tribal health steering committee for the phoenix area indian health service patient protection and affordable care act (aca) & indian healt

Tribal Health Steering Committee for the Phoenix Area Indian Health
Service
Patient Protection and Affordable Care Act (ACA) & Indian Health Care
Improvement Reauthorization and Extension Act (IHCIA)
Update
H.R. 3590, the Patient Protection and Affordable Care Act (ACA), was
signed into law by President Obama on March 23, 2010 as Public Law
(P.L.) 111-148. It included the permanent reauthorization of the
Indian Health Care Improvement Act, specifically S. 1790, that had
passed the U.S. Senate on December 24, 2009. A reconciliation measure,
H.R. 4872, Health Care and Education Reconciliation Act of 2010 (P.L.
111-152), was also adopted and signed into law on March 30, 2010. This
additional measure amended some of the health-related financing and
revenue provisions in the Affordable Care Act. The permanent
reauthorization of the Indian Health Care Improvement Act (IHCIA) was
included in Section 10221 of the Affordable Care Act.
The Affordable Care Act, as passed and amended, initiated major
reforms to the private health care insurance industry by enacting
increased consumer protections such as barring insurance companies
from discriminating based on pre-existing medical conditions, health
status, and or gender. It also established Health Insurance Exchanges
where individuals and small businesses can obtain affordable health
care coverage. The national expansion of Medicaid eligibility up to
133% of the Federal Poverty Level (FPL) also expands coverage to
include childless adults. Emphasis in both the private and public
sector is on prevention programs and primary care services. There are
numerous provisions in the ACA in which the participation of American
Indians as individuals, Tribes and Tribal organizations are included.
Affordable Care Act/IHCIA Implementation
The Office of National Health Care (ONHC) has published both proposed
and interim regulations in the Federal Register for public comment.
Regulations and specific agency ACA implementation began in 2010 and
will continue thru 2014. The extensive implementation involves the
Center for Consumer Information and Insurance Oversight (CCIIO) which
is charged to develop and enforce standards for health insurance
practices so that affordable and quality coverage will be available.
The agencies in the U.S. Department of Health and Human Services
(HHS), notably the Center for Medicare and Medicaid Services (CMS),
the HHS Regional offices, including the Indian Health Service are
extensively involved. Websites have been established by the
Administration so that individuals may access information on the
implementation of the ACA:
http://www.whitehouse.gov/issues/health-care/
http://www.healthcare.gov/
http://www.hhs.gov/ociio/index.html
Some agency specific information can be obtained by linking on the
following:
http://www.ihs.gov/PublicAffairs/DirCorner/index.cfm
http://www.cms.gov/Center/healthreform.asp
American Indian resources include:
http://www.tribalhealthcare.org/
http://www.nihb.org/
Through the dissemination of “Dear Tribal Leader Letters” by HHS, the
agency has been seeking input from the Tribes on interim policy
guidance and regulations. Yvette Roubideaux M.D., Director of the
Indian Health Service, has reported on IHCIA implementation at
national conferences, regional listening sessions and through the
transmission of correspondence to Tribal Leaders. IHS sent
correspondence to Tribal Leaders on, 5/12/10, 7/22/10, 10/5/10,
12/7/10 and 5/5/11 to provide updates on IHCIA implementation. Other
correspondence sent to Tribal Leaders by HHS covered various aspects
of the ACA and the IHCIA that involves Tribes. They include the
following:
Part II—Consumer Choices and Insurance Competition through Health
Benefit Exchanges,
Section 1311. Affordable choices of health benefit plans – “Dear
Tribal Leader Letters” were sent out on 10/4/10 and 11/12/10 from Jay
Angoff, Director, Office for Consumer Information and Insurance
Oversight, to initiate tribal consultation. The letters were co-signed
by Dr. Roubideaux. Comment was requested on the general planning and
establishment of state based Health Insurance Exchanges in the first
letter and the second letter discussed the standards the Exchanges
should be required to meet and on the Indian specific provisions in
the ACA such as cost sharing protections and exemption from the
mandatory health insurance enrollment. Once the proposed guidance and
request for comments was published in the Federal Register, the CMS
Tribal Technical Advisory Group (TTAG) proposed an Indian Health
Addendum be required in Exchange plan network provider contracts to
facilitate participation by programs operated by the IHS,
Tribes/Tribal organizations and urban Indian health programs.
Section 9021: Exclusion of health benefits provided by Indian tribal
governments – The Internal Revenue Service (IRS) issued a Frequently
Asked Questions (FAQ) document outlining the addition of Section 139D
to the Internal Revenue Code on 2/15/11. This provision is retroactive
to 3/23/10. It provides that gross income does not include the value
of any qualified Indian health care benefit provided by the IHS, a
Tribe or tribal organization to a member of a Federally recognized
Tribe. It also does not include the value of an accident or health
insurance plan or any medical care provided to a tribal member, spouse
or dependent.
Section 409, Access to Federal Health Insurance – A Dear Tribal Leader
Letter was first sent to the Tribes on 10/5/10 to initiate tribal
consultation by John Berry, Director of the Office of Personal
Management and Yvette Roubideaux, M.D., Director, Indian Health
Service. The provision authorizes Tribes operating programs under
ISDEAA or an urban Indian organization under Title V. of the IHCIA to
purchase coverage under the Federal Employees Health Benefits (FEHB)
program and the Federal Employees Group Life Insurance (FEGLI) for
their employees. An update on the tribal consultative process and
notification of the establishment of a tribal federal work group was
mailed to tribal leaders and urban Indian programs on 5/2/11.
Section 405, Sharing Arrangements with Federal Agencies and Section
407, Eligible Indian Veteran Service - The Department of Veteran
Affairs (VA) and the Indian Health Service Dear Tribal Leader Letter
of 11/12/10 provided Tribes the updated VA-IHS Memorandum of
Understanding. The MOU requires the organizations to establish a task
force to set priorities for action. Among these is that the VA is
required to pay for the services provided through IHS programs to
AI/ANs who are eligible for VA or DoD services. NIHB submitted comment
to the IHS on 5/25/11 stating that to date; a mechanism to conduct the
billing has not yet been established. This was a follow up to NIHB’s
previously submitted comments on this subject expressing a need for
urgency in moving forward with implementation.
Section 121, Indian Health Care Improvement Fund (IHCIF) – Amendments
to this section of the law prompted tribal consultation to improve the
IHCIF formula to determine the overall level of need funded for
federal or tribal facilities. Dr. Roubideaux released a “Dear Tribal
Leader Letter” on 12/30/10. IHS requested comments on whether or not
the formula should be updated now, the types of technical improvements
that are needed and if factors used in the formula should be adjusted.
Section 214, Tribal Epidemiology Centers (TECs) - Dr. Roubideaux
informed tribal leaders on 1/24/11 that as a result of the designation
of TECs as public health authorities in order to access IHS patient
data for public health surveillance and community health status
reporting the agency had developed a draft Data Sharing Contract (DSC)
as a template for agreements between TECs and the IHS that outlines
the process to access regional or Area data and also protect patient
privacy rights. Comment was requested on the draft DSC prior to final
implementation.
ACA/IHCIA Medicare & Medicaid Provisions – Tribes and tribal
organizations were notified of proposed rules pertaining to the
Medicare and Medicaid program contained in the ACA. The Center for
Medicaid and Medicaid Services (CMS) Tribal Technical Advisory Group
(TTAG) held ongoing discussion with the National Indian Health Board,
Area Health Boards and interested IHS/tribal/urban Indian program
staff on these issues. NIHB and the CMS TTAG collaborated to research
the impacts of the proposed rules. Below is a listing of some of the
recent tribal comments and the date they were submitted to CMS since
the beginning of fiscal year 2011:
*
CMS TTAG Advisement on the Definition of “Indian” under the
Affordable Care Act - The CMS TTAG transmittal of a position paper
in support of the definition, found at 42 C.F.R. § 447.50
substantiates the need to uniformly adopt the definition in order
to effectively implement the ACA, including the Exchange Plans,
Medicaid expansion, and the specific AI/AN provisions to avoid
administrative confusion and facilitate ease of enrollment.
(10/21/10)
*
Section 10201(i): Proposed Rule on the Review and Approval Process
for Section 1115 Demonstrations – The CMS TTAG supported the
proposed rule pertaining to experimental, pilot, and demonstration
projects approved under section 1115 of the Social Security Act
relating to Medicaid and the Children’s Health Insurance Program
(CHIP). (11/15/10)
*
Section 1311(c)(1)(C): Definition of Essential Community Providers
– NIHB position paper outlines the importance of Indian Health
Service, Tribal and Urban Indian Program providers being defined
as Essential Community Providers (ECPs) in order to ease
participation in health plan provider networks in the ACA
implementation of state-based Health Insurance Exchanges. (2/8/11)
o Section 2401: Proposed Rule on the Medicaid Community First Choice
Option – NIHB
comment to CMS encourages that States exercising the option to provide
home and community‐based attendant services take into account
implementation
efforts do not result in adverse impact on American Indians and Alaska
Natives (AI/AN)
who reside in/near Indian communities, where cultural norms differ.
(4/26/11)
*
Section 1332: Proposed Rule on the Application, Review, and
Reporting Process for Waivers for State Innovation – The rule
provides authority to the Secretary of HHS or the Secretary of the
Treasury (Secretaries) to waive any or all of the requirements
under the following sections of the ACA for health insurance
coverage within a State plan beginning on or after 1/1/17.
*
Part I of subtitle D of Title I (relating to the establishment of
qualified health plans);
*
Part II of subtitle D of Title I (relating to consumer choices and
insurance competition through health benefit exchanges);
*
Section 1402 (relating to reduced cost sharing for individuals
enrolling in qualified health plans);
*
Sections 36B (relating to refundable credits for coverage under a
qualified health plan);
*
4980H (relating to shared responsibility for employers regarding
health coverage);
*
5000A (relating to the requirement to maintain minimum essential
coverage) of the Internal Revenue Code.
These requirements may be waived only after a determination by the
Secretaries that the State plan provides coverage and benefits
comparable to the ACA. TTAG stated the potential impacts to AI/ANs if
financial and legal relationships to Indian health programs are not
addressed by states and if tribal consultation requirements are not
met. (5/13/11)
*
Section 3022: Medicare Shared Savings Program: Accountable Care
Organizations (ACO’s) – The proposed rules provides for the
formation of ACO’s by providers, hospitals and other suppliers of
related health care services serving at least 5,000 beneficiaries.
In response, NIHB submitted comments on the difficulty that the
rules will present to the ability of Indian health system
providers to form an ACO or to participate in an ACO. They found
that the ACO model may not be suitable, and there may be a need to
pursue alternative approaches through the Medicare Innovations
Center in order to achieve the objectives of the Medicare Shared
Savings Program. (6/6/11)
ITCA
6/22/11
ADDENDUM
Listing of Provisions in the Patient Protection and Affordable Care
Act (ACA) with American Indian/Alaska Native Applicability
(P.L. 111-148)
I. Expanded Access to Health Care (General Provisions)
*
Insurance reform for the uninsured/insured
*
Eliminates pre-existing condition medical restrictions in private
insurance plans
*
Establishment of a state based Health Insurance Exchange (HIX)
*
Employer responsibilities/small business insurance programs &
exemptions
*
Individual tax requirements, credits & exemptions
*
Medicare provider payment changes to obtain cost savings
*
Medicaid expansion to 133% of the FPL that includes childless
adults
*
State option to provide Health Homes for Medicaid enrollees with
chronic conditions to improve care coordination by a team of
providers
*
National health benefits package that provides an essential set of
services, including treatment for mental health and substance
abuse disorders
*
New Primary Care Benefits with no cost sharing
*
Insurance coverage of patient costs in clinical trials
II. American Indian/Alaska Native (AI/AN) Specific Provisions/Benefits
& Exemptions
*
Special AI/AN enrollment periods in Health Insurance Exchange
plans
*
No Cost Sharing for AI’s under 300% FPL
*
Exemptions to the mandated insurance requirement & tax penalties
*
Codification of IHS Payor of Last Resort Rule
*
Indian Health Service/Tribal/Urban (I/T/U) providers considered
“Express Lane” Entities for Medicaid/CHIP enrollment purposes
*
Medicare Part B (I/T/U outpatient hospital/clinic based services)
reinstatement
*
Prescription drugs through I/T/U’s counted towards TrOOP under
Medicare Part D
*
CMS Integrated Data Repository to include IHS/CHS claims and
payment data
*
Tribal government health insurance employee benefits considered
non-taxable
III. Healthcare Systems, Provider & Workforce Development/Grants -
Tribal Eligibility
*
Community based interdisciplinary Health Team grants to support
the patient
centered Medical Home
*
Competitive grants for Regional Trauma Systems for Emergency
Care (4 pilot
projects)
*
Trauma Care Centers and services in the I/T/U System (3 awards)
*
National Prevention, Health Promotion and Public Health Council
(Assistant
Secretary of Indian Affairs is a designated member)
*
Health Disparity Data Collection/Analysis Initiative (IHS-IHCIA
Funded Epidemiology Centers’ involvement)
*
National Health Care Workforce Commission (Tribal consultation
requirement)
*
Public Health Workforce Loan Repayment Program
*
Alternative Dental Health Care Providers Demonstration Project
*
Demonstration projects to provide low income individuals with
education, training, and career advancement to address health
professions workforce needs (3 awards)
*
Expanded Primary Care Physician Residency Program/100% Medicaid
reimbursement for primary care services/No co-pays for primary
care services
*
Healthy Aging, Living Well: Community Based Prevention and
Wellness Programs for ages 55-64 years of age (5 pilot programs)
*
Mental and Behavioral Health Education and Training Grants (focus
on minority serving institutions)
*
Establishment of the United States Public Health Sciences Track to
advance degrees in the medical, nursing, dental, pharmacy, public
health epidemiology, emergency response, behavioral health,
physician assistant and nurse practitioner fields
*
Demonstration project to address health professions workforce
needs (3 tribal grants)
*
Improvements under Medicare and Medicaid; testing of innovative
payment and service delivery models in certain geographic areas
IV. Health Promotion Disease Prevention Grants- Tribal Eligibility
*
3% set-aside Maternal, Infant, and Childhood Home Visiting Program
grants
*
Clinical and Community Preventative Services Task Force
participation
*
National Public-Private Education and Outreach Campaign on
Preventative Benefits
*
Grants for school-based health centers (Focus on primary health
services
and mental health and substance use disorder prevention services)
*
CDC American Indian oral healthcare prevention activities
*
State-Tribal collaborations for Prevention of Chronic Diseases in
Medicaid Community Transformation Grants (Dissemination of
evidence based prevention practices that reduce chronic disease
rates)
*
Establishment of a Pregnancy Assistance Fund to assist pregnant
and parenting teens and women
*
Training of graduate medical residents in preventive medicine
specialties
V. ACA Mental Health and Behavioral Health Provisions
*
Emergency psychiatric stabilization 3-year Medicaid demonstration
in up to eight
States to reimburse institutions for mental services provided to adult
Medicaid beneficiaries who require medical assistance.
*
Postpartum depression and psychosis support and education for
women;
research opportunities into causes, diagnoses, and treatments.
*
Medicaid coverage of comprehensive tobacco cessation services for
pregnant women including counseling and pharmacotherapy for
cessation of tobacco use. Cost-sharing prohibited for these
services.
*
Mental and behavioral health education and training grants to
schools that develop,
expand or enhance training programs in social work, graduate
psychology, professional training in child and adolescent mental
health, and pre-service or in-service training to paraprofessionals in
child and adolescent mental health.
- Grants to promote the use of community health workers that offer
interpretation and translation services, culturally appropriate health
education and information on behaviors, individual and community
health advocacy and some direct primary care services and screenings.
Section clarifies the definition and activities of community health
workers.
*
Co-locating primary and specialty care in community-based mental
health settings program authorizes $50 million in grants for
coordinated and integrated services.
4

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