1. 1 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Workshop #3: New Opportunities and Challenges For Indian Health Providers ______________________________________ Presentation for National Indian Health Board’s National Tribal Health Reform Implementation Summit Washington, D.C. April 19, 2011 Carol L. Barbero cbarbero@hobbsstraus.com

2. 2 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Workshop Objectives Identify new opportunities presented to Indian health programs Revenue-related Health Services Identify challenges involved with taking advantage of new opportunities Potential investment costs Staffing issues – recruitment, compensation, training Identify options, priorities for new services Tribal policymaking Open Discussion – What does your tribe/program need to do to get ready?

3. 3 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA New Opportunity: more 3 rd party revenue – Expansion of Medicaid to cover all people, including childless adults, up to 133% of Fed Poverty Level (FPL) Effective Jan 1, 2014 Challenges: Training for staff on enrollment requirements Outreach to eligible Indian patients to encourage enrollment May need additional billing clerks to handle increased Medicaid billing

4. 4 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA New Opportunity: more 3 rd party revenue – “Exchanges” to be created by States to facilitate purchase of insurance by uninsured individuals Uninsured = persons without Medicare, Medicaid, VA, Tricare, private health insurance, employee coverage IHS eligibility is not considered insurance coverage, so many Indians will be eligible for Exchange insurance Premium subsidies available for low-income up to 400% FPL Medicaid and Exchange to use same simple, integrated form Challenges: Staff training on how to use State Exchanges Outreach/education/enrollment assistance for eligible Indians Billing clerk recruitment, training to handle claims

5. 5 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Exchanges – more Tribal leadership decides whether to pay unsubsidized part of premiums for some, all eligible members What level of support would the Tribe be willing to make? Who would be eligible for any Tribally-sponsored payments? What is expected return to tribal health program in terms of potential insurance reimbursement? IHCIA Sec. 402 allows tribal health program to use IHS and other Federal funds to purchase insurance coverage for IHS beneficiaries Would mean diverting scarce health service dollars Point for discussion: What if a direct service tribe wants to do this? Could IHS funds be used?

6. 6 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Exchanges – more Facilitating enrollment and paying Exchange plan premiums only makes sense if the Indian health program can collect reimbursement from the plan Most effective way is for IHP to be in the provider network of the Exchange plan More assured of payment at in-network rates Easier access to specialists for in-network referrals ACA requires Exchange plans to admit “essential community providers” to their networks ECPs are providers who serve predominately low-income, underserved individuals Tribal advocates asked that HHS regulations designate I/T/Us as essential community providers – no answer yet

7. 7 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA New Opportunity: Chance to offer more services Support with enhanced 3 rd party revenues Authority in Sec. 205 of IHCIA for new services Hospice, Long-term care, Assisted Living and Home- and community-based care No new IHS appropriations for these services yet Challenges: Identify community needs, establish priorities for new services Develop new program protocols Are needed health care professionals available? More work for billing, administrative staff Is facility space available for new services? Identify equipment needs (e.g., dental chairs)

8. 8 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA New Opportunity: Focus on preventive health services Medicare 20% patient co-pay eliminated for – Annual wellness visit and personalized prevention plan Other preventive services as recommended by U.S. Preventive Services Task Force Enhanced focus on preventive services for adults in Medicaid School-based dental sealant program – grants to States, tribes, tribal organization, urban Indian organizations Challenges: Outreach to M + M patients to come in for these services Will additional health care professionals be needed? Correctly code Medicare bills to get 100% reimbursement

9. 9 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Challenge: Health care workforce availability Recruitment/retention of health care professionals is already difficult in many parts of Indian Country Recruitment for tribally-operated programs will be helped some by the “licensed in any state” authority in new IHCIA Sec. 221 Sec. 221 does not apply to urban Indian organizations National shortage of health professionals will be even more acute when up to 30 million more people get insured by 2019 Expect greater competition for health care professionals and staff such as billing clerks

10. 10 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA ACA Health Care Workforce Development Nearly ½ of ACA is devoted to programs to enlarge health care workforce and improve quality and effectiveness of health care delivery But it will still take years to produce more physicians, nurses, etc. IHS, tribes/tribal organizations, urban Indian orgs and tribal public health agencies are expressly eligible for many of these grant programs Most grant programs require appropriation of funds Grant announcements will appear in Federal Register Either monitor Federal Register yourself, or learn of grant opportunities through info from NIHB, NCAI, NCUIH, etc.

11. 11 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA IHCIA: Community Health Aide Program (CHAP) CHAP authority added in 1992 to address critical need for health care delivery in remote Alaska Native Villages Intensive course of study for paraprofessionals leading to CHAP certificate CHAPs work under supervision of AK regional health corporations Highly regarded, successful program IHCIA amended to authorize CHAP for tribes in Lower 48 BUT new appropriation is required for Lower 48 tribes’ programs, so sharpen your advocacy skills! NOTE: Law prohibits dental health aide technician program (DHAT) for Lower 48 tribes (due to opposition from American Dental Assn) except where State law permits mid-level dental providers IHS will have to establish program, course of study, certification process for Lower 48 program

12. 12 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Some Topics for Discussion What do you think will be needed at your tribe or program to take advantage of new opportunities? Is your Tribal Council aware of new opportunities that will require policy decisions? How should your tribe begin planning process? Do you have the facilities and staff to add new services and perform extra administrative tasks? Are there different efforts Direct Service Tribes should undertake?