1 Legislative & Policy Update NW Portland Area Indian Health Board Quarterly Board Meeting October 21, 2014

Report Overview 1.IHS Budget Update 2.ACA Updates 3.HHS STAC Meeting 4.IHS Director Listening Session 5.Contact Support Cost Recap 6.HRSA 340B Regulation 7.Indian Health Legislation

FY 2015 President’s Request $4.634 billion for Indian Health Service – $199 million increase (4.5%) is respectable? – Staffing & New Tribes funding $78.8 million takes increase down to $120.9 million (2.7%) * – $29 million program increase for CSC * – $15.4 million program increase for CHS – Adjustments of $10 million to restore 2014 reductions (CSC) Adjusting the increase for earmarks* leaves a balance of $91.9 million for current services (does not include CHS increase) NPAIHB estimates at least $223 million is needed to maintain current services President’s budget will be short by $131 million to fully fund inflation and population growth

FY 2015 Appropriations Update House & Senate have pending Interior Appropriations bills House bill is $96 million more than the Senate bill Senate bill requests only $2.5 million increase for CHS, while the House request is $50 million Senate bill includes small increases for H&C items

Sub-Sub Activity FY 2014 Final Operating Plan Senate S. 000 Change over FY 2014 Percent of Change SERVICES Hospitals & Health Clinics $ 1,790,904 $ 1,838,665$47,7612.7% Dental Services $ 165,290 $ 173,982$8,6925.3% Mental Health $ 77,980 $ 81,145$3,1654.1% Alcohol & Substance Abuse $ 186,378 $ 190,981$4,6032.5% Contract Health Services $ 878,575 $ 881,147$2,5720.3% Subotal, Clinical Services $ 3,099,127 $ 3,165,920$66,7932.2% Public Health Nursing $ 70,909 $ 75,640$4,7316.7% Health Education $ 17,001 $ 18,026$1,0256.0% Comm. Health Reps $ 58,345 $ 58,469$1240.2% Immunization AK $ 1,826 $00.0% Subtotal, Preventive Health $ 148,081 $ 153,961$5,8804.0% Urban Health $ 40,729 $00.0% Indian Health Professions $ 33,466 $00.0% Tribal Management $ 1,442 $00.0% Direct Operations $ 67,894 $ 68,065$1710.3% Self-Governance $ 4,727 $00.0% Contract Support Cost $ 587,376 $ 617,205$29,8295.1% Subtotal, Other Services $ 735,634 $ 765,634$30,0004.1% TOTAL, SERVICES $ 3,982,842 $ 4,085,515$102,6732.6%

House Bill vs. FY 2014 Sub-Sub Activity FY 2014 Final Operating Plan H.R Change over FY 2014 Percent of Change SERVICES Hospitals & Health Clinics $ 1,790,904 $ 1,857,625$66,7213.7% Dental Services $ 165,290 $ 176,154$10,8646.6% Mental Health $ 77,980 $ 82,025$4,0455.2% Alcohol & Substance Abuse $ 186,378 $ 193,824$7,4464.0% Contract Health Services $ 878,575 $ 929,041$50,4665.7% Subotal, Clinical Services $ 3,099,127 $ 3,238,669$139,5424.5% Public Health Nursing $ 70,909 $ 76,353$5,4447.7% Health Education $ 17,001 $ 18,263$1,2627.4% Comm. Health Reps $ 58,345 $ 59,386$1,0411.8% Immunization AK $ 1,826 $ 1,855$291.6% Subtotal, Preventive Health $ 148,081 $ 155,857$7,7765.3% Urban Health $ 40,729 $ 44,250$3,5218.6% Indian Health Professions $ 33,466 $ 48,342$14, % Tribal Management $ 1,442 $ 2,442$1, % Direct Operations $ 67,894 $00.0% Self-Governance $ 4,727 $ 5,727$1, % Contract Support Cost $ 587,376 $ 617,205$29,8295.1% Subtotal, Other Services $ 735,634 $ 785,860$50,2266.8% TOTAL, SERVICES $ 3,982,842 $ 4,180,386$197,5445.0%

ACA Updates HHS & IRS report AI/ANs may claim Hardship Exemption from Individual Responsibility payment when filing taxes – Simplifies the exemption claiming process – Previous process required filing form with HHS to await Exemption Certification Number – IRS Form 8965 allows members of Tribes and IHS eligible individuals to claim exemption by checking box “E” on form – 12 page instructions and form may be complicated and require training

Marketplace Updates Redetermination letters being sent by FFM and SBE in October 2 nd Open Enrollment period begins November 15 – February 15th FFM 76 screens down to 16 for basic application Phone capacity improved FFM will allow “Window shopping” IRS reconciliation of subsidies Enrollment expected to peak ~ 13 million. Six million enrolled in CY 2014 Personal responsibility payment $95 grows to $325 in 2015

Redetermination Updates Oregon – Medicaid & Exchange differences – Cover Oregon issuers sending renewal notices – Expedited Renewal – SNAP match option – short expedited form – Fast Track Renewal Letter and full application – Renewal [redetermination] Letters – (46,000 people) Washington – Renewal notices sent this week by QHP issuers – Approximately ~100K are eligible to auto renew in plan available – 47,000 will need to change plans and/or provide additional income informaiton – Washington Apple clients will receive redetermination days before the month they enrolled Idaho – Transferring eligibility from FFM to Your Health Idaho –

STAC Meeting Update First STAC meeting with Sec. Burwell – Priorities & Issues – G2G relationship & Tribal consultation – Implementation of Affordable Care Act – Indian Child Welfare Act Implementation – 477 Implementation – IHS Advance Appropriations – Expand Self-Governance in HHS – Contract Support Cost – Long Term solutions

Other STAC Meeting Issues IHS Director Roubideaux Updates on Contract Support Costs OMB presentation by Julian Harris, Associate Director for Health Programs – Working to find “balanced approach” and long-term solution to CSC funding – Recognizes unfairness of sequestration and Administration seeking higher discretionary caps for Indian funding – Committed to continuing to work with Tribal leaders thru the STAC CCIIO Report from Lisa Wilson – Cost Sharing issue for AI/ANs <100% FPL – Data to evaluate implementation ACF and Early Childhood education evaluation & funding issues

IHS Director Listening Session for Portland Area Held August 27 th at Embassy Suites Portland Airport Hotel Attendance was not very good: only 5-6 tribes attending. Issues included: – Tribal Consultation and FACA – Contract Support Costs: Mandatory funding and long term solutions – IHS Advance Appropriations – Facilities Funding and Staffing Issues – Regional Referral Specialty Care Center – CHS, LNF, and Resource Equity – SDPI restructuring

Contract Support Costs 3 Supreme Court Cases, Congressional Directives, and Administration policy for “full CSC payments” – Mar/Apr: IHS reports need to reprogram $10 million – Aug: IHS updates need to reprogram $48 million – Sept: IHS reports final reprogram of $25.1 million Changing amount “questions” IHS ability to project and monitor CSC needs? Changes due to ongoing reconciliation, pending negotiations on direct CSC and indirect costs, and resolution of new & expanded programs These issues will continue to plague the IHS for the next couple of years IHS Contract Support Cost Workgroup has proposed changes that should improve & stabilize the process

Veteran Access Choice & Accountability Act of 2014 August 7 th, President Obama signed Veterans Choice & Accountability Act (VACCA) – Intended to improve veterans access and choice to health care – Passes in wake of VA scandals involving lengthy wait times for appointments & falsified records – Act allows eligible Veterans to seek care at non-VA facilities – This includes IHS and Tribal facilities – Provides $10 billion in appropriations – Get your VA-IHS reimbursement agreements!

HRSA 340B Update Recent Court Decision in DC Circuit may have effect on 340B Drug Discount Program – HRSA in process of issuing Mega-regulation Regulation will redefine relationship between a patient and prescriber of drugs (provider) and now require that all prescriptions must be issued by a staff provider at a tribal clinic Unless Indian programs are exempt from such a rule, it will make prescriptions issued by providers serving patients of tribal health programs outside tribal clinic facilities under referral or contractual arrangements, or under tribal health plans contracting with provider networks, ineligible for 340B pricing This would vastly curtail tribal access to 340B pricing under the current system and add to the expense of providing health care to AI/ANs

CMS Tribal Consultation Policy is being revised August 20 th, CMS issues Dear Tribal Leader Letter that it intends to revise its Tribal Consultation Policy It is outdated due to ARRA, Transparency Regulations, Affordable Care Act and other changes DTLL seeks input from Tribes and State Medicaid Programs Board assisted to develop TTAG Comments and submitted Board comments TTAG Subcommittee chaired by Ron Allen has already met to review and begin revising the policy Important changes will include section on State/Tribal review of waivers, demonstration projects, and Transparency Regulations

NIHB Annual Consumer Conference Held in Albuquerque, NM – Sept 8-12 th There were a series of Listening Sessions – IHS, HRSA, VA, STAC, and CMS HRSA Tribal Consultation Policy Update Dental Health Aide Therapist (DHATs) and Oral Health Issues were big on the agenda SDPI special session and luncheon with TLDC Affordable Care Act Issues CMS Day Very good event!

Indian Health Legislation H.R Extending Medicare-like Rates for all CHS Services – Sponsored by Rep. Betty McCollum (MN) – Sen. Thune (SD) expected to introduce Senate bill has met some complications from AMA and Hospital Associations – Issues out of Aberdeen Area about certain hospitals not getting paid out of the CHS program Other Section 506 issues – Board Letter has been prepared

Indian Health Legislation H.R & S. 1570: IHS Advance Appropriations – July 15 th House hearing on H.R – Witnesses were Liz Fowler, IHS Finance; Cathy Abramson, NIHB Chair; Tim Schuerch, CEO Maniilaq Association – IHS position did not support nor opposed. Testimony explained it would benefit Tribes but IHS and didn’t address timlieness or inadequacy of appropriations – NIHB testimony explained strong Tribal support by every Area Health Board and national organizations – Maniilaq testified about improvements in administration of health programs

Indian Health Legislation Advance Appropriations Bills – H.R. 3229: Don Young & Ray Lujan – S. 1570: Begich, Udall, Murkowski Special Diabetes Program for Indians – House and Senate Sign-on letters Indian Definition Fix – S. 1575: Senators: Mark Begich (D-AK), Max Baucus (D- MT), Tom Udall (D-NM), Brian Schatz (D-HI), Al Franken (D- MN) Medicare-like Rates (Contract Rate Expenditure) - H.R Rep. Betty McCollum (D-MN) and Rep. Tom Cole (R-OK)

DateBIll #Title 03/31/2014S.2188 A bill to amend the Act of June 18, 1934, to reaffirm the authority of the Secretary of the Interior to take land into trust for Indian tribes. 03/26/2014S.2160Native American Children's Safety Act 03/13/2014S.2132 Indian Tribal Energy Development and Self- Determination Act Amendments of /25/2014S.2040Blackfoot River Land Exchange Act of /25/2014S.2041May 31, 1918 Act Repeal Act 02/06/2014S.1998Native Adult Education and Literacy Act of /16/2014S.1948Native Language Immersion Student Achievement Act

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