Tribal Readiness
Jennifer DuPuis, M.B.A.
Associate Director of Human Services
Fond du Lac Band of Lake Superior Chippewa
Tribal Self-Governance Consultation Conference
Arlington, VA
May 7, 2014
Key Opportunities
Plan Approach to Target Activities
Where are your biggest opportunities?
Study Populations
Fond du Lac Human Services
Population by Insurance Type 2013
Uninsured
18%
Commercial
37%
Medicare
8%
Medicaid
37%
Study Populations
Fond du Lac Uninsured Population
by Income Level 2010
251 - 300%
6%
over 400%
15%
201 - 250%
6%
151 - 200%
9%
134 - 150%
5%
301 - 400%
10%
0 -133%
49%
Tribal Sponsorship
Tribes, tribal organizations, and urban
Indian organizations are permitted to
pay premiums on behalf of eligible
individuals.




Medicare Part B (Reimbursement)
Medicare Part C
Medicare Part D
Qualified Health Plans
Target your low hanging fruit. Where is
the easiest place to start?
Tribal Sponsorship
Medicare Part D
Successful sponsorship program
informed us how worth while
sponsorship is.
In 2013, every $1 Fond du Lac spent on
Medicare Part D premiums, there was
over a $6 return.
Implementation
Policy & Procedures
You must establish and operate under
policies that have been approved by Tribal
Council.
 Contract Health Policy & Procedures
 Registration Policy & Procedures
 Patient Advocate Policy & Procedures
 Tribal Sponsorship Policy & Procedures
Implementation
1. Develop gates to access services that
include enrollment activities.
2. Educate staff and establish
uniformity of application of the
policy.
3. Gather, assess, and troubleshoot
specific real-life examples during
team meetings.
Enrollment Process
Patient Flow
Patient
Arrives
Patient
Registers
Demographics
are updated
Uninsured
individuals
referred to
Patient
Advocate
Patient Meets
With Patient
Advocate
Patient Sees
Provider
Eligibility for
Medicaid,
MNCare
(BHP),
Medicare, and
QHP’s is
checked
All uninsured patients are referred to
a Patient Advocate for insurance
eligibility check.
Enrollment Process
Contract Health Services
Because CHS is a payer of last resort, clients must
apply for other alternative resources available to
them.
Process to get through the “gate” for CHS
coverage:
1. All CHS eligible individuals who are uninsured must
complete the MNsure application process to determine
eligibility for Medicaid, MNCare, or Tribal Sponsorship.
2. Eligible individuals must accept Tribal Sponsorship,
which is of no cost to them or their family.
3. Descendents must complete the MNsure application
process during the open enrollment period.
Enrollment Process
Contract Health Services Waiver
“By declining premium sponsorship by
FDLTC, which is of no cost to me or my
family, I understand that I am denying an
alternative resource and will be waiving my
rights to CHS funds until I have secured
another form of health care coverage.”
Evaluate & Redesign
Monitor Progress
1. Be prepared to adjust your focus.
2. Target your enrollment processes
and adjust rules for payer groups.
3. Enforce flexibility with staff
assignments.
Marketing
Literature
Make literature your own. Use your
own photos and information.
Marketing
Patient Advocates
Educate clients and evaluate eligibility for
Medicare, Medicaid, MinnesotaCare,
MNsure and other employer/private
insurance programs.
1. Staff Expertise:
1. Familiar with all rules.
2. Relationally Rich
Environment:
1.
2.
3.
4.
One-on-one counseling.
Community member staff.
Plenty of time to talk.
Familiar with cultural
sentiments
5. Explains community benefits.
Marketing
Educating Clients
Why should IHS eligible individuals have
health insurance?
Although IHS makes a substantial
contribution to the overall health of
American Indians and Alaska Natives,
in most Indian communities, the level
of funding does not meet the need.
Tribes must generate other sources
of income.
Marketing
Patient Advocate Referrals
Electronic
Health
Records
Reports
Medical
Department
Referrals
Dental
Department
Referrals
Patient
Advocate
Pharmacy
Department
Referrals
Registration
Referrals
Contract
Health
Referrals
Building Business Office
Capacity
Third Party Billing
Experience
Competence
Measures of Competence
Administration
Budgeting
Monitoring
Managing Contracts
Credentialing
Contract Health Savings
Medicare Like Rates
Third Party Administrator
Comprehensive Care Services (CCStpa)
Blue Cross Blue Shield Discounts of 20-40%
CHS pays discounted amount plus 22% of
savings.
Example:
$1,000 bill – 40% discount = $600
CHS pays CCStpa $600 + 22% of savings = $688
Contract Health Savings
Medicare Like Rates
Third Party Administrator
Comprehensive Care Services (CCStpa)
Medicare Like Rate Discounts of 30-40%
CHS pays discounted amount plus per claim fee
of $9.50.
Example:
$1,000 bill – 40% discount = $600
CHS pays CCStpa $600 + $9.50 fee = $609.50
Contract Health Savings
Medicare Like Rates Savings 2012
BCBS Discounts
$375,488 Billed to CHS
$248,853 Paid by CHS
Savings of $126,635
MLR Discounts
$563,369 Billed to CHS
$172,221 Paid by CHS
Savings of $391,148
Total Savings of $517,783
Tribal Readiness Checklist
Key Opportunities
Plan approaches to target activities, and ask yourself “where are your biggest
opportunities?”
Study Populations
Use data from your electronic health record and the U.S. Census.
Tribal Sponsorship
Medicare and/or Qualified Health Plans.
Implementation
Establish policy and procedures, develop gates to access services, educate staff, and
troubleshoot examples.
Evaluate and Redesign
Monitor progress, target enrollment processes, and enforce flexibility with staff
assignments.
Marketing
Hire Patient Advocates, create a referral process, use your own literature for
materials, and educate patients.
Building Business Office Capacity
Have an experienced and competent billing department, and have processes in place
for Administration to monitor.
Contract Health Services
Create policy and procedures, and take advantage of Medicare Like Rates
Questions?
Thank You!