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able in what we are trying to do. We are not talking about simple mismanage- ment. We’re talking about fraud.” Meanwhile, legislative action will be necessary to implement some of the congress’ reforms, including significant increases in physicians’ Medicaid pay- ments, restoring the dual-eligible pay- ment cuts, maintaining a single state- wide preferred drug formulary, and enhancing due process for physicians accused of fraud, waste, or abuse. On the latter, Senate Bill 8 by Sen. Jane Nelson (R-Flower Mound) essen- tially codifies the HHSC-approved fraud rules. TMA officials are working with the senator to ensure that due process pro- tections and other safeguards are includ- ed. Because billing varies by specialty, for example, TMA would like to see a fraud-review panel that includes physi- cians and that verifies fraud allegation before HHSC begins holding payments.


Not your mother’s Medicaid Expanding Medicaid coverage in any way also requires huge amounts of po- litical will, and momentum appears to be building.


Beginning in 2014, PPACA allows expansion of Medicaid coverage to poor adults with incomes up to 138 percent of the federal poverty level. That is about 2 million people in Texas. The federal government will pick up the full tab for the expansion population for the first three years, then gradually reduce its contributions to 90 percent by 2020 and thereafter. Texas receives 60-percent matching federal funds for the current Medicaid program.


Some Democrats support full expan- sion of the current Medicaid program as allowed under PPACA. The Legislative Budget Board (LBB)


in February recommended funding to ex- pand Medicaid in its spending priorities


under the Senate budget bill, Senate Bill 1. An earlier LBB proposal supported a bid by some urban counties to use their tax dollars to fund a local expansion, al- though the federal government has said it would endorse only a statewide plan. However, Governor Perry has repeat- edly said Texas will not expand Medicaid. In his State of the State address to the


legislature in January, the governor de- clared that “Texas will not drive millions more into an unsustainable system, and that stance has not changed an iota.” He and other Republicans are con-


Texas Medical Board appearance?


Pending


When Unhappy Patients, Ad Problems or Competitor Accusations lead to a Texas Medical Board investigation, ISC hearing or SOAH trial, your choice of attorney could make the difference in your future.


cerned about the federal government’s ability to shift the cost of an expansion population back to the states after the first few years. Physicians are equally concerned, giv- en earlier broken promises by the federal government to fix what they say is a bro- ken Medicare payment system. That on- going battle over the Sustainable Growth Rate formula has added another layer of uncertainty for physician practices and access to care. But some Republicans now say they would consider a solution that allows Texas to reform its program and use federal expansion funds as they see fit. HHSC Commissioner Janek says he, too, is exploring options with the Centers for Medicare & Medicaid Services. Dr. Holcomb notes that such flexibil-


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ity already exists under PPACA for states to devise an expansion that differs from traditional Medicaid coverage, which for the most part covers children, the dis- abled, and elderly who are poor. For example, the law authorizes the use of patient copayments and deduct- ibles on a sliding scale, an idea Com- missioner Janek says he would support. Texas also could develop a narrower benefit package tailored to the expan- sion population of low-income, childless adults. Lastly, if states choose, they can bail out at any time if conditions change. “We must look beyond the federal gov- ernment’s expansion solution to design one especially for Texas and for Texans,” Dr. Speer said in a column published in Texas Weekly, an influential Austin politi- cal newsletter. Rep. John Zerwas, MD (R-Simonton), who sits on the House Appropriations


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