1. 1 Legislative & Policy Update NW Portland Area Indian Health Board Quarterly Board Meeting April 23, 2014

2. Report Overview 1.SDPI Update 2.Senate Committee on Indian Affairs 3.Indian Bills 4.FY 2014 & FY 2015 Budget Updates 5.CSC Update 6.DTLLs 7.ACA Exemptions

3. SDPI Extended thru FY 2015 H.R. 4302 Protecting Access to Medicare Act – Commonly referred to as the Sustainable Growth Rate bill -- SGR fix – Sec. 204 Extends the Special Diabetes Program for Indians thru FY 2015 – Sec. 210 Delays implementation of ICD-10 to Oct. 1, 2015 SDPI thru September 30, 2015 – Maintains $150 million per year less sequestered amount

4. Senate Committee on Indian Affairs New Chair: Sen. Jon Tester (MT) – Senators Cantwell and Crapo still on Committee Legislation & Hearings – FY 2015 President’s Budget – March 26 th – S. 1570 amend IHCIA for Advanced Appropriations – S. 919 amend ISDEAA to expand self- governance – Other Tribe specific and education, children related bills

5. Indian Health Legislation Advance Appropriations Bills – H.R. 3229: Don Young & Ray Lujan – S. 1570: Begich, Udall, Murkowski Special Diabetes Program for Indians – House and Senate Sign-on letters Indian Definition Fix – S. 1575: Senators: Mark Begich (D-AK), Max Baucus (D- MT), Tom Udall (D-NM), Brian Schatz (D-HI), Al Franken (D- MN) Medicare-like Rates?

6. FY 2014 Budget Highlights FY 2014 budget $303 million increase over FY 2013 Operating Plan*** – ***Caution: Only $78 million over the FY 2014 Pre-Sequester Amount – Loss of $175 million Program Increases for (Detail of changes): – $42.4 million for CHS – $24.9 million for facilities accounts – $71.9 million for staffing new facilities – $35 million for medical Inflation – $129.6 million for CSC

7. FY 2014 & CSC Funding IHS and BIA will fully fund CSC payments in FY 2014 and President’s FY 2015 budget proposes same – IHS estimated 2014 need: $587.4 million – FY 2013 Amt + 2014 Increase = $577.4 – IHS needed additional $10 million to cover CSC funding; consulted with Tribes about where to make the cuts Reductions total $10 million made as follows: – $3 million IHS Directors Fund – $5 million from Indian Health Professions – $1 million from Self-Governance – $1 million from Tribal Management

8. FY 2015 & CSC Funding President’s Request includes $29.6 million CSC increase IHS proposes to continue to fully fund CSC payments to tribes into the future IHS Contract Support Cost Workgroup has reconvened to address substantive policy issues – Develop FY 2014 Payout Plan (Refer to Handout) – Develop Standard AFA language to deal with IHS Anti- Deficiency Act concerns – Develop two-year appropriation authority – Develop strategies to deal with new/expanded programs and changing IDC rates following payout – Analyze data to better estimate CSC need for appropriations – Develop process to better estiamate CSC need; pass-throughs and exclusions

9. FY 2015 President’s Request $4.634 billion for Indian Health Service – $199 million increase (4.5%) is respectable? – Staffing & New Tribes funding $78.8 million takes increase down to $120.9 million (2.7%) * – $29 million program increase for CSC * – $15.4 million program increase for CHS – Adjustments of $10 million to restore 2014 reductions (CSC) Adjusting the increase for earmarks* leaves a balance of $91.9 million for current services (does not include CHS increase) NPAIHB estimates at least $223 million is needed to maintain current services President’s budget will be short by $131 million to fully fund inflation and population growth

10. FY 2015 Detail of Changes – $199,662 mil. increase FY 2014 Enacted Budget$ 4,434,515 CURRENT SERVICES: Adjustments for CSC$ 10,000 Medical Inflation$ 63,000 Pay Costs$ 2,572 Staffing New Facilities$ 70,818 Sub-total Current Services$ 146,390 PROGRAM INCREASES: New Tribes Funding$ 8,015 Purchased/Referred Care$ 15,428 Contract Support Costs$ 29,829 Sub-total Program Increases$ 53,272 FY 2015 PRESIDENT’S REQUEST$ 4,634,177

11. FY 2016 Budget Formulation National IHS Budget Formulation - Feb. 26-27, 2014 in Washington DC – Representatives Andy Joseph & Steve Kutz Recommended $779 million increase; 18% increase – $188 mil. for current services – $191 mil. for binding obligations (CSC, HFCPS, Staffing, New Tribes) – $337 mil. for program expansion (CHS, H&C, Mental Health, A/SA, Health Facilities other authorities) – $62 mil for other priorities (UIHP, facilities, dental, )

12. Dear Tribal Leader Letters April 2, 2014: DTLL on CSCs as it relates to the FY 2014 Consolidated Appropriations Act & Announcing on-going Consultation March 6, 2014: DTLL IHS Director Listening Sessions February 27, 2014: DTLL seeking input on MSPI & DVPI February 18, 2014: DTLL update on the IHS Consultation & follow-up to the August 2, 2012 letter February 12, 2014: DTLL Initiating consultation on CSC issues required in FY 2014 Consolidated Appropriations Act January 13, 2014: DTLL changing Aberdeen Area IHS to the Great Plains Area

13. TTAG/MMPC Updates ACA Policy Subcommittee is very active – Tribal Exemption & I/T/U hardship exemption – Referrals and Cost Sharing Exemptions – CMS Final 2015 Letter to Issuers in FFM – and Proposed Rule including Minimum QHP Certification Standards Revising the CMS Tribal Consultation Policy Evaluation of CMS Strategic Plan & Updates Alternatives for Medicaid Expansion: Arkansas Model and UCC Waivers Indian definition issues IRS/CMS Resource Exemptions Extending Medicare Like Rates to non-hospital based services ACA Educational materials Data projects and studies

14. Affordable Care Act Individual Mandate & Exemption What is the ACA Tax Penalty? What is the I/T/U Hardship Exemption and who is eligible? How to apply for the Indian Exemption or I/T/U Hardship Exemption? Additional Information related to exemptions and the application: – HHS instruction are forthcoming, tax filing information, – Do you need to reapply for the exemption? – What can you do to help Tribal members? Education Tribal members and program beneficiaries Make sure Tribal members understand the difference between Indian Exemption and the Hardship Exemption Prepare to offer eligibility letters Provide tax filing assistance 2014 Penalty = 1% household income; $95/adult 2015 Penalty = 2% household income; $325/adult 2016 Penalty = 2.5% household income; $695/adult

16. TTAG/MMPC Resources https://www.dropbox.com/home/Delegates/Temp%2 0Folder%20created%20by%20Jim https://www.dropbox.com/home/Delegates/Temp%2 0Folder%20created%20by%20Jim MMPC Action Items and Tracking List TTAG Roster of Pending Regulations and Assignments

17. Discussion?