Myra M. Munson, J.D., M.S.W. Sonosky , Chambers, Sachse, Miller & Munson LLP May 7, 2014

1. Maximizing Revenue and Minimizing CostTraining Sponsored byTribal Self-Governance Advisory CommitteeArlington, VA Myra M. Munson, J.D., M.S.W. Sonosky, Chambers, Sachse, Miller & Munson LLP May 7, 2014 myra@sonoskyjuneau.com

2. Sonosky, Chambers, Sachse, Miller & Munson, LLP • 302 Gold Street, Suite 201, Juneau, AK 99801 • 907-586-5880 Maximizing Revenue and Minimizing CostWebinar Presentation Sponsored byTribal Self-Governance Advisory CommitteeArlington, VA Myra M. Munson, J.D., M.S.W. May 7, 2014 myra@sonoskyjuneau.com Washington, DC Juneau, AK Anchorage, AK Albuquerque, NM San Diego, CA

3. Where to Start – Consider Roles Tribes juggle many roles: Tribal government Health provider Employer OBJECTIVE: To maximize revenue and minimize costs associated with health care, while achieving governmental objectives of improving the physical, spiritual, and economic well-being of members and community. Sonosky, Chambers, Sachse, Miller & Munson, LLP 302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880 TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 3

4. Tribal Opportunities: As a . . . Health Provider IHCIA § 206 – Third Party Recovery IHCIA § 401 – Reimbursement from Medicare, Medicaid & CHIP IHCIA § 408 – Right to Reimbursement from Federal Programs, including VA and DoD under § 405(c) ARRA § 5006 – Medicaid Cost-Sharing Protection ACA§§ 1402(d) and 2901(a) – Exchange Plan Cost-Sharing Protections IHCIA § 813 – FTCA for Services Provided to Non-Beneficiaries Electronic Health Record Incentive Payments ARRA § 5006 – Deemed Participating PPO by Medicaid Managed Care Plans and BBA of 1997 – No Mandatory Enrollment of AI/ANs in Medicaid Managed Care Plans ACA § 2202 Medicaid Presumptive Eligibility by Hospitals Sonosky, Chambers, Sachse, Miller & Munson, LLP TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 4

5. I/T/U Roles and Opportunities Purchaser of Health Services/Contract Health Services ARRA § 5006 and ACA §§ 1402(d) and 2901(a)– Cost-Sharing Protections ACA§ 2901(b) – Payer of Last Resort (25 U.S.C. § 1623(b)) MMA§ 506 – Medicare Like Rates Purchaser of Health Coverage for IHS Beneficiaries IHCIA§ 402 – Authority to Purchase Coverage or Health Services ACA Exchange Plan Coverage Medicare Part D ACA Exchange Plans Sonosky, Chambers, Sachse, Miller & Munson, LLP TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 5

6. I/T/U Roles and Opportunities Provider of Health Coverage for Employees (Indian and Non-Indian) IHCIA§ 409 – Federal Employee Health Benefit Plan ACA Medicaid Expansion Direct Delivery of Services Advocate for AI/ANs AND, most of these lists are not complete!!! There are other opportunities. Sonosky, Chambers, Sachse, Miller & Munson, LLP TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 6

7. But, Let’s Focus Most rights are not self-enforcing. Generating revenue and achieving savings require affirmative action and constant monitoring. No one part of the Tribe can do the work in isolation from the rest. Sonosky, Chambers, Sachse, Miller & Munson, LLP TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 7

8. Do You Know Who Is an “Indian” for What Purpose? See, Handout: Indian Health Services, Medicaid, Affordable Care Act: Who is Eligible for What? Sonosky, Chambers, Sachse, Miller & Munson, LLP 302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880 TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 8

9. Questions? This is your first chance; there will be others. Sonosky, Chambers, Sachse, Miller & Munson, LLP 302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880 TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 9

10. You Can’t Collect, If You Don’t Bill Must haves: Billing system or contractor Trained staff – coding, compliance, providers, billers Good negotiators A business focus And, even then there are challenges Sonosky, Chambers, Sachse, Miller & Munson, LLP 302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880 TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 10

11. Sec. 206 THIRD PARTY RECOVERYS. 1790 S. 125; 25 U.S.C. § 1621e *Right to recover reasonable charges (rather than reasonable expenses) or highest amount the payor would pay a non-governmental provider from insurance companies, HMOs, employee benefit plans, and tortfeasors, and any other responsible or liable third party Allows THOs to use the Federal Medical Care Recovery Act Allows self-insured tribes to authorize payment to IHS Allows THO to recover costs and attorney’s fees if prevail Status: Tribal health programs are increasingly aware of the importance of pursuing recovery as required by law; many insurers are unaware of the rules or actively resist. Litigation occurring to enforce tribal rights. Sonosky, Chambers, Sachse, Miller & Munson, LLP TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 11

12. Some Insurers Don’t Want to Pay ANTHC v. Premera Federal District Court for Alaska ruled on Summary Judgment motion that if an Indian tribe agreed to accept payments lower than its billed charges by contract (for example, discounting for preferred provider status), then the payment contract controls. Sonosky, Chambers, Sachse, Miller & Munson, LLP TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 12

13. What If There Is No Contract In the absence of a payment contract, the Court also ruled that the Indian health program is entitled to the higher of: (1) its reasonable charges or (2) an amount higher than its reasonable charges to the same extent non-governmental providers are entitled to receive that rate. Minimum payment under Alaska insurance regulations (80th percentile of charges in the geographic area) was the example used by the Court in its decision. Sonosky, Chambers, Sachse, Miller & Munson, LLP TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 13

14. What Hasn’t Been Ruled On There is no ruling yet on the extent to which (if any) insurers can reduce payments because the Indian health program is not part of its preferred network (some reduce by as much as 60%) (Premera, for example).  We think this is impermissible since Section 206 (1) allows recovery of “reasonable charges billed,” not discounted “out of network” rates, and (2) Section 206 covers managed care organizations, which by definition require individuals to stay in network (argument not made yet and not rules on yet). Sonosky, Chambers, Sachse, Miller & Munson, LLP TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 14

15. What’s Likely to Happen This litigation will take time. Efforts at mediation failed completely. Premera is simply not accepting the Court means what was said in the summary judgment ruling. It has filed two more motions trying to get the case dismissed. In the meantime, there has been discovery, and may still require further litigation about the facts, more motion practice, and possibly appeals. Don’t hold your breath! Sonosky, Chambers, Sachse, Miller & Munson, LLP TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 15

16. What Can You Do? Keep billing (or start if you’ve stopped). You won’t get paid if you don’t file a claim. Keep charges up-to-date. Charges are usually higher than what insurers pay routinely. You won’t know what the insurers are paying others, but you can know about your own charges. Sonosky, Chambers, Sachse, Miller & Munson, LLP TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 16

17. What Can You Do? continued Work claims. Denials are being routinely issued by some insurers that count on the Indian health system being too overwhelmed to refile and demand payment. Do not enter into any form of contract unless you are willing to accept the payment rates. The District Court for Alaska has ruled that if you’ve agreed to certain rates, you are stuck with them. Sonosky, Chambers, Sachse, Miller & Munson, LLP TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 17

18. What Can You Do? continued Read and review ALL the terms of any Agreement with an Insurer. Be sure the agreements do not have other terms that compromise the Indian health program or Tribe. And, this includes the CMS Tribal Addendum. Although there is a lot in it that is really helpful, there are provisions that may be problematic for your tribe. IF YOU SIGN AN AGREEMENT, BE SURE YOU ARE PREPARED TO LIVE WITH IT. Sonosky, Chambers, Sachse, Miller & Munson, LLP TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 18

19. Using Cost Sharing Protections to Generate Revenue and Achieve Savings IHCIA Sec. 4(5) defines “Contract Health Services” (CHS) to include referrals without commitment to pay, as well as those where there the I/T/U will take responsibility for payment. No Medicaid Premiums or Cost Sharing –ARRA 5006; 42 USC 1396o(j). AI/ANs referred by CHS to any provider are not responsible for any cost sharing. The provider payment may not be reduced by the amount of the cost sharing. Applies to Medicaid Expansion Cost Sharing Protections under Exchange Plans –ACA §§ 1402(d) and 2901(a): Must verify status with each plan and potential covered person Indians under 300% of poverty, enrolled in any Exchange plan, are exempt from cost sharing (25 U.S.C. § 1623(a)) No cost sharing for services provided by I/T/U and no deduction in payments to I/T/U Qualified Health Plan will be paid by HHS for the cost sharing Sonosky, Chambers, Sachse, Miller & Munson, LLP TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 19

20. COST AVOIDANCEMedicare Like Rates Basic Rule Effective July 5, 2007 – AMedicare enrolled hospital may not accept more than a Medicare Like Rate for services provided to an American Indian or Alaska Native (AI/AN) for any medical care purchased under the contract health services (CHS) program or a UIOpurchase for an urban Indian. If the I/T/U has an agreement that provides for lower payment for the CHS, then the hospital must accept the lower amount. BUT, many tribal programs are still not taking advantage of this. If not, is it too late? We don’t think so. But, there will be work involved. Reprice at least a sample of claims Make a request to the hospital to work out a settlement of past claims Follow-up if the hospital doesn’t cooperate BEGIN REPRICING IMMEDIATELY SO THAT YOU DO NOT CONTINUE TO PAY MORE THAN IS REQUIRED Negotiate MLR with other providers Sonosky, Chambers, Sachse, Miller & Munson, LLP TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 20

21. Don’t Leave Money on the Table! Medicare Quality Initiatives require affirmative action – otherwise, payment levels may be reduced. Physician Quality Reporting System (PQRS) Electronic Prescribing (eRX) Ambulatory Surgery Center (ASC) Quality Reporting See, “Reimbursement and Billing: Medicare Incentive Payments,” Presentation by Sherrie Varner, Choctaw Nation of Oklahoma, Medicare Policy Analyst & Affordable Care Implementation Team, at NIHB Annual Consumer Conference, August 2013. Sonosky, Chambers, Sachse, Miller & Munson, LLP TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 21

22. Questions? This is your second chance; there will be others. Sonosky, Chambers, Sachse, Miller & Munson, LLP 302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880 TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 22

23. YOU’VE GOT THE BASICS, WHAT’S NEXT? Sonosky, Chambers, Sachse, Miller & Munson, LLP 302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880 TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 23

24. Expand ServicesMore and Better Health Care and More $$$ ACA requires health plans to pay for more prevention and wellness Requires plans issued after 3/23/10 to provide certain preventive care without cost Specified screenings for adults with certain conditions such as high blood pressure or cholesterol, diabetes, and cancer Increases Federal share for certain preventive services if States do not charge co-pays Required Medicaid to cover tobacco cessation to pregnant women If you aren’t providing these services, you are missing an opportunity to improve health status and generate revenue. TRIBAL HEALTH PROGRAMS – include all your health programs in your ISDEAA funding agreement so you get the benefit of FTCA coverage and more certain reimbursement. Sonosky, Chambers, Sachse, Miller & Munson, LLP TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 24

25. More Expansion Serve tribal employees Serve other people in the community Expand direct services when the cost of CHS or claims exceed the cost of providing the services directly Sonosky, Chambers, Sachse, Miller & Munson, LLP 302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880 TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 25

26. eliminate silos inside and outside the Tribe Sonosky, Chambers, Sachse, Miller & Munson, LLP 302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880 TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 26

27. Employer: Consider Options Federal Employee Health Benefit Plan Risk based policies vs. self-insured coverage Be your own provider and keep the money within the Tribe and maximize opportunities to improve worker health Sonosky, Chambers, Sachse, Miller & Munson, LLP 302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880 TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 27

28. FEHB – An Option for Employee Insurance Coverage For more information: See Office of Personnel Management, Tribal Federal Employees Health Benefits Handbook Highlights, available at http://www.opm.gov/healthcare-insurance/indian-tribes/reference-materials/handbook-highlights.pdf OPM webpage for Tribes: http://www.opm.gov/healthcare-insurance/indian-tribes/health-insurance/ Dear Tribal Leader Letter: http://www.opm.gov/healthcare-insurance/indian-gtribes/hr-personnel/outreach-documents/122011letter.pdf (Dec. 21, 2011) Frequently Asked Questions:http://www.opm.gov/healthcare-insurance/indian-tribes/faqs 2014 Rates just announced: See, http://www.opm.gov/healthcare-insurance/healthcare/plan-information/premiums/#url=Premiums Sonosky, Chambers, Sachse, Miller & Munson, LLP TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 28

29. Tribal Health Provider Can be part of the solution to Tribal health costs! But, you have to overcome the myths. Is it really true: that you always have to wait for an appointment or when you arrive for an appointment? the quality isn’t as good as if you have private insurance? the services never pay for themselves? NO! But, it doesn’t matter if that is the general perception. Sonosky, Chambers, Sachse, Miller & Munson, LLP TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 29

30. Employer Strategie sAvoid Penalties For failure to provide required summaries (up to $1000 for each plan beneficiary to whom not provided) For failure to offer coverage Don’t offer too much coverage (Cadillac Plans – beginning 2018 if value of premiums exceeds $10,200 for individual or $27,500 for family (subject to inflation adjustments), a 40% excise tax may be imposed Sonosky, Chambers, Sachse, Miller & Munson, LLP 302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880 TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 30

31. What If Your State Hasn’t Adopted Medicaid Expansion? BE AN ADVOCATE Don’t give up. There is no deadline. Get your facts in line about the benefits – economic to the State, reducing uncompensated care, and better health for otherwise uncovered individuals. Get together with other advocates for Expansion and not just the hospitals. Try to keep the issue alive. Don’t let it disappear. Sonosky, Chambers, Sachse, Miller & Munson, LLP 302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880 TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 31

32. Ideas for a Work Plan Health planning work group: Council, Finance, Human Resources, Health Department, legal Catalog all health care provided: directly and through self-insurance, CHS, extended benefits to members, purchased insurance, reinsurance Make a timeline of when new requirements and costs may hit so you are ahead of them Evaluate impact of new requirements and opportunities Strategize options to reduce cost, improve impact of funds spent, increase revenue Influence policy: review all proposed State Medicaid rules and State Plan Amendments and Comment Don’t move to fast, but don’t wait too long! Sonosky, Chambers, Sachse, Miller & Munson, LLP TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 32

33. Questions? This is the last chance for this presentation, but all questions about maximizing revenues and minimizing costs are welcome. You can also send questions via the internet on the Health Reform page for the Self-Governance Communications and Education (SGCE) website: http://www.tribalselfgov.org/____NEWSGCE/___healthcare/Blog_page/healthblog2.html Sonosky, Chambers, Sachse, Miller & Munson, LLP 302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880 TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 33

34. References Where do I find these laws? What do the acronyms mean? Sonosky, Chambers, Sachse, Miller & Munson, LLP 302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880 TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 34

35. Citations for the Wonks ACA = Patient Protection and Affordable Care Act, Pub. L. 111-148 ARRA = American Recovery and Reinvestment Act of 2009, Pub. L. 1115 (Feb. 2009) CHIPRA = Children’s Health Insurance Program Reauthorization Act, Pub. L. 111-3 (Feb. 2009) IHCIA= Indian Health Care Improvement Act, Pub. L. 94-437, as amended, most recently by ACA § 10221, which enacted by reference S. 1790, as reported out of the Senate Committee on Indian Affairs in December 2009, with four amendments ISDEAA = Indian Self-Determination & Education Assistance Act, Pub. L. 93-437, as amended Sonosky, Chambers, Sachse, Miller & Munson, LLP TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 35

36. Even More for Wonks MMA= Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub. L. 108-173, amending § 1866(a)(1) of the Social Security Act. See, Sec. 506, codified at 42 U.S.C. § 1395cc(a)(1)(U), and regulations found at 42 C.F.R. § 136 and C.F.R. Title 42, Part 489, provider agreements and supplier approval. Sonosky, Chambers, Sachse, Miller & Munson, LLP TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 36

37. Acronyms for IHCIA and ACA ACA = Patient Protection and Affordable Care Act, Pub. L. 111-148 ARRA = American Recovery and Reinvestment Act of 2009, Pub. L. 1115 (Feb. 2009) AI/AN = American Indian/Alaska Native APTC = Advance Premium Tax Credit BBA = Balanced Budget Act of 1997 CCIIO = Center for Consumer Information and Insurance Oversight (part of CMS; used to be OCIIO) CHIP (or CHP) = Child Health Insurance Program CHIPRA = Children’s Health Insurance Program Reauthorization Act, Pub. L. 111-3 (Feb. 2009) CHSDA = Contract Health Service Delivery Area CMS = Centers for Medicare & Medicaid Services (agency within Dept. of Health & Human Services) EHB = Essential Health Benefits FEHB = Federal Employee Health Benefit Plan FEGLI = Federal Employees Group Life Act FPL = Federal Poverty Level IRC = Internal Revenue Code ISDEAA = Indian Self-Determination & Education Assistance Act, Pub. L. 93-437, as amended I/T/U = Indian Health Service/Tribal Health Program/Urban Indian Organization Sonosky, Chambers, Sachse, Miller & Munson, LLP 302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880 TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 37

38. More Acronyms MAGI = Modified Adjusted Gross Income MEDPAC = Medicaid and CHIP Payment and Access Commission MMA = Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub. L. 108-173 (Dec. 2003) MMPC = Medicare/Medicaid Policy Committee of the NIHB NIHB = National Indian Health Board OCIIO = Office of Consumer Information and Insurance Oversight in HHS QHP = Qualified Health Plan PCIP = Pre-Existing Condition Insurance Plan (often referred to as “high risk pool” plan) SHOP = Small Business Health Options Program TTAG = Tribal Technical Advisory Group to the CMS TrOOP= True Out-of-Pocket costs applicable to Medicare Part D UIO = Urban Indian Organization, as defined in IHCIA Sec. 4(29) VA = Department of Veterans Affairs And, there will be lots more! Sonosky, Chambers, Sachse, Miller & Munson, LLP 302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880 TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 38

39. Presenter Myra M. Munson is a partner in the Juneau office of Sonosky, Chambers, Sachse, Miller & Munson LLP, which specializes in representing tribal interests in Alaska and throughout the United States. She earned her bachelor's degree from the University of Alaska Fairbanks in 1972 and her law degree and master's degree in social work with honors from the University of Denver in 1980. After serving as Alaska Commissioner of Health and Social Services from 1986 to 1990, Ms. Munson joined the Sonosky Law Firm LLP where her practice has emphasized self-determination and self-governance, the Indian Health Care Improvement Act (IHCIA), Medicaid and other third-party reimbursement issues, and other health program operations issues. She was a technical advisor to the IHCIA National Steering Committee for over 10 years; assisted in drafting and editing substantial sections of the reauthorization; and testified before the Senate Committee on Indian Affairs. Ms. Munson is also a member of the National Indian Health Board Medicare & Medicaid Policy Committee, and a technical advisor to the Centers for Medicare and Medicaid Services Tribal Technical Advisory Group. She has been conducting extensive training on the Affordable Care Act and IHCIA since their passage and serves as a consultant to the National Indian Health Board with regard to training on and implementation of these new laws. In 2003, Ms. Munson was given the Denali Award by the Alaska Federation of Natives. and in 2009 the Healthy Alaska Native Foundation awarded her with its President’s Award. Sonosky, Chambers, Sachse, Miller & Munson, LLP 302 Gold Street, Suite 201, Juneau, AK 99801, 907-586-5880 TSAGC Webinar May 7, 2014 Maximizing Revenue and Minimizing Costs Slide 39