NMICoA Health Committee
Notes on Medicaid Modernization Strategysession
Kewa Health Corporation
May 3, 2012
Mr. Yepa group discussion leader
Group gave Introductions
Anthony Yepa KHCColinda Garcia Acoma
Paul Fragua Jemez
Ana Jaramillo Isleta
Erik Lujan NMICoA Health Committee
Ron Lujan NMICoA Health Committee
Leonard Montoya Ohkay Owengeh
Joseph Ray NAIL Laguna
Other members present, I apologize I donot have a copy of the sign in sheet.
State Corporation commission has nojurisdiction over Tribes due to Sovereignty unique to Kewa Corp. They have their own bylaws own employeepolicies.
Section 1115 research and demonstrationWaiver “Centennial Care” was submitted by the State of NM on April 25thto CMS. Language is similar to conceptpaper. The Waiver can be found on the NMHSD website www.hsd.state.nm.us
The state has sent first pitch to CMS,HHS hearings happened last week many tribes had one on one visits with HHSdelegation. Kewa comments were mostly on Centennial Care, telling momma and dadthat our sister, the state, is not following Federal Laws. We as tribes do have a right to go directlyto CMS; we also need to work with the state on some of these things.
Our basic presentations was okay Statego over some of the federal laws are already in place (ARRA, IHCIA, PL 93-638,Public Health Service Laws, Snyder Act)
Health care is and will always be afederal relationship/responsibility.
IHCIA allows for 638/CHS funds to beused on dialysis and Long Term care. Congress spells out what tribes can use funding for. All of theseprovisions are what provides us with the legal basis for providing services inour own communities. Hardest part forState and MCOs to understand. One majorpart of ARRA is that we cannot be mandated into an MCO, but on page 21 (Waiver)tells you that there will be mandatory enrollment in an MCO. This will create conflict for ourcommunities, if all the tribes have different positions then they’ll enjoy that(State) because nobody was together, we are here because we at least feel thatwe should be speaking in one voice, on the same page, we may have differentideas on how to approach.
Time for Philosophical discussions astribes is over i.e., no consultation, the horse is out of the barn, the statehas thrown the first punch it’s now up to us to either give a counter punch orride the storm out.
Comment: Health committee has been following the MCO argument since 2008 CoLTSmandated that everyone be included in MCO, 180 degrees form Salude start of the Opt out category, elders asked whyis state telling us what to do not Tribes. Overall umbrella for Health care isthe Federal government they are obligated through stated federal laws and we feelthat the state is sort of infringing on that sovereign status that Tribes haveby saying that you are going to me mandate to join whatever MCO we decide. CoLTS inclusion into Centennial Care willmake elders start at ground zero again with a new MCO. We are here to figureout the next steps that Tribes need to take together.
Comment: Paul Fragua 10 yrs on Jemez health board
Need to take action since the waiver hasalready been sent. United approach isneeded. Around HHS table was triballeadership and only they were allowed to speak. I have been in health carefield for 10 years yet am not allowed to speak. There are many people who workon these subjects that should be allowed to speak. Difficult to get/keep Tribal leadershipinformed on the every changing subject of healthcare. How do we gather all the tribes and differentgroups, AIPC NMICoA so that we do have a unified voice? And then take toHHS/CMS how do we get our leadership informed to take this message to State andCMS.
When it came to long term care Jemezwanted to start a PACE (program of all-inclusive care of elders) but found outdue to State regulations we couldn’t do it no matter how much we were preparedfor it.
How are we going to proceed?
How many tribes have taken action or whois taking the lead.
Those are probably those who are 638already, other are still IHS direct services tribes will defer to IHS; theycannot speak on behalf of the Tribes.
How do we package communication piecesand showcase programs that work. Bringon trends on self governance for those who are direct service tribes, to showhow Waiver will eventually impact them. They might not be heading towards 638 now but maybe in the future they willand they need to support this effort now so that they will be able to takeadvantage in the future.
Dollar bill example, start with onedollar and show how much goes to administration at each delivery.
Wayne Lahi: IHS vs. 638 how many are still directservices now. Will IHS will be around inthe future, with how many tribes are “638”ing more services I don’t know. Most tribes are taking ownership of healthcare, Santa Fe Hospital Service Unit, Santo Domingo taking shares out. IHS services based on out of hospital, andTribes are basing on community.
Change in leadership big issue, not alltribes are not represented, Tribal leaders spend half of their time beingorientated on their official duties. Idon’t see my tribe represented (Zuni) we have a service unit. National poverty levels big impact on healthcare. Funding from IHS to tribes is based on population and needs to bereviewed because when congress appropriates funds they go mostly to Area officeadministration, before it gets down to tribes they take their shares. What comes to tribes and 638 facilities ispractically nothing. Populations rise and fall but funding does not follow theusers, and if you look at the mechanisms there patients are counted once, theyshould be counted every time they come in for services. If we are going to be looking at this fromthe Tribal perspective then we need to be looking at the funding cost is toohigh compared to funding from IHS.
IHS was at consultations but commentswere not taken by state, State decisions are impacting IHS. Centennial Plan is no different than Salud,we are wasting time going back, and we need to take what worked from Salud.
Ron Lujan: Work with Ten Southern and Eight Northern governor’sorganizations get them to understand the concepts of Centennial care digest theinformation and get them to take it to AIPC. We discussed it after the March 20th meeting with Acoma andSanta Ana, lets develop a position paper leading to a resolution for AIPC fromgrassroots up, then the overall AIPC can make an informed vote.
Yepa: position papers have gone out,been shared within this group including the elders position from NMICoA HC andcenter on Law and Poverty. That’s who westarted, sooner or later, the leadership will say “oh I need to take it to mycouncil” someone (leadership, State) needs to make a decision. PPACA implementation is just around thecorner.
Wayne: Urban are mixed between NM andAll Tribes nationwide. We need to lookat economic issues surrounding urban and how are those people going to beenrolled and represented. State and Fedsonly listen to Tribal Leaders. Leaders don’t focus on subject matter. We needdesignation letters for experts to take part in discussions.
Yepa: it takes time and energy to do these things to go to all theseplaces. There are good things incentennial Care like the “Medical Homes” concept, but right now we are lookingat the bigger picture, like sovereignty issues and Fed law. Implementing Centennial Care is going to be abig issue with reenrollment finding new providers, etc. we have people who knowwhat’s going on and what the hardships for individuals are going to be (CHR,social workers, business offices). Thirdparty payments are crucial how will the changes affect us.
Paul Fragua: Are there some major pointsthat all the Tribes can agree on, so that we can move forward with a resolutionand discussions with CMS? I like to setthis up with history how we got here, starting with Snyder Act. Take all position papers and make a commonpaper out of all of them so that we can take to the overall Organizations. This is going to take a lot of work who is goingto take the lead on project and then who takes to the organizations? We need a couple of champions withinleadership to push position into governing organizations, councils.
Leonard Montoya: We are creating atribal resolution from Ohkay Owengeh with the councils support to take to EightNorthern. Then they take message fromthat same group to AIPC that way if theleadership says “I need to take it back to my council we can say no yourcouncil already know and approves”.
Paul Fragua: our position paper wasdeveloped by staff not the heath board, I want to look at it so that I can takeit to Council and then to Ten Southern.
Leonard Montoya: the State has beenmeeting individually with Tribes hoping that separately they don’t know what weare talking about, so they have a chance to meet with a tribal leader who maynot know a lot about Medicaid and Health Care. This they can get a leader to sign off and show support. By educatingthe leaders we can stop this from happening
Yepa: the Law is on our side PublicHealth Law, Social Security 18&19, PPACA, ARRA,
What are most tribes in agreement with?
Tribal Specific details need to be addedthen.
Colinda Garcia: Part of the challenge isall the issues and concepts we are raising on how to move forward are all goodhowever who is going to do this? Andbring to the Councils and AIPC. We allhave vested interest in how and what the State is going to do but we don’t haveany action steps in place. The state hasalready sent the waiver it is going to happen while we are still talking aboutit. How are we going to continue to movewithout these meetings taking place?
Yepa: talk is over its time to act, butwho among us is legitimized to do this? Without April leading the last effort the work group probably would nothave happened, so who is going to carry this? I can come up with information but until my health board Okays it I cant act.
Ron Lujan: what about the mini block grants can weaccess funds to help push this group forward?
Erik Lujan: not in the time frame we arelooking those will be available only after the MCOs have been chosen and theRFPS are approved
Yepa: We need to look at outside organizations too like what the MedicaidCoalition, we have common issues to see how they can we help. Timing is not right yet for grants.
Ron Lujan: We need a plan for after (the resolution andtalks with the State and CMS) like having a Carve out for Native Americans totake advantage of 100% FMAP or having our own MCO.
Yepa: that was one of our points butthat is a larger problem that we can’t change currently. The block grants are vague in the Waiverintentionally because they are just a concept or an example; they don’t evenknow how they are going to structure them or who is going to administer them.
Erik Lujan: The State wants the MCO’s to develop andimplement the Block Grants and then decided who gets the grants. We need to know which MCO would be willing towork with us on our terms.
Ron Lujan: we are going to Taos topresent Centennial care to Elders, they asked for us to educate them on thechanges.
Yepa: You can know everything you haveto trust and rely on others to help.
Erik Lujan: one of the main points isthat the Opt out needs to remain in place, that will give us (Tribes) the timeto develop our own programs the way we want them, even after Centennial caregoes into implementation, that way we still control the money, and where we gofor service, so that we can develop into an MCO or Medical Homes. That willgive us time to gather information from HSD from CoLTS and developcomprehensive programs. We don’t know if the MCO is the best route or if itwould be better to have our own insurance plan we just don’t have the data fromthe State. We need more time. Keepingthe opt category and maybe even expanding it will give us the time to decidewhat is best for our communities.
Paul Fragua: I think that’s one of those major points thatwe can all agree on, it’s a high priority
Yepa: Opt out is now called “freedom ofChoice”, 80% are still opted out. It’s allowed because of the ARRA laws. Going back to Colinda’s statement, who isgoing to carry this?
Paul Fragua: We need a simple documentnow then add on specifics later, something that I can take to Eight NorthernTen Southern and AIPC.
Ron Lujan: We presented at Acoma to educate members onCentennial Care, there response was we are going to have a community meeting toaddress this topic and we would like you to come and present what you presentedto us. We need that Tribal communitylevel involvement.
Yepa: We need to give them a “Chinese Menu” of what to do because smallertribes might not have experts.
Ron Lujan: What about legal aspects have a lawyer lookat it from all perspectives
Jemez and Kewa responses were from thatlegal view, and the State has a lot of the position papers on theirwebsite. There is nothing on the websitefrom about 80% of the Tribes
Fed and State look at that and saythat’s not enough to make a change.
Back to the “Who” who is going to leadand carry this group we are all invested in this we all have to report back toour tribes. Who is going to lead? We all have knowledge of some parts oraspects we all need to work together. State and Feds are not going to listen tojust one or two tribes.
Yepa: I am volunteering to start a paperand go from there.
Erik: I am willing to help with thisproject, and use outside organizations to help
Paul Fragua: Time wise we need to move quickly so that wecan get resolution from AIPC to CMS. I’d rather do something now then nothingbecause once it’s done it will be harder to undo.
Yepa: we need a single argument
Colinda: option to speak with AIPC toschedule a general conversation with Bill Brooks from CMS Dallas on what we cando next? We will have to designate a spokesman.
Joe Ray: Education of Tribal Leaders isvery important to help communities
Ron Lujan: Are the Liaisons hiding information, they arevery secretive.
Colinda: I think that they do know butcan’t say or have been directed not to share information.
Wayne Lahi: Tribes did voice oppositionbut did they back it up with a written statement. I am really for what we aredoing here but who is going to lead, continue to push and then back theposition or resolutions that this workgroup is proposing
Navajo is concern because they are a bigplayer, they know that already and they have expressed that they are forCentennial Care, they want to go along with the State, and they are looking atbecoming an MCO. IHS is in the same boatas the rest of us, but they cannot speak out/for the tribes that they stillserve.
We all need to go back to ourcommunities and tell them, councils and leadership what we have been talkingabout.
The State says that they are havingseparate programs that are going to be doing outreach and education to eligibleindividuals; we need to stay on top of these efforts.
Health Insurance Exchange (HIX) willserve those low income individuals who are over 18 and under 65 previously inthe SCI program, they will have to purchase Health Insurance through theExchange. The HIX will use income levels(Federal Poverty Level FLP) to dictate the level of subsidies given to pay forinsurance premiums. Ex. Under 100% FPLconsumer pays 0-10% of premium over 300% of FPL consumer pays 60-75%. SCI (1915 waiver) will be incorporated intoCentennial Care.
We can’t forget about the Federalobligation, if it is a federally subsidized program then why are our peoplethen having to pay premiums. That was part of our position paper (NMICoA HC)that if the feds are paying for services on reservation, why is the statehaving to be part of the funding stream.
Administration fees are taken each timeit passes hands.
Less money
100% FMAP
We need Documentation on how funding isused from HSD and MCOs.
As a group we need to start gatheringour own data so i.e. Medicaid enrollment, income levels, servicesneeded/provided.
From community side we have not receivedthis information about Centennial Care; we need to push for our communities tobe educated, because they do not understand. What can we do what has worked? We (Acoma) have educational meetings at senior centers, or open healthboard meetings, go to Health Benefits coordinators at ISD or IHS. It takes reading and then translatinginformation in a way that everyone can understand.
We can sponsor a facebook page? Orpublish a blog so that we can all access the information and comment. That wayif we find a new piece of information we can share it. If there is part of the waiver that isbeneficial you can share it.
We will draft it and then the workgroupwill view and comment then,
Workgroup members will take to TenSouthern and Eight Northern, the AIPC.
White Board Notes
BOARD
“Freedom of Choice” on Centennial Care
Centennial Care Waiver for NM wasalready sent April 25th
1) Generalconcepts/agreements
a. Fed Laws (AllTribes)
b. Agreement ofprovisions/recommendation (SomeTribes)
c. Special or unique to ______Tribes (TribalSpecific)
2) Whois going to Draft? Create Facebook/Blog?
Jemez will take to 10 southern
Ohkay Owengeh will take to 8 northern
Colinda will take to Chandler
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