Policy & Legislative Update NW Portland Area Indian Health Board Quarterly Board Meeting Hosted by The Yakama Nation October 10, 2017

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

Status of IHS Budgets

FY 2018 IHS Budget Congress passed a continuing resolution (CR) for FY 2018 budget which funds the government through December 8, 2017. President’s budget proposes a 5.2% decrease below FY 2017 enacted level for services and facilities. House bill proposes a 4.2% increase above FY 2017 enacted level for services and facilities. However, reallocates funds to IHCIF; so minimal increases across all line items Hill visits advocacy per our FY 2018 analysis Senate Appropriations Interior Environment and Related Agencies Subcommittee markup of Indian Health Service Budget week of October 16.

FY 2019/2020 IHS Budgets National Tribal Budget Formulation Workgroup’s Recommendations to IHS for FY 2019 Available at: http://www.nihb.org/legislative/budget_formulation.php FY 2020 Portland Area Budget Formulation Meeting November 30, 2017 in Portland, OR

Current & Pending Policy Issues

HHS Draft Strategic Plan for FY 2018-2022 HHS is seeking public comment on its draft Strategic Plan for Fiscal Years 2018-2022 -Comments due 10/26/17. Strategic Plan highlights how the Department will achieve its mission through 5 strategic goals Reform, strengthen, and modernize the Nation’s health care system; Protect the health of Americans where they live, learn, work, and play; Strengthen the economic and social well-being of Americans across the lifespan; Foster sound, sustained advances in sciences; and Promote effective and efficient management and stewardship.

CMS Policies Medicare Diabetes Prevention Program Proposed Rule NPAIHB submitted comments on 9/11/17. New Medicare Card Project Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers Compliance is required by 11/15/17  

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. CMS FAQ released January 18, 2017. Deadlines: January 18, 2018: Tribe must notify state of intent to change provider status – clinical provider to FQHC. January 30, 2021: Effective date

CMS New Direction for Innovation Center CMS is seeking comment on new direction for the CMS Innovation Center - Comments due 11/20/17. CMS is interested in testing models in the following areas: Increased participation in Advanced Alternative Payment Models (APMs); Consumer-Directed Care & Market-Based Innovation Models; Physician Specialty Models; Prescription Drug Models; Medicare Advantage (MA) Innovation Models; State-Based and Local Innovation, including Medicaid-focused Models; Mental and Behavioral Health Models; and Program Integrity.

IHS Policies IHS Contract Support Costs IHS Listening Sessions on RPMS and EHR DTLL on 6/26/17; listening sessions held in July and August. Response to VA moving to VistA and impact on IHS RPMS EHR. NPAIHB submitted comments on 8/30/17. Other IHS Announcements: DTLL on 8/25: IHS is accepting applications for the Small Ambulatory Program; due 12/1/17. New wait time standards policy: 28 days or less for primary care and 24 hours or less for urgent care. Creation of a search committee to fill key Area Director positions.

IHS Policies IHS Strategic Plan 2018-2022 Tribal Consultation and Urban Confer DTLL on 9/15/17 Listening session held in September Next listening session scheduled for October 18 Comments due 10/31/17 3 Strategic Plan Goals To ensure that comprehensive, culturally acceptable personal and public health services are available and accessible to AI/ANs; Promote excellence and quality through innovation of the Indian health system into an optimally performing organization; and Strengthen IHS program management and operations.

Legislation in 115th Congress

Legislation in 115th Congress Appropriations for FY 2018 Disaster Tax Relief and Airport and Airway Extension Act of 2017- Extends the SDPI (H.R. 3823) KIDS Act of 2017 (S.1827) Native Health and Wellness Act of 2017 (H.R. 3706) Native Health Access Improvement Act of 2017 (H.R. 3704) Restoring Accountability in the Indian Health Service Act of 2017 (S.1250) Special Diabetes Program for Indians Reauthorization Act of 2017 (S.747 & H.R. 2545) Independent Outside Audit of the Indian Health Service Act of 2017 (S.465) Drug Free Indian Health Service Act of 2017 (H.R. 3096) Tribal Veterans Health Care Enhancement Act (S.304) IHS Advanced Appropriations Act of 2017 (H.R. 235)

Indian Legislative Bills in 115th Congress Appropriations for FY 2018 Indian Health Service Budget Senate Appropriations Subcommittee for Interior, Environment and Related Agencies to Markup Indian Health Service Budget week of October 16. House bill (discussed in earlier slide). Secretary’s Minority AIDS Initiative Fund (SMAIF) Senate Appropriations Committee for Labor HHS Education and Related Agencies included $53.9 million for SMAIF. No funding in House Appropriations Committee bill. $3.6 million to IHS; over $1m to NPAIHB in FY 2017. Public Health Training Centers Senate Appropriations Committee for Labor HHS Education and Related Agencies included level funding $50k to NPAIHB in FY 2017 through NWPHTC.

Indian Legislative Bills in 115th Congress Disaster Tax Relief and Airport and Airway Extension Act of 2017 (H.R. 3823) Introduced by Rep. Kevin Brady (R-TX-8) on 9/25/2017 Extends several public health programs including SDPI. Includes $37,500,000 for SDPI for the first quarter of FY 2018 – extends SDPI to 12/31/17. Referred to the House Ways and Means Committee, the Committees on Transportation and Infrastructure, the Energy and Commerce Committee, the Financial Services Committee, and the Budget Committee on 9/25/2017. 9/28/17: Passed in the House and passed in the Senate with an amendment; House agreed to amendment without action. 9/29/17: Signed into law by the President.

Indian Legislative Bills in 115th Congress KIDS Act of 2017 (S.1827) Introduced by Sen. Orrin Hatch (R-UT) on 9/18/2017 5 year funding extension for CHIP (2022). Referred to the Senate Committee on Finance on 9/18/2017 Committee hearing on October 4, 2017.

Indian Legislative Bills in 115th Congress Native Health and Wellness Act of 2017 (H.R. 3706) Introduced by Rep. Raul Ruiz (D-CA-36) and co-sponsored by Rep. Frank Pallone Jr. (D-NJ-6) on 9/07/2017 Creates a tribal health block grant. Creates a grant program to recruit and mentor AI/AN youth and young adults. Referred to the House Energy and Commerce Committee on 9/07/2017

Indian Legislative Bills in 115th Congress Native Health Access Improvement Act of 2017 (H.R. 3704) Introduced by Rep. Frank Pallone, Jr. (D-NJ-6) and co-sponsored by Rep. Raul Ruiz (D-CA-36) on 9/07/2017. Establishes a grant program similar to the SDPI to increase access to substance abuse prevention and behavioral heath services for Tribes and Urban Indians. Referred to the Energy and Commerce Committee as well as to the Committee on Natural Resources and Ways and Means Committee on 9/07/2017. Referred to the Subcommittee on Indian, Insular and Alaska Native Affairs within the Committee on Natural Resources on 9/13/2017

Indian Legislative Bills in 115th Congress Native American Suicide Prevention Act of 2017 (H.R. 3473) Introduced by Rep. Raul Grijalva (D-AZ-3) on 7/27/2017. Requires States and their designees receiving grants for development and implementation of statewide suicide and early intervention and prevention strategies to collaborate with Tribes. Referred to the House Energy and Commerce Committee on 7/27/2017. Referred to the Subcommittee on Health under the Energy and Commerce Committee on 7/28/2017.

Indian Legislative Bills in 115th Congress Drug-Free Indian Health Service Act of 2017 (H.R. 3096) Introduced by Rep. Kristi Noem (R-SD) on 6/28/17; no other co-sponsors. To implement a mandatory random drug testing program for certain employees of the Indian Health Service, and for other purposes. 6/28/17: Referred to Committee on Natural Resources and Committee on Energy and Commerce.

Indian Legislative Bills in 115th Congress Restoring Accountability in the Indian Health Service Act of 2017 (S. 1250 & H.R. 2662) Senate and House bills Introduced by Sen. John Barasso (R-WY) and Rep. Kristi Noem (R-SD) on 5/25/17, respectively. This bill attempts to address quality of care issues occurring at some IHS-operated hospitals in the Great Plains Area and elsewhere. 5/25/17: Referred to House Senate and House Committees. S. 1250- 6/13/17: Senate hearings were held. H.R. 2662- 6/21/17: House Subcommittee hearing was held; Chairman Andy Joseph, Jr. testified.

Indian Legislative Bills in 115th Congress Trauma Informed Care for Children and Families Act of 2017 (S. 774 & H.R. 1757) Senate and House bills introduced by Sen. Heitkamp (D-ND) on 3/29/17 and by Rep. Davis (D-IL) on 3/28/17, respectively. 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: 3/28/17- Referred to House Committees on Education and the Workforce, Energy and Commerce Subcommittee on Health, and Ways and Means; and 4/12/17- Referred to Subcommittee on Crime, Terrorism, Homeland Security, and Investigations.

Indian Legislative Bills in 115th Congress Special Diabetes Program for Indians Reauthorization Act of 2017 (S.747 & H.R. 2545 Senate bill introduced by Sen. Tom Udall (D-NM) on 3/28/17; and House bill introduced by Rep. Norma Torres (D-CA) on 5/18/17 and has 13 co-sponsors. $150 million for FY 2018; and Reauthorizes the Special Diabetes Program for Indians (SDPI) for FY 2018 at $150m; and FY 2019-FY 2024 increase annually using medical inflation rate. S. 747 - 3/28/17: Referred to Committee on Health, Education, Labor and Pensions. H.R. 2545 - 5/19/17: Referred to House Energy and Commerce on Health.

Indian Legislative Bills in 115th Congress Independent Outside Audit of the Indian Health Service Act of 2017 (S. 465) 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 Separate Note: Rep. Greg Walden (R-OR) has created 14 member Bipartisan IHS Task Force.

Indian Legislative Bills in 115th Congress Tribal Veterans Health Care Enhancement Act (S. 304) 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. 6/15/17: Committee recommended that bill pass. 6/15/17: Committee created a report to accompany S.304.

National & Regional Meetings

HHS Secretary’s Tribal Advisory Committee (STAC) Last meeting was on September 21-22, 2017 in the Cherokee Nation; and December STAC meeting is cancelled. The next meeting will be January 17-18, 2018. Annual Tribal Budget Consultation proposed date is March 8-9, 2018. At September meeting, several requests were made to Secretary Price: Honor Tribal Consultation and Government-to-Government relationship and hold all HHS agencies accountable to HHS Consultation policy. Importance of Tribal Advisory Committees (TACs) and tribal/federal workgroups Opioid crisis in Indian Country: need for a federal/tribal workgroup to track funding and resources from states to tribes Provide Continued Support for Special Diabetes Program for Indians Improving the healthcare workforce recruitment and retention in Indian Country. Maintain Medicaid expansion for AI/AN and 100% FMAP Tribal exemption from Medicaid 1115 demonstration waiver work and enrollment requirements Getting Area Directors approved

MMPC & CMS TTAG Update Medicare, Medicaid and Health Reform Policy Committee’s (MMPC) –last face-to-face meeting was on August 22, 2017; last conference call was on July 19; Next conference call is October 10, 2017; and the next face-to-face meeting is on October 31, 2017. CMS TTAG – last face-to-face meeting was August 23-24, 2017; last conference call was on June 29; Next conference call is on October 11, 2017; and the next TTAG face-to-face meeting is November 1-2,2017

TTAG Issues Medicare Diabetes Prevention Program (MDPP) Medicare New Medicare Card Project 1115 Demonstration Waivers

MMPC Issues VA Roundtable: Reimbursement Agreements 100% FMAP/4 Walls Issue Future of RPMS MACRA Merit-based Incentive Payment System (MIPS) 1332 demonstration waivers and preservation of Indian cost sharing reductions

Discussion?