Two Houston families can both be on Texas Medicaid and still get two completely different bills — one that folds everything together, and one with a separate room-and-board charge on top. The difference comes down to which Medicaid program is paying, not how much care either parent needs.
Every few weeks a Houston family calls us confused about two Medicaid numbers that don't seem to line up. One relative is in a nursing facility and pays a single monthly amount to the facility. Another relative is in an assisted living community on the STAR+PLUS HCBS waiver, and on top of whatever the waiver covers, the family is still handed a separate room-and-board bill that runs several hundred dollars a month. Both relatives are on Texas Medicaid. Both went through the same agency, the Texas Health and Human Services Commission (HHSC). The bills still look nothing alike, and the reason is built into how each program is authorized under federal Medicaid law — not into how much either parent's care actually costs.
Why nursing facility Medicaid includes room and board
When Texas Medicaid pays a nursing facility, it isn't paying for a list of individual services the way it does under a waiver. It pays the facility a single daily rate, and HHSC's own guidance on how that rate is built is specific about what's bundled into it: room and board, medical supplies and equipment, personal needs items, social services, and over-the-counter drugs are all part of the same payment. The facility is paid based on a Resource Utilization Group (RUG) level, which comes from a clinical assessment (the Minimum Data Set, or MDS) done on each resident. In other words, the state sets one all-in rate per resident based on how much care that resident actually needs, and room and board rides along inside it automatically. There's no separate room-and-board invoice because the program was never structured to send one.
What happens to the resident's own income: "applied income"
That doesn't mean nursing facility Medicaid is free. A resident is still expected to contribute nearly all of their own income — Social Security, a pension, whatever it is — toward the cost of their care. Texas calls this "applied income," and HHSC's Medicaid for the Elderly and People with Disabilities handbook sets the personal needs allowance a nursing facility resident gets to keep for themselves at $75 a month. Everything above that, after a few narrow deductions, becomes the resident's applied income and is owed to the facility as their share of the Medicaid payment. Nursing facilities are required to make ongoing efforts to collect it, and HHSC's own FAQ for providers is blunt about what happens when a resident doesn't pay: after two unsuccessful monthly collection attempts, the facility notifies the managed care organization, and continued nonpayment can put the resident's placement at risk. So the resident's income doesn't disappear — it's simply built into the same all-in payment rather than showing up as its own line item.
Why STAR+PLUS HCBS works the opposite way
STAR+PLUS HCBS is a different kind of Medicaid benefit entirely. It's a Home and Community-Based Services waiver, which means Texas designed it specifically to pay for the services that let someone who qualifies for nursing-facility-level care stay out of a nursing facility instead — in an assisted living facility, an adult foster care home, or their own home. Because the whole point of the waiver is to fund services rather than a facility placement, HHSC's own STAR+PLUS Handbook is direct about the boundary: "STAR+PLUS HCBS program members are responsible for their room and board costs." Medicaid pays the assisted living facility for the personal care and other authorized HCBS services on the member's plan. It does not pay for the roof over their head or the food on their table. That part is between the resident and the facility, in real dollars, every month.
The room-and-board math, and why it isn't invented
HHSC doesn't leave the room-and-board amount up to negotiation from nothing — it sets a formula. Under the STAR+PLUS Handbook, the room-and-board charge for an HCBS member in an assisted living facility is based on the Supplemental Security Income (SSI) federal benefit rate, minus an $85 personal needs allowance. The Social Security Administration's maximum federal SSI payment for an individual in 2026 is $994 a month. Run the formula and the calculated room-and-board amount comes out to roughly $909 a month ($994 minus $85). HHSC's policy is also clear that this amount cannot be waived, though an individual assisted living facility is allowed to accept a member for less than the calculated rate if it chooses to. Two things to notice: this figure moves whenever the SSI federal benefit rate changes, typically each January, and it has nothing to do with what a specific Houston community charges private-pay residents — it's a statewide Medicaid formula, not a market rate.
The financial eligibility test is the same for both programs
Here's where the two programs stop looking different: HHSC applies the same income and resource limits whether your parent is applying for institutional nursing facility Medicaid or for the STAR+PLUS HCBS waiver. As of the current HHSC handbook, the monthly income limit is $2,982 for an individual and $5,964 for a couple, and the countable resource limit is $2,000 for an individual and $3,000 for a couple. Both programs also require an approved medical necessity determination showing the applicant needs a nursing-facility level of care — that clinical bar doesn't change depending on which setting the care happens in.
Families whose income runs over that monthly limit aren't automatically disqualified from either program. Texas allows a Qualified Income Trust, commonly called a Miller Trust, that can bring an over-income applicant back into eligibility for either nursing facility Medicaid or STAR+PLUS HCBS. HHSC documents the mechanics in its own handbook appendix on QITs. Setting one up correctly has real consequences if it's done wrong, so this is one of the few steps in Texas Medicaid planning where paying an elder law attorney for an hour of review is usually worth it.
One is a guarantee; the other has a waiting line
This is the difference that catches the most Houston families off guard, and it has nothing to do with money. Nursing facility care is a mandatory Medicaid benefit under federal law for people 21 and older. The federal Medicaid program's own guidance says states cannot restrict access to it through waiting lists once someone qualifies. If your parent meets the financial and medical criteria and needs nursing facility placement, Texas Medicaid has to pay for it — there's no capped number of slots to compete for.
STAR+PLUS HCBS is the opposite kind of benefit. It exists under a federal Section 1915(c) waiver, and states are specifically permitted to cap how many people a 1915(c) waiver serves at one time. Texas does exactly that, which is why STAR+PLUS HCBS runs an interest list rather than enrolling everyone who qualifies right away — we've covered how that interest list actually works in a separate guide. In practice, this means a Houston family that needs help paying for assisted living today may be looking at a wait before a STAR+PLUS HCBS slot opens, while a family whose parent needs nursing facility care can generally move forward as soon as the eligibility paperwork clears.
Which program actually fits your parent
Neither program is "better" in the abstract — they're built for different situations. Nursing facility Medicaid makes sense once a parent genuinely needs the level of skilled nursing, supervision, or round-the-clock care that a nursing facility provides, or when a family can no longer manage private pay for that level of care. STAR+PLUS HCBS makes sense for a parent who can safely remain in an assisted living community or at home with the right services in place, and who is willing to plan around the interest list and the separate room-and-board payment that comes with it. Some families end up moving between the two over time, as a parent's needs change; a person already approved for STAR+PLUS HCBS who later needs a higher level of care can typically be reassessed and transition into nursing facility Medicaid without starting the financial eligibility process over from scratch, since the same income and resource test already applies.
Starting the process in Harris County
Both programs start the same way: with a Medicaid application through Your Texas Benefits (the state's combined benefits application) and, for the assisted living or home-based path, contact with your local STAR+PLUS managed care organization or the Aging and Disability Resource Center. The paperwork asks the same financial questions either way, which is part of why families sometimes apply for one program and realize partway through that the other one actually fits their situation better.
If you're trying to figure out which path applies to your Houston-area parent, or you're already deep in an application and the room-and-board bill just showed up out of nowhere, call a free local advisor at (346) 385-3815. We can't file the Medicaid paperwork for you, but we can help you understand which program you're actually looking at and connect you with assisted living and nursing facility options across Harris, Fort Bend, Montgomery, Brazoria, and Galveston counties that work with each one.
Last updated September 20, 2026. This guide is general information for Greater Houston families, not medical, legal, or financial advice.
