Working Relationships, Holistic Approach Benefit Clients, County
When it comes to providing indigent health care, the trickle-down theory comes into play: Healthy relationships between all parties contribute to the health of the program and ultimately the health of the client.
“In my opinion, you have to have the backing of your board or Commissioners Court to have an efficient and effective indigent health care program,” said Brandy Fannon, former chairman of the Texas Indigent Health Care Association (TIHCA). “If your Commissioners Court, or hospital district board in my case, does not support you and communicate with you, then the patient is the one who loses out on good health care,” continued Fannon, administrator of the Garza County Health Care District.
Good provider relations is the other key to a well-run program, Fannon listed.
“If you have a good working relationship with clinics and hospitals, then you can provide better services for your indigent clients,” she emphasized.
Fannon has been involved with indigent health care since 2002, following 10 years in the medical field.
“I have always felt the need to help people,” she shared. The Garza County Health Care District became a member of TIHCA in 2003.
Fannon was asked to serve on the board in 2010 and was voted chair in 2019, a position she held through 2024.
Garza County is covered by the Garza County Health Care District, Fannon specified. These districts are also referred to as hospital districts. Qualifying individuals in Garza County have access to health care through this district, which sets its own budget and collects its own taxes. The district allocates $150,000 every year for medical/prescription services and provides a Pharmacy Assistance Program as well as a charity program.
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 County Indigent Health Care Program (CIHCP).
Unlike Garza County, Bell County is not fully covered by a hospital district or public hospital, and therefore runs a CIHCP.
Similar to Garza County, indigent clients in Bell County have access to a Prescription Assistance Program. In fact, Fannon points to the Bell County Indigent Health Care Program as “the most well-run program in the state.”
In 2020, Bell County launched the Bell County Indigent Health Care Collaborative, said Ebony Jackson, Bell County’s indigent health care program director and current chairman of TIHCA. The county has partnered with local community clinics to provide non-emergency basic health care services.
“This collaboration has reduced the dependence on emergency departments for primary care while increasing access to both regular and preventive services,” Jackson elaborated.
The Bell County Indigent Health Care Collaborative received an Achievement Award from the National Association of Counties (NACo) in 2022 recognizing the collaborative as an “innovative, effective county government program that strengthens services for residents.”
“By partnering with our local community health clinics, who already had infrastructure and resources in place for service and delivery of health care, we leveraged both what they can provide and what we can provide into more than either one of us could do our own,” said Bell County Judge David Blackburn.
Jackson summarized the Bell County indigent care approach as follows:
- Ensure health care needs are understood in the context of broader social circumstances.
- Adjust clinical care to accommodate any social barriers patients may face, ensuring that these factors do not hinder access to necessary services.
- Assist in connecting patients with the social resources they need, such as housing, food, or transportation, to improve overall well-being.
- Align health system resources with community-based services, creating a support network for patients.
- Advocate for community assistance that addresses social determinants of health, promoting long-term solutions that improve access to care and resources for vulnerable populations.
“I am grateful for the opportunity to continue making a difference by working with the counties that administer the indigent health care programs across Texas,” Jackson shared. “These services are not only greatly needed, but also deeply appreciated by those who rely on them.”
Like Fannon, Jackson appreciates the involvement and support of her leadership.
“The Bell County Indigent Health Care Collaborative is one of many projects that includes a Commissioners Court presence,” Jackson observed. “This shows the passion and willingness of our Commissioners Court to be involved in better serving the community. It is a win-win to update the Commissioners Court members, who work every day to build vigorous, safe, and flourishing communities.”
Indigent Health Care 101
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.
As mentioned earlier, 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.
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.
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, all of which are credited to the county’s 8 percent expenditure account:
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.
Counties may include 1115 Waiver intergovernmental transfer payments toward state assistance eligibility up to 4 percent of the GRTL, said CJCAT Senior General Counsel Jim Allison. However, there are three required findings under Section 61.036(e).
- The Commissioners Court must determine that the expenditure fulfills the county’s obligations to provide indigent health care under Chapter 61;
- The Commissioners Court must determine that the amount of care available through participation in the waiver is sufficient in type and amount to meet the requirements of Chapter 61; and
- The county must receive periodic reports from health care providers that receive supplemental or incentive payments under the 1115 Waiver that document the number and types of services provided to those eligible to receive services under Chapter 61.
For more information on DSHS and CIHCPs, go to https://www.hhs.texas.gov/services/health/county-indigent-health-care-program.