1. 2214 North Central Avenue, Phoenix, Arizona 85004 p 602.258.4822, f 602.258.4825 www.itcaonline.com

2. Patient Protection and Affordable Care Act/Indian Health Care Improvement Act Implementation Update Phoenix Area IHS Webinar January 17, 2013 2

3. Supreme Court Decision on the Affordable Care Act 3 In 2012, the Nation awaited the Supreme Court’s decision on the landmark case of National Federation of the Independent Business (NFIB) et al vs. Sebelius. On 6/28/12, Chief Justice Roberts announced that the constitutionality of the Patient Protection and Affordable Care Act (ACA) individual insurance mandate was based on the exercise of congressional taxing authority, as opposed to the authority exercised by Congress with regard to interstate commerce, which was argued by the Administration. This also affirmed the permanent reauthorization of the Indian Health Care Improvement Act (IHCIA) which authorizes appropriations as may be necessary to carry out the Act for fiscal year 2010 and each fiscal year hereafter. (25 U.S.C. § 1680o)

4. Supreme Court Decision on the Affordable Care Act Because the individual mandate was upheld, the Court did not need to decide what other parts of the statute were constitutional, except for a provision that requires States to comply with new eligibility requirements for Medicaid or risk losing all of their funding. On that question, the Court held that the provision is constitutional as long as States will only lose new funds if they do not comply with the new requirements, rather than lose all of their funding. 4

5. Supreme Court Decision on the Affordable Care Act "A State could hardly anticipate that Congress’s reservation of the right to “alter” or “amend” the Medicaid program included the power to transform it so dramatically. The Medicaid expansion thus violates the Constitution by threatening States with the loss of their existing Medicaid funding if they decline to comply with the expansion.“ S tates must now determine whether or not to opt-in or opt-out of the Medicaid Expansion. Governors, policy makers, Tribes and stakeholders will need to examine the benefits, challenges and options regarding Medicaid expansion. Tribal governments view Medicaid expansion as an important step to expand access to health care. 5

6. Affordable Care Act (ACA) Timeline & Overview of National Insurance Reforms 6

7. ACA Timeline… ACA signed into law on 3/23/10, instituted major health insurance reform that included establishing Health Insurance Exchanges, expanding Medicaid eligibility to 133% FPL and strengthening Medicare. In 2014, nearly all U.S. citizens and legal residents will be required to have health insurance that meets minimum requirements unless available coverage costs more than 8% of your income. All individuals below 100% FPL and others, including AI/AN’s are exempt from the insurance requirement. Sliding subsidies shall range in amount for individuals and families up to 400% FPL and there is no cost-sharing for AIAN’s Indians under 300% FPL for any insurance plan or package offered on the Exchange. 7

8. ACA Timeline… Major Policy Changes…so far: Immediate access to coverage for uninsured people with a serious pre-existing condition through high risk pool plans. Health insurance plans prohibited from denying coverage to children with pre-existing conditions. Health plans required to allow young people up to their 26th birthday to remain on their parents’ insurance policy. Health plans not allowed to rescind coverage except in instances of fraud or misrepresentation. Health plans required to provide minimum coverage without cost-sharing for preventive services, immunizations, and preventive care for infants, children, adolescents and women. 8

9. ACA Timeline… Process established to review increases in health plan premiums and insurers required to justify increases. Medicare eliminated co-payments for preventive services and preventive services exempted from deductibles. Medicare coverage for the annual wellness visit added. Funding increased for Community Health Centers and the National Health Service Corps for five years. Program established to support school-based health centers and nurse-managed health clinics. Closing the coverage gap in Medicare Part D plans begun. Discounts on covered brand-name and generic drugs to continue to grow until the ‘donut hole’ closes in 2020. 9

10. ACA Timeline… Effective in 2013: Health insurance administration to be simplified by adopting a single set of operating rules for eligibility verification, claims status, electronic funds transfer and health care payment and remittance. National Medicare pilot program to evaluate paying a bundled payment for acute inpatient services, physician services, outpatient hospital services and post-acute care. Increased Medicaid payments for primary care services provided by a physician in 2013 and 2014 with 100% federal funding. 10

11. ACA Timeline… Effective in 2014: Pre-existing condition medical restrictions for all private insurance to be eliminated. Affordable Insurance Exchanges will be in operation, administered by the state or CMS or as a partnership between the state and federal government. Individual small businesses and non-profits with up to 50 employees will be able to purchase Qualified Health Plan coverage. Medicaid expansion and Exchange plans to cover, at minimum, 10 broad categories of Essential Health Benefits. Limits to be placed on individual annual cost-sharing. 11

12. ACA Timeline… Medicaid expansion to cover all individuals ages 19-64. It includes adults without dependent children with incomes up to 133% FPL. States can choose to cover those above 133% FPL. ACA requires alignment of eligibility regulations and processes. Individuals will not have to apply to multiple programs. A one-stop-shop Exchange will assist individuals and small businesses obtain health insurance that includes Essential Community Providers in their networks. 12

13. ACA Timeline… Medicaid will use a Modified Adjusted Gross Income (MAGI) methodology to streamline screening and enrollment into four eligibility categories - adults, children, parents and pregnant women. Premium tax credits and cost-sharing subsidies for private insurance shall be available to eligible individuals and families with incomes between 133%-400% FPL when purchasing insurance through an Exchange. ACA to require commercial plans and the Federal Employees Health Benefits Plan to cover the patient care costs in clinical trials that are approved or funded by federal agencies. 13

14. ACA/IHCIA Regulation Development 14

15. Health Insurance Exchanges/ Medicaid Expansion Active regulation and the development of guidance by the U.S. Department of Health and Human Services (HHS), the U.S. Treasury/Internal Revenue Service (IRS) and the Office of Personnel Management (OPM) was underway in 2012: Essential Health Benefits (EHB) Bulletin (2/17/12) further defined the comprehensive package of covered services that will be available in individual and small group insurance plans both inside and outside of Affordable Insurance Exchanges and Medicaid plans. CMS Rule on ACA Section 1332 State Waivers (2/27/12) provides a mechanism for States to waive some provisions of the ACA if increased access to quality health care can be met through other innovative means. 15

16. Health Insurance Exchanges/ Medicaid Expansion CMS Rule on the ACA Section 1115 Waiver Transparency, finalized on 2/27/12, requires transparency, public notice procedures and codifies tribal consultation in the review and approval process of Medicaid/CHIP Section 1115 Demonstrations. CMS Rule on the Establishment of Exchanges and Qualified Health Plans, was finalized on 3/12/12. CMS Rule on the Eligibility for a Health Plan: Health Care Claims Transactions through Electronic Data Interchange was finalized on 3/21/12. 16

17. Health Insurance Exchanges/ Medicaid Expansion CMS Rule on Affordable Insurance Exchanges Standards Related to Reinsurance, Risk Corridors and Risk Adjustment, was finalized on 3/23/12. CMS interim Rule on Medicaid Program: Eligibility Changes was published on 3/23/12. Starting in 2014 existing categorical groups will be combined. Eligibility will be expanded to all individuals under the age of 65 with income at or below 133% FPL or if a state chooses, to individuals above this income level. New FMAP will go into effect to provide 100% Federal Match for 3 years for newly eligible individuals. In 2020, it will be reduced to 90% where it is to remain permanent. 17

18. Health Insurance Exchanges/ Medicaid Expansion CMS Rule on ACA Exchange Functions in the Individual Market: Eligibility Determinations: Exchange Standards for Employers, was finalized on 3/27/12. General Guidance on Federally-Facilitated Exchanges (CMS-CCIIO) issued 5/16/12. Comment period closed on 6/18/12. IRS/Treasury Rule on the Health Insurance Premium Tax Credit, for Individuals was finalized on 5/18/12. “Essential Health Benefits: List of the Largest Three Small Group Products by State” (CMS-CCIIO) was published on 7/3/12. Assists States select a benchmark that would serve as the reference plan for Essential Health Benefits for QHPs. 18

19. Health Insurance Exchanges/ Medicaid Expansion CMS Rule on Data Collection to Support Standards Related to Essential Health Benefits was finalized on 7/20/12. Health Care Reform Insurance Web Portal Requirements was published in the Federal Register on 8/15/12. Comments closed on 9/12/12. Dear Tribal Leader Letter from CMS/IHS requested comment on the Model Qualified Health Plan Addendum for Indian Health Providers on 11/19/12. The comment period closed on 12/19/12. 19

20. Health Insurance Exchanges/ Medicaid Expansion Patient Protection and Affordable Care Act; Standards Related to Essential Health Benefits, Actuarial Value, and Accreditation (CMS) was published on 11/20/12. Comment period closed on 12/26/12. Patient Protection and Affordable Care Act; Health Insurance Market Rules; Rate Review (CMS) was published on 11/26/12. Comment period closed on 12/26/12. Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2014 (CMS) was published on 12/7/12. Comment period ended on 12/31/12. 20

21. Health Insurance Exchanges/ Medicaid Expansion Patient Protection and Affordable Care Act: Establishment of Multi-State Plan Program (MSPP) for Affordable Insurance Exchanges (OPM) was published on 12/5/12. Comment period ended on 1/4/13. FAQ’s on Exchanges, Market Reforms, and Medicaid (CMS) was issued on 12/10/12. It answers questions on timeframes for state-federal partnership exchanges and on the Federally Facilitated Exchange. It also states that a state may apply at any time to run an Exchange in future years. Treasury/IRS proposed rule on Employer Shared Responsibility provisions issued on 12/28/12. Comment period closes on 3/18/13. 21

22. Indian Health Care Improvement Act ( IHCIA) Implementation 22

23. IHCIA Implementation Dear Tribal Leader Letters from Dr. Roubideaux have informed and updated Tribal Governments about several new and amended sections of the Indian Health Care Improvement Act in 2012, including; Section 121. Indian Health Care Improvement Fund Section 122. Catastrophic Health Emergency Fund Section 124. Other Authority for Provision of Services (Hospice, Long Term Care, Assisted Living and Home and Community Based Services) Section 125. Reimbursement from Certain Third Parties of Costs of Health Services (Tribal Facilities) Section 126. Crediting of Reimbursements 23

24. IHCIA Implementation… Section 127. Behavioral Health Training and Community Education Programs; Study; Hiring and Training Plan Section 129. Patient Travel Costs; Authorized Categories Section 130. Epidemiology Centers Section 132. Indians Into Psychology Program Section 133. Prevention, Control & Elimination of Communicable & Infectious Diseases Section 134. Methods to Increase Clinician Recruitment and Retention Issues Section 135. Liability for Payment 24

25. ACA/IHCIA Implementation… Section 137. Contract Health Services Administration and Disbursement Formula (GAO Report published 9/23/11) Section 141. Health Care Facility Priority System Section 151. Treatment of Payments Under the Social Security Act Health Benefits Programs Section 154. Sharing Arrangements with Federal Agencies Section 157. Access to Federal Health Insurance Section 173. Nevada Area Office Section 702. Behavioral Health Prevention & Treatment Services 25

26. ACA/IHCIA Implementation… Section 703. Memorandum of Agreement with the Department of the Interior to address alcohol, substance abuse and mental health issues Section 704. Comprehensive Behavioral Health Prevention and Treatment Program Section 708. Indian Youth Program Involvement (So. CA YRTC design funds included in FY 2012 enacted budget) 26

27. Most Recent IHCIA Activity In 2012, IHS initiated Tribal consultation on: – IHCIA long term care provisions – IHS/VA Memorandum of Agreement; reimbursement for direct care services – IHCIA data sharing provisions – IHCIA health care facilities construction policy – IHCIA provisions that require IHS confer with Urban Indian Health Organizations 27

28. ACA AI/AN Insurance Related Provisions & Regulatory Requirements 28

29. AI/AN Insurance Related Provisions & Regulatory Requirements AI/AN are exempt from the mandate requiring individuals to purchase of health insurance or paying a penalty. Exchanges must allow a process to identify exempt individuals. Exchanges are required to provide for special monthly enrollment periods for AI/AN. Exchanges are strongly encouraged to use of the Indian Addendum for QHP contracts with I/T/U providers. Exchanges must consult with Federally recognized Tribes. 29

30. AI/AN Insurance Related Provisions & Regulatory Requirements Indian Tribes, tribal organizations, and Urban Indian organizations are organizations that may be designated as “Navigators.” I/T/U’s added to list of agencies that could serve as an “Express Lane Agency” under Sec. 1902(e)(13) of the Social Security Act and determine eligibility for public benefit programs. No cost-sharing for AI/AN under 300% FPL enrolled in any individual market insurance plan offered through the Exchange. 30

31. AI/AN Insurance Related Provisions & Regulatory Requirements No cost-sharing under any Exchange plan for services provided by the I/T/U or through a CHS referral and the insurer may not reduce the payment to any such entity for items or services provided. I/T/U providers are the payers of last resort for services provided to AI/AN’s through such programs. 31

32. AI/AN Insurance Related Provisions & Regulatory Requirements Distributions and payments from AI/AN resources per Section 5006 of the American Recovery & Reinvestment Act (ARRA) and certain income exclusions codified in the Internal Revenue Code shall not be used in determining Medicaid or CHIP eligibility under MAGI. AI/AN income exemptions in the determination of MAGI- based income must be calculated on the Exchange calculator. 32

33. New and Amended Insurance Provisions of the IHCIA 33

34. New and Amended Insurance Provisions of the IHCIA Health Services Reimbursement from Certain Third Parties of Costs of Health Services– I/T/U shall have the right to recover from an insurance company, HMO, employee benefit plan, third party tortfeasor, or any other responsible or liable third party the reasonable charges billed for items or services provided or the highest amount that would be paid for goods and services outside of the government. (25 U.S.C. § 1621e) Absent a written agreement that may be renewed annually, IHS shall not have the right of recovery for services covered under a self-insurance plan funded by a Tribe, Tribal Organization or Urban Indian (25 U.S.C. § 1621e(f)) 34

35. New and Amended Insurance Provisions of the IHCIA Crediting of Reimbursements - The Secretary shall ensure that each Service Unit, Tribe, Tribal Organization and Urban Indian program receives 100% of its collections. Payments shall not be considered in determining the annual IHS appropriations level of funding. (25 U.S.C. §1621f) Liability for Payment (No Recourse) - A contract care provider does not have recourse against a patient for payment if the provider received notice that any patient who receives contract health care authorized by the Service is not liable for payment of any costs or charges, or if the claim has been deemed accepted. (25 U.S.C. §1621u) 35

36. New and Amended Insurance Provisions of the IHCIA Access to Health Services Purchasing Health Care Coverage - Tribes & Urban programs may use appropriations to purchase coverage through; 1) a tribally operated health care plan; 2) an authorized or licensed health care plan; 3) a health insurance provider or managed care plan; 4) a self-insured plan; 5) or a high deductible or health savings account plan. (25 U.S.C. §1642) Grants to Facilitate Outreach, Enrollment and Coverage of Indians Under Social Security Act Programs – I/T/U’s eligible for grant awards. (25 U.S.C. §1644) 36

37. New and Amended Insurance Provisions of the IHCIA Non-discrimination Reimbursement for Services - A Federal health care program must accept an entity operated by IHS, an Indian tribe, tribal organization, or urban Indian organization as a provider eligible to receive payment for health care services. (25 U.S.C. §1647(a)) Federal Employees Health Benefits Program - Allows Indian tribes, tribal organizations and urban Indian organizations to purchase coverage for its employees thru a Federal Employees Health Benefits Program. (25 U.S.C. §1647(b)) 37

38. New and Amended Insurance Provisions of the IHCIA Navajo Nation Medicaid Study - The Secretary is directed to conduct a study to determine the feasibility of treating the Navajo Nation as a state for purposes of Title XIX of the Social Security Act. (25 U.S.C. §1647(d)) Arizona, North Dakota and South Dakota Contract Health Services Delivery Areas (CHSDA’s) – Permanent designation. (25 U.S.C. § 1678, §1678a, §1679) Services to non-IHS beneficiaries - IHS and tribally-operated programs may provide health care services to non-IHS eligible beneficiaries if there is no diminution in services to AI/AN beneficiaries. (25 U.S.C. §1680c) 38

39. Health Insurance Exchange Planning with Tribal Governments 39

40. Health Insurance Exchange (HIX) Planning Arizona o The Governor’s office received a $29.8 Level I Establishment grant in November 2011. Planning was underway to establish policies and develop an Exchange website and call-in center where consumers and small businesses compare health insurance plans and enroll in a commercial or AHCCCS plan (Medicaid), CHIP (KidsCare) and SNAP. o The Arizona Tribal Health Insurance Exchange Work Group was formally established in 2012 with staff support provided by ITCA, Inc. Tribal recommendations were formulated and the HIX Tribal Consultation Policy was drafted and submitted to Governor Brewer. She announced on 11/28/12, however, that a state-based Exchange would not be established in Arizona. The Work Group will now focus on the FFE and related matters, e.g., Medicaid Expansion. 40

41. Health Insurance Exchange (HIX) Planning Nevada o Nevada’s Silver State Health Insurance Exchange received a Level Two Establishment grant totaling $50 million in August 2012, to accomplish the activities necessary to meet certification requirements, provide coverage to enrollees by January 1, 2014, and to be self-sustainable by January 2015. Nevada established the Exchange during the 2011 legislative session by passage of Senate Bill 440. There’s been progress on the drafting of the Tribal consultation policy and a Tribal Consultation meeting was held on 1/15/13 in Carson City, NV. o Nevada is one of the states that has decided to move forward on Medicaid Expansion. 41

42. Health Insurance Exchange (HIX) Planning Utah o Utah submitted a “letter of intent” in December 2012 to establish a state based Exchange. Funding received in September 2010 has allowed the state to move forward on their current Exchange, expand the Exchange-research to better target potential consumers and develop a web-based tool for eligibility purposes. o The Utah Health Exchange, established prior to the ACA is already open to small businesses with 2-50 employees. The website connects employers to insurance agents to assist in the application and underwriting process. Once the employer decides the contribution amount and the default plan, employees can shop for health care plans. o Utah is undecided on Medicaid Expansion as of 1/15/13. 42

43. Key Federal Implementation Dates January 1, 2013: States must demonstrate progress toward successful implementation of an Exchange, or the Secretary of will implement an Exchange in that State. February 15, 2013: State-Federal Partnership Exchanges required to submit Declaration Letter and Blueprint Application. October 1, 2013: Exchanges must begin an initial open enrollment period for individuals and small employers for coverage effective January 1, 2014. January 1, 2014: The Exchange must be fully operational. January 1, 2015: The Exchange must be self-sustaining and allowed to charge user fees or assessments. 43

44. Tribal Health Steering Committee Staff (ITCA, Inc.) : Alida Montiel, Health Systems Director (602) 258-4822, Ext. 1543 Alida.Montiel@itcaonline.com Alida.Montiel@itcaonline.com 44