State Now Paying Dual-Eligibles’ Medicare Deductible

The Texas Health and Human Services Commission (HHSC) restored the Medicare Part B deductible payment on Jan. 25 for patients eligible for both Medicare and Medicaid, also known as "dual eligibles."

From Jan. 25 on, the Texas Medicaid & Healthcare Partnership (TMHP), the Medicaid fee-for-service claims payer, is paying the full deductible amount owed. TMHP will automatically process claims filed before Jan. 25 back to Jan. 1.

TMHP has not announced when claims reprocessing will begin, but will publish the schedule on its website when known. If the patient is enrolled in a Medicare Advantage plan contracted with the state to pay dual-eligible patients' cost-sharing, the plan will restore payment of the deductible.

In 2011, the legislature ordered HHSC to cut dual-eligible payments to save money. The two-part reduction eliminated Medicaid's full payment of the annual deductible, which totals $147 in 2013, and stopped payment of dual-eligible patients' coinsurance if the Medicare payment for a service exceeded the Medicaid allowable, which is almost always the case for physician services. Together, the new policy resulted in more than a 20-percent payment reduction for physicians who care for those patients.

The restoration of the deductible comes none too soon. For the past year, the cut has wreaked financial havoc on physicians who care for this population, forcing a growing number of them to lay off staff, curtail services, or take out personal loans rather than stop seeing those patients. Unfortunately, many have been forced to limit the number of dual-eligible patients they will accept or even drop out of Medicaid. Physicians hardest hit were those who see large percentages of dual-eligible patients, many of whom are the poorest and sickest in Texas.

The Texas Medical Association organized rallies and met with state leaders asking for their help to restore the payments. A top priority for TMA during the 2013 legislative session is to restore the coinsurance payments.


Action, Feb. 1, 2013


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    Please include in your legislative arguments for dual-eligible patients that the "Managed Care Organizations" are keeping the majority of state funds for profit given that the money they are receiving for "Managed Care" of these patients is not being used to pay Doctors for the 20% co-insurance component which has to be adjusted and written off as a loss for practices. Yet they want Doctors to sign their "Long Term Services - Star Plus Waiver Program (SPW)" forms to provide patients with services in their homes. These services include Personal Care, Nursing Care, Medical Equipment, Installation of Ramps, etc. This does not make sense, Doctors carry the liability for home health, DME equipment, etc. without payment for the "Dual Eligible" population. If the money these organizations receive per patient is not being used for Doctors, then their profit margins will continue to increase. So who benefits in the end?

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