1. 1 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA The Indian Addendum Ensuring Meaningful ITU Provider Access to Health Insurance Exchanges Presented by: Elliott Milhollin NIHB 28 th Annual Consumer Conference

2. 2 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Key AI/AN Exchange Benefits Provide new revenue for Indian Health Programs –Allow billing of insurance for the Indian Health Program services –Reduce Contract Health Services expenditures by allowing billing of insurance plans for services supplied by CHS providers –Allow tribes to use federal health care dollars to pay premiums on behalf of members Federal premium subsidies are available for low-income individuals on sliding scale up to 400% of the Federal Poverty Level (FPL) Indians enrolled in Exchange plans would be exempt from all cost sharing when served by an I/T/U or CHS provider Open enrollment periods

3. 3 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA How Would it Work? Outreach and Education Develop a premium payment model Contract with Qualified Health Plans (QHPs) AI/AN beneficiary receives services at an ITU or other in- network provider and the costs of those services are billed to the Plan. AI/AN Cost-Sharing Exemption

4. 4 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Network Provider Status Unless ITU are offered contracts with Qualified Health Plans, AI/AN will have little incentive to participate Section 408 of the Indian Health Care Improvement Act Requires federally funded plans like the Exchanges to offer to contract with ITU providers Essential Community Provider definition includes tribal and urban programs

5. 5 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA What Does the Indian Addendum do? Provides a comprehensive list of all of the federal laws applicable to contracting with I/T/U providers and sets them out all in one place Becomes a standard contract provision in any contract between an I/T/U provider and a Qualified Health Plan Reduces disputes between ITU and QHPs Streamlines contracting between ITU and QHPs Allows meaningful ITU provider access to Exchange plans

6. 6 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Why we need an Indian Addendum QHPs may be unfamiliar with ITU providers and with their federal rights and responsibilities QHPs will likely contain standard contract language that may conflict with these rights Without a standard Indian contract addendum, disputes may arise between QHPs and ITU providers as to federal requirements

7. 7 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA The Indian Addendum – Demonstrated Success Modeled on the success of the Indian Addendum used in the Medicare Part D Prescription Drug Program CMS regulations require Part D plan sponsors to offer network contracts to I/T/U pharmacies in their service areas with a standard Indian contract Addendum. 42 CFR 423.120 This mechanism has proved to be efficient, effective and easy to use for both Part D plan sponsors and Indian health pharmacies; it is now a standard component of the Part D program.

8. 8 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Key provisions in the Indian Addendum No cost sharing payments for AI/AN served by I/T/Us and no reduction in payments to I/T/Us that would otherwise be due from the enrollee (ACA §1402(d)(2) (42 USC 18071(d)(2)) IHS and I/T/Us may limit the population they serve 42 CFR Part 136 and Sec. 813 of the IHCIA, 25 USC §1680c Federal Tort Claims Act coverage for IHS and extended by law to Indian tribes/tribal organizations and some urban Indian organizations, which precludes a plan from requiring acquisition of private malpractice insurance, a frequent provision in network contracts Preservation of Sovereign Immunity

9. 9 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Key provisions in the Indian Addendum A comprehensive list of federal laws that are generally applicable to I/T/Us. These include the Indian Self-Determination and Education Assistance Act, the Indian Health Care Improvement Act, the Federal Tort Claims Act, the Privacy Act, and the Health Insurance Portability and Accountability Act Non-taxable status of I/T/Us State licensing exemptions for providers. Sec. 221 and 408 of the IHCIA

10. 10 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Key Benefits of the Indian Addendum When specialty care is required, the Indian health program can better coordinate care by referring the patient to another in-network provider, avoiding red tape of being served by an out of network provider The Indian health program can be assured of receiving payment for covered services they provide The plans enrollment base will increase if Indian health programs have an incentive to enroll their Indian patients who do not have another form of insurance in an Exchange plan Exchange plans benefit from having a wider network of providers to serve their Indian enrollees

11. 11 HOBBS STRAUS DEAN & WALKER, LLP WASHINGTON, DC | PORTLAND, OR | OKLAHOMA CITY, OK | SACRAMENTO, CA Request for Comments on Indian Addendum HHS has requested comment on the “potential use of a standardized Indian heath provider contract addendum” Comment period has been extended to October 31, 2011 Proposed rule can be found at 76 Fed. Reg. 41866