1. Module 6 The Exchange and Native Americans 1

2. Learning Objectives New Mexico Indian Nations, Tribes and Pueblos – Sovereignty Federal Trust Obligation Overview of Indian Health System – Contract Health Services Program Affordable Care Act and American Indians Proof of Tribal Membership and Income Medicaid and American Indians The Exchange and Native Americans Outreach and Education Marketing Channels

3. New Mexico Indian Nations, Tribes & Pueblos New Mexico has 22 Indian Nations, Tribes and Pueblos - each has its own unique culture 19 Pueblos – each is an independent and separate community 2 Apache Tribes (Jicarilla and Mescalero) Navajo Nation plus satellite communities – Very large land base spanning 3 states – 5 Agencies including 3 in New Mexico (Eastern, Ft. Defiance, Shiprock) – 110 Chapters and 59 in New Mexico

4. Tribal Sovereignty Indian tribes are sovereign nations that predate the United States U.S. Supreme Court (Cherokee V. Georgia 1831) established Indian Tribes as “domestic dependent nations” with a government to government relationship subject to plenary authority of the U.S. Indian Tribes have the authority to maintain identity, values, culture, property, and legal rights against political and legal assault by local, community, state and even the Federal Government.

5. New Mexico Native Languages Keres - Acoma, Laguna, Zia, Santa Ana, San Felipe, Santo Domingo, Cochiti Tiwa - Taos, Sandia, Isleta, Picuris Tewa - Tesuque, Nambe, Pojoaque, San Ildefonso, Santa Clara, Ohkay Owingeh Towa - Jemez Zuni - Zuni Athabascan - Jicarilla Apache, Mescalero Apache, and Navajo

6. Urban Indian Communities Multi-tribal, not just New Mexico Tribes – Socially and culturally diverse (over 400 different tribes represented) – Various stages of assimilation May be highly transient – Dependent on services within the urban areas Seldom Viewed Along with Other Minority Groups New Mexico communities with large urban populations: – Albuquerque – Farmington – Santa Fe

7. Federal Trust Responsibility Unique legal relationship between U.S. government and tribal governments Tribal members have a unique legal and political status based on citizenship – not race Based on treaties, statutes, Executive Orders, and court decisions Legal obligation to provide economic and social programs necessary to raise standard of living and social well-being comparable to non- Indian society

8. Indian Health Service System The Indian Health Service (IHS) is the principal federal health care provider for Indian people – Funded at just 54% of the actual need Tribal Health Systems – 638 Contracts - Allows Indian Tribes and organizations to contract and operate programs provided by the Indian Health Service – Self-Governance Compacts - Allows the transfer of management of IHS resources to Tribal management and control Urban Indian Health Program – Funding supports 34 independent non-profit agencies in 19 states – Just 1% of total Indian Health Service budget

9. Contract Health Services Program Financing for health care provided away from an Indian Health Service (IHS) or tribal health care facility. Not an entitlement program and an IHS referral does not imply the care will be paid. Patient must meet the residency requirements, notification requirements, medical priority, and use of alternate resources. – Two-thirds of necessary health care services provided under this program are denied due to lack of funding

10. The Affordable Care Act and Native Americans American Indians who are eligible to receive services from an Indian health provider (Indian Health Service, Tribal 638 program, Urban Indian Health Program) are exempt from the individual mandate clause of the Affordable Care Act. – Tribal members can apply when they file their return in 2015 or apply for an exemption through the marketplace – Individuals who are not tribal members, but eligible to receive services from an Indian health provider, must apply for an exemption through the marketplace Indian Health Care Improvement Act was permanently reauthorized 10

11. What do Native Americans Need to Know About the Exchange? Members of federally recognized tribes, are entitled to special protections through the Exchange starting in 2014: – Special monthly enrollment periods to allow American Indians to enroll in a qualified health plan outside the yearly open enrollment period – Exempt from cost-sharing (co-pays, deductibles, co- insurance) if income is less than 300% FPL and enrolled in an Exchange plan – Exempt from cost-sharing regardless of income if enrolled in an Exchange plan and receiving covered benefits at the Indian Health Service, Indian tribe, tribal organization, urban Indian organization, or through Contract Health Service program. 11

12. To get special Exchange protections, American Indians will need to prove membership in a federally recognized tribe. Proof could include: Tribal identification card Certificate of Indian Blood Bureau of Indian Affairs form Authentic document from a tribe declaring membership for an individual – NAPPR can be contacted for those who need assistance proving Native American status. If applying for Marketplace coverage, in addition to basic information about household size and income, information about income from Indian trust land, natural resources, and items of cultural significance must be provided. – This income won’t be counted for Medicaid eligibility, but may be counted for the Exchange's purposes. 12 Proof of Tribal Membership and Indian Income

13. Medicaid and American Indians Currently, over 91,000 American Indians in New Mexico are enrolled in Medicaid - about 43% of all Native Americans in the state. American Indians are not automatically enrolled inCentennial Care (New Mexico’s Medicaid managed care program), as all other enrollees are (unless they are in the CoLTS program). Instead, they can enroll in the fee-for-service Medicaid program (Medicaid Exempt) unless they request to be enrolled in managed care. American Indian Medicaid beneficiaries are exempt from cost-sharing. Income from Indian trust land, natural resources, and items of cultural significance is not counted for Medicaid eligibility. 13

14. Important Implications The Indian health system is fragile and unstable. Most claims for services under Contract Health Services program are denied. American Indian consumers could benefit greatly from coverage options through the Exchange: – Could acquire low cost coverage (Bronze plan) and be exempt from out of pocket costs if income is less than 300% FPL

15. Exchange and Native Americans According to New Mexico state law, the Exchange must: – Establish a Native American Advisory Committee – Appoint a Native American Liaison The Exchange may establish a Native American Service Center to: – is accessible to Native Americans; – complies with the provisions of the federal Indian Health Care Improvement Act and Indian-specific provisions of the federal Patient Protection and Affordable Care Act; and – facilitates meaningful, ongoing consultation with Native Americans;

16. Questions? Need Help? NAPPR, Inc. Healthcare Education & Outreach Program 1-855-241-8137 rsprucebly@nappr.org 16 Contact Information