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
Washington, DC
Juneau, AK
Anchorage, AK
Albuquerque, NM
San Diego, CA
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?
• 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
*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
*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
*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. 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
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
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
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 Indian Organization
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?
“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
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:
(i) Is a member of a Federally-recognized Indian tribe;
(ii) 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?
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?
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
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
*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
*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
• 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
(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
*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
*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
*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
*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
*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
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 –
(1) Be permanent programs within the Service’s direct care program;
(2) Continue to be treated as Service units and operating units in the
allocation of resources and coordination of care: and
(3) 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
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
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
Sonosky, Chambers, Sachse, Miller & Munson, LLP
April 24, 2012
National Council of Urban Indian Health
Slide 28
AI/ANs VETERANS
Streamlining 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
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
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
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
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
*(?) 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
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
*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
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
Sonosky, Chambers, Sachse, Miller & Munson, LLP
April 24, 2012
National Council of Urban Indian Health
Slide 38
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
More about Exchanges
• Consultation with I/T/U:
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. § 155.130
Regulations enforce
right of AI/ANs to enroll in or change plans one time per month
(instead of only during annual enrollment)
42 C.F.R. § 155.420(d)(3).
• 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
•
•
•
•
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
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
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 Narrowed from 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
Medicaid Expansion
CMS-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
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
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
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April 24, 2012
National Council of Urban Indian Health
Slide 47
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 . . .
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
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
•
•
•
•
•
•
•
•
•
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
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Slide 51
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
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 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 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 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 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
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