mmpc - National Indian Health Board

II. Explanation of the Addendum for Indian Health Care Providers
1. Purpose of Addendum
Building on the success achieved in the Medicare Part D program, this Addendum for Indian
Health Care Providers has been developed for use in Exchange’s Qualified Health Plan
network contracts with Indian Health Care Providers. .
2. Definitions.
The definitions of terms used in the Addendum relate to federal laws.
3. Description of Health Care Provider.
This addendum can be used with different types of Indian health providers. This section gives
the opportunity to check the provider type that applies to the specific organization or facility
which is covered by the contract or agreement.
4. Cost-Sharing Exemption for Indians; No Reduction in payments.
Section 1402(d)(2) of the ACA provides that QHPs may not impose any cost-sharing on AI/AN
plan enrollees and may not reduce payments to an Indian Health Care Provider or contract health
services provider that would otherwise be due. The ACA directs the Secretary of HHS to
reimburse issuers for the increase in the actuarial value of the plan due to these costs.
5. Persons eligible for items and services from Indian Health Care Provider.
This section of the Addendum protects the QHP from charges of discrimination if the I/T/U
provider sees only people who are eligible IHS beneficiaries. Indian health programs are
generally not open to the public; they are established to serve AI/ANs, as provided in the IHCIA.
The applicable eligibility rules are generally set out in IHS regulations at 42 C.F.R. Part 136.
IHCIA §813 (25 U.S.C. §1680c) sets out the circumstances under which certain non-AI/ANs
connected with an AI/AN (such as minor children or a spouse) can receive services as
beneficiaries. IHCIA § 813 also authorizes services to certain other non-AI/ANs if carefully
defined requirements are satisfied.
6. Applicability of other Federal laws.
This section identifies a number of Federal laws that apply variously to IHS, Tribal health
programs, and urban Indian programs. These laws are briefly described here.
Anti-Deficiency Act, 31 U.S.C. §1341. This law applies to the Indian Health Service as a
Federal agency. It prohibits agency personnel from obligating the expenditure of Federal
funds in excess of appropriations made by Congress.
8/7/12 DRAFT COMPANION TO ADDENDUM – PAGE 3
Comment [A1]: Something to consider – in the
interest of brevity, should we just include a
description of selected provisions which require
clarification?
RESPONSE – If a summary of only certain
provisions is to be included, then perhaps only the
provisions listed in Section 6 could be included.