While meeting medical needs is the focus of a county-run indigent health care program, so often those who apply are facing challenges on multiple fronts.
“The majority of our staff are community health workers, so our assessments take a holistic approach to best help our clients,” shared Martha Hernandez, Fort Bend County Health and Human Services (FBCHHS) Indigent Health Care program manager.
“We search for all of the services for which the indigent patient may qualify,” elaborated Hernandez, a former chairman of the Texas Indigent Health Care Association. Examples of other sources of assistance include hospital charitable care, free cell phone application/processing, SNAP (food stamps), prescription assistance, and Medicare, Hernandez detailed.
“Our staff routinely assists individuals with applications for these programs as well as Social Security Administration documentation and follow-up/application processes,” Hernandez continued. “In addition, assessments for outside eligibility are processed for county residents whether or not they qualify for our program.”
Prior to the pandemic, clients were required to complete paperwork in person or find access to a fax machine, she added. The county allowed electronic submissions and signatures during COVID and decided to keep this benefit permanently.
“This option, to send in paperwork through dedicated email channels, is not only convenient, but has also helped with retention,” Hernandez noted.
When it comes to prescriptions, Fort Bend County has managed their assets in such a way that has allowed their indigent health care clients to obtain all of their prescriptions, even though the county program is limited to providing only three prescriptions per month for each client, Hernandez specified.
In addition, clients are referred to local free educational classes that can assist them with additional chronic illness management; they are also referred for yearly wellness and preventive exams/screenings, immunizations, and women’s/men’s health care checks.
“We have been able to help clients get more of what they need by referring them to, and assisting them with, outside applications for patient assistance programs provided by manufacturers who are able to present benefits beyond what our program can offer,” Hernandez detailed.
As a result, the number of clients who reach their maximum allowable amount per fiscal year has been significantly reduced, she reported. For example, in 2023, only five clients maxed out, and in 2022, only four reached the allowable amount; this is a decrease of more than 50 percent from previous years.
“Taking care of our most vulnerable residents should always be a top priority for government officials,” emphasized Fort Bend County Judge KP George. “I am proud of the FBCHHS Indigent Health Care program for providing quality and impactful service to our community.”
Indigent Health Care 101
Fort Bend County is one of over 135 counties that administer a County Indigent Health Care Program (CIHCP).
The Indigent Health Care and Treatment Act of 1985 found in Chapter 61 of the Health and Safety Code requires counties that are not completely covered by a hospital district or public hospital to provide basic health services to indigent residents through a county-run CIHCP.
Texas is home to 113 county-administered CIHCPs that cover the entirety of their respective counties, reported José Andrés Araiza, deputy chief press officer with the Texas Department of State Health and Human Services (DSHS) Office of Communications. In addition, 24 counties have a hospital district that does not cover the entire county; in those counties, the CIHCP covers the portion not covered by the hospital district.
Each state fiscal year, a county’s liability to provide health care services to each eligible county resident may be met in two ways or in a combination of both ways, whichever occurs first: Liability is met once a county has paid $30,000 for health care services for the eligible resident, or the county has paid for 30 days of inpatient care at a hospital or skilled nursing facility for the eligible resident, according to Health and Safety Code (HSC) Chapter 61, Section 61.035.
Once a county spends 8 percent of its General Revenue Tax Levy (GRTL) on indigent care, the county can then request financial reimbursement through the State Assistance Fund. If the state determines the county is eligible for reimbursement, the state may reimburse the county at least 90 percent of eligible costs above the 8 percent spending level. If DSHS fails to provide state funding to an eligible county, the county is not liable for payments for indigent health care services provided to its eligible residents after the county reaches the 8 percent expenditure level, according to HSC Chapter 61, Section 61.039.
During the 86th Regular Session of the Texas Legislature, lawmakers removed former rider 120, which had been used to cap the amount of money a county could request from the State Assistance Fund, Araiza said. Previously, an initial request could not exceed more than 10 percent of the total fund allocated for state assistance. Additional funds could be distributed as needed if no other counties required assistance. There is no longer a limit to the amount that a county may initially request, Araiza specified.
The 88th Regular Session of the Texas Legislature addressed the reporting of certain information by counties for indigent health care, reported Jennifer Ruffcorn with the HHS Office of Communications.
“House Bill 4510 amended the Health and Safety Code relating to the reporting of certain tax information to permit the Texas Health and Human Services Commission (HHSC) to require counties to provide tax information for the purpose of determining eligibility for state assistance,” Ruffcorn explained. HHSC will codify this requirement through an administrative rule amendment.
The CJCAT opposed Senate Bill 987, the original stand-alone bill for this additional reporting requirement, explained CJCAT Senior General Counsel Jim Allison. S.B. 987 passed both chambers but was vetoed by Gov. Greg Abbott. However, this new requirement was added to H.B. 4510 by a Senate amendment and approved.
Provision of Services
In order to qualify for the State Assistance Fund, counties are required to provide basic health care services to eligible residents and may elect to provide a number of DSHS-established optional health care services.
Effective March 2008, the optional health care services category was expanded to include “any other appropriate health care service that the local governmental municipality or entity deems appropriate and cost effective.” Before this addition, if a county wanted to pay for a particular service or equipment and it was not specifically in the rules, the county would not be eligible for state matching funds for that service or equipment, even if the county surpassed its 8 percent. With this change, these other expenditures can count toward the county’s 8 percent expenditure and be eligible for the State Assistance Fund.
The 83rd Texas Legislature addressed indigent health care expenditures associated with county jail inmates. House Bill 2454 amended the HSC to authorize a county to credit an expenditure on health care services for an inmate of a county correctional facility toward the county’s 8 percent. Counties may credit expenditures for eligible residents from other counties who are inmates in their county jail. Inmates, like all CIHCP applicants, apply using Form 3064 – Application for Health Care Assistance and note in the living arrangements section that they are in a county jail facility.
1115 Waiver
In December 2011, Texas received approval from the Centers for Medicare and Medicaid Services for a waiver that allows the state to expand Medicaid managed care while preserving hospital funding, provides incentive payments for health care improvements, and directs more funding to hospitals that serve large numbers of uninsured patients. The Texas Health Care Transformation and Quality Improvement 1115 Demonstration Waiver, referred to as simply the 1115 Waiver, replaced the Upper Payment Limit program.
On Jan. 15, 2021, DSHS received federal approval for extending the 1115 Waiver to Sept. 30, 2030.
