mmpc - National Indian Health Board

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An American Indian child that may not have enough blood quantum to be enrolled in a Tribe will be considered Indian under Medicaid. But not in Exchanges, because she lacks enough blood quantum to be enrolled in either of her parent’s tribe. An American Indian cannot enroll in his father’s tribe where tribal membership is passed from mother to child in what has been called matrilineal descent, and therefore he would not be considered AI/AN under Exchanges, even though he would qualify as AI/AN in Medicaid. An individual who has been determined to be AI/AN by the federal Bureau of Indian Affairs and has a Certificate of Indian Blood issued by that federal agency that is recognized by every other federal agency, is not recognized as Indian by the Federally-facilitated Exchange or state-based exchanges. A person enrolled in Medicaid as an AI/AN no longer meets the income criteria and does not purchase health insurance because she gets her care from her Tribal health clinic and assumes that she is exempt from tax penalties because she is AI/AN. However, IRS uses a different definition of AI/AN than Medicaid uses, and she finds out later that she does have to pay a tax penalty. The complications of Exchanges to administer and families to understand the varying definition of Indian and the high level of churning that is anticipated for AI/AN families will disenfranchise AI/AN families from participating in opportunities provided under the Affordable Care Act. In each of these cases, the individuals could be living in a family that is considered AI/AN, in an AI/AN community – perhaps even on a reservation, attending Indian schools funded by the federal government, and receiving their health services at an Indian Health Service clinic or hospital. They could be considered AI/AN for Medicaid, CHIP and every federal Indian program. And, still they would not be qualified for the special protections for AI/AN in Health Insurance Exchanges according to the current interpretation of ACA by the Department of Health and Human Services. As a result of the differences in how Exchange rules are being written and how Medicaid and CHIP rules are written, it is not possible to have a simple, streamlined application that relies on existing electronic data sources. The application must ask at least three different questions to determine who qualifies as Indian under the different programs. Those three questions take up a lot of space on an application which will be used by a lot of people who are not AI/AN, and they will confuse a lot of people who are AI/AN. If Exchanges use the same definition as Medicaid, CHIP and the Indian Health Service, they could use the electronic registration data base from the IHS as part of the application process. However, the more restrictive definition currently in use by Exchanges may require someone at every Exchange and at every Tribal government site to process paperwork that shows that an individual has a tribal enrollment card. Ironically, the ACA calls for self-attestation for almost every aspect of the application (except citizenship), and yet AI/ANs may be expected to provide documentation instead of using self-attestation to prove that they are a member of a Tribe or Alaska Native regional or village corporation. The Administration should be trying to make it easier for underserved individuals to enroll in health insurance through Exchanges, not more difficult. Operationally, it is going to be a nightmare to have different definitions of AI/AN for Medicaid, CHIP and Exchanges. Personnel at call centers, navigators, in-person assisters, and individuals working in Indian health clinics will have to explain to people why they are considered an Indian for one federally-funded program, but not for another. Explaining the benefits of this new program will be difficult enough. As health care providers bill Medicaid Plans and Qualified Health Plans, they will need to know whether cost sharing waivers apply for some AI/AN and not for others.
As people have changes in employment, income and family size, they will churn between Medicaid to Exchange coverage assuming that the same rules apply, only to find out later that they have been disenfranchised as AI/AN from Exchanges. This is a problem that can be solved easily by having Exchanges adopt the Medicaid definition of Indian and use the same types of verification that Medicaid uses. We didn’t agree, but understood the view of lawyers and others in HHS immediately after the law passed when they asserted that since there were three different “definitions,” these problems couldn’t be fixed without a “legislative fix.” However, HHS formally, and IRS informally, have agreed that the three statutory definitions have the same meaning. We know it is not likely that Congress will amend the ACA to fix this problem in the next few months while the single, streamlined applications are being designed. It is clearly time for the Administration to reconsider relying on a regulatory correction. There are many ways to justify aligning how these definitions are implemented to correspond to how the agencies most responsible for administering programs for Indians determine who is Indian. The attached paper discusses these. What is needed now is leadership at the highest levels to require that this problem is solved immediately through the issuance of regulations or similar guidance that applies the Medicaid definition of AI/AN to Exchanges. We would like to meet with you to discuss this issue and offer assistance to resolve it. For questions, please follow up with Jim Crouch, CRIHB Executive Director, at (916) 929-9761; or Jim Roberts, NPAIHB Policy Analyst, at (503) 347-7664. Sincerely yours, Michelle Hayward, Chairperson Andy Joseph, Jr., Chairperson California Rural Indian Health Board NW Portland Area Indian Health Board Redding Rancheria Tribal Council Member Colville Tribal Council Member Attachment: “Enabling Exchanges Implement a Streamlined Application Process: The Need for a Uniform Operational Definition of Indian to Efficiently and Accurately Identify Individuals Who Are Eligible for Special Benefits and Protections”
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MEDICARE, MEDICAID, & HEALTH REFORM
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GENERAL INFORMATION TABLE OF CONTEN
Page 5 and 6: Last Updated: November 12, 2012 2.
Page 7 and 8: Ref. # 2. Task/Issue Person(s) CMS
Page 9 and 10: Ref. # II. POLICY Task/Issue Person
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Page 15 and 16: IV. OUTREACH AND EDUCATION MMPC: SU
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Page 19 and 20: MMPC October 9, 2012 Teleconference
Page 21 and 22: To do List: -Myra will have draft b
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Page 25 and 26: with a “interim/acting”. Can al
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Page 51 and 52: October 17, 2012 Dr. Robert Petzel,
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Page 77 and 78: Summary T he Indian Health Service
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Page 81 and 82: Introduction Reliable determination
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Findings Table 10. Unadjusted Mean
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Findings Figure 13. Adjusted Mean T
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Analysis Group Compiled Findings fo
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Findings Adjusted Mean Payments for
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Findings Figure 18. Percent differe
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Findings providers for services nee
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Findings Figure 21. Medicaid Altern
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Conclusions and Recommendations pro
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Indian Health Service, 2012. Federa
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Tribal Consultation Policy HHS 1. P
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defined in Sections 8 and 9 of this
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2. Office of Intergovernmental Affa
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will give equal consideration to th
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provide Indian Tribes with a region
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4. Each Operating Division Head/Dep
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Department’s ability to address i
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17. Sovereignty - The ultimate sour
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1. Selection of workgroup co-chairs
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It is unclear if this was just an o
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November 14 -15, 2012 TTAG FACE TO
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AGENDA: Day 2 Thursday - Nov. 15, 2
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Subpart G--Social Services Block Gr
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organization applying for or receiv
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members of a tribe receiving direct
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is at or below the poverty line. (d
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under this part. Grantees that rece
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income home energy assistance progr
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Need for Uniform Operational Guidan
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Dear Tribal Representatives, Octobe
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There is a strong correlation betwe
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Wed. Nov 14 th : SDPI National Call
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Future MMPC Meetings & Conference C
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Regulation Review and Impact Analys
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64. Policy on Conferring with Urban
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RRIAR Ref. # 1.c. 8. 9. 13. Short T
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premium tax credit assistance and c
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Access to this benefit is criticall
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community providers for purposes of
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November 12, 2012 Centers for Medic
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_________ American Indian or Alaska
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November 9, 2012 Page 2 We are comm
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Tribal Consultation for Health Insu
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Background Analysis of Tribal Consu
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Analysis of Tribal Consultation Pol
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D. FFE Data Analysis of Tribal Cons
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John O'Brien Director, Healthcare &
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