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.

“Rita is frequently called upon as a resource for the County Judges and Commissioners Association of Texas, the Conference of Urban Counties, and the Texas Association of Counties on this topic,” offered Bell County Judge Jon Burrows. For example, in January Kelley was asked to present on indigent health care at the LBJ Seminar for Newly Elected County Judges and County Commissioners.

“Rita Kelley has been involved with indigent health care since the beginning,” summarized Bell County Commissioner Richard Cortese. “She has worked to provide health care for those who truly are qualified and hold the providers to guidelines set up by Medicaid, which gives the county the proper cost control.

“This has allowed the county to meet its obligation for indigent health care without going into the hole,” Cortese maintained.  In addition, she has helped navigate through the red tape of the 1115 Waiver.

“Much of our success has been because of Rita’s leadership,” Cortese concluded.

Burrows echoed Cortese, citing Kelley as one of the most knowledgeable, if not “the most knowledgeable person” involved in county indigent health care.

“Rita has been instrumental in establishing mutually beneficial relationships between Bell County and the local medical providers, allowing all parties to be more efficient and effective in the providing of medical care covered under the CIHCP,” Burrows declared.

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

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

Question 1: What is the definition of indigent health care?

When I speak to groups about the program, I generally say that the County Indigent Health Care Program is a statutory obligation of a county not totally covered by a public hospital or a hospital district, and that it is an eligibility-based health plan.  That said, I will tell you that if you ask the Department of State Health Services (state office), you will likely be told that CIHCP is NOT insurance.  Even so, when I describe it in these terms, people seem to get it.

Question 2: Who is eligible to receive indigent health care?

• RESIDENCY:  Residents of the county in areas of the county not covered by a public hospital or hospital district.
  • Residency is not equal to citizenship.  Although some counties have opted to disqualify non-citizens from the CIHCP, nothing in Chapter 61 provides any legal liability protection for a county that denies coverage to a non-citizen who would otherwise meet the eligibility criteria.
  • There is NO duration requirement for residency.
  • A person with no fixed resident (homeless) or a person who is new to the county and declares intent to reside there is considered a resident.
  • Examples of NON residents of the county:
    • inmate or resident of a state school or institution operated by a state agency;
    • inmate, patient or resident of a school or institution operated by a federal agency;
    • a minor student primarily supported by his/her parents whose home residence is in another county or state; and
    • a person who moves to the county solely to obtain health care
  • INCOME: Those who meet the maximum income criteria adopted by the county.  Minimum criterion is 21 percent of the Federal Poverty Level (FPL), although counties have the option to be less restrictive, up to 50 percent of the FPL, and continue to be eligible for state matching funds.
    • IF a county exceeds its 8 percent GRTL obligation and the state still has matching funds available, by law the county is required to continue running its program.
    • A county may adopt an income criteria beyond 50 percent GRTL, but expenditures for those who qualify at income beyond 50 percent FPL would not be countable toward the 8 percent GRTL obligation.
    • Types of income include earned (employment related) and unearned (cash gifts, pension, retirement, etc.). Certain income is exempt. Earned income is counted at net after allowable earned income deductions are applied to the gross/unearned income counted at gross.
  • RESOURCES:  Meet the resource (asset) test established by the state.
    • Resources are either countable or exempt.
      • Examples of exempt resources: burial plots, crime victims compensation, income producing property, personal possessions such as jewelry, any structure a person uses as a primary residence, to include out buildings, motor home, etc.
      • Examples of countable resources: insurance settlements, readily available liquid assets such as cash, CDs, stocks and savings.
    • Maximum of $3,000 when a person living in the home is aged or has disabilities and they meet relationship requirements.
    • $2,000 for all other households.
  • HOUSEHOLD COMPOSITION: The CIHCP household is a person living alone or two or more persons living together where legal responsibility for support exists, excluding disqualified persons.
    • Disqualified persons include those who receive or would receive Medicaid if they applied. This applies to households with members who are categorically eligible for Medicaid because of their minor child status or disability status; persons who receive TANF (Temporary Assistance to Need Families) benefits; Supplemental Security Income (SSI) benefits, other types of Medicaid benefits, and Medicaid recipients who partially exhausts some component of their Medicaid benefits.
    • NOTE:  Potential or actual Medicaid eligibility is the ONLY coverage that can be used as a reason to disqualify a person from the CIHCP. All other third party coverage, to include veteran’s health benefits, private insurance, etc., do NOT disqualify a person from the CIHCP, but these other public and private coverages become primary, and the CIHCP would only pay after the primary processes the claim and there is a remaining eligible balance. The CIHCP is payer of last resorts below federal, state and private health insurance.

Question 3: What is Bell County’s responsibility with regard to County Indigent Health Care?

The county MUST provide basic services: inpatient and outpatient hospital, physician services, family planning, lab/x-ray, prescriptions, medical screening, annual physical examinations, immunizations, skilled nursing facility (primarily for short-term physical rehabilitation) and rural health clinics, and MAY provide other optional services.

Question 4: Why did Bell County choose to create a separate office and fund a staff to administer its program? Why not merge indigent health care with another related office?

• Except in very small counties where the demand for indigent health care is extremely low, to be effectively administered and operated, the program requires a dedicated staff who has the knowledge and capacity to administer the program. The eligibility process is complex and requires understanding and knowledge, not only of the CIHCP guidelines, but at least the basics of Medicaid, Social Security Disability and Supplemental Security Income, along with the Veterans Administration health benefits, the local mental health authority, and other state and federal public resources that CIHCP applicants could access to reduce county costs. This is not to imply that all counties require full-time staff, but that whatever staffing is assigned to the CIHCP should be scheduled and dedicated in ways that are clearly defined and separate from other county offices (i.e. the treasurer’s office, etc.).  Failure of the county to take seriously the statutory CIHCP sets the county up for complaints and potential litigation by health care providers and others.

• The Bell County IHCP has always been administered as a separate and distinct program of the county, although at one time it operated under the umbrella of the Human Services Department, which included other staff that operated a program for short-term assistance for basic shelter, food, etc. I was the director over the West Bell County Human Services programs as well as the entire County Indigent Health Care Program. With growth of demand on indigent health and other health issues, in 2006 the county created the Indigent Health Services Department with the entire focus of the department to be indigent health care and related health-access issues of importance to the county.  The complexity of the administration and operations of the program can be broken down into three areas:
  • Administration: includes responsibility to effectively manage all aspects of the operation and the service delivery (8 percent GRTL) budget associated with the program; to keep the Judge and Commissioners apprised of their legal obligation and issues that could impact the court and/or the county; the interpersonal skills and ability to establish working relationships with health care providers, community resources, and other county departments such as the jail and probation to assure a system of service delivery and appropriate referrals; and the ability to effectively and accurately complete and maintain recipient records for audit trail and reporting purposes. Failure to effectively administer the program impacts the program’s ability to attract and maintain an adequate provider network, jeopardizes the ability to access state match, and could open the county up to time consuming complaints and possibly lawsuits for failure to implement the program in accordance with the law.
  • Eligibility Determination:  requires knowledgeable staff who demonstrate attention to detail; are allowed the time to effectively and accurately validate eligibility to the program and to assure that applicants meet the criteria to be eligible; and who are able determine any other public or private health care coverage for all or some services otherwise covered by the CIHCP. These staff members must also perform formal reviews on all eligible recipients at least every six months, and be responsive to the applicants to answer questions, make referrals for other services within the community, etc. Eligibility staff members operate under a state-defined 14-day time frame to determine eligibility once all requested documentation has been received.  Errors in eligibility determination create a county liability of up to $30,000 annually per applicant/recipient.
  • Claims Processing:  requires knowledgeable staff who demonstrate attention to detail in reviewing claims for accuracy, eligible/ineligible services and other pertinent claim information and discrepancies that may be identified on the claim, and who are allowed the time to effectively process the claims and complete all manual and/or electronic record keeping for audit trail and reporting purposes.  Duties include responsibility to respond to provider inquiries, appeals, etc. Claims processing should be in accordance with county accounts payable time frames. Errors in claims processing can include paying for duplicate claims and paying for services not eligible under the CIHCP guidelines or less restrictive county guidelines.

Question 5: What are some common misperceptions when it comes to county indigent health care?

• State Office (Department of State Health Services): Although the state office is tasked with developing and maintaining the CIHCP Handbook and providing technical assistance, it does not have the authority to dictate that counties comply. A state office representative may define the requirements of the program, but if a county chooses to operate outside the guidelines, the state has no authority to initiate any punitive action against the county. Even so, the county maintains its obligation under Chapter 61 of the Health and Safety Code regardless of any decision to operate outside the guidelines.
  • MISCONCEPTION: Reporting is only important and required if the county plans to seek state matching funds. This is not true although many counties do not see the need to report since they don’t expect state matching funds. The reports are required as a means to collect statewide data that could be helpful in planning and future legislation.
  • MISCONCEPTION: The county has the legal option to develop CIHCP policies that are more restrictive than the state-established guidelines.  This is not true. A county may establish less restrictive guidelines, but by law, is required to operate to be no more restrictive than the established guidelines for all areas of the program to include those associated with who is eligible and what services are eligible.
• MISCONCEPTION: The Local Mental Health Authority (LMHA) has the responsibility and the capacity to provide all necessary behavioral health and prescription services to those in the county who cannot pay. This is not true. The LMHA charge is first and foremost to the severely mentally ill with diagnoses of schizophrenia, severe depression and bipolar disorder. Those who apply for the CIHCP who also exhibit other types of behavioral health issues are poorly served when told that they cannot get mental health services from the county because they can get them from the local mental health authority. Additionally, waiting lists to be screened for services and to get an appointment with a psychiatrist at many local mental health authority sites range from 90-120 days.  Even those CIHCP applicants who also have one of the three priority diagnoses could benefit from CIHCP coverage of behavioral health services while awaiting access to the local mental health authority. Failure to provide behavioral health services through the CIHCP impacts increased utilization at the hospital emergency rooms with higher costs that the county may end up paying, and incarceration in the county jail where the cost to house and provide appropriate behavioral health medications, court costs and indigent defense is far greater to the county than if the county paid for the community-based counseling, treatment and medications.
• MISCONCEPTION: Pain medication and pain management services are not medically necessary; rather they only support a drug habit. This is not true. Although there is a small percentage who exhibit drug-seeking behavior, the majority of those with prescribed pain medication need the medication to manage chronic pain or recovery from surgery or injury. Failure to manage pain can actually lengthen the healing process, which could in turn create more clinic visits and possible readmissions to the hospital.  Additionally, those who suffer from chronic pain and do not have access to appropriate pain management resources may experience a decline in their health status, which in turn leads to more clinic visits and potential for hospitalization. A blanket “no pain medications” policy is not the most fiscally responsible practice for the CIHCP. There are ways for the county program to work with prescribers to determine medical necessity to assure that those who truly need the service have access to it.

Question 6: How can a county best ensure cost effectiveness and efficiency when it comes to administering indigent health care? What are the keys?

• An informed Commissioners Court that is supportive of the program as an important function of the local government.
• 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.
  • Paying an advanced nurse practitioner or a physician assistant costs less than paying a physician for the same service.
  • Paying for services performed at a freestanding ambulatory surgical center can be less costly than paying for surgery in a hospital setting.
  • Paying for counseling services can offset a mental health crisis that results in hospitalization or incarceration.
  • 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.
  • Paying for colostomy supplies and equipment reduces the potential for infections that could lead to hospitalization or result in death.
  • 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.
  • 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.
  • 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.
  • 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.

Question 7: Please provide a scenario or two that best describes the complexities and importance of proper staff and training.

• Social Security Administration.
  • 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”)
  • 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 in discussion with state technical assistance staff as well as making copies of the record for all panel members, the couple’s attorney, holding the actual hearing, etc. 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.

Question 8: Can you please comment on the 1115 Waiver and the Affordable Care Act (ACA) and their impact on indigent health care?

• Affordable Care Act:  The ACA has had no direct effect on the administration of the CIHCP because the requirement for all to have health insurance does not apply to those who fall within the CIHCP income guidelines.  However, it could have some impact on public hospitals and hospital districts that have income criteria that is 138 percent of the Federal Poverty Level or greater because those with income at or above this amount do have a responsibility to purchase private health insurance. Since there is no requirement for those who fall within the CIHCP income criteria to seek private insurance, the county remains the payer of last resorts below the ACA. Additionally, those who fall beneath the ACA criteria could opt to purchase private insurance, but would not be eligible for subsidies; they would be subject to the full premium costs. It would be an unaffordable option for them.  With that said, in Bell County we do not consider the ACA when determining eligibility, and when we deny because the applicant exceeds the income criteria, we refer to local hospital charity programs and to local free and community clinics.
• 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. The five-year waiver is in its fourth year.  There is talk that the state will submit a proposal to extend the waiver for three to five more years.
  • After much investigation and many meetings and conversations with local health care providers and other community stakeholders, Bell County chose to enter into affiliation agreements with local providers to fund Uncompensated Care with intergovernmental transfer of a portion of the county’s 8 percent GRTL for indigent health care. The plan has proven to reduce the cost of indigent health care services and also provide additional funds for local hospitals to apply to their Uncompensated Care balance.
  • Bell County also entered into two DSRIP IGT agreements for the purpose of
    • Creating a multi-agency Navigation (Case Management) project that includes a mental health component, to reduce the incidents of inappropriate emergency department or incarceration of those with certain chronic health conditions, substance abuse issues, and/or behavioral health needs.  Three of the Bell County eligibility staff were assigned additional duties to provide Navigation/Case Management to address barriers to accessing primary care and other non-emergency health needs. These barriers include but are not limited to lack of transportation, lack of knowledge on appropriate medical self-care and homelessness.
    • Increasing access to primary care services at a local free clinic that includes medical case management to address improved outcomes for certain chronic conditions.
  • 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.

Question 9: Based on your decades of experience, do you have any additional suggestions for counties tasked with providing indigent health care?

• Benefits of using electronic data system for records/eligibility and claims processing: Using an electronic data system is a benefit that not only saves time in eligibility determinations, collecting and storing data, retrieving records, and processing itemized claims, but also provides the ability to create reports on service delivery and expenditures that assist the county in developing an operational budget and in identifying trends in the program, and in auditing the records for appropriate eligibility and claims processing.
• Coordination of services between criminal justice system and indigent health: By working together, the CIHCP and criminal justice (jail, probation, special mental health dockets, etc.) within the county can reduce overall costs and realize improved outcomes of shared clients by assuring the individuals have access to resources at the community level. Assuring access to physical and behavioral health services at the community level reduces the chance of incarceration or hospitalizations, all of which carry higher costs for the county either through indigent health care, jail health, indigent defense, recidivism, and cost to house offenders, etc.
• TIHCA: The Texas Indigent Health Care Association operates under the nonprofit status of the Conference of Urban Counties and in partnership with the Texas Association of Counties. The TIHCA was initiated in April 2005 to improve the training and education opportunities for Chapter 61 entities responsible for administering indigent health care in the State of Texas. Membership in TIHCA is open to all entities that have responsibilities under Chapter 61 of the Texas Health and Safety Code. TIHCA can assist members in a number of ways including:
  • keeping programs up to date with the latest news and information;
  • strengthening inter-program dialogue and networking among programs;
  • providing educational opportunities to programs;
  • providing programs with technical support and peer review, and
  • developing pooled-purchasing opportunities so programs can use the power of group negotiating and purchasing to gain price reductions in areas including pharmacology, durable medical equipment and laboratory services.

For more information on the DSHS and CIHCPs, go to https://www.dshs.state.tx.us/cihcp/.