Legislative & Policy Update
NW Portland Area Indian Health Board
Quarterly Board Meeting
Great Wolf Lodge – Chehalis Tribe
January 27, 2015
1
Report Overview
1. IHS Budget Updates
2. CHS Meeting & MLR Regs & CHEF
3. FAAB & CHS Workgroups
4. MLR for non-hospital based services
5. ACA Updates
FY 2015 Budget Update (3A)
• Omnibus Bill finalizes FY 2015 IHS Budget
• $208 million increase (4.7%) is respectable in
current budget environment but not a good bill
• Bill only provides $54 million for program
increases which results in reprogramming base
to cover staffing new facilities, new tribes
funding, and contract support costs
• Full impact of budget won’t be known until IHS
makes available spending plan
• Due to Congress 30 days after enactment
FY 2015 Budget Update (3A)
• House & Senate have pending Interior
Appropriations bills
• House bill is $96 million more than the
Senate bill
• Senate bill requests only $2.5 million
increase for CHS, while the House request is
$50 million
• Senate bill includes small increases for H&C
items
FY 2015 Budget Update
Summary of Congressional Action
Comparing President's FY 2015 Request
to the Congressional Marks and Omnibus
($ i n 1,000s )
Health Services
Facilities
Total Budget
FY 2014
President
House
Senate
Omnibus
$3,982,842
$4,172,182
$4,180,386
$4,085,515
$4,182,147
$451,673
$461,995
$461,995
$460,234
$460,234
$4,434,515
$4,634,177
$4,642,381
$4,545,749
$4,642,381
$199,662
$207,866
$111,234
$207,866
4.5%
4.7%
2.5%
4.7%
Change vs. 2014
Percet of Change
Decent Budget Increases?
•
•
•
•
•
•
•
•
•
•
•
Overall H&C Accounts 3.2%
Dental Services 5.3%
Mental Health 4.1%
A&SA 2.5%
CHS 4%
Public Health Nursing 6.7%
Health Education 6%
* Indian Health Professions 44.5%
* Tribal Management 69%
* Self-Governance 21%
* Contract Support Costs 13%
Staffing and CSC Increase cut into
the $208 million budget increase: Here’s how?
Summary Analysis of FY 2015
Real Program Increase is $61.4 million
Dollars in
1,000s
Pct. of
Change
FY 2014 Final Budget
$
4,434,515
FY 2015 Enacted
$
4,642,381
$
207,866
4.7%
Kayenta;
CA YRTC;
Ft. Yuma;
Gila River
Increase
(Less Proposed Staffing in President's
Request for four projects)
$
70,818
(Less Required CSC Funds)
$
75,594
Reduces Overall Increase: $
146,412
Adjusted Program Incease for
ALL I/T/U programs
$
61,454
1.4%
Evaluating the Impact of Proposed Staffing &
New Tribes Funding on the FY 2015 Budget Increase
(Note: Selected Services Accounts)
FY 2015
Program
Increase
Proposed
Staffing
Proposed
New Tribes
Total
Staffing &
New Tribes
Actual
Program
Increase
Hospitals & Health Clinics
$45,885
$41,605
$3,584
$45,189
$696
Dental Services
$8,692
$8,224
$468
$8,692
$0
Mental Health
$3,165
$2,846
$319
$3,165
$0
Alcohol & Substance Abuse
$4,603
$4,314
$289
$4,603
$0
$35,564
$97,909
$56,989
$2,572
$7,232
$2,572
$64,221
$32,992
$33,688
Public Health Nursing
$4,731
$4,474
$257
$4,731
$0
Health Education
$861
$164
$1,025
$0
Comm. Health Reps
$1,025
$124
$124
$124
$0
Immunization AK
Subtotal, Preventive Health
$0
$5,880
$5,880
$0
$0
Urban Health
$2,875
$2,875
Indian Health Professions
$14,876
$14,876
Tribal Management
$1,000
$1,000
(Dollars in 1,000's)
SERVICES
Contract Health Services
Subotal, Clinical Services
$5,335
Direct Operations
$171
Self-Governance
$1,000
$1,000
$75,594
$95,516
$0
$171
$171
$75,594
$95,345
$199,305
$62,324
$7,948
$70,272
$129,033
$8,561
$8,494
$67
$8,561
$8,561
$207,866
$70,818
$8,015
$78,833
$129,033
Contract Support Cost
Subtotal, Other Services
TOTAL, SERVICES
Total, Facilities
TOTAL, IHS
$0
$545
$171
$171
$0
Portland Area FY 2017
Budget Formulation (3B)
• Session held Dec. 1-2, 2014 in Seattle
• Recommendations at 5% - $231.7 million
– Current Services $157.4 million
– PRC $74.3 million
• Recommendations at 17% - $787.8 million
–
–
–
–
–
Current Services $157.4 million
ACA & IHCIA & LTC $187.3 million
PRC $391 million
Restore Pay Act increases $48 million
Facilities: M&I, S&F, Equip. $80 million
• National Work Session February 10-11th
FAAB Update
Sacramento Meeting Nov. 12-13th
• Call with IHS Director time for next report to
Congress – March 23, 2016
• FAAB letter to IHS Director endorsing support for revised
HCFPS & recommendation it be sent to OMB
• FAAB letter to IHS National Budget Formulation
Workgroup Chairs re: funding for M&I
• FAAB affirms role of Needs Assessment Workgroup (NAW)
to serve as technical advisors to the FAAB membership
• FAAB appoints NAW to attend Jan/Feb. 2015
teleconference & begin process to develop master
planning criteria
Purchased & Referred Care Report
• Three Items: PRC Workgroup, MLR Regulations, and
CHEF Procedures
• PRC Workgroup Meeting in Denver (3C)
– Review Recommendations DTLLs
– CHEF regulations in development to lower threshold to $19
million; need legislation to cap threshold at set amount ($25
million)
– Discussion recommendations for MLR regulation
– Formula: GAO Recommendations
1. Adjust hospital access component to something other than “Yes”
or “No” measure
2. Formula should use “CHS Users” and not Active User Population to
allocate resources
3. Require Areas to notify IHS-HQ when deviating from formula
CHS Formula has two components. (1) 75% Cost Variable;
(2) 25% Access to Care [CHS Dependency]
American Chamber of Commerce
Research Association (ACCRA)
• Some want to change due to criticism that ACCRA does not
accurately measure price for all locales
• Self reported by Chambers not highly reliable
• OPTION: replace ACCRA with price data from ACA Insurance
Exchanges
• POTENTIAL: Plan filings by zip code data may be more reliable
to determine costs of health care & can be customized to
individual operating units
Hospital Measure – Access to Care
CHS Medicare-like Rate Regulation
• December 5th IHS issued regulation to apply
MLRs to non-hospital based charges
• In principle a great idea! ... but rule contains an
all or nothing “nuclear” requirement; it is not
optional; does not allow exemption for local
access issues or existing provider relationships
• Other concerns that rule undermines the need
for legislation?
• Comment period initially closed Jan. 16th, but has
been extended to February 4, 2015
• ***Individual Tribes will need to weigh in! A
Board letter will not be enough on this one.***
MLR Rule Summary (3D)
1.
2.
3.
Amends Sec. 506 to apply MLR to non-hospital based
charges
Allows negotiating lower than MLRs
Nuclear provision prohibits PRC payment to providers if
they do not agree to accept the MLR rates.
–
–
–
4.
5.
Could result in patient liability?
Restrict access if provider won’t accept rate
Other costs (travel) could be more than MLR rate
Currently no exemption for such circumstances in the
proposed rule
Some feel rule encroaches on Tribal sovereignty and
ISDEAA
MLR Rule Recommendations
1.
2.
3.
Retitle rule to remove references to it applying to “Health Care
professional services”. Sec. 506 already applies in limited
circumstances. Avoid this confusion.
Exempt Tribal contributions to CHS from the rule.
Develop exemptions for local circumstances:
A.
B.
C.
D.
4.
5.
6.
Exemption to respect on-going provider relationships even if this is
above MLRs.
When travel or other costs to an alternate provider would exhaust
any cost savings achieved by the rule.
When patient may have to travel more than XXX miles?
If Tribal health programs are within a XXX mile radius of a Critical
Access Hospital
Develop mechanism to enforce IHCIA § 135 “Liability for
Payment” to protect patients from balance billing
IHS to develop training and technical assistance to implement the
rule and resources to participate (unfunded mandate)
Set effective date for the rule to prepare for implementation.
ACA Updates
• Enrollment ends Feb. 15, 2015
– CHS savings has been very beneficial
– Medicaid collections are up for almost all Tribes
– Medicaid data is good however need more reliable
Exchange data to evaluate full impact
• IRS final instructions for Exemption Form 8965 &
Issued Publication 5187 “Health Care Law: What’s
New for Families”
– Covers tax issues of ACA; How “individual responsibility” can
be met; covers exemptions; 1040 Line 61 Health Care
• Tribal Employer Exemption from “employer
mandate” – (See Whitehouse Letter developed by
TTAG)
114th Congress Begins
• Legislative Plan Updated and preparation for lobby trips in
February
• President’s budget in February reinstating All Tribes meeting
• Senate Committee on Indian Affairs
– Chair, Sen. John Barrasso, WY – Physician, President WY Medical
Society, 4th ranking member in Republican Leadership
– Vice-Chair, Jon Tester, MT – previous chair, rancher, knows Board,
Andy, very supportive of NW
– Sen. Crapo and Sen. Cantwell (minority members same); majority
added Kansas Sen. Jerry Moran and Montana Sen. Daines
• House Resources Subcommittee on Indian Affairs
– Rep. Don Young (AK) continues to Chair
– Rep. Colleen Hanabusa (HI), is the Ranking Member
– Rep. Pete Defazio (D-OR); Doc Hastings (R-WA)
Discussion?