July 14, 1987 

Iionorabl. Chet Brooks 

Chairman 

Committee on Eealth and 

Elman services 

Texas State Senate 

P. 0. Box 12068 

Austin, Texas 78711 

Opinion No. JM-746 

R.: Obstetrical and post-natal 

services under the Indigent liaalth 

Care Act 

Dear Senator Brooks: 

You ask several questions about the Indigent FIealth Care Ate 

[hereinafter the act]. article 443gf. V.T.C.S. See art. 443af. 

91.02(10) (defining “public hospital”); see also Attorney General 

opinion m-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 ropuired to provide 

to indigents under section 3.01(a)(l) of the act. See also art. 

4430f. $11.03(a) (a public hospital may provide required services 

through other health-care providers); art. 4438f, 112.01 (a public 

hospital is liable for required servicer provided by other entities). 

Section 3.01.(a)(l) requires that counties provide “inpatient end 

outpatient hospital services as limited by this title.” It does ndt 

list specific services. gather, the Departmsnt of Realth is required 

to define the required services. V.T.C.S. ert. 4438f. 11.06(a). To 

fulfill that obligation. the department has promulgated rules 

governing required inpatient and outpatient hospital services. 40 

T.A.C. 914.201(l). (2) (1986). Those rules are general, and do not 

list specific types of required medicel care. The rules do provide, 

however. that “msdicelly necessary” services are required. 40 T.A.C. 

914.201(l). Medically necessary services for an eligible pregnant 

woman would unquestionably include some obstetrical and post-natal 

1. A county subject to the act must provide not only inpatient 

and outpatient hospital services but also other services including 

physician services. Art. 443gf. $3.01. 

p. 3467 
Bouorable Chat Brooks - Page 2 (J&746) 

services. See Final Report of the Tesk Force on Indigent Health Care 

(December 19m (indiceting that maternity care was one of the main 

concerns of the task force); see also art. 4438f, 81.06(a) (department 

is to define services in accordance with department rules relating to 

Medicaid progrsm): 40 T.A.C. 94.1804 (1985) (pregnint women who meet 

other applicable eligibility standards are eligible for Medicaid); 

V.T.C.8. art. 4447~ (Haternal and Infant Eealth Improvement Act). The 

dateruination of what specific services era medically necessary is a 

question of fact and cannot be resolved in the opinion process. 

Your second question is: 

Does a public hospital thet provided obstetrical and post-natel s.rvic.s 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 thoss services? 

Section 11.01 of the ect provides, in part: 

(a) Each public hospital shall provide the 

inpatient end 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 edditionel 

health care services to eligible residents during 

the operating year that ended before January 1, 

1985. the hospital shall continue to provide those 

s.rvic.s. 

(c) A public hospital may provide additional 

health care sarvices. 

If the obstetrical and post-natal services in question were 

medically necessary services required under the Indigent Realth 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 end 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(e) of the act. 

p. 3468 
Eionorable Chet Brooks - Page 3 (JM-746) 

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 car. 

services it offers unless it complies with the 

requirements of this section. 

(b) Not later then the 90th dey 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 maeting shall be held et a 

convenient time in a convenient location within 

the area the hospital has e legal obligation to 

serve. Members of the general public may testify 

at the meeting. 

p. 3469 
Bonoreble Chet Brooks - Page 4 (JI-746) 

(0) The commissioners court, city council, or 

board of -gers 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. (Bmphasis added). 

Section 13.02 of the act sxplicitly requires a public hospital to 

give notice and hold a public hearing before the hoapitel may reduce 

the services it offers or before the hospitel 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 detrimentel impact on access to health care for the 

residents the hospital serves." V.T.C.S. art. 4438f. 813.02(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 persdn meets 

the basic income and resources requirements established by the 

Departmane of Eealth under section 1.06 of the act or if that person 

meets a lass restrictive income and resources standard adopted by the 

public hospital. Section 10.02(f) provides es follows: 

A public hospital may adopt a less restrictive 

incoma end 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 standerd adopted by a 

hospital becomes stricter than the requirements 

established by the department, the hospital shall 

change its stendard to et leest 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 Eealth changes its standards to make them 

less restrictive, a public hospical 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 Commit= on Eeelth and Buman Services, filed in Bill File to 

S.B. No. 1, Legislative Reference Library (one purpose of Indigent 

Eealth 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. 

p. 3470 
n 

honorable Chet Brooks - Page 5 (JM-746) 

SUMHARY 

Under the Indigent Eealth Care Act, article 

4438f. V.T.C.S.. a public hospitelmust provide to 

eligible residents madically secassary inpatient 

end outpatient health-care sarv1c.s. The 

determination of whet specific services era 

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. 

Attorney General of Texas 

MARY KELLRR 

Executive Assistant Attorney General 

JUDGE ZOLLIE STBABUT 

Special Assistant Attorney Generel 

RICII GILPIN 

Chairman, Opinion Committee 

Prepared by Sarah Woalk 

Assistant Attorney General 

p. 3471