Lessons Learned and Promising Practices in AI/AN Outreach and Engagement Presented to the Washington Coalition on Medicaid Outreach December 18,2015 American Indian Health Commission for Washington State Presented by Vicki Lowe Executive Director

American Indian Health Commission for Washington State Created in 1994 by Washington State federally recognized tribes, Urban Indian Health Organizations (UIHO), and other Indian organizations; Provides a forum for addressing tribal-state health issues; Mission is to improve the health of American Indians and Alaska Natives (AI/AN) through tribal-state collaboration on health policies and programs that will help decrease disparities; Works on behalf of the 29 federally-recognized Tribes and 2 UIHO in the state.

American Indian Health Commission for Washington State AIHC Delegates officially appointed by Tribal Councils to represent each individual Tribe with UIHO representatives serve as members-at-large; Forum for achieving unity and guiding the collective needs of tribal governments and UIHO providing high-quality, comprehensive health care to AI/ANs in Washington; Goal behind promoting increased tribal-state collaboration is to improve the health status of AI/AN by influencing state and tribal health policy and resource allocation. A trusted Indian organization and is considered a best practice model in State-Tribal relations by Tribal and State leaders

Key Activities of the AIHC Identifying health policy issues and advocating strategies to address Tribal concerns; Coordinating policy analysis; Soliciting and collecting information from the state for Tribal review and response; Disseminating information to Tribal health programs and leaders; Promoting the government-to government relationship between tribes and state health agencies; Advances best and promising practices; Supports activities that prevent and reduce adverse health conditions and health disparities

AIHC Contract Work AIHC contracts with the following Washington State Agencies: Department of Health Health Care Authority Washington Health Benefit Exchange Office of the Insurance Commissioner

Lessons Learned and Promising Practices in AI/AN Outreach and Engagement Passage of the Affordable Care Act in 2010, permanently reauthorized the Indian Health Care Improvement Act. The combination of these two laws brought the opportunity of utilizing health insurance coverage to help fill in the healthcare gaps caused by the underfunding of Indian Health Services (I.H.S.)

Lessons Learned and Promising Practices in AI/AN Outreach and Engagement I.H.S. is the federal program that was intended to meet the Federal government’s obligation to provide health care to Indian people in the United States. Although health disparity rates among Native American and Alaska Indian (AI/AN) populations are high, this lack of funding equals poor access to care for most Indian people.

Lessons Learned and Promising Practices in AI/AN Outreach and Engagement Both the ACA and IHCIA provide benefits that are specific to AI/ANs. They include:  Exemption from tax penalty;  Ability to enroll in QHPs and change plans each month;  No cost sharing for Essential Health Benefits (EHB);  Establishment of Tribal Premium Sponsorship

Outreach and Education Efforts Encompass Many Issues  Education and Understanding  Staff  Communities  Leadership  Staffing -Tribal Assisters  Technology- Friend and Foe  What was learned?

Outreach efforts differ from non- Native population :  Exemption from mandate- no tax penalty for not signing up for coverage.  Used to getting coverage through the “tribal program”  Federal government has an obligation to provide care;  Open enrollment all year long, no timeframe for big push

Education and Understanding I/T/U Staff  Usually the first to recognize how coverage can help:  Referrals for specialty care  Saving the CHS funds  Third Party Revenue for Clinics  Easiest to educate, there are many opportunities for staff  They will do most of the work

Education and Understanding Leadership  Support of leadership is very important  Access to care and CHS program savings plus revenue all important concepts to convey  How does this coverage affect the Federal Governments obligation to provider healthcare to AI/ANs?

Education and Understanding Communities  Within each community there are informal leaders who can be your allies:  Respected Elders  Members of large families.  Community Events  Can work but you must know the issues ahead of time and have answers.

Staffing -Tribal Assisters  A Tribal Assister is specific to the WAHBE Navigator Program.  Tribal Assisters go through the same certification process as any other Navigator in Washington State.  They have an increased level of access in the HPF allowing them to verify an applicants enrollment in a federally recognized Tribe.  It is this verification that gives access to the AI/AN specific benefits  Zero or limited cost sharing  the ability to in a QHP enroll all year long and to change plans throughout the year.

Staffing -Tribal Assisters  Knowledge of the AI/AN specific benefits and how to correctly enter AI/AN information into the application AND  Computer skill are important; However, the following are just as important:  Understanding of the positive impacts of QHP and Medicaid coverage  Must be trusted members of communities  Have the ability to work together with clients  Not easily upset by negative comments

Staffing- Tribal Assi sters  The workload of the Tribal Assister is much more broad and complicated than was expected  Training required all year long to keep up with technology issues surrounding the AI/AN applications and other issues  Tribal Assisters need to coordinate with each other, and with many other tribal employees (e.g., Enrollment, Billing, ICW, etc.) to get the job done  Understanding of premium tax credits and IRS filing  How do we help Tribal members living away from their tribe?

Technology-Friend and Foe Electronic Application – Friend  Eligibility known as soon as application successfully submitted  Listed of any needed follow up given right away  Can alleviate the need to bring in paperwork  Application can actually be done over the phone Better participation if the application process is as painless as possible.

Technology-Friend and Foe Electronic Application - Foe  Technology was a greater barrier than expected  Issues with the identity verification  Separate applications for mixed households in order for zero or limited cost sharing to work  Complications with the AI/AN identification in the HPF  Lack of knowledge of AI/AN specific issues and benefits by WAHBE customer service staff  Involvement of the IRS and tax returns with premiums that are paid by someone else

What Was Learned?  Much work needs to be done just to get to begin to do Outreach and Education with our Tribal Members  The best resources are trusted members of your community- educate them as much as you can  Ongoing education of the “front line” staff is necessary.

What Was Learned?  Have to be willing to invest the time needed in order to build a program and get people to agree to apply  Earn trust  Show knowledge  Working together.  Don’t let technology issues keep people from getting on coverage

Other Things to Consider: Learn to recognize when you are dealing with Tribal politics, and don’t take things personally Need to ask the “right” questions to get the information needed for an application, for example –Are you “legally” married? –Will your income continue, or change in the next few months? You need a process to keep track of homeless people or “couch surfers”, and complete their applications correctly

Resources In Washington State:  AIHC Indian Health Care Reform Manual: issues/indian-health-care-reform-manual-for-wa- state/  Washington Health Benefit Exchange Partner Resources:

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