ihs self-governance advisory committee ......ihs tribal self-governance advisory committee c/o...

IHS SELF-GOVERNANCE

ADVISORY COMMITTEE (TSGAC)

QUARTERLY MEETING

March 28-29, 2018

Embassy Suites DC Convention Center

900 10th Street Northwest, Washington, DC 20001

Phone: (202) 739-2001

IHS Tribal Self-Governance Advisory Committee and Technical Workgroup

Quarterly Meeting

Wednesday, March 28, 2018 (1:00 pm to 5:00 pm)

Thursday, March 29, 2018 (8:30 am to 1:30 pm)

Embassy Suites Washington DC - DC Convention Center 900-10th Street NW

Washington, DC 20001

Phone: (202) 739-2001

Table of Contents

1. TSGAC Information

a. TSGAC Agenda

b. 2018-2019 SGCE Calendar

c. TSGAC Membership Matrix

d. Workgroup Assignment Matrix

2. TSGAC Committee Business

a. Approval of Meeting Summary (January, 2018) b. Approval of TSGAC Alternate Member for Bemidji Area c. Approval of TSGAC Primary/Alternate Member for Alaska Area d. TSGAC Correspondence Grid e. Final TSGAC comments on CMS-10401 2018-03-09 f. TSGAC letter to HHS Delegation Tribal Consultation Meeting dated 2_22_18 g. TSGAC Letter to TTAG on Review of Sample SBCs w-Attach 2018-03-01d h. TSGAC Ltr to IHS Leadership re Advanced Appropriations docx dated 2_14_18 i. TSGAC Ltr to IHS Leadership re Funding Agreement Negotiation Concerns

020518 3. Contract Support Costs Workgroup Update

a. TSGAC Workgroup Report CSC 2018 Q2M

b. Letter to Andrew Joseph 2-16-18

c. Weahkee to AJoseph 97.3 policy 030518

d. CSC Workgroup Recommendation to Acting IHS Director 030718

4. Indian Health Care Improvement Fund (IHCIF) Workgroup Update

a. TSGAC Workgroup Reporting Form IHCIF

b. IHCIF Workgroup Sub-Groups and Charges

c. IHCIF January Meeting Notes_Jan 30-31 2018

5. Office of Information Technology Update (OIT)

a. ISAC Charter

b. ISAC Representative Report

6. IHS Strategic Plan Update

a. IHS SP Workgroup meeting 6- Outline

b. IHS_SP_Workgroup_Mtg_6_Summary

IHS TRIBAL SELF-GOVERNANCE ADVISORY COMMITTEE c/o Self-Governance Communication and Education

P.O. Box 1734, McAlester, OK 74501 Telephone (918) 302-0252 ~ Facsimile (918) 423-7639 ~ Website: www.Tribalselfgov.org

INDIAN HEALTH SERVICE TRIBAL SELF-GOVERNANCE ADVISORY COMMITTEE

AND TECHNICAL WORKGROUP QUARTERLY MEETING Wednesday, March 28, 2018 (1:00 pm to 5:00 pm)

Thursday, March 29, 2018 (8:30 am to 1:30 pm)

Embassy Suites Washington DC - DC Convention Center 900-10th Street NW

Washington, DC 20001 Phone: (202) 739-2001

AGENDA

Wednesday, March 28, 2018 (1:00 pm to 5:15 pm) Meeting of IHS Tribal Self-Governance Advisory Committee (TSGAC) and Technical

Workgroup with P. Benjamin Smith, Deputy Director for Intergovernmental Affairs, IHS

1:00 pm Tribal Caucus

Facilitated by: Marilynn “Lynn” Malerba, Chief, Mohegan Tribe, and Chairwoman, Indian Health Service (IHS) Tribal Self-Governance Advisory Committee (TSGAC)

• Contract Support Cost Workgroup Recommendations

• IHS Director Nomination/OTSG Director Selection

• TSGAC Report to the Information Systems Advisory Committee (ISAC)

• Community Health Aide Program Workgroup Meeting – TSGAC alternate.

• Purchased and Referred Care Workgroup Meeting

• Indian Health Care Improvement Fund (IHCIF) Workgroup

• Advanced Appropriations – Government Accounting Office interviews

• Other Issues 2:00 pm Meeting Called to Order Welcome Invocation

Roll Call Introductions – All Participants & Invited Guests 2:15 pm TSGAC Opening Remarks

Marilynn “Lynn” Malerba, Chief, Mohegan Tribe, and Chairwoman, IHS TSGAC P. Benjamin Smith, Deputy Director for Intergovernmental Affairs, IHS

2:25 pm TSGAC Committee Business

• Approval of Meeting Summary (January 2018)

• Approval of nominated TSGAC Members/Alternates

• Annual Self-Governance Consultation Conference Update, April 22-26, 2018, Albuquerque, NM

http://www.tribalselfgov.org/

IHS TSGAC & Technical Workgroup Quarterly Meeting Page 2 March 28-29, 2018 – AGENDA

2:45 pm Office of Tribal Self-Governance Update Jennifer Cooper, Acting Director, Office of Tribal Self-Governance, IHS

• Headquarter PSFA Manual Update 3:00 pm Break 3:15 pm Legislative Update

Caitrin Shuy, Director of Congressional Relations, National Indian Health Board

• Appropriations

• Restoring Accountability in the IHS of 2017 (S 1250 & HR 2662)

• Legislation Related to Veterans Affairs

• Other Updates 3:40 pm Indian Health Service Budget Update Elizabeth Fowler, Deputy Director for Management Operations, IHS Terra Branson, Self-Governance Coordinator, Muscogee (Creek) Nation

• Fiscal Year 2018 Appropriations

• Fiscal Year 2019 President’s Budget Request

• Fiscal Year 2020 National Budget Formulation 4:00 pm Contract Support Costs Workgroup Update

Elizabeth Fowler, Deputy Director for Management Operations, IHS Mickey Peercy, Executive Director of Self-Governance, Choctaw Nation

4:20 pm Indian Health Care Improvement Fund (IHCIF) Workgroup Update

James C. Roberts, Senior Executive Liaison, Intergovernmental Affairs, Alaska Native Tribal Health Consortium, Tribal Co-Chair, IHCIF Workgroup (invited) Elizabeth Fowler, Deputy Director for Management Operations, Federal Co-Chair, IHCIF Workgroup

4:45 pm Patient Protection and Affordable Care Act (ACA) Implementation Update

Cyndi Ferguson, Self-Governance Specialist/Policy Analyst, SENSE, Inc. Doneg McDonough, Consultant, TSGAC

5:00 pm Recess until March 29, 2018

IHS TSGAC & Technical Workgroup Quarterly Meeting Page 3 March 28-29, 2018 – AGENDA

Thursday, March 29, 2018 (8:30 am – 1:30 pm) Meeting of IHS Tribal Self-Governance Advisory Committee (TSGAC) and Technical

Workgroup with P. Benjamin Smith, Deputy Director for Intergovernmental Affairs, IHS

8:30 am Welcome and Introductions


8:45 am Office of Information Technology Update (OIT) CAPT Mark Rives, DSc, Director, Office of Information Technology, IHS

• Veteran Affairs’ Migration to Cerner and Impact on the Resource and Patient Management System (RPMS) Update

• Future plans for RPMS

• ISAC Workgroup Update and New Charter

• Data available to support Tribal Sponsorship Programs (TSGAC Request to IHS to design an RPMS report)

9:15 am IHS Strategic Plan Update

Marilynn “Lynn” Malerba, Chief, Mohegan Tribe, and Chairwoman, IHS TSGAC CAPT Francis Frazier, Director, Office of Public Health Support, IHS

9:45 am Division of Behavioral Health Update Anna Johnson, Management Analyst, Division of Behavioral Health, IHS

• Update on IHS behavioral health initiatives

• Proposed Opioid program funding and planning 10:15 am Joint TSGAC and IHS Work Session and Development of Follow up Items

• Review Tribal Caucus discussion topics

• Recap Tribal priorities from TSGAC session

• Identify next steps and timeline 11:55 am Closing Remarks


12:00 pm Lunch 12:30 pm TSGAC Technical Workgroup Session 1:30 pm Adjourn TSGAC Meeting

2018 Calendar

Date Event Location

January 23-25, 2018

1st Quarterly Meeting Washington, DC-Embassy Suites DC Convention Center

March 27-29, 2018 2nd Quarterly Meeting Washington, DC Embassy Suites DC Convention Center

April 22-26, 2018 Tribal Self-Governance Annual Consultation Conference

Albuquerque Convention Center Albuquerque, NM

July 17-19, 2018 3rd Quarterly Meeting Washington, DC-Embassy Suites DC Convention Center

September 11-12, 2018 (Tentative)

Tribal Self-Governance Strategy Session

Doubletree Downtown St. Paul, Minnesota

October 1-4, 2018 4th Quarterly Meeting Washington, DC-Embassy Suites DC Convention Center

2019 Proposed Calendar

Date Event Location

January 22-24, 2019

1st Quarterly Meeting Washington, DC-Embassy Suites DC Convention Center

March 26-28, 2019 2nd Quarterly Meeting Washington, DC-Embassy Suites DC Convention Center

April 21-25, 2019 Tribal Self-Governance Annual Consultation Conference

Grand Traverse Resort and Spa, Traverse City, Michigan

July 16-18, 2019 3rd Quarterly Meeting Washington, DC-Embassy Suites DC Convention Center

September 10-12, 2019 Tribal Self-Governance Strategy Session

TBD

October 1-3, 2019 4th Quarterly Meeting Washington, DC-Embassy Suites DC Convention Center


P.O. Box 1734, McAlester, OK 74501 Telephone (918) 302-0252 ~ Facsimile (918) 423-7639 ~ Website: www.tribalselfgov.org

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MEMBERSHIP LIST (May 19, 2017)

AREA MEMBER (name/title/organization) STATUS CONTACT INFORMATION Alaska Jaylene Peterson-Nyren, Executive

Director Kenaitze Indian Tribe

Primary 150 N Willow St. Kenai, AK 99611 P: (907) 335-7200 Email: [email protected]

Gerald “Jerry” Moses, Senior Director Intergovernmental Affairs, Alaska Native Tribal Health Consortium

Alternate 4000 Ambassador Drive, LIGA Department Anchorage, AK 99508 P: (907) 729-1900 Email: [email protected]

Albuquerque Ruben A. Romero, Governor Pueblo of Taos

Primary PO Box 1846 Taos, NM 87571 P: 575-758-9593 ~ F: 575-758-4604 Email: [email protected]

Raymond Loretto, DVM, Tribal Council Representative Pueblo of Jemez

Alternate PO BOX 100 Jemez Pueblo, NM 87024 P: 575-834-7359 ~ F: 575-834-7331 Email: [email protected]

Bemidji Jane Rhol, Tribal Council Secretary Grand Traverse Band of Ottawa & Chippewa Indians

Primary 2605 N West Bay Shore Drive Peshawbestown, MI 49682-9275 P: (231) 534-7494 Email: [email protected]

VACANT Alternate

Billings Beau Mitchell, Council Member Chippewa Cree Tribe

Primary PO Box 544 Box Elder, MT 59521 Email: [email protected]

Shelly Fyant, Tribal Council Member The Confederated Salish and Kootenai Tribes of the Flathead Nation

Alternate PO BOX 278 Pablo, MT 59855 P: (406) 275-2700 ~ F: (406) 275-2806 Email:

California

Ryan Jackson, Council Member Hoopa Valley Tribe

Primary PO Box 1348 Hoopa, CA 95546 Email: [email protected]

Robert Smith, Chairman Pala Band of Mission Indians

Alternate 35961 Pala-Temecula Rd. Pala, CA 92059 P: 760-891-3519 ~ F: 760-891-3584 Email: [email protected]

Great Plains VACANT Primary

VACANT Alternate

Nashville Marilynn “Lynn” Malerba, Chief Mohegan Tribe of Connecticut TSGAC Chairwoman

Primary 5 Crow Hill Road Uncasville, CT 06382 P: 860-862-6192 ~ F: Email: [email protected]

TSGAC & Technical Work Group Membership List May 19, 2017

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Casey Cooper, Chief Executive Officer Eastern Band of Cherokee Indians Hospital

Alternate 43 John Crowe Hill Rd. PO Box 666 Cherokee, NC 28719 Email: [email protected]

Navajo Jonathan Nez, Vice President Navajo Nation

Primary PO BOX 7440 Window Rock, AZ 86515 P: (928) 871-7000 Email: [email protected]

Nathaniel Brown, Delegate of the 23rd Navajo Nation Council Navajo Nation

Alternate PO BOX 3390 Window Rock, AZ 86515 P: (928) 871-6380 Email: [email protected]

Oklahoma 1 John Barrett, Jr., Chairman Rhonda Butcher, Director Citizen Potawatomi Nation

Primary Proxy

1601 S. Gordon Cooper Dr. Shawnee, OK 74801 P: 405-275-3121 x 1157 F:405-275-4658 Email: [email protected]

Kay Rhoads, Principal Chief Sac and Fox Nation

Alternate 920883 Hwy 99 Stroud, OK 74079 P: (918) 968-3526 x 1004 F: (918) 968-1142 Email: [email protected]

Oklahoma 2 Jefferson Keel, Lt. Governor Chickasaw Nation

Primary PO Box 1548 Ada, OK 74821 P: 580-436-7232 ~ F: 580-436-7209 Email: [email protected]

Gary Batton, Chief Mickey Peercy, Executive Director Choctaw Nation of Oklahoma

Alternate Proxy

PO Box 1210 Durant, OK 74702 P: 580-924-8280 ~ F: 580-920-3138 Email: [email protected]

Phoenix VACANT

Primary

VACANT Alternate

Portland W. Ron Allen, Tribal Chairman/CEO Jamestown S’Klallam Tribe TSGAC Vice-Chairman

Primary 1033 Old Blyn Highway Sequim, WA 98382 P: 360-681-4621 ~ F: 360-681-4643 Email: [email protected]

Tyson Johnston, Vice President Quinault Indian Nation

Alternate P.O. Box 189 (1214 Aalis Drive) Taholah, WA 98587 P: 360-276-8211 ~ F: 360-276-4191 Email: [email protected]

Tucson Daniel L.A. Preston, III, Councilman Tohono O’odham Nation

Primary P.O. Box 837 Sells, AZ 85634 P: (520) 383-5260 Email: [email protected]

Anthony J. Francisco, Jr., Councilman Tohono O’odham Nation

Alternate P.O. Box 837 Sells, AZ 85634 P: (520) 383-5260 Email: [email protected]



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TSGAC TECHNICAL WORKGROUP AREA MEMBER (name/title/organization) STATUS CONTACT INFORMATION Alaska Brandon Biddle

Alaska Native Tribal Health Consortium

Tech Rep 4000 Ambassador Drive Anchorage, Alaska 99508 P: 907-729-4687 Email: [email protected]

Alberta Unok Deputy Director Alaska Native Health Board

Tech Rep 4000 Ambassador Drive Anchorage, Alaska 99508 P: 907-562-6006 Email: [email protected]

Albuquerque Shawn Duran Taos Pueblo

Tech Rep P.O. Box 1846 Taos, N.M. 87571 P: 575.758.8626 ext. 115 Email: [email protected]

Bemidji John Mojica Mille Lacs Band of Ojibwe

Tech Rep 43408 Oodena Drive Onamia, MN 56359 P: 320-532-7479 ~ F: 320-532-7505 Email: [email protected]

Billings Ed Parisian Chippewa Cree Tribe

Tech Rep PO Box 544 Box Elder, MT 59521 Email: [email protected]

California VACANT

Tech Rep

D.C. (National)

C. Juliet Pittman SENSE Incorporated

Tech Rep Upshaw Place 1130 -20th Street, NW; Suite 220 Washington, DC 20036 P: 202-628-1151 ~ F: 202-638-4502 Email: [email protected]

Cyndi Ferguson SENSE Incorporated

Tech Rep Upshaw Place 1130 -20th Street, NW; Suite 220 Washington, DC 20036 P: (202) 628-1151 ~ F: (603) 754-7625 C: (202) 638-4502 Email: [email protected]

Doneg McDonough

Tech Rep (Health Reform)

Phone: 202-486-3343 (cell) Fax: 202-499-1384 Email: [email protected]

Great Plains VACANT Tech Rep

Nashville Dee Sabattus United South and Eastern Tribes, Inc.

Tech Rep 711 Stewarts Pike Ferry, Suite 100 Nashville, TN 37214 Email: [email protected]

Navajo Patrese Atine Navajo Nation Washington Office

Tech Rep 750 First Street NE, Suite 1010 Washington, DC 20002 P: 202.682.7390 E-mail: [email protected]

Oklahoma Rhonda Farrimond Choctaw Nation

Tech Rep PO Box 1210 Durant, OK 74702 P: 580-924-8280 ~ F: 580-920-3138 Email: [email protected]


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Melanie Fourkiller Choctaw Nation Tribal Technical Co-Chair

Tech Rep PO Box 1210 Durant, OK 74702 P: 580-924-8280 ~ F: 580-920-3138 C: 918-453-7338 Email: [email protected]

Karen Ketcher Cherokee Nation

Tech Rep PO Box 948 Tahlequah, OK 74465 P: 918-772-4130 Email: [email protected]

Kasie Nichols Citizen Potawatomi Nation

Tech Rep 1601 S. Gordon Cooper Dr. Shawnee, OK 74801 P: 405.275.3121 ~ F: 405.275.0198 C: 405-474-9126 Email: [email protected]

Phoenix VACANT Tech Rep

Portland Jennifer McLaughlin Jamestown S’Klallam Tribe

Tech Rep 1033 Old Blyn Highway Sequim, WA 98382 P: (360) 681-4612 ~ F: (360) 681-4648 Email: [email protected]

Eugena R Hobucket Quinault Indian Nation

Tech Rep PO BOX 189 Taholah WA 98587 P: (360) 276-8211 ~ F: (360) 276-8201 Email: [email protected]

Tucson Veronica Geronimo Tohono O’odham Nation

Tech Rep P.O. Box 837 Sells, AZ 85634 P: (520) 383-5260 Email: [email protected]



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FEDERAL TECHS AREA MEMBER (name/title) STATUS CONTACT INFORMATION HQ Jennifer Cooper

Deputy Director, OTSG (Federal Tech Co-Chair)

OTSG Rep 801 Thompson Ave, Suite 240 Rockville, MD 20852 P: 301-443-7821 ~F: 310-443-1050 [email protected]

Jeremy Marshall Policy Analyst, OTSG

OTSG Rep 801 Thompson Ave, Suite 240 Rockville, MD 20852 P: 301-443-7821 ~F: 310-443-1050 [email protected]

Great Plains Sandy Nelson (POC) Director, Office of Tribal Programs

Area Rep 115 4th Avenue, SE, Suite 309 Aberdeen, SD 57401 P: 605-226-7276 ~F: 605-226-7541 [email protected]

Alaska

Lanie Fox (POC) Director, Office of Tribal Programs

Area Rep

4141 Ambassador Drive, Suite 300 Anchorage, AK 99508-5928 P: 907-729-3677 ~F: 907-729-3678 [email protected]

California Travis Coleman IHS Agency Lead Negotiator

Area Rep 650 Capitol Mall, Ste 7-100 Sacramento, CA 95814 P: 916-930-3927 ~F: 916-930-3952 [email protected]

Nashville Lindsay King IHS Agency Lead Negotiator

Area Rep 711 Stewarts Ferry Pike Nashville, TN 37214-2634 P: 615- 467-1521 ~F: 615-467-1625 [email protected]

Navajo Floyd Thompson Executive Officer IHS Agency Lead Negotiator

Area Rep Hwy 264 (St. Michael, AZ) Window Rock, AZ 86515-9020 P: 928-871-1444 ~F: [email protected]

Alva Tom (POC) Director, Indian Self-Determination

Area Rep Hwy 264 (St. Michael, AZ) Window Rock, AZ 86515-9020 P: 928-871-1444 ~F: 928-871-5819 [email protected]

Oklahoma Max Tahsuda Director, Tribal Self-Determination IHS Agency Lead Negotiator

Area Rep

701 Market Drive Oklahoma City, OK 73114 P: 405-951-3761 ~F: 405-951-3868 [email protected]

Portland Denise Imholt IHS Agency Lead Negotiator

Area Rep 1414 NW Northrup Street, Suite 800 Portland, OR 97209 P: 503-414-7792 ~F:503-414-7791 [email protected]

Tucson Robert L. Price (POC) Public Health Advisor, Office of Tribal Affairs

Area Rep 7900 South J Stock Road Tucson, AZ 85746 P: 520-295-2403 ~F:520-295-2540 [email protected]


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OTHER RESOURCES MEMBER (name/title) ORGANIZATION CONTACT INFORMATION Caitrin Shuy Director of Congressional Relations

National Indian Health Board P: 202-507-4085 Email: [email protected]

Devin Delrow Director of Federal Relations

National Indian Health Board P: 202-507-4072 Email: [email protected]

TSGAC Mailing Address: c/o Self-Governance Communication and Education


INDIAN HEALTH SERVICE TRIBAL SELF-GOVERNANCE ADVISORY COMMITTEE TECHNICAL WORKGROUP ASSIGNMENTS AND FOLLOW-UP ITEMS

JANUARY 24, 2018

1. Need to fill existing vacancies on the TSGAC Committee (Alternate from Bemidji

Area; and Primary and Alternate from Phoenix Area) – (SGCE) 2. Request meeting with Tribal leaders and new HHS Secretary and IHS

leadership. 3. IHS Strategic Plan Workgroup – Send a request to IHS to include SGCE on

notice of upcoming conference calls so that this information can be broadcast out to SG Tribe (SGCE)

4. Letter to IHS regarding failure to make payment within 10 days of apportionment (per the Title V statute and regulations) – (Geoff Strommer)

5. Letter to OMB regarding all IHS personnel should be deemed essential during any government shutdown

6. Request meeting Division of Civil Rights in coordination with NIHB and TTAG regarding exemption of Medicaid work requirements for AI/ANs. Need to discuss relationship between Tribes and the U.S. government.

7. Letter to House Subcommittee regarding exemption of IHS from budget sequestration (concern is stemming from the potential of hitting the budget cap which will force sequestration)

8. Letter to to HHS Secretary and Congressional Committee of jurisdiction regarding advance appropriations. (Need to review and update the white paper on Advance Appropriation). In letter to the Congressional Committee, make a request that IHS be asked to provide Technical Assistance.

9. Letter to HHS Secretary and IHS Acting Director regarding the need for better communication and review of all proposed sub-regulatory guidance being issued which directly impacts Tribes.

10. TSGAC Letter to Congressional Committee of jurisdiction regarding re-authorization of SDPI. Also have SGCE broadcast out sample letter encouraging SG Tribes to send individual letters.

11. Develop position paper on concerns with grant funding (Jeremy – CPN) 12. Letter to IHS regarding budget infrastructure needs, including IT and sanitation

deficiencies; and also direct funding for Tribes for these infrastructure needs (Mel - this item was on Chief’s list, but I believe that Liz Fowler suggested this might be better advanced through the Budget Formulation Workgroup)

13. Invite HHS to March TSGAC meeting to make a presentation and provide an update on the status of the HHS Re-Imagine Plan



INDIAN HEALTH SERVICE TRIBAL SELF-GOVERNANCE ADVISORY COMMITTEE AND TECHNICAL WORKGROUP QUARTERLY MEETING Wednesday, January 24, 2018 (8:am to 5:00 pm)

Embassy Suites Washington DC - DC Convention Center

900-10th Street NW Washington, DC 20001 Phone: (202) 739-2001

MEETING SUMMARY

Wednesday, January 24, 2018 (8-5 pm) Meeting of IHS Tribal Self-Governance Advisory Committee (TSGAC) and Technical Workgroup with RADM Michael D. Weahkee, Acting Director, IHS

Meeting Called to Order Welcome Invocation

Roll Call Introductions – All Participants & Invited Guests TSGAC Opening Remarks Marilynn “Lynn” Malerba, Chief, Mohegan Tribe, and Chairwoman, IHS TSGAC RADM Michael D. Weahkee, Acting Director and Principal Deputy Director, IHS

• RADM Weahkee expressed IHS appreciation for the group’s patience during this shutdown and IHS support of the TSGAC. The feedback and conversations are very important. Recruiting and retaining skilled professionals is vital to our success and we continue to build future capacity. Currently, taking application for Navajo and Great Plains as well as Nashville. These AD require demonstrated leadership, broad perspective and the highest ideal of public service. Important meeting of the IHCIA workgroup is next week. The first meeting will focus on the purpose and history of the fund and recent work to update the data. We will also begin discussion for future participation in the workgroup and we will provide update.

• Please see my recent letter on the CSC policy update. This was updated after many meetings of the CSC work group. Next CSC workgroup meeting will be held on March 6-7 in Albuquerque to discuss the recent letter and address the concerns raised by TSGAC and others.

• Opiod epidemic – had the opportunity to bring the agency perspective of the impact on AI/AN within a larger group. Forming a community health aid workgroup in early March. BH aids are trained professionals. Letter and information regarding the workgroup will be sent out soon.

• Budget – current CR funds the government through February 8th. We have funding for SPDI through 3/31/18. We are waiting final funding bills.


IHS TSGAC & Technical Workgroup Quarterly Meeting Page 2 January 24, 2018 – MEETING SUMMARY

• Update on Indian Health Strategic Plan – We received comments from 137 tribes and urban organizations. Anticipate a draft plan by end of January. We will then share out for 30 day comments. Will also hold a national call; with an date of completion by April 2018. Next steps will be outlined in further detail later in the day.

• I’m proud of the work we accomplished and we could not have done this without our tribal partners. I’m pleased that our efforts are producing results. Proud of our team.

• Tribal Comment – We want to engage with the HHS Secretary on some of these key issues.

TSGAC Committee Business

Approval of Meeting Summary (October, 2017) o Motion o Second o Passed without objection

Approval of TSGAC Primary and Alternate Members for Great Plains Area

o Approved

Input on agenda topics for next Joint TSGAC/Direct Service Tribes Advisory Committee (DSTAC) Meeting Office of Tribal Self-Governance Update Jennifer Cooper, Acting Director, Office of Tribal Self-Governance, IHS

OTSG Staff Update • Jennifer Cooper reported on 3 new SG tribes, including Pasqua Yaqui Huron Band of

Potawatomi; Match-E-Be-Nash-She-Wish Band of Pottawatomi. There are now 98 Compacts and 124 Funding Agreements. A rep from Gun Lake is also interested in serving as an alternate. Some of the topics from the ALN and Tribes include timely processing of FA and timely payments. Ongoing efforts to improve our overall process. We have identified some of the recommendations that were provided by TSGAC; one area is having a national ISDEAA council.

• Third workgroup is looking at OTSG support; reviewing FTE’s, ALN’s and looking at some position descriptions and expansion of some ALN activities. We will be moving forward with these workgroups and work plans.

• We had a lot of great momentum in the last ALN meeting. We will be meeting again next week to look at other areas of improvement.

• OTSG staff update – Anna Johnson received a promotion and joined another office at the agency. She served in many roles at OTSG for many years.

• PSFA Manual – Want to make sure that the systems and versions we have are the most recent. We encountered a few technical difficulties, so we’ll be moving forward with that activity.

• Tribal Comment: My understanding is that OTSG Director is contingent on the Secretary and that this become a priority; Jennifer is doing a great job and we’re supporting her in


this position permanently. RADM Weahkee noted that this is a high priority item once the SES moratorium is lifted. This is one of several positions that we’re waiting to finalize.

Indian Health Service Budget Update Elizabeth Fowler, Deputy Director for Management Operations, IHS

• Liz Fowler -noted that FY2018 is currently operating under a CR through 2/8/18 without any specific Indian health provisions. The timing of the shutdown didn’t allow for adequate planning ahead of time. Something that we need to do better. We’re holding internal discussion about how we can improve and requested Tribal input as well on their recommendations, including improvement on communications. TSGAC recommends that all IHS be deemed essential (send to OMB)

• Follow up item: Send letter to OMB regarding all IHS be deemed essential.

• FY2019 is still in pre-decisional phase and is planned to be released in early February. There could be a slight delay because of the shutdown, but we haven’t heard at this time.

• FY2020 national budget session is February 15-16 in Arlington, VA. The area submissions have been received. We’re working with a 36% increase. All of the consolidated information has been sent back to the Workgroup to prepare for the national workgroup session. A conference call to review meeting materials in advance is being planned and date will be announced shortly. New Co-Chairs will also be elected during the February meeting.

• HHS budget consultation session is scheduled for Feb. 28 and March 1st – just 2 weeks after the IHS budget session. Stacey Ecoffey is going to see if this can be changed, but it’s not sure if that will happened. However, Secretary’s Budget Council did agree to meet with the group in advance; which is a good opportunity and significant meeting.

• Tribal Comment – We’re concerned that no agenda for next week’s IHCIA Workgroup and background materials have been shared yet with the group.

• Tribal Comment – The importance of what we’re trying to accomplish with CMS (and how it relates to IHS) for example with regards to Medicaid rates, request for data, etc. we’ve been asking for almost double what we get to advance these efforts.

• Tribal Comment – There was a request for the IHCIA materials to be updated on the website. Did you say that the compilation tables have already gone out, we haven’t received it in OK. Liz responded that they did go out on January 2nd. If there is another shut down, will behavioral health staff be reporting. The designation is the same. We’re going to need advocacy to exempt IHS from sequestration. Request that IHS advocate for this.

• Tribal Comment- It would be good to have a list of what is essential and what is non-essential. Was very concerning to me that suicide prevention staff were not deemed


essential. How do cover these activities for the non-essential staff, which is why we’re advocating for all IHS staff to be deemed essential.

• RADM Weahkee: On advance appropriations, those requests have waned; and the shutdown gives us an opportunity to review those discussions. VA let all their patients know that they were continuing services during the shutdown because they have advance of appropriations.

• Criteria we work with it is the safety and protection of patients and equipment; which includes all the direct services and most of the HQ staff. Where we have area BH consultants were not included and will take this message back to include them as well as essential. We can use that as justification Follow up item: Send letter regarding advance appropriations to HHS Secretary and Committee of jurisdiction and request that IHS be asked for TA.

• Liz Fowler – we have not been asked to provide any TA on advance appropriations by Congress. We’ve been asked by HHS to provide only minimal comments. Request to meet with Tribal Budget Formulation workgroup with GAO on advance approps.

• Tribal Comment: noted the critical budget needs. We just completed an updated using the LNF formula and these are issues that we’ll raise with the Tribal Budget Formulation Workgroup. How do we get this done? How do we quantify it in using standing metrics to update our needs. Need to agree on the scope of work and take the next step to get a contractor to get this done. My main point is that we need someone to do a report (contractor).

• Tribal Comment – non-Indian medical facilities that serve Indian people. The local hospital is beginning to lay off staff. This is an important facility that we use here in town. Patients have to be transported over 70 miles away. There needs to be some coordination to secure funding that serve us.

• We need to engage CMS and our referral hospitals to take care of our speciality needs in Indian Country. We’re relying on these facilities.

• Ben Smith – HHS is holding weekly budget planning call which is held at 3 pm on Wednesdays and will occur over the next 5 weeks. 1-888-455-7075, passcode: 9189822 These calls are intended for Tribal leaders.

Office of Resource Access and Partnerships Update Terri Schmidt, RN, Acting Director, Office of Resource Access & Partnerships (Invited)

• Terri Schmidt wanted to give a update on PRC rate savings for physicians and non-hospital supplies and services in FY2017. We saved $252.9 million total; 19.2 million by Tribes that use the FI. There are tribes that implemented the PRC, but we don’t have that infor. $233.7 million in PRC for physicians and non-hospitals. $100.9 million; $20.4 by Tribes.

• We have been monitoring on-line providers and don’t have very many. But we do have some ambulance and dialysis. We have modified the FI contract to pay exactly as Medicare does.


• CVS/Caremark Issue – There have been weekly calls with our technical experts and Tribal reps. CVS is providing a list of plans that want to process their own claims. Weekly calls begin last Friday and will continue. Help Desk is not helpful. There is group working on these issues. Once we work out the program, CVS has been working us; once we get the process worked out, then we’ll let everyone know and send out a DTLL. We identified 3 groups and we haven’t started those other groups, but we’ll begin working with them.

• Tribal Comment – what is your estimated timeframe?

• Response- We will let you know.

• Tribal Comment– We appreciate Terri and the workgroup to address and fix these issues.

Office of Information Technology Update (OIT) CAPT Mark Rives, DSc, Director, Office of Information Technology, IHS Carol Chicharello, Deputy Director, Health Program Improvement and Support, IHS

• Capt Rives provided a PPT presentation. Cybersecurity events have dominated recent IHS activities. Health IT events – announcement of VA to switch to Cerner. They are currently doing a review to make sure that they have all the capabilities that were promised. Military health assessment 8-week period at four test sites. IHS response to VA actions – already planning a health IT modernization effort when VA made the announcement. Current status: Request for Info published for HIT modernization with responses due 2/1/18. RFI – achieves a greater understanding of products and services available. Review of national timeline. (8 year timeline). Continuing work for IT include New Medicare card and other routine updates. Working towards a broader HIT modernization initiative include the use of Healthshare.

• Tribal Comment – What is the update on Patient information and HIPPA. Covered under security and privacy approvals.

• Tribal Comment – How we might proceed with system transition – assess the capabilities and needs of the system.

• Response - We’re working with HHS and Chief Technology Officer in implementing Health Electronic Records.

• Tribal Comment – Please remember that some of us in Southern CA don’t have hospital and we use clinics that utilized Next Gen software and we recommend you become familiar with this as well.

Joint TSGAC and Acting IHS Director Discussion

• Tribal Comment: As part of the CSC workgroup, we gave in to 97/3 issue and this was intensely negotiated and we worked on that. These discussions included OGC. It feels like “a handshake that goes sour”! Mr. Hartz made a commitment at the last TSGAC meeting that under the SDSF would change the definition of non-Indian community and that didn’t happen. It’s a bald face lie; slip in the face. You can’t tell us that and not do it. It was promised to us. Don’t mislead the tribal reps.


• Tribal Comment: This is a big problem in Indian Country. We thought this would be fixed and now it’s the law of the land for at least one more fiscal year; and it impacts our boots on the ground staff.

• Response: Sometimes we need to step back and look at what the statute says and where those lines were drawn. We have identified opportunities to talk more about it and come to an understanding. OGC is our advisors, not decision makers. For CSC, we had the request elevated to the Acting Secretary level. There are instances where we have negotiated rulemaking, I’m being cautious about where we take the negotiated of policy discussion. I hear what you’re saying and it’s been elevated to the Department level. I told the STAC last week that I would like to push forward with a response to Chairman Joseph’s letter on CSC and then have a more in-depth conversation at the upcoming meeting. Mr. Hartz will be here this afternoon.

• RADM Meeks: one of the most concerning part of the SDF guidelines was the language dealing with non-Indian communities. Definition of Indian community’s language is in their and we will engage in discussions. It has been taken out of the guidelines now. Community project will be scored on the deficiency levels.

• Tribal Comment: When you run into these types of issues, you should err on the side of the Tribes.

• Tribal Comment: I get very annoyed with OGC. They are a legal advisor and they are not always right. I’m going to hold them accountable and you serve the Tribes and the Director. We worked hard for this policy and long, tense meetings. This is very disturbing from my perspective.

• RADM Weahkee: I respect the OGC team in place and we do rely on them quite heavily in a number of area. This was merely a legal decision, but there are also financial situations. I have full faith that we’ll work through this. Our Acting Secretary is a previous OGC attorney who works on CSC issues.

• Tribal Comment: Fair enough, I know that we both trying to do the right things. Policy should never be established based on the worst performer.

• Tribal Comment: I would ask that you be thoughtful of presentations from the CSC workgroup when you meet in March. I don’t think the Tribal position has changed and don’t understand where you’re coming from on your side. We want to have thoughtful conversations, so we would like the agenda and issues in advance.

• RADM Weahkee: I will be at the CSC meeting.

• Tribal Comment: It might be helpful to have a pre-meeting call and bring everyone up to speed so that they can think about before the meeting.

• RADM Weahkee: We’re working on information in advance. We’re waiting on GAO report that will be published any day now.

Division of Regulatory Affairs:


• Sub-regulatory guidance that are coming out that have impacts on policy making, but IHS division of Regulatory Affairs are not seeing these beforehand. We’re asking IHS to be more proactive.

• RADM Weakee: We have a great relationship with CMS. Kitty keeps in touch with us.

• Liz Fowler: Perhaps IEA might be helpful in helping us to weigh in on.

• Ben Smith: DHHS hosts an Inter-Department Council on Native American Affairs. IHS is co-chair to that Council. They are currently look at that charter and this is activity that they deal with. There are a lot of opportunities listening to the conversation today. Under HHS re-imagine, they’re looking at ways to streamline functions and these issues might be a good recommendation to raise. This seems like a system issue and whether it’s being dispersed to the appropriate operating division for review. Also something that can be brought up to STAC.

• Tribal Comment: It would be helpful to get the topics and updates from the Native American Council and vice versa and how we can share our issues with them.

• Ben Smith: This is certainly an area that we can improve on. They haven’t met for some time. Each operating division has a representative on the Council and there is a tribal liaison.

• Tribal Comment: Is there Charter on line and can we get them here to TSGAC.

• Ben Smith: There Charter is currently being updated right now. Legislative Update Caitrin Shuy, Director of Congressional Relations, National Indian Health Board (Invited)

• Stacy Bohlen and Caitrin Shuy provided an update and PPT presentation. (Also see the NIHB legislative packages.) NIHB Board will be meeting next week in DC. We will determine our legislative priorities. Upcoming conferences: Public Health Summit is May 22-24, 2018 and ACC is September 17-20, 2018.

• Current CR is through 2/8/18; will need to also determine the final cap for spending. We don’t have top line numbers yet. President’s budget request included a -$300 million decrease. House and Senate included higher levels in their budget.

• We’re disturbed that SDPI was not included in the CHIP re-authorization after being told repeatedly that it would be. Sounds like the decision came directly from the Speaker’s office. We’re still encouraging everyone to contact their members about this issue. Follow up item: Send letter on SDPI and keep pushing this issue. We have sample letters and can assist with any Hill visits.

• Restoring Accountability in the IHS of 2017 (S 1250 & HR 2662)

• Not moving quickly; Tribal SG language is included. Committees are working on amended bi-cameral process.

• Tax Reform Impact on Indian Health – repealed individual mandate in the ACA; goes into effect in 2019. Indians are already exempt from the mandate. CBO predicts that 13


million fewer people will have insurance coverage by 2027; and premiums will increase by 10% most years.

• Medicaid Work Requirements – Tribes have been universally opposed to these requirements. CMS Administrator Verma indicated that she directed CMS to give AI/ANl exemptions to the work requirements but the Division of Civil Rights stopped it. Follow up item: TSGAC to request meeting Division of Civil Rights and will coordinate with NIHB and TTAG who are also requesting the same.

• Mitigating METH Act – S. 2270. – This makes Tribes eligible under the State Response to Opioid Abuse Crisis grants.

• Veterans’ Health Legislation - Reaffirm and maintain the current agreements between VA, IHS and Tribal health programs. Does include some tribal exemptions. GAO is conducting a study on impacts of the MOUs.

• Tribal Health Priorities in the Farm Bill – NIHB participated in a roundtable with the SCIA; stressed the need for federal policy to support traditional food practices, Tribal sovereignty, and self-determination.

Health Resources and Services Administration (HRSA) Dr. Michael Toedt, Chief Medical Officer, IHS Melissa Ryan Dr. Paul Young Benjamin Smith, Deputy Director for Intergovernmental Affairs, IHS

• Health professional shortage areas

• Loan Repayment Program

• Alignment of data requirements with IHS

• Melissa Ryan: provided some background information on the current shortly areas.

Allows us to focus in areas of highest needs. In 2013, we embarked on a multi-year project to streamline our process and standardize data to increase transparency. We have a new on-line system. Our next phase of the system is to get additional information into the system. We’re also engaging with our IHS colleagues and tribal reps as well.

• Dr. Paul Young: the IHS has a similar program (purpose of loan repayment program is to fund physicians who are working within the IHS system. We work closely with HRSA, but there are significant differences between our two systems.

• Dr. Michael Toedt: I want to bring some context to this discussion. Grateful for the partnership with HRSA. I understand the import of bringing in our people to this program. When primary care providers are recruited and have eligibility and they may be asked to cover some in patient care, emergency care, or administrative duties which could jeopardize their loan re-payment.

• Mr. Ben Smith:TSGAC re-iterated our request to look at these uniform measures. This issue first emerged in the Title V negotiations with the Alaska co-signors several years ago. We are not able to consolidate or streamline these measures. What is the future of


these measures? We do have our IT is working on FAQ’s to provide general information about GPRA. Mr. Smith agreed to share with the TSGAC once available.

• Tribal Response: Can HRSA response to the question raised by Dr. Toedt where it limits a primary care provider?

• Melissa Ryan: responded that the language is currently in statute. We do have half-time service. I can take that back to review further to see if its regularly or policy issue.

• Melanie Fourkiller: In regards to HPSA, you’re working to getting them in the system. Why are they not in the system?

• Melissa Ryan: There are many difference types of HPSA designations. Our geographic and population designations need to be applied for and we need to look at the data to provide a score for them. Some are already decided by statute and regulation; which is where I/T/U are situated. Essentially, they are not in our system, but we are looking to put them in our system and moving towards in 2019.

• Dr. Toedt: What advice do you have for an organization that has an automatic eligibility and it lost.

• Melissa Ryan: Send us a message at: [email protected]

• Tribal Comment: We need to look at what our overall goals here, so that we can

increase our recruitment abilities.

Continuation of Joint Discussion with TSGAC and IHS Acting Director Geoff Strommer provided an overview of the concern regarding Payment Deadline for Self-Governance Funds:

➢ Title V specifically provides that the Tribe has the option to be paid within 10 days of apportionment.

➢ IHS taking position that 10 days of apportionment does not apply to Continuing Resolutions, but only applies when Congress appropriates a full year of funding at the beginning of a year. If that position were correct, a Tribe would never be eligible for timely payment.

➢ In our view, this is a complete misinterpretation of the provisions of Title V. A Tribe has challenged the decision, and it has implications for all Tribes.

• Is IHS going to abide by its own language that it negotiated. It makes this timeframe in the statute is meaningless; and it wasn’t the intent in previous practices in negotiations and in practice. I’m taking this opportunity about this unreasonable decision. Follow up item: TSGAC will send letter on this issue (Geoff Strommer will assist.)

• RADM Weahkee: This is an on-going forum and I don’t want that to interfere and are

deliberating internally on this issue and will respond back to Pasqua Yaquai on their January 2, 2018 letter.


• Mr. Ben Smith: responded that when the law was amended to include Title V, provisions have changed. I’m not going to comment on the current dispute with Pasqua Yaquai, but it raises the idea of building awareness and education, resulting in permanent legislation. SGCE helped to document some of the unknowns. Here we are 18 years later since the 2000 amendments and the need to have continual education of SG law and principals. I think we could all benefit to paying more attention into the SG training and knowledge transfer who participated in both the demonstration phase and current participation. There are a lot of different factors and there have been challenges.

• Ms. Liz Fowler: stated that we do make every effort to make payments as timely as we

can and we recognize that we do have some work to do on our business practices and consistencies.

• Tribal Comment: I’m a little bit alarmed by your response Mr. Smith. This has been an

issue for several years and the lack of consistency and lack of adequacy of trained staff. To hear that response is disappointing. IHS has systemically did not provide training itself. I’m very frustrated.

• Tribal Comment: Let’s look at the process and what we need to do to get this resolved

at a policy level. Let’s find a reasonable timely process. Let’s come up with a game plan whether it’s a CR or permanent legislation. This may require a workgroup perhaps. It needs to be clarified.

• Mr. Smith: noted that for those Tribes that first tested out SG, they were grant

documents and we used the PMS for the quarterly draw downs. Mr. Kevin Quinn was very instrumental in helping us streamline the process. Just recently, OTSG updated the database to conform with today’s standard of IT. Any SG tribes has access to their documents 24/7. There has been progress made and it’s been in conjunction with the TSGAC and Technical Workgroup. We have the mechanism to do this and get funds out as expeditiously as possible. Your success if our success. We have never had to reassume a PSFA from a SG Tribe. We need to work beyond this and find solutions.

• Tribal Comment: We’re looking at two issues here. (1) Whether the 10 day provision is

legal; and (2) any provision that was previously negotiated and included in an Agreement that another Tribe can use since the law hasn’t changed. A simple policy decision to implement that rule would go a long way. A good place to start would be to train ALNs to that rule.

• Jennifer Cooper: stated that they have heard these same frustrations from the ALNs as

well. Through out ALN meetings, we are looking at these issues regarding negotiation and payments. We are looking at solutions. We’re willing to work with TSGAC on this.

• RADM Weahkee: This is another reason to advocate for advance appropriations.

• Shawn Duran- Use technology to assist with the training.

IHS Strategic Plan Update and TSGAC Input Lynn Malerba, Chief Mohegan Tribe and Chairwoman, IHS TSGAC


RADM Michael D. Weahkee, Acting Director and Principal Deputy Director,IHS Francis Frazier, Director, Office of Public Health Support, IHS Ms. Frazier: stated that the work has been fast and furious. Workgroup is looking at the mission, vision and goals/objectives. We received over 137 comments--- comprehensive and covering the framework of the Plan. We currently have 78 priorities. Strategies have been proposed for each of the goals and objectives. Workgroup will finalize the strategies by Feb. 1st; will publish in Federal Register (30 day comment period). During the 30 day period, we will host a town hall activity. Comments received will be responded to in a follow up Federal Register Notice. Tribal Comment: stated some of the tribes are concerned that they haven’t had enough time and input in the Plan. Federal Register and Town Hall is not enough consultation. Webinar about the process to help educate them would be helpful. There needs to be a few in-person consultation sessions. It may extend the timeline, but if you want tribes to buy in, you should provide the opportunity. Dr. Toedt: thanked Chief for the input and we value tribal input; and we will take your recommendations into consideration. You have represented the group well. Tribal Comment: underscored the need and importance of tribal consultation.

Continuation of Joint Discussion with TSGAC and IHS Acting Director • Grants – How much funding is being moved into grant. Jeremy from CPN noted that

over half of the new funding for behavioral health budget is being moved into grant funding. The return answer from agencies is that if we split the money and spread it out, it gets thin, but the ability to provided excellent service for a short period of time doesn’t help either. We understand that these programs are well-meaning, but its not the best way to manage these programs and services. CPN is developing a position paper on this issue. Encourage you to look at other vehicles to getting this funding out in a better manner.

• Re-Image HHS – is moving quickly. Workgroup looking at how HHS regions are structured and how we can get better use of this structure. They know that Indian Health has their own Area structure. We will keep everyone engaged. In terms of HR organization, we still have the proposal that was developed during the previous Administration and ready to move forward on; some will require additional funding which is part of the delay in implementation.

• Follow up item: Request HHS to attend the next Quarterly meeting and make a presentation to the TSGAC.

• CMS Medicaid Work Requirements – We need to think of the practical effect and impact on Indian Health services. RADM Weahkee will also make the same request to Office of Civil Rights regarding exemption of Indian health.

• EMS Interagency Agreement – Why was the interagency agreement not renewed? The crux of the issue is that what was in place previously was not providing safe transport for patients.


• ACA Update: Doneg reported that a workgroup has been meeting to look at Medicaid issues including three priorities: (1) greater consistency across the country for eligibility for AI/ANs; (2) expand services; and (3) protect tribes when there is cut back on funding. Looking at some changes in law; scope of services (benefit packages) tied to Indian provider; and new optional/mandatory category for AI/ANs.

• New set of data on marketplace enrollment was recently received from TTAG/CMS. Overall enrollment went up 6.8%. (See TSGAC memo shared with group). For AI/ANs meeting the ACA definition of Indian, enrollment through the FFM grew by 20.7% from 2016 to 2017. We looked at the date state-by-state.

Closing Remarks Lynn Malerba, Chief, Mohegan Tribe and Chairwoman, IHS TSGAC RADM Michael D. Weahkee, Acting Director and Principal Deputy Director IHS Meeting adjourned at 4:40 pm

Alaska Tribal Health Compact C/O Alaska Native Health Board

4000 Ambassador Drive, Suite 101 Anchorage, AK 99508

March 7, 2018 Christopher Mandregan, Jr. Director Alaska Area Native Health Services Indian Health Service 4141 Ambassador Drive, Suite 300 Anchorage, AK 99508 Re: Alaska Representatives on Tribal Self-Governance Advisory Group Dear Mr. Mandregan, The Alaska Tribal Health Compact (ATHC), collectively represents the tribes and tribal organizations that carry out the health programs and services of the Indian Health Service pursuant to the Self-Determination and Education Assistance Act, Pub. L. 93-638. We write on behalf of the ATHC, to nominate Alaska Area Representatives, Ms. Diana Zirul as the Primary Representative, Mr. Gerald “Jerry” Moses as the Alternate Representative, and Ms. Alberta Unok as the Technical Representative. Contact information: Diana Zirul Tribal Council Member Kenaitze Indian Tribe 150 N Willow St. Kenai, AK 99611 Email: [email protected] Phone: (907) 335-7200 Gerald “Jerry” Moses Senior Director, Intergovernmental Affairs Alaska Native Tribal Health Consortium 4000 Ambassador Drive, LIGA Department Anchorage, AK 995087 Email: [email protected] Phone: (907) 729-1900

Alberta Unok Deputy Director Alaska Native Health Board 4000 Ambassador Drive, STE 101 Anchorage, AK 99508 Email: [email protected] Phone: (907) 743-2525 If you have any questions or if additional information can be provided, please contact Verné Boerner, President/CEO, Alaska Native Health Board at (907) 562-6006 or [email protected]. Sincerely,

__ ATHC Co-Lead Negotiator, ATHC Co-Lead Negotiator, Natasha Singh Diana Zirul Tanana Chiefs Conference Tribally-Elected Leader, Kenaitze Indian Tribe

Updated March 9, 2018

Summary of IHS Tribal Self-Governance Advisory Committee (TSGAC) Correspondence Year: 2015-2018

Updated: March 9, 2018

Ref.

#

Date Sent/

Received Addressed To Topic/Issue Action(s) Needed

Response Received

1. 3/9/18 CMS Regulations Comments on Standards Related to Reinsurance, Risk Corridors, and Risk Adjustment (CMS-10401/OMB control number 0938-1155)

Submission of TSGAC formal comments.

2. 3/1/18 W. Ron Allen TTAG Chair

Review of Summary of Benefits and Coverage (SBC) Documents

TSGAC report and recommendations on SBCs to coordinate the efforts of the TSGAC and the TTAG with an aim to secure needed revisions to the preparation and review of SBCs.

3. 2/22/18 HHS Consultation.gov TSGAC Delegate to 20th Annual HHS Budget Consultation Session

Appointment of Melanie Fourkiller

4. 2/14/18 RADM Weahkee, Acting Director, IHS

TSGAC Support for IHS Advance Appropriations

TSGAC request to IHS to inquire with GAO and ask them for a progress report on efforts to draft a report on the use of advance appropriations authority for healthcare programs across the Federal government, including problems encountered, any estimates of cost savings, and applications to the IHS.

Summary of IHS Tribal Self-Governance Advisory Committee (TSGAC) Correspondence – 2015-2018

Page 2 – Updated March 9, 2018

Ref.

#

Date Sent/


Response Received

5. 2/5/18 RADM Weahkee, Acting Director, IHS P. Benjamin Smith Jennifer Cooper Liz Fowler

Concerns about Inconsistencies in the IHS Funding Agreement Negotiation Process

TSGAC concerns about the current disagreement between IHS and a new Self-Governance Tribe regarding the timing and responsibility of the IHS to distribute Title V payments.

6. 1/8/18 CMS Regulations.gov Medicare Program; Contract Year 2019 Policy and Technical Changes to the Medicare Advantage, Medicare Cost Plan, Medicare Fee-for-Service, the Medicare Prescription Drug Benefit Programs, and the PACE Program (CMS-4182-P)

Official TSGAC comments


Level of Need Funded

IHS/Tribal Workgroup

TSGAC list of representatives to

serve on the Workgroup.

8. 11/22/17

RADM Weahkee, Acting Director, IHS

Response to October 6,

2017 IHS CHEF Letter

TSGAC Formal comments following Redding decision.


Response to October 6,

2017 IHS CHEF Letter

TSGAC Formal comments.



Ref.

#

Date Sent/


Response Received


IHS Strategic Plan Draft

Framework, 2018-2022

Transmittal of TSGAC formal comments.

11. 11/1/17 Phoenix Area Tribes Bemidji Area Tribes Great Plains Area Tribes

IHS Tribal Self-Governance

Advisory Committee

Member Vacancy

Request for Tribal nominations to fill TSGAC vacancies


Follow-up Items from Tribal

Self-Governance Advisory

Committee Meeting,

October 24-25, 2017

TSGAC Summary of Discussion, Recommendations, Next Steps.

Letter received 1/19/18 from RADM Weahkee in

response to the TSGAC issues raised.

13. 10/30/17 Jennifer Cooper, Acting

Director, OTSG

Self-Governance National Indian Health Outreach And Education (2016-2017)

Transmittal of Final report for 2016-2017

14. 10/30/17 Honorable Don Wright,

M.D., M.P.H., Acting

Secretary, HHS & Ms.

Kathleen McGettigan,

Acting Director, OPM

Senior Executive Service

(SES) Hiring Moratorium

TSGAC Request to Exempt Indian Health Service (IHS) from Moratorium

15. 10/27/17 HHS Office of the Assistant Secretary for Planning and Evaluation Strategic Planning Team Washington, DC 20201

Department of Health and Human Services Strategic Plan

TSGAC Formal Comments



Ref.

#

Date Sent/


Response Received


Request for Service Unit Data on Health Insurance Status of Active Users

TSGAC request for updated information for FY2017


Unpaid and Underpaid Third Party Benefits from Private Insurers

Joint TSGAC and DSTAC letter requesting IHS designate it a high priority to address the inappropriate and illegal action by insurance companies and benefit mangers erroneously under paying Indian health and Tribal facilities on behalf of all of Indian country.

IHS Acting Director responded to TSGAC and DSTAC

in letter dated 10/20/17.


Sanitation Deficiency System Guide for Reporting Sanitation Deficiencies for Indian Homes and Communities

TSGAC Request for Tribal Consultation

IHS Acting Director responded to TSGAC in a multi-

issue response letter dated 10/22/17.


OTSG Director Participation in the Office of Tribal Self-Governance Director Interview and Selection Process

IHS Acting Director responded to TSGAC in a multi-

issue response letter dated 10/22/17.

20. 8/1/17 National Indian Health Board

Jake White Crow Award TSGAC Letter of Support for Myra Munson’s Nomination – Jake White Crow Award

21. 7/31/17 RADM Weahkee

Recommendations for the IHS Scholarship and Loan Repayment Programs

TSGAC formal comments and recommendations.



Ref.

#

Date Sent/


Response Received

22. 7/31/17 Jennifer Cooper Acting Director, OTSG

Request for ACA/IHCIA National Outreach and Education Funding (FY2018)

Request for on-going funding of $300,000 for FY2018.

Funding received from OTSG for project year 2017-

2018 through an amendment to the Jamestown

S’Klallam Tribe Funding Agreement (September 2017.)

23. 6/22/17 The Honorable Thomas E. Price Secretary Department of Health and Human Services

Request for Tribal Consultation on HHS Reimagining Initiative and Invitation to the TSGAC Quarterly Meeting July 18-19, 2017

TSGAC invites the Secretary or a representative from the Department to attend the meeting to provide an update of the process and review future opportunities to formally provide our feedback.

24. 6/8/17 Bradley Crutcher Chairman Fort McDermitt Paiute and Shoshone Tribe

Welcome to Self-Governance and Congratulations

Invite to the next TSGAC meeting scheduled for July 18-19, 2017. As a Self-Governance Tribe in an IHS Area with a TSGAC Alternate delegate vacancy, the Fort McDermitt is eligible to submit a letter of nomination for any elected Tribal official or their appointee to serve as an Alternate delegate and select a technical workgroup member to support their work on behalf of the Area.



Ref.

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Date Sent/


Response Received

25. 6/8/17 Wilfrid Cleveland President Ho-Chunk Nation

Welcome to Self-Governance and Congratulations

Invite to the next TSGAC meeting scheduled for July 18-19, 2017. As a Self-Governance Tribe in an IHS Area with a TSGAC Alternate delegate vacancy, the Ho-Chunk Nation is eligible to submit a letter of nomination for any elected Tribal official or their appointee to serve as an Alternate delegate and select a technical workgroup member to support their work on behalf of the Area.

26. 5/26/17

Rear Admiral Chris Buchanan Acting Director, IHS

CHEF Final Rule TSGAC Request to Delay Catastrophic Health Emergency Fund Final Rule

27. 5/26/17

Rear Admiral Chris Buchanan Acting Director, IHS

Update to Level of Need Funded Data and Workgroup Request

TSGAC request for additional educational training regarding the Indian Health Care Improvement Fund (IHCIF), LNF calculations and plans to update information related to each

Letter dated 7/18/17 received from RADM Weahkee which addresses and responses to several TSGAC letters and issues raised during the March 2017 TSGAC Quarterly meeting.

28. 5/24/17 Ms. Seema Verma Administrator Centers for Medicare & Medicaid Services

Medicaid Work Requirements for American Indians and Alaska Natives

TSGAC Comments



Ref.

#

Date Sent/


Response Received

29. 5/18/17 Rear Admiral Chris Buchanan Acting Director, IHS

RADM Kevin Meeks Acting Deputy Director of Field Operations

Tribal Participation in the Department of Health and Human Services plan to carry out Executive Order 13781

Request to Schedule a Joint TSGAC/DST Call

30. 5/10/17 Rear Admiral Chris Buchanan Acting Director, IHS

CAPT Mark T. Rives, USPHS Director and Chief Information Officer Office of Information Technology, IHS

TSGAC Delegate to the Information Systems Advisory Committee (ISAC)

Advancement of A. Stewart Ferguson, PhD, Chief Technology Officer for the Alaska Native Tribal Health Consortium, as the TSGAC delegate for the IHS Information Systems Advisory Committee (ISAC).

31. 5/5/17 Nikki Bratcher Bowman, Acting Director Office of Intergovernmental and External Affairs U.S. Department of Health and Human Services

STAC National At-Large Primary Delegate Nomination

Formal nomination of Jefferson Keel, Lieutenant Governor of the Chickasaw Nation, for the National At-Large Primary Delegate position on the Department of Health and Human Services (HHS) Secretary’s Tribal Advisory Committee (STAC).

32. 5/1/17 Department of Health and Human Services

HHS 19th Annual Tribal Budget Consultation Session on the FY 2019 Budget Request

Written TSGAC Testimony Submitted



Ref.

#

Date Sent/


Response Received

33. 4/30/17 Jennifer Cooper Acting Director, OTSG

Self-Governance Health Reform National Outreach and Education Semi-Annual Report

Transmittal of 6-month Report

34. 4/11/17 Rear Admiral Chris Buchanan Acting Director

Formation of the Community Health Aid Program (CHAP) Workgroup

TSGAC Recommendations Letter received 6/11/17 from RADM Buchanan which

states the IHS is currently addressing administrative

details to establish the CHAP Workgroup, including

selecting participants, defining key issues and determining

meeting timelines.

35. 3/7/17 CMS via regulations.gov Market Stabilization Proposed Rule (CMS-9929-P)


36. 2/27/17 Rear Admiral Chris Buchanan Acting Director Indian Health Service

Self-Governance Negotiations and Create Agency Lead Negotiator Pilot Project

TSGAC Recommendations to Improve Self-Governance Negotiations and Create Agency Lead Negotiator Pilot Project

Letter received 3/24/17 from RADM Buchanan which

includes IHS responses to this and several other recent

issues raised by TSGAC during the January 2017

meeting.

37. 1/27/17 Norris Cochran Acting Secretary Department of Health and Human Services Rear Admiral Chris Buchanan Acting Director Indian Health Service

Support for Broad Exemption of Indian Health Service from Federal Hiring Freeze

TSGAC support and request for exemption from the hiring freeze for certain staff and contracted positions at the IHS



Ref.

#

Date Sent/


Response Received

38. 12/16/16 IHS Principal Deputy Director

Identification of Staff for

Developing Level of Need

Funded Data

TSGAC provided recommendations

regarding analysis of the Indian

Health Care Improvement Fund

(IHCIF) and the Level of Need

Funded (LNF)

39. 12/14/16 IHS Principal Deputy Director OTSG Acting Director

Final Report, “TSGAC

Report Network on

Adequacy in the Health

Insurance Marketplace:

Analysis of Two Tribal Sites”

Transmittal of Final Report, “TSGAC

Report Network on Adequacy in the

Health Insurance Marketplace:

Analysis of Two Tribal Sites”


Updated Contract Support Cost (CSC) Policy

Thank you letter and request that IHS develop a training and outreach plan for Tribal and Federal employees on the new CSC Policy.

41. 11/8/16 Leonard M. Harjo Chief Seminole Nation of Oklahoma

Congratulations and Welcome to Self-Governance

42. 11/8/16 John Berrey Chairperson Quapaw Tribe of Oklahoma

Congratulations and Welcome to Self-Governance

43. 11/8/16 Daniel L.A. Preston, III Anthony J. Francisco, Jr. Representatives Tohono O’odham Nation

TSGAC Tucson Area Representatives Appointment and Participation



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44. 11/4/16 IHS Director via consultation.gov

IHS Headquarter Re-alignment


45. 11/2/16 Dr. Richard A. Stone Principal Deputy Under Secretary for Health Veterans Administration

Request for the Information about the Veterans Administration’s Co-Payment Policy

TSGAC follow up letter from October meeting and discussion with Dr. Stone

46. 11/2/16 David J. Shulkin Under Secretary for Health Department of Veterans Affairs

Veteran Affairs’ Proposal to Consolidate Community Care Programs



Catastrophic Health Emergency Fund Proposed Rule (RIN 0905-AC97)


48. 10/31/16 OTSG Acting Director Self-Governance National Indian Health Outreach and Education

Transition of Final Report for 2015-2016

49. 10/28/16 Kitty Marx, CMS Tribal Technical Advisory Group (TTAG) Appointments

TSGAC Re-appointment of TTAG Reps



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Purchasing Health Care Coverage (IHS Circular 2016-08)


51. 10/5/16 CMS via regulations.gov HHS Notice of Benefit and Payment Parameters for 2018 (CMS-9934-P)

TSGAC Formal comments


FY 2015 Report to Congress on Administration of the Tribal Self-Governance Program

TSGAC comments and request to work with IHS to implement the suggested Tribal changes.


IHS Quality Framework Draft

TSGAC Comments on IHS Quality Framework Draft

54. 8/23/16 Dr. Baligh Yehia, MD Assistant Deputy Undersecretary for Health for Community Care Veterans Health Administration U.S. Department of Veterans Affairs

Opportunities for Partnerships between Tribal Health Programs and the Veterans Administration

TSGAC comments on the existing Indian Health Services/Tribal Health Programs-Veterans Administration (IHS/THP-VA) Memorandum of Understanding (MOU) and Choice Act Agreements

VA responded on 1/6/17. VA has suggested renewing

all existing THP agreements and the VA-IHS National

Reimbursement Agreement through December of

2018.

55. 8/16/16 HHS Regulations RIN 0991-AC06: Comments on Proposed Rule; Health and Human Services Grant Regulation: Published on July 13, 2016 (81 Federal

TSGAC formal comments to

proposed rule



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Register 45270, et seq.

56. 7/21/16 Mr. Benjamin Smith, Director, Office of Tribal Self-Governance, IHS

Request for ACA/IHCIA National Outreach and Education Funding (FY2017)

TSGAC formal request for funding

57. 7/14/16 Mr. Michael Fisher Lead Contract Specialist Indian Health Service

Solicitation Number 16-IHS-HQ-SS-0001



Request to Make Self-Governance Resources Available Publicly

TSGAC request to make negotiation

documents publicly availability on

the OTSG website as resources for

Self-Governance Tribes.

59. 6/17/16 Centers for Medicare & Medicaid Services (CMS) Department of Health and Human Services P.O. Box 8011 Baltimore, MD 21244-1850

Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Proposed Policy Changes and Fiscal Year 2017 Rates, et al. (CMS-1655-P)




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Response Received

60. 6/9/16 IHS Principal Deputy Director via [email protected]

Proposed IHS Contract Support Costs Policy


61. 5/20/16 Betty Gould, Regulations Officer Indian Health Service, Office of Management Services

Payment for Physician and Other Health Care Professional Services Purchased by Indian Health Programs and Medical Charges Associated With Non-Hospital-Based Care Final Rule (RIN 0917-AA12)


62. 5/13/16 Treasury TSGAC Formal Request for Targeted Partial Administrative Relief from Employer Shared Responsibility Provisions

Summary of recommendations from 5/9/16 Tribal/Treasury technical meeting re: potential options for implementing targeted partial administrative relief in order to align the ACA’s Employer Shared Responsibility provisions with the Federal government’s long-standing “special trust responsibilities and legal obligations” to provide health care services to Tribes and Tribal members, most recently re-stated in the reauthorization of the IHCIA.


Catastrophic Health Emergency Fund Proposed Rule (RIN 0905-AC97)

TSGAC formal comments on proposed rule

mailto:[email protected]



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TSGAC Comments on SASP Program Funding Distribution

TSGAC input on the Substance Abuse and Suicide Prevention program in preparation for the funding opportunity announcement planned for early June 2016

65. 5/6/16 Steve Petzinger, OMB Program Examiner

Follow up from March 2016 Tribal Self-Governance Advisory Committee Meeting

Summary of the main issues and actions discussed during TSGAC meeting

66. 5/5/16 CMS CMS-10458, “Consumer Research Supporting Outreach for Health Insurance Marketplace


67. 4/24/16 IHS Principal Deputy Director OTSG Director ORAP Acting Director

SG National Outreach and Education on ACA/IHCIA

Transmittal of 6-month Report

68. 4/18/16 The Honorable Sylvia Burwell, HHS Secretary The Honorable Robert A. McDonald, VA Secretary

Reimbursement Agreement between the Indian Health Service and Veterans Affairs

TSGAC request to include PRC services in reimbursement agreements between the IHS/Tribes and the VA, as soon as possible.

VA responded on 1/6/17. VA has suggested renewing

all existing THP agreements and the VA-IHS National

Reimbursement Agreement through December of

2018.

69. 4/18/16 Mary Smith, IHS Principal Deputy Director

CHEF Proposed Rule 42 CFR Part 136 - RIN 0905AC97, Catastrophic Health Emergency Fund, File Code 0905AC97

Request to Withdraw Proposed Rule, conduct Tribal Consultation and then reissue the rule.

IHS issued a Dear Tribal Leader Letter on June 1st stating stated that it will engage in additional consultation before moving forward with the rule.



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Recommendations for Health Care Facilities

TSGAC Recommendations 7/23/2016 – Response letter received from IHS. The

letter outlines IHS specific responses to each TSGAC

recommendation.

71. 4/11/16 Thomas West Kathryn Johnson Treasury Department

Excise Tax on Certain

Employer-Sponsored Health

Benefits

TSGAC Follow up comments from March 2016 quarterly meeting.

72. 4/5/16 Sylvia Matthews Burwell, Secretary, Andy Slavitt Acting Administrator, Centers for Medicare and Medicaid Services

Oklahoma Section 1115 Waiver Amendment Request



Request for Service Unit Data on Health Insurance Status and 2016 Appropriation

TSGAC formal request for two sets of data:

1. Health insurance status of Active Users, by Service Unit (all Service Units) 2. IHS appropriation, by Service Unit (all Service Units)

August 26, 2016. IHS provided the following data sets

back to the TSGAC: 1) health insurance status of active

Users by Service Unit; and 2) IHS appropriation by

Service Unit.

May 17, 2017. Due to HIPPA restrictions, IHS is unable to

provide data in smaller cell counts. The information

previously provided includes as much detail as legally

allowed.

74. 2/29/16 Office of Management and Budget Office of Information and Regulatory Affairs Attn: CMS Desk Officer

CMS–10519, Agency Information Collection Activities: Submission for OMB Review




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Response Received

75. 2/19/16 Centers for Medicare & Medicaid Services

Comments on CMS-9936-N; Waivers for State Innovation


76. 2/2/16 Dr. Debra Houry, MD, MPH Director, National Center for Injury Prevention and Control Centers for Disease Control and Prevention

CDC Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain; Docket CDC-2015-0112

Support for USET Comments on the Proposed Guidelines

3/1/16 - Response received from CDC. Acknowledged the TSGAC comments. CDC expects the final Guideline to help primary care providers offer safer, more effective care for patients with chronic pain and help reduce misuse, abuse and overdoes from opioids.

77. 1/15/16 Center for Consumer Information and Insurance Oversight, CMS, HHS

Comments on Draft 2017 Letter to Issuers in the Federally-facilitated Marketplaces

TSGAC Comments on Draft Letter

78. 1/13/16 Mr. Thomas West Tax Legislative Counsel Office of Economic Policy Department of Treasury

Invited to Jan 27-28, 2016 TSGAC Meeting

Continue discussion on Permanent Administrative Relief from Affordable Care Act’s Employer Mandate on Tribes for Tribal Member Employees

Response Received January 14, 2016. Mr. West and

others are unavailable, but continue to work on this issue

as it is related to Tribes.

79. 1/5/16 Jerry Menikoff, M.D., J.D. Office for Human Research Protections Department of Health and Human Services 1101 Wootton Parkway Suite 200

Rockville, MD 20852

HHS-OPHS-2015-0008 – Proposed Revisions to the Federal Policy for the Protection of Human Subjects

TSGAC Official Comments on Proposed Rule



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80. 12/21/15 Centers for Medicare & Medicaid Services

CMS-9937-P, Notice of

Benefit and Payment

Parameters for 2017

TSGAC Official Comments on Proposed Regulation

81. 11/17/15 Kitty Marx CMS

TSGAC comments Support for 100 Percent FMAP Proposal

82. 11/10/15 Mr. Robert McSwain Principal Deputy Director, IHS

Payment of Settlements to

Civil Service Employees

TSGAC requests that IHS provide an accounting to all Tribes of all payments made by IHS into the employee settlement fund by IHS Service Unit location, as well as the number of employees participating in settlement payments at each location.

83. 11/9/15 U.S. Department of Health and Human Services Office for Civil Rights

Nondiscrimination in Health Programs and Activities (RIN 0945-AA02). 80 Fed. Reg. 54172 (Sep. 8, 2015).

TSGAC comments in response to its proposed rule on Nondiscrimination in Health Programs and Activities (RIN 0945-AA02). 80 Fed. Reg. 54172 (Sep. 8, 2015).

84. 11/3/15

Mr. Robert McSwain Ms. Mary Smith IHS

Interpretation of Duplication

Provision in 25 U.S.C. § 450j-

1(a)(3)

TSGAC respectfully urges IHS to restore its prior position that funding for contract support costs will only be considered duplicative to the extent amounts for those items have been transferred in the Secretarial amount.

Response received from Mr. McSwain on 12/4/15.

Due to pending litigation, the IHS letter provides a

general response to the issues outlined in the TSGAC

original correspondence of 11/3/15.



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85. 11/3/15

Honorable Sylvia M. Burwell, Secretary Department of Health and Human Services

Final Rule related to expand the Medicare-Like Rate

TSGAC requests that HHS expedite the review and publication of the Final Rule related to expand the Medicare-Like Rate, entitled “Payment for Physician and Other Health Care Professional Services Purchased by Indian Health Programs and Medical Charges Associated With Non-Hospital-Based Care,” 79 Fed. Reg. 72160, originally published on December 5, 2014.

86. 10/27/15 Honorable Robert A. McDonald Secretary of Veterans Affairs

Comments on Veterans Access, Choice and Accountability Act of 2014 (Choice Act)

Comments on the Secretary of Veterans Affairs’ (VA) pending report to Congress concerning the consolidation of “all non-Department provider programs” pursuant to the Veterans Access, Choice and Accountability Act of 2014 (Choice Act).

87. 10/26/15 Dr. Elaine Buckberg Deputy Assistant Secretary for Policy Office of Economic Policy Department of Treasury

Request for Permanent Administrative Relief from Affordable Care Act’s Employer Mandate on Tribes for Tribal Member Employees

TSGAC provided a set of preferred options for addressing Tribal concerns pertaining to the imposition of the ACA’s employer coverage and reporting requirements as they pertain to Tribal member employees.


Request for Extension of Transition Relief from the Employer Mandate

TSGAC requested an extension of transition relief in implementation of the employer mandate from January 1, 2015 until at least January 1, 2016 and preferably to January 1, 2017.



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Excise Tax on Certain Employer-Sponsored Health Benefits

Tribal leaders interpret Section 4980I as not applying to Tribal government thereby interpreting this to mean that the excise tax does not apply to Tribal government plans. The legal analysis for this position is provided in TSGAC’s comments to the IRS on Notice 2015-16, submitted on May 15, 2015 (attached) to letter and again in further comments submitted on October 14, 2015 (also attached to letter).

90. 10/16/15 Mr. Robert G. McSwain Mr. Ben Smith Mr. Carl Harper

Transmittal of FINAL Self-Governance National ACA Education and Outreach Report

No action needed. Transmittal of final report for the time period October 1, 2014 through September 30, 2015.

91. 10/14/15 Internal Revenue Service P.O. Box 7604 Ben Franklin Station, Room 5203 Washington, DC 20044

Notice 2015-52 on Section 4980I — Excise Tax on High Cost Employer Sponsored Health Coverage

TSGAC comments and recommendations.

92. 10/13/15 CDR Mark Rives Chief Information Officer and Director Office of Information Technology Indian Health Service The Reyes Building 801 Thompson Avenue Rockville MD, 20852

TSGAC Representative to ISAC

Appointment of Jessica Burger.



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Response Received

93. 9/30/15 Mr. Jeff Wu Deputy Director Center for Consumer Information and Insurance Oversight Centers for Medicare and Medicaid Services

Response to Request for Tribal Consultation on Referrals for Limited Cost-Sharing Variation Plans

TSGAC comments and recommendations.

94. 8/28/15 Mr. Robert G. McSwain, Principal Deputy Director

Indian Health Service

Fiscal Year 2014 Report to Congress on the Administration of the Tribal Self-Governance Program

TSGAC input on report in response to IHS request for comments.


Exemption of Tribes from the ACA Employer Mandate

Invitation to October 2015 TSGAC Quarterly meeting to discuss topic.

Confirmed attendance for Oct 7, 2015 at 10:30 am.

Pre-briefing scheduled for Oct 2.

96. 8/4/15 Mr. Robert G. McSwain, Principal Deputy Director Indian Health Service

Quality Reporting Measures Request that IHS conduct an analysis and comparison of the GPRA and Clinical Quality Management approaches.

Response received from Mr. McSwain on October 5,

2015. Mr. McSwain notified the TSGAC regarding

implementation of a major change beginning in

FY2016 on GPRA clinical performance measures. The

IHS is prepared to implement the Integrated Data

Collection System Date Mart (IDCS DM), a new

reporting mechanism within the National Data

Warehouse.

3/30/16 – Letter received from IHS which includes a

comparative analysis of GPRA/GPRAMA Performance

Reporting and CMS Clinical Quality Management

requirements. This letter and analysis was distributed

to the TSGAC and discussed during the 3/30/16



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TSGAC meeting.

97. 8/4/15 Centers for Medicare and Medicaid Services Department of Health and Human Services Attn: CMS-10561

Comments on CMS-10561, ECP Data Collection to Support Qualified Health Plan (QHP) Certification for PY 2017

TSGAC Official Comments

98. 7/28/15 Geoffrey M. Standing Bear Principal Chief Osage Nation

Welcome to Self-Governance

99. 7/27/15 Mr. Robert G. McSwain, Principal Deputy Director


Multi-Purpose Agreement (MPA) and Joinder Agreement & ISAC Presentation

Address Tribal comments on MPA; and follow up with OIT to host Webinar regarding ISAC.

100. 7/27/15 Centers for Medicare and Medicaid Services

Comments on CMS-2390-P, “Medicaid and Children’s Health Insurance Program (CHIP) Programs; Medicaid Managed Care, CHIP Delivered in Managed Care, Medicaid and CHIP Comprehensive Quality Strategies, and Revisions Related to Third Party Liability: Proposed Rules

TSGAC provided a series of substantive comments (26 pages); along with accompanying attachments. The TSGAC comments mirror the model template developed by a team of health care experts from the MMPC/NIHB.



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101. 7/10/15 Carolina Manzano Chief Executive Officer Southern Indian Health Council, Inc.


102. 7/10/15 Vincent Armenta Tribal Chairman Santa Ynez Band of Chumash Indians


103. 7/10/15 Dan Courtney Chairman Cow Creek Band of Umpqua Tribe of Indians


104. 6/29/15 Mr. Robert G. McSwain, Acting Director


Determination of Contract Support Cost Requirements

TSGAC comments in response to IHS’s position that the amount of contract support costs (CSC) owed under its contracts and compacts with Tribes and Tribal organizations under the Indian Self-Determination Act (ISDA) is determined based on “incurred costs.”



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Response Received

105. 6/12/15 Mr. P. Benjamin Smith, Director, Office of Tribal

Self-Governance, Indian Health Service

Tribal Leadership Priorities for “Self-Governance National Indian Health Outreach and Education”

The TSGAC reaffirms the commitment to empower Tribal communities with the knowledge and tools needed to successfully manage and implement the Patient Protection and Affordable Care Act/Indian Health Care Improvement Act (ACA/IHCIA) provisions concerning health care insurance coverage options to improve the quality and access to care for Tribal citizens and Indian communities. TSGAC urges OTSG to amend the Agreement to renew and fund the “Self-Governance National Indian Health Outreach and Education” contract for FY2016



Payment of IHS Employee Settlements.

TSGAC provided comments to the

May 22, 2015 IHS Dear Tribal

Leader Letter (DTLL) on the

Payment of Employee Settlements.

For the current settlement described in the DTLL, and for any future settlements, the TSGAC strongly urges the IHS to reject the flawed plan to cut health care services and consider one or both alternatives proposed.

IHS Deputy Director provided a response back to Tribal Leaders on July 29, 2015. The letter addresses three questions about the settlement

that have been raised frequently in various

forums since then.



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107. 5/15/15 Internal Revenue Service

Notice 2015-16 on Section 4980I — Excise Tax on High Cost Employer-Sponsored Health Coverage

TSGAC Comments in Request to Notice from IRS.



Healing our Spirits

Worldwide Gathering

Request of IHS support in this effort and the participation of P. Ben Smith, Director, Office of Tribal Self-Governance (OTSG).

IHS Responded on August 29, 2015 to the TSGAC and

stated that Mr. Smith is confirmed to attend and

participate in the HOSW gathering.

109. 4/23/15

Mr. Robert G. McSwain, Acting Director


Detail of OTSG Deputy

Director

TSGAC request to Director to re-evaluate the detail and assign other staff to OUIHP as soon as practicable.

IHS Responded on August 29, 2015 to the TSGAC and

stated that OTSG Deputy Director has officially

returned to her position as of 7/27/15.



Special Diabetes Program

for Indians (SDPI)

TSGAC comments in response to

the DTLL request for

comments/consultation on the SDPI

programs.

111. 4/20/15 Mr. Robert G. McSwain Mr. Ben Smith Mr. Carl Harper

Transmittal of Self-

Governance National ACA

Education and Outreach

Report

No action needed. Transmittal of 6-

month report for the time period

October 1, 2014 through March 31,

2015.

112. 4/8/15 Mr. Robert G. McSwain, Acting Director Indian Health Service

Payment of Contract

Support Costs for MSPI and

DVPI funding

Request that the agency review this

issue and that, as committed during

3/24/15 TSGAC meeting, provide a

final decision to Tribes on the

eligibility of MSPI/DVPI for additional

A Dear Tribal Leader was sent out from IHS Acting Director McSwain on 6/22/15 with an update on how the IHS will move forward with MSPI and DVPI over the next five years. Response received from IHS Acting Director McSwain

on 5/18/15. Letter stated the IHS is not required to



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CSC funds within 30 days. provide additional funds beyond what is included in

the project budgets.

113. 4/8/15 Mr. Robert G. McSwain, Acting Director Indian Health Service

Thank you on Rates of CSC

Settlement and Claim

Resolutions

Continue timely resolution of

outstanding claims and consistent

full funding of CSC.

114. 4/3/15 Mr. Gregory E. Demske, Chief Counsel to the Inspector General Ms. Melinda Golub, Senior Counsel Mr. Amitava “Jay” Mazumdar, Senior Counsel Office of Counsel to the Inspector General

Thank you for participating in the Tribal Self-Governance Advisory Committee Quarterly Meeting, March 24, 2015

Further dialogue to occur during the Thursday, April 30th Breakout Session A7, Pursuing and Reinvesting Third Party Revenue, at the upcoming 2015

Annual Tribal Self-Governance

Consultation Conference in Reno,

NV

115. 2/26/15 The Honorable Derek Kilmer

Self-Governance Tribes

2015 Appropriations

Requests for the Bureau of

Indian Affairs

Joint letter from TSGAC/SGAC

116. 2/10/15 The Honorable Derek Kilmer

Self-Governance Tribes

2015 Appropriations

Requests for Indian Health

Service

Joint letter from TSGAC/SGAC



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117. 2/9/15 Chief Marilynn Malerba, Chairwoman TSGAC

Agency response to

information requested QHPs

to IHCPs in specific regions

CMS staff are available to address

specific QHP problems and provide

further assistance in the process

Response from Marilyn Tavenner, CMMS 2/2/15 to

letter dated 12/19/14


Agency response to the

ongoing and unprecedented

international Ebola crisis

Response from Dr. Y.Roubideaux, IHS Director,

1/31/15 to letter dated 10-17-14

119. 2/5/15 IHS Director,Dr. Y. Roubideaux

Mandatory Appropriations

for Contract Support Coasts

Appreciated partnership and looking

forward to working to advance long-

term solutions for funding CSC

120. 2/4/15 Betty Gould, Regulations Officer, IHS and Carl Harper, Director ORAP,IHS Submit via regulations.gov

Comments on IHS Proposed

Rule entitles “Payment for

Physician and Other Health

Care Professional Services

Purchased by Indian Health

Programs and Medical

Charges Associated with

Non-Hospital-Base Care

Being able to engage in Tribal

Consultation on the proposal


Concerns regarding

procedural consistency and

information sharing during

CSC negotiations on

Disputed claims

Response from Dr. Y. Roubideaux, IHS Director,

1/20/15 to letter dated 12-2-14



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122. 1/14/15 Ms Tracy Parker Warren Office of Public and Intergovernmental Affairs OTGR(075F)-VA

Comments Submitted

Response to Notice of TC:

Sec 102 © of the Veterans

Access, Choice and

Accountability Act of 2014

Urge the Reports enter into

agreements for reimbursement also

current agreements be used and

expanded where possible to speed

up implementation to eligible

veterans

123. 1/12/15 CCIIO-CMS-DHHS Comments on Draft 2016

Letter to Issuers in the

Federally-Facilitated

Marketplace

We are available to discuss any of

the recommendations contained in

the correspondence and attachment

on CMS-9944-P

124. 1/8/15 IHS Director, Dr. Y. Roubideaux

2015 TGSAC Quarterly

Meetings and Tribal Self-

Governance Annual

Conference Information

Adjustment to your schedule due to

changes for the January Qrtly

meetings

Response from Dr. Y.Roubideaux, IHS Director,

1/15/15 re: She will be in attendance Jan 28 also

attendance at March Mtg on the 24th

Submitted via: www.regulations.gov

March 9, 2018

Centers for Medicare & Medicaid Services (CMS) Office of Strategic Operations and Regulatory Affairs Division of Regulations Development Room C4-26-05 7500 Security Boulevard Baltimore, MD 21244-1850 RE: Comments on Standards Related to Reinsurance, Risk Corridors, and Risk Adjustment (CMS-10401/OMB control number 0938-1155) Dear CMS Official: I write on behalf of the Indian Health Service (IHS) Tribal Self-Governance Advisory Committee (TSGAC) to comment on the notice of proposed revisions to the information collection request (ICR) titled “Standards Related to Reinsurance, Risk Corridors, and Risk Adjustment” (Notice). The ICR addresses requirements for states and health plans associated with the reinsurance, risk corridors, and risk adjustment programs established under the Affordable Care Act (ACA). In the Notice, CMS proposes to revise the currently approved ICR to eliminate programs and update data collections to conform to Federal statute and regulations. In response to the Notice, the TSGAC wishes to comment on two issues related to the Indian-specific cost-sharing protections available to certain American Indians and Alaska Natives (AI/ANs) enrolled through a Marketplace.1 First, the TSGAC wishes to comment on health insurance issuer reporting of enrollee-level data related to the permanent risk adjustment program, specifically data that CMS uses in determining the adjustment for the receipt of cost-sharing reductions (CSRs) in the Federal risk adjustment model (referred to as the “induced utilization factor”). The TSGAC believes that continued collection of individual, enrollee-level data on the usage of CSRs and overall health care service utilization—for the purposes of determining the induced utilization factor—is justified and essential to ensuring a precise accounting of utilization among AI/ANs and the accurate reimbursement to issuers for induced utilization resulting from the provision of comprehensive, Indian-specific CSRs for certain AI/AN enrollees. Without the data needed to calculate an accurate induced utilization factor, a situation that could result in underpayments to certain health plans, plans might have a disincentive to enrolling AI/ANs and/or applying fully the comprehensive, Indian-specific CSRs. Second, the TSGAC wishes to highlight the potential for the costs of the Indian-specific cost-sharing protections to be shifted to Marketplace enrollees—including eligible AI/ANs themselves—

1 The comprehensive Indian-specific cost-sharing protections are available to individuals enrolled in a Federally-

recognized Tribe or shareholders in an Alaska Native village or corporation.


P.O. Box 1734, McAlester, OK 74501

Telephone (918) 302-0252 ~ Facsimile (918) 423-7639 ~ Website: www.Tribalselfgov.org

http://www.regulations.gov/

TSGAC Comments on CMS-10401 March 9, 2018 Page 2

due to the elimination of direct Federal funding of the CSRs and proposes modifying the Federal risk adjustment model to help address this concern. Discussion Background on Indian-Specific CSRs Section 1402(d) of the ACA provides critically important CSRs for AI/ANs who enroll in qualified health plans (QHPs) through a Marketplace. These Indian-specific cost-sharing protections—under which AI/ANs who meet the ACA definition of Indian pay no deductibles, coinsurance, or copayments when receiving essential health benefits—serve as one means of upholding the Federal trust responsibility to AI/ANs. Under sections 1402(d)(1) and (d)(2), eligible AI/ANs can enroll in either a zero or limited cost-sharing plan, depending on their income level and eligibility for premium tax credits (PTCs). Enrollees in zero cost-sharing plans have no cost-sharing, regardless of where and how they receive health care services. Enrollees in limited cost-sharing plans have no cost-sharing when they receive health care services through an IHS, Tribe or Tribal organization, or urban Indian organization (I/T/U) facility, as well as through an I/T/U referral to a non-I/T/U provider. The ACA also provides general cost-sharing protections for individuals who have a household income of up to 250% of the Federal poverty level (FPL) and enroll in a silver-level QHP.2 Issue 1: Continued Use of Accurate Induced Utilization Factor in Federal Risk Adjustment Model QHP issuers for 2018 will continue to receive an adjustment for the provision of CSRs as part of the Federal risk adjustment model.3 The risk adjustment program—which generally applies to non-grandfathered individual and small group market health plans, both inside and outside the Marketplace—redistributes funds from plans with lower-risk enrollees to plans with higher-risk enrollees. Under the program, health plans determine their average actuarial risk based on the individual risk scores of enrollees, and plans with lower actuarial risk make payments to plans with higher risk. As previously noted by CMS, the “goal of the Affordable Care Act risk adjustment program is to mitigate the impacts of possible adverse selection and stabilize the premiums in the individual and small group markets as and after insurance market reforms are implemented.”4 For 2018, the Federal risk adjustment model will provide issuers with an upward payment adjustment of 15% for zero or limited cost-sharing plan enrollees in bronze-level coverage, 12% for those in silver-level coverage, and 7% for those in gold-level coverage. In the most recent Notice of Benefit and Payment Parameters, CMS proposed to retain these adjustment factors for 2019, with the expectation of “adjusting these factors ... for the 2020 benefit year as enrollee-level data from the individual market will be available in time for proposal in that rulemaking.5

2 These general protections require QHP issuers to reduce cost-sharing in their standard silver plans, which have an AV

of 70%, to meet a higher AV: 94% for individuals up to 150% FPL, 87% for those from 151-200% FPL, and 73% for those from 201-250% FPL. 3 States that operate a Marketplace can either establish their own risk adjustment program or allow HHS to administer

one for the state; states that rely on a Federally-Facilitated Marketplace (FFM) must have HHS administer their program. HHS has developed a risk adjustment methodology for use by states or by the department on behalf of states; states electing to use an alternative model must seek Federal approval and submit annual reports to the department. See 45 CFR 153.320. 4 See 77 FR 73120, “Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for

2014” (CMS-9964-P). 5 See 82 FR 51071, “Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for

2019” (CMS-9930-P).


The TSGAC would like to encourage CMS to make future adjustments to the induced utilization factor based on individual, enrollee-level data and, to the extent possible, take into account in any adjustments the apparent significant variations in the degree to which some AI/ANs access the cost-sharing protections afforded under section 1402(d) of the ACA.6 One factor contributing to the variance in utilization of the CSR protections is the concentration of I/T/Us facilities in certain regions and the absence of I/T/U facilities in other regions. Without continued enrollee-level data, the induced utilization factor might greatly overstate or understate the CSR-related additional utilization costs for QHP issuers operating in and enrolling AI/ANs in a state or region of a state. In particular, insufficient compensation to issuers for Indian-specific CSR-related induced utilization costs could dissuade issuers from offering health plans in areas with greater concentrations of AI/AN enrollees (such as remote rural areas). It is also important to note that the need for maintaining an accurate induced utilization factor in the Federal risk adjustment model is likely to become more pressing over time, as two factors work to increase issuer costs associated with the Indian-specific CSRs.

First, AI/ANs are increasing their enrollment in health insurance secured through a Marketplace, a trend leading to a greater concentration of AI/AN CSR recipients in a Marketplace. In part, this is a result of AI/ANs gaining an increased understanding of the availability of the Indian-specific CSRs. CMS data show that the number of Tribal members (who meet the ACA definition of Indian and thus qualify for the Indian-specific CSRs) enrolled in Marketplace coverage rose from about 23,000 in 2015 to almost 33,000 in 2017 in states using the HealthCare.gov platform; from 2016 to 2017 alone, there was a 20.7% increase in enrollment of Tribal members in Marketplace coverage.7

Second, although there continues to be deficiencies in issuer understanding and compliance with the Indian-specific CSRs, compliance is improving. For example, a recent TSGAC review of two Indian-specific Summary of Benefits and Coverage (SBC) documents for eight QHPs offered across four states found that, in general, the zero cost-sharing plan SBCs were comprehensive and accurate, while the limited cost-sharing plan SBCs contained several inaccuracies (see more in Attachment A). And while instances of improper application of the Indian-specific CSRs continue for some AI/AN Marketplace enrollees, these cases are becoming less frequent and less systemic.

Fully compensating issuers that are applying the Indian-specific CSRs correctly is warranted and will (continue to) act as an incentive for issuers to serve AI/ANs better. Further, minimizing instances of rewarding non-compliance will help in aligning financial incentives with increased access to care for AI/ANs. Issue 2: Funding Indian-Specific CSRs Without Shifting Costs to Marketplace Enrollees Section 1402(d)(3) of the ACA directs the Department of Health and Human Services (HHS) to pay QHP issuers the amount necessary to offset any increase in the actuarial value (AV) of their plans as a result of the Indian-specific CSRs.8 However, the Trump administration on October 12, 2017,

6 See TSGAC comments on CMS-9964-IFC, dated April 30, 2013, at https://www.regulations.gov/document?D=CMS-

2012-0152-0490. 7 See CMS, "Table 1: American Indian and Alaska Native Applicants and Enrollees in the Federally-Facilitated

Marketplace,” for coverage years 2015, 2016, and 2017. 8 Section 1402(c)(3) includes a similar provision regarding the general CSRs.

https://www.regulations.gov/document?D=CMS-2012-0152-0490

https://www.regulations.gov/document?D=CMS-2012-0152-0490


announced that HHS will no longer make CSR payments to issuers, effective immediately, based on the legal opinion that Congress, through the passage of the ACA, authorized but never appropriated funding for the CSR payments.9 Despite the termination of these payments, the ACA requires issuers to continue to provide CSRs to eligible enrollees. To compensate for the loss of the CSR payments, issuers for 2018 typically have responded by funding these CSR protections through increased premiums (in some cases significantly), either on all of their ACA-compliant individual market plans (both inside and outside the Marketplace), only their silver-level plans inside and outside the Marketplace, or only their silver-level plans inside the Marketplace. The TSGAC asks CMS to consider modifying the Federal risk adjustment model for 2019 and beyond to account for the loss of CSR payments to QHP issuers for the Indian-specific CSRs. As noted above, in an effort to offset the loss of direct CSR payments from the Federal government, an approach has been taken in many states under which CSR-related increases in health plan premiums are largely focused on silver-level plans, as Marketplace enrollees eligible for the general cost-sharing protections must enroll in these plans to receive CSRs. It is important to note, however, that AI/AN Marketplace enrollees eligible for Indian-specific cost-sharing protections can enroll in bronze-level plans and still receive those protections; AI/ANs also are not required to be PTC-eligible in order to qualify for one version of the Indian-specific CSRs. The alternative funding approach discussed above in many cases has increased the value of PTCs, which are determined in part by the amount of the premium for the second-lowest-cost silver plan in a Marketplace. As such, AI/ANs who qualify for PTCs and enroll in a bronze plan in many cases are protected from CSR-related increases in health plan premiums. But to the extent the premium (and resulting PTC) increases are not adequate to cover the cost of the more comprehensive Indian-specific cost-sharing protections, there is a risk that some of the CSR-related costs could be (and have been) shifted to AI/AN enrollees themselves, through increased bronze plan premiums. In addition, AI/ANs who do not qualify for PTCs but do qualify for Indian-specific CSRs must bear the full cost of any CSR-related increases in bronze plan premiums. The above scenarios—whereby AI/AN Marketplace enrollees cover some or all of the costs/funding of the Indian-specific CSRs—do not seem to uphold congressional intent. And to the extent that AI/AN enrollment grows as a percentage of total Marketplace enrollment, the dynamic of AI/ANs “self-funding” their own cost-sharing protections also increases. Likewise, if the concentration of AI/AN enrollees in a Marketplace rises over time, it will become increasingly important that a more functional funding mechanism be found for the CSR-related costs, rather than continue to have issuers shift these costs to enrollees in the form of higher premiums or absorb the losses themselves. The TSGAC suggests that CMS consider making further adjustments to the induced utilization factor, or other components of the risk adjustment mechanism, to address these concerns. Doing so would have the combined effects of helping stabilize premiums in the Marketplace—the stated goal of the risk adjustment program—protecting AI/AN enrollees from self-funding the Indian-specific CSR protections, and minimizing financial incentives for issuers to avoid enrolling AI/ANs who are eligible for the comprehensive CSR protections.

9 See letter from then-Acting HHS Secretary Eric Hargan to CMS Administrator Seema Verma, dated October 12, 2017,

at https://www.hhs.gov/sites/default/files/csr-payment-memo.pdf.

https://www.hhs.gov/sites/default/files/csr-payment-memo.pdf


Recommendations In response to the concerns outlined above, the TSGAC requests that CMS continue to require QHP issuers to submit individual, enrollee-level data on the usage of CSRs. The TSGAC further asks that CMS make any future adjustments to the induced utilization factor based on enrollee-level data to capture the great variation in the degree to which some AI/ANs access the Indian-specific CSRs. In addition, the TSGAC urges CMS to consider modifying the Federal risk adjustment model, either through the induced utilization factor or through some other mechanism, to account for the loss of CSR payments to issuers for the Indian-specific CSRs for AI/AN enrollees. Conclusion Thank you for the opportunity to provide these comments on the Notice. If you have any questions or wish to discuss these comments further, please contact me at (860) 862-6192 or via email at [email protected]. Sincerely,

Marilynn “Lynn” Malerba Chief, The Mohegan Tribe of Connecticut Chairwoman, Tribal Self-Governance Advisory Committee

cc: Kitty Marx, Director, Division of Tribal Affairs/IEAG/CMCS Jennifer Cooper, Acting Director, Office of Tribal Self-Governance, IHS TSGAC Members and Technical Workgroup Devin Delrow, Director of Policy, National Indian Health Board




Submitted Via Email: [email protected] February 23, 2018 The Honorable Alex M. Azar II, Secretary U.S. Department of Health and Human Services Hubert H. Humphrey Building 200 Independence Ave, SW Washington, DC 20202

RE: Authorized Presenter – HHS Annual Tribal Budget Consultation, 2018 Dear Secretary Azar: I write to you on behalf of the Indian Health Service (IHS) Tribal Self-Governance Advisory Committee (TSGAC) to delegate and authorize our representative to present testimony at the HHS Annual Tribal Budget Consultation on March 1, 2018 in Washington, DC. The TSGAC represents 360 Tribal governments nationwide who have assumed and directly operate IHS health and related programs under the self-governance initiative. The number of Tribes participating in Self-Governance continues to grow annually as additional Tribes choose to exercise their inherent right to govern and protect the interests of their citizens. I hereby authorize Melanie Fourkiller, Choctaw Nation of Oklahoma and TSGAC Tribal Technical Co-Chair, to present the TSGAC testimony on my behalf at the consultation meeting. Written testimony will also be provided by the TSGAC for the national meeting. If you have any questions or require additional information, please contact me at [email protected]. Thank you. Sincerely,

Chief Lynn Malerba, Mohegan Tribe of Connecticut Chairwoman, IHS TSGAC cc: Stacey Ecoffey, Intergovernmental and External Affairs, Tribal Affairs, HHS





P.O. Box 1734, McAlester, OK 74501

Telephone (918) 302‐0252 ~ Facsimile (918) 423‐7639 ~ Website: www.Tribalselfgov.org

Sent electronically to: [email protected]

March 1, 2018 Mr. W. Ron Allen Tribal Chairman and CEO, Jamestown S’Klallam Tribe Chair, Tribal Technical Advisory Group (TTAG) 1033 Old Blyn Highway Sequim, WA 98382 RE: Review of Summary of Benefits and Coverage Documents Dear Chairman Allen: I write on behalf of the Indian Health Service (IHS) Tribal Self-Governance Advisory Committee (TSGAC) to report on a recent survey conducted by the TSGAC. The TSGAC reviewed a sample of Summary of Benefits and Coverage (SBC) documents to assess their accuracy in describing the cost-sharing protections provided to eligible American Indians and Alaska Natives (AI/ANs) under the Affordable Care Act (ACA).1 Specifically, the TSGAC reviewed sixteen Indian-specific SBCs describing bronze-level qualified health plans (QHPs) offered by eight issuers across four states. SBCs are a critical tool for educating (potential and current) enrollees in Marketplace plans about the cost-sharing protections available to them, as well as a tool for ensuring that the plans themselves understand and accurately apply the federal protections. We are providing this information to you in your role as Chairman of the TTAG in an effort to coordinate the efforts of the TSGAC and the TTAG with an aim to secure needed revisions to the preparation and review of SBCs. Background On February 14, 2012, CMS, in conjunction with the Departments of Labor and Treasury (collectively, the Departments), issued a final rule that included regulations requiring QHP issuers to prepare a single SBC for each plan offered through a Marketplace, as well as a general SBC template to help issuers meet this requirement.2 The Departments updated these

1 AI/ANs who meet the definition of Indian under the ACA and enroll in a Marketplace plan qualify for one of two types of comprehensive cost-sharing protections, meaning they pay no deductibles, co-insurance, or copayments when receiving essential health benefits (EHBs) from Indian health care providers (IHCPs) or non-IHCPs. Eligible AI/ANs with a household income between 100% and 300% of the federal poverty level (FPL) and who are eligible for premium tax credits can enroll in zero cost-sharing (Z-CSV) plans, and all others can enroll in limited cost-sharing (L-CSV) plans. Enrollees in Z-CSV plans do not need a referral from an IHCP to receive cost-sharing protections when served by non-IHCPs. Enrollees in L-CSV plans, however, must obtain a referral from an IHCP to avoid cost-sharing when served by non-IHCPs. 2 See TD 9575/CMS-9982-F, “Summary of Benefits, Coverage, and Uniform Glossary” (77 FR 8668), at https://www.gpo.gov/fdsys/pkg/FR-2012-02-14/pdf/2012-3228.pdf.

SGAC Review of SBCs March 1, 2018 Page 2

regulations and the general SBC template in a final rule issued on June 6, 2015.3 In comments on the proposed version of this second rule, the TTAG cited past inaccuracies in some SBCs voluntarily prepared by some issuers to describe zero cost-sharing variation (Z-CSV) and limited cost-sharing variation (L-CSV) plans and asked the Departments to develop sample language, for use by issuers in the preparation of SBCs, to describe how the Z-CSV and L-CSV plan variations impact cost-sharing for services received at in-network and out-of-network providers.4 The TTAG raised similar concerns in an earlier May 29, 2014, letter to the Center for Consumer Information and Insurance Oversight (CCIIO) at CMS, asking the agency, among other recommendations, to 1) require issuers to develop separate SBCs for each cost-sharing variation of their QHPs and 2) require Marketplaces to develop an SBC template for Z-CSV and L-CSV plans for use by issuers operating in their Marketplace.5 CMS subsequently took steps to address concerns about inaccuracies in SBCs prepared for Z-CSV and L-CSV plans. In the final Notice of Benefit and Payment Parameters for 2016,6 CMS amended 45 CFR 156.420 and 156.425 to require QHP issuers to provide SBCs that accurately represent plan variations, beginning no later than November 1, 2015; the rule also stipulated that issuers cannot combine information about multiple plan variations in one SBC. In addition, on July 13, 2016, after engaging with Tribal representatives, CMS released SBC templates for Z-CSV and L-CSV plans and posted these documents on the CCIIO Web site.7 Despite these efforts by CMS and Tribal representatives, Tribal representatives have continued to identify a number of examples of 1) inaccuracies in some SBCs and 2) incorrect application of the cost-sharing protections by QHP issuers. The TSGAC, in response to these deficiencies, decided to conduct a larger sampling of SBCs to determine the extent of the problems. Disappointingly, from this review of eight Z-CSV and eight L-CSV SBCs, inaccuracies in the L-CSV Indian-specific SBCs appear somewhat common, although much less so for Z-CSV plans. These inaccuracies have the effect of depressing enrollment in Marketplace plans and resulting in eligible AI/ANs not securing the cost-sharing protections guaranteed to them in federal law. We would like to emphasize that the inaccuracies in the reviewed SBCs are more than a paper failing as these inaccuracies have been found to mirror incorrect application of cost-sharing protections for AI/AN enrollees in Marketplace coverage.

3 See TD-9724/CMS-9938-F, “Summary of Benefits and Coverage and Uniform Glossary” (80 FR 34292), at https://www.gpo.gov/fdsys/pkg/FR-2015-06-16/pdf/2015-14559.pdf. 4 See TTAG “Comments on Summary of Benefits and Coverage and Uniform Glossary Proposed Rule (CMS-9938-P),” dated February 28, 2015, at https://www.nihb.org/tribalhealthreform/wp-content/uploads/2015/03/TTAG-Comments-on-CMS-9938-P.pdf. 5 See TTAG letter to CCIIO on “Qualified Health Plans and Indian-Specific Cost-Sharing Variations,” dated May 29, 2014, at https://www.nihb.org/tribalhealthreform/wp-content/uploads/2014/07/TTAG-Letter-to-CCIIO-QHPs-and-AI-AN-CS-Var-2014-05-20d.pdf. 6 The 2016 Notice of Benefit and Payment Parameters was issued on February 27, 2015. 7 CCIIO required issuers to use the new SBC templates and associated documents for the 2018 coverage year. See the 3/11/2016 CCIIO FAQ linked below.https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/FAQS-30_final-3-11-16.pdf


Findings

The TSGAC conducted a review of two Indian-specific SBCs for eight QHPs offered across four states. The TSGAC reviewed SBCs for bronze-level plans, as bronze-level coverage is the preferred option for AI/ANs eligible for the comprehensive Indian-specific cost-sharing protections.8 The findings are detailed in Attachment A: Analysis of SBCs for Zero and Limited Cost-Sharing Variations of Sample Marketplace Bronze Plans; Selected States, 2018.9 Key findings from the review of a sampling of SBCs include: In general, the Z-CSV plan SBCs are comprehensive and accurate, but the L-CSV plan

SBCs have several inaccuracies.

There is no consistency in the labeling of the SBCs to indicate that an SBC is for a Z-CSV or L-CSV plan, and several SBCs have no designation indicated on the front page of the SBC in this regard.

o The use of the term “300%” as an SBC descriptor for the L-CSV could be misleading, as eligibility for L-CSV plans extends to AI/ANs of any income level (and without regard to whether the AI/AN qualifies for premium tax credits).

In the series of terms that are defined in the SBC, a definition of AI/ANs (for purposes of eligibility for the Indian-specific cost-sharing protections) is not included.10

In one Z-CSV plan SBC, the SBC indicates “no charge” when using an IHCP but “not covered” when receiving services from a non-IHCP.11 Under a correct application of the Z-CSV protections, “no charge” for cost-sharing applies whether an enrollee is seen at an IHCP or non-IHCP.12

At least one L-CSV plan SBC indicates that cost-sharing protections apply to services received at IHCPs (when the IHCP is in-network) and not to services received at non-IHCPs with a referral from an IHCP (or at out-of-network IHCPs).13

Three of the L-CSV plan SBCs do not accurately describe the protections from payment of deductibles. The L-CSV plan SBCs should indicate that the Indian-specific cost-

8 Individuals eligible for the Indian-specific cost-sharing protections can enroll in a bronze-level plan and still receive the cost-sharing protections. For the general population, individuals must enroll in a silver-level plan to receive the partial cost-sharing protections available to those who have a household income at or less than 250% of the federal poverty level (FPL) and who are eligible for premium tax credits. 9 Web links to the reviewed SBCs are included in Attachment A. 10 Terms are defined in a linked Glossary Health Coverage and Medical Terms. 11 See footnote 6 in Attachment A. 12 However, “balance billing” charges might occur if an out-of-network provider does not accept the combined plan payment and patient cost-sharing as payment in full and charges an additional amount to the patient. 13 See footnote 9 in Attachment A.


sharing protections include payment of deductibles, as well as other types of patient cost-sharing.14

One L-CSV plan SBC incorrectly indicates, on pages 1-4, that cost-sharing payments are required, regardless of whether services are received at IHCPs or at non-IHCPs with a referral; however, the bottom of page 6 (last page) includes the following note:

"If you are a Native American enrolled on this plan and receive services directly from the Indian Health Service, Indian Tribe, Tribal Organizations, or Urban Indian Organization, or through referral under the contract health services, the services will not be subject to any Deductible, Co-payments, or Co-insurance."15

For clarity, the end note should be included as a note on all pages, or the tables should be revised to indicate in each cell that cost-sharing is waived at IHCPs or at non-IHCPs with IHCP referral.

Some L-CSV plan SBCs exclude (intentionally or through oversight) certain services from the Indian-specific cost-sharing protections,16 despite the fact that the protections apply to all covered essential health benefits (EHBs).

With regard to the “Coverage Examples,” some of the SBCs present the net estimated out-of-pocket (OOP) costs assuming the patient received services at an IHCP or at a non-IHCP with a referral; other SBCs present net estimated OOP costs assuming no benefit from the Indian-specific cost-sharing protections.17

Based on these findings, the TSGAC makes the following recommendations:

Determine which governmental agency is responsible for reviewing the SBCs, depending on the type of Marketplace, and clarify this in sub-regulatory guidance.

Indicate that reviews of SBCs are not performed merely to determine if SBC documents are posted at a live Web link but that a thorough evaluation of the content of SBCs is required.

Although the Z-CSV and L-CSV SBC templates are offered as a guide to issuers and the specific language contained in the templates are not mandated for use, in reviewing issuer SBCs, recommend specific language to correct inaccuracies or confusing descriptions.

14 For example, the SBC for the “Montana Health CO-OP: CONNECTED CARE BRONZE NALCS” (L-CSV) plan repeatedly states that enrollees must pay a deductible, and the SBC for a Molina bronze plan offered in New Mexico indicates that the deductible is eliminated only when enrollees are seen at an IHCP. Neither of these SBCs indicates that deductibles are waived at non-IHCPs with referral from an IHCP. Also, see footnote 11 in Attachment A. 15 See footnote 3 in Attachment A. 16 See footnotes 7 and 10 in Attachment A. 17 See footnotes 2a and 2b in Attachment A.


Establish consistent descriptors to place in the header on the front page of each Indian-

specific SBC—such as “AI/AN 02 CSV” and “AI/AN 03 CSV” or “AI/AN Z-CSV” and “AI/AN L-CSV “—and through a link to the “Glossary of Health Coverage and Medical Terms,” define the descriptors.

Through a link to the “Glossary of Health Coverage and Medical Terms,” indicate that “AI/AN” eligibility for the Z-CSV and L-CSV plans, in part, is limited to “an enrolled Tribal member in a federally-recognized Tribe or a shareholder in an Alaska Native regional or village corporation.”

Require issuers to present the net out-of-pocket costs in the Coverage Examples to reflect application of the Indian-specific cost-sharing protections (i.e., assuming enrollees receive services from an IHCP or from a non-IHCP through a referral from an IHCP) and insert a note indicating that cost-sharing might be greater if seen at a non-IHCP without referral from an IHCP.

o For example, an SBC prepared by Blue Cross Blue Shield of New Mexico for an L-CSV plan states: “Note: These numbers assume the patient received care from an IHCP provider or with IHCP referral at a non-IHCP. If you receive care from a non-IHCP provider without a referral from an IHCP your costs may be higher.”

Revise the CCIIO Z-CSV and L-CSV SBC templates, as appropriate, based on the review of existing SBCs.

Conclusion

Thank you for the opportunity to provide these concerns. We look forward to working with you and the TTAG (1) to present this information to CCIIO and (2) to ensure that these recommendations are considered, and implemented, as appropriate. If you have any questions or wish to discuss these issues further, please contact me at (860) 862-6192 or via e-mail at [email protected].

Sincerely,

Marilynn “Lynn” Malerba Chief, The Mohegan Tribe of Connecticut Chairwoman, Tribal Self-Governance Advisory Committee

cc: Kitty Marx, Director, Division of Tribal Affairs/IEAG/CMCS Devin Delrow, Director of Policy, National Indian Health Board Jennifer Cooper, Acting Director, Office of Tribal Self-Governance, IHS TSGAC Members and Technical Workgroup Attachment: Analysis of SBCs for Zero and Limited Cost-Sharing Variations (Z-CSVs and L-

CSVs) of Sample Marketplace Bronze Plans; Selected States, 2018

CSV

Designation

in Plan Name8

No Deductible

Indicated

No Copays/

Coinsurance

Indicated

Accurate

Coverage

Examples

CSV

Designation

in Plan Name8

No Deductible

Indicated

(for Services

Received at

IHCPs or Non‐

IHCPs with

Referral)

No Copays/

Coinsurance

Indicated

(for Services

Received at

IHCPs or Non‐

IHCPs with

Referral)

Accurate

Coverage

Examples

Alaska Premera Blue CrossPreferred Plus Bronze

5250 HSAPPO AI/AN Yes Yes Yes AI/AN 300% No

11

Only at In‐

Network

IHCPs9

No2a

BC BS of MontanaBlue Preferred Bronze PPO

201PPO None Yes Yes Yes None Yes

Not stated for

OPDs7 Yes

1

Montana Health CO‐OP Connected Care Bronze PPO NAZCS Yes Yes Yes NALCS No No No2b

PacificSource PSN Bronze HSA 6550 PPO (0) Yes Yes Yes (AI) Yes3 Yes3 No2b

BC BS of New MexicoBlue Community Bronze

HMO 201HMO4 None Yes Only at IHCPs6 Yes None Yes

Not stated for

OPDs7 Yes1

MolinaMolina Marketplace

BronzeHMO

4 Molina AI/AN

Zero PlanYes Yes Yes

Bronze AI/AN

Limited Cost

Sharing

Only at IHCPs

Only at In‐

Network

IHCPs5

Yes

New Mexico Health Connections Care Connect Bronze Plus HMO4 Zero CSR Yes Yes No

2a None Yes Only at IHCPs Yes1

Oklahoma BC BS of OklahomaBlue Preferred Bronze PPO

206PPO None Yes Yes Yes None Yes

Most

services10 Yes1

Notes:

4 Only HMOs are available in the New Mexico Marketplace. These plans generally have no out‐of‐network coverage.5 For New Mexico Marketplace plans, Molina considers all IHCPs "in‐network," regardless of whether they appear in the plan provider directory.6 Incorrectly indicates that health services are only covered at IHCPs.

Montana

New Mexico

1 This SBC correctly (1) calculates the patient cost‐sharing assuming application of the LCSV protections and (2) indicates that the coverage examples assume the services are received at IHCPs or at non‐IHCPs with a referral and that costs to

plan enrollees could increase if services are received at non‐IHCPs without a referral.

2b In the Coverage Examples, this SBC presents patient cost‐sharing as if the LCSV protections are not added. And, this SBC incorrectly indicates in a footnote that the coverage examples assume the services are received at IHCPs or at non‐

IHCPs with a referral and that costs to plan enrollees could increase if services are received at non‐IHCPs without a referral. (To correct: The footnote should remain and the Coverage Examples should be changed to reflect application of

the LCSV protections.)3 The tables in this SBC indicate cost‐sharing for services, regardless of whether they are received at IHCPs or at non‐IHCPs with a referral; however, the bottom of page 6 (last page) includes the following note: "If you are a Native American

enrolled on this plan and receive services directly from the Indian Health Service, Indian Tribe, Tribal Organizations, or Urban Indian Organization, or through referral under the contract health services, the services will not be subject to any

Deductible, Co‐payments, or Co‐insurance."

2a This SBC presents costs in the Coverage Examples as if there is no application of the LCSV protections. (To correct: (1) The Coverage Examples should be changed to reflect application of the LCSV protections; and (2) a footnote should be

added stating "The coverage examples assume the services are received at IHCPs or at non‐IHCPs with a referral and that costs to plan enrollees could increase if services are received at non‐IHCPs without a referral.)

7 For pharmacy services, does not include the statement "Cost sharing waived at non‐IHCP with IHCP referral" which is indicated for other services, such as physician services and tests. As such, incorrectly communicates that LCSV

protections do not apply to prescription drugs.

ATTACHMENT A: Analysis of Summaries of Benefits and Coverage (SBCs) for Zero and Limited Cost‐Sharing Variations (Z‐CSVs and L‐CSVs)

of Sample Marketplace Bronze Plans; Selected States, 2018

State Issuer Sample Bronze Plan

SBC Analysis

Z‐CSVs L‐CSVs

Plan

Type

Analysis of SBCs for Z‐CSVs and L‐CSVs (2018) ‐ 2018‐03‐01a Page 1 of 2

State Plan CSV Link

Z‐CSV https://www.premera.com/documents/042178_2018.pdf

L‐CSV https://www.premera.com/documents/042179_2018.pdf

Z‐CSV https://www.bcbsmt.com/sbc/2018/MT0550040‐02.pdf

L‐CSV https://www.bcbsmt.com/sbc/2018/MT0550040‐03.pdf

Z‐CSV

L‐CSV

Z‐CSV https://www.pacificsource.com/2018/SBC/23603MT0290004‐02.pdf

L‐CSV https://www.pacificsource.com/2018/SBC/23603MT0290004‐03.pdf

Z‐CSV https://www.bcbsnm.com/sbc/2018/NM0390079‐02.pdf

L‐CSV https://www.bcbsnm.com/sbc/2018/NM0390079‐03.pdf

Z‐CSV

L‐CSV

Z‐CSV http://mynmhc.org/care‐connect‐bronzeplus‐0‐hmo‐ind‐2018.pdf

L‐CSV http://mynmhc.org/care‐connect‐bronzeplus‐lim‐hmo‐ind‐2018.pdf

Z‐CSV https://www.bcbsok.com/sbc/2018/OK0320093‐02.pdf

L‐CSV https://www.bcbsok.com/sbc/2018/OK0320093‐03.pdfOklahoma

Care Connect Bronze Plus

Blue Preferred Bronze PPO 2

PSN Bronze HSA 6550

Blue Community Bronze HM

Molina Marketplace Bronzehttp://www.molinahealthcare.com/members/nm/en‐US/PDF/Marketplace/summary‐of‐benefits‐bronze‐zero‐2018.pdf

http://www.molinahealthcare.com/members/nm/en‐US/PDF/Marketplace/summary‐of‐benefits‐bronze‐lcs‐2018.pdfNew Mexico

Alaska

Montanahttps://www.mhc.coop/wp‐content/uploads/2018/2018_MT_Native_American_Connected_Care_BRZ_NAZCS_SBC.pdf

https://www.mhc.coop/wp‐content/uploads/2018/2018_MT_Native_American_Connected_Care_BRZ_NALCS_SBC.pdf

8 These SBC documents typically lack a descriptor on page 1 of the SBC labeling the document as the SBC for the 02/ZCSV or 03/LCSV. In addition, "AI/AN" needs to be defined through a live weblink (as are other terms used in the SBC);

could be defined as "American Indians and Alaska Natives (AI/ANs) are defined under the Affordable Care Act as enrolled Tribal members and shareholders in Alaska Native regional and village corporations."

10 For "Preventive care/screening/immunizations", a 30% co‐insurance is indicated at non‐IHCP, non‐participating providers. Could be remedied by adding "Cost sharing waived at non‐IHCP with referral from IHCP."

9 Incorrectly states that co‐insurance applies if receiving services at a non‐IHCP. Could be remedied by adding "Cost sharing waived at non‐IHCP with referral from IHCP."

11 SBC States that deductibles apply (without saying elimination of deductibles if seen at an IHCP or through referral from an IHCP. Could be remedied by adding "Deductibles do not apply at non‐IHCP with referral from IHCP."

Preferred Plus Bronze 5250

Blue Preferred Bronze PPO 2

Connected Care Bronze

Analysis of SBCs for Z‐CSVs and L‐CSVs (2018) ‐ 2018‐03‐01a Page 2 of 2



Sent electronically to [email protected]

February 14, 2018

RADM Michael Weahkee, Acting Director Indian Health Service 5600 Fishers Lane Rockville, MD 20857 Re: TSGAC Support for IHS Advance Appropriations Dear Acting Director Weahkee: I write to you on behalf of the Tribal Self-Governance Advisory Committee (TSGAC) to let you know that we were very happy to hear that you support advance appropriations for the Indian Health Service (IHS). We appreciate the attention you focused on the issue during the First Quarterly Meeting of the TSGAC on January 24, 2018. As we discussed, advance appropriations are critical to providing the IHS parity with the similarly situated Veterans Health Administration, and to ensuring that the consistent delivery of quality healthcare services in Indian Country. Self-governance Tribes are ready to work with you to make this initiative a reality. The Federal Government has a trust responsibility to protect the interests of Tribal nations, pueblos, and communities. Providing American Indian and Alaska Natives (AI/AN) with access to quality healthcare lies at the very heart of this responsibility. Yet, the ability of Self-Governance Tribes to address the essential healthcare needs of our Tribal citizens is severely hindered by the lack of full funding being made available on a timely basis by Congress through the appropriation process. Advance appropriations for the IHS would provide greater stability to AI/AN healthcare services. In the last decade, there has been only one fiscal year (FY 2006) in which the Interior, Environment and Related Agencies appropriations bill was enacted by the beginning of the fiscal year. These delays are very harmful to all Tribal healthcare providers. Both Self-Governance and Direct Service Tribes have prioritized this issue as a critical means of protecting our citizens' healthcare interests. Members of Congress and their staff have been educated about the need for this change and significant resources have been developed. We are happy to meet with you and your staff to discuss the most effective way we can work together to pursue this initiative.

The FY 2017 House Appropriations report for Interior, Environment and Related Agencies directed the GAO to issue a report on the use of advance appropriations for health care programs and its application to the IHS:

Advance Appropriations Report. The House Report asks for a Government Accountability Office (GAO) report and evaluation on the use of advance appropriations for healthcare programs across the federal government, and their application to the IHS:



TSGAC Letter RE: TSGAC Support for IHS Advance Appropriations

February 14, 2018 Page 2 of 2

– 2 –

“The Government Accountability Office is directed to report on the use of advance appropriations authority for healthcare programs across the Federal government, including problems encountered, any estimates of cost savings, and applications to the Indian Health Service.”

(H. Rept. 114-632, p. 89). As far as we know GAO has not done such a report. Would you be willing to inquire with GAO and ask them for a progress report on efforts to draft this report? I thank you for the opportunity to share our serious concerns on these important issues. If you have any questions or would like to discuss these comments in further detail, please contact me at [email protected]. Sincerely,

Chief Lynn Malerba, Mohegan Tribe of Connecticut Chairwoman, IHS TSGAC cc: Jennifer Cooper, Acting Director, Office of Tribal Self-Governance, IHS TSGAC Members and Technical Workgroup




February 5, 2018

RADM Michael Weahkee, Acting Director Indian Health Service 5600 Fishers Lane Rockville, MD 20857 P. Benjamin Smith, Deputy Director Intergovernmental Affairs 5600 Fishers Lane Rockville, MD 20857

Jennifer Cooper, Acting Director Office of Tribal Self-Governance 5600 Fishers Lane Rockville, MD 20857 Elizabeth Fowler, Deputy Director Management Operations 5600 Fishers Lane Rockville, MD 2085

RE: Concerns about Inconsistencies in the IHS Funding Agreement Negotiation Process Dear Acting Director Weahkee, Acting Director Cooper, Deputy Director Smith, and Deputy Director Fowler: I write to you on behalf of the Tribal Self-Governance Advisory Committee (TSGAC) to reiterate our concerns related to the Agency’s recent departure from established precedent in negotiating and recently denying standard language that has been in numerous existing funding agreements for over a decade. We are greatly concerned about the current disagreement between IHS and a new Self-Governance Tribe regarding the timing and responsibility of the IHS to distribute Title V payments. The Tribe submitted a final offer that included a provision requiring the IHS to make Title V payment either within 10 days of apportionment or on an incremental basis in the case of an applicable continuing resolution. The IHS rejected the offer, finding that it did not need to meet the requirements set forth at 25 U.S.C. § 5388(a) governing the transfer of self-governance funds. Section 5388(a) of the Indian Self-Determination and Education Assistance Act (ISDEAA) states, in relevant part, that:

Pursuant to the terms of any compact or funding agreement entered into under this subchapter, the Secretary shall transfer to the Indian tribe all funds provided for in the funding agreement … and provide funding for periods covered by joint resolution adopted by Congress making continuing appropriations … In any instance where a funding agreement requires an annual transfer of funding to be made at the beginning of a fiscal year, or requires semiannual or other periodic transfers of funding to be made commencing at the beginning of a fiscal year, the first such transfer shall be made not later than 10 days after the apportionment of such funds by the Office of Management and Budget to the Department, unless the funding agreement provides otherwise.


https://www.law.cornell.edu/definitions/uscode.php?width=840&height=800&iframe=true&def_id=25-USC-1264422296-1757435814&term_occur=211&term_src=title:25:chapter:46:subchapter:V:section:5388

https://www.law.cornell.edu/definitions/uscode.php?width=840&height=800&iframe=true&def_id=25-USC-1121892347-1757671252&term_occur=192&term_src=title:25:chapter:46:subchapter:V:section:5388

TSGAC Letter Re: Concerns about Inconsistencies in the IHS Funding Agreement Negotiation Process February 5, 2018 Page 2 of 2

25 U.S.C. § 5388(a) (formerly codified at 25 U.S.C. § 458aaa-7(a)) (emphasis added). We think that the statutory language is clear: Payments must be distributed within 10 days, unless a superseding budget resolution or funding agreement provision dictates otherwise. The IHS has negotiated and approved numerous funding agreements with other Tribes that include substantially similar language regarding the timing of payment. The IHS, however, chose to break with years of established precedent and reject the final offer, rendering the ISDEAA’s 10-day payment requirement essentially meaningless. The decision severely undermines the IHS’s credibility in the negotiation process and will have repercussions for all Self-Governance Tribes with IHS funding agreements. The TSGAC, thus, requests that, consistent with federal law, that the IHS reaffirm its commitment to abide by its negotiated agreements, which has, regrettably, been cast into doubt. As you know, over 360 Tribes currently participate in Tribal Self-Governance. That number will only continue to grow as additional Tribes choose to exercise their inherent right to govern and protect the interests of their citizens. To better ensure the successful operation of these programs, we need an IHS that is consistent and reliable in the administration of its negotiating responsibilities. Over the years, Tribal leaders have repeatedly expressed frustration about what they perceive as a systemic lack of proper negotiation training of Agency Lead Negotiators (ALNs). During our face-to-face meeting on January 24, 2018, all of you acknowledged that internal business policies need to be improved to ensure greater consistency in practice. Tribal members of the TSGAC, therefore, urge the IHS to adopt a nationwide policy that directs ALNs to accept compact and funding agreement provisions proposed by tribes during a negotiation that have already been negotiated and approved by the IHS in agreements with other Tribes. The IHS has followed this policy in Alaska for almost two decades with positive results. Expanding the policy nationwide would help minimize negotiation-related issues and, importantly, also help to minimize the perception of discrimination against new Self-Governance Tribes. I thank you for the opportunity to share our serious concerns on these important issues. If you have any questions or would like to discuss these comments in further detail, please contact me at [email protected]. Sincerely,

Chief Lynn Malerba, Mohegan Tribe of Connecticut Chairwoman, IHS TSGAC cc: TSGAC Members and Technical Workgroup



P.O. Box 1734, McAlester, Oklahoma 74501 Telephone (918) 302-0252 – Facsimile (918) 423-7639 – Website: www.tribalselfgov.org

WORKGROUP REPORTING FORM

NAME OF WORKGROUP (please check which Committee this report will be for) Contract Support Costs (CSC) Workgroup

DATE OF MEETINGS

March 6-7, 2018

LOCATION OF MEETINGS

Albuquerque, NM

COMMITTEE CHAIRMAN Andy Joseph, Councilor, Confederated Tribes of the Colville Reservation

COMMITTEE RECORDER Melanie Fourkiller, Choctaw Nation (for purposes of this report only)

ATTENDANCE (please list all present during the meeting)

AGENDA ITEM SUMMARY/HIGHLIGHTS (Committee action should be noted in this section)

Background 1. The IHS Acting Director announced by letter on December 21, 2017 that it had

unilaterally suspended a portion of the CSC policy carefully negotiated with Tribes and approved with Tribal Consultation (the 97/3 option for determining duplication of Service Unit funding).

2. Tribal Co-Chair Joseph responded by letter dtd January 3, 2018 which expressed displeasure with unilateral action; requested data IHS was relying upon for its decision; and requesting immediate reinstatement of the policy until Tribal Consultation was conducted. These requests were reiterated verbally by Tribal Leadership at TSGAC as well as HHS-STAC.

3. IHS Acting Director Weahkee responded to Co-Chair Joseph’s letter on February 16, 2018 (attached), in which he stated that former Acting HHS Secretary Eric Hargan had been briefed on the Tribal requests; stated that the IHS would not be reinstating the 97/3 policy at this time; and rejecting two key recommendations of the Tribal CSC members: payment of CSC on CHEF reimbursements and IHS grants.

March 5, 2018 Letter to CSC Workgroup (attached)

Upon arrival at the CSC Workgroup Meeting, the Tribal representatives received a letter from the Acting IHS Director dtd March 5, 2018. This letter included data on instances where the IHS-termed “Known IDC Associated with Service Unit Shares” did not comport with the 97/3 option. IHS staff asserted they would have no ability to negotiate in these instances if the Tribe were to opt for the 97/3 method. Tribes strongly disagreed with the validity of the data included in the “Known” column of the IHS-constructed chart.

Despite the continuing fundamental disagreements, the Tribal and IHS teams worked diligently to arrive at a recommendation to submit to the Acting Director. This required multiple exchanges of proposed language and caucuses.

Joint Recommendation to the Acting Director (attached)

The Language in Section 3 of the policy in BOLD (attached) is being recommended unanimously by the CSC WG (Tribal/Federal) to the Acting Director. Upon approval, a DTLL will be developed with the new language announcing a 30-day Tribal Consultation. [Note: although the Tribal representatives advocated for immediate reinstatement of the 97/3 policy pending these changes, the IHS representatives did not concur.]

Outstanding Issue and Future CSC Workgroup Meeting

In the course of the discussions on the 97/3 matter, the Tribes raised the issue of applicability of the Service Unit duplication options (section 3) to Indirect-Type negotiations. The Tribal members proposed language to clarify this issue in the policy, however, the Workgroup did not reach consensus. A small team will be developed of federal and Tribal members to review data associated with this issue, and the CSC WG will reconvene in approximately 45-60 days to revisit this matter.

RECOMMENDED TSGAC ACTIONS

1. Monitor for expedited Tribal Consultation and reinstatement of this portion of the CSC policy, and that the small CSC team is formed timely.

2.

Excerpt of Indian Health Manual, Chapter 3, Contract Support Costs – Part 6

CSC Workgroup Recommendation 3/7/18 in BOLD below

2. Negotiating Indirect-Type Costs. A lump sum amount for "indirect-type costs" may be negotiated with

awardees that do not have negotiated IDC agreements with their cognizant agency or that request

such a negotiation, even if they have a negotiated rate. This annual lump-sum amount may be

calculated by negotiating a fixed amount for "indirect-type costs." Categories of costs often

considered "overhead" or "indirect-type" are generally in the categories of:

Management and Administration; Facilities and Facilities Equipment; and General Services and

Expenses. More specific examples of indirect and indirect-type costs include but are not

necessarily limited to the following:

Management and Administration Facilities and Facilities Equipment

General Services and Expenses

Governing Body Building Rent/Lease/Cost Recovery

Insurance and Bonding

Management and Planning Utilities Legal Services

Financial Management Housekeeping/Janitorial Audit

Personnel Management Building and Grounds General Support Services

Property Management Repairs and Maintenance Interest

Records Management Equipment Depreciation/Use Fees

Data Processing ---- ----

Office Services ---- ----

As with all IDC, however, the negotiation of indirect-type CSC funding must ensure the amounts

are consistent with the definition of CSC in 25 U.S.C. § 5325(a)(2)-(3).

Indirect-type costs must be renegotiated not less than once every three years, but they can be

renegotiated more frequently at the awardee's option.

3. Alternative Methods for Calculating IDC Associated With Recurring Service Unit Shares. The

provisions of this section E(3) shall apply to the negotiation of indirect CSC funding in or after FY

2016 and to the calculation of duplication under 25 U.S.C. § 5325(a)(3), when: i) an awardee

assumes a new or expanded PFSA or added staff associated with a joint venture (in which case the

review is limited to those new or expanded PFSA or those additional staff); ii) an awardee includes

new types of costs not previously included in the IDC pool that is associated with IHS programs,

resulting in a change of more than 5% in the value of the IDC pool (in which case the review will be

conducted under Alternative A and will be limited to those new types of costs); or iii) an awardee

proposes and renegotiates the amount

Limited to the above circumstances, the awardee shall elect the method for determining the amount of IDC associated with the Service Unit shares and the remaining IDC that may be eligible for CSC funding, to identify duplication, if any, pursuant to 25 U.S.C. § 5325(a)(3), using one of two

options listed below or any other mutually acceptable approach. In connection with 3.iii, above, if an earlier funding agreement reflects a prior identification of duplicated Service Unit costs, then the parties shall negotiate a new duplicate amount considering the alternatives available under Alternative A, Alternative B, or any other mutually acceptable approach.

a. Alternative A. The awardee and the Area Director or his or her designee shall conduct a

case-by-case detailed analysis (Manual Exhibit 6-3-D) of Agency Service Unit share

expenditures to identify any IDC transferred in the Secretarial amount. The IDC funded in the

Service Unit shares will be deducted from the awardee's direct costs and total IDC, not to

exceed the amount included for that same cost in the awardee's IDC pool that would be

allocable to IHS under the IDC rate, to avoid duplication under 25 U.S.C. § 5325(a)(3) when

determining the indirect CSC funding amount as described above in 6-3.2E(1).

b. Alternative B. The awardee and the Area Director or his or her designee will apply the

following "split" of total Service Unit shares, the 97/3 method (Manual Exhibit 6-3-E):

i. 97% of the Service Unit shares amounts will be considered as part of the

awardee's direct cost base.

ii. 3% of the Service Unit shares amounts will be considered as IDC funding.

iii. If the amount considered IDC funding (3 percent) exceeds the awardee's

negotiated CSC requirements, the awardee shall retain the excess funds for

direct costs.

Once these 97/3 amounts are computed, they will be used in accordance with the terms of the IDC

rate agreement (or alternative method provided herein) for calculating the CSC requirement. The

remaining IDC need associated with the IHS PFSA will be eligible for payment as indirect CSC, as

provided in this chapter and 25 U.S.C. § 5325(a)(2)-(3). Manual Exhibit 6-3-D illustrates how

Alternative A (a detailed analysis) is calculated and Manual Exhibit 6-3-Eillustrates how Alternative

B (the 97/3 method) is calculated.

https://www.ihs.gov/ihm/index.cfm?module=dsp_ihm_pc_p6c3_ex_d

https://www.ihs.gov/ihm/index.cfm?module=dsp_ihm_pc_p6c3_ex_e

https://www.ihs.gov/ihm/index.cfm?module=dsp_ihm_pc_p6c3_ex_d

https://www.ihs.gov/ihm/index.cfm?module=dsp_ihm_pc_p6c3_ex_e


P.O. Box 1734, McAlester, Oklahoma 74501 Telephone (918) 302-0252 – Facsimile (918) 423-7639 – Website: www.tribalselfgov.org

WORKGROUP REPORTING FORM

NAME OF WORKGROUP -- Indian Health Care Improvement Fund (IHCIF) Workgroup

DATE OF MEETINGS

March 13-14, 2018 LOCATION OF MEETINGS

Phoenix, AZ

COMMITTEE CHAIRMAN Elizabeth Fowler and Jim Roberts

COMMITTEE RECORDER

ATTENDANCE (please list all present during the meeting)

AGENDA ITEM SUMMARY/HIGHLIGHTS (Committee action should be noted in this section) Sub-workgroup work session Each of the four sub-workgroups met for the morning to go over information and data

gathered and chart steps forward.

Sub-workgroup Updates Each of the four sub-workgroups gave a summary of their workgroup status, any new reports or task to be completed by IHS, and steps forward

Distance & Facilities Factor Discussion

This was included in the Access to Care sub-workgroup

Per Person Benchmark Discussion

The group had a consensus to utilize the National Health Expenditures as the benchmark with 4 of the 5 categories included.

User Count Discussion The group had a consensus to not explore service population any further. User Population will remain for now with the group exploring other options as add-ons, i.e., Non-CHSDA users

Sub-workgroup work session The sub-workgroups met for a while to outline any new data, reports, etc. needed from IHS

Conclude work session and Identify next steps

Each sub-workgroup outlined the technical assistance needed from IHS.

RECOMMENDED TSGAC ACTIONS

1. None requested at this time.

2.

3.

4.

5.

IHS/Tribal IHCIF Workgroup Sub-Groups

An IHS/Tribal workgroup is assessing the Indian Health Care Improvement Fund (IHCIF)

formula. During wide ranging discussions about it, many issues were identified for follow-up

and analysis by technical experts.

The charge for each sub-group is to investigate in greater detail the items listed for the group and

to report the group’s findings and recommendations back to the full workgroup for

consideration. Time permitting, each sub-group also may identify related issues or

options. Please summarize available factual data that underlie findings, implications, and

recommendations. Please list pros and cons (e.g., rationale for support and non-support).

Finally, determine whether any proposed changes to the IHCIF methodology are immediately

feasible or not and any administrative and reporting burden that implementing changes would

cause.

Four sub-groups have been established:

• Per Person Benchmark

• User Counts

• PRC Dependency

• Alternate Resources

Sub-Group: PER PERSON BENCHMARK Sub-Group Members (alphabetical by last name):

Jennifer Cooper, HQ, [email protected] Francis Frazier, HQ, [email protected] Lynn Malerba, Nashville, [email protected] Kasie Nichols, Oklahoma City, [email protected] Jim Roberts, Alaska, [email protected]

Action Assigned to / Status

Assess the rationale and impact of replacing the

Federal Employee Health Plans (FEHP) per user cost

benchmark with a benchmark based on national

health care expenditures (personal health care

services).

Team

Develop “side-by-side” LNF/IHCIF results under the

original FEHP and proposed benchmarks.

Revised the LNF calculation model to

optionally reference the National

Health Expenditure (NHE) price

benchmark. Side-by-side results can

be produced quickly when NHE data

are plugged into the model.

Compare purposes and services for each IHS budget

category (BAP, e.g., PRC, etc.) with national health

expenditure definitions to estimate correspondence or

lack of correspondence. Express as a percentage,

e.g., H&C 100%, Sanitation 0%

Team

Reprogramed the LNF model to

recalculate available IHS resources

based on either the FEHP

correspondence percentages or the

NHE correspondence percentages

when determined by the team.

Compare services and programs authorized in IHCIA

to types of spending in the national health care

expenditures. List major categories of un-funded

IHCIA services that correspond to national health

care spending. We anticipate that IHCIA mandates

more closely correspond to national health care

spending than mainstream insurance plans such as

FEHP BC/BS. Consider analyses developed by the

Budget Formulation workgroup or other sources.

Team






Sub-Group: USER COUNTS Sub-Group Members (alphabetical by last name):

Ann Arnett, Portland, [email protected] Chris Devers, California, [email protected] Jason Douglas, Bemidji, [email protected] Melissa Gower, Oklahoma City, [email protected] Kirk Greenway, HQ, [email protected] Ron Grinnell, Oklahoma City, [email protected] Dee Hutchison, Navajo, [email protected] Steven Kutz, Portland, [email protected] Robert Pittman, HQ, [email protected] Leslie Racine, Billings, [email protected] Jim Roberts, Alaska, [email protected] Dee Sabattus, Nashville, [email protected] Sheila Todecheenie, Phoenix, [email protected] Larry Voegele, Great Plains, [email protected]


Assess the rationale and impact for modifying

augmenting user counts now used in the

methodology. List any implications if any of

switching from an insurance plan benchmark to

the national health care expenditure benchmark.

Team

Cross-walk “Non-CHSDA” users among 263

service delivery areas.

Kirk Greenway and Area Office staff.

Created and provided to IHS additional

data templates for 12 Areas to cross-walk

Non-CHSDA counts among 263 local

sites.

Prepare side-by-side results of base user count

and base user count plus Non-CHSDA users

Cliff Wiggins

Revised the LNF calculation model to

optionally add Non-CHSDA counts. Side-

by-side results can be produced quickly

when data become available from IHS. In

continuing dialogue with Mr. Greenway

about IHS User counting algorithms.

Provided comment and analysis of 2 types

of Non-CHSDA algorithms.

Assess feasibility to augment each service

delivery area user count with all or portion of

Census based IHS “Service Population” counts.

Cross-walk Service population counts among

263 service delivery areas.

Team, Kirk Greenway, and Area Office

staff.

Prepare side-by-side results of base user count

and base user count plus Service Population

Cliff Wiggins















counts (if practical) for 263 service delivery

areas.

Revised the LNF model to recalculate by

optionally adding Service Population

increment counts. Side-by-side results can

be produced quickly if/when data become

available from IHS.

Assess the frequency that users (who are

assigned to a service delivery area by place of

residence) have encounters both in and outside

the service delivery area facilities places. Is this

problem isolated or prevalent? Assess feasibility

for site of service counts versus residence based

counts.

Kirk Greenway, etc.

Continuing dialogue about IHS User

counting algorithms. Analysis of 2 types of

Non-CHSDA algorithms.

Sub-Group: PRC DEPENDENCY Sub-Group Members (alphabetical by last name):

Melissa Gower, Oklahoma City, [email protected] Dee Hutchison, Navajo, [email protected] Liz Fowler, HQ, [email protected] Steven Kutz, Portland, [email protected] Mark LeBeau, California, [email protected] Rita Neuman, Billings, [email protected] Dee Sabattus, Nashville, [email protected] Larry Voegele, Great Plains, [email protected]


Assess the rationale and impact for adding

PRC Dependency type indicator to the

LNF methodology. The workgroup

expressed some concern that existing

“location based cost adjustments”

insufficiently reflect true needs where

hospitals are inaccessible.

Team

Identify objective indicators (data) of PRC

dependency and the weight such indicator

should have among all “location based

cost adjustments”

NOTE: Although not explicitly specified

as part of this charge, the LNF calculation

model was revised to include another

optional factor to address proposals made

by some work group members to reflect

higher costs connected to distance,

isolation, that restrict IHS users access to

private providers and other non-IHS

health care systems.

Team

A) LACK IHS HOSPITAL ACCESS:

Revised the LNF model to recalculate by

optionally adding a PRC-dependency factor. An

obvious candidate is the lack of access to an

IHS/Tribal Hospital which is currently part of the

PRC resource allocation formula. The revised

LNF model can handle either the PRC factor as is

(yes or no for the whole SDA), or refined to

identify the SDA population % without Hospital

access.

B) RESTRICTED ACCESS TO PRIVATE

PROVIDERS:

A second “Reduced Access” indicator was added

as an option to the LNF calculation model. The

indicator would measure the % of population in

each SDA with:

• Unrestricted Access – % of SDA

Population in or near Urban places

• Reduced Access - % of SDA Population

in small towns or rural places

• Wholly Restricted Access - % of SDA

Population in remote and isolated areas









A data collection template for all 263 SDAs (12

Areas) was provided if IHS chooses to collect this

data. Side by side LNF results can be generated

quickly if/when data become available.

Identify implications of a 2 bucket

allocation approach (e.g., a set aside for

PRC dependent sites) compared to a

single bucket approach augmented for

PRC dependency.

Team

Sub-Group: ALTERNATE RESOURCES (non-IHS Funding) Sub-Group Members (alphabetical by last name):

Ann Church, HQ, [email protected] Chris Devers, California, [email protected] Sarah Freeman, Portland, [email protected] Melissa Gower, Oklahoma City, [email protected] Clinton Gropp, Albuquerque, [email protected] Dee Hutchison, Navajo, [email protected] Desdemona Leslie, Phoenix, [email protected] Doneg McDonough, Technical Advisor, [email protected] Laura Platero, Portland, [email protected] Jim Roberts, Alaska, [email protected]


Section 1621 statute explicitly requires counting all sources of

services or resources available to AIANs. Technical staff

proposed augmenting the measure of alternate resources based on

State Medicaid Eligibility and survey data showing the

percentage of AIANs in each state covered by alternate resources.

Assess options and implications, both technical and contextual,

e.g., political for revising the LNF/IHCIF model.

Team

Review recent literature, data sources and/or studies of alternate

resources available to AIANs. Consider the feasibility of

adopting or not adopting such measures.

Team

Assess IHS datasets as a source of potential alternate resource

eligibility codes for potential indicators for each Area, State, or

individual service delivery area.

Team

Assess state maintain datasets as a source of potential alternate

resource eligibility information.

Team

Assess CMS datasets as a source of potential alternate resource

eligibility information.

Team

Seek input from “subject matter experts” from Indian country for

data sources, studies/projections that may be helpful, and input in

general.

Team











DRAFT

1

Indian Health Service IHS/Tribal Indian Health Care Improvement Fund Workgroup Meeting Notes Meeting Dates: January 30-31, 2018 Meeting Location: Holiday Inn DC/White House – 1501 Rhode Island NW Co-Chairs: Elizabeth Fowler, Federal Co-Chair, James Roberts, Tribal Co-Chair DAY 1 – January 30, 2018 Invocation & Opening Remarks Election of Tribal Co-Chair Jim Roberts – nominated, seconded, and accepted Cliff Wiggins & Group Review of the Indian Health Care Improvement Fund (IHCIF)

including the statute, formula, and prior allocations. Refer to PowerPoint presentations.

Several focus areas of the formula were identified for evaluation/discussion: user counts, the benchmark, local conditions, alternate resources, and formula thresholds.

DAY 2 – January 31, 2018 Chris Devers, CA Invocation Jim Roberts Opening Remarks: Suggested continuing with the current

formula for FY18 & allow the work of this group to evolve in phases. Based on the prior day’s discussion, more issues have been added which complicates the work that needs to be completed. Work on a revised formula would be in four major areas: Users, Alternate Resources, Benchmark, and PRC (move this part to the PRC workgroup)

Liz Fowler Opening Remarks: Timeline: Indication from House

Appropriations that Congress would like to see a revised formula for distribution of any funds that may be appropriated this year. In order to accomplish this, the workgroup needs to complete a set of recommendations by June 30, 2018, so they may undergo full tribal consultation and review by IHS leadership in time to issue any funds by the beginning of September 2018. Possibility of conversion to no-year funds, but not optimistic since they are currently single year. Review of handouts -> NOTE: “Draft document – For Internal Use Only” is not for public distribution, we have permission from RADM Weahkee to share with the workgroup although it is still a draft and hasn’t gone through clearance & review with Senior Leadership. Maybe use a phased approach to updating the formula.

DRAFT

2

Jim Roberts Review of the summary document outlining areas of focus developed the prior day and request for missing items: Address the Benchmark – look at a different benchmark instead of BCBS and convert to national health expenditure (NHE) model; *Alternate resources – develop subcommittee; *Users – consider workload vs user or some other hybrid; Travel distances; Facilities; Workload (*look at impacts of changes to the formula for these components)

Benchmark Current benchmark is the Federal Employee Health Plan (FEHP)

which is Blue Cross/Blue Shield (BCBS). Captures personal health care. National health expenditure (NHE) model – more reflective of services. Includes all care such as long-term care. Probably closest to BCBS, so is a good benchmark. Pros to NHE: is a frequently referred to indicator, Hospital-32%, MD-20%, Prescriptions-10%, Other-3%, Dental-4%, Residental-5%, Home Health-3%, Nursing Home Care-5%, DME-2%, Other medical products (non-DME)-2%. Go through IHCIA and compare to NHE. Agreed to look at using NHE as new Benchmark, now need a Data Comparison. Cliff: Need to do a comparison and data run, cross walk, side by side and look at what’s in the IHCIA. Need to complete before next IHCIF Meeting.

Benchmark Sub-Workgroup: NHE comparison & IHCIA

Federal Liaison to Sub-Workgroup: Francis Frazier, IHS Staff & Workgroup Members: Jennifer Cooper, Chief Lynn Malerba (POC), Jim Roberts, Kasie Nichols. Reminder, Budget Formulation workgroup has looked at unfunded IHCIA

Jim Roberts & Liz Fowler Meeting frequency: meet on monthly basis now through June,

giving technical staff time to prepare. Agency prepared to support meetings for the workgroup to get this complete. Work is the comparison, pulling out definition and comparison to the IHCIA.

Jason Douglas, Bemidji Area: Will we want to continue to use HQ user pop or change the definition because NHE includes nursing and User Pop doesn’t include that. Discuss during User Pop per Jim Roberts.

Users User Pop may not adequately capture the care at the local level.

If wrap-around used, does user count need to be expanded? Billing on primary care – workload (prevention). New authorities might not align with NHE (nurse visits). User population is an accepted metric used in other formulas, therefore changes have

DRAFT

3

the potential to spill over to other workgroups. The 2010 workgroup recommendation regarding user pop: imprecise measure to measure actual user for care, per Jason Douglas. Jim: an option may be to use 80% from User Count and 20% from workload (Pro-addresses influx of patients, Con-highly restrictive).

Group Vote on User Count: AK: User Pop, ABQ: User Pop because it’s concrete, BEM: User

Pop, BIL: User Pop, CA: User Pop, GPA: User Pop (Support a phased Approach), NAS: User Pop (Support Phased Approach) (Non-CHSDA Add-on, need a separate calculation for the gap, shouldn’t be remissive of it), NAV: User Pop, OK: User Pop, PHX: User Pop, PORT: User Pop, TUC: User Pop, Group: Phase 1) user Pop 2) Phase 2, IHS: Run numbers to the 50k non-CHSDA users and use as an add-on rather than workload, GP & NASH, evaluate in the Phase II pop, OK (Use Add-ons (50k that Cliff recommended non-CHSDAs)

Users Sub-Workgroup: Federal Liaison to Sub-Workgroup: Robert Pittman, Full

Committee: All Areas Report to Congress: Incorporate Phase I, Roselyn: share add on to workgroup prior to next meeting (50k)

Workload Workload: COTS users; IHS is not able to capture this from some

Tribes, which creates a data barrier. Larry Voegele: Look at the census and do an analysis (potential users). User vs. Service Population – see the chart provided. IHS: Look at Non-CHSDA User Report. Run numbers to the 50k users and use as an add-on rather than workload, perhaps the results will suggest that we add a component. Cliff: also look at patients that might show up in multiple operating units. Non-CHSDA by County or that report. Analysis: can look at individuals counted in one place, but get services in another. Frequency counts, by operating units.

Liz Fowler: We do have service population that is based on census data, we could use that. Our budget formulation always reflects 2.2M because that’s who we are responsible for.

Potential User Count: Look at Census Data? Alone or in Combo, by Area. Look for projections of potential users or a potential user adjustment. Census data has issues because of self-identification. IHS compile and look at report next meeting.

PRC Dependency Jim Roberts: Include PRC into the fund, how do we do that? Chief Malerba: Maybe intensity of need

DRAFT

4

Cliff: see slide (benchmark adjusted by site, Economies of scale factor). Melissa Gower: Service Population appears to include PRC Mark LeBeau: include PRC factor for those PRC dependent areas Mark LeBeau & Steve Kutz: Would like to form an Ad-Hoc workgroup

Group vote on PRC: Allocate in similar fashion as 75/25?

Tucson: bad idea for two pots, Port: Two Pots, PHX: One, OK: One, NAV: One, NAS: Further evaluation, GPA: One, CAL: Two, BIL: One, BEM: One, ABQ: One, AK: One Cliff: is there an alternative to add?

PRC Sub-Workgroup: Federal Liaison to Sub-Workgroup: Elizabeth Fowler; Members:

Mark LeBeau, Dee Sabattus, Dee Hutchinson, Melissa Gower, Larry Voegele, Steven Kutz

Alternate Resources CMS Payments, Mark LeBeau will work to get data from CMS

Group that he’s on NDW-only has eligibility data, per Kirk Greenway, NDW has insurance information based on eligibility

Must do something beyond the 25%, Start Broad, Multi-staged approach-using data sources, Large Scale perspective-look at pro/con politically Cliff: Broad charge Pros/Cons (political), What is available & when (question to CMS), Temporary place holder besides 75/25, look at a larger scale

Next Meeting: Scrub Data sources that are out there, State Data (variation), CMS data (MSIS), Medicaid Programs contract with Actuaries. Data separated by Tribal/non-Tribal payments, Kaiser Data. What are the limitations and pitfalls of data? Hone in on data source(s)

Alternate Resource – Subgroup Federal Liaison to Sub-Workgroup: Ann Church; Tribal Chair of

sub-workgroup: Melissa Gower; Members, Mark LeBeau, Chris Devers, Dee Hutchison, Desdemona Leslie, Steve Kutz, Doneg McDonough, ABQ Rep?

Jim Roberts Local Conditions, Travel Distances, & Formula Thresholds,

tabled for March 2018 Agenda Next Meeting Dates: March 13-14, Phoenix; April 12-13, Denver; May 16-17, Denver. Meeting Adjourned

INFORMATION RESOURCES MANAGEMENT Page 1 CHAPTER 2

INFORMATION SYSTEMS ADVISORY COMMITTEE CHARTER

Indian Health Manual (XX/XX/XX) TN 20XX-XX

8-2.1 INTRODUCTION.

A. Purpose. The Information Systems Advisory Committee (ISAC) is established to guide the development and management of information technologies and health information technologies used in the delivery of care within the Indian health system. The ISAC will assist in ensuring that information technology (IT) and health IT systems, projects, and initiatives result in:

Improving the patient experience of care (including quality and satisfaction);

Improving the health of populations; and

Reducing the per capita cost of health care.

Improve user experience

Meet regulatory, quality, and reporting requirements in a timely and effective

Recognizing that the health care delivery environment and information technologies that support it are rapidly changing, the ISAC will be flexible in interpreting the roles and rules of this document and revise them as necessary to best meet its goal.

B. Goal. The goal of the ISAC is to ensure that information systems and health IT systems are optimized to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level.

C. Authority. The ISAC will report to the Director, Indian Health Service (IHS). The ISAC will carry out the responsibilities and authorities as provided in this charter and delegated in writing by the Director, IHS.

D. Acronyms.

(1) DSTAC Direct Service Tribal Advisory Committee

(2) CIO Chief Information Officer

(3) CMO Chief Medical Officer

(4) IHS Indian Health Service

INFORMATION RESOURCES MANAGEMENT CHAPTER 2


TN 20XX-XX Draft (XX/XX/XX) Indian Health Manual

(5) I/T/U IHS/Tribal/Urban

(6) ISAC Information Systems Advisory Committee

(7) IT Information Technology

(8) NCCMO National Council of Chief Medical Officers

(9) NCEO National Council of Executive Officers

(10) NNLC National Nurse Leadership Council

(11) TSGAC Tribal Self-Governance Advisory Committee

(12) NIHB National Indian Health Board

(13) ISCC Information Systems Coordinator Committee

8-2.2 RESPONSIBILITIES.

A. Responsibilities. The ISAC is charged with the following responsibilities:

(1) Annually prioritize key initiatives in information systems to be addressed by the IHS.

(2) Advise the Director, IHS, on direction, priorities, and budget and resource allocation for information systems through development, review, and approval of strategic plans, human capital plans, tactical plans, and IT investment reviews.

(3) Promote and support efficient and effective use of health IT which:

a. improves the quality, safety, efficiency, and care coordination of population and public health;

b. reduces health disparities and improves access;

c. engages patients and their families;

d. supports organizations in managing the business of health care delivery.

e. ensures adequate privacy and security protections for IHS systems, network, and data inclusive of Protected Health




Information (PHI) and Personally Identifiable Information (PII).

(4) Develop a process for leveraging health IT in support of health care reform and quality improvement initiatives.

(5) Develop an inclusive, transparent, accountable, fair process and environment that supports collaboration between IHS, Tribal, and Urban (I/T/U) programs.

(6) Develop a process for working cooperatively with Tribes/Tribal organizations, States and other Federal agencies to share activities and costs to meet the information systems needs of Indian communities.

(7) Renew and strengthen advocacy and support for I/T/U health IT collaboration and communication.

(8) Promote the development, adoption and use of data and analytics, standard data sets, including development of analytic tools and disseminating information regarding the status of existing data sets, and marketing the need for maintaining standardized aggregate data.

(9) Promote the development, adoption and use of revenue cycle tools to maximize the ability of organizations to provide quality care through financial stability

(10) Establish and appoint ad-hoc working groups to provide advice and perform activities dealing with current IT initiatives and issues.

(11) Communicate with and report to ISAC member stakeholder groups.

(12) Identify and advocate for resources needed for information systems.

B. Meetings. The ISAC will meet at least twice annually to carry out its responsibilities either in person or virtually. Special meetings may be called by the IHS Director, co-chairs, or IHS CIO. A summary of motions will be produced for ISAC members within 5 working days. Minutes documenting action items and responsibilities will be produced within 15 working days of each meeting, distributed to ISAC, and made public.

C. Membership. Members of the ISAC:

(1) IHS Chief Information Officer




(2) Board member, National Indian Health Board

(3) DSTAC Member

(4) TSGAC Member

(5) NCCMO Member

(6) NCEO Member

(7) NNLC Member

(8) IHS ISCC Member

(9) IHS Chief Information Security Officer

(10) IHS Chief Health Informatics Officer

(11) IHS Deputy Director for Quality Health Care

(12) Director, Division of Facilities Operations, OEHE

(13) One at-large member from each IHS Area consisting of elected Tribal Leaders (or designees) will be appointed by the respective Area Director.

Attention will be given to providing for a diversity of perspective in terms of geography, size of program, and mode of service and/or contracting instrument.

Officially-appointed members will designate, in writing, an alternate who will serve in an official voting capacity in the event the member is absent.

X. Invitees:

The ISAC wishes to maintain a spirit of open forums which promotes the exchange of ideas and supports a robust discussion. In doing so, the ISAC wishes to maintain its status as exempt from the Federal Advisory Committee Act (FACA) as outlined in the statutory exemption to the FACA found in the Unfunded Mandates Reform Act (UMRA), 2 U.S.C. §1534(b) applies when:

(1) meetings are held exclusively between Federal officials and elected officers of State, local, and tribal governments (or their designated employees with authority to act on their behalf), acting in their official capacities; and




(2) such meetings are solely for the purposes of exchanging information, or advice relating to the management or implementation of Federal programs established pursuant to public law that explicitly or inherently share intergovernmental responsibilities or administration.

Invitees/Non-Voting participants may partake in ISAC meetings without formal designation provided their status conforms to the guidance stated in the FACA Exemption.

D. Chair. The ISAC is co-chaired by one tribal ISAC member and by one IHS ISAC member as outlined below.

(1) Tribal Chair: The Tribal chair position will alternate on a 2-year basis between the representative from the DSTAC then proceeding to the representative TSGAC then selected from one of the At-large tribal ISAC members before returning to the DSTAC representative then repeated.

(2) IHS Chair: The IHS chair position will rotate on a 2-year basis between the representative from the NCCMO, then proceeding to representative from the NNLC, and finally to the representative from the NCEO before returning to the NCCMO representative.

E. Membership Changes. Tribal members may resign by request to their respective IHS Area Directors through submission in writing.

(1) The ISAC may recommend, to an IHS Area Director, the replacement of any member who does not attend two consecutive committee meetings.

(2) Federal members are expected to attend.

F. Staff Support. Staff support will be provided by the IHS Office of Information Technology and can include personnel from I/T/U.

G. Technical Advisors. The ISAC may wish to receive technical advice from the National Council of Urban Indians or Urban Indian Health Programs. The ISAC may also wish to engage and receive advice from staff members from the NIHB or other similar representative and advocacy groups.

8-2.3 DECISION MAKING.




A. Quorum.

(1) A quorum will exist when at least half of the ISAC representatives are present. All decisions will be by majority vote of those present at each meeting.

(2) In the event of a deadlock decision, opposing arguments will be summarized, submitted to the Director, IHS, for determination and the outcome documented in the minutes.

B. Agenda Setting and Submission of Issues for Consideration. All ISAC members are encouraged to submit topics for potential inclusion in agenda. The ISAC co-chairs will jointly establish meeting agendas.

(1) For complex concerns, issue papers are encouraged to be submitted in advance for consideration as an in-depth discussion of background, alternatives, financial costs, benefits, and impacts, and other considerations may be beneficial.

(2) Agendas will be distributed to ISAC members approximately 10 working days before each meeting.

C. Charter Review.

(1) This charter will be reviewed on a biennial basis and as needed to evaluate its effectiveness and incorporate any improvements.

(2) Changes to the ISAC charter must be approved by a simple majority vote of the ISAC.

Tribal Self Governance Advisory Committee Representative Report

Date: March 13, 2018

Author: Stewart Ferguson

The Tribal Self Governance Advisory Committee (TSGAC) is extremely interested in the IHS activities to

explore and potentially adopt a COTS EHR. This may be the single most important IT issue facing the IHS

today and likely for many years to come. Due to this criticality, the TSGAC has significant concerns

about this activity that must be addressed:

• There does not appear to be a formal plan or timeline for moving forward with this undertaking.

o The “Modernization Taskforce” that was initially created to work on this effort has been

disbanded.

o An RFI was developed and submitted with little communication with ISAC.

o TSGAC expects that a project plan and timelines will be developed, reviewed and

approved through tribal consultation.

• Significant leadership and clinical engagement is required to develop the requirements and to

implement any such system(s).

o TSGAC highly recommends that IHS fill the vacated Chief Medical Information Officer

position as soon as possible, which would provide leadership not only from IT but also

across the agency.

• TSGAC recommends that each IHS budget specifically request financial resources needed for the

overall effort.

o TSGAC believes strongly that IHS needs to have dedicated staff to manage the entire

process – from an RFI through the RFP and to the acquisition and

implementation. TSGAC believe IHS has a significant lack of staffing to properly

manage this process. For example, the current “RFI Process” appears to be an “extra

duty” for current staff.

o Many tribal leaders know, from their own experience with COTS EHRs implementations,

that this is an enormous effort requiring dedicated staff. This project will have a

national impact and extremely long term effects on health care.

o TSGAC believes it would be appropriate to request that the IHS director apply the

appropriate level of staffing to this process – and to seek funding for this in future years.

TSGAC also notes that the ISAC Charter has been undergoing revisions for more than 6 months. The

revision process has lacked transparency, and a final version has yet to be submitted to leadership for

review and approval. TSGAC supports the potential for a more inclusive role of tribal leadership in the

ISAC membership and for broader participation by all areas. This is especially apropos as the ISAC

considers the massive COTS EHR project. TSGAC encourages ISAC to complete the review of the charter

and to bring that to TSGAC for review and approval.

Workgroup Meeting 6

IHS STRATEGIC PLAN WORKGROUP

FEBRUARY 1, 2018

Progress to Date Meetings 1-3 •Meeting 1 - November 14 • Kick off meeting to discuss the expectations of the Workgroup and the

Strategic Plan development process to date.

•Meeting 2 - November 29 • Review Workgroup Goal, Objectives and Strategies • Homework: Review Proposed Strategies

•Meeting 3 - December 13 • Determine if a proposed Strategy is really a Strategy or Charter/Activity • Homework: Mission and Vision Comments, Reword and Move Strategies

Recommendations

INDIAN HEALTH SERVICE / OFFICE OF PUBLIC HEALTH SUPPORT 2

Progress to Date Meetings 4-6 •Meeting 4 - January 10 • Review Move and Reword Recommendations • Homework: Vote on Move and Reword Recommendations

•Meeting 5 - January 17 • Finalize strategies • Homework: • Ranking of Mission and Vision Statement • Ranking of strategies for importance and impact by goal and objective

•Meeting 6 - February 1 • Recommend list of final strategies and top 3 mission and vision statements


Results

Mission and Vision Statements

Results - Mission Mission Statements

A. To raise the physical, mental, social and spiritual health of American Indians and Alaska Natives to the highest level.

B. The mission of Indian Health Service is to deliver high quality, timely, innovative, and culturally appropriate healthcare to American Indians and Alaska Natives and build healthier communities.

C. To raise the physical, mental, social, spiritual and environmental health of American Indians and Alaska Natives to the highest level.

D. To raise the physical, behavioral, social, environmental, and spiritual health of American Indians and Alaska Natives to optimal level, through high-quality and culturally relevant practices or services.

E. In partnership with Tribes, provide exceptional service to enhance the health and wellbeing of American Indian and Alaska Native People.


Results - Vision Vision Statements

A. No Vision

B. A health system that promotes Tribal ownership and pride.

C. Healthy communities through strong partnerships and quality health care.

D. A comprehensive, well-resourced health system that provides accountable, culturally appropriate care through all stages of life.

E. A health system that promotes cultural humility, transparent communication, employee accountability, financial stewardship, quality patient outcomes and tribal partnership.

F. A health system that delivers quality care and promotes healthy communities in partnership with Tribes and Urban Indian Organizations.


Draft Goals and Objectives GOAL 1 GOAL 2

To ensure that comprehensive, culturally acceptable personal and public health services are available and accessible to American Indian and Alaska Native people.

To promote excellence and quality through innovation of the Indian health system into an optimally performing organization.

Strengthen IHS program management and operations.

GOAL 3

Objectives: 1. Recruit, develop, and retain a

dedicated, competent, caring workforce.

2. Build, strengthen, and sustain collaborative relationships.

3. Increase access to quality health care services.

Objectives: 1. Create quality improvement

capability at all levels of the organization.

2. Provide care to better meet the health care needs of Indian communities.

Objectives: 1. Improve communication within the

organization, with Tribes and other stakeholders, and with the general public.

2. Secure and effectively manage assets and resources.

3. Modernize information technology and information systems to support data driven decision.


Results Prioritizing Strategies

Next Steps •Review workgroup recommendations by Senior Staff •Federal Register Notice •Tribal Consultation / Urban Confer •Finalize Strategic Plan •Implementation • Charters • Measures


Indian Health Service (IHS) IHS Strategic Plan 2018-2022

1

Workgroup Meeting 6 Summary February 2, 2018 2:00-3:30pm ET

Meeting Format: Conference Call and Adobe Connect Workgroup’s Purpose Provide IHS Strategic Plan recommendations to IHS senior staff, including recommending strategies for each of the draft goals and objectives. Welcome Thanks to each of the workgroups for your hard work on developing the Strategic Plan. The IHS Senior Leadership is regularly updated regarding your tireless work regarding the assignments and getting homework completed on the strategies and we are extremely appreciative. Your expertise and time commitment to this process is highly valued and invaluable. Thank you and keep up the good work. Progress to Date The IHS Federal-Tribal workgroup has held five meetings on: November 14, 2017, November 29, 2017, December 13, 2017, January 10, 2018 and January 17, 2018.

1. The first kick-off meeting provided an overview of the workgroup process from IHS Senior Leadership, an overview of the strategic plan process to date, projected timeline, and an introduction of important plan definitions.

2. During the second meeting, members reviewed comments received from tribal leaders, Urban Indian Organization leaders, and IHS staff.

o The first homework assignment was a tally sheet. The tally sheet required each individual to review and determine if a proposed strategy is a Strategy or Charter and if a Move or Reword is required.

o Additionally, workgroup members voted to extend the workgroup meeting time (one-hour to one-hour and thirty minutes) and dates (a fifth workgroup meeting was added to the schedule).

3. During the third meeting, members reviewed the proposed strategies to determine if the strategies are appropriate for the workgroup’s respective goal and objectives. Based on the homework submissions, the strategies were organized in a color-coded system (i.e. Green, Yellow and White-see Meeting 2 Summary for more information). Each workgroup identified the strategies and charters according to goal and objectives but did not have enough time to review the Move or Reword recommendations during meeting 3. o Workgroup members were sent an updated Reword and Move Excel worksheet to review

including a “summary” column. 4. During the fourth and fifth meeting members reviewed the aggregated reword and move

recommendations and ranking of importance and impact of each strategy in each goal and objective.

Meeting 6 Overview The goal of today’s meeting is to recommend a list of final strategies and to provide recommendations on the mission and vision statements.

Indian Health Service (IHS) IHS Strategic Plan 2018-2022

2

Voting Results for Mission Statement Workgroup members (or their designee) reviewed the results for the drafted mission statements. Workgroup members recommend the following statement:

• In partnership with Tribes to raise the physical, mental, social and spiritual health of American Indians and Alaska Natives to the highest level through high quality and culturally relevant practices.

Voting results for Vision Workgroup members (or their designee) reviewed the results for the drafted vision statements. Workgroup members recommend the following statement:

• Healthy communities through strong partnerships and quality health care systems.

Draft Goals and Objectives Each goal and objective were reviewed by the workgroup. Workgroup members were informed that the results will be presented to IHS Senior Leadership. Workgroup members were asked for suggestions, or if strategies can be combined, or missing content.

Next Steps

• Senior staff will review workgroup recommendations by IHS Senior Staff. Items will be forwarded to IHS Senior Leadership for their review and recommendation.

• Once a final plan is developed, a Federal Register Notice will be drafted for 30-day review. • The final strategic plan will be released by IHS Senior Leadership. • Implementation:

o Charters – will support the strategies o Measures – will serve as a guide to achieve the desired results.

• The workgroup members were asked to comment if the Goals and Objectives cover the strategies and to submit additional comments in the next few days to [email protected].

• The workgroup was also informed that they may be called upon in the future to assist in finalizing the IHS Strategic Plan.

Meeting Attendees Tamara Clay OTSG Miranda Carmen OCPS Raho Ortiz OUIHP CAPT Ann Arnett POR Minette Galindo OCPS CAPT Laura Herbison POR Steven Whitehorn OCPS CDR Micah Woodard POR John Longstaff OEHE Daniel Marino TUC Duane Phillips OHR Nicholas Barton OKC Paul Jung OHR Marilynn “Lynn” Malerba NAS Tina Conners ORAP Kasie Nichols OKC Lanie Fox AKA Jacqueline Manley SIHC Darren Crowe GPA CAPT Francis Frazier OPHS Robert Gemmell CAA Robert Pittman OPHS Genevieve Notah NAV Lucie Vogel OPHS Jon Brandt ODSCT Gene Robinson OPHS
