Fighting the System: Appealing the $100 Medical Co-Pay in Texa$

The Texa$ Legislature cut $60 million from the Texas Department of Criminal Justice (TDCJ) budget for 2012 and raised the medical co-pay from $3 per visit to $100 per year. They had the unrealistic expectation of collecting up to $15 million from the prisoners [see Prison Legal News, Oct 2012 p. 42]. As all of us have noticed, the TDCJ also enacted other corner cutting measures to save pennies. These include: cutting back on legal books at the law library, reducing education and rehabilitation programs, serving two meals on the weekend and dessert once a week, restricting indigent correspondence to 5 letters a month, banning freeworld stationary (so you must buy it from the commissary), and reducing the number of staff. The idea was to reduce expenses that would help Texa$ manage its massive budget shortfall.

This guide is about appealing the $100 medical co-pay in Texa$. It presents all the Co-Pay Exemptions that can be used to get your money back. We want to keep our very limited funds out of the hands of the TDCJ so that we can use it for more important purposes. Specifically, you are encouraged to spend any money you recover on educating and organizing others. Send a donation to Under Lock & Key to expand the pages in this valuable resource, create study groups and make copies of literature to study, copy and distribute grievance petitions to fight the corrupt grievance process and to end the limit on indigent correspondence, or buy stamps and envelopes for indigent prisoners who can’t buy for themselves. There are a lot of things we need to be doing with our limited funds, so we fight to keep this money from being appropriated by the state.

How Do We Appeal The Medical Co-pay?

It is rather simple. Get a Step One Grievance (I-127) and explain on it why you are exempt. If your Step One is denied, follow through with the same argument in a Step Two (I-128). You will be surprised at how often the Appeal is granted. The issue is that most medical departments systematically charge everyone the co-pay out of hope you are ignorant about the exemptions and fail to appeal it. They get away with this because there is no confirmation necessary for them to charge you (compared to commissary purchases, receiving legal mail, sending indigent correspondence - all need your confirmation - but not the medical co-pay). Here is a brief example: Co-pay is not to be assessed for any prisoner receiving a clipper shave pass as they have been diagnosed with a chronic and permanent dermatologic condition - “pseudofolliculitis barbae.” Diabetic prisoners who receive foot care, specifically toe nail trimming, as part of their chronic care treatment plan are not to be assessed a co-pay fee either.

The medical co-pay regulation can be found at Texas Government Code 501-063. The Administrative Director for it in TDCJ is AD 06-08. In relevant part, the Co-payment Determinations and Exemptions are found in Section III.

Here are the Exemptions:

1. Unless specifically exempted, offender-initiated visits shall be subject to a copayment (meaning that if you do not initiate the visit, i.e. work related or officer initiates it, then you are exempt).

2. A copayment shall NOT be charged if the health care service is the result of an emergency which includes, but is not limited to, injuries sustained as a result of an accident or assault. Such injuries shall be covered by the emergency visit exemption.

3. Copay shall NOT be charged if the health care services are related to the diagnosis or treatment of a communicable disease. Such services, including follow-up visits and testing, are exempt as either a chronic care visit or a department-initiated visit. Offenders shall not be charged for initiating communicable disease testing.

4. Initial requests for mental health reviews initiated by the offender are NOT subject to the copayment requirement. Emergency, follow-up, or chronic care requests for mental health reviews shall NOT be charged a copayment.

5. Follow-up visit related to the monitoring or treatment of a condition diagnosed in a previous visit with a health care provider are exempt from copayment charges.

6. Prenatal services, including the initial visit diagnosing pregnancy, subsequent examinations, testing, counseling and patient education services are specifically exempted from copayment requirements.

7. Physical or mental health screening, laboratory work, referrals and follow-up appointments provided or recommended as part of the initial intake diagnostic and reception process are exempt from the copayment requirement.

8. A health screening upon arrival at a new unit of assignment shall be considered a visit to a health care provider initiated by a health care provider and is exempt from the copayment requirement.

1. Prescriptions and medications are considered to be a result of a medical visit and follow-up procedures and are exempt from the copayment charge. No charge shall be assessed for accessing approved over-the-counter medications made available in the offender housing area.

10. A copayment applies to a single visit. An offender requesting a visit to a health care provider for multiple symptoms shall be charged only one copayment if the symptoms are addressed in the same visit. If a request for a visit with a health care provider results in scheduling of appointments with more than one provider, such as a dentist and a physician, the initial visit with each clinician is subject to the copayment requirement.

11. If an offender is being seen by a provider for services otherwise exempted from the copayment and during the course of the visit requests healthcare services related to a different condition then that being served, the additional request shall be treated as an initial offender-initiated visit, shall be documented in accordance with the walk in procedures, and are subject to the copayment requirement.

12. A copayment shall NOT be assessed for medical treatment of self-inflicted injuries. Offenders inflicting injuries on themselves shall be referred to mental health evaluations.

13. Offenders shall NOT be charged for “No-Shows” because a visit did not occur. The copayment requirement only applies if the offender is seen by a health care provider. “No-Shows” shall be documented in accordance with CMHC procedures.

14. Dental services are considered health care services and subject to the copayment requirements if the services are initiated by the offender. Exemptions from copayment requirements for emergencies, chronic care, follow-up, health screening and evaluations, and department initiated visits are to be applied in the same manner as for other health care services.

15. Physical evaluations following use of force incidents are required by TDCJ policy and are not subject to the copayment requirement.

16. Inpatient services are considered follow-up services and are not subject to the copayment requirement. These services include, but are not limited to, hospitalization, extended care nursing, hospice and unit infirmary inpatient care.

17. Procedures or testing ordered by a Court or performed pursuant to state law are exempt from the copayment requirement.

18. Services provided under contractual obligation established pursuant to the Interstate Corrections Compact or under an agreement with another state that precludes the assessment of a copayment shall be exempt from the requirement to charge.

Each One, Teach One

Share this guide with those who need it. If you are a good grievance writer, then help those who may not feel as confident. And be sure to encourage everyone to make good use of the money they win through these grievances. It is not enough to just keep $100 out of the hands of the TDCJ. If that money is spent on unnecessary canteen purchases or on drugs or services that are bad for your health and/or a waste of money, you haven’t actually accomplished anything. Spend this money on meaningful work to fight the criminal injustice system. Even a small donation can help with the education of others and the expansion of our work, and $100 can do a lot! Get in touch with MIM(Prisons) to make a donation or for more information about educating and organizing in Texas prisons and beyond.