Dual Eligible Payments to Be Partially Restored in 2013

Dr. Javier Saenz has struggled to keep his South Texas clinic open in the wake of legislative cuts to physicians treating patients eligible for both Medicare and Medicaid.
Dr. Javier Saenz has struggled to keep his South Texas clinic open in the wake of legislative cuts to physicians treating patients eligible for both Medicare and Medicaid.

Health care providers in Texas who treat dual eligible patients — those who qualify for both Medicare and Medicaid benefits — will get some relief in 2013. 

This week, state Sen. Juan “Chuy” Hinojosa, D-McAllen, took physicians and hospital officials from the Rio Grande Valley to meet with state leaders in Austin, with the goal of getting state health leaders to restore full payment of dual eligible patients' $140 Medicare deductible.

The delegation came away with an agreement to reinstate the deductible starting Jan. 1, 2013, state officials confirmed.

Elderly poor account for most of Texas' dual eligible patients — those old enough to qualify for Medicare, the federal insurance program, and economically disadvantaged enough to receive state help through Medicaid.

While Medicare acts as the primary health insurer for these patients, paying 80 percent of their bill, it won’t pay out until the $140 deductible is met. When the state stopped paying the deductible on Jan. 1 of this year — an effort to cut costs — doctors took the hit because the majority of their patients didn’t have the money to satisfy the deductible. Without a satisfied deductible, physicians lost out; they were only being reimbursed by Medicaid, which has lower reimbursement rates than Medicare.

Health care providers in the Rio Grande Valley and in South Texas have been disproportionally impacted. In some cases, more than 60 percent of their patient load is dual eligible.

Dr. Carlos Cardenas, a gastroenterologist in Edinburg and vice chairman of the Texas Medical Association's board of trustees, is among those doctors who made the trip to Austin to meet with Lt. Gov. David Dewhurst and House Speaker Joe Straus on Wednesday.

“They were very receptive and showed a willingness to help us work with the situation and certainly I think the result of the meeting was certainly a step in the right direction,” Cardenas said.

For Texas physicians treating dual eligible patients, the deductible cuts of the last session were just part of the problem. In 2011, lawmakers also directed the Health and Human Services Commission to stop paying Medicare coinsurance, which has traditionally made up the difference for doctors when federal Medicare reimbursement rates exceeded state Medicaid rates. 

Several providers in the Valley have been close to shutting down their practice as a result. Dr. Javier Saenz, a family physician in La Joya, has taken several loans out over the past year to continue to pay staff and keep his doors open.

Texas Medical Association President Michael Speer called this week’s development a great first step.

“The agreement reached needs to go into effect immediately," Speer said. "Every day counts. We now urge lawmakers to eliminate the rest of this cut as soon as possible.”

Hinojosa’s legislative staffers say having the coinsurance payment reinstated will be a bigger hurdle in the upcoming legislative session.

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