Editor’s Note: Our March issue covered the background of county indigent health care, patient eligibility, and county jail inmates. The following completes our two-part series.

In 1985, Rita Kelley was serving as the regional planner of Alcohol and Drug Abuse Services for the seven-county Central Texas Council of Governments (CTCOG) region. In June of that year, Walt Reedy, CTCOG executive director, walked into Kelley’s office and asked if she wanted to be a health planner.

“I asked him what I had to do, and he said nothing,” Kelley recalled. “Little did I know that the Senate Bill 1 Omnibus Indigent Health Care Act had just passed during special session with a tiebreaker vote by the lieutenant governor, and Walt was looking to me to lead our seven counties toward a September 1986 implementation.” Known as the Indigent Health Care and Treatment Act, this legislation tasked 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 County Indigent Health Care Program (CIHCP).

When all was said and done, CTCOG created a new department: Health Planning and Administration. Kelley began by administering the Maternal and Infant Health Improvement Act (MIHIA) for the seven counties and then implementing and administering the CIHCP in Bell, Coryell, Mills, San Saba, and Hamilton counties through contracts between CTCOG and the counties.

Kelley took leave for about three years before returning in 1993 as an employee of Bell County, where she took back administration of the program for Bell, Mills, and Hamilton counties. She currently administers the Bell and Mills CIHCPs, and she is a past chair of the Texas Indigent Health Care Association.

“I am fortunate to have the leadership and support of both the Bell and Mills County Commissioners Courts,” Kelley shared. “It would be very difficult to do this job if not.”

For the last three biennials, Kelley has been asked to explain the complexities of the indigent health care system to newly elected officials, and January 2019 was no different.

Along with explaining the nuts and bolts of the state mandates and county responsibilities, Kelley urged 200-plus officials gathered at the LBJ Seminar for Newly Elected County Judges and County Commissioners to determine whether or not they have a county-run indigent program, and if they do, to get to know their indigent health care coordinator.

“I’ve actually talked to coordinators who have never met their Commissioners Court,” Kelley shared with new officials gathered on Jan. 15 in Austin. “That shouldn’t be!”

County Progress would like to thank Rita Kelley for allowing us to tap into her expertise and help explain this important county responsibility.

How can a county best ensure cost-effectiveness and efficiency when it comes to administering indigent health care? What are the keys?

A major key to the success of the County Indigent Health Care Program operations is an informed Commissioners Court that is supportive of the program as an important function of the local government. Other suggestions are as follows:

Hire adequate staff and authorize them to attend training opportunities conducted by the state office, Texas Indigent Health Care Association, and others who conduct regional meetings and community meetings/trainings.

Provide for adequate work area to administer and operate the program. This should include private office space in which to conduct in-person or telephone interviews with applicants/recipients.

Provide the program with an adequate records-keeping and claims-processing system. Except with extremely small caseloads, the cost of an electronic records and claims processing system is offset by the accuracy of application and claims processing and the efficiency realized in having all data in a format that can be easily searched and audited; this provides reporting capabilities necessary to effectively manage the program and respond to internal as well as external inquiries on trends, etc.

Encourage the program administrator/staff to develop working relationships with other county departments where health care needs/costs for the same target population are realized (i.e. jails, adult probation) to streamline referrals and quicker access to services.

Encourage the program administrator/staff to develop working relationships with community health and human services representatives to increase the submission of appropriate referrals to the program. Bell County staff regularly provides information and training to other organizations and providers where people may be referred to assure that applications received by the CIHCP are complete and that the people who applied have a reasonable potential to meet the criteria at least based on income. This is important because every application received must be processed, with a decision made on eligibility. Case processing is a timely, complex, and often tedious process; applications that are appropriately completed and submitted generally take less time to process.

Consider the benefits of adopting some or all of the optional services available to counties.  Some of these optional services generate immediate cost-savings when claims are processed.  Others have the potential to reduce overall costs to the program and to the county as a whole. For example:

1. Paying an advanced nurse practitioner or a physician assistant costs less than paying a physician for the same service.
2. Paying for services performed at a freestanding ambulatory surgical center can be less costly than paying for surgery in a hospital setting.
3. Paying for counseling services can offset a mental health crisis that results in hospitalization or incarceration.
4. Paying for diabetic medical supplies and equipment allows the patient to best manage the disease and reduce the chance of acute medical episodes that require more costly medical services or result in death.
5. Paying for colostomy supplies and equipment reduces the potential for infections that could lead to hospitalization or result in death.
6. Paying for dental care, especially for those with chronic conditions such as diabetes and heart conditions, is often medically necessary to alleviate infections and other health impact to the entire body, which could result in higher medical costs or death.
7. Paying for vision care allows those with vision problems to be able to read prescription bottles, other medical instructions, etc., and addresses poor vision which could be a barrier to finding gainful employment and moving off the CIHCP.
8. Paying for home and community health allows patients to be discharged from the hospital sooner, thus reducing the overall cost of care and increasing the potential to heal more quickly and reduce the chance for readmission.
9. Paying for durable medical supplies such as crutches, walkers, or even wheelchairs allows for quicker release from the hospital, especially if there are no caregivers in the household, and enhances the healing process thus reducing the possibility of reinjury or readmission to the hospital.

Please provide a scenario or two that best describes the complexities and importance of proper staff and training.

Counties may pend determinations of eligibility for persons who meet the CIHCP criteria and are in the initial application stage for disability from the Social Security Administration (SSA), but once the person is denied and appeals, a county may make the person eligible and should track CIHCP expenditures as well the SSA disability status. The complexities of the SSA, its disability programs, and the partnership it holds between the SSA and the State of Texas in regard to Medicaid require staff training and periodic refreshment on the topic. These complexities can make it difficult for CIHCP staff to identify and follow up on when/if a person who has been on the CIHCP during the appellant stages of SSA determination may receive retroactive coverage of Medicaid for the same period of time that the CIHCP has paid claims.  Failure to understand and to know how to follow up with SSA and State of Texas Medicaid regarding status of disability application and retroactive coverage has the potential to keep the county from recouping all funds due for services provided within the retroactive Medicaid time frames.

Failure to recognize that all citizens age 65 and older should not be considered for the CIHCP results in the county providing services to a person who does not qualify because they are categorically eligible for Medicaid, or would receive income greater than the CIHCP criteria through SSA at age 65. Regardless of any reported disability, age is considered an automatic disability for the SSI program, and those who have paid into Social Security may begin receiving Social Security Benefits and Medicare at age 65.

Failure to recognize that those who have paid into Social Security have the option to begin receiving early Social Security retirement benefits at age 62 results in a county paying for services for a person who does not meet the eligibility criteria. The early retirement amount is considered unearned income and almost always exceeds the CIHCP income criteria. The CIHCP guidelines stipulate that a person should take advantage of all income that could be available.  This includes early SSA retirement benefits.

MISINFORMATION FROM PREDECESSORS

“The way we’ve always done it syndrome” can make the process challenging. In my communications with county program coordinators across the state, I sometimes hear about policies and practices that are believed to be within the guidelines in accordance to what a predecessor taught them, or because it’s how it’s always been done. I have been told about policies that exclude all but emergency services, policies that deny a person eligibility if he/she abuses alcohol and other substances, or policies that deny if the patient does not comply with physician recommendations. Training on the proper use of the handbook and proper administration as well as periodic refresher training is critical for even the seasoned staff.

A personal example of how easy it is to “forget” the specifics of some rules occurred a few years ago when I got busy and did not distribute a public notice “prior to” the beginning of the state fiscal year for one of the rural county programs we administered; rather it was distributed late into the first month of the new fiscal year.  Between the first of the month and the time I distributed the public notice, we had determined that a couple would not be eligible for the program because their unearned household income far exceeded the income criteria for the program. The household appealed the determination, and we followed our reconsideration and appeal policy by writing a very detailed letter on the reason for denial and inviting the household to request an appeal hearing if they still did not agree with our determination. The couple had an attorney friend who represented them to request a hearing. Our hearing process includes one hearing officer who is impartial to either the county or the client, and two other panel members who represent the local health care community and the county. Preparing for the hearing took many hours, and it became a very involved process. The couple’s attorney contended that because the county had not published the public notice in accordance with Chapter 61 of the Health and Safety Code, and because there was no record that the County Commissioners Court had annually established the minimum income criteria, that the county did not have an adopted income criteria, and thus any income would be considered within the guidelines. In the end, the panel upheld the denial but also reprimanded me for neglecting to comply strictly with the administrative requirements to post public notices prior to the beginning of the fiscal year and to assure that the county adopted minimum standards every year prior to or at the very beginning of the new fiscal year. To this date, I have assured that public notices that include minimum eligibility criteria be distributed on time and that the Commissioners Court adopts the criteria on an annual basis. In all the years I have administered the CIHCP for Bell and a few other counties, this is the ONLY appeal hearing that anyone has ever requested, and it was done so not because of any error to determining eligibility but because of noncompliance to a very basic guideline that I had become lax in administering. Although the error did not cost the county through payment of medical claims, it did cost the county, the state, the hearing panel, me, and my staff much time, effort, and anguish.

Can you please comment on the 1115 Waiver?

The 1115 Texas Medicaid Transformation Waiver presented a viable opportunity for counties to engage in an intergovernmental transfer (IGT) opportunity in which the county could have a guarantee that funds would come back to the local communities and provide services that were identified and deemed important to the local community, as opposed to a one-size-fits-all solution to transforming health care across the state. There are two ways a county could participate in the waiver: through Uncompensated Care affiliation agreements with local hospital providers, and through Delivery System Reform Incentive Payments (DSRIP) projects in which an eligible provider or public entity could implement services aimed at addressing local behavioral and physical health access and service delivery concerns.

In December 2017, the 1115 Waiver was renewed for an additional five years, through September 2022. The expenditure of 1115 Waiver funds may account for up to 4 percent of the GRTL, or half of the 8 percent a county must spend on indigent health care before state funding is available.

Bell County’s engagement in this waiver process has given opportunity for health care stakeholders to work together more closely to identify gaps in services and develop viable solutions that meet the distinct needs of the Bell County community. One of the greatest values I have experienced is a better working relationship with our local health care workers that has allowed mutually beneficial collaborations beyond the scope of the waiver. As the current waiver begins to wind down, there is on-going discussion among hospital and other stakeholders on what new funding mechanisms may be possible to continue the collaborative partnerships within Texas local communities to mitigate health care costs while assuring our local residents have the medical services they need. I encourage county officials to keep your eyes open and your minds flexible to what opportunities present themselves.

For more information on CIHCPs, go to https://www.dshs.texas.gov/cihcp/CIHCP-Administrator-Page/ or contact the County Indigent Health State Office of the Health & Human Services Commission.