TMA Opposes Dual Eligible Cuts

Eliminating payments for Medicare Part B coinsurance and deductibles to those eligible for both Medicaid and Medicare will save the state millions but it will "come at the expense of the health and well-being of some of the state's most vulnerable citizens," TMA President C. Bruce Malone, MD, told the Texas Health and Human Services Commission (HHSC) earlier this month.

Testifying at an HHSC hearing, Dr. Malone said the plan "not counting the deductible changes, would result in a 20-percent payment cut for physicians who care for these patients" and fuel physicians' exodus from both Medicare and Medicaid.”

The Texas Legislature directed HHSC to implement the change to reduce Medicaid costs. The rules, scheduled to take effect on Jan. 1, 2012, will eliminate payment of Medicare Part B coinsurance if the payment would result in Medicaid paying more than its allowable. If Medicaid pays more than Medicare, then the state would pay the coinsurance or up to the Medicaid allowable, whichever is less. HHSC previously implemented the same policy on Medicare Part A services.

Patients cannot be balance-billed.

Here are some examples. They are for illustration only. Medicare payments vary by region of the state.  

  • Example 1: Established dual-eligible patient has not met any of the Medicare deductible and is seen during a routine office visit. Physician bills Medicare CPT code 99213. Maximum Medicare allowable is $66.90 (rest of Texas). Medicare pays $0 because deductible has not been met. Medicaid will pay $33.27, the Medicaid allowable for this code. 
  • Example 2: Established dual-eligible patient has met $100 of $140 Medicare 2012 deductible. Patient is seen in office for routine office visit. Physician bills Medicare CPT code 99213. Medicare pays $21.52, which is 80 percent of the allowable after deductible.($66.90-$40). Medicaid will pay $11.75 ($33.27-$21.52).
  • Example 3: Established dual-eligible patient visits physician office for routine visit, Medicare deductible has been met. Physician bills Medicare CPT code 99213. Medicare allowable is $66.90. Medicare pays $53.52, 80 percent of the allowable. Physician bills Medicaid for the remaining 20 percent. Medicaid allowable is $33.27, so no coinsurance will be paid.  

Dr. Malone said the proposed rules "penalize the physicians who care for the sickest and frailest Medicare patients. They hit particularly hard practices in rural, inner-city, and border Texas, as those practices serve a disproportionate number of dually eligible Medicare patients. In addition to compromising the financial viability of these practices, we fear that the rules could result in fewer physicians willing to set up a practice in the communities that most need them."

He noted that TMA recognizes the need to reduce costs and is "a ready and willing partner with HHSC and the legislature to identify pragmatic solutions for reducing Medicaid costs," but said the proposal is "misguided." He urged HHSC to work with TMA "to identify other mechanisms to reduce Medicaid costs that will not jeopardize the ability of physicians to care for this population."

The proposed rules were published in the Oct. 21 Texas Register. Click on the link and scroll to page 7057.

HHSC will accept comments on the rules until Nov. 21. Email them to Stephanie Stephens, operations coordinator, Medicaid/CHIP Division; mail them to her at Mail Code H100, Texas Health and Human Services Commission, PO Box 85200, Austin, TX 78708-5200; or fax them to (512) 491-1977.

Action, Nov. 15, 2011

Last Updated On

February 03, 2012