioners draft custom QITs to handle multiple income sources.
• Spousal protections. Texas observes federal spousal-impoverishment rules at 42 U.S.C. § 1396r-5. The 2026 maximum CSRA is $162,660; minimum is $32,532. Texas has one of the highest maximum spousal-income allowances in the nation at $4,066.50/month.
• Five-year look-back and divisor. The look-back is 60 months from the application month for all transfers (institutionalized status). HHSC publishes the daily transfer-penalty divisor by bulletin; verify the divisor in effect on the case-action disposal date (currently $262.37 effective 9/1/2025).
• Homestead. The Texas Constitution's homestead protection is exceptional during life but does NOT shield the home from MERP at death if the home passes through probate. Plan with non-probate transfer mechanisms to mitigate MERP.
• STAR+PLUS. Most Medicaid-eligible adults age 21+ in Texas receive their LTSS through STAR+PLUS managed-care organizations. After HHSC determines financial eligibility, the MCO conducts the functional assessment and authorizes services.
• Community First Choice (CFC). CFC is an entitlement state-plan benefit (not a waiver) for individuals who meet an institutional level of care; covers personal attendant services, habilitation, emergency response, and assistive technology.
• Retroactive coverage. Federal law permits up to three months of retroactive Medicaid eligibility prior to the application month (42 U.S.C. § 1396a(a)(34)). Always request retroactive coverage where there are unpaid medical bills in the prior 90 days.
• Right to fair hearing. Denied or delayed applications carry a right to a fair hearing under 1 TAC Chapter 357; written request must generally be made within 90 days of the notice.
• Estate Recovery (MERP). Recovery is limited to the probate estate in Texas (1 TAC Chapter 360); proper non-probate planning during life is the most effective MERP mitigation. Hardship waivers are available.

15. SOURCES AND REFERENCES

• 42 U.S.C. § 1396a et seq. (Title XIX) — https://uscode.house.gov/
• 42 U.S.C. § 1396p (transfers, look-back, liens, recoveries, QITs)
• 42 U.S.C. § 1396r-5 (spousal impoverishment)
• 42 U.S.C. § 1396n(k) (Community First Choice)
• Tex. Hum. Res. Code Chapter 32 — https://statutes.capitol.texas.gov/Docs/HR/htm/HR.32.htm
• 1 Tex. Admin. Code Chapter 358 (MEPD) — https://texreg.sos.state.tx.us/
• 1 Tex. Admin. Code § 358.339 (Qualified Income Trusts)
• 1 Tex. Admin. Code Chapter 360 (MERP)
• HHSC MEPD Handbook — https://www.hhs.texas.gov/handbooks/medicaid-elderly-people-disabilities-handbook
• HHSC MEPD Handbook Appendix XXXVI (QITs) — https://www.hhs.texas.gov/handbooks/medicaid-elderly-people-disabilities-handbook/appendix-xxxvi-qualified-income-trusts-qits-medicaid-elderly-people-disabilities-mepd-information
• HHSC MEPD Handbook I-5100 (Transfer Divisor) — https://www.hhs.texas.gov/handbooks/medicaid-elderly-people-disabilities-handbook/i-5100-transfer-assets-divisor
• HHSC MEPD Handbook I-5200 (Penalty Start Date) — https://www.hhs.texas.gov/handbooks/medicaid-elderly-people-disabilities-handbook/i-5200-penalty-start-date
• HHSC Provider Finance Department Rate Tables — https://pfd.hhs.texas.gov/rate-tables
• Tex. Const. art. XVI, §§ 50–51 — https://statutes.capitol.texas.gov/
• Tex. Prop. Code Chapter 41 (homestead)
• HHSC STAR+PLUS — https://www.hhs.texas.gov/services/health/medicaid-chip/programs/starplus
• Form H1200 (Application) — https://www.hhs.texas.gov/regulations/forms

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. A Texas-licensed attorney must review and customize this packet before submission. Texas Medicaid figures, divisors, and program rules change frequently; verify all authorities before use.