Legislative Policy Update NW Portland Area Indian Health

Legislative & Policy Update NW Portland Area Indian Health Board Quarterly Board Meeting April 23, 2014 1

Report Overview 1. 2. 3. 4. 5. 6. 7. SDPI Update Senate Committee on Indian Affairs Indian Bills FY 2014 & FY 2015 Budget Updates CSC Update DTLLs ACA Exemptions

SDPI Extended thru FY 2015 • H. R. 4302 Protecting Access to Medicare Act – Commonly referred to as the Sustainable Growth Rate bill -- SGR fix – Sec. 204 Extends the Special Diabetes Program for Indians thru FY 2015 – Sec. 210 Delays implementation of ICD-10 to Oct. 1, 2015 • SDPI thru September 30, 2015 – Maintains $150 million per year less sequestered amount

Senate Committee on Indian Affairs • New Chair: Sen. Jon Tester (MT) – Senators Cantwell and Crapo still on Committee • Legislation & Hearings – FY 2015 President’s Budget – March 26 th – S. 1570 amend IHCIA for Advanced Appropriations – S. 919 amend ISDEAA to expand selfgovernance – Other Tribe specific and education, children related bills

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 (DMT), Tom Udall (D-NM), Brian Schatz (D-HI), Al Franken (DMN) • Medicare-like Rates?

FY 2014 Budget Highlights • FY 2014 budget $303 million increase over FY 2013 Operating Plan*** – ***Caution: Only $78 million over the FY 2014 Pre -Sequester Amount – Loss of $175 million • Program Increases for (Detail of changes): – – – $42. 4 million for CHS $24. 9 million for facilities accounts $71. 9 million for staffing new facilities $35 million for medical Inflation $129. 6 million for CSC

FY 2014 & CSC Funding • IHS and BIA will fully fund CSC payments in FY 2014 and President’s FY 2015 budget proposes same – IHS estimated 2014 need: $587. 4 million – FY 2013 Amt + 2014 Increase = $577. 4 – IHS needed additional $10 million to cover CSC funding; consulted with Tribes about where to make the cuts • Reductions total $10 million made as follows: – – $3 million IHS Directors Fund $5 million from Indian Health Professions $1 million from Self-Governance $1 million from Tribal Management

FY 2015 & CSC Funding • President’s Request includes $29. 6 million CSC increase • IHS proposes to continue to fully fund CSC payments to tribes into the future • IHS Contract Support Cost Workgroup has reconvened to address substantive policy issues – Develop FY 2014 Payout Plan (Refer to Handout) – Develop Standard AFA language to deal with IHS Anti. Deficiency Act concerns – Develop two-year appropriation authority – Develop strategies to deal with new/expanded programs and changing IDC rates following payout – Analyze data to better estimate CSC need for appropriations – Develop process to better estiamate CSC need; pass-throughs and exclusions

FY 2015 President’s Request • $4. 634 billion for Indian Health Service – $199 million increase (4. 5%) is respectable? – Staffing & New Tribes funding $78. 8 million takes increase down to $120. 9 million (2. 7%) * – $29 million program increase for CSC * – $15. 4 million program increase for CHS – Adjustments of $10 million to restore 2014 reductions (CSC) • Adjusting the increase for earmarks* leaves a balance of $91. 9 million for current services (does not include CHS increase) • NPAIHB estimates at least $223 million is needed to maintain current services • President’s budget will be short by $131 million to fully fund inflation and population growth

FY 2015 Detail of Changes – $199, 662 mil. increase FY 2014 Enacted Budget $ 4, 434, 515 CURRENT SERVICES: Adjustments for CSC $ 10, 000 Medical Inflation $ 63, 000 Pay Costs $ Staffing New Facilities $ 70, 818 Sub-total Current Services 2, 572 $ 146, 390 PROGRAM INCREASES: New Tribes Funding $ Purchased/Referred Care $ 15, 428 Contract Support Costs $ 29, 829 Sub-total Program Increases FY 2015 PRESIDENT’S REQUEST 8, 015 $ 53, 272 $ 4, 634, 177

FY 2016 Budget Formulation • National IHS Budget Formulation - Feb. 26 -27, 2014 in Washington DC – Representatives Andy Joseph & Steve Kutz • Recommended $779 million increase; 18% increase – $188 mil. for current services – $191 mil. for binding obligations (CSC, HFCPS, Staffing, New Tribes) – $337 mil. for program expansion (CHS, H&C, Mental Health, A/SA, Health Facilities other authorities) – $62 mil for other priorities (UIHP, facilities, dental, )

Dear Tribal Leader Letters • April 2, 2014: DTLL on CSCs as it relates to the FY 2014 Consolidated Appropriations Act & Announcing on-going Consultation • March 6, 2014: DTLL IHS Director Listening Sessions • February 27, 2014: DTLL seeking input on MSPI & DVPI • February 18, 2014: DTLL update on the IHS Consultation & follow-up to the August 2, 2012 letter • February 12, 2014: DTLL Initiating consultation on CSC issues required in FY 2014 Consolidated Appropriations Act • January 13, 2014: DTLL changing Aberdeen Area IHS to the Great Plains Area

TTAG/MMPC Updates • • • ACA Policy Subcommittee is very active – Tribal Exemption & I/T/U hardship exemption – Referrals and Cost Sharing Exemptions – CMS Final 2015 Letter to Issuers in FFM – and Proposed Rule including Minimum QHP Certification Standards Revising the CMS Tribal Consultation Policy Evaluation of CMS Strategic Plan & Updates Alternatives for Medicaid Expansion: Arkansas Model and UCC Waivers Indian definition issues IRS/CMS Resource Exemptions Extending Medicare Like Rates to non-hospital based services ACA Educational materials Data projects and studies

Affordable Care Act Individual Mandate & Exemption • • What is the ACA Tax Penalty? What is the I/T/U Hardship Exemption and who is eligible? How to apply for the Indian Exemption or I/T/U Hardship Exemption? Additional Information related to exemptions and the application: – HHS instruction are forthcoming, tax filing information, – Do you need to reapply for the exemption? – What can you do to help Tribal members? • Education Tribal members and program beneficiaries • Make sure Tribal members understand the difference between Indian Exemption and the Hardship Exemption • Prepare to offer eligibility letters • • Provide tax filing assistance 2014 Penalty = 1% household income; $95/adult 2015 Penalty = 2% household income; $325/adult 2016 Penalty = 2. 5% household income; $695/adult

TTAG/MMPC Resources • https: //www. dropbox. com/home/Delegates/Temp% 20 Folder%20 created%20 by%20 Jim • MMPC Action Items and Tracking List • TTAG Roster of Pending Regulations and Assignments

Discussion?