1. ACA: NATIVE AMERICAN PERSPECTIVE SEPTEMBER 22, 2014

2. OVERVIEW HEALTH CARE REFORM & THE FEDERAL TRUST RESPONSIBILITY 2014 ACA IMPLEMENTATION MODIFIED ADJUSTED GROSS INCOME (MAGI) RECOMMENDED DOCUMENTATION 2015 ACA IMPLEMENTATION EXEMPTION APPLICATION AI/AN PROTECTIONS

3. Health Care Reform & the Federal Trust Responsibility The ACA recognizes the federal trust relationship & strengthens tribal sovereignty through: Protection & enhancement of the IHS health care system with the passing of the Indian Health Care Improvement Act Greater access to quality health care with new sources of insurance coverage and grants Expansion of tribal government consultation in health care policy decision-making

4. ACA Implementation…2014 All individuals below 100% FPL and others, including American Indians, Alaska Natives and I/T/U users are not required to get insurance & are exempt from the shared responsibility tax payment that has to be paid beginning in 2015 Plus, there’s no cost-sharing for AI/AN’s at or below 300% FPL for any Health Insurance Marketplace plan at any level (bronze, silver, gold or platinum)

5. MAGI does not include… SSI, TANF, Veterans’ disability, Workers’ Compensation, child support, federal tax credits & cash assistance Foster care, guardianship or adoption assistance payments, scholarships & education grants not used for living expenses Distributions from Alaska Native Corporations & Settlement Trusts; from property held in trust by the Secretary of the Interior; from real property ownership interests related to natural resources & improvements & BIA student financial assistance (Note: An amount received as a lump sum shall only be counted as income only in the month received)

6. Recommended Tribal Documentation for Enrollment (AI/AN & I/T/U Users) Electronic data verification w/IHS RPMS Tribal enrollment card Certificate of degree of Indian blood Shareholder certificate for Alaska Native Regional or Village Corporation Tribal enrollment certificate Tribal Census Document Birth certificate linking child to parent Adoption certificate linking child to parent Foster care documentation linking child to AI/AN foster parent Disability determination linking child to AI/AN parent IHS/Tribal Form or Letter verifying eligibility for IHS Services Marriage Certificate with Tribal Spouse

7. ACA Implementation…2015 For the general population, open enrollment in the Marketplace begins on November 15, 2014 and ends on February 15, 2015 American Indians/Alaska Natives have special monthly enrollment periods anytime of the year in Marketplace plans The ACA does not change your eligibility to get health care services at an Indian Health care provider. AI/AN’s who enroll in a Marketplace health plan, Medicaid or CHIP may continue to receive these services

8. ACA Implementation…2015 IHS is not insurance. IHS provides medical and public health services. Insurance affords greater access to services at IHS, Tribal and Urban Indian program providers by increasing their revenue In some cases referrals to private providers is necessary through Contract Health Service (CHS) referrals. This is when having health insurance will help American Indians. This program was recently renamed as Purchased/Referred Care (PRC) American Indian people will benefit from increased revenue to the Indian health care system and greater access to care

9. ACA Implementation…2015 IRS Reporting – Individual Shared Responsibility Payment –Statutory Exemptions You’re uninsured for less than 3 months of the year You’re a member of a federally recognized tribe You’re incarcerated (either detained or jailed), and not being held pending disposition of charges You’re not lawfully present in the U.S. IRS Reporting - Individual Shared Responsibility Payment – Regulatory Hardship Exemptions Eligible for services through an Indian Health Service provider

10. American Indian Exemption Application Who can use this form? Members of federally recognized Tribes Individuals eligible to receive services at Indian health care providers: - IHS - Tribal - Urban

11. How do I prove that I am exempt? An application for exemption must be completed on the specific form for: American Indian/Alaska Natives Other individuals who are eligible to receive services from an Indian Health Care Provider Only one application required per tax household Only have to submit application once Need the following: Federally Recognized Tribes: Tribal membership (CDIB, enrollment card, etc.) Social Security Number Information about people in tax household Tribal member NOT enrolled in Federally Recognized Tribe: Eligible for services from IHS, tribal (638) or urban Indian health care provider. A letter from IHS Patients Benefits Coordinator can be requested.

12. Exemption Letter Family Names Exemption Certification Number

13. Affordable Care Act American Indian/Alaska Native Specific Protection

14. AI/AN Protections AI/AN are exempt from the mandate that requires individuals to purchase health insurance or pay a tax penalty (submit exemption application) Special monthly enrollment periods for AI/AN to facilitate and overcome barriers to enrollment will be established AIAN at or below 300% FPL who are federally recognized (or who meet the Indian hardship exemption) are exempt from cost-sharing in the Marketplace There is no cost-sharing (co-pays, co-insurance, deductibles) for Indians under any Marketplace plan for services provided by the I/T/U or through a CHS referral

15. AI/AN Protections Distributions and payments from AI/AN resources listed in ARRA Section 5006 and certain income exclusions codified in the Internal Revenue Code shall not be used in determining Medicaid or CHIP eligibility under the new streamlined MAGI methodology AI/AN income exemptions in the determination of MAGI-based income must be calculated on the Marketplace and Exchange calculator Qualified Indian health care benefits, including accident or health insurance that a Tribe buys for its members, a spouse or dependent, cannot be deemed as income by the IRS for tax purposes or for provision of benefits under the ACA

16. AI/AN Protections AI/AN income exemptions for Medicaid/CHIP: Alaska Native Corporation and Land Settlement Trusts Property Held in Trust Under the Supervision of the Secretary of the Interior Ownership Interest From Rents, Leases, Royalties, and Usage Rights Related to Natural Resources Sub-marginal Trust Lands held in Trust Distributions with a Unique Religious, Spiritual, Traditional, or Cultural Significance Bureau of Indian Affairs Student Financial Assistance Judgment Fund Distributions Tribal Trust Per Capita – Distributions to tribal members by the BIA or a Tribe from tribal trust income collections (i.e., lease rentals, right-of-way payments, oil, mineral or timber harvesting royalties)