affordable care act and purchased/ referred care aka contract health services terri schmidt r.n....
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Affordable Care Act and Purchased/ Referred Care aka Contract Health ServicesTerri Schmidt R.N.Director, Division of Contract CareOffice of Resource Access and PartnershipsIndian Health Service
Purchased/Referred Care aka Contract Health Services• Is an integral part of Indian Health Service and Tribal Health
Programs as PRC/CHS purchases health care services from private sector providers to support direct care facilities.
• PRC/CHS funding is limited by appropriations and regulations restrict PRC/CHS payment unless specific criteria are met.• No accessible direct care facility;• A member or descendant of a Federally recognized Tribe and live
on a reservation;• Reside in the CHS Delivery Area and be a member of the Tribe the
CHS Delivery Area was established for; or,• Reside in a CHS Delivery Area and meet close socioeconomic ties.
• PRC/CHS is the payer of last resort
Qualified Health Plans Cost Sharing and Minimum Essential Benefits• All QHPs are required to provide 10 Essential Health Benefits (EHB)• Ambulatory patient services,• Emergency services,• Hospitalization, • Maternity and newborn care,• Mental health & substance use disorder services including behavioral
health treatment• Prescription Drugs,• Rehabilitative and habilitative services and devices,• Laboratory services,• Preventive and wellness services and chronic disease management,• Pediatric services, including oral and vision.
• Cost –sharing provisions under ACA only apply to services that are considered EHBs or covered services
Zero Cost-sharing Plan PRC/CHS
Plan Member
Provider Referral Requirements
Limited to members of Federally Recognized Tribes, Alaska Native Corp. Shareholders and are at or under 300% poverty level
In Network(Always the First Choice)
A PRC referral is not needed for the patient to receive an EHB from an “in-network” non Indian health care provider.PRC/CHS Authorized referral is required to cover the cost of non EHBs or non covered services and balance of non EHB covered services up to the MLR for hospital based inpatient and hospital based outpatient services
Out of Network
A PRC/CHS Authorized referral is required to cover the cost of out of network charges
Limited Cost-sharing Plan PRC/CHS
Plan Member Type of Provider Referral Requirements
Limited to members of Federally Recognized Tribes, Alaska Native Corp.Shareholders with any level of income
In Network A PRC referral or a referral from an urban Indian organization is required to avoid cost-sharing for EHBs.This referral needs to be authorized for all EHB services provided for during this episode of care. There is no cost to the patient or PRC program as long as the patient is referred through the PRC program.A QHP plan referral from the QHP primary care provider may be required. PRC staff need to confirm with the QHP and assist the Patient in acquiring this referral.
Out of Network PRC/CHS authorized referral is required to cover costs not covered by the plan and any cost sharing or out of network charges that would otherwise be charged to the patient up to the MLR for hospital based inpatient and hospital based outpatient services.
Silver Plan with Cost Sharing Reductions Plan Member Type of Provider Referral Requirements
For IHS beneficiaries who are not members of Federally Recognized Tribes, Alaska Native CorpShareholders but are otherwise eligible for IHS and are below 250% FPL. Cost sharing reductions are based on income not Indian status.
In Network A PRC referral authorized for payment is required for the PRC eligible patient to avoid any cost-sharing expenses after the QHP payment is made.
In addition to the PRC referral authorized for payment, a referral from the QHP primary care provider may be required. To verify if an in-network plan referral is needed contact the patient’s QHP primary care provider and confirm. If needed, assist the patient in acquiring the QHP referral to avoid any cost-sharing
Standard Plan Plan Member Type of Provider Referral Requirements
For IHS beneficiaries who are not members of Federally Recognized Tribes, Alaska Native CorpShareholders but are otherwise eligible for IHS
In Network or out of Network
A PRC referral authorized for payment is required for the PRC eligible patient to avoid any cost-sharing expenses after the QHP payment is made.
In addition to the PRC referral authorized for payment, a referral from the QHP primary care provider may be required. To verify if an in-network plan referral is needed contact the patient’s QHP primary care provider and confirm. If needed, assist the patient in acquiring the QHP referral to avoid any cost-sharing
Questions
Terri Schmidt R.N.Director, Division of Contract CareOffice of Resource Access and PartnershipsIHS, [email protected]