Summer 2016

Rural Texas Physician is a quarterly electronic newsletter catering to physicians in the many rural areas of Texas caring for patients and their communities. TMA’s grassroots membership is the strength of the association. For general inquiries or newsletter comments, email

 Medicaid Reenrollment Application Deadline Has Passed. Have You Reenrolled?

The June 17 intermediate submission deadline for Medicaid reenrollment has passed. If you participate in the Medicaid program and haven’t submitted your application, please do so immediately. The Texas Health and Human Services Commission will process applications submitted after June 17 but can’t guarantee those applications will be finalized by the federal deadline of Sept. 24, which could result in these applicants’ disenrollment from Texas Medicaid and denial of payment. 

The reenrollment requirement applies to you if you participate in Medicaid managed care, traditional fee-for-service Medicaid (each active Texas Provider Identifier suffix), the Texas Vendor Drug Program, and long-term care services administered through the Texas Department of Aging and Disability Services. 

More Information
For acute care physicians reenrolling through the Texas Medicaid and Healthcare Partnership:  

If you need help, contact a TMHP provider enrollment representative at (800) 925-9126, option 3, or email

For ordering- and referring-only physicians: If your only relationship with Texas Medicaid involves ordering or referring services for Medicaid clients, you also must enroll with Texas Medicaid as a participating physician.  

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 TMA Calls for Major MACRA Revisions

The Sustainable Growth Rate (SGR) formula is history, and the federal rulemaking process is under way for provisions in the Medicare Care Access and CHIP Reauthorization Act of 2015 (MACRA). In SGR’s place, MACRA requires physicians to choose between two major payment tracks beginning in 2019: the Merit-Based Incentive Payment System (MIPS) and eligible alternative payment models (APMs). 

A TMA staff team spent nearly two months studying the Centers for Medicare & Medicaid Services’ (CMS’) draft rule to implement MACRA. TMA leaders say the draft would create a system that’s far too costly and complicated for physicians to use, especially physicians in small and rural practices. It brings no real promise of improved patient care, and it’s not what Congress ordered. TMA submitted a formal comment letter with 50 recommendations to rewrite key portions of the rule. 

The most critical of TMA’s 50 recommendations are these three:  

  • Significantly Expand the Low-Volume Threshold: According to TMA analysis, physicians who bill less than $250,000 in Medicare charges will spend more trying to comply with the MACRA rule than they could ever earn in bonuses — if they hit the hidden quality targets. CMS set the threshold at a paltry $10,000 in Medicare allowed charges. TMA told CMS to set the low-volume threshold at $250,000. That would exempt physicians who have no possibility of a positive return on their investment in the cost of reporting. For physicians with less than $250,000 of Medicare revenue, reporting should be optional, and physicians who attempt compliance should be exempt from any payment penalties.
  • Delay the Start: The rule will be finalized around Nov. 1. Practices will have to begin collecting data and making big changes in their operations on Jan. 1. TMA is extremely concerned that physicians, support staff, and electronic health record vendors won’t be ready. TMA told CMS the measurement period for 2017 should be reduced to six months and start no sooner than July 1. (Remember, the data collected in 2017 affect physicians’ Medicare payments in 2019.)
  • Set the Performance Threshold Low: The “performance threshold” is the most important factor affecting MACRA’s overall impact on small practices. CMS has complete discretion to set the performance threshold, which is the score a physician must earn to avoid penalties. The threshold also will determine how much MACRA will shift Medicare payments from smaller physician practices to larger groups and health care systems. To reduce the negative impact on small practices, TMA urged CMS to set the performance threshold at 15 percent in the first year of implementation.  

Turn to TMA’s new MACRA Resource Center for the latest information about Medicare payment reform and the new payment tracks that are coming soon. 

The resource center informs you about MACRA and connects you to TMA advocacy, education offerings, and tools to help you prepare for the upcoming transition to MIPS and APMs. Over time, and as TMA learns more about the new regulations governing MACRA implementation, the association will update the resource center to keep you up to date on everything you need to know about how physician payment reform will affect your practice, influence care delivery, and affect your bottom line. 

Visit the new TMA MACRA Resource Center to learn the basics, compare the two payment tracks, explore continuing medical education opportunities, connect to services, and more. 

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 TMA Asks HHSC to Request More Medicaid, Public Health Funds

It’s that time in the state’s two-year budget cycle when state agencies prepare funding requests for the Texas Legislature to consider in next year’s session. No agency’s budget is more important to physicians than that of the Texas Health and Human Services Commission (HHSC), whose massive portfolio includes the state’s Medicaid, public health, mental health, and women’s health programs.  

In an official letter to HHSC leadership, TMA and state specialty societies representing family physicians, pediatricians, and obstetrician-gynecologists laid out physicians’ funding priorities for the 2018-19 state budget. Competitive physician payments in Medicaid and reversal of the steep funding cuts for dual-eligible patients topped TMA’s list of recommendations.  

TMA also called for better funding for women’s preventive, primary, and behavioral health care; mental health and substance abuse services; local and state infectious disease surveillance; vaccination and antitobacco programs; and early childhood programs for children with developmental or physical disabilities. 

Since submission of comments on the 2018-19 state budget, Gov. Gregg Abbott, Lt. Gov. Dan Patrick, and House Speaker Joe Straus instructed state agencies to identify ways to cut spending by 4 percent compared with the current budget, exempting only a handful of programs, including Child Protective Services and mental health, from the directive. 

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CMS Extends Texas’ 1115 Medicaid Waiver by 15 Months

The Texas Health and Human Services Commission (HHSC) has reached an agreement with the federal Centers for Medicare & Medicaid Services (CMS) on a 15-month extension of the state’s 1115 Medicaid waiver. The waiver funds uncompensated care and the Delivery System Reform Incentive Payment Program (DSRIP) through December 2017 and will maintain its current funding. While physicians applaud the move, they say it doesn’t alleviate their concerns about a long-term solution to sustain funding for uncompensated care.

HHSC says it will work with CMS over the next 15 months to negotiate a longer-term extension. 

John Holcomb, MD, chair of the TMA Select Committee on Medicaid, CHIP, and the Uninsured, said in a statement the “extension is critical to Texas’ health care safety net” and “will allow the state of Texas to maintain uncompensated care pools for safety-net hospitals and providers and fund innovative projects to improve availability and quality of services to Medicaid and uninsured Texans.

He added that the extension of federal money, combined with local funds, totals $3.1 billion for 12 months for uncompensated care and another $3.1 billion to continue innovative projects to improve care delivery. There also will be an additional estimated prorated amount of $1.55 billion for the remaining three months of the extension. In total, the continuation of the funding will provide $7.75 billion dollars for uncompensated care and DSRIP. The waiver extension also allows Texas to continue the managed care model.  

“However, given CMS’ prior statements indicating enhancing access to care is a better long-term solution to reducing uncompensated care costs, Texas physicians are concerned about the enduring stability of the health care safety net without a long-term agreement in place to sustain it. This is just one step: We strongly encourage the Texas Legislature to devise a strategy to develop long-term direction that focuses on appropriate payments and use of health care resources on the front end rather than the back of the health care system,” Dr. Holcomb said. He added he’s hopeful the extension “will lay the groundwork for future expansion of access to care for Texans.”

DSRIP consists of local programs working to improve health care delivery costs and outcomes. 

There are 1,451 DSRIP projects across 20 regions in the state. In each region, a coalition of governments, hospitals, and health professionals develops novel solutions for containing health care costs while preserving access and quality. HHSC says most projects focus on increasing primary and preventive care. The waiver program also helps hospitals with uncompensated care costs. 

For more information about the 1115 Medicaid waiver, read “1115 Medicaid Waiver Up for Renewal” in the October 2015 issue of Texas Medicine

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 Use These Medicaid Tools to Help Get Paid More Efficiently

Medicaid’s new e-signature capability and its portal for verifying patients’ Medicaid eligibility and accessing their available health information are two ways to help cut down on the busywork in your office. 

As of April 1, 2016, Texas Medicaid Healthcare Partnership (TMHP), the administrator for Texas Medicaid and the Children with Special Health Care Needs Services Program, accepts electronic or digital physician signatures on prior authorization forms and supporting documentation.  

The signature must be derived using software that creates a digital signature logo with a system-generated date and time stamp or includes the logo of the digital software used. Examples of such software are RightSignatureTM, Adobe® eSign, and electronic health record software; there are others. (Neither TMA nor TMHP endorse any particular e-signature software.) 

TMHP won’t accept a handwritten, electronic, or digital signature if it is among other disallowed forms: a photocopy of a handwritten signature, an ink stamp of a handwritten signature, or a typed signature without a digital stamp. 

For transactions processed by a Medicaid/Children’s Health Insurance Program (CHIP) managed care organization (MCO), refer to the MCO for information about prior authorization.  

Dual Portal is a dual portal for verifying patients’ Medicaid eligibility and accessing their available health information. On one portal, Medicaid physicians and your staff can view information on a patient’s Medicaid eligibility, services, and treatments. On the second portal, patients can view their benefit and case information, print or order a Medicaid ID card, set up and view their Texas Health Steps alerts, and more. 

You and your staff can view such information as vaccination information, prescription drugs, past Medicaid visits, diagnoses and treatments, lab data, and Texas Health Steps alerts. In addition, the portal provides access to the Blue Button functionality to request a Medicaid patient’s available health information in a single tool.  

Follow the instructions contained in the Initial Registration Guide for Medicaid Providers to get started. To set up an account, you’ll need to have handy the following numbers: billing National Provider Identifier, billing taxonomy number, billing tax ID, and an internal claim number or encounter number. For more information, you can download the Welcome Packet from the initial Login page of

Visit TMA’s Medicaid and CHIP resource center for information and resources related to these programs. And, visit the TMA Education Center for a free webinar from Texas Health Steps, New Initiatives for Medicaid Providers. TMA provides many such benefits and services designed to help you get paid

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 Download Release Forms for New Mexico Patients to Sign

The passage of House Bill 270 by the New Mexico Legislature allows Texas physicians to obtain a signed agreement from New Mexico patients stating that should they wish to file a lawsuit they will do so in Texas court. To assist physicians in taking advantage of the law’s protections, the Texas Alliance for Patient Access (TAPA) has developed two forms, one for emergency treatment and one for voluntary treatment. You can download the emergency treatment and voluntary treatment forms (both English and bilingual) from the TMA website.  

In consultation with an attorney, TMA suggests physicians who treat New Mexico patients or patients living in other states consider adopting this language in the practice forms patients sign.  

HB 270, which TMA and TAPA supported, took effect on July 1. Learn more about the bill and the legal battle that threatens Texas physicians’ liability protections when treating patients from New Mexico in the June issue of Texas Medicine

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Plan a Helmet Giveaway During Hard Hats Month

As you dream about the cooler days of fall, start thinking about a bike helmet giveaway during October to celebrate TMA’s annual Hard Hats for Little Heads month. Your event can urge kids to “Get moving. Stay safe. Wear a helmet.” And it can help TMA cover all 254 of Texas’ counties

Physicians and residents, medical students, county medical societies, and TMA Alliance chapters can host events. Look for a fall festival or National Night Out event with which to pair a helmet giveaway, or check out these ideas for events to come up with another idea for your giveaway. 

TMA provides everything you need for a successful event: free helmets, banners, event signage, promotional flyers, educational handouts, and media relations support. When you purchase up to 50 helmets, TMA will match your purchase with free helmets. Helmets are $7.60 each, including shipping. Be sure to order your helmets and other supplies at least a month in advance.

Additionally, the Texas Academy of Family Physicians (TAFP) and the Texas Pediatric Society, the Texas Chapter of the American Academy of Pediatrics (TPS) offer their members a unique benefit. TAFP and TPS will cover the cost of up to 25 helmets for their members, and TMA matches that. So family physicians and pediatricians can get up to 50 helmets at no cost. And you can buy more helmets at TMA’s low price. 

To request an order packet, contact Tammy Wishard, TMA’s outreach coordinator, or call (512) 370-1470.  

Hard Hats for Little Heads is supported in 2016 through a TMA Foundation grant thanks to top donors — Blue Cross and Blue Shield of Texas, an anonymous physician and spouse, TMAF Make-A-Difference donors, and the Baptist Health Foundation of San Antonio — and generous gifts from TMA and TMA Alliance members, and friends of medicine. 

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