Do Texas public hospitals have to provide childbirth and prenatal care to indigent patients?

Texas AG Opinion JM-746: Obstetric Care Under the Indigent Health Care Act

Plain-English summary

A state senator asked several questions about the Indigent Health Care Act and whether public hospitals had to provide obstetrical and post-natal services to eligible patients. The Attorney General explained that public hospitals had to provide eligible residents the inpatient and outpatient services a county was required to provide to indigents under section 3.01(a)(1) of the act. The act did not list specific services; instead, the Department of Health defined the required services by rule, and its rules required "medically necessary" services. Medically necessary care for an eligible pregnant woman would include some obstetrical and post-natal services, but exactly which services were medically necessary in a given case was a question of fact the opinion could not resolve.

On the second question, the opinion distinguished two provisions of section 11.01. If the obstetrical and post-natal services were medically necessary and required under the act, discontinuing them would violate section 11.01(a). Separately, section 11.01(b) required a hospital to keep providing any additional services it had offered to eligible residents during the operating year that ended before January 1, 1985, even if those services were not otherwise required.

On the third question, the opinion concluded that section 13.02 required a public hospital to publish notice and hold a public hearing before it reduced the services it offered or made its eligibility standards more restrictive, and the governing body had to formally adopt a finding that the change would not have a detrimental impact on access to health care. The opinion added an important limit: a hospital could not use section 13.02 to set eligibility standards stricter than those established by the Department of Health under section 1.06.

Currency note

This opinion was issued in 1987. Subsequent statutory amendments, court decisions, or later AG opinions may have changed the analysis. Treat this page as historical context, not current legal advice. Verify current law before relying on any specific rule, deadline, or remedy mentioned here.

Common questions

Did public hospitals have to provide maternity care to indigent patients?

Public hospitals had to provide the medically necessary inpatient and outpatient services required under the act, which the opinion said would include some obstetrical and post-natal care for an eligible pregnant woman. Whether a particular service was medically necessary was a fact question.

Could a hospital drop obstetric services it used to offer?

Not freely. If the services were required as medically necessary, dropping them would violate section 11.01(a). And if the hospital had provided them during the operating year ending before January 1, 1985, section 11.01(b) required it to continue them even if they were not otherwise required.

Did a hospital have to hold a hearing before cutting services?

Yes. The opinion read section 13.02 to require published notice and a public hearing before a hospital reduced services or tightened eligibility, with the governing body formally finding that the change would not harm access to care.

Could a hospital set stricter eligibility rules than the state's?

No. The opinion concluded that a hospital could not adopt eligibility standards more restrictive than those set by the Department of Health under section 1.06, and had to loosen its own standards if the state made its standards less restrictive.

Background and statutory framework

The Indigent Health Care Act, article 4438f of the Texas civil statutes, required counties and public hospitals to provide a baseline of health care to eligible indigent residents. Rather than listing covered treatments, the act directed the Department of Health to define the required inpatient and outpatient services by rule, and the department's rules required "medically necessary" services. That structure left the concrete question of which services a given patient needed to be resolved case by case rather than in an opinion.

Two features of the act constrained how a hospital could scale back. Section 11.01(b) locked in additional services a hospital had provided during the operating year ending before January 1, 1985. And section 13.02 imposed procedural requirements, published notice at least 90 days ahead, a public hearing, and a formal finding of no detrimental impact on access, before a hospital could reduce services or restrict eligibility. The opinion also tied eligibility to the department's floor under section 1.06, so a hospital could not go below the state standard.

Citations and references

Statutory and regulatory authorities:

• Indigent Health Care Act, V.T.C.S. article 4438f (including sections 1.02, 1.06, 3.01, 11.01, 11.03, 12.01, 10.02, and 13.02)
• 40 Texas Administrative Code section 14.201 (required inpatient and outpatient services)
• Open meetings law, Chapter 271, Acts of the 60th Legislature, Regular Session, 1967 (Article 6252-17, Vernon's Texas Civil Statutes)

Source

• Landing page: https://www.texasattorneygeneral.gov/opinions/jim-mattox/jm-0746
• Original PDF: https://www.texasattorneygeneral.gov/sites/default/files/opinion-files/opinion/1987/jm0746.pdf

Original opinion text

Best-effort transcription from a scanned PDF. Minor errors may remain; the linked PDF is authoritative.

THE ATTORNEY GENERAL
OF TEXAS

July 14, 1987

Honorable Chet Brooks
Chairman
Committee on Health and Human Services
Texas State Senate
P.O. Box 12068
Austin, Texas 78711

Opinion No. JM-746

Re: Obstetrical and post-natal services under the Indigent Health Care Act

Dear Senator Brooks:

You ask several questions about the Indigent Health Care Act [hereinafter the act], article 4438f, V.T.C.S. See art. 4438f, §1.02(10) (defining "public hospital"); see also Attorney General Opinion JM-626 (1987). Your first question is whether a public hospital is required to provide obstetrical and post-natal services to eligible persons.

Public hospitals must provide, to eligible residents, the inpatient and outpatient services that a county is required to provide to indigents under section 3.01(a)(1) of the act. See also art. 4438f, §11.03(a) (a public hospital may provide required services through other health-care providers); art. 4438f, §12.01 (a public hospital is liable for required services provided by other entities). Section 3.01(a)(1) requires that counties provide "inpatient and outpatient hospital services as limited by this title." It does not list specific services. Rather, the Department of Health is required to define the required services. V.T.C.S. art. 4438f, §1.06(a). To fulfill that obligation, the department has promulgated rules governing required inpatient and outpatient hospital services. 40 T.A.C. §14.201(1), (2) (1986). Those rules are general, and do not list specific types of required medical care. The rules do provide, however, that "medically necessary" services are required. 40 T.A.C. §14.201(1). Medically necessary services for an eligible pregnant woman would unquestionably include some obstetrical and post-natal services.

1. A county subject to the act must provide not only inpatient and outpatient hospital services but also other services including physician services. Art. 4438f, §3.01.

See Final Report of the Task Force on Indigent Health Care (December 198[4]) (indicating that maternity care was one of the main concerns of the task force); see also art. 4438f, §1.06(a) (department is to define services in accordance with department rules relating to Medicaid program); 40 T.A.C. §4.1804 (1985) (pregnant women who meet other applicable eligibility standards are eligible for Medicaid); V.T.C.S. art. 4447c (Maternal and Infant Health Improvement Act). The determination of what specific services are medically necessary is a question of fact and cannot be resolved in the opinion process.

Your second question is:

Does a public hospital that provided obstetrical and post-natal services to eligible residents during the operating period that ended prior to January 1, 1985, violate section 11.01(b) of the act if the hospital does not continue to provide those services?

Section 11.01 of the act provides, in part:

(a) Each public hospital shall provide the inpatient and outpatient hospital services a county is required to provide under Subdivision (1) of Subsection (a) of Section 3.01 of this Act.

(b) If a public hospital provided additional health care services to eligible residents during the operating year that ended before January 1, 1985, the hospital shall continue to provide those services.

(c) A public hospital may provide additional health care services.

If the obstetrical and post-natal services in question were medically necessary services required under the Indigent Health Care Act, a public hospital would violate section 11.01(a), not section 11.01(b), if it discontinued provision of such services. If a public hospital provided obstetrical and post-natal services during the operating year that ended before January 1, 1985, subsection (b) of section 11.01 would require the public hospital to continue to provide those services, even if those services would not otherwise be required under section 11.01(a) of the act.

Your third question is:

Does section 13.02 of the act require a public hospital to make public notice and hold a public hearing before the hospital can reduce the scope of its services or further restrict eligibility for services?

Section 13.02 of the act provides:

(a) A public hospital may not change its eligibility standards to make the standards more restrictive and may not reduce the health care services it offers unless it complies with the requirements of this section.

(b) Not later than the 90th day before a change would take effect, the public hospital must publish notice of the proposed change in a newspaper of general circulation in the area served by the hospital and set a date for a public hearing on the change. The published notice must include the date, time, and place of the public meeting. This notice does not replace the notice required by the open meetings law, Chapter 271, Acts of the 60th Legislature, Regular Session, 1967 (Article 6252-17, Vernon's Texas Civil Statutes).

(c) Not later than the 30th day before the date on which the change would take effect, the public hospital shall conduct a public meeting to discuss the change. The meeting shall be held at a convenient time in a convenient location within the area the hospital has a legal obligation to serve. Members of the general public may testify at the meeting.

(d) The commissioners court, city council, or board of managers or other governing body of the hospital must formally adopt the finding that the change does not have a detrimental impact on access to health care. (Emphasis added).

Section 13.02 of the act explicitly requires a public hospital to give notice and hold a public hearing before the hospital may reduce the services it offers or before the hospital may make its eligibility standards more restrictive. In order to reduce services the appropriate governmental body must determine that "the change would not have a detrimental impact on access to health care for the residents the hospital serves." V.T.C.S. art. 4438f, §13.02(d).

Also in regard to section 13.02, we caution that its provisions do not allow a public hospital to make its eligibility standards more restrictive than those established by the Department of Health under section 1.06 of the act. Section 10.02(b) provides that a person is eligible for assistance from a public hospital if that person meets the basic income and resources requirements established by the Department of Health under section 1.06 of the act or if that person meets a less restrictive income and resources standard adopted by the public hospital. Section 10.02(f) provides as follows:

A public hospital may adopt a less restrictive income and resources standard at any time. If because of a change in the income and resources requirements established by the department under Section 1.06 of this Act the standard adopted by a hospital becomes stricter than the requirements established by the department, the hospital shall change its standard to at least comply with the requirements established by the department.

The act does not permit a public hospital to set eligibility standards that are more restrictive than those set by the Department of Health. Also, if the Department of Health changes its standards to make them less restrictive, a public hospital must also change its standards if they are more restrictive than the new standards established by the department. See Bill Analysis to S.B. No. 1, 69th Leg., prepared for Senate Committee on Health and Human Services, filed in Bill File to S.B. No. 1, Legislative Reference Library (one purpose of Indigent Health Care Act was to define "indigency"). Thus, a public hospital may make its eligibility standards more restrictive in accordance with the procedures set out in section 13.02 only if the new standards set are no more restrictive than those established by the Department of Health.

SUMMARY

Under the Indigent Health Care Act, article 4438f, V.T.C.S., a public hospital must provide to eligible residents medically necessary inpatient and outpatient health-care services. The determination of what specific services are medically necessary is a question of fact. A public hospital must continue to provide services it provided during the operating year that ended before January 1, 1985. In order to reduce the services it offers or to make its eligibility standards more restrictive, a public hospital must give notice and hold a public hearing in accordance with section 13.02 of the act.

Very truly yours,

JIM MATTOX
Attorney General of Texas

MARY KELLER
Executive Assistant Attorney General

JUDGE ZOLLIE STEAKLEY
Special Assistant Attorney General

RICK GILPIN
Chairman, Opinion Committee

Prepared by Sarah Woelk
Assistant Attorney General