Patient Protection and
    Affordable Care Act:

       Health Reform &
Indian Health Care Improvement
              Act

...
Outline

• Alaska Tribal Health System intro

• Indian Provisions in main bill

• Indian Health Care Improvement Act

• Im...
Indian Health Service
• Provides health care in recognition of government
  to government relationship between Tribes and ...
Alaska Tribal Health System
• Transition to tribally provided care

• Voluntary affiliation of 30 Alaskan tribes and
  tri...
Alaska Tribal Health Compact
• Alaska Native Tribal Health         •   Ketchikan Indian Community
  Consortium - 229      ...
Medical Care Service Levels
•   180 small community primary care centers
•   25 subregional mid-level care centers
•   4 m...
Opportunities for Tribes &
        Tribal Organizations

• Express authority to participate in grant
  programs
  – Workfo...
Opportunities for Tribes &
        Tribal Organizations
• Express Lane Agencies
  – I/T/U can enroll AI/ANs in Medicaid an...
Access and Workforce
• Interagency Access to Health Care in AK Task
  Force
  – Develop strategies to improve federal bene...
Individual Indian Provisions
• Exemption from penalty for individual
  mandate for health insurance
• AI/AN health benefit...
Indian Health Care
 Improvement Act
  Reauthorization
Indian Health Care Improvement Act
• Included in the Patient Protection and Affordable
  Care Act (Health Reform), P.L. 11...
Indian Health Care Improvement Act

• Permanent authorization; effective March
  23, 2010

• Recognizes the federal govern...
IHCIA Major Provisions
•   Title I: Workforce
•   Title II: Health Services
•   Title III: Facilities
•   Title IV: Access...
Title I – Workforce
• Sec. 112 – Health Professional Chronic Shortage
  Demonstration Program
  – IHS authority to fund de...
Title I – Workforce
• Sec. 121 – Community Health Aide Program
  – Authorizes national expansion
  – Dental Health Aide Th...
Title II– Health Services
• Sec. 205 – Other Authority for Provision of Services
   – Authorizes I/T/TOs to operate four t...
Title II– Health Services
• Sec. 212 – Cancer Screenings
   – Authorizes “other cancer screenings” beyond
     mammography...
Title II – Health Services
• Sec. 214 – Epidemiology Centers
  – Designates Epidemiology centers as “public
    health age...
Title II – Health Services
• Sec. 226 – Contract Health Services
  Administration and Disbursement Formula
  – Opens curre...
Title III – Health Facilities
• Sec. 301 – Health Care Facilities Priority System
   – Requires IHS, in consultation with ...
Title III – Health Facilities
• Sec. 311 – Other Funding, Equipment, and
  Supplies for Facilities
  – Authorizes other fe...
Title IV – Access to Health Services
• Sec. 401 – Treatment of Payments under SSA
  – Adds Children’s Health Insurance Pro...
Title IV – Access to Health Services
• Sec. 404 – Outreach and Enrollment in SSA
  and Other Health Benefit Programs
  – G...
Title IV – Access to Health Services
• Sec. 405 – Sharing Arrangements with Federal
  Agencies
   – Allows Secretary to en...
Title IV – Access to Health Services
• Sec. 408 – Nondiscrimination in Qualifications for
  Reimbursement
   – Makes I/T/U...
• Title V – Urban Indian Health
  – Grants Urban Indian programs broader program
    authority.
  – Requires IHS to “confe...
Title VII – Behavioral Health
• Title VII replaces current law’s substance abuse
  programs.
• Greatly expands behavioral ...
Title VIII – Miscellaneous
• Sec. 805 – Confidentiality of Medical QA
  Records
  – Allows for peer reviews to be conducte...
Title VIII – Miscellaneous
• Sec. 813 – Health Services to Ineligible
  Persons
  – Allows T/TO to make a determination to...
Title VIII – Miscellaneous
• Sec. 822 – Shared Services for Long-Term Care
  – Expressly authorizes IHS to provide, or ent...
Title VIII – Miscellaneous
• Sec. 827 – Prescription Drug Monitoring
  – Requires HHS to establish a prescription drug
   ...
Title VIII – Miscellaneous
• Sec. 831 – Traditional Health Care Practices
  – Excludes these services from FTCA coverage.
...
Overall Implications
             Individuals

• More services may be available through the
  I/T/U

• More opportunities ...
Overall Implications
               Providers

• More insured individuals
• Need for education and enrollment
• Marketing ...
Questions?

Valerie Davidson, Senior Director
Legal & Intergovernmental Affairs
Alaska Native Tribal Health Consortium
400...
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Health Reform & Indian Health Care Improvement Act

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Valerie Davidson, vice president of the Alaska Native Health Consortium, provides an overview of Federal Health Reform and the Indian Health Care Improvement Act and its potential impact the Native health system. The presentation was presented at the Sept. 2, 2010 Alaska Health Provider Forum.

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Health Reform & Indian Health Care Improvement Act

  1. 1. Patient Protection and Affordable Care Act: Health Reform & Indian Health Care Improvement Act Alaska Native Tribal Health Consortium September, 2010
  2. 2. Outline • Alaska Tribal Health System intro • Indian Provisions in main bill • Indian Health Care Improvement Act • Implications 2
  3. 3. Indian Health Service • Provides health care in recognition of government to government relationship between Tribes and the U.S. to members of federally recognized Tribes and their descendents • 3.3 million American Indians/Alaska Natives (AI/AN) in 561 federally recognized Tribes. – 229 Tribes in Alaska – 135,000 Alaska Natives (projected 163,000 by 2015) 3
  4. 4. Alaska Tribal Health System • Transition to tribally provided care • Voluntary affiliation of 30 Alaskan tribes and tribal organizations providing health services to Alaska Natives/American Indians (7,000 employees) • Each is autonomous and serves a specific geographical area 4
  5. 5. Alaska Tribal Health Compact • Alaska Native Tribal Health • Ketchikan Indian Community Consortium - 229 • Knik Tribal Council • Aleutian Pribilof Is. Assn - 13 • Kodiak Area Native Assn - 11 • Arctic Slope Native Assn - 8 • Maniilaq Assn - 12 • Bristol Bay Area Health Corp - 34 • Metlakatla Indian Community • Chickaloon • Mount Sanford Tribal Consortium - 2 • Chugachmiut - 7 • Norton Sound Health Corp-20 • Copper River Native Assn - 5 • Seldovia Village Tribe • Council of Athabascan Tribal • Southcentral Foundation Governments - 10 • SouthEast Alaska Regional • Eastern Aleutian Tribes Tribal Health Consortium - 18 • Native Village of Eklutna • Tanana Chiefs Conference - 42 • Eyak • Yakutat Tlingit Tribe • Kenaitze Indian Tribe • Yukon Kuskokwim Health Corp - 58 5
  6. 6. Medical Care Service Levels • 180 small community primary care centers • 25 subregional mid-level care centers • 4 multi-physician health centers • 6 regional hospitals • Alaska Native Medical Center tertiary care • Referrals to private medical providers and other states for complex care 6
  7. 7. Opportunities for Tribes & Tribal Organizations • Express authority to participate in grant programs – Workforce Grants – Maternal and Child Home Visitation • Children and expecting at risk for poor child and maternal health • Grants through states for 5 years • 3% set-aside for I/T/U ($45M) 7
  8. 8. Opportunities for Tribes & Tribal Organizations • Express Lane Agencies – I/T/U can enroll AI/ANs in Medicaid and CHIP (Denali KidCare) • Medicare Part B Services – Extends authority of I/T/Us to bill for these services retroactively to January 1, 2010 • Payor of Last Resort – extends rule by extending it to other federal programs (ie. VA, etc.) 8
  9. 9. Access and Workforce • Interagency Access to Health Care in AK Task Force – Develop strategies to improve federal beneficiary health care in Alaska within 180 days – Membership • Health & Human Services • Centers for Medicare & Medicaid Services • Indian Health Service • TRICARE • Army • Air Force • Veterans Administration • Veterans Health Administration 9
  10. 10. Individual Indian Provisions • Exemption from penalty for individual mandate for health insurance • AI/AN health benefits from tribes excluded from income for tax purposes • Cost Sharing under an Exchange Program – No cost-sharing for AI/ANs who receive their care through I/T/U or through Contract Health – No cost-sharing for AI/ANs up to 300% FPL 10
  11. 11. Indian Health Care Improvement Act Reauthorization
  12. 12. Indian Health Care Improvement Act • Included in the Patient Protection and Affordable Care Act (Health Reform), P.L. 111-148 as Title X, Part III, Section 10221 • Incorporates Senate Bill 1790 as reported out of the Senate Committee on Indian Affairs, except: – Removed • IHS scholarship tax exemption (these will remain taxable) • 100% Reimbursement for Medicare services for IHS facilities (remains at 80%) – Added • Dental Health Aide Therapy Clarification • Abortion provision that prohibits the use of federal IHS appropriations for abortions. 12
  13. 13. Indian Health Care Improvement Act • Permanent authorization; effective March 23, 2010 • Recognizes the federal government’s “special trust relationship and legal obligations to Indians” • Not an appropriation bill 13
  14. 14. IHCIA Major Provisions • Title I: Workforce • Title II: Health Services • Title III: Facilities • Title IV: Access to Health Services • Title V: Urban Indians • Title VI: IHS Organizational • Title VII: Behavioral Health • Title VIII: Miscellaneous 14
  15. 15. Title I – Workforce • Sec. 112 – Health Professional Chronic Shortage Demonstration Program – IHS authority to fund demo programs to address chronic shortages of health professionals. – Includes training and support of alternative provider types, such as CHA/Ps. Should also apply to DHATs. (See also sec. 5304 of PPACA which authorizes 15 grants for demo projects for training of alternative dental health providers). • Sec. 113 – Exemption from Licensing Fees – Exempts tribal employees from licensing fees to the same extent as IHS employees. 15
  16. 16. Title I – Workforce • Sec. 121 – Community Health Aide Program – Authorizes national expansion – Dental Health Aide Therapy (DHAT) limitations • Limits scope of service consistent with ADA settlement • Retains Alaska-only DHAT authority, but also allows IHS facilities where mid-level or DHAT is allowed by state law. • If other federal law authorizes mid-level dental practice, then IHS facilities not restricted. • Requires quality study. 16
  17. 17. Title II– Health Services • Sec. 205 – Other Authority for Provision of Services – Authorizes I/T/TOs to operate four types of programs: • Hospice Care • Long-term Care • Assisted Living • Home- and Community-based Care • Sec. 206 – Reimbursement from Certain Third Parties – Authority to recover “reasonable charges billed” for services provided to insured non-eligible individuals. – Allows T/TOs to collect from tortfeasors (e.g., auto insurer). 17
  18. 18. Title II– Health Services • Sec. 212 – Cancer Screenings – Authorizes “other cancer screenings” beyond mammography. • Sec. 213 – Patient Travel Costs – Includes “qualified escort” as authorized cost. 18
  19. 19. Title II – Health Services • Sec. 214 – Epidemiology Centers – Designates Epidemiology centers as “public health agency” under HIPAA allowing them greater access to data and health information. • Sec. 221 – Licensing – Extends “licensed in any state” exemption allowed for certain federal health care professional employees to tribal employees. 19
  20. 20. Title II – Health Services • Sec. 226 – Contract Health Services Administration and Disbursement Formula – Opens current CHS distribution formula for reevaluation via 3 step process: • Step 1. GAO Report on CHS program • Step 2. IHS-tribal consultation to determine whether current distribution formula should be modified • Step 3. If Secretary determines it necessary, a Negotiate Rulemaking Committee may be established to develop new distribution formula. 20
  21. 21. Title III – Health Facilities • Sec. 301 – Health Care Facilities Priority System – Requires IHS, in consultation with T/TOs, to establish a priority system allowing nomination of new projects every 3 years. • Grandfathers in projects listed in FY 2008 budget request. • Area Distribution Fund as a possible approach to meet unmet need for construction of health facilities. • Sec. 309 – Federally Owned Quarters – Authorizes T/TO to elect to directly operate and establish rental rates for federally-owned staff quarters and directly collect rents based on local rates. 21
  22. 22. Title III – Health Facilities • Sec. 311 – Other Funding, Equipment, and Supplies for Facilities – Authorizes other federal agencies to transfer funds for the “planning, design, construction, and operation of” health care and sanitation facilities to HHS/IHS. – Requires HHS/IHS to establish new regulations for “planning, design, construction, and operation of” Indian health care and sanitation facilities. – Applies the HHS/IHS regulations to the transferred funds. 22
  23. 23. Title IV – Access to Health Services • Sec. 401 – Treatment of Payments under SSA – Adds Children’s Health Insurance Program (in addition to Medicaid & Medicare) as source I/T can collect from. – Provides greater flexibility for T/TOs in use of funds collected under this section. • Sec. 402 – Purchasing Health Care Coverage – Allows T/TO/Us to use federal funds to purchase health benefits coverage for beneficiaries. 23
  24. 24. Title IV – Access to Health Services • Sec. 404 – Outreach and Enrollment in SSA and Other Health Benefit Programs – Grants and contracts for I/T/U to conduct outreach and enrollment activities for Indians. – May be used to pay beneficiary premiums or cost sharing. 24
  25. 25. Title IV – Access to Health Services • Sec. 405 – Sharing Arrangements with Federal Agencies – Allows Secretary to enter into arrangements with DoD and DVA to share facilities and services. – Directs DoD and DVA to reimburse I/T/TO for services provided to DoD/DVA beneficiaries notwithstanding any other provision of law. • Sec. 407 – Eligible Indian Veteran Services – Authorizes I/Ts to pay co-pays to DVA for services provided to IHS beneficiaries. – Provision was needed to facilitate arrangements for Indian veterans to receive care from DVA providers in I/T facilities. 25
  26. 26. Title IV – Access to Health Services • Sec. 408 – Nondiscrimination in Qualifications for Reimbursement – Makes I/T/U programs eligible to participate in any federal health care program without requiring state licensure as long as such programs meet the applicable state standards. • Sec. 409 – Access to Federal Insurance – Allows T/TO/Us operating any ISDEAA program (not just IHS) to purchase insurance coverage for their employees through the FEHB program. • Sec. 410 – General Exceptions – Exempts certain insurance products from being considered 3rd-Party Payer under IHCIA, e.g., AFLAC. 26
  27. 27. • Title V – Urban Indian Health – Grants Urban Indian programs broader program authority. – Requires IHS to “confer” with urban Indian programs. • Title VI – IHS Organizational – Some enhancements to authorities and responsibilities of IHS Director. – Establishes Office of Direct Service Tribes. 27
  28. 28. Title VII – Behavioral Health • Title VII replaces current law’s substance abuse programs. • Greatly expands behavioral health authorities: – Comprehensive behavioral health Prevention and Treatment – Indian Women Treatment – Indian Youth Program – Inpatient MH Facilities – FASD programs – Child Sexual Abuse Prevention and Treatment – Domestic and Sexual Violence Prevention and Treatment – Behavioral health research – Indian Youth Suicide Prevention 28
  29. 29. Title VIII – Miscellaneous • Sec. 805 – Confidentiality of Medical QA Records – Allows for peer reviews to be conducted within Indian health programs without compromising confidentiality of medical records. 29
  30. 30. Title VIII – Miscellaneous • Sec. 813 – Health Services to Ineligible Persons – Allows T/TO to make a determination to provide services to non-beneficiaries. – If T/TO makes this determination, services to non-beneficiaries are deemed provided under the ISDEAA agreement and FTCA applies. – Non-Service providers in IHS/tribal hospitals receive FTCA coverage when provided services under this section. 30
  31. 31. Title VIII – Miscellaneous • Sec. 822 – Shared Services for Long-Term Care – Expressly authorizes IHS to provide, or enter into ISDEAA agreements, for the delivery of long-term care to Indians: • Home and Community Based services • Hospice care • Assisted living and other residential services • Sec. 826 – Annual Budget Submission – Directs the President to include in the annual IHS budget request amounts that reflects changes due to inflation (CPI) and increase in user population. 31
  32. 32. Title VIII – Miscellaneous • Sec. 827 – Prescription Drug Monitoring – Requires HHS to establish a prescription drug monitoring program at I/T/U facilities. – Report due to Congress 18 months after enactment. • Sec. 828 – Tribal Health Program Option for Cost Sharing – Allows Title V tribal health programs to charge beneficiaries for services. – Unclear whether this applies to Title I programs. 32
  33. 33. Title VIII – Miscellaneous • Sec. 831 – Traditional Health Care Practices – Excludes these services from FTCA coverage. • Sec. 832 – HIV/AIDS Prevention and Treatment – Establishes a new Director of HIV/AIDS Prevention and Treatment within IHS to coordinate the agency’s efforts on this issue. 33
  34. 34. Overall Implications Individuals • More services may be available through the I/T/U • More opportunities for coverage • More options for care 34
  35. 35. Overall Implications Providers • More insured individuals • Need for education and enrollment • Marketing need due to options for care for insured • More opportunities to expand care • More collaboration with non-tribal partners • More opportunities for health workforce training 35
  36. 36. Questions? Valerie Davidson, Senior Director Legal & Intergovernmental Affairs Alaska Native Tribal Health Consortium 4000 Ambassador Drive, CADM Anchorage, AK 99508 vdavidson@anthc.org Phone 907-729-1900 36
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