ITEM NO. 2.5 NO ORDER ISSUED SPECIAL COMMISSIONERS' COURT AGENDA MONDAY, FEBRUARY 22, 1999 - 9:00 A. M. COMMISSIONERS' COURT AGENDA REQUEST PLEASE FURNISIi ONE ORIGINAL AND NINE COPIES OF TffiS REQUEST AND DOCUMENTS TO BE REVIEWED BY THE COURT. MADE BY: Buster Baldwin OFFICE: Commissioners Court MEETING DATE: March 8. 1999 TIME PREFERRED: SUBJECT: (PLEASE BE SPECIFIC) Information regarding Indigent Health Care. EXECUTIVE SESSION REQUESTED: (PLEASE STATE REASON) NAME OF PERSON ADDRESSING THE COURT: Commissioner Pct #I/Rac~uel Collazo ESTIMATED LENGTH OF PRESENTATION: IF PERSONNEL MATTER -NAME OF EMPLOYEE: Time for submitting this request for Court to assure that the matter is posted in accordance with Title 5, Chapt 551 and 552, Government Code, is as follows: Meeting scheduled for Mondays: THIS REQUEST RECEIVED BY: THIS REQUEST RECEIVED ON: 5:00 P.M. previous Tuesday. All Agenda Requests will be screened by the County Judge's Office to determine if adequate information has be prepared for the Court's formal consideration and action at time of Court Meetings. Your cooperation will appreciated and contribute towards you request being addressed at the earliest opportunity. See Agenda Request Ru Adopted by Commissioners' Court. February 17, 1999 This item is informational only. We want to bring you up to snuff on Indigent Health Care. BB .. Kerr County Indigent Health Care SPMH 710 Water St. Kerrville, Tegas 78028 (830)- 258-7428 Attachment to Kerr County Indigent Health Care Application Please have this form completed and signed by a neighbor or friend who is not related to you. I certify that I personally know Who resides at address of applicant Other persons living at that address It is my understanding that the above named applicant is employed by: Name Relations Address Phone Sienature Date AUTHORIZATION TO FURNISH INFORMATION 't ~~' _~"`~- r . AUTORIZACION PARR PROVEER INFORMACION ~~~ i~° ~f h aotii ~ ~.. Yo, '' dame orspoaae) . (Name of Applicant or Reup[eat) ~~ ~ ~ Espma o el Fsposo) (Hombre del Solicitante o Clirnte) living at - con residencia (Address/pircccion) do hereby authorize persons, organizations, or es- tablishments having information or records concern- ing me/us (or) my/our circumstances, to Curnish such information to a representative of the Kerr County Ind- igent Health Care Program. I hereby grant permission for the Kerr County India ent Health Care Program to obtain information ~rhich may have a bearing on my/our eligibility for assistance. Signature :applicant or RecipiendFirma-Solicitante o Clien[: Signature -SpousdFirma - Esposa(o) con esta autorizo a las personas, las organizaciones, o los ettablecimientos que tengan information o documentos sobre mi/nosotros o sobre mis/nuestras circunstancias, a que provean tal information al representante del Kerr Count Indigent Health Care Program. Con esta doy permiso al Kerr County Indigent Health Care Program pats que obtenga la information que pueda necesitar pars determiner mi/nuestra calificac- ion Para asistencia. DatdFecha DatdFecha ~. - ratn n-100 rap. ~ . cash o< property dur{ng the Isst tttre.,nordtts? ... ^ s~ ~ No s, 1 Id you or did anyone living with you setl, trade, or give away arty . viva con usted datero o slgtrta propledad? • -...... vendib o repaid usted o elgtuen qua ':aartte los tikimos tree mesas. ybaspasd, our household to receive thb month? ..~~ . 11. What fa the total Introme (money, cash, or checks) that you expect y rep'bir en este men antra s JI rasps (d(nero en efectivo o en dteque) 4~ asPm'an ' ZCutLtto es el total de being ?... ......:.......................................... . toted y lodes tae demos personas de su psa .......................... Yes 12 Do you or does anyone lving with you receive money from job training or work? ~ Si ^ No de un trabaJo o de entrenamiento pare tat trabaJo? ...................... tRetabe usted o alguna persona qua vrve con ttsted dtnero es 13. Do you charge anyone living with you for room and~or board? ^ St ^ No ue vrve con toted? ...................... ................ .................. yeobra usted por cuarto y comida a alguna persona q Ms, ratatlve:. ~~ ~ otfters? Yes 14, Does anyone in your household get cash, gifts, loans. or contributbns from Pare ~g~ u otros? ........... ^ S( ^ No ZRedbe alpluta persona de la case dinero, regales, pr8stamos, o corttrl'bttciortes de bs padres, parier>tes, 15. Does anyone get any other money, cash, or checks? (Include settool grattb, scholarships, bans. child support, unemployment, government checks, ttc.) ? ~ ~ T~ ~ ~ Yes ZReabe alguna persona de Ice case otro dinero ens ecuv'do~o ~~ ~t~ del ~biemo. etc.) . ................................. ^ Si ^ No betas. pr~stamos, sostemmtento pars ninon, Dag Pa 16. List all of your household's Income below. ! D81a siguiente infonnaddn pare ~as~~-esos A~ir~o nrr t ~ ~~ SECUam, NAME OF PERSON WORgNG NAME OP EMPLOYER, PERSON. OR ~~ RECi:IVED ENTER CtJUM NO. OR RECEMNG MONEY AGENCY THAT PROVIDES THE MONEY CAttTiDAD ~ ~ gEGDRO SOCIAL NOMBRE DE L.A PFSiSONA DUE TRA9AJA ~jtM(,eENCtiA 0UE FAGA EL~DINEAO O L Rt=C16E? REC181DA DE Q NUM. DE RECtJ1M0 OOUE RECIBE EL DINERO es ;, . ,lave you or has anyone living wish you worked in the past three months? ~ Sj ^ No Durance los tiltimos 3 mesas, Ltrabaj6 usted u otra persona qua viva can usted? .................... ............................. . Yes 18. Have you or has anyone living w(th you quit a Job in the last fi0 days? ue vrve con usted? ...................................... ^ Si ^ No Durante bs tiltimos 60 dies, ~renund6 a un trabajo usted u acre persona q Yes -_ ~ ^No 19. is anyone in your household on strike? .......................... Si ................................... ~Esta en huelga alguna persona de la case? .................... 20. Living ArrangementsN'rvienda e w caw: Check all tares that aPPtY to Your houaehold'JMarque las ~118s q~ se aW~^ Rendttg Own or Paying for Home No Pemuner>< Rabe ^ No Tango Residenda Pemlarterrie ^ Rerdo ^ Soy Dueiw de mi Casa o la Fstoy Compranda Live with Relathrcs or Fdends Migrant or Seasonal Farmworker ^Yryo o~rt Parientes o Amigos ^ Soy Trabajador Migratorio o de Temporada Tax ~ Nom. ~~ o„ -bm. p,ea anyone dw PaY these a~eewa ~ mtedT Telephone gyp de Is Casa Septao d. m Casa LR+Y otra Derma 0~ DaW salve t~ t~ Monthty Rarrt or Payment MonMH lJtiritlsa 7e141ono Rents o Abaa Menwet Papo Me~uuat de ~1O0E e S Y 1 No G' W 21. Does anyone In your household pay legally obligated child support to sotrteone who does not live In your home? ^ 8~ ^No EHay alguien en su case que gaga sostenimiento pars ninon obGgado por by a alguien qua no viva en su casa• • •. • • • • • • • • •' • " _ Yes 22. Da you pay anyone to care for a chiid or other household member so that~id n algtin nlno ofa otroJdbependiente? • •. • • • - • • • • ^ Si ^ No pare poder Vabatar usted o pars poder reabir entrenamiento, ~pa9 P~ 4 (month, week, day) per (men, semana, die) K "Yes," how much do you pay? S ~ Si marCa'Si ' Lcuanto page? ............... R "Yes," who? Yes ' 23. pre you or is anyone who lives with you pregnant? yEsta usted o alguien mss que viva con usted embarazada. ^ Sf ^ No Si mar~~'Sf,' LgtttBrt? Yes .... ^Si ^Nc ^' 'roes anyone have any unpaid medical bills from the last four months?mesas? .......................................... `_ ,Tiene alguien de su case aentas mt`'dit~s sin pagan de bs tiidmos cuatro 25. Does anyone have health irtsurarttx? • • • •-"• • •' ^ Sf Q Ne ZTiene alguien de su case seguro mr3dico? ...................................................................... es 26. Does anyone have monthly medical costs (bills, medicine, insurance, transportation, Noma ~)? yTiene alguien de su case gastos tnr3dicos mensuales (por ejempb, cuentas, medidtta, pagos de seguros. ~ ' t ^ c .......................^S N transportaabn.cuidado en case)? ........................... ~. ,: _: Torr raa~ w.too cover sh.w~-s~ ~~. l~fdkt?!4 ~!?~;sn~izn .,3 Ate,` APPLICATION FOR ASSISTANCE ~ , ".;,` The County Indigent Heakh Care Program (CIHCP) hasps people pay 6,P. for needed medial care- Whether You an get this help depends on .. a k ~Ee a.Qal your income, what you own, wham You live, other help you receive or . could receive, and other Itenur. ... ~- Try to answer as many questions as You can on this appllation. Be Trate de axrtezx aureto __.~ ~~~ • answer sll questions in Item 1, General Information, snd ._ • ~~ • sign and data the last page of the application. •_ .v Tum in or mail back your application today, even H you gnnot answer ntestar to tt all the questions. ~ ~?~" YOUR RESPONSIBILITIES - You may be asked to bring proof of what You write on your appliation a _ Puede que b tell the person Interviewing you. M you need help getting proof, the ~ wrtevista ~ person tnterviewing you will hdp. Examples of some of the things you may be asked to prove and things you can use for proof arc: • WHERE YOU LIVE AND PLAN TO CONTINUE I.IViNG. Possible Proof: mail that you received at your add esa~sehool rederiordrs voting records, Property tax, rcrd or mortgag license, other official identiflation, automobile registration. • YOUR INCOME. Possible Proof: pay cheek stubs, pay checks, W-2 tax forms or Income tax rctums, sales records, statements from employers, award letters, '~qal documents, statements from persons giving you money iATYDUOWNANDYYHATRIS~OaRTHestimates fmm car deafen, Possible Proof: property tax aPP ads selling similar ttems, statements from real estate ager)ts, bank statements. • OTHER HEALTH CARE COVERAGE. Possible Prooh award or claim lerien, Insurance policies, eouR doeumeMs, other legal papers. Information on nee and sex is vduntary. Intorrnatlon on Social Security numbers should be given M this intonnation is available. These types of information will not change your eligibility. You muss give information about medical insunnce and any other third party financially liable for medical services paid by the county for yourself and members of your household. By signing and wbmlriing this application, you arc agreeing to give the county the right to recover the cost of health care services provided by the county from any third parry. You may tx asked to apply for Medicaid, AFDC (Aid to Families with De- pendent Children), or SSI (Supplemental See ~ritYolohmve)applied but are are asked to apply for one of these prop ~ held until ou are waiting for an answer, your CIHCP application tF ~ arc not eligible for determined Ineligible for the other program(s). y these other programs, it you have answered all questions on the application, and H you have given all the proof asked tor, your application is complete. The CIHCP must determine tt you arc eligible within 14 days from the data you meet these requircmeMs. After fuming in your applicators, you must rcpoR within 14 days any changes in your address, income, resources, people living with You, or application for or receipt of SSI, AFDC or Medicaid. r fos servkioa r"riddioos'que neceaga. La elegbcTida~d Para esra kioa' y~igre~aaao'"s~~icimnte. sus posasiones, el agar donde - lus redba a qus ,real~~, Y otras consid°ra°°"as. r, en esfa IS Drams qUe P~• Asegirrese 'WmT1Ra s les prsgcadas Secadn 1, YJornraadn General, y ;~z::: k .q,~.,3 _..,_.__. _~.r.~~-_. idWd.o;, correo. mismo. ears st no ha podido !._,. 4up~~~~ - --d aen larr pruebas de que esaba en su so6alud o de b que ~ hags rrecesita ayuda pare obterrer las pruebas, le persona qu x-kA3a4G.T i,drY 9VI1ltAr ~t~ • . , ~, 4 +.•'+~:u~- ~ ~' nt~e'4ue ~+9a que P~ Y de Estos ears algrsras ejempbs,. •~.. ’ ~ - b que le puede aervrde pp~eba: `° v s;, « ~ ~ , .`.. _ -: `~~.~ °EL" ;~'MdpNDEVIGEQ'DONDETfENESUHOGARPERMANENTS. Posbles Pnasbax eoneo que teabib en esa dueccibr-, rbcords de la escuela, ' iegistro`s de votarme, taabos de, imprrestoa, rents o aboras de le case, la I'~cencia - Para nuuiejar#otra identdicaddri a6crai, al reabo de las places de! carro• ' • LOS iNGRESOS aC1ETENE :~' +.J... ~ .- - _' Pos3lea -'tabrtes''del_.~egrb de page. el dceque de page, ei comprobwde de salarros a impuestos (Forma W-2), le dedaraaon da unpuesto -federal, ei n3COrd de veMas, dedaradones de.emple le den duiero de concesan, doaanentos fiepaias, dedara±es de .-~ , , qUe • LAS pOSE510NE5 OUETtENE Y VALE CADA UNA. --. -_ Poste Pnrebas: ei avalcio parampuastos sobre le PmP~. avalrios hechos pa vendedt)tas de canoe, ,amucaos de Ice vertta de artiaibs pareddos, _. _ drres-de-ager>tes qua avenden propiedades, estado de cuentas del barxo. > .• .: • OTRA C~1RA PARA GAS1'OS MEDICOS. ~ '---.. `~ . Posales Pnrebes: cartes de redamo o de concesibn, pcLzas _de seguros, oaoeles de la oorte u olros dopsitentos ie9~• La rcdartrad6n sobre el sexo y la raze ea voluMaria. Si gene, a su Social, debe d+aargLbgps~. Este ifdamaadn . _,,:,;,, ~ _' mddicos y,de a tetCarO que tenga Ice Oebe der sobre _ ~ ~~ en be-nafido repagar ser6icios irrddicos Pa9~ Pre eels sol~ci-tad, usted de listed o ~'rmembros de su case. IM firmer Y Prey ei costo de servidas ~ rArr~iromele a darle aT`candado el dececlw de rea~perar mddicaa ~e iinni~ero.° .,111~d~ ~:,: : -,, . "" ;' ~" >_ `AFDC (Asislenoa a FamiGas con N'mos _.:.: `~~ fidoa de SSI lSeguridad de irgraso Supleme~• Si le hen soic4a beneli~'ds atgurro de estos prograrnas o si listed ya las ao6cdd y e~`ei~ierando to rcspuesta: w so6ahud de CIHCP puede ser defends haste qne dedaor que no es ebgble Para ba P namd°"ad°s. Si no es de le il. todas las pragu^tas ' elegrbb Para*etba, Programesr.~ so6ciprd,.y aihadado todos toe ~ qr,e i>~. Ya taanden ir-ocesar su apGq'~, 6r CIHCP liens Iat ptam 'de 14 dais pan determiner su • . sans ~~a~ ~ .,..... _ ~ , _ . ,. ,.• ,, de . su. soGadrd. rdtad'~ebe reporter derdm de un plazo de 14 di de d'uacadir; ingreso, recursa. el raknero de personas que ' viven cars use a~af soBala o nab~s3SS1, AFDC C o Medicaid. ~. 1. FlII In line (a) about yourseft. Fill in the remaining blanks for everyone who lives with you, whether or not you consider them household members: Uene el primer rengldn con infonnaddn sobre usted mismo. Uene otro rengidn pars calla persona us. t~ N de su case induyendo a las que viven en su case sin pertenecer a su caso de asisterxia. arfzfil ALEN sC-aou socuu_ SECURfTY q~p~p~p RES1nOlfE ESTA F.N LA NUMBER WHAT ION DATE OF DE lDS (1111 IEGAL I3gJF1A NUMEEO f>E NAME (1.asC Flrst. MIddN) TO YOU? BIRTH SEJ( RACE SEGUFtO SCCUII NOMBRE (Apellido, Ngnbres) RF1AC10N DE FECHA DE SEXO AAZA Y« No Yp ~ Yu No PARENTESCO NACIMIEHTO S( St Sf e....,c...ntlCNi,i,an,w SELF 2 Do others Ilve with you that you did net Ilst above? Yes H "Yes," how many? • Ha otras personas que viven con usted que r1o estAn en esta lista?............^ Si ^ No Si marca'Si; Zcu~ntas7 .... 11c Y or Medicaid txneflts hero else? Yes 3. Are you or Is anyone living with you receiving AFDC, Food Stamp, and/ >~ tEsta usted o alguna persona que viva can usted mabiendo benefidos de AFDC. Estampflias pars Comilla y!o Medicaid en otro {uga(1..... ^ Si No K "Yes," whero?~Si contesta'Si ; yDdnde? 4. Are you or k anyone in your household disqualifled from partidpating in the AFDC or Food Skimp program N Texas or anywhere else? Yes ~Esta usted o alguna persona de su case desrai~rxdo pars participar en el programs de AFDC o pare Comilla en Texas o en oUo lager?.. ^ Si ^ No _ . _ ,.,.__e,. r-w,.9 For now law?1tPor a/ine~ pempo7 5. Are you or is anyone living wtth you fleeing from law enforcement agencies, or in violation of a eorlditlon of probation or parole? Yes yEsta usted o alguna persona que viva con usted huyendo de las autoridades judidales y poflaales o ha violado alguna ^ Si ^ No condidbn de la Gbertad vigilada ola fbertad condidonal7 ........................................................................_ 6. Is anyone in your householddfsab{ed? ........:.............^St~ ^No LHay antra las personas de su caso alguna persona incapadfada? ....................................... 7. How much cash money do you and all those who live with you have (in pockets, bank accounts, anywhero else)? Entre usted y lodes las demos personas que viven con usted, Lcuanto dinero tienen a su dlsposid6rl (en bs bolsillos,las cuentas bancarias,o donde sea)? ................................................................................ 8. How many cars, trucks, or other vehicles does your household have? ...................................... LCudntos carton, camiones, u otros vehialos tienen las personas de su caso .............. t- v.arlAifo - Abb .nd MoNUMatca y Modes 2 Y.aryAno ~ ww and ModWMarca Y Modeb ~. Yw1Ano A Mab and Mod~UMaref Y Medab r in for a home, lot, land, gfe klsurarlce, or otiler thirys? ' • Yes 9. Do you (or does anyone Ifving with you} own or arc you pay g ~ villa. o ~~ otra ~? _ ^ ST ^ No - -•_ -----~- . -~..a ~ ~ ~^~ien oue viva con anted una case.. un bte, un terren0. una pd6ta de seglao . ~s~ t~+wTrnur rna essISTANCE 1 SOL1CfTUD DE A5151 tN[,;rA Y ;R 4W t > ~ (~ , s 'r-- ~ .p To: Applicant for Kerr County Indigent Health Care Assistance From: Raquel Collazo, Kerr County Indigent Health Care Coordinator This letter is to inform you of some of the services and procedures of the program for which you aze applying. Please read carefully and address any questions to the IHC office at 830-258-7428 Services r The Kerr County Indigent Health is a state mandated program'managed by Kerr County to assist eligible persons with health coverage for basic medical care on a temporary basis. Medical services received must be from Kerr County providers except when the service is not offered in Kerr County or on an emergency basis. KCIHC is a payor of last resort. Therefore, you may be asked to apply for other programs to which you might be eligible prior to determining your eligibiIin~ for IHC. Your application will be denied for refusal to seek or accept assistance from the available programs to which you may be eligible. Covered services must be medically necessary and ordered by a physician. Covered services have apre-determined le~~el of payment. Some physicians and services are billed at a higher cost. The difference between the IHC payment and the billed services is your responsibility. You are encouraged to talk with your physician or his/~er office staff regarding how to manage the remaining bill. Non-covered services include but are not limited to: over the counter medication, medical supplies, medical equipment, counseling, dentures, dental care, eye exams, eye glasses/contacts, chiropractors, medical transportation, hearing exams, hearing aids. immunizations, vaccines, and alcohol/drug abuse treatment. Your Responsibilities You must complete the application and attend apre-scheduled appointment to discuss your application ~~nth the KCIHC office. `` You must demonstrate proof of residency, income, resources. The attached application and cover sheet list several items you should bring with you to your appointment. Please read it carefully and bring as much of the proof as possible, as it will speed up-your application process. ff you need additional help obtaining some of the information, the interviewer will help. Important items are your drivers license or identification card, savings and checking account statements and pay stubs. You will be responsible for finding a physician who will treat you. 4 You are required to inform the physicians or agencies treating you of your eligibility for Indigent Health Care coverage. SECTION 2 EUGG3fUTY CR1772RIA ~ T Residency General Applicants must live in the Texas county in which they apply. A person lives in Requirements the county if • his fixed habitation is located in the county, and • he intends to tetrrrn to the county after any temporazy absences. Duration There are no durational requirements for residenry. Persons with no fixed Requiremenrts residence or rrew residents in the county who declare intent to remain in the county and who verify this intent, if questionable, are considered county residents. T~mry Persons do not lose their residence status because of temporary absences from the absences county. No time limits are placed on a person's absence from the county. For From County example, a migrant or seasonal worker may travel during certain times of the yeaz but maintains a fixed home and returns to that home after these temporary abserces. The worker does not lose residence status as long as he intends to return to his fixed home. If a person proves county residency at application, the person remains a county resident until factual evidence proves otherwise. gee ~Y A person cannot qualify for county health care assistance from more than one ~yG-rty county simultaneously. Guidelines Counties with eligible migrant farm workers, who meet the requirements for for Courrties county residence, should develop procedures for determining and reviewing with Migrants eligibility, and providing services while migrants aze temporarily absent from their county of residence in pursuit of employment. p Not Do not consider the following as county residents for CIHCP. They are ineligible. Considered .persons living in an area served by a public hospital or a hospital district; Residents • Inmates and residents of a state or a federal school or correctional facility and patients in federal institutions or state psychiatric hospitals; • Persons who moved into the county solely for the purpose of obtaining health care assistance; and • Minor students primarily supported by their parents whose home residence is in another county or state. CIHC 93-3 Budgeting Income icontin~ad- Famlyy Sim Adult and Adult with Children Caries and Couples . with Chidren Allirwr t~ldren OnIY 1 8 78 - 564 2 163 8125 92 3 188 Z06 130 4 226 ~ 231 154 5 251 Z68 198 6 288. 294 214 7 313 330 26'7 8 356 ~ 356 293 9 382 '.389 337 10 425 425 363 11 451 468 406 12 494 494 432 13 520 537 475 14 563 ~ 563 501 15• 589 ~ 544 • Add S43 for each additional howehoid mamba if the household sbal aioaeeds 15 P!rsans. C1HC 95-1 SECTION 2 ELIGIBILITY CRITERIA Page 18 Resources (continued) Resource Limk A household is not eligible if the total household resources exceeds ~,QQQ,,QQ anytime in the month. However, if the household contains a relative who is aged or disabled according to the following criteria, the household resources cannot exceed ,~• ~ not round up or down. A related person must have one of the following relationships either biologically or by adoption: -Mother or father - Grandmother or grandfather - Sister of brother - Aunt or uncle - First cousin - Niece or nephew - Stepmother or stepfather - First cousin once removed Relationship also extends to: - the spo»se of the relatives listed above, even after the marriage is terminated by death or divorce, _ ~ degree of great-great atrnt/uncle and niece/nephew, and -the degree of great-great-great grandmother/grandfather An aged person is someone age 60 or older as of the last day of the month for which benefits aze being requested. A disabled person includes: (1) People approved for SSI or Social Security disability or blindness. (2) Veterans who receive VA benefits because they aze rated a 100 % service- . connected disability or who, aocording to the VA, need regular aid and attendance or are permanently housebound. (3) Surviving spouses of deceased veterans who meet one of the following criteria according to the VA: -need regular aid and attendance, -permanently housebound, or -approved for VA benefits because of the veteran's death and could be considered permanently disabled for Social Security purposes. (4) Surviving children (any age) of a deceased veteran who the VA has determined are: - permanently incapable of self-support, or -has been approved for benefits because of the veteran's death and weld be considered permanently disabled for Social Security purposes. g for a Resource Limit (5) People receiving disability retirement benefits from an overnmern a envy (continued on next page) disability that could be considered permanent for Social Security purposes. CIHC 98-1