Medicaid, the Indian Health System, and Work Requirements Prese - - PowerPoint PPT Presentation

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Medicaid, the Indian Health System, and Work Requirements Prese - - PowerPoint PPT Presentation

Oct 08, 2022 268 likes •423 views

Medicaid, the Indian Health System, and Work Requirements Prese esented ted by: Devin vin Delrow, lrow, Director ector of Policy icy Medicaid What is it? Medicaid provides health coverage to millions of Americans, including eligible

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Prese esented ted by: Devin vin Delrow, lrow, Director ector of Policy icy

Medicaid, the Indian Health System, and Work Requirements

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Medicaid – What is it?

  • Medicaid provides health coverage to millions of Americans, including eligible low-

income adults, children, pregnant women, elderly adults and people with disabilities

  • Joint Federal and State Program
  • Funded by Federal Government and States
  • Managed by States according to certain federal requirements
  • Created in 1965 by adding Title XIX to the Social Security Act
  • Section 1115 of the Social Security Act permits states to test new approaches in

Medicaid that differ from federal rules

  • As of 2017, provides health care to 74 million people
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Medicaid Objectives

  • Objectives of the Program
  • Increase and strengthen overall coverage of low-income individuals in the

state;

  • Increase access to, stabilize, and strengthen providers and provider

networks available to serve Medicaid and low-income populations in the state;

  • Improve health outcomes for Medicaid and other low-income population in

the state; or

  • Increase efficiency and quality of care for Medicaid another low-income

populations through initiatives to transform service delivery networks

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Medicaid - How does it affect Tribes?

  • In 1976, the Indian Health Care Improvement Act amended the Social Security Act to

authorize Medicaid and Medicare reimbursement to Indian Health Service and Tribally operated health care facilities.

  • Congress recognized that these ““These Medicaid payments are viewed as a much-needed

supplement to a health care program which has for too long been insufficient to provide quality health care to the American Indian. . . .”

  • Congress acted to ensure that States would be reimbursed at a 100 percent federal

medical assistance percentage (FMAP) for Medicaid services to American Indians and Alaska Natives that are received through IHS and Tribally operated health care facilities.

  • Recognizes and Ensures that the trust responsibility for health remains with the federal

government and not the States.

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Medicaid – How Does it affect Tribes?

  • Medicaid Expansion
  • Expanded coverage to all individuals living at or below 138% of the federal poverty level

(FPL)

  • More AI/ANs who enrolled were able to get access to specialty care
  • Since the expansion of Medicaid some 237,000 American Indians and Alaska Natives

in 19 states have become insured.

  • IHS estimates that Medicaid accounts for roughly 70% of its 3rd Party Revenue
  • $840,000,000 in revenue to IHS
  • Medicaid is a Critical Resource for the Indian Health System
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2017 – Medicaid Reform

  • 2016 Elections – New Administration, New Congress
  • Expressed Support for Medicaid Reform
  • Congressional Actions
  • ACA Repeal and Replace
  • Block Grants/Caps
  • Medicaid Work Requirements
  • Administrative Actions
  • March 14th Letter to State Governors
  • Grant States more flexibility in operation of their Medicaid Programs
  • Fast track waivers and demonstration projects
  • Support work requirements
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Medicaid’s New Objectives

  • Old Objectives
  • Increase and strengthen overall coverage of

low-income individuals in the state;

  • Increase access to, stabilize, and strengthen

providers and provider networks available to serve Medicaid and low-income populations in the state;

  • Improve health outcomes for Medicaid and
  • ther low-income population in the state;
  • r
  • Increase efficiency and quality of care for

Medicaid another low-income populations through initiatives to transform service delivery networks

New Objectives

  • Improve access to high-quality, person-centered

services that produce positive health outcomes for individuals;

  • Promote efficiencies that ensure Medicaid’s

sustainability for beneficiaries over the long term;

  • Support coordinated strategies to address certain

health determinants that promote upward mobility, greater independence, and improved quality of life among individuals;

  • Strengthen beneficiary engagement in their

personal healthcare plan, including incentive structures that promote responsible decision- making;

  • Enhance alignment between Medicaid policies and

commercial health insurance products to facilitate smoother beneficiary transition; and

  • Advance innovative delivery system and payment

models to strengthen provider network capacity and drive greater value for Medicaid.

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Tribal Response

  • NIHB and TTAG have provided technical assistance to States that proposed to include

work requirements as a condition of eligibility for Medicaid

  • Kentucky
  • Indiana
  • Arkansas
  • Arizona
  • Wisconsin
  • Maine
  • New Hampshire
  • Utah
  • Mississippi
  • Kansas
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Work Requirements do not Work in Indian Country

  • The IHS System Relies on Medicaid
  • Work Requirements will not incentivize AI/ANs to work
  • Unlike other Medicaid enrollees, AI/ANs have a right to access IHS services.
  • AI/ANs would not need to meet mandatory work requirements to obtain coverage and

may instead simply elect not to enroll in Medicaid

  • Mandatory Work Requirements are Inconsistent with Federal Treaty and Trust

Obligations

  • Mandatory work requirements will pose an artificial barrier to access to the Medicaid

program that is unique to AI/ANs

  • The United States has a duty to implement programs like the Medicaid program in a way

that does not inadvertently raise barriers to participation by AI/ANs.

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Tribal Actions

  • May 2, 2017 – TTAG Letter to Administrator Verma on the Impact of Work

Requirements in Indian Country

  • June 13, 2017 – TTAG Letter to Secretary Price and Administrator Verma on Medicaid

Reform for the Indian Health System

  • June 13, 2017 – Joint NIHB/NCAI Letter to Secretary Price and Administrator Verma
  • n Medicaid Reform for the Indian Health System
  • July 15, 2017 – NIHB Comment on Wisconsin’s Waiver Application that proposes to

implement Work Requirements

  • August 23, 2017 – TTAG Meeting with CMS Leadership - Oppose Work Requirements,

Request AI/AN Exemption, Request Tribal Consultation

  • September 21, 2017 – STAC Meeting with Secretary Price – Oppose Work

Requirements, Request AI/AN Exemption, Request Tribal Consultation

  • November 1, 2017 – TTAG Meeting with CMS Leadership - Oppose Work

Requirements, Request AI/AN Exemption, Request Tribal Consultation

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Administration Actions

  • On January 11, 2018 CMS issued a Dear State Medicaid Director Letter entitled:

“Opportunities to Promote Work and Community Engagement Among Medicaid Beneficiaries”

  • Supported Continued State-Tribal Consultation
  • Encouraged States to Consider Tribal Work Support Programs as Meeting Requirements
  • January 12, 2018 – CMS Approved Kentucky Waiver Implementing Work

Requirements

  • January 17, 2018 – Administrator Verma met with Tribal Leaders at STAC and

Indicated CMS could not provide a blanket exemption for AI/AN due to “Civil Rights Concerns”

  • Recommended Talking to HHS Division of Civil Rights
  • January 17, 2018 – CMS Issued a Dear Tribal Leader Letter Stating that CMS Could

not provide an exemption for AI/ANs because of Civil Rights Reasons

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Tribal Response

  • February 14, 2018 – TTAG letter to CMS Opposing Work Requirements and Providing

Legal Memoranda on Incorrect Interpretation by the Division of Civil Rights

  • March 6, 2018 – TTAG Letter requesting an immediate meeting with the Office of

Civil Rights and CMS leadership on Work Requirements

  • April 11, 2018 – Tribal Delegation Met with CMS Leadership, CMS OGC, HHS OCR
  • HHS and CMS stated they could not provide a blanket exemption for AI/AN due to Civil

Rights and Constitutional Concerns

  • No Statutory Authority to Exempt
  • Could not provide specific information around their “concerns” due to ongoing litigation

and privileged communication

  • Invited CMS Leadership, OGC, and HHS OCR to meet with the STAC on May 9-10
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Next Steps

  • Congressional Action
  • Need to demonstrate impact of Medicaid Resources on the Indian Health System
  • Stress that Tribes have political status, NOT RACE
  • HHS and CMS have provided accommodations for AI/ANS based on their political

status before – WHY NOT NOW?

  • Let your STAC representatives know the impact, the loss of Medicaid will have on

your community

  • Work with your States on their Demonstration Waivers
  • Gain their support in Exempting AI/AN
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Thank you!

More info: www.nihb.org

  • Stacy Boglen, Executive Director, sbohlen@nihb.org
  • Carolyn Angus-Hornbuckle, Deputy Director and Director of Public

Health Programs and Policy, chornbuckle@nihb.org

  • Jessica Steinberg, Director of the Center for Indian Health Policy and

Research, jsteinberg@nihb.org

  • Devin Delrow, Director of Policy, ddelrow@nihb.org
  • Caitrin Shuy, Director of Congressional Relations: cshuy@nihb.org