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Myra M. Munson, J.D., M.S.W. National Indian Health Board

Sonosky , Chambers, Sachse, Miller & Munson, LLP. State Based Health Insurance Exchanges: What Do They Mean for Individual Indians and Tribes? TRIBAL RECOMMENDATIONS. Myra M. Munson, J.D., M.S.W. National Indian Health Board National Tribal Health Reform Implementation Summit.

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Myra M. Munson, J.D., M.S.W. National Indian Health Board

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  1. Sonosky, Chambers, Sachse, Miller & Munson, LLP State Based Health Insurance Exchanges: What Do They Mean for Individual Indians and Tribes?TRIBAL RECOMMENDATIONS Myra M. Munson, J.D., M.S.W. National Indian Health Board National Tribal Health Reform Implementation Summit. Washington D.C. – April 19, 2011 myra@sonoskyjuneau.com Washington, DC Juneau, AK Anchorage, AK Albuquerque, NM San Diego, CA

  2. Who Is an Indian? Objective: Assure consistent access to AI/AN-specific benefits and tax penalty avoidance. Problem: The ACA references three different statutory definitions (ISDEAA, IHCIA, and IRC). Recommendation: Use 42 CFR 447.50 consistently to implement the varying definitions of “Indian” in the Affordable Care Act. Sonosky, Chambers, Sachse, Miller & Munson, LLP S 4/20/11 NIHB National Tribal Health Reform Implementation Summit ● State Health Exchanges TRIBAL RECOMMENDATIONS Slide 2

  3. How Will State Exchanges and IRS Know Who Is an Indian? Objective: Eliminate barriers to AI/ANs having access to Exchange Plans and the special Indian-specific benefits provided to AI/ANs. Problems:The ACA requires documentation of citizenship. Exchanges. Exchange Plans and IRS needs to determine who is eligible for AI/AN-specific benefits and tax penalty avoidance? Recommendations: (1) Exchange Plans should accept any document issued by a federally recognized Tribe evidencing membership or enrollment in, or affiliation with, that Tribe as sufficient evidence of citizenship and of being AI/AN.See CHIPRA Sec. 211(b) amending 42 U.S.C. § 1396b(x)(3)(B)(v)(I).(2) Allow data matching with (or documentation provided by) I/T/U, BIA, Medicaid, and other sources that may have determined AI/AN status. (3) Accept attestation by the individual enrollee. Sonosky, Chambers, Sachse, Miller & Munson, LLP 4/20/11 NIHB National Tribal Health Reform Implementation Summit ● State Health Exchanges TRIBAL RECOMMENDATIONS Slide 3

  4. What Else Can Be Done to Reduce Barriers to Exchange Plan Enrollment? Navigators: Tribes and tribal health programs should be assisted to qualify as “Navigators” to Exchange Plans, including making resources available. To the extent there are no tribal Navigators in a State, any entity providing Navigator services should be required to interact with the I/T/U to ensure their materials fully address AI/AN issues and that they are designed to successfully achieve outreach into AI/AN communities and to assist AI/ANs to fully access all the benefits and protections to which they are entitled. Data Collection:Exchange plans should be required to capture data about all aspects of enrollment attempts and success by AI/ANs and to adjust outreach and enrollment processes if they are not fully reaching AI/ANs. Sonosky, Chambers, Sachse, Miller & Munson, LLP 4/20/11 NIHB National Tribal Health Reform Implementation Summit ● State Health Exchanges TRIBAL RECOMMENDATIONS Slide 4

  5. Make Sure the Web Application Process Is Really Seamless and Is AI/AN Friendly Recommendations: Require that web portals have information on them about AI/AN specific benefits and opportunities under Medicaid, CHIP, and Exchange Plans. Train call center employees about AI/AN specific benefits and opportunities. Develop culturally appropriate materials. Sonosky, Chambers, Sachse, Miller & Munson, LLP 4/20/11 NIHB National Tribal Health Reform Implementation Summit ● State Health Exchanges TRIBAL RECOMMENDATIONS Slide 5

  6. Indian Sponsorship Authority: Under Section 402 of the IHCIA, Indian tribes, tribal organizations, and UIOs are entitled to use IHS funds provided to them under their contracts, compacts, and grants to purchase health insurance. Recommendation: Require State Exchanges or Plans to allow a Indian entity to purchase or subsidize the enrollment of individuals the T/U chooses to cover by establishing mechanisms for the T/U to pay premiums collectively and directly on behalf of enrolled individuals. Sonosky, Chambers, Sachse, Miller & Munson, LLP 4/20/11 NIHB National Tribal Health Reform Implementation Summit ● State Health Exchanges TRIBAL RECOMMENDATIONS Slide 6

  7. I/T/U Protections:Essential Community Providers Objective: Ensure access by AI/ANs to culturally competent health care services by ensuring the viability of I/T/U health programs. Problem: Plans that do not treat the I/T/U as essential community providers may steer enrolled AI/ANs to other providers that are included in their networks depriving the AI/AN of the opportunity for truly integrated care and the I/T/U of needed resources. Recommendation: States should be required to designate I/T/U providers as essential community providers and Exchange plans should be required to include the I/T/U providers in their networks. Sonosky, Chambers, Sachse, Miller & Munson, LLP 4/20/11 NIHB National Tribal Health Reform Implementation Summit ● State Health Exchanges TRIBAL RECOMMENDATIONS Slide 7

  8. Special Laws that Protect the I/T/U Objective: Assure that all Plans are familiar with and will abide by laws requiring that I/T/Us are paid for services they provide to individuals with any third-party coverage (including managed care plans), and providing other protections, such as exemptions from certain State licensing laws. Problem:Most Plans will not be familiar with these laws and may view them as interfering with their basic operations. If there are no standardized materials, each I/T/U will have to invest in advocacy, negotiation, and possibly litigation to protect their health program operation. Recommendations: CMS endorse (or require) an Indian Addendum for Network Provider contracts between plans and I/T/U that sets out AI/AN and I/T/U specific terms. CMS require State exchanges to inform Plans about these laws and assist I/T/Us in enforcing them. Sonosky, Chambers, Sachse, Miller & Munson, LLP 4/20/11 NIHB National Tribal Health Reform Implementation Summit ● State Health Exchanges TRIBAL RECOMMENDATIONS Slide 8

  9. I/T/U Protections:Meaningful Use Incentive Payments Objective:Ensure that Indian health programs have access to all available resources to ensure implementation of meaningful use. Problem: Under current CMS direction to States, tribal and UIO health programs that have not enrolled in Medicaid as an FQHC may count only Medicaid encounters when determining their eligibility for incentive payments. Many programs will not meet the 25% threshold. Recommendation:CMS revise its direction to States to clarify that all tribal and UIO health programs receiving funding from the IHS fall within the definition of “FQHC” at 42 U.S.C. § 1396d(l)(2)(B) whether the program is enrolled in Medicaid as an FQHC or not, and, therefor are eligible to count all encounters with “needy individuals,” when calculating eligibility for incentive payments. Sonosky, Chambers, Sachse, Miller & Munson, LLP 4/20/11 NIHB National Tribal Health Reform Implementation Summit ● State Health Exchanges TRIBAL RECOMMENDATIONS Slide 9

  10. State Consultation with I/T/U Objective:Full participation by I/T/U in the development of Medicaid expansion and Exchange Plans to assure that AI/ANs and I/T/U health programs have an opportunity to participate. Problem: Without full exchange of views and information prior to decisions being made by States, it is likely that AI/AN specific issues will not be addressed. Recommendations:(1) Require States to engage in meaningful consultation with I/T/Us as a condition of State receipt of Federal planning and implementation funding using as a model the consultation requirements that apply to States before they can submit or have approved State Plan Amendments or waivers. (2) Continue CMS consultation on an ongoing basis. Sonosky, Chambers, Sachse, Miller & Munson, LLP 4/20/11 NIHB National Tribal Health Reform Implementation Summit ● State Health Exchanges TRIBAL RECOMMENDATIONS Slide 10

  11. References *4/13/11, Kris Locke and Mim Dixon for TSAGC, “Tribal Planning for Health Insurance Exchanges Begins Now.” *4/12/11, NIHB Issue Paper, “Indian Sponsorship under Exchange Plans.” 3/21/11, “Addendum for Indian Health Care Providers.” 3/9/11, TTAG Letter to CMS Administrator regarding Determination of Patient Volume in Tribal and Urban Indian Health Programs for Meaningful Use Incentives. *2/9/11, NIHB, “I/T/U Are Essential Community Providers.” 2/3/11, NIHBPaper, “Determination of Patient Volume in Tribal and Urban Indian Health Programs for Meaningful Use Incentives.” 12/17/10, NIHB Comment Letter to CCIIO re: Establishment of Standards for Exchanges. 11/16/10, NIHB, Comments in response to NPRM regarding Medicaid Review and Approval Process for Section 1115 Demonstrations 11/16/10, NIHB, Comments in response to NPRM regarding Medicare, Medicaid, and CHIP Provider Enrollment and Screening Fees and Requirements. *10/13/10, Approved by TTAG, “The Definition of ‘Indian’ under the Affordable Care Act.” 10/4/10, NIHB Comment Letter to OCCIO re: Planning and Establishment of State-level Exchanges 9/28/10, NIHB comments in response to interim final rule regarding high risk pool eligibility. * Included in Summit Tool Kit Sonosky, Chambers, Sachse, Miller & Munson, LLP 4/20/11 NIHB National Tribal Health Reform Implementation Summit ● State Health Exchanges TRIBAL RECOMMENDATIONS Slide 11

  12. 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 CCIIO= Center for Consumer Information and Insurance Oversight in CMS (formerly OCIIO) CHIP (or CHP) = Child Health Insurance Program CHIPRA = Children’s Health Insurance Program Reauthorization Act, Pub. L. 111-3 (Feb. 2009) CMS = Centers for Medicare & Medicaid Services DoD = Department of Defense FEHBP = Federal Employee Health Benefit Plan FPL = Federal Poverty Level HHS = Department of Health and Human Services HMO = health maintenance organization IHCIA = Indian Health Care Improvement Act, Pub. L. 94-437, as amended, 25 U.S.C. § 1601 et seq. (March 23, 2010) IHS = Indian Health Service Sonosky, Chambers, Sachse, Miller & Munson, LLP 4/20/11 NIHB National Tribal Health Reform Implementation Summit ● State Health Exchanges TRIBAL RECOMMENDATIONS Slide 12

  13. ACRONYMS FOR IHCIA AND ACA IRC = Internal Revenue Code ISDEAA = Indian Self-Determination & Education Assistance Act, Pub. L. 93-437, as amended, 25 U.S.C. § 450 et seq. I/T/U = Indian Health Service/Tribal Health Program/Urban Indian Organization 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 (now CCIIO) PCIP = Pre-Existing Condition Insurance Plan (often referred to as “high risk pool” plan) 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 IHCIASec. 4(29) VA = Veteran’s Administration Sonosky, Chambers, Sachse, Miller & Munson, LLP 4/20/11 NIHB National Tribal Health Reform Implementation Summit ● State Health Exchanges TRIBAL RECOMMENDATIONS Slide 13

  14. Presenter Myra M. Munson is a partner in the Juneau office of Sonosky, Chambers, Sachse, Miller & Munson LLP, 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 master's degree in social work and law degree with honors from the University of Denver in 1980. After serving as Alaska’s Commissioner of Health and Social Services from 1986 to 1990, Myra joined the Sonosky Law Firm 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. Ms. Munson 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 on Medicaid and Medicare provisions. She 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 has served 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 2011 she was awarded the President’s Award by the Healthy Alaska Native Foundation. Sonosky, Chambers, Sachse, Miller & Munson, LLP 4/20/11 NIHB National Tribal Health Reform Implementation Summit ● State Health Exchanges TRIBAL RECOMMENDATIONS Slide 14

  15. Notes Sonosky, Chambers, Sachse, Miller & Munson, LLP 4/20/11 NIHB National Tribal Health Reform Implementation Summit ● State Health Exchanges TRIBAL RECOMMENDATIONS Slide 15

  16. Notes Sonosky, Chambers, Sachse, Miller & Munson, LLP 4/20/11 NIHB National Tribal Health Reform Implementation Summit ● State Health Exchanges TRIBAL RECOMMENDATIONS Slide 16

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