IHCIA and Long-Term Care Sonosky, Chambers, Sachse, Miller & Munson, LLP IHCIA and Long-Term Care National Indian Health Board National Tribal Health Reform Implementation Summit Washington D.C. April 20, 2011 Myra M. Munson, J.D., M.S.W. myra@sonoskyjuneau.com Washington, DC Juneau, AK Anchorage, AK Albuquerque, NM San Diego, CA

Sonosky, Chambers, Sachse, Miller & Munson, LLP Authority and Policy *Sec. 2 Findings – New provision: “(2) A major national goal of the U.S. is to provide the resources, processes, and structure that will enable Indian tribes and tribal members to obtain the quantity of health care services and opportunities that will eradicate the health disparities between Indians and the general public of the U.S.” *Sec. 3 Policy – Acknowledgement of “special trust responsibility and legal obligations to Indians.” Sonosky, Chambers, Sachse, Miller & Munson, LLP 4/20/11 IHCIA and Long-Term Care Slide 2

Sonosky, Chambers, Sachse, Miller & Munson, LLP Objectives *For the first time they are the same as for the rest of the Nation. Healthy People 2010 ( or successor standards). See, www.healthypeople.gov. 25 U.S.C. § 1603(2); IHCIA Sec. 3(2) * Applies to Urban Indian Health Programs Sonosky, Chambers, Sachse, Miller & Munson, LLP 4/20/11 IHCIA and Long-Term Care Slide 3

Sonosky, Chambers, Sachse, Miller & Munson, LLP 2020 Objectives Address access; adolescent health; arthritis, osteoporosis & chronic back conditions; blood disorders & blood safety; cancer; chronic kidney diseases; diabetes; disability & secondary conditions; early/middle childhood; education & community-based programs; environmental health; family planning; food safety; genomics; global health; health communication and IT; health care associated infections; hearing & other sensory communication disorders; heart disease & stroke; HIV; immunizations & infectious diseases; injury & violence prevention; maternal, infant & child health; medical product safety; mental health; nutrition & weight status; occupational safety & health; older adults; oral health; physical health & fitness; public health infrastructure; quality of life & well-being; respiratory diseases; sexually transmitted diseases; social determinants of health; substance abuse; tobacco; vision Sonosky, Chambers, Sachse, Miller & Munson, LLP 4/20/11 IHCIA and Long-Term Care Slide 4

What Services Can Be Provided by an Indian Health Program? Any Service to Achieve the Objectives in §1602(2). Health Promotion/Disease Prevention (25 U.S.C. §1603) Traditional Health Care Practices. Expressly authorizes the Secretary to promote traditional health care practices, but limits liability of United States for provision of such services. (25 U.S.C. § 1680u; IHCIA Sec. 831) Sonosky, Chambers, Sachse, Miller & Munson, LLP 4/20/11 IHCIA and Long-Term Care Slide 5

Other Supportive Services 25 U.S.C. § 1621d ; IHCIA Sec. 205 Assisted living service, as defined in 12 USC 1715w(b), except need not be licensed, but must meet applicable standards for licensure Home- and community-based service means 1 or more services specified in 42 USC 1396t(a)(1)-(9) that are or bill be provided in accordance with applicable standards Hospice care all items and services in 42 USC 1395x(dd)(1)(A)-(H) and “such other services the THO determines are necessary and appropriate in furtherance Of that care Long-term care services as defined in section 7702B(c) of the Internal Revenue Code of 1986 Sonosky, Chambers, Sachse, Miller & Munson, LLP 4/20/11 IHCIA and Longterm Care Slide 15

Sonosky, Chambers, Sachse, Miller & Munson, LLP OTHER OPPORTUNITIES Shared Services for Long-Term Care. 25 U.S.C. § 1680l; IHCIA Sec. 822 Expressly authorizes sharing staff and other services between IHS or tribal health program and tribally operated long term care or related facility. Indian Health Care Delivery Demo. 25 U.S.C. § 1637; IHCIA Sec. 307 Encourages demonstration projects to test alternative means of delivering health services to AI/ANs through facilities and through alternative and innovative methods like community health centers and cooperative agreements with other community providers for sharing or coordinating use of facilities, funding, and other resources Sonosky, Chambers, Sachse, Miller & Munson, LLP 4/20/11 IHCIA and Long-Term Care Slide 7

AI/ANs VETERANS Streamlining and Opportunity Sharing arrangements authorized between IHS, Tribes and Tribal Organizations, and VA and DoD. 25 U.S.C. § 1645; IHCIA Sec. 405(a) Requires VA and DoD to reimburse IHS and Tribal health programs for services provided to beneficiaries of VA or DoD; 25 U.S.C. § 1645(c); IHCIA Sec. 405(c) Collaborations authorized between VA and IHS/Tribal health programs at Indian health program locations. 25 U.S.C. § 1647; IHCIA Sec. 407. Sonosky, Chambers, Sachse, Miller & Munson, LLP 4/20/11 IHCIA and Long-Term Care Slide 8

Other Options to Obtain Care *Purchasing Health Care Coverage. 25 U.S.C. § 1642; IHCIA Sec. 402. IHS funds made available to an I/T/U (including ISDEAA funds) may be used to purchase health benefits coverage for beneficiaries May consider need of beneficiaries May cover expenses for a self-insured plan, including administration and insurance to limit financial risks Sonosky, Chambers, Sachse, Miller & Munson, LLP 4/20/11 IHCIA and Long-Term Care Slide 9

More Acknowledgement of the Need for Long-Term Care Indian Health Care Improvement Fund now includes long-term care in clinical care. 25 U.S.C. § 1621(a)(5)(A); IHCIA Sec. 201 Report to Congress regarding facility needs now includes specialized health care facilities, including long-term care facilities. 25 U.S.C. § 1631; IHCIA Sec. 301. Sonosky, Chambers, Sachse, Miller & Munson, LLP 4/20/11 IHCIA and Long-Term Care Slide 10

SERVING NON-BENEFICIARIES Authority and Opportunity Health Services for Ineligible Persons. 25 U.S.C. § 1680c; Sec. 813; Eliminates requirement that Tribal health programs consider whether there are alternative services and expressly extends FTCA coverage Does not allow IHS to serve non-beneficiaries without approval of tribes in the Service Unit Sonosky, Chambers, Sachse, Miller & Munson, LLP 4/20/11 IHCIA and Long-Term Care Slide 11

Sonosky, Chambers, Sachse, Miller & Munson, LLP Licensing and Fees Non-Discrimination in Qualifications for Reimbursement. Provides for payment of I/T/U programs by any Federal health care program without regard to licensed status so long as meet other generally applicable requirements for participation (with an exception for Sec. 221) (25 U.S.C. § 1647a; IHCIA Sec. 408). Exemption from certain fees. Employees of tribal and urban health programs are exempt from fees imposed by federal agencies to the same extent that IHS employees and commissioned corps officers are exempt. Eg., DEA registration fees. (25 U.S.C. § 1616q; IHCIA Sec. 124). Unfortunately, this exemption does not expressly exempt the facilities from fees. Sonosky, Chambers, Sachse, Miller & Munson, LLP 4/20/11 IHCIA and Long-Term Care Slide 12