Module 6
The Exchange and Native
Americans
1
Learning Objectives
•
•
•
•
•
•
•
•
•
New Mexico Indian Nations, Tribes and Pueblos
– Sovereignty
Federal Trust Obligation
Overview of Indian Health System
– Contract Health Services Program
Affordable Care Act and American Indians
Proof of Tribal Membership and Income
Medicaid and American Indians
The Exchange and Native Americans
Outreach and Education
Marketing Channels
New Mexico Indian Nations,
Tribes & Pueblos
• New Mexico has 22 Indian Nations, Tribes and Pueblos - each has its own
unique culture
• 19 Pueblos – each is an independent and separate community
• 2 Apache Tribes (Jicarilla and Mescalero)
• Navajo Nation plus satellite communities
– Very large land base spanning 3 states
– 5 Agencies including 3 in New Mexico (Eastern, Ft. Defiance, Shiprock)
– 110 Chapters and 59 in New Mexico
Tribal Sovereignty
• Indian tribes are sovereign nations that predate the United
States
• U.S. Supreme Court (Cherokee V. Georgia 1831) established
Indian Tribes as “domestic dependent nations” with a
government to government relationship subject to plenary
authority of the U.S.
• Indian Tribes have the authority to maintain identity, values,
culture, property, and legal rights against political and legal
assault by local, community, state and even the Federal
Government.
New Mexico Native Languages
• Keres - Acoma, Laguna, Zia, Santa Ana, San Felipe, Santo Domingo,
Cochiti
• Tiwa - Taos, Sandia, Isleta, Picuris
• Tewa - Tesuque, Nambe, Pojoaque, San Ildefonso, Santa Clara, Ohkay
Owingeh
• Towa - Jemez
• Zuni - Zuni
• Athabascan - Jicarilla Apache, Mescalero Apache, and Navajo
Urban Indian Communities
• Multi-tribal, not just New Mexico Tribes
– Socially and culturally diverse (over 400 different tribes represented)
– Various stages of assimilation
• May be highly transient
– Dependent on services within the urban areas
• Seldom Viewed Along with Other Minority Groups
• New Mexico communities with large urban populations:
– Albuquerque
– Farmington
– Santa Fe
Federal Trust Responsibility
• Unique legal relationship between U.S. government and tribal
governments
• Tribal members have a unique legal and political status based on
citizenship – not race
• Based on treaties, statutes, Executive Orders, and court decisions
• Legal obligation to provide economic and social programs necessary
to raise standard of living and social well-being comparable to nonIndian society
Indian Health Service System
• The Indian Health Service (IHS) is the principal federal health
care provider for Indian people
– Funded at just 54% of the actual need
• Tribal Health Systems
– 638 Contracts - Allows Indian Tribes and organizations to contract and
operate programs provided by the Indian Health Service
– Self-Governance Compacts - Allows the transfer of management of IHS
resources to Tribal management and control
• Urban Indian Health Program
– Funding supports 34 independent non-profit agencies in 19 states
– Just 1% of total Indian Health Service budget
Contract Health Services
Program
• Financing for health care provided away from an Indian
Health Service (IHS) or tribal health care facility.
• Not an entitlement program and an IHS referral does not
imply the care will be paid.
• Patient must meet the residency requirements,
notification requirements, medical priority, and use of
alternate resources.
– Two-thirds of necessary health care services provided
under this program are denied due to lack of funding
The Affordable Care Act and Native
Americans
•American Indians who are eligible to receive services from an
Indian health provider (Indian Health Service, Tribal 638
program, Urban Indian Health Program) are exempt from the
individual mandate clause of the Affordable Care Act.
–Tribal members can apply when they file their return in
2015 or apply for an exemption through the marketplace
–Individuals who are not tribal members, but eligible to
receive services from an Indian health provider, must apply
for an exemption through the marketplace
•Indian Health Care Improvement Act was permanently
reauthorized
10
What do Native Americans Need to Know
About the Exchange?
•Members of federally recognized tribes, are entitled to special
protections through the Exchange starting in 2014:
–Special monthly enrollment periods to allow American
Indians to enroll in a qualified health plan outside the yearly
open enrollment period
–Exempt from cost-sharing (co-pays, deductibles, coinsurance) if income is less than 300% FPL and enrolled in an
Exchange plan
–Exempt from cost-sharing regardless of income if enrolled in
an Exchange plan and receiving covered benefits at the Indian
Health Service, Indian tribe, tribal organization, urban Indian
organization, or through Contract Health Service program.
11
Proof of Tribal Membership
and Indian Income
•To get special Exchange protections, American Indians will need to prove
membership in a federally recognized tribe. Proof could include:
• Tribal identification card
• Certificate of Indian Blood
• Bureau of Indian Affairs form
•Authentic document from a tribe declaring membership for an individual
–NAPPR can be contacted for those who need assistance proving Native
American status.
• If applying for Marketplace coverage, in addition to basic information about
household size and income, information about income from Indian trust land,
natural resources, and items of cultural significance must be provided.
–This income won’t be counted for Medicaid eligibility, but may be
counted for the Exchange's purposes.
12
Medicaid and American Indians
•Currently, over 91,000 American Indians in New Mexico are enrolled in
Medicaid - about 43% of all Native Americans in the state.
• American Indians are not automatically enrolled inCentennial Care (New
Mexico’s Medicaid managed care program), as all other enrollees are (unless
they are in the CoLTS program). Instead, they can enroll in the fee-for-service
Medicaid program (Medicaid Exempt) unless they request to be enrolled in
managed care.
•American Indian Medicaid beneficiaries are exempt from cost-sharing.
•Income from Indian trust land, natural resources, and items of cultural
significance is not counted for Medicaid eligibility.
13
Important Implications
• The Indian health system is fragile and unstable. Most claims
for services under Contract Health Services program are
denied.
• American Indian consumers could benefit greatly from
coverage options through the Exchange:
– Could acquire low cost coverage (Bronze plan) and be
exempt from out of pocket costs if income is less than
300% FPL
Exchange and Native Americans
• According to New Mexico state law, the Exchange must:
– Establish a Native American Advisory Committee
– Appoint a Native American Liaison
• The Exchange may establish a Native American Service Center
to:
– is accessible to Native Americans;
– complies with the provisions of the federal Indian Health
Care Improvement Act and Indian-specific provisions of
the federal Patient Protection and Affordable Care Act; and
– facilitates meaningful, ongoing consultation with Native
Americans;
Contact Information
Questions? Need Help?
NAPPR, Inc.
Healthcare Education & Outreach Program
1-855-241-8137
rsprucebly@nappr.org
16