TSGAC QM3 Final Meeting Packet - Tribal Self

Transcription

IHS SELF-GOVERNANCE ADVISORY COMMITTEE
(TSGAC)
QUARTERLY MEETING
JULY 21-22, 2015
Embassy Suites DC Convention Center
900 10th Street Northwest, Washington, DC 20001
Phone: (202) 739-2001
IHS Tribal Self-Governance Advisory Committee and Technical Workgroup
Quarterly Meeting
Tuesday, July 21, 2015 (8:00 am to 5:00 pm)
Wednesday, July 22, 2015 (8:30 am to 2:00 pm)
Embassy Suites Washington DC - DC Convention Center
th
900-10 Street NW
Washington, DC 20001
Phone: (202) 739-2001
Table of Contents
1. TSGAC AGENDA
•
•
2015-2016 TSGAC Calendar
TSGAC Membership Matrix
2. TSGAC Committee Business
•
•
•
•
March Quarterly Meeting Minutes
March Quarterly Meeting Assignment Matrix
TSGAC Correspondence Matrix
Navajo Area Nomination
3. Workgroup Reports
•
TTAG Workgroup Report
4. Information Technology: Meaningful Use and ICD-10
•
•
•
•
NIHB Comments on Meaningful Use – Stage 3
Multi-purpose Agreement
MPA Joinder Agreement
OIT Presentation
5. CSC Workgroup Update
•
•
IHS Dear Tribal Leader Letter RE: CSC Update (May 22, 2015)
TSGAC Response Letter to IHS CSC Update
6. Budget Update
•
•
•
Appropriations House Report for IHS
Senate Appropriations Mark Up
FY 2017 Tribal IHS Budget Request
7. Patient Protection and Affordable Care Act Implementation and Update
•
•
•
•
TSGAC Report on QHP Contracting with IHCPs
Six Month Report on TSGAC ACA Activities
TSGAC Tribal Priorities for Outreach and Education
TSGAC Memo – Status of Joint DST and TSG Initiative
8. Behavioral Health Discussion
•
•
IHS Dear Tribal Leader Letter RE: MSPI and DVPI
MSPI and DVPI Funding Announcement (Shorten)
DOI SGAC & Technical Workgroup Quarterly Meeting
March 25-26, 2015 – Agenda
•
Page 2 of 2
SDPI Update
9. Other Documents
•
•
•
IHS Dear Tribal Leader Letter RE: SDPI FY 2016 Decision
2015 Health Our Spirits Worldwide Invitation
Meeting Summary and Notes for Follow Up from DSTAC/TSGAC Joint Meeting
Draft Agenda 2-17-15 ver. 5
IHS TRIBAL SELF-GOVERNANCE ADVISORY COMMITTEE
c/o Self-Governance Communication and Education
P.O. Box 1734, McAlester, OK 74501
Telephone (918) 302-0252 ~ Facsimile (918) 423-7639 ~ Website: www.Tribalselfgov.org
INDIAN HEALTH SERVICE TRIBAL SELF-GOVERNANCE ADVISORY COMMITTEE
AND TECHNICAL WORKGROUP QUARTERLY MEETING
Wednesday, July 22, 2015 (8:30 am to 1:30 pm)
th
900-10 Street NW
Phone: (202) 739-2001
AGENDA
Meeting of IHS Tribal Self-Governance Advisory Committee (TSGAC) and Technical
Workgroup with IHS Acting Director Robert G. McSwain
8:00 am
Tribal Caucus
Facilitated by: Chief Marilynn (Lynn) Malerba, Mohegan Tribe of Indians of Connecticut
and Chairwoman, Indian Health Service (IHS) Tribal Self-Governance Advisory
Committee (TSGAC)
Legislative Update:
• Special Diabetes Program for Indians (SDPI)
• Self-Governance Authority Expansion – Indian Self-Determination and Education
Assistance Act (ISDEAA) Title VI Update
• Contract Support Costs (CSC) Mandatory Appropriation
• Medicare-Like Rates
• Sequester Exemption for Indian Programs
• Streamlining the Definition of Indian for Purposes of ACA Implementation
9:00 am
TSGAC Opening Remarks
Chief Marilynn (Lynn) Malerba, Mohegan Tribe of Indians of Connecticut and
Chairwoman, IHS TSGAC
9:10 am
IHS Opening Remarks and Update
Robert G. McSwain, Acting Director, Indian Health Service
9:30 am
Office of Tribal Self-Governance Update
P. Benjamin Smith, Director, Office of Tribal Self-Governance
9:45 am
Information Technology: Meaningful Use and ICD-10 Update
CDR Mark Rives, MBA, MSCIS, Director, Office of Information Technology, IHS
10:15 am
Break
IHS TSGAC & Technical Workgroup Quarterly Meeting
July 21-22, 2015 – AGENDA
Page 2
10:30 am
Contract Support Cost Workgroup Update and Discussion
• Mandatory Contract Support Cost FY 2016 President’s Budget Proposal
• Contract Support Cost Workgroup Report
Chief Marilynn (Lynn) Malerba, Mohegan Tribe of Indians of Connecticut
Chairman W. Ron Allen, Jamestown S’Klallam Tribe
Mickey Peercy and Rhonda Butcher, IHS Contract Support Costs Workgroup Members
Roselyn Tso, IHS CSC Team Lead
11:15 am
Discussion and Update on Budget Issues
• Status of FY 2016 President’s Budget Request for IHS
• Status of FY 2017 Budget Formulation
• Budget Summit Recommendations and Implementation
Elizabeth Fowler, Deputy Director for Management Operations, IHS
Melanie Fourkiller, TSGAC Technical Co-Chair and Policy Analyst
12:00 noon
TSGAC Members’ Executive Session with IHS Acting Director
1:30 pm
Patient Protection and Affordable Care Act (ACA) Implementation and Update
Mim Dixon, Consultant, Tribal Self-Governance Advisory Committee
Cyndi Ferguson, Self-Governance Specialist/Policy Analyst, SENSE Incorporated
2:00 pm
Behavioral Health Topic Discussion
• Methamphetamine and Suicide Prevention Initiative and Domestic Violence
Prevention Initiative
• Generation-Indigenous Suicide Prevention Initiative
• Tribal Action Plans (as authorized by the Tribal Law and Order Act)
Dr. Alec Thundercloud, Director, Office of Clinical and Preventive Services, IHS
Dr. Beverly Cotton, Director, Division of Behavioral Health, OCPS, IHS
3:00 pm
Break
3:15 pm
Joint TSGAC and IHS Acting Director Discussion
4:45 pm
Closing Remarks
Robert McSwain, Acting Director, Indian Health Service
Chief Marilynn (Lynn) Malerba, Mohegan Tribe of Indians of Connecticut and Chairwoman,
IHS TSGAC
Wednesday, July 22, 2015 (8:30 am – 1:30 pm)
Meeting of TSGAC and Technical Workgroup
8:30 am
Welcome
Invocation
Roll Call
Introductions – All Participants & Invited Guests
9:00 am
Opening Remarks
Chief Marilynn (Lynn) Malerba, Mohegan Tribe of Indians of Connecticut and
Chairwoman, IHS TSGAC
July 21-22, 2015 – AGENDA
Page 3
TSGAC Committee Business
• Approval of Meeting Summary (March 2015)
• Approval of 2016 Quarterly Meeting Calendar
• Navajo Area Nomination
9:45 am
CMS TTAG Update
• Medicaid Expansion
• FMAP for Medicaid
• CMS Managed Care Ruling
Mim Dixon, Consultant, Tribal Self-Governance Advisory Committee
Chief Marilynn (Lynn) Malerba, Mohegan Tribe of Indians of Connecticut and Chairwoman,
Indian Health Service (IHS) Tribal Self-Governance Advisory Committee (TSGAC)
Elliot Milhollin, Partner, Hobbs Straus Dean & Walker LLP
Kitty Marx, Director, Tribal Affairs Group, Office of External Affairs, CMS
10:15 am
Break
10:30 am
IHS and Tribal Performance Measures: Integrated Data Collection System Data Mart
Francis Frazier, (Acting) Director, Office of Public Health Support, IHS
11:00 am
TSGAC Technical Workgroup Meeting
12:00 pm
Adjourn TSGAC Meeting
2015-2016 Self-Governance Calendar
Date
July 21-22, 2015
July 22-23, 2015
Meeting
October 6-7,2015
October 7-8, 2015
January 26-27, 2016
January 27-28, 2016
March 29-30, 2016
March 30-31, 2016
TSGAC Quarterly Meeting
SGAC Quarterly Meeting
DOI Self-Governance 101 and IHS SelfGovernance Finance Training
2015 Tribal Self-Governance Annual
Strategy Session
IHS TSGAC Quarterly Meeting
DOI SGAC Quarterly Meeting
April 24-28, 2016
2016 Annual Consultation Conference
July 19-20, 2016
July 20-21, 2016
2016 Tribal Self-Governance Annual
Strategy Session
August 18-19, 2015
September 9-10, 2015
September 7-8, 2016
October 25-26, 2016
October 26-27, 2016
Location
Embassy Suites-DC
Convention Center
Mohegan SunUncasville, Connecticut
Hard Rock HotelCatoosa, OK
Embassy Suites-DC
Convention Center
Embassy Suites-DC
Convention Center
Embassy Suites-DC
Convention Center
Buena Vista PalaceOrlando, FL
Embassy Suites-DC
Convention Center
TBD
Embassy Suites-DC
Convention Center
Telephone (918) 302-0252 ~ Facsimile (918) 423-7639 ~ Website: www.tribalselfgov.org
MEMBERSHIP LIST
(July 27, 2015)
AREA
MEMBER (name/title/organization)
STATUS CONTACT INFORMATION
Alaska
Jaylene Peterson-Nyren
Executive Director, Kenaitze Indian
Tribe
Primary
Gerald “Jerry” Moses
Senior Director, Intergovernmental
Affairs, Alaska Native Tribal Health
Consortium
Alternate
Luis Romero, Governor
Pueblo of Taos
Primary
Raymond Loretto, DVM, Governor
Pueblo of Jemez
Alternate
Greg Matson, Vice Chairman
Oneida Tribe of Wisconsin
Primary
VACANT
Alternate
Beau Mitchell, Council Member
Chippewa Cree Tribe
Primary
Shelly Fyant, Tribal Council Member
The Confederated Salish and Kootenai
Tribes of the Flathead Nation
Alternate
Ryan Jackson, Council Member
Hoopa Valley Tribe
Primary
Robert Smith, Chairman
Pala Band of Mission Indians
Alternate
Marilynn (Lynn) Malerba, Chief
Mohegan Tribe of Connecticut
TSGAC Chairwoman
Primary
Casey Cooper, Chief Executive
Officer
Eastern Band of Cherokee Indians
Hospital
Alternate
Albuquerque
Bemidji
Billings
California
Nashville
Page 1 of 6
150 N Willow St.
Kenai, AK 99611
P: (907) 335-7200
Email: Jaylene@kenaitze.org
4000 Ambassador Drive, LIGA Department
Anchorage, AK 99508
P: (907) 729-1900
Email: gmoses@anthc.org
PO Box 1846
Taos, NM 87571
P: 575-758-9593 ~ F: 575-758-4604
PO BOX 100
Jemez Pueblo, NM 87024
P: 575-834-7359 ~ F: 575-834-7331
Email: Raymond.loretto.dvm@jemezpueblo.org
PO Box 365
Oneida, WI 54155
P: (920) 869-4403
Email: gmatson@oneidanation.org
PO Box 544
Box Elder, MT 59521
Email: beau@cct.rockyboy.org
PO BOX 278
Pablo, MT 59855
P: (406) 275-2700 ~ F: (406) 275-2806
Email:
PO Box 1348
Hoopa, CA 95546
Email: cbfdistrict@gmail.com
35961 Pala-Temecula Rd.
Pala, CA 92059
P: 760-891-3519 ~ F: 760-891-3584
Email: rsmith@palatribe.com
5 Crow Hill Road
Uncasville, CT 06382
P: 860-862-6192 ~ F:
Email: lmalerba@moheganmail.com
43 John Crowe Hill Rd.
PO Box 666
Cherokee, NC 28719
Email: Casey.Cooper@cherokeehospital.org
TSGAC & Technical Work Group Membership List
July 27, 2015
Navajo
Oklahoma
Oklahoma
Phoenix
Portland
Jonathan Nez, Vice President
Navajo Nation
Primary
PO BOX 7440
Window Rock, AZ 86515
P: (928) 871-7000
Email: jonmnez@yahoo.com
Nathaniel Brown, Honorable
rd
Delegate of the 23 Navajo Nation
Council
Alternate
PO BOX 3390
Window Rock, AZ 86515
P: (928) 871-6380
Email: nbrown@navajo-nsn.gov
John Barrett, Jr., Chairman
Rhonda Butcher, Director
Citizen Potawatomi Nation
Primary
Proxy
George Thurman, Principal Chief
Sac and Fox Nation
Alternate
Jefferson Keel, Lt. Governor
Chickasaw Nation
Primary
Gary Batton, Chief
Mickey Peercy, Executive Director
Choctaw Nation of Oklahoma
Alternate
Proxy
Lindsey Manning
Chairman, Shoshone-Paiute Tribes of
the Duck Valley Indian Reservation
Primary
1601 S. Gordon Cooper Dr.
Shawnee, OK 74801
P: 405-275-3121 x 1157
F:405-275-4658
Email: rbutcher@potawatomi.org
Route 2, Box 47
Stroud, OK 74079
P: 918-968-3526
Email::chief@sacandfoxnation-nsn.gov
PO Box 1548
Ada, OK 74821
P: 580-436-7232 ~ F: 580-436-7209
Email: lt.gov@chickasaw.net
PO Box 1210
Durant, OK 74702
P: 580-924-8280 ~ F: 580-920-3138
Email: mpeercy@choctawnation.com
PO BOX 219
Owyhee, Nevada 89832
P: 208-759-3100 ~ F: 208-759-3102
Email: manning.lindseyw@shopai.org
VACANT
Alternate
W. Ron Allen, Tribal Chairman/CEO
Jamestown S’Klallam Tribe
TSGAC Vice-Chairman
Primary
1033 Old Blyn Highway
Sequim, WA 98382
P: 360-681-4621 ~ F: 360-681-4643
Email: rallen@jamestowntribe.org
Tyson Johnston, Council Member
Quinault Indian Nation
Alternate
P.O. Box 189 (1214 Aalis Drive) Taholah, WA
98587
P: 360-276-8211 ~ F: 360-276-4191
Email: tjohnston@quinault.org
Page 2 of 6
TSGAC TECHNICAL WORKGROUP
AREA
MEMBER (name/title/organization)
STATUS CONTACT INFORMATION
Alaska
Dave Mather, Ph.D
Mather & Associates
Tech Rep
Brandon Biddle
Alaska Native Tribal Health Consortium
Tech Rep
Alberta Unok
Deputy Director
Alaska Native Health Board
Tech Rep
Albuquerque
Shawn Duran
Tech Rep
Bemidji
John Mojica
Mille Lacs Band of Ojibwe
Tech Rep
Billings
Ed Parisian
Chippewa Cree Tribe
Tech Rep
California
Jody Jeffers
Chief Financial Officer
North Fork Rancheria of Mono Indians of
California
C. Juliet Pittman
SENSE Incorporated
Tech Rep
Cyndi Ferguson
SENSE Incorporated
Tech Rep
Mim Dixon
Tech Rep
(Health
Reform)
Doneg McDonough
Tech Rep
(Health
Reform)
D.C.
(National)
Page 3 of 6
Tech Rep
1569 Northfield Rd
Fairbanks, AK 99709
P: 907-455-6942 ~ F: 907-455-7391
Email: mather.david@gmail.com
4000 Ambassador Drive
Anchorage, Alaska 99508
P: 907-729-4687
Email: bbiddle@anthc.org
Anchorage, Alaska 99508
P: 907-562-6006
Email: aunok@anhb.org
P.O. Box 1846
Taos, N.M. 87571
Office: 575.758.8626 ext. 115
Fax: 575.758.8831
Mobile: 575.741.0208
Email: SDuran@taospueblo.com
43408 Oodena Drive
Onamia, MN 56359
P: 320-532-7479 ~ F: 320-532-7505
Email: john.mojica@millelacsband.com
PO Box 544
Box Elder, MT 59521
Email: eparisian@rbclinic.org
P.O. Box 929
North Fork, CA 93643-0929
P: 559-877-2461 ~ F: 559-877-2467
Email: jjeffers@nfr-nsn.gov
Upshaw Place
th
1130 -20 Street, NW; Suite 220
P: 202-628-1151 ~ F: 202-638-4502
Email: pitt@senseinc.com
Upshaw Place
th
1130 -20 Street, NW; Suite 220
P: (202) 628-1151 ~ F: (603) 754-7625
C: (202) 638-4502
Email: cyndif@senseinc.com
4139 Dietz Farm Circle NW
Albuquerque, NM 87107
Phone (505)345-2221
Fax (505)345-2960
Email: mimdixon@hotmail.com
Phone: 202-486-3343 (cell)
Fax: 202-499-1384
Email: d.mcdonough@yahoo.com
July 27, 2015
Nashville
Dee Sabattus
United South and Eastern Tribes
Tech Rep
711 Stewarts Pike Ferry, Suite 100
Nashville, TN 37214
Email: dsabattus@usetinc.org
Hillary Andrews
United South and Eastern Tribes
Tech Rep
400 North Capitol Street, NW
Suite 585 Washington, DC 20001
Email: HAndrews@USETINC.ORG
Navajo
Carolyn Drouin
Navajo Nation Washington Office
Oklahoma
Mickey Peercy
Choctaw Nation
Tech Rep
Rhonda Farrimond
Choctaw Nation
Tech Rep
Melanie Fourkiller
Choctaw Nation
Tribal Technical Co-Chair
Tech Rep
Theodore Scribner
Chickasaw Nation
Tech Rep
Vickie Hanvey
Cherokee Nation
Tech Rep
Kasie Nichols
Citizen Potawatomi Nation
Tech Rep
Jennifer McLaughlin
Tech Rep
Jim Roberts
Northwest Portland Area Indian Health Board
Tech Rep
Eugena R Hobucket
Quinault Indian Nation
Tech Rep
Portland
Page 4 of 6
750 First Street NE, Suite 1010
Washington, D.C. 20002
P: 202.682.7390 ~ F: 202.682.7391
E-mail: cdrouin@nnwo.org
PO Box 1210
Durant, OK 74702
P: 580-924-8280 ~ F: 580-920-3138
Email: mpeercy@choctawnation.com
PO Box 1210
Durant, OK 74702
P: 580-924-8280 ~ F: 580-920-3138
Email: rfarrimond@choctawnation.com
PO Box 1210
Durant, OK 74702
P: 580-924-8280 ~ F: 580-920-3138
C: 918-453-7338
Email: mfourkiller@choctawnation.com
PO Box 1548
Ada, OK 74821-1548
P: 580-436-7214 ~ F: 580-310-6461
Email:theodore.scribner@chickasaw.net
PO Box 948
Tahlequah, OK 74465
P: 918-456-0671 ~ F: 918-458-6157
Email: Vickie-Hanvey@cherokee.org
1601 S. Gordon Cooper Dr.
Shawnee, OK 74801
P: 405.275.3121 ~ F: 405.275.0198
C: 405-474-9126
kasie.nichols@potawatomi.org
1033 Old Blyn Highway
Sequim, WA 98382
P: (360) 681-4612 ~ F: (360) 681-4648
Email: jmclaughlin@jamestowntribe.org
527 SW Hall #300
Portland, OR 97201
P: (503) 228-4185 ~ F: (503) 228-8182
Email: jroberts@npaihb.org
PO BOX 189
Taholah WA 98587
P: (360) 276-8211 ~ F: (360) 276-8201
Email: ehobucket@quinault.org
FEDERAL TECHS
AREA
MEMBER (name/title)
STATUS
CONTACT INFORMATION
HQ
Jennifer Cooper
Deputy Director, OTSG
(Federal Tech Co-Chair)
OTSG Rep
801 Thompson Ave, Suite 240
Rockville, MD 20852
P: 301-443-7821 ~F: 310-443-1050
Jennifer.Cooper@ihs.gov
Jeremy Marshall, Policy Analyst, OTSG
OTSG Rep
Rockville, MD 20852
P: 301-443-7821 ~F: 310-443-1050
Jeremy.Marshall@ihs.gov
Jessica Smith-Kaprosy, Policy Analyst, OTSG
OTSG Rep
Rockville, MD 20852
P: 301-443-7821 ~F: 310-443-1050
Jessica.Smith-Kaprosy@ihs.gov
Aberdeen
Sandy Nelson (POC)
Director, Office of Tribal Programs
Area Rep
115 4th Avenue, SE, Suite 309
Aberdeen, SD 57401
P: 605-226-7276 ~F: 605-226-7541
Sandy.Nelson@ihs.gov
Alaska
Evangelyn Dotomain (POC)
Director, Office of Tribal Programs
Area Rep
Anchorage, AK 99508-5928
P: 907-729-3677 ~F: 907-729-3678
Evangelyn.Dotomain@ihs.gov
California
Travis Coleman
IHS Agency Lead Negotiator
Area Rep
Nashville
Lindsay King
Area Rep
650 Capitol Mall, Ste 7-100
Sacramento, CA 95814
P: 916-930-3927 ~F: 916-930-3952
Travis.Coleman@ihs.gov
711 Stewarts Ferry Pike
Nashville, TN 37214-2634
P: 615- 467-1521 ~F: 615-467-1625
Lindsay.King@ihs.gov
Navajo
Floyd Thompson
Executive Officer/ IHS Agency Lead Negotiator
Area Rep
Alva Tom (POC)
Director, Indian Self-Determination
Area Rep
Max Tahsuda
Director, Tribal Self-Determination
(Acting) IHS Agency Lead Negotiator (Alaska)
Denise Imholt
Area Rep
Robert L. Price (POC)
Public Health Advisor
Office of Tribal Affairs
Area Rep
Oklahoma
Portland
Tucson
Page 5 of 6
Area Rep
Hwy 264 (St. Michael, AZ)
Window Rock, AZ 86515-9020
P: 928-871-1444 ~F: 928-871-5819
Floyd.Thompson@ihs.gov
Hwy 264 (St. Michael, AZ)
Window Rock, AZ 86515-9020
P: 928-871-1444 ~F: 928-871-5819
Alva.Tom@ihs.gov
701 Market Drive
Oklahoma City, OK 73114
P: 405-951-3761 ~F: 405-951-3868
Max.Tahsuda@ihs.gov
1414 NW Northrup Street, Suite 800
Portland, OR 97209
P: 503-414-7792 ~F:503-414-7791
Denise.Imholt@ihs.gov
7900 South J Stock Road
Tucson, AZ 85746
P: 520-295-2403 ~F:520-295-2540
Robert.Price@ihs.gov
July 27, 2015
OTHER RESOURCES
MEMBER (name/title)
ORGANIZATION
CONTACT INFORMATION
Laura Bird
Policy Analyst
National Congress of American
Indians
Caitrin Shuy
Director of Congressional Relations
National Indian Health Board
1516 P ST NW
Washington, DC
Email: Lbird@ncai.org
P: 202-507-4085
Email: cshuy@nihb.org
TSGAC Mailing Address:
Page 6 of 6
Telephone (918) 302-0252 ~ Facsimile (918) 423-7639 ~ Website: www.Tribalselfgov.org
INDIAN HEALTH SERVICE TRIBAL SELF-GOVERNANCE ADVISORY COMMITTEE
AND TECHNICAL WORKGROUP QUARTERLY MEETING
Tuesday, March 24, 2015 (8:00 am to 5:00 pm)
Wednesday, March 25, 2015 (8:30 am to 2:00 pm)
th
900-10 Street NW
Phone: (202) 739-2001
Meeting Summary
Tuesday, March 24, 2015 (8:00 am to 5:00 pm)
Meeting of IHS Tribal Self-Governance Advisory Committee (TSGAC) and Technical
Workgroup with IHS Acting Director Robert G. McSwain
Tribal Caucus
•
TSGAC hosted a Tribal Caucus prior to the March quarterly meeting. During the caucus the
TSGAC prepared for a meeting with the Office of Inspector General and discussed other
caucus issues in preparation for the meeting with Acting Director McSwain.
Invocation
Chairman Vanderhoop of Wampanoag of Gay Head (Aquinnah) provided an opening invocation.
Roll Call
Alaska:
Oklahoma 1:
Oklahoma 2:
Albuquerque:
Nashville:
Portland:
Jaylene Peterson-Nyren, Executive Director, Kenaitze Indian Tribe
Rhonda Butcher, Self-Governance Coordinator, Citizen Potawatomi Nation,
Proxy for Chairman Barret
Vickie Hanvey, Self-Governance and Government Resources Coordinator, Proxy
for Chief Baker
Mickey Peercy, Self-Governance Executive Director, Choctaw Nation, Proxy for
Chief Batton
Luis Romero, Governor, Taos Pueblo
Shawn Duran, Tribal Administrator, Taos Pueblo
Tobias Vanderhoop, Chairman, Wampanoag of Gay Head (Aquinnah)
Stephanie White, Treasurer, Wampanoag of Gay Head (Aquinnah)
Jennifer McLaughlin, Self-Governance Analyst, Jamestown S’Klallam Tribe,
Proxy for Chairman Allen
Opening Remarks
Mickey Peercy, Self-Governance Executive Director
Mr. Peercy provided welcoming remarks and reviewed the TSGAC agenda.
March 24-25, 2015 – Meeting Summary
Page 2
Opening Remarks
Acting Director McSwain expressed appreciation for the opportunity to meet with TSGAC and
explained that he would only be present for the first day of the meeting due to other
commitments.
During his opening remarks the Acting Director also shared that the President’s Fiscal Year
2016 (FY16) request continued to prove his commitment to Indian Country and health care for
American Indians and Alaska Natives. Congressional members were also interested in the
request because for the first time in history IHS presented during four separate hearings on the
President’s FY16 Budget Request. Despite the recent change to Dr. Roubideaux’s role within
the Department of Health and Human Services (HHS), she acted as lead witness during the
hearings.
The Acting Director reassured TSGAC members that he was up-to-date on IHS issues and
priorities and did not foresee a drastic change in the agency’s future.
OIG Alert and Congressional Dialogue
Greg Demske, Chief Counsel, Office of Inspector General, Department of Health and Human Services
Melinda Golub, Senior Counsel, Office of Counsel to the Inspector General, Department of Health and
Human Services
Amitava “Jay” Mazumdar, Senior Counsel, Office of Counsel to the Inspector General, Department of
Health and Human Services
• Ms. Golub and Mr. Mazumdar provided a short presentation about the role the Office of
Inspector General (OIG) plays within HHS and explained how the audit alert was generated and
released. Below are a few notes from their presentations.
o OIG is Responsible for conducting audits and investigations to protect HHS programs.
o There are twenty-four OIG field offices
o The report to Congress twice a year and ultimately try to promote the prevention of fraud
and abuse
o There are five components within OIG
 Office of audit services
 Office of evaluation & inspections
 Office of investigations
 Office of counsel to the inspector general
 Office of management and policy
o OIG publishes regular reports and an annual work plan
 One item in the work plan is on the quality of care in the IHS hospitals
 They also share many resources on their website for those operating HHS
programs.
 The Tribal alert was posted on the website in an effort to raise awareness about
possible fraud and abuse.
o The Tribal alert grew out of the fraud and alert process. Which has a long history of
providing information on how to comply with HHS regulations around using those funds.
 They provide resources including
• Compliance guidance documents
• Interpretation legal regulations
• Guidance for oversight responsibilities
• Testimony and speeches provided by OIG
Page 3
•
o
Special fraud alerts
o Issued to the public
o Identify problems and go into a fair amount of detail that providers
need.
• Other guidance
o Alerts to physicians and Tribal alerts
o These are shorter and explain general trends that may be at risk
for continued abuse
The Tribal Alert falls into the “other guidance” provided.
 OIG plans to conduct many more investigations, under the guardian project
looking very deeply into the use of HHS grant dollars in Tribes.
• They do not believe there are any systemic problems, however, they’ve
noted there are not always internal controls to oversee their use.
• Additional compliance programs may be necessary.
What effect might this have on other Self-Governance legislation?
Nick Matiella, Legislative Assistant, for The Honorable John McCain, U.S. Senate
•
McCain’s amendments were meant to protect the integrity of the Self-Governance program
o Add additional site visit opportunities for review
o Keeps the threshold for audits low at $500,000
o Required IHS to provide Tribes with technical assistance to build internal control
standards
Mike Andrews, Majority Staff Director & Chief Counsel, SCIA
Rhonda Harjo, Majority Deputy Chief Counsel, SCIA
Brandon Ashley, Majority Senior Policy Advisory, SCIA
Anthony Walters, Minority Staff Director & Chief Counsel, SCIA
• The US Senate Committee on Indian Affairs is trying to move the bill forward before Memorial
Day.
• This is great opportunity to get S. 286 plus the amendments to move forward. Having support
from OIG is a great sign that things are moving forward.
Tribal Discussion
•
•
•
Can you provide some examples of how there was abuse in the past?
o OIG
 There was no systemic audit to share examples now.
 ACA allows the Secretary to retrocede ability to direct bill Medicare, Medicaid,
and CHIP.
• They did notice that some Title I Tribes did not know they are supposed
to use reimbursements
• Some Tribes did not have internal controls, which allows employees to
redirect or syphon money.
 They were hearing from Assistant US Attorneys that Tribes did not know about
the regulations.
 There was no robust education process in Indian Country either.
Is there are particular part of Indian Country where you are seeing the frequency is higher?
o OIG
 They are seeing issues in both Title I and V Tribes
 The often conduct an audit and investigation
Are there specific resources on the OIG website that are helpful to Tribes?
Page 4
OIG
 Are there other ways that they can be helpful in providing tools for compliance?
 Evaluate the website resources
 Video, training materials, and compliance guidance resources.
TSGC Members proposed that some technical advisors and IHS need to work together to
prepare resources about reimbursement policies and requirements for Tribes
Rhonda Butcher noted that Tribes have been starved of Contract Support Costs (CSC), which
would support the audits and development of internal controls and is likely leading to some of
these issues. This really is an example of why full CSC funding is necessary to correctly
support HHS programs.
Were the McCain proposed amendments proposed by OIG?
o Nick Matiella
 Amendments from McCain were not proposed by OIG, but do try to get to the
heart of protecting the integrity of the program.
 The other alternative considered was allowing for a negotiated rulemaking
process where the agency to develop internal control standards
Acting Director committed to try and standardize internal controls and do more to support Title I
Tribes.
TSGAC members encouraged OIG to utilize the regional and national network of organizations
to provide training and share best practices.
TSGAC members also expressed sizeable differences between the funding levels provided to
CMS and IHS and that the alert did not seem to match the concern that OIG is currently
expressing. Members also recommended stronger partnerships to avoid future unintended
consequences
OIG recognized that the release may not have been the most effective way to get to the
substance of the discussion.
OIG responded that they desired to get the best information to the public in the most effective
way and committed to making sure that the direction is coming from the Tribes and providing
the same messages.
OIG suggested that Tribes meet more often to provide compliance information for hospital
billing, etc.
Is there way for us to work together and find solutions so that OIG could be supportive of SelfGovernance Expansion?
o OIG would not comment directly on Title IV or V expansion.
o They did suggest that if Tribes are considering expansion, that internal controls be
adopted or recognized to support the Title V expansion program. They also stated they
may be willing to provide guidance on proposed internal controls.
o
•
•
•
•
•
•
•
•
•
•
• The Director reported that three Tribes officially entered into Self-Governance in 2015:
o Southern Indian Health Council
o Cow Creek Band of Umqua Indian
o Santa Ynez Band of Chumash Indians
• To date the Self-Governance Tribes have 87 compacts and 112 funding agreements
representing nearly 1.8 billion dollars transferred from IHS control to Tribal control.
• Together these funds support over 350 Federally Recognized Tribes.
• When combined with Title I Tribes, more than half the IHS budget, 2.5 billion dollars, is being
transferred to Tribes.
•
•
•
•
•
Page 5
The theme for this year’s conference is “A Legacy for Future Generations” could not be more
indicative of the growth in policy and maturity of the government-to-government relationship
since passage of the Indian Self-Determination and Education Assistance Act (ISDEAA) forty
years ago.
OTSG has responded to a number of requests for technical assistance, including interest in
entry to Self-Governance and training new staff and leadership about the program.
OTSG co-hosted a training with the DOI in California in February to provide training and
technical assistance in financial aspects of Self-Governance, particularly around funding tables.
OTSG is also conducting interview to hire a staff assistant to support the office.
OTSG is working to update the database and plans to have the update completed by summer
time.
Discussion
•
•
•
•
•
Why do Office of Environmental Health and Engineering dollars come later than others? What is
causing the delay?
o OTSG has brought the delay to the attention of Mr. Hartz and his staff and is tracking the
issues they’ve heard about through other negotiations.
o Liz Fowler agreed to look into the issue and report back what she learned.
o She mentioned that some of the delay is likely related to the process needed to update
the workload and determining final allocations.
o She agreed that IHS would look at the possibility of sending money by category versus
project.
The tables for facilities is not entirely transparent and it is difficult to determine what are the
residuals withholdings and Tribal share determinations from the table. You cannot follow the
appropriations process from beginning to the table provided. Can we take a look clarifying the
table and providing a more transparent process to determine the final table?
o Liz Fowler agreed to follow up on the issue and report back.
What will/has the role been for Acting Director?
o He will continue the same agenda and consultation agenda as previously set forth.
What is the new HHS Role for Dr. Roubideaux?
o She advises the Secretary regarding several agency priorities, including
 Representing the Secretary in hearings regarding the President’s FY16 Budget
request;
 Overseeing AI/AN advising to the Secretary;
 Continuing implementation of ACA and several aspects of the law;
 Promoting behavioral health; and
 Assisting in the launch of Generation Indigenous.
OTSG has posted the planning, negotiation and management grants for Tribes pursuing SelfGovernance Compacts. The applications are due June 1, 2015.
Discussion and Update on Budget Issues
Elizabeth Fowler, Deputy Director for Management Operations, IHS
Melanie Fourkiller, TSGAC Technical Co-Chair and Policy Analyst
• Fowler shared a few updates about FY 2015
o PRC increase allocation was made to the areas on February 13, 2015
o Everyone should have received their increase in their funding agreements
o Pay cost increase of 2.5 million. Those were allocated on March 11, 2015 to the area
offices.
• Status of FY 2017 Budget Formulation
o Completed the national work session in February for HHS and IHS
•
Page 6
o The next step is to evaluate that process and start planning for FY 2018
Budget Summit Recommendations and Implementation
o Should be included in the formulation process and the planning meeting at Annual
Conference
Lunch and TSGAC Members’ Executive Session with IHS Acting Director and HHS Senior
Advisor to the Secretary for American Indians and Alaska Natives
Contract Support Cost Workgroup Update and Discussion
Mickey Peercy and Rhonda Butcher, IHS Contract Support Costs Workgroup Members
Yvette Roubideaux, M.D., M.P.H., Senior Advisor to the Secretary for American Indians and Alaska
Natives, HHS
• Update from February CSC Meeting
o IHS is requesting new and expanded requests come in by March 31st
o Workgroup has adopted the ACC template
o IHS will roll out the template in a Dear Tribal Leader Letter (DTLL), they also
recommended that standardized pass-through and exclusions be included in the DTLL
o The workgroup requested a clarification of reconciliation process.
•
Comments on the FY2016 Presidents Budget CSC Mandatory on February 9th
o The comments are being compiled and will be shared with the CSC workgroup group
o The Administration has provided all the information to the Hill
o We need Tribal support
o The Administration is still trying to find a champion
•
CSC for Methamphetamine and Suicide Prevention and Domestic Violence Prevention
Initiatives
o Tribal members of the workgroup believes that the need to get as much as possible is
more important than ever.
o They also believe that because litigation is over CSC for these two programs creates a
win-win situation for everyone.
o The agency has had conflicting positions and should clarify before other action is taken.
Joint TSGAC and IHS Acting Director Discussion
• Medicare-Like Rate
o IHS received 54 comments regarding the proposed regulation.
o They will share comment if they are able.
o They are trying ascertain the timeline in publishing the final rule and implementation.
o There will be a briefing at the PRC meeting in the upcoming weeks.
• Expansion of Title V
o HHS still believes a formal process via legislation is needed before adoption and
expansion of Title V.
o Though the workgroup was going to talk about principles to inform legislation, Congress
will have to propose legislation and then talk to the administration about the proposal.
o There are legal provisions in the law that need to be changed before agencies feel
comfortable moving forward.
o Secretary Burwell is asking that HHS leads find a solution and officials are asking if it
has to the full-blown Self-Governance model or another model could be considered.
o The outcomes are already defined, maybe we need to identify additional pathways
o
o
•
Page 7
All of the agencies are starting their FY17 proposals, perhaps TSGAC should consider
meeting with agencies to request legislative proposals to support expansion.
The basic concern is that SG Tribes are unsure of the forum to talk about expansion, but
Dr. Roubideaux is happy to try to facilitate a few meetings on this in the future. And will
try to make sure Tribes are at the table.
OEHE
o Working on the funding tables to create more transparency
Closing Remarks
•
The Acting Director thanked the committee for their feedback, agreed to follow up on notes and
to stay attentive to the issues.
Yvette Roubideaux, M.D., M.P.H., Senior Advisor to the Secretary for American Indians and
Alaska Natives, HHS
•
•
HHS remains committed to making progress, even with changes in the Administration.
She explained she is trying to figure out how to leverage her opportunities and prioritize or
efforts with the Secretary.
Review strategic plan document and prepare for DSTAC/TSGAC joint meeting.
Wrap Up and Preparation for Wednesday, March 25, 2015
Wednesday, March 25, 2015 (8:30 am – 2:00 pm)
Meeting of TSGAC and Technical Workgroup
Welcome
Melanie Fourkiller, Policy Analyst, Choctaw Nation; and Tribal Technical Co-Chair, TSGAC
Invocation
Clyde Romero of Taos Pueblo provided the morning invocation.
TSGAC Committee Business
• Approval of Meeting Summary (January 28, 2015)
o MOTION: Approved by acclamation
•
Approval of the Strategic Plan
o MOTION: Approved by acclamation
•
DSTAC-TSGAC Inaugural Joint Meeting
o TSGAC Members proposed the following ideas for the upcoming meeting:
 Smaller delegation and a more informal meeting test
 Identify shared priorities
 Discuss future joint meetings together
 Teleconference availability for additional meetings
 Determine action and/or follow up items
 Share ideas about Tribal Sponsorship Models under the ACA
Page 8
•
Confirmation of Alaska Alternate Representative
o MOTION: Alternate Representative, Gerald “Jerry” Moses, was approved by
acclamation
•
SGCE provided updates about the Annual Consultation Conference, recruited additional
moderators and recorders, and sought approval for the final Conference agenda.
Interfacing Resource and Patient Management System (RPMS) with Proprietary Systems and
OIT Survey Results
CDR Mark Rives, MBA, MSCIS, Director, Office of Information Technology, IHS
Yvette Roubideaux, M.D., M.P.H., Senior Advisor to the Secretary for American Indians and Alaska
Natives, HHS
• IHS conducted a survey as part of the operational analysis for RPMS, infrastructure, and
National data warehouse
• It’s a survey of stakeholders, not really a systemic review and included end users, technicians,
and developers
• There were in-person surveys and interviews.
• Themes from the survey included:
o Negative feedback:
 Feasibility
 Usability
 Interoperatability
 Interface was antiquated
o Positive Feedback:
 Eye care and population tracking makes the system stand out from other
commercial programs
o Improve communication around RPMS and future work was necessary from participant’s
perspectives.
• Paid for service model to be included to create stakeholders and survey data about those users.
• Developers stated that the organization is getting more complicated and training when
developers leave the work is left hanging a bit
• Four contractors work on four RPMS development and that has created friction
o IHS is replace all contracts this year to emphasize the demarcation of work.
• Tribal discussion
o Do you have a handout that summarizes all of those issues?
 There are slides that will be shared with the committee.
o Is there a timeline to address some of those?
 The office is working through a number of issues as quickly as possible and
some is tied to Meaningful Use required updates.
• Interoperability?
o Meaningful Use (MU) has been the driver of the need to be interoperability
o Incentive payments resulted in significant revenue for Indian Country
o Patient Summary and records can now connect to a larger network
o IHS is ahead of the game the challenge is meeting the new regulations and
requirements
o IHS is reviewing alternative delivery models
o Meaningful Use is to create quality measurement and provide patient data at the
appropriate time
o IHS has met MU 1 & 2
Page 9

o
o
o
o
o
Once IHS achieves interoperability they have to make sure that data is secure,
that is the part that seems to be holding up the process for developers.
There is good news out that IHS may be able to meet the next step in MU 2
 Steep curve for 2015 calendar year
Tribes may want to provide comments to the MU Part 3 rules currently out for comment
to allow RPMS users to meet the requirement.
Dear Tribal Leader Letter on the Multi-purpose user is coming out soon and should
provide an opportunity for comment.
Is there funding available to support updating third party system?
 Not for Tribes searching for interoperability of third party systems.
How do Tribes connect to the federal network for local needs?
 ONC is trying to layout a network that meets these more complicated need.
Patient Protection and Affordable Care Act (ACA) Implementation and Update
Doneg McDonough, Consultant, Tribal Self-Governance Advisory Committee
Cyndi Ferguson, Self-Governance Specialist/Policy Analyst, SENSE Incorporated
o The team continues to host regularly scheduled webinars
o January - VA Agreements
o February – Hot current issues for ACA [will continue quarterly]
o March – Tribal sponsorship
o Webinars are recorded and questions are summarized for archival purposes
o Success Stories
o Two site visits and two stories have been completed
 Two remaining are Fond du Lac and Southcentral Foundation
o The goal is to share the first two stories at the Annual Conference.
o Then finally, a glossy magazine for waiting rooms that will be accessible from the SG
website.
o Premium Sponsorship Webinar
o IHS sent out a notice to Direct Service Tribes (DST) and resulted in great interest.
o The team will focus on how IHS will make sure that premium sponsorship is available
across the spectrum of IHS facilities.
o Medicaid expansion remains a critical for Tribal health facilities, if expanded to every
state roughly a billion dollars additionally each year.
o A negative decision in the King v. Burwell case could result in some states without
federal tax credits.
o 26,000 AI/AN reported enrollment in the marketplace in March reporting
o Return on sponsorship enrollment is approximately 100% on average. However, Tribes
are flagging some problems in recouping payments…requiring additional work to
improve those systems.
o The ACA Team is working on a Special Project: Qualified Health Plan (QHP) Contracting with
Indian Health Providers (IHPs)
o They are trying to measurer the extent to which the QHPs are offering contracts to IHPs
o In the Federal Marketplace each health program has to offer a contract with an Indian
addendum.
 Results are mixed, however where active health boards exist health plans are
offering contracts
o Those states where it’s not required results are significantly different.
o Materials are available on SGCE information
o TTAG workgroup report is also available in the meeting materials
o Tribal Discussion
o
Page 10
The collaboration that has developed over the last couple of years has been helpful for
advocacy and policy priorities.
Annual CSC Calculation Tool Demonstration
• CSC workgroup has made suggestions to improve the template to simply the CSC policy
options
• Feedback from TSGAC
o We need to make sure there is agency history that can explain the tool
o Communication to all the Tribes about this tool is required
o Should live within Self-Governance offices
o The tool that has been used on the BIA side required an OMB number, because it is a
form
o Update on the needs report is necessary, because the last one included 2011 data
• Has IHS submitted the needs report to the Departmental clearance process?
o The clearance process can be protracted and long so it is unclear when the next needs
report will be released.
Adjourn TSGAC Meeting
MOTION
Wampanoag Tribe of Gay Head (Aquinnah) made a motion to adjourn the meeting.
Cherokee Nation seconded the motion.
The motion to adjourn was approved and the meeting was adjourned at 11:59 AM
Eastern.
Technical Workgroup
Assignment Matrix – January 2015 Quarterly Meeting
Updated: July 13, 2015
Technical Workgroup Co-Chairs:
Melanie Fourkiller, Tribal Co-Chair
Jennifer Cooper, Federal Co-Chair
1.
2.
3.
Assignment
Person(s)
Responsible
Date Task
Originated
Status
All correspondence with Secretary:
discuss impact, relationships, and
teamwork (refer to TSGAC summary
7/30/14). If the TSGAC specifically
desires a response from the Sec’y, the
letter should state so.
Continue to gather data from all Areas
about impact of CR/shutdown. Specific
programmatic impact, such as layoffs,
closed programs, PRC, bad patient
outcomes, etc. Reach out to the Health
Directors in each Area.
Develop and include in IHS SelfGovernance Policy protocols for selfgovernance negotiations, including but not
limited to expectations for information and
document sharing and protocol for proper
communication with Tribal leadership.
Review with TSGAC. (see April 10, 1997
letter to TSGAC from previous IHS
Director).
All
July 31, 2014
INFORMATIONAL ONLY.
Consider when drafting
correspondence to HHS
Secretary.
Terra Branson
July 31, 2014
Ongoing – SGCE will
continue to gather this data
via survey during the Annual
Consultation Conference.
Ben Smith
OTSG
July 10, 2013
In progress. Include on
future TSGAC agenda.
Mickey Peercy
Rhonda Farrimond
Melanie Fourkiller
Cyndi Ferguson
Jennifer LaMere
Small working team
developed to assemble
recommendations on
formalizing IHS delegations,
decision memos and letters
from implementation of SG.
1997 IHS Director
Letter
4.
5.
6.
7.
[SG Negotiations issue – whether IHS
ALNs should accept provisions (at Tribal
option) that have been previously
negotiated in other Compacts/FAs, to the
extent applicable to that Tribe.]
Set up meeting with OMB (Julian Harris)
through Reina Thiele, White House, re:
Tribal 3rd party data being requested and
effects of CRs (alternatives to Advanced
Appropriations).
Appropriations “Think Tank” -- Develop
ideas/options for: (1) Potential solutions to
CRs (alternatives to Advanced
Appropriations, such as an entire year CR
with a “true up”, etc; and (2) Long term ‘fix’
for Contract Support Cost appropriations
(alternatives to Mandatory Appropriations).
Develop a Tribally-driven protocol for
applying the FACA exemption for
Workgroups and Tribal Advisory
Committees (TACs).
Provide orientation to the new members of
TSGAC and Technical Workgroup.
W. Ron Allen
Jennifer McLaughlin
July 31, 2014
Hold and monitor for any
future action needed.
White paper developed.
Carolyn Crowder
(Lead)
Brandon Biddle
Caitrin Shuy
Liz Malerba
Lloyd Miller
July 31, 2014
Jody Jeffers
Melanie Fourkiller
NCAI
October 9, 2014
Ongoing – Submitted LongTerm CSC recommendations
on August 28, 2014;
Requested an “anomaly”
from OMB for CSC funding
on September 5, 2014; held
Budget Summit on Oct 1314, 2014.
In progress, workshop to be
held at the Annual
Consultation Conference.
TSGAC Co-Chairs
OTSG Rep
July 31, 2014
1
Need to identify a time for a
conference call.
Melanie Fourkiller
Mim Dixon
January 28, 2015
Letter commending Acting Director Robert
McSwain on rates of CSC settlement and
claim resolutions.
Follow up regarding employer mandate in
the ACA.
Clint Hastings
January 28, 2015
Mim Dixon
January 28, 2015
Develop comments on Meaningful Use 3
Proposed Regulations. Comments due
May 29, 2015.
Letter to representatives of the OIG
General Counsel thanking them for
attending TSGAC meeting and identifying
any next steps
Coordinate and develop agenda for Joint
DSTAC/TSGAC to be held May 13, 2015
Doneg McDonough
March 25, 2015
Monitor. MMPC has
requested engagement of
White House on this issue.
NIHB submitted comments.
Pitt
Cyndi Ferguson
March 25, 2015
Completed.
Rhonda Farrimond
Clyde Romero
OTSG
SGCE
March 25, 2015
Completed. Notes and
follow up from meeting
provided to TSGAC.
8.
Letter to CMS requesting timely contract
provider data and collection of future data.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
Letter to IHS Director regarding
transparency in funding tables for Facilities
Acct, timeliness of fund distribution,
application of formulas to OEHE funds,
and funding for Small Ambulatory Grants
and Dental Health Stations
Confer with TSGAC Co-Chairs regarding
HHS SG Expansion, i.e., potential
conference call with Dr. Yvette
Roubideaux to “bring people back to the
table, have a conversation, and reorient
the initiative from barriers to solutions.”
Transmit/brief Dr. Roubideaux on the
Tribal Concept Paper.
Develop metrics to evaluate effectiveness
of MLR after implementation.
Letter to IHS Acting Director reaffirming
his commitment to provide a response
within 30 days regarding application of
CSC to the MSPI/DVPI programs, and
thanking him in advance for the response.
Attend the IHS Budget Formulation
evaluation meeting at the Annual SG
Consultation Conference. Provide
feedback to the TSGAC as necessary.
Send welcome and congratulation letters
to the three new SG Tribes, invite to
TSGAC and provide a packet of
information
Send follow up letter from SGCE to
Senator McCain regarding OIG alert.
Develop a recommended draft of language
for CSC Mandatory Appropriations
Schedule TSGAC conference call on CSC
Mandatory Appropriations Language after
completion of item 22.
Letter to Acting IHS Director
recommending setting CSC Workgroup
meeting as soon as practicable.
Meeting Summary for March 24-25
TSGAC Meeting.
TTAG sent a letter received
negative response. Might still
require TSGAC action.
TSGAC Survey underway of
I/T/U sites.
Completed.
March 25, 2015
March 25, 2015
Mickey Peercy (PRC
Workgroup)
Doneg McDonough
Dave Mather
April 13, 2015
March 25, 2015
Completed.
Clyde Romero
March 25, 2015
Completed.
SGCE
March 25, 2015
Completed.
Terra Branson
Jennifer McLaughlin
Geoff Strommer
Lloyd Miller
SGCE
March 25, 2015
Completed.
March 25, 2015
Completed.
March 25, 2015
Completed.
Melanie Fourkiller
April 13, 2015
Completed.
SGCE
March 25, 2015
Completed
2
Summary of IHS Tribal Self-Governance Advisory Committee (TSGAC) Correspondence
Year: 2015
Updated: June 30, 2015
Ref.
#
Date Sent/
Received
Addressed To
Topic/Issue
1.
7/10/15
Carolina Manzano
Chief Executive Officer
Southern Indian Health
Council, Inc.
Welcome to SelfGovernance
2.
7/10/15
Vincent Armenta
Tribal Chairman
Santa Ynez Band of
Chumash Indians
3.
7/10/15
Dan Courtney
Chairman
Cow Creek Band of
Umpqua Tribe of Indians
4.
6/29/15
Mr. Robert G. McSwain,
Acting Director
Determination of Contract
Support Cost Requirements
Mr. P. Benjamin Smith,
Director, Office of Tribal
Self-Governance, Indian
Tribal Leadership Priorities
for “Self-Governance
National Indian Health
Outreach and Education”
Indian Health Service
5.
6/12/15
Health Service
Page 1 – Updated June 30, 2015
Action(s) Needed
TSGAC comments in response to
IHS’s position that the amount of
contract support costs (CSC) owed
under its contracts and compacts
with Tribes and Tribal organizations
under the Indian Self-Determination
Act (ISDA) is determined based on
“incurred costs.”
The TSGAC reaffirms the
commitment to empower Tribal
communities with the knowledge
and tools needed to successfully
manage and implement the Patient
Protection and Affordable Care
Act/Indian Health Care Improvement
Act (ACA/IHCIA) provisions
Response Received
Summary of IHS Tribal Self-Governance Advisory Committee (TSGAC) Correspondence – 2015
Ref.
#
Date Sent/
Received
Addressed To
Topic/Issue
Action(s) Needed
concerning health care insurance
coverage options to improve the
quality and access to care for Tribal
citizens and Indian communities.
6.
6/9/15
Acting Director
Payment of IHS Employee
Settlements.
7.
5/15/15
Internal Revenue Service
Notice 2015-16 on Section
4980I — Excise Tax on High
Cost Employer-Sponsored
Health Coverage
8.
4/23/15
Acting Director
Detail of OTSG Deputy
Director
TSGAC urges OTSG to amend the
Agreement to renew and fund the
“Self-Governance National Indian
Health Outreach and Education”
contract for FY2016
TSGAC provided comments to the
May 22, 2015 IHS Dear Tribal
Leader Letter (DTLL) on the
Payment of Employee Settlements.
For the current settlement described
in the DTLL, and for any future
settlements, the TSGAC strongly
urges the IHS to reject the flawed
plan to cut health care services and
consider one or both alternatives
proposed.
TSGAC Comments in Request to
Notice from IRS.
TSGAC request to Director to reevaluate the detail and assign other
staff to OUIHP as soon as
practicable.
Response Received
Ref.
#
9.
Date Sent/
Received
4/21/15
Addressed To
Topic/Issue
Action(s) Needed
Acting Director
Special Diabetes Program
for Indians (SDPI)
TSGAC comments in response to
the DTLL request for
comments/consultation on the SDPI
programs.
10. 4/20/15
Mr. Robert G. McSwain
Mr. Ben Smith
Mr. Carl Harper
Transmittal of SelfGovernance National ACA
Education and Outreach
Report
No action needed. Transmittal of 6month report for the time period
October 1, 2014 through March 31,
2015.
11. 4/8/15
Acting Director
Payment of Contract
Support Costs for MSPI and
DVPI funding
Request that the agency review this
issue and that, as committed during
3/24/15 TSGAC meeting, provide a
final decision to Tribes on the
eligibility of MSPI/DVPI for additional
CSC funds within 30 days.
12. 4/8/15
13. 4/3/15
Acting Director
Mr. Gregory E. Demske,
Chief Counsel to the
Inspector General
Ms. Melinda Golub,
Senior Counsel
Mr. Amitava “Jay”
Mazumdar, Senior
Counsel
Thank you on Rates of CSC
Settlement and Claim
Resolutions
Continue timely resolution of
outstanding claims and consistent
full funding of CSC.
Thank you for participating
in the Tribal SelfGovernance Advisory
Committee Quarterly
Meeting,
March 24, 2015
Further dialogue to occur during the
Thursday, April 30th Breakout
Session A7, Pursuing and
Reinvesting Third Party
Revenue, at the upcoming 2015
Annual Tribal Self-Governance
Consultation Conference in Reno,
Response Received
A Dear Tribal Leader was sent out from IHS Acting
Director McSwain on 6/22/15 with an update on how
the IHS will move forward with MSPI and DVPI over
the next five years.
Response received from IHS Acting Director McSwain
on 5/18/15. Letter stated the IHS is not required to
provide additional funds beyond what is included in
the project budgets.
Ref.
#
Date Sent/
Received
Addressed To
Topic/Issue
Office of Counsel to the
Inspector General
Action(s) Needed
NV
14. 2/26/15
The Honorable Derek
Kilmer
Self-Governance Tribes
2015 Appropriations
Requests for the Bureau of
Indian Affairs
Joint letter from TSGAC/SGAC
15. 2/10/15
The Honorable Derek
Kilmer
Self-Governance Tribes
2015 Appropriations
Requests for Indian Health
Service
Joint letter from TSGAC/SGAC
16. 2/9/15
Chief Marilynn Malerba,
Chairwoman
TSGAC
Agency response to
information requested QHPs
to IHCPs in specific regions
CMS staff are available to address
specific QHP problems and provide
further assistance in the process
17. 1/31/15
Chairwoman
TSGAC
Agency response to the
ongoing and unprecedented
international Ebola crisis
18. 2/5/15
IHS Director,Dr. Y.
Roubideaux
Mandatory Appropriations
for Contract Support Coasts
Response Received
Response from Marilyn Tavenner, CMMS 2/2/15 to
letter dated 12/19/14
Response from Dr. Y.Roubideaux, IHS Director,
1/31/15 to letter dated 10-17-14
Appreciated partnership and looking
forward to working to advance longterm solutions for funding CSC
Ref.
#
Date Sent/
Received
Addressed To
Topic/Issue
19. 2/4/15
Betty Gould, Regulations
Officer, IHS and Carl
Harper, Director
ORAP,IHS
Submit via
regulations.gov
Comments on IHS Proposed
Rule entitles “Payment for
Physician and Other Health
Care Professional Services
Purchased by Indian Health
Programs and Medical
Charges Associated with
Non-Hospital-Base Care
20. 1/20/15
Chairwoman
TSGAC
Concerns regarding
procedural consistency and
information sharing during
CSC negotiations on
Disputed claims
21. 1/14/15
Ms Tracy Parker Warren
Office of Public and
Intergovernmental Affairs
OTGR(075F)-VA
Comments Submitted
Response to Notice of TC:
Sec 102 © of the Veterans
Access, Choice and
Accountability Act of 2014
Urge the Reports enter into
agreements for reimbursement also
current agreements be used and
expanded where possible to speed
up implementation to eligible
veterans
22. 1/12/15
CCIIO-CMS-DHHS
Comments on Draft 2016
Letter to Issuers in the
Federally-Facilitated
Marketplace
We are available to discuss any of
the recommendations contained in
the correspondence and attachment
on CMS-9944-P
Action(s) Needed
Response Received
Being able to engage in Tribal
Consultation on the proposal
Response from Dr. Y. Roubideaux, IHS Director,
1/20/15 to letter dated 12-2-14
Ref.
#
Date Sent/
Received
23. 1/8/15
Addressed To
IHS Director,Dr. Y.
Roubideaux
Topic/Issue
2015 TGSAC Quarterly
Meetings and Tribal SelfGovernance Annual
Conference Information
Action(s) Needed
Adjustment to your schedule due to
changes for the January Qrtly
meetings
Response Received
Response from Dr. Y.Roubideaux, IHS Director,
1/15/15 re: She will be in attendance Jan 28 also
attendance at March Mtg on the 24th
P.O. Box 1734, McAlester, Oklahoma 74501
Telephone (918) 302-0252 – Facsimile (918) 423-7639 – Website: www.tribalselfgov.org
WORKGROUP REPORTING FORM
NAME OF WORKGROUP (please check which Committee this report will be for)
Technical Workgroup
HHS Secretary’s Tribal Advisory Committee (STAC)
Budget Formulation Workgroup
Facilities Appropriation Advisory Board (FAAB)
Tribal Leaders Diabetes Committee (TLDC)
AI/AN Health Research Advisory Group
Information Systems Advisory Committee (ISAC)
Contract Support Costs (CSC) Workgroup
Health Promotion/Disease Prevention Policy Group
CDC Tribal Consultation Advisory Committee
(TCAC)
x
Tribal Technical Advisory Group (CMS-TTAG)
HHS Self-Governance Tribal Federal Workgroup
(SGTFW)
The MMPC retreat was held
LOCATION OF
in San Diego, CA
MEETINGS
TTAG: April 8, next
meeting scheduled for
July 15-16 (prior to
completion of this report)
MMPC: April 1, June 1516 (retreat)
COMMITTEE CHAIRMAN W. Ron Allen
Mim Dixon
COMMITTEE RECORDER
ATTENDANCE (please list all present during the meeting)
W. Ron Allen, Melanie
Mim Dixon, Doneg
Fourkiller
McDonough, Technical
Advisors
DATE OF
MEETINGS
AGENDA ITEM
SUMMARY/HIGHLIGHTS (Committee action should be noted in this section)
Protecting 100% FMAP
under Medicaid Expansion
There is concern that CMS may be considering changing the rules for federal medical
assistance participation (FMAP) for services delivered through Tribal health programs to
people who are enrolled in Medicaid Expansion programs. This may be an issue when
states request waivers for their Medicaid Expansion.
TSGAC technical advisors assisted in the preparation of a TTAG letter to CCIIO
requesting confirmation that eligibility determinations are being made correctly for the
“03”/limited cost-sharing protections for AI/ANs enrolled in Marketplace coverage. Staff is
also working to ensure I/T/Us retain authority over issuing “referrals for cost-sharing” for
persons enrolled under “03” protections when receiving services from non-I/T/U providers.
The CMS AI/AN Strategic Plan Addendum calls for the CMS Tribal Consultation Policy to
be revised by November 2014. CMS held an All Tribes call on this on September 15, and
comments were due by October 1, 2014. CMS provided further edits to the Tribal draft
that was submitted in December 2014. This revised policy has not yet been completed.
The Managed Care regulations are being revised by Medicaid for the first time since
2003. The Notice of Proposed Rule Making (NPRM) was released on May 26, 2015 and
comments are due July 27. The proposed rule is lengthy and a team of people are
working on the response, including TSGAC technical advisors.
The Employer Mandate in ACA requires all employers with more than 100 full time
employees to offer them health insurance. Some Tribes feel that this is creating an
economic hardship and is not consistent with the federal trust responsibility. One Tribe
has filed a lawsuit. MMPC has discussed the problem with high ranking officials in IRS.
Along with other national Indian organizations, MMPC/TTAG is seeking a White House
meeting on this issue. NIHB is working with several people in Congress for a legislative
fix. This meeting is also being coordinated with TSGAC leadership and technical staff.
Eligibility for Indian-specific
cost-sharing protections
under Marketplace coverage
CMS Tribal Consultation
Policy
Managed Care Regulations
Tribal Employer insurance
mandate
AI/AN Enrollment in
Medicaid, CHIP and
Marketplace plans
CCIIO Tribal Workgroup
I/T/U Participation in QHP
provider networks
ACA performance metrics
Definition of Indian in
Exchanges
Payment for Services
provided by Tribes
Medicare Provider-based
rules
Medicare Part B premiums
and co-pays
Medicare Payment Reforms
Medicaid Estate Recovery
TTAG Data Subcommittee met by teleconference on May 26, 2015, to review two tables
of summary data provided by CMS. For all the FFM, only 125,882 AI/AN individuals
applied and 66 percent (83,654) were determined eligible for QHPs and less than one
percent (799) were eligible for Medicaid. Among Tribal members determined eligible for
QHPs, only 20 percent (26,256) selected plans. The data raise questions about whether
people are being properly enrolled in limited cost sharing plans.
At the TTAG meeting on November 19, 2014, CCIIO Director Kevin Counihan offered to
establish a joint CCIIO/Tribal Workgroup. One meeting has been held and the next
meeting is being scheduled for July 16, 2015.
The CMS 2015 letter to issuers requires all QHPs in the FFM to make a good faith effort
to offer contracts with the Indian Addendum to all I/T/Us. TTAG is concerned about how
CMS will monitor and enforce this provision. In addition, TTAG would like this provision:
1) put into regulations; and, 2) extended to state-operated Marketplaces. CMS has
reported that all QHPs have provided contracts with the Indian Addendum to all I/T/Us.
CMS and the TTAG have asked the I/T/Us to let them know if there are cases where this
is not true. TSGAC has completed its research project on this issue.
While CMS has provided some information, they have resisted working with TTAG to
better define data needs and produce the data requested. This is on the agenda for the
next CCIIO Workgroup meeting targeted in July 2015.
TTAG, NCAI, NIHB, and TSGAC leadership and technical advisors are continuing to look
for a vehicle for a legislative fix for the definition of Indian in ACA. Recent budgets
passed by both the House and the Senate have included language directing HHS to
better synchronize the various definitions of Indian.
Recent analysis has shown that cost sharing reductions are not being applied properly for
people who have insurance through the FFM and receive services at a Tribal facility (and
also at non-ICHPs). This may be a result of the improper assignment of people to limited
cost sharing plans. TSGAC technical advisors have worked with NIHB to write a letter
about this problem, and it is on the CCIIO Work Group agenda.
Southern Ute Indian Tribe has requested, and TTAG has supported their request, to have
Tribal Consultation on grandfathering the use of the Encounter Rate for Medicare for
hospital-based provider services. Recent interpretation that hospitals and clinics are
required to have same operating Board is a threat to Tribal sovereignty and the selfdetermination/self-governance process.
MMPC has suggested that TTAG work on getting Medicare to allow group payment from
Tribes for Part B premiums (similar to Part D), and also eliminate the co-pays for AI/AN.
Value based purchasing and other payment reforms may reduce Medicare payments for
IHS and Tribal hospitals that do not score high enough on quality measures. MMPC has
formed a workgroup to consider these issues.
While this applies primarily to people over 55 who may not otherwise qualify for long term
care or community-based services, fear of estate recovery deters others from enrolling in
Medicaid. STAC has requested the HHS Secretary to use her authority to waive estate
recovery for AI/AN. CMS is working with the TTAG Outreach and Education
Subcommittee to develop consumer education materials on Medicaid estate recovery.
RECOMMENDED TSGAC ACTIONS
1.
2.
3.
4.
Legislative advocacy:
a. Make the definition of Indian in ACA the same as in Medicaid.
b. Statutory requirement for Medicare-like rates for ambulatory services provided through CHS/PRC.
c. Exempt Tribes from the employer mandate under ACA.
Advocate with HHS Secretary to:
a. Use authority for an administrative fix for definition of Indian in ACA.
b. Use existing authority to waive Medicaid estate recovery for AI/AN
Continue to monitor developments in the implementation of ACA, participate in Tribal Consultations and policy
subcommittees, and make formal comments. Current focus is:
a. Proper assignment of people to limited cost sharing plans and proper application of cost sharing
reductions in payment of invoices for services provided by I/T/U.
b. Data for better monitoring of enrollment
c. Network adequacy and assuring the IHCPs receive contracts with the Indian Addendum
Advocate for implementation of the CMS AI/AN Strategic Plan, 2015-2018, as revised Feb 20, 2014.
Submitted via http://www.regulations.gov
May 29, 2015
Centers for Medicare & Medicaid Services
Department of Health and Human Services
P.O. Box 8013
Baltimore, MD 21244-8013
Re:
Medicare and Medicaid Programs; Electronic Health Record Incentive ProgramStage 3, CMS-3310-P
On behalf of the National Indian Health Board (NIHB), I write to submit comments on the
Medicare and Medicaid Programs; Electronic Health Record Incentive Program-Stage 3
proposed rule.
Established in 1972, the NIHB is an inter-Tribal organization that advocated on behalf of Tribal
governments for the provision of quality health care to all American Indians and Alaska Natives
(AI/AN). The NIHB is governed by a Board of Directors consisting of a representative from
each of the twelve Indian Health Service (IHS) Areas. Each Area Health Board elects a
representative to sit on the NIHB Board of Directors. In areas where there is no Area Health
Board, Tribal governments choose a representative who communicates policy information and
concerns of the Tribes in that area with the NIHB. Whether Tribes operate their entire health
care program through contracts or compacts with IHS under Public Law 93-638, the Indian SelfDetermination and Education Assistance Act (ISDEAA), or continue to also rely on IHS for
delivery of some, or even most, of their health care, the NIHB is their advocate.
Thank you for the opportunity to respond to the Notice. We set out our comments and
suggestions below.
I.
Background
One of the stated goals of the American Recovery and Reinvestment Act (ARRA), enacted in
February 2009, is to increase the “Meaningful Use” of Electronic Health Record (EHR)
technology among medical providers.1 The Centers for Medicare and Medicaid Services (CMS)
established an incentive program using ARRA funds to encourage eligible providers and
hospitals to adopt and use EHR technology. To achieve Meaningful Use (MU) and receive EHR
MU incentives, participating providers and facilities must meet certain criteria established by
CMS with the Office of the National Coordinator for Health Information Technology (ONC).
The incentives were designed to be released in three stages over several years. Stage 1 MU
1
The HITECH Act (Title IV of Division B of the ARRA, together with Title XIII of Division A of the ARRA).
1
RE: Medicare and Medicaid Programs; EHR Incentive Program-Stage 3
May 29, 2015
requirements have been divided into 15 core set objectives and 10 menu set objectives. Stage 2
builds on the requirements of Stage 1, and additionally, focuses on the interoperability and
exchange of information between health care settings.
In addition to the incentive program, CMS also has a penalty structure in place for those not
meeting MU. These penalties will come in the form of congressionally mandated payment
adjustments which will be applied to Medicare eligible professionals who are not meaningful
users of Certified Electronic Health Record (EHR) Technology under the Medicare EHR
Incentive Programs. These payment adjustments will be applied beginning on January 1, 2015,
for Medicare eligible professionals. (Medicaid eligible professionals who can only participate in
the Medicaid EHR Incentive Program and do not bill Medicare are not subject to these payment
adjustments.)
Payment adjustments are mandated to begin on the first day of the 2015 calendar year, and CMS
will apply a prospective determination for payment adjustments. Therefore, Medicare eligible
professionals must demonstrate MU prior to the 2015 calendar year in order to avoid the
adjustments.
The third and final stage, Stage 3 builds on the first two stages and sets out the requirements that
EPs, eligible hospitals, and critical access hospitals (CAHs) must achieve in order to meet MU,
qualify for incentive payments and avoid downward payment adjustments. Beginning in 2018,
all providers will report on the same definition of MU at the Stage 3 level regardless of their
prior participation.
For Stage 3, CMS is proposing to establish a single set of objectives and measures to meet the
definition of MU that all providers must report in a calendar year, starting in 2017. In addition,
CMS is proposing that beginning in 2017, Medicaid EPs and eligible hospitals demonstrating
meaningful use for the first time in the Medicaid EHR Incentive Program, would be required to
attest for an EHR reporting period for any continuous 90-day period in the calendar year for
purposes of receiving an incentive, as well as avoiding the payment adjustment under the
Medicare Program. Finally, the proposed rule describes exceptions for the lack of availability of
internet access or barriers to obtain IT infrastructure, a situation found throughout Indian
Country.
I.
Discussion re: Indian Country
The following discussion of the proposed regulations is given from the viewpoint of the 566
federally recognized Tribes throughout the United States. These Tribes are made up of
American Indian/Alaska Natives (AIAN) who reside in some of the most rural locations in
Alaska and the lower 48 states. Not only are many Tribes located in rural areas but they are also
plagued by high unemployment, extreme poverty, and disparate health outcomes2.
We agree with many of the provisions of the proposed rule, particularly those that help simplify
and align reporting periods (calendar year for EPs and eligible hospitals) as well as the allowance
for a 90-day reporting period. We also support the exceptions for the lack of availability of
2
Indian Health Service, Disparities, http://www.ihs.gov/newsroom/factsheets/disparities/ (last visited May 27,
2015).
2
May 29, 2015
internet access or barriers to obtain IT infrastructure. The rural nature of what is referred to as
“Indian Country” not only causes difficulty with IT infrastructure but even the most basic
technological needs like access to running water or electricity can be hard to come by.
II.
Discussion re: Proposed Regulations, Definitions Across the Medicare Fee-forService, Medicare Advantage, and Medicaid Programs
NIHB agrees with the proposal to create a single EHR reporting period aligned to the calendar
year. A stated goal of Stage 3 was to realign and simplify the reporting process and we agree
this would work with other CMS quality reporting programs such as the Physician Quality
Reporting System (PQRS). We further agree that having a single EHR reporting period based on
the calendar year allows for a single attestation period.
For Stage 3 of meaningful use, CMS proposes to continue to allow states to specify the means of
transmission of the data and otherwise change the public health agency reporting objective.
NIHB respectfully requests that IHS, Tribal Health Clinics, Urban Indian Clinics (I/T/Us) be
granted the same allowance given the reasons stated above concerning internet access in remote
and rural areas. Furthermore, given the government to government relationship enjoyed by
federally recognized Tribes the allowance should not be denied nor be up for debate.
NIHB agrees with the proposed rule to eliminate the need for providers to individually report on
measures for which providers are already meeting the threshold, otherwise known as “topping
out” (care standards that have been widely adopted). This lessens the reporting burden; however,
it must be taken into consideration that I/T/Us may not be “topping out” on the most basic
measures which if this is the case, calls for flexibility in the way CMS determines if a provider
has met MU.
CMS notes that while Stages 1 and 2 allowed the use of paper-based formats for certain
objectives and measures, the proposed rule would discontinue this policy for Stage 3. As
mentioned before in this comment and will be mentioned again, I/T/Us in Indian Country should
be excluded from this proposal due to the lack of internet access for many Tribes.
Individually identifiable health information protected by the HIPAA Rules is known as
“protected health information” and that information in electronic form is known as “electronic
protected health information” or “ePHI”. The HIPAA Security Rules require covered entities
and business associates to conduct a security risk analysis to assess the potential risks to the ePHI
they create, receive, maintain, or transmit. The chronic and dramatic underfunding of the Indian
Health System makes the comprehensive, continuous technical assistance that is necessary to
achieve and sustain MU out of reach for almost all providers and clinics in the Indian Health
System. (This picture contrasts with that of many providers in the general population, and
certainly those practicing in the medium to large medical systems. Those providers have already
demonstrated the ability to access this type of technical assistance.) The fact remains that federal
funding is not aligned with federal EHR/MU requirements; the I/T/U system is not well funded;
Tribal Shares assigned to the Office of Information Technology (OIT) which are taken by Tribes
who desire to use these shares to develop their own systems effectively reduces the support
available at the Service Unit, Areas & Headquarters levels. When new technologies are
3
May 29, 2015
developed by OIT to meet MU by redirecting funding from other agency priorities because there
are no dedicated resources assigned to support them, there is no mechanism in place for the
Tribes to participate, nor are there Tribal Shares or other funds made available for Tribes to
develop something similar. The federal/tribal system is not set up as a business which can
upfront costs for IT development which might be recouped later through reimbursements or
payments. IHS is dependent on annual appropriations which do not align with costs associated
with the new EHR/MU requirements. This is a huge disadvantage for the I/T/U which is already
disadvantaged from severe underfunding to meet basic health care needs. Consequently, running
security risk analysis is expensive and beyond the financial means of most, if not all, I/T/Us.
Electronic prescribing or “eRx” is one of eight objectives and measures for MU in 2017 and
subsequent years. CMS proposes to require EPs to generate and transmit permissible
prescriptions electronically and eligible hospitals and CAHs must generate and transmit
permissible discharge prescriptions electronically (eRx). While we agree this may reduce the
occurrence of prescription drug-related adverse events and a worthwhile goal, we would
maintain that for Indian Country and I/T/Us there are very few, if any, pharmacies within their
organization and there are no pharmacies that accept electronic prescriptions within 10 miles of
the EP’s practice location at the start of his or her EHR reporting period. This is due to the rural
nature of Indian Country and the I/T/Us that operate there. Therefore, a blanket exclusion for all
I/T/Us should be granted. The same rationale should be applied in those instances when a
hospital issues refills upon discharge for medications the patient was taking when they arrived at
the hospital.
Another proposed objective and measure for MU in 2017 concerns Clinical Decision Support
(CDS). CDS concerns positive impact on the quality, safety, and efficiency of care delivery.
Unfortunately, I/T/Us in Indian Country will have difficulty meeting MU for 2017 if they have to
have computerized alerts and reminders for providers and patients; information displays or links;
context-aware knowledge retrieval specifications; InfoButtons; clinical guidelines; conditionspecific order sets; focused patient data reports and summaries; documentation templates;
diagnostic support; and contextually relevant reference information as the proposed rule
suggests. For the aforementioned reasons expressed regarding the lack of electronic
infrastructure, wifi, internet, and adequate hardware, we would ask this objective and measure
not apply to I/T/Us and an additional exclusion apply.
The proposed objective and measure regarding Computerized Provider Order Entry (CPOE) is
not attainable for the same reasons CDS cannot be attained. Stage 3 requires including
diagnostic imaging such as ultrasound, magnetic resonance, and computed tomography in
addition to traditional radiology. Most I/T/Us may have traditional radiology such as x-ray
equipment but ultrasound, MRIs, and CT scans are not commonly found in I/T/Us. If they do
have the equipment they are more than likely not to have a technician who can operate the
machine. NIHB suggests an additional exclusion for Indian Country.
The proposed objective and measure which allows patients to view, download, and transmit their
health information to a third party and engage in patient-centered communication for care
planning and care coordination plus have timely access to their full health record is a good idea
and one that NIHB agrees will result in good health outcomes; however, in Indian Country not
4
May 29, 2015
only do the I/T/Us not have the necessary tools (wifi, internet, hardware, etc.), but the patients
typically have less. Due to financial hardship and poor infrastructure, patients in Indian Country,
by and large, cannot meet this objective and measure. An exclusion to the “no paper allowed”
doctrine for MU Stage 3 is requested for I/T/Us and patients in Indian Country. Likewise, the
application-program interfaces (APIs), which would allow providers to enable new
functionalities to support data access and patient exchange must be tempered in light of the
previous discussion on electronic needs. Although the API would allow the patient the ability to
download or transmit their health information to a third party, Indian Country generally does not
have the means or ability to accomplish the download or transmission.
In the Patient Electronic Access to Health Information objective, “provides access” is defined as
a situation where the patient has all the tools they need in order to gain access to their health
information including any necessary instructions or user identification information. As stated
previously, a large number of patients in Indian Country do not have access to the internet or the
required hardware. We support the exclusion that states that any clinic located in a county that
does not have 50% or more of their housing units with 4Mbps broadband availability and where
a significant section of the patient population does not have access to broadband internet. 3
Regarding the objective entitled “Coordination of Care through Patient Engagement”, we
reiterate our previous discussion on the lack of infrastructure in Indian Country and agree that
counties that do not have 50% or more of its housing units with 4Mbps broadband availability
can be found in Indian Country and therefore I/T/Us should be excluded.
The purpose of the objective entitled “Transitions of Care,” is to ensure a summary of care
record is transmitted or captured electronically and incorporated into the EHR for patients
seeking care among different providers in the care continuum, and to encourage reconciliation of
health information for the patient. This objective promotes interoperable systems and supports
the use of CEHRT to share information. There is still some concern over the summary of care
measure based on the current status of health information exchange and the ability to partner
with other organizations at this time. A more practical approach would be to allow for a
demonstration of the capability of a facility and consider implementation of rates in the future.
We note that the Office of the National Coordinator for Health Information Technology’s (ONC)
2015 Edition proposed rule includes a criterion for capturing the unique device identifier for
implantable medical devices. Such surgical procedures are not performed by I/T/Us but are
referred under the Purchased Referred Care program of the Indian Health Service.
Consequently, this objective of the proposed rule has no relevance in Indian Country. The
exclusions regarding patient encounters in a county that does not have 50% or more of its
housing units with 4mbps broadband availability is relevant and raised as an exclusion for I/T/Us
and Indian Country in general.
The last objective, “Public Health and Clinical Data Registry Reporting,” focuses on the
importance of the ongoing lines of communication that should exist between providers and
public health agencies (PHAs) or between providers and clinical data registries (CDRs). There is
concern regarding the new requirement on bidirectional immunization exchange. This
3
80 Fed. Reg. 16,754 (March 30, 2015).
5
May 29, 2015
functionality was not part of the EHR certification experience nor does it have comprehensive
ability for the state to participate in this service, and will require additional development for
vendors that has not been anticipated in the current year. Regarding the exclusions listed in the
discussion for a public health agency that is not capable of receiving electronic syndromic
surveillance data, we would reiterate I/T/Us are not capable of sending the required electronic
syndromic surveillance data due to the aforementioned lack of infrastructure.
III.
Discussion re: Provisions of the Proposed Regulations, Certified EHR
Technology (CEHRT) Requirements
We support Secretary in seeking to avoid redundant or duplicative reporting and aligning certain
aspects of the reporting clinical quality measures (CQMs) component of MU under the Medicare
EHR Incentive Program and Physician Quality Reporting System (PQRS) for EPs. We also
support the avoidance of redundant or duplicative reporting of CQM reporting requirements for
the Medicare and Medicaid EHR Incentive Program for eligible hospitals and CAHs in the
Inpatient Prospective Payment System (IPPS). In addition, NIHB agrees that the CQM reporting
period for EPs, eligible hospitals, and CAHs should be on a calendar year and a continuous 90day reporting period that is the same 90-day period as the EHR Reporting Period.
The attestation exception in certain circumstances where electronic reporting is not feasible,
should apply to I/T/Us for 2017 and 2018.4 The certification issue is outside the control of the
providers due to extreme financial need and the inadequate infrastructure. CMS has given states
the option of how electronic reporting of CQMs occur. Tribes should be given the same option
due to their government to government relationship with the federal government.
Regarding EHR reporting in 2017 and subsequent years, we agree with the proposal that for
CQM reporting in 2018 and subsequent years, providers participating in the Medicare program
must electronically report, where feasible (emphasis added) and that attestation to CQMs would
no longer be an option except in circumstances where electronic reporting is not feasible
(emphasis added).5 Consequently, for I/T/Us in Indian Country where electronic reporting is not
feasible an alternative process must be allowed.
The HITECH Act requires reductions in payments to EPs, eligible hospitals, and CAHs that are
not meaningful users of certified EHR technology. The Secretary may on a case-by-case basis
exempt an EP who is not a meaningful user for the reporting period if it would result in a
significant hardship, such as in the case of an EP who practices in a rural area without sufficient
internet access (emphasis added).6 This exception is subject to an annual renewal and may not
be granted for more than 5 years. We contend that given the fact Indian Country health care is
underfunded by 56%, I/T/Us should be given a permanent exception to the reporting rules. The
hardship exceptions were enumerated in the Stage 2 final rule and Indian Country meets the
majority, if not all, of the types of hardships listed. The same rationale stated in the above
paragraph applies to the reduced update to the IPPS standardized amount for eligible hospitals
and the adjustment for cost periods for CAHs.
4
Id. at 16,770.
Id. at 16,773.
6
Id. at 16,777.
5
6
May 29, 2015
We agree with many of the provisions of the proposed rule and support the exceptions detailed
above. Thank you for the opportunity to respond to this proposed rule. We look forward to
working with you to ensure that these proposed objectives and measures do not harm the
delivery of health care services for American Indians and Alaska Natives.
Sincerely,
Lester Secatero, Chair
National Indian Health Board
7
Joinder Agreement
Attachment 1 – Joinder Agreement
THIS JOINDER AGREEMENT made effective with the last signature and executed as of the date set
below, by and between the Indian Health Service (the “IHS”) and _________________________ (the
“New Member”) makes New Member a party to that Multi-Purpose Agreement dated _________
among the IHS, as amended (the “MPA”).
RECITALS:
A. The New Member desires to become a Member of the Exchange and gain access to the
Network.
B. The IHS has approved the New Member’s application subject to the condition that the New
Member executes this Joinder Agreement.
C. AMENDMENTS - Any amendments to the MPA and this Joinder Agreement shall not be
effective until the IHS and the New Member have evidenced their consent in a writing which
is signed, dated and attested to by their respective authorized representatives.
D. REPRESENTATIONS - All representations and warranties of fact made by the New Member,
including those in Sections 3.03 and 4.04(b)-(f), inclusive, and any other designations made
by the New Member contained in the MPA, including this Joinder Agreement, are fully
authorized by the New Member and are complete, truthful and accurate.
E. AUTHORITY. The New Member represents that the person executing this MPA on its behalf
is duly authorized to do so in accordance with the procedures in force and effect on behalf
of the New Member. The New Member also represents that the Authorized Users have
either authorized it to make the representations on their behalf as stated in this MPA or will
be required to provide such authorizations to the New Member before accessing or utilizing
the system set in place by this Agreement.
AGREEMENT:
NOW, THEREFORE, in consideration of good and valuable consideration, the receipt and
sufficiency of which are hereby acknowledged, the undersigned hereby agree as follows:
1. JOINDER. The New Member is hereby made a party to the MPA, and agrees to be bound by, and
shall comply with, the terms thereof. From the date hereof, the New Member shall be a
“Member” as that term is defined in the MPA and shall be subject to all of the duties and
obligations and entitled to the rights and benefits of a Member as provided therein.
2. ACKNOWLEDGEMENT. The New Member hereby acknowledges that it has received and
reviewed a copy of the MPA and fully agrees with and will comply with its terms and conditions.
3. REAFFIRMATION. The terms and provisions of the MPA remain in full force and effect in all
respects.
4. COUNTERPARTS. This Joinder Agreement may be executed in any number of counterparts, each
of which shall be an original, but all of which taken together shall constitute one and the same
instrument.
5. REIMBURSEMENT. To the extent the applicable Appropriation Act continues to authorize the
IHS to provide goods and services Tribes and Tribal Organizations on a reimbursable basis, or
pursuant to 25 U.S.C. § 458aaa-7 (for Title V Compacts), tribal contractors are responsible for
reimbursing IHS for the full cost of aggregation services and technical support. For tribes that
have left their shares with IHS, there is no cost because IHS retains the responsibility to provide
IT services. For tribes that have taken their shares, but bought back all IT services from IHS,
there is likewise no additional cost. In all other cases, such reimbursement shall be determined
on a case by case basis in accordance with the terms and conditions of each contractor’s
contract or compact and annual funding agreement, as well as any applicable buyback
agreements.
Participating Urban Indian Health Programs are responsible for reimbursing IHS for the full cost
of aggregation services and technical support, in accordance with 42 U.S.C. § 254a(b), which
provides that such reimbursements shall be credited to the applicable IHS appropriation.
IN WITNESS WHEREOF, the undersigned have caused this Joinder Agreement to be executed, all
as of the day and year first written above.
New Member
_______________________________
Printed Name
_____________________________________
Printed Name
_______________________________
Title
_____________________________________
Title
_______________________________
Date
_____________________________________
Date
________________________________
Signature
_____________________________________
Signature
County of ___________________)
State of _____________________)
7/27/2015
TSGAC
Office of Information Technology Update
CDR Mark Rives, DSc
ICD-10
• RPMS successfully completed testing for ICD-10
• ICD-10 upgrades were released in a controlled fashion on June 18, 2015.
• OIT has facilitated upgrades on June 20th, June 27th, and July 11th
• Bemidji, Great Plains, Portland, Alaska, California
• The final OIT-facilitated upgrade will occur on Saturday, August 1st
• Oklahoma City, Phoenix, Portland, Tucson, Navajo, Billings Areas.
• Subsequently all remaining upgrades will be conducted by area and
site level support staff with OIT staff on call.
1
7/27/2015
ICD-10
• A number of change requests have been submitted based on issues
uncovered during beta testing. The RPMS Change Control Board (CCB)
is vetting and prioritizing each change.
• OIT is planning for ICD-10 maintenance release in August 2015 to
address any critical issues uncovered during the expanded
deployment.
ICD-10 Outreach
• Monthly calls Area ICD-10 Coordinators and HIM Consultants
• ICD-10 Check list notices distributed and posted to the listserv and to
the IHS ICD-10 website
• The ICD-10 Module of the ORAP On-line tool “go-live” July 1.
• This module contains baseline data
• aids in monitoring and analyzing the revenue cycle for provider,
• coding and billing impacts before and after the compliance date.
• The ICD-10 team has provided regular ICD-10 updates to the Area
GPRA Coordinators at our quarterly webinars or annual meetings.
• www.ihs.gov/icd10
2
7/27/2015
Meaningful Use – Overview of remaining steps
• Install 2014 Certified EHR
• Sign data sharing agreements
• Onboard with the RPMS network
• Patient outreach and patient engagement
• Provider use of the RPMS Network
• Attest for MU2
Meaningful Use – Participation Agreements
• The IHS Multi-Purpose Agreement (MPA) and an interim set of RPMS
Network policies were signed by the IHS Director on June 22nd.
• IHS was able to expand the RPMS Network pilot to include participating
tribal and urban sites.
• The RPMS Network Policy Working Group is actively reviewing and
dispensing with those comments now.
• The approved version of the MPA, the MPA Joinder Agreement (i.e. the
MPA signing document), and the interim RPMS Network Policies will be
published on the IHS Meaningful Use website no later than Friday, July
24th.
• In the meantime, copies of these documents can be obtained from the
RPMS Network deployment lead Mr. Michael Fairbanks,
michael.fairbanks@ihs.gov
3
7/27/2015
Meaningful Use - RPMS Network
• The pilot deployment for the RPMS Network (Master Patient Index
(MPI), Personal Health Record (PHR), Health Information Exchange
(HIE) and Direct) which are required for Meaningful Use, Stage 2
attestation, has expanded to include participating tribal and urban
programs.
• The first tribal on-boarding occurred on Thursday, July 2nd, in California Area.
• The pilot will continue to expand to include all participating federal, tribal,
and urban programs.
• Area and site administrators are leading the on-boarding of the remaining
sites between now and September 30th.
• The focus should be on sites that intend to attest for Meaningful Use in 2015
for the October 1 – December 31, 2015, reporting period.
The Sequoia Project
• IHS is also approaching a key milestone in its effort to become a trusted
participant in the nation-wide health information exchange.
• In 2012, The Sequoia Project, previously known as Healtheway, previously
known as the Nationwide Health Information Network (NwHIN), was
chartered as a non-profit 501(c)(3) to advance the implementation of
secure, interoperable nationwide health information exchange.
• The Sequoia Project primarily focuses on query-based exchange (i.e.
provider searches for patient records across organizational boundaries).
• IHS is wrapping up its last round of production level interoperability testing
with the Sequoia Project and anticipates its first partner testing beginning
soon with the Veterans Administration.
• More info: http://sequoiaproject.org/
4
7/27/2015
IT Security
• Made Changes to our network to increase security
• We are being pro-active. We have not had a breach
• Changes for users and system administrators mandated by OMB and
HHS
• Changes reflect modern security practices (e.g. even Gmail can use
two-factor now.)
Questions
CDR Mark Rives, DSc
Phone:// 301-443-2019
Email:// Mark.Rives@IHS.GOV
5
DEPARTMENT OF HEALTH & HUMAN SERVICES
Public Health Service
Rockville MD 20852
MAY 22 2015 Dear Tribal Leader:
I am writing to provide an update on Contract Support Costs (CSC). The Indian Health Service
(IHS) continues to make CSC a priority. This letter is intended to provide an update on the
following areas related to CSC: 1) status of resolving past year claims for unpaid CSC; 2) fiscal
years (FY) 2014 and 2015 CSC payment and reconciliation activities; 3) implementation of an
Annual CSC Calculation (ACC) Estimation Tool; 4) negotiation of direct CSC; 5) the FY 2016
President’s Budget proposal to make CSC a mandatory appropriation beginning in FY 2017; and
6) IHS CSC Workgroup activities.
Status of Resolving Past Year Claims for Unpaid CSC
IHS continues to make progress on resolving past year claims presented under the Contract
Disputes Act for unpaid CSC. As of May 8, IHS has extended settlement offers on 1,249 claims
and has settled 947 claims in the amount of approximately $705.5 million. IHS remains focused
on resolving the remaining claims, with a goal of extending offers on all claims received by
January 1, 2015, by the end of the calendar year. The continued success of our efforts to resolve
past claims is due in part to the working relationship with Tribes. Please direct any questions
regarding the status of your claim to your IHS Area Director. In addition, you may ask your
attorney to contact the Office of the General Counsel.
FY 2014 CSC Payment and Reconciliation Activities
The FY 2014 Consolidated Appropriations Act did not specify a limit on the total funds available
for payment of CSC; therefore, IHS’s goal is to pay full CSC, as defined by the Indian SelfDetermination and Education Assistance Act (ISDEAA), for FY 2014. To ensure the Agency
met its goal to pay full CSC need in FY 2014, IHS developed a more detailed and consistent
reconciliation process to fully fund the estimated CSC need and to account for the variables that
can change the estimated CSC need throughout the year. For FY 2014, IHS reconciled and paid
CSC in April, September, and December 2014 and April 2015. IHS has worked to improve
communication with each Tribe to ensure that IHS and Tribes use the most current data
necessary to accurately estimate each Tribe’s full CSC need.
The following are the steps used for data and funding reconciliation:


IHS reviews and updates CSC data on a monthly basis, with a primary focus on updating
any changes in the variables that can change the CSC estimated need (i.e., paid funding
amount, changes in the Tribe’s indirect cost rate, and changes in pass-throughs and
exclusions associated with the Tribe’s indirect cost rate).
Based on the monthly data reconciliation findings, the IHS initiates a payment
reconciliation.
Page 2 – Tribal Leader



IHS notifies Tribes when there are changes in the estimated CSC need based on the best
available data, using an Annual CSC Calculation (ACC) Estimation Tool described
below.
IHS will work with the Tribe to modify a Tribe’s Title I annual funding agreement (AFA)
or amend a Tribe’s Title V funding agreement (FA) to pay any additional CSC need.
In cases where a Tribe has received a CSC overpayment, the IHS will work with the
Tribe to recover the overpayment funds and modify the Tribe’s Title I AFA or amend the
Tribe’s Title V FA to update full estimated CSC amounts in the ISDEAA agreement with
the IHS.
IHS interprets the ISDEAA to authorize CSC funding for those actual costs that Tribes incur that
meet the definition of CSC as described in the ISDEAA at 25 U.S.C. § 450j-1(a). IHS relies, in
part, on the Tribe’s final audited costs and, in most cases, the applicable indirect cost rate
negotiated with Tribes’ cognizant federal agencies. To accurately calculate a Tribe’s full
estimated CSC need, the IHS also reviews costs for reasonableness and duplication. For
example, for FY 2014, if the Tribe chose to use an indirect cost rate to estimate its CSC need,
IHS expects that the final costs could be determined in FY 2016 once the Tribe receives its FY
2014 indirect cost rate, or later. Therefore, FY 2014 CSC reconciliation will be open until final
costs are determined.
FY 2015 CSC Payment and Reconciliation Activities
Similar to FY 2014 payment and reconciliation activities, the IHS is in the process of
completing its first FY 2015 reconciliation. We expect to make payments to Tribes no later than
May 30, 2015. Payments will be based on: funds paid to date; a Tribe’s most current indirect
cost rate, where applicable; and applicable pass-through and exclusions as negotiated by the
Tribe in the Tribe’s negotiated indirect cost rate agreement. In addition, the IHS will assess the
reasonableness of costs and duplication, consistent with the ISDEAA and the IHS CSC Policy.
IHS will modify Title I AFAs or amend Title V FAs for any additional payments based on
reconciled data used to estimate full CSC.
Implementation of an Annual CSC Calculation (ACC) Estimation Tool
In January 2015, IHS implemented the ACC Estimation Tool, which will be used by IHS to
assure that full estimated CSC need is calculated in a consistent manner using the best and most
current information. The ACC Estimation tool supports a transparent means to calculate each
Tribe’s full estimated CSC need at any given time. IHS intends to share a completed ACC
Estimation tool in advance of CSC negotiations to support full and open discussion. The IHS
looks forward to sharing the ACC Estimation tool at IHS Area Tribal meetings and providing
additional training on the information necessary to estimate CSC need. Please contact your
Area Director for information related to upcoming trainings in your Area.
Negotiation of Direct CSC
When a Tribe negotiates and enters into a contractual agreement with the IHS under the
ISDEAA, the Tribe receives the amount of funding the Secretary would have otherwise provided
for the operation of the program, function, service, or activity (PFSA) or portion thereof,
typically referred to as the “Secretarial amount.” The ISDEAA authorizes an additional amount
for CSC, which consists of the reasonable costs for activities which must be carried out by the
Tribe or Tribal organization as a contractor to ensure compliance with the terms of the contract
and prudent management, but which are activities not normally carried out by IHS in its direct
operation of the programs, or are provided by the Secretary in support of the contracted program
from resources other than those under the contract. Eligible CSC includes the costs of
reimbursing each Tribal contractor for the reasonable and allowable costs for direct program
expenses and additional administrative expenses related to the overhead incurred by the Tribal
contractor in connection with the operation of the PFSA pursuant to the contract, except that
CSC cannot be duplicative; i.e., CSC cannot be paid for activities that are already funded in the
amount transferred by the Secretary.
The majority of direct CSC need typically consists of fringe costs that are not already funded as
part of the Secretarial amount. In the IHS CSC Policy, fringe costs are a group of five items,
including Federal Insurance Contributions Act (FICA); life, health, and disability insurance;
retirement; workers’ compensation insurance; and unemployment insurance. In accordance with
the IHS CSC Policy, IHS has historically agreed, as to this group of fringe benefit costs, to total
the amounts already provided in the Secretarial amount for FICA, retirement, and life, health and
disability insurance, and compare these amounts to the reasonable and necessary fringe benefit
costs of the Tribe (which also include additional costs for workers’ compensation and
unemployment insurance) for the transferred PFSAs. Consistent with IHS CSC Policy, the IHS
calculates direct CSC utilizing the most current actual cost data. In FY 2014, IHS reviewed data
across the Agency to determine the fringe costs for the three items already provided to a Tribe in
its Secretarial amount, as required by the IHS CSC Policy. For FY 2015 direct CSC
negotiations, IHS will use the Agency’s final actual fringe costs for those three items for FY
2014, to determine those costs already transferred to a Tribe in its Secretarial amount. IHS will
consider proposals for other eligible direct CSC costs as detailed in the IHS CSC Policy.
Consistent with the IHS CSC Policy, the IHS applies the Office of Management and Budget
(OMB) non-medical inflation rate to a Tribe’s estimated direct CSC need each year that the
Tribe chooses not to renegotiate its need. To simplify this process, the IHS will apply the final
OMB non-medical inflation rate from the previous year to the previous year’s negotiated direct
CSC need to arrive at the current year estimated need. For example, the final rate for FY 2014,
1.6%, will be applied to arrive at the updated direct CSC need for FY 2015.
The FY 2016 President’s Budget Proposal to make CSC a Mandatory Appropriation
On February 9, IHS announced Tribal Consultation to invite input on the FY 2016 President’s
Budget proposal to make CSC funding mandatory starting with the FY 2017 appropriation. The
proposal seeks to reclassify CSC as mandatory funding, rather than discretionary funding. The
proposal has four components:
1) A three-year mandatory appropriation, which provides a specific amount for each year to
fully fund CSC;
2) No-year funding that allows funding to be available to IHS to carry over in future years;
3) New CSC estimates will be provided as a part of the reauthorization process every three
years; and;
4) In addition to the current amount, up to 2% of CSC totals can be used for administrative
capacity and program management.
IHS has received a number of responses from Tribes with overwhelming support for the proposal
to reclassify CSC as mandatory funding. IHS will continue to provide updates regarding the
status of the mandatory funding proposal at national and regional listening sessions. For
additional information on how the proposal will interact with the discretionary caps and how it is
scored under the Statutory Pay-As-You-Go Act of 2010 (PAYGO), IHS defers to OMB.
IHS CSC Workgroup Activities
The IHS CSC Workgroup continues to hold face-to-face meetings and telephone or video
conference calls. A majority of the Workgroup’s focus is discussion of options that would
simplify and streamline the work to negotiate full CSC need. The CSC Workgroup played an
instrumental role in the development of the ACC Estimation Tool. I appreciate the valuable
work of the CSC Workgroup and will continue to share their recommendations and outcomes.
We appreciate your input and remain committed to work with Tribes on solutions to this very
important issue. Thank you for your ongoing support and partnership, which has been critical in
achieving progress on CSC-related issues. We welcome your comments, suggestions, and
recommendations on any of the topics in this update. Please send your input to
consultation@ihs.gov.
Sincerely,
/Robert G. McSwain/
Robert G. McSwain
Acting Director
Sent electronically Denise.Turk@ihs.gov
Original sent USPS
June 29, 2015
Robert McSwain, Acting Director
The Reyes Building
801 Thompson Avenue, Suite 400
Rockville, MD 20852
RE:
Determination of Contract Support Cost Requirements
Dear Acting Director McSwain,
On behalf of Self-Governance Tribes, we write to express our concern over the Indian
Health Service’s position that the amount of contract support costs (CSC) owed under its
contracts and compacts with Tribes and tribal organizations under the Indian SelfDetermination Act (ISDA) is determined based on “incurred costs.”
The Indian Health Service (IHS) incurred cost approach was first developed as a way
to calculate damages for unpaid CSC in settlements of breach of contract claims. However,
your Dear Tribal Leader Letter of May 22, 2015 states that IHS has now applied this
approach to the CSC payment and reconciliation process beginning with fiscal year 2014.
We also understand that IHS may be contemplating incorporating this incurred cost approach
into future revisions of its CSC Policy as set out in Part 6, Chapter 3 of the IHS Indian
Health Manual (“CSC Policy”). For the reasons discussed below, we strongly urge IHS to
abandon the incurred cost approach and to honor the longstanding process currently set out in
the CSC Policy for determining full CSC need.
First and foremost, the incurred cost approach cannot be squared with the statutory
provisions of the ISDA. Those provisions require that contract funds (including CSC) must
be added to the contracts at the start of each contract period, and may be carried over (and
are therefore not repaid to the agency) if not spent by the Tribe in that year, all without any
reduction in subsequent year funding. The ISDA also requires that its provisions must be
construed in favor of contracting Tribes and tribal organizations. IHS’s CSC Policy is
generally consistent with these requirements and provides that the full amount of CSC owed
each year includes a negotiated sum for direct CSC, plus indirect cost funding determined
either by applying a negotiated indirect cost rate to the direct cost base or by incorporating a
lump-sum amount negotiated with IHS. An incurred cost approach that departs from or
modifies the CSC Policy violates the ISDA and is strongly opposed by Tribes.
The incurred cost approach also imposes a serious hardship on contracting and
compacting Tribes. Since this approach relies on a retroactive determination of expenditures,
the final amount of CSC owed for a given contract year cannot be identified until final audits
are completed, which can be two or more years later. This extended and indefinite
Letter to Robert McSwain, Acting Director, IHS
Re: Determination of Contract Support Cost Requirements
Page 2 of 7
June 29, 2015
“reconciliation” period—which the agency has stated could last up to five years after the
contract year—leads to significant uncertainty and complicates tribal accounting practices,
thereby undermining the ISDA’s goals of encouraging tribal self-determination and selfgovernance. It is also inconsistent with the indirect cost rate system utilized by Tribes and
tribal organizations (along with most other government contractors) to recover indirect costs,
which already adjusts based on actual expenditures.
IHS's Development of the Incurred Cost Approach
In June 2012 the Supreme Court for the second time held the government liable in
damages for CSC underpayments. The Court's ruling came in a tribal lawsuit against the
BIA, Salazar v. Ramah Navajo Chapter, and the Federal Circuit extended the ruling to IHS in
Arctic Slope Native Association v. Sebelius. (The first Supreme Court decision on this issue,
against IHS, was Cherokee Nation v. Leavitt (2005).)
After these rulings, IHS began settling damage claims for CSC underpayments. In
the course of this work, IHS hired an accounting firm to perform a forensic audit of each
claimant Tribe’s finances for every claim year. Through this process the agency formulated
its “incurred cost” or “actual cost” methodology. Pursuant to this methodology, IHS asserted
it was only liable in damages for the difference between the costs a tribal contractor spent or
"incurred" each year, and the amounts the agency paid. In adopting this methodology, IHS
relied, in part, on a single statement in the Ramah decision that referred to “the full amount
of 'contract support costs' incurred by Tribes in performing their contracts[,]” even though
nothing in that opinion addressed how to calculate damages for CSC claims or what
constitutes the "full amount" of CSC owed under ISDA contracts. 1 Tribes generally opposed
use of the incurred costs method, but ultimately the methodological dispute did not preclude
many settlements since there were a multitude of competing approaches for computing
contract damages.
Although IHS originally applied this methodology only to determine damages for
breach of contract, IHS has now stated that it intends to apply this method to also determine
the price of an ISDA contract—how much CSC is owed under the contract. In a May 22,
2015 Dear Tribal Leader Letter, you stated:
IHS interprets the ISDEAA to authorize CSC funding for those actual costs
that Tribes incur that meet the definition of CSC as described in the [ISDA] at
25 U.S.C. § 450j-1(a). IHS relies, in part, on the Tribe's final audited costs
and, in most cases, the applicable indirect cost rate negotiated with Tribes'
cognizant federal agencies. To accurately calculate a Tribe's full estimated
CSC need, the IHS also reviews costs for reasonableness and duplication. For
example, for FY 2014, if the Tribe chose to use an indirect cost rate to
estimate its CSC need, IHS expects that the final costs could be determined in
FY 2016 once the Tribe receives its FY 2014 indirect cost rate, or later.
Therefore, FY 2014 reconciliation will be open until final costs are
determined.
1
See Letter from Yvette Roubideaux, Director, Indian Health Service, to Tribal Leaders (Sept. 24, 2012).
Page 3 of 7
June 29, 2015
Though the IHS represented to the appropriations committees that it was not employing a
five-year reconciliation process for pricing and paying CSC dues under ISDA contracts, the
approach described in the May 22 letter could result in exactly that. That is because, under
the incurred cost approach, IHS will not be able to determine the contract price, including the
full amount of CSC, until months or years after the end of each contract year and after the
agency has completed its new “reconciliation” process. This approach treats ISDA contracts
as cost-reimbursement contracts in violation of the ISDA, and substantially burdens
contracting and compacting Tribes and tribal organizations. For these reasons, Tribes remain
vehemently opposed to the incurred costs approach.
The Incurred Cost Approach Is Harmful to Tribes and Tribal Organizations
The agency's cost incurred method severely disrupts a Tribe’s financial recording and
accounting procedures. This is due in part to the added administrative burden and
uncertainty inherent in a system that requires the parties to keep open as many as six fiscal
years at once during an ongoing reconciliation process, handing funds back-and-forth based
on when costs are incurred rather than how much is owed. This uncertainty and inflated
administrative burden (for Tribes and the IHS) seriously undermines tribal self-determination
and self-governance and threatens the stability of government and program operations.
Critically, the incurred cost approach penalizes routine tribal carryover decisions.
IHS treats CSC paid but not expended in a given year as an overpayment that must be
“recovered.” But when IHS pays the correct amount under the CSC Policy, the simple fact
that a Tribe elects to carry over program funding and associated CSC to the following year
does not alter the amount owed and create an overpayment, any more than does the carryover
of program funds. But, as discussed below, Tribes have a statutory right to determine when to
spend their funding without affecting their entitlement to these funds. The incurred cost
approach is an affront to this fundamental right of self-governance.
Further, IHS’s approach is inconsistent with the indirect cost rate system used by
Tribes and tribal organizations, and which IHS has long committed to using for calculating
indirect contract support costs. This system is already tied to actual incurred costs in that
indirect cost rates are adjusted upward or downward by the cognizant federal agency in
future years based on a comparison of the rate-generated amount with actual, audited costs
incurred during the year in which the rate applies. 2 Thus, if a Tribe's incurred costs in a
given year are less than the rate-generated indirect cost amount, the government will be
relieved of future payment obligations (because the Tribe's rate will decrease) to compensate.
The same is true of under recoveries: if a Tribe incurs costs that exceed the amount reflected
in the Tribe’s fixed rate, then the Tribe’s future rate (and therefore the government's payment
obligation) is increased to adjust for the difference. This system was designed to avoid
retroactive adjustments to contract payments, which are administratively burdensome, while
remaining fairly rooted in actual costs. It avoids the handing back-and-forth of funds that the
IHS's approach entails; is widely used in government contracting; and has been honored by
both Tribes and the IHS in the past.
2
According to the Interior Business Center, approximately 85% of Tribes and tribal organizations negotiate
indirect cost rates using this “fixed-with-carryforward” system.
Page 4 of 7
June 29, 2015
The IHS’s incurred cost approach to pricing contracts is in conflict with the indirect
cost rate system. One problem is that the reconciliation payments contemplated under the
incurred cost approach would not avoid subsequent rate increases or reductions, because the
carryforward template adjusts only for the difference between actual expenditures and the
rate-generated amount, and does not take into account the amount actually paid.
Additionally, the IHS is only one of several federal agencies for which a Tribe's indirect cost
rate is used. All federal programs (and the agencies that administer those programs) are
linked in the carryforward template based on their proportional shares of total expenditures.
Therefore, the IHS cannot make independent adjustments to its own indirect cost obligations
without effectively invalidating the entire indirect cost rate carryforward process.
More fundamentally, contracting Tribes and tribal organizations, like other
government contractors, should be able to rely on the indirect cost rate negotiated with their
cognizant agency and should not be required to negotiate with the federal government
twice—once with its cognizant agency, and then a second time with IHS as part of the
“reconciliation process.” That is why the IHS is required to honor a Tribe or tribal
organization's indirect cost rate. See 2 C.F.R. § 200.414(c)(1) (negotiated rates must be
accepted by all Federal awarding agencies unless deviation required by statute or regulation
or approved by agency head based on documented justification); see also Ramah, Partial
Settlement Agreement III (all federal agencies, including IHS, must honor the rates
negotiated pursuant to the OMB circular). 3 As noted, these rates are negotiated and awarded
based in large part on prior years’ audited costs and thus are rooted in actual expenditures for
reasonable and allowable costs. They are negotiated with sophisticated federal agencies
well-versed in the applicable rules and requirements. There is no reason for IHS to secondguess this system based on its own incurred cost approach, nor does the ISDA permit it to do
so.
The Incurred Cost Approach Is Unlawful under the ISDA
The IHS approach is not only impractical and in conflict with the indirect cost rate
system; it is also illegal. The ISDA makes plain that CSCs are calculated pursuant to a fixed
methodology. ISDA contracts simply are not designed as cost-reimbursable contracts, and to
treat them as such is inconsistent with the provisions of the ISDA.
First, the ISDA provides that “[u]pon the approval of a self-determination contract,
the Secretary shall add to the contract the full amount of funds to which the contractor is
entitled . . . .” 25 U.S.C. § 450j-1(g) (emphasis added). 4 This provision mandates that the
agency must pay a Tribe’s full CSC amount up front and at the same time the Tribe receives
its Secretarial amount. Section 450j-1(g) controls without regard to how a Tribe eventually
spends the funds in carrying out the contract. Similarly, another statutory section provides
that, at a Tribe's option, all contract funds are due in a single lump-sum payment at the
beginning of the contract year
(§ 450l(c), Model Agreement § 1(b)(6)(B)(i)).
3
Partial Settlement Agreement III also insulated BIA and IHS from claims relating to the calculation of the rate
as long as the rate was negotiated using one of the new templates and the rate negotiated was applied to
generate IDC need. To the extent IHS seeks to abandon this rate or adjust it further, the agency may be
violating this agreement, and/or subjecting itself to liability for rate miscalculation claims.
4
All statutory cites are to 25 U.S.C. unless otherwise indicated.
Page 5 of 7
June 29, 2015
Second, the Act provides that, once contract funds are paid to a Tribe, those funds
may be rebudgeted and reallocated in whatever manner the Tribe deems best for the delivery
of services to its people. § 450j-1(o). This provision goes to the heart of the federal selfdetermination policy.
Third, under the Act unspent contract funds are never paid back to the agency;
instead, the Act authorizes Tribes to carry over all unspent ISDA funds and to spend them in
the next year. Moreover, when funds are carried over in this manner the Act mandates there
is to be no reduction in a Tribe's subsequent ISDA funding due in that subsequent year.
These provisions include CSC funds. § 450l(c), Model Agreement § 1(b)(9)(A). None of
these provisions, as set out in the statute and the contract, can be squared with the IHS's
notion that a Tribe is only entitled to be reimbursed for costs actually "incurred" (including
overhead costs) and must therefore repay CSC amounts paid pursuant to 25 U.S.C. § 450j1(g) but not expended within the contract year. 5
IHS’s incurred cost approach is also foreclosed by legislative history explaining the
addition of Section 110’s remedial provisions and explaining Congress’s decision to extend
the Contract Disputes Act to the ISDA. Here, Congress actually rejected the “incurred cost”
method for calculating unpaid CSC. The Senate Report accompanying the 1988
Amendments makes this clear:
[T]he Bureau has argued that even if the self-determination contractor was
entitled to receive the amount of indirect costs generated by its indirect costs
rate . . . the contractor could not recover the difference between the amount it
was entitled to receive under the contract, and the amount the Bureau paid.
That is, the contractor could not recover ordinary contract damages for the
Bureau's breach in failing to fully fund the contract. The type of funding
violation involved in that instance was not the product of a Congressional
appropriation shortfall, but of a unilateral decision by the BIA to fund indirect
costs for the contractor pursuant to a method other than that provided for in
the contract and the applicable law. The rationale offered by the BIA for this
argument was that since the contractor had not received the funds it was
entitled to receive, it had also not spent them and, therefore, had not incurred
5
It is true that the word “incurred” is used in § 450j-1(a)(3) (contract support costs must “include” certain
specified "incurred" costs). While this subsection provides that contract support costs must include these
“incurred” costs, it certainly does not provide that they are limited to such costs. It is an elementary rule of
statutory construction that the word “includes” means “includes but is not limited to.” See OFFICE OF THE
LEGIS. COUNSEL, U.S. HOUSE OF REPS., HOLC GUIDE TO LEGIS. DRAFTING, § VII(A), available at
legcounsel.house.gov/HOLC/Draft-ing_Legislation/Drafting_Guide.html#VIIA. Moreover, the single use of
the word “incurred” in § 450j-1(a)(3) cannot be read to undo the entire statutory scheme which, as noted in text,
requires that CSC be added to the contracts at the start of each contract period and may be carried over if not
spent by the Tribe in that year without any reduction in subsequent year funding.
It is significant, if not determinative, that certain types of costs provided under the ISDA—namely, start-up and
preaward costs—are limited by the statute to the costs which are actually “incurred.” See § 450j-1(a)(5)-(6).
This tells us that Congress clearly knew how to limit the payment of costs in such a manner, when that was its
judgment. It also tells us that Congress chose not to do so with respect to direct and indirect CSC. “[W]here
Congress includes particular language in one section of a statute but omits it in another section of the same Act,
it is generally presumed that Congress acts intentionally and purposely in the disparate inclusion or exclusion.”
INS v. Cardoza-Fonseca, 480 U.S. 421, 432 (1987) (internal quotation and quotation marks omitted).
Page 6 of 7
June 29, 2015
any costs which could be recovered as an indirect cost under the contract.
Clearly, this is an unacceptable argument.
S. Rep. No. 100-274, at 37 (1987). While this passage addresses use of the incurred cost
methodology in the context of contract damages, it demonstrates that Congress did not
believe that incurred costs and full contract funding were equivalent. Further, the Senate
Report makes clear that Congress understood that the ordinary indirect cost rate system is to
be utilized by contracting Tribes and tribal organizations to determine the amount owed
under a contract. Id. at 9.
To the extent there is any ambiguity in the statute about whether the CSC due is to be
calculated based on IHS’s new “incurred cost” theory or based on the contract price at the
commencement of each contract period, the statute makes clear that such ambiguity must be
resolved in favor of Tribes. The Supreme Court has said that “[c]ontracts made under ISDA
specify that ‘[e]ach provision of the [ISDA] and each provision of this Contract shall be
liberally construed for the benefit of the Contractor . . . .’ 25 U.S.C. § 450l(c), (model
agreement §1(a)(2)).” Ramah, 132 S. Ct. at 2191. The Supreme Court has interpreted this
language to mean that the Government “must demonstrate that its reading [of the ISDA] is
clearly required by the statutory language.” Id. (emphasis added). See also Ramah Navajo
Chapter v. Lujan, 112 F.3d 1455, 1461-2462 (10th Cir. 1997) (“[I]f the Act can reasonably
be construed as the Tribe would have it construed, it must be construed that way.” (internal
citations omitted)). The IHS’s reading of the statue to require a five year reconciliation
period to price the amount of CSCs due under a contract is not “clearly required” by any
statutory language. Rather, the statute can just as easily be read—and is most naturally
read—to require that the contract price be determined at the time of contract award.
The Incurred Cost Approach Is not Supported by the Ramah Decision
The incurred cost approach is also not supported by the Ramah decision. The Court
in Ramah noted several times that a tribal contractor is entitled to the full amount of CSC
under the ISDA. See, e.g., Ramah, 132 S. Ct. at 2186, 2190–91, 2195. Nothing in Ramah
even hints that the “full” CSC mandated by the ISDA is defined by costs incurred.
The majority in Ramah used the term “incurred” only once, and only in passing
during the Court’s introductory summary of the case. It was not part of the Court’s holding,
because the Court had not yet begun to even state the issues presented, much less to resolve
them. Ramah’s clear holding is that the agency must pay the “full amount” of contract
support costs due in the first place, as defined by the agency’s “contractual promise” and the
ISDA. 6
The Incurred Cost Approach Is Contrary to the IHS CSC Policy
The IHS CSC Policy has long explained how the full amount of CSC will be
calculated. As detailed in that Policy, the full amount includes a negotiated sum for direct
CSC plus indirect CSC, with the latter determined either by applying a negotiated indirect
cost rate to the direct cost base or by a lump-sum agreement. This approach has been used
6
The Court held that the government's contractual promise was binding: "The Government's contractual
promise to pay each tribal contractor the 'full amount of funds to which the contractor [was] entitled,' § 450j1(g), was therefore binding." Id. at 2190–91 (alternation in original).
Page 7 of 7
June 29, 2015
by the IHS for decades to calculate the full amount of CSC owed to tribal contractors. It has
also been reflected in decades of annual IHS shortfall reports submitted to Congress.
IHS’s incurred cost approach is contrary to this Policy because it does not treat the
negotiated lump-sum or indirect-rate driven CSC amount as the final sum that a Tribe is
entitled to be paid for that year, as the Policy states. Instead, the incurred cost approach
holds that those amounts are subject to later adjustment based on IHS's incurred cost
analysis. For the reasons already discussed, Tribes would oppose any revision to the CSC
Policy that replaces the current method for determining each Tribe’s full “CSC requirement”
with an incurred cost approach.
Conclusion
IHS must administer ISDA contracts in conformity with the law, and it must interpret
any ambiguities in the law in favor of contracting and compacting Tribes. The incurred cost
approach to CSC fails this basic metric. It also abandons IHS’s CSC Policy. Although the
CSC Policy would benefit greatly from being updated to reflect the current full funding
environment for CSC, its basic approach to calculating the full CSC requirement has worked
well and is consistent with the ISDA. Tribes strongly oppose any IHS plans to abandon that
Policy in favor of a new “incurred cost” approach that substantially and illegally burdens
tribal self-determination and self-governance.
If you have questions or would like to discuss this letter in further detail, please
contact Chief Malerba at (860) 862-6192, lmalerba@moheganmail.com or Chairman Allen at (360)
681-4621 or email rallen@jamestowntribe.org. Thank you.
Sincerely,
Chief Lynn Malerba
The Mohegan Tribal Government
Chairwoman, IHS Tribal Self-Governance
Advisory Committee
Cc:
Vice-Chairman, IHS Self-Governance
Advisory Committee
TSGAC Members and Technical Workgroup
74
DEPARTMENT OF HEALTH AND HUMAN SERVICES
INDIAN HEALTH SERVICE
The provision of Federal health services to Indians is based on
a relationship between Indian Tribes and the U.S. Government
first set forth in the 1830s by the U.S. Supreme Court under Chief
Justice John Marshall. Numerous treaties, statutes, constitutional
provisions, and international laws have reconfirmed this relationship. Principal among these is the Snyder Act of 1921, which provides the basic authority for most Indian health services provided
by the Federal government to American Indians and Alaska Natives. The Indian Health Service (IHS) provides direct health care
services in 28 hospitals, 61 health centers, three school health centers, and 34 health stations. Tribes and tribal groups, through contracts and compacts with the IHS, operate 17 hospitals, 249 health
centers, six school health centers, and 70 health stations (including
164 Alaska Native village clinics).
INDIAN HEALTH SERVICES
smartinez on DSK4TPTVN1PROD with HEARING
Appropriation enacted, 2015 ..............................................................
Budget estimate, 2016 .......................................................................
Recommended, 2016 ...........................................................................
Comparison:
Appropriation, 2015 ....................................................................
Budget estimate, 2016 ................................................................
$4,182,147,000
4,463,260,000
4,321,539,000
+139,392,000
¥141,721,000
The Committee recommends $4,321,539,000 for Indian Health
Services, $139,392,000 above the fiscal year 2015 enacted level and
$141,721,000 below the budget request. In addition to the table at
the end of this report, the recommendation includes the following
instructions and changes to the budget request:
Staffing for New Facilities.—The recommendation includes
$16,222,000 for the staffing of newly opened health facilities, as requested. Funds for the staffing of new facilities are limited to facilities funded through the Health Care Facilities Construction Priority System or the Joint Venture Construction Program that have
opened in fiscal year 2015 or will open in fiscal year 2016. None
of these funds may be allocated to a facility until such facility has
achieved beneficial occupancy status.
Dental Health.—The recommendation includes $178,959,000 for
dental health, $4,977,000 above the fiscal year 2015 enacted level.
The Service is encouraged to coordinate with the Bureau of Indian
Education to establish a pilot program integrating preventive dental care at schools within the Bureau system.
Purchased/Referred Care (formerly Contract Health Services).—
The recommendation includes $935,726,000 for Purchased/Referred
Care. The Committee urges the Service, Tribes, and the congressional authorizing committees to make reasonable and expeditious
progress to address the concerns and recommendations made by
the Government Accountability Office (GAO), most notably with regard to unfair allocations, third-party overbilling, and under-enrollment in other qualifying Federal programs.
The Committee urges the Service to work expeditiously with the
relevant Congressional authorizing committees to enact authorization for the Service to cap payment rates for non-hospital services,
as recommended by the Government Accountability Office (GAO
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75
13–272). Failure to do so costs the program an estimated $30 million annually that could be used to purchase more services.
Contract
Support
Costs.—The
recommendation
includes
$717,970,000 as requested for full funding of estimated contract
support costs. Bill language has been added making these funds
available until expended and protecting against the use of other appropriations to meet unanticipated shortfalls. The Service is directed to work with Tribes and tribal organizations to ensure that
budget estimates continue to be as accurate as possible.
Eligibility.—The Committee recognizes the Federal government’s
trust responsibility for providing healthcare for American Indians
and Alaska Natives. The Committee is aware that the definition of
who is an ‘‘Indian’’ is inconsistent across various Federal health
programs, which has led to confusion, increased paperwork and
even differing determinations of health benefits within Indian families themselves. The Committee therefore directs the Department
of Health and Human Services, the Indian Health Service, and the
Department of the Treasury to work together to establish a consistent definition of an ‘‘Indian’’ for purposes of providing health
benefits.
Urban
Indian
Health.—The
recommendation
includes
$44,410,000 for Urban Indian Health, $806,000 above the fiscal
year 2015 enacted level and the budget request. The agency is directed to include current services estimates for Urban Indian
Health in future budget requests. The Committee notes the agency’s failure to report the results of the needs assessment directed
by House Report 111–180. Therefore the recommendation includes
a reduction to the Service leadership budget, along with bill language requiring a program strategic plan developed in consultation
with urban Indians and the National Academy of Public Administration.
Shortage of Health Care Providers.—The Service is encouraged to
work with Tribes and health care organizations to find creative
ways to address the Service’s health care provider shortage, including improvements to the credentialing process.
INDIAN HEALTH FACILITIES
smartinez on DSK4TPTVN1PROD with HEARING
Appropriation enacted, 2015 ..............................................................
Budget estimate, 2016 .......................................................................
Recommended, 2016 ...........................................................................
Comparison:
Appropriation, 2015 ....................................................................
Budget estimate, 2015 ................................................................
$460,234,000
639,725,000
466,329,000
+6,095,000
¥173,396,000
The Committee recommends $466,329,000 for Indian Health Facilities, $6,095,000 above the fiscal year 2015 enacted level and
$173,396,000 below the budget request. In addition to the table at
the end of this report, the recommendation includes the following
instructions:
Staffing for New Facilities.—The recommendation includes
$1,584,000 for the staffing of newly opened health facilities as requested. The stipulations included in the Indian Health Services
account regarding the allocation of funds pertains to this account
as well.
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I';\201 GHEPT\O()['t'jll \BILL\llltt'l'ioI'FY 1(i.Xll\!
,\l)PHO.
11
[COMMITTEE PRINT]
NOTICE: This bill is a draft for use of the Committee and
its Staff only, in preparation for markup.
Calendar No. 000
114TH C(JXGHESN
1ST t-}EKNIO:-i
s.oooo [Report No. 114-0001
;}laking' appropriations 1'01' the Depal'tnwllt of tht' Illtl'I'ior, I'llvi 1'011 nWllt, and
r!!iatt'd llg'enei('s for the fiS(~al yeaI' t'lHlillg' 8!'ptprnber ;'Hl, ~01tj, amI
for other pUlvoses.
IX rrHE SENATE OP rrHEUXITED SrrATES
,Jr:'\E,201;; ,\If;. }I n{Ko\Y~KI, from til(' Committ('l' on ApproIH'iatioI1s. l"('pOI,tPd the following' Ol'ig'inal hill; whieh was I'pad twi('(' and pla(·ed on til(' eukmi;ll' A BILL
l\laking apPl'opl'iatiom; for the Department of' tlw lnt('l'ior,
environment, and l'<:iatt'd ag'('lH'ies for the' fiscal year
ending September 80, 2016, and for other purposes.
1
Bf! it enacted by tJw Senate and House rd'Reprcsenta
2 tives ({(tlw United Stutes q(Arnerim in Confjress asselnbh;ci,
June 14,2015 (3:20 p,m.)
:-;E:-\. ,\l'PHO.
I' ;\:!O 1 Mmp'!\OGt'l'pl \HI LL,\lrlit'l'iorFY 1li.xlIll
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1 any imdl unohligated
2 pil'e
011
halallee~
not so tl'HIiSfelTed shall ex
:September 20, 20lH: Pnwided firrtlwr, 'rhat, in
3 order' to enhanee the safety of Bureau field
emplo~Yees,
the
4 Bureau may nse funds to purdmse ulIifol'lllS or' other iden
5 tif)1.ug Cll'tiPies of dothillg for personnel.
6
COl\"THACT HlTPOILT COHTH
7
1'''01' payments to tribes and tribal organizations for
8 eontraet support costs assoeiated with Indian Self-Deter
9 minatioll and Edneation Assif;tanee .Ad agreements with
10 the Bureau of Iudian Affain; for
fif-;(~al
yeaI' 201 H, I·meh
11 sums elf; lllay he neeessal',v, whieh shall be Clyailahle fot'
12 oblig'ation through S('ptembl'l' 80, 2017: Pnwided, That
13 amounts ohlig'ated but lIot expel1ded hy a trihe or tribal
14 organization for eontrad Hupport eoM:s for snell agr'ee
15 llll'nts for the current fiRcal year :shall be applied to
16 tract RUppOl't
17
~UhSl\(ttH)nt
('ost~
('011
otherwise (luI' for ~lwh agreenwnts for
fiscal ,vcars: Proln'ded .tll rther, rrhat, uotwith
18 standing any otiWl' provision of law, no amounts madl'
19 Hyailable Ulldl'1' thil-l heading' shall be Clyailable for transfer
20 to another budget ae('oullt.
21
('Ol\":-)'fHlTTIO:\
22
(Il\"CIXDIl\"O 'l'lt1\l\"SFEH OF F{i:\DR)
23
For l'onstnH'tioll, I'cpail',improYement, and rnainte
24 lWll('\.' of irrigation and power s,\'stems, Imildings, utilities,
25 and othl'l' faeilities, ineluding arehiteetnral and engineel'
June 14,2015 (3:20 p.m.)
t' ;\20 1 (iR EP'l,\(/(irept\BILL\ll11et'iol'I<'V 1(i.xlII]
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104
1 abled ehildl'en as llla~' he lw('essary for tlw IHlrpos<.' of car'
2 rying out its functions
UIHlpl'
til(' Imliyiduals with Disabil
3 ities Edu('atioll Act (20 F.Ke. ] 400, et seq.): Prol'ilJed
4 firr1her, That til(' [lldiall Health
5
Illay
(~are
ImfH'ovement }'"'\1IId
bp mwd, as Bepded, to (,Hl'J'~' out adhities t:\l)i(~an~'
6 f'ulHll'Ci Ulldpl' tlI<.' Illdian Health Paeilitit's
7
(l('(,Ollllt.
COr\'rtUCT kt'PPOHT COSTk
8
For lm,nnpnts to tribes and trihal org'HnizlltioIls for
9 eontr'Het support (,08t8 associated with Indian Self-Detel'
10 minatioll and Education J-\ssistam'(' Aet Hg'l'f'emcnts with
11 the Indian Health 8('1'Viee for fiseal year 2016, I-nteh sums
12 as may be Il(:,eessar.v: Prouidcd, That alllOlmt:-; obligated
13 hut not exp('lll\ed hy a trihe or tribal oq!auizatiull for
14 trm·t
~mpport
costs for
SUt·h
COJl
ag"pements for the ('ul'rent
15 fiseal year shall bp applied to eOllt1'act support costs othe1'
16 wise dm' for sneh agl'('('uwnts for subsequent fiseal Y('UI'S:
17 Prot'ided fildher, That, notwithstanding' any otlwl' p1'm'i18
SiOll
of law, no amoHnts made anlilable under this lwading'
19 shall be available for tnuH.;f('l' to anothl'1' budg'et aeeount.
20
21
I~DJ.A~ I1EALTIl FACILITIES
:F'OI' ('onstruetion, I'P]>air, maintenau('<.\
22 and equiplll('nt of health and related
impron~ment,
anxiliar~r
faeilitie:-;,
23 illeJndillg quat'ters for persoIllld; preparation of plans,
24 speeifieatiom;;, and dnm'ingsj aequisition of sites, IHll'elwse
25 and eredioll of lllodular building'S, and pnrehasef-i of trail-
June 14, 2015 (3:20 p.m.)
T u r ning the Corner
in Indian Health
Treaty and Trust
Obligations:
Writing a New Future
for American Indians
and Alaska Natives
1.
Photo Credit: James Cook, 1990 The Centennial Ride to Wounded Knee
The National Tribal Budget Formulation
Workgroup’s Recommendations on the
Fiscal Year 2017 Budget
May 2015
Tribal Co-Chairs
Councilmember Andrew Joseph, Jr.
Confederated Tribes of the Colville Reservation
Portland Area
Councilmember Gary Hayes
Ute Mountain Ute Tribe
Albuquerque Area
1
TABLE OF CONTENTS
Table of Contents................................................................................................................................................................. 2
Executive summary ............................................................................................................................................................ 3
Tribal Total Needs Based Request : $29.96 Billion ................................................................................................ 4
Tables: FY 2017 Tribal Recommendations ............................................................................................................... 5
Introduction .......................................................................................................................................................................... 7
1st Recommendation: Phase-In Full Funding of IHS at $29.96 Billion ......................................................... 12
2nd Recommendation: Present a 22% increase in IHS Budget…………...........................................................14
3rd Recommendation: Recommend a Higher Increase in H&C for Local Priorities .......... 35
4th Recommendation: Fund IHCIA New Authorities at $300 Million ........................................................... 36
5th Recommendation: Permanent Exemption from Sequestration….............................................................37
Other Recommendations .............................................................................................................................................. 38
Conclusion ........................................................................................................................................................................... 41
Acknowledgements ......................................................................................................................................................... 43
Appendix.............................................................................................................................................................................. 44
 APPENDIX A: HOT ISSUES BY IHS SERVICE AREAS ............................................................................. 44
 APPENDIX B: DHHS GRANTS SUMMARY ............................................................................................ 69
2
EXECUTIVE SUMMARY
FY 2017 represents a landmark opportunity for this Administration to turn the corner in Indian health
Treaty and Trust obligations, and to finally, bring to justice the promises made to Tribes. It is time to
write a new future for American Indians and Alaska Natives (AI/AN). This Administration and Congress
have it in their power to eliminate the gross health disparities experienced in Tribal communities, and
offer our new generations hope for a better life in our own homeland.
Tribal leaders express appreciation for the Indian Health Service (IHS) budget increases put forth in good
faith by President Obama during his terms in office. While these funds have prevented irreparable
deterioration in existing health services, in reality however, the increases have done little to address the
deep disparate health issues plaguing Tribal communities. The majority of these increases have largely
only provided a stopgap measure for inflation, staffing for new facilities, payment of Contract Support
Cost (CSC) obligations, population growth, and facilities. This leaves very little funding, if any, to target
the alarming disparities facing Indian communities. At the national session, Tribal leaders reported that
they are forced to cut basic programs such as Purchased and Referred Care (PRC), Specialty and Dental
services, deny patient travel, and ignore upgrades needed to ensure safe patient care through meaningful
use of Electronic Health Records (EHR). In addition, they are often forced to defer much needed facilities
maintenance and repairs or medical equipment purchases, thereby reducing the quality of direct patient
care.
This grim reality is corroborated by discouraging health statistics reported annually by the Indian Health
Service. The American Indians and Alaska Natives life expectancy is 4.2 years less than the rate for all
other race populations in the United States. AI/ANs suffer disproportionally from a variety of afflictions
including alcoholism, diabetes, unintentional injuries, and suicide. When considering the level of funding
appropriated to IHS, these statistics are not surprising. In 2014, the IHS per capita expenditures for patient
health services were just $3,107, compared to $8,097 per person for health care spending nationally. The
First Peoples of this nation should not be last when it comes to health. In response to this legacy challenge
to provide meaningful change, the National Tribal Budget Formulation Workgroup strongly recommends
the following:
Tribal Total Needs Based Request: $29.96 Billion Phased in over 12 Years
FY 2017 Tribal Budget Recommendations: $6.2 Billion (Highlights below)
 Increase FY 2016 President’s IHS Budget by a minimum 22% in FY 2017:
o $157.4 million for full funding of current services
o $325 million for binding fiscal obligations*
o $591.7 million for program expansion increases
 Request a higher percentage budget increase in Hospitals & Clinics budget line to provide additional
flexible “Services” budget line item funding which will be used by the IHS Areas to fund local budget
priorities
 Provide an additional $300 million in the “Services” budget line to implement the provisions authorized in
the Indian Health Care Improvement Act (IHCIA)
 Advocate that Tribes and Tribal programs be permanently exempted from sequestration
*includes placeholder estimates for CSC, Staffing for new facilities & new Tribes
3
The FY2017 22% budget request reflects the minimal amount needed to cover inflationary costs which
will keep current services whole, and to pay for current fiscal obligations of the Indian Health Service,
identified by placeholder estimates based on present-day information only, for Contract Support Cost,
new facility staffing and funding for new Tribes. It also proposes a minimum of $591.7 million to provide
for meaningful expansion of programs and services in FY2017. This amount includes a larger program
increase in the Hospital & Clinics budget line in order to provide Areas with the funding and flexibility to
address local budget priorities. For example, Tribal local priorities address funding for emergency and
specialty Purchased/Referred Care (PRC) for remote communities or culturally-appropriate Substance
Abuse Treatment programs in multiple Areas. On top of this, in FY 2017, the Tribes are repeating their
request to add $300 million to fund the new authorities contained in the long-fought-for Amendments to
the Indian Health Care Improvement Act. This
$29.96 BILLION
widely supported bi-partisan bill must have
funding behind it or it will be yet another empty
TOTAL TRIBAL NEEDS B UDGET
promise made to this nation’s First Peoples. In
$29.96 billion request for services & facilities:
addition, Tribes request that the Administration
restore all prior year cuts/shortfall and support
 $15.82 billion for Medical Services
permanent exemption from sequestration.
 $1.66 billion for Dental and Vision Services
 $3.71 billion for Community & Public
Proposing a responsible budget which fully honors
Health Services
the federal trust responsibility, and that provides
 $8.77 billion for facility upgrades and
real increases for service expansion, will turn the
upfront costs (non-recurring investments)
corner in Indian and federal relations. Together,
The costs are calculated using comparisons with
other federal benchmarks such as federal
employee vision and dental coverage and
current IHS spending ratios. Population data is
estimated based on expanded user populations
for IHS eligible AI/ANs. One time facility
upgrades included in this calculation would not
be required year after year. After the initial
investment recurring infrastructure costs are
built into annual per capita cost factors, which
is typically between 6 to 8 percent of the
average US health care spending for capitalized
costs associated with space. This model
establishes the parameters needed to obtain
rough parity with the population at large.
we can make progress to achieve our dream of
health parity for all American Indians/Alaska
Natives (AI/AN). This will enable every Native
young person to be treated like a valuable member
not only of his or her nation, but also of the
American family - providing Native youth with an
equal shot at the American Dream. Let us together,
put behind us the traumatic history, which has
delimited the past relationship between the United
States and American Indian and Alaska Native
Tribes. Instead, let us write a new future in the
spirit of respect and honor, which brings health,
and hope for our next generations and instills a
morale right of dignity for our elders who have
endured.
“Turning the Corner in Indian Health Treaty and Trust Obligations:
Writing a new Future for American Indians and Alaska Natives”
4
TABLES: FY 2017 TRIBAL RECOMMENDATIONS
FY 2017 National Tribal Recommendation
Planning Base - FY 2016 President's Budget $5,102,985,000
Current Services & Binding Agreements
Current Services
Federal Pay Costs
Tribal Pay Costs
Inflation (non-medical)
Inflation (medical)
Population Growth
Binding Agreements
New Staffing for New & Replacement Facilities
Contract Support Costs - Need
Health Care Facilities Construction (Planned)
Program Expansion Increases - Services
Hospitals & Health Clinics
Dental Services
Mental Health
Alcohol and Substance Abuse
Purchased / Referred Care (formerly CHS )
Public Health Nursing
Health Education
Community Health Representatives
Alaska Immunization
Urban Indian Health
Indian Health Professions
Tribal Management Grants
Direct Operations
Self-Governance
Contract Support Costs - New & Expanded
Program Expansion Increases - Facilities
Maintenance & Improvement
Sanitation Facilities Construction
Health Care Facilities Construction-Other Authorities
Facilities & Environmental Health Support
Equipment
GRAND TOTAL
$ Change over Planning Base
% Change over Planning Base
Date
$482,440,000
$157,440,000
8,173,000
9,989,000
8,510,000
63,318,000
67,450,000
$325,000,000
75,000,000
150,000,000
100,000,000
$591,702,700
200,000,000
31,185,900
67,495,900
77,600,900
200,000,000
584,000
457,000
557,000
3,000
10,000,000
564,000
0
128,000
328,000
2,799,000
$48,514,000
21,589,000
13,927,000
7,560,000
438,000
5,000,000
$6,225,641,700
$1,122,656,700
22.0%
Feb 11, 2015
5
TOTAL, BUDGET AUTHORITY
5,102,985
89,097
115,138
185,048
226,870
23,572
639,725
1,936,323
181,459
84,485
227,062
984,475
3,413,804
79,576
19,136
62,363
1,950
163,025
43,604
48,342
2,442
68,338
5,735
717,970
886,431
4,463,260
8,173
0
0
0
1,025
0
1,025
5,259
708
245
156
2
6,370
274
33
5
0
312
13
15
0
423
15
0
466
7,148
0
0
0
1,595
0
1,595
11,711
1,241
548
1,252
2
14,754
504
118
404
13
1,039
194
15
0
550
15
0
774
16,567
9,989 18,162
0
0
0
570
0
570
6,452
533
303
1,096
0
8,384
230
85
399
13
727
181
0
0
127
0
0
308
9,419
0
0
0
973
788
1,761
21,154
1,672
880
2,843
32,466
59,015
713
237
917
29
1,896
646
0
0
0
0
0
646
61,557
989
980
1,308
2,217
808
6,302
23,441
1,731
927
2,877
32,483
61,459
734
239
917
29
1,919
711
744
49
566
78
0
2,148
65,526
967
1,432
0
3,730
406
6,535
33,581
3,028
1,438
3,535
15,814
57,396
1,281
318
1,110
35
2,744
775
0
0
0
0
0
775
60,915
1,956
2,412
1,308
7,542
1,214
14,432
3,697
143,008
68,733
6,000
2,913
7,664
48,299
133,609
2,519
675
2,431
77
5,702
1,680
759
49
1,116
93
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 100,000
0
0
0
0
0 100,000
75,000
0
0
0
0
0
0
0
0
0
75,000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 150,000
0 150,000
75,000 150,000
8,510 63,318 71,828 67,450 157,440 75,000 ###### 100,000
989
980
1,308
1,244
20
4,541
2,287
59
47
34
17000
2,444
21
2
0
0
23
65
744
49
566
78
0
1,502
3,969
CURRENT SERVICES
(Dollars in T housands)
Detail of Changes
FY 2017 National Tribal Recommendation
325,000
0
0
100,000
0
0
100,000
75,000
0
0
0
0
75,000
0
0
0
0
0
0
0
0
0
0
150,000
150,000
225,000
112,642
131,477
293,916
234,850
29,786
802,671
2,280,056
218,645
154,894
312,327
1,232,774
4,198,696
82,679
20,268
65,351
2,030
170,328
55,284
49,665
2,491
69,582
6,156
870,769
1,053,947
5,422,971
23,545
16,339
108,868
7,980
6,214
162,946
343,733
37,186
70,409
85,265
248,299
784,892
3,103
1,132
2,988
80
7,303
11,680
1,323
49
1,244
421
152,799
167,516
959,711
FY 2017
+/FY 2016
PB
Feb 23, 2015
640,217 6,225,642 1,122,657
21,589
13,927
7,560
438
5,000
48,514
200,000
31,186
67,496
77,601
200,000
576,283
584
457
557
3
1,601
10,000
564
0
128
328
2,799
13,819
591,703
INCREASES
Binding Agreements
Pay
Inflation
Current Staffing
Binding
2017
Presidents Federal Tribal
Pay
NonInflation Pop Services for New CSC
HCFC Agreements Program National
Budget
Pay
Pay Subtotal Medical Medical Subtotal Growth Subtotal Facilities Shortfall (Planned) Subtotal Increases Recomm
FY 2016
FACILITIES
Maintenance & Improvement
Sanitation Facilities Construction
Health Care Facilities Construction
Facilities & Environmental Health Support
Equipment
TOTAL, FACILITIES
Program
SERVICES
Hospitals & Health Clinics
Dental Services
Mental Health
Alcohol & Substance Abuse
Purchased/Referred Care
Total, Clinical Services
Public Health Nursing
Health Education
Community Health Representatives
Immunization AK
Total, Preventive Health
Urban Health
Indian Health Professions
Direct Operations
Self-Governance
Contract Support Costs
Total, Other Services
TOTAL, SERVICES
6
22.0%
26.4%
14.2%
58.8%
3.5%
26.4%
25.5%
17.8%
20.5%
83.3%
37.6%
25.2%
23.0%
3.9%
5.9%
4.8%
4.1%
4.5%
26.8%
2.7%
2.0%
1.8%
7.3%
21.3%
18.9%
21.5%
% Change
over
Plng Base
INTRODUCTION
In the defining six years of his Administration, President Obama has courageously set forth policies
reinforcing his stated commitment to strengthen the unique government-to-government relationship
between the United States and sovereign Tribal Nations. Each year Tribes have seen moderate increases
within the Indian Health Service (IHS) budget and increased access to other funding opportunities within
the Department of Health and Human Services.
"This country faces a continuing federal deficit
Unlike other Administrations, President Obama has
and tight budget. The federal government also has
made a concerted effort to apportion increases to
important responsibilities to Indian people. Those
support Indian programs within his proposed budget
responsibilities require funding.”
to Congress. However, these increases have only
-Senator John Barrasso, Chairman, Senate
been enough to cover inflation proofing and to meet
Committee on Indian Affairs, February 24, 2015
existing mandated obligations; there have been few
dollars, if any, to expand services necessary to bring
true health parity for American Indians and Alaska Natives. Sadly, despite these positive efforts to
increase the IHS budget, there still exists a huge gap when comparing per capital health spending between
Indian health and other federal healthcare programs.
The National Tribal Budget
Formulation Workgroup members
include Tribal representatives from
each of the 12 IHS Service Areas who
are tasked with consolidating budget
recommendations developed by
Tribal leadership and program staff of
the 12 IHS Areas (regions) into a
national set of budget and health
priorities for a given fiscal year. The
Workgroup provides input and
guidance to the IHS Headquarters
budget formulation team throughout
the remainder of the budget
formulation cycle for that fiscal year.
In FY 2015, for example, IHS received an increase of
$207.9 million, most of which is being used to cover
inflation and binding obligations and to restore cuts from
FY 2014. Similarly, in FY 2014, IHS received an increase
of $304 million over FY 2013 enacted levels. Most of this
increase was required to fully fund contract support costs
(CSC), as well as new staffing packages, at the direction
of Congress. The joy of seeing an increase in IHS
appropriations quickly dampened when the agency had no
choice but to cut an additional $10 million from Services
to pay for CSC and staffing costs. No funds were
available to restore sequestration cuts from FY 2013, nor
to adjust for actual inflationary increases and population
growth. As a provider of direct healthcare services, the
IHS must be treated like other federal health provider
agencies and be held harmless from future sequestration.
When budgets are developed, they must minimally
include enough funds to maintain current services, and
must provide a meaningful increase to make an impact on
chronic health disparities.
FY 2017 represents the final opportunity for this Administration to create an unprecedented legacy, which
will shift the focus from the past travesties imposed upon this country’s first citizens, and move towards
redefining relations build on a new respect and honor of trust with sovereign Tribes. While inflation and
other required appropriation priorities have hindered progress toward improved health performance
outcomes, the final 2017 budget proposed by the Obama Administration can significantly reverse this
trend. By preparing a budget that fully honors the federal trust responsibility, we will not only reduce, but
also eliminate the health disparities between the Native peoples and other Americans. The target for the
IHS budget of $29.96 billion over twelve years contained in this request offers a lasting legacy for
7
President Obama and his cabinet. It will serve to rewrite a better future for deserving Native American
youth and will correct an injustice suffered by our elders by giving back their dignity.
It is imperative that President Obama visibly launch a sustainable plan to achieve full funding. It must
start with putting forward, in this last budget of his administration, a FY 2017 legacy proposal which
will create a better future for Indian peoples to include:
1. Phased- in Full Funding of IHS - Total Tribal Needs Budget of $29.96 Billion Over 12 Years
2. A minimum 22 % increase in the overall IHS budget over the FY 2016 President’s Budget request,
subject to adjustments for actual FY 2017 CSC, New Facility staffing, and New Tribes
3. A higher percentage budget increase in Hospitals & Clinics budget line to allow flexible service
expansion funding which will be used by the IHS Areas to fund local budget priorities
4. $300 million on top of the 22% to begin to implement the provisions authorized in the Indian Health
Care Improvement Act (IHCIA)
5. Permanent exemption from sequestration
Turning the Corner…
The federal budget for AI/AN is not just a fiscal document
About the Indian healthcare delivery
between sovereign Nations. It is indeed, the execution of a
system: The Indian healthcare delivery
moral, ethical, and legal commitment. The U. S. federal
system consists of services and programs
government recognizes Tribal nations as “domestic
provided directly by IHS; Indian Tribes and
dependent nations” and Congress has long recognized the
Tribal organizations who are exercising
sovereignty of Native Nations, citing treaties, made between
their rights of self-determination and selfsovereign nations, as the Supreme Law of the Land. These
governance; and services provided through
early treaties, reaffirmed by Executive Orders,
urban organizations that receive IHS grants
Congressional actions and two centuries of Supreme Court
and contracts (collectively, the “Indian
case law, provide the basis for Congress to apportion funds
healthcare system” or I/T/U). The Indian
for Indian Health care services for the benefit of all AI/ANs.
healthcare system has a user population of
Tribes are the only citizen group allowed to have formal
2.2 million individuals. Currently, the IHS
consultation into the federal budget formulation process.
FY 2014 budget is $4.6 billion. That is only
The annual budget request reflects the extent to which the
(on average, system wide) 59% of the level
United States chooses to honor its promises of justice,
of need.
health, and prosperity to Indian people. When national
budget requests for Indian health care fall short of providing
even the most basic level of services equitably to all Tribal members, Tribal communities suffer. It is no
wonder that visitors to remote Tribal reservations or villages are moved to describe Tribal living
conditions as “third world” in nature. Ironically, it is oft time easier for these same third world countries
to receive foreign aid, than it is for our own “domestic dependent nations,” to receive funding for even
basic health care. It is tragically still a truth that many families are forced to make tough decisions between
seeking health care or to pay for food or living expenses. This is unconscionable in a country promising
equality and justice for all its citizens.
Washington must take a stronger stand to uphold its legal trust responsibility to Tribal Nations. Congress
and this Administration must turn the corner by fully honoring its treaty and trust obligations to Indian
Country. It is what our Tribal forefathers agreed to when giving up lands and rights for peaceful
coexistence. It is a matter of honor. It is what great Nations do.
8
Writing a New Future…
Federal trust responsibility written into negotiated treaties and agreements is the foundation for the
provision of federally funded health care to all members of the 566 federally recognized Indian Tribes,
bands, and Alaska Native villages in the United States. Fulfilment of this trust responsibility can only
occur if the Administration requests funds and Congress appropriates them. This Administration, more
than any other, has made great strides to engage with Tribes in meaningful consultation at all levels of
government about budget and other Tribal concerns. This FY 2017 budget request, as proposed and fully
funded, will serve to write a new future in U.S. –Tribal relations. It will empower Tribal communities
with the necessary resources to implement services and programs to make lasting improvements in the
health and wellness of Tribal members. It will bring parity and hope at this critical turning point for Indian
peoples who are weary of facing another decade of promises without action.
….For Our Next Generations
This Administration has made it a priority to visit Indian country to see firsthand some of challenges which
stand in the way health and wellness for Indian youth. Socio-economic ills and lack of resources have
crippled many Tribes in their mission to take a holistic approach to solve health disparities facing
members. Efforts to reform national health care will have a profoundly negative impact on Tribes, if not
properly managed and funded. Indian health care services are
already under-resourced; new mandates such as Electronic “Throughout our nation’s history, the
Health Records Meaningful Use requirements, and United States has made a solemn
performance reporting requirements without equal access to commitment to provide health care
sustainable systems to capture and report on performance through the treaties and agreements it
outcomes, only serve to exacerbate this. Adequate funding negotiated with the Tribes. We have to
honor that commitment. Support for the
must be provided so that Tribes are not left even further
Budget of the IHS helps ensure that we
behind. Tribes must have the resources to hire and retain a
do that. Congress has stepped up and
qualified workforce, and to arm them with clinical quality data provided significant increases for Tribal
systems necessary to address chronic and urgent care needs in health programs over the last several
this new age of health reform. The hope for a healthier future years, but we clearly have a lot of work
lies in an abyss for our children, and our children’s children, to do.”
if the right action is not taken now to address widening funding
Senator Tom Udall (D-NM)
gaps.
March 11, 2015
It will take more than just inflation proofing and funding for existing obligations, to finally end longstanding inequities in health status for First Americans. The health of AI/ANs, while improving in some
areas, is still grave, with the AI/AN life expectancy that is 4.2 years less than the rate for the U.S. all races
population. The Centers for Disease Control and Prevention (CDC) issued a report in April 2014 noting
that AI/ANs death rates nearly 50 percent greater than non-Hispanic Whites.
According to IHS data, AI/AN people die at higher rates than other Americans from alcoholism (552%
higher), diabetes (177% higher), unintentional injuries (138% higher), homicide (82% higher) and suicide
(65% higher). Additionally, AI/ANs suffer from higher mortality rates from cervical cancer (1.2 times
higher); pneumonia/influenza (1.4 times higher); and maternal deaths (1.4 times higher). An alarming
number of Tribes are reporting a sharp increase in both prescription and illegal drug abuse.
HIV/STDs cases are becoming epidemic on some reservations. Indian Country is asking for an urgent
call to action to help combat these issues. We request that the Administration make these issues a key
priority when developing the FY 2017 budget request.
9
Alarming health risks attributed to historical trauma, poverty
and a lack of adequate prevention and treatment resources,
also continue to burden Tribal communities. According to
IHS data, 39 percent of AI/AN women experience intimate
partner violence, which is the highest rate of any ethnic
group in the United States. One in three women in AI/AN
President Ronald Reagan communities will be sexually assaulted in her lifetime.
1983 Statement on Indian Policy AI/ANs suffer at higher rates from psychological distress;
feelings of sadness, hopelessness and worthlessness; feelings
of nervousness or restlessness and suicide. Additionally, public health risks related to alcohol and
substance abuse are widespread in many Tribal communities, leading to other health and socio-economic
disparities such as poverty, mental illness, and increased mortality from liver disease, unintentional
injuries and suicide. Dental health concerns also continue to affect AI/ANs at higher rates than other
Americans do. Ninety percent of AI/AN children suffer from dental caries by the age of eight, compared
with 50 percent for the same age in the US all races population. Our children ages 2 to 5 have an average
of six decayed teeth, when children in the U.S. all races population have only one.
“We shall continue to fulfill the federal trust
responsibility for the physical and financial
resources we hold in trust for the tribes and their
members.
The fulfillment of this unique
responsibility will be accomplished in
accordance with the highest standards”
The Indian health care delivery system, in addition to significant health disparities, also faces significant
funding disparities, as evidenced by the per capita spending between the IHS and other federal health care
programs. In 2014, the IHS per capita expenditures for patient health services were just $3,107, compared
to $8,097 per person for health care spending nationally. Compared to IHS calculations of expected cost
for a blend of Federal Employee Health Benefits, average IHS per user spending in 2014 was only 59%
of calculated full costs. The actual percentage varies widely between IHS areas, with some funded at
much less than 59% of need. New health care insurance opportunities beginning in 2014 and expanded
Medicaid in some states may expand health care resources available to American Indians and Alaska
Natives. However, these new resource opportunities come with a cost for billing, collections and
compliance and are no substitute
for the fulfillment of the federal
trust responsibility. With the
funding gap already reaching
upwards of $25 billion, even if
100% of these were recouped and
put into services, the huge budget
gap and associated health
disparities will remain. It will be
some time before reliable data is
available to determine the impact
of these changes on American
Indians and Alaska Natives.
10
Five Year Trend
Budget Requests Inflationary & Fixed Costs
Compared with
Enacted Indian Health Service Appropriations
“One of these days we will move on to the next world some call it Heaven, our Chiefs and passed Council will ask
us, “Why did you ask for only a small budget for our People when you could have asked for everything you needed?”
Andy Joseph, Jr. Tribal Co-Chair, National Budget Formulation Work Group
“Our need is $29 billion, at the rate we are going we will never get there. When you look at Indian country and
look at healthcare overall, it is not enough – they need to pass resolutions that will hold that the way the budget is,
is an injustice and HIS must uphold their trust responsibility. As we go through priorities today and tomorrow, all
the priorities are important – we get the crumbs. Everything in our community is a priority. We have to list these
things: Diabetes, Cancer, facilities, all are important. I wish congress could learn how we have to budget less each
year to try to meet the needs of our communities. Our average age of tribal deaths since 1990 is 50 for males and
54 for females. This is not acceptable.”
Gary Hays, Tribal Co-Chair, National Budget Formulation Work Group
11
FY 2017 TRIBAL BUDGET RECOMMENDATIO NS AND PRIORITIES
 1 s t Recommendation: Phase-In Full Funding of IHS - Total Needs Based
Budget of $29.96 Billion Over 12 Years
Early in 2003, the Workgroup met to develop the national Tribal budget recommendations for FY 2005.
Tribal leaders were disheartened that the planning base for the IHS budget was $2.85 billion, less than
15% of the total funding required to meeting the health care needs for AI/ANs. This level of funding was
not even sufficient to maintain current services in the face of inflation and increases in the Indian
population. Tribal leaders warned that continued under-funding would thwart the Tribes and IHS’s efforts
to address the serious health disparities experienced by our AI/AN people. To address this shortfall, IHS,
Tribal and Urban programs worked together to develop for the first time a true Needs Based Budget (NBB)
and for FY 2005, proposed a IHS NBB totaling $19.5 billion. This includes amounts for personal health
services, wrap-around community health services and facility investments.
The FY2005 Budget Formulation Workgroup responsibly proposed a 10-year phase-in plan, with
substantial increases in the first two years and more moderate increases in the following years as this
Workgroup understood that meeting the NBB of $19.5 billion in one fiscal year was unlikely, due to the
importance of balancing the Federal budget and other national priorities. Furthermore, IHS and Tribal
health programs lacked the health infrastructure to accommodate such a large program expansion at one
time. The most significant aspect of the 10-year plan was that it would require a multi-year commitment
by Congress and Administration to improve the health status of AI/ANs.
That was 10 years ago. In the intervening years and with failure to produce necessary funding to fulfill
this 10-year plan, the health disparities between AI/ANs and other populations continued to widen, and
the cost and amount of time required to close the funding disparity gap has grown. The NBB has been
updated every year, using the most current available population and per capita health care cost
information. The IHS need-based funding aggregate cost estimate for FY 2017 is now $29.96 billion,
based on the FY 2014 estimate of 2.7 million eligible AI/ANs served by IHS, Tribal and Urban health
programs. With the lack of adequate increases over the years, the phase-in of the NBB at $29.96 billion
would need to occur over the next 12 years.
12
FY 2017 AI/AN Needs Based Funding
Aggregate Cost Estimate
GROSS COST ESTIMATES
Source of Funding is not estimated
SERVICES
Medical Services
$ Per Capita
$5,836
Medical services and supplies provided by health care professionals;
Based on 2008 FDI benchmark
Surgical and anesthesia services provided by health care professionals; ($4,100) inflated to 2013 @4%
Services provided by a hospital or other facility, and ambulance
per year
services; Emergency services/accidents; Mental health and substance
abuse benefits; Prescription drug benefits.
Need Based on
FY 2014
Existing Users
at I/T Sites
Need based on
FY 2014
Expanded
for Eligible AIAN
at I/T/U Sites*
1,594,229
2,710,893
Billions
Billions
$9.30
$15.82
$ Per Capita * Users
$ Per Capita* Eligible AIAN
$0.97
$1.66
$2.18
$3.71
$7,816
$12.46
$21.19
$ Per Capita
Billions
Billions
Facility Upgrades Upfront Costs
$6.51
$8.77
Annualized for 30 year useful Life
$0.38
$0.51
Dental & Vision Services
Dental and Vision services and supplies as covered in the Federal
Employees Dental and Vision Insurance Program
Community & Public Health
Public health nursing, community health representatives, environmental
health services, sanitation facilities, and supplemental services such as
exercise hearing, infant car seats, and traditional healing.
Total Annualized Services
FACILITIES
$611
2008 BC/BS PPO Vision ($87)
and Dental benchmarks ($342)
inflated to 2012 @4% per year
$1,369
19% of IHS $ is spent on Public
Health. Applying this ratio, $1,316
per capita = (.19/.81*$5611).
IHS a s s es s ed fa ci l i ti es condi ti on (ol d, outda ted, i na dequa te) a nd ha s es ti ma ted a one-ti me cos t of $6.5b to upgra de a nd moderni ze. A 30 yea r
us eful l i fe a s s umpti on i s us ed to es ti ma te the a nnua l i zed cos t (a s s umi ng 4% i nteres t) of the upgra des .
TOTAL
Total Annualized Services +
One-time Upfront Facilities Upgrades
$18.97
$29.96
13
 2 n d Recommendation: Present a 22% Increase in the Overall IHS Budget
from the FY 2016 President’s Budget Request Planning Base
While the Workgroup’s and Tribes’ primary recommendation remains full funding of the IHS NBB,
Tribes in each Area were asked to prepare budget recommendations at specific funding levels. Taking the
Area recommendations, the Workgroup recommends an increase of 22% or $1.1 billion over the FY 2016
President’s proposed IHS Budget. This includes $157.4 million for Current Services, $325 million for
Binding Agreements with Tribes and $640.2 million in Program Increases Expansion. Current Services
and other Binding Agreements provide the base for program increases designed to expand services. These
base costs, which are necessary in order to maintain the status quo, must be accurately estimated and fully
funded before any real program expansion can begin. The Program Expansion Increases are the additional
funding needed to address critical health services and new facility authorities aimed at slowing the
growing health disparity rates in Tribal communities.
Program Expansion Increases
Additional Program Expansion Increases totaling $640.2 million are needed to address the urgent AI/AN
health disparities related to Program Expansion for Services and Facilities. In order to address obligated
costs due to medical inflation, all 12 IHS Areas identified the Purchased/Referred Care and Hospitals &
Clinics (H&C) line items as key priorities for increased funding. H&C includes funding for the Indian
Health Care Improvement Fund, Health Information Technology, and Long Term Care, as well as general
H&C increases. Top Tribal priorities are reflected by the critical line item increases listed below.





Increase funding for Purchased/Referred Care (PRC)1 by $200 million.
Increase funding for H&C by $200 million.
Increase funding for Alcohol & Substance Abuse Services by $77.6 million.
Increase funding for Mental Health by $67.5 million to address resource deficiencies at behavioral
health programs that are providing outpatient and emergency crises services and community based
prevention programs.
Increase funding for Dental Services by $31.2 million.
If the requested Program Expansion increases continue to be overlooked, AI/ANs will continue to live
sicker and die younger than other American citizens do and will continue to drain existing available
resources for costly urgent, emergent and chronic care at higher rates than other populations. Turning the
corner on health for Indian people, requires serious determination. This Administration has made this a
priority for years, and we hope that the last budget proposed will be one of that truly sets a legacy for our
people.
1
Formerly called Contract Health Services
14
Planning Base for FY 2017
FY 2016 President’s Budget of $5,102,985,000 x 22% = $1,122,656,700
Current Services (Fixed cost estimates): $157,440,000
All 12 Areas recommended funding for Federal and Tribal pay, inflation (medical and non-medical)
and population growth
Binding Agreements (Fixed cost estimates)
$325,000,000
Contract Support Costs Need (estimate)
$150,000,000
Health Care Facilities Construction Projects (estimate)
$100,000,000
Staffing Costs for Newly-Constructed Facilities (estimates)
Program Expansion – Top 5
$75,000,000
$576,282,700
1. Hospitals & Health Clinics
$200,000,000
2. Purchased / Referred Care
$200,000,000
3. Alcohol & Substance Abuse
$77,600,900
4. Mental Health
$67,495,900
5. Dental Services
$31,185,900
Other Budget Recommendations
$63,934,000
6. Maintenance & Improvement
$21,589,000
7. Sanitation Facilities Construction
$13,927,000
8. Urban Health
$10,000,000
9. Health Care Facilities Constr./Other Authorities
$7,560,000
10. Equipment
$5,000,000
11. Contract Support Costs – New & Expanded
$2,799,000
12. Public Health Nursing
$584,000
13. Indian Health Professions
$564,000
14. Community Health Representatives
$557,000
15. Health Education
$457,000
16. Facilities & Environmental Health Support
$438,000
17. Self-Governance
$328,000
18. Direct Operations
$128,000
19. Alaska Immunization
$3,000
15
Current Services & Binding Agreements (Fixed Costs)
AI/ANs believe that all known expected cost obligations must be transparent in the budget request in order
to demonstrate the true funding base required to sustain current services and meet obligated fiscal
requirements. It is from this true funding base that recommendations for real program increases can begin.
These cost obligations include actual federal & Tribal pay costs, true medical and non-medical inflation,
population increases, “must have” staffing and construction project requirements, Contract Support Costs
(CSC), and all expected off-the-top mandatory assessments. Understating the amount necessary to meet
these fiscal obligations creates a false expectation that increased funding is available to expand program
services when, in fact, funding levels may not even be sufficient to maintain the status quo. The
workgroup strongly recommends that full funding for Current Services and obligated fiscal requirements
at the actual projected costs be funded as reflected in this section.
Current Services (Fixed costs) +$157.4 million
The FY 2016 President’s Budget request included an increase of $147 million for direct and tribally
provided health care services to cover increased costs associated with population growth, pay cost
increases for medical workers and medical inflation, and ensure continued levels of health care services.
Unfortunately, the proposed $147 million falls short of actual need, specifically in population growth,
only covering $56.7 million of the total population growth need of $82 million. Population growth
estimates are determined by a 1.5% increase.
The FY 2017 Tribal Budget Request includes an increase of $8.2 million for Federal Pay Costs and $10
million for Tribal Pay Costs. Competitive pay for both Tribal and federal employees is crucial to ensuring
that the Indian health system is able to recruit and retain qualified staff, which directly affects our ability
to provide quality care to patients. In addition, the Workgroup feels strongly that commissioned officers,
civil service, and Tribal employees should be exempt from any federal employee pay freeze that may be
16
imposed in FY 2017. If Tribes and IHS are to retain quality health professionals it is critical that we honor
these employees by providing a competitive wage.
The Current Services request also includes $8.5 million for Non-Medical Inflation and $63 million for
Medical Inflation. However, the actual inflation rate for different components of the IHS health care
delivery system is much greater. As a component of the Consumer Price Index (CPI), inpatient hospital
care is currently at 4.3% and outpatient hospital care is at 3.8%. The Workgroup asserts that the rates of
inflation applied to H&C, Dental Health, Mental Health, and PRC in developing the IHS budget should
correspond to the appropriate components in the CPI. Otherwise, the estimates developed by IHS
underestimate the true level of funding needed to maintain current services.
Another $67.5 million in Current Services funding is requested for Population Growth to address increased
services needs arising from the increase in the AI/AN population, which in recent years has been growing
at an average rate of 1.5% annually.
Despite historic increases since 2009, the IHS remains severely underfunded far below need. In FY 2013,
sequestration cuts devastated tribal communities throughout the United States. In a health care delivery
system that has been chronically underfunded for decades, this was pure disaster for clinics across Indian
Country. Losing these dollars, combined with a calamitous federal government shutdown at the start of
2014, has nullified many of the funding gains of the last six years. When compounded with rising medical
inflation and population growth, Indian Health budgets are quickly trending backwards.
Binding Agreements (Fixed costs) +$325 million
New Staffing for New & Replacement Facilities +$75 million (estimate)
An estimated $75 million is requested to fund new staffing and operating costs for FY 2017. IHS
construction funds are targeted to expand service sites experience overcrowding by building new or
renovating existing facilities. Additional funding is included in the budget to support staffing and
operating costs for new and expanded facilities. This recommendation amount is subject to adjustment
based on the status of actual projects completed in FY 2016, which become ready for staffing packages.
Contract Support Costs +$150 million (estimate)
An estimated $150 million is requested for reasonable costs for activities that Tribes/Tribal Organizations
must carry out to support health programs and for which resources were not otherwise provided.2 The
Indian Self-Determination and Education Assistance Act requires that 100% of these costs be paid, and is
therefore this budget line is considered to be a Binding Agreement. In FY 2014, more than $2.5 billion
of the IHS appropriation was administered by Tribes/Tribal Organizations under contracts and compacts,
and the assumption of programs, services, functions and activities by Tribes/Tribal Organizations under
the Act continues to grow. The FY 2016 President’s Budget Request included a proposal to reclassify
Contract Support Costs from discretionary to a mandatory appropriation beginning in FY 2017, which
2
After the Tribal Budget Formulation Workgroup completed its national Budget Recommendations for IHS, the President’s Budget was
submitted for Fiscal Year 2016, identifying CSC requirements for a three-year period, FY 2017-2019. In doing so, the IHS identified $800
million as required to fund all CSC requirements in FY 2017. As this line item is identified as a Binding Agreement, and notwithstanding
the estimated funding level by IHS, the appropriation should include such sums that are necessary to fully fund this contractual requirement,
realizing that the exact amount will not be known until closer to the appropriated fiscal year.
17
would pair the appropriation authority with the legal requirement to pay these costs. Tribes universally
support this concept.
Health Care Facilities Construction (Planned) +$100 million
In FY 2017, $100 million is requested for previously approved health facility construction projects in
accordance with the IHS health care facilities 5-year plan. HCFC budget line is historically underfunded
due to the demands of providing actual health care to AI/AN patients.
New Tribes Funding $0 (estimate)
At the time this budget was formulated, no information was available regarding newly federally
recognized Tribes requiring funding in FY 2017. However, this is subject to adjustment if newly
recognized Tribes are identified in the Budget appropriations year.
Total FY 2017 Request for Fixed Costs:
Current Services $157,440,000
 Federal Pay Costs $8,173,000
 Tribal Pay Costs $9,989,000
 Inflation (non-medical) $8,510,000
 Inflation (medical) $63,318,000
 Population Growth $67,450,000
Binding Agreements $325,000,000
 New Staffing for New & Replacement Facilities $75,000,000 *
 Contract Support Costs - Need $150,000,000*
 Health Care Facilities Construction (Planned) $100,000,000
 Newly Recognized Tribe Funding $ 0*
*these placeholders are estimates only and are subject to adjustment based on actual requirements
Program Expansion Increases – Services Budget
Because FY 2017 is the last Budget that Obama Administration will submit, we call upon the
Administration to use this as an opportunity to draft a budget that will set a precedent for the goal of
achieving full funding of the Tribal needs-based budget of $29.96 billion over the next 12 years.
To accomplish this, the Workgroup recommends the FY 2016 Budget Program Increases outlined in this
section of the budget request which will continue the significant progress made by this Administration in
the past 4 years to bring AI/AN into parity with other citizens of the United States.
Hospital & Clinics: +$343.7 million
Adequate funding for Hospitals & Clinics (H&C) is a critical Tribal budget priority for the 650 hospitals,
clinics, and health programs that operate on or near Indian reservations. This core budget line item
18
provides or the direct service delivery to AI/ANs. IHS/Tribal/Urban Indian (I/T/U)-managed facilities are
predominantly located in rural settings with service at many locations limited to primary care, due to
inadequate funding. IHS H&C funding supports essential direct care medical services, including inpatient
care, routine and emergency ambulatory care, and medical support services, such as laboratory, pharmacy,
nutrition, diagnostic imaging, medical records, physical therapy, and other ancillary services. H&C funds
also support community health initiatives targeting health conditions disproportionately affecting AI/ANs,
such as specialized programs for diabetes, maternal and child health, women’s health, and elder health.
The demands on the IHS H&C are continuously challenged by a number of factors such as the increased
demand for services related to trends in significant population growth, the increased rate of chronic
diseases, rising medical inflation, difficulty in recruiting and retaining providers in rural health care
settings, and the lack of adequate facilities and equipment. For many AI/ANs, this represents the health
care access in its entirety, both in terms of monetary resources but also facility access. Consequently, any
underfunding of H&C equates to no health care. For many in Indian Country, there are no alternatives.
TRIBAL EPIDEMIOLOGY CENTERS
Tribal Epidemiology Centers (TECs) work in partnership with the local Tribes to improve the health and well-being of their
Tribal community members by offering culturally-competent approaches to reduce health disparities faced by AI/AN
populations. Epi-centers serve a critical function as the only public health authorities for Indian Country. Yet, the national
average amount received to support TECs is only $360,000 each year, far short of the $1 million per TEC requested. This
funding level, which includes indirect costs, has been flat for the past 5+ years. Essential functions that the IHCIA states that
Tribal Epi-Centers should fulfill are:
1. Collect data relating to, and monitor progress made toward meeting, health status objectives
2. Evaluate existing delivery systems, data systems, and other systems that impact the improvement of Indian health;
3. Assist in identifying highest-priority health status objectives and the services needed to achieve those objectives,
based on epidemiological data;
4. Make recommendations for the targeting of services needed by the populations served;
5. make recommendations to improve health care delivery systems for Indians and urban Indians;
6. Provide requested technical assistance in the development of local health service priorities and incidence and
prevalence rates of disease and other illness in the community; and
7. Provide disease surveillance and assist Indian tribes, tribal organizations, and urban Indian communities to promote
public health.
Clearly, $360,000 annually is inadequate to achieve these functions. Costs, particularly personnel costs, keep increasing but
funding has remained flat so the dollars buy less and less over time. Inadequate funding creates issues with hiring and retaining
qualified and capable staff and uncertainty for multi-year public health project planning and implementation.
With additional funding TECs would be able to increase capacity to provide the essential public health functions, and public
health infrastructure. TECs would provide critical and timely data-related support to meet tribal health priorities, as identified in
the Indian Health Care Improvement Act. (e.g. funds to support adequate number of biostatisticians, EHR programmer/analysts,
epidemiologists, and data visualizers)
We request that the Administration prioritize Epi-Centers in its FY 2017 Budget Request. We also request that IHS work with
the Centers for Disease Control and Prevention to ensure that funds available at that agency are also reaching the Tribal EpiCenters.
One key component of this budget line item is access to basic quality preventative care. Tribes understand
the commitment at HHS to require that federal funds be used to make meaningful impact on health
outcomes. This will never be achieved if we must continue to use our scarce resources to meet basic
19
primary and urgent care needs. Our communities suffer from significantly higher mortality rates from
cancer, diabetes, heart disease, suicide, tooth decay, and substance abuse. Preventative care programs
help to stop these costly burdens before they start. Yet, with funds primarily directed to cover fixed and
inflationary costs at the service unit level, little is left over to make significant, long-term progress toward
the health of AI/ANs. This Administration can make a difference with targeted, funding going to Tribal
communities. Furthermore, we recommend that Tribes have the flexibility to develop and implement their
own preventative programs. Evidence clearly shows that culturally appropriate approaches ultimately
have the best chance of success.
A critical component of realizing full potential of H&C is funding of new authorities under the IHCIA.
The expanded provisions in this law represent a promise made by the federal government to improve
greatly the health of our people, yet five years later, most of these new programs remain unfunded. This
stands as yet another broken agreement by the federal government. Meanwhile, elders continue to go
without care, preventative health in Indian Country lags far behind the rest of the county, and our clinics
are woefully in need of qualified medical professionals. FY 2017 should be the year where the
Administration commits to funding these authorities so that we can finally begin to see the impacts of a
law that was over 20 years in the making. This special initiative should on top of base-level H&C funding.
Health Information Technology (H&C) +16 million
As the United States medical community is now adopting certified electronic medical records and
reporting clinical quality measures electronically, the IHS is now in its 17th year (for the 2018 budget) of
reporting electronic performance results for GPRA/GPRAMA clinical measures from IHS’s electronic
health record, the Resource and Patient Management System (RPMS). The future of quality reporting in
the IHS is twofold: centralization of national, clinical performance reporting and alignment of clinical
measures with national standard measures, where appropriate. This new direction aligns with the
Affordable Care Act’s National Strategy for Quality Improvement in Health Care (National Quality
Strategy) as well as the HHS Measurement Policy Council’s (MPC) efforts to align core performance
measures.
Beginning in FY 2017, IHS will produce aggregated, clinical performance measure results from our new
centralized Integrated Data Collection System Data Mart (IDCS DM) housed within IHS’s National Data
Warehouse (NDW). The IDCS DM will increase national performance data collection since performance
results will expand to represent the IHS direct, tribal and urban (I/T/U) User Population. The IDCS DM
will use all data exported to the NDW including RPMS and non-RPMS files as well as the data supplied
by the fiscal intermediary. The same exports that are used to calculate IHS’s User Population will be used
to calculate performance results, which will reduce the reporting burden for I/T/U facilities. Users will
be able to access secure, web-based reports that contain no patient identifying information – just aggregate
numerators and denominators. IDCS DM reports will be as current as the last data refresh in the NDW,
which occurs on a weekly basis. The IDCS DM will be a new, more efficient way to program and report
clinical performance measures in a centralized location.
The IHS/Tribal/Urban Indian facility uses secure information technology (IT) to improve health care
quality, enhance access to specialty care, reduce medical errors, and modernize administrative functions
consistent with the Department of Health and Human Services (HHS) enterprise initiatives. For FY 2017,
the Workgroup recommends $10 million to maintain current investments and an additional $6 million to
continue to implement meaningful use requirements at all remaining IHS operated facilities.
20
Information technology is essential to effective quality health care delivery and efficient resource
management in the IHS system. Health care is information-intensive and increasingly dependent on
technology to ensure that appropriate information is available whenever and wherever it is needed.
Deployment of EHR requires addition resources to support Tribal and IHS hospitals and clinics, Area IT
offices who provide technical support, and IHS headquarters, who develop the software applications and
enterprise architecture, as well as security compliance.
The IHS I/T/U IT infrastructure includes people, computers, communications, and security that support
every aspect of the IHS mission. The IT infrastructure platform is an architecture that incorporates
government and industry standards for the collection, processing, storage, and transmission of
information. The IHS I/T/U IT program is managed as a strategic investment, is fully integrated with the
agency's programs, and is critical to improving service delivery across the Indian health care system.
Revenue generation is supported through the practice management third party billing package. Without
proper IT infrastructure and support, the ability of tribes to meet Meaningful Use and ICD-10 requirements
is severely compromised, resulting in lost revenue that would otherwise support quality patient services.
Furthermore, IT provides monitoring methods to identify trends in population health, can support AI/AN
enrollment in clinical trials (with proper design and integration) and documents need and performance
measurements for grant funding.
With limited resources devoted toward transition to ICD-10 and meeting ongoing CMS Meaningful Use
standards, it is critical to take a strategic approach that does not ignore the day-to-day operational
management and maintenance of both RPMS and non-RPMS systems. Health IT is no longer just a
business solution but has evolved to become a necessary extension of patient care; it is imperative that
current investments in IT be managed with dedicated resources and stable funding for on-going capital
planning and investment. Capital Planning and Investment Control (CPIC) makes sure that IT investments
line up with the IHS mission, goals, objectives, and supports business needs, while minimizing risks and
maximizing returns throughout the investment's life cycle. CPIC relies on systematic selection, control,
and continual evaluation processes to ensure meeting investment objectives.
Investments in IT enhance organizational performance. When carefully managed, IT can improve business
processes, make information widely available, and reduce the cost of providing essential Government
services. As IT rapidly evolves, the challenge of realizing its potential benefits also becomes much greater.
Dental Services: +$37.2 million
Dental health is a top Tribal health priority. The $37.2 million increase includes inflation plus $31.2 in
program increases to address this growing health disparity. Dental disease can affect overall health and
school and work attendance, nutritional intake, self-esteem, and employability. This disease is preventable
when appropriate public health programs are in place.
21
THE IMPORTANCE OF THE DENTAL HEALTH AIDE THERAPIST MODEL
CASE STUDY: NW Portland Area Oral Disease
Early Childhood Caries (ECC) is the most prevalent chronic disease of childhood and is five times more prevalent
than asthma. Approximately 70 percent of AI/AN children experience dental decay in their primary dentition
(baby teeth). Almost half of those children have severe ECC, which causes both pain and infection and can affect
a child’s overall health and well-being. A Washington State Department of Health survey evaluated the oral health
status and treatment needs of children in Washington State. Compared with the survey’s random sample of
elementary school children, 37% of AI/AN children had a history of rampant decay, as compared with 15% of all
children surveyed. The findings suggest a problem with dental access that is confirmed by IHS data showing that
AI/AN children are served by fewer dentists, are less likely to be served by fluoridated water systems, and have
greater treatment needs than the general population. In addition to the burden of disease, there is a tremendous
backlog of dental treatment needs among AI/AN dental patients in all age groups. Unfortunately, sufficient
staffing and facilities are simply not available to meet all the dental needs of the AI/AN population.
A National Solution: The DHAT Model
Where authorized under state law, the Dental Health Aide Therapist (DHAT) model provides services in areas
where regular dental care is not available. DHATs live and work in the communities they serve providing
continuity of care, increasing dental health literacy, and providing a valuable service that prevents far costlier
expenditures down the road. Pioneering this cost-efficient and effective method of providing much needed dental
services; Alaska has 27 certified DHATs providing direct access to care to over 35,000 AI/AN people. This
program provides a rewarding career for people wishing to remain in their villages while serving their people. The
program also provides two-year post high school dental provider education targeted at rural Alaska students from
areas where access to dental care is limited. Students complete two years of education to provide basic dental
restorative services (fillings and extractions) and prevention program implementation. A supervisor provider
works as part of a team led by a licensed dentist. The DHAT Educational Program has annually generated an
average of 76 jobs (dental assistants, training program faculty, management, and ancillary staff) and generated $9
million in economic activity in rural Alaska (Scott and Co., 2010 Survey of Tribal Health System Dental
Directors). The DHAT model has proven effective, but the training program is primarily grant funded and
currently at risk of closing down unless stable funding is secured.
The Workgroup strongly recommends that the IHS work to expand the use of DHATs throughout the I/T/U service delivery
area by working within current law.
According to the IHS, over 80 percent of AI/AN children ages 6-9 years suffer from dental caries, while
less than 50 percent of the U.S. population ages 6-9 years have experienced cavities. AI/AN children ages
2-5 years exhibit an average of six decayed teeth, while the same age group in the U.S. population averages
one decayed tooth. Furthermore, preventative care is one of the most critical aspects to ending dental
disease for AI/ANs and we urge the Administration to support robustly preventative dental programming
in its FY 2017 budget.
The IHS Dental program supports the provision of dental care through clinic-based treatment and
prevention services, oral health promotion, and disease prevention activities, including topical fluoride
application and dental sealants. The demand for dental treatment remains high due to the significant dental
caries rate among AI/AN children. Funds are used for staff salaries and benefits, contracts to support
dental services, dental lab services, training, supplies, and equipment. These funds are needed primarily
to improve preventive and basic dental care services, as over 90% of the dental services provided by I/T/Us
are used to provide basic and emergency care services. More complex rehabilitative care (such as root
22
canals, crown and bridge, dentures, and surgical extractions) is extremely limited, but may be provided
where resources allow.
For the general U.S. population there are
approximately 1,500 patients per dentist, while there
are more than 2,800 AI/AN patients per dentist
employed by the IHS and tribal dental clinics. It is
essential that dental clinics serving the AI/AN
population operate efficiently while also devoting time
and dollars to the primary prevention of dental
disease. Most dental professionals do not receive
adequate training in terms of either clinic efficiency or
community-based prevention.
Mental Health: +$70.4 million
Tribal leaders identified that Mental Health is a top concern and recommended a $70.4 million increase
total (includes inflation and an additional $67.5 million in program increases) above the Fiscal Year 2016
Budget Request. Without a major infusion of resources in FY 2017, IHS and tribal programs will continue
to have limited staffing for their outpatient community based clinical and preventive mental health
services. Further, any inpatient and intermediate services, such as adult and youth residential mental health
services and group homes, which are sometimes arranged through states and counties, will have to be
accessed off the reservation or outside the Tribal system.
Access to adequate care, from local para professional providers to contracted specialty care providers is
critical to address the vast mental health needs for American Indians and Alaskan Natives who seek care
from their Tribal health and direct service facilities. AI/ANs
suffer high rates of chronic exposure to stress3, which impacts the
overall health and wellbeing of individuals and communities.
Additionally many tribes recognize historical trauma, the crossgenerational transmission of trauma from historical losses (e.g.,
loss of population, land, and culture), as the root of
disproportionate rates of depression, suicide, reoccurring trauma
from domestic violence and sexual assault. Historical trauma,
which Duran refers to as “Soul wounding” can be described as
unresolved generational trauma, generated by historical policies
of genocide, boarding schools, relocation and more currently
child welfare practices. New epigenetic research 4 provides
support of physiological impact of historical trauma. These
experiences, and the subsequent loss of traditional kinship
systems, traditional language, spiritual practices and cultural
American Foundation for Suicide Prevention
3
R.A. Bulatao, NBe. Anderson Understanding racial and ethnic differences in health late in life: A research agenda. The National Academies
Press, Washington, DC (2004)
A. Crawford. “The trauma experienced by generations past having an effect in their descendants”: narrative and historical trauma among
Inuit in Nunavut, Canada. Transcultural Psychiatry, 0 (0) (2013), pp. 1–31
4
23
VISITING INDIAN COUNTRY
When President Obama and First Lady Michelle initially
arrived on the Standing Rock Indian Reservation on June 13,
2014, they visited with a group of Lakota teenagers.
“Before we came here, Michelle and I sat with an amazing
group of young people. I love these young people. I only
spent an hour with them. They feel like my own. And you
should be proud of them – because they’ve overcome a lot,
but they’re strong and they’re still standing, and they’re
moving forward. And they’re proud of their culture. But they
talked about the challenges of living in two worlds and being
both “Native” and “American.” And some bright young
people like the ones we met today might look around and
sometimes wonder if the United States really is thinking
about them and caring about them, and has a place for them,
too.
“There’s no denying that for some Americans the deck has
been stacked against them, sometimes for generations. And
that’s been the case for many Native Americans. But if we’re
working together, we can make things better. We’ve got a
long way to go. But if we do our part, I believe that we can
turn the corner. We can break old cycles. We can give our
children a better future. I know because I’ve talked to these
young people. I know they can succeed. I know they’ll be
leaders not just in Indian Country, but across America. And
we’ve got to invest in them and believe in them and love
them, and that starts from the White House all the way down
here.”
President Obama also spoke to economic development,
tribal sovereignty, education, justice, tribal courts and
violence against women.
values impact the core of self-worth and identity, and
has left a legacy of familial and community grief, and
a cycle of economic conditions that continue to
contribute to the extraordinary mental health needs.
Tribes, Tribal programs and direct service facilities
are in various stages of implementing trauma
informed care in their health care programs. Safety,
trustworthiness,
choice,
collaboration,
and
empowerment are the core values of a traumainformed culture of care. In 2007, the National
Center for Health Statistics noted that AI/ANs
experience serious psychological distress 1 ½ times
more than the general population.
In 2013 (the most recent year for which data are
available), 41,149 suicide deaths were reported in the
United States, making suicide the tenth leading cause
of death for Americans. That year, someone in the
U.S. died by suicide every 12.8 minutes. At least 90
percent of all people who died by suicide were
suffering from a mental illness at the time, most often
depression. Of particular concern, AI/AN represent
the highest rates of suicide of any group in the U.S.
for all ages.
An eleven-year study (1999-2010) by the Dr.
Jacqueline Gray, University of North Dakota, reveals
the suicide rate for AI adolescents and young adults
from 15-34 is 2.5 times the national average for that
age group.
As an example, in Alaska, Alaska Native people were 5.1 times more likely to be hospitalized for a suicide
attempts and self-harm than non-Natives statewide (2002-2010, 26.8 and 5.3 per 10,000, respectively,
p<0.05). Alaska Native people aged 20-29 years had the highest intentional injury death rate of any age
group (133.4 per 100,000). The rate for this age group was 2.6 times the age-adjusted rate for all ages
(51.6 per 100,000, p<0.05). (ANTHC epicenter)
Unlike other groups where the suicide rate increases with age, AI/AN rates are highest among the youth
and decrease with age. Without adequate resources to address mental health needs, rates of suicide of
AI/ANs will continue its current trend.
The IHS National Tribal Advisory Committee on Behavioral Health was established in 2008. The
Committee has provided technical support to the IHS Behavioral Health Work Group, composed of Tribal
and urban Indian health representatives who are providers and experts in the field of behavioral health.
Since that time, the Committee and the Work Group advised IHS on the development of the National
American Indian/Alaska Native Behavioral Health Strategic Plan (2011-2015). This was a critical process,
as the plan relays that the future of AI/AN health depends on how effectively behavioral health is
24
addressed by our families and communities and integrated in our local health care delivery systems. The
plan provides an honest assessment of a wide spectrum of mental health disorders and illnesses and
community wide challenges that effect many AI/AN communities. It also lays out positive community
and cultural approaches and traditional practices balanced with western approaches that would be
implemented to address urgent, short term and longer term needs. These include some of the prevailing
and serious issues such as depression, suicide, domestic violence and co-occurring mental health and
substance abuse disorders.
The plan takes into serious consideration how the passage of the Affordable Care Act, which included a
major revamping of the Indian Health Care Improvement Act section on Behavioral Health, that is the
cornerstone to aid the development of inpatient, outpatient and prevention services essential to the overall
health of Tribal communities and each community member.
Alcohol and Substance Abuse Treatment: +$85.3 Million
Of the challenges facing AI/AN communities and people, no challenge is more far reaching than the
epidemic of alcohol and other substance abuse. Tribal leaders understand this and have once again
identified it as a top budget priority for FY 2017. The Workgroup recommends a program increase of
$85.3 million over FY 2016 (for both inflation plus $77.6 million for program expansion). Without a
major infusion of funding, AI/AN people will continue to be consistently over represented in statistics
relating to alcohol and substance abuse disorders in which higher rates of methamphetamine, cocaine and
marijuana use are reported.
From 2000 through 2013, the age-adjusted rate
for drug-poisoning deaths involving heroin
increased for all regions of the country, nearly
quadrupled from 0.7 deaths per 100,000 in 2000
to 2.7 deaths per 100,000 in 2013. Most of the
increase occurred after 2010 and the greatest
increase is seen in the Midwest.5
“I will tell you, as persuasive as I like to believe I might have
been in coming up with solutions, I do not think I could match
the conversation that the President and First Lady had with
six Native American youth who told their stories. The things
that the president is going to remember Is not me yacking on
about housing, I think their take away will be those six
amazing youth leaders who have had life challenges that most
people could only imagine. They experience things that
children their age should not have to have been confronted
with – whether it be experiences involving suicide, parental
addiction or whatever else there was.
These numbers are consistent with the reports
throughout Indian Country about increases of
heroin addiction. Also, with more stringent
regulations around prescription opioids, more
people are turning to heroin as a relatively cheap
and apparently easy accessible alternative.
Several hospitals in Alaska have seen an alarming
increase of infants born in 2014 addicted to
heroin. The growing use of heroin has spurned a
resurgence of public health issues like Hepatitis.
What I will really remember is a young Native American girl
sitting next to Nicole Archambault the chairman’s wife who
was literally shaking with excitement. When the president
turned and looked at her, she burst into tears. It was a
reminder to me, as the President and First Lady were
spending that time there, they were demonstrating: ‘You
children are valued and you are important, that is why we're
here.’ You could see that pride in the people that
participated.”
Senator Heidi Heitkamp [D-ND]
Reflects on Historical Presidential Visit to North Dakota
Review of medical records from 2002 -2011
indicated that alcohol was documented as being associated with 63.2% of all intentional injury
5
Drug-poisoning Deaths Involving Heroin: United States, 2000–2013Read
Holly Hedegaard,
more at M.D., M.S.P.H.; Li-Hui Chen, M.S., Ph.D.; and
Margaret Warner, Ph.D
http://indiancountrytodaymedianetwork.com/2014
/06/24/sen-heitkamp-reflects-historic-presidential-25
visit-north-dakota-155439?page=0%2C3
hospitalizations and 32.2% of all unintentional injury hospitalizations among AI/AN, based on blood
alcohol and breathalyzer tests and other notes in the patient’s medical record. Almost three out of five
(57.5%) suicide attempt and self-harm hospitalizations among Alaska Native people were reported as
alcohol-related.
Now that Tribes manage a majority of alcohol and substance abuse programs, IHS is in a supportive role
to assist the Tribes plan, develop and implement a variety of treatment modalities. The collaboration has
resulted in more consistent evidenced-based and best practice approaches to address substance abuse
disorders and addictions in a more cultural appropriate manner. At the community level, this is
accomplished through individual and group counseling, peer support, and inpatient and residential
placement. Treatment approaches also include traditional healing techniques that link the services
provided to traditional cultural practices and spiritual support for the individual AI/AN that Tribal
programs have found successful. The Wellbriety Movement, based on the teachings of Native elders,
includes a variety of holistic treatment programming for AI/ANs struggling with substance abuse. The
term Wellbriety conveys both sobriety and wellness. The GONA (Gathering of Native Americans) process
reflects the Native concept of the four levels of human development and responsibility, providing a
structure for community gatherings addressing substance abuse. These are just 2 examples of cultural
approaches that aid in healing.
IHS funding supports the operation of youth residential treatment facilities and services for women with
children up to age 24, but as in all health care, third party reimbursement has become increasingly relied
upon by these facilities. Medicaid reimbursement is an important resource, however not fully accessible
and always contingent on state policies with regard to the level of reimbursement for covered and optional
services if adopted in a State Medicaid Plan. The Youth Regional Treatment Centers, for example, serve
tribal youth from multiple states and youth do not obtain residential status for at least 30 days. Limited
funding often results in placement decisions based on the availability of alternate resources and the
providers’ clinical recommendations.
The National American Indian/Alaska Native Behavioral Health Strategic Plan (2011-2015) provides a
comprehensive approach to address alcohol and substance abuse and its tragic consequences, including
death, disabilities, families in crisis and multi-generational impacts. IHS, Tribal and urban Indian health
alcohol and substance abuse programs continue to focus on integrating primary care and behavioral health
services, being more responsive to emerging trends and the instituting best and promising practices that
align with culture based prevention and treatment.
Domestic violence rates are alarming, with 39% of AI/AN women experiencing intimate partner
violence—the highest rate in the U.S. It should be noted that Congress and this Administration recently
highlighted the need to address the major issues of violence and sexual and domestic abuse against AI/AN
women in the re-authorization of the Violence Against Women Act (VAWA) (Public Law 113-4) and the
Tribal Law and Order Act (TLOA) (Public Law 111-211). Alcohol and other substance abuse is often a
precursor to these serious issues in Tribal communities. In addition to that, Section 714 of the Indian
Health Care Improvement Act Provisions Passed in the Patient Protection and Affordable Care Act (P.L.
111-148), authorizes the establishment of a culturally appropriate program, in each IHS area, to prevent
and treat Indian victims of domestic and sexual violence and perpetrators of domestic and sexual violence
in Indian households.
26
These authorities will enhance efforts and provide potential funding and coordination of effort among
agencies in the area of alcohol and substance abuse prevention, treatment, data analysis and community
based research.
Purchased/Referred Care Program
(PRC): +$248.3 million
The PRC program pays for urgent and emergent and other
critical services that are not directly available through IHS
and Tribally operated health programs when:
1. No IHS direct care facility exists,
2. The direct care facility cannot provide the required
emergency or specialty care, and
3. The facility has more demand for services than it can
currently meet.
Funding for PRC remains a critical priority for all Tribes. For
this reason the recommendation of $248.3 million includes an
inflation adjustment plus an addition $200 million in new
funding. The PRC budget supports essential health care
services from non-IHS or non-Tribal providers and includes
inpatient and outpatient care, emergency care, transportation,
and medical support services such as diagnostic imaging,
physical therapy, laboratory, nutrition, and pharmacy
services. These funds are critical to securing the care needed
to treat injuries, cardiovascular and heart disease, diabetes,
digestive diseases, and cancer, which are among the leading
causes of death for AI/ANs.
As the national trend to attract and retain qualified healthcare
providers continues to become more challenging, we see a
correlation of increasing need for PRC referrals.
With current funding levels already insufficient to meet the
demand, this exacerbates disparities in care and outcomes for
AI/ANs. Additionally, the recent trend to construct smaller
joint venture outpatient ambulatory care centers will likely
increase the reliance on PRC resources for hospital-based
care.
In FY 2012, IHS denied 186,353 eligible PRC cases eligible,
and; again in FY 2013 denied services for 213,360 PRC
eligible PRC cases AI/ANs. This upward trend demonstrates
that the PRC need continues to grow in the IHS system and
that additional resources are needed to address this chronic
and underfunded need.
MEDICARE LIKE RATES FOR PRC
In addition to providing additional funding for
PRC, one common-sense solution to ensure that
these funds to go further would be for PRC
reimbursements to be paid non-hospital
providers are made at “Medicare Like Rates.” In
2003, Congress amended the Medicare law to
authorize the Secretary of Health and Human
Services to establish a rate cap on the amount
hospitals may charge IHS and Tribal health
programs for care purchased from hospitals
under the PRC program. However, hospital
services represent only a fraction of the services
provided through the PRC system.
On April 11, 2013, the Government
Accountability Office (GAO) issued a report
that concluded, “Congress should consider
imposing a cap on payments for physician and
other nonhospital services made through IHS’s
CHS program that is consistent with the rate paid
by other federal agencies.” We agree: these
savings would result in IHS being able to
provide approximately 253,000 additional
physician services annually. This number will
even be greater when you consider Tribally-run
programs.
The Workgroup appreciates the work that the
Administration has done to move this issue
forward through the rulemaking process and
look forward to working with you as the rule
moves forward. However, a statutory change
would be a better option. Enacting legislation to
require Medicare Like Rate payments for IHS
PRC would guarantee access to care and ensure
compliance with the rate.
We urge the Administration to work with
Congress to see that this no-cost beneficial
change is enacted.
27
At current funding levels, many IHS and Tribally
operated programs are only able to cover Priority I
services to preserve life and limb and are often unable
to meet patients’ needs fully within even this one PRC
service category. Many Tribes are forced to ration care
by delaying or denying Priority II referrals. These
delays and denials often cause the patients’ health to
get worse, leading to higher treatment costs down the
road and sometimes death. Failure to pay PRC claims
also means that patients are often given only
symptomatic treatment, leading to worse health
outcomes and increased long-term costs to the Indian
health delivery system.
51ST STATE FOR MEDICAID
Access to PRC dollars also varies widely between IHS
areas, due to the decision to expand Medicaid in some
states and not others. For example, Albuquerque Area
has noted that some facilities are now referring Priority
IV cases when last year they were only referring
Priority I cases, due to New Mexico’s decision to enact
Medicaid Expansion. Others, however, are not even
meeting Priority I. AI/ANs in states like South Dakota,
Oklahoma, and Alaska are held hostage by the state
government’s decision not to expand Medicaid.
This is a key reason why Tribes are asking for a 51st
State for Medicaid for Indian Country that would be
administered by the federal government. Allowing
IHS or another federal agency to administer Medicaid
rather than going through states would ensure that
Indian People are getting the care they need. This
would better articulate the federal government trust
responsibility, circumvent states opting not to utilize
Medicaid expansion, eliminate unnecessary passthrough expense to the states and provide all Tribes
with an equitable level of service across the country.
Public Health Nursing: +$3.1 million
Public Health Nursing (PHN) is a community healthnursing program that focuses on promoting health and
quality of life and preventing disease and disability.
The PHN program provides quality, culturally
sensitive primary, secondary, and tertiary health
promotion and disease prevention nursing services to
individuals, families and community groups. Home‐
based services are most often related to chronic disease
management, safety and health maintenance care for elders, investigation and treatment of communicable
disease, breastfeeding promotion, pre/postnatal education, parenting education, and screening for early
diagnosis of developmental problems. However, PHN also offers traditional food programs that focus on
food choices that are not only culturally appropriate but consider health challenges for AI/ANs, health
system patient navigator assistance programs, tobacco cessation programs, cancer screening programs,
onsite emergency care assistance, and community mental health support, education, and programs. The
request includes inflation plus $584,000 in expanded services.
Health Education: +$1.1 million
The Health Education program supports the provision of community, school, and worksite health
promotion, patient and professional education, and the development of educational materials for staff,
patients, families, and communities. Current focus areas include health literacy, patient-provider
communications, and the use of electronic health information by and for patients. The need for health
education activities is important in order to empower AI/AN patients to become better informed about
their own personal health and the wellness of their Tribal communities. The request includes inflation
over the FY2016 base plus $457,000 in program expansion.
Community Health Representatives (CHR): +3 million
The CHR program helps to bridge the gap between AI/AN individuals and health care resources through
outreach by specially trained members of the Tribal community. CHRs integrate basic medical knowledge
about health promotion and disease prevention with local community knowledge. They often play a key
role in follow-up care and patient education in Native languages and assist health educators implement
prevention initiatives. Their role is crucial in Indian country. They are considered an integral member of
the health care team.
28
With the opportunity provided under the IHCIA, which expands the permissible uses of appropriated funds
to include community-based care, additional resources are needed to increase CHR trainings and increase
the CHR workforce. The request includes inflation plus $557,000 in expanded services.
Alaska Immunization: +$80,000
Hepatitis B Program: Viral hepatitis, including hepatitis B, and other liver diseases continue to be a health
disparity for AI/ANs in Alaska. The Alaska Native Tribal Health Consortium (ANTHC) Hepatitis B
Program continues to prevent and monitor hepatitis B infection, as well as hepatitis A and hepatitis C
infections, throughout the state of Alaska. In FY14, maintained high vaccine coverage was reported;
hepatitis A vaccination coverage was 93% and hepatitis B vaccination coverage was 97%.
Immunization (Hib) Program: Immunization is a fundamental health prevention activity for Alaska Native
people. In 1990, elevated rates of Haemophilus Influenzae B (Hib) among Alaska Native children
prompted an immediate call to action for increased vaccination coverage, especially in Alaska Native
communities with limited access to care. High vaccination
coverage rates have resulted in a 99% reduction in Hib
meningitis and vaccination coverage rates amongst Alaska
TAX EXEMPT STATUS FOR IHS
Native children continue to be the highest in Alaska. The
LOAN REPAYMENT
ANTHC Immunization Program maximizes the prevention
of vaccine-preventable disease by providing directed
Indian Health Service (IHS), Tribal and
Urban facilities serve smaller, often rural
resources, staff training, and coordination to tribes in Alaska.
populations with primary medical care and
Support services also include site visits and consultation for
community based health care services.
the varying electronic health records (EHR) systems within
each tribal health organization to facilitate immediate access
IHS relies upon student loan repayment
to complete vaccine records. Dedicated immunization
programs to recruit and retain medical
professionals. However, these funds are
funding has ensured continued access to vaccines in Alaska
taxable, drastically reducing the number of
Native communities and high vaccine coverage for Alaska
medical professionals that can be acquired
Native children and adults. The request includes a small
with limited funds. If there were a taxprogram increase of $3,000 plus inflation of $77,000.
exempt status, the program would be able to
fund an additional 105 loans. A productive
strategy to increase the number of medical
Urban Indian Health: +$11.7 million
professionals in Indian Country without
Our request is for a program increase of $10 million, plus
increasing the budget, therefore, would be to
inflation over the FY 2016 base, for a total of $11.7 million.
allow these limited funds to be tax exempt.
Thirty-six Urban Indian Health Programs provide health care
and substance abuse services in fulfillment of the federal trust
The Workgroup urges the Administration to
continue to support this legislative change in
responsibility to more than 100,000 AI/ANs each year.
its FY 2017 Budget.
Operating in 21 states, these programs are funded from an
IHS line item of only $43.6 million, which is less than 1% of
the total IHS budget. Urban Indian Health Programs are
unable to access PRC funding and other resources from the general IHS budget, and consequently have
become adept at leveraging their modest base funding with additional health care dollars from other
federal agencies, states, and foundations. Urban Indian Health Programs offer services to all AI/ANs.
Indian Health Professions: +$1.3 million
Because IHS focuses on primary and community based care, the need for professional well-staffed
facilities is key for prevention and treatment for AI/ANs. Indeed, this lack of access to quality healthcare
29
contributes to a life expectancy of 4.2 years less for AI/AN individuals. Just over half of this request is
for inflation proofing plus an additional $564,000 to expand funding to address unmet need.
The Indian Health Professions program manages the IHS Scholarship and Loan Repayment programs,
health professions training related grants, and recruitment and retention activities for IHS and intern/
externship programs.
The program enables AI/ANs to enter into health care professions through a system of preparatory,
professional, and continuing educational assistance programs that serve as a catalyst for community
development by enabling AI/AN health care professionals to further Indian self-determination through the
delivery of health care. The program also assists in the recruitment and retention of qualified health and
mental health professionals to work in the Indian health system. The program utilizes technology to
provide educational and training opportunities virtually as well as clinical experience and continuing
education credits. Statewide support through Locum pools help with personnel for “hard to fill” and high
demand professions. The program helps fund statewide-centralized databases for professionals to allow
efficient tracking and reporting of continuing education and training. Generally, individuals who come
to IHS on the student loan repayment program stay with IHS for eight years, thereby providing a more
stable continuum of care for our people.
Tribes continue to support efforts by the agency to engage in creative recruitment and retention practices
for staff. However, more needs to be done. Some IHS Areas experience vacancies for medical
professionals up to five years. In the long-term, this means that clinics close, thereby denying care to
AI/ANs. With a nation-wide physician shortage, this problem is only likely to grow. It is vital that the
Administration work with Congress to be able to offer competitive pay rates and better working
environments.
Tribal Management Grants: +$49,000
The purpose of the Tribal Management Grant (TMG) Program is to assist federally recognized Tribes and
Tribal organizations in assuming all or part of existing IHS programs, services, functions, and activities
(PSFAs) under self-determination and operate these programs at the Tribal level. TMG also assists
established self-determination contractors and self-governance compactors to further develop and improve
their management capability and conduct health program planning.
The Tribal Management Grant Program provides discretionary, competitive grants to Tribes and Tribal
organizations to conduct planning and evaluation, including the development of any management systems
necessary for contract/compact management and the development of cost allocation plans for indirect cost
rates; and to plan, design, and evaluate Federal health programs serving the Tribe, including Federal
administrative functions. The program provides resources to allow Tribes to analyze PSFAs to determine
if management by a Tribe or Tribal organization is practicable and develop the accompanying
organizational and governmental infrastructure, as well as internal management systems needed to carry
out effectively these PSFAs.
This grant opportunity is an important resource for Tribal capacity-building and technical assistance
needed to empower Tribes and Tribal organizations to exercise rights under the Self-Determination and
Education Assistance Act. All federally-recognized Tribes and Tribal organizations are eligible to apply
for Tribal Management Grants. Priority is given to newly recognized Tribes and Tribes and Tribal
organizations addressing material audit weaknesses.
30
Direct Operations: +$1.2 million
The Direct Operations budget supports the leadership and overall management of IHS. This includes
oversight of employees, facilities, finances, information, and administrative support resources and
systems. Funding is allocated to IHS Headquarters, Area Offices, and Tribal shares. These funds ensure
that the IHS is able to perform its essential residual functions in support of the I/T/U. In addition, it
provides management support for direct service Tribes and system-wide administrative functions,
contributing to better health outcomes for AI/ANs. The request includes inflation plus $128,000 for
expansion of services.
Another essential function of IHS’ Direct Operations is Tribal Consultation. The agency is continually,
and rightfully, consulting with Tribes and their representatives in Workgroups, advisory committees, and
other negotiations. These meetings require not only support for basic meeting functions such as travel
and facility space, but also technical support for Tribal leaders to engage in meaningful consultation. All
of these functions are essential to maintaining the government-to-government relationship and the trust
responsibility. Funds should be specifically allocated in FY 2017 to support technical advisors and
meeting travel for these consultations.
Self-Governance: +$421,000
The Self-Governance budget supports negotiations of Self-Governance compacts and funding agreements,
oversight and coordination of the Agency Lead Negotiators (ALN), technical assistance on Tribal
consultation activities, analysis of new authorities in the IHCIA, Self-Governance Planning and
Negotiation Cooperative Agreements, and funding to support the activities of the Tribal Self-Governance
Advisory Committee, which advises the IHS Director on self-governance policy issues. The request
includes inflation plus $328,000 to expand Self-Governance support in FY 2017.
Title V of the ISDEAA provides the IHS statutory authority to enter Planning and Negotiation Cooperative
Agreements to assist Tribes in planning and negotiation activities associated with self-governance.
Cooperative Agreement awards involve much more substantive Federal program-specific involvement
than a grant, which is key to a successful self-governance planning and negotiation process.
These Cooperative Agreements provide resources to Tribes first entering self-governance as well as
existing Self-Governance Tribes interested in expanding their current PSFAs. Title V of the ISDEAA
requires that a Tribe or Tribal Organization complete a planning phase to the satisfaction of the Tribe. The
planning phase must include legal and budgetary research and internal Tribal government planning and
organization preparation relating to the administration of health care programs. The planning phase helps
Tribes to make informed decisions about which PSFAs to assume and what organizational changes will
be necessary to support those PSFAs.
These Cooperative Agreements also provide resources to Tribes to help defray the costs related to
preparing for and conducting self-governance negotiations. This enables a Tribe to set its own priorities
when assuming responsibility for IHS PSFAs and assist the Tribe during the negotiation of a selfgovernance compact and funding agreement. Self-Governance formalizes and recognizes the
government-to-government relationship between the United States and each Tribe, and empowers Tribes
to plan, design and carry out programs and activities that are most responsive to the health care needs of
their communities.
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Program Expansion Increases - Facilities Budget
The Workgroup recommends a program increase of $48.5 million for Indian Health Facilities over the
FY 2016 President’s Budget and $100 million to address Binding Agreements for pending Health Care
Facility Construction projects for a total increase of $148.5 million.
Maintenance & Improvement (M&I): +$23.5 million
The recommended amount represents a program increase of $23.545 million ($2 million in current
services +$21.5 million in program increases) above the FY 2016 President’s Budget request for the M&I
line item of $89 million. All Tribal Area budget formulation sessions reported the critical need for a
program increase in this category. The recommended M&I funds increase are to support and enhance the
delivery of health care and preventive health services and to safeguard interests in real property. M&I
funds are distributed to four categories: routine maintenance, M&I projects, environmental compliance
and demolition. Routine maintenance funds are used to pay for the following typical maintenance
activities: emergency repairs, preventative maintenance activities, maintenance supplies and materials,
building service equipment replacement, training, and local projects. This amount is also referred to as
“sustainment” or the amount necessary to sustain a facility in its current condition. M&I Project Funds
are for larger projects that accomplish major repairs and improvements of primary mechanical, electrical,
and other building systems as well as public law compliance. Environmental compliance and demolition
funds are distributed by headquarters to the Areas with approved project documents.
Maintenance and improvement funding allocated to the Areas is based on the total supportable space of
eligible IHS programs. The Indian Health Service has approximately 1,371,000 square meters of
supportable space, federal and tribal, eligible to receive maintenance and improvement funding. Based
on the total amount of M&I available and the total amount of supportable space eligible for M&I funding
IHS is at “sustainment.” The IHS is only able to fund routine maintenance. There is no funding available
for M&I projects. The IHS has a documented Backlog of Essential Maintenance, Alteration, and Repair
(BEMAR) for each facility eligible to receive M&I. The total amount of BEMAR for IHS is
approximately $467 million. Therefore, increased funding is needed, to continue to address routine
maintenance, address environmental compliance, energy reduction projects and to start to reduce the
BEMAR.
Increased maintenance and improvement funding will also allow IHS to improve infrastructure, building
systems (boilers, emergency generators, chillers, etc.) of health facilities. The increased funding will
allow facilities to replace aging generators, boilers, chillers, HVAC systems, electrical systems, and
plumbing systems. Renovating and upgrading the existing building infrastructure will extend the useful
life of existing buildings allowing health care services to continue. Keeping existing facilities in excellent
condition is a number one priority since funding for new health facilities is very limited. Increased funding
allows facilities the ability to renovate, expand and improve buildings and building systems to keep up
with the utility requirements for state of the art medical equipment thus ensuring enhanced medical care
to all Native Americans and Alaska Natives.
The mission of the IHS is to raise the physical, mental, social, and spiritual health of American Indians
and Alaska Natives to the highest level. Ensuring that the Indian Health Service has well maintained,
adequate sized and current up to date infrastructure to provide health care is ensuring the physical, mental,
social and spiritual health of American Indians and Alaska Natives is raised to the highest level.
32
Sanitation Facilities Construction (SFC): +$16.3 million
The recommended amount represents a $16.339 million increase ($2.4 million in current services for
binding agreements + $21.6 million in program expansion) above the FY 2016 President’s Budget of $115
million for the SFC line item. Due to the remoteness of Tribal communities and lack of infrastructure, the
need for improvements and maintenance of water supply, sewer systems and solid waste facilities remain
substantial. The SFC program is an important Indian health disease prevention program. It yields positive
results by directly improving environmental conditions making a positive impact on the health of
individuals on a day-today basis thereby reducing medical care costs.
IHS reported in the FY 2016 Congressional Justification that at the end of FY 2014, the list of documented
sanitation project deficiencies totaled $3.39 billion. Of these projects, $1.93 billion is the amount needed
for projects considered economically and technically feasible. It was reported that about 217,000 or
approximately 56 percent of AI/AN homes need improvements and that about 6.1 percent of the homes
are without potable water.
For years, the appropriation level has not been sufficient to address the backlog. A $13.9 million increase,
however, would help many families improve their lives by providing water wells or connecting their
homes to community water and waste water systems and upgrading and maintaining these systems. These
projects would be prioritized from the IHS Sanitation Deficiency System inventory.
The provision of sanitation facilities is an extension of primary health care delivery. The availability of
essential sanitation facilities can be a major factor in breaking the chain of waterborne communicable
disease episodes but by no means is their value limited to disease intervention. Safe drinking water
supplies and adequate waste disposal facilities are essential preconditions for health promotion and disease
prevention efforts. Efforts by other public health workers are much more effective when safe water and
adequate wastewater disposal systems are in place.
Patients admitted to the hospital have longer lengths of stay due to lack of sanitation facilities at home.
An example of this is an elderly patient with a broken hip who should be discharged home but has no
indoor water and sewer facilities and typically uses an outhouse located a long distance from the home.
Many of these patients end up being admitted to off reservation nursing homes where exposure to
nosocomial infections may worsen the chance of good outcome and return home.
The provision of sanitation facilities also has other far-reaching, positive effects. The availability of such
facilities is of fundamental importance to social and economic development. In turn, such development
leads to an improved quality of life and an improved sense of well-being.
A recent cost benefit analysis indicated that for every dollar IHS spends on sanitation facilities to serve
eligible existing homes, at least a twentyfold return in health benefits is achieved. The IHS Sanitation
Facilities Construction Program has been the primary provider of these services since 1960.
The IHS Areas that Tribes reported significant need to increase the SFC line item include Alaska,
California, Navajo (AZ, NM, UT), Phoenix (AZ, NV, UT), Portland (OR, WA, ID) and the Tucson Area
in southern Arizona.
Health Care Facilities Construction (HCFC):
Authorities: +$7.56 million
Binding Obligations: +$100 million & New
33
The recommended increase for the Health Care Facilities Construction line item is $100 million above the
FY 2016 President’s Budget request. Tribes are keenly aware that the lack of facilities is a major barrier
to access to adequate health care in Indian Country. This could easily be remedied by increasing the funds
necessary to begin construction of projects listed for decades on the IHS HCFC priority list and,
additionally, by advancing parterships with Tribes to implement a new national health care facility
planning and construction system. Both are required under the Indian Health Care Improvement Act.
Dedicated resources for construction should be one of the highest priorities of the Administration and is
necessary to improve quality of health care for AI/AN. Some of the existing facilities are very dated with
an average age of 47 years and have surpassed their useful lives. The facilities are grossly undersized for
the identified user populations, which has created crowded, even unsafe, conditions among staff, patients,
and visitors. In many cases, the management of existing facilities has relocated ancillary services outside
the main health facility; often times to modular office units, to provide additional space for primary health
care services. Such displacement of programs and services creates difficulties for staff and patients,
increases wait times, and create numerous inefficiencies within the health care system.
While the total amount identified currently for HCFC projects exceeds $2.1 billion, an additional $100
million would allow one or two additional projects to complete design and progress through construction.
In addition, new IHS funded health facilities in remote and isolated areas typically must include a request
to include funds to construct government quarters to provide suitable housing to support the recruitment
and retention of medical professionals and ancillary staff.
Lastly, of major concern to Tribes who do not have projects on the priority list, is the number of years and
the amount of funds it will take to complete these projects before they can even get on the priority. The
IHS Health Facilities Construction Priority System (HFCPS) or Priority List is the assembly of “justified”
projects dating back to 1994.
The IHCIA authorizes New Authorities in which Tribes may initiate innovative approaches or
demonstration projects to deliver health care, which are identified in the law. For these purposes, an
additional amount of $7.56 million is requested in FY 2017 for this purpose.
Ten of the 12 IHS Areas support this level of increase to the HCFC line item. Three Areas, Navajo,
Phoenix and Tucson indicated it was a major priority. Three Areas, Billings (MT, WY), Phoenix and
Portland noted that Tribes would benefit by funding New Authorities.
Facilities & Environmental Health Support (FEHS): +$8 million
A recommended increase of $8 million ($7.5 million for current services and $438,000 in program
expansion) is sought for this line item. The FEHS staff provides important levels of support to operate
and maintain the real property and buildings in the Indian health care system. In addition, these
professionals plan and design new and replacement facilities projects and support sanitation facilities
construction and environmental health services activities.
A new health facility improves access to care and the quality of care by improving the design
(functionality) and increasing the size of facilities to better support existing and new health services.
When new IHS health facilities are approved for construction, the subsequent staffing packages provide
additional providers and improved access to basic and expanded health care services. In addition, new
IHS funded health facilities in remote and isolated areas typically include the construction of government
34
quarters to provide suitable housing to support the recruitment and retention of medical
and ancillary staff.
professionals
FEHS staff ensures that the IHS continues to demonstrate its commitment toward quality health care by
maintaining their facility accreditation/certifications, undertaking quality improvement initiatives, and
meeting established quality performance targets. A number of facilities seek The Joint Commission
accreditation or Centers for Medicare and Medicaid Services (CMS) certification.
Equipment: +$6.2 million
Tribes recommend a program increase of $6.2 million (current services at $1.2 million and program
expansion of $5 million) for Equipment above the FY 2016 President’s Request of $23.5 million.
Equipment funds are critically needed for new and routine replacement of medical equipment, to obtain
new and like-new medical equipment through the Department of Defense and to procure ambulances for
IHS and Tribal emergency medical services programs. Tribal leaders believe that by making this increase
available more preventative screening and diagnostic services provided in IHS and tribal healthcare
facilities relieves the need to refer some of the cases to PRC providers. An important investment must be
made to allow IHS and Tribal facilities to acquire telemedicine and Electronic Health Record technologies.
The last significant increase to purchase equipment came through the 2009 American Reinvestment and
Recovery Act (ARRA), in which a portion of ARRA funding was used for this purpose. Since then
subsequent allocations have not kept pace with replacement requirements which are necessary to ensure
quality care and the safety of our patients.
For example, as the existing health care facilities continue to age, the associated building equipment and
components deteriorate to a point of failure and the decreasing availability of replacement parts on this
aged equipment ultimately disrupt the already limited health care services. The piping systems providing
potable water for health services frequently experience failures, which require the shutting down of
systems for extended periods of time and patient care is disrupted until appropriate repairs can be made.
The rural and often isolated conditions associated with many IHS health facilities complicates the repair
of failed systems and extends the time required to make needed repairs. The constant system failures
deplete designated maintenance and improvement funds and require the use of third party collections or
other funding sources that would otherwise be used for direct patient care. In terms of medical and
laboratory equipment, the IHS makes every attempt to keep pace with changing and updated technologies;
however, as a result of limited equipment funds, IHS health facilities typically use equipment well beyond
its expected useful life.
 3 r d Recommendation: Higher Increase in H&C for Local Priorities
This recommendation addresses an emerging concern expressed by Tribes that the roll-up of budget
priorities at the national level, coupled with the formula-basis used to distribute appropriated funds,
restricts the ability of Tribes to have access to non-formula funds to address local health issues. Local
priority health issues and budget priorities are identified within the Hot Topics section of this document
for each IHS Area. Congress no longer has the ability to “earmark” funds to address local health crises in
their districts, and often times local health crises do not rise up to a level of a national health initiative like
the Special Diabetes Program for Indians. As such, an innovative approach must be created to allow the
flexibility needed to fund critical health issues identified by Tribes within each Area. This request includes
35
an additional increase within the Hospital & Clinics budget line, which can be used by the agency, in
consultation with the Tribes, to address these local budget needs.
Examples of local priorities that never make it to the national level for funding include the village built
clinic lease issue in the Alaska Area, the methamphetamine in pregnant women crisis in the Billings Area,
the STD/HIV prevention and screening for Tribal jails in the Navajo Area, and the need for Detox services
in the Phoenix Area, among others. The Indian Health Service does not have any flexibility in existing
budget lines to address local issues. Providing an additional amount within the H&C budget line would
provide resources needed to address crisis level issues, which impact the life and safety of Tribal
communities.
A CASE STUDY: IMPROVING HEALTH THROUGH EQUITABLE FEDERAL
FUNDING FOR INDIAN COUNTRY
As a means of targeting improved health for Indians, one example is the need to request special
allocation of funds for Hepatitis C Virus (HCV) similar to what has been provided to the VA. Beginning
at a small scale in 2014, select IHS, Tribal and Urban facilities began treating American Indian and
Alaska Native (AI/AN) people for HCV with the class of Directly Acting Antivirals (DAAs) recently
approved by the the Food and Drug Administration. These drugs represent a breakthrough. Prior to the
introduction of the new high-cost treatment therapies in January 2014, the treatments for Hepatitis C
were often ineffective and presented considerable side effects to the user. By contrast, new DAAs are
more effective at curing patients with HCV, present significantly fewer side effects than earlier options,
and are much simpler to administer. Cure of HCV significantly decreases the risk of progression of
disease to cirrhosis, liver failure, liver cancer, and death. IHS wants to ensure all AI/AN with HCV can
access treatment. The new DAAs, as with all, are expensive even with federal discounts, which is a
significant barrier to initiating and scaling up treatment in proportion to the clinical needs of our patients.
IHS requests similar funds to scale as what was allocated to the Veterans Administration for HCV
treatment in 2014 (370 million) and what they requested for 2015-2017 (697-660 million). IHS requests
95 million in 2016, 180 million in 2017 and 170 million in 2018, projecting treatment of 1,500 people
in 2016, 2,800 people in 2017 and 2,650 people in 2017.
The Workgroup urges the Administration to begin supporting IHS as it does VA, starting with increased
funding for the FY 2016 Budget and including amounts for FY 2017 and FY 2018.
 4th Recommendation: Fund Indian Health Care Improvement Act New
Authorities at $300 Million
The implementation of the Indian Health Care Improvement Act (IHCIA) remains a top priority for Indian
Country. IHCIA provides new authorities for Indian health care, however additional funding is needed to
fully implement the Act. The recommendations described elsewhere in this document are to provide for
the services that IHS already provides; however, at least an additional $300 million is critically needed in
order to begin to implement and fund the new priorities in IHCIA. Tribes fought for over 10 years to
36
renew IHCIA and the Administration and Congress should act to fulfill the promise enacted by the 2010
law.
Tribes recommend that IHS reprogram existing resources to take advantage of these new authorities that
would be more beneficial for their communities, when requested and consulted. The battle for IHCIA
renewal was over ten years in the making. When this historic law was signed, Indian Country was elated
by the promise of a new and more efficient health care delivery system for AI/AN people. However, five
years later many of the provisions of the Act remain unfunded, and in many ways, repesents yet another
broken promise for Indian people.
The American health care delivery system has been revolutionized while the Indian health care system
waited for the reauthorization of the IHCIA. For example, mainstream American health care increased
focus on prevention as a priority and coordinated mental health, substance abuse, domestic violence, and
child abuse services into comprehensive behavioral health programs is now standard practice. Replicating
these same improvements for Tribes in the IHCIA was a critical aspect of the reauthorization effort. The
time and resources paid off with the permanent reauthorization of IHCIA. Highlights of what is contained
in the IHCIA Reauthorization include:
o Updates and modernizes health delivery services, such as cancer screenings, home and community
based services and long‐term care for the elderly and disabled.
o Establishes a continuum of care through integrated behavioral health programs (both prevention and
treatment) to address alcohol/substance abuse problems and the social service and mental health needs
of Indian people.
One key component is supporting the health professional development in Indian Country. For instance,
Section 112 of the law which Authorizes the Secretary to fund demonstration programs for Indian health
programs to address chronic shortages of health professionals. This could go a long way in ending the
chronic lack of health professionals in Indian Country. Additonally, the law authorizes the establishment
of a mental health technician program within IHS to train Indians as mental health technicians to provide
community-based mental health care to include identification, prevention, education, referral, and
treatment services.
An additional $300 million will only begin to scratch the surface of implementing these new budget
authorities. While we understand the tight fiscal constraints that govern the budget request, it is crucial
for the Administration to begin to make these funds a priority in next year’s budget. With a direct request
to make this a priority from the Adminsitration, Congress is much more likely to provide funding for
these critical programs in FY 2017.
 5 t h Recommendation Permanent Exemption from Sequestration
In FY 2013, Indian Health programs were subject to a 5.1 percent automatic, across the board cut. This
means a staggering $220 million left the IHS, which already is under funded by an average of 41%. Several
Members of Congress publicly stated that this was clearly an oversight, and that IHS should not have been
held to the full sequester. Nevertheless, Tribes and federally run IHS direct service programs were left
with an impossible choice – either deny services or subsidize the federal trust responsibility. In fact, many
37
did close their doors for several days per month and forced others to deliver only PRC for Priority I. The
Indian Health Service is one of only four federally funded services providing direct patient care; however,
it was the only one of the four, not exempted from sequestration. This oversight, which created an unsafe
hardship for Indian patients seeking care, must be permanently corrected.
For fiscal years 2014 and 2015, Congress has found a way out of
sequestration for discretionary programs. However, the Budget Control
Act (BCA) (P.L. 112-25), has mandated sequestration each year
through FY 2021. Indian health simply cannot take any more
sequestration cuts. Section 256 of the BCA explicitly holds IHS to 2
percent for any year other than FY 2013. However, with an already
underfunded rate of 59 percent for the IHS, even a 2 percent cut is too
much. Tribes should not be held responsible for the inability of the
federal government to balance its books.
“Our country’s financial
troubles are not really
stemming from our obligations
to Indian Country, and
frankly, we’re not doing a
good job in fulfilling those
obligations.”
Senator Maria Cantwell (D-WA)
November 14, 2013
Should sequestration occur in FY 2016, the Workgroup encourages the Administration to work with
Congress to ensure that Tribes do not find themselves in this situation again, and the FY 2016 budget
should reflect that commitment by permanently exempting the IHS from sequestration.
Program
Population Served
Social Security
Retirees, Survivors and Individuals with Disabilities
Medicare
Citizens/Residents 65 Years or Older, Individuals with
Disabilities or End-Stage Renal Disease
Medicaid and Children’s Health
Insurance Program
Low-Income Families with Dependent Children, Pregnant
Women, Individuals with Disabilities
Veterans Affairs Programs
Veterans
Indian Health Service – Special Diabetes
Program for Indians
American Indians and Alaska Natives with Diabetes
Sequestration
Exempt
1
Exempt
Exempt
Exempt
2.0
Indian Health Service –
American Indians & Alaska Natives
5.1
Services and Facilities
1
Note: Medicare is subject to a 2% reduction cut. The reductions in Medicare spending would come from payments to various
health care providers, but beneficiaries would not be directly impacted. Beneficiaries may feel the effects if the payment cuts
lead physicians and hospitals to stop treating Medicare beneficiaries.
 Other Policy Recommendations
Advance Appropriations for the Indian Health Service
For several years, Tribes across Indian Country have voiced their support for Advance Appropriations for
the Indian Health Service. An advance appropriation is funding that becomes available one year or more
38
“We need to ensure that the health of Indian
people is not subject to the whims of political
stonewalling, much like it was during the
recent
government
shutdown
and
sequestration.”
after the year of the appropriations act in which it is
contained. 6
This means, that IHS and Tribal health
providers would not have to have funding inconsistency or
disruption when managing their health care delivery.
Currently, our programs must make long-term health care
decisions with only short-term funding guaranteed.
Advance appropriations would allow Indian health
programs to effectively and efficiently manage budgets,
coordinate care, and improve health quality outcomes for
AI/ANs. This change in the appropriations schedule will
help the federal government meet its trust obligation to Tribal governments and bring parity to federal
health care system. IHS and Tribal health administrators would not waste valuable resources, time and
energy re-allocating their budget each time Congress passed a continuing resolution. Indian health
providers would know in advance how many physicians and nurses they could hire without wondering if
funding would be available when Congressional decisions funnel down to the local level. Health care
services in particular require consistent funding to be effective.
- Senator Jon Tester (D-MT), Senate
Committee on Indian Affairs, April 2, 2014
For example, in Alaska, short-term funding means basic operating costs are more expensive. Heating oil
is a major expense in this region, but it is cheaper if you buy in bulk in September, rather than buying in
bits and pieces as continuing resolutions come out from Congress. In September, health providers can buy
oil that is pulled in by barge, but by November or December the oil must be flown in which dramatically
increases the cost. Indian health budgets operate on the margins and delayed appropriations make this
situation even worse. No private health provider would operate this way, and I/T/Us should not have to
either.
“Now, the care that our veterans receive should
The Veterans’ Administration (VA) achieved
never be hindered by budget delays. I've shared this
advance appropriations for its health programs in
concern with Secretary Shinseki, and we have
2009. That legislative change received support
worked together to support advanced funding for
from this Administration. IHS, like the VA, also
veterans' medical care. What that means is a timely
provides direct health care to individuals. We
and predictable flow of funding from year to year,
encourage the Administration to support parity
but more importantly, that means better care for our
between VA and IHS and to request advance
veterans.”
appropriations for IHS in its FY 2016 Budget.
Renewal of the Special Diabetes Program for
- President Barack Obama, April 9 2009
Indians
As part of the Balanced Budget Act of 1997,
Congress established the Special Diabetes Program for Indians (SDPI) to address the growing epidemic
of Type 2 diabetes in American Indian and Alaska Native (AI/AN) communities. The Special Diabetes
Program for Type 1 Diabetes (SDP) was established at the same time to address the serious limitations in
Type 1 diabetes research resources. Together, these programs have become the nation’s most strategic,
Advance appropriations differs from “forward funding,” which allows funds to become available beginning late in the
budget year and is carried into at least one following fiscal year. Forward funding is counted against the same budget year.
Advance appropriations is counted only in the budget year for which the appropriated dollars will be spent.
6
39
successful and comprehensive effort to combat diabetes. SDPI is transforming lives and changing the
diabetes landscape in America.
According to the Centers for Disease Control and Prevention (CDC), AI/AN adults have the highest ageadjusted prevalence rate of diagnosed diabetes compared to other major racial and ethnic groups at 16.1
percent. By comparison, this is almost twice the rate for the total U.S. adult population. Some regions of
Indian Country have diabetes rates as high as 33.5 percent, with specific communities having Type II
diabetes reach a level as high as 60 percent.
Today, SDPI is funded at a level of $150 million per year and supports 404 diabetes treatment and
prevention programs in 35 states. With funding for this critical program set to expire on September 30,
2015, Tribes are requesting a renewal of this program of $200 million/ year for 5 years. While we
understand an increase in funds during this budgetary environment is difficult, SDPI has been level-funded
since 2002. This represents an effective decrease. Calculating for inflation, $150 million in 2002 would
be about $115 million in 2014 – or 23 percent less. In order to keep the momentum of this important
program alive, it is critical that the federal government continue to invest in SDPI, which will save millions
in preventative care over the long term. When taking into account additional Tribes that have gained
federal recognition since 2002, the dollars are even scarcer.
Without long-term reauthorization, the critical infrastructure that the Tribes have built to address the Type
2 diabetes epidemic in Indian Country and has greatly contributed to the success of SDPI will be lost. A
delay in renewal will mean loss of SDPI staff – loss of jobs – that will severely impact tribal health: both
in terms of patient health and community economic health.
40
CONCLUSION
This Administration has in its power the historic opportunity to write a new future for American Indians
and Alaska Natives. Finding a relatively miniscule $29.96 billion out of the annual federal budget to
improve the health status of it First citizens will not only turn the corner in Indian health treaty and trust
obligations but it is the right thing to do. The human impact on this nation’s first people will be immediate
and profound. Not only will monumental strides be made to honor the Trust responsibility accepted by
the U. S. Government in past treaties and agreements with Tribal Chiefs and sovereign Tribes, but also
President Obama and his administration will leave a legacy, which will represent an epic advancement in
the traumatic history between U.S.-Tribal relations.
Like Congress, this Administration understands that programs, services, functions and activities provided
to AI/ANs through compacts, contracts, and direct operations of the IHS are Tribal trust and treaty
obligations grounded in the Constitution and numerous federal laws. This President has the power to
honor these treaties by advancing a budget which meaningfully addresses gross health disparities and
which offers a true promise of hope for 1.2 million Tribal members. President Obama must leave his
legacy by acting now to provide a meaningful increase of at least 22% for the IHS in FY 2017 and to put
into action a plan for future Administrations to fund 100% of our $29.96 Billion Tribal Needs budget.
Americans, who understand the history of the U.S. and Tribal relations, strongly support the need for our
government to honor the treaties made with sovereign Tribes. Those who have met with Tribal leaders
are surprised that such deplorable health conditions continue to exist on reservations and in villages; many
have expressed a willingness to partner with Tribes to advocate for change. They understand the injustice
of continuing to disregard the health and lives of all Native Americans who have paid with their lives,
their lands, and their sovereign rights. Future generations of Americans will hold our government in
account for its responsibilities to American Indians and Alaska Natives. It is time to end the unnecessary
death and suffering occurring every day in Indian communities – centuries of neglect are now an urgent
humanitarian cry for justice and equity for our First Peoples. Our Native youth deserve a chance at a better
future. Our elders deserve the rest and peace that comes with knowing their fight is over. Our country
deserves the honor of living up to its morale and binding obligations to American Indians and Alaska
Natives.
Working Together NOW– Writing a New Future for
Indian Health
We urge you, as our President, to resolutely turn the corner in Indian Health Treaty and Trust obligations
and write a brighter new future for all American Indians and Alaska Natives.
Together, we have the collective power to work with an informed Congress to make measurable
improvements in the health status and quality of life of America’s First Peoples. You have heard our
people voice emotional and desperate concerns during numerous Tribal consultation sessions. You have
witnessed the innocent hope in our youth contrasted against the growing weariness of our elders. You
have empathized with despair felt when socio-economic conditions and lack of funding challenge the best
of the best of our Tribal leaders. You can re-write the future. In this constrained environment, Congress
relies on the Administration to exercise its duty to recommend a responsible budget, one which reasonably
addresses the disparate healthcare needs of American Indian and Alaska Native peoples. Working within
41
the Budget Control Act constraints, Tribes can no longer rely solely on Congress to right size to our budget
unmet needs. The Administration must work with Tribal leaders as partners to set a new path forward.
As this and future Administrations move to reform America’s health care system, it is imperative that
Tribes not continue to be left behind. With the right resourcing, the Tribal health system can be the model
for true, low-cost sustainable health care delivery. A budget of 22% in FY 2017 with a strategy to phasein the $29.96 billion is necessary to achieve reform within the Indian health care system and raise health
parity for all American Indian and Alaska Native citizens. We understand that this presents a fiscal
challenge, but we believe in the President and our Great country’s valiant commitment to justice.
Throughout this Administration, President Obama has continually spoken of the need to keep the promises
made to AI/ANs – now is the time for action, we must turn the corner and write a new and better
future for American Indians and Alaska Natives.
“We haven’t solved all our problems. We’ve got a long road ahead.
But I believe that one day, we’re going to be able to look back on
these years and say that this was a turning point.”
President Barack Obama
White House Tribal Nations Conference
December 2, 2011
42
ACKNOWLEDGEMENTS
National Tribal Budget Formulation Workgroup Area Representatives
Alaska
Victor Joseph, President/ Chairman, Tanna Chiefs Conference
Verne Boerner, President/CEO, Alaska Native Health Board, Native Village of Kiana, Alaska Tribal Health
Caucus
Albuquerque
Raymond Loretto, Governor, Pueblo of Jemez
Gary Hayes, Ute Mountain Ute Tribe
Bemidji
Phyllis Davis, Councilmember, Match-e-be-nash-she-wish Band of Pottawatomi Indians of Michigan
Robert Two Bears, Representative, Ho-Chunk Nation Legislature
Billings
Darwin St. Clair, Chairman, Eastern Shoshone Tribe
Darrin Old Coyote, Chairman, Crow Tribe
California
Stacy Dixon, Chairman, Susanville Indian Rancheria
Mark Romero, Tribal Chairman, Mesa Grande Band of Mission Indians
Great Plains
John S. Steele, President, Oglala Sioux Tribe
Harold Frazier, Chairman, Cheyenne River Sioux Tribe
Nashville
Rita Gonsalves, Health System Administrator, Mashpee Wampanoag
Shaylynn Raphaelito, Health Director, American Indian Community House
Navajo
Leonard Tsosie, Navajo Nation Council Delegate
Theresa Galvan, Health Services Administrator
Oklahoma
Marshall Gover, President, Pawnee Nation
John Williams, Osage Nation
Phoenix
Amber Torres, Vice Chairperson, Walker River Paiute Tribe
Emilio Escalanti, Council Member, Quechan Tribe
Portland
Andy Joseph Jr., Councilmember, Colville Tribal Business Council
Steven Kutz, Council member, Cowlitz Indian Tribe
Tucson
Wavalene Romero, Vice Chairman Tohono O’odham Nation
Peter Yucupicio, Chairman, Pascua Yaqui Tribal Council
Special thanks to all IHS
Staff, especially the IHS
Budget Formulation staff,
for assistance in preparation
of this document.
Tribal Technical Workgroup
Technical Support Team
Alaska – Gerald Moses and Jacoline Bergstrom
Dee Sabbattus – Nashville
Albuquerque – Sandra Winfrey and Maria Rickert
Alida Montiel – Phoenix
Bemidji – Jeff Bingham
Jim Roberts – Portland
Billings – Tafuna Tusi and Garland Stiffarm
Great Plains – Jerilyn Church
Rudy Soto – National Council on
Urban Indian Health
Nashville – Kevin Tarrant
Caitrin Shuy - NIHB
Navajo – Alva Tom and Margaret Morgan-Benally
Carolyn Crowder – NIHB
Oklahoma – Melanie Fourkiller and Mark Rogers
Phoenix – Alida Montiel
Portland – Joe Finkbonner and Jim Roberts
Tucson – Rachael Vilson-Stoner
43
APPENDIX
 APPENDIX A: HOT ISSUES BY IHS SERVICE AREAS
ALASKA
ISSUE: Village Built Clinic Lease Program Shortfalls
The Village Built Clinic (VBC) lease program is a unique and critical component of the health care delivery system in rural
Alaska. The delivery of quality health care is dependent on having a well-maintained clinic facility. Obtaining adequate and
fair funding for the VBC lease program has been a priority of the Alaska Tribal Health System (ATHS) for many years. The
dramatic increases in energy costs in rural Alaska have accentuated the funding crisis. We are requesting that IHS fully fund
the VBC leases at $17 million.
VBC leases, administered by the IHS, are used to fund of the costs associated with health clinics in rural Alaska. VBCs are the
sole health care facilities for their communities in the vast, predominantly road-less regions of rural Alaska. Current funding
levels for the VBC leases provide only a fraction of the operations costs resulting in deteriorating clinic buildings, reduced
operations, deferred building maintenance, accreditation compliance problems and ultimately a threat to the provision of safe
patient care in the villages. In some cases, there is no running water to the clinic. It’s difficult to imagine it’s a reality that there
are instructions on how to provide a urine sample in an outhouse at these clinics, bearing in mind that these are in areas where
temperatures are often at subzero levels, but reality it is. Even in clinics with running water they must often choose between
paying for heating oil or janitorial services (or other maintenance/operation expenses as highlighted later), which adversely
impacts patient/provider health and safety.
BACKGROUND: Community Health Aide Program (CHAP) – Alaska Native people in rural communities depend on local
health clinics as their only source of primary health care. The CHAP is mandated by Congress as the instrument for providing
basic health care services in remote Alaska Native villages. The CHAP is the backbone of the rural health care system and in
many cases provides the only local source of health care for many Alaska Native people. Certified Community Health
Aide/Practitioners, Dental Health Aide Therapists and Behavioral Health Aide/Practitioners provide ongoing services based
out of the village clinic facilities. In addition, medical, dental, eye care, and behavioral health professionals itinerating to the
villages from the regional hospitals use the clinics.
Alaska has about 170 VBCs, generally owned by the local city, tribal government or the regional tribal health corporation
serving that community. The IHS leases the clinic facilities in order to provide clinic space for the CHAP. Unfortunately, years
of underfunded lease payments have left many of the clinic facilities in disrepair, and in some cases closed. Rural Alaska was
fortunate that many of the clinics were upgraded or replaced through partnership between the clinic owners and the Denali
Commission. Unfortunately, continued underfunding of the VBC lease program will also jeopardize this investment in our
communities.
CHRONIC UNDERFUNDING: Since the mid-1970s, the IHS has consistently under-funded the VBC leases. The last
significant increase to the program occurred in 1989, at which time the number of clinics funded was also increased. VBC lease
program has not received an increase to its base since then. In FY 2006, a study showed the lease payments to the villages
covered only 55 percent of operating costs statewide. The costs of doing business in rural Alaska have increased tremendously
since then. In order
to hold the system of care together, financial responsibility for the village clinics has shifted from the IHS to the village
governments and/or regional health corporations.
MAINTENANCE AND OPERATIONS: VBC leases are “Full Service Leases” which cover most basic expenses involved
with maintenance and operation of the clinic facilities. Those expenses include basic rental costs (loan
amortization/depreciation, fuel, electric, water/sewer/refuse, janitorial services/ supplies, maintenance and repair
services/supplies and building insurance). In 2011 the IHS developed revised Guidelines for Environmental Health Practices
at Village Health Clinics to provide a tool for annual inspections of the VBC-leased Facilities. For most clinics, the IHS lease
monies do not cover the actual cost of fuel, electricity, and water/sewer bill let alone provide funds sufficient to maintain a high
quality healthcare environment.
44
HOT TOPICS BY IHS SERVICE AREA
This crisis in funding clinic operation and maintenance costs now threatens decades of investments by the federal government,
rural Alaska villages, and regional tribal health organizations.
RECOMMENDATION: The Alaska Tribes request an increase of recurring funding (currently at $4.5 million/year) to the IHS
in the amount of $12.5 million (for a total of $17.0 million/year), to adequately fund operation and maintenance of VBCs leased
by the IHS in rural Alaska.
ISSUE: IHS Advance Appropriations
Late funding has significantly hampered budgeting, recruitment, retention, provision of services, facility maintenance and
construction efforts of tribal and IHS health care providers. Providing sufficient, timely and predictable funding is needed to
ensure the federal government meets its obligation to provide health care for American Indian and Alaska Native people.
BACKGROUND: Since FY 1998, appropriated funds for medical services and facilities through IHS have not been provided
before the commencement of the new fiscal year and only one year (FY 2006) when the Interior, Environment, and Related
Agencies budget, which contains the funding for IHS, has been enacted by the beginning of the fiscal year.
In FY 2010, the Veterans Administration (VA) medical care programs achieved advance appropriations. The fact that Congress
has implemented advance appropriations for the VA medical programs provides a compelling argument for tribes and tribal
organizations to be given equivalent status with regard to IHS funding. Both systems provide direct medical care and both are
the result of federal policies. Just as the veterans groups were alarmed at the impact of delayed funding upon the provision of
health care to veterans and the ability of the VA to properly plan and manage its resources, tribes and tribal organizations have
similar concerns about the IHS health system.
RECOMMENDATION: Work with Congress to take the necessary steps for IHS funding to begin an advanced appropriations
cycle so that tribal health care providers, as well as the IHS, would know the funding a year earlier and would not be subject
to continuing resolutions.
ISSUE: Contract Support Costs
In the FY2016 Budget Request to Congress, the Administration has proposed that Contract Support Costs (CSC) be transitioned
from the discretionary budget to the mandatory category. If the proposal were enacted, CSC would be made mandatory for
three years, (FY2017-FY2019) with increases each year to account for the estimated growth in future CSC need. The funding
would also be reclassified as “no year” funding and therefore available to be carried over in future years. This legislative change
will guarantee legal compliance to fully pay CSC, while ensuring that these payments do not take limited funds from the other
areas of the IHS services budget.
BACKGROUND: CSC are the funds that Tribes and Tribal organizations receive from the government to manage health and
other programs that were previously operated by the federal government. The CSC funding obligation should not have been
achieved at the expense of other Tribal programs.
RECOMMENDATION: For FY 2015 and beyond, Tribes are requesting that Congress continue to fully fund CSC without
requiring cuts from other IHS programs. Furthermore Alaska tribes advocate for enacting the transition to Mandatory funding
of CSC as early as FY2016; and ensure that Direct Services budgets at IHS are not impacted by this change.
ISSUE: Long-term Care/Eldercare
Alaska tribal health organizations are opting for nursing rather than assisted living because the rates are cost-based in Alaska.
More tribal health organizations might be interested in assisted living if IHS provided some operating funding for individuals
needing care, but not nursing-level care. These services include residential care, such as nursing homes and assisted living
facilities, home and community-based services, caregiver services, case management and respite care.
BACKGROUND: The authority for IHS to offer and fund long-term care services presents great promise for meeting the needs
of our Elders and those with disabilities. Alaska Native elders and those with disabilities should have access to the long-term
services and support necessary to remain healthy and safe while retaining as much independence as possible in their
communities.
RECOMMENDATION: Alaska tribes urge the IHS to target funds to implement LTC services as authorized under the IHCIA.
There is also a need to support and coordinate the efforts of IHS and the Centers for Medicare & Medicaid Services to address
reimbursement and certification/regulatory issues.
45
ISSUE: Behavioral Health
Alaska experiences the highest rate of suicide per capita in the United States with Alaska Natives experiencing a higher risk of
suicide than any other ethnic group. Alaska also continually ranks as one of the most dangerous states for women with regard
to victimization of intimate partner or sexual violence. Alaska has one of the highest alcohol consumption rates per capita in
the nation. Evidence suggests that individuals that are addicted or abuse substances—use this as a coping mechanism to deal
with a history of trauma. All of which culminate to create a cycle of violence, trauma, abuse, that perpetuates from one
generation to the next and impacts the health and wellness of entire communities not in a domino fashion from one to the next,
but in wave fashion extending from the center and heaving outward and all around and catching all in its wake.
Behavioral Health services provide a net that can catch the boulders before they strike. These services also build retaining walls
to help protect family, friends, and communities when calamity does strike. Behavioral health directly affects physical health
and is key to a holistic approach to wellness and improving the overall health of our People and our Communities. Alaska tribes
have three recommendations:
Combine Mental Health and Alcohol & Substance Abuse Line Items
Behavioral Health is a more holistic view on caring and treating both mental health and alcohol & substance abuse. The
delineation pits one area above the other in priority, which on the local level can vary greatly with the national averages.
This hinders programs in ability to address one or the other. It also hinders taking an integrated approach by creating silos
of care.
BACKGROUND: While individuals may have a mental health disorder without a substance use disorder and vice versa,
a substantial number of individuals suffer co-occurring disorders and for those who don’t have a co-occurring disorder,
they are at higher risk of developing a co-occurring disorder.
RECOMMENDATION: In the interest of preventative care, and holistic approaches and granting tribes the ability to be
responsive to their needs with regard to behavioral health, Alaska recommends that the two separate line items, mental
health and the Alcohol & Substance Abuse line items be combined into a single line item.
Increase funding for Tele-Behavioral Health
BACKGROUND: Tele-behavioral health capabilities (Video Tele-conferencing—VTC) are essential to Alaska to expand
services to rural communities. Many of our Alaskan villages reside in remote areas off the road system, which contribute
to the lack of access to care. VTC offers promise, but some areas still require infrastructure development. In many villages
digital connectivity is non-existent or rely on a satellite-based Internet system that is slow and unreliable. According to the
Federal Communications Commission nearly 81% of rural Alaska residents lack access to modem broadband services with
sufficient speed needed (new benchmark of 25 megabits per second for downloads) for high quality voice, data and video.
In Alaska there is real difficulty in recruiting and retaining clinicians, psychiatrists and other behavioral health providers
statewide. Due to the remoteness of villages across the state and difficulty with transportation to these villages, maintaining
licensed providers in every rural community is impossible. Therefore Tele-behavioral health is a significant and crucial
component to the spectrum of resources within Alaska’s Behavioral Health programs.
RECOMMENDATION: Increase funding for tribal behavioral health programs to appropriately supply clinics throughout
the state with Video Tele-Conferencing equipment and the necessary Internet connectivity in order to expand service
delivery access to village based services.
Increase funding for Behavioral Health Workforce Development (Staff Recruitment & Retention)
BACKGROUND: Alaska is fortunate to expand services through its Behavioral Health Aide Model focusing on
prevention, intervention, treatment, case management and aftercare for those who are affected by trauma, substance use
and mental illness.
However, traumatized individuals or those with substance use and/or mental health disorders experience difficulty trusting
others, including behavioral health providers, to begin their healing processes. This is exasperated by staff turnover.
Alaska’s behavioral health programs statewide struggle with hiring Masters level qualified and licensed providers
necessary to improve the quality, quantity and consistency of the behavioral health workforce in Alaska.
46
RECOMMENDATION: Increase funding for support of recruiting, retaining and training culturally responsive Alaska
Native behavioral health providers; including supporting Alaska Native students studying within the field of psychology
through initiatives such as Alaska Native Community Advancement in Psychology with the mission is to increase the
number of Alaska Native college students majoring in psychology, graduating with a psychology degree and to promote
working in the behavioral health field throughout Alaska Native communities.
ISSUE: Special Diabetes Program for Indians
Few programs have proven to be as effective as the Special Diabetes Program for Indians (SDPI) has proven to be. Tribes are
implementing evidence-based approaches that are attesting to the improvement of quality of life, lowering treatment costs, and
yielding better health outcomes for tribal members. However, the disparities still exist. The progress made as a result of the
SDPI is at risk due to shorter authorization periods, flat funding and more tribes needing access to SDPI funds. As reported in
the Indian Health Service Special Diabetes Program for Indians 2011 Report to Congress:
SDPI not only provides the resources that enable the 404 grant programs to employ hundreds of health care
professionals but also supplies the tools that help hundreds more receive training in delivering quality diabetes
services. This strong network of professionals has dramatically increased access to diabetes medical care and
prevention services for tens of thousands of American Indian and Alaska Native people.
SDPI resources put a spotlight on diabetes. These resources enable local communities to concentrate on providing
essential services to prevent and treat diabetes—services that are not often reimbursable by third party payers. The
spotlight on diabetes would fade quickly without SDPI funding as communities would not have the resources to deal
with the diabetes epidemic.
BACKGROUND: The flat funding has meant that the existing programs have already lost purchasing power. Diluting the funds
further to include more tribes would adversely affect the current programs.
RECOMMENDATION: Alaska Tribes request for a minimum increase of $50 million for a new total of $200 million. Current
programs should be held harmless and with the additional funds, allow for tribes not currently funded to apply.
ALBUQUERQUE
At the Albuquerque Area's 12/ 15/14 consultation, the tribes were concerned that only the top 5 priorities would be
considered at the National Session. The tribal representatives agreed to choose the top 5 based on the number of service
units that voted for the line item, but there were additional line items that received votes that weren't in the top 5. The
Albuquerque tribes wanted to insure that these were also considered as priorities for the Albuquerque Area. Budget
Narratives for these additional topics have also been attached. Additional priorities in order of votes for the Albuquerque
Area tribes were:
• M&I
• Health Care Facilities Sanitation Facilities Urban
• Health Ed CHR
• Contract Support Costs
• Equipment
• PHN
• Self-Governance
The Ute Mountain Ute Tribe recognizes that such items as Maintenance & Improvement, Sanitation Facilities Construction,
Health Care Facility Construction, and Equipment are severely underfunded. The Tribe recognizes that the current facilities
are aging (most over 30 years versus the private sector which is well under 10 years of age). It is not only just the age of the
facilities which require significant funds to maintain but the inefficient design which hinders efficient patient care. Please
also note that the overall lack of space is preventing the hiring of additional providers.
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The ASU tribes agreed that the Health Care Facilities Construction Line Item has been underfunded for many years. Funding
to support the construct ion of new facilities of the IHS is needed to support current services and the expansion of additional
prevention and outreach.
Some IHS facilities are (or have) reached critical mass in age and they need to be replaced with new modern buildings. The
old buildings and structures make it difficult to provide basic services. The older buildings were not designed with expansion
in mind and therefore it is difficult (or too expensive) to modify older building to increase access to care; adding more exam
rooms and office space. The outdated design of older buildings often times contributes to poor patient/work flow which
creates bottlenecks in flow process and inefficiencies throughout the service line including high heating and cooling cots.
Limited access and poor work flow not only delays care it can also prevent care. The lack of access to care also limits the
ability for the Service Units to generate and collect much needed third party revenue. This revenue is needed in many cases
to supplement the annual appropriations.
The need for new, modern, up to date facilities ranging from dental offices to full service hospitals is dire within service
unit areas, specifically in remote and rural communities. The ASU campus was built in the early 1930s; the facility was
initially created as an inpatient hospital, it is now used as an ambulatory care clinic. The design is outdated and is not
conducive to easy access and clinic flow. Many of the IHS facilities are outdated and should be replaced with modern
structures. Additional funding will help with providing more new construction throughout Indian Country.
The Pueblo of Laguna specifically supports the Joint Venture (JVC) program. Replacement and repair of health care
facilities within tribal communities is a critical need to ensure the provision of quality health services. Many facilities on
reservation are older than 40 years in age and retrofitting and renovation are not cost effective.
The Mescalero Apache Tribal community lacks adequate water & sewer services to serve about 35% of the tribal
members that requ ire the service for new homes. There is a waiting list for members to obtain services.
The To'Hajiilee community has a poor domestic water system which creates health problems and diseases due to lack of potable
water and adequate sewer systems. As a result, the local people have to haul potable water from Albuquerque in water barrels
for drinking, cooking and other domestic use. The Indian Health Service started to develop the domestic water system in the
1960's and over the next 40 years expanded the system to serve 375 water customers. The Canoncito water wells are very
shallow and require allot of maintenance due to the infiltrations of sand into the pumps and casings.
The water quality is also very poor and has a very bad smell. In the early 60's the IHS. had the contractors use asbestos
water lines as the main trunk lines for 8 miles and today these asbestos pipes are still in use. This is another reason people
don 't drink the water. For the 17% budget increase, Canoncito allocated $61m for the budget line items Sanitation Facilities
Construction to improve water and sewage systems.
The Zuni tribe stated that the $325 million being recommended under the Binding Obligations is insufficient to cover all
needs. The RNSB, Inc. had a water emergency situation due to their water system constantly going down. The Pine Hill
Health Clinic ceased seeing patients until such time its water pressure is at an acceptable level. The Ramah Navajo
community water system had been installed by Indian Health Service and the Bureau of Indian Affairs over thirty (30)
years ago. The water system has lived its useful life making it difficult and expensive to operate and maintain the systems.
In addition, the EPA has cited numerous violations regarding the Pine Hill water system. EPA has threatening the
operations of the health center and the school system.
As for the Pueblo of Zuni, the tribe will be constructing a new elementary which will combine the enrollment of the two
present schools. This enrollment will be approximately 700 students. This will bring on the need for additional faculty
housing. There are also approximately 25 plus new residential home being built as indicated above. Improvement in the
sewage and water system is needed on a continued basis for areas that do not meet the present health standards.
The Urban Indian Health Line Item has been underfunded for many years. Funding to support the urban operations of the
IHS is needed to support current services and the expansion of additional prevention and outreach. Funding for Urban Indian
Health Services within IHS should be a high priority due to the increasing urban Native population. Urban Indian
communities are inter-tribal and represent over half of the Native American population in the U.S., yet they lack access to
sufficient health services . Urban Indian clinics are greatly underfunded. For most urban Natives the Urban Indian Health
Service is the only means of receiving health care. Most of these urban facilities are small in size and offer only limited
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services. Increasing funding for Urban Indian Health will allow more dollars to be spent on new positions (routine/specialty
care) to meet the patient demand for increase access to care as well as improvements to our systems including expanding
clinic hours and providing urgent care services.
A greater proportion or an increase in funding needs to be allocated to community-driven, culturally respectful, multi-year
behavioral programs to improve the screening, diagnosis, treatment , and survival of our Native population. With most urban
settings there is a large homeless population. Many of the homeless patients experience a wide range medical, dental, and
behavior health issues.
Additional funding will help with providing more services, education, and prevention. Quality and access will be improved
with increased funding by enabling urban Indian health programs to increase
their capacity to serve more patients (thereby decreasing wait times for appointments, emergency
room utilization, increasing the number of patients with a medical home etc.), improve their internal systems (e.g. ,hire more
support staff, create responsive triage systems, etc.) to be more efficient and effective thereby decreasing barriers to
accessing services, and increase the types of services available (e.g. ,add specialty care or ancillary services such as
pharmacy, lab, etc.) to maximize patients' treatment adherence and health outcomes.
These increases also take into account those factors that impact the cost for delivering services-- inflation, population
growth, staffing need, etc. Increased funding should allow for staff trainings in customer service for the requested budget
increase for urban Indian health. Also, funding should allow for eligible urban Indian health programs providing direct
health services to pursue accreditation including patient centered medical home accreditation which emphasizes more
patient-centered services that include customer service oriented (e.g., increased access to their providers, medical records,
etc. resulting in improved levels of satisfaction among their patients) . Given the changes in the health care environment
including competition among health care providers, customer service is a priority for urban Indian health programs including
FNCH.
IHS is a good investment because the increases will enable urban Indian programs to continue to provide and improve their
culturally sensitive health delivery systems to address the holistic needs of their patients. These increases will not only
improve access to direct services but also outreach and education, both critical for reaching more unserved American
Indians and for maximizing health outcomes among urban Indians. IHS is a unique health care program that provides a
unique service delivery system unmatched by other health care providers. In this sense, IHS is a good investment because
of its holistic and culturally sensitive approach to care. There are no health care entities that address these needs at no cost
to the urban Indian community. If urban Indian programs continue to be underfunded, these programs will be rendered
incapable of meeting the needs of its target population. Funding in many ways dictates the volume and quality of services
provided. Program must be able to address the rising health care costs associated with wrap around services.
The Denver Indian Health and Family Services, Inc. (DIHFS) proposes to use a budget increase to fund a full time Medical
Director as the organizations clinical leader and to fund a part time dentist. Each of these positions is important to providing
care to our American Indian/Alaska.
Native population in the Denver area. Currently DIHFS does not have a medical director. The need for a full time medical
director will oversee the clinical care in the facility, work with the interdisciplinary team to ensure quality care and
implement appropriate clinical policies, procedures, and programs, and work with the facility administration regarding staff
management and survey issues, quality assurance activities, and education and training for providers and clinical staff. The
Denver Urban dental clinic only provides clinic services 3 days a week. Adding another part time dentist will allow our
clinic to open up two more service days for our community. Currently, we are booked into February 2015. Being the only
Al/AN clinic in the Denver area, we have an unmet need. Expanding in this area is very essential to helping our community
with their dental needs. DIHFS is the only Al/AN clinic in the Denver area. Access to healthcare is certainly a priority;
therefor e DIHFS would like to see IHS allocate funds in our area of need. Improving customer service is one of DIHFS
highest priorities. I.H.S could provide training webinars that are culturally appropriate in customer service. Investing in
healthcare is not only an investment, but a priority. Again, with DIHFS serving the Al/AN, our funds are stretched among
many programs. If IHS invests more funds to our urban program, we can provide the quality care needed in serving our
community.
The First Nations Community Health Source (FNCH) will use a budget increase to reduce the inequities in funding by
addressing the need for increased funding among urban Indian health programs. Specifically, there is a need for additional
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direct medical services to support the provision of essential health services including routine and urgent ambulatory care,
medical support services such as laboratory, pharmacy, behavioral health screenings, nutrition education, etc.,to address the
chronic health, urgent care, and preventative health care needs among the urban Indian population .This also includes
specialized programs for maternal and child health, family planning, communicable diseases, youth services, women's
health, men's health, elder care, pre- and post-natal care, etc.
The impact of this increase is that it will address the increased service costs arising from the growth of the urban Indian
population which continues to grow each year. Funding this increase will enhance the ability of urban Indian programs
including First Nations Community Health Source (FNCH) to meet the current demand for services. Urban Indian health
programs provide affordable, quality, and culturally competent medical care and public health case management services as
well as wrap around services for urban Indians who do not have access to the resources offered through IHS or tribally
operated health care facilities. FNCH proposes to use the increased funding to expand its medical providers to include 1.0
FTE Pediatricians ($180,000),1.0 FTE Family Practice Physicians ($200, 000) and 2.0 FTE Medical Assistants ($65,000).
The addition of these positions will expand the provision of health services available for American Indians of all life cycles.
Additionally FNCH will use the increase to fund Alcohol and Substance Abuse services to decrease the incidence and
prevalence rates of alcohol and substance use rates among the urban Indian population to a level that is lower or equal to
the rates for the general US population through a network of urban Indian community based emergency, inpatient, outpatient
treatment and rehabilitation services. This funding will support the efforts of urban Indian programs in developing a
continuum of care of services that range from substance abuse prevention education, systems navigation, outpatient and
inpatient treatment, and step down levels of care. Also, the impact of this funding increase is to address the special needs of
urban Indians with co-occurring disorders with both mental illness and substance dependency. FNCH proposes to use the
increased funding to hire a 1.0 FTE Psychiatrist ($220,000) who will be co-located in primary care due to increased demand
for psychiatric services by clinic patients. The psychiatrist will provide psychopharmacology treatment, psychiatric
assessments and consultations and clinical treatment services. Having a FTE Psychiatrist will increase access to psychiatric
services, which are extremely limited in Albuquerque with unacceptable wait times for appointments. FNCH will also use
the increase to fund Mental Health Services to address the mental health needs (e.g., historical trauma, depression, domestic
violence, behavior-related chronic disorders, etc.) among the urban Indian population. Mental health services will include
both clinical and preventative care services with a spectrum of services ranging from crisis intervention, triage, psychiatry,
psychological assessments, screenings, case management, prevention programming, outreach, health education, and
individual, group, family and other treatment modalities. Mental health disabilities have a profound impact on the
individuals, their families and their communities.
Many urban Indians experience depression and an overwhelming sense of isolation due to their separation from their natural
supports on the reservation. This is further compounded by challenges experienced with their day-to-day living (e.g.,
homelessness, unemployment, etc.). FNCH proposes to use the increased funding to hire a .50 FTE Child Psychiatrist
($150,000) to provide psychiatric consultations and treatment to youth and children. FNCH also proposes to use the funding
to hire a 1.0 FTE licensed behavioral health clinician (e.g., Psychologist, Social Worker or Independently Licensed
Clinician) ($65,000) to provide clinical services including group, individual, and family counseling services to all life cycles.
FNCH will also use the increase to fund Diabetes prevention services to address the disproportionately high rates of diabetes
among the urban Indian population. Services will decrease the incidence and prevalence rates of diabetes among the urban
Indian population to a level that is lower or equal to the rates for the general US population through a network of urban
Indian community based prevention education services (e.g. healthy lifestyle education and promotion) that incorporate
culturally appropriate and evidence based practices proven effective in preventing diabetes among American Indians. The
onset of diabetes can result in a host of medical, dental, behavioral health and other problems including premature deaths
and suffering. FNCH proposes to use the increased funding to hire a 1.0 FTE Clinical Diabetes Educator ($75,000), 2.0 FTE
Community Health Workers ($80,000) to provide diabetes prevention education using evidence based practices to decrease
diabetes risk among the urban Indian community.
FNCH will use the increase to fund Immunizations and Methamphetamine and Suicide Prevention programs to prevent
premature deaths from the lack of immunizations, Methamphetamine use and Suicide. Services will decrease the incidence
and prevalence rates of deaths due to the lack of immunizations, Methamphetamine use and/or suicide to a level that is below
or equal to the rates for the general US population through a network of community based prevention education programs
that increase access to services, incorporate culturally appropriate and evidence based practices proven effective among
American Indians. FNCH proposes to use the increased funding to hire a 2.0 FTE Licensed Clinician Clinical ($150,000) to
provide mental health screenings to assess risk and mental health treatment and referrals for individuals assessed to be at
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risk for suicide. FNCH also proposes to hire a 1.0 FTE Public Health Nurse ($65,000) to provide immunizations in the
community with home visits, outreach activities, etc. to high risk patients with complex health care needs.
FNCH will also use an increase to fund HIV/AIDS services to provide HIV testing and counseling, cas management, medical
care and prevention education to decrease rates of HIV/AIDS among urban Indian communities. FNCH proposes to hire 2.0
FTE HIV Prevention Case Managers ($90,000) to provide HIV prevention education using evidence based practices,
confidential HIV testing and counseling and referrals for STD, Hepatitis C and Hepatitis B testing to high risk populations.
Finally, FNCH will use an increase to fund health promotion/disease prevention services to prevent premature and
unnecessary deaths by providing activities directed to the promotion of healthy lifestyles, community partnerships ,and
disease prevention education to all life cycles of the urban Indian communities. This increase can support the hiring of
community outreach workers/health educators with knowledge and cultural sensitivity to change community acceptance
and utilization of health care resources, including decreased emergency room utilization for routine care, and use of
community based networks and services to enhance health promotion and disease prevention.
FNCH proposes to hire 2.0 FTE Community Health Workers ($75,000) to provide health education, community outreach
and health screenings.
The Pueblo of Laguna stated that an increase in Health Education funds will aid in addressing the needs for behavior
change, education and self-care through well-trained professionals in tribal communities. Health education is critical to
case management.
CHR
The Pueblo of Laguna noted that the roles of CHRs in case management and patient navigation is invaluable to patients
accessing care when a health and disease issue arises. CHRs are able to provide information, interpretation and assist in
accessing services by coordinating transportation or providing the services directly.
CSC
The Zuni Tribe noted that there was a Congressional mandate to Indian Health Service to fund Tribal Grantees at 100% for
Contract Support Cost but not allocating additional funds to the IHS budget to cover the cost. We are recommending that
additional 7.6% of these funds be allocated for CSC. Funds are available to cover current services and binding obligations, but
not for CSC. We understand that this will continue to affect IHS's delivery of services as more Tribes contract these services
with IHS and long term solutions need to be identified to address this issue. The delivery of services will affect tribes if CSC
continues to be an issue. Tribal Leaders along with support from the IHS director needs to advocate Congressional support to
increase the IHS budget. Primarily Tribal Leaders need to advocate for increasing the budget for IHS.
PHN
The Pueblo of Laguna specifically supported the PHN program. PHNs are critical in providing case management for patients
and working as the linkage between 1.H.S. providers, Tribal services, and managed care organizations and non-reservation
based care systems. PHNs that are registered nurses and provide direct services generate a source of revenue for the tribal
system or IHS for patient care in the homes and community. The ACA has embedded case management into health care delivery
with Public Health Nurses, CHRs, Navigators and other field based providers that work in partnership with PHNs.
Impact of 638 Contracting on Direct Service Tribes
In November 2011, the Indian Health Service and the Pueblo of Santo Domingo successfully completed negotiations on a $3.2
million PL-93-638 contract. In January of 2012, Kewa Pueblo Healthcare Corporation (KPHC), the tribal entity charged with
carrying out the terms of the contract, assumed control of 100% of Santo Domingo’s tribal shares in Dental Services, Mental
Health, Substance Abuse, and Public Health Nursing. With the contract, KPHC also assumed control of 63% of Santo
Domingo’s Hospitals and Clinics tribal shares, with the remainder retained within the Santa Fe Service Unit (SFSU) to support
services based at the Santa Fe Indian Hospital (SFIH) such as urgent care. The Pueblo of Santo Domingo elected for 100% of
their Contract Health Services (now Purchase Referred Care) shares to remain within the Santa Fe Service Unit.
In fiscal year 2011, the SFSU collected $2 million in third party collections from services provided at the Santo Domingo
Health Center. In response to the loss of $5.2 million in operational funds, the
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SFSU reduced urgent care services at the SFIH from 24 hours a day to 12 hours a day, reduced staffing to support a maximum
of four inpatients, and closed all surgical services. This reduction in services resulted in the elimination of more than 50
positions within the SFSU.
The SFSU’s constituent tribes fully support the right of any tribal government to enter into self-governance contracts and
compacts with the Indian Health Service. These same tribes also recognize that the SFSU’s unique structure of having nine
tribes’ shares consolidated into one service unit imposes a degree of uncertainty for long-term planning. In particular, if one
or several tribes within the SFSU elect to contract some or all of their tribal shares, the remaining tribes who elect to remain
under direct service may find that their residual services are not comparable to those provided previously. Additionally, with
the loss of the economy of scale gained from the pooled resources from many tribes, these direct service tribes may be unable
to enter into meaningful self-governance contracts and compacts of their own.
Consequently, remaining direct service tribes experience frustrations such as: inability to do long-term planning with the
SFSU, which cannot precisely predict from one year to the next what their operational funds will be; inability to reassure their
tribal members that a self-governance agreement would lead to comparable or better health care services while at the same time
inability to reassure their tribal members that the direct services in the SFSU are secure; and inability to persuade members of
Congress that multi-tribe service units such as the SFSU may require special appropriations after self-governance contracts and
compacts are negotiated in order to protect the access-to-care interests of the remaining direct service tribes.
BEMIDJI
ISSUE
1.
2.
3.
4.
5.
6.
7.
FUNDING PARITY
HEALTH DISPARITIES
PURCHASED/REFERRED CARE
FACILITY CONSTRUCTION
PRESCRIPTION DRUG ABUSE AND DIVERSION
NOTIFICATION OF CONSULTATION MEETINGS AND/OR COMMENT PERIODS
HEALTHCARE REFORM IMPLEMENTATION AND IMPACT
BACKGROUND
1.
Tribes noted Funding Parity as a ‘hot issue’ as the Area is the lowest funded in the IHS according to the Level of Need
Funded/Federal Disparities Index (LNF/FDI) scores. Bemidji Area is identified as the lowest LNF score in IHS at
49.8% while the Agency’s overall average is 55.6% according to 2010 data.
2.
Bemidji has some very high health disparities in heart disease and cancer, accidental injuries, as well as diabetes. The
last comparative data from 1999-2001 showed the Area leading the Agency in Heart Disease - #1, Malignant
Neoplasms (Cancers) - #2, and Diabetes - #3. Tribes identified specific program areas where funding and attention
are needed: Dental, Mental Health (MH), Alcohol & Substance Abuse (ASA), and Long Term Care (LTC). Tribes
shared anecdotally that
the impact of poor Dental funding results in all age groups having poor oral health leading to poor nutrition. This is
especially concerning when dealing with toddlers. Tribes also recognize that issues regarding prescription or other
drug abuse/use/misuse are oftentimes linked to MH. The increase in MH and ASA funding is needed to address the
root of the problem with counseling while providing the appropriate treatment to address any physical addiction.
Tribes in the Area already operate LTC facilities and specific funding would assist Tribes in their efforts to meet the
growing need.
3.
Purchased/Referred Care (PRC) is a ‘hot issue’ for the Area for several reasons: the geographic challenges of
remoteness and therefore access to specialty care; the lack of funding parity coupled with the higher health disparities
of Area users vs. the IHS as well as varied level/type of service available from a Tribe. Bemidji Area is very PRC
dependent (72% eligibility overall and significant health disparities) due to a lack of hospitals and specialty care in
ITU programs. Programs must use priorities.
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4.
Bemidji Area Tribal programs have limited opportunity to receive federal funding for healthcare facilities
construction. The majority of Area Tribes may only access Small Ambulatory Grants ($2M maximum award) or apply
for Joint Venture (JV). However, to date no Tribes have received JV funds in the Area. IHS Construction programs
need more funding in these programs in order for Tribes to have access to facility construction dollars. In addition,
IHS criteria may need revision to allow greater access/eligibility.
5.
Prescription Drug Abuse and Diversion: Declared as a public health emergency on the three reservations with direct
service programs and listed as a major problem by contracting and compacting Tribes at HHS Tribal consultation
meetings. This is a multifaceted problem that requires involvement of Tribal Leaders, law enforcement, education,
health care professionals, States, Federal Agencies and the community to solve. There is also a need for alternative
resources such as physical therapy, behavioral health and buy-in to pain treatment utilizing alternatives to abused
medications.
6.
Tribes note concern about the notification timeframes regarding consultation meetings and/or comment periods. The
Agency’s 30-day response timeframe limits the opportunity for Tribal programs to assemble subject matter experts
and provide a comprehensive and thoughtful response to consultation matters.
7.
IHS, Tribal, and Urban (ITU) programs note challenges and concerns regarding the implementation of the Affordable
Care Act on January 1, 2014. Examples of challenges include limited consultation with Tribes by States, limited
information regarding the impact to urban programs, and the inconsistency of implementation of Medicaid expansion.
Building on the last challenge, a concern is the anticipated increased collections, in States with Medicaid expansion
which could create a greater disparity with Tribes in States that do not have Medicaid expansion. The inconsistent
implementation could adversely impact Tribes in MI and WI when the Bemidji area is already the lowest funded in
the Agency.
SITUATION
1.
The Area needs increased funding to meet the demand of a growing population
2.
The Area needs increased funding to address the severe health disparities and chronic disease burden. In addition, the
Area needs increased funding to address the behavioral health needs to include suicide prevention, substance abuse
prevention and treatment and accidental deaths.
3.
The Area continues to utilize PRC in the federal and Tribal programs. Approximately 2/3 of the Area Tribes are
considered very small Tribes and therefore do not typically have the capacity to provide comprehensive health services
through conventional methods of a clinic and must rely upon PRC to provide services that are equivalent to and beyond
the scope of a clinic. Coupling this reality with rural locations and difficult recruitment efforts to fill vacant positions
only increases the demand on PRC appropriations.
4.
While some Area Tribes have received Small Ambulatory grants, none have qualified for Joint Venture agreements.
The triad of underfunding (reference LNF), remoteness, and Tribal size, creates a cost prohibitive environment for
many Tribal programs to pursue capital investments. Federal funding and a facilities construction methodology that
empirically addresses this triad need to be considered to promote equity and advancement for Bemidji Tribes.
5.
Area-wide collaboration between HHS Region V/IHS and ITU is on-going. Monthly teleconference calls, coordinated
by HHS Region V and IHS, have been held for 2.5 years and are transitioning to Tribally-lead calls with planning for
next steps underway.
6.
Additional time during the comment period would allow Tribes the opportunity to participate and provide input to
important Agency decisions.
7.
The Area hosted various trainings in FY2013 for the ITU programs to identify challenges, improve knowledge, and
explore opportunities to maximize the ACA authorities/implementation. Trainings will continue to evolve in FY2014
to meet the changing needs and concerns of ITU programs.
BILLINGS
ISSUE: Contract Support Cost (CSC)
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BACKGROUND: The Billings Area FY 2014 Recurring Base budget for CSC was $10,750,680. In IHS's plan to fully fund
the CSC need, identified reductions from Headquarters, IHS, reconciliations, and adjustments were made to fully fund CSC
to each individual tribe in FY 2014. The Billings Area is comprised primarily of seven (7) Direct Service Tribes and two (2)
Self Governance Tribes.
SITUATION: As discussed at the Billings Area 2017 Budget Formulation meeting, after reconciliation the Billings Area
IHS was required to reprogram from Hospitals and Clinics (HC) $90,000.
The Billing Area Office absorbed $45,000 and each Service Unit absorbed their percentage of the remaining $45,000. This
percentage was based on the Billings Area Federal Recurring Base and each individual Service Unit's portion of Federal
Recurring Base. Although the respective tribes were not affected fiscally, the local Service Unit budget was decreased by:
Blackfeet Service Unit
$ 9,914
Crow
Ft. Belknap
Ft. Peck
Northem Cheyenne
Wind River
Flathead (PRC staff)
Billings Area Office
TOTAL
$ 13,925
$ 4,943
$ 5,137
$ 6,055
$ 4,669
$
358
$ 45,000
$ 90,000
Provided this status, the Billings Area Tribes comments centered primarily on Congress providing 100% funding for
Contract Support Costs in future fiscal years. This would alleviate the fact that, although $90,000 is relatively small, HC
has been decreased which has a negative impact on provided to their respective Indian communities. The tribes expressed
concern that if not fully funded in FY 15, this could also have a negative impact on current services as well as the upcoming
years.
Upon receipt of the FY 2015 Budget, the Billings Area will coordinate and communicate with the tribes on final P.L. 93638 Annual Funding Agreement amounts. Also, if any, amounts to be absorbed by the individual Service Units this will
be communicated to the tribes as well.
ISSUE: PURCHASED/REFERRED CARE
BACKGROUND: Insufficient funding levels
SITUATION: At the beginning of the fiscal year current base funding for Billings Area supports all Priority levels,
depending on the funding and needs of each specific Service Unit. However, it is common that as the Service Unit PRC
programs advance through the year only Priority I (loss of life and limb) will be referred. This action is taken to ensure
the programs stays within available funds.
With additional funding we'd be able to better meet the overall and ongoing health care needs of our patients.
In FY2014 the Billings Area's unmet need for medical priority 1 was $10,664,549 = (9,668 cases). Deferred was $4,243,038
= (2,852 cases) and unfunded Contract Health Care Catastrophic Fund cases were 185 equivalent to $1,344,353.
Service Units have been forced to use any available 3rd Party resources (Medicare, Medicaid, and Private Insurance) to pay
for care when PRC funds have been exhausted. In FY 2014, $2.2 million dollars of 3rd Party revenue had to be used for
PRC.
Although there have been increases from FY2009 -FY2014, the impact of the rescission and sequester in FY2013 ($2.9
million) was devastating to an already underfunded program. For example, FY 2009 Billings Area total unmet need was
$49,254,691. FY 2009-FY2014 program increases were $16,653,097 which represents 33% of FY2009 total need. With
medical inflation and population growth for these years estimated at $11,232,846, the Billings Area net increase for all
these years was only $5,420,251.
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ISSUE: ALCOHOL AND SUBSTANCE ABUSE
BACKGROUND: Increased Alcohol and Substance Abuse.
SITUATION: According to the P.L. 93-638 Contracted Tribal Substance Abuse Programs AccuCare 's Aggregate Report
Generation System (ARGS) report, all substance abuse patients assessed by the Billings Area Tribal Substance Abuse
Programs indicate that the Primary Alcohol/Drug of Choice is:
 Alcohol 60.09%,
 Heroin 0.02%,
 Methadone 0.026%,
 Opiates/Analgesics 0.73%,
 Barbiturates 0.06%,
 Other Sedative/hypnotic/tranquilizer I 0.06%, Cocaine 0.03%,
 Amphetamine/Meth. 3.49%,
 Cannabis 5.12%,
 Inhalants 0.15%,
 Alcohol and multiple drugs addictions 11.65%.
Methamphetamine use has continued to increase in the State of Montana and Wyoming and this increase has also been seen
in pregnant women. Alcohol and methamphetamine abuse inutero is a significant issue in the Billings Area. Mother's ability
to participate in treatment programs is limited because treatment centers who will take prenatal patients and her children are
limited. At one of the Service Units in 2012, 44% of the babies born had Inutero Drug Exposure (IUDE) (15% to
methamphetamine, 6% to alcohol). Additional funding for the Alcohol and Substance Abuse Program would provide the
tribes a mechanism to help their community members and schools, hire additional professional staff, treatment opportunities,
etc.
GREAT PLAINS
Area Hot Issues – Budget Related
Medicare Like Rates - Enacting Medicare Like Rates for referred non-hospital services could save the IHS millions per year
for the purchased/referred care program. Given the Great Plains Region strong dependence on contracted care not only for
hospitalizations but for also for specialty care office visits, Medicare Like rates could significantly alleviate the tremendous
burden on the PRC budget.
Purchased / Referred Care – Provider payment delays & Patient transportation:
As mentioned in above priorities, underfunding for PRC in addition to antiquated information echnology systems result in
consequences that affect quality of care. An emerging issue in the Great Plains is the growing burden of uncompensated care
on the major contracted providers.
The administrative process used by the IHS is uniform throughout the entire nation when administering PRC. Following all of
these requirements is a significant administrative burden on private sector providers and the IHS, as the process is manual,
paper-driven susceptible to errors and slow. As currently administered the process is slow and susceptible to errors. Finally,
the payment process is delivered through a national fiscal intermediary who is required to issue payment via paper checks and
remittance advices, adding substantial reconciliation efforts for providers.
Along with the administrative costs there are undesirable consequences through the existing IHS PRC process. Payments for
private sector care are often denied due to appropriation or budget limits and medical priority determinations. When payments
are denied, it is possible an individual tribal member will be responsible for the payment of provided services, which generates
a financial burden for the individual and the provider.
The tables below reflect the top 10 providers for purchased and referred care, and the billed services outpatient services and
what was paid by the IHS.
55
Top Ten Providers of
Outpatient Services
Fiscal Year 2013
Facility Name
Total Billed Charges
IHS Payment
Rapid City Regional Hospital
$
9,443,851
$ 1,727,952
Black Hills Dialysis
$
6,533,225
$ 1,555,426
Coteau Des Prairies Hospital
$
3,213,526
$ 1,442,169
Trinity Hospital (Minot)
$
5,290,543
$ 1,029,712
Sanford Chamberlain
$
2,387,348
$ 835,079
Mercy Hospital, Devils Lake
$
2,139,823
$ 725,929
Sanford Bismarck
$
3,247,522
$ 674,980
Altru Hospital, Grand Forks
$
2,820,102
$ 518,325
Black Hills Surgical Hospital
$
1,580,765
$ 488,671
St Mary's Hospital, Pierre, SD
$
1,903,401
$ 367,548
One of the primary reasons provided in South Dakota for the lack of support for the Medicare Like Rates legislation is attributed
to unsettled PRC claims.
SD/ND CHSDA - Sec. 192. Of the IHCIA permanently establishes a single contract health services delivery area consisting
of the states of North Dakota and South Dakota for the purposes of providing purchased and referred care. IHS Headquarters
has indicated that appropriations are required to expand the CHSDAs to include all counties in ND and SD, as required in the
IHCIA.
As with previous year’s requests, the Great Plains Tribal Chairman’s Health Board, Board of Directors reiterates its request to
IHS Headquarters for the following:
•
The Aberdeen Area Office or Headquarters should prepare an analysis of the estimated cost to implement this
provision in the IHCIA.
•
Modify the User Population calculation process to count all users in the ND and SD CHSDA. This change should be
retroactive if possible. If not possible, it should be put into effect such that the estimated users who receive services,
but are not currently counted in ND and SD user populations, are included in the next fiscal year’s official user counts.
•
IHS Headquarters should calculate the funding lost to ND and SD Tribes by not including these users in the user
population. The dollar amount of these funds should be provided to ND and SD Tribes in proportion to their adjusted
user counts. The funds should be taken off the top of the next appropriation.
•
A report should be provided to ND and SD Tribes showing how the adjustments have been made prior to the following
year’s appropriation.
IHS Budget appropriations Formula – the Great Plains Leadership would like a detailed review of the current IHS budget
formula used to determine appropriations.
56
NASHVILLE
#
ISSUE
1
Budget Representation for Urban Programs
The IHS Urban Indian Health Program
supports contracts and grants to 34 urban health
programs funded under Title V of the Indian
Health Care Improvement Act. The Urban
Indian Health Program line item is distributed
through contracts and grants to the individual
Urban Indian Health programs. The
distribution is based upon the historical base
funding of these programs. The funding level is
estimated at 22% of the projected need for
primary care services. Eighteen (18) additional
cities have been identified as having an urban
population large enough to support an Urban
Indian Health Program. 2010 Census data
shows that 71% of all
American Indians and Alaska Natives live in
urban centers. The President’s FY2014 budget
marked the third straight year that funding for
urban Indian health fell below 1% of total
Indian Health Service funding.
2
3
4
BACKGROUND
Fully Fund Contract Support Costs
There has been a long history of contract
support costs being underfunded and shortfalls.
According to NCAI, "In amending the 1975
Indian Self Determination Act Congress in
1988 recognized that failure of BIA and IHS to
fully fund contract support costs often resulted
in program reductions".
RECOMMENDATION/ STATUS
It is important to bear in mind that urban Indian health programs
are funded from a single IHS line item, and do not have access to
funding appropriated to other areas of the IHS budget. Thus, any
increase the Administration has proposed for the broader Indian
Health Service budget will not benefit urban Indian health
programs or the Native communities they serve. It is critical that
Congress direct resources to the urban Indian health line item in
order to provide health care services to urban Indian patients.
Additional recommendations are the inclusion of urban programs
in:
100% federal match for Medicaid services – a protection already
enjoyed by IHS and tribal facilities (100% FMAP would provide
states with 100% of the cost of payments made to urban Indian
health providers for services provided to American Indian
Medicaid patients, rather than requiring the states to assume a
percentage of the cost of Indian health care).
Federal Tort Claims Act - unlike IHS and tribal health programs,
urban Indian health programs are required to spend thousands of
program dollars each year to purchase malpractice insurance for
their providers. Given the extremely sparse funding that is
appropriated to serve American Indians in urban centers, urban
Indian health programs should not be required to spend these
precious resources on insurance coverage – especially since IHS
and tribal programs have long been exempted from this burden.
1."Direct appropriation of funds for CSC would be critical to
ensure that CSC remains fully funded".
2."Empower the IHS Director to request reprogramming of
funds direct to the comptroller".
Medicare Like Rates for Nonhospital Services
A recent Government Accountability Office USET, along with National Indian Health Board and other Tribal
(GAO) report revealed that the Indian Health organizations, is currently working towards the introduction of
System is paying up to 70% more than other legislation in both chambers of Congress that would extend the
purchasers of care, including Medicare, Medicare-Like Rate cap to nonhospital services. An official
Medicaid, and private insurers, for nonhospital indication of support from the Indian Health Service would aid
services. Under current law, the reimbursement the advancement of this proposal.
rate for hospital services purchased by I/T/Us
is capped at Medicare-Like Rates. If this rate *This is a reoccurring hot issue for the Nashville Area
were extended to nonhospital services, the
GAO report found that Indian Health Service
federal sites alone would save at least $32
million annually. This savings would allow
precious CHS dollars to stretch further in an era
of reduced appropriations.
Advance Appropriations for the Indian Health Service (IHS)
57
Since Fiscal Year 1998, appropriated funds for
the Indian Health Service have been released
after the beginning of the new fiscal year. Most
often caused by a Congressional failure to enact
prompt appropriations legislation, late funding
has severely hindered Tribal and IHS health
care providers’ budgeting, recruitment,
retention, provision of services, facility
maintenance, and construction efforts.
Congress has recognized the difficulties
inherent in the provision of direct health care
that relies on the appropriations process and
traditional funding cycle and has appropriated
beginning
with
FY
2010,
advance
appropriations for the VA medical care
accounts. Advance appropriations is funding
that becomes available one year or more after
the year of the appropriations
act in which it is contained, allowing for
increased certainty and continuity in the
provision of services.
As the only other federally funded provider of direct health care,
IHS should be afforded the same budgetary certainty and
protections extended to the VA. H.R. 3229 and S.1570, The
Indian Health Service Advance Appropriations Act of 2013, have
been introduced in the House and Senate, respectively.
*This is a reoccurring hot issue for the Nashville Area
5
The Special Diabetes Program for Indians (SDPI)
In response to the disproportionately high rate With a diabetes incidence rate of 22.6% in the Nashville Area,
of type 2 diabetes in American Indians and prompt reauthorization of the SDPI is crucial for the maintenance
Alaska
Native (AI/AN)
communities, of critical program and staffing infrastructure. Additionally,
Congress passed the Balanced Budget Act in Tribes that were federally-recognized after 1998, including two
1997 establishing the SDPI as a grant program Nashville Area Tribes, are not currently eligible to apply for SDPI
for the prevention and treatment of diabetes at grants. A multi-year reauthorization could provide an opportunity
a funding level of $30 million per year for five for these and other Tribes not currently managing an SDPI grant
years.
With funding increased through to begin to combat diabetes in their communities.
subsequent reauthorizations, SDPI is currently
funded at $150 million per year and has been From 2014 Impact Statements/Testimony:
given a one year extension for FY 2015 and not The Special Diabetes Program for Indians has been of great
permanent reauthorization. The SDPI funds benefit to the Tribe in addressing some of the most significant
have enhanced diabetes care and education in factors contributing to these complications that our citizens have
AI/AN communities, establishing innovative endured. Without this program our patients will suffer from the
and culturally appropriate strategies to combat lack of educational training, prevention activities, and we go back
the diabetes epidemic. As a result, the program to treating the disease only.
has been immensely successful in reducing
costly complications and the incidence of the *This is a reoccurring hot issue for the Nashville Area
disease itself.
6
Alcohol and Substance Abuse Treatment Facilities in Nashville Area
The high rates of alcohol and substance abuse, New facilities or program dollars to address alcohol and substance
mental health disorders, suicide, violence, and abuse treatment.
behavior-related chronic diseases in American
Indian and Alaska Native (AI/AN)
No additional funds have been earmarked for new treatment
communities are well documented. Each of
facilities in the Nashville area. There are currently two treatment
these serious behavioral health issues has a
facilities serving the Nashville area including Unity Healing
profound impact on the health of individuals,
Center, an adolescent drug treatment center located in Cherokee,
families, and communities. For example,
NC and the Partridge House, an inpatient addiction program for
AI/ANs are significantly more likely to report
adults located in Akwesasne, NY.
past-year alcohol and substance use disorders
than any other race, and suicide rates for AI/AN
58
people are 1.7 times higher than the U.S. allraces rate. The documented connections
between behavioral health issues and chronic
diseases underscore the need for holistic and
integrated solutions. Access to culturally
competent alcohol and substance abuse
treatment programs in the Nashville Area is
limited by the number of facilities available and
the cost per patient (currently $10,000 for a 90
day program and more for Intensive Outpatient
Treatment).
7
Pilot project for Premiums
Beginning in 2014, the Affordable Care Act
provides an opportunity for an estimated
579,000 uninsured American Indians and
Alaska Natives to get affordable health
insurance coverage. Exchanges may permit
Indian tribes, tribal organizations, and urban
Indian organizations to pay the QHP premiums
for qualified individuals, subject to terms and
conditions set by the Exchange. As more tribal
members are participating in state and federal
marketplaces, 48,103 plan selections indicated
membership in a federally recognized tribe in
April 2014, there is interest in the analysis of
the cost of premiums and the use of tribal
resources to cover those premiums for
individuals.
Additionally, including funding to implement section 827 of the
Indian Health Care Improve would be of benefit. Prescription
Drug Monitoring (PDM) Program. Nashville recommends
allocating funds to develop a PDM program that are carried out
by Tribes, IHS and/or Urban programs.
The proposed pilot project for tribal premium sponsorship would
answer, what is most cost effective for tribes?
-Tribes reimburse members individually for the cost of premiums
-Tribe pays for premiums from resources other than contract
dollars
There are several resources available for tribal premium
sponsorship including:
Edward Fox – Tribal Premium Sponsorship *sample policies and
procedures are available
Tribal Premium Sponsorship Programs
USET’s collaboration with other Area Health Boards, Tribal
Education and Outreach Consortium developed several tribal
sponsorship
tools
that
can
be
located
on
at
www.nativeexchange.org
NAVAJO
Correctional Health Services
ISSUE
Inmate behaviors pose a significantly high risk to HIV acquisition and are least likely to seek
health care services.
BACKGROUND
Incarcerated American Indians experience extremely high rates of STDs and health disparities. Tribal Jails are unable to
meet health care needs due to limited resources and lack of awareness of health care needs of inmates, lack of collaboration
between Department of Corrections and health care providers. Tribal jails are small, lack of infrastructure, lack of
staffing, and respond only to urgent medical conditions. Inmates are at higher risk for STDs, substance abuse problems
(i.e. alcohol related offenses, Domestic Violence), and sexual risk-taking.
SITUATION
Tribal jails offer a unique opportunity for STD education, screening, and testing for a population that might be hard to
reach and to control STDs and HIV in high risk populations. Tribal jails are small which may hold up to 10 -24 detainees
or mid-level 25-49 and a selected few may more than 49 inmates at one time.
Health Education will increase awareness of STD and HIV risk factors, transmission, symptoms, benefits of regular
screening by understanding the test/rapid screening, and health check-ups, emphasize safer sex knowledge &
complications of STDs, provide safer sex skill training, and encourage safe sexual and drug use behaviors.
59
With Resolution C0-50-14 establishing the Navajo Nation Health Department is in a position to establish correctional
HIV screening policies as determined by tribal or federal statutes. Less than half of State prison systems (21) reported
testing all inmates for HIV at admission, while in custody, or upon release (Source: CDC HIV testing Implementation
Guidance for Correctional Settings, January 2009).
Emerging Infectious Disease
The term "emerging infectious disease" refers to diseases of infectious origin whose incidence in humans has either increased
within the past two decades or threatens to increase in the near future. Environmental influences on human health can severely
impact the Navajo people if we are not prepared. Diseases can be transmitted from animal species to humans through viruses.
HIV, bird flu, ebola, enterovirus D68, as well as Giardia and Cryptosporidia are such diseases that impact human health.
There are three main pathogens (Escherichia coli or E.coli, Giardia, and Cryptosporidium ) that are contributing factors to
Waterborne illness. Twenty seven percent of the Navajo homes do not have access to safe water with the majority in the
western portion of the NN.
SITUATION
Water hauling is essential and due to distance, lack of funds to drill wells, and build water infrastructure, risks to individuals'
health is high. Water hauling containers including polyethylene tanks (plastic tanks) 300-500 gallon tanks may eventually
develop fungus and algae growths because individuals haul water from unregulated livestock wells. Water from these
sources is of unknown quality. Over 3,000 livestock wells were built for livestock use only, according to the Navajo Nation
Water Resources Department. The livestock wells pump water into uncovered storage tanks. The water is subject to
contamination by dead birds and other dead animals. Some storage tanks contain soiled diapers and trash. Most
contamination occurs during the summer monsoon months with floods that seep into the water wells due to low water well
casings. Hand pump wells are also used by some residents for domestic use. These hand pump wells were built in the 1950s
by 1.H.S./P.H.S. as evidenced by the cement base of the pump, have been subjected to animal excreta, debris, freon, asbestos
from vehicle brakes dumped in the ditches, as well as anti-freeze, and oil. Home septic tanks are not managed by home
owners that can overflow and create a health hazard as potential exposure to Hepatitis and Cholera, for example.
Modular Dental Facilities and Staffing
ISSUE
Modular dental units to be placed at various service units, including the requisite staff
Background: The Navajo Area dental program is able to see less than 29% (the current GPRA objective) of the user
population each year. Also, the dental program is unable to meet the Early Childhood Caries objective for dental access for
children aged 0-2. This has resulted in 60.0% of children aged 0-5 needing additional dental treatment.
RECOMMENDATION
The American Dental Association standard for the dentist to population ratio is 1:1200. Most service units across Navajo have
a ratio offrom 1:3600 to 1:4200, when fully staffed. Simply creating additional FTEs will not suffice. The industry standard
for efficiency is to have at least two dental chairs per dentist. Hence, bringing on additional dentists without building
infrastructure may actually reduce the access to dental care.
Modular dental units are pre-fabricated units which can be placed in smaller communities, allowing less travel costs to seek
dental care. They are a standalone facility, which can provide a full range of general dental services. A five chair clinic will
require two dentists, five assistants, and one clerk. Initial costs would include $15,000 for site preparation, $676,000 for the
modular building including set up, $416,000 for equipment and instruments. Annual costs include $550,000 per annum for
staff salaries and benefits and $50,000 for supplies.
Given that new facilities are not in the future of all Navajo service units, modular facilities can fulfill the need for additional
access to dental care.
Proposed Amount: $6,900,000 for four units, with annual amount of $240,000 for 10 years.
Uranium Exposure
ISSUE
Abandoned Uranium mine waste continues to pose public health threats to Navajo communities and residents through water,
air and land contamination. There is dire need to escalate public health education that will decrease exposure risks and
increase prevention.
BACKGROUND
60
According to the Indian Health Service Regional Differences in Indian Health 2002-2003 Edition, the infant death rate among
the Navajo people is 8.5 deaths per 1000 live births, compared to 6.9 deaths per 1000 live births among all races. Only 61%
of Navajo mothers with live births received prenatal care in the first trimester as compared to 83% of all U.S. mothers. The
Navajo Birth Cohort Study has found that many Navajo families are not aware of the health threats; cancer, asthma, birth
defects and learning disabilities.
SITUATION
Navajo Nation land base is host to 1,100 uranium mine waste tailings and 531 of those are now identified for cleanup. 70%
of the Navajo Chapters exposed to the uranium tailings. However, the costs for adequate remediation are not attainable.
Therefore, the congressional mandated Navajo Birth Cohort Study will be ending August 2016. We highly recommend that
(8) Public Health Educators to work with the Navajo Birth Cohort Study program under the Navajo Community Health
Program/Navajo Department of Health. This will cost $2.5 for (4) years.
Memorandum of Understanding Between VA and IHS
The health care reimbursement rate of $342 per patient visit does not cover the actual cost of the health care provided to
Native American Veterans.
Proposed Change: Reimbursement health care service to AI/AN Veterans should be based on line-item billing. Medications
should be billed at cost.
BACKGROUND
The Indian Health Services was given approval on May 1, 2013 to bill the VA for all our Native Veterans.
The Memorandum of Understanding sets forth mutually agreed upon goals:
• Increase access, improve quality of health and leverage strengths.
• Patient-centered collaboration, communication.
• Effective partnerships and sharing agreements in consultation with Tribes.
• Ensure appropriate resources of services for AI/AN Veterans.
• Health-promotion & disease-prevention for AI/AN Veterans to address community - based wellness.
SITUATION
• Services are generally billed by line-item for each patient. A patient bill typically exceeds the $342
reimbursement rate. For an example, Emergency Services for a patient could be
$1,258.50 yet only $342.00 would be reimbursed by the VA. Line-item billing would be better because it
would then cover the cost providing the best possible health care to AI/AN Veterans while achieving the goals
of the MOU.
• Similarly, VA patients receiving care typically have prescriptions for medications associated with concerns
addressed in the office visit. Currently, only medications with a cost of $20.00 or more are considered for
payment. Ideally, all mediations would be billed at cost.
OKLAHOMA CITY
1. Expanded Authority
Maximize the authority given by the IHCIA to provide facilities and services, such as, medical rehabilitation, long-term care,
elder care and behavioral health/substance abuse. The OCA recommends the development of a pilot project that addresses
these types of facilities.
2. Medicaid Expansion
Lack of expansion in Oklahoma has directly affected the opportunity to collect additional third party revenue. Patients that
may have been covered under this expansion will continue to be covered by PRC. The tragic result is limited access of care
for the patient population that would have been covered by a Medicaid expansion.
In addition, there is inconsistency between the scope of services between States creating a disparity for AI/AN patients. The
OCA recommends that IHS explore a direct relationship with CMS for the Medicaid program. In addition, the OCA
recommends that IHS funding formulas be evaluated to adjust for Tribes in States that do not have Medicaid expansion.
61
3. Entitlement
Funding for the IHS program should be considered mandatory (versus discretionary) funding within the Federal budget.
4. Extend FTCA to Oklahoma City and Tulsa programs
With the passage of IHCIA, both the Indian Health Care Resource Center (Tulsa) and the Oklahoma City Indian Clinic were
deemed to be permanent programs within IHS’ direct care program. All other direct care programs within IHS are covered by
Federal Torts Claim Act (FTCA) therefore by extension these two programs should also have equal status and receive FTCA
coverage.
In addition to federal and tribal employees, employees of eligible Federally Qualified Health Centers (FQHCs) funded by the
Public Health Service as community and rural health centers are deemed to be covered entities and qualify for FTCA protection.
Commissioned Officers currently assigned to OKCIC and IHCRC are deemed to be covered under FTCA. It is assumed by
extension that civil servants who may be assigned to OKCIC and IHCRC programs in the future should also be covered under
FTCA.
5. Ensure IHCIA (or ACA) remains
Ensure IHCIA survives any congressional or judicial action to repeal components of the ACA.
6. ICD-10 Implementation
Implementation of ICD-10 is currently an unfunded mandated requiring significant resources. The OCA tribes request that
funding be made available in support of this effort.
PHOENIX
Electronic Health Record, Coding & Third Party Billing: Staff training for EHR and third party billing including coding and
compliance must be consistent.
Information Technology (IT) Services: Tribes and urban Indian programs identified the need for comprehensive IT services.
They noted the lack of funds to keep up with current technologies and their ability to comply with new requirements, such as,
fully implementing the Electronic Health Record within all facilities.
Shortage of Health Care Providers at I/T/U Facilities: Tribes and urban Indian health programs both noted the difficulty they
face with regard to recruitment and retention of professional health care providers. While the factors vary some of the programs
noted that the issues are as basic as resources are not sufficient to hire needed staff or to sustain the infrastructure to expedite
billing and reimbursement in order to enhance resources. Rural and frontier locations have these issues to contend with along
with the struggles to attract professionals to these locations.
Dental Health: Tribes and urban Indian programs identified dental services as a significant need across the Phoenix Area.
Dental decay among children requires significant attention. Adults, in most states are restricted from obtaining alternative
resources to cover dental services. Medicaid coverage is largely limited to emergency dental services as an optional benefit. It
is hoped that this may be remedied as Health Insurance Marketplace and state based Marketplaces have begun to offer
information about affordable dental plans.
Crises & Detox Services: To address alcohol and substance abuse, several of the Tribes noted that current funding barely meets
their needs and that one of the critical services that is lacking on many reservations is detox services. These services aid
individuals in serious situations. Further injury or death can be prevented if a safe detoxification environment can be provided.
62
Prevention and Education for Youth: Tribes and urban programs identified this issue as a major focus area. As a national
strategy, educating youth about serious public health and chronic diseases and behavioral health issues would provide an
opportunity to turn the tide on health disparities affecting Indian people.
Replacement of Outdated Medical, Dental and Optical Equipment: The need to replace outdated equipment was identified by
several Tribes and Urban Indian health programs and is essential in order to provide better medical care.
PORTLAND
ISSUE: Autism
BACKGROUND: Autism is a developmental disability significantly that affects verbal and nonverbal communication and
social interaction. Other characteristics of autism are engagement in repetitive activities and stereotyped movements, resistance
to environmental change or change in daily routines, and unusual responses to sensory experiences. Autism adversely affects
a child's educational performance and ability to learn. A recent report issued by the State of Oregon indicates that 84,707 kids
are in special education as a consequence of autism. The report shows that since 2008-09, the number has risen by 2,727 kids
-- a 3.3 percent growth rate, which is faster than Oregon's population growth of 2.6 percent in that period. 7 Systems will soon
be stretched to capacity to respond to the growing population who may require additional support services. Tribal leadership
has reported that the effects of autism are starting to impact Tribal communities. While autism has been present in the Tribal
system, it more recently is starting to become a greater concern, and also having a financial impact on Tribal education and
health budgets.
RECOMMENDATION: IHS and BIA need to collaborate to provide resources to screen on all AI/AN children for Autism
Spectrum Disorder (ASD) by their second birthday, and use consistent process for the identification evaluation. Promote the
training of personnel throughout I/T/U agencies. Support increased funding for Early Intervention/Early Childhood Special
Educations by providing additional resource for the BIE and state agencies need to do more to assist Tribes.
ISSUE: Uranium contamination on reservations
BACKGROUND: The Midnite Mine, located on the Spokane Tribe of Indians Reservation in Eastern Washington State was
operated by the Dawn Mining Company under a lease from the Spokane Tribe of Indians from 1954 until 1981. In addition to
radioactive contamination from uranium, heavy metals such as arsenic, cadmium, and manganese have been identified in local
surface and groundwater (ATSDR, 2007, 2009). In addition to the Midnite Mine, another mine located on the reservation,
Sherwood, and a uranium ore mill site just across the reservation boundary, the Ford Mill, both employed a large number of
tribal members, potentially contributing both direct occupational exposure as well as secondary exposure of employees’ family
members and community members. Trucks hauled ore from the mines to the mill using roads that passed through the most
populated areas of the reservation. The Spokane Tribal leadership continues to be concerned about the health effects of this
mine on its tribal population and wants IHS to do more about it.
RECOMMENDATION: IHS and CDC should use health data to determine the impact and address this health issues with
other federal agencies (i.e. EPA, CDC, IHS, BIA, etc.). The Spokane Tribe of Indians has long been interested in pursuing
funding for a RESEP clinic in the Northwest. The IHS and other federal agencies should fund a RESEP clinic that is central
accessible by patients from Northwest Tribes most affected by uranium mining-related exposure including the Nez Perce Tribe
and the Coeur d’Alene Tribe (ID), Confederated Tribes of the Umatilla Indian Reservation and Confederated Tribes of
Warm Springs (OR) and Confederated Tribes and Bands of the Yakama Nation and The Confederated Tribes of the Colville
Reservation (WA).
ISSUE: Public Health Emergencies
7
Oregon Statewide Report Card, An Annual Report to the Legislature on Oregon Public Schools 2013-14, Oregon
Department of Education, p.78, www.ode.state.or.us
63
BACKGROUND: While Tribal health programs have public health and medical care infrastructure it is often underfunded
and may lack the capacity to respond effectively to health, natural, and manmade disasters. Too often population density is
often a primary consideration in the allocation of emergency preparedness resources, it is important to recognize that public
health emergencies and disasters can and do occur on Indian reservations and in rural areas in proximity to Tribes, and that the
impact of these emergencies can be felt on all Americans regardless of geography. One need only consider the far reaching
impacts of natural disasters, agricultural blight, and infectious diseases to realize the interconnectedness of our reservation,
rural and urban citizens.
The recent public health emergencies dealing with the Ebola outbreak in the United States is yet another example. Tribes
expressed concerns regarding the cost of deployment of IHS Commissioned Corp officers to combat Ebola, protecting AI/AN
communities from exposure to the Ebola virus, and communications with Tribal leadership. While IHS facilities may have
established infection control procedures IHS facilities are not equipped to deal with the Ebola virus. IHS and Tribal facilities
in most cases do not have isolation rooms, full body protective gear, and other things necessary to contain the Ebola virus.
RECOMMENDATION: In order to ensure the readiness of the Tribal governments in times of crisis, an important
consideration is that, while the Federal and state governments need to be financial partners in this endeavor, resources and
implementation must also occur at the local Tribal level.
ISSUE: Heroin use
BACKGROUND: Opioids are a class of drugs chemically similar to alkaloids found in opium poppies. Historically they have
been used as painkillers, but they also have great potential for misuse. Repeated use of opioids greatly increases the risk of
developing an opioid use disorder. The use of illegal opiate drugs such as heroin and the misuse of legally available pain
relievers such as oxycodone and hydrocodone can have serious negative health effects. Nearly 17,000 overdose deaths in 2011
were related to prescription opioid medications. In 2013, among persons aged 12 or older, the rate of current illicit drug use
was 3.1 percent among Asians, 8.8 percent among Hispanics, 9.5 percent among whites, 10.5 percent among blacks, 12.3
percent among American Indians or Alaska Natives, 14.0 percent among Native Hawaiians or Other Pacific Islanders, and 17.4
percent among persons reporting two or more races. 8
RECOMMENDATION: Portland Area tribal leaders have noticed that heroin use is on the rise in their communities and
stress the importance of prevention and treatment funding to address this growing issue. There is a tremendous need to increase
culturally competent treatment and supportive services by providing additional funding to Youth Regional Treatment Centers.
ISSUE: Providers limiting/refusing Medicaid patients
BACKGROUND: With an increased enrollment of individuals now eligible for Medicaid, Indian health providers have
noticed an increase demand for services. With respect to specialty care and dental care Tribal health programs have also noticed
an increase in providers refusing to serve Indian patients because they are at capacity or do not take Medicaid (dentists). One
program in Washington has surveyed dentists within a 60 mile radius and could only find two dentists that took Medicaid and
one of those programs was the tribe itself.
RECOMMENDATION: Portland Area Tribes recommend that CMS require states to pursue options with Medicaid managed
care providers to ensure that they must offer contracts to Tribal health programs using a Indian addendum similar to the Part D
and QHP addenda. This will assist to make referrals for specialty care. Portland Area Tribes also recommend that IHS support
and pilot alternate approaches for providing oral health delivery similar to the Alaska DHAT model.
ISSUE: Hepatitis C drugs
BACKGROUND: Hepatitis C Virus (HCV) affects an estimated 150 million persons worldwide, and about 5 million in the
United States. In the US, an estimated 75% of HCV occurs among persons. Born between 1945 and 1965, most of whom do
not know they are infected. Recent data from The Department of Veteran Affairs (VA) showed that 10% of veterans born 19451965 were confirmed positive with HCV, a rate that was seen among American Indian and Alaska Native (AI/AN) veterans as
well.9 Based on these and other national data, there are many tens of thousands of HVC patients in Indian County with a high
proportion of them undiagnosed. Most persons exposed to HVC will develop a chronic form of the infection, which can have
8
Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, U.S Department of Health and Human
Services Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality
http://www.samhsa.gov/atod/opioids
9 Backus, Lisa I., et al. (2013). Hepatitis C Virus screening and prevalence among US veterans in Department of Veterans Affairs Care.
Journal of the American Medical Association, Internal Medicine, 173.16: 1549--‐1552.
64
no symptoms for decades. HCV leads to highly elevated risk of death from liver disease, including cirrhosis, liver cancer, endstage liver disease, chronic liver disease (CLD) and other complications. AI/AN have much higher rates of deaths from Chronic
Liver CLD, including premature cirrhosis and liver cancer. The CLD death rate among AI/AN was 3.5 times higher, cirrhosis
as 4 time higher, and hepatocellular cancer was 2.5 times higher than that of Whites. 10 HCV is the leading cause of liver
transplants in the US.
HCV Treatment
Past treatment for HCV lasted several months, presented severe side effects, required consistent injections, and had high
failure rates. Within the last year, treatment for the four HCV genotypes found in the United States has improved
dramatically – with three new treatments regimens being recommended. The new regimens can be taken orally, have few
side effects for contraindications, and have treatment times shortened to a range of 8 to 12 weeks for almost all patients.
Sustained virology response (SVR; patient effectively ‘cured’) has consistently improved with new treatments, and the latest
regimens are resulting in SVR rates of > 90% according to current data. Obtaining HCV SVR has been cited as reducing liver
failure by 90% and liver cancer by 70% 11,12
New Drugs called Direct Acting Agents (DAAs) including harvoni, sofosbuvir, simeprevir, and ledipasvir, are approved – with
more DAAs expected in the near future. These drug regimens represent a revolution in treatment that is shorted, more effective
and less toxic than the previous generation of HCV treatment options. These regimens are oral-only, last 8-24 weeks, have few
side effects, and have shown cure rates of 76 percent to 99 percent. The shorter treatment times, low toxicity, and high success
rates of these drugs make HCV largely manageable at the primary care level for many HCV patients if there is specialist support
available at key junctures such as intake and determination of treatment regimen.
The Cost Barrier
The new treatment regimens are extremely expensive. Of note, two of the new HCV medicines cost over $1,000 per pill,
making a 12-week regimen over $100,000. Insurance companies, state Medicaid programs, the VA and Indian Health Service
(IHS) cannot afford the high cost of treatment for large numbers of patients, which has resulted in only those patients with the
most severe liver disease qualifying for HCV treatment, although earlier treatments would have prevented fibrosis and cirrhosis.
So far, IHS has successfully accessed various pharmaceutical companies’ patient assistance programs (PAPs). Although PAPs
carry a heavy paperwork burden for both the patient and the provider, they obtain some or all of the needed HCV drugs for
free.
The national response to HCV has begun with an emphasis for scaled up screening and treatment. Currently only a handful of
IHS, Tribal, or Urban Indian health (I/T/U) sites are treating HCV patients. Relying upon PAPs does not represent a scalable
or sustainable solution to meeting outstanding HCV treatment needs in Indian Country. The high costs of the new regimens
and the perceived cost barriers are serving as a strong disincentive for I/T/U sites to initiate broader screen and treatment
programs.
Potential Budget Impact
In the last 12 months, IHS has spent $1.2 Million on HCV medications through the Pharmaceutical Prime Vendor. Of this total,
#$1 million was spent on Sofosbuvir alone. The cost for treatment averages approximately $72,000 per patient. The cost for
treating 25,000 patients would be $1.8 billion.
Separately, Human Resources impacts and costs are projected but have not be formally assessed. These include:



Clinical training/lab burden.
Paperwork burden to secure medications via patient assistance programs.
Routine appointment to monitor patients.
10
Suryaprasad, Anil, et al. (2014). Mortality caused by chronic liver disease among American Indians and Alaska Natives In the United
States, 1999–2009. American Journal of Public Health,104.S3: S350--‐S358
11 Lok, Anna S., et al. (2012). Preliminary study of two antiviral agents for hepatitis C genotype 1. New England Journal
Of Medicine,366.3: 216--‐224,
11 Ghany, Marc G., et al. (2009). Diagnosis, management, and treatment of hepatitis C:An update. Hepatology 49.4: 1335--‐
1374.
12
Van der Meer, Adriaan J., et al. (2012). Association between sustained virological response and all--‐cause mortality
Among patients with chronic Hepatitis C and advanced hepatic fibrosis. Journal of the American Medical Association,
308.24: 2584--‐2593.
65
RECOMMENDATION: Portland Area Tribes recommend that I/T/U sites receive the clinical and administrative support
related to diagnosis and treatment for HCV patients. Even if a clinic treats only a small cohort of patients at a time, many lives
will be saved. While it is difficult to project the current and future rate of HCV-related deaths and complications, available
data shows the impact of HCV is high, and growing. A recent IHS study showed that HCV hospitalizations more than tripled
in recent years. 13 CLD mortality has been significantly increasing from 1999-2009. One prominent study estimated CLD to be
the 4th leading cause of death among AI/ANs, a rate that is nearly three times higher than the Ai/AN mortality rate for diabetes.
ISSUE: Tulalip shooting
BACKGROUND: Youth violence refers to harmful behaviors that can start early and continue into young adulthood. The
young person can be a victim, an offender, or a witness to the violence.
Youth violence includes various behaviors. Some violent acts—such as bullying, slapping, or hitting—can cause more
emotional harm than physical harm. Others, such as robbery and assault (with or without weapons), can lead to serious injury
or even death.
Deaths resulting from youth violence are only part of the problem. Many young people need medical care for violence-related
injuries. These injuries can include cuts, bruises, broken bones, and gunshot wounds. Some injuries, like gunshot wounds, can
lead to lasting disabilities.
Violence can also affect the health of communities. It can increase health care costs, decrease property values, and disrupt
social services.14 A number of factors can increase the risk of a youth engaging in violence. However, the presence of these
factors does not always mean that a young person will become an offender.
Risk factors for youth violence include: Prior history of violence; Drug, alcohol, or tobacco use; Association with delinquent
peers; Poor family functioning; Poor grades in school; Poverty in the community.
Among 10 to 24 year-olds, homicide is the leading cause of death for African Americans; the second leading cause of death
for Hispanics; and the third leading cause of death American Indians and Alaska Natives. 15
(http://www.cdc.gov/violenceprevention/youthviolence/schoolviolence/data_stats.html)
RECOMMENDATION: IHS should develop better internal systems to develop crisis plans and supply mental health
providers in emergency situations like the shootings at Tulalip and Red Lake. Often Tribes do not know that such plans may
even exist (if they do), or what the protocols are for seeking IHS assistance. IHS should also conduct training and technical
assistant to IHS and Tribal health programs about these plans and protocols so that Tribes are better equipped to respond to
emergency situations.
ISSUE: Human Trafficking
BACKGROUND: Human trafficking is a serious federal crime with penalties of up to imprisonment for life. Human
trafficking involves a person to perform commercial sex related acts, labor or services, through the use of force, fraud, or
coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery. In comparison to other
racial and ethnic groups, Native women remain the most frequent victims of physical and sexual violence in the U.S. and in
Canada. In the U.S., their rate for sexual assault and rape in 2000 was 7.7 per 1,000 women versus 1.1 for White women, 1.5
for African American women, 0.2 for Asian women, and 0.6 for Hispanic women. Over 30% of Native women have
experienced an attempted or completed rape in their lifetimes, versus 17.9 % of Whites, 18.8% of African Americans, and 6.8%
of Asians (Tjaden & Thoennes, 2006).”
13
Byrd, K. K., et al. (2011). Changing trends in viral hepatitis--‐associated hospitalizations in the American Indian/Alaska
Native population, 1995–2007. Public Health Reports, 126.6: 816.
14 Centers for Disease Control and Prevention. Youth risk behavior surveillance—United States, 2011. MMWR, Surveillance Summaries
2012;61(no. SS-4)
Behaviors that Contribute to Violence on School Property Fact Sheet, CDC
15 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and
Reporting System (WISQARS) [online]. (2010). [cited 2012 Oct 19] Available from www.cdc.gov/injury.
Understanding Youth Violence Factsheet, CDC
66
There are several common risk factors among victim’s poverty, young age, limited education, lack of employment
opportunities, homelessness, run-away, history of substance abuse. Native women and children are often target because they
are desperate to meet their survival needs. In many case Tribal communities are not prepared to recognize or provide services
for those individuals who are being trafficking. The following recommendations are from the Alaska Native Task Force on
Sex Trafficking:
RECOMMENDATION: Tribes need assistance to begin to address this issue. IHS should coordinate with other federal
agencies that have jurisdictional responsibilities for dealing with the effects of human trafficking (i.e. SAMHSA, DOJ, BIA,
FBI, etc.) so that responsibilities are more clearly defined. Resources are also need to implement prevention and prosecution
activities.
ISSUE: Cost for Outreach and enrollment into ACA
BACKGROUND: Portland Area Tribes are concerned that they had to perform many administrative activities related to
education, outreach and enrollment for Medicaid and the Insurance Exchanges. In most instances in the private sector, these
costs were accommodated by funding organizations to conduct such services or performed by the State itself. Tribes were
funded very little if at all to conduct such activities yet had their tribal personnel carry out this work. This disrupted patient
care as tribes had to shift resources away from carrying out direct health care and other associated administrative activities.
Often the state outreach and education assistance is inadequate to address or respond to the questions and needs of Indian
people. Tribal health programs are in best position to do this however they lack the necessary capacity to do the jobs they are
financed to do (provide direct health care) and also carry out the responsibilities of the state and federal government.
RECOMMENDATION: IHS and CMS need to find a mechanism to directly fund these administrative costs for Tribes. The
states get reimbursed for such activities and Tribes should too, as to not infringe on patient care.
TUCSON
Diabetes prevalence
The Tohono O’odham Nation is the 2nd largest tribe, and is aware we have the highest prevalence rate of 20.1%. Although
much has been accomplished by the SDPI program to provide real returns, one is the development of a comprehensive diabetes
management program that would improve patient care. Services would include diabetes education, oral health, foot care, eye
care and through the curriculum components, which includes behavioral health that focuses on the patient. Efforts to continue
the collaborate and communicate between the Tohono O’odham Department of Health and Human Services and Indian Health
Service is beneficial to the outcome of the patients overall care to treat and prevent diabetes in ways that significantly reduce
this disease By efforts with both entities.
SITUATION
The Tohono O’odham Nation Health Department, SDPI program offers diabetes education and prevention that will improve
patient care for all tribal members. To improve overall patient care the Indian Health Services and the Tohono O’odham Nation
Department of Health and Human Services are working to establish an electronic health record system; to assist in capturing
the diabetes education and prevention services information is documented, thus would have an impact on improving patient
care.
Equipment Replacement
ISSUE
Equipment Replacement, lack of funds to replace medical equipment.
BACKGROUND
The Pascua Yaqui Tribe is in need of new medical equipment and the distribution formula for equipment dollars is based on
square footage which creates a challenging situation for the Pascua Yaqui Tribe.
SITUATION
67
For the Pascua Yaqui Tribe there are no Indian Health Service facilities, medical services are rendered directly and indirectly
through a non-traditional system of subcontracts and 90% of the funding received is Purchased/Referred Care (PRC). The
equipment funding Pascua Yaqui Tribes receives only supports a small clinic space.
Urban Health Funding
ISSUE
Title V Contract Funds, request additional funding for Urban Indian population increases.
BACKGROUND
The Tucson Indian Center serves the Urban Native American Population of Metropolitan Tucson, providing health promotion,
preventative services, education, outreach, and referral services to a population of 44,817. Since 2012, the active client
population has increased 21.9% and there have been no corresponding Budget Increases to the Urban Health Funding.
SITUATION
The Tucson Indian Center request additional Title V Contract Funds for the population growth $111,690 and $16,164 for
medical inflation which was 2.6% at June 2014 (2.6% of $621,690).
68
 APPENDIX B: DHHS GRANTS SUMMARY
Introduction
Tribes and Tribal organizations receive a disproportionately low number of Department of Health and
Human Services (HHS) grant awards. While IHS is the primary agency providing health care delivery
for AI/ANs, the federal trust responsibility is the responsibility of all government agencies, including other
departments within HHS. During the last several years, Tribes have developed a strong working
relationship with HHS leadership and its agencies. While these conversations are frequently productive,
much remains to be done as Tribes are consistently left-out of key funding opportunities. Across HHS,
agency leadership often understands and
supports the unique situation of Tribal
governments but bureaucratic processes
that score grant applications are stacked so
EXPANSION OF SELF GOVERNANCE AT
that Tribes often miss out on critical
HHS
opportunities.
The reasons for this are multi-faceted and
involve
statutory,
regulatory,
administrative or policy issues.
For
instance , many Tribal communities do not
meet stringent eligibility criteria for
certain federal grants or do not have the
staff or capacity to write grant applications
that are competitive with state agencies or
large universities. Other barriers involve
matching fund requirements or lack of
knowledge about traditional healing
practices among grant reviewers.
The
Tribal
Budget
formulation
Workgroup recommends that HHS use its
administrative authority to overcome some
of these barriers and advocate for statutory
change when necessary. The following
report will address some of these concerns
and ask the HHS to clearly look at this
information.
Expansion of Tribal Self-Governance at HHS also supports
Tribal requests to expand Tribal Self-Governance to agencies
at HHS beyond the IHS. A 2003 study done by HHS
determined this was feasible. The Obama Administration
reopened this dialogue with Tribes and convened a
workgroup to discuss this further.
The workgroup
determined self-governance expansion was feasible but that
legislation would be needed to move forward with expanding
self-governance at HHS. Tribes are eager to work with HHS
on the development of a legislative proposal that would
expand self-governance. For many Tribes, the choice to selfgovern ensures efficiency, accountability and best practices
in managing and operating Tribal programs and
administering federal funds at the local level. We reiterate
the request of the Secretary’s Tribal Advisory Committee to
renew a Tribal Federal workgroup be established to continue
the work left undone (Pilot Title VI of ISDEA) at the
cessation of the Self Governance Tribal Federal Workgroup
(SGTFW) two years ago.
Statutory Barriers to Accessing Grants at HHS
It is no secret that Tribal communities experience some of the worst health disparities in the country. The
average life-expectancy for AI/ANs is 4.2 years less than the national average, but on some reservations,
it is as low as 48. That’s actually 14 years less than the lifespan in Haiti – the poorest country in the
Western Hemisphere. Our population suffers disproportionately from cancer, diabetes, heart disease,
substance abuse and suicide. Clearly, more must be done to ensure that our people are not living sicker
and dying younger.
69
DHHS GRANTS SUMMARY
Tribal governments enjoy a government-to-government relationship with the United States but often do
not have the same status as state governments when it
comes to accessing grants. Out of the 10 block grants
that HHS administers, 16 four do not allow Tribes to
access them directly. To access those funds, Tribal
HIV PREVENTION AND
governments must go through the states, which have a
OUTREACH
very mixed record of ensuring money ever reaches the
Tribes. Of those block grants where tribes can access
The Centers for Disease Control and Prevention
them directly, few of the block grants have robust
(CDC) has funded organizations in the past
participation by tribes who receive these funds
specifically to work with American Indian and
directly. It is likely that many Tribes do not even
Alaska Native communities on HIV prevention,
know that direct funding is available in these cases.
and this funding has helped to establish and reaffirm national leaders in HIV prevention, care
and treatment in Indian Country. However,
during the last round of funding for five-year
grants, CDC did not fund any AI/AN-specific
organization to provide support or capacity
building. This failure to fund Tribal
organizations is especially troubling when
considering the rates of HIV incidence in
American Indian and Alaska Native
communities has continued to rise over the past
decade while the rates have fallen in other
communities.
See: PS14-1403, “Capacity Building Assistance for
High-Impact HIV Prevention.”
Other statutory barriers involve requirements for
matching funds that may be prohibitive for underserved groups that lack resources for the match.
Tribes are often at a disadvantage for programs with
allocation formulas based on numbers of clients or
anticipated costs that may be biased against small or
rural communities with small numbers of participants
and the inability to spread costs across a larger client
base. While statutory requirements are often necessary
to design programs that meet the need identified by
Congress, it is critical that the Administration identify
these barriers and work with Congress to make
concessions on some of these factors.
Regulatory / Administrative Barriers
Tribal governments and Tribal organizations often experience barriers to accessing grants at the
Administrative and Regulatory level is well. These include:
 Lack of resources to track and identify grant opportunities;
 Unique grant application and management requirements for programs across agencies;
 The inherent advantage previous HHS grantees have in the award process;
 Lack of explicit statements about eligibility in grant announcements; and
 Implementation requirements designed for projects targeted at state governments vs. Tribal
governments.
Many of the Tribal communities who are most in need of HHS grant funding are those with limited
capacity and resources to employ a robust grant writing team that could compete with a state government
or university. Few of these Tribes have the ability to sift through all federal opportunities, let alone, apply.
16
Child Care and Development Block Grant; Community Mental Health Services Block Grant; Community Services Block
Grant; Low Income Home Energy Assistance Block Grant; Maternal and Child Health Services Block Grant
Preventive Health and Health Services Block Grant; Social Services Block Grant; Substance Abuse Prevention and
Treatment Block Grant; Temporary Assistance to Needy Families; Title V Abstinence Education Block Grant
70
DHHS GRANTS SUMMARY
The federal government should be targeting Tribal communities when it writes grant announcements and
reviews applications.
The requirements in some grant announcements for specific detailed data on prevalence of disease
conditions or “need” for services are a barrier for some Tribes and Tribal organizations, particularly those
in rural areas. For example, some grant announcements require that only evidence-based practices be used
in a grant program; however, traditional Tribal practices may not be evidence-based or not yet researched
as such. Language in the announcement needs to recognize these traditional practices and/or set up
alternative standard of proof for evidence-based practice. Language such as “Tribal/ethnic/culturallyspecific approaches are acceptable” could be incorporated into the grant announcement to encourage
culturally appropriate responses.
Regarding the grant review process, some grant reviewers have very limited or no understanding of AI/AN
history, culture, geography, and resource limitations. In addition, even when no minimum population base
was specified in the eligibility criteria, some reviewers ranked AI/AN applications lower because of the
small number of people that would be reached by the grant program. Those that have applied for grants
that were primarily research-oriented or had a significant evaluation component also stated that HHS
agencies relied heavily on academic reviewers who placed disproportionate emphasis on academic
credentials and degrees and discounted extensive experience of proposed staff because they did not have
academic experience. Finally, some DHHS agencies sometimes do not provide adequate information on
the reasons their application was rejected, and this is a barrier to learning how to improve future
applications.
Recommendations
Tribes recommend several policy changes at the agency level to ensure that Tribal communities are
receiving access to grant funding at HHS:
 Advocate in Congress for direct access to Tribes for federal grant programs
 Provide Grant opportunities directly to Tribes instead of funneling through state governments,
and work with Congress to change statute when necessary.
 Provide specific, targeted, outreach to Tribal communities when grant funding becomes available.
This should target all Tribal governments, but especially those in areas with great need.
 Explicitly honor traditional health methods in drafting grant announcements and in reviewing grant
applications
 Recruit grant reviewers who are experienced in working with Tribal governments. If not available,
HHS should provide cultural competency training for each grant reviewer at the department
 Fund additional capacity building grants so that smaller or less resourced Tribes may be able to
access the grant funds more consistently
71
Photo Credit: James Cook, 1990
The Centennial Ride to Wounded Knee
On December 29, 1990, photographer James Cook caught sight in the distance of the more than 350 horseback riders who
were recreating the ride to Wounded Knee, South Dakota, as part of a centennial memorial of the massacre that occurred
there in 1890. The riders were near the end of their 7-day, 300-mile journey.
Since 1986, the descendants of those killed at Wounded Knee Creek have recreated the ride to the site. More than 350 men,
women and children were to be escorted by US troops so they could be transported to Omaha, Nebraska, to be resettled on
Indian reservations. When a medicine man and others failed to comply, a shoot-out ensued. In less than an hour, 150 Lakota
and 25 soldiers were dead. A three-day blizzard followed the battle, freezing the dead bodies and killing the wounded.
The weather Cook experienced as he tried to document the ride mirrored the blizzard of 1890. Temperatures hovered around
-54 degrees and harsh winds blew across the arid landscape. He learned early on to rewind the film slowly, or, stiffened by
the cold, it would shatter. If he exhaled when his face was too close to the camera, his breath would freeze his face to the
viewfinder.
Cook began photographing native peoples in the late 1980s because, as he says, the richness of the culture fascinated him.
Cook is of European descent, but says he doesn't know much about his own cultural heritage. "I started realizing that the
Native Americans had a lot going with their cultural roots and preserving their heritage," he says. "I admire that; I envy that."
To Cook, photographing Native Americans is about documenting a specific point in history. "It's all evolving,
and I think it's important to document things as they are in our day and age," he says. The passage of time is evident in his
"The Ride To Wounded Knee" image as well. "We got the headdresses and horses, but one of the riders is wearing
a snowmobile outfit as well," he says.
72
Network Adequacy and Essential Community Provider Inclusion in
Marketplace Health Plans Serving Indian Country
Findings and Recommendations
Report Prepared by:
Tribal Self-Governance Advisory Committee (TSGAC)
May 26, 2015
Network Adequacy and Essential Community Provider Inclusion
in Marketplace Health Plans Serving Indian Country
Findings and Recommendations
May 26, 2015
Executive Summary
Members of the Tribal Self-Governance Advisory Committee (TSGAC) to the Indian Health Service
(IHS) and members of the Tribal Technical Advisory Group (TTAG) to the Centers for Medicare and
Medicaid Services (CMS) have heard a number of concerns about the lack of compliance by
qualified health plan (QHP) issuers with Indian health care provider (IHCP)-specific contracting
provisions. As indicated in the CMS Center for Consumer Information and Insurance Oversight
(CCIIO) 2015 Issuer Letter, QHP issuers in the Federally-Facilitated Marketplace (FFM) are required
to offer contracts to all IHCPs operating in the QHP service area, and the contract offers are to
incorporate the QHP (Indian) Addendum for IHCPs and meet minimum “good faith” terms.
The intent of these contracting requirements is to implement the network adequacy and essential
community provider (ECP) provisions of the Patient Protection and Affordable Care Act (Affordable
Care Act or ACA). But more specifically, the aim is to further the federal Indian trust responsibility
to Tribes with regard to providing needed health care services to eligible individuals. This trust
responsibility is advanced by ensuring IHCPs receive adequate compensation for services rendered
and by enabling IHCPs to gain in-network provider status.
In order to gain a more comprehensive—and systematic—understanding of QHP compliance with
federal requirements, and to evaluate whether these provisions are having the intended impact,
the TSGAC conducted a study of QHPs contracting with IHCPs.
The study focused on sub-state service areas in five states. The findings are likely to be
representative of all states, although the states selected might overstate the extent of QHP
compliance with federal requirements. This is due to the areas selected for study being
represented by some of the most highly-engaged tribal representatives. Having tribal
representatives highly engaged in Marketplace issues promotes greater awareness of IHCP-related
provisions among QHP issuers and oftentimes leads to greater compliance by the QHP issuers.
A set of key findings and recommendations are shown below. A more expansive listing of findings
with supporting data is contained in the full report that follows the Executive Summary.
Overall Finding (1): Many QHPs have been certified to offer coverage in a Marketplace despite
including few, if any, available IHCPs as in-network providers.
RECOMMENDATION: With regard to QHPs with few or no in-network IHCPs, the TSGAC
recommends that CCIIO take proactive action to determine the reasons for the provider
network deficiencies and if the plans meet federal network adequacy (45 CFR § 156.230(b)) and
ECP (45 CFR § 156.235) standards.
TSGAC Report on Medicaid Expansion
May 26, 2015
Page 3
Overall Finding (2): Government-established IHCP-specific regulations matter, as the existence of
the IHCP-specific requirements in the FFM resulted in a substantially greater number of QHP
contract offers to IHCPs in FFM states than in non-FFM states.
RECOMMENDATION: The TSGAC recommends that CCIIO require non-FFM states to adopt
policies to ensure QHP issuers in their state meet the federal network adequacy (45 CFR §
156.230(b)) and ECP (45 CFR § 156.235) standards, and absent meeting the standards institute a
back-up mechanism requiring the adoption of the requirements in the CCIIO 2015 and 2016
Issuer Letters if a state otherwise does not meet the standards.
Finding in FFM States (1): Some QHP issuers in FFM states were found to be not in compliance
with CCIIO requirements.
RECOMMENDATION: The TSGAC recommends that CCIIO review the detailed findings in this
report to correct non-compliance and investigate in other (non-studied) states to determine if
similar problems are occurring.
Finding in FFM States (2): Even when there was compliance by QHP issuers with the requirement
to offer contracts to IHCPs, there were few, if any, IHCPs in QHP provider networks.
RECOMMENDATION: The TSGAC recommends that CCIIO review a sample of contract offers to
determine if the offers meet the “good faith” standard pertaining to payment rates.
Finding in Non-FFM States: Non-FFM states have not adopted the key Indian-specific
requirements that are applicable in FFM states.
RECOMMENDATION: See Overall Finding (2).
IHS-Related Finding: As a general rule, IHS facilities did not attempt to contract with QHPs, which
might be resulting in impediments to patients when attempting to access non-IHS providers and a
loss of revenues to IHS.
RECOMMENDATION: The TSGAC recommends that IHS compare the rates offered to IHS
providers by QHP issuers with either (1) the rates received when billing as non-in network
providers or (2) the rates received when billing under Indian Health Care Improvement Act
(IHCIA) Section 206 authority.
Self-Governance Tribes-Related Finding: Interest and capacity of IHCPs to contract as in-network
providers varied across the IHCPs studied, with some IHCPs working aggressively to gain innetwork status and others not.
RECOMMENDATION: The TSGAC recommends that TSGAC members consider sharing
experiences with QHP contracting, including identifying effective strategies to gain in-network
status and comparing results from seeking IHCIA Section 206 compliance by QHP issuers.
May 26, 2015
Page 4
Introduction
Members of the TSGAC to IHS and members of the TTAG to CMS have heard a number of concerns
about the lack of proactive action taken by QHP issuers with regard to contracting with IHCPs. In
order to gain a more comprehensive—and systematic—understanding of this issue, the TSGAC
conducted a study of QHPs contracting with IHCPs.
The TSGAC selected five geographically disperse sub-state regions for the study. The regions have a
mix of tribal organizations, urban Indian organizations, and IHS facilities, collectively referred to in
this report as IHCPs. 1 In addition, three of the regions are located in states with an FFM, and two of
the regions are located in states with hybrid Marketplaces. In order to facilitate data gathering, a
final criterion used to select regions for the study is that tribal representatives in the state are
actively involved in Marketplace issues.
The three FFM states are Wisconsin, Maine, and Oklahoma. The other two states are Nevada,
which has a federally-supported state-based Marketplace, and Oregon, which has a hybrid
Marketplace. Each of these states has responsibility for “plan management” functions.
In the view of TSGAC leadership, the ultimate goals of the network adequacy and related ECP
provisions contained in the ACA are two-fold:
•
Further the federal Indian trust responsibility 2 to ensure AI/AN enrollees in QHPs have
access to needed health services, including through available IHCPs;
•
Ensure IHCPs receive adequate compensation for services rendered (which will enable IHCPs
to meet the health care needs of tribal members) and allow IHCPs to participate as innetwork providers (which will facilitate referrals, when needed, from IHCPs to other
providers with minimum barriers).
The TSGAC is submitting this report to the CCIIO with the aim of furthering our joint responsibilities
to ensure that AI/ANs have timely access to needed health care services and that IHCPs have the
resources necessary to provide or arrange for such services.
Summary findings and recommendations are shown below. The IHCP-specific requirements
applicable to QHPs offered in FFM states and non-FFM states also are detailed below. State-specific
survey results are summarized in the tables and narratives contained in attachments. Additional
detail from the surveys is available from the TSGAC for some measures.
Key Findings
◊
Compliance by QHP issuers with existing CCIIO IHCP-specific requirements, and inclusion of
IHCPs in QHP networks, remains a work in progress.
1
IHCPs also referred to as Indian Health Service, Indian Tribe, Tribal organization, and urban Indian organization
providers, or I/T/Us.
2
http://www.bia.gov/FAQs/
May 26, 2015
Page 5
o Some QHP issuers (in FFM states) appear to have complied with CCIIO IHCP-specific
contracting requirements and include numerous IHCPs in plan networks.
o Other QHP Issuers (in FFM and non-FFM states) offered no contracts to IHCPs,
offered contracts without inclusion of the QHP Addendum, and/or included no
IHCPs in plan networks.3
o For example, according to interviews with IHCPs in Wisconsin, at least two of the
eight QHP Issuers did not offer contracts to IHCPs in their service areas, including
Ambetter from MHS Wisconsin and Common Ground Health Coop.
◊
Many QHPs have been certified to offer coverage in a Marketplace despite including few, if
any, available IHCPs as in-network providers.
o This finding is true even when multiple IHCPs operate within the QHP’s service area.
o In Oklahoma, 50 percent (one of two) of the QHP issuers do not include an IHCP in
their plan network.
o In Nevada, 80 percent of the QHP issuers operating in the region studied do not
have IHCPs in their plan network.
◊
Even where there was at least partial compliance by QHP issuers with the requirement to
offer contracts to IHCPs in the QHP’s service area, there are few, if any, IHCPs in the QHP’s
provider network.
o For example, among the eight QHP issuers operating in the Wisconsin region
studied, only one network (serving four of the QHP issuers) lists one of the twelve
available IHCPs in their network. The other QHPs list zero IHCPs as in-network. As
such, 60 percent of the QHPs on the FFM in the four Wisconsin zip codes included
do not have any IHCPs in network.
◊
Interest and capacity of IHCPs to contract as in-network providers varied across the IHCPs
studied, with some IHCPs working aggressively to gain in-network status and others not.
o Despite IHCP interest and efforts in Nevada, only one IHCP is in any of the QHP
networks, and this one contract was in place prior to 2014 and does not include the
QHP Addendum.
◊
In general, IHS facilities have chosen to not contract with QHPs and to secure
reimbursement for services through IHCIA Section 206 authority.
o For example, the IHS Warm Springs Health & Wellness Center in Oregon is not part
of any QHP network, and the IHS facilities in Oklahoma have not yet entered into
contracts, with both reporting reliance on section 206.
3
During the 2015 Coverage Year studied, QHP issuers were required to include the QHP Addendum in contract
offers.
May 26, 2015
Page 6
◊
Some QHPs were not in compliance with CCIIO’s IHCP-specific requirements.
o At least two of the eight QHP issuers in Wisconsin did not offer contracts to the
IHCPs in their service area.
o In Oklahoma, one QHP issuer did not include the QHP Addendum in contract offers.
o One IHCP in Wisconsin reported that only two of the eight QHP issuers included the
QHP Addendum in their contract offers (a requirement in effect for the 2015
coverage year).
◊
Non-FFM states have not adopted the key IHCP-specific requirements that are applicable in
FFM states.
o Only one non-FFM state (Oregon) adopted one of the core IHCP-specific provisions
(i.e., requirement for QHP Issuers to offer contracts to all IHCPs in the plan’s service
area). Oregon did not adopt a second companion provision (i.e., requirement that
QHP Issuers include the QHP Addendum with the contract offer).
◊
Government-established IHCP-specific regulations matter.
o In FFM states—where IHCP-specific standards contained in the CCIIO Issuer Letter
apply—IHCPs are much more likely to be in-network providers, as compared with
those in non-FFM states where these standards are not required.
o In Nevada, a non-FFM state, there are no Marketplace-imposed requirements to
offer to contract with IHCPs or to use or include the contents of the QHP Addendum.
To date, there have been no contract offers made by any of the QHP issuers to any
of the IHCPs in Nevada.
◊
QHP issuers’ understanding of, and compliance with, applicable IHCP-specific standards is
highest in states with engaged tribal representatives.
o In Maine, tribal representatives educated one QHP Issuer that, initially, reported not
being aware of some IHCP-specific contracting requirements. Ultimately, the three
non-closed panel plans in Maine appear to have complied with the requirement to
offer contracts using the QHP Addendum.
◊
In order to facilitate collection of needed data, states selected for inclusion in this study
were states with some of the most active tribal representatives. Selection of these states is
likely to have skewed the findings of this report, resulting in an overstatement of the degree
to which states are complying with the federal network adequacy and ECP standards.
◊
Many IHCPs are uncertain if QHP issuers offered contracts to the IHCP.
o IHCPs were able to report when they are aware of QHP issuers offering contracts,
but without knowing when and to whom contract offers were made (as represented
May 26, 2015
Page 7
by QHP Issuers to CMS/CCIIO), the IHCPs were oftentimes not able to validate or
refute general statements of compliance by QHP issuers.
◊
IHCPs rarely were able to determine if contract offers made by QHP Issuers were in
compliance with the CMS/CCIIO “good faith” standard that payment rates and other terms
are such “that a willing, similarly-situated, non-ECP provider would accept or has accepted.”
o In Oklahoma, one IHCP was offered “very low” inpatient hospital rates (which were
reported as being paid to an IHS facility in the state), although the IHCP was able to
negotiate more acceptable rates.
◊
QHP issuer online information about in-network providers is oftentimes inconsistent with
the understanding of IHCPs as to whether they are in network.
o When this is the case, such as occurred with IHCPs in Wisconsin, IHCPs typically
understand that they are in network but the online directory does not include the
IHCPs.
◊
“Closed panel” QHPs remained closed to IHCPs.
o Harvard Pilgrim Health Plan in Maine and Kaiser Permanente in Oregon do not
include IHCPs.
o An IHCP in Wisconsin is using authority under IHCIA section 206 to secure payment
from a closed panel QHP.
◊
Tribal representatives previously recommended that CMS/CCIIO apply the IHCP-specific
contracting requirements applicable in FFM states to QHP issuers operating in non-FFM
states, or at least “urge State-based Exchanges to employ the same standard” in order to
signify that states have the authority to apply such standards.
o In the final rule on Benefits and Payment Parameters for 2016,4 CMS stated, “We
urge State Exchanges to employ the same standard when examining adequacy of
ECPs as outlined in §156.235, including the requirement that issuers offer contracts
to all IHCPs in the plan’s service area.”
o To date, there has not been further adoption of the FFM’s IHCP-specific standards
by non-FFM state Marketplaces.
◊
The decision by CCIIO to not share with the TSGAC a complementary set of QHP issuersupplied information on contract offers made to IHPCs (e.g., if, when, to whom, and
whether the QHP Addendum was incorporated into the contract offer) hindered the ability
of the TSGAC researchers to determine if contract offers were made to each IHCP.
Recommendations
4
Preamble to the Final Rule on CMS-9944, Notice of Benefit and Payment Parameters for 2016, 80 FR 10837.
May 26, 2015
Page 8
The TSGAC recommends that CCIIO:
◊
Retain IHCP-specific contracting requirements in FFM states.
◊
With regard to QHPs with few or no in-network IHCPs, determine the reasons for the
provider network deficiencies and if the plans meet federal network adequacy and ECP
standards.
◊
Require non-FFM states to adopt policies to ensure QHP issuers in their state meet the
federal network adequacy (45 CFR § 156.230(b)) and ECP (45 CFR § 156.235) standards, and
absent meeting the standards institute a back-up mechanism requiring the adoption of the
requirements in the CCIIO 2015 and 2016 Issuer Letters if a state otherwise does not meet
the standards.
◊
Review the detailed findings in this report to correct non-compliance and investigate in
other (non-studied) states to determine if similar problems are occurring.
◊
Review a sample of contract offers to determine if the offers meet the “good faith”
standard pertaining to payment rates.
◊
Establish alternative reference payment rates that enable IHCPs to determine if the QHP
issuer’s offer is in compliance with the regulations. Alternatively, CCIIO could perform a
review of proposed rates if requested by an IHCP.
In addition to the above recommendations to CCIIO, the TSGAC recommends that IHS compare the
rates offered to IHS providers by QHP issuers with either (1) the rates received when billing as nonin network providers or (2) the rates received when billing under Indian Health Care Improvement
Act (IHCIA) Section 206 authority. The TSGAC also recommends that TSGAC members consider
sharing experiences with QHP contracting, including identifying effective strategies to gain innetwork status and comparing results from seeking IHCIA Section 206 compliance by QHP issuers.
May 26, 2015
Page 9
Exhibit A: Standards for QHPs on Network Adequacy and ECPs
Applicable Standards
ACA includes broad standards for QHPs on network adequacy and inclusion of ECPs. These
standards are found at ACA §1311(c)(1)(B) and (C).
CMS/CCIIO issued regulations implementing these requirements at 45 CFR §156.230 and 45 CFR
§156.235.
In addition, CMS/CCIIO issued sub-regulations providing further guidance and specifications on the
requirements for network adequacy and ECP inclusion. This guidance is contained in an “Issuer
Letter,” which is issued and updated annually by CMS/CCIIO and applicable to the subsequent
Coverage Year (e.g., the 2016 Issuer Letter was finalized in 2015 and applicable to the 2016
Coverage Year).
The hierarchy of the network adequacy and ECP requirements are displayed in the diagram below.
All Marketplaces
Affordable Care Act
Network Adequacy Standards
Essential Community Provider Provisions
CMS / CCIIO Regulations
FFM
CMS / CCIIO Guidance Documents
• All ECP
• Indian health care providers
General Standards Applicable in All States: Network Adequacy and ECPs [ACA §1311(c)(1)(B) and
(C)]
•
Network adequacy [45 CFR §156.230]
–
A QHP issuer must ensure that the provider network for each of its QHPs is
sufficient in numbers and types of providers, including providers that specialize in
May 26, 2015
Page 10
mental health and substance abuse services, to assure that all services will be
accessible without unreasonable delay.
•
Provide information to enrollees on availability of in-network and out-of-network providers
[45 CFR §156.230(b)]
–
•
A QHP issuer must make its provider directory for a QHP available to the
Marketplace for publication online in accordance with guidance from the
Marketplace and to potential enrollees in hard copy upon request. In the provider
directory, a QHP issuer must identify providers that are not accepting new patients.
ECPs [45 CFR §156.235]
–
A QHP issuer must have a sufficient number and geographic distribution of ECPs,
where available, to ensure reasonable and timely access to a broad range of such
providers for low-income, medically underserved individuals in the QHP’s service
area, in accordance with the Marketplace’s network adequacy standards.
–
ECPs serve predominantly low-income, medically underserved populations and
include, but are not limited to, safety net providers that are eligible to participate in
the 340B Drug Pricing Program in these categories: Federally Qualified Health
Centers (FQHCs), Ryan White providers, family planning providers, IHCPs, and
specified hospitals.
Standards Applicable in Non-FFM States 5
In non-FFM states, the specific implementing rules that operationalize the general standards on
network adequacy and ECPs are to be determined by the respective state.
To date, CMS/CCIIO has not required application of the implementing rules described below for
FFM states to non-FFM states.
Standards Applicable in FFM States
For a QHP to be certified for an FFM:
5
•
The issuer must offer contracts to all IHCPs in the QHP’s service area.
•
Issuer contract offers must be in “good faith,” meaning the offer must contain terms—
including payment rates—that a willing, similarly-situated, non-ECP provider would accept
or has accepted.
•
The issuer must offer contracts “using the recommended model QHP Addendum for IHCPs
developed by CMS.” 6
In states with the state performing Plan Management functions, the State is able to apply state-developed standards
and is not required to apply the FFM-specific regulations applicable in other FFM states.
May 26, 2015
Page 11
•
In addition, the issuer must “ensure at least 30 percent of available ECPs in each plan’s
service area participate in the provider network.” 7
For QHPs intending to operate in an FFM state but not meeting the above requirements, the QHP is
permitted to provide a narrative justification that the network established provides an adequate
level of service for low-income and medically underserved enrollees. The narrative is to include an
attestation that the issuer has satisfied the “good faith” contract offer requirement with IHCPs and
other ECPs.
6
In the 2016 Issuer Letter (applicable to the 2016 Coverage Year), CMS/CCIIO modified the standard pertaining to
the QHPAddendum. CMS/CCIIO required QHP issuers to, in the contract offers to IHCPs, “apply the special terms
and conditions necessitated by Federal law and regulations as referenced in the recommended model QHP
Addendum for IHCPs developed by CMS,” rather than explicitly require use of the QHP Addendum (2016 Issuer
Letter, page 67). But for the 2015 Coverage Year, the QHP Addendum is required to be included in the contract
offers made by QHP Issuers.
7
For an “Integrated Issuer,” which is a QHP issuer that provides a majority of covered professional services through
physicians employed by the issuer or through a single contracted medical group, an alternate standard on ECPs
applies and is contained in federal regulations at 45 CFR §156.235(a)(2) and (b).
May 26, 2015
Page 12
Exhibit B: State Summary Tables
Table 1:
STATE OF MAINE
Qualified
Health
Plan
Anthem
BCBS
Harvard
Pilgrim
Maine
Community
Health
Options
Number of Plan Offerings by Zip Code
Network Provider Contracts Signed
Pleasant Indian
PenobPoint Township
scot
4769
4730
4667
4668
4468
Micmac
Houlton
12
12
12
12
12
yes
yes
no
yes
yes
4
4
4
4
4
no
no
no
yes
no
9
9
9
9
9
yes
no
yes
yes
yes
Contract with Individual Providers
Contract with Tribal Facility
Only Physical Therapy Provider
Table 2:
STATE OF NEVADA
Qualified Health
Plan
Anthem BCBS
Nevada Health Co-op
Assurant Health
HPN-My HPN
Prominence Health
Number of Plan Offerings by Zip
Code
89427
10
4
89406
10
4
89502
12
4
6
14
12
89460
11
4
6
12
Schurz
Reno
WashSU
Fallon Sparks
oe
no
no
no
no
no
no
no
no
no
no
yes
no
yes
no
May 26, 2015
Page 13
Table 3:
STATE OF OKLAHOMA
Qualified Health
Plan
BCBS of OK
GlobalHealth
Code
74820
74884
74859
23
23
23
12
12
12
Chickasaw Wewoka
Creek
yes
no
yes
no
no
no
Table 4:
STATE OF OREGON
Qualified Health
Plan
Code
ATRIO
BrideSpan Health Co.
Health Republic
Kaiser Permanente
LifeWise HP of OR
Moda Health
OR Health Co-op
PacificSource HP
Providence HP
97761
0
5
13
0
9
8
9
10
4
97347
6
5
16
5
9
10
9
10
4
97801
0
5
13
0
9
8
9
10
4
Warm
Grand
YellowSprings
Ronde
hawk
no
yes
no
no
yes
no
no
yes
no
no
no
no
no
yes
no
no
yes
yes
no
yes
yes
no
yes
no
no
yes
yes
May 26, 2015
Page 14
Table 5:
STATE OF WISCONSIN
Qualified Health
Plan
Number of Plan Offerings by Zip Code
54155
Ambetter from MHS
Health Wisconsin
Anthem BCBS
Arise Health Plan
Common Ground
Healthcare Coop
Dean Health Plan
Molina Marketplace
Security Health Plan
of Wisconsin, Inc.
UnitedHealthcare
54520
54135
53204
Network Provider Contracts
Signed
Forest
Menom
Oneida County
-inee
33
12
35
33
12
35
no
no
no
18
9
3
18
3
no
no
yes
no
yes
10
8
10
no
yes
yes
no
3
10
3
10
Attachment 1
STATE OF MAINE
The Tribal Self-Governance Advisory Committee commissioned a study on “Network Adequacy
and Essential Community Provider Inclusion in Indian County”. The State of Maine was one of
the areas chosen to study. The State of Maine is a Federally-Facilitated Marketplace (FFM).
Maine has expanded Medicaid. As a FFM, there is a requirement of Issuers of Qualified Health
Plans (QHPs) to offer contracts to all Indian Health Care Providers (IHCPs). There is also a
recommendation for the QHPs to use the QHP Indian Addendum when contracting with IHCPs.
For the study, we chose the eastern one-third side of Maine, including Aroostook, Washington,
and Penobscot counties. This area is known for its farming, mostly producing potatoes and
blueberries, and fishing. The Indian Health Service operates one outpatient health center, and
three (3) Tribes operate a health center. It is worthy to note that the Passamaquoddy Tribe has
three distinct self-governing communities within the tribe’s ancestral homeland, two of which
operate a health center. Zip codes were chosen for this study where the following IHCP facilities are
located:
1.
2.
3.
4.
5.
IHS Micmac Service Unit in Presque Isle, Maine
Houlton Band of Maliseet Indians in Houlton, Maine
Passamaquoddy Tribe of Pleasant Point in Perry, Maine
Passamaquoddy Tribe of Indian Township in Princeton, Maine
Penobscot Nation in Old Town, Maine
The following are the Qualified Health Plans that are offered in each of the zip codes for the
above-referenced facilities:
1. Zip Code 04769 (IHS Micmac Service Unit)
a. Anthem Blue Cross and Blue Shield has 12 plan offerings
b. Harvard Pilgrim has 4 plan offerings
c. Maine Community Health Options has 9 plan offerings
2. Zip Code 04730 (Houlton Band of Maliseet Indians)
3. Zip Code 04667 (Passamaquoddy Tribe of Pleasant Point)
4. Zip Code 04668 (Passamaquoddy Tribe of Indian Township)
5. Zip Code 04468 (Penobscot Nation)
Maine Study Narrative
Page 1 of 2
5/26/2015
Attachment 1
In summary, there are three insurance companies operating in the five zip code areas. Among
the three, two lists all except one of the IHCPs are in their network, according to the
information offered online. All health centers except the Passamaquoddy Tribe at Pleasant
Point are included in the Anthem Blue Cross and Blue Shield Provider networks (Blue Choice
PPO, Pathway, and Pathway X). One health center (Passamaquoddy Tribe at Indian Township)
reported they were in the Harvard Pilgrim provider network. However, after an extensive
search of that network, they were not listed. Ms. Melanson reported to me they are in network
because they are billing and getting paid for one patient who has Harvard Pilgrim. All health
centers, except Houlton Band of Maliseet Indians are included in the Maine Community Health
Options provider networks, and Houlton Band reports they are in the process of obtaining a
contract with Maine Community Health Options. Currently 33% of the plans on the FFM in
these five zip codes do not have any IHCPs in their network.
Four of the five health centers had existing contracts with two of the three qualified health
plans in this region. The information reported was somewhat inconsistent, however, it appears
two of the three, Anthem Blue Cross and Blue Shield and Maine Community Health Options, did
offer a contract with an Indian Addendum to each of the health centers. Ms. Liz Neptune who
is a Nashville Area TEOC-U representative reported that Maine Community Health Options did
not know about the Indian Addendum, she shared a copy with them and all the health
directors. It seems that was a beneficial activity. For the most part the rates offered were
Medicare Like Rates and were non-negotiable, with one health center reporting that Maine
Community Health Options offered 120% of Medicare rates.
Based on the survey, one of the three qualified health plans did not offer contracts to the IHCPs
in their area, Harvard Pilgrim. It was reported that those contract offers did include the CMS
Model Indian Addendum.
The factors for considering whether to enter into contracts with the QHP’s included such items
as the Insurer was also the Insurer for the employee’s health insurance, the majority of
patient’s insurance is through Maine Community Health Options, and they wanted to ensure
they would receive reimbursements for patient visits.
Attached to this narrative are the questions and answers that were obtained while performing
the research on the State of Maine and IHCP.
Since Maine is a FFM, it seems the requirements imposed on Issuers to offer contracts to IHCPs
with a recommendation to use the QHP Indian Addendum was followed, with the exception of
Harvard Pilgrim.
Maine Study Narrative
Page 2 of 2
5/26/2015
Attachment 2
NASHVILLE AREA (MAINE)
Maine is a federally facilitated Marketplace. Maine did not expand Medicaid in 2014. As a FFM Maine QHP's are required to offer contracts to all I/T/U's in the state. IHS Nashville Area Office operates 1 federal/direct service program and four (4) tribes provide outpatient
services. These facilities represent the Eastern Side of the state and includes IHS and tribal health systems.
I/T/U #1
I/T/U #2
I/T/U #3
I/T/U #4
I/T/U #5
List of IHCP in Region
IHS Micmac Service Unit, Aroostook
County, 8 Northern Road, Presque
Isle, ME 04769, Tele 207-764-7219
Houlton Band of Maliseet Indians,
Aroostook County, Maliseet Center for
Health and Wellness, 3 Clover Circle,
Houlton, ME 04730, Tele 207-5322240
Passamaquoddy Tribe Pleasant
Point, Pleasant Point Health Center,
Washington County, PO Box 351,
Perry, ME 04667, tele 207-853-0644
Passamaquoddy Health Center
(Indian Township), Washington
County, 401 Peter Dana Point Road,
PO Box 97, Princeton, Maine 04668,
tele 207-796-2321
Penobscot Nation, Penobscot County,
Ruth Attean Davis Health Building, 23
Wabanaki Way, Old Town, Maine 04468,
tele 207-827-6101
Contact Person
Theresa Cochran, Director (207-7647219), email:
Theresa.Cochran@ihs.gov; Katie M.
Espling, Business Office, email:
Katie.Espling@ihs.gov
Patti Bechard, Director (207-5322240); email:
pbechard@maliseets.com
Andrea Hanson, Director 207-7962321, ext. 14;
ahanson@nspitnashville.ihs.gov;
Kirk Altvater, Asst. Director (207-854- Sandy Melanson, 207-796-2321 ext. Jill MacDougall, Director (207-817-7404),
email: Jill.MacDougall@ihs.gov
0644); email: Kirk.Altvater@ihs.gov 16
List of QHPs Offering Coverage in Zip Code of IHCP Facility
Anthem BCBS - 12 plans; Harvard
Pilgrim - 4 plans; Maine Community
Health Options - 9 plans
Pilgrim - 4 plans; Maine Community
Pilgrim - 4 plans: Maine Community
List of IHCP in QHP Network
Anthem BCBS - Yes; Harvard Pilgrim None; Maine Community Health
Options - Yes
Anthem BCBS - Yes; Harvard Pilgrim None; Maine Community Health
Options - In progress
Anthem BCBS - None; Harvard Pilgrim Anthem BCBS - Yes; Harvard Pilgrim - Anthem BCBS - Yes; Harvard Pilgrim - None; Maine Community Health
Yes; Maine Community Health
None; Maine Community Health Options Options - Yes
Options - Yes
Yes
Provider Network Name
Maine Community Health Options;
Blue Choice PPO, Pathway, and
Pathway X
Blue Choice PPO, Pathway, and
Pathway X
Pilgrim - 4 plans: Maine Community
Anthem BCBS - 12 plans; Harvard Pilgrim 4 plans: Maine Community Health Options 9 plans
Maine Community Health Options;
Blue Choice PPO, Pathway and
Pathway X; Harvard Pilgrim
Maine Community Health Options; Blue
Choice PPO, Pathway, and Pathway X
Did IHCP have contract with QHP/issuer prior to 2014? Does QHP/issuer consider
consideration of old contract in compliance with requirements? (I understand
some issuers may just keep operating with old contracts and consider having met Anthem BCBS - Yes; Maine Community
requirements, which may mean old, low rates and no Indian Addendum.)
Health Options - Yes
Yes; Don't know
Yes with MCHO
Harvard Pilgrim and Anthem BCBS
were both existing agreement
No
If yes, was the Indian Addendum used and were rates satisfactory?
Contract Offer made by QHP to IHCP
Unknown
Unknown
Yes
MCHO - Yes
Yes, accepted what was offered
MCHO - Yes
No, No opportunity to negotiate
MCHO and Anthem BCBS
Contract Offer accepted by IHCP
BCBS - Yes
MCHO - Yes
BCBS - Yes as existing agreement;
MCHO - Yes
Unknown
MCHO - Yes
MCHO - Yes
Did Contract Offer include Model QHP Addendum
BCBS - Yes
Unknown
Yes
Not sure
Yes
Jill said it was unknown; Liz Neptune
reported that MCHO did not know about
the Indian Addendum so she shared a copy
with both MCHO and the tribal health
directors.
Unknown
Yes
Non-negotiable
Non-negotiable
Were payment rates offered in contracts such that a willing, simiarly-situated, nonMCHO - 120% of Medicare
ECP would accept or has accepted
Maine Study Spreadsheet - Attachment 2
Page 1 of 2
5/26/2015
Attachment 2
What factors did IHCPs consider in determining whether to enter into a contract
with QHP
Aetna, BCBS FEP and Anthem BCBS is
offered to employees at the Houlton
Band of Maliseet Indians
Wanted to contract with MCHO
ahead of time before marketplace
opened for enrollment where MCHO
Wanted to make sure they received
was most popular so likelihood of
patients choosing them was high.
payment
Evaluations of QHPs offered in non-FFM states, identify the requirements imposed
on the QHPs pertianing to contracting with IHCPs and whether issuers complied
with these requierments
See Above
See Above
See Above
Maine Study Spreadsheet - Attachment 2
Page 2 of 2
See Above
Only two approached us
See Above
5/26/2015
Attachment 3
STATE OF NEVADA
and Essential Community Provider Inclusion in Indian County”. The State of Nevada was one of
the areas chosen to study. The State of Nevada is a federally-supported stated-based
Marketplace called “Nevada Health Link.” Nevada did expand Medicaid. Nevada Health Link
does not require Issuers of Qualified Health Plans (QHPs) to offer contracts to all Indian Health
Care Providers (IHCPs), nor do they require the QHPs to use the QHP Indian Addendum when
contracting with IHCPs.
For the study, we chose the western side of Nevada, including Mineral, Churchill, Washoe, and
Douglas counties. This area is largely rural, although Reno is located in Washoe County. The
Indian Health Service operates one hospital and two outpatient health centers, and four (4)
Tribes provide outpatient health services. Zip codes were chosen for this study where the
following IHCP facilities are located:
1.
2.
3.
4.
Indian Health Service Schurz Service Unit Health Center in Schurz, Nevada
Fallon Paiute-Shoshone Tribe, Fallon Tribal Health Center in Fallon, Nevada
Reno Sparks Tribal Health Center in Reno, Nevada
Washoe Tribal Health Center in Gardnerville, Nevada
1. Zip code 89427 (IHS Schurz Service Unit)
a. Anthem Blue Cross Blue Shield has 10 plan offerings
b. Nevada Health Co-op has 4 plan offerings
2. Zip code 89406 (Fallon Tribal Health Center)
b. Nevada Health CO-OP has 4 plan offerings
3. Zip code 89502 (Reno Sparks Tribal Health Center)
c. Assurant Health has 6 plan offerings
d. HPN-My HPN has 14 plan offerings
e. Prominence Health Plan has 12 plan offerings
4. Zip code 89460 (Washoe Tribal Health Center)
c. Assurant Health has 6 plan offerings
d. Prominence Health Plan has 12 plan offerings
In summary there are five insurance companies operating in the four zip code areas. Among
the five, only one IHCP is in any of the QHP provider networks. Reno Sparks Tribal Health
Nevada Study Narrative
Page 1 of 3
5/26/2015
Attachment 3
Center is a part of Health Plan of Nevada (HPN-My HPN) provider network referred to as “HMO
Provider Directory for Northern Nevada” and Prominence Health provider network referred to
as “Premier HMO North Network and HealthFirst HMO Network - "Choice Plus." And, the
reason Reno Sparks is in these provider networks at all is due to an existing contract that was in
place prior to 2014, which has no Indian Addendum included. This means that currently 80
percent of the plans in these four zip code areas do not have any IHCPs in network.
Angie Wilson, Director, Reno Sparks Tribal Health Center was the point of contact on this study.
Ms. Wilson previously expressed her concerns with the lack of QHP offers to contract with
IHCPs at the November Tribal Technical Advisory Group meeting in Washington, DC. Ms.
Wilson and I reviewed the questions listed below. She agreed to discuss these with other
Indian Health Care Providers at their next meeting, which was held on January 13, 2015. The
meeting included IHCPs from the western side of the state (which our study is focused on), but
also included the Paiute Tribe, the Northern Nevada Tribes, and the Indian Health Service Elko
service unit, and the southern Nevada Tribes. A Nevada Health Link representative was also in
attendance at the meeting.
All the Indian Health Care Providers in attendance reported that they were treated the same
and had the same answers to the following questions. The answers are listed in the attached
table, “IHS Phoenix Area (Nevada) Research Questionnaire”:
1. Does Nevada Health Link require Issuers to offer contracts to Indian Health Care
Providers?
2. Does Nevada Health Link require Issuers to offer contracts to IHCP with the Model
Indian Addendum?
3. Were there other requirements imposed on the Issuers/QHP’s pertaining to contracting
with Indian Health Care Providers?
4. Do you believe those requirements were complied with by the Issuers/QHPs?
5. If no, why not?
6. Did your facility have a contract with each QHP/Issuer prior to 2014?
7. If yes, did the QHP/issuer consider the old contract to be in compliance with the
requirements to have a contract with IHCP or ECP?
8. If yes, was the QHP Indian Addendum used and were rates satisfactory?
9. Was a contract offer made by each of the Issuers to your health center?
10. Was the contract offer accepted by the health center?
11. Did the contract offer include the Model QHP Indian Addendum?
12. Were payment rates offered in the contracts such that a willing, similarly-situated, nonECP (Essential Community Provider) would accept or has accepted?
13. What factors did you consider in determining whether to enter into a contract with each
QHP?
Nevada Health Link is governed by the Silver State Exchange Board (“Board”). The IHCPs
located in Nevada have been advocating them (1) to have a Tribal Advocate on their Board as
an Advisory position and (2) to have the Board make it mandatory to include the Indian
Page 2 of 3
5/26/2015
Attachment 3
Addendum in any QHP contracts with IHCPs. When the IHCPs discussed with the Board the
need for Issuers to offer contracts, the reply from the Board was, “Hopefully they will in the
future.” In addition, the Board’s attitude has been that the Board wants all the IHCPs to
contract or none of them to contract, even though the IHCPs have explained to the Board that
Tribes are different, and contracting should be an individual choice of each Tribe / IHCP.
Currently, there are no requirements by Nevada Health Link imposed on Issuers pertaining to
contracting with IHCPs, including no requirement on QHP issuers to offer contracts to IHCPs
and no requirement to use the QHP Indian Addendum. It seems there is a lack of awareness
and understanding at the Board about tribal health programs and the Indian Addendum.
To date, there have been no contract offers made by any of the QHP issuers to any of the IHCPs
in Nevada.
The IHCPs in the State of Nevada do want to enter into agreements with the QHPs, and so do
using the QHP Indian Addendum. It is important that the QHP issuers gain an understanding of
the Indian Addendum and how many of the AI/ANs who are enrolled in QHPs access care
through the tribal health delivery system, with subsequent referrals to outside providers. In
addition, it is also important that the IHCPs are able to bill for services covered within their
health programs, especially when some Tribes are sponsoring premiums for QHP enrollees who
are AI/ANs in their Purchased Referred Care programs and/or tribal populations.
It is worth noting that one dental insurer (Liberty Dental) did reach out to the Reno Sparks
Tribal Health Center about contracting, but no follow up has ensued.
the research on the State of Nevada and IHCP. Since Nevada has no requirements imposed on
issuers to offer a contract to all IHCPs there is no requirements to meet.
Page 3 of 3
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Attachment 4
IHS PHOENIX AREA (NEVADA) RESEARCH QUESTIONNAIRE
Nevada is a federally-supported state-based Marketplace called "Nevada Health Link." Nevada did expand Medicaid in 2014. Nevada Health Link has no requirements on Qualified Health Plan (QHP) issuers regarding Indian Health Care Providers (IHCPs). The Indian Health Service (IHS)
operates one hospital and two outpatient health centers, and four (4) Tribes provide outpatient health services. The region selected is located in the western side of the State and is served by IHS and the tribal health system providers.
I/T/U #1
I/T/U #2
I/T/U #3
I/T/U #4
Fallon Paiute-Shoshone Tribe, Churchill County,
Fallon Tribal Health Center, 565 Rio Vista Drive,
Washoe Tribal Health Center, Douglas County, 1588
Fallon, NV 89406,
Reno Sparks Tribal Health Center, Washoe County, Watasheamu Road, Gardnerville, NV 89460;
Tele 775.423.6075
Tele 775.265.4215
1715 Kuenzil St., Reno, NV 89502
List of IHCPs in Region
IHS Schurz Service Unit Health Center, Mineral
County, Drawer A, Schurz, NV 89427; Tele
775.773.2345
Contact Person:
Loron Ellery, Acting CEO
Angie Wilson, Director; 775-329-5162;
Jolene Aleck – Business Manager; 775-423-3634 awilson@rsicclinic.org
Andrea Lawrence; 775-265-4215
Anthem BCBS-10 plans: Nevada Health CO-OP-4
plans
Anthem BCBS-12 plans; Nevada Health CO-OP-4
plans; Assurant Health-6 plans; Health Plan of
Anthem BCBS - 10 plans; Nevada Health CO-OP - Nevada (HPN-My HPN)-14 plans; Prominence
4 plans
Health Plan-12 plans
Anthem BCBS-11 plans; Nevada Health CO-OP-4
plans; Assurant Health-6 plans; Prominence Health
Plan-12 plans;
QHP-11346-IHCP-ECP
Anthem BCBS - None; Nevada Health CO-OP Anthem BCBS - None; Nevada Health CO-OP - None None
QHP-11401-IHCP-ECP
Anthem BCBS - None; Nevada Health CO-OP None; Assurant Health - None; Health Plan of
Nevada (HPN-My HPN) - Yes (4 providers);
Prominence Health - Yes
QHP-11350-IHCP-ECP
Anthem BCBS - None; Nevada Health CO-OP - None;
Assurant Health - None; Prominence Health - None
Health Plan of Nevada (HPN-My HPN): HMO
Provider Directory for Northern Nevada; and
Prominence Health "Premier HMO North Network"
and HealthFirst HMO Network - "Choice Plus"
Does Nevada Health Link (state exchange) require Issuers to offer contracts to IHCP?
No, not that we are aware
Does Nevada Health Link (state exchange) require Issuers to offer contracts to IHCP
with the Model QHP Indian Addendum?
No
No
No
No
Not that we (tribal health programs) are aware
Were there other requirements imposed on the Issuers/QHP's pertaining to contracting
with IHCP?
Do you believe requirements were complied with by the Issuers/QHP's?
If the issuers/QHP's were required, they have not
complied
If the issuers/QHP's were required, they have not If the issuers/QHP's were required, they have not
complied
complied
If the issuers/QHP's were required, they have not
complied
If no, why not?
I think that they are unaware of or do not
understand tribal health programs and/or the
importance of the Indian Addendum
No
No
Yes, prior contracts with Health Plan of Nevada
(HPN-My HPN) and Prominence Health. We do not
know if QHP issuer believes they are in compliance
with Essential Community Provider (ECP)
requirements.
No
No
No
Did IHCP have contract with QHP/issuer prior to 2014? Does QHP/issuer consider
consideration of old contract in compliance with requirements? (I understand some
issuers may just keep operating with old contracts and consider having met
requirements, which may mean old, low rates and no Indian Addendum.)
If yes, was the QHP Indian Addendum used and were rates satisfactory?
Page 1 of 2
No the QHP Indian Addendum was not used
No
No
Nevada Study Spreadsheet - Attachment 4 Sheet1
Attachment 4
IHS PHOENIX AREA (NEVADA) RESEARCH QUESTIONNAIRE
Nevada is a federally-supported state-based Marketplace called "Nevada Health Link." Nevada did expand Medicaid in 2014. Nevada Health Link has no requirements on Qualified Health Plan (QHP) issuers regarding Indian Health Care Providers (IHCPs). The Indian Health Service (IHS)
operates one hospital and two outpatient health centers, and four (4) Tribes provide outpatient health services. The region selected is located in the western side of the State and is served by IHS and the tribal health system providers.
I/T/U #1
I/T/U #2
I/T/U #3
I/T/U #4
N/A
N/A
N/A
N/A
Did Contract Offer include Model QHP Indian Addendum
N/A
N/A
N/A
N/A
Were payment rates offered in contracts such that a willing, similarly-situated, non-ECP
would accept or has accepted
N/A
N/A
N/A
N/a
We want to enter into agreements with the QHP's
using the Indian Addendum. It is important that
QHP's understand the addendum and how many of
our AI/AN access care through the tribal health
delivery system, with referrals to outside providers.
It is also important that we are able to bill for
services covered within our tribal health programs,
especially when tribes are sponsoring premiums
for the PRC and/or tribal populations.
What factors did IHCPs consider in determining whether to enter into a contract with
QHP
Evaluations of QHPs offered in non-FFM states, identify the requirements imposed on
the QHPs pertaining to contracting with IHCPs and whether issuers complied with these
requirements
See Above
Page 2 of 2
See Above
See Above
See Above
Nevada Study Spreadsheet - Attachment 4 Sheet1
Attachment 5
STATE OF OKLAHOMA
and Essential Community Provider Inclusion in Indian County”. The State of Oklahoma was one
of the areas chosen to study. The State of Oklahoma is a Federally-Facilitated Marketplace
(FFM). Oklahoma has not expanded Medicaid. As a FFM, there is a requirement of Issuers of
Qualified Health Plans (QHPs) to offer contracts to all Indian Health Care Providers (IHCPs).
There is also a recommendation for the QHPs to use the QHP Indian Addendum when
For the study, we chose the south central region of Oklahoma, including Pontotoc, Seminole,
and Okfuskee counties. This area is rural, mostly farmland, that is southeast of Oklahoma City
about 1-1/2 to 2 hours. The Indian Health Service operates one outpatient health center, and
two (2) Tribes both have a health system, including a hospital with outlying outpatient health
centers. Zip codes were chosen for this study where the following IHCP facilities are located:
1. Chickasaw Nation Medical Center in Ada, Oklahoma
2. IHS Wewoka Indian Health Center in Wewoka, Oklahoma
3. Muscogee (Creek) Medical Center in Okemah, Oklahoma
1. Zip code 74820 (Chickasaw Nation Medical Center)
a. Blue Cross and Blue Shield of Oklahoma has 23 plan offerings
b. GlobalHealth has 12 plan offerings
2. Zip code 74884 (IHS Wewoka Indian Health Center)
3. Zip code 74859 (Muscogee (Creek) Medical Center)
In summary, there are two insurance companies in the three zip code areas. Among the two,
only one lists both tribal IHCP as in their network, according to the information offered on line.
After reviewing the networks in these plans, both tribal health systems are included in two of
the three Blue Cross and Blue Shield of Oklahoma QHP provider networks. Those two QHP
provider networks include the Blue Choice PPO and the Blue Preferred PPO. The Chickasaw
Nation health system is also included in the QHP provider network “Blue Advantage PPO.” It is
interesting to note that the Indian Health Service Wewoka Indian Health Center does not have a
contract with any of the Qualified Health Plans. I talked with the Oklahoma City Area Office
Business Office Manager and she said that there might be a few service units in Oklahoma that
have had a contract with an insurer but that it is not consistent throughout Oklahoma.
However, she is in the process of working with Blue Cross and Blue Shield of Oklahoma to enter
Oklahoma Study Narrative
Page 1 of 2
5/26/2015
Attachment 5
into a contract that will cover all of the Oklahoma Area. The reason for no contracts is that
there isn’t a need since the Insurers pay the Indian Health Service facilities under Section 206 of
the Indian Health Care Improvement Act. This means that currently fifty percent of the plans
on the FFM in these three zip codes do not have IHCPs in network.
Both QHPs made contract offers to the IHCPs in Oklahoma, with only one, Blue Cross and Blue
Shield, including the Indian Addendum. Only the Muscogee Creek Nation had existing contracts
with both Insurers. Just as a note, Global Health knew about the Indian Addendum because
the Policy Analyst for the Oklahoma City Area Indian Health Board met with both Insurers and
went over the Indian Addendum and the contracting process for IHCP previous to the offers of
contracting to the IHCP.
The factors for considering whether to enter into contracts with the QHPs included items as
negotiating the contracts for satisfactory payment rates, and the insurers wanting the facilities
to utilize their credentialing process.
the research on the State of Oklahoma and IHCP.
Since Oklahoma is a FFM, it seems the requirement imposed on Issuers to offer a contract to all
IHCPs with a recommendation to use the CMS Model Indian Addendum was followed in
Oklahoma for the most part.
Oklahoma Study Narrative
Page 2 of 2
5/26/2015
Attachment 6
IHS OKLAHOMA AREA (OKLAHOMA) RESEARCH QUESTIONNAIRE
Oklahoma is a federally facilitated Marketplace. Oklahoma did not expand Medicaid in 2014. As a FFM Oklahoma QHP's are required to offer contracts to all I/T/U's in the state. Oklahoma Area Office operates both inpatient and outpatient
facilities in Oklahoma as well as numerous tribes. These facilities represent the South Central region of Oklahoma and includes IHS and two (2) tribal health systems.
I/T/U #1
I/T/U #2
List of IHCPS in Region
Chickasaw Nation Medical Center, Pontotoc
County, 1921 Stonecipher Blvd, Ada,
Oklahoma 74820, Tele: (580) 436-3980
Contact Person:
Millie Blackmon, CEO,
Brenda Teel, Business Office Manager, email: millie.blackmon@ihs.gov; Pamela Strope,
brenda.teel@chickasaw.net
IHSAO Business Office
Karen Knight, Business Office Manager, cell:
918-752-8320; work: 918-756-4333, x245;
karen.knight@creekhealth.org
Blue Cross and Blue Shield of Oklahoma (23);
GlobalHealth (12)
GlobalHealth (12)
GlobalHealth (12)
BCBS - Yes; GH - No
None
BCBS - Yes; GH - No
Blue Advantage PPO; Blue Choice PPO; Blue
Preferred PPO
N/A
Blue Choice PPO; Blue Preferred PPO
Did IHCP have contract with QHP/issuer prior to 2014? Does QHP/issuer consider consideration
of old contract in compliance with requirements? (I understand some issuers may just keep
operating with old contracts and consider having met requirements, which may mean old, low rates
and no Indian Addendum.)
No
A few of OK service units had a contract, but
basically said they don't need a contract
because IHCIA says they will pay
Yes, both Insurers; No, both offered new
contracts
If yes, was the QHP Indian Addendum used and were rates satisfactory?
N/A
Yes since the Indian Addendum was released
by CMS
BCBS - Yes; GH - No, but MCN has requested an
amendment
Yes, both Insurers
BCBS - Yes; GH - No
Yes, both Insurers
BCBS - Yes; GH - still working on contract
Oklahoma City Area IHS Office is working on an
Area wide contract with BCBS
Yes
Did Contract Offer include Model QHP Indian Addendum
BCBS - Yes; GH - still working on contract
BCBS - Yes
BCBS - Yes; GH - No
BCBS-Yes; all have been paying under Section
206
BCBS - For clinics. negotiation was not a choice as
they have a state rate across the board; For
hospital, we negotiated an increase; GH negotiated; Overall a 25-60% increase in rates
was negotiated; rates offered were for IHS and
they were very low
Were payment rates offered in contracts such that a willing, similarly-situated, non-ECP would
accept or has accepted
Oklahoma Study Spreadsheet - Attachment 6
Yes
Page 1 of 2
IHS Wewoka Indian Health Center, Seminole
County, P.O. Box 1475, Wewoka, Oklahoma
74884, (405) 257-7326
I/T/U #3
Muscogee (Creek) Medical Center, Okfuskee
County, 309 North 14th, Okemah Oklahoma
74859, Tele: (918) 758-3101 or (918) 623-1424
5/26/2015
Attachment 6
What factors did IHCPs consider in determining whether to enter into a contract with QHP
Payment Rates
Credentialing - they wanted us to go through
their credentialing process
Rates and Terms
Evaluations of QHPs offered in non-FFM states, identify the requirements imposed on the QHPs
pertaining to contracting with IHCPs and whether issuers complied with these requirements
See Above
See Above
See Above
Oklahoma Study Spreadsheet - Attachment 6
Page 2 of 2
5/26/2015
Attachment 7
STATE OF OREGON
and Essential Community Provider Inclusion in Indian County”. The State of Oregon was one of
the areas chosen to study. The State of Oregon is a state-based exchange called “Cover
Oregon.” However, in 2015 Cover Oregon transferred to the federally-facilitated marketplace.
Oregon has expanded Medicaid. Cover Oregon required all Qualified Health Plans (QHPs) to
offer contracts to all Indian Health Care Providers (IHCPs) but do not require the CMS Model
Indian Addendum.
For the study, we chose the northern part of Oregon, including Jefferson, Polk, and Umatilla
counties. The Portland Area Indian Health Service covers the states of Washington, Oregon, and Idaho
and operates six Federal health facilities in five Tribal communities and one at Chemawa Indian School.
Tribes operate health facilities under the authority of the Indian Self-Determination and Education
Assistance Act (Public Law 93-638, as amended), Titles 1 and V. Twenty-three Tribes have Title V
compacts and there are twenty-four Tribes or Tribal organizations that contract under Title 1. Overall,
Tribes administer more than 74% of the Portland Area budget authority appropriation through SelfDetermination contracts or Self-Governance compacts. In Oregon, the Indian Health Service operates
two outpatient health centers, and four (4) Tribes provide outpatient health services. Zip codes
were chosen for this study where the following IHCP facilities are located:
1. IHS Warm Springs Health & Wellness Center in Warm Springs, Oregon
2. Grand Ronde Health & Wellness Center in Grand Ronde, Oregon
3. Yellowhawk Tribal Health Center in Pendleton, Oregon
1. Zip code 97761 (IHS Warm Springs Health & Wellness Center)
a. BrideSpan Health Company has 5 plans
b. Health Republic has 13 plans
c. LifeWise Health Plan of Oregon has 9 plans
d. Moda Health has 8 plans
e. Oregon’s Health Co-op has 9 plans
f. PacificSource Health Plans has 10 plans
g. Providence Health Plan has 4 plans
2. Zip code 97347 (Grand Ronde Health & Wellness Center)
a. ATRIO Health Plan has 6 plans
b. BrideSpan Health Company has 5 plans
c. Health Republic has 16 plans
d. Kaiser Permanente has 5 plans
e. LifeWise Health Plan of Oregon has 9 plans
f. Moda Health has 10 plans
g. Oregon’s Health Co-op has 9 plans
Oregon Study Narrative
Page 1 of 2
5/26/2015
Attachment 7
h. PacificSource Health Plans has 10 plans
i. Providence Health Plan has 4 plans
3. Zip code 97801 (Yellowhawk Tribal Health Center)
a. BrideSpan Health Company has 5 plans
b. Health Republic has 13 plans
c. LifeWise Health Plan of Oregon has 9 plans
d. Moda Health has 8 plans
e. Oregon’s Health Co-op has 9 plans
f. PacificSource Health Plans has 10 plans
g. Providence Health Plan has 4 plans
In summary, there are nine insurance companies operating in the three zip code areas. Among
the nine, none lists all IHCPs in their networks. Eight of the nine lists one IHCP in their network,
and three of the nine list two IHCPs in their network. The IHS Warm Springs Health & Wellness
Center is not a part of any network. They said they have not signed any contract because of
Section 206 of the IHCIA. The Grand Ronde Health & Wellness Center is in all networks, except
Kaiser Permanente, which is a closed panel plan. The Yellowhawk Tribal Health Center is in
three of the seven networks. Currently, only the closed panel plan in these three zip codes
does not have any IHCPs in their network.
It seems that most of the Qualified Health Plans did offer to contract with each of the health
centers, however, the Indian Addendum was not included, nor required. Grand Ronde said
they thought the Indian Addendum had not been finalized but that the Indian Addendum would
solve lots of the issues which result in them not having all contracts.
Yellowhawk Tribal Health Center said they have not worked to contract with all Qualified Health
Plans since they have not gone forward with a Tribal Sponsorship Program.
as the number of patients served with insurance plans and the usage of the CMS Model Indian
Addendum.
the research on the State of Oregon and IHCP.
Under Cover Oregon, the Qualified Health Plans were required to offer a contract with all
I/T/U’s in the state. It seems that for the most part the regulations to offer a contract were
followed in Oregon, except for Kaiser Permanente.
Oregon Study Narrative
Page 2 of 2
5/26/2015
Attachment 8
Portland Area (State of Oregon)
Oregon is a state-based exchange called CoverOregon which will be transferring to the FFM in 2015. Oregon did Expand Medicaid in 2014. Cover Oregon requires all QHPs to offer contracts to all I/T/U's in the state with the CMS Model Indian Addendum. Indian Health Service provides Outpatient Services at two (2) facilities in Oregon.
There are nine (9) tribes in Oregon who provide outpatient health services. These facilities represent the Northern Region of the state and includes both IHS and Tribal health systems.
I/T/U #1
I/T/U #2
I/T/U #3
IHS Warm Springs Health & Wellness Center, Jefferson County, PO Confederated Tribes of Grand Ronde Oregon, Polk County, 9605 Grand Ronde Road, Grand
Box 1209, Warm Springs, OR 97761, Tele: 541-553-1196
Ronde, OR 97347, Tele: 503-879-2075; email: GRHWC@grandronde.org
Yellowhawk Tribal Health Center, Umatilla County, PO Box 160,
73265 Confederated Way, Pendleton, OR 97801, Tele: 541-966-9830
Contact Person
Carol A. Prevost, MHSA, RN, CEO, email: carol.prevost@ihs.gov;
Jeremiah Johnson, email: jeremiah.johnson@ihs.gov
Jeffrey D. Lorenz, Executive Director, Health Services, email: jeff.lorenz@grandronde.org; Jill Tim Gilbert. Health Director, email: timgilbert@yellowhawk.org;
Hafliger, Accreditation Coordinator, email: Jill.Hafliger@grandronde.org
Linda Hettinga, email: LindaHettinga@yellowhawk.org
List of QHP's Offering Coverage in the Zip Code of IHCP Facility
BridgeSpan Health Company-5 plans; Health Republic-13 plans;
LifeWise Health Plan of Oregon-9 plans; Moda Health-8 plans;
Oregon's Health COOP-9 plans; PacificSource Health Plans-10 plans;
Providence Health Plan-4 plans
ATRIO Health Plans-6 plans; BridgeSpan Health Company-5 plans; Health Republic-16 plans;
Kaiser Permanenta-5 plans; LifeWise Health Plan of Oregon-9 plans; Moda Health-10 plans;
Oregon's Health COOP-9 plans; PacificSource Health Plans-10 plans; Providence Health Plan-4
plans
None
ATRIO Health Plan - Facility is in First Choice Health PPO, Providers are in ATRIO Provider
Directory; BridgeSpan Health Company - PT in ValuePPO Network; Health Republic - Providence
Network; LifeWise Health Plan of Oregon - Bronze HSA EPO, Oregon EPO, Preferred or PPO;
Moda Health - Connexus Network; Oregon's Health Co-op - Broad Network, Pharmacy is in
Select Network; PacificSource Health Plan - Basic Health Plan PSN, BrightIdea, BrightPath,
Choice PSN, Elect, HMO PSN, HMO PSN NW, Medishield PSN, NIHN PPO, Oregon Standard SHN, Portability, Preferred PSN, Preferred PSN NW, Prime, Prime PSN, PSN, SmartAlliance,
Moda Health - Connexus Network; Oregon's Health Co-op - Broad
SmartChoice, SmartHealth; Providence Health Plan - Providence EPO Network, Providence
Network & Select Network; Providence Health Plan - EPO Network,
Choice Network, and Providence Connect Network
Choice Network, & Connect Network for Pharmacy Only
Did IHCP have contract with QHP/issuer prior to 2014? Does QHP/issuer consider consideration of old
contract in compliance with requirements? (I understand some issuers may just keep operating with old
contracts and consider having met requirements, which may mean old, low rates and no Indian
Addendum.)
No, have not signed any contract because of Section 206 of the
IHCIA; a large majority of our patient population is not covered by
an employee based plan, and opted for exemption if they did not
qualify for Medicaid vs. pay for any health benefits out of pocket.
The QHP/Issuer considered old contracts for Pharmacy agreements
to be in compliance.
No
No, and we still are not contracted with any QHP; We hve a contract
with Moda Health which is specifically for Oregon Health Plan at the
current time. This is our CCO in Umatilla County.
Yes, pertaining to Pharmacy Agreements.
N/A
N/A
Yes, but due to a lack of definitive instructions to contract, our
service unit has depended on Section 206 to receive payment
Yes
No, we received a request to contract for three of the QHPs, not
including Oregon Health Plan (our CCO) or Moda
No
Have a "clinic" contract with LifeWise, PacificSource, and Moda. The Providence contract is
with the individual providers.
No
BridgeSpan Health Company-5 plans; Health Republic-13 plans;
LifeWise Health Plan of Oregon-9 plans; Moda Health-8 plans; Oregon's
Health COOP-9 plans; PacificSource Health Plans-10 plans; Providence
Health Plan-4 plans
No this is something we have to insist upon and created some
unwarranted confusion to the process
Generally no. LifeWise has offered something, but it has not been finalized at this time.
One from Pacific Source had the Indian Addendum, LifeWise totally
refused when QHPs first came into play and they were required to
reach out to Tribes. All requests Yellowhawk received was shared with
NPAIHB.
Were payment rates offered in contracts such that a willing, simiarly-situated, non-ECP would accept or
has accepted
N/A
As far as we know, yes.
No
Number of patients that would opt in for coverage, regional
unemployment, resources, tribal 638 programs understanding of
the system and implications of NOT contracting (tribal vs. fedeal
portions of the practice)
One of the reasons we don't have ALL CLINIC contracts is because of the issues that an
Addendum would fix, i.e., Trial sovereignty, etc.
Since we did not go forward yet with a Tribal Sponsorship Program, we
have not worked with any QHP with regard to contracts
Evaluations of QHPs offered in non-FFM states, identify the requirements imposed on the QHPs
pertianing to contracting with IHCPs and whether issuers complied with these requierments
See Above
See Above
See Above
Oregon Study Spreadsheet - Attachment 8
Page 1 of 1
5/26/2015
Attachment 9
STATE OF WISCONSIN
and Essential Community Provider Inclusion in Indian County”. The State of Wisconsin was one
of the areas chosen to study. The State of Wisconsin has a Federally-Facilitated Marketplace
(FFM). Wisconsin has not expanded Medicaid. As an FFM, there is a requirement of Issuers of
Qualified Health Plans (QHPs) to offer contracts to all Indian Health Care Providers (IHCPs).
There is also a recommendation for the QHPs to use the QHP Indian Addendum when
For the study, we chose the East Central region of Wisconsin, including Outagamie, Forest,
Menominee and Milwaukee counties. This area is known for its farming and forestry. Tribes
operate eleven (11) outpatient health centers, and there is one urban Indian health center in
Wisconsin. It is worthy to note that the Gerald L. Ignace Urban Indian Health Center in
Milwaukee was included in this study, but did not respond to the survey. Zip codes were
chosen for this study where the following IHCP facilities are located:
1.
2.
3.
4.
Oneida Tribe of Indians of Wisconsin in Oneida, Wisconsin
Forest County Potawatomi Health & Wellness Center in Crandon, Wisconsin
Menominee Tribal Clinic in Keshena, Wisconsin
Gerald L. Ignace Urban Indian Health Center in Milwaukee, Wisconsin
1. Zip code 54155 (Oneida Community Health Center)
a. Ambetter from MHS Health Wisconsin has 33 plan offerings
b. Anthem Blue Cross and Blue Shield has 12 plan offerings
c. Arise Health Plan has 35 plan offerings
d. Common Ground Healthcare Coop has 18 plan offerings
e. Dean Health Plan has 9 plan offerings
f. Molina Marketplace has 3 plan offerings
g. United HealthCare has 10 plan offerings
2. Zip code 54520 (Forest County Potawatomi Health & Wellness Center)
a. Molina Marketplace has 3 plan offerings
b. Security Health Plan of Wisconsin, Inc. has 8 plan offerings
c. United HealthCare has 10 plan offerings
3. Zip code 54135 (Menominee Tribal Clinic)
a. Molina Marketplace has 3 plan offerings
b. United HealthCare has 10 plan offerings
4. Zip code 53204 (Gerald L. Ignace Urban Indian Health Center)
a. Ambetter from MHS Health Wisconsin has 33 plan offerings
b. Anthem Blue Cross and Blue Shield has 12 plan offerings
c. Arise Health Plan has 35 plan offerings
d. Common Ground Healthcare Coop has 18 plan offerings
Wisconsin Study Narrative
Page 1 of 2
5/26/2015
Attachment 9
e. Molina Marketplace has 3 plan offerings
f. United HealthCare has 10 plan offerings
In summary, there are eight insurance companies operating in the four zip code areas. Among
the eight, only the Aspirus Network, which includes Anthem BCBS, Arise Health Plan, Security
Health Plan, and United HealthCare, lists one of the IHCP as in their network, according to the
information offered on line. However, the survey of IHCPs indicates that three of the plans
have IHCPs in network: Molina, Security Health Plan, and UnitedHealth Care. In addition,
Oneida is in the process of signing contracts with Anthem BCBS, Arise Health Plan, and United
HealthCare, which would bring the total to six out of eight. This means that currently over 60
percent of the plans on the FFM in these four zip codes do not have any IHCPs in network.
It is not clear whether all eight insurance companies offered contracts with the Indian
Addendum to the ICHPs in their areas. Two of the three tribal facilities had existing contracts
with Molina Marketplace, however, the IHCP’s weren’t listed in the networks, which could be
that those existing contracts were for Medicare and Medicaid. The existing contract with
Molina did include the CMS Model Indian Addendum and the rates were consistent with
Medicaid and Medicare rates. Forest County said they have been in the Aspirus Network since
2007, which includes both the Security Health Plan and the United HealthCare plan. The
Menominee Tribal Clinic doesn’t seem to have any contracts for the Marketplace, only Molina
for Medicaid & Medicare, although their facility is not listed in any of the Provider Directories.
Dean Health Plan refused to contract with the Wisconsin I/T/U’s. After further research the
Dean Health Plan is a closed panel plan. CMS Division of Tribal Affairs is working with Oneida
Tribe to ensure they are receiving reimbursement under Section 206 for Dean Health Plan.
Based on the survey, at least two of the eight qualified health plans did not offer contracts to
the I/T/U’s in their area, including Ambetter from MHS Health Wisconsin and Common Ground
Healthcare Coop. Oneida Tribe reported that only Molina Marketplace and Arise Health Plan
offered the CMS Model Indian Addendum.
as the amount of business the I/T/U has done with the Insurer in the past and the amount of
unpayable claims due to a lack of contract, reimbursement rates, and to receive some level of
reimbursement for services as over 95% of their patients are Native American and eligible for
direct care services and without the contract they would have written off 100% of the payment
for services.
the research on the State of Wisconsin and IHCP. Since Wisconsin is a FFM, it seems the
requirement imposed on Issuers to offer a contract to all IHCPs with a recommendation to use
the QHP Indian Addendum was not precisely followed in Wisconsin.
Wisconsin Study Narrative
Page 2 of 2
5/26/2015
Attachment 10
Bemidji Area (State of Wisconsin)
Wisconsin is a federally facilitated Marketplace. Wisconsin did not expand Medicaid in 2014. As a FFM Wisconsin QHP's are required to offer contracts to all I/T/U's in the state. Bemidji Area Office doesn't operate any programs in Wisconsin. Eleven (11) tribes in Wisconsin provide outpatient services. These facilities represent the East Central region of the state and includes tribal health systems and an urban health center.
I/T/U #1
I/T/U #3
I/T/U #4
Forest County Potawatomi Health & Wellness Center, Forest County, Physical
Oneida Tribe of Indians of Wisconsin, Outagamie County, Oneida Community Health Center, PO Address: 8201 Mish Ko Swen Drive, Mailing Address: PO Box 396, Crandon, WI
Box 365, Oneida, WI 54155, Tele 920-869-2711
54520, Tele 715-478-4300
Menominee Tribal Clinic, Menominee County, PO Box 970, Keshena, WI
54135, Tele 715-799-3361
Gerald L. Ignace Urban Indian Health Center, Milwaukee County, 1711
South 11th Street, Milwaukee, WI 53204, Tele 414-383-9526
Contact Person:
Debbie Danforth, email: ddanforth@oneidanation.org; David Larson, email:
dlarson@oneidanation.org
Jerry Waukau, email: jerryw@mtclinic.net; Laurie Bolvin, email:
laurieb@mtclinic.net
Brenda Duke, COO, email: Bduke@gliihc.net; Margie Makowski, email:
mmakowski@gliihc.net
List of QHP's Offering Coverage in the Zip Code of IHCP Facility
Ambetter from MHS Health Wisconsin (33); Anthem BCBS (12); Arise Health Plan (35); Common
Molina Marketplace (3); Security Health Plan of Wisconsin, Inc. (8); UnitedHealthcare
Ground Healthcare Coop (18); Dean Health Plan (9); Molina Marketplace (3); UnitedHealthcare (10) (10)
Molina Marketplace (3); UnitedHealthcare (10)
Could not find any, however the Oneida Community Health Center says they are in Molina
Marketplace.
Aspirus Network which includes Security Health Plan and United HealthCare
Did IHCP have contract with QHP/issuer prior to 2014? Does QHP/issuer consider consideration of old contract in compliance with
requirements? (I understand some issuers may just keep operating with old contracts and consider having met requirements, which may
mean old, low rates and no Indian Addendum.)
Yes with Molina Marketplace
Yes, through Aspirus Network; We have been contracted with Aspirus Network in the
area since 2007. The contract includes Security Health Plan and United HealthCare
with the exception of Molina Marketplace. Aspirus does contract with the Molina
Yes with Molina, entered into on 7/1/2013; We updated the contract, don't
Medicaid Plans.
remember the exact reasons why
Molina and Arise included the Addendum in the new contracts
No
Yes, the Addendum was used and the rates are consistent with Medicaid and
Medicare rates
No, Dean specifically refused after our request for a contract. We are in the process of signing
contracts with Anthem BCBS, Unitedhealthcae and Arise.
Aspirus does not contract with Molina Marketplace, except for the Molina Medicaid
Plans
Yes, we were unable to finalize one with UnitedHealthCare due to some
language that needed to be changed at our request
Yes
Molina and Arise included the Addendum
Aspirus does not contract with Molina Marketplace. Asprius does contract with the
Molina Medicaid Plans
N/A
Yes
Yes
Were payment rates offered in contracts such that a willing, similarly-situated, non-ECP would accept or has accepted
Yes
N/A
Not sure who might or has accepted
The amount of business that we have done with them in the past, and the amount of unpayable
claims due to lack of contract
Reimbursement Rates
We entered into the contract to receive some level of reimbursement for our
services - over 95% of our patients are native American and eligible for direct
care services. Without the contract we would have written off the services
100%
Evaluations of QHPs offered in non-FFM states, identify the requirements imposed on the QHPs pertaining to contracting with IHCPs and
whether issuers complied with these requirements
See Above
See Above
See Above
Wisconsin Study Spreadsheet - Attachment 10
I/T/U #2
Lynette Tahtinen email: lynette.tahtinen@fcpotawatomi-nsn.gov
Page 1 of 1
Ambetter from MHS Health Wisconsin (33); Anthem BCBS (12); Arise
Health Plan (35); Common Ground Healthcare Coop (18); Molina
Marketplace (3); UnitedHealthcare (10)
Molina for Medicaid/Medicare/Other products that we might agree on from
time to time; HC Exchange (Didn't find in Provider Directory)
No
5/26/2015
Attachment 11
Require IHCP Contract
Recommend IA
Met IHCP Contract
Met IA
Yes
Yes
Yes
All except Dean Health Plan
No
Yes
No Answer
Only Molina and Arise
N/A
Yes
No Answer
IHS Micmac
Houlton Band of Maliseet
Passamaquoddy Tribe of Pleasant Point
Passamaquoddy Tribe of Indian Township
Penobscot Nation
Yes
Yes
Yes
Only MCHO
Unknown
Only MCHO
Only MCHO
All except Harvard Pilgrim
BCBS Yes
Unknown
Yes
Not sure
Unknown
Oklahoma
Chickasaw Nation
IHS Wewoka
Muscogee (Creek) Nation
Yes
Yes
Yes
Yes
BCBS Yes
Yes
BCBS Yes
BCBS Yes
BCBS Yes
Nevada
IHS Schurz
Fallon Paiute-Shoshone
Reno Sparks
Washoe Tribal
Nevada Health Link
No
No
No
No
No
No
No
No
No
No
Oregon
IHS Warm Springs
Grand Ronde
Yellowhawk Tribal
Cover Oregon
Yes
No
Yes
Yes
All except Oregon Health Plan and Moda
No
No
No
State
Wisconsin
Facility
Oneida Tribe
Forest Co Potawatomi
Menominee Tribal
Urban Center
Maine
Spreadsheet - Attachment 11
FFM
State-Based
Page 1 of 1
5/26/2015
Self-Governance Health Reform National Outreach and Education
Semi-Annual Report
April 2015
Introduction
The Jamestown S’Klallam Tribe (JST) and U.S. Department of Health and Human Services
(HHS) amended their multi-year funding agreement in September 2014 to transfer $300,000 to
JST for the performance period October 1, 2014 - September 30, 2015, for “Self-Governance
National Indian Health Outreach and Education.” This semi-annual report is a required
deliverable and covers the six-month period from October 1, 2014, through March 31, 2015.
The funding amendment requires the Tribal Self-Governance Advisory Committee (TSGAC) to
manage and provide outreach, education, technical research and analytical support nationally to
Self-Governance Tribes on the Patient Protection and Affordable Care Act/Indian Health Care
Improvement Act (ACA/IHCIA). The overall objective is to improve Indian health care by
conducting training and technical assistance across Self-Governance Tribal communities to
ensure that the Indian health care system and all American Indians/Alaska Natives (AI/ANs) are
prepared to take advantage of the new health insurance coverage options which will improve
the quality and access to health care services, and increase resources for AI/AN health care.
TSGAC submitted a Work Plan for 2014-2015 to the IHS Office of Tribal Self-Governance
(OTSG) on October 24, 2014 outlining the proposed activities and process for meeting the
identified deliverables. The 2014-2015 Work Plan builds on JST’s successful program of
training and technical assistance during 2013-2014, as documented in the final report for that
year. The Work Plan is organized into the following sections:
1.
2.
3.
4.
Policy Analysis
Technical Assistance
Training
Positive Impact Stories
Final Approval for the 2014-2015 Work Plan was received from OTSG on November 14, 2014.
This progress report is organized to correspond to the four sections listed above.
Self-Governance Health Reform National Outreach and Education – Semi-Annual Report
April 2015
Page 2
Policy Analysis
Policy Papers and Comments on Proposed Regulations. Technical advisors continue to work
with national Indian organizations to analyze proposed regulations related to ACA/IHCIA
implementation and draft responses on behalf of TSGAC. Recent issues include:






Development of TSGAC Comments on CMS-9944-P; Notice of Benefits and
Payment Parameters for 2016
Development of TSGAC Comments on Draft 2016 Letter to Issuers in the
Federally-Facilitated Marketplace
Updated ACA/IHCIA White Paper with objectives and strategies
Memo and analysis of Tribal Premium Sponsorship (included in the January 2015
TSGAC meeting packages.)
Drafted analysis of CMS-9938-P, Summary of Benefits and Coverage and Uniform
Glossary, and offered recommendations applying to the Indian-specific costsharing protections (included in comments submitted by TTAG February 28,
2015).
TSGAC Comments submitted on the IHS proposed rule of Medicare-Like Rates
February 4, 2015.
Preliminary Study of Network Adequacy: The 2015 Issuer Letter released by the Center for
Consumer Information and Insurance Oversight (CCIIO) contains requirements on issuers
offering Qualified Health Plans (QHPs) through a Federally-Facilitated Marketplace (FFM).
Preliminary research and analysis has been conducted in a select number of states/regions and
QHPs in those states/regions to determine:



How many of the QHPs have Indian Health Care Providers (IHCPs) in their
preferred provider networks;
Whether contract offers were made by QHPs to some or all of the IHCPs; and,
What factors were considered by IHCPs in determining whether to enter into a
contract with a QHP.
Data have been collected from specific zip codes in OK, WI, OR, AZ, ME and NV.
A joint TSGAC/Tribal Technical Advisory Group (TTAG) letter was sent to the Centers for
Medicare and Medicaid Services (CMS) Administrator on 12/19/14 requesting information on
whether QHPs offered contracts to IHS, Tribal and Urban (I/T/U) programs. Associated Talking
Points for Tribal leadership was also prepared. The response received from the CMS
Administrator on 2/9/15 will be incorporated into the TSGAC final study on Network
Adequacy. CMS has stated that each issuer/QHP represented to CMS that it offered contracts
to the I/T/Us in its service area, and the offers are understood to have met the CMS
requirements. This CMS expectation is being compared to the experiences of the I/T/Us in the
QHP service areas that we are studying. IHS has been requested to provide data on
contracting offers made to IHS facilities; however, that information has not been received (as of
4/7/15).
April 2015
Page 3
It is expected that information from this preliminary study will help to inform discussions of this
topic at a meeting with the Director of CCIIO scheduled for May 7, 2015.
Measuring Enrollment through the Marketplaces. To further the ability to measure outcomes of
TSGAC and other Tribal organization activities, TSGAC prepared a set of data metrics to track
progress with AI/AN enrollment through Marketplaces into QHPs and Medicaid. Data elements
were circulated with MMPC and TTAG for review prior to submitting request to CMS.
Initially, CMS agreed to provide the requested data by January 16, 2015. While two measures
of enrollment were provided during the TTAG Data Symposium held on February 18, 2015 (the
number of people enrolled in zero cost sharing plans and limited cost sharing plans through the
Federally-Facilitated Marketplace); other information that was requested has not yet been
provided. This issue is the #1 priority for the newly formed TTAG CCIIO/Tribal Workgroup initial
meeting to be held with the Director of CCIIO on May 7, 2015.
Technical Assistance
SGCE Website (Health Care Reform) Updated: The Question and Answer section on the
SGCE website was updated and re-organized on November 14, 2014, to include the following
areas:
A. Marketplace Enrollment
B. Premium Tax Credits and Cost-Sharing Reductions
C. Tax Penalty Exemptions
D. Employer-Sponsored Coverage
E. Veterans
F. Other
The website allows for users to submit questions at any time. The Question and Answer section
is continually and regularly updated as needed based on input and requests that are submitted
through the website as well as those questions raised during Webinars. In December 2014, the
health care reform portion of the SGCE website was further updated and simplified in a more
user-friendly format so that information can be found easily.
The entire SGCE website, including the health care reform sub-section, is currently undergoing
a comprehensive update and revision. A revised mock-up has been shared and information will
be more streamlined once the new website is launched in May 2015.
Technical Assistance Provided through SGCE Website. Tribes are continuing to use the SGCE
website to pose questions regarding ACA. As of April 1, 2015, all questions submitted through
the Website have received a response which has been posted so that all Tribes can have
access to the information.
Correspondence. TSGAC has submitted comments on a number of key ACA/IHCIA issues,
including the following:
April 2015
Page 4







Letter to IHS Acting Director RE: Comments on IHS Proposed Rule entitled “Payment
for Physician and Other Health Care Professional Services Purchased by Indian
Health Programs and Medical Charges Associated with Non-Hospital-Based Care,”
79 Fed. Reg. 72160 (December 5, 2014), submitted February 4, 2015.
Letter to VA regarding Comments Submitted In Response to Notice of Tribal
Consultation: Section 102(c) of the Veterans Access, Choice and Accountability Act of
2014, submitted January 14, 2015.
Comments on Draft 2016 Letter to Issuers in the Federally-Facilitated Marketplace,
submitted January 12, 2015.
Comments on CMS-9944-P; Notice of Benefits and Payment Parameters for 2016,
submitted December 22, 2014.
Letter to CMS Administrator RE: Request for Information on Contract Offers made by
Issuers of Qualified Health Plans, submitted December 19, 2014.
Letter to IHS Director RE: Tribal Consultation on Medicare-like Rates (MLR)
Regulations and/or Guidance, submitted November 10, 2014.
Letter to HHS and Treasury Secretaries RE: Appreciation for Recent Announcement
on Exemption from Tax Penalty for American Indians/Alaska Natives, submitted
October 16, 2014.
Communication around key moments or events through the grant period to increase education
efforts. Broadcast notices and e-mails have been sent to all Self-Governance Tribes by SGCE
on the following dates with the subjects listed:
4/8/15
 IHS Reimbursement Rates for CY2015
 Premium Sponsorship Options for Tribes
 ACA Break-Out Sessions for Annual Conference
2/13/15
 Tribal Sponsorship through a Marketplace
 Essential Community Providers (ECP) List
1/23/15
 Federal Poverty Level Guidelines for 2015 (“2015 FPL”)
1/15/15
 Notice on Updated ACA/IHCIA Outreach and Education Information (Webinars,
Trainings and Supporting Documents)
12/18/14
 Urban Institute Report on Projection on Reducing Racial Disparities for Uninsured
American Indians/Alaska Natives

Effect on Congressional Districts if the Supreme Court invalidates insurance
subsidies to federally-run Exchanges in King vs. Burwell
12/9/14
 Claiming the Exemption to the Tax Penalty for Not Having Insurance
 Advanced Payment of Premium Tax Credits for Health Insurance
 Tribal Hospitals can do Presumptive Eligibility for Medicaid
 Ways to File Appeals and Complaints with a QHP and a Marketplace
April 2015
Page 5
11/24/14
 Expanded Flexibility for Tribal Employers under FEHB Program
11/21/14
 Affordable Care Act (ACA) Day of Action: National Day of Tribal Enrollment
11/19/14
 Notice of November 30, 2014 Deadline for Application to Waive Penalties for not
Achieving Meaningful Use
 Notice of Updated Q&A’s on Website
 In response to the US Supreme Court decision to consider King v. Burwell, a
survey of states was prepared to identify which states have, to date, taken some
action to indicate a potential to convert to a state-based marketplace if needed to
retain premium tax credits for the state’s residents. (Memo circulated with
TSGAC & MMPC).
Development of Tools and Resources. In preparation for training and broadcasts of information,
a number of PowerPoint presentations and other products were developed. These include:








Tribal Sponsorship of Beneficiaries for Health Insurance Coverage through a
Marketplace ( PowerPoint)
Updated and Simplified: Indian-specific Exemptions from ACA Tax Penalty for Not
Maintaining Minimum Essential Coverage (PowerPoint)
Q&A, CMS/CCIIO, “Cost-Sharing Reductions for Contract Health Services”, May 9,
2014
“(Sample) Referral – Indian-specific Cost-sharing Protections”, March 19, 2015
Explanation of “(Sample) Referral – Indian-specific Cost-sharing Protections”, March
19, 2015
TSGAC Handout: Federal Poverty Levels Applicable in 2015, January 23, 2015
TSGAC Brief: Tribal Sponsorship of Marketplace Enrollees, January 12, 2015
TSGAC Tribal Sponsorship of Beneficiaries for Health Insurance Coverage through a
Marketplace, March 18, 2015
Innovative Ideas. The JST Amendment calls for sharing information, innovative ideas,
challenges and solutions, and to provide progress reports. One innovative idea that is being
explored is the potential for collaboration between Direct Service Tribes (DST) and TSGAC to
create pilot projects for DST to have an agreement with IHS on premium sponsorship. Four
Tribes have expressed an interest in becoming pilot project sites.
Training
Evaluation of ACA/IHCIA Training Materials on Self-Governance Communication and Education
(SGCE) Website. A thorough evaluation of the existing Webinar and Training materials,
including PowerPoint presentations and documents, was conducted. A series of updates and
recommendations were provided in a summary matrix that was submitted to OTSG on
December 11, 2014, and approved on December 30, 2014. All of the recommendations were
completed and posted on the SGCE website by January 14, 2015. No changes have been
made to original recorded Webinar videos due to cost and time constraints. However, any
significant updates in content have been noted on the SGCE Website.
April 2015
Page 6
Identifying Training Needs of Self-Governance Tribes. The TSGAC conducted an on-line
survey in October 2014 to learn about Tribal preferences for ACA training and technical
assistance. Consultants met with TSGAC at the quarterly meeting held October 8, 2014, to get
input about their needs, including both an opportunity for discussion and a survey.
Webinars. The primary means of delivering training has been Webinars. Four Webinars were
conducted in this 6-month period and have been held from noon to 1:30 pm Eastern time.
Participation in the Webinars has ranged from 105 to 240 people. The 1-1/2 hour Webinars
were conducted live, recorded and later posted on the Self-Governance Communication and
Education (SGCE) website along with the PowerPoint presentations and related resource
materials to allow for wider accessibility and use by IHS, Tribal and Urban (I/T/Us) health care
users and programs. Time was allocated throughout the Webinar(s) for participants to raise
questions. All questions not answered were recorded, summarized and responses were drafted
and posted on the SGCE website. All attendees received a personalized Certificate for their
participation in the Webinar(s).
Following the Webinars, all participants were sent an on-line evaluation. The input received was
overwhelming positive and constructive. (A summary of the evaluations is provided as
Appendix A below). The dates and topics of Webinars provided in the first six months are:




“Updated and Simplified!!! Securing an Exemption from the Affordable Care Act’s Tax
Penalty for Not Maintaining Minimum Essential Coverage,” presented by Doneg
McDonough, October 22, 2014.
“Update on IHS/VA Agreements and Opportunities for Tribes,” presented by Myra
Munson, January 21, 2015.
“Current Topics with Affordable Care Act Implementation,” presented by Doneg
McDonough, February 12, 2015.
“Premium Sponsorship Options for Tribes,” presented by Doneg McDonough, March 18,
2015.
Self-Governance Annual Conference Workshops. Four break-out sessions on topics related to
ACA/IHCIA have been planned for the 2015 Annual Tribal Self-Governance Consultation
Conference to be held in Reno, NV, April 27-30, 2015:




Tribal Sponsorship Premium Program: Challenges and Remedies
ACA Tax-Related Issues: Exemption from ACA’s Tax Penalty, Reconciliation of Premium
Tax Credits, Etc.: Problems Faced and Lessons Learned
Affordable Care Act Tribal Success Stories
The Politics of ACA Implementation
April 2015
Page 7
Positive Impact Stories
Progress. Four Tribes and Tribal Organizations from four different states have agreed to
partner with TSGAC for the Success Stories project: Citizen Potawatomi Nation (OK), Coeur
d’Alene Tribe (ID), Fond du Lac Band of Lake Superior Chippewa (MN), and Southcentral
Foundation (AK). Preparations to recruit participants included a summary of the project, a list of
photos needed, contracts with photographers at each site, consent forms for consumers and
providers, lists of sample interview questions, and standard forms for receipts for honoraria.
Interviews with four or five consumers, as well as administrators, have been conducted at the
first two sites and photographs have been taken. The other two site visits are scheduled for
May and June 2015.
Products. Composite stories have been prepared as handouts for the Citizen Potawatomi
Nation (CPN) and the Coeur d’Alene Tribe (CDA). Three of the participating groups will present
information about their Tribal Sponsorship programs at the ACA Success Stories breakout
session at the 2015 Annual Tribal Self-Governance Consultation Conference in Reno, NV, April
30, 2015.
Distribution. Two handouts (one each featuring CPN and CDA) have been prepared for
inclusion in the registration packets for the Annual Self-Governance Consultation Conference in
Reno, April 27-30, 2015. After the Conference, the handouts will be distributed electronically by
SGCE to all Self-Governance Tribes. A page is being constructed on the SGCE website where
the press releases can be downloaded in Word format so that they can be used by Tribes in
their newspapers and other applications. Additional distribution options are under consideration.
Individual and composite stories and photos are being created for a magazine layout which will
be completed by the end of the project period; however, there is no funding in the current 20142015 JST Amendment for printing and distribution of the magazine.
Other Activities
In addition to the policy analysis, training and technical assistance activities enumerated in this
final report, there were many efforts to coordinate with the IHS, HHS, and other national NIHOE
groups. Technical staff have participated in meetings and monthly teleconferences with other
National Tribal organizations and partners, including National Congress of American Indians,
National Indian Health Board and the National Council of Urban Indian Health to assist in
coordinating efforts and reduce any duplication of AI/AI training materials.
Attachment: Appendix A: Evaluation of Self-Governance Health Reform Training and Technical
Assistance Plan (2014-2015), April 2015.
For more information on this report, please contact Cyndi Ferguson at cyndif@senseinc.com
April 2015
Page 8
Attachment A
Summary from Webinar Evaluation Survey Reports
As part of the 2014-2015 Work Plan, four ACA Webinars have been conducted in the first six month
period (October 2014-March 2015). The dates and topics of Webinars provided include:




“Updated and Simplified!!! Securing an Exemption from the Affordable Care Act’s Tax Penalty for
Not Maintaining Minimum Essential Coverage,” presented by Doneg McDonough, October 22,
2014.
“Update on IHS/VA Agreements and Opportunities for Tribes,” presented by Myra Munson,
January 21, 2015.
“Current Topics with Affordable Care Act Implementation,” presented by Doneg McDonough,
February 12, 2015.
“Premium Sponsorship Options for Tribes,” presented by Doneg McDonough, March 18, 2015.
Approximately 210 registrants completed and participated in the 10/22/14 Webinar; 128 registrants in the
1/21/15 Webinar; 105 registrants in the 2/12/15 Webinar; and, 240 registrants in the 3/18/15 Webinar.
Following completion of the Webinar(s), participants were asked to complete a brief evaluation survey.
Evaluation Categories
Participants were asked to rank the following items on a scale of 1 to 5; with 1 being the lowest
(disagree) and 5 being the highest (agree):




Issues were relevant and presented in a user-friendly manner
PowerPoint presentation and materials were informative and helpful
Presenter(s) were responsive to questions
Length of Webinar provided sufficient time to cover the issues
Chart 1 – Content Delivery (All Webinars Combined)
Summary of Evaluation Responses
69%
5 - Agree
24%
Issues Relevant and
Presented in UserFriendly Manner
4
3
7%
2
0%
1 - Disagree
1%
0%


20%
40%
60%
80%
Participants were very complimentary of the information and issues presented.
Overall, 93% of participants ranked this category as either 4 or 5.
April 2015
Page 9
Chart 2 – Resource Materials (All Webinars Combined)
64%
5 - Agree
27%
The PPT
presentations and
materials were
informative
4
3
6%
2
0%
1 - Disagree
3%
0%


20%
40%
60%
80%
Copies of the PPT presentations were shared 1 day in advance for all the Webinars.
Chart 3 – Responsive to Questions (All Webinars Combined)
59%
5 - Agree
18%
The presenter(s)
were responsive to
my questions.
4
3
20%
2
3%
1 - Disagree
1%
0%


20%
40%
60%
80%
Opportunities were provided at various points throughout the Webinar(s) for participants to raise
questions. However, time was not sufficient to answer all questions during the Webinar(s). For
those questions that were not answered, a written summary was provided and posted on the SelfGovernance Communication and Education (SGCE) website following the Webinar(s).
April 2015
Page 10
Chart 4 – Length of Webinar(s)-
2%
The length of
the Webinar
provided
sufficient time
to cover the
issues.
5 - Agree
57%
4
3
24%
2
10%
1 - Disagree
7%
0%


20%
40%
60%
80%
It appears that additional time may be needed for the Webinars.
Overall, only 59% percent of participants ranked this category as either 4 or 5.
The following summarizes additional comments received for each respective Webinar:
10/22/14 Webinar - “Updated and Simplified!!! Securing an Exemption from the Affordable
Care Act’s Tax Penalty for Not Maintaining Minimum Essential Coverage”
Please list other topics you would like to have covered in future trainings:

Cost Sharing Protections for AI/AN

Native American Premiums waived for Child Health Plus

Primary care and behavioral health integration
Please share any additional comments:

Good job!

I am glad that I participated; it was very informative.

Thanks for all the hard work.

I tried to take notes, but presenter spoke too fast.
April 2015
Page 11
1/21/15 Webinar- “Update on IHS/VA Agreements and Opportunities for Tribes”

ACA/IHCIA Regulation and Policy Involvement

Status of Expansion of Medicare-Like-Rates

Care Coordination between VA / IHS and Tribal Health Programs - overview of specialty services
and programs available to eligible Veterans and access to these programs

More on VA

MORE WITH IHS FACILITIES

Will there be monies to improve IHS facilities for the veterans to utilize the Indian Health
Services-- in the clinics with the doctors, nurses, mental health, pharmacies, and dental services
provided?

For some of the Tribal Veteran Cemetery plots, Veteran Buildings and Memorials--- need
assistance with these facilities being established

Can Mobile units to visit the reservations that provide treatment and services to come out more
often?

Presenter did a very good job of covering topics related to subject of today's Webinar and gave
many good insights. Thank you for a job well done.

This Webinar was very timely, clear and informative.

Excellent information & presentation!

Recommend that presentations which involve both VA and IHS agencies that those agencies
are a part of the presenter panel - even if it is only to assist with Q&A and shows interagency
collaborations. Otherwise, very helpful overview and history of the program.

Webinar was very informative. How can I obtain information on today webinar?
2/12/15 Webinar - “Current Topics with Affordable Care Act Implementation”

More details on the provider contracts and how challenges are being overcome. While we have
tried to be proactive to get our Tribal clinic contracted with private insurers, I am not sure how
successful we have been with the QHPs. We have had challenges getting our providers
credentialed on some plans because they are not licensed in state, which is supposed to be ok
for IHS/Tribal clinics, but somehow doesn't work well yet in practice.
April 2015
Page 12

Indian - specific cost sharing protections......need more detailed information.

I would like to see more in-depth information about hardship exemptions. In the facility I work in
we have a lot of descendants and they are opting not to pursue marketplace insurance or they fall
in the gap and are unable to get insured but still need to become exempt from the shared
responsibility payments.

Now that we have had a year of the ACA and some T/TO/U organizations are paying for
insurance for their members, can we discuss numbers? What were the barriers? What was the
savings to the organizations or were there any savings? Did they require the member to use their
health facility if insurance premiums where paid by the organization? Was there a formula used to
present to the board to show savings/loss?

Very good topics.

I wish there was a simple straight forward brochure that we could personalize to our own Tribe to
hand out to people. We had materials dispensed in the beginning, but we have learned so much
more since two years ago. We need an updated brochure of ACA for Natives with marketplace
specified, explains the tax credit process, finer and main points only.

More Tribal sponsorship programs, such as Medicare Part D. If any I/T/U facilities are
implementing this as a program? What are the savings?

At one point there were technical difficulties that caused the main person to be offline for about 5
minutes, but then it was resolved and the discussion continued.

This was a very good Webinar. I have covered quite a bit of this ground from the point of view of
the Tribe's employer health plan, and I appreciated the perspective from the clinic. Really good
job, and I'm sure I'll being going back to the slides. And listening to more webinars if you
continue to have them. Thanks!

I like that the presenters are very knowledgeable and informative about the topics. They don't
leave us in the dark. Thanks for all the information. It allows us to assist our patients properly.

The Webinar was very informative to my job duties as a Patient Benefit Coordinator. Thank you
for clarifying some questions I had about the Exemption process.
3/18/15 Webinar - “Premium Sponsorship Options for Tribes Premium Sponsorship
Options for Tribes”

More information on the Cost Sharing Protection and Limited Cost Sharing Protection.

Anything on ACA, Tribes as a whole, employers and governments, that offer self-insured health
plans, Tribal employer mandate.

The Tribal Education Outreach Consortium had a spread sheet that could be used to calculate
savings for sponsorship. http://www.nativeexchange.org/directors_sponsorship.php
April 2015
Page 13

Tribal Sponsorship for MCD Part B & D premiums. More info on this topic, Tribal Premium
Sponsorship, for both tribal members and tribal employers. Also any info and/or templates that
become available on exactly how to enact the Sponsorships.

I believe that the Marketplace should have a Native American Liaison, who we could contact
regarding questions gearing toward the Native American population, because when I call the
Marketplace regarding certain issues that I come across. They seem to read a script of the same
stuff I have read and it something that we cannot seem to find in the policy or guidelines. It’s like
we just come to a dead end road with no answers.

Great presenter

The webinar was great, but not long enough to cover all topics.

Presenter did a great job on this topic. I realize we did not have enough time to cover everything
and answer all the questions, but I don't recommend a longer Webinar. I think it would be better
to break the topic into several Webinars.

The information provided is relevant and useful. Would like more information to be able to
present to Administration and decision makers.

I would like more information on how a Tribe/THO would sponsor MCR premiums; being SSA
deducts these premiums from benefits.

Thank you for the presentation!
Telephone (918) 302-0252 ~ Facsimile (918) 423- 7639 ~ Website: www.tribalselfgov.org
Sent Via Email: Benjamin.Smith@ihs.gov
Original sent via USPS
June 12, 2015
Mr. P. Benjamin Smith
Director, Office of Tribal Self-Governance
Suite 240, The Reyes Building
801 Thompson Avenue
Rockville, MD 20852-1627
RE: Tribal Leadership Priorities for “Self-Governance National Indian Health
Outreach and Education”
Dear Mr. Smith:
On behalf of the Tribal Self-Governance Advisory Committee (TSGAC), thank you
for your continued investment in the Self-Governance National Indian Health
Outreach and Education project. We write to reaffirm our commitment to empower
Tribal communities with the knowledge and tools needed to successfully manage
and implement the Patient Protection and Affordable Care Act/Indian Health Care
Improvement Act (ACA/IHCIA) provisions concerning health care insurance
coverage options to improve the quality and access to care for our Tribal citizens
and Indian communities. In order to fulfill this objective, we urge you to amend the
Agreement between the U.S. Department of Health and Human Services and the
Jamestown S’Klallam Tribe to renew and fund the “Self-Governance National Indian
Health Outreach and Education” contract for FY2016 for $300,000.
As you know, the ACA/IHCIA contains important benefits for American
Indians/Alaska Natives. The objective of this project is to improve Indian Health
Care by increasing awareness and understanding of the ACA/IHCIA through the
provision of policy analysis, outreach, education, training and technical assistance to
Tribes nationwide. Although we have made great strides educating Tribes about
these benefits through our outreach efforts, as reflected in our April 2015 SemiAnnual Report, it is essential that we continue these efforts to strengthen our
collaboration with Tribal beneficiaries. We are confident that further outreach and
education will lead to improved beneficiary understanding, experience, and a
reduction of overall Indian healthcare expenditures resulting in improved health care
outcomes.
Letter to P. Benjamin Smith, Director, OTSG
Re: Tribal Leadership Priorities for “Self-Governance
National Indian Health Outreach & Education”
June 12, 2015
Page 2 of 3
The TSGAC has identified a list of priorities to advance the National Indian
Healthcare mission in FY2016 to include the areas of policy analysis, technical
assistance, training, and positive success stories. The following major activities will
be the focus of the Self-Governance Health Reform National Outreach and
Education agenda for FY2016:
•
•
•
•
•
•
•
•
•
•
•
•
•
Continue collaboration with National Indian organizations to analyze proposed
regulations and emerging issues related to the ACA/IHCIA implementation
and to draft responses on behalf of the TSGAC;
Disseminate findings and advocate for implementation of recommendations
from study on Network Adequacy and continue monitoring of Tribal
participation in QHP networks;
Collect and disseminate data that tracks American Indian/Alaska Native
enrollments through the Marketplaces into Qualified Health Plans and
Medicaid, and analysis of barriers and opportunities;
Maintain an open question and answer forum regarding the ACA on the SelfGovernance Communication and Education (SGCE) website;
Advise TSGAC and draft correspondence on key ACA/IHCIA issues;
Broadcast notices and emails and post them on the SGCE website;
Develop PowerPoint presentations, graphics, and issue briefs to be used as
resource materials;
Continue webinars which have been the primary means of delivering training
to Tribes and has been overwhelmingly positive and constructive;
Include breakout sessions on the ACA/IHCIA at the 2016 Annual Tribal SelfGovernance Consultation Conference, as well as other national meetings,
such as the NIHB Consumer Conference;
Continue to provide technical assistance to Tribes and Tribal health
organizations with implementation of the ACA and IHCIA, and broadly
disseminate to other Tribes and Tribal health organizations the experiences
learned from the technical assistance;
Provide technical assistance regarding sponsorship and billing opportunities
to ensure economic viability of Tribal health programs;
Gather Tribal Success Stories; and,
Continue collaboration between Direct Service Tribes and Self-Governance
Tribes to share information, innovative ideas, challenges and solutions on
premium sponsorship and how best to address employer requirements under
the ACA.
With regard to the final item listed above, we would like to discuss with you various
funding options that would allow funding from IHS to Area Health Boards, Tribes,
and/or Tribal health organizations, such as in Montana-Wyoming, Great Plains, and
Navajo, to contribute to this evolving demonstration project. In addition, we would
like to publish a Tribal Success Stories Magazine pending the availability of
additional funding to support this effort.
Letter to P. Benjamin Smith, Director, OTSG
Re: Tribal Leadership Priorities for “Self-Governance
National Indian Health Outreach & Education”
June 12, 2015
Page 3 of 3
We look forward to our continued collaboration to advance these important
healthcare initiatives in partnership with the Indian Health Service. If we can be of
further assistance, please do not hesitate to contact me at (860) 862-6192 or via
email at lmalerba@moheganmail.com or Chairman Allen at (360) 681- 4621 or via
email at rallen@jamestowntribe.org.
Sincerely,
Chief Lynn Malerba
Mohegan Tribe
Chairwoman, TSGAC
cc:
Vice-Chairman, TSGAC
Mr. Robert McSwain, Acting Director, Indian Health Service
TSGAC and Technical Workgroup Members
Joint Initiative of Direct Service Tribes and Self-Governance Tribes:
Tribal Sponsorship Through a Marketplace 1
July 9, 2015
On May 13, 2015, the Direct Service Tribal Advisory Committee (DSTAC) and the Tribal SelfGovernance Advisory Committee (TSGAC) held their first joint meeting. At the meeting, a joint
initiative was discussed with the TSGAC and DST leadership with the aim to ensure that all Tribes—
no matter where on the spectrum of Direct Service to Self-Governance—have the ability to engage
in sponsorship of Tribal members through a Health Insurance Marketplace (Joint Initiative). The goal
of the Joint Initiative is to greatly expand the resources available to provide health care services to
Tribal members by capturing the federal assistance (premium tax credits and cost-sharing
protections) made available for Marketplace enrollees. This memorandum provides a status report
on the Joint Initiative.
In the month prior to the joint meeting, the TSGAC hosted a Webinar to inform Self-Governance Tribes
and others about key aspects of the Patient Protection and Affordable Care Act (Affordable Care Act or
ACA). 2 The topic of the Webinar was “Tribal Sponsorship of Beneficiaries for Health Insurance
Coverage Through a Marketplace.” Announcements of the Webinar were widely circulated not only to
Self-Governance Tribes, but also to IHS facilities and Direct Service Tribes.
The Webinar reviewed the ACA provisions that make available through a Marketplace significant
federal resources to assist individuals in purchasing health insurance coverage and in removing the
deductibles and other cost-sharing amounts typically required under such coverage. In addition, the
Webinar presented information on options available to Tribal employers to: (1) meet their obligations
under the ACA; and, (2) maximize resources available to Tribal members through a Marketplace.
The number of participants in the Webinar was well over 150. Many of the participants represented
Direct Service Tribes, and several of these representatives contacted the TSGAC following the Webinar
to express an interest in evaluating whether it would be beneficial for their Tribe to engage in premium
sponsorship of Tribal members. 3 Some of the individuals who contacted the TSGAC indicated that they
had preliminary discussions with IHS regional offices on the topic of Tribal premium sponsorship and
1
This brief is for informational purposes only and is not intended as legal advice. For questions on this brief, please
contact Doneg McDonough, TSGAC Technical Advisor, at DonegMcD@Outlook.com.
This Webinar is one of a series conducted as a component of a contract the TSGAC has in place with the Indian Health
Service (IHS).
2
3
Tribal members are defined here as persons eligible for services from IHS, Indian Tribes and tribal organizations, or
urban Indian organizations (I/T/Us).
that the regional offices were not familiar with the practice and/or were not receptive to assisting in
establishing a Tribal sponsorship program. 4,5
A number of Tribes have expressed interest in pursuing and participating in this Joint Initiative. TSGAC
technical advisors have engaged with a number of Tribes on the Joint Initiative. In particular, TSGAC
technical advisors participated in training sessions at meetings of the Rocky Mountain Tribal Leaders
Council in Billings, Montana, and the Great Plains Tribal Chairmen’s Health Board in Spearfish, South
Dakota.6
TSGAC technical advisors also have met with IHS staff to address two issues: (1) Developing standard
language to be included in contracts or funding agreements between an I/T/U and the IHS when an
I/T/U intends to undertake Tribal sponsorship of Tribal members through a Marketplace; and, (2)
designing a Resource and Patient Management System (RPMS)-based report that will facilitate
reporting on revenues received from sponsored Tribal members.
A handful of Tribes have submitted letters indicating the Tribe will provide data needed for analyses of:
(1) sponsorship of uninsured Tribal members through a Marketplace; and, (2) consideration of options
(including a Marketplace) for meeting the ACA employer coverage requirements. Importantly, the
letters also authorize the sharing of the analysis with other Tribes to facilitate education across Direct
Service and Self-Governance Tribes.
Going forward, on-going support from TSGAC and DST leadership and IHS will be critical to the success
of this Joint Initiative. Resources will continue to be pulled from a number of sources to advance the
Joint Initiative, but additional resources will be needed. Participating Tribes/Area Health Boards have
been covering travel expenses for TSGAC technical assistance; the National Congress of American
Indians (NCAI) has contributed to funding the analysis of employer options; and the TSGAC is
supporting the work of analyzing the potential impact of Tribal premium sponsorship. The TSGACproposed scope of work for the TSGAC-IHS ACA outreach contract for fiscal year 2016 includes the
following items, which will—in part—be focused on the Joint Initiative:
•
Provide technical assistance regarding sponsorship and billing opportunities to ensure the
economic viability of tribal health programs; and,
•
Provide technical assistance to Tribes and Tribal health organizations on implementation of the
ACA and the Indian Health Care Improvement Act (IHCIA) and broadly disseminate to other
Tribes and Tribal health organizations the experiences learned from this technical assistance.
4
Section 402 of the Indian Health Care Improvement Act (IHCIA)4 states that Tribes, tribal organizations, and urban
Indian organizations (T/TO/Us) can use funds made available through the Indian Self-Determination and Education
Assistance Act (ISDEAA) or programs under the Social Security Act (namely, Medicare, Medicaid, and the Children’s
Health Insurance Program) to purchase health insurance coverage, such as coverage through a Marketplace, for tribal
members.
5
In addition, guidance documents issued by the federal Centers for Medicare and Medicaid Services (CMS) specifically
authorize payment of premiums and cost-sharing by T/TO/Us on behalf of Marketplace enrollees. CMS confirmed and
further clarified this in a February 7, 2014, guidance letter that specifically authorized payment of premiums by T/TO/Us
on behalf of Marketplace enrollees. (http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/thirdparty-payments-of-premiums-for-qualified-health-plans-in-the-marketplaces-2-7-14.pdf)
6
Additional interest in evaluating options under the ACA has been expressed by other Direct Service and SelfGovernance Tribes.
July 9, 2015
Page 2 of 2
Rockville MD 20852
JUN 22 2015
Dear Tribal Leader:
On February 6, the Indian Health Service (IHS) sent a letter to Tribal Leaders requesting tribal
input on the next phase of the Methamphetamine and Suicide Prevention Initiative (MSPI) and
the Domestic Violence Prevention Initiative (DVPI), a five-year competitive award cycle set to
begin after the completion of the demonstration project phase. I am writing to provide you with
an update on how the IHS will move forward with MSPI and DVPI over the next five years.
National Funding Distribution Formula
Based on the majority of feedback received in response to the February 6 letter and other
opportunities for consultation, IHS will continue to use the current national funding distribution
formula to allocate funding for both MSPI and DVPI among the IHS Areas. This formula was
originally developed in consultation with Tribes and the IHS National Tribal Advisory
Committee (NTAC) on Behavioral Health with the goal of concentrating the limited MSPI and
DVPI funding in locations with the greatest need. The MSPI and DVPI national funding
distribution formula is based on population, poverty, and disease burden.
Overall Funding Amounts
The DVPI funding for Fiscal Year (FY) 2015 will remain at the same level as FY 2014 for all
IHS Areas. An additional amount of $600,000 will be allocated for Urban Indian Health
Program (UIHP) DVPI projects. This allocation supports the NTAC recommendation to restore
the UIHP DVPI grants without reducing funding to other DVPI programs. Previously, in FY
2010–2012, DVPI funded Urban Indian Health Program (UIHP) grantees in the amount of
$524,000.
In FY 2015, IHS will adopt the NTAC recommendations to provide additional guidance and
support for MSPI projects and improved support for local evaluation, since community-level
program information can promote sustainability. This support will take the form of regional
representatives in at least seven IHS Area Offices with the largest numbers of funded projects to
provide consistent guidance and administration. Regional evaluators will provide technical
assistance on data collection and program evaluation to all 12 IHS Areas.
With this new evaluation resource, individual projects will not be required to set aside up to 20
percent of their budget for local evaluation. Instead, the regional evaluators will work with
funded projects to ensure efforts are coordinated to demonstrate the impact locally, regionally
and nationally, supporting evidence that program efforts are making an impact within the
community. To support these resources, MSPI funding available for project awards will be
reduced from $13,100,000 for IHS and Tribal projects and $1,188,000 for UIHPs to $12,500,000
for IHS and Tribal projects and $1,000,000 for UIHPs in FY 2015.
Page 2 - /Tribal Leader/
In addition, the February 6 letter requested feedback on varying award amounts versus using a
standardized award amount. In response to feedback favoring the variable amounts, IHS will
award varying amounts ranging from $50,000 to no more than $300,000.
Funding Mechanism
The distribution of funds for MSPI and DVPI projects has previously involved a number of
different funding mechanisms. In order to provide consistency and prevent confusion in the new
funding cycle, IHS will fund all MSPI and DVPI projects through a grant mechanism for Tribal
and UIHP MSPI and DVPI awardees. The new MSPI/DVPI grant program will prevent
confusion regarding the allowable costs, including indirect costs, to be included in the budget, a
standard requirement for all federal financial assistance. IHS facilities will continue to receive
funding through program awards.
Eligibility and Selection Criteria
In the demonstration project phase, MSPI and DVPI project sites included Tribes, IHS facilities,
Area Offices, Tribal organizations, Indian health boards, Youth Regional Treatment Centers
(YRTCs), and UIHPs. The variety of types of awardees was due to the original manner in which
the MSPI and DVPI recipients were selected based in part on input gathered from Tribes in each
IHS Area. Recommendations on eligibility received following the February 6 letter varied
greatly, and there was no consensus recommendation. The IHS has determined that eligibility
for the new MSPI/DVPI award cycle will be limited to federally recognized Tribes, IHS
facilities, Tribal organizations, YRTCs, and UIHPs. The selection criteria will be standardized
across all IHS Areas and applicants will not compete for funding with applicants from other IHS
Areas. Selection criteria will be based on the following factors:
1.
2.
3.
4.
5.
Statement of Need – 35 points
Proposed Approach/Project Plan – 20 points
Organizational Capacity – 15 points
Plan for Collecting Local Data – 20 points
Budget and Justification – 10 points
The highest amount of points for MSPI and DVPI applications will be given in the category of
“Statement of Need.” Given the limited amount of funding for MSPI and DVPI, IHS requested
input on how to determine greatest need among applicants. The majority of responses were in
favor of using community data to demonstrate level of need.
I am aware of the challenges many AI/AN communities face surrounding data being readily
available to demonstrate the level of need. In light of the consultation feedback and in
consideration of the challenges around available data, IHS will accept data sources such as IHS
Trends in Indian Health, epidemiological data from Tribal Epidemiology Centers and IHS Area
Offices or Service Units, State data, or national data (e.g., the Substance Abuse and Mental
Health Services Administration’s National Survey on Drug Use and Health, National Center for
Health Statistics, Centers for Disease Control and Prevention reports, and U.S. Census data).
This list is not comprehensive, and applicants may submit other data, as appropriate to their
program.
Page 3 - /Tribal Leader/
Program Components and Reporting Requirements
The IHS plans to allow funding for four purpose areas in MSPI and two purpose areas in DVPI.
Reporting requirements will move to an annual report and will be according to the purpose area
selected in the application. In certain circumstances, eligible applicants may wish to apply to
more than one purpose area.
The MSPI, purpose areas are:
1) Purpose Area 1: Conduct community and organizational needs assessments to develop a
strategic plan and data sharing system
2) Purpose Area 2: Provide suicide prevention, intervention, and postvention services
3) Purpose Area 3: Provide methamphetamine prevention, treatment, and aftercare services
4) Purpose Area 4: Provide youth interventions and positive development activities to
support the Generation Indigenous Initiative
The DVPI purpose areas are:
1) Purpose Area 1: Provide domestic and sexual violence prevention, advocacy, and
coordinated community response activities
2) Purpose Area 2: Provide forensic healthcare treatment services for victims of domestic
and sexual violence
The IHS anticipates the announcement requesting new applications for FY 2015 to be published
in a Federal Register notice on or around June 26. Applications will be due 60 days after the
Federal Register notice is issued. For additional information, please visit our websites at
www.ihs.gov/mspi or www.ihs.gov/dvpi. If you have any questions, please contact Dr. Beverly
Cotton, Director, IHS Division of Behavioral Health, by e-mail at beverly.cotton@ihs.gov or by
telephone at (301) 443-2038. Thank you for your continued work to address these serious issues
in our communities.
Sincerely,
/Robert G. McSwain/
Robert G. McSwain
Acting Director
This document is scheduled to be published in the
Federal Register on 07/08/2015 and available online at
http://federalregister.gov/a/2015-16744, and on FDsys.gov
Billing Code: 4165-16
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Division of Behavioral Health
Office of Clinical and Preventive Services
Methamphetamine and Suicide Prevention Initiative
Announcement Type: New – Limited Competition
[Funding Announcement Number: HHS-2015-IHS-MSPI-0001]
[Catalog of Federal Domestic Assistance Number (CFDA): 93.933]
Key Dates
Application Deadline Date: September 8, 2015
Review Date: September 14-18, 2015
Earliest Anticipated Start Date: September 30, 2015
Signed Tribal Resolutions Due Date: September 11, 2015
Proof of Non-Profit Status Due Date: September 8, 2015
I.
Funding Opportunity Description
Statutory Authority
The Indian Health Service (IHS), an agency which is part of the Department of Health
and Human Services (HHS), is accepting applications for a five-year funding cycle to
continue the planning, development, and implementation of the Methamphetamine and
Suicide Prevention Initiative (Short Title: MSPI). This program was first established
by the Consolidated Appropriations Act of 2008, Pub. L. No. 110-161, 121 Stat. 1844,
2135, and has been continued in the annual appropriations acts since that time. This
program is authorized under the authority of 25 U.S.C. 13, the Snyder Act, and the Indian
Health Care Improvement Act, 25 U.S.C. 1601-1683. The amounts made available for
the MSPI shall be allocated at the discretion of the Director of IHS and shall remain
available until expended. IHS utilizes a national funding formula developed in
consultation with Tribes and the National Tribal Advisory Committee (NTAC) on
behavioral health, as well as conferring with urban Indian health programs (UIHPs). The
funding formula provides the allocation methodology for each IHS Service Area. This
program is described in the Catalog of Federal Domestic Assistance under 93.933.
Background
From September 2009 – August 2015, IHS funded 130 IHS, Tribal, and UIHPs that
participated in a nationally coordinated six-year demonstration pilot project, focusing on
providing methamphetamine and suicide prevention and intervention resources for Indian
Country. The MSPI promotes the use and development of evidence-based and practicebased models that represent culturally-appropriate prevention and treatment approaches
to methamphetamine use and suicide prevention from a community-driven context. For a
complete listing of demonstration pilot projects, please visit
www.ihs.gov/mspi/pilotprojects.
Purpose
The primary purpose of this grant program is to accomplish the MSPI goals listed below:
1. Increase Tribal, UIHP, and Federal capacity to operate successful
methamphetamine prevention, treatment, and aftercare and suicide prevention,
intervention, and postvention services through implementing community and
organizational needs assessment and strategic plans.
2. Develop and foster data sharing systems among Tribal, UIHP, and Federal
behavioral health service providers to demonstrate efficacy and impact.
3. Identify and address suicide ideations, attempts, and contagions among American
Indian and Alaska Native (AI/AN) populations through the development and
implementation of culturally appropriate and community relevant prevention,
intervention, and postvention strategies.
4. Identify and address methamphetamine use among AI/AN populations through
the development and implementation of culturally appropriate and community
relevant prevention, treatment, and aftercare strategies.
5. Increase provider and community education on suicide and methamphetamine use
by offering appropriate trainings.
6. Promote positive AI/AN youth development and family engagement through the
implementation of early intervention strategies to reduce risk factors for suicidal
behavior and substance abuse.
Funded projects are not expected to address all of the MSPI goals, only those relevant to
the Purpose Area for which they are applying.
To accomplish the MSPI goals, IHS invites applicants to address one of the Purpose
Areas below:

Purpose Area 1: Community and Organizational Needs Assessment and Strategic
Planning

Purpose Area 2: Suicide Prevention, Intervention, and Postvention

Purpose Area 3: Methamphetamine Prevention, Treatment, and Aftercare

Purpose Area 4: Generation Indigenous Initiative Support
In certain circumstances, applicants may choose to apply for more than one Purpose
Area. If this is the case, applicants must submit a separate application for each Purpose
Area. IHS encourages applicants to develop and submit applications that emphasize
cross-system collaboration among the Purpose Areas, the inclusion of family, youth and
community resources, and the application of cultural approaches.
Evidence-Based Practices, Practice-Based Evidence, Promising Practices, and Local
Efforts
IHS strongly emphasizes the use of data and evidence in policymaking and program
development and implementation. Applicants under Purpose Area 2, Purpose Area 3,
and Purpose Area 4 must identify one or more evidence-based practice, practice-based
evidence, best or promising practice, and/or local effort that they plan to implement in the
Project Narrative section of their application. The MSPI website
(http://www.ihs.gov/mspi/bestpractices/) is one resource that applicants may use to find
information to build on the foundation of prior methamphetamine and suicide prevention
and treatment efforts, in order to support the IHS, Tribes, and UIHPs in developing and
implementing Tribal and/or culturally appropriate methamphetamine and suicide
prevention and early intervention strategies.
Purpose Areas
Purpose Area 1: Community and Organizational Needs Assessment and Strategic
Planning: Lessons learned from the demonstration pilot project phase of the MSPI
revealed the need for AI/AN communities to have access to resources, funding, and
technical assistance to assess the needs of their community for suicide and/or
methamphetamine use to develop strategic approaches and leverage community and
organizational resources before implementing specific programs. Strategic planning is
especially critical to maximize available resources and eliminate duplicative efforts.
Strategic planning should address gaps in policies and resources, as well as program
barriers. Planning should focus on utilizing data from the community and organizational
needs assessment to ensure coordinated community responses as well as system linkages
for suicide prevention and methamphetamine use services. Based on the community and
organizational needs assessment and analysis, projects will develop a strategic plan to
address suicide and/or methamphetamine use (or other addicting substances). IHS is
seeking applicants to address MSPI goals #1 and #2 by addressing the following two
items:
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Assess and develop strategic approaches of leveraging community and
organizational resources to address suicide and methamphetamine use; and
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Develop data sharing systems for continuous assessment and strategic planning.
Purpose Area 2: Suicide Prevention, Intervention, and Postvention: The focus of
Purpose Area 2 is on the prevention, intervention, and postvention of suicide, suicide
contagion, and suicide attempts or ideations among AI/AN populations.
IHS is seeking applicants to address MSPI goals #3 and #5 by focusing on the following
broad objectives:
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Expand available behavioral health care treatment services;
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Foster coalitions and networks to improve care coordination;
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Educate and train providers in the care of methamphetamine and other substance
use disorders;
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Promote community education to prevent the use and spread of
methamphetamine;
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Improve health system organizational practices to improve treatment services for
individuals seeking treatment for methamphetamine and other substance use
disorders that contribute to suicide;
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Establish local health system policies to address methamphetamine use and other
substance use disorders that contribute to suicide;
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Integrate culturally appropriate treatment services; and
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Implement trauma informed care services and programs.
Purpose Area 3: Methamphetamine Prevention, Treatment, and Aftercare: The focus of
Purpose Area 3 is on the prevention, treatment, and aftercare for methamphetamine use
(and other addicting substances) among AI/AN populations. In addition to prevention
programming, MSPI funds can be used to provide behavioral health treatment services
(i.e., direct services including in-patient and out-patient treatment, intervention, and
aftercare).
IHS is seeking applicants to address MSPI goals #4 and #5 by focusing on the following
broad objectives:
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Expand available behavioral health care treatment services;
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Foster coalitions and networks to improve care coordination;

Educate and train providers in the care of methamphetamine and other substance
use disorders;

Promote community education to prevent the use and spread of
methamphetamine;

Improve health system organizational practices to improve treatment services for
individuals seeking treatment for methamphetamine and other substance use
disorders that contribute to suicide;

Establish local health system policies to address methamphetamine use and other
substance use disorders that contribute to suicide;
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Integrate culturally appropriate treatment services; and
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Implement trauma informed care services and programs.
Purpose Area 4: Generation Indigenous Initiative Support: The focus of Purpose Area 4
is to promote early intervention strategies and implement positive youth development
programming to reduce risk factors for suicidal behavior and substance abuse. IHS is
seeking applicants to address MSPI goal #6 by working with Native youth ages 8 to 24
years old on the following broad objectives:
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Implement evidence-based and practice-based approaches to build resiliency,
promote positive development, and increase self-sufficiency behaviors among
Native youth;
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Promote family engagement; and
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Increase access to prevention activities for youth to prevent methamphetamine
use and other substance use disorders that contribute to suicidal behaviors, in
culturally appropriate ways.
Limited Competition Justification
There is limited competition under this announcement because the authorizing legislation
restricts eligibility to Tribes that meet specific criteria. See the Consolidated
Appropriations Act of 2008, Pub. L. No. 110-161, 121 Stat. 1844, 2135.
II.
Award Information
Type of Award
Grant.
Estimated Funds Available
The total amount of funding identified for the current fiscal year (FY) 2015 is
approximately $12,500,000. IHS expects to allocate funding for the 12 IHS service areas
as described below. Applicants will be awarded according to their location within their
respective IHS service area and will not compete with applicants from other IHS service
areas. UIHP applicants will be selected from a category set aside for UIHP applicants
only. UIHP awards will be $100,000 each. The amount of funding available for
competing and continuation awards issued under this announcement are subject to the
availability of appropriations and budgetary priorities of the Agency. IHS is under no
obligation to make awards that are selected for funding under this announcement.
Anticipated Number of Awards
The number of anticipated awards is dependent on the number of applications received in
response to the announcement and available funds. The funding breakdown by area is as
follows:
Alaska IHS Service Area
IHS expects to provide $1,684,000 in total awards ranging from $50,000 to $300,000 for
a 12-month project period.
Albuquerque IHS Service Area
IHS expects to provide $703,000 in total awards ranging from $50,000 to $150,000 for a
12-month project period.
Bemidji IHS Service Area
Billings IHS Service Area
California IHS Service Area
Great Plains IHS Service Area
Nashville IHS Service Area
Navajo IHS Service Area
Oklahoma City IHS Service Area
Phoenix IHS Service Area
Portland IHS Service Area
Tucson IHS Service Area
Urban Indian Health Programs
IHS expects to provide $1,000,000 in total awards for a 12-month project period.
Project Period
The project period is for five years and will run consecutively from September 30, 2015,
to September 29, 2020.
Continuation Applications
The current funding announcement is a request for the submission of proposals for a fiveyear project proposal; however due to the limited amount of funding available for
competing and continuation awards issued under this announcement, the funds are
subject to the availability of appropriations and budgetary priorities of the Agency (also
reference "Estimated Funds Available" in this section, "Award Information"). Therefore,
awardees will be required to submit a Continuation Application at the end of each
project year (dates to be determined) after the initial funding award for Project Year 1,
which will assist in determining continued funding from Project Year to Project Year for
the five-year project funding cycle. Awardees will be required to submit an entire
application package including all components listed under “Content and Form
Application Submission” in the GrantsSolutions System to assist in determination of
continued funding.
7/27/2015
Special Diabetes Program
for Indians (SDPI)
FY 2016
IHS Tribal Self-Governance Advisory Committee
July 21, 2015
Background
• In FY 2016, SDPI will enter it’s 19th year
• Congress passed legislation in April 2015:
– 2-year SDPI authorization at $150 million (m) per year
• National Tribal Consultation/Confer
– Dear Tribal Leader and Urban Indian Organization Leader
Letters sent by IHS Acting Director on March 19 and May 3,
2015, respectively
– Input received from across the country
– Tribal Leaders Diabetes Committee (TLDC) meeting held
May 14, 2015
• Letters to Tribal and Urban Leaders with IHS Acting Director’s
decisions: June 29, 2015
1
7/27/2015
IHS Acting Director’s Decisions on
SDPI FY 2016
1. SDPI set-aside funds ($1m) formerly assigned to CDC will
now be assigned to the Community-Directed (C-D) grant
program
2. New and competing continuation Funding Opportunity
Announcement (FOA)
3. No changes to the national funding formula
--User population 30%, diabetes burden 57.5%, Tribal size adjustment 12.5%
4. More recent data (FY 2012) will be used in the funding
formula (user population, diabetes prevalence)
5. SDPI Diabetes Prevention and Healthy Heart (DP/HH)
Initiative program will be merged into the SDPI C-D
program
SDPI Diabetes Prevention and Healthy
Heart Initiatives
• DP/HH will be merged with the SDPI Community-Directed
(C-D) grant program
– Current DP/HH grantees are funded through September 29, 2016
– Can then request no-cost extensions up to September 2017
– 3-month grant close-out period (up to December 2017)
• C-D programs that would like to implement activities/services
similar to those done as part of the DP/HH Initiatives can do so
by either:
o Selecting an appropriate Best Practice
o Proposing DP/HH activities/services as part of “Other
Activities/Services not related to selected Best Practice”
• DP/HH Toolkits available soon
2
7/27/2015
SDPI Community-Directed Grant
Program
• Funding Opportunity Announcement (FOA)
– Will be posted on Federal Register and available in Grants.gov soon
– 5-year project period (contingent on funds availability)
• Funds will be awarded to all applicants who successfully
meet application criteria
– Competition is to achieve a fundable score on the objective
application review (not against each other)
• Applications must be complete, good quality, and submitted on
time.
– Grant regulations do not allow revisions after the application deadline date.
– Applications which are incomplete, of insufficient quality, and/or late will
not be awarded SDPI funds.
SDPI FY 2016 C-D Grant Amounts
• $25.4m from merging DP/HH into C-D plus $1m formerly assigned to
CDC = $26.4m
– $1m will go to increase the Urban set-aside from $7.5m to $8.5m/year
– $25.4m will go into C-D to provide funding for:
• Tribes not currently funded by SDPI
• Use of more current data: will hold Areas harmless
• Increase in funds to all Areas
• Won’t know final C-D grant amounts until about January 2016
– FY 2016 applicants will apply for same amount as received in FY 2015
– Steps to determine FY 2016 grant amounts:
• Need to know which sites successfully applied
• Areas will discuss with grantee sites: Area funding formula, which data to use
in Area formula, any Area set-asides
• Areas will then calculate the grant amounts for each grantee
• Grantees who will receive more than they applied for will then submit
supplemental budget and program information
3
7/27/2015
Budget Period for FY 2016
• One budget cycle starting in FY 2016
– January 1 to December 31, 2016
• How this affects current C-D grantees for their FY
2015 budget cycle:
– Cycle 1: Funding coverage for Oct-Dec 2015
– Cycle 2: No change
– Cycle 3: Overlap 3 months with FY 2015
– Cycle 4: Overlap 6 months with FY 2015
Upcoming DDTP Training
Webinars
• FY 2016 SDPI Community-Directed Application
Orientation
– Tuesday, July 28th @ 3pm EDT
• FY 2016 SDPI Diabetes Best Practice Overview
– Thursday, July 30th @ 3pm EDT
• August training dates: 3, 7,11, 12, 18, 20, 25, 27
• September dates to be determined based on needs of
applicants
4
7/27/2015
Thank you
www.diabetes.ihs.gov
diabetesprogram@ihs.gov
5
Rockville MD 20852
JUN 29 2015 Dear Tribal Leader:
I am writing to provide you with my decisions on the fiscal year (FY) 2016 funding
distribution and formula for the Indian Health Service (IHS) Special Diabetes Program for
Indians (SDPI). The IHS is delighted that the SDPI has been authorized for an additional
two years through FY 2017 at the current funding level of $150 million per year. With your
partnership and support, SDPI programs will be able to continue to provide important
diabetes treatment and prevention services in our communities.
On March 19, 2015, I sent a letter to Tribal Leaders to initiate a consultation on the SDPI
funding distribution and formula as the IHS must issue a new SDPI funding opportunity
announcement (FOA) for FY 2016. I want to thank all of the Tribal leaders who submitted
input through IHS Area consultation sessions, letters, and e-mails to consultation@ihs.gov.
In addition, I met with the Tribal Leaders Diabetes Committee (TLDC) on May 14, where we
reviewed the consultation input received from Tribes in all IHS Areas. During this meeting, the
TLDC members provided final recommendations for each of the consultation questions.
In FY 2016, the SDPI will enter its nineteenth year. Many things have changed over the
years that affect how SDPI grantees provide services, including rising inflationary medical
and staff costs, as well as shifts in American Indian and Alaska Native (AI/AN) user
population data. However, the last time the SDPI itself was changed was in FY 2004. It is
time for the SDPI to evolve to address these changes and be reinvigorated for the work ahead.
As such, I have made the following decisions for the SDPI FY 2016 funding distribution and
formula:
1. SDPI set-aside funds formerly assigned to the Centers for Disease Control and Prevention’s Native Diabetes Wellness Program will now be assigned to the
SDPI Community-Directed (C-D) grant program. 2. In FY 2016, the IHS will utilize a new and competing continuation FOA, allowing all
federally recognized Tribes to apply for funding.
3. No changes will be made to the national funding formula.
4. More recent data (FY 2012) will be used in the funding formula to address changes in
AI/AN user population and diabetes prevalence that have occurred over the past decade.
5. The SDPI Diabetes Prevention and Healthy Heart (DP/HH) Initiative program will be
merged into the SDPI C-D grant program.
Page 2 - Tribal Leader
The SDPI DP/HH grantees have done a remarkable job in accomplishing what they were
funded to do: demonstrate that intensive programs focusing on diabetes prevention and
cardiovascular disease (CVD) risk reduction in patients with diabetes can be implemented
successfully in AI/AN communities. The SDPI DP/HH grantees deserve our gratitude and
respect for all they have accomplished since FY 2004. It is now time to use those funds to
allow other communities to incorporate what they have taught us. SDPI C-D grantees will
continue to have the option to provide diabetes prevention and CVD risk reduction programs
and will soon have the SDPI DP/HH toolkits available online to help them do so.
By merging the SDPI DP/HH funds into the SDPI C-D grant program, not only will no Area
lose funds from any of the decisions above, but all Areas and Urban SDPI C-D programs will
have an increase in funds. I know these additional funds are needed to offset inflation and
other costs that have accumulated for SDPI C-D grantees since the last funding increase in
FY 2004. In addition, I hope that SDPI C-D grantees will take this opportunity to examine
their program for changes that can be made to improve existing services, as well as consider
providing some new ones.
Please note that, as the SDPI FY 2016 application process will be competitive, it is essential
that complete, quality applications be submitted by the due date, which will be announced soon.
Grant regulations do not allow for any revisions once the due date has passed. SDPI C-D funds will
be awarded to all applicants who successfully meet the application criteria, however, applications
which are incomplete, of insufficient quality, and/or late will not be awarded SDPI funds.
If you have any questions relating to the SDPI, please contact Dr. Ann Bullock, Acting
Director, Division of Diabetes Treatment and Prevention, IHS, by telephone at (844) 447-3387.
For questions relating to SDPI grant application procedures or related concerns, please contact
Ms. Tammy Bagley, Acting Director, Division of Grants Management, IHS, by telephone at
(301) 433-5204. Thank you for your partnership with the IHS in the important work of diabetes treatment and
prevention in the AI/AN communities that we serve.
Sincerely,
/Robert G. McSwain/
Robert G. McSwain
Acting Director
Direct Service Tribes Advisory Committee and Tribal Self-Governance Advisory Committee
Joint Meeting
Summary
May 13, 2015
Invocation, Introductions and Opening Remarks
Acting Director Robert McSwain
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This meeting has been in the works for several years; is a historic event.
Appreciate that many were able to travel great distance to be at this meeting today.
About access to care, and how we can work together to get it done.
Tribal Consultation and Tribal Partnerships are high priorities of the IHS.
Began in Indian Health in 1976, the year after passage of the ISDEAA; Tribes have come a long
way and things have greatly evolved since then.
Now we have the annual Tribal Leaders Meeting in the White House.
On our agenda we will discuss Contract Support Costs – made great strides in this area.
Affordable Care Act has involved a great deal of work with CMS and the Department.
Review of other items on the agenda.
Chief Lynn Malerba, Chairwoman, TSGAC
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Work on areas of mutual concern and interest to each other.
Whether choices are self-governance or direct, they are both self-determining choices.
Seek to open better lines of communication, as well as more indepth analysis of issues we can
work on together.
Improve Budget Process and to hold Congress accountable. Seek to make the IHS budget
mandatory; no other Federal health program is on the discretionary side.
Join our voices together – there is power in numbers.
Need to get away from “disease du jour” funding, but rather focusing on access to care, primary
care and preventative care that would prevent debilitating disease.
Donnie Garcia, Treasurer, DSTAC
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Represent Albuquerque Area on DSTAC as well as on the NIHB.
Representing Chairwoman, Sandra Ortega today.
Request to have a Joint meeting has been long-standing.
DSTAC established in 2005; choice of Direct Service is expression of self-determination.
Priorities of the DSTAC:
o Budget
o Chronic Disease Initiative Management (diabetes heart disease, cancer)
o Mental Health
o Health Promotion and Disease Prevention
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Maternal Child Health Care
Oral Health
Budget Discussion
Elizabeth Fowler, Deputy Director of Management Operations
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Description of the Budget Process undertaken by the Congress.
Basis for push to have Advanced Appropriations is to avoid a lapse/delay in Appropriations for
IHS.
VA has this authority; they are able to adjust their request as well. With two year authority,
they are able to request adjustments in the intervening appropriation year, while still having the
standing appropriation.
“Forward Funding” is when an additional amount for a future year is appropriated in the current
FY – adding additional funding in the current year appropriations. This is also counted against
the year it is appropriated, which would have to fit under spending caps.
With Advanced Appropriations, it is counted against two different spending cap years.
IHS has discussed how the VHA budget works with VA. Their concern was that they would be
able to request an adjustment to their budget in the overlapping year. Their experience has
been that this opportunity has been increasingly limited. The strictest interpretation of the
Advanced Appropriations is that no adjustment would be possible for two years.
Therefore, the IHS is still evaluating whether this is the best approach for the agency, because
some budget items are harder to predict that far out.
Discussed Advanced Appropriations with both the Department and with OMB. They would like
to address the issues arising from CRs and Government Shutdown; however, they are asking HIS
to provide specific types of information to understand if AA is the best solution. Question is
what makes IHS different from the other agencies during a CR or a Shutdown. They have been
presented with anecdotal data, but they are looking for more hard data on this.
Acting Director McSwain: We are more like the four Federal health systems, rather than the
rest of the Federal budget, as it goes to CRs and Federal Shutdown. If we were able to continue
to request adjustments in year two, we could address less predictable line items like CSC.
Liz Fowler: The Department and OMB are not sympathetic to the argument that CRs present a
tremendous workload to the OTSG for example. At first, they thought that Tribes were not
getting funded during a CR; but now that they understand that Tribes are getting the same
percentage of funding. So the question becomes what are the issues that Tribes are facing. HIS
understands the need for planning and budgeting. However, they want to see numbers and
data.
Chief Malerba: Advanced Appropriations does not score any higher, and we want parity with
other Federal health programs.
NIHB: we have a letter to request support of the IHS for Advanced Appropriations.
Looking at a set of National data to make a clear case to justify Advanced Appropriations
o Recruitment and retention – staff that are lost as a result of not being able to enter a full
employment agreement?
o Contracts entered at beginning of the FY – cost is less for a year-long contract, versus a
short term contract
Effect of deferrals of purchasing equipment
PRC – highest volume of PRC needed during winter months, but only straight percentage
of funds received. Thus we have the effect of denied/deferred care that would not
otherwise be.
o Clarify and stress the mechanics of an Advanced Appropriation – to be clear it is not
forward funding. There is a concern that it could be implemented in such a way to not
allow interim request for adjustment.
Liz Fowler: in discussing with VHA the successes were (1) the stakeholders; and (2) the
subcommittee only deals with VA matters, which makes it a bit different as compared to IHS
(which is in Interior Appropriations).
Acting Director McSwain: if asked about Advanced Appropriations, the agency has been given
the green light to give Technical Assistance to Congressionals if asked. This is different than in
previous fiscal years.
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Roselyn Tso, IHS Contract Support Cost Lead
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Still making progress on prior year CSC claims.
Still reconciling 2014 CSC payments, and also making payments on 2015 (updated to April 1,
2015).
Tracking every dollar to minimize impact on the Services budget.
Focus on Training in each of the Regions upon Tribal request, currently in the Great Plains.
Tribes are very interested in learning more about CSC, but also forming additional assumptions
(under self-determination, Title I and Title V).
Improving business practices and communication between the Area Offices and HQ. This
includes calculations and payments of CSC.
Chief Malerba: Thanks to IHS and the CSC Workgroup for standardizing calculations and making
processes consistent. Tribes are still advocating for the effort to separate the CSC from the rest
of the IHS Services Appropriation. Support the President’s Budget request but prefer that it be
made permanent.
Roselyn Tso: Have reached out to the BIA Federal team to attempt better collaboration and
consistency. Agree that the CSC Workgroup that there have been valuable products of that
work. Have rolled out the ACC Template for calculation; now working on additional templates.
Would like to demonstrate these soon to the DSTAC and the TSGAC. These new templates will
roll up into the existing templates. Will work with the CSC Workgroup before anything is rolled
out.
Perhaps tag the CSC Workgroup meeting onto the next TSGAC in July.
Affordable Care Act Update
Geoffrey Roth, Senior Advisor to the Director, IHS
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17 million individuals in US have enrolled in some type of insurance, or now have insurance
through parents or receiving Medicaid/Medicare
Today, we are going to talk about Tribal Premium Sponsorship and overview of the results of the
ACA in Indian Country
Doneg McDonough, Technical Advisory, TSGAC
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TSGAC has been holding a series of webinars on the ACA.
Did a webinar recently on Tribal Premium Sponsorship, with interest by Direct Service Tribes.
Discussions of how DS Tribes can partner with IHS to provide premium sponsorship.
Establish a template or approach to make premium sponsorship accessible to any Tribe who
wishes to enter it.
Overview of Premium Sponsorship as an opportunity to take a relatively small amount of money
and translate it into a greater amount of benefits.
Perhaps there can be a template developed with workable provisions to facilitate Tribal ability
to enter a premium sponsorship program.
Discussion of what the arrangement would be in a Direct Service scenario. The funding would
have to be made available from the existing appropriation. The IHS had studied it early, and it
was difficult for IHS to do it alone. IHS is continuing to look at this from their standpoint, but
involving the Tribes may provide a pathway forward.
Raho Ortiz, Office of Resource Access and Partnerships
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Update on the overall results of the ACA.
Approximately 23,000 AI/AN have enrolled in the Marketplace. (self-identified)
Discussion of the barriers to enrollment in the Marketplace, for both AI/AN and others.
Discussion of Education and Outreach efforts: value of coverages, benefits, special protections
and Coverage to Care
Discussion of the forums being provided for outreach and enrollment
Presented overview of the training/education provided to IHS staff. More than 300 IHS have
been trained to be CACs or TACs. Patient benefits coordinators are being provided tools and
scripts to discuss the ACA with patients.
Description of partnerships with Areas, Tribal organizations and advisory committees, Area
health boards, NIHB, etc for outreach and education.
Current issues – presented in meeting of the TTAG with the new CCIIO Director regarding the
Marketplaces:
o Data metrics for AI/AN enrollment
o Network adequacy for I/T/Us
o Indian exemption issues
o Definition of Indian in the ACA
o Payment Reform efforts
Continued efforts of HIS:
o Reducing number of the uninsured.
o Working with CMS to provide CAC training
o Partnering with national and regional organizations for outreach and education
o Using the IHS business plan template to plan, execute and evaluate ACA implementation
o Requiring IHS Areas to share their business plans with the Tribes in the Area
www.healthcare.gov/tribal
www.tribalhealthcare.org
www.ihs.gov/aca
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Chief Malerba: the TSGAC has been working on a paper proposing a direct relationship between
the Federal government and Tribes for Medicaid programs and funding.
Geoff Roth: The Secretary has, at the request of the STAC, become involved in the Employer
Mandate issues, which she will follow up with the STAC in the future.
Office of Inspector General (OIG) Presentation
Melinda Golub, Senior Counsel, Office of Counsel to the Inspector General, and Amitava “Jay”
Mazumdar, Senior Counsel, Office of Counsel to the Inspector General, HHS
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Overview of the OIG operations, history, budget and mission. (See Powerpoint)
Reviewed the OIG Alert to Tribes and Tribal Organizations, dated November 24, 2014
o Background and Motivation
 Ultimately our hope is to persuade our agency to take effort to get more specific
and concrete technical assistance to IHS and Tribes.
 The Alerts provided are to address the over 99% of providers that want to do
the right thing, and simply just need the information about how to put the
systems in place to avoid any problems.
 Podcasts on compliance programs, anti-kickback and other related statutes.
Pamphlets to Healthcare Boards of Directors on compliance, etc. Covers a wide
variety of compliance issues.
 Last three or four years, the OIG has been focused more on IHS:
• Hotline or other reports of issues that must be dealt with;
• Interest from the Congress on IHS programs every single year;
• Aware that what makes IHS beneficiaries of high interest to OIG, is that
they are among the most vulnerable population.
• One aspect of this OIG interest, has been the Alerts; it has also included
investigations of IDEAA programs (compact and contract). In common
was a lack of Internal Controls to detect waste fraud and abuse.
 OIG alert of November, 2014 came out of the investigations, to summarize what
the statute says about the use of Medicaid/Medicare dollars.
o OIG has been receiving input that, “These are OUR dollars and WE choose how to spend
them.” The Alert is an attempt to provide notice that the OIG knows of this issue, and
these funds needs to be monitored.
o OIG has made no assertion that this is a systemic problem – that all Tribes have this
issue. The aim then is to address the issue by reaching out through various venues to
communicate how to safeguard funding.
OIG publishes an annual plan on its website (including any work planned for IHS).
Discussion of the value of and the fundamental components of Compliance Programs. Guidance
can be found at www.oig.hhs.gov
Purchase and Referred Care Update – Medicare Like Rates
Carl Harper, Director, Office of Resource Access and Partnerships
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ORAP oversees PRC ($914 million) and 3rd party collections.
President’s Budget for PRC in FY 2016 is a $70 million increase.
A great deal of unmet need still exists. The PRC Workgroup has asked that more work be done
to document the unmet need.
Still need about $750 million or more in PRC funding to meet the demand.
Regulations for CHEF have been developed, in coordination with the PRC Workgroup. Lowers
the threshold to $19k. There are also provisions that it should increase with inflation, however,
may result in the threshold creeping back up to $25k.
Manuals and policies and procedures are also being updated for PRC overall.
Renewing the Fiscal Intermediary and the federal acquisition process to acquire an FI.
Chief Malerba: we are looking towards incorporating PRC into the VA Reimbursement
Agreements, what is the status? A: It continues to be discussed with VA.
Chief Malerba: Need to continue to work with those states that haven’t expanded Medicaid on
the Sec 1115 Waiver process to extend our dollars further.
Tribal comment: Still an issue to get the transportation for patients to get the specialty care
they need. We need to work on getting providers that are closer to the patients. A: Will take
note of this and see where we can provide support.
Tribal comment: Patients also have issues when they must get prescriptions refilled for
specialists – they must return to the Dr. and PRC is incurring another patient visit cost. A: These
are good comments, and we will look at it.
Question: Are you seeing less demand for CHEF with the ACA. A: There really isn’t less
demand, but are just able to pay for more numbers of cases.
Medicare Like rates rules soon to be issued. Tribal consultation was requested and received.
o Tribes supported this strongly.
o CMS has not had difficulty enforcing with hospitals; with other providers it is not as easy
to enforce.
o 57 comments were received.
 9 simply supported the proposed rule
 38 supported, but requested that there be flexibility included to negotiate a
higher rate, where provider choice might be limited. Additionally, these Tribes
wanted a provision to “opt out.”
o Consideration for the Tribal comments for MLR are being incorporated.
o VA has not had very much problem with providers; however, there are not as many
remote VA locations.
o After meeting with Senior IHS staff, redrafted the rule, which will be deliberated by HHS
and OMB.
o Will likely be another 60 day comment period before it is made final.
o Chief Malerba: Would like a letter from the Director that Tribes can send to Providers
once the regulation goes into effect to emphasize the new regulation. Also, Tribes
continue to be interested in advancing legislation for MLR that may be easier to enforce
than a regulation. Also would like to see a set of metrics defined to evaluate how
successful the regulations are.
Generation Indigenous (Gen-I)
Dr. Susan Karol, Chief Medical Officer
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Presidential initiative to focus on youth.
Two organizations responsible for Gen I: Center for NA Youth and UNITY (Meeting to be held at
Renaissance in Washington DC)
IHS has two things we are working on:
o Youth advisory councils. Will be moving out to the field. Hospitals and clinics will have
their local Councils to discuss issues in their area to hear priorities from the youth.
Representatives of these hospitals and clinics will comprise Area Councils, and
representatives of Area Councils will comprise a National Council.
o Pathway program at HQ. Designed to attract students to enroll in an array of programs
with paid opportunities throughout the federal system. Will start this summer
(hopefully July 1), age 17 or so through 24 (depending on state law). Students will be
paid as interns at our sites. One position description designed, with others to follow.
They will work towards 600 hours, which will give them credit as a Federal employee
and launch a potential career.
th
July 9 conference –
o Youth are asked to pledge or take the challenge for Gen-I. Can be a group or individual
challenge. As they accomplish their goals, they will be recognized.
o Deadline for students to pledge is May 15th (Friday). Need to get the word out for
students to pledge to Gen I.
o Students that pledge will be invited to the UNITY conference.
$25 million increase requested for 2016, if funded, will be slated for Behavioral Health activities:
providers, MSPI, suicide prevention, substance abuse counseling, etc. SAMHSA has also
requested $25 million increase to be distributed in grants.
Direct Services Tribes Update
Chris Buchanan, Director, ODSCT
•
•
•
•
•
•
Described the mission and goal for the IHS/Office of Direct Service and Contracting Tribes.
Described the agency priorities for IHS.
DSTAC health priorities have also been discussed. Oral health was added in 2015.
ODSCT
o NIHB liaison
o Database for Title I and DS Tribes
o Self-Determination Activities
o Tribal Management Grants
o CSC
o Newly recognized Tribes
Tribal Delegation Meetings – common issues include:
•
o Staffing
o Housing
o Recruitment and retention
o PRC
o Behavioral Health
o Facilities
Listening Sessions with Tribal Leaders
P. Benjamin Smith, Director, OTSG
•
•
•
•
•
•
•
•
•
•
•
Regardless of the Office, IHS has a common mission.
Program Analysts – assist in information related to PSFAs in the IHS, member of the Title V team
Policy Analysts – implementation of new law and regulations (such as ACA), reviewing policy
issues
Financial Analysts – Title V team member as well; awards are centralized in HQ, so these
analysts make all amendments and payments to SG Tribes.
Secretary and Staff Assistant
SG is Tribally-driven; the Federal government interacts in a programmatic way.
Description of the benefits of SG;
Presented the numbers of Tribes participating and how they have grown over the years.
Over 1/3 of the IHS budget is now managed by SG Tribes.
Special Projects: GPRA pilots; ACA Outreach and Education; SG Database Update; Information
Technology Services Catalogue
Training and Technical Assistance provided by OTSG.
DSTAC/TSGAC Joint Meeting
May 13, 2015
Follow Up Items
Advanced Appropriations
•
Need to formulate data and real experiences for the Office of Management and Budget
and HHS to use in its justification for IHS Advanced Appropriations.
o Looking at a set of National data to make a clear case to justify Advanced
Appropriations
o Possible Measurements:
 Recruitment and retention – staff that are lost as a result of not being able
to enter a full employment agreement?
 Contracts entered at beginning of the Fiscal Year – cost is less for a yearlong contract, versus a short term contract
 Purchasing Equipment – Effect of delays and deferrals of purchased
equipment
 Purchased and Referred Care – highest volume of PRC needed during
winter months, but only straight percentage of funds received. Thus we
have the effect of denied/deferred care that is avoidable with year-long
appropriations.
 Clarify and stress the mechanics of an Advanced Appropriation – to be
clear it is not forward funding. There is a concern that it could be
implemented in such a way to not allow interim request for adjustment.
o If National data cannot be compiled from Tribes, then perhaps a significant
sample size?
Contract Support Cost Workgroup
•
CSC Workgroup Meeting (perhaps during the week of TSGAC in July, 2015): Ben, Chris
and Roselyn.
Premium Sponsorship
•
Develop a proposal or template for participation in Premium Sponsorship for IHS/Direct
Service Tribes.
Purchased and Referred Care
•
•
•
Desire to incorporate Purchased and Referred Care (PRC) into the VA Reimbursement
Agreements
Need to continue to work with those states that have not expanded Medicaid on the Sec
1115 Waiver process to extend our dollars further.
Transportation issues remain steady for IHS patients to get the specialty care they need.
o Develop a strategy to get providers that are closer to the patients.
•
Update IHS policy to reduce costs:
o Specifically, patients that must get prescriptions refilled for specialists – they
must return to the specialty provider and PRC is incurring another patient visit
cost just to refill a prescription.
Medicare Like Rates
•
Request for a letter from the IHS Director that Tribes can send to Providers once the
regulation goes into effect to emphasize the new regulation.
o
o
Continue to advance legislation for MLR that may be easier to enforce than a
regulation.
Develop a set of defined metrics to evaluate how successful the regulations are.

TSGAC QM3 Final Meeting Packet - Tribal Self

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