Legislative Update Ocean Shores, WA

1. Legislative UpdateOcean Shores, WA April 17, 2012

2. Overview • FY 2013 President’s Request • Contract Support Cost Updates • 112th Congress & Legislation • Oregon CCOs • TTAG Issues • Q&A

3. IHS FY 2013 President’s Request • President’s Request $115.9 million increase; 2.7% • NPAIHB Budget Analysis estimates $403 million to maintain current services • Inflation: $213.5 million • Population Growth: $90.4 million • CSC Shortfall: $99.3 million • IHS CJ explains Detail of Changes: • Current Services: $85.6 million for Federal Pay costs, medical inflation, staffing new facilities • Program Expansion: $30.3 million for CHS, Health IT (ICD-10), Direct Ops, CSC, M&I • Program Decrease in Facilities Construction $3.5 million

4. IHS FY 2013 President’s Request • Current Services: $85.6 million • Federal Pay Costs $2.4 million • Medical Inflation $33.9 million • Staffing new facilities $49.3 million • Program Increases (Reprogramming) • CHS increase $20 million • HIT ICD-10 $6 million • Direct Operations $1.1 million • Contract Support Costs $5 million • Maintenance & Improvement $1.5 million • Health Facilities Construction $3.6 million

5. Contract Support Cost Update • New interest in CSC issues driven by funding • FY 2010 $116 million increase; 41% increase • FY 2012 $74 million increase; 19% increase • FY 2013 $5 million; will drive up shortfall • IHS Director reconvened the Contract Support Cost Workgroup – Andy Joseph, Jr., Chairperson • First Workgroup Meeting Mar. 31-Feb. 1, 2012 • Charged to evaluate Dr. Grim 2007 changes for “new/expanded programs”; and provide recommendations • Meeting met at an impasse with the IHS Director due to lack of CSC data • CSCWG position was grant access to data or absent data, Workgroup “cannot and will not, proceed with its assessment of the 2007 Manual.”

6. Contract Support Cost Update • CSCWG/Andy Joseph Letter Feb. 22, 2012 letter requesting: • Access to data not the IHS CSC Report, information completion of reports, funding allocations from past years, redline of IHS recommended changes to CSC Manual • Contention around preparation for March CSC Workgroup meeting resulted in IHS Director cancelling • March 2, 2012, Dear Tribal Leader...effectively by-passed the CSC Workgroup • DTLL request input on new/expanded funding in FY 2012; and Tribal concerns about access to Tribe’s CSC data • NPAIHB Freedom of Information Act (FOIA) Request for items outlined in Feb. 22nd letter • IHS denied and NPAIHB has appealed to the Secretary

7. NPAIHB CSC Letters • February 22, 2012 Letter on “New/Expanded Programs” (sent March 16th) • 2007 change to CSC Policy by Dr. Grim • Portland Tribes support fairness & equity • Promotes self-determination opportunities for DST • NPAIHB supports up to $10 million for new/expanded programs; balance to shortfall • March 30, 2012 Letter on Data Confidentiality • Discussion on history of CSC policy and Tribal consultation • Changes have to be respectful of Tribal leaders recommendations and past work • Transparency promotes trust with the Agency and among Tribes – fairness & equity • Public information via NBC, Single Audit Act, Congressional reports • Assist to advocate for IHS budget and CSC • Northwest Tribes supportive of sharing CSC data

8. OMB Proposal for developing Indirect Cost Rates • OMB Federal Register Notice, Feb. 28, 2012 • Proposal will have an effect on Tribes • Concept proposal now, policy later, expect notice of proposed rule to follow • Changes for Single Audit Act • Multi-year IDC rates • Good & Bad • NPAIHB Analysis sent to Tribes April 11th • Board Comments, Analysis, and sample comment letter for Tribes • Make sure to get to your Finance/Mgmt staff responsible for developing IDC proposals

9. Senate Committee on Indian Affairs Update • Focus on technical & Native Hawaiian issues • Blood quantum, land/reservation, water, gaming, and cultural and preservation • Native Hawaiian Issues • Health care, home ownership • NH Health Care Improvement Act • NH Government Reorganization • SCIA focus is building health record for 113th Congress; awaiting Supreme Court • Hearing on IHS Budget March 12, 2012

10. State Policy Issues • Oregon’s Health Reform & Coordinated Care Organizations • Tribal provisions included in legislation* • Global Budgets & Alternative Payment Methods* • Mandatory Enrollment* • Indian Health Benefit Package* • Options for providing specialty care • Tribal Consultation • NPAIHB letter on CCO implementation recommendations • NPAIHB file letter to preserve Tribes ability to become CCOs

11. State Exchange Work • Exchange Analysis Papers • Exchange Impact Analysis on Tribal Health Programs • Justification for QHPs to Contract with Tribal Health Programs • Tribes as Navigators • Tribal Sponsorship of Premiums & Group Payer Arrangements • CO-OP Analysis & Tribes • Exchange IT Assessment, Tribal identification and documentation • Indian Definition & Documentation • Reference Guide to Federal Indian Laws & Regulations for Exchange Planning

12. Exchange Establishment • Tribal Consultation: NPR requirement for Exchange Plans to have TCP • Exchange Consumer Assistance Tools: • Website, Call Centers, Calculators, Navigators, Outreach & Education • Payment of Premiums; Group Payers • Indian Protections & definition of Indian • Reimbursement, QHP participation, network adequacy • Essential Community Providers • Other comments on IHCIA

13. Questions/Discussion Jim Roberts, Policy Analyst Northwest Portland Area Indian Health Board jroberts@npaihb.org