County-Run Programs Provide Basic, Optional Services
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). 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 Health and Human Services (HHS) 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.
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 HHS 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.
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 HHS-established optional health care services. Specifically, counties must provide the following, all of which are credited to the county’s 8 percent expenditure account:
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Optional health care services include the following HHS-established services:
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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, HHS 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, reported Jim Allison, senior general counsel of the County Judges and Commissioners Association of Texas. 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 HHS and CIHCPs, go to https://hhs.texas.gov/services/health/county-indigent-health-care-program.