1. Inter Tribal Council of Arizona Affordable Care Act (ACA) AI/AN Outreach & Enrollment Arizona Enrollment Assistance Training September 15, 2014 1

2. Health Care Reform & the Federal Trust Responsibility The ACA recognizes the federal trust relationship & strengthens tribal sovereignty through: Protection & enhancement of the IHS health care system with the passage of the Indian Health Care Improvement Act, Greater access to quality health care with new sources of insurance coverage and grants, Expansion of tribal government consultation in health care policy decision-making. 2

3. ACA/IHCIA Training & Enrollment Activity In 2012, IHS funded a National Initiative to educate Tribal Leaders & Tribal Health Officials & to begin ACA consumer education. In 2013, IHS implemented a ACA Business Plan. Certified Application Counselors (CAC’s) have been added to the IHS workforce (NAO-62, PAO-27, TAO-8, PYT-8, Native Health-1). Navigators are working at TCRHCC & NAC thru AACHC. 3

4. Training/Enrollment Activity Inter Tribal Council of Arizona, Inc. received its first ACA training grant in 2012. The current grant is in place through December 2014. ITCA provides training to the Tribes in the Phoenix and Tucson IHS Areas (Arizona, but not the Navajo Nation, 3 of 8 Tribes in Utah and all of Nevada). The Arizona Marketplace Workgroup grant runs through November 2014. Tribes will recommend an outreach & education strategy in terms of ACA implementation and provide other policy recommendations to the Governor’s office. 4

5. Affordable Care Act Implementation in Indian Country 5

6. ACA Implementation…2014  Nearly all U.S. citizens/legal residents are now required to have health insurance that meets minimum requirements unless available coverage costs more than 8% of your income.  You are covered if you have job based coverage, Medicare, Medicaid/CHIP, TRICARE/VA, a Marketplace Plan or an individual policy outside of the Marketplace.  All individuals below 100% FPL and others, including American Indians, Alaska Natives and I/T/U users are not required to get insurance & are exempt from the shared responsibility tax payment that has to be paid beginning in 2015. 6

7. ACA Implementation…2014  The ACA provides ways to help people get health insurance. Individuals and families with incomes at or below 400% FPL are eligible to get tax credits for subsidies to help pay for premiums. The Health Insurance Marketplace can pay it monthly to the plan the individual enrolls in.  Plus, there’s no cost-sharing for AI/AN’s at or below 300% FPL for any Health Insurance Marketplace plan at any metal level (bronze, silver, gold or platinum). 7

8. ACA Medicaid Changes…2014 The Medicaid Expansion option allows states to expand eligibility & obtain increased Federal funding. Governor Brewer signed the Medicaid Restoration Plan into law on 6/17/13. It restored coverage to those between 100-133% of the Federal Poverty Level, including Childless Adults AHCCCS coverage for these groups started on 1/1/14. 8

9. ACA Medicaid Changes…2014 State Medicaid programs are now required to use the new Modified Adjusted Gross Income (MAGI) methodology and streamline screening and enrollment into four eligibility categories – children, pregnant women, parents/caretaker relatives and other adults. 9

10. MAGI does not include… -SSI, TANF, Veterans’ disability, Workers’ Compensation, child support, federal tax credits & cash assistance -Foster care, guardianship or adoption assistance payments, scholarships & education grants not used for living expenses. -Distributions from Alaska Native Corporations & Settlement Trusts; from property held in trust by the Secretary of the Interior; from real property ownership interests related to natural resources & improvements & BIA student financial assistance. (Note: An amount received as a lump sum shall only be counted as income only in the month received). 10

11. ACA Implementation…2014 The 2013 Poverty Guidelines for Household Income of the lower 48 States and the District of Columbia will be used to determine eligibility for seeking financial assistance: 100% FPL/1 person=$11,490100% FPL/4 Persons=$23,550 133% FPL/1 person=$15,282133% FPL/4 persons=$31,322 300% FPL/1 person=$34,470300% FPL/4 persons=$70,650 400% FPL/1 person=$45,960400% FPL/4 persons=$94,200 11

12. Recommended Tribal Documentation for Enrollment (AI/AN & I/T/U Users) Electronic data verification w/IHS RPMS Tribal enrollment card Certificate of degree of Indian blood Shareholder certificate for Alaska Native Regional or Village Corporation Tribal enrollment certificate Tribal Census Document Birth certificate linking child to parent Adoption certificate linking child to parent Foster care documentation linking child to AI/AN foster parent Disability determination linking child to AI/AN parent IHS/Tribal Form or Letter verifying eligibility for IHS Services Marriage Certificate with Tribal Spouse 12

13. ACA Implementation…2015  For the general population, open enrollment in the Marketplace begins on November 15, 2014 and ends on February 15, 2015.  American Indians/Alaska Natives have special monthly enrollment periods anytime of the year in Marketplace plans.  The ACA does not change your eligibility to get health care services at an Indian health care provider. AI/AN’s who enroll in a Marketplace health plan, Medicaid or CHIP may continue to receive these services. 13

14. ACA Implementation…2015 IHS is not insurance. IHS provides medical and public health services. Insurance affords greater access to services at IHS, Tribal and Urban Indian program providers by increasing their revenue. In some cases referrals to private providers is necessary through Contract Health Service (CHS) referrals. This is when having health insurance will help American Indians. (This program was recently renamed as Purchased/Referred Care (PRC). American Indian people will benefit from increased revenue to the Indian health care system and greater access to care. 14

15. ACA Implementation…2015 IRS Reporting – Individual Shared Responsibility Payment If you can afford health insurance, but choose not to buy it, you must pay a fee known as the individual shared responsibility payment when you file your federal income tax return in 2015. The ACA requires you and each member of your family to either: Have minimum essential coverage, or Have an exemption from the responsibility to have minimum essential coverage, or Make a shared responsibility payment when you file your 2014 federal income tax return in April 2015. People with health insurance coverage do not need to do anything more than maintain that coverage. Tax forms will be developed to report the information. 15

16. ACA Implementation…2015 IRS Reporting – Individual Shared Responsibility Payment Payment Calculations The fee in 2014 is 1% of your yearly income or $95 per person for the first year, whichever is higher. The fee increases every year. In 2015, it’s 2% of your income or $325 per person and in 2016, it's 2.5% of income or $695 per person, whichever is higher. The payment for an uninsured child is ½ of the adult rate. The individual who claims the dependent will be responsible for the payment 16

17. ACA Implementation…2015 IRS Reporting – Individual Shared Responsibility Payment – Statutory Exemptions You’re uninsured for less than 3 months of the year The lowest-priced coverage available to you would cost more than 8% of your household income You don’t have to file a tax return because your income is too low You’re a member of a federally recognized tribe. You’re a member of a recognized health care sharing ministry You’re a member of a recognized religious sect with religious objections to insurance, including Social Security and Medicare You’re incarcerated (either detained or jailed), and not being held pending disposition of charges You’re not lawfully present in the U.S. 17

18. ACA Implementation…2015 IRS Reporting - Individual Shared Responsibility Payment – Regulatory Hardship Exemptions Eligible for services through an Indian Health Service provider Homeless Evicted in the past 6 months or facing eviction or foreclosure Shut-off notice from a utility company Recently experienced domestic violence Death of a close family member Experienced a fire, flood, or other natural or human-caused disaster that caused substantial damage to your property Filed for bankruptcy in the last 6 months Medical expenses you couldn’t pay in the last 24 months which resulted in substantial debt 18

19. ACA Implementation…2015 IRS Reporting - Individual Shared Responsibility Payment - Hardship Exemptions (cont.) Another person is required by court order to give medical support to a dependent child. In this case, you do not have to pay the penalty for the child. As a result of an eligibility appeals decision, you’re eligible for enrollment in a qualified health plan (QHP) through the Marketplace, lower costs on your monthly premiums, or cost- sharing reductions when you weren’t enrolled in a Marketplace plan. Your state didn’t expand eligibility for Medicaid. Your individual insurance plan was cancelled. 19

20. American Indian Exemption Application WHO CAN USE THIS FORM? Members of federally recognized Tribes Individuals eligible to receive services at Indian health care providers: - IHS - Tribal - Urban

21. American Indian Exemption Application Tax Household = any person you are claiming as dependents on your 2014 taxes Adults Dependents Do not include dependents who are not asking for the exemption

22. American Indian Exemption Application Members of federally recognized Tribes only need to complete Questions 1-7. Leave rest of page blank. Important Note: Each person in “Tax household” or those claimed as “dependents” need to complete Section 2.

23. When should I submit the application?  Exemption applications are now available – Paper copy only (no electronic copies) – Get paper copy online: http://marketplace.cms.gov/applications-and-forms/tribal- exemption.pdf http://marketplace.cms.gov/applications-and-forms/tribal- exemption.pdf – Get a paper copy from Certified Application Counselors at IHS facilities. Mail to: Health Insurance Marketplace-Exemption Processing 465 Industrial Blvd. London, KY 40741 2014 Tax Season – Submit exemption application before filing taxes – Receive “Exemption Certification Number.” – Use on 2014 Tax filing form

24. How do I prove that I am exempt? An application for exemption must be completed on the specific form for: – American Indian/Alaska Natives – Other individuals who are eligible to receive services from an Indian Health Care Provider Only one application required per tax household Only have to submit application once Need the following: – Federally Recognized Tribes: Tribal membership (CDIB, enrollment card, etc.) Social Security Number Information about people in tax household Tribal member NOT enrolled in Federally Recognized Tribe: – Eligible for services from IHS, tribal (638) or urban Indian health care provider. A letter from IHS Patients Benefits Coordinator can be requested.

25. Affordable Care Act American Indian/Alaska Native Specific Protections 25

26. AI/AN Protections Health Insurance Marketplace/State Exchanges: AI/AN are exempt from the mandate that requires individuals to purchase health insurance or pay a tax penalty. A process to identify exempt individuals must be allowed. The law states that the HHS Secretary will set the requirements for what information needs to be provided by individual AI/AN’s. Special monthly enrollment periods for AI/AN to facilitate and overcome barriers to enrollment will be established. 26

27. AI/AN Protections Health plan networks must include Essential Community Providers that serve low-income and medically underserved individuals. The regulation encourages the use of the Model Indian Addendum to contract with I/T/U providers. Stakeholders/advocates must be consulted on enrolling hard to reach populations. Guidance requires consultation with Tribes on policy and operational facets that affect AI/AN. Indian Tribes, Tribal organizations, and Urban Indian organizations are organizations that may be designated as “Navigators.” 27

28. AI/AN Protections AIAN at or below 300% FPL who are federally recognized (or who meet the Indian hardship exemption) are exempt from cost-sharing in the Marketplace. There is no cost-sharing (co-pays, co-insurance, deductibles) for Indians under any Marketplace plan for services provided by the I/T/U or through a CHS referral. Health programs operated by I/T/U’s shall be the payers of last resort for services provided to Indians. 28

29. AI/AN Protections Medicare/Medicaid/CHIP: Reimbursement for all Medicare Part B services by Indian hospitals and clinics reinstated. All costs incurred by I/T/U’s and the AIDS Drug Assistance Program in dispensing pharmaceuticals shall be counted as “true out-of-pocket” costs by AIAN’s enrolled in Medicare Part D plans. Medicaid State agencies are required to consult with Tribes in the development of Waivers and Medicaid & CHIP State Plan Amendments (SPAs) and submit documentation of consultation to CMS. (ARRA Section 5006(e)) 29

30. AI/AN Protections I/T/U’s added to list of agencies that could serve as an “Express Lane Agency” under Sect. 1902(e)(13) of the Social Security Act and allowed to determine presumptive eligibility for public benefit programs. Distributions and payments from AI/AN resources listed in ARRA Section 5006 and certain income exclusions codified in the Internal Revenue Code shall not be used in determining Medicaid or CHIP eligibility under the new streamlined MAGI methodology. 30

31. AI/AN Protections AI/AN income exemptions in the determination of MAGI-based income must be calculated on the Marketplace and Exchange calculator. Qualified Indian health care benefits, including accident or health insurance that a Tribe buys for its members, a spouse or dependent, cannot be deemed as income by the IRS for tax purposes or for provision of benefits under the ACA. 31

32. AI/AN Protections AI/AN income exemptions for Medicaid/CHIP: Alaska Native Corporation and Land Settlement Trusts Property Held in Trust Under the Supervision of the Secretary of the Interior Ownership Interest From Rents, Leases, Royalties, and Usage Rights Related to Natural Resources Sub-marginal Trust Lands held in Trust Distributions with a Unique Religious, Spiritual, Traditional, or Cultural Significance Bureau of Indian Affairs Student Financial Assistance Judgment Fund Distributions Tribal Trust Per Capita – Distributions to tribal members by the BIA or a Tribe from tribal trust income collections (i.e., lease rentals, right-of-way payments, oil, mineral or timber harvesting royalties). 32

33. ACA Training Project Staff Alida Montiel, Health Systems Director (602) 258-4822, Ext. 1543 alida.montiel@itcaonline.com Verna Johnson, Health Program Manager (602) 258-4822, Ext. 1584 verna.johnson@itcaonline.com Cynthia Freeman, Public Benefits Program Coordinator (602) 258-4822, Ext. 1554 cynthia.freeman@itcaonline.com 33

34. AI/AN Protections American Indian members who are active or previous users of the IHS, Tribal health programs operated under P.L. 93-638, or urban Indian health programs are exempt from premiums and other cost sharing in Medicaid/CHIP. AI/AN enrolled in AHCCCS Managed Care Plans can continue to get services through an I/T/U even if the I/T/U provider is not a provider in the individual AI/AN’s managed care network. 34

35. Thank you for this opportunity! Questions? 35