Sonosky, Chambers, Sachse,
Miller & Munson, LLP
A Good Plan Come Together
Reauthorization of the IHCIA:
Expanding Authority, Parity, & Opportunity
Myra M. Munson, J.D., M.S.W.
NIHOE ● National Tribal Health Reform Training
April 18, 2012
myra@sonoskyjuneau.com
Washington, DC
Juneau, AK
Anchorage, AK
Albuquerque, NM
San Diego, CA
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)
AND
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April 18, 2012
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Slide 2
The Affordable Care Act
The reauthorization and amendment of the IHCIA is
found in Section 10221 of Pub. L. 111-148, the
Patient Protection and Affordable Care Act, signed
by the President March 23, 2010, which enacted by
reference S. 1790, as reported out of the Senate
Committee on Indian Affairs in December 2009, with
four amendments.
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Slide 3
REAUTHORIZATION PROCESS
• 1999 National Steering Committee Formed
• Principles adopted by Tribal Leaders
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Expand authority
Increase resources and revenue
Streamline and modernize
Treat the whole person throughout all stages of life
Review, review, review
11 Years of Congressional Advocacy
Compromise and Hold the Line
Do what you can when you can – Any bill moving. . .
MMA, CHIP, ARRA, ACA
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Slide 4
What Resulted from 11 Years of Advocacy?
• Acknowledgement of Federal Responsibility – findings &
policy
• Authority – expanded objectives; new programs
• Parity – eg. exemptions from fees & licensing; access to
Federal Employee Benefit Insurance; peer review
• Opportunity – recovery from Federal health programs and
other third party payers; purchasing insurance for
beneficiaries; services to non-beneficiaries; sharing
arrangement with other providers
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Slide 5
MMA – Brought Us
*Medicare Like Rates -- Sec. 506 (42 USC 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.
Authority to Bill Medicare Part B – Sec. 630 (42 USC 1395qq(e)(1)(A).
5 year authority.
*Medicare Part D Drug Benefit – Special Protection for
AI/ANs
*Applies to Urban Indian Organizations (UIO), also
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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
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Slide 7
CHIPRA
Childhood Obesity Demonstration Project – Sec. 401(e)
Tribes (as defined in IHCIA Sec. 4) are eligible
School-based Health Centers – Sec. 505(a) (42 USC 1397jj(9))
Definitions include schools of Indian tribe or tribal organization and
sponsoring facility includes programs administered by IHS, BIA, or a
tribe or tribal organization
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Slide 8
ARRA Sec. 5006
*No Medicaid Premiums or Cost Sharing – 42 USC 1396o(j).
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AI/ANs referred by CHS to any provider is 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)
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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 –
Requires State Medicaid programs to consult with IHS, Tribes and
Tribal Organizations, and UIOs
*TTAG –
Formalized in statute the CMS Tribal Technical Advisory Group
Added IHS and NCUIH
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Slide 10
ACA +
*Payer of Last Resort – Sec. 2901(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.”
Part B Billing Authority – Sec. 2902.
Extended permanently
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Slide 11
More from the ACA
Indian Specific Protections in Health Reform
Special Enrollment – Sec. 1311(c)(6)(d). Exchange plans must provide
Indians with special monthly enrollment periods
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 tax pur
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
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Slide 12
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
• 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
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Slide 13
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)
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Slide 14
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.
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Slide 15
But, Best of All,
Reauthorization of and
Amendments to the
Indian Health Care Improvement Act
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ACKNOWLEDGEMENT
Sec. 825 Permanent Reauthorization
Sec. 2 Findings – New provision: “(2) A major national goal of
the U.S. is to provide the resources, processes, and structure
that will enable Indian tribes and tribal members to obtain
the quantity of health care services and opportunities that
will eradicate the health disparities between Indians and the
general public of the U.S.”
Sec. 3 Policy – Acknowledgement of “special trust
responsibility and legal obligations to Indians.”
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Slide 17
OBJECTIVES AND PARITY
*Sec. 3(2) Objectives – For the first time they are the same
as for the rest of the Nation. Healthy People 2010 ( or
successor standards). See, www.healthypeople.gov.
2020 Objectives Address: access; adolescent health; arthritis, osteoporosis
& chronic back conditions; blood disorders & blood safety; cancer; chronic kidney
diseases; diabetes; disability & secondary conditions; early/middle childhood;
education & community-based programs; environmental health; family planning; food
safety; genomics; global health; health communication and IT; health care associated
infections; hearing & other sensory communication disorders; heart disease & stroke;
HIV; immunizations & infectious diseases; injury & violence prevention; maternal,
infant & child health; medical product safety; mental health; nutrition & weight status;
occupational safety & health; older adults; oral health; physical health & fitness; public
health infrastructure; quality of life & well-being; respiratory diseases; sexually
transmitted diseases; social determinants of health; substance abuse; tobacco; vision
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Slide 18
Definitions – So We Don’t Get Confused
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].
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LICENSING AND FEES PARITY
Sec. 221 Licensing. Exempts licensed and certified tribal health
program employees from licensure in the state where they are
practicing so long as they are licensed or certified in some state.
*Sec. 408 Non-Discrimination in Qualifications for
Reimbursement. 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
*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.
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INSURANCE
Authority, Parity, and Opportunity
*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
*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.
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Slide 21
SERVING NON-BENEFICIARIES
Authority and Opportunity
Sec. 813 Health Services for Ineligible Persons.
Eliminates requirement that Tribal health programs consider
whether there are alternative services and expressly extends
FTCA coverage
Does not allow IHS to serve non-beneficiaries without
approval of tribes in the Service Unit
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Sec. 206 THIRD PARTY RECOVERY
Authority and Opportunity
*Right to recover reasonable charges (rather than
reasonable expenses) 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
• Allows THOs to use the Federal Medical Care Recovery Act
• Allows self-insured tribes to authorize payment to IHS
• Allows THO to recover costs and attorney’s fees if prevail
• Applies to urban Indian organizations
• Protects existing laws, including medical lien laws
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*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)
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Slide 24
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
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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 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
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Sec. 205 SUPPORTIVE SERVICES
PROGRAM EXPANSION
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
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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
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Slide 28
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
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Slide 29
AND, MORE ABOUT FACILITIES
Sec. 307 Indian Health Care Delivery Demo. Adds convenient
care service
Sec. 309 Tribal Management of Federally Owned Quarters.
Authorized tribal health programs to set their own rates.
Sec. 311 Other Funding. Allows other agencies to transfer
funds to IHS for health and sanitation facility construction and
operation.
Sec. 312 Modular Component Facilities Demo
Sec. 313 Mobile Health Stations Demo
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OTHER PROGRAM EXPANSION
Sec. 212 Mammography & Other Cancer Screening - includes
other cancers.
Sec. 218 Infectious Diseases - expanded beyond tuberculosis
Sec. 704 Comprehensive Behavioral Health Authority
Sec. 712 Fetal Alcohol Spectrum Disorders Programs
Sec. 713 Child Sexual Abuse Prevention and Treatment
Programs
Sec. 714 Domestic and Sexual Violence Prevention and
Treatment
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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
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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
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UIO Provisions of Note
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.
Sec. 514 Conferring with UIOs. IHS must confer, “to the maximum
extent practicable, with UIOs in carrying out the IHCIA.
Sec. 515. Expanded Authority. Covers all programs under sections 218,
702, and 708(g).
Sec. 516. Community Health Representatives.
Sec. 517. Use of Federal Facilities and Sources of Supply.
Sec. 518. Health Information Technology grants.
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OPPORTUNITIES TO EXPLORE AND LEARN
Sec. 411 Navajo Nation Medicaid Agency Feasibility
Study.
Sec. 214 Epidemiology centers.
Secretary must grant tribal epi centers access to “data,
data sets, monitoring systems, delivery systems, and other
protected health information in possession of the
Secretary.”
Sec. 401(d)(3)(B). Coordination of Information.
IHS must provide the CMS Administrator with information
about enrolled providers and other info CMS may require
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OVERSIGHT
Sec. 827 Prescription Drug Monitoring. Requires the
Secretary to work with the Attorney General and Secretary of
Interior to establish a prescription drug monitoring program
and report to Congress within 18 months.
Lots of Studies
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Slide 36
DON’T FORGET, IT DIDN’T ALL CHANGE
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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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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
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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
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Slide 39
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)
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Slide 40
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
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Slide 41
ACRONYMS FOR IHCIA AND ACA
UIO = Urban Indian Organization, as defined in IHCIA
Sec. 4(29)
VA = Department of Veterans Affairs
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Slide 42