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This
article covers TEXAS Medicaid only, but your state may soon follow.
Overview:
Texas Medicaid plans to no longer pay providers if they will receive
a Medicare payment at least equal to the Medicaid Allowable Fee
Schedule.
Discussion:
Patients that have both Medicare and Medicaid are known as Dual
Eligibles. Normally Medicaid pays any Medicare deductibles and the
20% co-pay in such situations. Providers are reimbursed the Medicare
Allowable Fee Schedule for their services. However with the new
proposal Medicaid will not pay any charges above the Medicaid
Allowable Fee Schedule. A common scenario would be that the Medicare
allowable is greater than the Medicaid allowable and therefore would
not pay. This essentially equates to a 20% reduction in Medicare
reimbursements if the patient also has Medicaid. Providers are
specifically prohibited by federal law from attempting to collect
these unpaid charges from the patient. (Dialysis services are
excluded from these cuts)
See the
tab “In the News” for an understanding of how important
this cut may be to your financial health.
Multiply the (% of Dual Eligible patients) X (~20% reduction) to
compute the approximate % reduction in collections. If for example
your client’s patients are ~15% Dual Eligible, then (.15 X .20
= .0300) or a 3% reduction in collections is calculated. If your
profit margin as a billing company is 5%, then you may anticipate a
3% / 5% or 60% reduction in profit.
You may
visit the Texas Register, October 21, 2011, Volume 36 Number 42,
Pages 7045-7212 online at:
http://www.sos.state.tx.us/texreg/archive/October212011/PROPOSED/1.ADMINISTRATION.html#20
A copy
of the proposal is below.
RadPayor
Computer Assisted Management
PART
15. TEXAS HEALTH AND HUMAN SERVICES COMMISSION
CHAPTER 354. MEDICAID HEALTH SERVICES
The Texas Health and Human Services Commission (HHSC) proposes to amend
§354.1041, concerning Benefits for Medicare/Medicaid Recipients;
§354.1143, concerning Coordination of Title XIX with Parts A and
B of Title XVIII; and §354.1149, concerning Exclusions and
Limitations.
Background
and Justification
The Texas Medicaid program pays the coinsurance and deductibles for
Medicare services provided to certain individuals, referred to as
dual eligibles, who are eligible for both Medicare and Medicaid. The
purpose of the proposed rule amendments is to align Medicaid policies
on payment of cost sharing for Medicare Parts A and B services
provided to dual eligibles, pursuant to the 2012-2013 General
Appropriations Act (Article II, House Bill 1, 82nd Legislature,
Regular Session, 2011).
The proposed rule amendments limit payments for Medicare Part B services
provided to dual eligibles to no more than the Medicaid payment
amount for the same service, with the exception of renal dialysis
services. This is currently the policy for Medicare Part A hospital
services, but not for Medicare Part B physician and other outpatient
services.
If the Medicare payment amount equals or exceeds the Medicaid payment rate
for a Part B service, HHSC will not make a cost sharing payment under
the proposed rule amendments. If the Medicare payment amount is less
than the Medicaid payment rate, HHSC will pay the lesser of: (1) the
Medicare deductible/coinsurance amount; or (2) the difference between
the Medicaid and Medicare rates. For renal dialysis services, cost
sharing payments are reduced by five percent pursuant to House Bill
1, which phases in the policy for renal dialysis services.
This change also applies to services provided through Medicare Part C.
Texas makes monthly capitation payments to Medicare Advantage Plans
(MAPs) that contract with the state for Medicare Part C services. The
monthly capitation payment amount will be changed to $10 based on the
policy change for cost sharing for Part B services. For dual
eligibles enrolled in MAPs that do not contract with the state, cost
sharing payments are made on a fee-for-service basis.
The Medicaid state plan also will be updated to reflect these changes.
Section-by-Section Summary
HHSC proposes the following change to §354.1041:
Revise paragraph (1) to specify that the Medicaid payment provisions for
Medicare coinsurance and deductibles are described in §354.1143.
HHSC proposes the following changes to §354.1143:
Change the title of §354.1143 to "Coordination of Medicaid with
Medicare Parts A, B, and C" to clarify the subject of this rule.
Revise subsection (a)(1) by inserting "as specified in this section,"
and other edits to clarify that Medicaid payment provisions for
Medicare Parts A and B cost sharing obligations are specified in this
section.
Revise subsection (b) by inserting "Except as otherwise specified in
subsection (c) of this section" to indicate that the Medicaid
payment provisions in this subsection apply to Parts A, B, and C (for
Medicare health plans not contracted with HHSC), except as otherwise
provided in subsection (c).
Remove "Part A" from subsection (b)(1) and (2) to reflect that the
payment provisions for coinsurance and deductibles in these
subsections apply to Parts A, B, and C (for Medicare health plans not
contracted with HHSC).
Add new subsection (b)(3) to indicate that HHSC may phase in the policy
change for renal dialysis services.
Add new subsection (c) to indicate that for Part C Medicare Advantage
Plans that receive a capitated payment from HHSC for Medicare cost
sharing obligations, a health care provider may only seek payment for
a dual eligible's Medicare cost sharing from the plan.
Replace references to "the department" with "HHSC" and
update other language throughout the rule.
HHSC proposes the following change to §354.1149:
Revise subsection (a)(12) to specify that the Medicaid payment provisions
for Medicare coinsurance and deductibles are described in §354.1143.
Revise outdated references throughout the rule.
Fiscal Note
Greta Rymal, Deputy Executive Commissioner for Financial Services, has
determined that for each year of the first five years the amendments
are in effect, there will be a fiscal impact to state government. The
effect on state government for the first five years the amendments
are in effect is an estimated savings in general revenue of
($183,765,565) for state fiscal year (SFY) 2012, ($291,158,271) for
SFY 2013, ($301,330,074) for SFY 2014, ($310,744,041) for SFY 2015,
and ($320,670,309) for SFY 2016. There are no significant foreseeable
fiscal implications relating to costs or revenues of local
governments. There is no anticipated negative impact on local
employment that would affect a local economy.
Figure:
1 TAC Chapter 354 - Preamble
Small and Micro-Business Impact Analysis
Ms. Rymal has also determined that there may be an adverse economic
impact to small business or micro-business to comply with the
proposed amendments, as a result of the reduction in Medicare
coinsurance and deductible payments.
Under §2006.002 of the Government Code, a state agency proposing an
administrative rule that may have an adverse economic effect on small
businesses must prepare an economic impact statement and, generally,
a regulatory flexibility analysis. The economic impact statement
estimates the number of small businesses subject to the rule and
projects the economic impact of the rule on small businesses. The
regulatory flexibility analysis describes the alternative methods the
agency considered to achieve the purpose of the proposed rule while
minimizing adverse effects on small businesses. A regulatory
flexibility analysis is not required if the proposed rule is required
by a state or federal mandate, nor is it required if there are no
alternatives that are consistent with the health, safety, and
environmental and economic welfare of the state.
Since HHSC plans to limit Medicaid's liability for coinsurance and
deductibles for certain Medicare services provided to dual eligibles,
there will be an indirect impact on physicians and other outpatient
providers who provide services to dual eligible clients and bill
Medicaid for the associated coinsurance and deductibles.
It is estimated that approximately 88 percent of the providers that bill
Medicaid for Part B services to dual eligible clients could be
affected by these policies. The extent of the potential indirect
adverse economic impact on smaller practices, or the exact number of
practices that could be affected in future years, is difficult to
project from existing data. HHSC estimates that the policy change
could reduce Medicaid payments to physicians and other providers
statewide by about $442 million in state fiscal year 2012. The impact
of the reduction will vary by provider type.
The purpose of the proposed rule amendments is to comply with legislative
direction to reduce Medicaid expenditures for the economic welfare of
the state. HHSC has determined that, considering the purpose and
direction provided by the 82nd Texas Legislature and the statute
under which these rule amendments are proposed, it is not feasible to
reduce the effect on small businesses in a manner that is consistent
with the economic welfare of the state. HHSC has found that there are
no alternatives to the requirements imposed by the proposed amended
rules; therefore, a regulatory flexibility analysis is not required.
Public Benefit
Billy Millwee, Associate Commissioner for Medicaid and CHIP, has determined
that for each year of the first five years the proposed amendments
are in effect, the public will benefit from adoption of the
amendments. The anticipated public benefit is that HHSC will be in
compliance with state and federal law and that Medicaid will pay no
more than the Medicaid rate regardless of whether a service is
provided to a Medicaid-only client or to a client who is dually
eligible for Medicaid and Medicare. Federal
law prohibits providers from billing dual eligibles for cost sharing
amounts not paid by the Medicaid program.
Regulatory Analysis
HHSC
has determined that this proposal is not a "major environmental
rule" as defined by the Government Code, §2001.0225. A
"major environmental rule" is defined to mean a rule the
specific intent of which is to protect the environment or reduce
risks to human health from environmental exposure and that may
adversely affect in a material way the economy, a sector of the
economy, productivity, competition, jobs, the environment, or the
public health and safety of the state or a sector of the state. This
proposal is not specifically intended to protect the environment or
reduce risks to human health from environmental exposure.
Takings Impact Assessment
HHSC
has determined that this proposal does not restrict or limit an
owner's right to his or her property that would otherwise exist in
the absence of government action and, therefore, does not constitute
a taking under the Government Code, §2007.043.
Public Comment
Written comments on the proposal may be submitted to Stephanie Stephens,
Operations Coordinator, Medicaid/CHIP Division, Mail Code H100, Texas
Health and Human Services Commission, P.O. Box 85200, Austin, Texas
78708-5200; by fax to (512) 491-1977; or by e-mail at
stephanie.stephens@hhsc.state.tx.us within 30 days of the publication
of this proposal in the Texas Register.
Public Hearing
A public hearing is scheduled for November 4, 2011 from 2:00 p.m. to
3:30 p.m. (central time) in the John H. Winters Building, Public
Hearing Room, 125-E, located at 701 W. 51st Street, Austin, Texas.
Persons requiring further information, special assistance, or
accommodations should contact Leigh A. Van Kirk at (512) 491-2813.
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