Untitled Texas Attorney General Opinion
GA-0983
Tex. Att'y Gen.Jul 2, 2013Background
- HHSC rule 354.1143 sets the methodology for paying Medicare Part B deductibles and coinsurance for Medicaid beneficiaries who are also Medicare-eligible ("dual eligibles").
- The rule provides that HHSC will not pay the Medicare deductible/coinsurance on a crossover claim when the Medicare payment equals or exceeds the Medicaid rate; when Medicare pays less, HHSC pays up to the lesser of the deductible/coinsurance or the Medicaid shortfall; an exception allows higher payments if needed for access or cost-effectiveness.
- Texas Human Resources Code § 32.050(c) mandates that Medicaid pay Medicare deductibles and coinsurance for ambulance services provided to dual eligibles.
- The Attorney General was asked whether HHSC’s rule 354.1143 impermissibly conflicts with § 32.050(c).
- HHSC amended the rule after a 2012–2013 Appropriations Act rider referencing cost-containment ("Medicare Equalization"), but the rider did not purport to change substantive law.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether HHSC rule 354.1143 may limit payment of Medicare deductible/coinsurance for ambulance services to dual eligibles contrary to Tex. Hum. Res. Code § 32.050(c) | Rule valid; cost-containment and rule language govern payments (HHSC relies on appropriations rider as context) | Statute mandates payment for ambulance services; agency cannot adopt a rule that conflicts with statute | The rule conflicts to the extent it limits HHSC’s statutory obligation; statute controls and the rule is impermissible in those respects |
Key Cases Cited
- Vista Healthcare, Inc. v. Tex. Mut. Ins. Co., 324 S.W.3d 264 (Tex. App.—Austin 2010) (agency rules are presumed valid)
- TGS-NOPEC Geophysical Co. v. Combs, 340 S.W.3d 432 (Tex. 2011) (courts give deference to agency rule interpretations unless plainly erroneous or inconsistent)
- State v. Pub. Util. Comm’n, 131 S.W.3d 314 (Tex. App.—Austin 2004) (agency may not adopt rules contrary to governing statutes)
- Strake v. Court of Appeals for First Supreme Judicial District, 704 S.W.2d 746 (Tex. 1986) (appropriations riders cannot amend substantive law)