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A Survey of Indian Health Provisions in Patient Protection a Affordable Care Act (Pub.L. 111-148; enacted March 23, 2010) Carol L. Barbero Hobbs, Straus, Dean & Walker, LLP <cbarbero@hobbssstraus.com> May, 2010. Enhanced Access to Health Insurance

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A survey of indian health provisions in patient protection a affordable care act

  • A Survey of

  • Indian Health Provisions in

  • Patient Protection a Affordable Care Act

  • (Pub.L. 111-148; enacted March 23, 2010)

  • Carol L. Barbero

  • Hobbs, Straus, Dean & Walker, LLP

  • <cbarbero@hobbssstraus.com>

  • May, 2010


A survey of indian health provisions in patient protection a affordable care act

  • Enhanced Access to Health Insurance

  • Expectation: Some 30 million uninsured Americans will gain access to some form of health insurance coverage

    • Medicare, Medicaid, CHIP, private insurance

  • Indian Health Impact:

    • More Indians will be able to acquire coverage

      • Acquire on their own; purchase by tribe; purchase with ISDEAA funds

    • Opportunity for Indian health programs to increase third-party collections


A survey of indian health provisions in patient protection a affordable care act

  • Medicaid Expansion

  • 2010: States allowed (not required) to expand Medicaid to persons up to 133% FPL

    • Regular FMAP applies to expansion

  • 2014: All Medicaid programs required to cover persons at/below 133% FPL

    • Will provide coverage for non-elderly, non-disabled, non-pregnant childless adults who are not currently covered by Medicaid

    • 100% FMAP for expansion population

  • Impact: More Indian people will qualify for Medicaid coverage


A survey of indian health provisions in patient protection a affordable care act

  • Insurance Exchanges; Subsidies

  • “Exchange” = marketplace for information on health insurance products offering acceptable coverage

    • Operated by each state (or HHS Secretary)

    • Up and running Jan. 1, 2014

    • No government-run “public option”

    • Exchange products available to uninsured individuals and small businesses

  • Premium subsidies on sliding scale for individuals up to 400% of FPL


A survey of indian health provisions in patient protection a affordable care act

  • Indian-specific Exchange features

  • Indian individuals are eligible to purchase coverage through Exchange

  • Monthly “window” for Indian enrollment in Exchange insurance plan

  • No cost-sharing for Indians up to 300% FPL

  • No Indian patient may be assessed cost sharing for services provided by I/T/U or CHS provider

  • HHS pays the cost of Indian cost-sharing protections


A survey of indian health provisions in patient protection a affordable care act

  • Express Lane Agencies”

  • Public agencies that determine eligibility for income-based programs

    • E.g., Temporary Assistance for Needy Families (TANF)

  • States allowed (but not required) to rely on Express Lane Agency eligibility determinations for Medicaid, CHIP

    • Facilitate enrollment of kids in Medicaid, CHIP

  • IHS, tribes, tribal organizations, urban Indian organizations now have Express Lane Agency status

  • Effective March 23, 2010


A survey of indian health provisions in patient protection a affordable care act

  • Persons with Pre-Existing Conditions

  • Temporary program beginning in 2010

  • Make insurance coverage available to individuals –

    • Uninsured for 6 months or longer and

    • Who have pre-existing conditions

  • Ends in 2014 when the law’s consumer protections become effective

  • In Fall 2010, insurers ill be prohibited from denying coverage to kinds with pre-existing conditions


A survey of indian health provisions in patient protection a affordable care act

  • Individual Coverage Mandate

  • Objective: require all Americans to acquire some form of health insurance

    • Medicare, Medicaid, CHIP, private insurance

  • Enforced through tax penalties

  • Members of Federally-recognized Indian tribes are exempt from penalties

  • Individual Mandate requirement is being challenged in court by opponents


A survey of indian health provisions in patient protection a affordable care act

  • Tribally-provided Health Care Benefits

  • New law excludes value of health insurance and services provided to a tribal member by IHS or tribe from individual member’s gross income

  • Exclusion was high priority for Indian Country

    • IRS had said tribally-provided health insurance was taxable to individual tribal member

  • Effective March 23, 2010

  • “No inference” on whether such benefits provided prior to enactment are or are not excluded from member’s gross income


A survey of indian health provisions in patient protection a affordable care act

  • Indian Medicare Changes

  • Medicare Part B: Permanent authority for IHS, tribal programs to collect for all Part B services

    • Authority to collect for some Part B services expired Dec. 31, 2009

    • Effective retroactively to Jan. 1, 2010

  • Medicare Part D: Value of drugs dispensed by I/T/U pharmacy will count as if Indian patient paid for them

    • Corrects problem in original Medicare Part D law

    • Will enhance opportunities for I/T/U pharmacies to bill Part D drug plans

    • Effective Jan. 1, 2011


A survey of indian health provisions in patient protection a affordable care act

  • Payer of Last Resort

  • Puts in the law IHS’s regulation making IHS, tribal programs the payer of last resort

  • Impact: Any other insurance coverage carried by Indian patient is required to pay first

  • POLR rule now applicable to urban Indian organizations

  • Maximizes authority to collect third-party revenues

    • Medicare, Medicaid, CHIP, private insurance


A survey of indian health provisions in patient protection a affordable care act

  • Maternal + Child Home Visitation Program

  • New program for home visits to families with young children + expecting children who are at risk of poor maternal and child health

  • Federally-funded through grants to states

    • Funds already appropriated for 2010-2014

  • Tribes, tribal organizations, urban Indian organizations are eligible grantees

  • 3% of funds set-aside for Indian grants

    • Value of set-aside: $45 million over 5 years


A survey of indian health provisions in patient protection a affordable care act

  • Health Disparities Data Collection

  • HHS to collect data from Federal health programs by –

    • Race, ethnicity

    • Sex

    • Primary language

    • Disability status

  • Purpose: Monitor health disparity trends

  • Data will be collected from IHS programs

  • Tribal Epidemiology Centers are to be provided with health disparities analyses performed through this effort


A survey of indian health provisions in patient protection a affordable care act

  • Health Workforce Development

  • About ½ of the new law is devoted to health workforce development programs

  • Expansion of health workforce is vital to meet increased demand for care as more Americans acquire insurance coverage

  • IHS, tribes, tribal organizations, tribal public health agencies, urban Indian organizations eligible for many new programs

  • Most new programs will require appropriations

  • Watch for grant announcements