Ready for Reform! Port Gamble S’Klallam Tribe Washington State on the pleasant side of the Puget Sound on the Kitsap Peninsula with treaty rights stretching to the Olympic Peninsula, the Pacific Ocean and Canada Ed Fox Health Director Port Gamble S’Klallam Tribe Port Gamble S’Klallam Tribe Washington State on the pleasant side of the Puget Sound on the Kitsap Peninsula with treaty rights stretching to the Olympic Peninsula, the Pacific Ocean and Canada Ed Fox Health Director Port Gamble S’Klallam Tribe

6 Elements of Port Gamble S’Klallam Tribe’s readiness 1. Staffing: Support current monitor need for additional 2. Outreach and Education on Health Care reform tied to our Eligibility and Enrollment capacity 3. Make the Accounting system produce needed information for decision making-which option--- buy insurance or buy ‘risk’ 4. Continue to pay for health insurance and prepare for expansion of sponsorship 5. Electronic Health Record system 6. Work with other Tribes through other organizations.

Ready for Reform! October 1, 2013 Launch of Medicaid, CHIP, Basic Health, Health Insurance Exchange Portal (Website) The information in this presentation was given to Tribal Council September 2011 Tribal Council meeting. Port Gamble S’ Klallam Tribe is well known for it steady and deliberate approach to addressing the needs of its Tribal members with many innovative programs and firsts to its credit. Examples include: Medicaid Eligibility Pilot Project, Tribal Court, ICW Title IV-E, Medicaid Administrative Match (MAM), Basic Health Plan Sponsor.

Alignment with 4 Key elements of Health Care Reform 1. Medicaid Expansion 2. Health Insurance Exchange 3. Health Insurance Market Reforms No pre-existing conditions for all in 2014 (true for children now) 4. Cost Control OR Coordinated Care Organizations (payment reform) WA Duals Project Quality Improvement, Information Technology Sharing health information with specialists and hospitals

Outreach example Newsletter Articles On October 1, 2013 the state Health Care Health Insurance Exchange will be open for enrollment. If you are uninsured you will go to a website (often with one of our staff assisting) and we will determine your eligibility and enroll you in any of the publically-funded health insurance programs that exist If you are not eligible for public insurance we will explore private options or cover your health care needs through the regular health program of the tribe. Health Exchange-offered plans. One application will determine which program fits your income and family situation best. That’s it except for the details. Nearly every month (24 times) in the next two years, I plan to update you on the implementation of health care reform for the Tribe.

Other Topics so far 1. Children’s Health Insurance Program (Apple Health), Medicaid and importance of current programs 2. Basic Health article supporting current and potential program in 2014 Current is an early expansion of Medicaid for up to 133% of Federal Poverty Level (FPL) Future 138% to 200% of poverty 90% of Indian Uninsured in WA below 200% FPL 3. How the underinsured act like the uninsured-and why we want community to believe they do have access to full range of health care services that do not threaten their finances.

1. Staffing for 2014 We are adequately staffed with long-term (many years of experience working for Port Gamble S'Klallam Tribe) employees and will continue to support the expected need for additional staffing for expansion of health insurance with 2014 reforms. Review staffing needs! Retain and Recruit Staff Business office two employee 10 and 16 years service Clinical manager 15 years service Dr 10 years Health Director just started July 20, 2011.

2. Refine eligibility and enrollment Pilot Project for Medicaid/CHIP eligibility and enrollment we already have the nation’s best Tribal effort to determine eligibility and enroll our patients in health care plans in a way that is sensitive to the unique federal responsibility for health care services to American Indians and Alaska Natives made initial request for CMS waiver to state. In 2006 CMS agreed that this was feasible, in 2008 training began. We also participate in the Medicaid Administrative Match program (the first in the nation since 1999) to recoup some of the costs associated with this activity. MAM will be key to paying for expansion, pays ½ cost.

TANF, SNAP, LIHEAP Families in need of assistance come to our Children and Family Services Department offices. 2 staff at CFS have same capability to enroll for Medicaid and CHIP so family does not have to go to clinic (1 block away). Tribe operates its own Tribal Assistance for Needy Families program, in addition to work assistance, medical applications are completed along with any other need like food assistance, day care. Pilot Project requires that staff receive same training as any other state worker to check income, employment, and other verification of application information. Education is a big component of all our efforts to support families.

3. Make the Accounting system produce needed information The Health Services Department operates its own sophisticated full service accounting system with Customize management reports and detailed tracking of expenditures that works seamlessly with our Business office that manages the contract health services program. They maintain our great relationships with the local medical community by paying our bills promptly. CHS works closely with Medical team in clinic to identify any troubling trends and suggest needed corrective actions.

4. Continue to pay for health insurance One key aspect of health care reform will allow tribes to sponsor the health care of its Indian patients and the Port Gamble S'Klallam Tribe has many years of experience in doing just that through the Basic Health Plan. We already reimburse for Medicare Part B and for Medicare Part D (and assists tribal members in understanding their choices ) Over 10 years of ‘sponsorship’, as a sponsor the Tribe is Billed for a state Basic Health Plan for individuals and families and that may continue under the health exchange’s plans Tribe would like to Sponsor tribal members and some others for Exchange Plans, but only for plans who pay the the clinic when their insured get services at our clinic and hopefully allow us to referral patients without a second opinion and visit by a plan DR.

5. Health IT and Electronic Health Records We have already begun (3 years) the implementation of electronic health records that will be essential to our health finances (to bill and receive timely payment) and health care quality improvement that is a required component of health care reform’s delivery system changes. NextGen is our ‘solution.’ Participate in State and Regional Health Exchange efforts Health Information Exchange (another HIE!) allows us to check Onehealthport.com for insurance coverage and benefits of our patients-will grow into much more Care Coordination (sometimes known as Accountable Care Orgs) is in the near future. We will pass $1 million of spending on this effort by 2012 or 13.

6. Working with Other Tribes and IHS 24 months and counting, but we have a head start on most Tribes so we will be ready. The Port Gamble S'Klallam Tribe is a member of : American Indian Health Commission for Washington State, the lead tribal/urban organization for health care in Washington and the Northwest Portland Area Indian Health Board, the regional (area-wide) Tribal organization for Indian health and health care reform nationally. Keep Tribal Leadership informed on the potential and pitfalls of HC Reform-it could be the best thing (next to the IHCIA and the ISDEAA) for Indian health and our chance to provide for all the health care needs of our community.

6 Elements of Port Gamble S’Klallam Tribe’s readiness Staffing: Support current monitor need for additional Outreach and Education on Health Care reform tied to our Eligibility and Enrollment capacity Make the Accounting system produce needed information for decision making-which option--- buy insurance or buy ‘risk’ Continue to pay for health insurance and prepare for expansion of sponsorship Electronic Health Record system Work with other Tribes through other organizations.

Port Gamble S’Klallam Tribe Appreciates You for your attendance and feedback ---This meeting was sponsored by the Port Gamble S’Klallam Tribe and we would like to thank: Port Gamble S’Klallam Tribe Tribal Leadership for their support Port Gamble S’Klallam Tribe Staff American Indian Health Commission of Washington State with funding from the Health Care Authority of Washington Swinomish Tribe for the Sockeye Salmon… The estimated cost to other Tribes for their staff to attend was $20,000 (at $300-$350 per person for 60 tribal attendees).