Change in Texas Medicaid policy may affect some patients co-pays

By Joni Lovvorn • January 25th, 2012

A new state Medicaid policy could leave some elderly and low-income Texans without access to certain treatments, including crucial cancer medications, critics say.
Starting today, Medicaid will no longer cover the full co-payment of patients who also qualify for Medicare, a change that would affect 333,000 people known as “dual-eligible” clients.
The change is expected to save $1.1 billion over the remainder of the two-year budget cycle, about $475 million of which will be state funding, according to state health officials.
However, the Texas Medical Association and state Sen. Wendy Davis, D-Fort Worth, say the financial ramifications for physicians could force them to limit the number of dual-eligible patients they treat because the cost of service would not be adequately covered.
In particular, providers who treat cancer patients with chemotherapy medications have raised concerns that the change could make it “difficult to impossible” for patients to receive their medications, Davis wrote in a letter last week to the Texas Health and Human Services Commission.
“I would like to know how the Heath and Human Services Commission evaluated the anticipated impact of these reimbursement cuts,” she wrote.
Stephanie Goodman, a health and human services spokeswoman, said in an e-mail response to the Star-Telegram that the state is looking into Davis’ concerns and has asked the state medical association to help identify doctors or specialists disproportionately affected.
The process will reveal whether “we need to make any changes or exempt certain kinds of providers or services from the new policy,” she said

Dual eligibility
Dual-eligible clients generally qualify for Medicare because of their age and for Medicaid because of their income. More than half of dual-eligible patients live on incomes of less than $10,000 per year. Half also have multiple health conditions, such as diabetes and congestive heart failure, according to the Kaiser Family Foundation.
“If you are dual-eligible, you essentially have no income and no assets,” said Dr. Bruce Malone, president of the Texas Medical Association.
These patients usually require more physician time because of the need to coordinate visits with specialists and ancillary services, he said.
The change arose from an effort during the state legislative session to reduce Medicaid costs without reducing the level of service, Goodman said. For most dual-eligible clients, Medicare pays for services first and Medicaid covers what is left, including premiums and co-pays.
Under current policy, Medicaid covers the full co-pay for a service even if the Medicare rate is higher than what Medicaid would have paid for the same service, she said. Under the new policy, Medicaid will only cover the co-pay up to the Medicaid rate.
An example: Under the current policy, if a client receives a service for which the Medicare rate is $100, then Medicare pays the provider $80 and Medicaid pays the remaining $20, she said. Under the new policy, if the Medicaid rate for the same service is $90, Medicaid would only pay $10 toward the co-pay.
Seventeen other states already have similar co-pay limits on dual-eligible clients, she said. Texas lawmakers, grappling with a $27 billion budget deficit, directed the commission to change Texas’ policy, too.

‘Sickest and frailest’
In testimony before the health commission in November, Malone acknowledged the difficult budget situation that lawmakers faced, but he cited a 2003 study that found that dual-eligible clients were less likely to receive outpatient care after such policy changes.
Medicare payments are already insufficient to cover the rising cost of services, he said.
A medical association 2011 physician survey on Medicare participation found that 25 percent of those who responded limit the number of new Medicare patients they accept, and 8 percent accept no new Medicare patients.
“The proposed rules penalize physicians who care for the sickest and frailest Medicare patients,” Malone said.

Source: Alex Branch, Read more here:


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