Centers for Medicare & Medicaid Services Tribal Self-Governance Conference May 21, 2009

1. Centers for Medicare & Medicaid ServicesTribal Self-Governance ConferenceMay21, 2009

2. CMS(Centers for Medicare & Medicaid Services) Department of Health and Human Services (DHHS) Administers Medicare, Medicaid and Children’s Health Insurance Program (CHIP) Serves over 90 million beneficiaries Annual Budget of over $415 billion CMS plays a key role in the overall direction of the U.S. health care system CMS Organizational Overview

3. AI/AN populations served by IHS – 1.9 million AI/AN enrolled in: Medicare: 179,794 Medicaid: 793,835 CHIP: 26,744 FY 2009, IHS estimates Medicare & Medicaid reimbursements will exceed $750 million The revenues collected at each service unit varies from 15% to 50% of the service unit’s hospital and clinics operating budgets CMS AI/AN Beneficiaries

4. CMS Organizational Overview 10 CMS Regional Offices

5. At each CMS Regional office, there is a Native American Contact (NAC) who is available to provide technical assistance to Tribal programs The name and contact information for the NACs is available at the end of this handout Contact your NAC if your tribal program has questions about billing and reimbursements; and/or questions about Medicare, Medicaid and CHIP beneficiary services CMS Resources to Assist Tribes

6. NACs work with the Tribal Affairs Group, Office of External Affairs, CMS, located in Baltimore The Tribal Affairs Group serves as a liaison between the Agency and Tribal communities and other Federal Agencies in regards to AI/AN health and CMS programs. Director of TAG is Kitty Marx, who can be reached at kitty.marx@cms.hhs.gov CMS Resources to Assist Tribes

7. In FY 2009, the TAG, working with NACs and the IHS, will hold Area Trainings on Medicare, Medicaid, and CHIP issues Trainings begin in June 2009 – check with your Area Office on date and location Agendas are developed to meet Area needs and include such topics as: Medicare and Medicaid 101 CHIPRA and ARRA provisions Area specific topics CMS Training for Tribal Programs

8. Children’s Health Insurance Program Reauthorization Act (CHIPRA) reauthorizes the CHIP program for FY 2009 through FY 2013 American Recovery and Reinvestment Act (Recovery Act) provides funding opportunities to jumpstart the economy, creates new jobs and addresses long-neglected needs The following is a summary of some of the provisions in CHIPRA and the Recovery Act that are specific to Indian heath programs and AI/AN beneficiaries CHIPRA and Recovery Act

9. Section 201: outreach and enrollment Provides for $100 million for all enrollment and outreach activities – $80 million for outreach and enrollment grants to States and other eligible entities $10 million for national enrollment campaign, including outreach materials for Native Americans $10 million set aside for outreach to Indian children through grants to Indian Health providers and urban Indian organizations CHIPRA and Indian Health

10. Requires the Secretary to encourage States to take steps for enrollment of Indians into Medicaid and CHIP Includes outstationing eligibility workers Entering into State agreements with I/T/Us Requires CMS to take necessary steps to facilitate agreements between States and Tribes Exempts from a State’s 10% administrative cap for outreach & enrollment activities of Indian children Section 202 – Increased Outreach and Enrollment of Indians

11. Applies citizenship documentation requirements CHIP Effective July 2006, documentation from a Federally-recognized Tribe (such as a Tribal enrollment card or certificate of degree of Indian blood) is satisfactory evidence of citizenship and identity For Tribes located in States having an international border and whose membership includes non-U.S. citizens, the Secretary is to issue regulations, after Tribal consultation, identifying other forms of documentation Until such regulations are effective, Tribal enrollment/ membership documents for purposes of proving both citizenship and identity are sufficient Section 211: Tribal Documentation

12. Exempts AI/ANs from Medicaid cost-sharing for services received directly or through I/T/Us Exempts Indian-specific property in determining Medicaid and CHIP eligibility Exempts Indian-specific property from Medicaid estate recovery Section 5006 of the Recovery Act: Protections for Indians under Medicaid/CHIP

13. Codifies in law the current FACA-exempt TTAG and adds one representative each for IHS and Urban Indian organizations Requires States to consult with Tribes on Medicaid and CHIP issues have a direct effect on Indian health programs Enhanced protections Indian health programs and for AI/ANs enrolled in Medicaid managed care Section 5006 (cont’d)

14. All Tribes’ Calls beginning Friday, June 5th through Thursday, July 2nd – 2:00 – 4:00 PM ET Purpose of calls is to solicit tribal input on Recovery Act and CHIPRA Toll free number: 1-888-455-5059, passcode Tribal Affairs July 10th – Tribal Consultation Session to be held in Denver, immediately after Indian Health Summit, July 7-9th CMS Tribal Consultation

15. 1915(c) Waivers (Home and Community Based Waivers) Deficit Reduction Act State Plan Options 1915(i) HCBS state plan option 1915(j) Self-directed personal care option Money Follows the Person (MFP) demo grants Program for All Inclusive Care for the Elderly - PACE Key CMS LTC Community Based Programs

16. Case Management Homemaker/chore Home health aide services Personal care Adult day health Habilitation Respite care HCBS Covered Services - both 1915(c) and 1915(i)

17. Provide community based long-term care and support as an alternative to institutional placement. Allow a State to waive certain provisions of the Social Security Act. Statewideness Comparability of services Income and resource requirements HCBS Waivers (1915c)

18. 284 HCBS Waiver Programs More than 1 million participants $21.2 Billion: 7.5% of total Medicaid spending 24% of all Medicaid long-term services spending 67% of all Medicaid community service spending HCBS National Overview

19. States may opt to offer self-directed personal care services, including those offered by family members Provide items that increase independence or substitute for human assistance Planning, budgeting, spending and service delivery are individualized and directed by the person and those closest to him or her Incorporate participant direction into existing or new HCBS waivers. State Plan Option for Self-Directed Personal Care DRA Section 1915 (j)

20. Medicaid Demonstration program to transition individuals from institutional settings (e.g. nursing homes) to homes in their communities Individual has to be in an institutional setting for at least 6 months to qualify Population includes: elderly, persons with physical disabilities, development disabilities, mental illness, dual diagnosed Money follows the Person

21. 29 States & DC awarded MFP grants to transition 35,000 individuals through 2011 States with Tribal populations: California, Connecticut, Iowa, Kansas, Louisiana, Michigan, Nebraska, New York, North Carolina, North Dakota, Oklahoma, Oregon, Washington, Wisconsin MFP Grants

22. Designed to keep elders out of nursing home facilities Comprehensive Medical and LTC Services Adult Day health center, primary care and rehabilitation Integrated Team Management Care Integrated Medicare and Medicaid Financing PACEProgram of All-Inclusive Care for the Elderly

23. Cherokee Elder Care is first PACE to be sponsored by a Tribe Not limited to Cherokee tribal members Must be 55 years or older Certified by state to need nursing home level of care Must live in a PACE service area eldercare.cherokee.org Cherokee Elder Care

24. Medicaid money must flow through the state; Tribe(s) may explore an agreement with State agency Can waive statewideness and designate geographic area, ex., a Reservation Tribe(s) may tailor services and provider qualifications (can be specific to a tribe) 100% FMAP for some HCBS services under compacting - 638 Authority LTC options for Tribes

25. Eligible Tribal Memberscan apply to be consumers for benefits in their area. Qualified Tribal Providerscan contract with the State or administering agency as a waiver provider or to perform certain administrative functions. Tribal Governmentscan perform a wide range of administrative functions re HCBS program operations on behalf of the State Medicaid Agency. Accessing LTC services

26. Region I – Boston (CT, ME, MA, NH, RI, VT) – Nancy Grano (617) 565-1695 nancy.grano@cms.hhs.gov Region II – (NY, NJ, PR, Virgin Islands) – Julie Rand (212) 616-2433 julie.rand@cms.hhs.gov Region III – Philadelphia (DE, DC, MD, PA, VA, WV) – Tamara McCloy (215) 861-4220 tamara.mccloy@cms.hhs.gov Region IV – Atlanta (AL, NC, SC, FL, GA, KY, MS, TN) – Dianne Thornton (404) 562-7464 dianne.thornton@cms.hhs.gov Region V – Chicago (IL, IN, MI, OH, WI) – Pam Carson (312) 353-0108 pam.carson@cms.hhs.gov CMS Native American Contacts

27. Region VI – Dallas (AR, LA, NM, OK, TX) Dorsey Sadongei (214) 767-4425 eudora.sadongei@cms.hhs.gov Region VII – Kansas City (IA, KS, MO, NE) Nancy Rios (816) 426-6460 nancy.rios@cms.hhs.gov Region VIII – Denver (CO, MT, ND, SD, UT, WY) Cynthia Gillaspie (303) 844-4725 cynthia.gillaspie@cms.hhs.gov Region IX – San Francisco (AZ, CA, HI, NV, Guam, Northern Mariana Islands, American Samoa) Rosella Norris (415) 744-3611 rosella.norris@cms.hhs.gov Region X – Seattle (AK, ID, OR, WA) Cecile Greenway (206) 615-2428 cecile.greenway@cms.hhs.gov CMS Native American Contacts

28. Questions?CMSOARRAQUESTIONS@CMS.HHS.GOVCMSCHIPRAQUESTIONS@CMS.HHS.GOVFor more information visit the CMS AI/AN Center: www.cms.hhs.gov/center/ir.asp