Thoughtful, Focused Approach Serves Clients, County
While indigent health care is a state-mandated service, Ellis County sees beyond the statutes.
“Our goal is to assist our county residents in returning to work or obtaining Social Security benefits,” shared Terri Klein, director of the Ellis County Indigent Health Care Program. “We pride ourselves on walking with our clients until they reach their goals.”
Indigent health care includes providing basic medical health care for those that are low income and fall at or below 21 percent of the federal poverty limits, Klein explained, as detailed in Health and Safety Code Chapter 61, known as the Indigent Health Care and Treatment Act.
Ellis County goes beyond the basic requirements by connecting clients with multiple resources including the Supplemental Nutrition Assistance Program (SNAP) and Medicaid benefits when applicable, job leads, and any other resources that are discovered as essential.
Indigent health care is budgeted at 8 percent of the General Revenue Tax Levy (GRTL) and includes the 1115 Waiver (explained below) contracted with Hope Health, Klein stated. This contract allows indigent clients in Ellis County to receive basic health care, dental services, women’s health, and behavioral health services.
Balancing Client and County
“Ellis County is diligent in providing the best medical care while also considering the budget and the taxpayer,” Klein observed.
For example, the Texas Commission on Jail Standards requires counties to pay the medical expenses of inmates, Klein verified. When inmates are booked, they are deemed indigent without being screened and receive medical care while incarcerated through in-house and off-site services when considered necessary. Ellis County has implanted an insurance verification system for inmates with medical issues; if the inmate has coverage, the county requires the medical provider to bill the insurance and then rebill the county with an EOB (explanation of benefits) prior to payments being made.
“By ensuring any active insurance is billed as primary, the county is left to cover the remaining balance at Medicaid rates, in turn saving the county money,” Klein observed. The county jail also has a contract with the local behavioral health authority, which is managed by the behavioral health director. This process has also provided continuous care after release from jail.
“We, as a county, recognize the vital need for both indigent and inmate health care, but we also face the reality that these state-mandated responsibilities create a significant financial burden on local taxpayers,” said Ellis County Judge John Wray. “We remain committed to ensuring essential care for our most vulnerable residents and those in our custody, while maintaining fiscal discipline and efficient use of resources. Providing care with compassion and accountability is our guiding principle, and we strive to balance both every day.”
The rising cost of health care impacts everyone, including the county, Ellis County Commissioner Lane Grayson observed. With that said, “our Commissioners Court has consistently worked to meet this need for the those in our community who need it most. We are extremely fortunate to have Terri Klein leading our Indigent Health Care Program. Her diligent work in reviewing requests and qualifying individuals has saved taxpayers thousands of dollars over the years, while still providing excellent resources for our inmates and indigent community.”
Trauma-Informed Approach
Kaitlyn Bruch, M.A., LPC, is the director of Trauma Informed Practice with Williamson County Juvenile Services and has provided general training on indigent health care.
“Taking a trauma-informed approach can benefit counties providing indigent care in a multitude of ways,” Bruch shared.
According to Texas Health and Human Services, there are six core principles of trauma-informed care: 1) Safety, 2) Trust and Transparency, 3) Peer Support, 4) Collaboration, 5) Empowerment, Voice, and Choice, and 6) Humility and Responsiveness. A more simplified version is provided by Dr. David Cross, Co-founder of Trust-Based Relational Intervention®, in the form of the Three Pillars of Traumawise Care: 1) Safety, 2) Connection, and 3) Coping.
“At their core, these principles aim to work with individuals who have experienced trauma in a way that allows them to feel seen and valued, avoids re-traumatization, and puts them on the path toward healing,” Bruch explained.
Using the trauma-informed approach in the indigent health setting helps those completing intake interviews gather more accurate and complete information, Bruch specified.
“Establishing relationships built on trust and transparency with clients increases the odds that clients will show up for future appointments with county providers,” Bruch continued. “A pattern of interactions that leaves the client feeling safe and supported will not only benefit the well-being of the client, but can also improve job satisfaction for the staff, ultimately improving retention and resulting in a cost-saving benefit for the county. Most importantly, counties providing individualized care in a trauma-sensitive manner are meeting the true needs of the people they’re serving, resulting in safer, healthier, more resilient communities.”
Indigent Health Care 101
Williamson County’s Indigent Health Care Program is part of the Williamson County and Cities Health District, as explained at https://bit.ly/wilco-care. The Ellis County Indigent Health Care Program is administered in-house by Klein.
As mentioned earlier, The Indigent Health Care and Treatment Act of 1985 found in Chapter 61 of the Health and Safety Code (HSC) 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. Texas is home to 113 county-administered CIHCPs that cover the entirety of their respective counties, confirmed Thomas Vazquez, assistant press officer for the Texas Health and Human Services Commission. 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 HSC Chapter 61, Section 61.035.
Once a county spends 8 percent of its 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 for at least 90 percent of eligible costs above the 8 percent spending level. If the Texas Department of State Health Services (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.
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. Specifically, counties must provide the following, all of which are credited to the county’s 8 percent expenditure account:
- Immunizations Medical Screening Services
- Laboratory and X-Ray Services
- Family Planning Services
- Physician Services
- Three Prescriptions Per Month
- Skilled Nursing Facility Services
- Annual Physical Examinations
- Inpatient Hospital Services
- Rural Health Clinics
- Outpatient Hospital Services, Including Hospital-Based Surgical Center Services
Optional health care services include the following DSHS-established services, which count toward the county’s 8 percent expenditure and are eligible for the State Assistance Fund:
- ambulatory surgical center services;
- diabetic and colostomy medical supplies and equipment;
- durable medical equipment;
- home and community health care services;
- social work services;
- psychological counseling services;
- services provided by physician assistants, nurse practitioners, certified nurse midwives, clinical nurse specialists, and certified registered nurse anesthetists;
- dental care;
- vision care, including eyeglasses;
- services provided by federally qualified health centers, as defined by 42 U.S.C. Section 1396d(l)(2)(B);
- emergency medical services;
- physical and occupational therapy services; and
- any other appropriate health care service identified by department rule that may be determined to be cost-effective.
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, scan here: (QR CODE)
https://www.hhs.texas.gov/services/health/county-indigent-health-care-program.
