enrolling indian country: building capacity to reach tribal communities

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Enrolling Indian Country: Building Capacity to Reach Tribal Communities


• Be aware of health care provisions available to registered tribal members

• Identify best practices for effective partnership development with tribal outreach groups, tribes and individual members

• Connect with other professionals interested in tribal engagement and leave with personal connections to support your work

• Leave with tangible next steps to engage local tribes and tribal members

Session Objectives


Kitty Marx, DirectorDivision of Tribal Affairs Center for Medicaid and CHIP Services

Indian Health 101: History & Overview of the Indian Health System


Who is an Indian?

• There are 567 federally recognized Indian tribes

• Ethnically and culturally diverse• 250 languages actively spoken • Tribal members are recognized by

their individual tribe:• Evidenced by tribal

membership, enrollment, or other documents showing descendancy from parents, grandparents, or other ancestors


American Indians and Alaska Natives in the United States

• Per the 2010 Census, there are 5 million American Indians and Alaska Natives (AI/ANs)

• 2.2 million AI/ANs receive health services from the Indian Health Service (IHS), an agency of Department of Health & Human Services (HHS)

• Many AI/ANs are eligible for and are enrolled in Medicare, Medicaid, CHIP and the Marketplace.

• Access to CMS benefits serve as an important source of health care coverage for tribal communities and supplemental funding to IHS.


• The Federal government entered into close to 400 treaties with Indian Tribes between 1778 and 1871.

• Indian Tribes exchanged over millions of

acres of land to the U.S. Government.

• Many of the treaties contain provisions which explicitly include promises to provide health care.

• Indian health care is considered by many Tribal members as “pre-paid” treaty rights.

Federal Responsibility to Provide Health Care Based on Treaties


• The Federal government recognizes Indian Tribes as sovereign nations and this government-to-government relationship distinguishes American Indians and Alaska Natives from all other ethnic groups in the U.S.

• U.S. Constitution: Basis of government-to-government relationship

o Indian Commerce Clauseo Treaty Clauseo Supremacy Clause

• Federal trust responsibility is upheld by: o Court decisions – Cherokee Nation vs. Georgia (1831)o Federal Laws and Regulations o Presidential Executive Orders – November 5, 2009o Agency tribal consultation policies

Federal Trust Responsibility


IHS is not insurance but a comprehensive health care delivery system that provides health care in hospitals and clinics.

The Indian Health Care Improvement Act (IHCIA), first enacted in 1976, was reauthorized and made permanent by the Affordable Care Act of 2010.

In 1976, Congress enacted Title IV of the IHCIA to provide authority to IHS hospitals and clinics to receive reimbursement for services rendered to Medicare and Medicaid patients.

Congress recognized that many AI/ANs were eligible for Medicare and Medicaid services but had no access to services and providers, unless they traveled off reservation to private/public providers hundreds of miles away.

Indian Health Care Improvement Act


Dawn Coley, Director of Tribal Health Care Reform National Indian Health Board

Tribal Health Care Reform Outreach and Education


The Indian Health Care System

• The Indian Health Service (IHS) (I), tribes and tribal organizations (T), and urban Indian organizations (U) are the three components of the Indian health care system.

• 45 Indian hospitals • Over 600 Indian health centers,

clinics, and health stations, including urban programs

• When specialized services aren’t available at these sites, health services may be purchased from public and private providers through the Purchased/Referred Care Program, formerly known as Contract Health Services.


CMS Programs

CMS administers the following programs:

Medicare

Medicaid Children’s Health Insurance

Program (CHIP)

The Health Insurance Marketplace


Benefits for Tribal Communities: ACA

• Permanently reauthorizes the Indian Health Care Improvement Act (IHCIA) and strengthens the Indian Health Service’s role in health delivery.

• Strengthens the IHS and ensures that AI/ANs will be able to continue to receive services from IHS, tribal organizations, and urban Indian organizations.


• For purposes of Medicaid and CHIP, an AI/AN is a member of a federally recognized tribe, an Alaska Native Claims Settlement Act (ANCSA) corporation shareholder, or any individual eligible to receive services from IHS.

• For purposes of the Marketplace, an AI/AN is limited to members of a federally recognized tribe or ANCSA shareholders.

Definition of American Indian/Alaska Native


• Medicaid and/or CHIP (ARRA Protections)

• Resource Exemptions/Income Exclusions

• Cost Sharing Exemptions• Estate Recovery

Protections• Managed Care

Protections• States/Tribal consultation

Benefits for Tribal Communities: Medicaid

Provides special protections for AI/ANs to increase access to health coverage through:


• 100% FMAP for Medicaid-covered services provided through Indian Health and Tribal 638 facilities.

• No cost sharing for AI/ANs in Medicaid and CHIP.

• I/T/U Providers and facilities are exempt from local licensure by the State as long as they substantially meet provider requirements.

Benefits for Tribal Communities: Medicaid


• Special enrollment periods and the ability to switch plans monthly

• Cost-sharing reductions in zero cost-sharing and limited cost-sharing at any level plan, depending upon income

• Ability to apply for an exemption from the individual shared responsibility payment

Benefits for Tribal Communities: Marketplace


Members of federally recognized Indian tribes, ANCSA corporation shareholders, and their descendants, and other Indians who are otherwise eligible for services from an Indian health care provider have the following Medicaid and CHIP protections:

Do not have to pay premiums or enrollment fees and can enroll at any time

Tribal documents accepted as proof of citizenship and identity

If they receive care from an Indian health care provider or through referral to a non-Indian provider, do not have to pay any cost sharing

AI/AN Medicaid and CHIP Protections


Certain types of Indian income and resources are not counted when determining Medicaid or CHIP eligibility:

Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties

Payments from natural resources, farming, ranching, fishing, leases, or profits from Indian trust land (including reservations and former reservations)

Money from selling things that have tribal cultural significance, such as Indian jewelry or beadwork

AI/AN Medicaid and CHIP Protections


Lesa Evers, Tribal Relations Manager Montana Department of Public Health and Human Services

The Ground Game: Working In Indian Country Across Montana


Distances:West to East = 650+ milesNorth to South = nearly 400 miles

Know The Playing Field

Montana Indian Reservations

About 7% of population

About half live off the reservation in urban communities


They’ve changed

Complicated

Exceptions & Exemptions

New language

Require interpretation

At times seems easier not to play

Study The Game Rules


Have fun

Actively engage

Keep working hard

Tackle the challenges

Know the game plan may not go as expected

Don’t give up

Keep Your Head In The Game


Build your team

Be inclusive

Recruit – bring in new players, rotate, rest

Support each other

Recognize that everyone brings a set of skills to the game

Be A Team Player


Millions of people now have health coverage

Montana expanded Medicaid to a whole new population

Indians have health coverage, many for the first time ever

Good partnerships established (ex. DPHHS, CIO and IHS outreach on Montana Indian reservations)

Innovative approaches developed (ex. Two Tribes in Montana determining Medicaid eligibility on their own reservations)

Review The Game Highlights


Get Prepared For What’s Ahead

Stay positive

Keep building your team

Develop a strategy

Use your tips

Learn from your losses

Celebrate your wins


Erik Lujan, Assistant DirectorHealth Education & Outreach Program NAPPR, Inc.

Creating Partnerships with Native American Communities


Who are our Native American Partners?

• Native American Tribes and Nations• Some areas will have consortiums of Tribes:

Iroquois, Pueblos • “Urban” Native American organizations

• Most Urban organizations will have a good idea of the need and can help Identify consumers

• IHS/Tribally Operated Facilities• Most IHS/ Tribally operated facilities employ

“Benefits Coordinators” that assist Native consumers with enrollment and application processes

• Most have Community Health Representatives (CHR) that are trusted individuals with in the community


Engaging Communities

• Approaching Tribal Leadership• Tribes usually have a Protocol for Non-Native

Americans to engage with them • Remember Tribes are SOVEREIGN

Governments they are not required to engage with you, know your “Ask”

• Reach out to local IHS or Tribally operated health providers

• Information on location and contact information can be found at www.ihs.gov

• Consider formalizing your partnership• Once you have made contact consider entering

into an MOU or MOA if time permits and the Tribes allow.

• Formalizing will help assure a Tribe that you are serious about providing assistance and can provide clear guidance on the “cans” and “cannots”

http://www.ihs.gov/


Creating a Coordinated Plan

• Take some time, with identified partners, to consider what can be accomplished with in your allowed time

• Are there local resources, for example Community Health Representatives and Benefits Coordinators?

• Is there work space with internet connectivity available?

• In some parts of Native America the ACA is still new, you may need to provide training on Native American Provisions and enrollment requirements

• Inquire and be aware of cultural sensitivity practices, most tribes can provide

• Participate in already established events (when allowed)

• Make sure you have a visible, sustained presence in the community through out the allowed time

Consider:

• Realistic Goals • Available

resources• Any Training

needs• Limitations that

may exist• Community

engagement• Duration of

effort


Communication is Critical

• Set a schedule with partners • Depending on how many partners and location, set up regular

conference calls or in-person meetings if resources allow• Technical Assistance

• Partners and on the ground workers, will have questions on eligibility and enrollment, providing immediate responses demonstrates your commitment and reliability to partners and consumers

• Messaging is more than talking points• One mistake is to only provide simple talking points outreach and

enrollment need to be able to answer a consumers 2nd and 3rd question• Example: 1. What is the ACA? 2. How will it affect me? 3. I have IHS why

do I needed additional coverage?


Be Willing and Able to Adapt

• One size does not fit all. Each community, even if they are the same Tribe, is different.

• Tribes will have varying levels of: resources, population and eligibility

• Level of allowed community engagement will vary as will when you are allowed to be in the community

• If the established techniques stop being effective you must be able to adapt your plan

• Be willing to “add to” local resources not “replace” them


Ask the Panel


Takeaways and Next Steps


Dawn ColeyDirector of Tribal Health Care Reform Outreach & EducationNational Indian Health [email protected]

Lesa EversTribal Relations ManagerMontana Department of Public Health & Human [email protected] Erik LujanAssistant Director, Health Education & Outreach ProgramNAPPR, [email protected] Kitty MarxDirector, Division of Tribal AffairsCenter for Medicaid and CHIP [email protected]

Contact The Panel

Erik LujanAssistant Director, Health Education & Outreach ProgramNAPPR, [email protected]

Kitty MarxDirector, Division of Tribal AffairsCenter for Medicaid and CHIP [email protected]

mailto:[email protected]






enrolling indian country: building capacity to reach tribal communities

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