TRIBAL PREMIUM SPONSORSHIP PROGRAM
POLICIES and PROCEDURES August, 2014
Photo by Earl Hooper
Acknowledgements; Port Gamble S’Klallam Swinomish Tribe and input from in-person visits with Confederated Tribes of the Colville Reservation, Tulalip Tribes, Makah Nation, Quinault
Nation, Lummi Nation, Nisqually and Muckleshoot Tribe.
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TRIBAL PREMIUM SPONSORSHIP PROGRAM ........................................................................................ 4
INTRODUCTION ................................................................................................................................ 4
Purpose .............................................................................................................................................................................. 4
Timeline and History ........................................................................................................................ 4
TERMS OF PARTICIPATION ................................................................................................................ 5
RESPONSIBILITIES, TPSP ..................................................................................................................... 5
Segregation of FUNDS FOR SPONSORSHIP OF PREMIUMS ................................................................... 6
Health Plan Finder ............................................................................................................................ 6
Health Plan Finder Payments ............................................................................................................. 7
Special Provisions- ACA .................................................................................................................... 7
T RIBAL C ONSULTATION ................................................................................................................................................. 8
T RIBES P AYING P REMIUMS ........................................................................................................................................... 8
E SSENTIAL C OMMUNITY P ROVIDERS ......................................................................................................................... 8
T HIRD P ARTY P AYER ...................................................................................................................................................... 8
I NDIAN A DDENDUM ......................................................................................................................................................... 9
N AVIGATORS ...................................................................................................................................................................... 9
D EFINITION OF I NDIAN .................................................................................................................................................. 9
V ERIFICATION OF I NDIAN S TATUS .............................................................................................................................. 9
Business Case for Sponsorship Program ......................................................................................... 10
Eligibility ........................................................................................................................................ 10
Plan Choice .................................................................................................................................... 10
Monthly enrollment option ............................................................................................................. 11
Alternate Resources ........................................................................................................................ 11
Alternate Resource (includes TPSP) Policy & Procedure .................................................................... 11
Medicaid......................................................................................................................................... 12
Medicare, Medicare A, Medicare B, Medicare C, Medicare D ............................................................. 12
Private Insurance ............................................................................................................................ 12
Contract Health Service Program ..................................................................................................... 12
CATASTROPHIC HEALTH EMERGENCY FUND .................................................................................... 13
YOUR TRIBE’S NAME TRIBE CONTRACT HEALTH SERVICE ................................................................. 13
CATASTROPHIC HEALTH EMERGENCY FUND (CHEF): ........................................................................ 13
FUNDING LIMITATIONS: .................................................................................................................. 13
CONTRACT HEALTH SERVICES DELIVERY AREA ................................................................................ 14
CONTRACT HEALTH SERVICES ......................................................................................................... 14
Emergency ..................................................................................................................................... 14
E-Sign ............................................................................................................................................. 14
TRIBAL PREMIUM SPONSORSHIP DELIVERY AREA .............................................................................. 15
PERSONS TO WHOM CHS WILL BE PROVIDED ................................................................................... 15
Funds Available .............................................................................................................................. 15
Services .......................................................................................................................................... 15
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TRIBAL PREMIUM SPONSORSHIP/ CONTRACT HEALTH SERVICE ELIGIBILITY REQUIREMENTS .............. 15
Your Tribe’s Name Tribe Contract Health Services Establishment of Residence for Contract Health Services
Eligibility ....................................................................................................................................................................... 15
Documentation ............................................................................................................................... 17
Eligibility ........................................................................................................................................ 17
Close Economic and Social Ties ...................................................................................................... 17
Students ......................................................................................................................................... 17
Transients ....................................................................................................................................................................... 17
NOT TPSP Eligible -CHS Eligible ....................................................................................................... 17
Non-Indian Pregnant Woman – Same as CHS if Patient of Clinic ....................................................... 18
Authorities ..................................................................................................................................... 19
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The Your Tribe’s Name Tribe Will Purchase Health Insurance for Contract Health
Service Eligible Uninsured Community Members who are Eligible for Tax Subsidies in the new Washington Health Benefits Exchange (Marketplace).
Official Launch May, 2014
Vision of the Program: To Connect Tribal Members and Their Families to the Health
Insurance Coverage that is Most Appropriate for Them, The Tribe, and the Health Services
Department Program
INTRODUCTION
Purpose
This Tribal Premium Sponsorship Program Tribal Premium Sponsorship Program manual consolidates the policy, procedures, and guidance for the effective management of the
Indian Health Service (IHS) Contract Health Services (CHS) Program and alignment with the
Your Tribe’s Name Tribe, PGST, Tribal Premium Sponsorship, and TPSP program. The authority to manage the operation of the TPSP Program is delegated to the greatest degree possible to the Health Director, Business Office Manager and Contract Health Services
Manager.
 The Tribal Premium Sponsorship Program was developed between August 2013 and
April 2014.
 Presented to Tribal Council, March 2014
 Presented to Directors and Managers
 Council Approval, by motion, March 2014.
 May, 2014 Launch Date of TPSP.
 Training of in-person assisters and sponsorship representatives, January-May 2014.
 January 1, 2014 coverage begins for Marketplace plans.
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TERMS OF PARTICIPATION
There are additional participant requirements above those required for Indian Health
Service, IHS, Contract Health Service, (CHS), program’s for sponsorship.
 Information about income and verification of income (could be simply selfattestation) or verification of IRS provided income from 2013 tax filing.
 All Uninsured who do not have employer sponsored health care insurance are eligible which means: o You can’t drop coverage and expect Tribal Premium Sponsorship without prior verification of eligibility for subsidies.
 Update Income Information.
 Respond to requests for information from Tribal Staff, State or Federal agencies
 Agree to work with sponsorship representative (a Healthplanfinder designation).
 Agree to apply for financial assistance to pay health insurance.
 Agree to apply full tax credit to premium
 Agree to provide your current insurance card.
 Follow CHS policies including using the Your Tribe’s Name Tribal Health Clinic for primary care and referrals.
Health Services Director, The Director, will: Establish general policies regarding the administration of the TPSP program in the IHS for the first year in coordination with the
Health Committee.
 Establish standards of performance
 Assess the performance of the TPSP program.
 Assess the long-term purpose and direction of the program and its contribution to
CHS program to ensure maximum effectiveness of the program in meeting the health needs of Indian people.
 Formulate long-term plans and objectives for the future development of the TPSP program.
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 Provide staff assistance in matters of general policies and procedures.
 Prepare budget justification for the total TPSP program.
 Financial controls. Ensure funding and financial controls follow tribal requirements.
 Promptly and appropriately respond to TPSP appeal denials by Health Advisory
Committee appeal.
 Establish and implement a management control system for the TS.
 Develop and establish policies and methods for the direction, control, review, and evaluation of the TPSP programs.
 Maintain records for planning and for controlling funds as required.
 Promptly and appropriately respond to TPSP appeal denials
Segregation of FUNDS FOR SPONSORSHIP OF PREMIUMS
Funds for premiums shall be segregated in a fund or money market account by the Your
Tribe’s Name Tribe sufficient to fund six months of Insurance premiums. Estimate for 40-
70 community members is $120,000 to $180,000.
The Washington State Health Benefit Exchange. The marketplace for the purchase of health plans and determination of and access to federal tax credits.
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Delegation of Authority
Health Services Department will set up all financial arrangements for the payment of sponsored community members.
Tax Subsidy
The sponsored eligible will work with tribal in-person assister or navigator to access 100% of the subsidy
(based on their income) to be applied toward the premium payment to health plan (carriers).
Tax Reconciliation
The IRS will determine any tax liability or refund necessary from changes in income over the course of enrollment in a QHP. The TPSP Health fund will pay any IRS tax obligations (reconciliation). The Tribal member or sponsored person will be reimbursed unless there is an admission of misreporting of income.
Tax Refund for use in subsequent year’s sponsorship
Community members participating in the TPSP are required to deposit any premium tax credit reconciliation tax refund in the TPSP Trust Fund, money market account, or reserve if they wish to participate in future sponsorship years.
Affordable Care Act Provisions Relevant to American Indians/ Alaska Natives
The Affordable Care Act includes specific provisions relevant to American Indians and Alaska Natives (AI/ANs) purchasing coverage in Exchanges, including the following:
– AI/ANs with household incomes below 300 percent of the federal poverty level who are enrolled in a Qualified Health Plan (QHP) offered through the individual market Exchange will not have to pay any cost-sharing; no deductible, no copays, no other cost sharing.
– If an AI/AN is enrolled in a QHP and receives services directly from IHS, Indian tribe, tribal organization, urban Indian organization or through the Contract Health Service program, the individual will not have to pay any cost sharing for those services;
– Exchanges are to provide special monthly enrollment periods for AI/ANs; and
– Members of Indian tribes are exempt from the individual responsibility payment for not complying with the requirement to maintain essential insurance coverage.
Indian Provisions of the Exchange Final Rule
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 Tribal Consultation
 Tribes Paying Premiums
 Essential Community Providers
 Third Party Payer
 Navigators
 Establishment of Network Adequacy for Certification of Qualified Health Plans
 Definition of Indian
 Verification of Indian Status
T
RIBAL
C
ONSULTATION
The Exchange final rule requires States to regularly consult with Federally recognized Tribes that are located within the geographic region of the Exchange on policies that have tribal implications.
This requirement does not preclude States from seeking input from all tribal organizations and urban Indian organizations.
HHS encourages States to develop a Tribal Consultation Policy that is approved by the State, the Exchange, and
Tribe(s).
HHS recognizes the potential that FFEs will have to improve access to health coverage for American Indians and Alaska Natives in States that do not establish State-based Exchanges. HHS intends to consult with Tribes to implement FFE policies that impact American Indians and Alaska Natives.
T RIBES P AYING P REMIUMS
Exchanges may permit Indian tribes, tribal organizations, and urban Indian organizations to pay the QHP premiums for qualified individuals, subject to terms and conditions set by the Exchange.
We recognize that some Exchanges may wish to work with tribal governments to facilitate payment on behalf of enrollees, including aggregated payment. We encourage Exchanges to include this option as part of its consultation with tribal governments.
E SSENTIAL C OMMUNITY P ROVIDERS
In the final rule, the definition of an essential community provider is taken from section 1311 of the
Affordable Care Act.
The definition identifies essential community providers as providers that serve predominantly low-income, medically underserved individuals and cites providers defined in section 340B of the Public Health Service
Act.1
• Includes urban Indian organizations and tribal organizations’ outpatient clinics.
• Exchanges may identify additional providers as essential community providers based upon local needs.
1.
42 U.S.C. § 1396r-8 (Section 1927 of the Social Security Act)
T
HIRD
P
ARTY
P
AYER
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The Indian Health Care Improvement Act (IHCIA) provides that all Indian health providers have the right to recover from any third party payers, including insurance companies:
– Up to the reasonable charges billed for providing health services; or
– If higher, the highest amount the insurer would pay to other providers to the extent that the patient or another provider would be eligible for such recoveries.
In the final rule preamble, we note that section 206 of IHCIA applies to all third party payers, including QHPs.
I
NDIAN
A
DDENDUM
Your Tribe’s Name Tribe will work with other tribes to develop an acceptable Indian Addendum for use in contracting..
In-person Assisters
The Your Tribe’s Name Tribe will continue to access the Medicaid Administrative Match program to pay for
50% (or 75% if allowed) of the cost of enrollment activities for the Medicaid program (and initial screening for both Medicaid and Marketplace insurance). In addition tribal staff will complete necessary training to become in-person assisters and sponsorship representatives.
N AVIGATORS
Tribal Navigator funding is for enrollment in Marketplace Insurance plans. Subject to final rules the TPSP will access all permissible funding to reimburse for enrollment in tribally purchased marketplace insurance through the Healthplanfinder. See in-person assisters and tribal sponsorship representatives.
D EFINITION OF I NDIAN
Tribes support using the same definition of Indian used for Medicaid and HHS received comments regarding the three definitions of Indian in the Affordable Care Act as they pertain to special enrollment periods, costsharing reductions, and individual responsibility exemptions.
HHS does not have administrative flexibility to align these definitions with IHS or Medicaid definitions.
Any modification would require legislative action.
HHS is providing technical assistance to Congress regarding alignment of these definitions.
V ERIFICATION OF I NDIAN S TATUS
If an applicant attests that he or she is an Indian, the Exchange must verify Indian status.
The Exchange must rely on any electronic data sources that are available to the Exchange and have been approved by HHS for this purpose. If approved data sources are unavailable, an individual is not represented in the source, or the source is not reasonably compatible with an applicant’s attestation, the Exchange must follow inconsistency procedures. Where permitted authorize staff will attest to tribal membership for Your
Tribe’s Name Tribe tribal members.
Hardship Exemption
CHS business office will work with all patients to ensure they obtain exemption from the penalty assessed for not having health insurance.
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Year one of the sponsorship program will cover all community members whose insurance plan costs are equal to or less than the expected expenditures for the category of eligible.
The Health Services Department will employ experienced and trained benefits counselors to assist community members in their selection of the best coverage option. In-person assisters is a term used mainly for those who screen for eligibility for Medicaid and enroll, where eligible, in Medicaid.
are one type of assister established to determine eligibility for exchange health plans.
1.
Determine eligibility for subsidy
2.
Verify Indian Status for cost sharing benefits
3.
Help with QHP selection
4.
Advise on wraparound payments.
CORE Eligibility
1.
All members of household with income between 139 and 300% of poverty
Expanded Eligibility (depending on availability of funds0
1.
Some otherwise not eligible may be covered with Tribal funds should funding become available.
2.
Expanded eligibility depends on funding and continued successful cooperation of the terms of participation
3.
Plan for making all tribal members in Washington state eligible in 2015.
1.
The Sponsorship Program only supports the purchase of the bronze option in the Healthplanfinder
Marketplace for enrolled tribal members.
2.
The Sponsorship Program does not support the choice of a catastrophic program since subsidies are not available under this plan choice.
3.
The TPSP has the option of recommending a ‘preferred’ qualified health plan, but will consider the special needs of applicant in choosing a plan.
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1.
TPSP does not support changes in health plans, but on a case by case basis can approve one change in a calendar year.
2.
American Indians do have the option to change plans once a month, but TPSP will not approve discretionary changes in plans without approval of the program.
3.
Exercising a change is permitted, but tribal funds may not be approved for a second plan based on this discretionary choice allowed under the law.
Your Tribe’s Name Tribe Contract Health Services Non-Compliance with Applying for
Alternate Resources Policy
Purpose:
To outline the process for Your Tribe’s Name Tribe Contract Health Services members who do not follow through with applying for alternate resources. Alternate resources may include, but are not limited to, Medicare, Medicaid, Vocational Rehabilitation, Veteran’s
Administration, private insurance, Crippled Children’s Programs, Victims of Crime, and any other State or Federal programs.
Eligibility:
Any person covered by Your Tribe’s Name Tribe Contract Health Services.
Policy:
The Your Tribe’s Name Tribe requires all Contract Health Services eligible individuals to apply for alternate resources to help offset the cost of health care for the program.
1.
Eligible persons need to follow through with applying for alternate resources if asked to do so by the Contract Health Services office including the TPSP.
2.
Staff in the Contract Health Services office will be available to assist the eligible member with the TPSP application process.
3.
An outreach person will be available to come to the member’s house to assist with the application process. This service will be limited to Contract Health Services members residing or working on the Your Tribe’s Name Tribe Reservation.
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4.
The TPSP eligible member is required to direct the Health Plan Finder to provide duplicate communication to the CHS office address. The TTPSP member may use the CHS office’s mailing address to have the staff assist with any information requests from alternate resources to ensure continuation of coverage.
5.
This is an option on the online application where premium payments due.
6.
Members who do not follow through on applying for alternate resources will receive a termination letter from the Contract Health Services office.
7.
Members who do not update their income information will face potential termination.
8.
The member will have an additional 30 days (as of the date of the termination letter) to finalize the application process for the alternate resource they are eligible for. Failure to complete the application process within the 30 days will result in termination of the members Contract Health Services benefits.
9.
The member will not be eligible for Contract Health Services coverage until a complete application for alternate resources has been submitted to the Contract Health Services office.
10.
Any charges incurred for any health related care during the uncovered time period would be the member’s responsibility.
Medicaid has no cost to the Health Services Department and is the required option for uninsured under 139% of poverty.
Medicare insurance is the required primary insurance for eligibles with wrap around payments for costs not covered by Medicare.
Some cases may require the purchase of private insurance outside the Health Path Finder exchange.
See CHS manual. The TPSP is a part of the CHS program and all CHS rules apply.
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The fund appropriated by Congress to partially cover the IHS portion of medical expenses for catastrophic illnesses and events that are covered by IHS CHS medical priorities. The IHS will pay, from the CHEF, for cases that are covered by IHS CHS medical priorities. The IHS is not responsible to cover cases that are expensive but outside the CHS medical priorities.
Catastrophic health emergency funding is made available to all Tribes throughout the nation who are eligible for CHS and Indian Health Service (IHS) care. The CHEF program is administered and funded by the IHS. Catastrophic cases are defined as a single case or single incident where health care costs have reached a threshold of about $20,000
(changes).
NOTE: An example of a single incident would be five program eligibles injured in a single auto accident. When the collective health care costs for the five program eligibles reach the current threshold, CHEF program becomes the primary source of funding for payment of any medical bills exceeding the threshold amount.
For purposes of the PGSKT PLAN, PGSKT CHS funding shall not exceed the threshold costs for a single case or incident as established by IHS guidelines.
NOTE: In all cases, alternate resources shall be exhausted prior to any coverage under the IHS CHEF or PGSKT CHS catastrophic health care coverage.
Because of funding limitations, the IHS CHEF and PGSKT CHS catastrophic programs will no longer consider a patient’s illness to be catastrophic for reimbursement purposes, 90 days after discharge from an inpatient facility.
OBLIGATIONS IN EXCESS OF $50,000: Should a single case or incident exceed $50,000, the PGSKT CHS office reserves the right to require medical and financial documentation.
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The care provider may be required to explain why it is inappropriate to transfer a patient to a less costly facility or provider, such as an IHS inpatient facility or V.A. facility where the same medical benefits may be available as from a care provider in the network.
THRESHOLD NOTIFICATION: It shall be the responsibility of the PGSKT CHS office to notify the IHS CHEF office for filing of program recipients. Specific documentation and program filing requirements may be found in the PGSKT CHS policies and procedures manual. It shall also be the responsibility of the PGSKT CHS office to file for any funding available from the stop-loss coverage available through the PGSKT CHS catastrophic program.
The geographic areas within which CHS will be made available. Kitsap county.
Health services paid by the IHS that are provided to eligible AI/ANs by non-IHS public or private providers (e.g., dentists, physicians, hospitals).
CONTRACT HEALTH SERVICES ELIGIBLE, TRIBAL PREMIUM SPONSORSHIP ELIGIBLE
A person as defined in as being eligible for CHS thus eligible for the Tribal Premium
Sponsorship Program
Any medical condition for which immediate medical attention is necessary to prevent the death or serious impairment of an individual’s health.
The electronic equivalent of a hand-written signature requiring user authentication and verification, such as a digital certificate, smart card, or biometric methods. On June 30,
2000, Congress enacted the “Electronic Signatures in Global and National Commerce Act,”
(E-SIGN) to expand the use of electronic records and signatures in interstate and foreign commerce and ensure the validity and legal effect of contracts entered into electronically.
E-SIGN ensures that contracts and purchase orders entered into electronically will be legally
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effective and valid, and that consumers who enter into contracts electronically have the same protections they have when contracting in the “brick and mortar” world.
Kitsap County is the county of residence for all sponsored beneficiaries in TPSP.
All approved Contract Health Service Delivery Areas (CHSDA) are specified in 42 CFR
§136.22 and may be changed only in accordance with the Administrative Procedures Act (5
U.S.C. 553).
Tribal Premium Sponsorship Eligible follows CHS Eligibility, with differences noted below:
Authority
The CFR, Title 42 Part 136 is the appropriate citation for all correspondence to providers and AI/AN patients. This IHM chapter should not be cited as the authority for making decisions on eligibility or payment denials.
There is no authority to authorize payment for the insurance premium under the TPSP program unless funds are made available by the Tribe.
Beyond Qualified Health Plan-provided service- Follow CHS Policy payment allowed.
Your Tribe’s Name Tribe Contract Health Services Establishment of Residence for
Contract Health Services Eligibility
P URPOSE :
To verify permanent residence for persons wanting to establish eligibility for Contract
Health Services benefits.
P OLICY :
The Your Tribe’s Name Tribe requires all persons who are trying to establish eligibility for
Contract Health Services benefits to provide proof of permanent residence on either the
Your Tribe’s Name Tribe Reservation, or in Kitsap County depending on their tribal enrollment status.
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P
ROCEDURE
1.
Eligible persons need to follow through with providing valid proof of permanent residence in either Kitsap County or on the Your Tribe’s Name Tribe Reservation.
2.
Proof of permanent residence includes: proof of being registered with the Port Gamble
S’Klallam Housing Authority, documents in the person’s name mailed to the address of residence, and or a signed affidavit from the homeowner, within the service area, the eligible person is living with.
Failure to provide valid proof of residence will result in denial of eligibility for the Contract
Health Services program and TPSP.
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An AI/AN claiming eligibility for CHS has the responsibility to furnish the CEO or the Tribal program with documentation to substantiate the claim.
The definition of eligibility for CHS shall be consistent with Title 42 CFR § 136.23. If local rules and Title 42 CFR §136.23 conflict, Federal regulations prevail. To be eligible for CHS an individual must:
1. Be eligible for direct care as defined in 42 CFR §136.12;
2. Reside within the U.S. on a Federally-Recognized Indian reservation; or
3. Reside within a CHSDA and;
4. Be a member of the Tribe or Tribes located on that reservation; or
5. Maintain close economic and social ties with that Tribe or Tribes.
The basis for determining a person’s close economic and social ties i s established by the Tribe(s) served and may include the following:
1. The person is married to or is the child of an eligible member of the Tribe; or
2. The Tribe determines and certifies that the person has close economic and social ties with the Tribe whose reservation is located within the CHSDA.
Students up to age 26 are eligible under the family insurance eligibility in many cases. Where they are not the
TPSP will examine eligibility according to the individual’s circumstances without regard to study status.
Transients
Persons who are traveling or who are temporarily employed, such as seasonal or migratory workers, are not eligible for the TPSP.
Not Health Plan Eligible:
 Dependents of an employee with employer sponsored insurance.
 Children and spouses are typically not eligible for subsidies so they are not eligible for the TPSP.
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American Indian/Alaska Native Children Adopted by Non-Indian Parents. Indians adopted by non-Indian parents must meet all CHS requirements to be eligible for care e.g., reside within a CHSDA).
Foster Children. American Indian/Alaska Native children who are placed in foster care outside a CHSDA by order of a court of competent jurisdiction and who were eligible for
CHS at the time of the court order shall continue to be eligible for CHS while in foster care.
Section 813(a)(1) of the IHCIA, states in part: “Any individual who-(A) has not attained 19 years of age, (B) is the natural or adopted child, step-child, foster-child, legal ward, or orphan of an eligible Indian, and (C) is not otherwise eligible for the health services provided by the Service, shall be eligible for all health services provided by the Service on the same basis and subject to the same rules that apply to eligible Indians until such individual attains 19 years of age.”
Refer to CHS Office to review eligibility
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Your Tribe’s Name Tribe Tribal Council, Washington State Health Authorities, i.e.
Washington Health Benefit Exchange, PGST Health Services Director - See All CHS Rules ,
Authorities, Delivery Codes of Federal Regulations, ,(CFR’s)
“Geographic Composition of the Contract Health Service Delivery Areas (CHSDA) and Service
Delivery Areas (SDA) of the Indian Health Service,” Federal Register (FR): June 21, 2007
(Volume 72, Number 119) Pages 34262-34267
1. “Persons to whom services will be provided.” 42 Code of Federal Regulations (CFR),
Title 42, §136.12 (3)
2. “Definitions.” 42 CFR §136,21
3. “Establishment of contract health service delivery areas.” 42 CFR §136.22
4. “Redesignation of contract health service delivery areas.” 42 CFR §135.22(b)
5. “Persons to whom contract health services will be provided.” 42 CFR §136.23
6. “Priorities for contract health services.” 42 CFR §136.23(e)
7. “Payor of last resort.” 42 CFR §136.61
8. “Administrative Procedures Act,” 5 United States Code (U.S.C.) 500, et seq.
9. “Alaska Native Claims Settlement Act,” 43 U.S.C. 1601 et seq.
10. “The Victims of Crime Act of 1984” 42 U.S.C. 112, §10601
11. “Indian Civil Rights Act of 1968,” 25 U.S.C. 1301, et seq.
12. “Eligibility of California Indians,” Rancheria Act of August 18, 1958, (72 Statutes at
Large (STAT.) 619)
13. “Social Security Amendments of 1972,” Public Law (P.L.) 92-603
14. “Indian Self-Determination and Education Assistance Act,” P.L. 93-638, as amended
15. “Indian Health Care Improvement Act,” P.L. 94-437, as amended
16. “Electronic Signatures in Global and National Commerce Act,” P.L. 106-229
17. “Federal Managers’ Financial Integrity Act of 1982,” P.L. 97-255
18. “The Fiscal Year (FY) 1987 Appropriations Act for the IHS,” P.L. 99-591
19. “Consolidated Omnibus Budget Reconciliation Act of 1985,” P.L. 99-272, Section
17003
Definitions
INDIAN TRIBE
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Any Indian Tribe, band, nation, group, Pueblo or community, including any Alaska Native village or Native group, which is Federally-recognized as eligible for the special programs and services provided by the United States (U.S.) to AI/ANs, because of this status.
RESERVATION
Any Federally Recognized Indian Tribe’s reservation, Pueblo, colony, or Rancheria, including former reservations in Oklahoma, and Alaska Native regions established pursuant to the
Alaska Native Claims Settlement Act (43 U.S.C. 1601, et seq.) and Indian allotments.
RESIDENCE
Where a person lives and makes his or her home as evidenced by acceptable proof of residency or acceptable proof established by the Service Unit.
SERVICE
The Indian Health Service.
TRIBAL HEALTH DIRECTOR
The Director of a tribally operated program, or his/her designee, authorized to make decisions on payment of CHS funds pursuant to a P.L. 93-638 contract.
TRIBAL MEMBER
A person who is an enrolled descendent of a Federally Recognized Tribe or is granted Tribal membership by some other criteria in the Tribal constitution.
TRIBAL SELF INSURANCE
This Tribal Premium Sponsorship Program manual consolidates the policy, procedures, and guidance for the effective management of the Indian Health Service (IHS) Contract Health
Services (CHS) Program and alignment with the Your Tribe’s Name Tribe, PGST, Tribal
Premium Sponsorship, and TPSP program. The authority to manage the operation of the
TPSP Program is delegated to the greatest degree possible to the Health Director, working with the Health Services Manager, Business Office Manager and Contract Health Services
Officer
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A health plan that is funded solely by a Tribe or Tribal organization and for which the Tribe or Tribal organization assumes payment for health services covered under the plan either directly or through an administrator. The plan may be re-insured, but the Tribe or Tribal organization must bear some risk.
ACRONYMS
1.
ACA – Affordable Care Act
2.
CFR - Code of Federal Regulations
3.
CHEF - Catastrophic Health Emergency Fund
4.
CHS - Contract Health Services
5.
CHSDA - Contract Health Service Delivery Area
6.
CHS/MIS - Contract Health Services/Management Information System
7.
CHSO - Contract Health Service Officer
8.
HIPAA - Health Insurance Portability and Accountability Act
9.
IHCIA - Indian Health Care Improvement Act
10.
QHP - Qualified Health Plan
11.
RPMS - Resource and Patient Management System
12.
TPSP –Tribal Premium Sponsorship Program
13.
U.S.C. - United States Code
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