11/30/15

Tribal Relations 2015 –

A Year in Progress

Wyoming Medicaid

Wyoming Department of Health, Division of Healthcare Financing

Authored by: Lindsey D. Schilling

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Introduction:

The Division of Healthcare Financing (DHCF) compiled this report to serve as a

comprehensive outline of current and ongoing efforts taken by Division to sustain,

promote, and strengthen the working relationship between the Division and Wyoming’s

Northern Arapahoe and Eastern Shoshone Tribal Health leadership. The Division has

established a mechanism for notification and education of upcoming changes to policy,

as well as identified recommendations for maximizing available Medicaid dollars payable

to qualified Tribal Health facilities. This year-end report will detail all activities in which

the Division has participated or initiated in 2015 with the intent of sustaining its current

role in supporting the healthcare infrastructure on the Wind River Reservation.

This report has been divided into the following sections:

Standing Meetings

State Plan Amendment Notifications

Additional Funding Resources

New Action Items – Detail and Status

1115 Tribal Waiver Workgroup

Annual Rate Updates

Standing Meetings:

The Division provides representation for various recurring Tribal Health related events.

The list below outlines these events, and includes the 2015 dates of attendance. The

Division’s goal is to enhance State-Tribal relations and remain available and accessible to

the Tribal Health leadership. The Division has been represented to date by Tom Forslund,

Director, Wyoming Department of Health, Teri Green, State Medicaid Agent, Lindsey

Schilling, Provider Operations Administrator, Sheree Nall, Provider Services Manager and

Amy Guimond, Tribal Waiver Manager.

Provider Relations visit – (annual, May 28, 2015)

o Eastern Shoshone – 5 attendees

o IHS – 3 attendees

Bi-weekly Tribal Workgroup meetings for 1115 Waiver

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o July 28, 2015

o August 18, 2015

o September 1, 2015

o September 15, 2015

o September 29, 2015

o October 13, 2015

o November 4, 2015

o November 10, 2015 (no attendance due to Tribal holiday and other

meetings that ran long for Tribes/IHS)

Wyoming Department of Health (WDH) Tribal Leadership Advisory Council –

Riverton, WY

o August 13, 2015

o December 1, 2015

Legislative Select Committee on Tribal Relations, Riverton, WY (bi-annual or as

scheduled, currently scheduled for November 30, 2015 and December 1st)

State Plan Amendment Notifications:

As part of the established Tribal consultation process, any proposed change to existing

Medicaid State Plan is communicated in detail to those individuals identified by each

Tribe. Each notification is distributed through secure email with a read receipt request,

enabling Division staff to ensure appropriate distribution. The Division then follows-up

within fifteen (15) days of distribution to assess the need for additional conversation with

Tribal leadership and other Tribal representatives. Each designated Tribal representative

is provided an opportunity to contact the Division with additional questions or request a

meeting to review the proposed change. From the date of the initial notification, the

Division closes the Tribal comment period thirty (30) days after initial distribution. The

proposed state plan amendment (SPA) is then submitted to the Centers for Medicare and

Medicaid Services (CMS) for formal review and approval.

Since May 2015, the Division has submitted or is in the process of submitting the following

SPAs or waiver amendments after issuing appropriate Tribal notification:

May 1, 2015 - Wyoming Chiropractic Services – As a result of 2015 legislation,

Medicaid submitted a state plan amendment to CMS for the coverage of

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chiropractic services. The Division received an email of support from Cathy

Keene and Kellie Webb from the Eastern Shoshone Tribe.

May 1, 2015 - Physician Assistant (Ordering, Referring and Prescribing Provider)

Enrollment – As part of the Affordable Care Act legislation implementation,

Medicaid is required to enroll and screen all ordering, referring and prescribing

providers. This will require that Physician Assistants, Nurse Practitioners and all

other ordering, referring or prescribing provider enroll. The Division submitted a

request to CMS for inclusion of all ordering, referring and prescribing providers

to State Plan. The Division received an email of support from Cathy Keene,

representing the Eastern Shoshone Tribe.

August 19, 2015 – Reimbursement Increase to Long Term Care Waiver Providers

– Medicaid submitted a waiver amendment to CMS requesting authority to

increase the payment rate for the following services: personal care attendant,

respite care services and skilled nursing.

August 27, 2015 – Tribal Consultation Amendment – Medicaid has requested

Tribal feedback on this proposed state plan amendment which would formally

revise the Tribal Consultation process to include the WDH Tribal Leadership

Advisory Council as an additional consultation mechanism. The Division received

comments from the Northern Arapaho Tribe. This item will be an agenda item

for continued discussion during the December 1, 2015 Tribal Leadership Advisory

Council meeting.

October 19, 2015 – Guardianship Fees - Medicaid submitted a state plan

amendment to CMS requesting authority to increase the personal needs

allowance from $20 to $75 per month for institutionalized individuals.

Additional Funding Resources:

The Division continues to focus on sharing information related to additional funding

resources that may be applicable and available to Wyoming Tribes. The following is a list

of additional resources shared with appropriate Tribal Health representatives:

IHS & Home Health Services – the Division finalized IHS enrollment and payment

for home health services being delivered to current Medicaid recipients. Through

previous Committee testimony, it was revealed that IHS was delivering services

currently allowable for reimbursement under Medicaid State Plan without billing

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for them. With the establishment of appropriate enrollment IDs and revenue

codes, IHS can now bill for all covered home health services. On July 21, 2015, the

Division held a conference call with IHS to discuss home health services including

documentation, revenue codes and billing. To date (November 18, 2015) no billing

has been received for these services.

IHS and Transportation Services – On July 16, 2015, the Division held a conference

call with IHS to discuss current transportation services provided by IHS and how

the Division may be able to support reimbursement for those services. Once a

transportation letter agreement is completed, IHS can bill for services provided.

On July 28, 2015, an email was sent to IHS requesting information for the

agreement which was forwarded by the Wyoming IHS facility to Billings on August

4, 2015. On August 24, 2015 and November 4, 2015, a follow up email was sent

requesting the information. To date no additional information has come from IHS

for completion of the required letter of agreement. To date (November 18, 2015)

final processes have not been completed to provide for Medicaid reimbursement

of transportation services through IHS.

IHS and the Division – On July 7, 2015, a conference call was held to discuss year

over year payment trends, ideas on ways IHS and the Division may work

cooperatively to improve Medicaid participation and encourage continued

enrollment of qualified beneficiaries for maximization of Medicaid funding. There

was a discussion of barriers and issues with initial and re-enrollment processes.

Medicaid is prepared to support operational needs of IHS in any upcoming policy

changes or enhancements enacted to encourage continued Medicaid enrollment.

White Buffalo Enrollment – The provider enrollment for White Buffalo as a

substance abuse and behavioral health provider is complete and active. White

Buffalo received training from the Division regarding billing. On October 19, 2015,

the Division received an email requesting a conference call to discuss billing and

incorporating services from the Arapaho Clinic. The Division sent back dates and

times for a conference call. White Buffalo indicated they were working with the

former biller from IHS and would wait to schedule a meeting until they identified

the main challenges with billing. To date (November 18, 2015) no billing has been

received.

A provider enrollment application was sent in by the Northern Arapaho Tribe for

the Arapahoe Healthcare Clinic. The Division has been working with Jeanne

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Lajeunesse to make sure all components of the application have been turned in

for processing. The initial submission of the application was denied due to lack of

ownership information and additional documentation required by federal and

state regulation.

Eastern Shoshone Tribal Health is now enrolled as a 638 Clinic. On April 18 2015,

the Division was instructed by Cindy Smith at CMS to enroll this clinic and

determine services at a later date. The Tribal Health Director (Cathy Keene)

submitted the enrollment on May 20, 2015. The Clinic has been enrolled under

provider number 140025800. As of May 27, 2015 additional documentation

required to set up revenue codes by service had not been received. On July 15,

2015, Eastern Shoshone Tribal Health (Claudia Russell) forwarded an email from

CMS to the Division regarding services at the Clinic. On July 22, 2015, the Division

responded with questions for additional information requesting services and staff

providing services. On September 17, 2015 the Division held a conference call

with Eastern Shoshone Tribal Health staff (Claudia Russell and Cathy Keene)

regarding services at the Clinic, providing long term care services and

transportation services. Notes and action steps were documented. A summary

of action steps was sent to the Division and Eastern Shoshone staff on October 21,

2015. The Eastern Shoshone Tribe has submitted an enrollment to become a

provider for Home and Community Based Services and Long Term Care Waiver. A

contract was also sent by the Division to Cathy Keene on November 10, 2015 to

become a provider of transportation services. Changes to the contract were made

by the Division at the request of Cathy Keene and resent for signature on

November 12, 2015. Documentation required to set up the revenue codes and

services for the Clinic has not been received. To date (November 18, 2015) no

billing has occurred.

New Action Items – Detail and Status:

During each of the face to face meetings facilitated by the Division as requested by Tribal

Health representatives, formal meeting minutes were drafted and approved by all

attendees. In addition, a list of action items was created for formal follow-up by the

Division and/or Tribal Health representatives. Below is a list of those action items, and

the status of the required follow-up.

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1) Cathy Keene and Sara Robinson to provide dates and times for high fidelity wrap

around training at the Tribal Health Clinic.

Wyoming Response: No dates or times for additional training have been provided to the Division. Cathy has been actively in touch with Magellan, the State’s new Care Management Entity, and has been provided information on provider training, credentialing and enrollment processes.

2) Lisa Brockman and Sheree Nall to set up a call with Cathy Keene and staff (Eastern Shoshone Recovery Center) to review services currently being billed and additional opportunities for billing covered services to Medicaid.

Wyoming Response: A call took place on Nov. 4, 2014 with CMS Regional Office, Cathy Keene, Sheree Nall, and Lindsey Schilling. Additional conversation flushed out requirements for the ES Tribal Health to enroll as a recognized 638 for issuance of the encounter payment for covered services. CMS was to provide confirmation of a current 638 for ES Tribal Health, and Sheree is currently evaluating services for which payments are being sought. Eastern Shoshone Tribal Health is now an enrolled Medicaid provider pending final service documentation needed for establishing rates and revenue codes for billing. To date (November 18, 2015), the required documentation has not been received and no services have been billed.

3) WDH Tribal Leadership Advisory Council

Wyoming Response: On August 14, 2015, the first Tribal Leadership Advisory Council Meeting was held in Riverton. Twenty-eight individuals were in attendance and lunch was provided by the Division of Healthcare Financing through the college. Full meeting minutes and presentation documents are included as Attachment A. Agenda items included:

Northern Arapaho – summary of tribal information, health disparities and Northern Arapaho youth presentations

Eastern Shoshone – summary of tribal information and health disparities

IHS – presentation on definition of health from two cultural backgrounds, historical trauma, understanding current health/medical care conditions at the Wind River Unit (WRSU) and pursuit of health equity

Presentations from WDH staff on programs and initiatives

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The policy enacted by Director Forslund with approval and support from both Tribes and IHS outlined the designation of two leadership members from each Tribe and one from IHS that would contract with the WDH to receive reimbursement for participation in meetings and mileage when traveling to Cheyenne. The Division has sent two contracts out to the designated Northern Arapaho participants and has received one back. The Division is still in need of additional information to complete the contract received and has sought the needed information from the designee. The Eastern Shoshone Tribe (Cathy Keene) is still waiting for direction from the Business Council regarding the designation of two individuals to contract with the Division. The Division has continued to work with the Eastern Shoshone Tribe and IHS to establish contact information for their contracts through email and during workgroup meetings. Due to members not yet being assigned it is assumed that interim members of the WDH Tribal Leadership Advisory Council are the same as those designated to participate in the 1115 Tribal Waiver Workgroup. These individuals are Cathy Keene and Claudia Russell from the Eastern Shoshone Tribe, Richard Brannan and Carlton Underwood from the Northern Arapaho Tribe and Alice Moore from Indian Health Services.

Topics for the upcoming WDH Tribal Leadership Advisory Council Meeting include the following:

Review of the Tribal Consultation state plan amendment (SPA) which now incorporates the Tribal Leadership Advisory Council.

Review of the group charter created to provide for agreed upon goals and operational processes for member of the Advisory Council. A draft charter has been developed and shared. Feedback will be sought during the upcoming Advisory Council Meeting.

1115 Tribal Uncompensated Care Demonstration Waiver update and public comment hearing.

Site visits and facility tours of the Tribal Health facilities.

Discussion regarding Long Term Care Waiver renewal and other SPA changes.

The next Tribal Leadership Advisory Council meeting is tentatively scheduled on the day opposite of the Select Committee for Tribal Relations healthcare meeting (December 1, 2015).

1115 Tribal Waiver Work Group:

Initiated by the Division and the CMS Regional Office, weekly workgroup meetings were

scheduled starting July 30, 2014. Initially, the goal was to identify target populations,

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goals, services, and the logistics involved with requesting and implementing an 1115

Tribal Uncompensated Care Waiver. After the initial months’ worth of meetings, Tribal

representatives began meeting with CMS independently of the workgroup.

On November 17, 2014 Director Forslund and Teri Green met with Tribal representatives

in Cheyenne to review the final concept paper – a culmination of the Tribes’ work with

CMS. The Department has approached CMS concerning several outstanding questions

that would need to be addressed prior to assessing the feasibility, administrative costs

and global costs of submitting, implementing and supporting the waiver as developed,

and is still awaiting word on these clarifications. The Division and its representatives are

open to further exploring ways to support the Tribes’ efforts.

During the 2015 General Legislative Session, a federal funding placeholder was approved

in the Division’s upcoming budget year for waiver funding should a program be approved

by CMS. The Tribal Health Leadership (Cathy Keene, Richard Brannan, and Alice Moore)

committed to funding all administrative costs incurred by the Division for the

development, submission and maintenance of an 1115 Tribal Uncompensated Care

waiver.

The Tribal Waiver Manager started on July 1, 2015. The first workgroup meeting was held

on July 15, 2015 and meetings have continued bi-monthly. The workgroup originally

started with six members – one member from each Tribe, one member from IHS and three

Division staff. The Division requested that each Tribe and IHS have an alternate.

Alternates were designated and forwarded from both Tribes and IHS. On September 1,

2015 additional individuals (not identified to be alternates) were added to the work group

meetings by the Northern Arapaho Tribe.

Original members and alternates include:

Eastern Shoshone Tribe – Catherine Keene and Claudia Russell

Northern Arapaho Tribe– Richard Brannan and Carlton Underwood

Indian Health Services, Wind River Service Unit – Alice Moore and Margaret

Cooper

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Eight Division-Tribe workgroup meetings have taken place and three additional meetings

have occurred with CMS (one CMS meeting was cancelled due to lack of Tribal

participation). The notes for these meetings have been attached as Attachment B.

Consultation meetings between the Division, CMS, IHS and Tribes – 1115 Waiver

o August 7, 2015 (no tribal participation)

o August 21, 2015

o September 02, 2015

Consultation meeting between the Division and CMS

o November 12, 2015 discussion regarding concept paper and waiver

application

The Eastern Shoshone Tribe set up a conference call on September 9, 2015 to initiate

collaboration with the National Indian Health Board (NIHB) to gather needed information

regarding uninsured numbers for the Wyoming AI/AN population. A phone call was also

conducted on August 21, 2015 with the California Rural Indian Health Board to discuss

the challenges and successes of the state’s implementation of their 1115 Uncompensated

Care Waiver. Ultimately, Tribal Health designees and the Wind River Service Unit (IHS)

have provided crucial information and data needed to complete an initial application of

the Demonstration waiver.

The final waiver concept paper, as reviewed and approved by all workgroup members,

was officially submitted to CMS on October 15, 2015. The Tribal Waiver Manager

continues to work on the Waiver application as we wait for comment on the concept

paper. During discussions with Lane Terwilliger (CMS), CMS indicated the Division did not

need to wait for CMS comments on the concept paper prior to beginning the public

comment period or submission of the initial waiver application. The Division released a

final draft of the waiver application for public comment on November 17, 2015.

Anticipated schedule for 1115 Demonstration Tribal Uncompensated Care Waiver:

November 16-December 16 – 1115 Demonstration Tribal Uncompensated Care Waiver

application published for public comment (up to three public comment hearings will take

place, tentative dates November 30, December 1 & December 3).

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On or before December 31, 2015 – Formal submission 1115 Demonstration Waiver

application to CMS for review.

July 2016 – Implementation of 1115 Demonstration Tribal Uncompensated Care Waiver

with supplemental issued as agreed upon in fully executed contracts between the Division

and qualified Tribal Health providers.

Annual Rate Updates:

On an annual basis, the Office of Management and Budget (OMB) update the federal

encounter rates for services provided by IHS and other Tribal 638 facilities. Under current

Medicaid State Plan, IHS and enrolled Tribal 638 facilities are eligible for the payment of

two (2) separate encounters per day per Medicaid client. In addition, the Division makes

the payment change effective Jan. 1 to mirror the federal effective date. This action

results in a mid-year mass adjustment and lump sum payment to these qualified facilities

for services already rendered and billed.

The following is a list of the most recent rate increases implemented for 2015:

Provider: Indian Health Service *Fees are paid per patient encounter, up to two (2) encounters per day 0779 Health Check Screening – increased from $342.00 to $350.00 0500 Medical Encounter (within the IHS clinic) – increased from $342.00 to $350.00 0512 Dental Encounter (within the IHS clinic) – increased from $342.00 to $350.00 0519 Optometric Encounter (within the IHS clinic) – increased from $342.00 to $350.00 0259 Pharmaceutical Encounter (within the IHS clinic) – increased from $342.00 to $350.000771 WY VIP Administration – increased from $342.00 to $350.00 0987 Hospital Encounter (paid when the IHS physician is at the hospital) – increased from $266.24 to $271.56 0421 Physical Therapy - $266.24 to $271.56 0441 Speech Therapy - $266.24 to $271.56 0431 Occupational Therapy - $266.24 to $271.56 0551 Skilled Nursing - $266.24 to $271.56 0561 Social Worker - $266.24 to $271.56 0571 Home Health Aide - $266.24 to $271.56

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Provider: Eastern Shoshone Tribal Health –Recovery Program *Fees are paid per patient encounter, up to two (2) encounters per day 0500 Medical Encounter (within the IHS clinic) – increased from $342.00 to $350.00 Provider: Morning Star Manor * Fee is paid on a per diem basis for all Native American and Non-Native American clients. Per Diem Rate increased from $266.24 to $271.56 Numbers for Morning Star from May – November 2015 14 Native Americans (100% FMAP), 2 “other” (50/50 FMAP) and 8 White/Caucasian (50/50 FMAP)

Provider: Telehealth

IHS facility may increase access to specialty providers elsewhere throughout Wyoming.

On Monday May 19, the Division received a request from Cindy Smith, CMS

Regional Office, to participate in a call regarding tele-health opportunities.

The meeting was requested by the Eastern Shoshone Tribe. The Division,

CMS, and Tribe are currently working to determine a feasible date and

time.

Provider Enrollment:

With the enactment of the Affordable Care Act, CMS finalized CFR §455.414 requiring

states to implement new provider enrollment and screening provisions. The Affordable

Care Act (ACA) requires that all Medicaid providers be screened and reenroll at least every

5 years. Prior to May 1, 2014, the Division of Healthcare Financing sent out notice

detailing all steps for reenrollment and the requirement to complete the process by

December 31, 2015. Four notices have been sent to providers requesting they reenroll

by the December 31, 2015 deadline. If providers do not reenroll by the deadline their

provider number and agreement may be deactivated.

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Upon review of the data sent out bi-weekly by the Program Integrity Unit, two tribal

facilities still need to complete the reenrollment process. The Tribal Waiver Manager

contacted the Indian Health Services provider and followed up with an email on

September 28, 2015 and November 3, 2015 discussing the process and deadline for

reenrollment of their facility. An email was also sent on September 28, 2015 and

November 3, 2015 to the Eastern Shoshone Tribe indicating they have one facility that

needs to reenroll. The Eastern Shoshone Tribe have started the process of reenrolling

the facilities, asking for guidance regarding these reenrollments. In addition the Eastern

Shoshone Tribe has started the enrollment process to become a Long Term Waiver

Provider.

Summary:

Throughout 2015, the Division has worked to increase Tribal participation in routine

conversations regarding proposed policy and coverage changes, provider challenges, and

overall healthcare system reform and gaps. Wyoming’s Tribal communities are an integral

part of the State’s demographic infrastructure and have a pertinent role in the

conversation.

The Division has and will continue to remain open and willing to work collaboratively with

Tribal leaders to identify and leverage existing opportunities for maximizing available

Medicaid funding. The Division is aware of the ongoing healthcare challenges and health

disparities within our Tribal Communities. As additional opportunities become available,

the Division will explore those options and provide the Tribal leadership with the guidance

and process knowledge necessary for the effort to be successful.