Can a Texas county require indigent health care applicants to be U.S. citizens or qualified aliens?

Plain-English summary

Tom Green County, through its County Attorney and on behalf of the county treasurer, wanted to know whether the commissioners court could write its own rule limiting county indigent health care to residents who are U.S. citizens or "qualified aliens" under federal law. The AG concluded that the county could not add that kind of categorical citizenship test on its own.

The reasoning starts with the Texas Indigent Health Care and Treatment Act, codified in chapter 61 of the Health and Safety Code. It makes counties (along with public hospitals and hospital districts) responsible for health care for certain low-income people, but only as the "payor of last resort," when no other public or private source of payment is available. Eligibility turns on two things: being an "eligible county resident" and meeting income and resource standards set by the Texas Department of State Health Services. The AG noted that neither the residence requirement nor the income-and-resources standards draws any line based on citizenship or alienage. A county must adopt the eligibility standards it will use each fiscal year, and the statute lets a county be more generous than the state minimum but bars it from being more restrictive.

From there the AG applied a settled rule about county power: a commissioners court has only the authority the Texas Constitution and statutes expressly grant it, plus what is necessarily implied. Because the Act gives a county no authority to screen residents by citizenship, and county standards must stay consistent with state law and the Department's minimum standards, the AG concluded that state law does not authorize a commissioners court to adopt a citizenship-or-qualified-alien restriction.

There is a federal overlay, though. A county's indigent health care still has to operate consistently with the federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996, known as the Welfare Reform Act, which defines "qualified alien" and generally limits certain state and local public benefits to qualified aliens. So the AG concluded that whether a particular eligible alien resident can actually receive a particular benefit depends on the federal provisions governing that specific benefit, not on a local rule the county writes for itself.

Currency note

This opinion was issued in 2016. 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. The state and federal law on immigration status and eligibility for public benefits has been an active area of legislation and litigation, so the rules described here may have changed since 2016; confirm the current Health and Safety Code provisions and the current federal standards before relying on these specifics.

What the opinion meant for those who asked

Tom Green County and county commissioners courts (as the opinion described it): The opinion described the Texas Indigent Health Care and Treatment Act as setting eligibility on residence plus income and resources, with no citizenship or alienage distinction, and described a commissioners court as lacking state-law authority to adopt a stricter citizenship-based restriction.

County indigent health care programs (as the opinion described it): The opinion described a county's eligibility standards as permitted to be less restrictive than the Department of State Health Services' minimum standards but not more restrictive, and described the county as the payor of last resort under the Act.

Eligible residents who are not citizens (as the opinion described it): The opinion described whether an eligible alien county resident actually receives a specific benefit as depending on the federal Welfare Reform Act provisions governing that benefit, and noted that alien status by itself does not preclude being a county resident.

Common questions

Can a Texas county refuse indigent health care to non-citizens?
The AG concluded that a county cannot adopt its own categorical citizenship or qualified-alien restriction. The Act sets eligibility on residence and on income and resources and makes no distinction based on citizenship or alienage, and a commissioners court has no state-law authority to add one.

Who qualifies for county indigent health care under Texas law?
The opinion described eligibility as an "eligible county resident" who meets the income and resource standards established by the Texas Department of State Health Services, with the county acting only as the payor of last resort when other sources of payment are unavailable.

Can a county set stricter eligibility rules than the state?
The AG concluded that it cannot. A county must adopt eligibility standards each fiscal year, and those standards may be less restrictive than the Department's minimum standards but must not be more restrictive.

Does federal immigration law still affect who receives these benefits?
The AG concluded that it does. The county's provision of health care to aliens may not be inconsistent with the federal Welfare Reform Act of 1996, which defines "qualified alien" and limits certain public benefits, so whether an eligible alien resident receives a specific benefit depends on that federal law.

Does being an alien make someone a non-resident of the county?
The opinion noted, citing a prior AG opinion, that an individual's status as an alien does not preclude the person from being a state or county resident under state statutes establishing public benefit programs.

Background and statutory framework

The Texas Indigent Health Care and Treatment Act, codified in chapter 61 of the Health and Safety Code, requires counties, public hospitals, and hospital districts to provide or arrange health care for certain indigent persons, with the county serving as the payor of last resort (Tex. Health & Safety Code § 61.022). Eligibility has two components: being an "eligible county resident" and meeting income and resources standards, with residence presumed based on a person's home or fixed place of habitation (Tex. Health & Safety Code §§ 61.002, 61.003). The Texas Department of State Health Services sets the minimum eligibility standards and the application, documentation, and verification procedures, and a county must adopt standards that may be less restrictive than the state minimum but not more restrictive (Tex. Health & Safety Code §§ 61.006, 61.008, 61.023; 25 Tex. Admin. Code §§ 14.1-.201). The AG read these provisions as drawing no distinction based on citizenship or alienage.

Applying the rule that a commissioners court has only expressly granted or necessarily implied powers (City of San Antonio v. City of Boerne, 111 S.W.3d 22, 29 (Tex. 2003)), the AG concluded a county may not adopt a citizenship-based eligibility restriction the Act does not authorize. The county's program nonetheless remains subject to the federal Welfare Reform Act of 1996, which defines "qualified alien" and generally limits certain state and local public benefits to qualified aliens (8 U.S.C. §§ 1621, 1641(b)), and chapter 62 separately provides Medicaid coverage for a child who is a qualified alien (Tex. Health & Safety Code § 62.105). The AG concluded that whether an eligible alien county resident may receive a given benefit depends on the federal provisions governing that specific benefit.

Citations

Statutory and regulatory provisions:

• Tex. Health & Safety Code § 61.002 (definition of "eligible county resident")
• Tex. Health & Safety Code § 61.003 (residence presumption)
• Tex. Health & Safety Code § 61.006 (Department minimum eligibility standards and procedures)
• Tex. Health & Safety Code § 61.008 (Department rules for eligibility determinations)
• Tex. Health & Safety Code § 61.022 (county as payor of last resort for eligible residents)
• Tex. Health & Safety Code § 61.023 (county-adopted standards may be less, not more, restrictive)
• Tex. Health & Safety Code § 62.105 (Medicaid coverage for a child who is a qualified alien)
• 25 Tex. Admin. Code §§ 14.1-.201 (County Indigent Health Care Program rules)
• 8 U.S.C. § 1621 (limits on state and local public benefits for aliens)
• 8 U.S.C. § 1641(b) (definition of "qualified alien")

Cases:

• City of San Antonio v. City of Boerne, 111 S.W.3d 22, 29 (Tex. 2003)

Source

• Landing page: https://www.texasattorneygeneral.gov/opinions/ken-paxton/kp-0059
• Original PDF: https://www.texasattorneygeneral.gov/sites/default/files/opinion-files/opinion/2016/kp0059.pdf

Original opinion text

Best-effort transcription from the official PDF. Minor extraction artifacts were corrected; the linked PDF is authoritative.

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 commissioners
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 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 of 8 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 of San Antonio v. City of Boerne, 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.

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

[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.texasattorneygeneral.gov/opinion/requests-for-opinion-rqs ("Request Letter").

[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.