Transcript Alaska Tribal Health System

Patient Protection and
Affordable Care Act:
Health Reform &
Indian Health Care Improvement
Act
Alaska Native Tribal Health Consortium
April 2012
Outline
• Health Reform Highlights
• Health Reform (non-IHCIA Indian Provisions)
• Indian Health Care Improvement Act
• Implications
• Next Steps
2
Health Reform Highlights
•
•
•
•
•
•
•
•
•
•
•
Insurance Exchanges
Subsidies
Medicaid
Medicare
Insurance Reforms
Individual Mandates
Employer Mandates
Paying for Reform
Extending Access to Care
Workforce
Alaska Federal Task Force
3
Health Insurance Exchanges
• State-based
• Eligibility:
– Self-employed and
– Uninsured individuals
• Start up funding for states until Jan 1, 2015
• Separate exchanges available for small
businesses
• Special enrollment periods for AI/ANs
4
Subsidies
• Eligibility
–
–
–
–
Individuals and families
Between 100% and 400% federal poverty level
Cannot be eligible for Medicaid, Medicare
Cannot be covered by employer
• Premium credits based on sliding fee scale
– 2% of income for family at 133% FPL
– 4% of income for family at 150% FPL
– 9.5% of income for family at 400% FPL
5
Medicaid
• Def: Medicaid provides “Aid” based on income
– Federally authorized
– State administered
• Expands eligibility to 133% of FPL
• Expands eligibility to childless adults in 2014
– Optional
– Mandatory in 2014
• 100% Federal Medical Assistance Percentage
(FMAP) for expansions 2014 through 2016
6
Medicaid cont’d
• “Express Lane Agencies”
– Generally avail for TANF eligibility
– I/T/U can now be Express Lane Agencies for
determining
• Medicaid
• CHIP (Denali KidCare)
7
Medicare
• Def: Medicare provides “Care” to elderly (65+ and
people of all ages who live with disabling
conditions recognized by CMS)
• Addresses “doughnut hole”
– Part D drug benefit gap between $2,830 and $3,810.
• $250 rebate for those who hit the donut hole by
2010
• 50% discount on name brand drugs for those in the
doughnut hole eff. 2011
8
Medicare cont’d
• M’Care preventive services covered eff. 2010
• Permanent I/T/U authority for collection of
Part B services retroactive to Jan 1, 2010.
• $500 B in Medicare cuts in the next 10 years
9
Insurance Reforms
• Insurance companies cannot exclude people with
preexisting conditions
– Children; eff. 6 months after enactment
– Adults; eff. 2014
• Dependent children can stay on parent’s health
plan until age 26 so long as they are not offered
coverage through an employer
• Catastrophic coverage available for purchase for
young adults in their 20s; eff. 2014
– Lower premiums
– Typically kicks in after $6,000 out of pocket
10
Insurance Reforms cont’d
• Insurers cannot limit
– lifetime coverage for kids and adults eff. 2010
– annual coverage eff. 2014
• Insurance companies must cover:
– Certain prevention services (immunizations,
cancer screening for women, children’s
preventive services, etc.)
• No rescissions of insurance after individual
gets sick eff. 6 months after enactment
11
Individual Mandates
• Individuals must purchase insurance by 2014
or face a tax penalty of up to $695.
• Individual American Indians/Alaska
Natives exempt from this penalty
• However, individuals may choose to
purchase insurance
12
Employer Impact
• If <50 employees, no penalty
• If >50 employees, penalty for employer if:
– no insurance offered to employees;
– any employee receives government subsidized
insurance through exchange
• Penalty of $2,000 per employee after the first 30
employees
13
Employer Impact cont’d
• Tax credits to businesses
– If < 25 employees with avg salary of $50,000,
then subsidies available
• “Cadillac Tax”
– 40% excise tax on the portion of employer
health plans that exceed $10,200 for individuals
and $27,500 (excluding dental and vision)
14
Costs
• CBO score of $938 B over 10 years
• Tax implications, eff. 2013
– Medicare Payroll tax of 2.35% (currently 1.45%) for:
• Individuals with incomes > $200,000 and
• Married couples with incomes > $250,000
– 3.8% tax on unearned income (dividends and interest)
for high-income taxpayers
• “Cadillac Tax”: 40% excise tax on the portion of
most employer-sponsored health coverage
(excluding dental and vision) > $10,200 a year for
individuals and $27,500 for families.
15
Costs cont’d
• Deductions for unreimbursed medical
expenses:
– 10% of adjusted gross income (currently 7.5%)
• Flexible spending accounts:
– limits the amount of money to pay medical
expenses to $2,500 eff. 2013.
16
Access and Workforce
• Community Health Centers (330 Clinics)
expansion eff. 2011
• Maternal and Child Home Visitation
– Children and expecting at risk for poor child
and maternal health
– Grants through states for 5 years
– 3% set-aside for I/T/U ($45M)
17
Access and Workforce
• Interagency Access to Health Care in AK Task
Force
– Develop strategies to improve federal beneficiary health
care in Alaska within 180 days
– Membership
•
•
•
•
•
•
•
•
Health & Human Services
Centers for Medicare & Medicaid Services
Indian Health Service
TRICARE
Army
Air Force
Veterans Administration
Veterans Health Administration
18
Access and Workforce
• Workforce
– Scholarships, Student Loan Repayment eff. 2011
– Grants for I/T/U
19
Non-IHCIA Indian Provisions
• Exemption from penalty for failure to
comply with individual mandate for health
insurance
• AI/AN health benefits from tribes excluded
from income for tax purposes
• Cost Sharing under an Exchange Program
– No cost-sharing for AI/ANs who receive their
care through I/T/U or through Contract Health
– No cost-sharing for AI/ANs up to 300% FPL
20
Non-IHCIA Indian Provisions
• Express Lane Agencies
– I/T/U can enroll AI/ANs in Medicaid and
CHIP (Denali KidCare)
• Medicare Part B Services
– Extends authority of I/T/Us to bill for these
services retroactively to January 1, 2010
• Payor of Last Resort
– extends rule by extending it to other federal
programs
21
Indian Health Care
Improvement Act
Reauthorization
Indian Health Care Improvement Act
• Included in the Patient Protection and Affordable
Care Act (Health Reform), P.L. 111-148 as Title X,
Part III, Section 10221
• Incorporates Senate Bill 1790 as reported out of the
Senate Committee on Indian Affairs, except:
– Removed
• IHS scholarship tax exemption (these will remain taxable)
• 100% Reimbursement for Medicare services for IHS facilities
(remains at 80%)
– Added
• Dental Health Aide Therapy Clarification
• Abortion provision that prohibits the use of federal IHS
appropriations for abortions.
23
Indian Health Care Improvement Act
• Permanent authorization; effective March
23, 2010
• Recognizes the federal government’s
“special trust relationship and legal
obligations to Indians”
• Not an appropriation bill
• No new negotiated rulemaking
requirements
24
IHCIA Major Provisions
•
•
•
•
•
•
•
•
Title I: Workforce
Title II: Health Services
Title III: Facilities
Title IV: Access to Health Services
Title V: Urban Indians
Title VI: IHS Organizational
Title VII: Behavioral Health
Title VIII: Miscellaneous
25
Title I – Workforce
• Sec. 112 – Health Professional Chronic Shortage
Demonstration Program
– IHS authority to fund demo programs to address chronic
shortages of health professionals.
– Includes training and support of alternative provider types,
such as CHA/Ps. Should also apply to DHATs. (See also
sec. 5304 of PPACA which authorizes 15 grants for demo
projects for training of alternative dental health providers).
• Sec. 113 – Exemption from Licensing Fees
– Exempts tribal employees from licensing fees to the same
extent as IHS employees.
26
Title I – Workforce
• Sec. 121 – Community Health Aide Program
– Authorizes national expansion
– Dental Health Aide Therapy (DHAT) limitations
• Limits scope of service consistent with ADA settlement
• Retains Alaska-only DHAT authority, but also allows
IHS facilities where mid-level or DHAT is allowed by
state law.
• If other federal law authorizes mid-level dental practice,
then IHS facilities not restricted.
• Requires quality study.
27
Title II– Health Services
• Sec. 205 – Other Authority for Provision of Services
– Authorizes I/T/TOs to operate four types of programs:
• Hospice Care
• Long-term Care
• Assisted Living
• Home- and Community-based Care
• Sec. 206 – Reimbursement from Certain Third
Parties
– Authority to recover “reasonable charges billed” for
services provided to insured non-eligible individuals.
– Allows T/TOs to collect from tortfeasors (e.g., auto
insurer).
28
Title II– Health Services
• Sec. 212 – Cancer Screenings
– Authorizes “other cancer screenings” beyond
mammography.
• Sec. 213 – Patient Travel Costs
– Includes “qualified escort” as authorized cost.
29
Title II – Health Services
• Sec. 214 – Epidemiology Centers
– Designates Epidemiology centers as “public
health agency” under HIPAA allowing them
greater access to data and health information.
• Sec. 221 – Licensing
– Extends “licensed in any state” exemption
allowed for certain federal health care
professional employees to tribal employees.
30
Title II – Health Services
• Sec. 226 – Contract Health Services
Administration and Disbursement Formula
– Opens current CHS distribution formula for
reevaluation via 3 step process:
• Step 1. GAO Report on CHS program
• Step 2. IHS-tribal consultation to determine whether
current distribution formula should be modified
• Step 3. If Secretary determines it necessary, a
Negotiate Rulemaking Committee may be
established to develop new distribution formula.
31
Title III – Health Facilities
• Sec. 301 – Health Care Facilities Priority System
– Requires IHS, in consultation with T/TOs, to establish
a priority system allowing nomination of new projects
every 3 years.
• Grandfathers in projects listed in FY 2008 budget request.
• Area Distribution Fund as a possible approach to meet unmet
need for construction of health facilities.
• Sec. 309 – Federally Owned Quarters
– Authorizes T/TO to elect to directly operate and
establish rental rates for federally-owned staff quarters
and directly collect rents based on local rates.
32
Title III – Health Facilities
• Sec. 311 – Other Funding, Equipment, and
Supplies for Facilities
– Authorizes other federal agencies to transfer funds for
the “planning, design, construction, and operation of”
health care and sanitation facilities to HHS/IHS.
– Requires HHS/IHS to establish new regulations for
“planning, design, construction, and operation of”
Indian health care and sanitation facilities.
– Applies the HHS/IHS regulations to the transferred
funds.
33
Title IV – Access to Health Services
• Sec. 401 – Treatment of Payments under SSA
– Adds Children’s Health Insurance Program (in addition
to Medicaid & Medicare) as source I/T can collect
from.
– Provides greater flexibility for T/TOs in use of funds
collected under this section.
• Sec. 402 – Purchasing Health Care Coverage
– Allows T/TO/Us to use federal funds to purchase
health benefits coverage for beneficiaries.
34
Title IV – Access to Health Services
• Sec. 404 – Outreach and Enrollment in SSA
and Other Health Benefit Programs
– Grants and contracts for I/T/U to conduct
outreach and enrollment activities for Indians.
– May be used to pay beneficiary premiums or
cost sharing.
35
Title IV – Access to Health Services
• Sec. 405 – Sharing Arrangements with Federal
Agencies
– Allows Secretary to enter into arrangements with DoD
and DVA to share facilities and services.
– Directs DoD and DVA to reimburse I/T/TO for
services provided to DoD/DVA beneficiaries
notwithstanding any other provision of law.
• Sec. 407 – Eligible Indian Veteran Services
– Authorizes I/Ts to pay co-pays to DVA for services
provided to IHS beneficiaries.
– Provision was needed to facilitate arrangements for
Indian veterans to receive care from DVA providers in
I/T facilities.
36
Title IV – Access to Health Services
• Sec. 408 – Nondiscrimination in Qualifications for
Reimbursement
– Makes I/T/U programs eligible to participate in any
federal health care program without requiring state
licensure as long as such programs meet the applicable
state standards.
• Sec. 409 – Access to Federal Insurance
– Allows T/TO/Us operating any ISDEAA program (not
just IHS) to purchase insurance coverage for their
employees through the FEHB program.
• Sec. 410 – General Exceptions
– Exempts certain insurance products from being
considered 3rd-Party Payer under IHCIA, e.g., AFLAC.
37
• Title V – Urban Indian Health
– Grants Urban Indian programs broader program
authority.
– Requires IHS to “confer” with urban Indian
programs.
• Title VI – IHS Organizational
– Some enhancements to authorities and
responsibilities of IHS Director.
– Establishes Office of Direct Service Tribes.
38
Title VII – Behavioral Health
• Title VII replaces current law’s substance abuse
programs.
• Greatly expands behavioral health authorities:
– Comprehensive behavioral health Prevention and
Treatment
– Indian Women Treatment
– Indian Youth Program
– Inpatient MH Facilities
– FASD programs
– Child Sexual Abuse Prevention and Treatment
– Domestic and Sexual Violence Prevention and
Treatment
– Behavioral health research
– Indian Youth Suicide Prevention
39
Title VIII – Miscellaneous
• Sec. 805 – Confidentiality of Medical QA
Records
– Allows for peer reviews to be conducted within
Indian health programs without compromising
confidentiality of medical records.
40
Title VIII – Miscellaneous
• Sec. 813 – Health Services to Ineligible
Persons
– Allows T/TO to make a determination to
provide services to non-beneficiaries.
– If T/TO makes this determination, services to
non-beneficiaries are deemed provided under
the ISDEAA agreement and FTCA applies.
– Non-Service providers in IHS/tribal hospitals
receive FTCA coverage when provided services
under this section.
41
Title VIII – Miscellaneous
• Sec. 822 – Shared Services for Long-Term Care
– Expressly authorizes IHS to provide, or enter into
ISDEAA agreements, for the delivery of long-term care
to Indians:
• Home and Community Based services
• Hospice care
• Assisted living and other residential services
• Sec. 826 – Annual Budget Submission
– Directs the President to include in the annual IHS
budget request amounts that reflects changes due to
inflation (CPI) and increase in user population.
42
Title VIII – Miscellaneous
• Sec. 827 – Prescription Drug Monitoring
– Requires HHS to establish a prescription drug
monitoring program at I/T/U facilities.
– Report due to Congress 18 months after enactment.
• Sec. 828 – Tribal Health Program Option for
Cost Sharing
– Allows Title V tribal health programs to charge
beneficiaries for services.
– Unclear whether this applies to Title I programs.
43
Title VIII – Miscellaneous
• Sec. 831 – Traditional Health Care Practices
– Excludes these services from FTCA coverage.
• Sec. 832 – HIV/AIDS Prevention and
Treatment
– Establishes a new Director of HIV/AIDS
Prevention and Treatment within IHS to
coordinate the agency’s efforts on this issue.
44
Overall Implications
Individuals
• More services may be available through the
I/T/U
• More opportunities for coverage
• More options for care
45
Overall Implications
Providers
• More insured individuals
• Need for education and enrollment
• Marketing need due to options for care for
insured
• More opportunities to expand care
• More collaboration with non-tribal partners
• More opportunities for health workforce
training
46
Overall Implications
Employers
• Dependent coverage up to 26 years old if
qualified
• Potential higher insurance premiums due to
excise tax on “Cadillac Plans”
47
Questions?
Valerie Davidson, Senior Director
Legal & Intergovernmental Affairs
Alaska Native Tribal Health Consortium
4000 Ambassador Drive, CADM
Anchorage, AK 99508
[email protected]
Phone 907-729-1900 Cell: 907-350-0572
48