ihcia and aca opportunities and challenges n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
IHCIA and ACA Opportunities and Challenges PowerPoint Presentation
Download Presentation
IHCIA and ACA Opportunities and Challenges

Loading in 2 Seconds...

play fullscreen
1 / 58

IHCIA and ACA Opportunities and Challenges - PowerPoint PPT Presentation


  • 144 Views
  • Uploaded on

Sonosky , Chambers, Sachse, Miller & Munson, LLP. IHCIA and ACA Opportunities and Challenges. National Council of Urban Indian Health April 24, 2012 Myra M. Munson, J.D., M.S.W. myra@sonoskyjuneau.com.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'IHCIA and ACA Opportunities and Challenges' - keon


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
ihcia and aca opportunities and challenges

Sonosky, Chambers, Sachse,

Miller & Munson, LLP

IHCIA and ACAOpportunities and Challenges

National Council of Urban Indian Health

April 24, 2012

Myra M. Munson, J.D., M.S.W.

myra@sonoskyjuneau.com

Washington, DC Juneau, AK Anchorage, AK Albuquerque, NM San Diego, CA

roadmaps

Roadmaps

You have to know where you are, if you want to figure out how to get where you want to go.

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 2

so where are we

So, where are we?

The Administration is moving full speed ahead

Some States are implementing; others are still on the fence

The Supreme Court is considering

Health Providers are trying to position themselves

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 3

a quick review of opportunities that are not in the ihcia amendments or aca

A quick review of opportunities that are NOT in the IHCIA amendments or ACA

*Medicare Like Rates – MMA Sec. 506 (42 U.S.C. § 1395cc(a)(1)(U));

42 CFR Part 136.

A Medicare enrolled hospital may not receive more than a Medicare Like Rate for services provided to an American Indian or Alaska Native (AI/AN) for any medical care purchased under the contract health services (CHS) program or UIO purchase for urban Indian. IHCIA Sec. 4(5) defines CHS to include referrals without commitment to pay.

*Medicare Part D Drug Benefit – Special Protection for AI/ANs

*Applies to Urban Indian Organizations (UIO), also

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 4

chipra

CHIPRA

*Outreach & Enrollment Grant Set Aside – Sec. 201 (42 USC 1397mm(b)(2))

10% set aside plus access to generally available funds for outreach and enrollment of children “who are Indians” (as defined in IHCIA Sec. 4)

*Increased State Outreach & Enrollment – Sec. 202 (42 USC 1320b-9).

Citizenship Documentation – Sec. 211(b)(1) (42 USC 1396b(x)(3)(B))

Medicaid must accept a document issued by a federally recognized Tribe evidencing membership or enrollment

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 5

arra sec 5006

ARRA Sec. 5006

*No Medicaid Premiums or Cost Sharing – 42 USC 1396o(j).

AI/ANs referred by CHS to any provider are not responsible for any cost sharing.

The provider payment may not be reduced by the amount of the cost sharing

Property Exemptions for Medicaid – 42 USC 1396a(ff)

Estate Protection – 42 USC 1396p(b)(3)

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 6

arra sec 50061

ARRA Sec. 5006

*Medicaid Managed Care – 42 USC 1396u-2.

Must pay Indian health care providers (i.e. I/T/U) for services provided to AI/AN (including Indian FQHCs)

*Consultation – 42 U.S.C. § 1396a(a)(73)

Requires State Medicaid programs to consult with IHS, Tribes and Tribal Organizations, and UIOs

*TTAG – ARRA § 5006(e)(1)

Formalized in statute the CMS Tribal Technical Advisory Group

Added IHS and NCUIH

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 7

what didn t change in title v

What Didn’t Change in Title V

Sec. 501 Purpose – establish programs in urban centers to make health services more accessible to urban Indians

Sec. 502 Contracts and Grants with UIO – Authority pursuant to Snyder Act

Sec. 503 Contracts and Grants for Provision of Health Care and Referral Services

Sec. 504 Contracts and Grants for Determination of Unmet Health Care Needs

Sec. 505 Evaluations; Renewals

Sec. 506 Other Contract and Grant Requirements

Sec. 507 Reports and Records

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 8

what else didn t change in title v

What Else Didn’t Change in Title V

Sec. 508 Limitation on Contract Authority – Cannot exceed amounts appropriated for such purposes

Sec. 509 Facilities Renovation – to assist with maintaining The Joint Commission requirements

Sec. 510 Urban Indian Health Branch

Sec. 511 Grants for Alcohol and Substance Abuse Related Services

Sec. 513 Urban NIAAA Transferred Programs

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 9

definitions that didn t change

Definitions That Didn’t Change

Sec. 4 –

(13) Indians or Indian

(27) Urban Center – any community which has a sufficient urban Indian population with unmet health needs to warrant assistance under title V, as determined by the Secretary

(28) Urban Indian – any individual who resides in an urban center, as defined in subsection (27) and who meets one or more of the criteria in subsection (13)(1) through (4) [same as 42 CFR 447.50(ii)(A) through (D)]

(28) Urban IndianOrganization

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 10

but who is an indian under the aca

But, Who Is an Indian under the ACA?

“The term “Indian tribe” means any Indian tribe, band, nation, pueblo, or other organized group or community, including any Alaska Native village or group or regional or village corporation as defined in or established pursuant to the Alaska Native Claims Settlement Act, which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status of Indians.”

IRC Sec. 45A(c)(6) only

IHCIA Sec. 4(14), ISDEAA Sec. 4(d), AND IRC Sec. 45A(c)(6)

IHCIA Sec. 4(14) only

“Indian” means a person who is a member of an Indian tribe (includes Alaska Natives). See, definitions above, 42 CFR 36 (IHS Eligibility Regulations) and 42 CFR 447.50 (CMS implementation of ARRA cost sharing protections)

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 11

how does cms define indian 42 cfr 447 50

How Does CMS Define “Indian”? 42 CFR 447.50

For purposes of [Medicaid program], Indian means any individual defined at 25 USC 1603(c), 1603(f), or 1679(b), or who has been determined eligible as an Indian, pursuant to Sec. 136.12. This means the individual:

Is a member of a Federally-recognized Indian tribe;

Resides in an urban center and meets one or more of the following four criteria:

(A) Is a member of a tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated since 1940 and those recognized now or in the future by the State in which they reside, or who is a descendent, in the first or second degree, of any such member;

(B) Is an Eskimo or Aleut or other Alaska Native;

(C) Is considered by the Secretary of the Interior to be an Indian for any purpose; or

(D) Is considered to be an Indian under regulations promulgated by the Secretary;

(iii) Is considered by the Secretary of the Interior to be an Indian for any purpose; or

(iv) Is considered by the Secretary of Health and Human Services to be an Indian for purposes of eligibility for Indian health care services , including as a California Indian, Eskimo, Aleut, or other Alaska Native.

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 12

so where are we with the definition of indian

So, where are we with the definition of Indian?

Advocates have asked for HHS and IRS to rely on the Medicaid regulation to clarify the meaning of the statutory definition.

CMS has agreed that the IHCIA and ISDEAA definitions are operationally identical. Improvement over proposed rule, but . . .

Members of Congress considering whether to try to fix it

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 13

what about implementation of the ihcia amendments
What About Implementation of the

IHCIA Amendments?

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 14

so we don t get confused let s not forget the new definitions

So We Don’t Get Confused, Let’s Not Forget the New Definitions

Sec. 4 –

(12) Indian health program means (A) any health program administered directly by the Service; (B) any tribal health program; and (C) any Indian tribe or tribal organization to with the Secretary provides funding pursuant to section 23 of the Act of June 25, 1910 (25 USC 47) (commonly known as the ‘Buy Indian Act’).

(25) Tribal Health Program means an Indian tribe or tribal organization that operates any health program, service, function, activity, or facility funded, in whole or part, by the Service through, or provided for in, a contract or compact with the Service under the [ISDEAA].

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 15

consultation and conference

Consultation and Conference

*Policy Sec. 3(5) “to require that all actions under [the IHCIA] be carried out with active and meaningful consultation with Indian tribes and tribal organizations, and conference with urban Indian organizations, to implement [the IHCIA] . . .

*Sec. 514 Conferring with UIOs. IHS must confer, “to the maximum extent practicable, with UIOs in carrying out the IHCIA.

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 16

sec 206 third party recovery 25 u s c 1621e

Sec. 206 THIRD PARTY RECOVERY25 U.S.C. § 1621e

*Right to recover reasonable charges or highest amount the payor would pay a non-governmental provider

from insurance companies, HMOs, employee benefit plans, and tortfeasors, and any other responsible or liable third party

Recovery from tortfeasors

Allows THOs to use the Federal Medical Care Recovery Act

No special claims processing rules can be imposed

Allows THO to recover costs and attorney’s fees if prevail

Applies to urban Indian organizations (see subsection (i))

Protects existing laws, including medical lien laws

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 17

sec 401 reimbursement from medicare medicaid and chp

*Sec. 401 Reimbursement from Medicare, Medicaid, and CHP

Expanded to Children’s Health Insurance

Applies to all programs (rather than facilities)

100% pass through to program providing services (up from 80% for IHS directly operated)

Expands allowable “use of funds,” including to achieve the objectives under Sec. 3 of the Act

No preferential treatment for beneficiary with Medicaid, Medicare or CHIP

I/T/U must provide IHS a list of each provider enrollment number (or other identifier)

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 18

sec 207 crediting reimbursement and protection against offset

*Sec. 207 Crediting Reimbursement and Protection Against Offset

(a) All reimbursements received by I/T/U shall be credited to the unit that generated it.

(b) The IHS may not offset or limit any amount obligated to any Service Unit or entity receiving funding from the Service because of the receipt of reimbursements under subsection (a).

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 19

new employee insurance option

New Employee Insurance Option

*Sec. 409 Access to Federal Insurance. Allows a tribe or tribal organization carrying out programs under the ISDEAA, or an urban Indian organization with IHS funding, to buy federal health insurance for the employees of the tribe, tribal organization, or urban Indian organization.

OPM is actively implementing now with monthly notices and opportunities to join.

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 20

licensing standards

Licensing & Standards

*Sec. 408 Non-Discrimination in Qualifications for Reimbursement.25 U.S.C. § 1647a. Provides for payment of I/T/U programs by any Federal health care program without regard to licensed status so long as meet other generally applicable requirements for participation

But not, Sec. 221, which exempts licensed tribal health program health professional employees from licensing in the state in which they practice

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 21

insurance now and after 2014

INSURANCENow and After 2014

*Sec. 402 Purchasing Health Care Coverage.

IHS funds made available to an I/T/U (including ISDEAA funds) may be used to purchase health benefits coverage for beneficiaries

May consider need of beneficiaries

May cover expenses for a self-insured plan, including administration and insurance to limit financial risks

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 22

fees parity

FEES PARITY

*Sec. 124 Exemption from certain fees.

Employees of tribal and urban health programs are exempt from fees imposed by federal agencies to the same extent that IHS employees and commissioned corps officers are exempt. Eg., DEA registration fees.

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 23

other provisions

OTHER PROVISIONS

*Sec. 805 Medical Quality Assurance Records & Qualified Immunity. Provides authority for peer review to occur without compromising confidentiality of medical records and the review process

Sec. 831 Traditional Health Care Practices. Expressly authorizes the Secretary to promote traditional health care practices, but limits liability of United States for provision of such services

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 24

what did change in title v

What Did Change in Title V

Sec. 502(b) – IHS’s authority to impose conditions is subject to Section 506 (requested by NSC in 1999)

Sec. 512 Treatment of Certain Demo Projects. Tulsa Clinic and Oklahoma City Clinic demonstration projects shall –

Be permanent programs within the Service’s direct care program;

Continue to be treated as Service units and operating units in the allocation of resources and coordination of care: and

Continue to meet the requirements and definitions of an urban Indian organization in this Act, and shall not be subject to the provisions of the ISDEAA.

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 25

other reminders of opportunities

Other Reminders of Opportunities

Sec. 515. Expanded Authority. Notwithstanding any other provision of the IHCIA, IHS may establish programs, including grants to UIOs, “that are identical to any programs established” under sections 218 (prevention, control and elimination of communicable diseases), 702 (behavioral health prevention and treatment services), and 708(g) (multidrug abuse program).

Sec. 516. Community Health Representatives – UIOs may used CHRs trained under section 107

Sec. 517. Use of Federal Facilities and Sources of Supply.

Sec. 518. Health Information Technology grants.

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 26

more expanded authority and opportunity under title v

More Expanded Authority and Opportunity under Title V

Sec. 516. Community Health Representatives – IHS may allow UIOs to employ CHRs trained under section 107.

Sec. 517. Use of Federal Facilities and Sources of Supply

Sec. 518. Health Information Technology grants.

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 27

other changes important to tribal health programs
OTHER CHANGES IMPORTANT

TO TRIBAL HEALTH PROGRAMS

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 28

ai ans veterans streamlining and opportunity

AI/ANs VETERANSStreamlining and Opportunity

Sec. 405(a) Authorizes sharing arrangements between IHS, Tribes and Tribal Organizations, and VA and DoD.

Sec. 405(c) Requires VA and DoD to reimburse IHS and Tribal health programs for services provided to beneficiaries of VA or DoD

Sec. 407 Authorizes collaborations between VA and IHS/Tribal health programs at Indian health program locations

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 29

other opportunities to share

OTHER OPPORTUNITIES TO SHARE

Sec. 822 Shared Services for Long-Term Care.

Expressly authorizes sharing staff and other services between IHS or tribal health program and tribally operated long term care or related facility.

Sec. 307 Indian Health Care Delivery Demo.

Encourages demonstration projects through IHS, tribes, or tribal health programs to test alternative means of delivering health services to AI/ANs through facilities and through alternative and innovative methods like community health centers and cooperative agreements with other community providers for sharing or coordinating use of facilities, funding, and other resources

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 30

sec 205 supportive services program expansion for indian health programs

Sec. 205 SUPPORTIVE SERVICESPROGRAM EXPANSION FOR INDIAN HEALTH PROGRAMS

Assisted living service, as defined in 12 USC 1715w(b), except need not be licensed, but must meet applicable standards for licensure

Home- and community-based service means 1 or more services specified in 42 USC 1396t(a)(1)-(9) that are or bill be provided in accordance with applicable standards

Hospice care all items and services in 42 USC 1395x(dd)(1)(A)-(H) and “such other services the THO determines are necessary and appropriate in furtherance Of that care

Long-term care services as defined in section 7702B(c) of the Internal Revenue Code of 1986

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 31

sec 119 community health aide program expanding outside alaska

Sec. 119 COMMUNITY HEALTH AIDE PROGRAMExpanding Outside Alaska

Extends program outside Alaska, except DHATs

Provided funding must be found

Consider grants for alternative care providers and third-party reimbursement (Medicaid can pay for CHAP services)

No limit on services by other dental health aides

Allows Tribes to use mid-level dental providers on the same basis as authorized by the State

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 32

facilities

FACILITIES

Sec. 301 Health Facilities

Requires a Report of Facility Needs within 1 year

comprehensive, national, ranked list of all health care facility needs for facilities, including inpatient; outpatient; specialized facilities like long-term care and alcohol & drug treatment; wellness centers, staff quarters, including renovation and expansion needs

Requires a Comptroller General Report regarding Methodology for Facility Priorities

*Authorizes Innovative Approaches and in (f) requires confernce with UIOs re: developing such approaches

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 33

and more about facilities

AND, MORE ABOUT FACILITIES

*(?) Sec. 311 Other Funding. Allows other agencies to transfer funds to IHS for planning, design, construction or operation of health care or sanitation facility to achieve purposes of this Act [not limited to tribes and tribal organizations]

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 34

authority and protection

AUTHORITY AND PROTECTION

Sec. 828 Tribal Health Program Option for Cost Sharing.

Acknowledges authority of tribal health programs to charge Indians for services, but retains the limit on being required to do so.

Continues the prohibition on IHS charging AI/ANs for services or requiring any Tribal health pro to charge.

Sec. 206(f) IHS Recovery from Tribal Self-Insurance

Prohibition continues unless the Tribe expressly authorizes it for periods that cannot exceed one year

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 35

aca and the ihcia

ACA and the IHCIA

*Payer of Last Resort – ACA Sec. 2901(b); 25 U.S.C. § 1623(b).

Health Programs operated by I/T/U are the payers of last resort for services provided to AI/ANs for services provided through such programs “notwithstanding any Federal, State, or local law to the contrary.”

*No Cost Sharing for Under 300% – ACA Sec. 1402(d) and 2901(a); 25 U.S.C. § 1623(a). AI/ANs with income at or below 300% of FPL enrolled in coverage under a State exchange are exempt from cost sharing.

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 36

more indian specific provision in aca expand previous protections

More Indian Specific Provision in ACAExpand Previous Protections

Cost Sharing Protections under Exchange Plans – Sec. 1402(d) and 2901(a)

Indians under 300% of poverty, enrolled in any Exchange plan, are exempt from cost sharing (Also see, 25 U.S.C. § 1623(a))

No cost sharing for services provided by I/T/U and no deduction in payments to I/T/U

Qualified Health Plan paid the cost sharing by HHS

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 37

implementation of other aca provisions
Implementation of Other ACA Provisions

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 38

exchanges recommendations and responses

Exchanges:Recommendations and Responses

I/T/U as In Network Providers: No, but it isn’t necessary, given the protections of Sections 206 and 408 of IHCIA

I/T/U as Essential Community Providers: 42 C.F.R. § 156.235. Not necessarily, but there must be a sufficient number and geographic distribution of ECPs are to be included in each QHP and I/T/U providers fall within the definition of ECP.

Require Use of an Addendum Setting Out Special Conditions:No, but will permit Exchanges to require them

Require Exchanges to Accept Aggregated Premiums from I/T/U: No, but speaks favorably of the advantages and will permit Exchanges to set up mechanism

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 39

more about exchanges

More about Exchanges

Consultation with I/T/U: 42 C.F.R. § 155.130 Exchanges must consult with many stakeholders including Federally recognized tribes. Rejected request to include tribal organizations and urban Indian organizations, although noted that they may be included in other stakeholder categories, “We therefore encourage States to consult with tribal and Urban Indian organizations.”

Special Enrollment: 42 C.F.R. § 155.420(d)(3). Regulations enforce right of AI/ANs to enroll in or change plans one time per month (instead of only during annual enrollment)

Verification of Being AI/AN: Have requested additional comment

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 40

navigators and other outreach

Navigators and Other Outreach

I/T/U eligible to be navigators, but all navigator funding is State and CMS won’t require States to necessarily fund I/T/U

Providers may be navigators

Rejected request for Indian desks at Call Centers; will not impose specific requirements. CMS believes the needs are addressed in 42 C.F.R. § 155.205(a) which requires call centers to be able to “address the needs of consumers requesting assistance.”

Web Access: Requests for Indian specific calculations – will be considered when develop more specific guidance

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 41

federal exchange

Federal Exchange

Still waiting for proposed rules, but clearly will be a lot of deference given to States.

Acknowledgement that the Federal exchange will be subject to consultation requirement.

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 42

accountable care organizations

Accountable Care Organizations

Governance Flexibility. Rigidity in NPRM rejected. Not all participants have to be members of governing board (provided 75% of governing body are ACO participants; no requirement for proportionate control.

I/T/U can be or participate in ACO– without State license, if they can meet the other requirements

Quality Performance Standards Narrowedfrom 66 across 5 domains to 33 across 4.

ACO Not at Risk for First Three Years – allowed to reconsider at the end of that time

FQHC/RHC May Form Independent ACO

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 43

medicaid expansion cms 2349 f final interim rule

Medicaid ExpansionCMS-2349-F (Final, Interim Rule)

Allows Medicaid agencies to delegate determinations to a nongovernmental Exchange for MAGI populations.

Lump sum payments will be treated like it is now under SSI and Medcaid; i.e. will not bar eligibility

Cross State Border Issues – no change in basic residency rules, but will work with States

AI/AN Property Exemptions – See 42 C.F.R. § 435.603(e)(3)

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 44

still open for comment til 5 7 12

Still Open for Comment til 5/7/12

§431.300(c)(1) and (d) and §431.305(b)(6) – Safeguarding information on applicants and beneficiaries.

§435.912 – Timeliness and performance standards for Medicaid.

§435.1200 - Coordinated eligibility and enrollment among insurance affordability programs.

§457.340(d) – Timeliness standards for CHIP.

§457.348 – Coordinated eligibility and enrollment among CHIP and other insurance affordability programs.

§457.350(a), (b), (c), (f), (i), (j), and (k) – Coordinated eligibility and enrollment among CHIP and other insurance affordability programs.

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 45

more from the aca indian specific protections in health reform

More from the ACAIndian Specific Protections in Health Reform

Tax Penalty Exemption – ACA Sec. 1411(b)(5)(A) (42 USC 18081) and ACA Sec. 1501(e)(3) (26 USC 5000A(e)(3)). Indians exempt from tax penalty for failure to maintain minimum essential coverage

*(?) Gross Income Exclusion – ACA Sec. 9021; IRC Sec. 139D. For for tax purposes does not include the value of health care services or insurance purchased by poses the value of health services or insurance provided or purchased by a Tribe or Tribal Organization (“or through a third-party program funded by the IHS”) is excluded from gross income not include the value of health care services or insurance purchased by

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 46

background and references
BACKGROUND AND REFERENCES

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 47

most recently

Most Recently. . .

ACA – Patient Protection and Affordable Care Act, Pub. L. 111-148 (March 23, 2010)

IHCIA – Indian Health Care Improvement Act, Pub. L. 94-437, (1976) as amended most recently by PPACA, Section 10221 (25 USC 1601 et. seq.) (March 23, 2010), which incorporated by reference S. 1790, as reported by the Senate Committee on Indian Affairs in December 2009, with four amendments

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 48

and before that

And, Before That . . .

ARRA – American Recovery and Reinvestment Act of 2009, Pub. L. 111-5 (Feb. 2009)

CHIPRA – Children’s Health Insurance Program Reauthorization Act, Pub. L. 111-3 (Feb. 2009)

MMA – Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub. L. 108-173 (Dec. 2003)

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 49

and more basically

And, More Basically

ISDEAA – Indian Self-Determination and Education Assistance Act, Pub. L. 93-638, (1975), as amended most recently by the Tribal Self-Governance Amendments of 2000, Pub. L. 106-260

Snyder Act – Pub. L. 67-85, Nov. 2, 1921, 25 USC 13 (providing for appropriations to the BIA for relief of distress and conservation of health) and

Transfer Act-- Pub. L. 83-568, Aug. 5, 1954 (transferring responsibility for health from BIA to PHS)

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 50

first don t forget it didn t all change

First, DON’T FORGET, IT DIDN’T ALL CHANGE

Purpose, Policy & Definitions

Title I Health Professions

Title II Health Programs

Title III Facilities

Title IV Funding and Access

Title V Urban Indian Programs

Title VI IHS Organization

Title VII Behavioral Health

Title VIII Miscellaneous

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 51

history of ihcia

HISTORY OF IHCIA

ENACTED September 30, 1976

As Pub. L. 94-437

Amended by:

Pub. L. 96-537 (12/17/80)

Pub. L. 100-579 (10/31/88)

Pub. L. 100-690 (11/18/88)

Pub. L. 100-713 (11/23/88)

Pub. L. 101-630 (11/28/90)

Pub. L. 102-573 (10/29/92)

Pub. L. 104-313 (10/19/96)

Pub. L. 105-277 (10/21/98)

Pub. L. 105-362 (11/10/98)

Pub. L. 106-417 (11/1/2000)

Pub. L. 111-148 (3/23/2010), Section 10221

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 52

acronyms for ihcia and aca

ACRONYMS FOR IHCIA AND ACA

ACA = Patient Protection and Affordable Care Act,

Pub. L. 111-148

ARRA = American Recovery and Reinvestment Act of 2009, Pub. L. 1115 (Feb. 2009)

AI/AN = American Indian/Alaska Native

CHIP (or CHP) = Child Health Insurance Program

CHIPRA = Children’s Health Insurance Program Reauthorization Act, Pub. L. 111-3 (Feb. 2009)

CHSDA = Contract Health Service Delivery Area

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 53

acronyms for ihcia and aca1

ACRONYMS FOR IHCIA AND ACA

CMS = Centers for Medicare & Medicaid Services

DHAT = Dental Health Aide Therapist

DoD = Department of Defense

FEHBP = Federal Employee Health Benefit Plan

FPL = Federal Poverty Level

HHS = Department of Health and Human Services

HMO = health maintenance organization

IHCIA = Indian Health Care Improvement Act,

Pub. L. 94-437, as amended

IHS = Indian Health Service

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 54

acronyms for ihcia and aca2

ACRONYMS FOR IHCIA AND ACA

IRC = Internal Revenue Code

ISDEAA = Indian Self-Determination & Education Assistance Act, Pub. L. 93-437, as amended

I/T/U = Indian Health Service/Tribal Health Program/Urban Indian Organization

MAGI = Modified Adjusted Gross Income

MEDPAC = Medicaid and CHIP Payment and Access Commission

MMA = Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub. L. 108-173 (Dec. 2003)

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 55

acronyms for ihcia and aca3

ACRONYMS FOR IHCIA AND ACA

MMPC = Medicare/Medicaid Policy Committee of the NIHB

NIHB = National Indian Health Board

OCIIO = Office of Consumer Information and Insurance Oversight in HHS

PCIP = Pre-Existing Condition Insurance Plan (often referred to as “high risk pool” plan)

TTAG = Tribal Technical Advisory Group to the CMS

TrOOP = True Out-of-Pocket costs applicable to

Medicare Part D

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 56

acronyms for ihcia and aca4

ACRONYMS FOR IHCIA AND ACA

UIO = Urban Indian Organization, as defined in IHCIA

Sec. 4(29)

VA = Veteran’s Administration

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 57

presenter

Presenter

Myra M. Munson is a partner in the Juneau office of Sonosky, Chambers, Sachse, Miller & Munson LLP, which specializes in representing tribal interests in Alaska and throughout the United States. She earned her bachelor's degree from the University of Alaska Fairbanks in 1972 and her law degree and master's degree in social work with honors from the University of Denver in 1980. After serving as Alaska Commissioner of Health and Social Services from 1986 to 1990, Ms. Munson joined the Sonosky Law Firm where her practice has emphasized self-determination and self-governance, the Indian Health Care Improvement Act (IHCIA), Medicaid and other third-party reimbursement issues, and other health program operations issues. She was a technical advisor to the IHCIA National Steering Committee for over 10 years; assisted in drafting and editing substantial sections of the reauthorization; and testified before the Senate Committee on Indian Affairs. Ms. Munson is also a member of the National Indian Health Board Medicare & Medicaid Policy Committee, and a technical advisor to the Centers for Medicare and Medicaid Services Tribal Technical Advisory Group. She has been conducting extensive training on the Affordable Care Act and IHCIA since their passage and serves as a consultant to the National Indian Health Board with regard to training on and implementation of these new laws. In 2003, Ms. Munson was given the Denali Award by the Alaska Federation of Natives.

Sonosky, Chambers, Sachse, Miller & Munson, LLP

April 24, 2012 National Council of Urban Indian Health Slide 58