1 Legislative & Policy Update NW Portland Area Indian Health Board Quarterly Board Meeting Hosed by Lummi Tribe January 19, 2016

Report Overview 1.IHS Appropriations & Omnibus 2.Contract Support Cost Updates 3.Indian Health Legislation in 114 th Congress 4.100% FMAP & TTAG Updates 5.Legislation pending

FY 2016 Omnibus FY 2016 President Request $460 million increase – House bill is $315 less than President’s Request – 3.1% – Senate bill is $324 million less than President’s Request – 2.9% – $8.6 million difference with House mark higher FY 2016 Omnibus passed December 18, 2015 Provides $4.8 billion for IHS programs, $295 million less than President’s Request $165 million increase over FY 2015 level, a 3.6% increase

FY 2016 IHS Budget Highlights Very modest budget increases for H&C and Prevention accounts with exception of A&SA funding No funding for medical inflation or population growth $19.4 million is included for pay act increases Across the board H&C and Prevention receive less than 1.5% increase Alcohol & Substance Abuse receive additional $14 million, a 7.5% increase over FY 2015 CHS Program is flat line funded at $914 million CSC receives $55 million increase, a 8.3% increase Facilities accounts receive very good increases of $20 million for M&I, Sanitation, Construction

FY 2016 IHS Budget Facilities Programs receive good increases Maintenance & Improvement additional $20 million after 2-3 years of flat line funding 37% increases Sanitation Facilities $20 million increase, 25% increase Health Facilities Construction $20 million increase—President requested $100 million increase California YRTC facilities funding is included

Contract Support Costs FY 2016 final appropriation includes indefinite appropriation for CSC IHS continues to meet with CSC Workgroup & initiated Tribal Consultation on its Policy – Tribal Redline with IHS responses prepared Denver meeting nearly imploded over developing letter on duplication and pass through issues—speaks to the relationship with Tribes & IHS Outstanding issues: – Cost incurred approach for reconciliation – Pass through and exclusions – Types of CSC reviewed for Duplication/Reconciliation – IHS marks to Tribal redline change some current practice

IHS CSC Practice and impact on Health Programs The costs incurred approach may impact Tribes that allocate CSC to their general fund IHS reconciliation process requires program to spend all health funding If you do not spend 100% of your funding, there is a requirement to pay back CSC funds on unspent program dollars This could pose accounting issues for Tribes that do not reserve CSC for health programs In carry over situations, CSC could have been spent by Tribe, and now poses an accounting issue for where the funds to pay back IHS will come from? Tribes may want to consider adopting accounting practice to deal with this issue.

CMS 100% FMAP Update CMS is still reviewing comments on its proposed 100% FMAP White Paper January 11, 2016, CMS letter to South Dakota reveals framework of new policy and CMS anticipates issuing SMD letter the construct of the SD letter 1.CMS intends to allow 100% FMAP by non-I/T providers when a “written care coordination arrangement” are met 2.Non- I/T provider must be enrolled as participating Medicaid Provider 3.Established relationship patient and qualified practitioner at I/T facility (in person visit or telehealth) 4.Patient records retained by facility 5.100% FMAP will be made on a permanent basis for such services

100% FMAP Update Next steps for CMS – Issue SMD letter outlining South Dakota framework – Develop minimum standards for “care coordination arrangement” (caution policy about referred services vs. authorized services) – Defining arrangements between IHS/Tribal facilities and Medicaid Providers – Defining the scope of Medicaid services – Defining billing and payment arrangements (I/T makes referrals and Medicaid provider bills, will require agreements) – CMS indicates technical assistance available to the states and to the Tribes

Accountable Health Communities Model Grants CMMI announced 5 year funding opportunity for up to $157 million to test screening for health related social needs Community based, non-profits, hospitals, and tribal organizations are eligible Program will require health personnel to screen patients for social issues like hunger, housing, domestic violence which can affect health care – Housing instability – Food insecurity – Utility needs – Interpersonal violence – Transportation needs /employment Funds are not for direct services but rather linkage types of activities CMS will award 44 cooperative agreements; Letter of intent is due February 8, 2016

Medicaid Access Rule Published November 10, 2015, CMS issued IFR for “Methods for Assuring Access to Covered Medicaid Services” Rule requires States to document access to care standards and provider payment rates Intent of the rule to ensure that payment rates are sufficient to attract providers on a geographic basis across a state Rule establishes standards for access to care and payment rates This can assist Tribes that are unable to get patient in for specialty care if clients are not enrolled in managed care States are required to complete access monitoring review by July 1, 2016—Tribes should ask to be part of this process Medicaid managed care rule pending...good language for Indian health programs

Veterans Choice Act Final Rule Issued October 29 th NFR to implement Section 101, which established the Veterans Choice Program VCP expands access to non-VA care for veterans who qualified based on either wait time or distance from a VA facility IHS programs are eligible to participate in this program as participating providers, criteria include: 1.Wait times exceed 30 days 2.Live over 40 miles from VA facility or excessive burden to travel by ferry, air, boat to reach facility VA Tribal affairs staff will be here at QBM to answer questions

STAC Meeting Update CMS report of 100% FMAP was front and center ACA Updates and referrals, call center, Medicaid expansion with FFM ACA Employer Mandate fix Veteran Administration and IHS interoperability around services and MOA reimbursement agreements SAMHSA block grant funding and suicide in Indian Country IHS employee union settlement and worksheet of settled amounts by Area – None in Portland Area IHS discussed changes to SDPI funding Idaho 1915(b) Waiver for behavioral health services

Legislative Issues for second session of the 114 th Congress Employer Mandate Advance Appropriations SDPI Reauthorization IHCIA Technical Amendments Medicare-like Rates for outpatient services Contract Support Costs mandatory funding and reconciliation language

Indian Legislative Bills in 114 th Congress S. 286 – Department of Interior Tribal Self- Governance Act of 2015 – Introduced by Sen. John Barasso; Co-sponsors include Senators Tester, Murkowski, Crapo, Schatz, Franken – Amends Title IV of of ISDEAA to make it consistent with Title VI, the Self-Governance Program for HHS – Creates the same administrative efficiencies for DOI that have been in place for HHS programs. – Sen. McCain Amendments cause alarm going to mark-up but were withdrawn and had to do with “OIG Alert to Tribes on the use of ISDEAA and 3 rd Party Funds” – S. 286 passed Senate by Unanimous Consent and has now been sent to the House for consideration – Title IV Task Force is trying to find a primary sponsor in the House

Indian Legislative Bills in 114 th Congress Senate bill Exempts Tribal Programs from Sequestration – S would exempt IHS, BIA, HUD and other Indian programs from sequestration required under the Budget Control Act of 2011 – Introduced by Sen. Tester (MT); only one cosponsor Sen. Udall (NM) House bill Exempts Tribal Programs from Sequestration – H.R same companion bill to S – Introduced by Rep. Young (AK); Co-sponsors include Representatives Cole (OK), Ruiz (CA), McCollum (MN) Both bills referred to Budget Committees Likely to die in Committee Likely best chance to avoid sequester for Indian programs is language in specific appropriations (Interior, HUD, Labor-HHS)

Indian Legislative Bills in 114 th Congress Exemption from ACA Employer Mandate (Shared Responsibility) – Tribal Jobs Employment and Protection Act – S Introduced by Sen. Daines (MT); Co- sponsors Senators Crapo (ID) and Thune (SD) – H.R introduced by Rep. Noem (SD); Co- sponsors Representatives Cole (OK) and Zinke (SD) – Senate bill referred to Finance; House bill referred to Ways & Means Cadillac Tax amendment? If passed what will the President do?

Indian Legislative Bills in 114 th Congress S Family Stability and Family Kinship Act of 2015 – Introduced by Sen. Wyden; Co-sponsors Sen. Bennett, Brown, Cantwell, Casey, Gillbrand, Menendez, Schumer, Stabenow, Warner – Reforms the federal finance system supporting state and child welfare services – Funds preventive services and kinship placements for children at risk of foster placement – Current law creates incentives to place Indian children outside of families in order to receive federal funding – Encourages child welfare system to forego alternatives to prevent breakup of families like parent training, mental health counseling, trauma recovery, etc.

Discussion?