82nd Legislature Slashes Funding
Eleven Texas counties received approximately $2.68 million in state matching funds in 2011 to help offset the cost of indigent health care, according to the latest Texas Department of State Health Services (DSHS) County Indigent Health Care Program (CIHCP) spending data report.
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 CIHCP; there are 143 CIHCPs in the state. 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, said Jan Maberry, manager of the DSHS County Indigent Health Care Program.
In FY2011, the state was able to reimburse 100 percent due to available funds, Maberry said. The 81st Legislature appropriated an original amount minus a post-session reduction that netted an amount of $9,380,404, according to the CIHCP. The 82nd Legislature’s appropriated amount is $4,403,759, a decrease of some 53 percent.
The decrease in funding will have an impact on the counties that have historically received state funds, Maberry stated. In FY2011 the department had approximately $2.68 million in state funds for reimbursement for 11 counties that expended 8 percent of their tax levy. This fiscal year, the department has approximately $211,000.
“After the counties expend their local funds and receive a small allocation from the state, some counties have indicated that they may close their indigent health care programs,” Maberry related.
According to the Department of State Health Services, the new 1115 Medicaid waiver has presented an opportunity for counties to examine their current health care delivery systems and explore partnerships within their communities to help their indigent populations. Mayberry encouraged counties to keep checking the Health and Human Services Commission website for updated information (http://www.hhsc.state.tx.us/1115-waiver.shtml.)
“If people happen to live in a wealthy county, they will receive better care than if they happen to live in a poor, rural county,” declared Red River County Judge Morris Harville. “Every year we can barely make our budget, yet we must set aside 8 percent of that amount for the care of our indigent population, which is a large percentage of our population. We run out of funds every year in the first three months…I am hopeful that 1115 will be of some help in improving this situation.”
Additional Legislative Changes
Six legislative bills were passed during the 82nd session that made changes to Chapter 61, the legislation that authorizes the CIHCP. However, two bills will have the biggest implications for the county-run programs, Maberry indicated. House Bill 871 provides the opportunity for counties to provide physical and occupational therapy services for their eligible residents. These services are not required or considered basic health care services, but are considered optional services allowing counties to choose these services if the counties deem them to be cost effective. Also, Senate Bill 420 allows counties to choose different eligibility requirements than those previously required, for applicants who are sponsored aliens. Both bills require rule changes, and the rulemaking procedure is currently underway.
Basic, Optional Services
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, Maberry said. Specifically, counties must provide the following:
- 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 – new
- 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,” Maberry said.
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, Maberry said.
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.
“I encourage judges and commissioners to learn as much as they can about the program,” Maberry said. “Don’t go into it blindly. After all, you’re potentially going to spend quite a bit of money on indigent health care.”
DSHS conducts training sessions in Austin with the following remaining in 2012:
April 10, 11, & 12
July 17, 18, & 19
The target audience includes those who administer the CIHCP for their county, hospital district or public hospital. The training classes are 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,” said Karen Gray, program specialist and primary care group trainer with the 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 said. 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 said.
“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 the trainees a head start.
Throughout the past few years, a couple of commissioners court members have pursued DSHS training, Gray said.
“I think they do understand the program a lot better after they learn the complexities of eligibility and bill payment,” Maberry added.
Gray concurred, describing the training as an “eye-opening process” that would 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. H – By Julie Anderson