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New guidelines expand access to healthcare


More people in Indian River County will qualify for low-cost healthcare after a vote by the Hospital District Board to change its criteria for who is considered medically indigent from 150 percent of federal poverty guidelines to 200 percent, effective in October.

The board also made it easier to sign up for county-funded care.

The new guidelines mean a family of four making $50,200 or less will be eligible for subsidized healthcare under the Hospital District’s mandate. That care is delivered by low-cost clinics and other agencies which are then reimbursed through the Hospital District, which is funded by taxpayers.

The move edges the taxing district closer to income guidelines of the Cleveland Clinic, which in January took over Indian River Medical Center.

Cleveland Clinic provides free care to uninsured patients earning up to 250 percent of the poverty guidelines, and offers assistance to patients earning up to 400 percent. Insured patients include those with commercial insurance as well as Medicaid and Medicare.

The Hospital District, which still owns the hospital and leases it to Cleveland Clinic, considers the move to 200 percent an interim step while it continues to pay $500,000 a month toward indigent patient care at the hospital.

Those payments, which are about 20 percent less than the district paid before Cleveland’s Jan. 1 takeover, will end in 26 months, at which time Cleveland Clinic will bear the full burden of caring for uninsured poor patients at the hospital with its generous 250-percent policy.

At that point, the district, which will continue to pay for medically indigent care outside the hospital, should have a clearer idea of how many more patients it will cover at the 200 percent level as the county grows. And it should be able to better judge the tax dollars required to cover still more patients if the District Board decides to raise the income ceiling to 250 percent of federal poverty guidelines.

The unanimous vote of the elected District Board came despite hesitancy from two trustees with opposite concerns. Trustee Ann Marie McCrystal supported a move to 250 percent now, rather than waiting for the district’s hospital indigent care obligations to end in June 2022.

“Raising this to 200 percent rather than 250 percent is no more than a baby step toward addressing the healthcare needs of our most vulnerable residents,” McCrystal said.

She went on to challenge concerns by Trustee Tracy Zudans that the move could force a hike in the district’s property tax rate. Taxpayers currently pay less than a dollar per $1,000 worth of property value to the Hospital District, though as McCrystal pointed out, the district’s charter allows it to levy a tax of up to $5 per $1,000 of property value.

“I’m just concerned this could cost taxpayers a lot of money,” said Zudans. She appeared reassured when Board Chairwoman Marybeth Cunningham said the district could reevaluate the expansion of the income ceiling if resulting services prove too expensive.

The district tallies its patient population by the number of people who have signed up for Care Cards, which patients must present at participating agencies like Treasure Coast Community Health, Mental Health Association, VNA, and Partners in Women’s Health, among others.

It has been a challenge to get residents to sign up for a Care Card even when they qualify. For that reason, the District Board’s vote included moves to simplify the sign-up process, including easing requirements for proof of residency and income. The measure also included a provision for district coverage if patients seeking medically necessary care have exhausted their insurance benefits.

Under the current 150 percent of poverty guideline, around 4,500 residents are thought to be eligible for Hospital District reimbursement. Raising the income requirement to 200 percent could add 1,700 people, based on 2016 U.S. Census figures analyzed by the District.

But those numbers are fluid since, beginning in October, it will be easier to apply for a district care card.

In addition, trustees noted, some people who fall within the income guidelines but who currently buy insurance through the Affordable Care Act Marketplace may opt for Hospital District coverage instead.

In January, the Hospital District’s executive director Ann Marie Suriano and district treasurer Allen Jones attempted to estimate the cost of going to 250 percent of poverty guidelines from the current 150 percent. Their estimates ranged from an extra $1 million to $1.7 million a year  that would need to be given out to district agencies in order to cover those extra patients.

“But then it occurred to me we might be giving an incentive to some people to stop buying insurance,” Jones told the board in its monthly chairman’s meeting. “If you look at the people between 150 to 250 percent [of federal poverty levels], you’ll find that 8,147 are buying insurance today. If the district starts covering these people, some of them will stop buying,” Jones said.

If 1,000 people stopped buying insurance, and instead got a Care Card, it could up the increase in Hospital District expenditures to $2.3 million.

“It depends on your assumptions,” Jones said. “The data that blew my mind was that there are 150,000 people in this county, in round numbers, and 43.9 percent earn 250 percent or less of federal poverty guidelines.”

“It’s a true, true picture in this county that a lot of people don’t get,” said McCrystal.

Cleveland Clinic Indian River Hospital’s charity care policy is already in place and is a substantial expansion over the previous policy.

The hospital now provides free care, both emergency and medically necessary, for those making 250 percent of federal poverty guidelines, which amounts to $62,500 for a family of four.

And for those earning up to 400 percent of poverty guidelines, Cleveland Clinic Indian River provides discounts on a sliding scale. If a patient’s bill totals more than 15 percent of gross annual income, Cleveland Clinic will arrange for the bill to be discounted.

Cleveland Clinic taking over all indigent care costs at the hospital in 2022 is expected to save county taxpayers $195 million over the next 30 years, according to attorneys involved in the hospital changeover.