April 17, 2020 |  Issue 20-12  Missed Last Week's Washington Report? Click Here to Visit our Archives!

Community Health Aide Program (CHAP) TAG Vacancies
 In February 2018, with the announcement of CHAP expansion to Tribes beyond Alaska, IHS created a CHAP Tribal Advisory Group.

 Information on CHAP and CHAP TAG, including vacant  positions, is available on the CHAP
website .

Join the National Partnership for Dental Therapy!
Click HERE for more information!

Stay Current: Health Alerts from the CDC!
Don't wait for the emergency to arrive before signing up for emergency alerts from the Centers for Disease Control & Prevention!

Follow NIHB on Twitter and Instagram
Top Story
InsuranceWhat is the impact of health insurance for American Indian and Alaska Natives (AI/ANs) who are patients of Indian health programs during the COVID-19 Crisis?
This article examines the impact of health insurance status during the COVID-19 pandemic. The data cited in the paper comes from the U.S. Census Bureau's American Community Survey and is supplemented by state-level reports and administrative data from the Centers for Medicare, Medicaid, and Children's Health Services and the Indian Health Service.

Private Employer Plans
About 32% of AI/ANs with access to IHS programs have coverage through employer-sponsored health plans. The impact of COVID-19 will vary by plan and its cost sharing provisions.

COVID-19: Many health plans are required to provide payment for COVID testing and treatment without copays or cost sharing, in some states this is an insurance requirement by states' insurance regulations. In addition, many health insurance plans have voluntarily removed cost sharing. It is important to note that ERISA, Employer self-insured plans, are not regulated by states and many Tribes do have self-insured plans. Employees who are laid-off have 18 month of eligibility if they are willing to pay the full cost of the health plan (COBRA), but most AI/ANs will choose their Indian health program instead of continuing private coverage.

Health Insurance Provided through Health Care Exchanges
About 100,000 AI/ANs are enrolled in these plans. Enrollment is greater in states without Medicaid expansion, with large numbers of enrolled tribal members, with tribal sponsorship of premiums, and a high percentage of AI/ANs between 100% and 300% of the federal poverty level.

COVID-19: The federal government requires that all exchanges' health plans provide payment for COVID testing, but the insured are required to pay for treatment with copays and cost sharing.

If someone is laid-off from a job with an employer-sponsored health plan they have 60 days to enroll in an exchange health plan under the "special enrollment" provision. The Trump Administration has decided not to join all thirteen state exchange plans in creating an open enrollment period for all the uninsured who live in states that have not opened their own state exchange. That means only the recently unemployed uninsured are eligible for the existing special enrollment period.

The good news is that over 90% of AI/ANs 65 and older have at least Medicare Part A, and some research suggests over 90% with Part A also have Part B or one of the Part C options. A smaller, but unknown percentage have prescription coverage in Part C or Part D.

COVID-19: Those will original Medicare Part A and Part B will be subject to cost sharing for COVID-19 testing and treatment. (at the time of writing). Medicare Advantage plans will not charge copays or cost-sharing for COVID-19 testing and treatment. This is an evolving crisis however and the reader should check the current status of exemptions from cost sharing.

About 35% of all patients of Indian health programs are enrolled in Medicaid. However, with recent layoffs, many AI/ANs may lose their employer-sponsored coverage. Many have never had Medicaid so it will be important that outreach and education efforts are tailored to the recently unemployed.

COVID-19: Several provisions of the COVID-19 legislation impact Medicaid including the offer of an increase in the FMAP by 6.2% points (Medicaid 'bump') in exchange for the maintenance of effort requirements to essentially not reduce eligibility or add administrative burdens for enrollment.

The Underinsured
Many AI/ANs are employed in service industries, in particular in the hospitality industry, which has some of the highest rates of high deductible health insurance plans with high cost sharing provisions. There is no estimate of the number of 'underinsured AI/ANs'. This is an important category because the health care behavior of the underinsured is similar to that of the uninsured.

COVID-19: When an underinsured person considers going to a primary care provider or an emergency room they often pause and wait longer than is medically advisable. The result can be disastrous, particularly during an epidemic like COVID-19.

Uninsured AI/ANs are most at risk during the COVID-19 crisis and the patients of Indian health programs are more likely to be uninsured than those who are not patients of these programs. Care is sought too late and often at the wrong location (often emergency rooms). Primary care and the regular maintenance of chronic conditions is neglected and the results are worsened conditions and often a higher cost of health care to address the result of this neglect.

COVID-19: Unless clear guidance is given about whether or not treatment costs will be paid by the federal government, many will continue to act as if they are uninsured. Currently, doubt remains about federal funding and other specifics of proposals to pay for COVID-19 related medical costs despite several reports that the Administration is considering this provision using funds from the $100 billion 'hospital fund.'

IHS-funded Tribal and Direct Service health programs
Tribal communities see their health programs as the fulfillment of the federal trust responsibility to provide care that is equal to that of any other American, which means many AI/ANs consider Indian health programs their main source of health care services. In addition to funding for the direct care provided by insurance coverage, one portion of the IHS budget known as Purchased and Referred Care (PRC) is available for care provided by specialists and hospitals and other providers and services.

COVID-19: As third party revenue goes down due to social distancing and reduced provider hours at health programs, costs and expenditures will rise as patients seek care at non-I/T facilities. There is already a severe strain on the PRC budget as bills are processed for this care. In addition, large medical expenses occurring this late in FY 2020 are not likely to be paid by the Comprehensive Health Emergency Fund if this fund is already exhausted with the claims of a normal pre-COVID-19 expenses.

One can only conclude that health insurance, private or public, will not be sufficient to cover the increase in demands for preventive and medically necessary services due the increased demands of the COVID-19 pandemic. A system already struggling in a normal year cannot be expected to marshal an adequate response to the crisis without massive inputs of resources: financial and administrative. Tribal governments are best able to decide where these resources should be deployed. New funding needs to be flexible and sufficient to the demands of this new challenge to an already financially compromised system of care.

RoundtableHouse Natural Resources Chair Hosts Virtual Roundtable with Tribal Leaders and Stakeholders

House Natural Resources Chair Raúl M. Grijalva (D-AZ.) hosted a virtual roundtable with Tribal leaders this Friday, April 17 on the federal response to the coronavirus pandemic in Indian Country. Roundtable panelists included Minnesota Lt. Governor Peggy Flanagan, Navajo Nation President Jonathan Nez, Governor of the Pueblo of Santa Clara Michael Chavarria, CEO of the Great Plains Tribal Chairmen's Health Board Jerilyn Church, and Vice Chairwoman of the Alaska Native Health Board Diana Zirul Most recently, Chair Grijalva  sent a letter  to the Federal Emergency Management Agency seeking more information on how the multi-agency COVID-19 response will assist tribes in establishing medical response facilities and triage units.  In March, the Committee launched an online Coronavirus Resource Center at  https://bit.ly/2WwiPjo  that includes information for Native American communities and a special form for tribes to describe their coronavirus experiences at  https://bit.ly/2IZFWur .

To view the recording of the Virtual Roundtable, click here. 
CommentExtensionPandemic, All-Hazards Preparedness and Advancing Innovation Act Extension of Comment Period
On April 4, 2020 HHS released a notice on the extension of a comment period for the Pandemic and All-Hazards Preparedness and Advancing Innovation Act. The specific section of the act that requires comment discusses recommendations related to maintaining an adequate national blood supply. HHS would like feedback on the challenges associated with the continuous recruitment of blood donors, the continuous adequacy of the blood supply, implementation of the transformation monitoring system and other measures to promote safety and innovation for maintaining the supply. The extended deadline for comments are due June 21, 2020.

TTAGLetterTTAG submits letter to CMS with CARES Act funding recommendations
On April 11, 2020, the Tribal Technical Advisory Group (TTAG) to the Centers for Medicare and Medicaid Services' (CMS) wrote a letter to CMS, giving recommendations on how to distribute Coronavirus Aid, Relief, and Economic Security (CARES) Act funding in a way that considers Tribes. To read the full letter, click here.

FederalFAQFederal Agencies Pen FAQs on Coronavirus Laws
Together with the Department of Labor and the Treasury, the Department of Health and Human Services issued a set of Frequently Asked Questions (FAQs) about the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security (CARES) Act to better help people to understand the laws.  The FAQ provides an overview of the FFCRA and CARES Acts, and explains that the CARES Act amended §6001 of FFCRA to expand the range of diagnostic services that insurance plans must cover without cost-sharing or prior authorization. To read the FAQ, click here.
PRCAuditHHS Office of Inspector General Conducts Audit of Indian Health Service Purchased/Referred Care Program Claims
The Indian Health Service (IHS), through the Purchased/Referred Care (PRC) Program, pays for private providers to deliver health care services to American Indian/Alaska Natives (AI/ANs), where those services are not available through IHS or Tribal facilities and programs. The Office of the Inspector General (OIG) of the Department of Health and Human Service (HHS) conducted a review of 802,470 claims paid between October 2013 and June 2016 for 120,818 beneficiaries. The HHS OIG evaluated the IHS PRC program following reports related to Tribes paying more than the Medicare rates, timeliness of claim processing and PRC referrals, and issues regarding quality of care. Out of the 100 claims OIG evaluated, it found that 82 were not reviewed, approved, or paid according to federal requirements. Federal requirements (at 42 CFR, Part 136) encompass (1) beneficiary eligibility, (2) medical necessity and priority, (3) timeliness of notification of healthcare services, (4) IHS status as payor of last resort, (5) timeliness of claim approval, and (6) timeliness of claim payments. OIG found that IHS did not have controls in place to prevent its Referred Care Information System (RCIS) from accepting claims that were missing information. The OIG also found that IHS did not always track certain processes, and that providers did not always submit completed claims. Knowing that the PRC program is integral to providing comprehensive health care services to AI/ANs, IHS has already taken corrective actions to address concerns raised by the report. Read the report HERE.

SurveyResponsesNIHB Requesting Responses to 2nd COVID-19  Needs and Priorities Survey

The National Indian Health Board (NIHB) is asking for Tribes' continued assistance in assessing the Coronavirus Disease 2019 (COVID-19) prevention and response capacity in Indian Country. An initial survey was distributed on March 3rd, 2020 and received over 190 responses, providing much needed information in advocating for funding for Indian Country, as was approved by Congress in the Coronavirus Aid, Relief, and Economic Security Act or CARES Act last week. NIHB thanks you all for the response.

As the pandemic continues to expand across the nation and challenges our public health infrastructure and capacity on a daily basis, it is crucial that NIHB continue to hear the needs of Tribes.  This second survey will assess current and expected needs for medical countermeasures, workforce, infrastructure, and communication in response to COVID-19.
We ask that you please consider the questions at the link below and share any information you can with NIHB.
This survey should take about 10-15 minutes to complete. You can access the survey here:  https://survey.az1.qualtrics.com/jfe/form/SV_56WOzrDU1jkmpcF

IHS COVID-19 All Tribes CAll
Please see below for call information to the  IHS' All Tribes Call on Thursday, April 23rd at 4:00 PM Eastern . This call is intended to update Tribes on the Coronavirus Disease 2019 (COVID-19). Tribal Leaders will have an opportunity to provide comments and ask questions to federal officials. IHS has also scheduled a COVID-19 call for the following week at the same time-call info is the same for both calls.

Date:   Thursday, April 23rd
Time:  4 :00 PM - 5:30 PM (Eastern)
Conference Call:   800-857-5577 | Participant Passcode:  6703929
Webinar Adobe Connect:   https://ihs.cosocloud.com/r4k6jib09mj/ | Participant Password:  ihs123
Rural Communities Opioid Response Program Notice of Funding Opportunity
Application Deadline: April 24, 2020
HRSA recently released the Rural Communities Opioid Response Program (RCORP) notice of funding opportunity (HRSA-20-031). HRSA plans to award approximately 89 grants to rural communities as part of this funding opportunity. Applications are due by Friday, April 24, in Grants.gov .
Successful RCORP-Implementation award recipients will receive $1 million for a three-year period of performance to enhance and expand substance use disorder (SUD), including opioid use disorder (OUD), service delivery in high-risk rural communities. They will implement a set of core SUD/OUD prevention, treatment, and recovery activities that align with HHS' Five-Point Strategy to Combat the Opioid Crisis.
FraudsScamsFederal Agency Information to Prevent Frauds and Scams
The target audience for CMS ITU Trainings includes:
  • Business Office staff
  • Benefits Coordinators
  • Patient Registration staff
  • Medical Records staff
  • Purchased/Referred Care staff
Please click here to access the schedule of virtual CMS ITU trainings. 
910 Pennsylvania Avenue, SE
Washington, DC 20003
Main Phone: 202-507-4070
Fax: 202-507-4071
Thank you for visiting the Washington Report!