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Legislative & Policy Update

NW Portland Area Indian Health BoardQuarterly Board Meeting

October 21, 2013

Budget Update• 16 Day Government Shutdown

– Furloughs of over 800,000 federal employees – Suspension of services not exempt by Anti-deficiency Act – IHS suspended meetings, grant & contract activity, payments,

ISDEAA negotiations, and CDA claims– Issues: ACA financing; debt ceiling; ACA-PTC & cost-sharing

verification • What is in the anatomy of the CR Deal?

– Provides Continuing Resolution to Jan. 15, 2014– Government back to work last Thursday, Oct. 17th

– Repayment for essential workers; Back pay for furloughed workers

– New clock on debt-ceiling to February 7, 2014 (Ted Cruz)

H.R. 2775 Continuing Appropriations Act 2014

• Funds continuing operations, projects, or activities conducted in FY2013 at the current levels.

• Requires the rate for operations be calculated [reduced] based on FY2013 requirements (Sequester)

• Prohibits high rates or complete distribution of appropriations at the beginning of FY2014 for some programs.

• Provides compensation of federal employees furloughed as a result of any lapse in appropriations

• Directs agencies to pay for FY 2014 activities if they used their own resources

• ACA tax credit and cost-sharing verification and HHS-OIG issue report to Congress on effectiveness

• (Sec. 1002) Default Prevention Act of 2013 • http://thomas.loc.gov/cgi-bin/bdquery/z?d113:HR02775:@@@D&su

mm2=m&

Appropriations Update

• H.R. 2775 CR thru January 15th – H.J

. Res. 80, American Indian and Alaska Native, Health, Education, and Safety Act

• FY 2012 Final Amount = $4.306 billion

• FY 2013 Post Sequester = $4.131 billion

• President’s 2014 Request = $4.430 billion – $124 million over FY 2012 level (2.9% increase)

• House FY 2014 = $4.130 billion

• Senate FY 2014 = $4.434 billion

Senate & House Budget Resolutions

Indian Health Service FY 2014 BudgetComparing Enacted FY 2012, FY 2013, and President's FY 2014 Request;

And House & Senate Interior Apprpriaiton MarksPrepared by: NW Portland Area Indian Health Board - 7/23/2013

President's Request FY 2013 Final Operating PlanHouse

Interior Mark-up

Senate Interior

Bill 8-1-13

Sub-Sub Activity FY 2012Budget

President's FY 2014 Request

FY 2013Operating

Plan

Change Over

FY 2012

Pct of Change

HouseSubcomm.

Mark

House Subcomm.

Mark

Hospitals & Health Clinics 1,810,966$ 1,865,630$ 1,749,072$ (61,894)$ -3.4%Dental Services 159,440$ 168,225$ 156,653$ (2,787)$ -1.7%Mental Health 75,589$ 79,873$ 74,131$ (1,458)$ -1.9%Alcohol & Substance Abuse 194,297$ 196,405$ 185,154$ (9,143)$ -4.7%Contract Health Services 843,575$ 878,575$ 801,258$ (42,317)$ -5.0% 878,575$ 843,237$

Total, Clinical Services 3,083,867$ 3,188,708$ 2,966,268$ (117,599)$ -3.8%

Public Health Nursing 66,632$ 71,194$ 66,282$ (350)$ -0.5%Health Education 17,057$ 17,677$ 16,552$ (505)$ -3.0%Comm. Health Reps 61,407$ 61,661$ 58,304$ (3,103)$ -5.1%Immunization AK 1,927$ 1,931$ 1,826$ (101)$ -5.2%

Total, Preventive Health 147,022$ 152,463$ 142,964$ (4,058)$ -2.8%

Urban Health 42,984$ 43,049$ 40,729$ (2,255)$ -5.2%Indian Health Professions 40,596$ 40,602$ 38,467$ (2,129)$ -5.2%Tribal Management 2,577$ 2,577$ 2,442$ (135)$ -5.2% 36,000$ Direct Operations 71,653$ 71,845$ 67,894$ (3,759)$ -5.2%Self-Governance 6,044$ 6,049$ 5,727$ (317)$ -5.2%Contract Support Cost 471,437$ 477,205$ 447,788$ (23,649)$ -5.0% 477,205$ 476,705$

Total, Other Services 635,292$ 641,327$ 603,047$ (32,245)$ -5.1%

Total, Services 3,866,181$ 3,982,498$ 3,712,279$ (153,902)$ -4.0% 3,712,486$ 3,982,842$

FACILITIES Maintenance & Improvement 53,721$ 53,721$ 50,919$ (2,802)$ -5.2%Sanitation Facil ities Constr. 79,582$ 79,582$ 75,431$ (4,151)$ -5.2%Health Care Fac. Constr. 85,048$ 85,048$ 77,238$ (7,810)$ -9.2%Facil . & Envir. Hlth Supp. 199,413$ 207,206$ 193,578$ (5,835)$ -2.9%Equipment 22,582$ 22,582$ 21,404$ (1,178)$ -5.2%

Total, Facilities 440,346$ 448,139$ 418,570$ (21,776)$ -4.9% 417,053$ 451,673$

TOTAL, IHS 4,306,528$ 4,430,637$ 4,130,849$ (175,679)$ -4.1% 4,129,539$ 4,434,515$

Clinical Service Accounts

President's Request FY 2013 Final Operating PlanHouse

Interior Mark-up

Senate Interior

Bill 8-1-13

Sub-Sub Activity FY 2012Budget

President's FY 2014 Request

FY 2013Operating

Plan

Change Over

FY 2012

Pct of Change

HouseSubcomm.

Mark

House Subcomm.

Mark

Hospitals & Health Clinics 1,810,966$ 1,865,630$ 1,749,072$ (61,894)$ -3.4%Dental Services 159,440$ 168,225$ 156,653$ (2,787)$ -1.7%Mental Health 75,589$ 79,873$ 74,131$ (1,458)$ -1.9%Alcohol & Substance Abuse 194,297$ 196,405$ 185,154$ (9,143)$ -4.7%Contract Health Services 843,575$ 878,575$ 801,258$ (42,317)$ -5.0% 878,575$ 843,237$

Total, Clinical Services 3,083,867$ 3,188,708$ 2,966,268$ (117,599)$ -3.8%

Preventive Health Accounts

President's Request FY 2013 Final Operating PlanHouse

Interior Mark-up

Senate Interior

Bill 8-1-13

Sub-Sub Activity FY 2012Budget

President's FY 2014 Request

FY 2013Operating

Plan

Change Over

FY 2012

Pct of Change

HouseSubcomm.

Mark

House Subcomm.

Mark

Public Health Nursing 66,632$ 71,194$ 66,282$ (350)$ -0.5%Health Education 17,057$ 17,677$ 16,552$ (505)$ -3.0%Comm. Health Reps 61,407$ 61,661$ 58,304$ (3,103)$ -5.1%Immunization AK 1,927$ 1,931$ 1,826$ (101)$ -5.2%

Total, Preventive Health 147,022$ 152,463$ 142,964$ (4,058)$ -2.8%

Other Services Accounts

President's Request FY 2013 Final Operating PlanHouse

Interior Mark-up

Senate Interior

Bill 8-1-13

Sub-Sub Activity FY 2012Budget

President's FY 2014 Request

FY 2013Operating

Plan

Change Over

FY 2012

Pct of Change

HouseSubcomm.

Mark

House Subcomm.

Mark

Urban Health 42,984$ 43,049$ 40,729$ (2,255)$ -5.2%Indian Health Professions 40,596$ 40,602$ 38,467$ (2,129)$ -5.2%Tribal Management 2,577$ 2,577$ 2,442$ (135)$ -5.2% 36,000$ Direct Operations 71,653$ 71,845$ 67,894$ (3,759)$ -5.2%Self-Governance 6,044$ 6,049$ 5,727$ (317)$ -5.2%Contract Support Cost 471,437$ 477,205$ 447,788$ (23,649)$ -5.0% 477,205$ 476,705$

Total, Other Services 635,292$ 641,327$ 603,047$ (32,245)$ -5.1%

Total, Services 3,866,181$ 3,982,498$ 3,712,279$ (153,902)$ -4.0% 3,712,486$ 3,982,842$

Facilities Accounts

President's Request FY 2013 Final Operating PlanHouse

Interior Mark-up

Senate Interior

Bill 8-1-13

Sub-Sub Activity FY 2012Budget

President's FY 2014 Request

FY 2013Operating

Plan

Change Over

FY 2012

Pct of Change

HouseSubcomm.

Mark

House Subcomm.

Mark

FACILITIES Maintenance & Improvement 53,721$ 53,721$ 50,919$ (2,802)$ -5.2%Sanitation Facil ities Constr. 79,582$ 79,582$ 75,431$ (4,151)$ -5.2%Health Care Fac. Constr. 85,048$ 85,048$ 77,238$ (7,810)$ -9.2%Facil. & Envir. Hlth Supp. 199,413$ 207,206$ 193,578$ (5,835)$ -2.9%Equipment 22,582$ 22,582$ 21,404$ (1,178)$ -5.2%

Total, Facilities 440,346$ 448,139$ 418,570$ (21,776)$ -4.9% 417,053$ 451,673$

TOTAL, IHS 4,306,528$ 4,430,637$ 4,130,849$ (175,679)$ -4.1% 4,129,539$ 4,434,515$

Ardmore OK - $8.9 million Tishomingo OK - $5.3 million

Vinita OK - $1.8 million Tazlina AK - $500K

Wasilla AK - $17.7 million Kenai AK – $1 million

Fairbanks AK - $20 million Barrow AK - $6.8 million

Nome AK - $13.6 million San Carlos AZ - $1.3 million

Indian Health Legislation• Advance Appropriations Bills

– H.R. 3229: Don Young & Ray Lujan– S. 1570: Begich, Udall, Murkowski

• Special Diabetes Program for Indians – House and Senate Sign-on letters

• Indian Definition Fix – S. 1575: Senators: Mark Begich (D-AK), Max Baucus (D-

MT), Tom Udall (D-NM), Brian Schatz (D-HI), Al Franken (D-MN)

• IHCIA Technical Amendments

IHS Director Confirmation Hearing

• SCIA confirmation hearing June 12, 2013• SCIA has placed a hold on IHS Director confirmation until

they are satisfied with received reports: – Four IHS Areas has conveyed dissatisfaction on issues – Aberdeen Investigation continues to plague IHS– Area Office Reviews: SCIA wants reports of findings – CHS formula: adding mortality and morbidity to formula– Health Facilities construction & staffing issues – CSC issues and Administration’s proposal in FY 2014

• SCIA and HHS-Secretary have received Tribal leaders letters requesting Administration withdraw nomination or SCIA not move forward with confirmation.

• STAC Meeting: HHS Secretary weighs in support of Directors

Contract Support Cost Update• July 31-August 1: CSC Summit Hosted by ANHB, ANTHC,

CRIHB, NPAIHB, USET & NTCSCC• 3 Supreme Court cases have affirmed Tribes right to be paid

full CSC payments • Ramah decision requires federal government to pay Tribes

full CSC if the agency has sufficient appropriation • Administration proposed statutory ‘amendment-by-

appropriation’ – Eliminate Tribes’ future contract recovery rights – Proposal gives legal effect to amounts in a “table” provided to the

Appropriations Committees– Since Tribal contract is “subject to the availability of appropriations,”

limits legal remedy of Tribes and skirts Supreme Court decisions– No Tribal consultation on the Administration’s proposal!

Tribal Contract Support Cost Summit

CSC Policy Landscape is changing: Cherokee and Ramah court decisions, Administration & Agency policy changes, settlement of past CSC Claims, and lack of CSC funding

Alaska Native Health Board

Alaska Native Tribal Health Consortium

California Rural

Indian Health Board

Northwest Portland Area Indian Health

Board

United South and

Eastern Tribes, Inc.

National Tribal Contract

Support Cost Coalition Members

Tribal Contract Support Cost Summit – Objectives

• Legal, financial, and ISDEAA policy experts addressed recent CSC policy developments

• Tribal only meeting did not include federal program personnel provided open and candid discussion

• Agenda Issues over two days included: 1. Litigation Update and Agency responses2. Settlement of past year’s claims & documentation 3. Administration’s FY 2014 CSC Proposal 4. Discussion of Ramah options 5. CSC Tribal Consultation Issues 6. Moving forward with CSC Issues

Tribal CSC Summit Recommendations

1. Tribal Consultation 2. Reject the Administration’s FY 2014

Proposal3. Supreme Court Option Explanations4. IHS Settlement Process

TTAG/MMPC Updates • ACA Policy Subcommittee is very active

– Tribal Exemption & I/T/U hardship exemption – Medicare PPS for Federally Qualified Health Centers: no more

multiple encounters – November 18th– CMS-R-267 Medicare Advantage Program Requirements-Due

November 17th – HHS-OS-20475-60D Survey of Providers for the Evaluation of the

Regional Extension Center Program-Due November 18th • Revising the CMS Tribal Consultation Policy • Evaluation of CMS Strategic Plan & Updates • Alternatives for Medicaid Expansion: Arkansas Model and UCC Waivers • Indian definition issues • QHP contraction and payment issues related to IHCIA section 206 and

408 (Reimbursement Subcommittee) • IRS/CMS Resource Exemptions • Extending Medicare Like Rates to non-hospital based services • ACA Educational materials • Data projects and studies

TTAG/MMPC Resources • https://

www.dropbox.com/home/Delegates/Temp%20Folder%20created%20by%20Jim

• MMPC Action Items and Tracking List

• TTAG Roster of Pending Regulations and Assignments

IHS Dear Tribal Leader Letters1. DTLL on IHS Virtual Summit – September 25, 20132. DTLL on CSC Update – September 9, 20133. DTLL on CHR Training – August 8, 2013 4. DTLL on Special Diabetes Program for Indians – June 19, 2013.5. DTLL on Contract Support Costs – June 12, 2013.6. DTLL on Contract Health Services – May 6, 2013.7. DTLL on MSPI & DVPI – May 6, 2013.8. DTLL on CSC Follow-up 9/24/2012 – March 26, 2013. 9. DTLL on draft IHS Sexual Assault Policy, Part 3, Chap. 29 – March 22, 2013.10. DTLL on CHS increases for referrals for prevention services in follow-up to

8/2/2012 – January 15, 201311. DTLL on CSC Issues in follow-up to 9/24, 2012 letter – January 14, 2013. 12. DTLL on UIHP Conferring Policy – January 11, 2013.13. DTLL on OIT PFSA and Tribal Shares – January 11, 2013.

What will Your Marketplace Look Like?

Medicaid Expansion for Indian Country

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