Enrolling Indian Country: Building Capacity to Reach Tribal Communities

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Enrolling Indian Country:
Building Capacity to Reach Tribal Communities

• Be aware of health care provisions available to registered
tribal members
• Identify best practices for effective partnership development
with tribal outreach groups, tribes and individual members
• Connect with other professionals interested in tribal
engagement and leave with personal connections to
support your work
• Leave with tangible next steps to engage local tribes and
tribal members
Session Objectives

Kitty Marx, Director
Division of Tribal Affairs
Center for Medicaid and CHIP Services
Indian Health 101:
History & Overview of the
Indian Health System

Who is an Indian?
• There are 567 federally recognized
Indian tribes
• Ethnically and culturally diverse
• 250 languages actively spoken
• Tribal members are recognized by
their individual tribe:
• Evidenced by tribal
membership, enrollment, or
other documents showing
descendancy from parents,
grandparents, or other
ancestors

American Indians and Alaska Natives
in the United States
• Per the 2010 Census, there are 5
million American Indians and Alaska
Natives (AI/ANs)
• 2.2 million AI/ANs receive health
services from the Indian Health
Service (IHS), an agency of
Department of Health & Human
Services (HHS)
• Many AI/ANs are eligible for and are
enrolled in Medicare, Medicaid, CHIP
and the Marketplace.
• Access to CMS benefits serve as an
important source of health care
coverage for tribal communities and
supplemental funding to IHS.

• The Federal government entered into
close to 400 treaties with Indian Tribes
between 1778 and 1871.
• Indian Tribes exchanged over millions of
acres of land to the U.S. Government.
• Many of the treaties contain provisions
which explicitly include promises to
provide health care.
• Indian health care is considered by many
Tribal members as “pre-paid” treaty rights.
Federal Responsibility to Provide
Health Care Based on Treaties

• The Federal government recognizes Indian Tribes as sovereign
nations and this government-to-government relationship
distinguishes American Indians and Alaska Natives from all other
ethnic groups in the U.S.
• U.S. Constitution: Basis of government-to-government
relationship
o Indian Commerce Clause
o Treaty Clause
o Supremacy Clause
• Federal trust responsibility is upheld by:
o Court decisions – Cherokee Nation vs. Georgia (1831)
o Federal Laws and Regulations
o Presidential Executive Orders – November 5, 2009
o Agency tribal consultation policies
Federal Trust Responsibility

IHS is not insurance but a comprehensive health care delivery
system that provides health care in hospitals and clinics.
The Indian Health Care Improvement Act (IHCIA), first enacted
in 1976, was reauthorized and made permanent by the Affordable
Care Act of 2010.
In 1976, Congress enacted Title IV of the IHCIA to provide
authority to IHS hospitals and clinics to receive reimbursement
for services rendered to Medicare and Medicaid patients.
Congress recognized that many AI/ANs were eligible for
Medicare and Medicaid services but had no access to services
and providers, unless they traveled off reservation to
private/public providers hundreds of miles away.
Indian Health Care Improvement Act

Dawn Coley, Director of Tribal Health Care Reform
National Indian Health Board
Tribal Health Care Reform
Outreach and Education

The Indian Health Care System
• The Indian Health Service (IHS) (I),
tribes and tribal organizations (T), and
urban Indian organizations (U) are the
three components of the Indian health
care system.
• 45 Indian hospitals
• Over 600 Indian health centers,
clinics, and health stations, including
urban programs
• When specialized services aren’t
available at these sites, health services
may be purchased from public and private
providers through the
Purchased/Referred Care Program,
formerly known as Contract Health
Services.

CMS Programs
CMS administers the
following programs:
 Medicare
 Medicaid
 Children’s Health Insurance
Program (CHIP)
 The Health Insurance Marketplace

Benefits for Tribal Communities: ACA
• Permanently
reauthorizes the Indian
Health Care Improvement
Act (IHCIA) and
strengthens the Indian
Health Service’s role in
health delivery.
• Strengthens the IHS and
ensures that AI/ANs will
be able to continue to
receive services from
IHS, tribal organizations,
and urban Indian
organizations.

• For purposes of Medicaid and
CHIP, an AI/AN is a member of a
federally recognized tribe, an
Alaska Native Claims Settlement
Act (ANCSA) corporation
shareholder, or any individual
eligible to receive services from
IHS.
• For purposes of the
Marketplace, an AI/AN is limited
to members of a federally
recognized tribe or ANCSA
shareholders.
Definition of American Indian/Alaska Native

• Medicaid and/or CHIP
(ARRA Protections)
• Resource
Exemptions/Income
Exclusions
• Cost Sharing Exemptions
• Estate Recovery
Protections
• Managed Care
Protections
• States/Tribal consultation
Benefits for Tribal Communities: Medicaid
Provides special protections for AI/ANs to increase
access to health coverage through:

• 100% FMAP for Medicaid-
covered services provided
through Indian Health and
Tribal 638 facilities.
• No cost sharing for AI/ANs in
Medicaid and CHIP.
• I/T/U Providers and facilities
are exempt from local licensure
by the State as long as they
substantially meet provider
requirements.
Benefits for Tribal Communities: Medicaid

• Special enrollment periods
and the ability to switch plans
monthly
• Cost-sharing reductions in
zero cost-sharing and limited
cost-sharing at any level plan,
depending upon income
• Ability to apply for an
exemption from the individual
shared responsibility payment
Benefits for Tribal Communities: Marketplace

Members of federally recognized
Indian tribes, ANCSA corporation
shareholders, and their descendants,
and other Indians who are otherwise
eligible for services from an Indian
health care provider have the
following Medicaid and CHIP
protections:
 Do not have to pay premiums or
enrollment fees and can enroll at any
time
 Tribal documents accepted as proof of
citizenship and identity
 If they receive care from an Indian
health care provider or through referral
to a non-Indian provider, do not have
to pay any cost sharing
AI/AN Medicaid and CHIP Protections

Certain types of Indian income and
resources are not counted when
determining Medicaid or CHIP
eligibility:
 Per capita payments from a tribe
that come from natural resources,
usage rights, leases, or royalties
 Payments from natural resources,
farming, ranching, fishing, leases,
or profits from Indian trust land
(including reservations and former
reservations)
 Money from selling things that have
tribal cultural significance, such as
Indian jewelry or beadwork
AI/AN Medicaid and CHIP Protections

Lesa Evers, Tribal Relations Manager
Montana Department of Public Health and Human Services
The Ground Game: Working In
Indian Country Across Montana

Distances:
West to East = 650+ miles
North to South = nearly 400 miles
Know The Playing Field
Montana Indian Reservations
About 7%
of population
About half live
off the
reservation in
urban
communities

They’ve changed
Complicated
Exceptions & Exemptions
New language
Require interpretation
At times seems easier not to play
Study The Game Rules

Have fun
Actively engage
Keep working hard
Tackle the challenges
Know the game plan may not go as expected
Don’t give up
Keep Your Head In The Game

Build your team
Be inclusive
Recruit – bring in new
players, rotate, rest
Support each other
Recognize that everyone brings a set of skills to the game
Be A Team Player

Millions of people now have health coverage
Montana expanded Medicaid to a whole new population
Indians have health coverage, many for the first time ever
Good partnerships established (ex. DPHHS, CIO and IHS outreach on
Montana Indian reservations)
Innovative approaches developed (ex. Two Tribes in Montana
determining Medicaid eligibility on their own reservations)
Review The Game Highlights

Get Prepared For What’s Ahead
Stay positive
Keep building your team
Develop a strategy
Use your tips
Learn from your losses
Celebrate your wins

Erik Lujan, Assistant Director
Health Education & Outreach Program
NAPPR, Inc.
Creating Partnerships with
Native American Communities

Who are our Native American Partners?
• Native American Tribes and Nations
• Some areas will have consortiums of Tribes:
Iroquois, Pueblos
• “Urban” Native American organizations
• Most Urban organizations will have a good idea
of the need and can help Identify consumers
• IHS/Tribally Operated Facilities
• Most IHS/ Tribally operated facilities employ
“Benefits Coordinators” that assist Native
consumers with enrollment and application
processes
• Most have Community Health Representatives
(CHR) that are trusted individuals with in the
community

Engaging Communities
• Approaching Tribal Leadership
• Tribes usually have a Protocol for Non-Native
Americans to engage with them
• Remember Tribes are SOVEREIGN
Governments they are not required to engage
with you, know your “Ask”
• Reach out to local IHS or Tribally operated health
providers
• Information on location and contact information
can be found at www.ihs.gov
• Consider formalizing your partnership
• Once you have made contact consider entering
into an MOU or MOA if time permits and the
Tribes allow.
• Formalizing will help assure a Tribe that you
are serious about providing assistance and can
provide clear guidance on the “cans” and
“cannots”

Creating a Coordinated Plan
• Take some time, with identified partners, to consider
what can be accomplished with in your allowed time
• Are there local resources, for example Community
Health Representatives and Benefits Coordinators?
• Is there work space with internet connectivity
available?
• In some parts of Native America the ACA is still new,
you may need to provide training on Native American
Provisions and enrollment requirements
• Inquire and be aware of cultural sensitivity practices,
most tribes can provide
• Participate in already established events (when
allowed)
• Make sure you have a visible, sustained presence in
the community through out the allowed time
Consider:
• Realistic Goals
• Available
resources
• Any Training
needs
• Limitations
that may exist
• Community
engagement
• Duration of
effort

Communication is Critical
• Set a schedule with partners
• Depending on how many partners and location, set up regular
conference calls or in-person meetings if resources allow
• Technical Assistance
• Partners and on the ground workers, will have questions on eligibility
and enrollment, providing immediate responses demonstrates your
commitment and reliability to partners and consumers
• Messaging is more than talking points
• One mistake is to only provide simple talking points outreach and
enrollment need to be able to answer a consumers 2nd and 3rd question
• Example: 1. What is the ACA? 2. How will it affect me? 3. I have IHS
why do I needed additional coverage?

Be Willing and Able to Adapt
• One size does not fit all. Each community, even if they are the
same Tribe, is different.
• Tribes will have varying levels of: resources, population and
eligibility
• Level of allowed community engagement will vary as will when you
are allowed to be in the community
• If the established techniques stop being effective you must be able
to adapt your plan
• Be willing to “add to” local resources not “replace” them

Ask the Panel

Takeaways and
Next Steps

Dawn Coley
Director of Tribal Health Care Reform
Outreach & Education
National Indian Health Board
dcoley@nihb.org
Lesa Evers
Tribal Relations Manager
Montana Department of Public
Health & Human Services
levers@mt.gov
Contact The Panel
Erik Lujan
Assistant Director, Health Education &
Outreach Program
NAPPR, Inc.
elujan@nappr.org
Kitty Marx
Director, Division of Tribal Affairs
Center for Medicaid and
CHIP Services
kitty.marx@cms.hhs.gov

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Enrolling Indian Country: Building Capacity to Reach Tribal Communities