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Top Story
Omnibus$2.5 Trillion Spending and COVID-19 Stimulus Deal Reached - Congress Now in Mad Dash Towards Passage
After months of impasse in negotiations, and at the 11th hour, Congress clinched a bipartisan and bicameral deal on a roughly $900 billion COVID-19 pandemic stimulus bill. The package is attached to a massive $1.4 trillion Fiscal Year (FY) 2021 omnibus appropriations package - which includes all twelve appropriations bills including the Interior, Environment, and Related Agencies bill that funds the Indian Health Service (IHS).

Alongside the stimulus and appropriations package are a slue of year-end policy riders including tax extenders, clean energy provisions, education provisions, and comprise legislation to address surprise medical billing. The surprise billing package provides the federal cost savings to pay for a 3-year extension of the Special Diabetes Program for Indians (SDPI). 

On Sunday December 20, Congress passed a one-day continuing resolution (CR) while lawmakers hammered out the remaining text on the stimulus package. But given the massive size of the proposal, it may take Congress several days to finish enrolling and printing the bill, and preparing it for submission to the President's Desk. As a result, Congress decided to include an additional 7-day CR to ensure government funding did not expire while lawmakers and staff took the final administrative and procedural steps towards passing the gigantic year-end package.

To read the full legislative text of the entire year-end package click here
  • Division G: FY 2021 Interior, Environment & Related Agencies Appropriations
  • Division H: FY 2021 Labor-Health and Human Services Appropriations
  • Division M-N: COVID-19 Response & Relief Supplemental Appropriations Act
  • Division BB: Surprise Billing legislation and SDP/SDPI reauthorization
For a section-by-section on the stimulus package, click here
For the Explanatory Statement (Report) for FY 2021 Interior, click here
For the Explanatory Statement (Report) for FY 2021 LHHS, click here

Special Diabetes Program for Indians
After 15 months of short-term extensions - equaling six in total - Congress has finally reached an agreement on long-term reauthorization of the Special Diabetes Program for Indians (SDPI). As a result of a bipartisan and bicameral agreement on surprise medical billing, Congress was able to secure the cost savings to pay for a three-year extension of SDPI - through the end of FY 2023. 

Unfortunately, the reauthorization does not include an increase in funding for SDPI long sought by the Tribes and NIHB. Instead, it maintains SDPI funding at $150 million annually - the same level since 2004. Tribes and NIHB submitted countless letters alongside national partner organizations urging an increase to SDPI to $200 million annually. While bipartisan legislation was introduced to achieve this goal, it did not make it into the final package. Relatedly, the SDPI reauthorization does not include a critical legislative amendment to permit Tribes and Tribal organizations to receive SDPI awards pursuant to Title I contracting or Title V compacting agreements under the Indian Self-Determination and Education Assistance Act (ISDEAA). NIHB remains committed to securing these changes in the 117th Congress in close collaboration with the incoming Biden-Harris Administration.

Surprise Medical Billing
On Friday December 11, the four congressional committees that had been spent nearly two years working on a legislative solution to address surprise medical billing - the House Energy and Commerce Committee; Senate Health, Education, Labor, and Pensions Committee (HELP); House Ways and Means Committee; and House Education and Labor Committee - finally announced a bipartisan, bicameral deal.

The deal holds patients harmless of surprise medical bills in both emergency and non-emergency situations - including from air ambulance providers - by only requiring that patients be liable for the *in-network* costs of their care. The new law would require providers and insurers to negotiate a payment for the remaining portions of the bill (which used to be sent to patients as "surprise" bills prior to this legislation) within 30 days. If insurers and providers can't arrive at an agreement within 30 days, the dispute goes to a neutral third-party arbiter who is required to consider the median in-network reimbursement rate, the training level of the provider, and other factors.

The arbiter cannot consider the Medicare or Medicaid payment rate as a viable option for reimbursement. In addition, insurers are required to submit reports on prescription drug and medical costs to the federal government. NIHB was able to secure language ensuring that the existing protections for American Indians and Alaska Natives (AI/ANs) against surprise billing under the Indian Health Care Improvement Act, and the requirement that inpatient hospitals accept Medicare-Like Rates as payment in full under Purchased/Referred Care (PRC) agreements be maintained.

COVID-19 Stimulus Package
After months of negotiations, Congress finally settled on a roughly $900 billion compromise stimulus package in response to the ongoing COVID-19 pandemic. The package reauthorizes $284 billion in loans under the Paycheck Protection Program (PPP); $300 in weekly unemployment insurance for jobless workers through March 14, 2021; and $600 stimulus checks for every adult making up to $75,000 ($150,000 for couples) including $600 per child.

***Note: President Trump has publicly now announced he will not sign a bill unless it includes stimulus checks of $2000 per adult. The House is expected to enter a pro forma session on Christmas Eve (December 24) to vote on added this amendment.*** 

The package includes a $210 million IHS, Tribal, and urban Indian (I/T/U) set-aside in funding for vaccine distribution, administration, and other related needs. Importantly, the section includes language authorizing awardees to use funds to reimburse costs associated with vaccine promotion, education, or any related expense incurred prior to enactment of the stimulus package. In addition, it outlines a $790 million I/T/U set-aside for COVID-19 testing, contact tracing, surveillance, and other needs. Both set-asides include language authorizing transfer of funds to IHS for immediate distribution to Tribal programs.

The package also includes a minimum $125 million I/T/U set-aside for mental and behavioral health needs under the Substance Abuse and Mental Health Services Administration (SAMHSA). In a major victory, the package also includes $1 billion for Tribal broadband infrastructure development under the National Telecommunications and Information Administration within the U.S. Department of Commerce. The stimulus package also sets-aside $800 million for Native American housing programs, and $7 million for Tribal nutrition programs under the Older Americans Act.

In another major win, the package extends the deadline for expending CARES Act Coronavirus Relief Funds until December 31, 2021. It also authorizes the Secretary of Health and Human Services to extend Medicare waivers for use of telehealth until the end of 2021.

FY 2021 Appropriations - Indian Health Service
The bipartisan, bicameral agreement funds the Indian Health Service (IHS) at $6.23 billion in FY 2021, coming in at roughly $189 million over the FY 2020 enacted level. As NIHB previously reported, there was a significant gap between the House and Senate marks for IHS for FY 2021, with the House coming in at roughly $281 million higher than the Senate. The final agreement is much closer to the Senate mark for IHS, which provided a lower increase for IHS overall above enacted.

The final agreement includes an indefinite appropriation for 105(l) lease agreements at $101 million. Importantly, it gives IHS the authority to obligate the funds over two fiscal years - until the end of FY 2022. Tribes and NIHB vehemently opposed statutory restrictions on Tribal eligibility to enter into lease agreements, such as (but not limited to) any constraints based on the square footage of a Tribal health facility. The final appropriations package does NOT include any restrictions based on square footage, but does require that lease agreements "...commence no earlier than the date of receipt of the lease proposal. This would end the IHS practice of back-paying lease costs to the start of the fiscal year, which had contributed to the unpredictability of lease costs and issues in estimating future costs associated with the lease.

While the appropriations package increases the IHS budget by roughly $189 million overall, over half of the increase - 53% - goes towards the indefinite appropriation for 105(l) alone. Given the strict spending caps associated with the Interior budget for FY 2021, creation of the indefinite appropriation for 105(l) led appropriators to divert funds from other important line items. Specifically, Congress funds the Hospitals and Health Clinics (H&HC) line item at $2.238 billion for FY 2021 - roughly $86 million below FY 2020 enacted, which was at $2.324 billion. Within the line item, appropriators earmark $5 million for maternal health needs, $5 million for Alzheimer's prevention and treatment, $5 million for Tribal Epidemiology Centers (TECs), and a new $5 million initiative on HIV and Hepatitis C. Congress also sets aside $2 million in the H&HC line item for the Tribal DHAT training programs.

The package also maintains $5 million for nationalization of the Community Health Aide Program (CHAP), which is equal to the FY 2020 enacted level. Relatedly, the Senate mark rejects the proposal from the President's Budget to consolidate funding for CHAP, Health Education, and Community Health Representatives (CHRs), instead opting to keep these funding line items separate, as the Tribes prefer. The package also outlines small increases for Purchased/Referred Care, Alcohol & Substance Abuse, Mental Health, and other line items in the IHS budget.

Funding for Important Tribal Programs Outside IHS
The majority of Tribally-specific programs remain level funded at their FY 2020 enacted levels, with a few slight increases to certain programs. For example, Congress maintains the $15 million set-aside under the Health Resources and Services Administration for placements of National Health Service Corps officers within IHS, Tribal and urban Indian facilities. 

Office of the Secretary
For the first time, Congress allocates a $1.5 million Tribal set-aside under the Minority HIV/AIDS Prevention and Treatment Program. This is a big win that Tribes and NIHB had pushed for many years.

Centers for Disease Control and Prevention
Under CDC, the final appropriations package outlines a $1 million increase in funding for the Good Health and Wellness in Indian Country (GHWIC) program to $22 million overall for FY 2021. Unfortunately, the final package does not include a separate $150 million in Tribal funds for public health infrastructure and program development that was outlined the House LHHS appropriations bill. Given the significant challenges and gaps in Tribal public health infrastructure nationwide, NIHB is very disappointed that the final bill omits this crucial Tribal set-aside.

Substance Abuse and Mental Health Services Administration
The agreement for SAMHSA provides slight increases to Tribal funds above FY 2020 enacted levels. For instance, the Tribal Behavioral Health Grants are funded at $41.5 million overall in FY 2021 ($20.75 million for mental health and $20.75 million for substance abuse). Congress retains the $50 million Tribal set-aside in opioid response grants, but increases the medication-assisted treatment set aside to $11 million. In addition, the American Indian/Alaska Native (AI/AN) set-aside in Zero Suicide grants are increased to $2.4 million, while the AI/AN Suicide Prevention Initiative is retained at $2.931 million

For any questions regarding the final package, contact NIHB Congressional Relations Associate, Erin Morris, at emorris@nihb.org. 
GRANTS AND RESOURCES
CAPITOL HILL UPDATES
NativeThree Native Veterans Health Bills Become Law, Provides Greater Access to Healthcare Services 
The National Indian Health Board (NIHB) applauded Congress for passing several significant bills - Native American Veterans PACT Act, the Veterans Affairs Tribal Advisory Committee Act and the PRC for Native Veterans Act - that impact the delivery, access and coordination of healthcare for American Indian and Alaska Native veterans who receive care from both the Indian Health Service (IHS) and Veterans Administration (VA).
The Native American Veterans PACT Act eliminates copayments for American Indian and Alaska Native (AI/AN) veterans accessing VA healthcare and removes a significant barrier for AI/AN veteran's care. The PACT Act also brings parity between those AI/AN veterans receiving services at VA and those who receive services through the Indian Health Service (IHS) and Medicaid. Currently, AI/AN veterans must pay a copayment before receiving services at the VA. In the fiscal year 2017, approximately 30% of AI/AN veterans were charged copayments, averaging approximately $281.56 per veteran.
The Veterans Affairs Tribal Advisory Committee Act of 2019 establishes a VA Tribal Advisory Committee (VATAC) that and provides a discussion forum to gain useful feedback from Indian Country issues and solutions within the VA and advises the Secretary on improving policy, programs and services for AI/AN veterans.
The PRC for Native Veterans Act amends the Indian Health Care Improvement Act (IHCIA) to clarify that the VA and the Department of Defense are required to reimburse the IHS and Tribally-run health programs for healthcare services provided to AI/AN veterans through an authorized referral. Before the bill, the VA did not reimburse IHS or Tribally-run programs for the cost of services provided by the Purchased Referred Care (PRC) program. IHS is codified under federal law as the payer of last resort. 
FEDERAL ADMINISTRATION AND STATE GOVERNMENT UPDATES
B340Final Rule on the Administrative Dispute Resolution and 340B Drug Pricing Program
On December 14, HHS and HRSA published a final rule on the "340B Drug Pricing Program." This rule will require all drug manufactures and covered entities who participate in the 340B Program to comply with requirements and procedures involved in an administrative dispute resolution process. The purpose of the administrative dispute resolution process is designed to fix certain claims by covered entities that have been overcharged for specific outpatient drugs by manufactures, as well as specific claims by manufacturers that have been made after an audit. A panel is also involved with the resolution of disputes related to overcharging, duplicate discounts, or diversion. This final rule is effective January 13, 2021.
RequirementsA Proposed Rule from CMS on New Requirements for States
On December 18, CMS released a proposed rule on new requirements imposed on states for Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities and Qualified Health Plan issuers. This proposal will improve the electronic exchange of healthcare data and processes related to prior authorization. Also detailed in this rule is the adoption of implementation guidelines intended to provide support on the Application Programming Interface policies. This proposed rule is intended to improve health information exchanges, as well as provide patients and providers with more efficient access to complete health records. Comments on this proposed rule are due January 4, 2021. 
MinorityHHS Seeking Nominations for the Advisory Committee on Minority Health
On December 4, HHS released a notice from the Office of Minority Health seeking nominations to appoint a member to their Advisory Committee on Minority Health. The committee focuses on improving the health and healthcare of minorities to reduce racial and ethnic health disparities. Specifically, the committee is seeking voting members who are not officers or employees of the federal government. In the year 2021 the committee will have 6 vacancies that will need to be filled. Nominations are due March 4, 2021.
TeleCOVID-19 TeleECHO Information Session from IHS
On December 21, IHS announced a series of virtual sessions on recent updates concerning the COVID-19 response in Indian Country. The first session will be held on January 7, 2021 and will primarily center around COVID-19 response updates, while the second session held on January 21, 2021 will center around a discussion from the vaccine allocation and distribution panel. IHS will also be holding a session on February 4, 2021 which will detail Monoclonal Antibodies.
FEMAFEMA Seeking Feedback on their Comprehensive Preparedness Guide
On December 19, FEMA announced needed feedback on their "Comprehensive Preparedness Guide (CPG) 101: Developing and Maintaining Emergency Operations Plans." These guidelines are intended to assist planners in understanding and analyzing existing threats or hazards when producing emergency operation plans. Specifically, the National Integration Center is looking for input from community partners who can comment on areas of the guidelines that may be confusing, areas where their best practices may be provided or areas where additional jobs aids or work force training opportunities may be included. To create a more accessible platform for community partners FEMA will be hosting a series of webinars for feedback and to make changes to the guide. Comments on these guidelines are due January 25, 2021. 
GRANTS & RESOURCES
COVIDResourcesCall for Tribal COVID-19 Resources
The National Indian Health Board (NIHB) is seeking to create a pool of resources which Tribes can access when planning or implementing their own COVID-19 response. To this end, NIHB is asking Tribes to share with us any tools, operational plans, guides, policies, communication products, etc. that has helped your Tribe combat this pandemic. The materials can be de-identified, if needed. These resources will be placed online within NIHB's COVID-19 Tribal Response Center alongside other community health materials. We hope this aids Tribes to build on successes and support each other in the collective effort to mitigate the impact of the pandemic on Indian Country.

To submit any materials or resources, please email Courtney Wheeler (cwheeler@nihb.org). If you have any questions, please contact Courtney Wheeler.

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