Stanislaus County Municipal Code Ch. 9.60 Indigent Health Care Program

The Stanislaus County health services agency shall administer the county's indigent health care program (hereinafter referred to as IHCP), a program to provide health care to indigent residents of Stanislaus County.

(Ord. CS 270 §1, 1987; Ord. CS 810 §1, 2002)

A. It is the policy of Stanislaus County to afford notice and an opportunity for a fair hearing to participants in IHCP who believe themselves to be adversely affected by IHCP decisions concerning eligibility for the program or scope of program benefits. Typical fair hearing issues would include questions of residency, patient monetary assets, and definition of program benefits.

B. A fair hearing is not available for the following issues:

1. Patient's eligibility expiration;

2. Patient's failure to apply for participation in the IHCP;

3. Lost eligibility documents;

4. Patients whose demands for specific medical services have not been approved or recommended by the patient's attending physician;

5. Patient's demand for specific medical services while a treatment authorization request (TAR) is under review for less than thirty days from the date of request by the patient's attending physician;

6. Medical judgments of the attending physician or health services agency staff.

(Ord. CS 270 §2, 1987; Ord. CS 810 §1, 2002)

The IHCP is a program limited to providing medical services for indigent residents in Stanislaus County. The financial eligibility for the IHCP shall generally be determined according to the criteria established by the California Medi-Cal Program except as directed by resolution adopted by the Stanislaus County board of supervisors.

(Ord. CS 270 §3, 1987; Ord. CS 810 §1, 2002)

The health services agency shall adopt policies and procedures consistent with this chapter, state, local and federal law. All policies and procedures adopted pursuant to this authority shall be made available to the public at the time of final adoption. The health services agency shall post and make available to the public a description of the services and the procedures available under this program within thirty days of adoption of the ordinance codified in this chapter.

(Ord. CS 270 §4, 1987; Ord. CS 810 §1, 2002)

Medical benefits to be provided in the IHCP shall be as adopted annually in the county health services plan and budget by resolution of the Stanislaus County board of supervisors.

(Ord. CS 270 §5, 1987; Ord. CS 810 §1, 2002)

A. "Fair hearing board" means a three-member body charged by the board of supervisors with the duty of conducting administrative appeals under this chapter.

B. "Health care professional" means a non-physician professional in the health care environment, including a registered nurse, physician assistant, or health care manager experienced in a broad area of health care management.

C. "Medical director" means the health services agency medical director.

D. "Person" means patient, patient's parent or guardian, or patient's spouse.

E. "Program coordinator" means the IHCP coordinator charged with the duty of managing the program or his or her designee.

F. "Written request" means a request in writing stating the patient's name, address, phone number, and a brief description of the questioned action.

(Ord. CS 270 §6, 1987; Ord. CS 810 §1, 2002)

The chairman of the board of supervisors shall appoint a three-member IHCP fair hearing board to hear appeals pursuant to this chapter. The fair hearing board shall consist of a member of the State Bar of California, who shall act as chairman, a physician practicing in the county of Stanislaus, and a health care professional. Neither the physician nor the health care professional shall have been involved with or have prior knowledge of the matter brought before the panel. Proposed members shall be selected as follows:

1. The county chief executive officer shall submit to the board of supervisors the name of a member of the State Bar of California who shall not be an employee in a county service.

2. The health services agency shall submit the name of a physician practicing in Stanislaus County to the board of supervisors and the name of a health care professional.

(Ord. CS 270 §7, 1987; Ord. CS 278 §3, 1988; Ord. CS 810 §1, 2002)

There are two avenues of notices provided IHCP patients for which a fair hearing is available:

A. Patients determined ineligible by a health services agency patient financial counselor (PFC) shall receive a copy of their rejected application and a statement in plain, understandable language of the following:

1. The factual reason for the determination;

2. The right to a fair hearing;

3. The procedure to obtain a fair hearing;

4. The right to be represented by another person at the hearing;

5. The time limit to request a hearing. The rejected application shall be delivered to the patient no later than thirty days after the date of the application. The PFC shall be responsible for preparing and delivering the rejected application to the patient;

6. The particular eligibility criteria utilized in an adverse determination so as to provide the patient/applicant with notice of the reasons for the decision.

B. Patients denied a specific medical procedure requested by their attending physician shall be given a denial form prepared by the program coordinator which shall state in plain, understandable language the following:

1. The factual reasons for the determination;

2. The right to a fair hearing;

3. The procedure to obtain a fair hearing;

4. The right to be represented by another person at the hearing;

5. The time limit to request a fair hearing;

6. The particular standard utilized in an adverse determination so as to provide the patient/application with notice of the reasons for the decision.

(Ord. CS 270 §8, 1987; Ord. CS 278 §§1, 2, 1988; Ord. CS 810 §1, 2002)

A. The IHCP fair hearing board is authorized to determine only two issues when reviewing denials of eligibility or treatment under this program:

1. The eligibility of the patient for IHCP enrollment based on residency, assets, ability to pay, eligibility for other medical aid programs; and

2. Whether a specific treatment, procedure, device, or medication, is included within the summary of medical benefits adopted by the board of supervisors.

B. The fair hearing board shall have authority to:

1. Subpoena patient financial counselors or the person who made the eligibility determination as witnesses upon a showing of good cause by the party requesting their attendance and if the hearing panel determines that their presence would be useful or necessary to make a decision;

2. Subpoena documents upon a showing of good cause if the hearing panel determines that the documents sought would be useful or necessary in making a decision;

3. A party to the hearing or panel itself may request the issuance of a subpoena. A request for a subpoena shall be accompanied by a statement indicating the reason for the attendance of the patient financial counselor or the person who made the eligibility determination and/or the production of documents, including a statement of the materiality of the witness and/or document to the issues of the hearing.

(Ord. CS 270 §10, 1987; Ord. CS 278 §4, 1988; Ord. CS 810 §1, 2002)

A. A written request for a fair hearing must be received by the program coordinator within thirty days of the mailing date or date of personal delivery of the notice of action document, i.e., a rejected IHCP application, or treatment denial notice. The fair hearing request shall be accompanied by a medical information and records release form executed by the patient for release of only that medical information which is directly related to the issues that are the subject of the hearing. In situations where the hearing panel determines that additional information would be useful or necessary to make a decision, the panel is authorized to request a release of additional medical information from the applicant.

B. The program coordinator or person designated by him/her shall respond to the written request within fifteen days of receiving the request.

C. The program coordinator shall schedule a date, place, and time for the hearing by the fair hearing board and notify the patient or the patient's designated representative in writing, no later than ten calendar days before the hearing. Notice shall only be provided to a patient's designated representative if the patient has submitted a written notice of representation to the program coordinator at the time of requesting a fair hearing.

D. The program coordinator shall prepare and serve on all parties, or their designated representatives, a position statement no later than five working days before the scheduled hearing. The program coordinator's position statement shall specify the facts supporting the denial or termination and shall be accompanied by the rejected IHCP application form, treatment denial form, medical records, or other documents as may be applicable.

E. The program coordinator shall arrange for all appropriate facilities for hearing the appeal before the fair hearing board including recording equipment and a hearing room. At the time of hearing, the fair hearing board shall first take evidence from the county as to the reasons for denial or termination of benefits. The fair hearing board shall then receive evidence from the patient or his or her representative justifying award or continuation of benefits. Both the patient and the county shall have a right to cross-examine all witnesses appearing at the hearing and introduce documentary and oral evidence, including all or a portion of the patient's medical record or other evidence supporting their respective positions. The fair hearing board shall assemble and preserve the record of all evidence, including exhibits received at the hearing.

Although the burden of proof in all cases shall be on the county, the patient/applicant has the burden of going forward to prove that they have completed the IHCP application and enrollment process.

F. Within ten working days following the hearing, the fair hearing board shall prepare a written statement of findings of facts and a decision based upon the evidence from the hearing which shall be final and binding on the parties.

G. No later than ten calendar days after the fair hearing board makes its decision and within sixty calendar days of filing the request for appeal, unless the hearing board has extended or continued the hearing date at the request of either the patient or the program coordinator, the program coordinator shall send the decision to the patient or the patient's designated representative and to the health services agency managing director or designee. The program coordinator will maintain a central file in his or her office containing all notices, records, exhibits, and decision of the fair hearing board for a period of not less than one hundred twenty calendar days.

(Ord. CS 270 §11, 1987; Ord. CS 278 §§5, 6, 1988; Ord. CS 810 §1, 2002)

The Stanislaus County board of supervisors hereby adopts the provisions of the Code of Civil Procedure Section 1094.6 for review of proceedings and determinations under this chapter.

Any petition for review of a fair hearing board decision shall be filed not later than ninety days following the date on which the fair hearing board made its decision.

(Ord. CS 270 §11, 1987; Ord. CS 810 §1, 2002)