Texas Medicaid Covered Services for Seniors (2026)

Texas Medicaid covered services for seniors 65 and older run well past basic doctor visits. A senior who qualifies through STAR+PLUS, the state's managed care program for adults 65 or older and adults with disabilities, gets primary and specialty care, hospital care, prescription drugs, behavioral health, vision, and personal attendant services.1 For members who qualify on the basis of Supplemental Security Income (SSI), there is no copay.2 The hard part is knowing what is fully covered, what is limited (adult dental, mainly), and how to actually use each benefit.

In This Guide

• Key Takeaways
• What Texas Medicaid Covered Services Does STAR+PLUS Include?
• What Are the Prescription Drug Rules?
• Is Adult Dental Covered?
• What About Vision and Hearing?
• How Does Behavioral Health Work?
• How Do I Get a Ride to Appointments?
• Can I Use Telehealth?
• What Long-Term Care Stays at Home?
• Which Texas Medicaid Covered Services Are Limited or Excluded?
• When Do I Need Prior Authorization?
• How Do I Find a Doctor Who Takes Medicaid?
• What Do I Do If a Service Is Denied?
• Who to Call in Texas
• Frequently Asked Questions
• Learn More

What Texas Medicaid Covered Services Does STAR+PLUS Include?

Most Texas seniors on Medicaid receive their care through STAR+PLUS, the state's managed care program for adults 65 or older and adults with disabilities.7 Base STAR+PLUS covered services for all members include the following.

Doctor Visits and Preventive Care

STAR+PLUS covers primary and specialty physician care, including annual checkups and Texas Health Steps preventive services.1 You choose a primary care provider (PCP) when you enroll in your managed care organization (MCO), and that PCP coordinates the rest of your care.

Hospital Care

Inpatient and outpatient hospital services are covered base benefits under STAR+PLUS.1 Emergency care never requires prior authorization, even at an out-of-network facility.8

Therapy and Long-Term Services

STAR+PLUS also covers behavioral health, vision, nursing facility care, personal attendant services, and day activity and health services as base benefits.1 Members who meet a nursing-facility level of care can add home- and community-based services through the STAR+PLUS HCBS program, described further below.

What Are the Prescription Drug Rules?

Texas Medicaid covers prescription medications through the Vendor Drug Program (VDP), which maintains a statewide formulary and a Preferred Drug List (PDL).3 STAR+PLUS members receive the drug benefit through their MCO and generally pay no copay for covered medications.

• Preferred drugs are available without prior authorization, though they may still be subject to clinical prior authorization.3
• Non-preferred drugs require prior authorization from your prescriber.3
• The PDL is updated twice a year (a January update and a July update) based on the Drug Utilization Review Board's recommendations.3
• Check the formulary first. The Formulary Drug Search at txvendordrug.com tells you whether a medication is covered and whether it needs prior authorization.3

Having your full medication list ready when you see a new doctor saves time. If a drug you need is non-preferred or off-formulary, your prescriber can submit a prior authorization request to your MCO.

Is Adult Dental Covered?

This is where Texas Medicaid is thinnest for adults. Under the base program, adult dental coverage is mostly limited to emergency dental treatment, meaning procedures necessary to control bleeding, relieve pain, and eliminate acute infection.4

Beyond the base program, individual STAR+PLUS MCOs may offer value-added dental services. These are extras each plan chooses to provide, and they vary by MCO and service delivery area and can change at any time, so check your specific plan's current benefits for amounts and covered procedures.4 Value-added dental is not required to be used up before STAR+PLUS HCBS waiver dental services.4

HCBS Waiver Dental

If you are on the STAR+PLUS HCBS waiver, dental coverage is broader. The waiver covers dental services with an annual cost limit of $5,000 per individual service plan (ISP) year, and the MCO may waive that cap on request only when the services of an oral surgeon are required.4 Waiver dental is provided only after all other available resources, except value-added services, have been exhausted, and the dentist must be licensed by the Texas State Board of Dental Examiners and enrolled with Texas Medicaid.4

If you also have Medicare, note that Original Medicare (Parts A and B) does not cover routine dental such as cleanings, fillings, extractions, dentures, or implants; some Medicare Advantage plans add dental as an extra benefit.9

What About Vision and Hearing?

STAR+PLUS covers vision services, including eye exams and Medicaid-covered eyeglasses, as a base benefit.10 On hearing, clients of any age are eligible to receive medically necessary hearing aid devices and services under Texas Medicaid.10

Individual MCOs may add value-added vision and hearing benefits, such as an annual eyewear allowance or a hearing-aid allowance. These extras vary by plan and can change, so check your specific MCO's current benefits for the amounts.10 If you suspect hearing loss, ask your PCP for a referral to an audiologist in your MCO's network.

How Does Behavioral Health Work?

STAR+PLUS covers behavioral health, including mental health treatment and substance use treatment, as a base benefit.6 MCOs typically deliver behavioral health through a designated behavioral-health network, so check which providers are in-network before scheduling. To reach your plan's behavioral-health line, use the member-services number on your plan ID card.6

Texas Medicaid permits behavioral-health services to be delivered by telehealth, including synchronous audio-only (phone) visits, which are designated by modifier FQ for behavioral health.6

How Do I Get a Ride to Appointments?

Texas Medicaid covers non-emergency medical transportation, but how you arrange it depends on how you receive your Medicaid.

Fee-for-service Medicaid members (and Children with Special Health Care Needs and Transportation for Indigent Cancer Patients clients) who have no other way to get to a covered appointment use the Medical Transportation Program (MTP), run by the Texas Health and Human Services Commission (HHSC).5

• Call 877-633-8747 (877-MED-TRIP) at least 2 business days before the appointment (longer for travel beyond your home county).5
• Covered rides include trips to a doctor's office, dentist's office, hospital, drug store, or any place that provides covered healthcare services.5
• STAR+PLUS and other managed-care members instead arrange non-emergency transportation through their MCO's transportation benefit, using the transportation contact number on their plan ID card.5

This benefit is underused. If your parent lives alone and does not drive, confirm which line applies to their coverage and put that number in their phone.

Can I Use Telehealth?

Texas Medicaid allows telehealth through several methods: synchronous audiovisual (live video), synchronous audio-only (phone), and store-and-forward technology, and it covers home telemonitoring (now used interchangeably with remote patient monitoring).6 Since September 2022, audio-only delivery has been permitted, with modifier 93 for non-behavioral-health audio-only services and modifier FQ for behavioral-health audio-only services.6

Providers must be enrolled in Texas Medicaid and licensed to practice in Texas.6 Confirm with your provider whether a given service is offered by telehealth, since availability depends on the service and the provider.

What Long-Term Care Stays at Home?

Beyond medical care, STAR+PLUS covers long-term services and supports that help seniors stay at home:

• Personal attendant services for help with bathing, dressing, grooming, eating, and household tasks.1
• Day activity and health services for supervised group care with nursing support.1

For seniors who need an entitlement program rather than a waiver, Community Attendant Services (CAS) provides non-medical personal care with no interest list. Authorized attendant hours cannot exceed 42 per week for a priority person or 50 per week for all other people.11

The STAR+PLUS HCBS waiver adds in-home nursing, respite care, home-delivered meals, minor home modifications, emergency response services, assisted living, and therapies, drawn from the Texas Healthcare Transformation and Quality Improvement Program Section 1115 waiver.7 The HCBS arm is not an entitlement: HHSC maintains a statewide interest list, and as of late 2025 approximately 15,850 people were on it.12

Which Texas Medicaid Covered Services Are Limited or Excluded?

The table below sorts the common questions into what STAR+PLUS covers as a base benefit, what is limited, and what it does not pay for.

If you are unsure whether something is covered, call your MCO's member services line before the appointment. A "no" after the fact is worse than checking first.

When Do I Need Prior Authorization?

Some STAR+PLUS services require your MCO's approval before you can receive them. This is called prior authorization (PA), and it is generally the provider's responsibility to obtain.8

Services That May Need Prior Authorization

Examples include non-emergency inpatient hospital admissions, certain surgeries and cardiology procedures, chemotherapy, select specialty (non-preferred) medications, and certain durable medical equipment.8 The exact PA list varies by MCO and year, so confirm with your plan.

What Doesn't Need Prior Authorization

Prior authorization is generally not required for emergency or urgent care.8 Routine primary care visits and preventive screenings also do not require it.

How Fast Your MCO Must Decide

Under the 2024 CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), which applies to Medicaid managed care plans, impacted payers must, beginning in 2026, send prior authorization decisions within 72 hours for expedited (urgent) requests and within 7 calendar days for standard (non-urgent) requests for medical items and services.8 If your MCO denies, reduces, or terminates a service, you have appeal rights, covered below.

How Do I Find a Doctor Who Takes Medicaid?

Finding a provider who accepts Texas Medicaid starts with your MCO, which maintains its own network of primary care providers, specialists, hospitals, pharmacies, and behavioral-health providers within your service delivery area.13

• Use your MCO's online provider directory or call the member-services number on your plan ID card.13
• Call the Texas Enrollment Broker Helpline at 1-800-964-2777 for help choosing or switching MCOs if your current plan does not have enough providers in your area.14
• Call 2-1-1 (211Texas.org) for general Medicaid assistance and referrals.13

Calling ahead to confirm a provider still accepts your specific MCO plan is worth the two minutes, because provider directories are not always current.

What Do I Do If a Service Is Denied?

If your MCO denies, reduces, or terminates a service, you have the right to challenge it.15

The HHS Office of the Ombudsman Managed Care Helpline at 1-866-566-8989 handles complaints about a managed care plan and can help you understand your options.14

Who to Call in Texas

Learn More

Find personalized help understanding Texas Medicaid coverage at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.