Texas Medicaid covers doctor visits, hospital stays, emergency care, prescription drugs, mental health and substance use treatment, pregnancy and postpartum care, and long-term services for seniors and people with disabilities. Children receive a broader package than adults, including comprehensive dental, vision, and hearing benefits. What any one person gets depends on which Medicaid program they qualify for, since Texas delivers nearly all coverage through managed care plans rather than a single uniform benefit.
Core Medical Services
Every Texas Medicaid managed care plan covers the basics of medical care: regular visits with a primary care provider, hospital inpatient and outpatient services, emergency room visits, X-rays and lab work, and access to specialists through referral.1Texas Health and Human Services. STAR Medicaid Managed Care Program Members pick a primary care provider who coordinates their care.
Hospital inpatient coverage has limits. A stay is capped at 30 days per spell of illness, with a new spell starting only after at least 60 consecutive days separate the stays. There is also a $200,000 cap per beneficiary per benefit year for hospital inpatient services, with exceptions for approved organ transplants.2Texas Health and Human Services. Texas Medicaid Limitations and Exclusions
Prescription Drugs
Texas Medicaid pays for prescription medications with no copays and no out-of-pocket costs.3Texas Health and Human Services. Texas Medicaid Prescription Drug Coverage Managed care members generally face no monthly limit on the number of prescriptions they can fill.4Texas Medicaid & Healthcare Partnership. Medicaid Managed Care
A statewide Preferred Drug List, updated each January and July, governs which drugs are available without extra steps. Preferred drugs can be filled with no prior authorization. Non-preferred drugs require the prescribing doctor to submit a prior authorization request, which can be based on documented allergic reactions, manufacturer shortages, risk of adverse effects, or the patient already being stable on the current medication.3Texas Health and Human Services. Texas Medicaid Prescription Drug Coverage If authorization can’t be obtained right away, pharmacies can dispense a 72-hour emergency supply.5Texas Vendor Drug Program. Preferred Drugs
Managed care plans have to contract with any willing pharmacy, which means enrollees can use more than 95 percent of pharmacies in the state.3Texas Health and Human Services. Texas Medicaid Prescription Drug Coverage
Mental Health and Substance Use Treatment
Covered mental health services include psychiatric diagnostic evaluations, individual and family psychotherapy, psychological and neuropsychological testing, medication management, and crisis intervention. Mental health rehabilitative services include skills training, psychosocial rehabilitation focused on independent living and employment, and peer specialist services.6Texas Medicaid & Healthcare Partnership. Behavioral Health
For substance use disorders, coverage runs from evaluation through individual and group counseling, outpatient treatment, residential treatment, outpatient and residential withdrawal management, and medication-assisted treatment through opioid treatment programs. Many behavioral health services can be delivered through telehealth, including audio-only visits.6Texas Medicaid & Healthcare Partnership. Behavioral Health Children in STAR Medicaid can access behavioral health services without a referral from their primary care provider, and applied behavioral analysis for children diagnosed with autism spectrum disorder is covered.7Blue Cross and Blue Shield of Texas. Behavioral Health
Outpatient behavioral health visits with enrolled practitioners are capped at 30 per calendar year, though additional visits can be authorized case by case.8Texas Administrative Code. Section 354.1149 Two Medicaid waivers reach beyond standard coverage for people with serious conditions: the Youth Empowerment Services waiver for children and the Home and Community-based Services for Adult Mental Health waiver.9Hogg Foundation for Mental Health. Medicaid
Dental Care
Dental coverage splits sharply by age. Children 20 and younger receive comprehensive dental care through dental maintenance organizations, covering general dentistry, preventive cleanings, restorative work, and orthodontia.4Texas Medicaid & Healthcare Partnership. Medicaid Managed Care
Adults 21 and older get only emergency dental care, such as pain relief and infection treatment, with an annual cap of $5,000 per person.10Brident. Medicaid Dentures and dental implants for adults are excluded.2Texas Health and Human Services. Texas Medicaid Limitations and Exclusions Adults enrolled in the STAR+PLUS waiver for home and community-based services do have dental included in their package, but that is a narrow population.11Medicaid Planning Assistance. Texas Medicaid STAR+PLUS
Vision and Hearing
Vision coverage includes routine vision testing, medically necessary eye exams by an ophthalmologist or optometrist, and eyewear including frames, lenses, and contact lenses. Hearing coverage includes screenings, diagnostic evaluations by licensed audiologists, and nonimplantable hearing aids with accessories and fitting visits.12Texas Medicaid & Healthcare Partnership. Vision and Hearing Services
Children get more. Federal EPSDT rules require Medicaid to cover hearing aids, eyeglasses, replacement batteries, and cochlear implants for children even if those items aren’t covered for adults.13Medicaid.gov. Vision and Hearing Screening Services for Children and Adolescents
Pregnancy and Postpartum
Medicaid for Pregnant Women covers prenatal visits, prenatal vitamins, labor and delivery, and postpartum care. Prescription drugs, vaccines, and dental care are also covered during pregnancy.14Texas Children’s Health Plan. For Pregnant Members
Since March 2024, Texas has extended postpartum Medicaid and CHIP coverage from two months to 12 months under House Bill 12. The 12-month period begins the month after a pregnancy ends, and women do not need to reapply. Coverage continues for the full period regardless of changes in circumstances, with narrow exceptions for moving out of state, voluntary withdrawal, death, or fraud.15Texas Medicaid & Healthcare Partnership. HB 12 Postpartum Extension
Separately, the Healthy Texas Women program operates under a federal 1115 waiver and offers family planning and preventive services to women ages 15 to 44 with household income at or below about 204 percent of the federal poverty level. It covers contraception, pregnancy testing, STI screening and treatment, breast and cervical cancer screening, immunizations, and screening and treatment for diabetes, hypertension, and high cholesterol. An enhanced tier, HTW Plus, adds physical health, mental health, and substance use benefits during the first 12 months after a pregnancy.16Texas Medicaid & Healthcare Partnership. Healthy Texas Women Program
Children’s Preventive Benefits Under Texas Health Steps
For children from birth through age 20, Texas Medicaid includes a comprehensive preventive benefit called Texas Health Steps, the state’s version of the federal Early and Periodic Screening, Diagnostic, and Treatment program. It covers medical checkups on a set schedule, developmental and autism screenings, adolescent mental health screenings, lead testing, tuberculosis screening, immunizations, and oral evaluations with fluoride varnish.17Texas Medicaid & Healthcare Partnership. THSteps Quick Reference Guide
One feature matters more than the rest: if a screening identifies a health problem, Medicaid must cover the treatment even when that specific service isn’t part of the state’s standard benefit package.18Texas Health and Human Services. Texas Health Steps Providers That’s how children end up with hearing aids, cochlear implants, and other items adults can’t get.
Long-Term Services for Seniors and People With Disabilities
STAR+PLUS is the managed care program for adults 21 and older with disabilities or those 65 and older. On top of standard medical care, it covers long-term services and supports: personal assistance with daily activities, in-home nursing, occupational and physical therapy, respite care for caregivers, emergency response services, and service coordination.19Texas Health and Human Services. STAR+PLUS
The STAR+PLUS Home and Community-Based Services waiver adds a broader package for people who need a nursing-facility level of care but want to stay at home or in the community. Waiver services include assisted living, adult foster care, home-delivered meals, home modifications for safety and accessibility, adaptive medical equipment, employment assistance, and transitional services for people leaving nursing homes. Many of these can be consumer-directed, letting participants hire their own caregivers, including family members other than a spouse.11Medicaid Planning Assistance. Texas Medicaid STAR+PLUS Slots are limited and a waiting list forms when they fill.
STAR Kids covers children and young adults 20 and younger with disabilities. Benefits include prescription drugs, hospital care, primary and specialty care, preventive care, personal care services, private duty nursing, and durable medical equipment and supplies. Every STAR Kids member gets a service coordinator who conducts at least one in-person assessment per year and develops an individualized service plan.20Texas Health and Human Services. STAR Kids
Texas also runs five other home and community-based waivers for specific populations: Community Living Assistance and Support Services for people with conditions like cerebral palsy and spina bifida that appeared before age 22; Deaf Blind with Multiple Disabilities; Home and Community-based Services for people with an intellectual disability or related condition; the Medically Dependent Children Program for medically fragile children; and Texas Home Living for people with an intellectual disability living in a family or own home. These programs can cover attendant care, in-home nursing, respite care, therapies, medical equipment, employment supports, and assisted living.21The Arc of Texas. Medicaid Waivers Demand exceeds slots, and waiting lists for some waivers can stretch up to 16 years. A separate program, Community First Choice, provides attendant services without a waitlist for Medicaid-eligible people who need an institutional level of care.
Rides to Medical Appointments
If you have no other way to get to a covered appointment, Texas Medicaid’s nonemergency medical transportation program covers rides to doctors, dentists, hospitals, and pharmacies through public transit, taxis, van services, and commercial transportation for out-of-city appointments. It also pays for gas, meals, and lodging when overnight travel is needed for a child 20 or younger.22Texas Health and Human Services. Nonemergency Medical Transportation Program
Rides generally have to be requested at least two business days ahead, or five business days for out-of-county trips. Same-day requests work for hospital discharges and same-day provider visits. An Individual Transportation Participant option lets Medicaid reimburse gas money or pay a friend, relative, or neighbor to drive.22Texas Health and Human Services. Nonemergency Medical Transportation Program
What It Costs You
Most Texas Medicaid enrollees pay no premiums and no copays. Prescription drugs are free, and Children’s Medicaid is free. Federal rules bar cost sharing for emergency services, family planning, pregnancy-related care, and preventive services for children. Children, terminally ill individuals, and people in institutions are fully exempt from any out-of-pocket charges.23Medicaid.gov. Cost Sharing Out-of-Pocket Costs
One exception: the Medicaid Buy-In for Children program, which serves families of children with disabilities whose income exceeds standard Medicaid limits, charges monthly premiums on a sliding income scale.24Texas Administrative Code. Section 361.115
What Texas Medicaid Does Not Cover
Several categories are excluded. Cosmetic surgery is not covered unless it repairs an accidental injury or improves the function of a malformed body part. Infertility treatments, custodial care, experimental procedures, and services provided outside the United States are excluded. Routine foot care such as corn removal and nail trimming is not covered, nor are special shoes or foot supports except through the home health program.8Texas Administrative Code. Section 354.1149
Adult dental is emergency only, and adult dentures are excluded. A draft policy revision from 2024 proposed excluding prescription medications and surgical procedures for gender transition, except for individuals with a medically verifiable genetic disorder of sex development.2Texas Health and Human Services. Texas Medicaid Limitations and Exclusions Services covered by workers’ compensation are excluded, as are services provided by immediate family members or household members, with a narrow exception for personal care services.8Texas Administrative Code. Section 354.1149
One boundary worth naming: Texas has not expanded Medicaid under the Affordable Care Act. Most working-age adults without children or a qualifying disability do not qualify for Medicaid at all, regardless of income, so none of these benefits reach them through this program.