PowerPoint Presentation

Inter Tribal Council of Arizona Affordable Care Act (ACA) AI/AN Outreach & Enrollment Arizona Enrollment Assistance Training September 15, 2014

1Health insurance reforms1

Health Care Reform & the Federal Trust Responsibility The ACA recognizes the federal trust relationship & strengthens tribal sovereignty through:Protection & enhancement of the IHS health care system with the passage of the Indian Health Care Improvement Act,Greater access to quality health care with new sources of insurance coverage and grants,Expansion of tribal government consultation in health care policy decision-making.

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ACA/IHCIA Training & Enrollment ActivityIn 2012, IHS funded a National Initiative to educate Tribal Leaders & Tribal Health Officials & to begin ACA consumer education.In 2013, IHS implemented a ACA Business Plan. Certified Application Counselors (CACs) have been added to the IHS workforce (NAO-62, PAO-27, TAO-8, PYT-8, Native Health-1). Navigators are working at TCRHCC & NAC thru AACHC.

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Training/Enrollment ActivityInter Tribal Council of Arizona, Inc. received its first ACA training grant in 2012. The current grant is in place through December 2014. ITCA provides training to the Tribes in the Phoenix and Tucson IHS Areas (Arizona, but not the Navajo Nation, 3 of 8 Tribes in Utah and all of Nevada).The Arizona Marketplace Workgroup grant runs through November 2014. Tribes will recommend an outreach & education strategy in terms of ACA implementation and provide other policy recommendations to the Governors office.

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Affordable Care Act Implementation in Indian Country

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ACA Implementation2014 Nearly all U.S. citizens/legal residents are now required to have health insurance that meets minimum requirements unless available coverage costs more than 8% of your income. You are covered if you have job based coverage, Medicare, Medicaid/CHIP, TRICARE/VA , a Marketplace Plan or an individual policy outside of the Marketplace. All individuals below 100% FPL and others, including American Indians, Alaska Natives and I/T/U users are not required to get insurance & are exempt from the shared responsibility tax payment that has to be paid beginning in 2015.

6Buying a policy outside of the Marketplace can be an option to consider if you dont qualify for premium tax credits. Most of these plans include the 2014 rights and protections.

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ACA Implementation2014The ACA provides ways to help people get health insurance. Individuals and families with incomes at or below 400% FPL are eligible to get tax credits for subsidies to help pay for premiums. The Health Insurance Marketplace can pay it monthly to the plan the individual enrolls in.Plus, theres no cost-sharing for AI/ANs at or below 300% FPL for any Health Insurance Marketplace plan at any metal level (bronze, silver, gold or platinum).

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ACA Medicaid Changes2014

The Medicaid Expansion option allows states to expand eligibility & obtain increased Federal funding.Governor Brewer signed the Medicaid Restoration Plan into law on 6/17/13. It restored coverage to those between 100-133% of the Federal Poverty Level, including Childless Adults AHCCCS coverage for these groups started on 1/1/14.

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CHIP: Childrens Health Insurance Program (KidsCare)SNAP: Supplemental Nutrition Assistance ProgramTANF: Temporary Assistance for Needy Families

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ACA Medicaid Changes2014State Medicaid programs are now required to use the new Modified Adjusted Gross Income (MAGI) methodology and streamline screening and enrollment into four eligibility categories children, pregnant women, parents/caretaker relatives and other adults.

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MAGI does not include-SSI, TANF, Veterans disability, Workers Compensation, child support, federal tax credits & cash assistanceFoster care, guardianship or adoption assistance payments, scholarships & education grants not used for living expenses. Distributions from Alaska Native Corporations & Settlement Trusts; from property held in trust by the Secretary of the Interior; from real property ownership interests related to natural resources & improvements & BIA student financial assistance.(Note: An amount received as a lump sum shall only be counted as income only in the month received).

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ACA Implementation2014The 2013 Poverty Guidelines for Household Income of the lower 48 States and the District of Columbia will be used to determine eligibility for seeking financial assistance:

100% FPL/1 person=$11,490100% FPL/4 Persons=$23,550133% FPL/1 person=$15,282133% FPL/4 persons=$31,322300% FPL/1 person=$34,470300% FPL/4 persons=$70,650400% FPL/1 person=$45,960400% FPL/4 persons=$94,200

11Affordable Care Act (42 U.S.C. 18081), requires an Exchange to make an advance determination of eligibility for individuals enrolling in coverage through the Exchange and seeking financial assistance. At the time of enrollment, the Exchange determines (1) whether the individual meets the income requirements for advance credit payments, and (2) the amount of the advance payments. Per 42 U.S.C. 18082, the advance payments are made monthly to the issuer of the qualified health plan in which the individual enrolls.

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Recommended Tribal Documentation for Enrollment (AI/AN & I/T/U Users) Electronic data verification w/IHS RPMS Tribal enrollment card Certificate of degree of Indian blood Shareholder certificate for Alaska Native Regional or Village Corporation Tribal enrollment certificate Tribal Census Document Birth certificate linking child to parentAdoption certificate linking child to parentFoster care documentation linking child to AI/AN foster parentDisability determination linking child to AI/AN parentIHS/Tribal Form or Letter verifying eligibility for IHS Services Marriage Certificate with Tribal Spouse

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ACA Implementation2015For the general population, open enrollment in the Marketplace begins on November 15, 2014 and ends on February 15, 2015.American Indians/Alaska Natives have special monthly enrollment periods anytime of the year in Marketplace plans. The ACA does not change your eligibility to get health care services at an Indian health care provider. AI/ANs who enroll in a Marketplace health plan, Medicaid or CHIP may continue to receive these services.

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ACA Implementation2015IHS is not insurance. IHS provides medical and public health services. Insurance affords greater access to services at IHS, Tribal and Urban Indian program providers by increasing their revenue. In some cases referrals to private providers is necessary through Contract Health Service (CHS) referrals. This is when having health insurance will help American Indians. (This program was recently renamed as Purchased/Referred Care (PRC). American Indian people will benefit from increased revenue to the Indian health care system and greater access to care.

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ACA Implementation2015IRS Reporting Individual Shared Responsibility PaymentIf you can afford health insurance, but choose not to buy it, you must pay a fee known as the individual shared responsibility payment when you file your federal income tax return in 2015.

The ACA requires you and each member of your family to either:Have minimum essential coverage, orHave an exemption from the responsibility to have minimum essential coverage, orMake a shared responsibility payment when you file your 2014 federal income tax return in April 2015.

People with health insurance coverage do not need to do anything more than maintain that coverage. Tax forms will be developed to report the information.

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ACA Implementation2015IRS Reporting Individual Shared Responsibility Payment

Payment Calculations

The fee in 2014 is 1% of your yearly income or $95 per person for the first year, whichever is higher. The fee increases every year. In 2015, its 2% of your income or $325 per person and in 2016, it's 2.5% of income or $695 per person, whichever is higher.

The payment for an uninsured child is of the adult rate. The individual who claims the dependent will be responsible for the payment

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ACA Implementation2015IRS Reporting Individual Shared Responsibility Payment Statutory Exemptions

Youre uninsured for less than 3 months of the yearThe lowest-priced coverage available to you would cost more than 8% of your household incomeYou dont have to file a tax return because your income is too low Youre a member of a federally recognized tribe. Youre a member of a recognized health care sharing ministryYoure a member of a recognized religious sect with religious objections to insurance, including Social Security and MedicareYoure incarcerated (either detained or jailed), and not being held pending disposition of chargesYoure not lawfully present in the U.S.

17Hardship exemption form17

ACA Implementation2015IRS Reporting - Individual Shared Responsibility Payment Regulatory Hardship Exemptions

Eligible for services through an Indian Health Service providerHomelessEvicted in the past 6 months or facing eviction or foreclosureShut-off notice from a utility companyRecently experienced domestic violenceDeath of a close family memberExperienced a fire, flood, or other natural or human-caused disaster that caused substantial damage to your propertyFiled for bankruptcy in the last 6 monthsMedical expenses you couldnt pay in the last 24 months which resulted in substantial debt

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ACA Implementation2015IRS Reporting - Individual Shared Responsibility Payment - Hardship Exemptions (cont.)

Another person is required by court order to give medical support to a dependent child. In this case, you do not have to pay the penalty for the child.As a result of an eligibility appeals decision, youre eligible for enrollment in a qualified health plan (QHP) through the Marketplace, lower costs on your monthly premiums, or cost-sharing reductions when you werent enrolled in a Marketplace plan.Your state didnt expand eligibility for Medicaid.Your individual insurance plan was cancelled.

1919American Indian Exemption Application

Who can use this form?Members of federally recognized TribesIndividuals eligible to receive services at Indian health care providers: - IHS- Tribal- Urban 20American Indian Exemption Application

Tax Household = any person you are claiming as dependents on your 2014 taxesAdultsDependents Do not include dependents who are not asking for the exemption American Indian Exemption Application

Members of federallyrecognized Tribes onlyneed to completeQuestions 1-7.

Leave rest of pageblank.Important Note: Each person in Tax household orthose claimed as dependentsneed to complete Section 2. When should I submit the application? Exemption applications are now availablePaper copy only (no electronic copies)Get paper copy online: http://marketplace.cms.gov/applications-and-forms/tribal-exemption.pdfGet a paper copy from Certified Application Counselors at IHS facilities.Mail to: Health Insurance Marketplace-Exemption Processing 465 Industrial Blvd. London, KY 407412014 Tax SeasonSubmit exemption application before filing taxesReceive Exemption Certification Number. Use on 2014 Tax filing formHow do I prove that I am exempt?An application for exemption must be completed on the specific form for: American Indian/Alaska NativesOther individuals who are eligible to receive services from an Indian Health Care ProviderOnly one application required per tax householdOnly have to submit application onceNeed the following: Federally Recognized Tribes: Tribal membership (CDIB, enrollment card, etc.)Social Security NumberInformation about people in tax householdTribal member NOT enrolled in Federally Recognized Tribe: Eligible for services from IHS, tribal (638) or urban Indian health care provider. A letter from IHS Patients Benefits Coordinator can be requested.

Affordable Care Act American Indian/Alaska NativeSpecific Protections

25Cover 2013 reqs pertaining to AIAN25

AI/AN Protections

Health Insurance Marketplace/State Exchanges:AI/AN are exempt from the mandate that requires individuals to purchase health insurance or pay a tax penalty. A process to identify exempt individuals must be allowed. The law states that the HHS Secretary will set the requirements for what information needs to be provided by individual AI/ANs. Special monthly enrollment periods for AI/AN to facilitate and overcome barriers to enrollment will be established.

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AI/AN Protections

Health plan networks must include Essential Community Providers that serve low-income and medically underserved individuals. The regulation encourages the use of the Model Indian Addendum to contract with I/T/U providers. Stakeholders/advocates must be consulted on enrolling hard to reach populations. Guidance requires consultation with Tribes on policy and operational facets that affect AI/AN.Indian Tribes, Tribal organizations, and Urban Indian organizations are organizations that may be designated as Navigators.

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AI/AN Protections

AIAN at or below 300% FPL who are federally recognized (or who meet the Indian hardship exemption) are exempt from cost-sharing in the Marketplace. There is no cost-sharing (co-pays, co-insurance, deductibles) for Indians under any Marketplace plan for services provided by the I/T/U or through a CHS referral. Health programs operated by I/T/Us shall be the payers of last resort for services provided to Indians.

28Call Center QAs (9/4/13) - For American Indians and Alaska Natives eligible to enroll in the Marketplace, there are special provisions in the law that eliminate most cost sharing, including co-pays, deductibles, and co-insurance, but AI/ANs are not exempt from paying premiums. How much your premium will be depends on your income. People with higher incomes may have to pay monthly premiums, while people with lower incomes may be eligible for programs that cover the cost of premiums. When you use the Marketplace website, you will find out if you qualify for programs that pay all or a portion of the health insurance premiums. 28

AI/AN Protections

Medicare/Medicaid/CHIP:Reimbursement for all Medicare Part B services by Indian hospitals and clinics reinstated.

All costs incurred by I/T/Us and the AIDS Drug Assistance Program in dispensing pharmaceuticals shall be counted as true out-of-pocket costs by AIANs enrolled in Medicare Part D plans.

Medicaid State agencies are required to consult with Tribes in the development of Waivers and Medicaid & CHIP State Plan Amendments (SPAs) and submit documentation of consultation to CMS. (ARRA Section 5006(e))

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AI/AN Protections

I/T/Us added to list of agencies that could serve as an Express Lane Agency under Sect. 1902(e)(13) of the Social Security Act and allowed to determine presumptive eligibility for public benefit programs.

Distributions and payments from AI/AN resources listed in ARRA Section 5006 and certain income exclusions codified in the Internal Revenue Code shall not be used in determining Medicaid or CHIP eligibility under the new streamlined MAGI methodology.

30American Recovery and Reinvestment Act (ARRA) was signed into law on 7/1/10. The definition of Indian and types of Indian income that are not to be calculated to determine the individuals level of income for Medicaid eligibility are contained in this law.

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AI/AN Protections

AI/AN income exemptions in the determination of MAGI-based income must be calculated on the Marketplace and Exchange calculator.

Qualified Indian health care benefits, including accident or health insurance that a Tribe buys for its members, a spouse or dependent, cannot be deemed as income by the IRS for tax purposes or for provision of benefits under the ACA.

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AI/AN Protections

AI/AN income exemptions for Medicaid/CHIP: Alaska Native Corporation and Land Settlement TrustsProperty Held in Trust Under the Supervision of the Secretary of the Interior Ownership Interest From Rents, Leases, Royalties, and Usage Rights Related to Natural ResourcesSub-marginal Trust Lands held in TrustDistributions with a Unique Religious, Spiritual, Traditional, or Cultural SignificanceBureau of Indian Affairs Student Financial Assistance Judgment Fund Distributions Tribal Trust Per Capita Distributions to tribal members by the BIA or a Tribe from tribal trust income collections (i.e., lease rentals, right-of-way payments, oil, mineral or timber harvesting royalties).

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ACA Training Project Staff

Alida Montiel, Health Systems Director(602) 258-4822, Ext. 1543alida.montiel@itcaonline.com

Verna Johnson, Health Program Manager(602) 258-4822, Ext. 1584verna.johnson@itcaonline.com

Cynthia Freeman, Public Benefits Program Coordinator (602) 258-4822, Ext. 1554cynthia.freeman@itcaonline.com

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AI/AN Protections

American Indian members who are active or previous users of the IHS, Tribal health programs operated under P.L. 93-638, or urban Indian health programs are exempt from premiums and other cost sharing in Medicaid/CHIP. AI/AN enrolled in AHCCCS Managed Care Plans can continue to get services through an I/T/U even if the I/T/U provider is not a provider in the individual AI/ANs managed care network.

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Thank you for this opportunity!Questions?

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