NATIONAL INDIAN HEALTH OUTREACH & EDUCATION

Nati onal Tribal Health Reform Training

Wednesday and Thursday, Apri l 18 & 19, 2012Mysti c Lake Casino at Prior Lake, MN

Working with States: How to Implement Health Reform While Partnering with Your State

• State-Based Health Insurance Exchanges

• Federal Employee Health Benefits Plan

• Consumer Operated and Oriented Plans (CO-OPs)

• Pre-Existing Condition Insurance Program

• Medicaid Expansion and Eligibility

The Affordable Care Act ProvidesNew Healthcare Options For Tribal Members:

New Health Insurance Exchanges

• Starting in 2014, if you own a small business or your employer doesn’t offer insurance, you will be able to buy it directly in an Affordable Insurance Exchange Market.

• An Exchange is an insurance marketplace for individuals and small businesses to buy coverage.

• Exchange Marketplaces will offer you a choice of health plans that meet certain benefits and cost standards.  

EVERY State Will Have A Health Exchange

• One-Stop Shopping and Accessibility: – Will supply easy to understand, standard information

• Provides credits & subsidies to purchase insurance: – Will provide credits and subsides up to 400% of the federal poverty level

to help individuals and families purchase insurance.

• Out of pocket limits: – Plans in the health insurance Exchanges will have a cap on what

insurance companies can require in out-of-pocket expenses, such as co-pays and deductibles.

[Small business tool screen grab]

EVERY State Will Have A Health Exchange

• According to section 1311(d)(6) of the Affordable Care Act, Exchanges are required to consult with certain groups of stakeholders as they establish their programs and throughout ongoing operations.

• Each Exchange that has one or more Federally-recognized tribes must engage in regular and meaningful consultation and collaboration with such tribes and their tribal officials on all Exchange policies that have tribal implications.

State Exchanges MUST Collaborate with Tribes

• The Federal Employees Health Benefits (FEHB) Program became effective in 1960. It is the largest employer-sponsored group health insurance program in the world.

• Section 409 of the Affordable Care Act entitles Indian tribes, tribal organizations, and urban Indian organizations to purchase FEHB coverage, rights, and benefits for their common law employees.

Tribal Eligibility-Federal Employee Health Benefits

Tribal FEHB Eligibility Requirements:If a tribal employer participates in FEHB, which tribal employees are eligible?

Full-time and part-time tribal employees who are considered common law tribal employees who meet FEHB eligibility requirements are eligible to enroll in FEHB. Also, seasonal tribal employees who work more than six months in a year are eligible to participate in FEHB. For more information on the common law standard, please refer to pages 2 through 5 of the following Internal Revenue Service (IRS) document http://www.irs.gov/pub/irs-utl/x-26-07.pdf.

Which tribal employees are not eligible?

Contract employees, tribal retirees, and volunteers are not eligible to enroll. Please refer to the Tribal FEHB Handbook for more information on the types of tribal employees that are not eligible to enroll in the FEHB Program

Are family members eligible?

Family members eligible for coverage under a tribal employee’s Self and Family FEHB enrollment are a spouse (including a valid common law marriage) and children under age 26, including legally adopted children, recognized natural children, and stepchildren. A foster child is included if the tribal employee certifies that the child meets the FEHB foster child requirements. Children age 26 or older who are incapable of self-support, if their disabling condition began before age 26, may also be eligible under a tribal employee’s Self and Family enrollment. Note: Because the FEHB Program is a Federal program, the Defense of Marriage Act (DOMA) is applicable. DOMA defines a marriage as the “legal union between one man and one woman as husband and wife.” Thus, same

Which family members are not eligible?

A tribal employee’s grandchildren (unless the tribal employee certifies that the child meets foster child requirements); parents; siblings; and in-laws are not eligible.

Are tribal retirees eligible to enroll?

No, tribal retirees are not eligible to enroll.

• CO-OPs are a new type of non-profit health insurer, created by the Affordable Care Act .

• These insurers are run by their customers. • CO-OPs are meant to offer consumer-friendly, affordable health

insurance options to individuals and small businesses.• The federal government is offering loans to non-profit organizations to

help establish CO-OPs.• CO-OPs are required to meet the same state and federal quality and

financial standards as other health insurance plans.• The health care law encourages CO-OP plans to offer better

coordination of consumers’ medical care.

Consumer Operated and Oriented Plans (CO-OPs)

What CO-Ops Mean for You

• By January 1, 2014, you may have the opportunity to buy health insurance coverage from a CO-OP for yourself or your family. If you’re a small business owner, you may be able to buy health coverage for your employees from a CO-OP.

• You and your fellow members elect the board of directors. A majority of these directors must themselves be CO-OP customers. CO-OPs must use profits to lower premiums, improve benefits, or improve the quality of members’ health care.

• As an individual or small business owner, you may be able to join others in creating a CO-OP and apply for a federal loan to help get it started. 

Pre-Existing Condition Insurance Program

• Provides affordable insurance for Americans who have been uninsured for six months due to a medical condition.

• The PCIP provides a health coverage option if:– you have been uninsured for at least six months, – you have a pre-existing condition or have been denied health

coverage because of your health condition, – and are a U.S. citizen or are residing here legally

• www.PCIP.gov

Coverage Expansions: Medicaid

Expands Medicaid Program by 2014

• Available to individuals under age 65 with incomes up to 133% of the Federal Poverty Level – $14,000 for an individual – $29,000 for a family of four

• States receive 100% federal funding for the first three years to support the expansion– phasing to 90 % federal funding in subsequent years

Regional Director Contact Information

Marguerite Salazar,Regional Director, Region VIIIU.S. Department of Health and Human ServicesMarguerite.Salazar@hhs.gov303-844-3372

Marjorie McColl PettyRegional Director, Region VIU.S. Department of Health and Human ServicesMarjorie.Petty@hhs.gov(214) 767-3301