Washington Health Benefit Exchange Serving American Indians/Alaska Natives Summer 2013

Purpose and Objectives Purpose This training module is to provide an overview of serving American Indians and Alaska Natives (AI/ANs) in Washington’s Healthplanfinder 2 Objectives Upon completion of this training you will: ▪ Understand the Federal responsibility to AI/AN for health care ▪ Have a general understanding of the Indian health system and why it is important in the Exchange ▪ Understand the special benefits afforded to AI/AN in the ACA and Exchange

Training Module Contents ▪ Federal Responsibility for Indian Health Care ▪ State-Exchange Responsibilities to Tribes and Urban Indian health organizations ▪ Indian Health Care Delivery System ▪ Special Provisions/Protections for AI/AN ▪ Benefits to AI/AN ▪ Eligibility ▪ Issues important to AI/AN ▪ Let’s review ▪ Knowledge Check ▪ Indian Health Disparities

4 United States has a responsibility to provide for the health care needs of Native people Treaty Executive Orders Court CasesStatute Federal Trust Responsibility for Indian Health TRIBAL SOVEREIGNTY "The definition of sovereignty is to have control over your own lands, and resources, and assets, and to have control over your own vision for the future, and to be able to absolutely determine your own destiny.” the late Wilma Mankiller, Cherokee Nation President Key Point

Treaties Established Health Care Services 5 “And the United States finally agree to employ a physician to reside at the said central agency, who shall furnish medicine and advice to their sick, and shall vaccinate them; the expenses of …medical attendance to be defrayed by the United States, and not deducted from the annuities.” Treaty of Point Elliot, 1855, Article 14

6 Tribal-State Government-to-Government WHBE Tribal Consultation Policy Exchange is required to develop a process for Tribal Consultation Establishes a clear and concise consultation and collaboration process between the WHBE and federally-recognized tribal Governments as required by Affordable Care Act Tribal Advisory Workgroup: collaboration and identification of issues with Tribal implications Tribal Liaison: works with Tribes, Urban Indian health programs, Exchange staff and In-Person Assisters to facilitate positive relationships and assure uninsured AI/AN can enroll in Healthplanfinder Key Point

Indian Health Care Delivery System ▪ Federal Indian Health Service ▪ U.S. Department of Health & Human Services ▪ Serves approximately 1.5 million AI/AN ▪ IHS is NOT considered insurance; entitlement based on federal Indian policy and law ▪ Goal - improve AI/AN health status, uphold federal government obligations ▪ Area Offices ▪ Portland Area Office - WA, Oregon, Idaho ▪ Washington State Indian Health System ▪ 29 federally recognized Tribes, 2 Urban Indian Health Programs ▪ 34 health care facilities - operated by the federal IHS, Tribes or urban Indian health programs; services free of charge to AI/AN ▪ Contract Health Services – Tribes/Urban Programs pay for healthcare services outside of their clinics Key Point

So Why Do AI/AN Need to Enroll in Washington Healthplanfinder? ▪ Indian Health Service Funding Inadequacies ▪ 60% of level of need ▪ Indian Health Care Disparities ▪ Worst health outcomes overall than any other population in Washington ▪ In WA State, 1 out of 3 AI/AN experience high blood pressure ▪ 18% of AI/AN suffer from asthma compared to 9% of general population ▪ 11% of AI/AN have diabetes compared to 7% of general pop ▪ 10% of AI/AN suffer from heart disease and stroke compared to 6% of general population 8 Key Point

Why AI/AN Benefit from Healthplanfinder con’t. ▪ AI/AN Uninsured in WA ▪ 23.1% compared to overall WA at 13.4% ▪ 45,000 AI/AN 9

Myths as Barriers to Indian Health 10 ▪ “All Indians get all their health care through a separate government system” ▪ “Indians do not need regular health care coverage” ▪ “Indians are not eligible for Medicaid or Medicare or other public benefits”

AI/AN Special Benefits and Protections in ACA ▪ AI/AN living in Washington State will be eligible for additional benefits when Washington Healthplanfinder opens in October 2013 ▪ The Affordable Care Act includes a number of provisions that outline special rules for American Indian and Alaska Native enrollment in Washington Healthplanfinder 11

Special Protections for Enrolled AI/AN 12 N O DEDUCTIBLES N O CO - PAYMENTS N O CO - INSURANCE COSTS AI/AN with Income below 300% of Federal Poverty Level (FPL) Key Point

Special Provisions for Enrolled AI/AN con’t No Federal Mandate – AI/AN are not subject to tax penalty for not enrolling in minimum health care coverage No Costs for Using Indian Health Services - no co-pays or other costs for AI/AN who receive health care services or receive a referral from Indian Health Service, a Tribe, a Tribal organization or Urban Indian Health program Special Enrollment Options – limited enrollment periods do not apply to AI/AN; An AI/AN can enroll in or change a health plan on a monthly basis Key Point

Special Provisions for AI/AN con’t Income Exemptions for AI/AN Alaska Native Corporations and Settlement Trusts; distributions from property held in trust; distributions and payments from fishing, natural resource extraction and harvests; distributions from ownership of natural resources and improvements; payments from ownership of items that have unique religious, spiritual, traditional, or cultural significance according to Tribal Law or custom; and, student financial assistance from Bureau of Indian Affairs education programs). “Plain Language” reference document being developed for IPA use Key Point

New Protection for AI/AN Descendants ▪ New Federal Rule: No penalty for not enrolling in a QHP or having Minimum Essential Coverage (MEC) for Tribal descendants ▪ Checking the Box: “Tribal descendant” or “User of IHS services” 15

Verifying AI/AN Enrollment Status ▪ Process within WA Healthplanfinder ▪ Only Tribal Assisters can manually verify ▪ Other In-Person Assisters can facilitate verification documentation download ▪ Exchange will generate reports to WA State Tribes for verification ▪ Without documentation, AI/AN has 90 days to provide ▪ Eligible in 90 day period for special benefits ▪ “Good faith effort” clause may extend period 16 Eligibility for health coverage in a QHP is NOT tied to AI/AN status. If no AI/AN documentation is available, the AI/AN can still receive coverage through the Exchange with no special benefits!

AI/AN Verification Reference 17

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19 Provide outreach and awareness activities Inform AI/ANs about special provisions afforded them under the ACA Maintain expertise in eligibility, enrollment and program specifications Facilitate an individual’s selection of a qualified health plan Assist individuals in applying for premium subsidies Enter information related to an individual’s application and enrollment in the Washington Healthplanfinder Tribal Assisters – Role & Responsibilities

Knowledge Check Federally-recognized Tribes and Alaska Native corporations have a government-to-government relationship with the U.S. government. They are considered sovereign nations. This means: A.They govern their own lands and people B.They have one leader C.They impose no rules 20

Knowledge Check 21 The Exchange Tribal Advisory Workgroup helps with: A.Determining the Federal rules imposed upon AI/AN. B.Determining which individuals are AI/AN. C.Helps in on-going communication and collaboration with the Exchange on issues that impact AI/AN. D.Establishing Tribal policy regarding the ACA.

Knowledge Check 22 High poverty rates and limited access to high-quality health care are the main causes of: A.Poor health in the AI/AN populations. B.Low tax rates. C.Limited access to housing.

Knowledge Check 23 The federal Indian Health Services is: A.The Association that determines the amount of money a AI/AN pays for their health care coverage. B.The principal federal health care provider and health advocate for Indian people. C.The agency that determines the taxes imposed on AI/AN.

Knowledge Check 24 American Indians and Alaska Natives who are enrolled in federally-recognized Tribes or registered with Alaska Native corporations do not have to pay deductibles, co-payment or co-insurance under a Qualified Health Plan in the Exchange if they are… A.Paying very high premiums. B.Related to someone that works with the Exchange. C.Making an income below 300% of the Federal Poverty Level.

Knowledge Check 25 The only cost to AI/AN that have an income of less than 300% of the FPL is premium payments. When comparing QHPs in the Washington Healthplanfinder, an AI/AN individual or family who meet these income criteria, would want to look for a QHP that best fits his/her healthcare needs with… A.The lowest premium because co-pays and deductibles do not apply. B.The highest premium because that is fair to everyone. C.A Gold level plan because the premiums are lowest.

Knowledge Check 26 If an AI/AN does not secure health care coverage they will be… A.Subject to the individual mandate and a tax penalty will be imposed on them. B.Put in jail. C.AI/AN are not subject to the individual mandate.

Knowledge Check 27 An AI/AN can enroll in a qualified health plan or change plans… A.On a monthly basis rather than waiting for the standard Open Enrollment period (by the 23 rd of the current month to be eligible for the 1 st of the following month) B.Must enroll during the open enrollment period like everyone else. C.Can enroll at any time during the month for coverage effective on the first of the month they enroll in.

Knowledge Check 28 AI/AN are exempt from reporting all of the following forms of Income except… A.Distributions from property held in trust B.Income from Tribal distributions of casino revenues C.Distributions and payments from fishing, natural resource extraction and harvests

Knowledge Check 29 An AI/AN completes an application and pays their first month’s premium for a QHP by the 23 rd day of the month. During the 90 day waiting period for AI/AN to verify their Tribal enrollment status, she or he… A.Has benefits beginning on the first day of the following month with special provisions B.Has benefits beginning on the first day of the following month without special provisions C.Has no benefits until the required documentation has been provided and uploaded in to the Healthplanfinder.

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Thank you! Congratulations! You have completed Serving American Indians/Alaska Natives course!

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