Who pays the medical bills for an indigent inmate held in a Texas county jail?

Plain-English summary

A county jail still has to keep its prisoners alive and treated, but somebody has to pay the medical bills. When the prisoner is indigent, the Karnes County Auditor wanted to know whether that cost falls on the county, the local hospital district, or somewhere else. The Attorney General said the answer depends on one thing above all: where the inmate lives.

If the indigent inmate is a resident of a hospital district, that district pays. The Texas Constitution and the laws creating hospital districts put the duty to care for needy residents on the district, and the Attorney General had long read that duty to follow the resident into jail, even a jail in another county. So a Karnes County Hospital District resident who lands in the Karnes County Jail is the district's responsibility, and a person from another county's hospital district who ends up jailed in Karnes County is still that home district's responsibility. The older idea that a county simply pays for "its prisoners" gives way to the constitutional command aimed at hospital districts.

If the inmate instead lives in the service area of a public hospital, that public hospital is ultimately on the hook. And if the inmate lives somewhere with no hospital district and no public hospital service area, the cost falls on the inmate's home county. That last point had shifted: an earlier opinion put the bill on the county where the person was jailed, but a 1991 change to the law routed these costs through the Indigent Health Care and Treatment Act, which makes the county of residence the ultimate payer. The Attorney General was clear this was general guidance, not a final word on every situation, and pointed out unresolved wrinkles, such as inmates who are not Texas residents, disputes over where someone actually lives, and the chance that the paying entity can recover the money from other sources.

Currency note

This opinion was issued in 1993. 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. Chapter 61 of the Health and Safety Code and article 104.002 of the Code of Criminal Procedure have been amended since 1993, so confirm current law before relying on anything described here.

Background and statutory framework

The opinion equated "indigent" with "eligible" as that term is used in the Indigent Health Care and Treatment Act, chapter 61 of the Health and Safety Code (see § 61.002(3), (4)). The Act assigns responsibility for indigent care by where the person lives: hospital districts and public hospitals cover their "eligible residents" (subchapter C), while counties cover "eligible county residents," meaning those who do not live in the service area of a hospital district or public hospital (subchapter B).

For a resident of a hospital district, section 61.055 requires the district to provide the health care services and treatment the constitution and the district's enabling legislation require. The Karnes County Hospital District was created coextensive with the county (Acts 1969, 61st Leg., ch. 591), and its enabling act together with Texas Constitution article IX, section 9 require it to provide medical care for its needy residents. Prior opinions (JM-643 (1987), JM-487 (1986), H-703 (1975)) held that this duty reaches district residents held in county jails.

For an inmate residing in another hospital district, that district pays. As Attorney General Opinion JM-643 explained, although Code of Criminal Procedure article 104.002(a) and its predecessors indicated a county is liable for its prisoners' medical expenses, the constitution's provisions making hospital districts responsible for their needy inhabitants prevail, even when the district's resident is treated while jailed in another county.

For an inmate residing in a public hospital's service area, the public hospital is ultimately responsible (Health & Safety Code §§ 61.052, 61.054, 61.060, with definitions and exclusions in §§ 61.002(11), 61.051(b)).

For an inmate who lives in no hospital district or public hospital service area, JM-643 had placed liability on the county of incarceration. But article 104.002(d) was amended in 1991 (Acts 1991, 72d Leg., ch. 434, § 1(d)). As amended, a person who received medical, dental, or health services as a county-jail prisoner must pay for them; if the prisoner is an "eligible county resident" under section 61.002, the providing county or hospital district has a right of subrogation to the prisoner's recovery from any source, limited to the cost of services, the prisoner remains obligated to reimburse, and the county or district may seek reimbursement under chapter 61 and recover its expenditures in a civil action. In light of that amendment, the cost of care for an "eligible county resident" is payable under the Indigent Health Care and Treatment Act, and section 61.022 makes the inmate's county of residence ultimately responsible (see also V.T.C.S. art. 2351, subdiv. 6; AG Opinions JM-552 (1986), MW-33 (1979)).

Citations

• Health & Safety Code ch. 61 (Indigent Health Care and Treatment Act); § 61.002 (definitions); § 61.055 (hospital district duty); § 61.052 (public hospital duty); § 61.022 (county responsibility); § 61.022(b) (county as payor of last resort); §§ 61.003, 61.004 (resolving residency)
• Code of Criminal Procedure art. 104.002, art. 104.002(d) (prisoner liability for medical services; subrogation and reimbursement)
• Tex. Const. art. IX, § 9 (hospital districts and care for needy residents)
• Acts 1969, 61st Leg., ch. 591 (Karnes County Hospital District enabling act)
• Acts 1991, 72d Leg., ch. 434, § 1(d) (1991 amendment to article 104.002(d))
• V.T.C.S. art. 2351, subdiv. 6
• Attorney General Opinions JM-643 (1987), JM-487 (1986), H-703 (1975), JM-552 (1986), MW-33 (1979), DM-37 (1991)

Common questions

Who pays for an indigent inmate's medical care in a Texas county jail?
It depends on residence. The Attorney General concluded that a hospital district pays for its resident inmates, a public hospital pays for inmates from its service area, and the county of residence pays for an "eligible county resident" who lives in no hospital district or public hospital service area.

Does the county where the jail sits always pay?
No. The opinion concluded that a hospital district's constitutional duty to care for its needy residents prevails over the older notion that a county pays for "its prisoners," so a resident of one district who is jailed in another county is still the home district's responsibility. And for someone with no district or public hospital, a 1991 amendment shifted the cost to the county of residence rather than the county of incarceration.

What changed with the 1991 amendment to article 104.002(d)?
The amendment made prisoners liable to pay for medical services they receive and gave the paying county or hospital district a right of subrogation and reimbursement through chapter 61. The Attorney General read it to route the cost of care for an "eligible county resident" through the Indigent Health Care and Treatment Act, making the county of residence the ultimate payer.

Can the county or hospital district recover the money it spends?
Yes, potentially. The opinion noted the county is the "payor of last resort" under section 61.022(b), and that under article 104.002(d) the prisoner remains obligated to reimburse and the county or district may pursue subrogation, apply for reimbursement under chapter 61, or recover its expenditures in a civil action.

What did the opinion not decide?
It did not address responsibility for prisoners who are not Texas residents, and it cautioned that it could not anticipate every issue. It also pointed to Health & Safety Code sections 61.003 and 61.004 for resolving disputes over where an inmate actually resides.

Source

• Landing page: https://www.texasattorneygeneral.gov/opinions/dan-morales/dm-0225
• Original PDF: https://www.texasattorneygeneral.gov/sites/default/files/opinion-files/opinion/1993/dm0225.pdf

Original opinion text

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

Office of the Attorney General
State of Texas

DAN MORALES
ATTORNEY GENERAL

June 8, 1993

Honorable Clem R. Cannon
Karnes County Auditor
200 East Calvert
Karnes City, Texas 78118

Opinion No. DM-225

Re: Liability for costs of health care provided to indigent inmates of the Karnes County Jail (RQ-420)

Dear Mr. Cannon:

You ask who is responsible for paying medical bills for indigent prisoners incarcerated in Karnes County Jail. We cannot anticipate all issues that may arise with respect to responsibility for the costs of indigent prisoners' medical care. We offer the following discussion for your general guidance.

We note first that, for purposes of the following discussion "indigent" will mean "eligible" as used in the terms "eligible county resident" or "eligible resident" in the Indigent Health Care and Treatment Act, codified as chapter 61 of the Health and Safety Code. See Health & Safety Code § 61.002(3), (4) (definitions). That act provides generally for hospital districts' or public hospitals' responsibility for the costs of providing medical care for their "eligible residents," id. subch. C, and for counties' responsibility for such costs for "eligible county residents," i.e., those who do not reside in the service area of a hospital district or public hospital, id. subch. B.

For indigent, or "eligible," persons who are residents of hospital districts, section 61.055 of the Indigent Health Care and Treatment Act (the "act") provides that a hospital district must provide the health care services and treatment required by the constitution and the district's enabling legislation. As you indicate, the Karnes County Hospital District has been created in Karnes County and is coextensive with the county. Acts 1969, 61st Leg., ch. 591, at 1764. The district's enabling act and the constitution require the district to provide medical care for its needy residents or inhabitants. Id. § 3; Tex. Const. art. IX, § 9. Prior opinions of this office have consistently opined that a hospital district's duty to provide medical care for their indigent residents extends to such residents when they are held in county jails. Attorney General Opinions JM-643 (1987); JM-487 (1986); H-703 (1975). Thus, it is our opinion that the Karnes County Hospital District is responsible for the medical costs of an indigent jail inmate who is a resident of that district. See generally Health & Safety Code ch. 61, subch. C.

Also, for such an indigent inmate who is a resident of another hospital district, the hospital district of his residence is responsible for the costs of medical care, pursuant to that district's enabling legislation and the requirements of the constitution. Attorney General Opinions JM-643; JM-487. As noted in Attorney General Opinion JM-643 in 1987, despite the indication in subpart (a) of article 104.002 of the Code of Criminal Procedure and its predecessor provisions that the county is liable for the medical expenses of its prisoners, the express provisions of the constitution, making hospital districts, where created, responsible for the medical care of their needy inhabitants, must be read to prevail, even in the situation where such a hospital district's resident receives medical care while incarcerated in another county's jail.

Similarly, for indigent inmates of the Karnes County Jail who reside in the service area of a public hospital, it is the public hospital which is ultimately responsible for the cost of health care provided at the jail. See Health & Safety Code § 61.052 (public hospital's responsibility for eligible residents of its service area); see also id. §§ 61.002(11) (definition of public hospital), 61.051(b) (hospitals not considered public hospitals), 61.054 (service obligations), 61.060 (liability for payment for services provided).

With respect to an indigent inmate of the Karnes County Jail who does not reside in Karnes County and whose residence is not embraced in any hospital district or public hospital service area, we note first that Attorney General Opinion JM-643 concluded, in 1987, that the liability for medical care of such indigent inmates of a county jail was to be borne by the county of incarceration, and not by the county of residence. Since the issuance of Attorney General Opinion JM-643, article 104.002, subpart (d) of the Code of Criminal Procedure, has been amended. Subpart (d) currently provides:

A person who is or was a prisoner in a county jail and received medical, dental, or health related services from a county or a hospital district shall be required to pay for such services when they are rendered. If such prisoner is an eligible county resident as defined in Section 61.002, Health and Safety Code, the county or hospital district providing the services has a right of subrogation to the prisoner's right of recovery from any source limited to the cost of services provided. A prisoner, unless the prisoner fully pays for the cost of services received, shall remain obligated to reimburse the county or hospital district for any medical, dental, or health services provided, and the county or hospital district may apply for reimbursement in the manner provided by Chapter 61, Health and Safety Code. A county or hospital district shall have the authority to recover the amount expended in a civil action.

Acts 1991, 72d Leg., ch. 434, § 1(d), at 1597-98.

In light of the current provisions of article 104.002(d), it is our opinion the costs of medical care provided to a prisoner who is an "eligible county resident" as defined in the Indigent Health Care and Treatment Act, section 61.002, i.e., one who is not a resident of a hospital district or public hospital service area, are now payable under the latter act. Section 61.022 of that act makes a county ultimately responsible for health care for its "eligible county residents." Thus, responsibility for costs of medical care provided to such an "eligible county resident" when incarcerated in the Karnes County Jail would be ultimately with his county of residence. See also V.T.C.S. art. 2351, subdiv. 6; Attorney General Opinions JM-552 (1986); MW-33 (1979).

In that the question of residence decides the matter of responsibility for medical care in the instances discussed above, we note the Health and Safety Code provides for the resolution of residency questions. Health & Safety Code §§ 61.003, 61.004.

Again we caution, that we cannot anticipate or resolve all questions that may arise with respect to indigent prisoners' health care expenses. We specifically note, for example, that we do not consider here the responsibility for costs of medical care for prisoners who are not Texas residents. Also, as the above-quoted provisions of article 104.002(d) clearly anticipate, Karnes County or its hospital district may have recourse to other sources of payment for indigent prisoners' health care costs depending on the facts of the particular case. The provisions of the Indigent Health Care and Treatment Act further make it clear that the above-discussed entities' ultimate responsibility for such costs may depend on the availability of payment from other sources. See, e.g., Health & Safety Code § 61.022(b) (county as "payor of last resort"). Also, eligibility requirements and the kind of care covered may vary depending on the particular entity responsible. See, e.g., id. §§ 61.008, 61.023, 61.052; Attorney General Opinion DM-37 (1991).

SUMMARY

Subject to the given caveats, the Karnes County Hospital District is responsible for the costs of medical care provided to its indigent residents incarcerated in the Karnes County Jail. Other hospital districts or public hospitals are responsible for such costs with respect to their indigent residents incarcerated in the Karnes County Jail. The county of residence of an indigent inmate of the Karnes County Jail who does not reside in a hospital district or public hospital service area is responsible for the costs of his medical care.

DAN MORALES
Attorney General of Texas

WILL PRYOR
First Assistant Attorney General

MARY KELLER
Deputy Attorney General for Litigation

RENEA HICKS
State Solicitor

MADELEINE B. JOHNSON
Chair, Opinion Committee

Prepared by William M. Walker
Assistant Attorney General