1. Ready for Reform! Port Gamble S’Klallam Tribe October 30, 2013 Washington State on the pleasant side of the Puget Sound on the Kitsap Peninsula with treaty rights stretching to the Olympic Peninsula, the Pacific Ocean and Canada Port Gamble S’Klallam Tribe October 30, 2013 Washington State on the pleasant side of the Puget Sound on the Kitsap Peninsula with treaty rights stretching to the Olympic Peninsula, the Pacific Ocean and Canada

2. Navajo Language Star Wars

3. Tribal Sponsorship of health insurance Tribal Sponsorship of health insurance One key aspect of health care reform will allow tribes to pay premiums for the health care insurance of its community members. The Port Gamble S'Klallam Tribe has many years of experience in doing just that through the Basic Health Plan and Medicare Part B and D. We assist tribal members in understanding their choices for Medicare Part D and Medicaid. Over 10 years of ‘sponsorship’ of experience assisting individuals and families and that may continue under the health exchange’s Qualified Health Plans-especially if those plans allow our health program to be the medical home for our patients in their plans (hopefully with referrals to their network of providers).

4. Ready for Reform Initiative began 20 months ago, February 1 2012.

7. Tribal Sponsorship Program Vision of the Program: To Connect Tribal Members and their families to the health insurance coverage that is most appropriate for them and the health services department program. Work with their employer paid insurance Work with our CHS funding to pay for insurance, pay for cost sharing, buy specialist care. Work with the State Medicaid Program, Apple Health-now as large as our Indian Health Service Funding. We encourage all community members to work with us as they make decisions with us on how to compare, combine, and choose all the options available to them. Come to us for assistance.

8. Timeline and History of the Tribal Sponsorship Program The TSP developed between February 2012 and October 2013. Historical information and review of the PGST Tribal/ State Basic Health Program. PGST was a leader in Basic Health with the 3 rd largest Tribal program, 150 of the approximately 1,200 tribal members (2011) were sponsored by the Port Gamble S’Klallam Tribe. In January 2010 Basic Health became Medicaid Expansion under the WA State Bridge Waiver. In 2010 premiums were no longer required as Medicaid expanded to 133% of the federal poverty level and the state-funded Basic Health ended and became a Medicaid Waiver Program-childless adults, but same asset and resource tests. Our experience with Basic Health developed policies and procedures, which brought health insurance to 150 community members. We have a great deal of experience with the issues raised by an insurance payment program. PGST has worked on (a now a twelve year) Tribal Community Service State Pilot Project program that allowed us to determine eligibility, verify income and enroll in Medicaid. That ended (abruptly on October 1, 2013)

9. WA Tribes vary in the number of patients –active users

13. Eligibility for Sponsorship 1. Currently CHS eligible 2. Eligible for Tax Credits in the Exchange/Marketplace 3. Under 300% of federal poverty level or insurance premiums is 50% of actual cost (with reduction due to tax credit). We expect to buy $110,000 to $150,000 of insurance for 50 uninsured, CHS eligibles, who are under 300% FPL. We expect $50,000 to $65,000 will be paid to us for their care and another $229,000 to $286,000 will be paid by health plans to specialists and hospitals.

14. Key Income Level is 300% FPL No deductibles No copays Bronze level has lowest rates Because it has highest cost sharing AIANs eligible for Exchange who under 300% on average save over $2,000 with Bronze plan Bronze is cheaper because there is higher cost sharing

16. Income Levels

17. Alignment with 4 Key elements of Health Care Reform 1. Medicaid Expansion 2. Health Insurance Exchange 3. Health Insurance Market Reforms No pre-existing conditions for all in 2014 4. Cost Control (Payment and Delivery Reform) Quality Improvement, Information Technology Managing chronic conditions sharing health information with specialists.

18. Refine eligibility and enrollment Refine eligibility and enrollment Pilot Project for Medicaid/CHIP eligibility and enrollment we already have the nation’s best Tribal effort to determine eligibility and enroll our patients in health care plans in a way that is sensitive to the unique federal responsibility for health care services to American Indians and Alaska Natives. We also participate in the Medicaid Administrative Match program (the first in the nation since 1999) to recoup some of the costs associated with this activity. Over $100,000 to tribe every year, but declining in recent years. MAM will be key to paying for Medicaid enrollment, pays ½ cost. Tribal Assister’s and Navigator programs may provide some financial assistance.

19. 6 Elements of Port Gamble S’Klallam Tribe’s readiness Staffing: Support current monitor need for additional Outreach and Education on Health Care reform tied to our Eligibility and Enrollment capacity Make the Accounting system produce needed information for decision making-which option--- buy insurance or buy ‘risk’ Continue to pay for health insurance and prepare for expansion of sponsorship Electronic Health Record system enhancement to support innovation in care management Work with other Tribes through other organizations.

20. Thanks for Participating

21. 205,000 AIANs in Washington = $1 billion