THE INDIAN HEALTH CARE SYSTEM IN WASHINGTON STATE. Making it work with few resources and many rules

Transcription

1 THE INDIAN HEALTH CARE SYSTEM IN WASHINGTON STATE Making it work with few resources and many rules

2 Federal Trust Responsibility to Tribes The federal government has a trust relationship with the tribes that is derived from treaties, statutes, and opinions from the Supreme Court. The federal government has a legal obligation to protect tribal sovereignty and property. See Worchester v. Georgia, 31 U.S. 515 (1832) and Cherokee Nation v. Georgia, 30 U.S. 1(1831).

3 IHS Funding The federal government spends 50% less per capita on Native American health care than other groups for which it has this responsibility including prisoners and Medicaid recipients. Less than $1,700 per year, per person.

4 The Indian Health Care Delivery System: Three Types of Providers Indian Health Care Providers (I/T/Us)

5 Types of Health Care Services Provided by I/T/Us I/T/U Facility Referral & Coordination Dental Medical Behavioral Specialty Care Inpatient Care

6 PRC as Payor Of Last Resort The Indian Health Service will not be responsible for or authorize payment for contract health services to the extent that the Indian is eligible or would be for alternate resources if he or she were to apply for them. 42 CFR Subpart G (a) and (b)

7 PRC and Alternate Resources Alternate resources include health care providers and institutions, health care programs for the payment of health services including but not limited to: programs under titles XVIII or XIX of the Social Security Act (i.e., Medicare, Medicaid); State or local health care programs; and private insurance. 42 CFR Subpart G (c)

8 Fed. Gov t. failure to meet trust responsibility Alternate Resources Employer Requires AI/AN to use other resources* Qualified Health Plans Medicaid Tribes/UIHPs forced to fill in the gaps Medicare Other *42 CFR IHS is payor of last resort

9 I/T/U Right to Recovery & Rate I/T/Us have a right to recover from an insurance company, health maintenance organization, employee benefit plan the reasonable charges billed, or if higher, the highest amount the third party would pay for care and services furnished by providers other than governmental entities Section 206(a) of the Indian Health Care Improvement Act, 25 U.S.C. 1621e(a) 9

10 Federal Limitations on State Law and Contracts with I/T/U Providers No law of any State, or of any political subdivision of a State and no provision of any contract, insurance or health maintenance organization policy, employee benefit plan, self-insurance plan, managed care plan, or other health care plan or program entered into or renewed after November 23, 1988, shall prevent or hinder the right of recovery of the United States, an Indian tribe, or tribal organization under subsection(a). IHCIA, Section 206, 25 USC 1621e(c) 10

11 ACA Benefits & Protections Offered through the Exchange Assistance with health insurance premiums (the amount that must be paid for the individual's health insurance or plan. Usually paid monthly, quarterly or yearly). AI/AN* monthly enrollment/change of plans Assistance with outof-pocket costs (aka COST SHARING. The share of costs covered by individual s insurance that he pays out of his own pocket. Deductibles, copayments, co-insurance). AI/ANs* exempt from tax penalties for not having insurance covered *This protection applies only to individuals enrolled in federally recognized tribes.

12 Right to Recovery Qualified Health Plans If an AI/AN enrollee is provided a service or item by an I/T/U or through a PRC referral, the issuer shall not reduce payment to the I/T/U by the amount of any cost-sharing that would be due from the Indian but for subparagraph (A). ACA, Section 1402(d)(2)(B), 42 U.S.C (d)(2)(b) See also 206(a) (25 USC 1621e(a)) 12

13 The I.H.S. All Inclusive Rate Services provided to Medicaid-eligible AI/AN patients in IHS or tribal facilities can be reimbursed at 100% FMAP. Since CMS reimburses these expenses at a rate of 100%, services provided to Medicaid-eligible Native American patients in IHS or tribal facilities cost the state nothing. Non-Indians served at your facility can be reimbursed at the state's usual FMAP, not at 100% FMAP. 100% FMAP provides a significantly higher Medicaid reimbursement for tribally provided services than for other state Medicaid services. FMAP amounts are adjusted every 3 years.

14 When the State Makes Changes That Upset the Apple Cart: 1115 Global Waiver Integration of Medical & Behavioral Health Services Healthier Washington/ Medicaid Transformation State Law SB 6312 Fed. Application 1915(b) Waiver Transition from Fee-For- Service to Value-Based Purchasing Creation of Accountable Communities of Health

15 The Carve Out - How It Happened Medicaid Transformation, in part, is a move to utilize Managed Care for Medicaid participants. Section 1932 of the Social Security Act exempts AI/ANs from having to enrolling in Managed Care. When I/T/Us bill Managed Care Plans, they don t directly receive the encounter rate. Managed Care Entities (RSNs, BHOs, MCOs) can create an access barrier for AI/ANs receiving care in the I/T/U system.

16 The Carve Out continued Effective April 1, 2016, SOW moved Medicaid benefits for mental health and substance use disorder to a new Managed Care Entity- BHOs Tribes had historically poor relationships with RSNs and had requested to work with the State on a Tribal Centric Behavioral Health Plan. DSHS was unable to implement a TCBH plan before the move to BHO s. Tribe s and UIHPs in Washington State requested for SUD benefits for AI/ANs to be carved out of the MH and SUD integration while working on a implementing at Fee For Service TCBH Plan by July 1, 2017.

17 1915(b) Waiver & American Indians/Alaska Natives Excludes AI/AN from managed care delivery system for substance abuse disorder services but includes AI/ANs in the BHO system for mental health care services above the access-to-care standard. Managed Care (BHOs) AI/AN Mental Health Services (above access to care standard) Fee-for- Services AI/AN SUD Services (except Clark & Skamania)

18 I/T/Us Surviving Medicaid Transformation: Tribes will continue to work to improve the FFS Medicaid program: it works best with the current I/T/Us system in Washington State. AI/ANs still have many issues when they need to receive care outside the I/T/U system Tribes and UIHPs will continue to work with the State and Federal Governments to protect and improve programs currently in place.

19 It s complicated not just a Facebook status THE INDIAN HEALTH CARE SYSTEM IN WASHINGTON STATE Vicki Lowe, Executive Director American Indian Health Commission for Washington State vicki.lowe.aihc@outlook.com