Policy & Legislative Update NW Portland Area Indian Health Board Quarterly Board Meeting Hosted by the Quinault Indian Nation April 18, 2017

Report Overview Status of IHS Budgets New Administration Current & Pending Policy Issues Legislation in 115th Congress National & Regional Meetings

Status of IHS Budgets

FY 2017 IHS Budget Congress enacted a second continuing resolution (CR) for FY 2017 for the period of December 10, 2016 to April 28, 2017. Based on FY 2016 levels and under the authority and conditions of the FY 2016 appropriations. Congress is working on a FY 2017 Omnibus Appropriations Bill for last five months. On March 27, 2017, Administration proposed cuts to domestic discretionary spending which included IHS prevention programs (submitted late, likely not considered). Another CR is possible if Omnibus Appropriations Bill is not enacted.

FY 2018 IHS Budget Detailed budget anticipated in May, 2017. President’s FY 2018 “Skinny Budget” was released on 3/16/17 Proposes a 17.9% decrease to HHS Mentions that budget supports services delivered by IHS because services provided to “low-income and vulnerable populations.” Detailed budget anticipated in May, 2017. Based on FY 2016 enacted levels.

FY 2019 IHS Budget FY 2019 Evaluation/FY 2020 Planning meeting National Tribal Budget Formulation Workgroup’s Recommendations to IHS for FY 2019 Available at: http://www.nihb.org/legislative/budget_formulation.php Fully fund IHS at $32 billion phased in over 12 years HHS/IHS Budget Tribal Consultation on March 30, 2017 in DC FY 2019 Evaluation/FY 2020 Planning meeting April 24-25, 2017 in Spokane, WA

New Administration

Presidential Actions Memorandum for the Heads of Executive Departments and Agencies – Hiring Freeze, 1/23/17 Executive Order (E.O.) No. 13765: Minimizing the Economic Burden of the Patient Protection and Affordable Care Act Pending Repeal, 1/24/17 E.O. No. 13771: Reducing Regulation and Controlling Regulatory Costs, 1/30/17 E.O. No. 13777: Enforcing the Regulatory Reform Agenda, 2/24/17 Executive Order No. 13781: Comprehensive Plan for Reorganizing Executive Branch, 3/13/17 E.O. No. 13784: Establishing the President’s Commission on Combating Drug Addiction and the Opioid Crisis , 4/30/17

Letter from HHS Secretary & CMS Administrator to Governors Letter (dated 3/14/17) focused on improving collaboration with states for more effective program management in these areas: Improve Federal and State program management Support Innovative Approaches to Increase Employment and Community Engagement See Judicial Review of Medicaid Work Requirements under Section 1115 Demonstrations, dated 3/28/17 Align Medicaid and Private Insurance Policies for Non-Disabled Adults Provide Reasonable Timelines and Processes for Home and Community-Based Services Transformation Provide States with More Tools to Address Opioid Epidemic

Current & Pending Policy Issues

CMS 4 Walls Limitation CMS determined that If a Tribal facility is enrolled in the state Medicaid program as a provider of clinical services under 42 CFR 440.90, the Tribal facility may not bill for services furnished by a non-Tribal provider or Tribal employee at the facility rate for services that are provided outside of the facility. Per CMS, under FQHC designation there is no requirement that the services be provided within the 4 walls. Section 1905 of the SSA recognizes outpatient Tribal clinics as FQHCs. In order to not have any revenue losses, Tribal health programs have to work with their respective Medicaid agencies to change their designation to an FQHC. CMS FAQ released January 18, 2017. Deadlines: January 18, 2018: Notify state of intent to change provider status January 30, 2021: Effective date

CMS Market Stabilization Proposed Rule (CMS-9929-P) Proposed rule proposes changes designed to help stabilize the individual and small group health insurance markets. Specifically, it proposes to amend: Standards relating to special enrollment periods, guaranteed availability, and timing of annual enrollment period in 2018 plan year; Standards related to network adequacy and essential community providers for QHPs; and Rules on actuarial value requirements. Interim final rule or final rule forthcoming.

Indian Health Service IHS Notice to Propose the Re-Designation of the Service Delivery Area for the Tolowa Dee-ni’ Nation (Smith River Rancheria), dated March 31, 2017 Comments due May 1, 2017 IHS Dear Tribal Leader Letter on Return of Funds to Treasury, dated March 28, 2017

Other Brief Updates IHS Contract Support Costs New CSC Policy approved in October, 2016 IHS has resumed settling past-year CSC claims IHS Catastrophic Health Emergency Fund (CHEF) Final regulation not issued Update on Redding Rancheria v. Price IHS Tribal Premium Sponsorship Program No update on circular

Other Brief Updates-Cont’d IHS Community Health Aide Program Work group being convened. IHS Lease Proposals Under 105(l) of ISDEAA Two USDC-DC decisions state that 105(l) of ISDEAA and implementing regulations require IHS to fully-compensate lease with tribe or tribal organization.

Legislation in 115th Congress

Legislation in 115th Congress Repeal and Replace of Affordable Care Act Reauthorization of the Special Diabetes Program for Indians (S. 747) Independent Outside Audit of the Indian Health Service Act of 2017 (S. 465) Tribal Veterans Health Care Enhancement Act (S. 304) Trauma-Informed Care for Children and Families Act of 2017 (H.R. 1757) Other: Access to Insurance for All Americans Act (H.R. 1408) Indian Health Service Hiring Freeze Exemption Act (H.R. 981) IHS Advanced Appropriations Act of 2017 (H.R. 235)

Indian Legislative Bills in 115th Congress Repeal and Replace of Patient Protection and Affordable Care Act (ACA) American Health Care Act (pulled 3/24/17) The fight is not over! Tribes must continue to let their representatives know priorities in any health care reform: benefits of Medicaid expansion, no block granting, 100% FMAP, Indian Health Care Improvement Act, Indian provisions in ACA and AI/AN cost sharing protections in Marketplace, etc. ACA can also be undermined through administrative and regulatory process.

Indian Legislative Bills in 115th Congress S. 747 – Special Diabetes Program for Indians Reauthorization Act of 2017 Introduced by Sen. Tom Udall (D-NM) on 3/28/17. $150 million for FY 2018 Reauthorizes the Special Diabetes Program for Indians (SDPI) from FY 2019-FY 2024 with medical inflation rate increase. 3/28/17: Referred to Committee on Health, Education, Labor and Pensions.

Indian Legislative Bills in 115th Congress S. 465- Independent Outside Audit of the Indian Health Service Act of 2017 Introduced by Sen. Mike Rounds (R-SD) on 2/28/17 with co-sponsors Sen. James Lankford (R-OK) and John McCain (R-AZ). Requires an independent outside audit of the Indian Health Services with report to Congress. 2/28/17: Referred to Committee on Indian Affairs

Indian Legislative Bills in 115th Congress S. 304 – Tribal Veterans Health Care Enhancement Act Introduced by Sen. John Thune (R-SD) and Sen. Mike Rounds (R-SD) on 2/3/17. Amends the Indian Health Care Improvement Act to allow the Indian Health Service to cover the cost of a copayment of an Indian or Alaska Native veteran receiving medical care or services from the Department of Veterans Affairs, and for other purposes. 3/29/17: Referred to Committee on Indian Affairs.

Indian Legislative Bills in 115th Congress S. 774 & H.R. 1757 – Trauma Informed Care for Children and Families Act of 2017 Introduced by Sen. Heitkamp (D-ND) on 3/29/17 and Rep. Davis (D-IL) on 3/28/17. Addresses the psychological, developmental, social and emotional needs of children, youth, and families who have experienced trauma, and for other purposes. Establishes task force to develop best practices, training, Native American Technical Assistance Resource Center and grant funding. Actions: S. 774: 3/29/17- Referred to HELP Committee H.R. 1757: 4/12/17- Referred to Subcommittee on Crime, Terrorism, Homeland Security, and Investigations

National & Regional Meetings

HHS Tribal Consultations National HHS Budget Tribal Consultation- March 30, 2017 in DC Region 10 Tribal Consultation- April 10, 2017 in Suquamish

HHS STAC Meeting Update Last meeting was March 7-8, 2017 Tribal leaders met with HHS Secretary Tom Price. “Patients, people and partnerships” Tribal Leaders made several requests, including: Honor Tribal Consultation and Government-to-Government Relationship More federal funding beyond IHS Expand ISDEAA Self-Determination and PL 477 Assist in Treating Opioid Abuse and Addiction Provide Continued Support for Special Diabetes Program for Indians Maintain Medicaid expansion for AI/AN and 100% FMAP

MMPC & CMS TTAG Update Medicare, Medicaid and Health Reform Policy Committee’s (MMPC) – face-to-face meeting February 28th; last conference call was on April 5th Face-to-face strategy session is May 16-17, 2017. CMS TTAG – face-to-face meeting March 1st -2nd; last conference call was on April 12th Next conference call June 14, 2017. Face-to-face meeting is June 12-14, 2017 in DC.

Discussion?