                                             KEN PAXTON
                                        ATTORNEY GENERAL OF TEXAS



                                              January 25, 2016



The Honorable Chris Taylor                                 Opinion No.      KP-0059
Tom Green County Attorney
122 West Harris                                            Re: Authority of a county comm1ss10ners
Criminal Justice Center                                    court to establish requirements for indigent
San Angelo, Texas 76903                                    health care under the Texas Indigent Health
                                                           Care and Treatment Act and relevant federal
                                                           law (RQ-0041-KP)

Dear Mr. Taylor:

        On behalf of the Tom Green County Treasurer, you ask about a county commissioners
court's authority to establish requirements to provide indigent health care under the Texas Indigent
Health Care and Treatment Act (the "Texas Act") and the federal Personal Responsibility and
Work Opportunity Reconciliation Act of 1996 (the "Welfare Reform Act"). 1 You note that the
Texas Act bases eligibility for indigent health care in part on whether the person is a county
"resident." Request Letter at 4-5. You ask whether a commissioners court may require an alien
who is a resident of the county to be a citizen or a "qualified alien" under the Welfare Reform Act
to receive county indigent health care. See id. at 1.

        The Texas Act, codified in chapter 61 of the Health and Safety Code, requires counties,
public hospitals, and hospital districts to provide or arrange to provide health care for certain
indigent persons. TEX. HEALTH & SAFETY CODE§§ 61.001-.068. A county must provide health
care "to each of its eligible county residents" as prescribed by subchapter B, chapter 61, but only
as "the payor of last resort" and "only if other adequate public or private sources of payment are
not available." Id. § 61.022. Eligibility has two primary components-a residence requirement
and income and resources standards. An. "eligible county resident" is a "resident of a county who
does not reside in the service area of a public hospital or hospital district" who meets the income
and resources standards established under subchapter A, chapter 61. Id.§ 61.002(2)-(3). A person
is presumed to be a resident of the county "in which the person's home or fixed place of habitation
to which the person intends to return after a temporary absence is located," or "[i]f a person does
not have a residence, the person is a resident of the governmental entity or hospital district in which
the person intends to reside." Id.§ 61.003(a)-(b).                            ·

      The Texas Department of State Health Services (the "Department") establishes the
"minimum eligibility standards and application, documentation, and verification procedures for

        1
          See Letter from Honorable Chris Taylor, Tom Green Cty. Att'y, to Honorable Ken Paxton, Tex. Att'y Gen.
at 1-2 (July 31, 2015), https://www.texasattomeygeneral.gov/opinion/requests-for-opinion-rqs ("Request Letter").
The Honorable Chris Taylor - Page 2                (KP-0059)



counties to use in determining eligibility" under the Texas Act. Id. § 61.006(a); see also id.
§ 61.008 (requiring Department rules for a county's determination of eligibility); 25 Tex. Admin.
Code §§ 14.1-.201 (Tex. Dept. of State Health Servs., County Indigent Health Care Program).
The Department's standards for the income and resources component of eligibility take into
consideration a person's receipt of or eligibility for federal benefits which, in some instances, may
preclude eligibility for county indigent health care benefits. TEX. HEALTH & SAFETY CODE
§ 61.006(c)-(e). A county must adopt the eligibility standards it will utilize for the fiscal year,
which may be less restrictive than the standards the Department establishes under the Texas Act,
but must not be more restrictive. Id. § 61.023(b), (d). Neither the residence requirement nor the
income and resources component of eligibility makes distinctions based on citizenship or alienage.
See Tex. Att'y Gen. Op. No. JC-0394 (2001) at 2 (stating that "[a]n individual's status as an alien
does not preclude him or her from being a state or county resident under state statutes establishing
public benefit programs"). 2

        Nevertheless, a county's provision of indigent health care benefits under the Texas Act is
subject to the Welfare Reform Act. See generally Tex. Att'y Gen. Op. No. JC-0394 (2001)
(discussing a hospital district's provision of indigent health care); Welfare Reform Act of 1996,
Pub. L. No. 104-193, 110 Stat. 2105 (codified as amended in scattered sections of8 U.S.C. and 42
U.S.C.). The Welfare Reform Act expressly defines "qualified alien" and, with exceptions,
generally allows only qualified aliens to be eligible for certain state or local public benefits. 8
U.S.C. §§ 1621, 1641(b). But while an individual must first be eligible to receive services under
the Texas Act, the county's provision of county health care "services to aliens may not be
inconsistent with" the Welfare Reform Act. Tex. Att'y Gen. Op. No. JC-0394 (2001) at 2.

         You specifically ask whether a commissioners court may adopt its own standards
restricting county indigent health care to residents who are citizens or are qualified aliens. Request
Letter at 1-2. A county commissioners court has only those powers expressly granted by the Texas
Constitution and statutes and powers necessarily implied to accomplish its assigned duties. City
ofSan Antonio v. City ofBoerne, 111 S.W.3d 22, 29 (Tex. 2003). Although a commissioners court
is required to adopt the county's eligibility standards, such county standards must be consistent
with state statutes and the minimum standards adopted by the Department. See TEX. HEALTH &
SAFETY CODE §§ 61.022, .023(b), (d). Thus, because the Texas Act does not make distinctions
based on citizenship or alienage, state law does not authorize a commissioners court to adopt such
restrictions. Ultimately, whether an alien who is an eligible county resident under the Texas Act
as enacted by the Texas Legislature may receive county indigent health care will depend on the
relevant provisions of the federal Welfare Reform Act governing the specific benefits at issue.




         2
           The only references in the Texas Act to aliens concern sponsored aliens. Cf TEX. HEALTH & SAFETY CODE
§§ 61.008(a)(6), (c), .012. Chapter 62 provides coverage under the state Medicaid program for a child who is a
qualified alien. Id. § 62.105.
The Honorable Chris Taylor - Page 3         (KP-0059)



                                      SUMMARY

                      State statutory and administrative law prohibits a county
              commissioners court from adopting county requirements that
              categorically restrict eligibility for county indigent health care
              contrary to state and federal law. Whether an alien who is an eligible
              county resident under the Texas Indigent Health Care and Treatment
              Act may receive county indigent health care will depend on the
              relevant provisions of the federal Personal Responsibility and Work
              Opportunity Reconciliation Act of 1996 governing the specific
              benefits at issue.

                                             Very truly yours,




                                             KEN PAXTON
                                             Attorney General of Texas



CHARLES E. ROY
First Assistant Attorney General

BRANTLEY STARR
Deputy Attorney General for Legal Counsel

VIRGINIA K. HOELSCHER
Chair, Opinion Committee

WILLIAM A. HILL
Assistant Attorney General, Opinion Committee
