Tribal Technical Advisory Group Update

1. Tribal Technical Advisory GroupUpdate NIHB Consumer Conference September, 2011

2. Outline • Introduction to the TTAG • Why Medicaid, CHIP and Medicare are Important • Successes • Opportunities / Challenges of ACA • Medicaid and Medicare Policy Committee invitation

3. Tribal Technical Advisory Group • Tribal advisory committee to CMS Administrator • Enhance Government-to-Government relationship • Honor Federal trust responsibilities • Increase understanding between CMS and Tribes • Does not substitute for tribal consultation • Representatives • Tribal leader or designee from each IHS Area (12) • National Indian Health Board (1) • Tribal Self-Governance Advisory Committee (1) • National Congress of American Indians (1) • Urban Indian Health Program (1) • Indian Health Service (1)

4. Don Warne (Aberdeen) Valerie Davidson (Alaska), Chair Carolyn Finster (Albuquerque) Kathy Hughes (Bemidji) Patricia Enos-Bergie (Billings) Jim Crouch (California) Donita Stephens (Nashville) Rex Lee Jim (Navajo) Judy Goforth Parker (Oklahoma) David Reede (Phoenix) Pearl Capoeman-Baller (Portland) Grace Manuel (Tucson) W. Ron Allen (TSGAC), Co-Chair H. Sally Smith (NIHB) Jason Dollarhide (NCAI) Carmelita Skeeter (NCUIH) Carl Harper (IHS) TTAG Membership

5. Cecelia Fire Thunder (Aberdeen) Jim Lamb (Alaska) TBA (Albuquerque) Phil Norrgard (Bemidji) Donna Buckles-Whitmer (Billings) James Russ (California) Dee Sabattus (Nashville) Roselyn Begay (Navajo) Rhonda Butcher (Oklahoma) Pam Thompson (Phoenix) Jim Roberts (Portland) Chester Antone (Tucson) Mickey Peercy (TSGAC) TBA (NIHB) Juana Majel-Dixon (NCAI) Toni Lodge (NCUIH) Dorothy Dupree (IHS) TTAG Alternates

6. Why focus on Medicaid, Medicare, and CHIP? • Indian Health Service only receives half of the level of funding needed to provide basic health care services. • No medical inflation increases. • Due to the gap between IHS funding and need, health services (including Long Term Care services) to AI/ANs are severely rationed.

7. Authority to Bill • Due to this disparity, Congress authorized IHS facilities to recover reimbursements from: • Medicaid, • Medicare, • State Children’s Health Insurance Programs, and • Private insurance

8. States Benefit with Medicaid • For average Medicaid beneficiary, CMS pays: • Federal Medical Assistance Percentage (FMAP) to States to help pay for Medicaid services • States make up the difference. • For a $1,000 service in a state with 58% FMAP: • $ 580 federal dollars • $ 420 state match $1,000 total

9. States Benefit with Medicaid • For AI/AN Medicaid beneficiaries: • States receive 100% FMAP, • For care receive in an IHS facility in recognition of the federal trust responsibility • For a $1,000 service in a state with 58% FMAP for AI/AN who receives care in IHS facility : • $1,000 federal dollars • $ 0 state match $1,000 total • $420 savings to the State General Fund when AI/AN Medicaid patients use the Indian Health System.

10. What does this mean? • In order for AI/ANs to be able to access Medicaid, Medicare, and CHIP programs in a meaningful and sustainable way, cooperation is required by all three: • IHS / Tribally Operated Programs / Urban Programs • CMS • States

11. Example of LTC implementation challenge in Indian Country: • Sustainability: 4 must-haves for Self-Governance Tribes • Tribe • Design program to meet needs • Negotiate language in Funding Agreement (FA) • Indian Health Service • Negotiate acceptable FA language • CMS • Provides 100% Federal Medical Assistance to the State for Medicaid • State • Provides Medicaid reimbursement to the Tribe

12. New Reality • For 100% FMAP to apply, it must be included in the State Plan • Some States are cutting budgets • Reimbursements • Programs • Educate states about opportunities for savings: • Enhance I/T/U ability to provide care

13. Some Progress • Children’s Health Insurance Program Reauthorization Act (CHIPRA) • American Recovery & Reinvestment Act (ARRA) • Patient Protection & Affordable Care Act • Indian Health Care Improvement Act

14. Recommended PPACA measures • Significantly increase rate of health care coverage for AI/AN • Financially strengthen Indian Health providers so programs can expand service capacity and access to health care • Significantly reduce AI/AN health disparities • Ensure that tribal leaders and staff receive PPACA training and resources to enroll people

15. Recommended PPACA measures • Ensure that our communities benefit from new grant and other funding opportunities • Implement Indian specific provisions effectively and efficiently • Expressly mention I/T/Us in regulation to protect the Indian Health system from adverse unintended consequences • Require all HHS agencies to engage in meaningful tribal consultation on implementation

16. Opportunities • Cost Sharing under an Exchange Program • No cost-sharing for AI/ANs who receive their care through I/T/U or through Contract Health • No cost-sharing for AI/ANs up to 300% FPL • Income exemptions for certain property • Reimbursement from VA/DoD • Stronger reimbursement language

17. Challenges • Benefits are dependent on the definition of Indian • Income/incentive payments and penalties • Need Indian addendum for Exchange Plans • Data requirements

18. Want more? • Medicaid and Medicare Policy Committee (MMPC) of the NIHB • Sally Smith, Chair of the MMPC • Conference calls held to discuss all Medicaid, Medicare, and CHIP policy issues. • To join, contact Tyra Baer at NIHB at tbaer@nihb.org

19. Questions? Valerie Davidson, TTAG Chair Ron Allen, TTAG Co-Chair ANTHC Jamestown S’Klallam Tribe Ph: 907-729-1900 Ph: 360-681-4621 Email: vdavidson@anthc.org Email: rallen@jamestowntribe.org Kitty Marx Tyra Baer CMS Tribal Affairs Group National Indian Health Board Ph: 410-786-8619 Ph: 202-507-4070 Email: kitty.marx@cms.hhs.gov Email: tbaer@nihb.org www.cmsttag.org