mmpc - National Indian Health Board

I. Purpose.
DRAFT EXPLANATION OF ADDENDUM
FOR INDIAN HEALTH CARE PROVIDERS TO NETWORK PROVIDER
AGREEMENTS OF HEALTH PLANS OFFERING PRODUCTS ON
HEALTH INSURANCE EXCHANGES
CMS has developed the attached Addendum for Indian Health Care Providers to promote
inclusion of Indian health care providers in qualified health plan (QHP) provider networks and
help health insurance issuers develop health plans that comply with the QHP certification
standards set forth in 45 CFR Part 156. Based upon a similar standardized contract addendum
used in the Medicare Part D program, this addendum has been developed for QHP issuers to use
when contracting with Indian Health Care Providers.
The federal government has a historic and unique relationship with American Indian and Alaska
Native (AI/AN) tribes. The purpose of this addendum is to further the aims of the Federal trust
responsibility by fostering participation of Indian health care providers in QHP networks, and
help issuers meet QHP certification standards, particularly with respect to network adequacy and
access to essential community provider participation. In adhering to QHP certification standards,
QHP issuers will need to reach out to Indian health care providers in many parts of the country.
It is anticipated that the addendum will assist health plans meet the “sufficient number and type
of provider” criterion required for QHP certification, and will facilitate acceptance of network
contracts by Indian health providers.
Most AI/AN people access care through their longstanding providers in the Indian health system.
As a result, an important consideration in evaluating network adequacy and essential community
provider accessibility will be the extent to which a QHP includes Indian providers in their
networks and whether it can assure that services to AI/AN consumers will be accessible without
unreasonable delay.
Offering contracts that include the Addendum will provide QHPs with an efficient and effective
way to establish network contract relationships with Indian Providers, and also ensure that
American Indian and Alaska Native consumers can continue to be served by their Indian
provider of choice. Indian tribes are entitled to special protections and provisions under Federal
laws, which are described further in Section II.
The addendum identifies specific provisions that have been established in Federal
law that apply when contracting with Indian Health Care Providers (i.e. I/T/Us). Use of this
Addendum benefits both QHPs and the Indian Providers by lowering the perceived barriers to
contracting, assuring QHP issuers comply with key Federal laws that apply when contracting
with Indian providers, and minimizing potential disputes. AI/ANs consumers will be better
served if their QHP encourages Indian providers to coordinate their care through the QHP
network.
8/7/12 DRAFT COMPANION TO ADDENDUM – PAGE 1