Texas Medicaid helps low-income people in Texas get health care. The Texas Health and Human Services Commission (HHSC) runs the program.
Every year, millions of Texans use it. These include kids, pregnant women, older adults, and people with disabilities.
In 2025, the program focuses on preventing health problems. It stresses low-cost treatment and easy access. Managed care organizations (MCOs) handle care for almost 97% of members.
If you want to know what Texas Medicaid covers, this guide explains it all. It covers services, dental benefits, and prescriptions.
For eligibility requirements and how to apply, check out our page to learn more about Texas Medicaid.
What Texas Medicaid Must Cover
All states must offer certain health benefits set by the federal government. Texas covers them all. These include stays in the hospital, both short-term and long-term. They also cover doctor visits, lab tests, X-rays, and family planning.
| Mandatory Benefit Category | What’s Included | Who It Covers |
|---|---|---|
| Inpatient & Outpatient Hospital | Hospital stays, surgeries, emergency care, lab tests, X-rays | All members |
| Doctor Visits | Primary care, specialist visits, preventive checkups | All members |
| Emergency Services | Ambulance rides, ER visits, stabilization care | Everyone, including undocumented individuals |
| Texas Health Steps (EPSDT) | Regular checkups, vaccines, vision/hearing tests, mental health screenings | Children under 21 |
| Long-Term Care | Nursing homes, home health care | Elderly and people with disabilities |
| Family Planning | Contraception, counseling, related services | Adults of reproductive age |
Nursing homes and home health care are required for people who need long-term help.
Kids under 21 get special protection. This comes from the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit.
In Texas, it’s called Texas Health Steps. It provides regular checkups, shots, and tests for eyes, ears, and growth. It also includes checks and treatment for mental health to catch issues early.
Emergency services get full coverage. You do not need approval first. This covers ambulance rides and hospital care to make you stable. It helps even people without papers until the emergency ends.
For older adults and people with disabilities, Medicaid covers mental health stays in the hospital.
It also covers care homes for those with intellectual disabilities and nursing homes. Most people who qualify pay no copays for these.
Optional Benefits Texas Adds
Texas offers extra benefits beyond what the federal rules require. These help more people get care and cut costs over time.
The state picks these services. The federal government matches the funding. The state updates them each year to fit community needs.
| Optional Benefit | What It Includes | Who Benefits Most |
|---|---|---|
| Prescription Drugs | FDA-approved medications, 12-month birth control supply | All members |
| Dental & Vision | Emergency dental for adults, full coverage for kids | Age-dependent |
| Transportation (NEMT) | Rides to medical appointments and pharmacies | Members without transportation |
| Personal Care Services (PCS) | Help with daily tasks like bathing, dressing, eating | Elderly and disabled individuals |
| Telehealth | Video visits, remote monitoring for chronic conditions | Rural residents, homebound patients |
| Home & Community Waivers | CLASS, MDCP programs, respite care, home modifications | People avoiding institutional care |
| Behavioral Health (MAT) | Medication-Assisted Treatment for substance abuse | Individuals with addiction |
| Postpartum Coverage | 12 months after birth through Healthy Texas Women Plus | New mothers |
In 2025, extra benefits include drug coverage, some dental and eye care, and home-based services under waiver programs. These waivers let people get help at home. Telehealth and remote monitoring help those with long-term illnesses.
The state also covers rides to doctor visits for those without cars. This is non-emergency medical transportation services (NEMT). Personal care services (PCS) help with daily tasks. Special mental health support includes Medication-Assisted Treatment (MAT) for drug or alcohol problems.
Pregnant women and new moms get coverage for up to 12 months after birth. This comes through Healthy Texas Women (HTW) Plus. It includes mental health care and heart checks after delivery.
Home and community programs like Community Living Assistance and Support Services (CLASS) and Medically Dependent Children Program (MDCP) keep people out of institutions. They offer breaks for caregivers, tools to adapt homes, and job help.
Doctor Visits and Primary Care
Texas Medicaid pays for all needed doctor visits and basic care. Each member picks a primary care provider (PCP). This can be a doctor, nurse, or clinic. The PCP handles your health and sends you to specialists if needed.
Regular visits, yearly checkups, and care for ongoing illnesses are all covered. Kids get full checkups through Texas Health Steps. This includes shots and growth tests. Adults get family planning, tests for infections, and cancer checks.
You can use video visits from home, especially in small towns. These work for:
- Regular checkups and follow-up appointments
- Mental health counseling sessions
- Prenatal care for expectant mothers
- Chronic disease management
Many plans add free classes on health or ways to stay fit. Need to locate a provider near you? Use our tool to find Medicaid doctors that accept your coverage.
Hospital and Outpatient Services
Hospital care is a key part of what Texas Medicaid covers. It pays for stays in the hospital and visits for the day. This includes operations, tests, and emergency help.
Most adults have a limit of 30 days in the hospital per stay under basic plans. Kids under 21 have no limit. Day visits cover lab work, X-rays, kidney dialysis, and quick operations.
Texas has programs to reward hospitals. One is the Comprehensive Hospital Increase Reimbursement Program (CHIRP).
It gives over $6 billion in 2025 to raise care quality and access. After a hospital stay, you can use video for follow-up care. This helps avoid going back.
Your specific coverage may vary depending on whether you’re enrolled in fee-for-service or managed care—compare managed care health plans to see how benefits differ by plan type.
Prescription Drug Coverage
Texas runs its drug program through the Vendor Drug Program (VDP). It covers most medicines approved by the FDA. These are on the state’s preferred drug list (PDL).
Drugs on the list get full coverage. Others need approval first. Adults in the basic Medicaid plan get up to three drugs a month. Most people in managed care plans get as many as they need.
Special pharmacy benefits include:
- Birth control and family planning drugs in 12-month supplies
- 72-hour emergency supply while waiting for approval
- Full coverage for chronic disease medications
- Medicare Part D coverage for dual-eligible members
Texas updates its drug list often. It adds new ones for long-term and mental health needs. People with both Medicare and Medicaid get most drugs through Medicare Part D.
Mental and Behavioral Health Services
Texas Medicaid covers all kinds of mental health and drug or alcohol treatment. This includes checks by a mental health doctor, talk therapy (alone, with family, or in groups), drug management, and hospital stays for mental health.
| Service | Coverage Details | Special Programs |
|---|---|---|
| Psychiatric Evaluations | Full coverage, no copay | Available via telehealth |
| Individual Therapy | Unlimited sessions when medically necessary | Video therapy statewide |
| Family/Group Therapy | Covered for all ages | Community-based options |
| Medication Management | Psychiatric drugs on PDL covered | MAT for substance abuse |
| Inpatient Mental Health | Hospital stays for crisis care | Adults and children |
| Youth Services | YES program for emotional issues | Ages 3–18 |
| Adult Home Services | HCBS-AMH for community support | Prevents hospitalization |
Video therapy is growing across the state. It helps people who can’t go to a clinic. Programs for kids like Youth Empowerment Services (YES) help those with big emotional issues. Adults can get home-based help through Home and Community-Based Services for Adult Mental Health (HCBS-AMH).
In 2025, Texas puts over $150 million into the Directed Payment Program for Behavioral Health Services. This blends body and mind care. It helps catch problems early.
Dental and Vision Coverage
Dental and eye care change based on your age and group. Kids under 21 get full dental care through Texas Health Steps and the Children’s Health Insurance Program (CHIP).
This covers cleanings, checkups, fillings, crowns, and braces if needed for health reasons. For complete information about what’s covered for kids, see our guide to Texas Medicaid dental benefits.
| Service Type | Children (Under 21) | Adults (21+) |
|---|---|---|
| Dental Cleanings | ✅ Covered (2x per year) | ❌ Emergency only |
| Dental Exams | ✅ Fully covered | ❌ Emergency only |
| Fillings & Crowns | ✅ Covered | ❌ Emergency only (some plans may vary) |
| Orthodontics (Braces) | ✅ If medically necessary | ❌ Not covered |
| Eye Exams | ✅ Annual exams covered | ⚠️ Only if medically necessary |
| Glasses/Contacts | ✅ Covered | ⚠️ Post-surgery or injury only |
Adults often get only emergency dental work. Some plans add basic cleanings or fixes. To understand what your plan includes, review our detailed dental benefit information or contact your MCO directly.
Eye care covers checkups, glasses, and contacts for kids. Adults get it if a doctor says it’s needed, like after an injury or surgery.
Preventive and Emergency Services
Texas Medicaid puts prevention first. It covers yearly checkups, shots, cancer tests, blood work for cholesterol and sugar, and women’s wellness visits through Healthy Texas Women.
Covered preventive services:
- Annual physical exams and wellness visits
- Immunizations for all ages
- Cancer screenings (mammograms, colonoscopies, cervical cancer)
- Blood tests for cholesterol and diabetes
- Women’s health services through Healthy Texas Women
For emergencies, it covers any threat to life or health. This includes ER trips, ambulance rides, and care to make you stable. You never need approval first. It works even outside your plan’s doctors.
Long-Term Care and Support Services
Texas Medicaid offers many long-term care choices for older adults and people with disabilities. This includes nursing homes, care centers for those with intellectual disabilities (ICFs/IID), and home options through waivers.
Available support services:
- Personal care aides for daily activities
- Home modifications for accessibility
- Respite care for family caregivers
- Assistive technology and adaptive equipment
Programs like STAR+PLUS and PACE mix doctor care with long-term help. They make support easier for older people.
Therapy, Equipment, and Supplies
Therapy covers physical, work-related, and speech help for recovery or growth. Kids get as much as needed under EPSDT. Adults may need approval first.
Medicaid pays for strong medical gear (DME) like wheelchairs, oxygen, and sugar test tools. It also covers fake body parts and braces. Big-cost items need pre-approval to check if they’re truly needed.
Service Limitations and Prior Authorization
Some benefits have rules based on age, health issues, or price. For example, adults have drug limits per month. Hospital stays have day caps. Dental has yearly spending limits.
| Service | Limitation | Prior Authorization Required? |
|---|---|---|
| Prescription Drugs (Adults) | 3 medications per month (fee-for-service) | Yes, for non-PDL drugs |
| Hospital Stays (Adults) | 30 days per admission | No, for emergencies |
| Hospital Stays (Children) | No limit | No |
| Dental (Adults) | Emergency only, yearly caps vary | Depends on procedure |
| DME (Wheelchairs, etc.) | Based on medical necessity | Yes, for high-cost items |
| Therapy Sessions | Unlimited for kids, limited for adults | Yes, for adults after initial sessions |
| Non-PDL Medications | Case-by-case approval | Yes |
| Home Modifications | Through waiver programs only | Yes |
You often need approval first for non-list drugs, hard therapies, or special gear. Your MCO handles these. They can help if you appeal a no. HHSC updates rules often to make things fairer and cut unfair denials.
The Bottom Line
Texas Medicaid is a key help for families who might skip care without it. It mixes must-have federal benefits with extra state ones. This gives wide, low-cost coverage for almost all health needs.
To understand where your situation fits in the bigger picture, you can learn more about Texas Medicaid. Always check the newest info with HHSC or your plan. Rules and doctor lists can change.
FAQs
1. What services are always covered by Texas Medicaid in 2025?
Essential care like doctor visits, hospital services, lab tests, family planning, and preventive screenings are always included. Children get full dental, vision, and behavioral health coverage through Texas Health Steps.
2. Does Texas Medicaid cover prescriptions?
Yes. Most medications on the state’s preferred drug list are fully covered. Others may need prior authorization.
3. Do adults get dental and vision benefits?
Adults usually get emergency dental care only. Some plans include limited vision benefits, depending on the provider network and plan design under Texas Medicaid dental benefits.
4. Can Medicaid pay for therapy or rehabilitation?
Yes. Physical, occupational, and speech therapy are covered for children and adults when medically necessary.
5. What if I don’t have transportation to my doctor?
You may qualify for non-emergency medical transportation services (NEMT) to and from medical appointments or pharmacies.
6. Is long-term care included in Medicaid 2025?
Yes. Nursing homes, assisted living, and home-based support services are covered for those who qualify.
7. How do I know if a service needs prior authorization?
You can contact your health plan’s member services or check your online portal to see if approval is required, and you can also compare managed care health plans to see how each one handles authorizations.
8. Where can I check my benefits or renew my coverage for 2025?
Log in to YourTexasBenefits.com or call your MCO’s customer service line for the most accurate information, or visit our main guide to learn more about Texas Medicaid.
