Kewa Position paper

Pueblo of Kewa Position paper that was sent to NM HSD

Sidonie Squier,

Cabinet Secretary, HSD
2009 Pacheco Street
Box 2348
Santa Fe, NM  87504

Re: Response to HSD Concept Paper on Centennial Care February 12, 2012

Ms. Squier,

Health care for Native Americans has historically been a federal relationship with Native tribes throughout the United States. It started with the Snyder Act, the creation of the Public Health Service, PL 93-638, the Social Security Acts specifically Title 18 and 19 and the Indian Health Care Improvement Act (IHCIA). More recently, the American Reinvestment and Recovery Act, (ARRA), permanent authorization of the IHCIA under the Patient Protection and Affordable Care Act (ACA) significantly impacts the controlling legislation affecting Centennial Care. The Kewa Pueblo Health Corporation (KPHC) maintains that there are ‘Federal protections’ for Natives and Native health facilities under Federal laws:

Under the ACA, there is no mandatory participation for Natives to enroll in Managed Care nor is there a penalty if a Native does not buy health insurance.

Under ARRA, Section 5006 and 42 U.S.C.§ 1396o(j) stipulates no premiums or cost sharing for services by Indian health programs or CHS referrals. Also, under 42 U.S.C. §1396u-2(h) has special rules for Indian enrollees, Indian providers and alternative prompt payment arrangements.

Public Law 93-638, the Indian Self Determination and Education Assistance Act are contracts/compacts that define and describe the Programs, Functions, Services and Activities (PFSAs) assumed by Tribes under this law. PFSAs are contracted health systems with regulations describing implementation of Indian health care administratively, clinically and by various preventive and support service delivery systems.

It took Tribes years to work with Congress to get permanent legislation authorized in passing the IHCIA. Under the new law, Sec 206, 340-B stipulates that Indian Health Service and Tribal 638 facilities be reimbursed the highest reimbursement rates for outpatient services. There are other provisions and sections that the State, along with CMS, need to review the IHCIA including PL 106-417 cited as the ‘Alaska Native American Indian Direct Reimbursement Act of 2000’. 

The new Federal legislation termed the Tribal Law and Order Act has Sections requiring behavioral health services, credentialing, domestic violence and adolescent treatment programs including psychiatric inpatient requirements.

In addition, as difficult and cumbersome as it may be, the State is required to consult with Tribes under Federal and State laws. There is the Federal Executive Order signed by President Obama, the requirement under ARRA, the State of New Mexico Collaborative Act and the CMS Tribal consultation policy signed in November of 2011. In addition, there are separate agreements with the Veterans Administration, Public Health Service Acts and OMB/OPM regulations.

There are special protections under various Federal Laws applicable to Indian Health Service, Tribes and Urban (ITUs) organizations. Some that are significant to Centennial Care concepts are: the OMB reimbursement rates should remain, no cost sharing with ITUs for care provided at their facilities and referred to outside facilities through the ITUs and 100% FMAP reimbursed to Indian Health and Tribal 638 facilities. 

 As you can realized the Native health care is legally a Federal Trust relationship first and foremost.  As you are required to learn and negotiate with CMS and federally mandated requirements, the Native tribes have been doing this since the US Constitution was created. As frustrating as it may be, the State, Federal Government/CMS and Tribes will still need to communicate, understand and follow the various Federal laws before Centennial Care is developed and implemented in this State.

The KPHC response follows the Goals as outlined in the Centennial Care concept paper:

Goal 1: To assure that Medicaid enrollees in the program receive the right amount of care at the right time in the most cost effective or ‘right’ settings.

• The filing of a single Section 1115 waiver and through the procurement and contracting that is planned will invite and bring the same MCOs that have been contracted with the State in recent years past. Strong and enforceable contract language needs to be developed to meet the goals and concepts identified in the concept paper.

• Patient-centered medical home is a very good idea and concept. If the State is to use ITU facilities for case management and coordination, funding and staffing increases will be needed. All 6 Federally mandated services that are federally described will have to be incorporated into the current Indian Health Service and 638 federally contracted and regulated PFSAs.

• Fee for Service (FFS) has to remain. FFS as shown in other States and past practices in this State show that Rural and Frontier areas have limited MCO facilities and providers in these remote communities. We suggest another designation category for the State called ‘Reservation areas’.  MCOs have had their own challenges in accessing Rural, Frontier and Reservations areas and examples by Indian Health and Tribal providers, business office managers will validate access, referral, service limitations and reimbursement issues.

 Goal 2: To assure that the Care being purchased by the State is measured in terms of Quality and not Quantity.

• What have we learned from the past few years with the MCOs, Saluds, COLTs and Behavioral Health Contractors? Where is the data collections and reporting showing the outcome measures under those health care delivery systems?

• Is HEDIS in place now? How can ITUs interface with the State IT systems that exist in Reservation areas? Are IT upgrades part of the cost reimbursements formula or start up formulas?

• What successful evidence based practices will be used for chronic health care? Diabetes? How will such practices be integrated with existing federally regulated PFSAs under Tribal 638 programs and best practices in ITU communities? Will such evidence based practices be incorporated to existing practices by ITUs and be culturally responsive to ITU communities?

Goal 3: Bending the Cost Curve

• Reimbursement rates are established for Indian Health and 638 facilities again by Federal laws. As noted in the IHCIA, the highest reimbursable rates are to remain with ITUs. The 100% FMAP should continue as costs in Reservation areas are simply more expensive. The MCOs can validate these high costs from their access and payment histories.

• Prior quarter coverage for Native health care will not work nor is it cost effective. Simply enrolling in a Health Plan with no past history of care, access provisions, and questionable service definitions at this time will eliminate Native enrollees.

• The use of Health Homes with intensive care management provided at the ‘point of service’ is an excellent idea if staffing and facility funding is available. The Incentives identified are also good suggestions however, there may be other ideas. The Peer to Peer comparative data review is an approach needing evaluation constructs and review.

• Federal laws guide ITUs on credentialing and have been questioned by State MCO providers in the past. All State providers will need to be educated as part of their contracts in working with ITU facilities and Native health care rights under Federal Laws.

Goal 4: To Streamline Services in preparation of expected increase in membership beginning 2014.

• KPHC offers that dual eligible strategies will need planning and discussion with ITU social workers, clinical providers and business office coordinators before any plans are developed with Native dual eligibles. There needs to be clear definitions, supported by regulations and not arbitrary decisions as to who is eligible, what services are covered by each entity, streamlining access issues, billing protocols and limitations of each eligibility criteria.

• Care Coordination by MCOs at a level appropriate to each enrollee and risk stratification will be a challenge. Health Assessments with IT upgrades will take time and communications streamlining will need written procedures. Monitoring and long term care with support services is very limited in Reservation areas now. How will Care coordinators be assigned? How will quality metrics be baselined and established for medical homes?

• Behavioral Health Carve-in. How will the MCOs provide for residential and inpatient treatment at sub-capitation rates?  Why sub-capitation rates? What economic and empirical data is used to declare sub-capitation rates?  Prior authorizations for residential services is not and should not be requested by Federal and Tribal facilities as these facilities are mandated by Public laws to provide these services under their Federal admission policies.

• The Core Service Agencies include all ITUs? Most CSAs are located in metropolitan areas just like MCOs. How do CSAs reach and provide specialized services to the Reservation areas?  Most ITUs do not have the funding or ability to provide specialized services.

• Adolescent residential treatment and psychiatric inpatient treatment for youth is mandated by PL 99-570 and the Tribal Law and Order Acts. How will sub-capitation apply for these services as compared to negotiated CMS rates? How will the SMI and SED, psychiatric inpatients be placed and coordinated by MCOs and more importantly, reimbursed? Will tribal court placement orders be accepted by State and MCO inpatient facilities?

• Mini-Grants identified in the plan to develop pilot sites need to be established with ITUs before 2014. To understand and participate in the various aspects of the plan KPHC recommends separate meetings with Tribes on 1) Application and Enrollment process, 2) ITU as Providers in the Exchange plans, 3) Enrollment assistance, outreach, 4) Group Purchasing and Sponsorships of tribal members and 5) Native benefits and federal protections. These sessions should include IT infrastructure, third party administrator and transitioning of reimbursement procedures. The communications with tribes needs to begin now before we meet with our Tribal members.