1. 1 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA To Insure or Not to Insure Opportunities for Tribes in the New Health Insurance Exchanges Presented by: Elliott Milhollin National Tribal Health Reform Implementation Summit April 19, 2011

2. 2 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Health Insurance Exchanges in the Patient Protection and Affordable Care Act One major goal of the PPACA is to make health insurance available to the more than 40 - 50 million people in the United States who are currently uninsured In 2008, uninsured Americans received $116 billion in health care These costs were estimated to increase annual premiums by $1017 for family coverage and $368 for individual coverage Source: Hidden Health Tax: Americans Pay a Premium, Families USA, May 2009, at www.familiesusa.org

3. 3 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Health Insurance Exchanges in the Patient Protection and Affordable Care Act The PPACA requires that everyone have health insurance -- either through a federal or state program, through employer insurance, or through individually purchased insurance Beginning in 2014, there is a penalty imposed on individuals without health insurance -- ACA Sec. 1501 (adding Sec. 5000A to the Internal Revenue Code) Members of Indian Tribes are exempt from the penalty for non- compliance with the requirement to obtain health insurance -- ACA Sec. 1501(b); IRC Sec. 5000A(e)(3)

4. 4 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA What is a Health Insurance Exchange? PPACA creates Health Insurance Exchanges to make it easier for individuals to comply with the insurance mandate Only individuals without insurance and small businesses are eligible to purchase health insurance through an Exchange Health Insurance Exchanges are State-designed and operated –Run by State governments or non-profits set up by the State –States have the option not to create Exchanges, in which case the federal government will operate an exchange for the residents of the state –Multi-state Exchanges are optional Exchanges must be operational beginning January 1, 2014 –Many States are developing them now

5. 5 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA What is a Health Insurance Exchange? Website where consumers can compare health insurance plans with different levels of benefits and premiums, and purchase insurance Health insurance plans must provide certain information and a minimum level of benefits in order to participate in an Exchange as a Qualified Plan Websites will allow consumers to conduct detailed comparisons of different plans, which will be rated by the government or non-profit running the exchange The functions of the Exchange website will also be accessible through a toll-free telephone line

6. 6 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Opportunities for Tribes in Exchanges A Tribe may elect to purchase insurance for IHS beneficiaries who do not have another form of insurance –Many Indians will be eligible for low-income subsidies that are available only through Exchanges –Tribe may elect to pay all or part of the unsubsidized part of the premium for its beneficiaries Provide new revenue for Indian Health Programs –Allow billing of insurance for the Indian Health Program services –Reduce Contract Health Services expenditures by allowing billing of insurance plans for services supplied by CHS providers

7. 7 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Who is Eligible to Purchase Insurance on an Exchange? Uninsured individuals and small businesses (SHOP Exchange) Individuals who have other forms of insurance such as Medicare, Medicaid, Children’s Health Insurance Program, TRICARE, VA Benefits, or Employer Insurance (with some limits) will be screened out -- ACA Sec. 1413 Individuals must be citizens of the United States and residents of the State in which the Exchange is located -- ACA Sec. 1312(f).

8. 8 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Exchange Benefits Competitively priced health insurance Insurance purchased for qualified IHS beneficiaries could increase third party collections by Indian Health programs Federal premium subsidies are available for low-income individuals on sliding scale up to 400% of the Federal Poverty Level (FPL) –400% FPL for family of 4: $88,200 Indians enrolled in Exchange plans would be exempt from all cost sharing when served by an I/T/U or CHS provider Indian enrollees with incomes up to 300% FPL who receive services outside of the I/T/U system would be exempt from premiums –300% FPL for family of 4: $66,150

9. 9 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Federal Subsidies Sliding scale premium tax credits available to individuals with incomes at or below 400% federal poverty level (FPL) who purchase insurance within an exchange plan Tax credit subsidies make the premiums you pay based on your income. –Payments range from 2 percent of income at 133 percent FPL to 9.5 percent of income at 400 percent FPL -- ACA Sec. 1401(a)

10. 10 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Indian cost sharing exemption AI/AN enrolled in an Exchange plan have no cost sharing requirement if services provided by an I/T/U or through CHS program AI/AN enrolled in an Exchange with income at or below 300% FPL have no cost sharing requirement for services provided by anyone –ACA Sec. 1402(d)

11. 11 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Considerations for Tribes Assess population with potential to access Exchange plan insurance –How many uninsured beneficiaries do you have? –How many uninsured beneficiaries would qualify for premium subsidies and/or cost sharing exemptions? Determine whether the Tribe would be willing to pay the unsubsidized portion of Exchange plan premiums for their IHS beneficiaries –Tribes can use federal funds to pay premiums. IHCIA Sec. 402, 25 U.S.C. §1642 –Premiums paid for tribal members are not taxable income to the individual member. ACA Sec. 9021. –Compare the premium costs with the expected reimbursements from insurance Establish criteria Tribe will use to determine which beneficiaries qualify for tribal payment of exchange plan premiums

12. 12 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Considerations for Tribes Create a plan to encourage members to enroll in Exchange plans –Assign staff to conduct outreach and education –Create a tribal communication plan on the benefits of enrolling in Exchange plans Tribal payment of premiums and cost sharing exemption Potential increased revenue for Indian Health Programs All applicants will be screened for Medicaid eligibility Work with States to ensure Tribes and IHS beneficiaries can fully participate in Exchange plans –Many states currently developing exchange plans –Required to consult with stakeholders, including Tribes –Ensure that I/T/U can participate as in-network providers for exchange plans

13. 13 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Implementation Issues Sponsorship of Exchange Premiums Indian Health Program provider participation in Exchange Network

14. 14 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Indian Sponsorship Model Indian Sponsorship Model developed by tribal advocates working with NIHB T/Us develop their own criteria as to who to sponsor and any limit on premium assistance to provide T/Us conduct outreach and assessment T/Us provide assistance in signing beneficiaries up for exchange plans T/Us negotiate a mechanism with Exchange plan to provide the T/U sponsor with a master bill on a periodic basis so that the sponsor can collectively pay all premiums with a single payment

15. 15 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Indian Sponsorship Model Center for Consumer Information and Insurance Oversight (CCIIO) developing regulations to assist states in establishing Exchanges Tribal advocates have made proposal to require state Exchanges to allow T/U sponsorship of premiums

16. 16 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Access to Provider Networks of Exchange Plans Tribes may have to negotiate to become network providers for plans listed on the Exchange in their state Section 206 of the IHCIA gives Indian health providers the right to collect reimbursement from 3 rd party insurers even without a network contract with an Exchange plan –Section 206 provides that Indian health providers have the right to receive reasonable charges, or, if higher, the highest amount a plan would pay for the same care delivered by other providers A network contract is more favorable, as it allows for reimbursement without having to assert rights under Section 206 on a case-by-case basis, and may provide other benefits such as better access to specialty providers

17. 17 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Access to Provider Networks Provider networks of Exchange Plans must include “Essential Community Providers” – those providers that serve predominately low-income, medically-underserved individuals (ACA Sec. 1311) Tribes seeking ECP designation for all I/T/Us in regulations being developed by CCIIO. ECP designation will allow I/T/Us to avoid having to assert their right to full reimbursement under Section 206 of the IHCIA on a case by case basis Without ECP status, Tribes will have far less incentive to purchase insurance coverage for their members

18. 18 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Questions?