Fort Bend County’s Indigent Health Care Program distinguishes itself by adopting a holistic approach to patient care. While the core mission is to address the medical needs of its indigent residents, the program recognizes and tackles the multifaceted challenges these individuals often face.
Martha Hernandez, program manager for Fort Bend County Health and Human Services (FBCHHS) Indigent Health Care and former chairman of the Texas Indigent Health Care Association, emphasized this comprehensive strategy. “The majority of our staff are community health workers, so our assessments take a holistic approach to best help our clients,” Hernandez explained. This method ensures that the program delves beyond immediate medical concerns to identify and address other contributing factors to an individual’s health and well-being.
The program actively seeks out all available resources for which an indigent patient might be eligible. Hernandez detailed the breadth of assistance they explore: “We search for all of the services for which the indigent patient may qualify,” including hospital charitable care, free cell phone assistance, SNAP (Supplemental Nutrition Assistance Program) benefits, prescription assistance programs, and Medicare. This proactive approach ensures that residents receive support from various avenues, maximizing their access to care and essential services.
FBCHHS staff play a crucial role in guiding individuals through the often-complex application processes for these supplementary programs. “Our staff routinely assists individuals with applications for these programs as well as Social Security Administration documentation and follow-up/application processes,” Hernandez stated. This hands-on assistance extends beyond program enrollees. “In addition, assessments for outside eligibility are processed for county residents whether or not they qualify for our program,” ensuring that all residents have access to information and support in navigating the social safety net.
Recognizing the barriers to access, Fort Bend County implemented changes to streamline the application process. Previously, in-person paperwork submission or faxing was required. However, during the COVID-19 pandemic, the county introduced electronic submissions and signatures, a change that has been made permanent due to its effectiveness.
“This option, to send in paperwork through dedicated email channels, is not only convenient, but has also helped with retention,” Hernandez noted. The ease of electronic submission has improved program accessibility and reduced administrative burdens for applicants.
Furthermore, the Fort Bend County Indigent Health Care Program has optimized its resources to ensure clients have access to necessary medications. Despite a program limit of three prescriptions per month per client, strategic asset management allows clients to obtain all their prescribed medications, according to Hernandez.
Beyond prescription assistance, the program proactively connects clients with resources for chronic disease management and preventative care. Clients are directed to local free educational classes to aid in managing chronic illnesses and are also referred for annual wellness and preventive exams, screenings, immunizations, and gender-specific health checks.
The program also leverages external partnerships to enhance the benefits available to clients. “We have been able to help clients get more of what they need by referring them to, and assisting them with, outside applications for patient assistance programs provided by manufacturers who are able to present benefits beyond what our program can offer,” Hernandez explained. By tapping into pharmaceutical manufacturer patient assistance programs, the county can extend the reach of its services and provide more comprehensive support.
These multifaceted efforts have yielded significant results in reducing the number of clients reaching program limits. Hernandez reported a substantial decrease in clients maxing out on program benefits. In 2023, only five clients reached the maximum allowable amount, and in 2022, only four, marking a reduction of over 50 percent compared to previous years.
County Judge KP George underscored the importance of this program and its impact on the community. “Taking care of our most vulnerable residents should always be a top priority for government officials,” Judge George stated. “I am proud of the FBCHHS Indigent Health Care program for providing quality and impactful service to our community.”
Understanding Indigent Health Care Programs in Texas
Fort Bend County is among the majority of Texas counties that administer a County Indigent Health Care Program (CIHCP). These programs are mandated by the Indigent Health Care and Treatment Act of 1985, outlined in Chapter 61 of the Health and Safety Code. This legislation requires counties not fully covered by a hospital district or public hospital to provide essential health services to indigent residents through a county-run CIHCP.
José Andrés Araiza, deputy chief press officer with the Texas Department of State Health and Human Services (DSHS) Office of Communications, reported that Texas has 113 county-administered CIHCPs that provide coverage throughout their respective counties. Additionally, 24 counties have hospital districts that do not encompass the entire county, and in these instances, the CIHCP covers the areas outside the hospital district’s jurisdiction.
The financial responsibility of counties for indigent health care is defined by state law. Each state fiscal year, a county’s liability for health care services for an eligible resident is capped at $30,000 in payments or 30 days of inpatient care at a hospital or skilled nursing facility, whichever comes first, as per Health and Safety Code (HSC) Chapter 61, Section 61.035.
To mitigate the financial burden on counties, the State Assistance Fund is available. Once a county’s spending on indigent care reaches 8 percent of its General Revenue Tax Levy (GRTL), it can apply for reimbursement from this fund. If deemed eligible, the state may reimburse the county for at least 90 percent of eligible costs exceeding the 8 percent threshold. Crucially, if the DSHS cannot provide state funding, the county’s liability for indigent health care payments ends once the 8 percent expenditure level is reached, as detailed in HSC Chapter 61, Section 61.039.
A significant legislative change during the 86th Regular Session of the Texas Legislature removed rider 120, which had previously capped the amount counties could request from the State Assistance Fund. Araiza explained that prior to this change, initial requests were limited to 10 percent of the total state assistance fund. The removal of this cap means there is no longer a limit to the initial amount a county can request, providing greater financial flexibility for counties with substantial indigent health care needs.
The 88th Regular Session of the Texas Legislature introduced new reporting requirements for counties related to indigent health care. Jennifer Ruffcorn, also with the HHS Office of Communications, explained that House Bill 4510 amended the Health and Safety Code to allow the Texas Health and Human Services Commission (HHSC) to require counties to submit specific tax information to determine eligibility for state assistance. This requirement will be formalized through an administrative rule amendment by HHSC.
Effective September 2024, HB 4510 mandates that each indigent health care coordinator request specific information from the county tax assessor-collector and auditor for submission to the DSHS, according to CJCAT Program Director Rick Thompson. This information includes the county’s sales tax revenue, general revenue tax levy, and taxable property value.
Jim Allison, CJCAT Senior General Counsel, noted that CJCAT had opposed Senate Bill 987, the initial bill proposing this reporting requirement. While S.B. 987 was passed by both legislative chambers, it was vetoed by Governor Greg Abbott. However, the reporting requirement was subsequently added to H.B. 4510 as a Senate amendment and ultimately approved.
Services Provided Under CIHCP
To qualify for State Assistance Fund reimbursement, counties must provide a set of basic health care services to eligible residents and have the option to offer additional optional health care services established by the DSHS.
A significant expansion of optional services occurred in March 2008, allowing counties to include “any other appropriate health care service that the local governmental municipality or entity deems appropriate and cost effective.” Prior to this change, counties could not receive state matching funds for services or equipment not explicitly listed in the rules, even if their indigent health care spending exceeded the 8 percent threshold. This amendment enabled counties to count a broader range of expenditures towards the 8 percent threshold and qualify for State Assistance Fund reimbursement.
The 83rd Texas Legislature addressed indigent health care expenditures related to county jail inmates. House Bill 2454 amended the HSC to permit counties to credit healthcare service expenditures for county correctional facility inmates towards their 8 percent spending level. This provision extends to eligible residents from other counties incarcerated in their county jail. Inmates, like all CIHCP applicants, use Form 3064 – Application for Health Care Assistance and indicate their incarceration status in the living arrangements section.
The 1115 Waiver and Its Impact
In December 2011, Texas secured federal approval from the Centers for Medicare and Medicaid Services for an 1115 Waiver. This waiver allows Texas to expand Medicaid managed care while preserving hospital funding, provides incentives for healthcare quality improvements, and directs more funding to hospitals serving a high number of uninsured patients. Known as the Texas Healthcare Transformation and Quality Improvement 1115 Demonstration Waiver, or simply the 1115 Waiver, it replaced the Upper Payment Limit program. The 1115 Waiver was extended to September 30, 2030, with federal approval granted on January 15, 2021.
Allison reported that counties can include 1115 Waiver intergovernmental transfer payments towards state assistance eligibility, up to 4 percent of the GRTL. However, this is contingent on three 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 care available through waiver participation is sufficient in type and amount to meet Chapter 61 requirements.
- The county must receive regular reports from healthcare providers receiving supplemental or incentive payments under the 1115 Waiver, documenting the number and types of services provided to those eligible under Chapter 61.
For further information on DSHS and CIHCPs, please visit: https://www.hhs.texas.gov/services/health/county-indigent-health-care-program.
In conclusion, the Fort Bend County Indigent Health Care Program exemplifies a commitment to comprehensive care by addressing not only the medical needs but also the broader life circumstances of its indigent residents. Coupled with the state-level framework of CIHCP and the State Assistance Fund, programs like Fort Bend’s play a critical role in ensuring access to healthcare for vulnerable populations across Texas.
