Medicaid Eligibility Requirements
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Must reside in a Medicaid-certified facility for 30 consecutive days.
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Must be eligible for Supplemental Security Income (SSI) from the Social Security Administration or be determined by the Texas Health and Human Services Commission to be financially eligible for Medicaid.
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Must meet medical necessity requirements — certification by a physician that the individual has a medical condition that requires daily skilled nursing care. The need for custodial care only does not constitute medical necessity.
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Financial eligibility is determined by the Texas Health and Human Services Commission. For more information, please visit their website .
Medicare Eligibility Requirements
Medicare is a health insurance program for:
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people age 65 or older,
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people under age 65 with certain disabilities, and
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people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant).
Part A Hospital Insurance - Most people don't pay a premium for Part A because they or a spouse already paid for it through their payroll taxes while working. Medicare Part A (Hospital Insurance) helps cover inpatient care in hospitals, including critical access hospitals and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Beneficiaries must meet certain conditions to get these benefits.
Part B Medical Insurance - Most people pay a monthly premium for Part B. Medicare Part B (Medical Insurance) helps cover doctors' services and outpatient care. It also covers some other medical services that Part A doesn't cover, such as some of the services of physical and occupational therapists and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary.
Prescription Drug Coverage - Most people will pay a monthly premium for this coverage. Starting January 1, 2006, new Medicare prescription drug coverage will be available to everyone with Medicare. Everyone with Medicare can get this coverage that may help lower prescription drug costs and help protect against higher costs in the future. Medicare Prescription Drug Coverage is insurance. Private companies provide the coverage. Beneficiaries choose the drug plan and pay a monthly premium. Like other insurance, if a beneficiary decides not to enroll in a drug plan when they are first eligible, they may pay a penalty if they choose to join later.
Medicare Part A coverage for skilled nursing facilities - Post-hospital extended care services furnished to inpatients of a skilled nursing facility are covered under Medicare Part A, the hospital insurance program. Daily Medicare skilled nursing facility co-insurance payments are paid for residents who are eligible for both Medicare and Medicaid.
In order to have payment made for post-hospital extended care services, the individual must have been an inpatient of a hospital for a medically necessary stay of at least 3 consecutive calendar days. In addition, the individual must have been transferred to a participating skilled nursing facility within 30 days after discharge from the hospital.
Care in a SNF is covered if all of the following three factors are met:
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The patient requires skilled nursing services or skilled rehabilitation services, i.e., services that must be performed by or under the supervision of professional or technical personnel.
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The patient requires these skilled services on a daily basis ; and
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As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF.