Legislative & Policy Update

1. Legislative & Policy Update NW Portland Area Indian Health Board Quarterly Board Meeting Great Wolf Lodge – Chehalis Tribe January 27, 2015

2. Report Overview • IHS Budget Updates • CHS Meeting & MLRRegs & CHEF • FAAB & CHS Workgroups • MLR for non-hospital based services • ACA Updates

3. FY 2015 Budget Update (3A) • Omnibus Bill finalizes FY 2015 IHS Budget • $208 million increase (4.7%) is respectable in current budget environment but not a good bill • Bill only provides $54 million for program increases which results in reprogramming base to cover staffing new facilities, new tribes funding, and contract support costs • Full impact of budget won’t be known until IHS makes available spending plan • Due to Congress 30 days after enactment

4. FY 2015 Budget Update (3A) • House & Senate have pending Interior Appropriations bills • House bill is $96 million more than the Senate bill • Senate bill requests only $2.5 million increase for CHS, while the House request is $50 million • Senate bill includes small increases for H&C items

5. FY 2015 Budget UpdateSummary of Congressional Action

6. Decent Budget Increases? • Overall H&C Accounts 3.2% • Dental Services 5.3% • Mental Health 4.1% • A&SA 2.5% • CHS 4% • Public Health Nursing 6.7% • Health Education 6% • * Indian Health Professions 44.5% • * Tribal Management 69% • * Self-Governance 21% • * Contract Support Costs 13%

7. Staffing and CSC Increase cut into the $208 million budget increase: Here’s how?

9. Portland Area FY 2017Budget Formulation (3B) • Session held Dec. 1-2, 2014 in Seattle • Recommendations at 5% - $231.7 million • Current Services $157.4 million • PRC $74.3 million • Recommendations at 17% - $787.8 million • Current Services $157.4 million • ACA & IHCIA & LTC $187.3 million • PRC $391 million • Restore Pay Act increases $48 million • Facilities: M&I, S&F, Equip. $80 million • National Work Session February 10-11th

10. FAAB Update Sacramento Meeting Nov. 12-13th • Call with IHS Director time for next report to Congress – March 23, 2016 • FAABletter to IHS Director endorsing support for revised HCFPS& recommendation it be sent to OMB • FAABletter to IHS National Budget Formulation Workgroup Chairs re: funding for M&I • FAAB affirms role of Needs Assessment Workgroup (NAW) to serve as technical advisors to the FAAB membership • FAAB appoints NAW to attend Jan/Feb. 2015 teleconference & begin process to develop master planning criteria

11. Purchased & Referred Care Report • Three Items: PRC Workgroup, MLR Regulations, and CHEF Procedures • PRC Workgroup Meeting in Denver (3C) • Review Recommendations DTLLs • CHEF regulations in development to lower threshold to $19 million; need legislation to cap threshold at set amount ($25 million) • Discussion recommendations for MLR regulation • Formula: GAO Recommendations 1. Adjust hospital access component to something other than “Yes” or “No” measure 2. Formula should use “CHS Users” and not Active User Population to allocate resources 3. Require Areas to notify IHS-HQ when deviating from formula

12. CHS Formula has two components. (1) 75% Cost Variable; (2) 25% Access to Care [CHS Dependency]

13. American Chamber of Commerce Research Association (ACCRA) • Some want to change due to criticism that ACCRA does not accurately measure price for all locales • Self reported by Chambers not highly reliable • OPTION: replace ACCRA with price data from ACA Insurance Exchanges • POTENTIAL: Plan filings by zip code data may be more reliable to determine costs of health care & can be customized to individual operating units

14. Hospital Measure – Access to Care

15. CHS Medicare-like Rate Regulation • December 5th IHS issued regulation to apply MLRs to non-hospital based charges • In principle a great idea! ... but rule contains an all or nothing “nuclear” requirement; it is not optional; does not allow exemption for local access issues or existing provider relationships • Other concerns that rule undermines the need for legislation? • Comment period initially closed Jan. 16th, but has been extended to February 4, 2015 • ***Individual Tribes will need to weigh in! A Board letter will not be enough on this one.***

16. MLR Rule Summary (3D) • Amends Sec. 506 to apply MLR to non-hospital based charges • Allows negotiating lower than MLRs • Nuclear provision prohibits PRC payment to providers if they do not agree to accept the MLR rates. • Could result in patient liability? • Restrict access if provider won’t accept rate • Other costs (travel) could be more than MLR rate • Currently no exemption for such circumstances in the proposed rule • Some feel rule encroaches on Tribal sovereignty and ISDEAA

17. MLR Rule Recommendations • Retitle rule to remove references to it applying to “Health Care professional services”. Sec. 506 already applies in limited circumstances. Avoid this confusion. • Exempt Tribal contributions to CHS from the rule. • Develop exemptions for local circumstances: • Exemption to respect on-going provider relationships even if this is above MLRs. • When travel or other costs to an alternate provider would exhaust any cost savings achieved by the rule. • When patient may have to travel more than XXX miles? • If Tribal health programs are within a XXX mile radius of a Critical Access Hospital • Develop mechanism to enforce IHCIA§ 135 “Liability for Payment” to protect patients from balance billing • IHS to develop training and technical assistance to implement the rule and resources to participate (unfunded mandate) • Set effective date for the rule to prepare for implementation.

18. ACA Updates • Enrollment ends Feb. 15, 2015 • CHS savings has been very beneficial • Medicaid collections are up for almost all Tribes • Medicaid data is good however need more reliable Exchange data to evaluate full impact • IRS final instructions for Exemption Form 8965 & Issued Publication 5187 “Health Care Law: What’s New for Families” • Covers tax issues of ACA; How “individual responsibility” can be met; covers exemptions; 1040 Line 61 Health Care • Tribal Employer Exemption from “employer mandate” – (See Whitehouse Letter developed by TTAG)

19. 114th Congress Begins • Legislative Plan Updated and preparation for lobby trips in February • President’s budget in February reinstating All Tribes meeting • Senate Committee on Indian Affairs • Chair, Sen. John Barrasso, WY – Physician, President WY Medical Society, 4th ranking member in Republican Leadership • Vice-Chair, Jon Tester, MT – previous chair, rancher, knows Board, Andy, very supportive of NW • Sen. Crapo and Sen. Cantwell (minority members same); majority added Kansas Sen. Jerry Moran and Montana Sen. Daines • House Resources Subcommittee on Indian Affairs • Rep. Don Young (AK) continues to Chair • Rep. Colleen Hanabusa (HI), is the Ranking Member • Rep. Pete Defazio (D-OR); Doc Hastings (R-WA)

20. Discussion?