“A major key to the success of the County Indigent Health Care Program operations is an informed Commissioners Court that is supportive of the program as an important function of the local government.” Rita Kelley, Director, Bell County Indigent Health Services

County Indigent Health Care Q&A

 

     In 1985, Rita Kelley was serving as the regional planner of Alcohol and Drug Abuse Services for the seven-county Central Texas Council of Governments (CTCOG) region. In June of that year, Walt Reedy, CTCOG executive director, walked into Kelley’s office and asked if she wanted to be a health planner.

“I asked him what I had to do, and he said nothing,” Kelley recalled. “Little did I know that the Senate Bill 1 Omnibus Indigent Health Care Act had just passed during special session with a tiebreaker vote by the lieutenant governor, and Walt was looking to me to lead our seven counties toward a September 1986 implementation.” Known as the Indigent Health Care and Treatment Act, this legislation tasked 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).

When all was said and done, CTCOG created a new department: Health Planning and Administration. Kelley began by administering the Maternal and Infant Health Improvement Act (MIHIA) for the seven counties and then implementing and administering the CIHCP in Bell, Coryell, Mills, San Saba, and Hamilton counties through contracts between CTCOG and the counties.

Kelley took leave for about three years before returning in 1993 as an employee of Bell County, where she took back administration of the program for Bell, Mills, and Hamilton counties. She currently administers the Bell and Mills CIHCPs, and she is a past chair of the Texas Indigent Health Care Association.

“I am fortunate to have the leadership and support of both the Bell and Mills County Commissioners Courts,” Kelley shared. “It would be very difficult to do this job if not.”

For the last three biennials, Kelley has been asked to explain the complexities of the indigent health care system to newly elected officials, and January 2019 was no different.

Along with explaining the nuts and bolts of the state mandates and county responsibilities, Kelley urged 200-plus officials gathered at the LBJ Seminar for Newly Elected County Judges and County Commissioners to determine whether or not they have a county-run indigent program, and if they do, to get to know their indigent health care coordinator.

“I’ve actually talked to coordinators who have never met their Commissioners Court,” Kelley shared with new officials gathered on Jan. 15 in Austin. “That shouldn’t be!”

County Progress would like to thank Rita Kelley for allowing us to tap into her expertise and help explain this important county responsibility.

 

Question 1: Will you please explain the background of county indigent health care?

Indigent health care relates to a century-old Texas law that allows Commissioners Courts to “provide for the support of paupers, residents of their county, who are unable to support themselves.” The legislative act that created the County Indigent Health Care Program spells out criteria in Chapter 61 of the Health and Safety Code relating to income, residency, household composition, and resources. This definition should not be confused with broader uses and definitions of the term “indigent” by other entities.

When I speak to groups about the program, I generally say that the County Indigent Health Care Program is a statutory obligation of a county not totally covered by a public hospital or a hospital district, and that it is an eligibility-based health plan. With that said, I will tell you that if you ask the Texas Health and Human Services Commission (state office), you will likely be told that CIHCP is NOT insurance. Even so, when I describe it in these terms, people seem to get it.

 

Question 2: Who is eligible to receive indigent health care?

RESIDENCY: Residents of the county in areas of the county not covered by a public hospital or hospital district may be eligible. Residency is not equal to citizenship. Although some counties have opted to disqualify non-citizens from the CIHCP, nothing in Chapter 61 provides any legal liability protection for a county that denies coverage to a non-citizen who would otherwise meet the eligibility criteria. There is NO duration requirement for residency. In addition, a person with no fixed resident (homeless) or a person who is new to the county and declares intent to reside there is considered a resident.

Examples of NONresidents of the county include:

• inmate or resident of a state school or institution operated by a state agency;
• inmate, patient, or resident of a school or institution operated by a federal agency;
• a minor student primarily supported by his/her parents whose home residence is in another county or state; and
• a person who moves to the county solely to obtain health care assistance.

INCOME: Those who meet the maximum income criteria adopted by the county are eligible. The minimum criterion is 21 percent of the Federal Poverty Level (FPL), although counties have the option to be less restrictive, up to 50 percent of the FPL, and continue to be eligible for state matching funds.

IF a county’s indigent health care costs exceed 8 percent of its GRTL and the state still has matching funds available, by law the county is required to continue running its program.

A county may adopt an income criteria beyond 50 percent GRTL, but expenditures for those who qualify at income beyond 50 percent FPL would not be countable toward the 8 percent GRTL obligation.

Types of income include earned (employment related) and unearned (cash gifts, pension, retirement, etc.). Certain income is exempt. Earned income is counted at net after allowable earned income deductions are applied to the gross/unearned income counted at gross.

RESOURCES: Residents of the county must meet the resource (asset) test established by the state. Resources are either countable or exempt. Examples of exempt resources include burial plots, crime victims’ compensation, income-producing property, personal possessions such as jewelry, and any structure a person uses as a primary residence, to include out buildings, motor home, etc.

Examples of countable resources include insurance settlements and readily available liquid assets such as cash, CDs, stocks, and savings. Those eligible may have a maximum of $3,000 when a person living in the home is aged or has disabilities and meets relationship requirements; the maximum is $2,000 for all other households.

HOUSEHOLD COMPOSITION: The CIHCP household is a person living alone or two or more persons living together where legal responsibility for support exists, excluding disqualified persons. Disqualified persons include those who receive or would receive Medicaid if they applied. This applies to households with members who are categorically eligible for Medicaid because of their minor child status or disability status; persons who receive TANF (Temporary Assistance to Needy Families) benefits, Supplemental Security Income (SSI) benefits, and other types of Medicaid benefits; and Medicaid recipients who partially exhaust some component of their Medicaid benefits.

Important Note: Potential or actual Medicaid eligibility is the ONLY coverage that can be used as a reason to disqualify a person from the CIHCP. All other third-party coverage, to include veteran’s health benefits, private insurance, etc., do NOT disqualify a person from the CIHCP, but these other public and private coverages become primary, and the CIHCP would only pay after the primary processes the claim and there is a remaining eligible balance. The CIHCP is payer of last resorts below federal, state, and private health insurance.

 

Question 3: In 2013, H.B. 2454 clarified how health care expenditures for county jail inmates could be counted toward a county’s 8 percent GRTL as addressed in Chapter 61.036d. What was the intent of this legislation, and how does it impact the County Indigent Health Care Program?

     Per the Bill Analysis: “The parties express concern that many inmates are unwilling to provide the required financial information on the application, thereby preventing a county from using those expenditures to qualify for state assistance.  H.B. 2454 seeks to address this concern by simplifying the process for counties to comply with the requirements to access state assistance funds for indigent health care.”

     Bearing this in the mind, legislation also states that it is services that are rendered to an “eligible resident.” There is an abbreviated Form 100A available for inmate application to assist in recordkeeping in regards to assuring services were for an eligible resident.

This section of Chapter 61 speaks to the determination of eligibility for the county indigent health care program as it relates to county jail inmates. However, this section does NOT change the health care services that are eligible to be counted toward the 8 percent GRTL. The services provided to a county jail inmate and the payment rates used must still fall within the guidelines outlined for all other eligible residents of the county. The legislation stipulates an expenditure (singular) for an eligible resident (singular).

Question 4: In regard to health services provided to jail inmates, does the 30 day/$30,000 maximum benefit and other CIHCP service delivery limitations apply when counting toward the 8 percent GRTL?

     Utilizing IHC funds as outlined by 61.036 does not place a limit on services/expectations that may be outlined in other legislation, including the provision of health care services to inmates as outlined in other Texas statues. The obligation of services would not be reduced or refused. Counties have deferred to the sheriff’s fund to provide any additional services required by an inmate after $30,000 has been provided.

 

Question 5: What is Bell County’s responsibility with regard to County Indigent Health Care?

The county MUST provide basic services: inpatient and outpatient hospital, physician services, family planning, lab/x-ray, prescriptions, medical screening, annual physical examinations, immunizations, skilled nursing facility (primarily for short-term physical rehabilitation), and rural health clinics, and MAY provide other optional services.

Counties do have limited liability in that each eligible resident has benefits capped at $30,000 of expenditures for services provided in a fiscal year or a maximum of 30 inpatient days in a fiscal year. A county may also close payment for services if the county expends 8 percent of its GRTL on eligible services in a fiscal year and the State does NOT have any matching funds available for the county to continue services.

 

Question 6: Why did Bell County choose to create a separate office and fund a staff to administer its program? Why not merge indigent health care with another related office?

Except in very small counties where the demand for indigent health care is extremely low, to be effectively administered and operated, the program requires a dedicated staff who has the knowledge and capacity to administer the program. The eligibility process is complex and requires understanding and knowledge, not only of the CIHCP guidelines, but at least the basics of Medicaid, Social Security Disability, and Supplemental Security Income, along with the Veterans Administration health benefits, the local mental health authority, and other state and federal public resources that CIHCP applicants could access to reduce county costs. This is not to imply that all counties require full-time staff, but that whatever staffing is assigned to the CIHCP should be scheduled and dedicated in ways that are clearly defined and separate from other county offices (i.e. the treasurer’s office, etc.). Failure of the county to take seriously the statutory CIHCP sets the county up for complaints and potential litigation by health care providers and others.

The Bell County IHCP has always been administered as a separate and distinct program of the county, although at one time it operated under the umbrella of the Human Services Department, which included other staff that operated a program for short-term assistance for basic shelter, food, etc. I was the director over the West Bell County Human Services programs as well as the entire County Indigent Health Care Program. With growth of demand on indigent health and other health issues, in 2006 the county created the Indigent Health Services Department with the entire focus of the department to be indigent health care and related health-access issues of importance to the county. The complexity of the administration and operations of the program can be broken down into three areas:

First, you have administration, which includes the responsibility to effectively manage all aspects of the operation and the service delivery (8 percent GRTL) budget associated with the program; to keep the Judge and Commissioners apprised of their legal obligation and issues that could impact the court and/or the county; the interpersonal skills and ability to establish working relationships with health care providers, community resources, and other county departments such as the jail and probation to assure a system of service delivery and appropriate referrals; and the ability to effectively and accurately complete and maintain recipient records for audit trail and reporting purposes. Failure to effectively administer the program impacts the program’s ability to attract and maintain an adequate provider network, jeopardizes the ability to access state match, and could open the county up to time-consuming complaints and possibly lawsuits for failure to implement the program in accordance with the law.

Second, you have eligibility determination, which requires knowledgeable staff who demonstrate attention to detail; are allowed the time to effectively and accurately validate eligibility to the program and to assure that applicants meet the criteria to be eligible; and who are able determine any other public or private health care coverage for all or some services otherwise covered by the CIHCP. These staff members must also perform formal reviews on all eligible recipients at least every six months, and be responsive to the applicants to answer questions, make referrals for other services within the community, etc. Eligibility staff members operate under a state-defined 14-day time frame to determine eligibility once all requested documentation has been received. Errors in eligibility determination create a county liability of up to $30,000 annually per applicant/recipient.

Third, you have claims processing, which requires knowledgeable staff who demonstrate attention to detail in reviewing claims for accuracy, eligible/ineligible services and other pertinent claim information and discrepancies that may be identified on the claim, and who are allowed the time to effectively process the claims and complete all manual and/or electronic record keeping for audit trail and reporting purposes. Duties include responsibility to respond to provider inquiries, appeals, etc. Claims processing should be in accordance with county accounts payable time frames. Errors in claims processing can include paying for duplicate claims and paying for services not eligible under the CIHCP guidelines or less restrictive county guidelines.

 

Question 7: What are some common misperceptions when it comes to county indigent health care?

Although the Texas Health and Human Services Commission is tasked with developing and maintaining the CIHCP Handbook and providing technical assistance, it does not have the authority to dictate that counties comply. A state office representative may define the requirements of the program, but if a county chooses to operate outside the guidelines, the state has no authority to initiate any punitive action against the county. Even so, the county maintains its obligation under Chapter 61 of the Health and Safety Code regardless of any decision to operate outside the guidelines.

There are several areas that often require clarification:

MISCONCEPTION: Reporting is only important and required if the county plans to seek state matching funds. This is not true, although many counties do not see the need to report since they don’t expect state matching funds. The reports are required as a means to collect statewide data that could be helpful in planning and future legislation.

MISCONCEPTION: The county has the legal option to develop CIHCP policies that are more restrictive than the state-established guidelines. This is not true. A county may establish less restrictive guidelines, but by law is required to operate to be no more restrictive than the established guidelines for all areas of the program to include those associated with who is eligible and what services are eligible. Attorney General Opinion # KP-0059 reiterates the limited authority of a county to make changes to the program outside the state-established guidelines in the response to Tom Green County regarding a county’s authority to establish requirements for indigent health care under the Texas Indigent Health Care and Treatment Act and relevant federal law ((RQ-0041-KP): You specifically ask whether a commissioners court may adopt its own standards restricting county indigent health care to residents who are citizens or are qualified aliens. Request Letter at 1-2. A county commissioners court has only those powers expressly granted by the Texas Constitution and statutes and powers necessarily implied to accomplish its assigned duties. City of San Antonio v. City of Boerne, 111 S.W.3d 22, 29 (Tex. 2003). Although a commissioners court is required to adopt the county’s eligibility standards, such county standards must be consistent with state statutes and the minimum standards adopted by the Department. See TEX. HEAL TH & SAFETY CODE §§ 61.022, .023(b), (d). Thus, because the Texas Act does not make distinctions based on citizenship or alienage, state law does not authorize a commissioners court to adopt such restrictions. Ultimately, whether an alien who is an eligible county resident under the Texas Act as enacted by the Texas Legislature may receive county indigent health care will depend on the relevant provisions of the federal Welfare Reform Act governing the specific benefits at issue.

 

     MISCONCEPTION: The Local Mental Health Authority (LMHA) has the responsibility and the capacity to provide all necessary behavioral health and prescription services to those in the county who cannot pay. This is not true. The LMHA charge is first and foremost to the severely mentally ill with diagnoses of schizophrenia, severe depression, and bipolar disorder. Those who apply for the CIHCP who also exhibit other types of behavioral health issues are poorly served when told that they cannot get mental health services from the county because they can get them from the local mental health authority. Additionally, waiting lists to be screened for services and to get an appointment with a psychiatrist at many local mental health authority sites range from 90-120 days. Even those CIHCP applicants who also have one of the three priority diagnoses could benefit from CIHCP coverage of behavioral health services while awaiting access to the local mental health authority. Failure to provide behavioral health services through the CIHCP impacts increased utilization at the hospital emergency rooms with higher costs that the county may end up paying, and incarceration in the county jail where the cost to house and provide appropriate behavioral health medications, court costs, and indigent defense is far greater to the county than if the county paid for the community-based counseling, treatment and medications.

MISCONCEPTION: Pain medication and pain management services are not medically necessary; rather they only support a drug habit. This is not true. Although there is a small percentage who exhibit drug-seeking behavior, the majority of those with prescribed pain medication need the medication to manage chronic pain or recovery from surgery or injury. Failure to manage pain can actually lengthen the healing process, which could in turn create more clinic visits and possible readmissions to the hospital. Additionally, those who suffer from chronic pain and do not have access to appropriate pain management resources may experience a decline in their health status, which in turn leads to more clinic visits and potential for hospitalization. A blanket “no pain medications” policy is not the most fiscally responsible practice for the CIHCP. There are ways for the county program to work with prescribers to determine medical necessity to assure that those who truly need the service have access to it.

 

Question 8: How can a county best ensure cost-effectiveness and efficiency when it comes to administering indigent health care? What are the keys?

A major key to the success of the County Indigent Health Care Program operations is an informed Commissioners Court that is supportive of the program as an important function of the local government. Other suggestions are as follows:

Hire adequate staff and authorize them to attend training opportunities conducted by the state office, Texas Indigent Health Care Association, and others who conduct regional meetings and community meetings/trainings.

Provide for adequate work area to administer and operate the program. This should include private office space in which to conduct in-person or telephone interviews with applicants/recipients.

Provide the program with an adequate records-keeping and claims-processing system. Except with extremely small caseloads, the cost of an electronic records and claims processing system is offset by the accuracy of application and claims processing and the efficiency realized in having all data in a format that can be easily searched and audited; this provides reporting capabilities necessary to effectively manage the program and respond to internal as well as external inquiries on trends, etc.

Encourage the program administrator/staff to develop working relationships with other county departments where health care needs/costs for the same target population are realized (i.e. jails, adult probation) to streamline referrals and quicker access to services.

Encourage the program administrator/staff to develop working relationships with community health and human services representatives to increase the submission of appropriate referrals to the program. Bell County staff regularly provides information and training to other organizations and providers where people may be referred to assure that applications received by the CIHCP are complete and that the people who applied have a reasonable potential to meet the criteria at least based on income. This is important because every application received must be processed, with a decision made on eligibility. Case processing is a timely, complex, and often tedious process; applications that are appropriately completed and submitted generally take less time to process.

Consider the benefits of adopting some or all of the optional services available to counties. Some of these optional services generate immediate cost-savings when claims are processed. Others have the potential to reduce overall costs to the program and to the county as a whole. For example:

1. Paying an advanced nurse practitioner or a physician assistant costs less than paying a physician for the same service.
2. Paying for services performed at a freestanding ambulatory surgical center can be less costly than paying for surgery in a hospital setting.
3. Paying for counseling services can offset a mental health crisis that results in hospitalization or incarceration.
4. Paying for diabetic medical supplies and equipment allows the patient to best manage the disease and reduce the chance of acute medical episodes that require more costly medical services or result in death.
5. Paying for colostomy supplies and equipment reduces the potential for infections that could lead to hospitalization or result in death.
6. Paying for dental care, especially for those with chronic conditions such as diabetes and heart conditions, is often medically necessary to alleviate infections and other health impact to the entire body, which could result in higher medical costs or death.
7. Paying for vision care allows those with vision problems to be able to read prescription bottles, other medical instructions, etc., and addresses poor vision which could be a barrier to finding gainful employment and moving off the CIHCP.
8. Paying for home and community health allows patients to be discharged from the hospital sooner, thus reducing the overall cost of care and increasing the potential to heal more quickly and reduce the chance for readmission.
9. Paying for durable medical supplies such as crutches, walkers, or even wheelchairs allows for quicker release from the hospital, especially if there are no caregivers in the household, and enhances the healing process thus reducing the possibility of reinjury or readmission to the hospital.

 

Question 9: Please provide a scenario or two that best describes the complexities and importance of proper staff and training.

Counties may pend determinations of eligibility for persons who meet the CIHCP criteria and are in the initial application stage for disability from the Social Security Administration (SSA), but once the person is denied and appeals, a county may make the person eligible and should track CIHCP expenditures as well the SSA disability status. The complexities of the SSA, its disability programs, and the partnership it holds between the SSA and the State of Texas in regard to Medicaid require staff training and periodic refreshment on the topic. These complexities can make it difficult for CIHCP staff to identify and follow up on when/if a person who has been on the CIHCP during the appellant stages of SSA determination may receive retroactive coverage of Medicaid for the same period of time that the CIHCP has paid claims. Failure to understand and to know how to follow up with SSA and State of Texas Medicaid regarding status of disability application and retroactive coverage has the potential to keep the county from recouping all funds due for services provided within the retroactive Medicaid time frames.

Failure to recognize that all citizens age 65 and older should not be considered for the CIHCP results in the county providing services to a person who does not qualify because they are categorically eligible for Medicaid, or would receive income greater than the CIHCP criteria through SSA at age 65. Regardless of any reported disability, age is considered an automatic disability for the SSI program, and those who have paid into Social Security may begin receiving Social Security Benefits and Medicare at age 65.

Failure to recognize that those who have paid into Social Security have the option to begin receiving early Social Security retirement benefits at age 62 results in a county paying for services for a person who does not meet the eligibility criteria. The early retirement amount is considered unearned income and almost always exceeds the CIHCP income criteria. The CIHCP guidelines stipulate that a person should take advantage of all income that could be available. This includes early SSA retirement benefits.

MISINFORMATION FROM PREDECESSORS (“The way we’ve always done it syndrome”) can make the process challenging. In my communications with county program coordinators across the state, I sometimes hear about policies and practices that are believed to be within the guidelines in accordance to what a predecessor taught them, or because it’s how it’s always been done. I have been told about policies that exclude all but emergency services, policies that deny a person eligibility if he/she abuses alcohol and other substances, or policies that deny if the patient does not comply with physician recommendations. Training on the proper use of the handbook and proper administration as well as periodic refresher training is critical for even the seasoned staff.

A personal example of how easy it is to “forget” the specifics of some rules occurred a few years ago when I got busy and did not distribute a public notice “prior to” the beginning of the state fiscal year for one of the rural county programs we administered; rather it was distributed late into the first month of the new fiscal year. Between the first of the month and the time I distributed the public notice, we had determined that a couple would not be eligible for the program because their unearned household income far exceeded the income criteria for the program. The household appealed the determination, and we followed our reconsideration and appeal policy by writing a very detailed letter on the reason for denial and inviting the household to request an appeal hearing if they still did not agree with our determination. The couple had an attorney friend who represented them to request a hearing. Our hearing process includes one hearing officer who is impartial to either the county or the client, and two other panel members who represent the local health care community and the county. Preparing for the hearing took many hours, and it became a very involved process. The couple’s attorney contended that because the county had not published the public notice in accordance with Chapter 61 of the Health and Safety Code, and because there was no record that the County Commissioners Court had annually established the minimum income criteria, that the county did not have an adopted income criteria, and thus any income would be considered within the guidelines. In the end, the panel upheld the denial but also reprimanded me for neglecting to comply strictly with the administrative requirements to post public notices prior to the beginning of the fiscal year and to assure that the county adopted minimum standards every year prior to or at the very beginning of the new fiscal year. To this date, I have assured that public notices that include minimum eligibility criteria be distributed on time and that the Commissioners Court adopts the criteria on an annual basis. In all the years I have administered the CIHCP for Bell and a few other counties, this is the ONLY appeal hearing that anyone has ever requested, and it was done so not because of any error to determining eligibility but because of noncompliance to a very basic guideline that I had become lax in administering. Although the error did not cost the county through payment of medical claims, it did cost the county, the state, the hearing panel, me, and my staff much time, effort, and anguish.

 

Question 10: Can you please comment on the 1115 Waiver?

The 1115 Texas Medicaid Transformation Waiver presented a viable opportunity for counties to engage in an intergovernmental transfer (IGT) opportunity in which the county could have a guarantee that funds would come back to the local communities and provide services that were identified and deemed important to the local community, as opposed to a one-size-fits-all solution to transforming health care across the state. There are two ways a county could participate in the waiver: through Uncompensated Care affiliation agreements with local hospital providers, and through Delivery System Reform Incentive Payments (DSRIP) projects in which an eligible provider or public entity could implement services aimed at addressing local behavioral and physical health access and service delivery concerns.

In December 2017, the 1115 Waiver was renewed for an additional five years, through September 2022. 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 on indigent health care before state funding is available.

Bell County’s engagement in this waiver process has given opportunity for health care stakeholders to work together more closely to identify gaps in services and develop viable solutions that meet the distinct needs of the Bell County community. One of the greatest values I have experienced is a better working relationship with our local health care workers that has allowed mutually beneficial collaborations beyond the scope of the waiver. As the current waiver begins to wind down, there is on-going discussion among hospital and other stakeholders on what new funding mechanisms may be possible to continue the collaborative partnerships within Texas local communities to mitigate health care costs while assuring our local residents have the medical services they need. I encourage county officials to keep your eyes open and your minds flexible to what opportunities present themselves.

 

For more information on CIHCPs, go to https://www.dshs.texas.gov/cihcp/CIHCP-Administrator-Page/ or contact the County Indigent Health State Office of the Health & Human Services Commission.