Health and Human Services: CindaHughes

8/14/2019 Health and Human Services: CindaHughes

http://slidepdf.com/reader/full/health-and-human-services-cindahughes 1/6

F IRST VICE-PRLSIDINTJeffersonKtelCh i c kaw NAmn

T H ~ A S U R E RW. R o n Atlen

larnenwnSxlalllam lrihc

E A ~ I ~ R NKIA~O,MhJoeGrayson, Ir.Chnokn?Natw

MIDW~STRohert C h i sUnckbridgp,Mui~

NURIHEASIRandy N o bh'arragdod

NORTI!WESTtmie9-rC w Am- I r i h

PACIFIC

Cheryl S e i h rL4'6yuf

ROCKY M o o n IA INCad VmneCrow r r i b o

SCIUTHEAsI

Leon Jacob5It + 7 r 1 b

SourntRk PLAINSSteve J d n w r nAbsmlw .%chsmw

S o u ~ r i w t s rManuelM r lUte ~Wouofattl le Tribe

NCAl HEADQUARTERS1301 Cor>necrir!rlAvenue, N\,VSuite 2 0 0Washington, DC 20036

N A T I O N A L C O N G R E S S O F A M E R I C A N I N D I A N S

RECOMMENDA~ONSN THE FUTURE F

MEDICAIDROGRAMS

November Id , 2006

On behalf of mo re than 500 tribal nations, the National Cong ress of American Indians (NCAJ)is pleased to present comments calling for the inclusionofAmericanhdians and Alaska

Native (MAN) eneficiaries of Medicaid services in the final report of the Medicaid

Commission. NCAI is a member of the Centers for Medicaid arid Medicare Services (CMS)

Tribal Technical Advisory Group (TTAG). TTAG is a group of elected tribal leaders, or an

appointed representative from their Area, who are nominated from the twelve areas of thelndian Health Services (MS) delivery System. The TTAG serves as an advisory corntnittee to

the CMS on important health care matters associated with th e Medicare, Medicaid, and State

Chldren Health Insurance Programs.

Ensuring the well beingofour tribal chldren and families is on e of our highest priorities andgreatest responsibilities as tribal governments. While tribal governments have leanled how to

reduce or overcome many of the barriers that w e face in serving our children and families,securing adequate levels of funding for tribal services is still our greatest challenge. Ourapproach lo addressing these budgetary an d policy issues is based on ou r political status assovereign nations and the unique trust relationship the federal governme~~tas with tribal

governments. Ihesc principles of law have a constitutional o r i g n an d define how we view

our relationship with th e federal government and al l of th e agencies that operate within i t .

T h s relationship differs greatly from any status as an ethnic minority population.

TheCharter for the Medicaid Cornniission requires recommendations to fulfill tw o goals, to

find savings an d to make the program better. As a member of TTAG, NCAI has a unique

understanding of the potential neg ative impacts of sorne th e proposed savings delineated by

the Cornmission.

BACKGROUND

Medicaid C ommission member, Valerie Davidson, sent a letter to the Comm ission containingmuch information regarding the trust responsibility that the federal governmentha s to providehealth care to theMAN population. Her letter contains all the relevan[ documentation

regarding the issues discussed in th e fotlowing NCAI comments.

Many AWANs endure health conditions and a Ievel of health care funding that would be

unacceptable to mosk otherU.S. citizeos. A vast range of public health indicators demonstratethat American Lndians continue to suffer disproportionately from a variety of illnesses and

diseases. The life expectancyofNative Americans is nearly six years less than m y other race

or e t h c group in America. The &ant mortality rate is 150% greater for Indians than that ofCaucasian infants. Thrteenpercent of Native deaths occur in those younger than 25, a rate

three times higher than the average U.S. population. The U.S. Commissionon Civil f i g h t s

reported in 2003 that M A N S are " 650 percent more likely to die from tuberculosis, 31 8

percent more likely to die from diabetes, and 204 percent more Iikely to suffer accidentaldeath compared with other groups."

1 3 0 1 C O N N E C T I C U T A V E . , N W .

SUITE 200

W A S H I N G T O N . D C 2 0 0 3 6



NCAI RECOMMENDATIONSN THE FUTURE OF

MEDICADPROGRAMS

administration to the patient, likelihood of negative maclion, difficulty instorage and wchllife and other factorsthathealth providers with a widely dispersedpatient population whohave limited access to health care facilities must consider.

NCAI rea mm ad s that my provisionto d o w states to restrict the Medicaid formulary shouldbe modified to ensure that Indianhealth systems are exempt fromsuch limitations.

RehibumanentMethodology. Among theproposals made by Health andY man Services(HHS) is one o changethebasis for reimbwsemmt from AverageWholaalePrice: rAWP")

to Average Sales Price ("ASP') and o limit the dispensingfee. Indian health system

pharmacy programsdo notoperate like commercial p b c i e s . They serve a distinct

population under unique conditions. They areaffectedby small size, remote locations,and a

limited iafrrtstructm,andhave few opportunities to achieve economiesof scds. Plus, allMSand T n i harmacies arepart of a hospital or clinic operation. Indim health system

pharmacists provide c o d i n g ondrugadministrationand usage, and work frompatients'

medical records; they do not merely fd aphysician's written prescription. All of these factors

affect "efficiency"and therefore cost.

Further,on an average pmcription, the payment from Medicaid is 21 percent less han the

documented costofproviding thedrugbthepatient. Any reduction in ~ ~ e n l

melhdolqgy that is intended to reducethe overall recovery from that based onAWP willcertainly m u lt in furtherun-reimbursedcosts.

NCAl recommends: (1) If thebasis of reimbmement is changed, provide for flexibility inthe dispensing fee to assure that states canprotect access nml and remote locations. (2)

Provideexpressly that pphartllacies of theWan h l t h system m y onhue to be reimbursedon he basisofAWP less apercentageplus a dispensing fee.(with.neitherthe percentageor

dispensing fee to be smaUer than, that paid in FY 20051, unless and until the hhst ructure for

determining the average costof acquisition, phannacyprogram administration, and dispensing(includingpatient counseling)on an ongoing basis isdeveloped by M S nd made available torribal health programs.

Asset Policy. The lndian health system has relatively few direclly operated long erm care

Eacilities. The system is gradually developing home- and community-based long term care

alternatives. Medicaid may be the onlymcans by which an AYAN elder can acquire longterm care. AVAN elders are generally reluctant to apply forMedicaid, however due to their

deeply rooted belief that they are entitled to receive care from the IHS without persona1expense and their fear of losing heir, generally, few assets.

AVAN elders and othersneeding Medicaid long term care should not have to exchange heir

estates,especially of unique assets, in order to obtain the care that MS houId be able to makeavailable, but emnot due to it s limited resources.

NCAI recommends that at a minimum, all,assets of AVAN individuals described in CMS7sStateMedicaid Manual, Section 38 l0.A.7 should be exempt from Medicaid eligibilitycalculations and estale recovery provisions.

CostSharing. "Cost sharing" is a somewha! generic term that can apply to premiums,co-

paymentq and deductibles. Cost sharing poses a unique financial barrier to care for all

MANSwho are IHS beneficiaries. IHS is prohibited from charging its beneficiaries for

of 6



NCAI RECOMMENDATIONSN THE FUTURE OF

MJ~DIcAIDPROGRAMS

hervices. 'fTherefare,thepurpose of cost-sharing- encouragmgappropriatecorisumerresponsibility and utihzation- s not accomplished. Instead, enrollee cost-sharing is merely

cost-shfted to underfunded lndian programswho either absorb the costs through lower

reiinbursementsor cash outlays f b m their Contrad H ealh Services YCHS") budgets, if the

MIAN is referred by an Indian health programto another health provider. The CHS providermay not charge the IHS beneficiary, so the Indianhealth program pays the co-pay or

(1 cductible.

Ti States are to be givenadditiond flexibility with regard to cost sharing, it must not come at

the expense ofMANSor Indian health system providers. NCAI recommends that the cwrent

law provisions regarding SCHIP should be retained and expanded to apply to a11AIlANs whoarc o~henvise ligible to participate in a state's Medicaid program.

Coverageof Certain Services. One proposal advocates for increased flexibility in the

rnandrttory and optional services that stat= may offer in their Medicaid program. There are

iwcl services of parlicularconcern; F d m t l y Qualified Health Center ("FQHC") servicesand

Early, Periodic, Screening, Diagnosis and Treatment ("EPSDT'? sewices. Many tribal clinicsare enrolled in Medicaid as an FQHC. FQHC services are not recognized as a benefit

category in the SCfIlP statute. EPSDT is a critical service that should remain mandatory for

a l l beneficiaries, Saviugs in the short-term shouldnot b e attemptedat the expenseof

ir~creasedong-term costs. EPSDT is a critical componentofdisease prevention and of earIy

identificationof cMd abuse and other conditions that affect a chiId's health that will almost

certainly result in increased costs to the Medicaid program if not addressed early on.

Smce AI/ANs are especially dependent on M e l c a i d , a change in covered provider types and

services iu s an especially large impact. Any such reduction will further reduce h e level of

runding available to the already drastically under-funded Indian health system. NCAIrc.comnends: ( I ) Do not permit FQHC apd EPSDT services to be eliminated or limited

without hrther study of the impact oa access. (2) I f states are allowed to eliminate anymandatory Medicaid servicesorprovider types, provide an exemption that requires continued

reimbursementto Lndian health programs on a basis at least equivalent to that authorizedunder the state's Medicaid plan in FY 2005.

ComparabiIityandStat-deness. Under submitted proposals, states could vary benefits and

conditions of participation from cou~ltyo county or regon to regon. Such provisions haveth e potential to very negatively impact Indian health programs. While many states have

achieved a good working relationship with the tribes and Indian 1 1 ~ 1 t hrograms in their state,

those relationsllipsvary substantially and are often influenced by stateltribal issues unrelatedto health care delivery. Implementationof this level of proposed flexibility could deliberately,

or inadvertently, severely affect access to Medicaid by AYANs who Iive on or near a

reservation that the state ~boseo include in the geographc regions to which it chose to l im i tservices. To prevent even the possibility of such outcomes, certain protections need to be

present if stich flexibility is granted.

NCAI recommends that states should be prohibited from offering benefit packages that are less

in amount, duration, or scope to AVAN Medicaid beneficiaries than the benefits packages they

affer to any other group ofMedicaid beneficiaries anywhere in the state. This "most favorednation" rule should apply with respect to a11 NAN Medicaid beneficiaries, regardlessof

whether they live on or near a reservatio~~.



Managed Care. SCHIP allows states to requireparticipation in managed care,unIikeMedicaid which prohibits a state from requiring anMAN to enroll in a managecare entityunless the managed care entity i s theWS, tribal hdrh,program,or an urban M i an healthprogram. This limitationm sm hat AVAN Medicaidbeneficiaries are not involuntarily

enrolled in a non-lndian managed care entity. The experience with such ~ l l m e n t ss thatthey disrupt continuity of the culturally competent care provided by their IndianMthprogram, and, if for any reasan the managed care entity does not enroll the Indian healthprogram as one of its providers, results in the Indian heakh program providing uncompertsaled

care, while tbe managed care entity benefits from p~mium8rom the state. NCAIrecommends them bea retentionon the limitation onmanaged care enrollment found at 42U.S.C. § 1396~-2(a)(2)(C), nd extend it to SCHIP.

WaiverA u th o ty . NCAIrecommends: (1) The Secretary should be prohibited h m ranting

any waiva, w pproving any erm or condition in such a waiver, that results in a reduction in

benefits, or an a c m s e in cost sharing, for anyWAN bcneficinry. (2) Tht Secretary should beprohibitedh m ranting any waiver, or approving any erm or condition in such a waiver, that

is likely to shiftcosts to the federalMS budgel by d u c i n g Medicaid revenues to an Indianhealth program or increase the costs that sucha provider must incur in comlmtion withpremium or costsharingrequirements applicabletoM A N eneficiaries.

PaymentRef~rmsndMedicaidAdm inistrative Claiming.

The r)epartmwtof H d t h and Human Senices proposes to curb what it describes as various

mechanisms that states use to allow government providers to return federal Medicaid back tothe states, which in turnusethe funds to draw down additional fdml dollars. It also

proposes to curtail Medicaid administrative spending that it views as inefficient. Bothproposals create concern for tribal health programs. Several States have e n t d nto contracts

with tribes under which tribes carry out certain Medicaid outreach and educationfunctions

under Medicaid Administrative Match ("MAM") agreements. Audits of these contracts haveshown excellent accountability for hnds and compliancewith regulations. These agreements

have helped t r k mprove Medicaid participation, which is often well below what wouldkexpected given the relatively low incomeof AYANs. Tribes are anessential partner to assist

with Medicaid administration functions. The undercnr~Ument fMAN will be further

exacerbated is MAM funding for tribes is reduced.

NCAI recommends: (1) Do not impose ne w ormore restrictivelimits on reimbwxmmt for

Medicaid outreach,education, and enrollment activities. (2) Do not limit the extent to which

tribal contributions can be used to match federal expenditures for those activities.

Access to health care by MANS s limited by the gmgmpbic constraints imposedby the

locations ofreservations and otherAYAN communities and by th e substantial under-fundingof he Indian heafh system,evnl when Medicaid revenue (and other third-party revenue) is

taken into account. Savings in the cost of theMedicaid progmm should not come at theexpense of shifting costs and reducing revenue to Indian health programs.

Healthy communitiescan lead Lndian Country into overall wellness and positiveeconomic,

educational,and social development. Adopting these m o m e n d a t ons is a vitar step inhelping the first Americans lo bridge the health disparities gap that currently exists in thiscountry. Halkhy families are the keystone tohealthy communities.



N C M RECOMMENDATIONSN TH E FUTURE F

MEDICAIDROGRAMS

NCAI realizesthat Congress aid the Administration must make difficult budget choices thisyear. As elected officials themselves, tribal leaders certainly understand the competing

priorities that must be weigh d. However, the federal government's solemn responsibility to

address the serious needs facing Indian Country remains unchanged, whatever the economic

climateand

competifigprioritiesm ybe.

W et

NCAI urge theM d i c a i d Commission tomake a strong, across-the-board commitment tomeeting the federal trust obligation by

irlcluding AVAN health issues in its final report. Such a commitment, coupled with continued

efforts to strengthen tribal governments and to clarify thegovernment-to-government

relationship,tmIywill make a difference in helping us to sllgportsafe, stable, and healthyfamilies in Indian Country.

of 6

Health and Human Services: CindaHughes

Documents

Transcript of Health and Human Services: CindaHughes