Indian Health Service: Implications of the Affordable Care Act Carol Chicharello, Deputy Director, Health Program Improvement & Support Branch Phoenix Area Indian Health Service 8th Annual CAH Performance Improvement Summit (August 2, 2013) Wild Horse Pass Casino & Resort – Gila River Indian Community

Presentation Overview

• Indian Health Service (IHS)

• IHS Budget Challenges

• Budget Formulation Process

• Phoenix Area Budget

• Affordable Care Act (ACA) Opportunities

• Major Changes

• Business Planning

• Phoenix Area Impacts in Arizona

• Other Changes

• Next Steps

Indian Health Service (IHS)

• HHS division responsible for providing federal health services to eligible American Indians and Alaska Natives (AI/AN)

• Mission: To raise the physical, mental, social, and spiritual health of AI/AN to the highest level.

• Goal: To assure that comprehensive, culturally acceptable personal and public health services are available and accessible to AI/AN people.

• Foundation: To uphold the Federal Government’s obligation to promote healthy AI/AN people, communities, and cultures and to honor and protect the inherent sovereign rights of Tribes.

Indian Health Service (IHS)

Indian Health Service (IHS)

IHS Budget Challenges

IHS Budget Formulation Process

Phoenix Area

Recommendation

National

Recommendation

IHS Budget

Submission

President's Budget

Request

Congressional

Appropriated

Budget

Clinical Services 3,955 3,762 3,187 3,187 2,966

Perventive Health 208 196 151 151 143

Urban Health 73 55 43 43 41

Indian Health Professions 43 45 41 41 38

Tribal Management 3 3 2 3 2

Direct Operations 84 79 72 73 68

Self-Governance 6 6 6 6 6

Contract Support Costs 727 675 476 476 448

Diabetes Funds 150 150 150 150 147

Reimbursables 878 866 1,374 1,132 1,102

6,127 5,837 5,502 5,262 4,961

Incremental % of Change -4.73% -5.74% -4.36% -5.72%

Overall decrease from Phoenix Area Budget Recommendation to Congressional Appropriated Budget -19.03%

(in million of dollars)

IHS Budget Challenges

Phoenix Area Budget –

Fiscal Year 2013 Under Continuing Resolution

FY 2013

Recurring BaseRescission

(0.2%)

Sequester (4.97833534%)

FY 2013

Budget

w/Cuts

Clinical Serivces 203,600,816 (407,202) (10,115,661) 193,077,953

Preventative Health 15,286,400 (30,572) (759,485) 14,496,343

Urban Health 2,481,300 (4,963) (123,280) 2,353,057

Direct Operations 3,197,825 (6,396) (158,880) 3,032,549

Contract Support Costs 22,084,060 (44,168) (1,097,220) 20,942,672

Contract Support Health 68,127,634 (27,295) (3,390,263) 64,710,076

Totals 314,778,035 (520,596) (15,644,789) 298,612,650

(in thousa nds of dolla rs)

PHOENIX AREA FUNDING LEVELS

Affordable Care Act (ACA) Opportunities

• ACA Major Changes in 2013-2014

• Medicaid Expansion

• Health Insurance Marketplace

• VA/IHS Reimbursement

• Phoenix Area Facilities in Four States (AZ, CA, NV, UT)

• Increase in Access to Care to non-Indian health care providers

• Increase in Third Party Reimbursements

• Increase in Contract Health Service Budget Savings to pay for services provided to individuals with no alternate resources

ACA Opportunities

• IHS ACA Business Planning – Area Office and Service Unit Coordination

• Ensure that the number of patients remains stable or increases

• Ensure that third party revenue remains stable or increases

• Ensure priority customer service and quality of care and an Indian health care system that continues to improve over time

• IHS ACA Business Plan Template

• Assess Local Environment for Health Insurance Marketplace

• Assess Patient Workload and Revenue Impact

• Assess Current Staffing, Workload, Facility Space

• Assess Referral and Prior Authorization Processes

• Determine Eligibility Process New Changes

• Assess Data Reporting Requirements

• Determine Marketing Strategy

• Qualified Health Plan Relations

ACA Opportunities

IHS Headquarters

Phoenix Area Office

Phoenix Area Office ACA Workgroup

Phoenix Area-Wide ACA Workgroup

Phoenix Area ACA Outreach & Education

Subcommittee

Service Unit ACA Teams

National Business Office Coordinators

Committee

NBOC ACA Subcommittee

Service Unit, Area-Wide, Area Office, and National ACA Efforts

MEDICAID RESTORATION & EXPANSION

ACA Opportunities

Medicaid Restoration & Expansion

• Medicaid Expansion – State option to expand eligibility to 133% FPL (beginning January 1, 2014)

• Arizona: Governor signed Restoration/Expansion Legislation (impact: 300,000)

• California: Legislature passes Medicaid Expansion (impact: 1.4 million)

• Nevada: Moving forward with Expansion (impact: 204,000)

• Utah: Legislation passed prohibiting implementation of expansion without Legislative approval; not moving forward at this time (impact: 123,000)

• Colorado Service Unit serves American Indian and Alaska Native (AI/AN) residents from Arizona, California and Nevada (as well as AI/AN from other states)

Medicaid Restoration in Arizona

AHCCCS American Indian Health Program Enrollment of Childless Adults (since Enrollment Freeze in July 2011)

5,000

7,000

9,000

11,000

13,000

15,000

17,000

19,000

21,000

23,000

Source: AHCCCS Administration

Medicaid Restoration in Arizona

AHCCCS Uncompensated Care Payments by Phoenix Area IHS Facility (April 6, 2012 – May 31, 2013)

$-

$5,000,000

$10,000,000

$15,000,000

$20,000,000

$25,000,000

$2,067,545 $556,505

$233,006 $163,144

$2,203,131

$22,532,193

$1,950,786

$394,084

$3,505,130

$121,646

Source: AHCCCS Administration

Medicaid Restoration in Arizona

Estimated CHS Costs for AI/AN Childless Adults in Arizona

by Phoenix Area IHS Facility (April 6, 2012 – March 31, 2013)

$-

$500,000

$1,000,000

$1,500,000

$2,000,000

$2,500,000

$3,000,000

$3,500,000

$4,000,000

$4,500,000

Parker PeachSprings

Supai Ft. Yuma Hopi PIMC San Carlos Whiteriver

$874,644

$522,828 $579,360

$251,004

$2,124,324 $2,035,356

$1,426,824

$4,332,996

Source: Phoenix Area Office

Medicaid Expansion in Arizona

Potential Annual Reimbursements for the AI/AN Medicaid Expansion

Population in Arizona by Phoenix Area IHS Facility

$0

$5,000,000

$10,000,000

$15,000,000

$20,000,000

$25,000,000

DesertVisions

Ft. Yuma Hopi Parker PeachSprings

PIMC San Carlos Whiteriver Supai Clinic

$74,101 $453,032

$3,759,201

$2,254,524 $776,870

$20,594,006

$5,572,712

$12,638,152

$220,458

Source: Phoenix Area Office

Medicaid Expansion in Arizona Potentially Eligible AI/AN in Arizona under Medicaid Expansion and

“Woodwork” Population

(Uninsured under 133% FPL)

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

DesertVisions

Ft. Yuma Hopi Parker PeachSprings

PIMC San Carlos Whiteriver Supai Clinic

28 244

2297

765 369

9939

2538

3854

114

HEALTH INSURANCE MARKETPLACE

ACA Opportunities

Health Insurance Marketplace

• Health Insurance Marketplace • Enrollment begins October 1, 2013; Coverage begins January 1, 2014 • Individual & Family Market

• Individuals with incomes up to 400% may be eligible for an advance premium tax credit (around $94,200 for a family of 4)

• AI/AN with income up to 300% FPL are exempt from copays, coinsurance, deductibles (around $70,650 for a family of 4)

• AI/AN have special monthly enrollment periods • Tribes may elect to pay for their members’ premiums • Hardship Exemption from Individual Mandate – AI/AN who are eligible

to receive services from an Indian health care provider

• State Decisions • Arizona: Federally-Facilitated Marketplace • California: Covered California (state-based) • Nevada: Nevada Health Link (state-based) • Utah: Federal and State Partnership

Health Insurance Marketplace in Arizona

Estimated # of AI/AN Eligible for

No Cost Sharing and Premium Subsidy (133-300% FPL)

0

1000

2000

3000

4000

5000

6000

7000

8000

DesertVisions

Ft. Yuma Hopi Parker PeachSprings

PIMC San Carlos Whiteriver Supai Clinic

21 186

1751

584 281

7578

1935

2938

87

Health Insurance Marketplace

• Qualified Health Plan (QHP) Addendum for Indian Health Care Providers • Persons Eligible for Services • Insurance and Indemnification • Licensure of Health Care Professionals • Dispute Resolution • Governing Law • Medical QA Requirements

• Area-Level Coordination of QHP Contracts • Contracts reviewed /cleared by Regional Office of General Counsel

• Area and Service Unit Considerations

• Electronic Claims Submission and Timely Filing • Rate Negotiation • Coordination of Care

VA/IHS REIMBURSEMENT AGREEMENT

ACA Opportunities

VA/IHS Reimbursement

• VA/IHS Memorandum of Understanding – Signed 10/1/2010

• To establish coordination, collaboration, and resource-sharing between the VA and IHS to improve the health status of AI/AN veterans.

• VA/IHS Reimbursement Agreement – Signed on 12/5/2012

• To facilitate reimbursement by the VA and IHS for certain health care services, specifically Direct Care Services provided by the IHS to eligible AI/AN Veterans. Accreditation is required.

• Implementation

• Phase 1 (Jan-June 2012): 10 IHS pilot sites selected to develop Local Implementation Plans and begin billing the VA for direct care services provided to eligible AI/AN veterans

• Phase 2 (July 2013 forward): Implementation at all other federal sites

VA/IHS Reimbursement Potential Annual Inpatient

Reimbursement Potential Annual Outpatient

Reimbursement

$0

$50,000

$100,000

$150,000

$200,000

$250,000

$300,000

$13,964

$296,400

$209,989

$8,506

$75,790

$0

$200,000

$400,000

$600,000

$800,000

$1,000,000

$1,200,000

$111,671

$260,967 $202,272

$1,197,980

$326,585

$626,080

Next Steps – ACA Business Planning

• Training of All Staff and In-Person Assisters

• Outreach and Education

• AI/AN Specific Materials and Consistent Messaging

• Partnership with Direct Service Tribes and Tribal Programs

• Consultation with Tribes and Community

• Customer Service and Process Improvement

• Provider of Choice

• Medical Home

• Cultural Competency

• Patient Reception

• Monitoring of Workload, Productivity and Staffing Levels

Questions

•Carol Chicharello Deputy Director

Health Program Improvement & Support Branch

Phoenix Area Indian Health Service

Carol.Chicharello@ihs.gov

(602) 364-5117