Lawmakers Address Inmate Care, 1115 Waiver Projects
By Julie Anderson, Editor
Seven Texas counties received $269,183 in state matching funds in 2013 to help offset the cost of indigent health care, just slightly more than last year’s disbursement of $223,768 in state support, according to the latest reports.
The Indigent Health Care and Treatment Act of 1985 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 County Indigent Health Care Program (CIHCP); Texas is home to 143 CIHCPs. Each fiscal year a county is liable for $30,000 or 30 days of hospitalization or nursing-home care per eligible resident, whichever comes first.
Once a county spends 8 percent of its general revenue tax levy (GRTL) on indigent care, the county can then request state matching funds, with the state reimbursing the county at least 90 percent of all costs above the 8 percent spending level.
If the department fails to provide state assistance funds, the county is not liable for payments for health care services provided to its eligible residents after the county reaches the 8 percent expenditure level.
All of the money earmarked for FY 2013 was dispersed, according to the Department of State Health Services (DSHS). The 83rd Texas Legislature appropriated $323,522 in state assistance funds for FY 2014 and again for FY 2015. The 82nd Legislature’s appropriated amount totaled $4,403,759, a decrease of some 53 percent from the prior biennium. The state assistance fund was reduced from $2.6 million in FY 2011 to $223,768 in FY 2012.
Along with approving a slight funding increase for this biennium, lawmakers made two significant changes related to qualified expenditures with regard to inmate health care and usage of the Texas Health Care Transformation and Quality Improvement Program Waiver (1115 Waiver).
In order to qualify for state matching funds, 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. Specifically, counties must provide the following, all of which are credited to the county’s 8 percent expenditure account:
- Medical screening services
- Annual physical examinations
- Inpatient hospital services
- Outpatient hospital services, including hospital-based ambulatory surgical center services
- Rural health clinics
- Laboratory and x-ray services
- Family planning services
- Physician services
- Payment for not more than three prescription drugs per month
- Skilled nursing facility services
Optional health care services include the following DSHS-established services:
- Ambulatory surgical centers (freestanding) services
- Diabetic and colostomy medical supplies and equipment
- Durable medical equipment
- Home and community health care services
- Psychotherapy services provided by a licensed clinical social worker (LCSW), a licensed marriage family therapist (LMFT), a licensed professional counselor (LPC), or a psychologist
- Physician assistant services
- Advanced practice nurse – a nurse practitioner, a clinical nurse specialist, a certified nurse midwife (CNM), or a certified registered nurse anesthetist (CRNA)
- Dental care
- Vision care, including eyeglasses
- Federally qualified health center (FQHC) services
- Emergency medical services
- Physical and occupational therapy services
- Other medically necessary services or supplies that the local governmental municipality/entity determines to be cost-effective
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 counties’ 8 percent expenditure and be eligible for state matching funds.
The 83rd Texas Legislature addressed indigent health care expenditures associated with 1) county jail inmates, and 2) 1115 Waiver projects.
First, House Bill 2454 amended the Health and Safety Code 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 now credit expenditures for eligible residents from other counties who are inmates in their county jail. The DSHS developed a new simplified application form that counties may use to determine the eligibility of inmates who are in their county jail.
Second, Senate Bill 872 amended the Health and Safety Code to authorize a county to credit an intergovernmental transfer to the state toward their 8 percent if the transfer was made to provide health care services as part of the 1115 Waiver. 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 before state funding is available.
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. This waiver replaces the current Upper Payment Limit (UPL) program and will be in effect until September 2016.
Last year the DSHS touted the 1115 Waiver as an opportunity for counties to examine their current health care delivery systems and explore partnerships within their communities to help their indigent populations. (http://www.hhsc.state.tx.us/1115-waiver.shtml.)
“While the Section 1115 Medicaid Waiver funding may relieve some of the county indigent health care burden, we will need to evaluate this impact as the projects are implemented,” said Jim Allison, general counsel to the County Judges and Commissioners Association of Texas.
Commissioners Courts interested in learning more about the varied aspects of their county’s indigent health care program are eligible to attend training sessions offered by the DSHS.
“We always encourage County Judges and Commissioners to attend DSHS CIHCP trainings, particularly the basic training,” said Chris Van Deusen, DSHS press officer. “It can be helpful because when policymakers at the highest levels of county government understand CIHCP law, policies and procedures, the program operates more cohesively and results in better outcomes for clients and the community.”
The target audience includes those who administer the CIHCP for their county, hospital district or public hospital; the training classes are also beneficial for new staff, supervisors, and those simply needing a refresher course.
“I think it’s an excellent idea for Commissioners Court members to attend,” recommended Karen Gray, program specialist and primary care group trainer with DSHS. “Even though you may not have a direct, hands-on responsibility or position with the indigent program, if it’s something that you manage or falls under your jurisdiction, it would be an excellent idea for you to attend.”
The classes cover Chapter 61 and include eligibility and bill payment policies, Gray described. Classroom instruction is followed by hands-on exercises designed to “put the knowledge and new skills to the test.”
For example, participants are presented with unique situations, such as a self-employed applicant who does not have thorough bookkeeping in place, or a single mom who receives child support. Indigent health care applicants usually present extenuating circumstances; they are not your “typical two-parent, two-child, dad works, and mom stays at home with the kids” household, Gray explained.
“We try to give participants the skills to handle the many unique situations,” she continued. And while the training certainly won’t address all possible scenarios, it will give trainees a head start.
Throughout the past few years, a couple of Commissioners Court members have pursued DSHS training.
Gray described the training as an “eye-opening process” that will help Commissioners Courts appreciate the needs of their indigent health care departments.
To learn more about the County Indigent Health Care Program including handbook revisions, spending data and training dates, go to www.dshs.state.tx.us/cihcp.