1. Tribal Readiness Jennifer DuPuis, M.B.A.
Associate Director of Human Services
Fond du Lac Band of Lake Superior Chippewa
Tribal Self-Governance Consultation Conference
Arlington, VA
May 7, 2014

2. Qualified Health Plans
Key Opportunities
Plan Approach to Target Activities Where are your biggest opportunities?
Medicare
Medicaid
Basic Health Plan
Qualified Health Plans

3. Study Populations

4. Study Populations

5. Target your low hanging fruit. Where is the easiest place to start?
Tribal Sponsorship
Tribes, tribal organizations, and urban Indian organizations are permitted to pay premiums on behalf of eligible individuals.
Medicare Part B (Reimbursement)
Medicare Part C
Medicare Part D
Qualified Health Plans
Target your low hanging fruit. Where is the easiest place to start?

6. Tribal Sponsorship Medicare Part D
Successful sponsorship program informed us how worth while sponsorship is.
In 2013, every $1 Fond du Lac spent on Medicare Part D premiums, there was over a $6 return.
Includes some self pay. Revenues were all med part d – money spent on premiums was lower than actual premium cost.

7. Implementation Policy & Procedures
You must establish and operate under policies that have been approved by Tribal Council.
Contract Health Policy & Procedures
Registration Policy & Procedures
Patient Advocate Policy & Procedures
Tribal Sponsorship Policy & Procedures
Every TC is different. Some may be anxious for you to get policy in writing, some may be sluggish. Only you know how to work with your TC. If you don’t have it written down, you shouldn’t be doing it. There are too many factors to not have it in writing. The more you understand, the better off you are.

8. Implementation
Develop gates to access services that include enrollment activities.
Educate staff and establish uniformity of application of the policy.
Gather, assess, and troubleshoot specific real-life examples during team meetings.

9. Patient Meets With Patient Advocate
Enrollment Process
Patient Sees Provider
Patient Meets With Patient Advocate
Patient Registers
Patient Arrives
Patient Flow
Eligibility for Medicaid, MNCare (BHP), Medicare, and QHP’s is checked
Demographics are updated
Uninsured individuals referred to Patient Advocate
All uninsured patients are referred to a Patient Advocate for insurance eligibility check.

10. Enrollment Process Contract Health Services
Because CHS is a payer of last resort, clients must apply for other alternative resources available to them.
Process to get through the “gate” for CHS coverage:
All CHS eligible individuals who are uninsured must complete the MNsure application process to determine eligibility for Medicaid, MNCare, or Tribal Sponsorship.
Eligible individuals must accept Tribal Sponsorship, which is of no cost to them or their family.
Descendents must complete the MNsure application process during the open enrollment period.
Hardest process is to put gates in place. Success depends on the strength of the person enforcing gates and processes. Perception and language you use is key.

11. Contract Health Services Waiver
Enrollment Process
Contract Health Services Waiver
“By declining premium sponsorship by FDLTC, which is of no cost to me or my family, I understand that I am denying an alternative resource and will be waiving my rights to CHS funds until I have secured another form of health care coverage.”
We are on their side, everyone wins when we are on the same team.

12. Evaluate & Redesign Monitor Progress Be prepared to adjust your focus.
Target your enrollment processes and adjust rules for payer groups.
Enforce flexibility with staff assignments.
#3 – everyone should be responsible for everything, not only single parts of processes.

13. Marketing
Literature Make literature your own. Use your own photos and information.
Newspapers, Lobby TV’s, radio station, social media.

14. Marketing
Patient Advocates
Educate clients and evaluate eligibility for Medicare, Medicaid, MinnesotaCare, MNsure and other employer/private insurance programs.
Staff Expertise:
Familiar with all rules.
Relationally Rich Environment:
One-on-one counseling.
Community member staff.
Plenty of time to talk.
Familiar with cultural sentiments
Explains community benefits.
Real marketing comes with face-to-face environment.

15. Marketing
Educating Clients Why should IHS eligible individuals have health insurance? Although IHS makes a substantial contribution to the overall health of American Indians and Alaska Natives, in most Indian communities, the level of funding does not meet the need. Tribes must generate other sources of income.
Why squander tribal resources when state or federal government will pay?

16. Patient Advocate Referrals
Marketing
Patient Advocate Referrals
Patient Advocate
Medical Department Referrals
Dental Department Referrals
Pharmacy Department Referrals
Contract Health Referrals
Registration Referrals
Electronic Health Records Reports

17. Building Business Office Capacity
Third Party Billing
Experience
Competence
Measures of Competence
Administration
Budgeting
Monitoring
Managing Contracts
Credentialing

18. Contract Health Savings
Medicare Like Rates
Third Party Administrator
Comprehensive Care Services (CCStpa)
Blue Cross Blue Shield Discounts of 20-40%
CHS pays discounted amount plus 22% of savings.
Example:
$1,000 bill – 40% discount = $600
CHS pays CCStpa $ % of savings = $688

19. Contract Health Savings
Medicare Like Rates
Third Party Administrator
Comprehensive Care Services (CCStpa)
Medicare Like Rate Discounts of 30-40%
CHS pays discounted amount plus per claim fee of $9.50.
Example:
$1,000 bill – 40% discount = $600
CHS pays CCStpa $600 + $9.50 fee = $609.50
All services have different discounts.

20. Contract Health Savings
Medicare Like Rates Savings 2012
BCBS Discounts
$375,488 Billed to CHS
$248,853 Paid by CHS
Savings of $126,635
MLR Discounts
$563,369 Billed to CHS
$172,221 Paid by CHS
Savings of $391,148
Total Savings of $517,783 A

21. Tribal Readiness Checklist
Key Opportunities
Plan approaches to target activities, and ask yourself “where are your biggest opportunities?”
Study Populations
Use data from your electronic health record and the U.S. Census.
Tribal Sponsorship
Medicare and/or Qualified Health Plans.
Implementation
Establish policy and procedures, develop gates to access services, educate staff, and troubleshoot examples.
Evaluate and Redesign
Monitor progress, target enrollment processes, and enforce flexibility with staff assignments.
Marketing
Hire Patient Advocates, create a referral process, use your own literature for materials, and educate patients.
Building Business Office Capacity
Have an experienced and competent billing department, and have processes in place for Administration to monitor.
Contract Health Services
Create policy and procedures, and take advantage of Medicare Like Rates

22. Questions?

23. Thank You!