1 Legislative & Policy Update NW Portland Area Indian Health Board Quarterly Board Meeting Hosted by Nez Perce Tribe April 20, 2016

Report Overview 1.President’s FY 2017 IHS Budget 2.Contract Support Costs 3.100% FMAP Update 4.Catastrophic Health Emergency Fund 5.Medicare-Like Rates for Non-Hospital Providers 6.Confidentiality of Substance Use Disorder Patient Records 7.STAC Meeting Update 8.CMS TTAG Update 9.Legislative Issues 114 th Congress

President’s FY 2017 IHS Budget President’s FY 2017 IHS Budget Request is $5.2 billion, a $377 million increase – 7.9% increase above FY 2016 enacted budget Purchased and Referred Care is $962 million, a $48 million increase – 5.3% increase over FY 2016 enacted budget – Does not restore the $46 million lost in FY 2016 (no increase from FY 2015 to FY 2016) Contract Support Costs is $800 million, an $82 million increase – 11.4% increase over FY 2016 enacted budget Includes mandatory spending for Special Diabetes Program for Indians and the new Crisis response and Behavioral Health initiatives

Contract Support Costs President’s FY 2017 IHS budget proposes an increase of $82m above FY 2016 level for Contract Support Costs (CSC) In FY 2018 and beyond, the Administration proposes to reclassify CSC as a mandatory. Several recommended changes to the CSC Policy were made following the March CSC Workgroup meeting. Dear Tribal Leader sent out on 4/11/16 providing a 60-day comment period on the revised policy. Three Tribal Consultation sessions, then review of comments by CSC Workgroup, and Final Policy anticipated to be completed by early August.

100% FMAP Update On February 26, 2016, CMS issued a letter to State Health Officials re-interpreting the scope of services to be considered “received through” an I/T to qualify for 100% FMAP: 1.“Received through” now includes any services that an I/T is authorized to provide according to IHS rules, and that are also covered under the approved Medicaid state plan, including long-term services and supports (LTSS). 2.May also include transportation (emergency and non- emergency) and other related travel expenses if it is a covered service under the Medicaid state plan. 3.I/T’s request for service from a non-I/T provider must be in accordance with a “care coordination agreement” and non-I/T provider must be a Medicaid provider. 4.Two billing options presented: (a) non-I/T provider bills Medicaid directly; or (b) I/T handles all billing. 5. Effective upon execution of a written care coordination agreement. CMS to issue a FAQ on new policy.

Catastrophic Health Emergency Fund (CHEF) Proposed rule issued on January 26, 2016 (81 Fed. Reg. 4239–44). Sets threshold cost at $19,000 for catastrophic illness or disaster. Adds “tribal” resources to the list of alternate resources. No Tribal consultation on this rule before it was issued. At TSGAC quarterly meeting, a request for Tribal consultation was made to IHS Deputy Director. Comment period was extended to May 10, 2016 [81 Fed. Reg –52 (Mar. 11, 2016)].

Medicare-Like Rates (MLR) to Non-Hospital Providers Final rule with comment period issued on March 21, 2016 – 81 Fed. Reg Extends MLR to physicians and other health care professional services and non-hospital based services (non-hospital providers). Applies to IHS-operated PRC programs and urban Indian health programs, and Tribes/Tribal organizations if they opt-in. Allows I/T/Us to negotiate or pay non-hospital providers MLRs, i.e. some providers may not see patients if the rate is too low.

Medicare-Like Rates (MLR) to Non-Hospital Providers-cont’d Definition of “referral” issue Statement in Annual Funding Agreement I/U should implement the rule ASAP but must implement the rates no later than 3/21/17 Basic statement in Annual Funding Agreement (AFA) needed for Tribal health programs to opt in Rule effective on May 20, 2016 but comments are being accepted up to this date.

Confidentiality of Substance Use Disorder Patient Records Proposed rule issued on February 9, 2016 (81 Fed. Reg. 6988). Updates and modernizes regulations issued in 1987 under 42 CFR Part 2. Impacts programs operating under ISDEAA and those operating health centers under HRSA grants. Meant to protect use of substance abuse information against individuals which would lead them not to seek needed treatment. Proposes to align regulations with advances in the health care delivery system. Comment period ended on April 11, A request for Tribal consultation was made by NPAIHB.

STAC Meeting Update Last meeting was March 1-2; next meeting is June 7-8 Tribal leaders made several requests to Secretary Burwell, including: – Ensure that Special Diabetes Program for Indians (SDPI) is properly funded; and provide status on report to Congress on SDPI – Continue to advocate on mandatory funding for Contract Support Costs – Raise mental health and suicide issues in Indian Country to the White House Council on Native American Affairs, and initiate a study to understand and address the epidemic – Provide Tribal Consultation on Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) payment reforms -- Merit Based Incentive Payment Systems (MIPS) v. Alternative Payment Models (APMs) – Provide a timeline on the release of the proposed rule on adoption and foster care analysis and reporting system (AFCARS) – Establish a Senior Level Tribal Advisor position within the Assistant Secretary’s Office at the Administration for Children and Families

CMS TTAG Update Face-to-face meeting February 25-26, 2016 in DC; conference call on April 13, 2016 – Priority Issues – CMS Division of Tribal Affairs Update All Tribes webinar on 4/27/16 at 11:00am PST to review updated Tribal Consultation Policy April Tribal consultations in Washington and Idaho I/T/U Training Schedule Regional Consultations (Region X on May in Suquamish) – Highlight of last call: Stephen Cha, Director State Innovations Group, CMMI/CMS -- RFI will be released soon which may allow for an all payer model for a community or region rather than entire state. Interested in seeing this on a reservation or with a Tribe.

Legislative Issues 114 th Congress Department of Interior Tribal Self-Governance Act of 2015 (S. 286) Advance Appropriations (H.R. 395) Tribal Programs Exemption from Sequestration (S. 1497/H.R. 3063) Employer Mandate (S. 1771/H.R. 3080) Family Stability and Family Kinship Act of 2015 (S. 1964) Native American Suicide Prevention Act of 2015 (H.R. 3166) Ongoing: – IHCIA Technical Amendments (S. 2114) – SDPI Permanent Reauthorization – Contract Support Costs mandatory funding and reconciliation language

Indian Legislative Bills in 114 th Congress S. 286 – Department of Interior Tribal Self- Governance Act of 2015 – Introduced by Sen. John Barasso on 1/28/15; co-sponsors include Senators Tester, Murkowski, Crapo, Schatz, Franken – Amends Title IV of of ISDEAA to make it consistent with Title VI, the Self-Governance Program for HHS – Creates the same administrative efficiencies for DOI that have been in place for HHS programs. – S. 286 passed Senate on 7/7/15 by Unanimous Consent – Referred to House Natural Resources Subcommittee On Indian, Insular and Alaska Native Affairs on 8/4/15

Indian Legislative Bills in 114 th Congress H.R. 395 – Indian Health Service Advance Appropriations Act of 2015 – Introduced by Rep. Young (AK-R) on 1/14/15; co-sponsors include Senators Kirkpatrick (AZ-D), Huffman (CA-D), Lujan (NM-D) – Amends IHCIA to authorize Advance Appropriations for the Indian Health Service and Indian Health Service Facility Accounts – Referred to House Natural Resources Subcommittee on Indian, Insular and Alaska Native Affairs on 3/2/15

Indian Legislative Bills in 114 th Congress Senate bill Exempts Tribal Programs from Sequestration – Introduced by Sen. Tester (MT-D) and Sen. Udall (NM-D) on 6/3/15 – S would exempt IHS, BIA, HUD and other Indian programs from sequestration required under the Budget Control Act of 2011 House bill Exempts Tribal Programs from Sequestration – H.R same companion bill to S – Introduced by Rep. Young (AK-R) on 7/14/15; co-sponsors include Representatives Grisham (NM-D), Cole (OK-R), Ruiz (CA-D), McCollum (MN-D) Both bills referred to Budget Committees

Indian Legislative Bills in 114 th Congress Exemption from ACA Employer Mandate (Shared Responsibility) – Tribal Employment and Jobs Protection Act – S introduced by Sen. Daines (MT-R) on 7/15/15; co-sponsors Senators Round (SD-R), Crapo (ID-R) and Thune (SD-R) – H.R introduced by Rep. Noem (SD) on 7/15/15; 25 bi-partisan co-sponsors – Senate bill referred to Finance; House bill referred to Ways & Means

Indian Legislative Bills in 114 th Congress S Family Stability and Family Kinship Act of 2015 – Introduced by Sen. Wyden (OR-D) on 8/5/15; co-sponsors Sen. Bennett, Brown (OH-D), Cantwell (WA-D), Casey (PA-D), Gillibrand (NY-D), Menendez (NJ-D), Schumer (NY-D), Stabenow (MI-D), Warner (VA-D) – Reforms the federal finance system supporting state and child welfare services – Funds preventive services and kinship placements for children at risk of foster placement – Current law creates incentives to place Indian children outside of families in order to receive federal funding – Encourages child welfare system to forego alternatives to prevent breakup of families like parent training, mental health counseling, trauma recovery, etc. – Referred to Finance Committee on 8/5/15

Indian Legislative Bills in 114 th Congress H.R Native American Suicide Prevention Act of 2015 – Introduced by Rep. Grijalva (AZ-D) on 7/22/15; co- sponsors are Reps. Ruiz (CA-D), Huffman (CA-D), Young (AK-R), Moore (WI-D), McCollum (MN-D), Grisham (NM-D), Salmon (AZ-R), Napolitano (CA-D) and Cole (OK-R). – Amends the Public Health Service Act to require a state or state-designed entity to seek Tribal consultation as a condition of receiving a grant or cooperate agreement for development/implementation of a statewide youth suicide and early intervention and prevention strategy. – Referred to Energy & Commerce, Subcommittee on Health on 7/24/15.

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