Ready for Reform!

1. Ready for Reform! Port Gamble S’Klallam Tribe Washington State on the pleasant side of the Puget Sound on the Kitsap Peninsula with treaty rights stretching to the Olympic Peninsula, the Pacific Ocean and Canada Ed FoxHealth Director Port Gamble S’Klallam Tribe

2. Tribal Sponsorship of health insurance • One key aspect of health care reform will allow tribes to pay premiums for the health care insurance of its community members. • The Port Gamble S'Klallam Tribe has many years of experience in doing just that through the Basic Health Plan and Medicare Part B and D. • We assist tribal members in understanding their choices for Medicare Part D and Medicaid. • Over 10 years of ‘sponsorship’ of experience assisting individuals and families and that may continue under the health exchange’s Qualified Health Plans-especially if those plans allow our health program to be the medical home for our patients in their plans (with referrals to their network of providers).

3. Ready for Reform Initiative began February 1 2012.

5. Tribal Sponsorship Program • Vision of the Program: To Connect Tribal Members and their families to the health insurance coverage that is most appropriate for them and the health services department program.

6. Timeline and History of the Tribal Sponsorship Program • The TSP developed between February 2012 and June 2013. • Historical information and review of the PGST Tribal/ State Basic Health Program. PGST was a leader in Basic Health with the 3rd largest Tribal program, 150 of the approximately 1,000 tribal members (2011) were sponsored by the Port Gamble S’Klallam Tribe. • In January 2010 Basic Health became Medicaid Expansion under the WA State Bridge Waiver. In 2010 premiums were no longer required as Medicaid expanded to 133% of the federal poverty leveland the state-funded Basic Health ended and became a Medicaid Waiver Program-childless adults, but same asset and resource tests. • Our experience with Basic Health developed policies and procedures, which brought health insurance to 150 community members.  We have a great deal of experience with the issues raised by an insurance payment program. • PGST has worked on (a now a twelve year) Tribal Community Service State Pilot Project program that allows use to determine eligibility, verify income and enroll in Medicaid.

7. Eligibility, - Uninsured Eligible • Eligibility (subject to change) is similar to Contract Health Services eligibility, but restricted to Port Gamble S’Klallam Trial Members and their families. • All uninsured Port Gamble S’Klallam Tribe Tribal members living in Kitsap County are potentially eligible for sponsorship in the same manner as they are for Contract Health Services • You can’t have access to employer-sponsored insurance and access Exchange plan and subsidies. • This means many spouses dependents won’t be eligible even if uninsured- as they are expected to access employer plan. • CHS will have funds available for their health care needs if CHS –eligible-that does not change.

8. Eligibility of Uninsured2 Groups: Core (1st year) &Expanded Eligibility(2nd year if funds available) • CORE eligibility Group ---all are eligible because it is believed (at this time) that the cost of insurance is less than the payments to our health program + the costs savings to CHS (due insurance paying providers instead of CHS paying). • Elders-over 55 years old (Exchange plans are no more than 3 times lowest cost age group for highest cost age group-thus these plans are a ‘bargain.’ • Income level < 300 % FPL- Family of 3 $57 K since there is no cost sharing, no deductibles, no copays-saving on average at least $2,000 per insured. • Those working in Hazardous Occupations-for example, Fishing. • Those in poor health determined by a Health Assessment (Chronic health conditions) or simply looking at bills.

9. Key Income Level is 300% FPL Bronze level has lowestrates Because it has highest Deductibles No deductibles No copays AIANs eligible for Exchange who under 300% on average save over $2,000 with Bronze plan Bronze is cheaper because there is higher cost sharing

11. Expanded Eligibility • If savings are great and funds are available the S’Klallam Tribal Sponsorship Program could expand • Those in expanded eligible groups may include: • Under 55, but over 300% of poverty level. • All uninsured who do not have employer sponsored health care insurance. • Dependents of employed persons, but this will be very expensive and CHS is likely source of payment for this group. • TSP will decide whether it will pay for employer-offered dependent coverage or purchase health exchange coverage for dependents of employees.

12. Alignment with 4 Key elements of Health Care Reform • Medicaid Expansion • Health Insurance Exchange • Health Insurance Market Reforms No pre-existing conditions for all in 2014 (true for children now) • Cost Control (Payment and Delivery Reform) • Quality Improvement, Information Technology Sharing health information with specialists and hospitals

13. Refine eligibility and enrollment • Pilot Project for Medicaid/CHIP eligibility and enrollment we already have the nation’s best Tribal effort to determine eligibility and enroll our patients in health care plans in a way that is sensitive to the unique federal responsibility for health care services to American Indians and Alaska Natives. • We also participate in the Medicaid Administrative Match program (the first in the nation since 1999) to recoup some of the costs associated with this activity. Over $100,000 to tribe every year, but declining in recent years. • MAM will be key to paying for expansion, pays ½ cost. • Assister’s and Navigator programs will provide some financial assistance.

14. 6 Elements of Port Gamble S’Klallam Tribe’s readiness • Staffing: Support current monitor need for additional • Outreach and Education on Health Care reform tied to our Eligibility and Enrollment capacity • Make the Accounting system produce needed information for decision making-which option--- buy insurance or buy ‘risk’ • Continue to pay for health insurance and prepare for expansion of sponsorship • Electronic Health Record system • Work with other Tribes through other organizations.