Form 3086 is used by entities to provide information to Texas Health and Human Services Commission (HHSC) for:
- Total number of unduplicated clients served;
- Total expenditures for the state fiscal year for a county, public hospital or hospital district;
- Top five diagnoses of clients served; and
- Federal Poverty Guideline (FPG) percent the entity used to determine client eligibility.
When to Prepare
At the end of each state fiscal year (after August 31), entity completes and submits Form 3086 to the County Indigent Health Care Program (CIHCP) by September 30. Form 3086 must be submitted even if no expenditures were made for that state fiscal year.
The person completing Form 3086 faxes form to HHSC CIHCP at 512-776-7203. It is not necessary to mail completed Form 3086 once it has been faxed.
File the completed form for county records and maintain at least until the end of the third complete state fiscal year following the date on which Form 3086 is submitted.
Entity Name and State Fiscal Year – The person completing the form enters the entity name and state fiscal year.
Type of Entity You Represent – Check the box for County, Public Hospital or Hospital District.
I. Total Number of Unduplicated Clients Served – Enter the number. Do not count the same individual more than once.
How many of these clients are Supplemental Security Income (SSI) appellants? – Enter the number.
II. Total Expenditures – Enter the net total dollar amount spent in the state fiscal year (September 1 through August 31) regardless of the fiscal year in which the entity operates. Exclude the dollar amount spent on 1115 Waiver. Break the total expenditures down into the following categories:
- Physician Services
- Prescription Drugs
- Hospital Inpatient Services
- Hospital Outpatient Services
- Laboratory/X-ray Services
- Skilled Nursing Facility Services
- Family Planning Services
- Rural Health Clinic Services
- State Hospital Contracts
- Optional Health Care Services
III. Totals – Enter the amount of dollars spent if an intergovernmental transfer (IGT) was made to provide health care services as part of the Texas Healthcare Transformation and Quality Improvement Program waiver. Four percent of the General Revenue Tax Levy (GRTL) may be allowed toward eligibility for state assistance. Enter the totals for:
- Delivery System Reform Incentive Payment (DSRIP) Projects
- Uncompensated Care
- Expenditures for 1115 Waiver
IV. Diagnoses – Enter the top five most frequent diagnoses for the entity’s clients.
V. Federal Poverty Guideline Percent Used to Determine Eligibility – Enter the percent the entity used to determine eligibility, such as 21%, 25%, 50%, 100%, 150%, etc.
Signature of Person Submitting Form, Area Code and Phone No. and Date – The person submitting the form signs it, enters his or her area code and phone number and the date.