1. Policy & Legislative Update
NW Portland Area Indian Health Board
Quarterly Board Meeting
Hosted by the Cow Creek Band of Umpqua Tribe of Indians
July 18, 2017

2. Report Overview Status of IHS Budgets Administration
Current & Pending Policy Issues
Legislation in 115th Congress
National & Regional Meetings

3. Status of IHS Budgets

4. FY 2017 IHS Budget
Congress passed a FY 2017 Omnibus Appropriations Bill on May 4, 2017 which funds the government through September 30, 2017.
IHS budget increased by $232 million above FY 2016 level (4.83% increase) for a total budget of $5 billion.
Behavioral health initiatives were funded.

5. FY 2018 IHS Budget
President’s FY 2018 Budget was released on May 23, 2017.
IHS significantly decreased!
$301 million (6%) below FY 2017 enacted level.
No inflation increases are included.
Across all line items: Decreases from 1.5% to 100% except Direct Operations (2.7% increase)

6. FY 2019 IHS Budget FY 2019 Evaluation/FY 2020 Planning meeting
National Tribal Budget Formulation Workgroup’s Recommendations to IHS for FY 2019
Available at:
Fully fund IHS at $32 billion phased in over 12 years
FY 2019 Evaluation/FY 2020 Planning meeting
April 24-25, 2017 in Spokane, WA

7. Administration

8. Presidential Actions
Memorandum for the Heads of Executive Departments and Agencies – Hiring Freeze, 1/23/17
Executive Order (E.O.) No : Minimizing the Economic Burden of the Patient Protection and Affordable Care Act Pending Repeal, 1/24/17
E.O. No : Reducing Regulation and Controlling Regulatory Costs, 1/30/17
E.O. No : Enforcing the Regulatory Reform Agenda, 2/24/17
Executive Order No : Comprehensive Plan for Reorganizing Executive Branch, 3/13/17
E.O. No : Establishing the President’s Commission on Combating Drug Addiction and the Opioid Crisis , 4/30/17

9. Current & Pending Policy Issues

10. CMS 4 Walls Limitation
CMS determined that If a Tribal facility is enrolled in the state Medicaid program as a provider of clinical services under 42 CFR , the Tribal facility may not bill for services furnished by a non-Tribal provider or Tribal employee at the facility rate for services that are provided outside of the facility.
Per CMS, under FQHC designation there is no requirement that the services be provided within the 4 walls.
Section 1905 of the SSA recognizes outpatient Tribal clinics as FQHCs.
In order to not have any revenue losses, Tribal health programs have to work with their respective Medicaid agencies to change their designation to an FQHC.
CMS FAQ released January 18, 2017.
Deadlines:
January 18, 2018: Notify state of intent to change provider status
January 30, 2021: Effective date

11. Other CMS Policies
Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers (published 9/16/16)
Compliance is required by 11/15/17 for participation in Medicare.
Applies to all 17 provider and supplier types.
In Portland Area, does not apply to IHS or Tribal clinics unless they are an FQHC registered under Medicare.
CMS Medicare Program- FY 2018 Updates to Quality Payment Program
Allows for exemption of small providers in the program by increasing the low-volume threshold to $90k or less in Medicare Part B charges or 200 or less Medicare patients annually.
Comments due on 8/21/17.

12. IHS Policies
IHS Seeking Comments on Information Technology Service Catalog
Dear Tribal Leader Letter (DTLL) on 6/28/17; comments due 8/4/17.
IHS Listening Sessions on RPMS and EHR
DTLL on 6/26/17; listening sessions held on 7/6/17 & 7/10/17.
Response to VA moving to VistA and impact on IHS RPMS EHR.
IHS Update of Facilities Engineering Deficiency System (FEDS)
DTLL on 6/26/17.
FAAB made recommendation that the IHS require all federal sites, and encourage all tribal sites, to update the FEDS database by 9/1/17.

13. IHS Policies-Cont’d IHS Listening Session on Behavioral Health
DTLL on 6/23/17.
Listening Session is on 8/15/17 at the AI/AN National Behavioral Health Conference in Tulsa, OK.
IHS Update on Behavioral Health Initiatives
DTLL on 5/10/17.
IHS Effort to Combat Opioid Epidemic
DTLL on 5/2/17.
IHS National Committee on Heroin, Opioid, and Pain Efforts (HOPE Committee) established.
Hope Committee to focus on six elements.

14. IHS Policies-Cont’d IHS Contract Support Costs
DTLL on 4/26/17 announcing training modules at:
IHS has resumed settling past-year CSC claims.
IHS Catastrophic Health Emergency Fund (CHEF)
Final regulation not issued.
Update on Redding Rancheria v. Price.
IHS Community Health Aide Program
IHS will be convening a national workgroup.

15. IHS Policies-Cont’d IHS Lease Proposals Under 105(l) of ISDEAA
Two USDC-DC decisions state that 105(l) of ISDEAA and implementing regulations require IHS to fully-compensate lease with tribe or tribal organization.

16. Legislation in 115th Congress

17. Legislation in 115th Congress
Repeal and Replace of Affordable Care Act – and American Health Care Act & Better Care Reconciliation Act (H.R. 1628)
Reauthorization of the Special Diabetes Program for Indians (S. 747 & H.R. 2545)
Independent Outside Audit of the Indian Health Service Act of 2017 (S. 465)
Restoring Accountability in the Indian Health Service Act of 2017 (S & H.R. 2662)
Drug Free Indian Health Service Act of 2017 (H.R. 3096)
Tribal Veterans Health Care Enhancement Act (S. 304)
Trauma-Informed Care for Children and Families Act of 2017 (H.R. 1757)
Other:
Access to Insurance for All Americans Act (H.R. 1408)
Indian Health Service Hiring Freeze Exemption Act (H.R. 981)
IHS Advanced Appropriations Act of 2017 (H.R. 235)

18. Indian Legislative Bills in 115th Congress
American Health Care Act of 2017 (H.R. 1628) & Better Care Reconciliation Act (ACA Repeal and Replace)
Some of the key provisions in Senate bill include:
Institutes a per capita spending limit in 2020; and allows state option to have a state-run block grant.
Retains Medicaid 100% FMAP for IHS and Tribal Clinics.
Phases out Medicaid Expansion by 2024.
Imposes work requirements for people on Medicaid except for the elderly, pregnant women and those who are disabled.
Retains ACA tax credits in 2018 and 2019.
Reduces tax credit eligibility down to 350% in 2020.
Repeals ACA cost sharing protections in 2020.
Allows states to opt out of the essential health benefits.

19. Indian Legislative Bills in 115th Congress
Special Diabetes Program for Indians Reauthorization Act of 2017 (S. 747 & H.R. 2545)
Senate bill introduced by Sen. Tom Udall (D-NM) on 3/28/17; and House bill introduced by Rep. Norma Torres (D-CA) on 5/18/17 and has 13 co-sponsors.
$150 million for FY 2018; and
Reauthorizes the Special Diabetes Program for Indians (SDPI) for FY 2018 at $150m; and
FY 2019-FY 2024 increase annually using medical inflation rate.
S /28/17: Referred to Committee on Health, Education, Labor and Pensions.
H.R /19/17: Referred to House Energy and Commerce on Health.

20. Indian Legislative Bills in 115th Congress
Independent Outside Audit of the Indian Health Service Act of 2017 (S. 465)
Introduced by Sen. Mike Rounds (R-SD) on 2/28/17 with co-sponsors Sen. James Lankford (R-OK) and John McCain (R-AZ).
Requires an independent outside audit of the Indian Health Services with report to Congress.
2/28/17: Referred to Committee on Indian Affairs
Separate Note: Rep. Greg Walden (R-OR) has created 14 member Bipartisan IHS Task Force.

21. Indian Legislative Bills in 115th Congress
Restoring Accountability in the Indian Health Service Act of 2017 (S & H.R. 2662)
Senate and House bills Introduced by Sen. John Barasso (R-WY) and Rep. Kristi Noem (R-SD) on 5/25/17, respectively.
This bill attempts to address quality of care issues occurring at some IHS-operated hospitals in the Great Plains Area and elsewhere.
5/25/17: Referred to House Senate and House Committees.
S /13/17: Senate hearings were held.
H.R /21/17: House Subcommittee hearing was held; Chairman Andy Joseph, Jr. testified.

22. Indian Legislative Bills in 115th Congress
Drug-Free Indian Health Service Act of 2017 (H.R. 3096)
Introduced by Rep. Kristi Noem (R-SD) on 6/28/17; no other co-sponsors.
To implement a mandatory random drug testing program for certain employees of the Indian Health Service, and for other purposes.
6/28/17: Referred to Committee on Natural Resources and Committee on Energy and Commerce.

23. Indian Legislative Bills in 115th Congress
Tribal Veterans Health Care Enhancement Act (S. 304)
Introduced by Sen. John Thune (R-SD) and Sen. Mike Rounds (R-SD) on 2/3/17.
Amends the Indian Health Care Improvement Act to allow the Indian Health Service to cover the cost of a copayment of an Indian or Alaska Native veteran receiving medical care or services from the Department of Veterans Affairs, and for other purposes.
3/29/17: Referred to Committee on Indian Affairs.
6/15/17: Committee recommended that bill pass.

24. Indian Legislative Bills in 115th Congress
Trauma Informed Care for Children and Families Act of 2017 (S. 774 & H.R. 1757)
Senate and House bills introduced by Sen. Heitkamp (D-ND) on 3/29/17 and by Rep. Davis (D-IL) on 3/28/17, respectively.
Addresses the psychological, developmental, social and emotional needs of children, youth, and families who have experienced trauma, and for other purposes.
Establishes task force to develop best practices, training, Native American Technical Assistance Resource Center and grant funding.
Actions:
S. 774: 3/29/17- Referred to HELP Committee.
H.R. 1757:
3/28/17- Referred to House Committees on Education and the Workforce, Energy and Commerce Subcommittee on Health, and Ways and Means; and
4/12/17- Referred to Subcommittee on Crime, Terrorism, Homeland Security, and Investigations.

25. National & Regional Meetings

26. HHS STAC Meeting Update
Last meeting was on March 7-8, 2017; and June STAC meeting cancelled.
HHS Secretary has scheduled a STAC strategic planning session on July
Next meeting is on September
At March meeting, several requests were made to Secretary Price:
Honor Tribal Consultation and Government-to-Government Relationship
More federal funding beyond IHS
Expand ISDEAA Self-Determination and PL 477
Assist in Treating Opioid Abuse and Addiction
Provide Continued Support for Special Diabetes Program for Indians
Maintain Medicaid expansion for AI/AN and 100% FMAP

27. MMPC & CMS TTAG Update
Medicare, Medicaid and Health Reform Policy Committee’s (MMPC) – face-to-face meeting February 28th; last conference call was on April 5; and face-to-face strategy session was on May 16-17, 2017.
Next face-to-face meeting is on August 22, 2017 in DC.
CMS TTAG – face-to-face meeting March 1st -2nd; last conference call was on June 14th.
July face-to-face was rescheduled to August 23-24, 2017 in DC.

28. Discussion?