Inter-Departmental Correspondence

County Counsel and Health System



October 17, 2008


October 28, 2008







Honorable Board of Supervisors


Charlene A. Silva, Interim Chief, Health System

Michael P. Murphy, County Counsel


Medically Indigent Policy Revisions



Adopt a Resolution accepting the proposed revisions to the County’s Healthcare for the Medically Indigent policy, in alignment with the County’s Welfare and Institutions Code Section 17000 responsibilities.



Commitment: Ensure basic health and safety for all

Goals 5: Residents have access to healthcare and preventative care.


This Resolution contributes to this commitment and goal by revising the aspects of the County’s Medically Indigent policy necessary to accomplish the dual goals of improved patient access and County financial position in the delivery of healthcare.



On March 25, 2008, your Board approved a twelve-month implementation plan for the Health System Redesign Initiative (Redesign). This plan was developed in follow-up to the in-depth assessment of the County’s role in healthcare delivery completed by Health Management Associates (HMA), accepted by your Board on February 5, 2008, and as the final planning phase recommendations of the Blue Ribbon Task Force on Adult Health Care Coverage Expansion (BRTF), approved by your Board on May 20, 2008. Responsibility for leadership of the County’s indigent care policy, which was previously held by the County Manager’s Office, was delegated to the Redesign leadership group, which includes the County Manager, and the senior executives leading San Mateo Medical Center, the Health Department and the Health Plan of San Mateo (HPSM).


The County’s Healthcare for the Medically Indigent policy was last revised in December 2005. San Mateo County fulfills its section 17000 responsibility through the Wellness, Education, Linkages, Low-Cost (WELL) program. The medically indigent policy outlines the specifics of the WELL program, including scope of services, eligibility requirements, and enrollment, appeals and waiver processes.



In follow-up to the WELL Indigent Care Pilot study led by the County Manager’s Office, and work on streamlining eligibility and administration, the Redesign group developed recommended policy changes for the medically indigent policy. The Redesign workgroup sought the feedback of the Legal Aid Society of San Mateo County as part of the process of developing these recommendations. The proposed changes promote improved alignment with the Medi-Cal program, unified administrative practices across the WELL program and the ACE program (which is the Blue Ribbon Task Force pilot effort funded by the State and Federal governments), and more cost-effective administration of the WELL program. As described in the Redesign Implementation Update submitted to your Board, these policy changes will be followed by recommended administrative changes that will be brought to your Board that place responsibility for unified coverage administration of indigent care programs within HPSM, as piloted within the ACE program.


As the Redesign effort, with the strong partnership with the Human Services Agency, targets maximal enrollment and retention of clients in Medi-Cal as a core strategy for health system financial sustainability, it has become clear that some of the WELL eligibility and enrollment practices could be improved. Specific policy changes that improve alignment with Medi-Cal include exempting a client’s primary residence (if they are a home-owner) from the calculation of asset-eligibility and implementing an estate recovery rather than a lien approach within bill collections practices. Other changes implement uniform policies across WELL and ACE.


The policy changes related to increased administrative effectiveness include, for example, a slight change in the annual enrollment fee (from $250 to $240) to ease pro-rating of billing and balance calculations and specific authority to conduct re-screening of eligibility at the time of an emergency room visit or hospitalization, to promote timely follow-up on areas of eligibility that promote financial sustainability. In addition, there are a few areas of further work to be completed for which we request the vesting of authority in the Health System Chief or her designee, to ensure appropriate alignment of financial and patient access goals.



There is no Net County Cost associated with adoption of this Resolution. The Redesign Initiative supports $6.65 million in expected cost savings and revenue enhancements included in the FY 2008-09 Adopted Budget for the San Mateo Medical Center which incorporates no increase in General Fund contribution.