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May 11-15, 2020
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May 13, 2020

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FourthPrioritiesCongressional Native American Caucus Sends Tribal Priorities to House Appropriations for Fourth COVID-19 Package
On Wednesday May 6, Congressional Native American Caucus Co-Chairs Rep. Deb Haaland (D-NM) and Rep. Tom Cole (R-OK) sent a bipartisan letter to House Appropriations Chair Nita Lowey (D-NY) and Ranking Member Kay Granger (R-TX) urging the inclusion of Tribal priorities in the fourth supplemental package expected to be introduced in the House in the coming weeks. 

In response to overwhelming concerns in Indian Country, the caucus has outlined several priorities with specific focus on the Indian health system, including: 
  • IHS & Tribally Operated Facilities
    • $1 billion - Purchased/referred care
    • $1.215 billion - Hospitals and clinics
    • $1.7 billion - Emergency 3rd party reimbursements relief funds for IHS, tribal programs and UIOs.
    • $85 million - Equipment purchases and replacements
    • Authorize Medicaid reimbursements for Qualified Indian Health Provider Services 
    • Provide reimbursements for services furnished by Indian Health Care Providers outside of an IHS or Tribal Facility
  • IHS Health care facilities construction funded at $2.5 billion. including Joint Venture program and funding for construction and equipment
  • IHS sanitation facilities construction funding at $1 billion
  • Request to waive the 25% cost-share requirement for Tribes as direct recipients of FEMA public assistance
To read the full letter outlining all Tribal priorities, click here. 
In This Issue:



ThirdPartyBipartisan Lawmakers call on Congress to Support Third Party Relief Fund
On May 4, Rep. Raul Ruiz (D-CA) and Rep. Markwayne Mullin (R-OK) co-authored a letter to Speaker of the House Nancy Pelosi (D-CA) and House Minority Leader Kevin McCarthy (R-CA) calling for dedicated and  significant funding in the next COVID relief package to replenish shortfalls in third party reimbursement from Medicare, Medicaid, and private insurance for  Indian Health Service (IHS), Tribal Health Programs and Urban Indian  Organizations (I/T/U) to recovery from significant COVID-19 related losses in revenue, particularly related to third-party reimbursement revenue to the I/T/U system. 

Many I/T/U facilities have stopped conducting elective procedures, enacted social distancing guidelines, and have reduced in person patient visits to protect their communities from COVID-19. Unforunately, this has also had the effect of reducing third party revenue streams that are critical to keeping the Indian health system afloat. Third party reimbursements from private insurance, as well as Medicare and Medicaid, contribute to a significant portion of Tribal health care funding by helping finance essential services, workforce, and related needs. 

The letter was signed by 47 House member from both parties in anticipation to the fourth COVID-19 funding package expected to be introduced in the coming weeks. 

To read the letter to House leadership,click here. 
FinalAllocationIndian Health Service Announces Final Allocations of CARES Act Funding 
On April 23, the Indian Health Service (IHS) announced where the agency intends to allocate the remaining $367 million of CARES Act funding of the $1.032 Billion appropriated by Congress on March 27, 2020.  Read the IHS Dear Tribal Leader Letter for further details of allocation areas. 

This funding includes:
  • $125 million transferred from the IHS services account to facilities account for medical equipment ($74 million), maintenance and improvements ($41 million), sanitation and potable water needs ($10 million);
  • $50 million for IHS health programs and Tribal health programs to support Community Health Representatives (CHRs) and Public Health Nursing (PHN);
  • $20 million to support Urban Indian Organizations (UIOs); and
  • $172 million that will remain at IHS Headquarters to manage the following activities: testing kits and supplies, Tribal Epidemiology Centers for surveillance coordination, telehealth expansion and delivery, public health activities, non-clinical staff support and a reserve to address unanticipated needs.
    • $5 million to provide additional COVID-19 test kits;
    • $26 million to support Tribal Epidemiology Centers and national surveillance coordination activities at IHS Headquarters. Each Tribal Epidemiology Center will receive $2 million;
    • $95 million to support the expansion of telehealth activities across Indian Country, including purchasing equipment, software, and services directly related to the delivery of telehealth;
    • $6 million for public health support activities, including partnerships with key stakeholders to broaden messaging about COVID-19 prevention, response, and recovery in Indian Country;
    • $10 million for non-clinical Federal staff support that will include deep cleaning of office space, equipment for teleworkers, protection for non-clinical staff, and non-clinical staff overtime; and 
    • $30 million to address unanticipated needs in the near future.
As for the previous funding decision, the IHS announced its previous distribution decision on April 3, 2020. The IHS letter announcing their previous funding decision of the $600 Million, which also announced $65 Million for IHS' electronic health record is available at this link

COVID19Senate and House Democrats Call on Trump Administration to Fill Gaps in COVID-19 Data and Mobilize Resources to Affected Communities
Sen. Elizabeth Warren (D-MA) and Rep. Ayanna Pressley (D-MA) co-authored letters to Director Redfield of the Centers for Disease Control and PRevention (CDC) and a separate letter to Vice President Pence calling on the Administration to fill the gaps in COVID-19 demographic data and mobilize resources to the hardest hit communities, joined by a coalition of Democratic lawmakers.  

The letters call attention to the disproportionate impact of the COVID-19 pandemic on communities of color and the need for improved data on population-specific health disparities. For Tribes, the lawmakers urged CDC to provide direct funding and work more collaboratively with Tribal governments and Tribal Epidemiology Centers. The Senators also urged the CDC to work closely with its Tribal Advisory Committee to identify and implement Tribal public health priorities. They urged Congressional leadership to include their legislation in the next relief package. 

The Paycheck Protection and Health Care Enhancement Act reqires the  U.S. Department of Health and Human Services (HHS) to issue monthly reports on the data it collects related to race, ethnicity, sex, age, and geographic location of those who have been tested, hospitalized, or died from COVID-19. Members of Congress are now calling on the CDC to rectify gaps in the implementation of this new law and use the data to target resources toward the communities that are most affected.

"We know that the disparities in our society did not begin with the COVID-19 pandemic, but this crisis has exposed the deep inequality in the health and economic security of our communities. It is therefore essential to use all available data to identify its disproportionate impact on marginalized communities, to let this data guide our response, and to mobilize resources to the communities that are most in need," the Members wrote.

The Members also raised alarm about the lack of dedicated CDC funding and resources to Tribal governments and organizations to build public health infrastructure in Indian Country, urging CDC to work directly with the Indian Health Service (IHS) to better coordinate disease surveillance strategies in Tribal and urban Indian communities. They also urged close collaboration with Tribal governments, Tribal Epidemiology Centers, and the CDC/Agency for Toxic Substances and Disease Registry Tribal Advisory Committee.

In their letter to Vice President Pence, they urged involving IHS in these efforts and meaningfully engaging with Native communities and tribal leaders, among other steps.

BHOFundingBipartisan Group of Lawmakers Seek Emergency Funding for Behavioral Health Organizations in Next Coronavirus Stimulus Package
Sen. Elizabeth Warren (D-MA)  and  Rep. Joe Kennedy III (D-MA) , along with
Senators Edward J. Markey (D-MA), Chris Murphy (D-CT) and Debbie Stabenow (D-MI); and R epresentatives Doris Matsui (D-CA), Paul Tonko (D-NY), John Katko (R-NY) and 68 of their Senate and House colleagues, sent a letter to Congressional leadership requesting emergency funding for mental health d and addiction treatment providers as the nation grapples with the COVID-19 pandemic. With many behavioral health organizations (BHOs) at risk of closing their doors as a result of the pandemic, the members of Congress are seeking at least $38.5 billion for BHOs across the country in the next COVID-19 stimulus package.

For Indian Country, the lawmakers called for dedicated funding for the Mental Health and Alcohol/Substance Abuse line items in the Indian Health Service (IHS) budget, and for more funding for the Tribal Behavioral Health Grants administered by teh Substance Abuse and Mental Health Services Administration (SAMHSA). 

"With a growing number of Americans in need of behavioral health services and many BHOs at risk of closing, the nation is headed towards another public health crisis," the lawmakers wrote. "To avert another large-scale public health crisis, we must pass a stimulus package that prioritizes the financial security of these vital health care providers and the health of millions of Americans."

Despite the health and economic impacts of the pandemic and the growing number of patients seeking counseling services, BHOs are projected to lose nearly $40 billion in revenue as a direct result of increased staff overtime to meet patient need, increased need for PPE, and the implementation of telehealth services.

The letter notes that the number of Americans struggling with mental illness will only continue to grow as families and individuals face the emotional and economic repercussions of the pandemic and called on Senate and House leadership to provide BHOs with at least $38.5 billion in direct emergency funding so that they may continue to provide critical services to the countless people who rely on them.
RuralDistributionIndian Health Care Providers Excluded from HHS Distribution of CARES Act Funding to Facilities in High Impact and Rural Areas 
Last week, HHS announced that it would send $12 billion to hospitals in COVID-19 hot spots, or "high impact" areas. The money is divided in two pools:
  • $10 billion for hospitals in areas with 100 or more COVID-19 patients
    • This includes NY, NJ, and IL
  • Nearly $2 billion for ~395 hospitals that have treated low-income or uninsured COVID-19 patients
Please note that this funding came from the $100b Provider Relief fund, which was part of the CARES Act. For more information, click here to see the article in Politico.

Rural hospitals are also getting $10 billion in bailout funding which HHS will distribute. According to the Department, the money will arrive via direct deposit in a few days. Rural hospitals in Texas, Minnesota, and Iowa are getting the largest distribution. The allocation to rural providers is broken down by state and the qualifying facility types include:
  • Rural Acute Care General Hospitals
  • Critical Access Hospitals (CAH)
  • Rural Health Clinics (RHC)
  • Community Health Centers located in rural areas
Despite repeated calls from Tribal leaders and officials to ensure Indian Country was meaningfully included in distribution of both the rural and hotspot funds, on Monday May 4 HHS official confirmed that zero IHS or Tribal facilities were included in the distribution of either funding pots. 

NIHB continues to strongly advocate that HHS increase the set-aside provider relief funding for Indian Country. Currently, only $400 million has been specifically dedicated to Indian Health Care Providers, out of $100 billion in CARES funding for provider relief. 

InteroperabilityCMS Delays Implementation of the Interoperability Final Rule Due to COVID-19
CMS republished the final Interoperability and Patient Access rule on May 1, 2020, to extend the implementation time for requiring hospitals, including Critical Access Hospitals (CAHs), to send electronic patient event notifications of a patient's admission, discharge, and/or transfer to another healthcare facility or to another community provider or practitioner. Due to the COVID-19 public health emergency, CMS is extending the implementation timeline for the admission, discharge, and transfer (ADT) notification Conditions of Participation (CoPs)  by an additional six months. Payers originally had until January 2, 2021 to implement the policies outlined in the final rule, but  the extension gives them until July 1, 2021 to comply. There are two main policies in the final ruling payers must work to implement: the Patient Access API and the Provider Directory API. The rule intends to provide patients with greater access to their health information and better coordinate their own health care as a part of the MyHealthEData initiative.
The Department of Health and Human Services (HHS) Office of the National Coordinator for Health IT (ONC) also extended the enforcement time of its complementary final rule, Interoperability, Information Blocking, and Health IT Certification by six months, with enforcement of some provisions beginning November 2, 2020. ONC will begin enforcing two of the new conditions of certification (CoCs) on September 30, 2020 (three months from the June 30, 2020, compliance date in the final rule). View Enforcement Discretion Dates and Timeframes.The ONC and CMS complementary rules are meant to give patients safe and secure access to their health data and are the most extensive healthcare data sharing policies the federal government has implemented. Under these new rules, CMS is mandating that states send enrollee data daily beginning April 1, 2022 for beneficiaries enrolled in both Medicare and Medicaid. To see more information on the rules, and on the new Office of Inspector General authorities under the ONC rule, please see the Press Release.

SweepingChangesTrump Administration Issues Second Round of Sweeping Changes to Support U.S. Healthcare System During COVID-19 Pandemic
On April 30, 2020, the Centers for Medicare and Medicaid Services  ( CMS) released new regulatory waivers and rule changes for expanding care to the nation's seniors, creating flexibilities for the healthcare system for the reopening of America and ramping up testing for COVID-19. Specific flexibilities include no longer requiring an order from the treating physician for beneficiaries to get COVID-19 testing. CMS is also interested in ensuring hospitals and healthcare facilities have the capacity to handle COVID-19 by setting up temporary expansion sites and increasing the number of beds for COVID-19 patients without facing reduced payments for indirect medical education. Currently most provider based hospital outpatient departments that relocate off-campus are paid at lower rates, these flexibilities will allow certain provider based hospital outpatient departments that relocate to obtain a temporary exception and continue to be paid under the outpatient prospective payment system (OPPS) . Similarly, long-term acute care hospitals can now accept any acute-care hospital patients and be paid at a higher Medicare payment rate.

Other flexibilities include increasing access to telehealth, augmenting workforce healthcare and putting patients over paperwork by giving Medicare plans relief from many reporting and audit requirements so they can focus on patient care. Many of these CMS temporary changes will be effective immediately. Providers and states do not need to apply for these blanket waivers and can begin using these flexibilities immediately. In addition, CMS is also requiring nursing homes to inform residents and their families of COVID 19 cases in their facilities. Click here for more information on these regulatory flexibilities.

UpperLimitsUpdates to the Affordable Care Act Federal Upper Limits
The updated Affordable Care Act Federal Upper Limits (FUL) calculated in accordance with the Medicaid Covered Outpatient Drug final rule with comment are now available on the Pharmacy Pricing page of website. States will have up to 30 days from the May 1, 2020 effective date to implement these updated FULs. See the CMS announcement HERE .

Trump Administration Releases COVID-19 Telehealth Toolkit to Accelerate State Use of Telehealth in Medicaid and CHIP
On April 23, the Trump Administration released a new toolkit to help states identify and address barriers to telehealth coverage during an emergency. The toolkit is meant to help states to accelerate adoption of broader telehealth coverage policies in the Medicaid and Children's Health Insurance Programs (CHIP) during the COVID-19 pandemic. This release on the toolkit builds on CMS' actions to provide states with tools and guidance to support their ability to care for their Medicaid and CHIP beneficiaries during this public health emergency.

CHIPwaiversCMS Releases COVID-19 Toolkits and Other Resources to Help States Apply For Medicaid and CHIP Program Waivers
In March, CMS released a toolkit for states to use when applying for the various emergency authorities in order to combat the COVID-19 outbreak. The toolkit includes information on how to apply for 1115 and 1135 waivers, as well as 1915(c) Appendix Ks and Emergency State Plan Amendments. The toolkit's purpose is to simplify the application process by including commonly requested items in a template and allowing states to choose which powers they need in order to respond to the crisis. Since its release, states have been taking advantage of this toolkit. NIHB has been tracking each state's approved 1115 and 1135 waivers and SPAs here. Each state's one-pager provides a summary of approved provisions."

RHCsCMS Announces New and Expanded Flexibilities for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) During the COVID-19 Public Health Emergency (PHE)
CMS issued guidance for administrators, managers, or directors at a RHCs or FQHCs that includes the payment rate for telehealth services, how to bill for telehealth services, and expanded virtual communications services. The CARES Act allowed FQHCs and RHCs to utilize telehealth and act as distant site providers during a Public Health Emergency (PHE).Distant site telehealth services approved under the Physician Fee Schedule can be furnished by any health care practitioner working for the RHC or the FQHC within their scope of practice, and even from the practitioner's home. Payment for telehealth health services during the PHE (from January 27, 2020 through the end of the PHE) is $92. Billing is segmented into two periods. Per the guidance, virtual communication services have been expanded to include digital evaluation and management services. Administrators must be aware how each service interacts with billing. More information is available in the guidance.

AdvancePaymentCMS Discontinues Advance Payment Program for Providers
On Monday, April 27, CMS announced that it would discontinue its Advance Payment Program after giving nearly $60 billion in advances to Medicare Part A providers and nearly $40 billion in advances to Part B providers. On March 28, 2020, CMS expanded the program to assist providers with cash flow issues that many providers face in the wake of COVID-19. Advances from CMS must be repaid within one year, or less, depending on the provider/supplier type.
New and pending Advance Payment Program applications will instead be evaluated for CMS' Accelerated Payment Program. CMS will reevaluate all pending and new applications for Accelerated Payments in light of historical direct payments made available through HHS's Provider Relief Fund. Significant additional funding will continue to be available to hospitals and other healthcare providers through other programs. To read the full announcement, click here.

Please see below for call information to the  IHS' All Tribes Call on Thursday, May 7th 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, May 7th
Time:  4 :00 PM - 5:30 PM (Eastern)
Conference Call:   800-857-5577 | Participant Passcode:  6703929
Webinar Adobe Connect: | Participant Password:  ihs123
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. 
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