Texas Medicaid home-care pathways generally authorize a set number of attendant hours based on assessed need, not round-the-clock coverage as families picture it. The Texas Health and Human Services STAR+PLUS Handbook is blunt about one of the services families hope will fill the night: protective supervision “is not intended to provide 24-hour care.” The overnight gap is where families end up either filling shifts unpaid or facing a facility decision under pressure. That is the decision hiding inside a yes-or-no question about 24-hour care.

You promised your mother she would never be “put in a home.” Someone then said Medicaid would keep her there. What nobody said out loud is whether that means a paid person in the house at 2 a.m., or a capped daytime hour budget that still leaves you sleeping in the recliner with one ear open.

Jessica Cannon is a CPA with 28 years of financial experience and a Certified Dementia Practitioner. She works with families nationwide through virtual coaching, with in-person roots in Austin and Central Texas.

Key Insights

Texas Medicaid can pay for in-home attendant help. That is not the same as continuous paid coverage. Federal Medicaid rules let states run home and community-based services so people can stay at home rather than in an institution. CMS describes those waiver programs as following an individualized, person-centered plan of care. A plan of care is not a promise of a person in the house at 2 a.m. Protective supervision is supervision only, is not a Community First Choice benefit, and is not intended as 24-hour care. Form H2060 says authorized hours cannot exceed 50 for STAR+PLUS Program members. Respite is short-term relief with a 30-day annual ceiling unless the managed care organization approves more. Private duty nursing, as Texas describes it, is a children’s benefit, not a general adult-dementia overnight service. The decision in front of you is how to read a partial hour budget against the night.

Table of Contents

• Does Texas Medicaid pay for 24-hour in-home care for someone with dementia?
• What is protective supervision, and how is it different from ordinary attendant hours?
• When families ask for 24-hour care, which parts are attendant hours, respite, private-duty nursing or unpaid family coverage?
• What decides the number of hours before you know whether overnight coverage is possible?
• What happens to the overnight gap, and what does it cost the family?
• How do you compare a capped hour budget with facility cost?
• Where does help reading the hours, the denial letter and the timeline together come in?

Does Texas Medicaid pay for 24-hour in-home care for someone with dementia?

Not in the way most families mean “24-hour.” STAR+PLUS, Texas’s Medicaid managed-care program that combines medical care with long-term services, can authorize personal assistance services in the home. Those hours come from an assessment of need, recorded on Form H2060, the Needs Assessment Questionnaire and Task/Hour Guide, or on the Community First Choice assessment. The handbook that governs STAR+PLUS home and community-based services says protective supervision is authorized when informal support is unavailable. It also says that service is not intended to provide 24-hour care.

So “Medicaid covers in-home care” and “Medicaid will put someone in the house all night” are different sentences. The first can be true. The second is the sentence the handbook refuses. For the mechanics of how many hours a plan currently lists, start with Texas Medicaid in-home care hours.

What is protective supervision, and how is it different from ordinary attendant hours?

Protective supervision, in the STAR+PLUS Handbook, exists “to assure the health and welfare of a member with a cognitive impairment, memory impairment or physical weakness.” It is supervision only. It does not include the delivery of personal care tasks. The examples the handbook gives are the nights families already know: wandering outside, turning on an appliance, trying to walk and falling.

Ordinary attendant hours help with bathing, dressing, meals and the household tasks that keep a home safe. Protective supervision is the watch, not the washcloth. It is authorized by the managed care organization. It is not routinely authorized for someone who can safely live alone. It is not a benefit of Community First Choice, the state-plan attendant option most members use for personal help. It can still appear on an individual service plan even when the person also receives Community First Choice.

That last distinction matters. Families often hear “attendant hours” and picture one pool of time that can be stretched through the night. In Texas, the night watch and the daytime tasks can sit in different columns, and one of those columns is written so that it will not become 24-hour coverage.

When families ask for 24-hour care, which parts are attendant hours, respite, private-duty nursing or unpaid family coverage?

Four different things get folded into the phrase “24-hour care.” They do not pay the same way.

Personal attendant hours are assessed task by task. Form H2060 tells the assessor to turn minutes into a weekly hour total, then says authorized hours cannot exceed 50 for all STAR+PLUS Program applicants and members. The Community Care Services Eligibility Handbook says a person without priority status may receive no more than 50 hours of service per week, and a person with priority status no more than 42. Community Attendant Services and Primary Home Care, the related state-plan attendant programs, use the same kind of ceiling: 50 hours a week, or 42 for a person with priority status. All of these caps are weekly budgets for help with daily tasks.

Respite is short-term relief for the primary caregiver. The STAR+PLUS Handbook caps it at 30 days per individual-service-plan year, which the handbook equates to 720 hours, unless the managed care organization approves more. Respite is a break, counted against that 30-day limit.

Private duty nursing in Texas Medicaid is described in the STAR Kids handbook as a Texas Health Steps Comprehensive Care Program benefit for members who need continuous skilled nursing beyond ordinary home-health visits. That is a children’s pathway, not a general adult-dementia overnight nurse. Do not read it as 24-hour home nursing for a parent.

What remains, when the authorized hours end, is unpaid family coverage. That is not a Medicaid benefit. It is the recliner.

Community First Choice, the federal state-plan option Texas uses for attendant help, covers personal assistance, habilitation, an emergency-response device and training to manage attendants. Federal rules tie those services to an assessed need in a person-centered plan. They do not convert an assessment into a 24-hour paid post. Protective supervision, as Texas writes it, sits outside Community First Choice.

What decides the number of hours before you know whether overnight coverage is possible?

An assessment. Form H2060 records tasks, minutes and a weekly hour total for STAR+PLUS Program personal assistance. Form H6516 does the Community First Choice version. Form H2060-A is the addendum that records protective-supervision hours as their own line. The managed care organization authorizes from that picture.

The assessment writes the hour budget, and the hour budget is what you have to read against the night before anyone talks about a facility. Eligibility, applying and requesting more hours are covered in Texas Medicaid eligibility for seniors, how to apply and how to request more in-home hours.

What happens to the overnight gap, and what does it cost the family?

The gap is the hours the authorization does not cover. Someone fills them. Often that someone is you.

The cost shows up in three places at once. A working daughter leaves a job, or keeps the job and does not sleep. A crisis placement happens without anyone comparing the total cost of the night to the total cost of a facility. Savings get spent while the window to sign documents is still open, or already closing. None of those are Medicaid rules. They are what a partial hour budget does to a household that promised the house.

The STAR+PLUS Handbook’s own examples of why protective supervision exists are overnight problems (wandering outside, turning on an appliance, trying to walk and falling), and those are the hours a weekly task budget does not automatically cover.

Medicare does not close this gap either. The companion page on whether Medicare or Medicaid covers in-home care is the place for that distinction. How families pay when the authorization stops is how to pay for in-home dementia care.

How do you compare a capped hour budget with facility cost?

Put both on the same page, with numbers. Take the 50-hour weekly ceiling Form H2060 sets on its task and hour authorization as a sample budget, out of the 168 hours in every week. Protective supervision hours are recorded separately on Form H2060-A, and the handbook says that service is not intended to provide 24-hour care either. On the sample budget, 118 hours a week fall to somebody else, and the eight hours from 10 p.m. to 6 a.m. account for 56 of them.

Now price those nights. CareScout’s Cost of Care Survey 2025 puts the Texas median for a non-medical in-home caregiver at $30 an hour, so paying privately for 56 overnight hours is a potential $1,680 a week, or up to about $7,280 a month at that median rate. The same survey puts the potential monthly cost of a Texas assisted living community at a median $5,666, and of a Texas nursing home at a median $5,627 for a semi-private room and $7,604 for a private one.

Read side by side, the promise to keep Mom at home with paid nights can cost as much as the facility the family was trying to avoid, before a single extra daytime hour is bought. That is the quiet arithmetic of a capped hour budget, and a family deserves to see it before a crisis makes the decision for them. Rates vary by city and by care need, so your own quotes go into the same columns. Nursing home versus memory care versus in-home care is the comparison frame, and how families pay for long-term dementia care is the money frame.

Where does help reading the hours, the denial letter and the timeline together come in?

Jessica’s lane is reading a Medicaid denial letter, an hour authorization and a care-cost timeline together, the same way she reads a Medicare letter against a memory-care contract. She works with families nationwide through virtual coaching, with in-person roots in Austin and Central Texas. Ongoing monthly coaching is the form that lasts past one confusing letter. The discovery call is a short video call to see whether that help fits.

Frequently Asked Questions

Q: Can I get 24-hour home care through a Texas Medicaid waiver?

A: Not as families usually mean 24-hour. STAR+PLUS can authorize assessed attendant hours in the home, including through its home and community-based services path for people who would otherwise meet nursing-facility criteria. Protective supervision can be added when informal support is unavailable. The STAR+PLUS Handbook still says that service is not intended to provide 24-hour care. Read the authorization you have, not the phrase “waiver.”

Q: Is there a limit on protective supervision hours for dementia in Texas?

A: Texas does not publish a separate dementia-only hour cap for protective supervision. What it does publish is the nature of the service: supervision only, not personal care, not a Community First Choice benefit, and not intended as 24-hour care. For state-plan STAR+PLUS personal assistance on Form H2060, authorized hours cannot exceed 50. Protective-supervision hours are recorded on the H2060-A addendum and authorized by the managed care organization from assessed need.

Q: Does Texas Medicaid pay for private-duty nursing at home overnight?

A: Not as a general adult-dementia benefit. Texas describes private duty nursing as a Texas Health Steps Comprehensive Care Program service for STAR Kids members who need continuous skilled nursing beyond ordinary home-health visits. That is a children’s pathway. An adult parent with dementia is assessed for attendant hours and, where it applies, protective supervision, not for a standing overnight nurse under that policy.

Q: Who can help me read a Texas Medicaid hour authorization or denial?

A: The managed care organization that wrote the authorization is the first reader. An elder law attorney in Texas can speak to appeals and to the documents around capacity. Jessica’s lane is reading the hour letter, the denial and the care-cost timeline together through monthly coaching. She is not the agency and she does not file the appeal. The discovery call is a video conversation about whether that reading is what you need.

Citations

• STAR+PLUS Handbook 6100, Home and Community-Based Services, Texas Health and Human Services. Protective supervision is supervision only, is appropriate for cognitive or memory impairment or physical weakness, is not intended to provide 24-hour care, and is not a benefit of Community First Choice https://www.hhs.texas.gov/handbooks/starplus-handbook/6100-home-community-based-services
• Form H2060, Needs Assessment Questionnaire and Task/Hour Guide, Texas Health and Human Services. Authorized hours cannot exceed 50 for all STAR+PLUS Program applicants and members https://www.hhs.texas.gov/regulations/forms/2000-2999/form-h2060-needs-assessment-questionnaire-taskhour-guide
• Form H2060-A, Addendum to Form H2060, Texas Health and Human Services. Worksheet for recording estimated weekly PAS hours for protective supervision https://www.hhs.texas.gov/regulations/forms/2000-2999/form-h2060-a-addendum-form-h2060
• Form H6516, Community First Choice Assessment, Texas Health and Human Services. CFC assessment for people 21 and over; records weekly PAS and habilitation hours from assessed need. https://www.hhs.texas.gov/regulations/forms/6000-6999/form-h6516-community-first-choice-assessment
• Community Care Services Eligibility Handbook 4600, Primary Home Care and Community Attendant Services. Priority status no more than 42 hours a week; others no more than 50 https://www.hhs.texas.gov/handbooks/community-care-services-eligibility-handbook/4600-primary-home-care-community-attendant-services
• STAR+PLUS Handbook 7300, Respite Care Services. Annual limit 30 days, equivalent to 720 hours, unless the MCO approves more https://www.hhs.texas.gov/handbooks/starplus-handbook/7300-respite-care-services
• STAR+PLUS Handbook 1100, Program Overview. STAR+PLUS combines acute care with long-term services and supports, including in-home help and respite as short-term supervision https://www.hhs.texas.gov/handbooks/starplus-handbook/1100-program-overview
• STAR Kids Handbook 4300, Private Duty Nursing. PDN is a THSteps-CCP benefit for STAR Kids members who need continuous skilled care beyond ordinary home-health visits https://www.hhs.texas.gov/handbooks/star-kids-handbook/4300-private-duty-nursing
• Community First Choice overview, Texas Health and Human Services. CFC personal assistance, habilitation, emergency response and support management https://www.hhs.texas.gov/providers/long-term-care-providers/long-term-care-provider-resources/community-first-choice-cfc
• 42 CFR Part 441 Subpart K, Community First Choice. Federal attendant services tied to assessed need in a person-centered plan https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-441/subpart-K
• Home and Community-Based Services 1915(c), Medicaid.gov. States can develop HCBS waivers so people can receive long-term services at home rather than in an institution; services follow an individualized, person-centered plan of care https://www.medicaid.gov/medicaid/home-community-based-services/home-community-based-services-authorities/home-community-based-services-1915c
• CareScout, Cost of Care Survey 2025, Median Cost Data Tables (published 2 March 2026; data July through November 2025). Texas medians, as potential costs: non-medical caregiver $30 an hour ($68,640 a year on a 44-hour week); assisted living community $5,666 a month; nursing home semi-private room $5,627 a month and private room $7,604 a month https://assets.carescout.com/x/8fcb50422f/282102.pdf

Related reading

• Texas Medicaid In-Home Care Hours
• How to Request More Medicaid In-Home Care Hours in Texas
• Does Medicare or Medicaid Cover In-Home Care?
• Nursing Home vs Memory Care vs In-Home Care
• How Families Pay for Long-Term Dementia Care
• How reactive caregiving can cost families up to $750K, and what proactive planning saves
• Financial Wellness for Family Caregivers
• The Proactive Caregiver Method

About this article. Jessica Cannon is a CPA with 28 years of financial experience and a Certified Dementia Practitioner. She provides financial coaching, not legal or medical services. This article is general information about how these systems work, not advice about your situation, and it is not a substitute for the advice of an attorney. It is not medical advice, and it is not individualized tax or financial advice.

For the legal instruments themselves, including wills, powers of attorney and guardianship, you will need a licensed attorney in your own state. Medicaid and long-term care rules also differ by state and change over time, so any Texas detail here is an example rather than a rule that will apply to you.