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IHCIA and ACA Opportunities and Challenges National Council of Urban Indian Health April 24, 2012 Myra M. Munson, J.D., M.S.W. Washington,

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Presentation on theme: "IHCIA and ACA Opportunities and Challenges National Council of Urban Indian Health April 24, 2012 Myra M. Munson, J.D., M.S.W. Washington,"— Presentation transcript:

1 IHCIA and ACA Opportunities and Challenges National Council of Urban Indian Health April 24, 2012 Myra M. Munson, J.D., M.S.W. Washington, DC Juneau, AK Anchorage, AK Albuquerque, NM San Diego, CA Sonosky, Chambers, Sachse, Miller & Munson, LLP

2 Roadmaps You have to know where you are, if you want to figure out how to get where you want to go. April 24, 2012 National Council of Urban Indian Health Slide 2 Sonosky, Chambers, Sachse, Miller & Munson, LLP

3 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 April 24, 2012 National Council of Urban Indian Health Slide 3 Sonosky, Chambers, Sachse, Miller & Munson, LLP

4 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 April 24, 2012 National Council of Urban Indian Health Slide 4 Sonosky, Chambers, Sachse, Miller & Munson, LLP

5 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 April 24, 2012 National Council of Urban Indian Health Slide 5 Sonosky, Chambers, Sachse, Miller & Munson, LLP

6 ARRA Sec *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) April 24, 2012 National Council of Urban Indian Health Slide 6 Sonosky, Chambers, Sachse, Miller & Munson, LLP

7 ARRA Sec *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 April 24, 2012 National Council of Urban Indian Health Slide 7 Sonosky, Chambers, Sachse, Miller & Munson, LLP

8 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 April 24, 2012 National Council of Urban Indian Health Slide 8 Sonosky, Chambers, Sachse, Miller & Munson, LLP

9 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 April 24, 2012 National Council of Urban Indian Health Slide 9 Sonosky, Chambers, Sachse, Miller & Munson, LLP

10 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 (ii)(A) through (D)] (28) Urban Indian Organization April 24, 2012 National Council of Urban Indian Health Slide 10 Sonosky, Chambers, Sachse, Miller & Munson, LLP

11 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 (CMS implementation of ARRA cost sharing protections) April 24, 2012 National Council of Urban Indian Health Slide 11 Sonosky, Chambers, Sachse, Miller & Munson, LLP

12 How Does CMS Define “Indian”? 42 CFR 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 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. April 24, 2012 National Council of Urban Indian Health Slide 12 Sonosky, Chambers, Sachse, Miller & Munson, LLP

13 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 April 24, 2012 National Council of Urban Indian Health Slide 13 Sonosky, Chambers, Sachse, Miller & Munson, LLP

14 What About Implementation of the IHCIA Amendments? April 24, 2012 National Council of Urban Indian Health Slide 14 Sonosky, Chambers, Sachse, Miller & Munson, LLP

15 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]. April 24, 2012 National Council of Urban Indian Health Slide 15 Sonosky, Chambers, Sachse, Miller & Munson, LLP

16 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. April 24, 2012 National Council of Urban Indian Health Slide 16 Sonosky, Chambers, Sachse, Miller & Munson, LLP

17 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 April 24, 2012 National Council of Urban Indian Health Slide 17 Sonosky, Chambers, Sachse, Miller & Munson, LLP

18 *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) April 24, 2012 National Council of Urban Indian Health Slide 18 Sonosky, Chambers, Sachse, Miller & Munson, LLP

19 *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). April 24, 2012 National Council of Urban Indian Health Slide 19 Sonosky, Chambers, Sachse, Miller & Munson, LLP

20 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. April 24, 2012 National Council of Urban Indian Health Slide 20 Sonosky, Chambers, Sachse, Miller & Munson, LLP

21 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 April 24, 2012 National Council of Urban Indian Health Slide 21 Sonosky, Chambers, Sachse, Miller & Munson, LLP

22 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 April 24, 2012 National Council of Urban Indian Health Slide 22 Sonosky, Chambers, Sachse, Miller & Munson, LLP

23 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. April 24, 2012 National Council of Urban Indian Health Slide 23 Sonosky, Chambers, Sachse, Miller & Munson, LLP

24 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 April 24, 2012 National Council of Urban Indian Health Slide 24 Sonosky, Chambers, Sachse, Miller & Munson, LLP

25 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. April 24, 2012 National Council of Urban Indian Health Slide 25 Sonosky, Chambers, Sachse, Miller & Munson, LLP

26 Other Reminders of Opportunities Sec 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 Community Health Representatives – UIOs may used CHRs trained under section 107 Sec Use of Federal Facilities and Sources of Supply. Sec Health Information Technology grants. April 24, 2012 National Council of Urban Indian Health Slide 26 Sonosky, Chambers, Sachse, Miller & Munson, LLP

27 More Expanded Authority and Opportunity under Title V Sec Community Health Representatives – IHS may allow UIOs to employ CHRs trained under section 107. Sec Use of Federal Facilities and Sources of Supply Sec Health Information Technology grants. April 24, 2012 National Council of Urban Indian Health Slide 27 Sonosky, Chambers, Sachse, Miller & Munson, LLP

28 OTHER CHANGES IMPORTANT TO TRIBAL HEALTH PROGRAMS April 24, 2012 National Council of Urban Indian Health Slide 28 Sonosky, Chambers, Sachse, Miller & Munson, LLP

29 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 April 24, 2012 National Council of Urban Indian Health Slide 29 Sonosky, Chambers, Sachse, Miller & Munson, LLP

30 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 April 24, 2012 National Council of Urban Indian Health Slide 30 Sonosky, Chambers, Sachse, Miller & Munson, LLP

31 PROGRAM EXPANSION FOR INDIAN HEALTH PROGRAMS 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 April 24, 2012 National Council of Urban Indian Health Slide 31 Sonosky, Chambers, Sachse, Miller & Munson, LLP

32 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 April 24, 2012 National Council of Urban Indian Health Slide 32 Sonosky, Chambers, Sachse, Miller & Munson, LLP

33 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 April 24, 2012 National Council of Urban Indian Health Slide 33 Sonosky, Chambers, Sachse, Miller & Munson, LLP

34 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] April 24, 2012 National Council of Urban Indian Health Slide 34 Sonosky, Chambers, Sachse, Miller & Munson, LLP

35 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 April 24, 2012 National Council of Urban Indian Health Slide 35 Sonosky, Chambers, Sachse, Miller & Munson, LLP

36 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. April 24, 2012 National Council of Urban Indian Health Slide 36 Sonosky, Chambers, Sachse, Miller & Munson, LLP

37 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 April 24, 2012 National Council of Urban Indian Health Slide 37 Sonosky, Chambers, Sachse, Miller & Munson, LLP

38 Implementation of Other ACA Provisions April 24, 2012 National Council of Urban Indian Health Slide 38 Sonosky, Chambers, Sachse, Miller & Munson, LLP

39 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. § 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 April 24, 2012 National Council of Urban Indian Health Slide 39 Sonosky, Chambers, Sachse, Miller & Munson, LLP

40 More about Exchanges Consultation with I/T/U: 42 C.F.R. § 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. § (d)(3). Regulations enforce right of AI/ANs to enroll in or change plans one time per month (instead of only during annual enrollment) Verification of Being AI/AN: Have requested additional comment April 24, 2012 National Council of Urban Indian Health Slide 40 Sonosky, Chambers, Sachse, Miller & Munson, LLP

41 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. § (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 April 24, 2012 National Council of Urban Indian Health Slide 41 Sonosky, Chambers, Sachse, Miller & Munson, LLP

42 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. April 24, 2012 National Council of Urban Indian Health Slide 42 Sonosky, Chambers, Sachse, Miller & Munson, LLP

43 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 April 24, 2012 National Council of Urban Indian Health Slide 43 Sonosky, Chambers, Sachse, Miller & Munson, LLP

44 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. § (e)(3) April 24, 2012 National Council of Urban Indian Health Slide 44 Sonosky, Chambers, Sachse, Miller & Munson, LLP

45 Still Open for Comment til 5/7/12 § (c)(1) and (d) and § (b)(6) – Safeguarding information on applicants and beneficiaries. § – Timeliness and performance standards for Medicaid. § Coordinated eligibility and enrollment among insurance affordability programs. § (d) – Timeliness standards for CHIP. § – Coordinated eligibility and enrollment among CHIP and other insurance affordability programs. § (a), (b), (c), (f), (i), (j), and (k) – Coordinated eligibility and enrollment among CHIP and other insurance affordability programs. April 24, 2012 National Council of Urban Indian Health Slide 45 Sonosky, Chambers, Sachse, Miller & Munson, LLP

46 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 April 24, 2012 National Council of Urban Indian Health Slide 46 Sonosky, Chambers, Sachse, Miller & Munson, LLP

47 BACKGROUND AND REFERENCES April 24, 2012 National Council of Urban Indian Health Slide 47 Sonosky, Chambers, Sachse, Miller & Munson, LLP

48 Most Recently... ACA – Patient Protection and Affordable Care Act, Pub. L (March 23, 2010) IHCIA – Indian Health Care Improvement Act, Pub. L , (1976) as amended most recently by PPACA, Section (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 April 24, 2012 National Council of Urban Indian Health Slide 48 Sonosky, Chambers, Sachse, Miller & Munson, LLP

49 And, Before That... ARRA – American Recovery and Reinvestment Act of 2009, Pub. L (Feb. 2009) CHIPRA – Children’s Health Insurance Program Reauthorization Act, Pub. L (Feb. 2009) MMA – Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub. L (Dec. 2003) April 24, 2012 National Council of Urban Indian Health Slide 49 Sonosky, Chambers, Sachse, Miller & Munson, LLP

50 And, More Basically ISDEAA – Indian Self-Determination and Education Assistance Act, Pub. L , (1975), as amended most recently by the Tribal Self-Governance Amendments of 2000, Pub. L Snyder Act – Pub. L , 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 , Aug. 5, 1954 (transferring responsibility for health from BIA to PHS) April 24, 2012 National Council of Urban Indian Health Slide 50 Sonosky, Chambers, Sachse, Miller & Munson, LLP

51 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 April 24, 2012 National Council of Urban Indian Health Slide 51 Sonosky, Chambers, Sachse, Miller & Munson, LLP

52 HISTORY OF IHCIA ENACTED September 30, 1976 As Pub. L Amended by: Pub. L (12/17/80) Pub. L (10/31/88) Pub. L (11/18/88) Pub. L (11/23/88) Pub. L (11/28/90) Pub. L (10/29/92) Pub. L (10/19/96) Pub. L (10/21/98) Pub. L (11/10/98) Pub. L (11/1/2000) Pub. L (3/23/2010), Section April 24, 2012 National Council of Urban Indian Health Slide 52 Sonosky, Chambers, Sachse, Miller & Munson, LLP

53 ACRONYMS FOR IHCIA AND ACA ACA = Patient Protection and Affordable Care Act, Pub. L ARRA = American Recovery and Reinvestment Act of 2009, Pub. L (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 (Feb. 2009) CHSDA = Contract Health Service Delivery Area April 24, 2012 National Council of Urban Indian Health Slide 53 Sonosky, Chambers, Sachse, Miller & Munson, LLP

54 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 , as amended IHS = Indian Health Service April 24, 2012 National Council of Urban Indian Health Slide 54 Sonosky, Chambers, Sachse, Miller & Munson, LLP

55 ACRONYMS FOR IHCIA AND ACA IRC = Internal Revenue Code ISDEAA = Indian Self-Determination & Education Assistance Act, Pub. L , 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 (Dec. 2003) April 24, 2012 National Council of Urban Indian Health Slide 55 Sonosky, Chambers, Sachse, Miller & Munson, LLP

56 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 April 24, 2012 National Council of Urban Indian Health Slide 56 Sonosky, Chambers, Sachse, Miller & Munson, LLP

57 ACRONYMS FOR IHCIA AND ACA UIO = Urban Indian Organization, as defined in IHCIA Sec. 4(29) VA = Veteran’s Administration April 24, 2012 National Council of Urban Indian Health Slide 57 Sonosky, Chambers, Sachse, Miller & Munson, LLP

58 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 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. April 24, 2012 National Council of Urban Indian Health Slide 58 Sonosky, Chambers, Sachse, Miller & Munson, LLP


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