1. Deep Dive: Indian Exemption Alaska Primary Care Association Alaska Outreach & Enrollment Fall Training September 17, 2014 1

2. Overview  What is the Indian Exemption?  Who needs to complete the Indian Exemption?  Indian Exemption vs. Hardship Exemption  Indian Exemption Processing & Challenges  Group Activity 2

3. What is the Indian Exemption? Under the Affordable Care Act (ACA) everyone must have some form of credible health care coverage, or 1. Qualify for an exemption (there are many types) 2. Face a tax penalty (shared responsibility payment) Any AN/AI who does not have health care coverage, an exemption, or faces a tax penalty will CONTINUE to receive the same care and services at their tribal clinic or local health care facility. 3

4. Who Needs to Complete the Indian Exemption? Anyone who DOES NOT have any form of health care coverage: - Medicare (lifetime) - VA Health Benefits (lifetime) - Medicaid/Denali KidCare - Private/Employer’s Insurance - Coverage through the Marketplace/Healthcare.gov 4

5. Who Needs to Complete the Indian Exemption? However, we recommend everyone who does not have lifetime health care coverage to apply! Why? - Less worry if you lose your coverage. - It’s a lifetime exemption. - Won’t face a tax penalty! 5

6. Tax Penalty Individuals must have health care coverage by 2014, have an exemption, or face a tax penalty. 2014: $95 per adult and $47.50 per child - Up to $285 for a family Or 1% of family income, whichever is greater. 2016: $695 per adult and $347.50 per child - Up to $2,085 for a family Or 2.5% of family income, whichever is greater. 6

7. Alaska Natives/American Indians Alaska Native and American Indian people are exempt from the requirement to purchase insurance. Eligibility for the exemption requires: –Enrollment in a Federally Recognized Tribe, –Alaska Native Claims Settlement Act (ANCSA) shareholder status (village or regional), –Certificate of Indian Blood, or –Eligibility to receive services from an Indian Health Service (IHS) facility/Tribal health care provider. 7

8. 2 Categories of AN/AI Exemptions Depending on documentation type, AN/AIs will either receive an: 1. Indian Exemption 2. Hardship Exemption 8

9. Indian Exemption 9 For AN/AIs who... 1) Enrolled member of Federally- Recognized Tribe 2) Shareholder in a Alaska Native Corporation 3) CIB with Tribe/ANCSA Enrollee Number Lifetime exemption Eligible to receive special provisions for AN/AI’s - Monthly enrollment option - No cost sharing (income 100% - 300% FPL) – Family of 4 - $89,460 Exemption can be applied for by paper application or when filing taxes.

10. Documentation Type for Indian Exemption

11. 11 Documentation Type for Indian Exemption

12. Hardship Exemption For AN/AIs who … 1) Certificate of Indian Blood (with no tribal or ANCSA enrollment number) 2) Eligible to receive service from a Tribal Health Facility/IHS with no tribal or corporation enrollment Lifetime exemption NOT eligible to receive special provisions for AN/AI’s - Must use open enrollment period - Not eligible for cost sharing Exemption can only be applied for with the paper application. 12

13. Documentation Type for Hardship Exemption 13

14. Documentation Type for Hardship Exemption 14

15. How to Complete the Application Based on tax household size. All members of the tax household, even if they are non- Native need to be included; however they will not receive an AN/AI exemption, only under certain circumstances. Again, those with lifetime health benefits DO NOT need to apply. Applications are mailed to the Exemption Processing Center. 15

16. Step 1: Tell Us About Yourself Completed by the head of household or single individual. Can be non-Native or Native person.

17. 17 For those enrolled in a Federally Recognized Tribe, ANCSA Shareholder, or CIB with Tribe/ANCSA Enrollment Number. *The person in Step 1 ALSO needs to fill out a Step 2 form. * 1-7 MUST be completed, unless the person does not need exemption, end at 6. Step 2(a)

18. 18 For those who have a CIB, but NO Enrollee Number/Tribe name OR those who have a letter stating they are eligible to receive IHS services. * Must go through ALL questions 1-11. Step 2(b) 10. Enter Date of Birth or the day person became eligible to receive services from tribal health facility. 11. N/A or put in date if there is an end date for the individual.

19. Step 3 & 4: Complete the Form The person listed on Step 1 will sign and date the application. Applications are mailed to the address in Step 4. Navigators and assistors are not allowed to mail the exemption for applicants.

20. What to Expect Receive a letter from the processing center. Each person will receive a determination of the type of exemption: Indian, Hardship, or none. Each person who is eligible for an exemption will receive a Exemption Certificate Number (ECN). 20

22. Common Issues Reported 1. People haven’t received their exemption letter(s) back 2. Hardship Exemption issued instead of the Indian Exemption 3. No ECN issued OR some family members receive an ECN, some don’t 4. Two different letters with two sets of numbers 5. Not accepting NANA Shareholder Cards (reportedly no longer an issue)

23. How to Assist Customers for Each Error 1.People haven’t received their exemption letter(s) back -Currently working on applications sent in late December 2013 –March 2014 2. Hardship Exemption issued instead of the Indian Exemption - DO NOT file an appeal. Use the ECN for now – IRS will not differentiate.

24. How to Assist Customers for Each Error 3. No exemption certificate number (ECN) issued OR some family members get an ECN, some don’t -File another application for the family member ONLY, make a copy of the letter, and write a cover page 4. Two different letters with two sets of numbers - Keep both documents, but pick one ECN to use. Will not be corrected at this time.

25. Exemption Processing Centers Different from the Health Insurance Marketplace No way to follow up on exemptions by calling 1-800-318-2596 Processing: 1. Application gets scanned into system within secure facility 2. Staff go through background check 3. Staff not allowed to have cell phones/personal electronics, access to internet, or ability to copy information

26. The Exemption Processing Center Consumer’s Caller ID may read the following: -Health Insurance MP; or -606-260-4191 (Kentucky); or -479-877-3203 (Arkansas); or -636-698-6320 (Missouri); or -580-354-7707 (Oklahoma). -No way to call back the exemption processors* The exemption processing centers are calling people – To confirm personal information such as Last four digits of social security number(s) Names Date of birth - AN/AI script authorized & released by CMS

27. How You Can Help! Keep track of each Indian Exemption Issue -Each person’s name -Each person’s date of birth -Community -Issue type -Email list to: nancy.goetschius@cms.hhs.govnancy.goetschius@cms.hhs.gov Nancy Goetschius, Tribal Contact at CCIIO & CMS & CC’ srhaggitt@anthc.org.srhaggitt@anthc.org

28. Questions? Thank You! Shannon Haggitt Alaska Native Tribal Health Consortium 4141 Ambassador Drive, 2 nd Floor Anchorage, Alaska 99508 907-729-2873 srhaggitt@anthc.org www.anthctoday.org/aca

29. Group Activity 29 Each group has a different scenario. Fill out the Indian Exemption based on the scenario. Report back - How many applications? - Who? - What type of exemption? Why? - What questions?

30. Scenario 1 Jack P. Frost (06/15/88) is not married and files his taxes as “Single.” He lives with his girlfriend, Gerty Heath (02/19/89). Neither Jack nor Gerty are Alaska Native or American Indian. Jack claims two dependents on his taxes; –Christofer A. Frost (11/4/10), his son from a previous marriage, who is Alaska Native, and who is a member of a federally recognized tribe. –Hermione J. Frost (12/20/12), Jack’s daughter with Gerty, who is not Alaska Native or American Indian. 30

31. Scenario 2 John (1/5/82) and Delta Dawn (8/20/84) are married and file their taxes as “Married Filing Jointly.” John is not Alaska Native or American Indian. Delta is Alaska Native and a member of a federally recognized tribe. The couple has two dependents; –Raine Dawn (9/17/08), their daughter, and a member of a federally recognized tribe. –Candice Smyth (3/23/10), John’s niece of whom he and Delta have legal custody and is not Alaska Native or American Indian. According to the custody agreement made on 8/15/10 John’s niece is eligible to receive health care through Indian Health Services until she turns 18. 31

32. Scenario 3 Jack (11/22/88) and Jill (8/8/88) Hill are married. They file their taxes as “Married Filing Jointly.” They currently have no dependents. Jack is Alaska Native, but Jill is not. Jack is a member of a federally recognized tribe. Jill is pregnant and is due 2/29/15. Jill is eligible for health care through the local Indian Health Services through the end of her pregnancy. 32

33. Scenario 4 Betty Brown (3/8/70) is the mother of Jason Brown (4/27/96) and Justice Brown (9/5/00). Jason lives with his mother and sister, but has a full-time job and plans on filing his own taxes next year. Betty Brown is a shareholder of an Alaska Native Corporation. Jason and Justice both have a Certificate of Indian Blood, stating they are descendants. Neither is enrolled in a tribe or corporation. 33

34. Scenario 5 David Davidson (6/6/68) and Margie Davidson (4/4/70) are married and file their taxes as “Married Filing Jointly.” David receives VA Health Benefits and Margie has no insurance. Both David and Margie are members of a federally recognized tribe. Their daughter, Janet Davidson (9/10/90) and their granddaughter, Morgan Hunter (12/24/12) live with them. Janet is currently working and files her own taxes and claims Morgan as a dependent. Janet has no insurance and Morgan has Denali KidCare. Janet is a member of a federally recognized tribe and Morgan has a Certificate of Indian Blood from the BIA and it states her tribe’s name and enrollment number. 34

35. Scenario 6 John Deere (1/28/1982) and Jessica Anderson (5/8/1984) are a non- married couple, who have one child Jackson Deere (8/14/09) John works and has employer’s insurance and Jessica only works part- time and doesn’t meet the income guidelines to file taxes. John claims Jackson on his taxes. Neither Jessica nor Jackson has health care coverage. John is not Alaska Native or American Indian. Jessica and Jackson are members of a federally recognized tribe. 35