Post on 25-Jul-2020
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