"KanCare" Kansas 1115 Waiver with the NA portion still "opted Out"

I got Kansas's 1115 Waiver "Kancare" off the Center for Medicare and Medicaid (CMS.gov) yesterday,  and reading the Native American Specific portion of the Waiver (the last 10 pages or so) I found that Kansas really understands Tribes, the Federal obligation and the Government to Government relationship.  The 4 Tribes in Kansas cited several laws that proved that States DO NOT HAVE the RIGHT to MANDATE Native Americans into MANAGED CARE.  The way the waiver is worded the Tribes allowed their members to be automatically "OPTED INTO" Managed care with the Ability to then choose to be "OPTED OUT'.  This is the point that we here in NM need to make other Tribes still have the an "OPT OUT" catagory.


http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ks/ks-kancare-pa.pdf

Center on Law and Poverty Comments on Resubmitted Centennial Care 1115 Waiver

A Few Quick Comments on the Resubmitted Centennial Care 1115 Waiver
by Quela Robinson From The Center on Law and Poverty


The final 228-page proposal submitted today contains changes which represent important victories for the 550,000 New Mexicans currently enrolled in the program. The state is no longer planning to reduce eligibility for the Working Disabled and Pregnancy Medicaid programs to the bare minimum required by federal law. Instead, the final proposal preserves current eligibility levels so that working disabled individuals under 250% of the federal poverty level (FPL) and pregnant women under 185% FPL can continue to get coverage.  However, eligibility for the Medicaid category that provides Family Planning services will be reduced for people with incomes under 185% FPL to 138% FPL and eligibility for the Breast and Cervical Cancer program will be reduced from 250% FPL to 138% FPL.

HSD will also delay implementation of a proposal to stop paying for the medical bills of individuals who have received healthcare services in the three months prior to becoming officially enrolled in Medicaid. The current policy, known as “retroactive coverage” ensures that healthcare providers are paid for services and it alleviates financial hardship and expensive debt for low-income families. The Department has chosen to eliminate this coverage in July 2014, rather than in January of that year, explaining that Medicaid enrollees will be given an extra six months to seek coverage after healthcare reform takes full effect on January 1, 2014. However, the proposal will still burden many low-income New Mexicans. The Department has no plans to do outreach or address existing barriers in the application process to ensure that every person who qualifies for Medicaid is enrolled in the program. As a result, many individuals will not know they are eligible and will not apply until they need healthcare services and have unpaid medical bills.

Significantly, the state has also included a new proposal to extend twelve month “continuous eligibility” to adults enrolled in Medicaid. This ensures that individuals won’t lose Medicaid if their employment or income changes over the course of one year. This is a major new benefit that will create stable and continuous coverage for hourly, temporary or seasonal workers whose income often fluctuates, or for those who are temporarily unemployed.

Despite these important changes, one of the most controversial proposals from the original waiver application remains. The state intends to move forward with imposing co-pays on Medicaid patients when they visit emergency rooms but turn out not to have had actual emergencies, despite almost uniform opposition from Medicaid recipients, providers and hospitals. These fees will heavily impact patients who cannot get care due to New Mexico’s severe provider shortage. As a result, the proposal will likely fall short of the federal law's requirement that states ensure that there are actually accessible and available alternatives for care before these fees can be charged.

In sum, the final Centennial Care application contains promising new changes that protect Medicaid beneficiaries. However, there continue to be cuts to retroactive coverage and new fees for emergency room use that will impact low-income New Mexicans. It also appears that the state is moving forward with mandating enrollment of Native Americans into managed care, despite firm rejection of this proposal at every tribal consultation. Lastly, the final waiver application makes no mention of whether the state will be taking up the opportunity under healthcare reform to extend Medicaid to every low-income adult under 138% FPL.

The final Medicaid application is available on HSD’s website:http://www.hsd.state.nm.us/Medicaid%20Modernization/index.html

ABQ Journal Article "Medicaid Reforms Proposed"

http://www.abqjournal.com/main/2012/08/18/news/medicaid-reforms-proposed.html


Medicaid Reforms Proposed
By Barry Massey / The Associated Presson Sat, Aug 18, 2012



SANTA FE – Gov. Susana Martinez’s administration asked the federal government Friday to approve a revised plan to overhaul a program providing health care for a fourth of New Mexico’s population.
The Human Services Department’s latest Medicaid proposal comes nearly six months after the administration initially unveiled a blueprint to improve health care for needy New Mexicans while slowing the growth of a program costing nearly $4 billion a year. About a fourth of the money comes from the state budget, with the federal government paying the remainder.
The administration hopes to implement the Medicaid overhaul in January 2014.
Human Services Secretary Sidonie Squier said the broad outlines of the administration’s original Medicaid overhaul remain unchanged. No enrollment cuts are proposed, and there’s no planned reduction in rates paid to health care providers.
After the department received additional comments from the public and providers, changes were made to ensure Medicaid coverage for more low-income pregnant women and disabled New Mexicans who are working. Previous eligibility proposals would have required some of those people to pay for coverage through a state-run health insurance exchange planned under a federal health care law. The working disabled on Medicare also would have been precluded from getting supplemental health coverage through the exchange.
The department is sticking with a proposal to require Native Americans to obtain Medicaid services through managed care organizations.
Tribal leaders have expressed concerns that a switch to managed care could limit access to health care providers for Native Americans living in remote areas.
But Squier said the department is confident that won’t happen, because the overhaul proposal makes clear that Medicaid-eligible Native Americans can continue to use their current primary care providers through the federal Indian Health Service or other tribal health systems. That will happen regardless of whether a doctor or clinic is part of a managed care network or has a contract with the managed care company. The department also has committed to ensuring prompt reimbursement for Medicaid services by tribal health care providers.

ABQ Journal Article "GOP Wasting Time on ACA Repeal"

http://www.abqjournal.com/main/2012/08/19/opinion/gop-wasting-time-on-aca-repeal.html




GOP Wasting Time on ACA Repeal
By Sen. Jeff Bingaman / Democrat, New Mexico on Sun, Aug 19, 2012



In June the Supreme Court upheld the vast majority of the Affordable Care Act. Still, Republicans in the House of Representatives continue to press for the law’s repeal.

This is a waste of time. Instead, we need to get to work on fixing our broken health care system. The time has come to stop fighting over ACA and instead focus on implementing it.

Across the country, the law is already working. Under ACA, millions of Americans benefited from free preventive health services last year, and women now have access to the full range of recommended preventive health services they need at no cost. ACA also requires that at least 80 percent of health care premiums be spent providing high-quality health care, not boosting the bottom line of insurance companies. Implementation of the fraud, waste and abuse protections in the law recovered $4.1  billion in taxpayer dollars in 2011 alone.

I am a strong supporter of ACA because New Mexico will benefit tremendously.

New Mexico has one of the highest rates of uninsured people in the country – nearly one in five residents lack health insurance. Uninsured New Mexicans still get lifesaving health services when they need it, but only because insured New Mexicans subsidize these costs through higher premiums. ACA expands health care coverage to more uninsured residents, saving all families money. According to one study, New Mexican households will have an additional $1,756 in their pockets in 2019 due to this law. 

Here in New Mexico, we’re seeing other important benefits as well. Twenty-six thousand young New Mexicans have gained coverage because the ACA requires their parents’ health insurance plans to cover them until they turn 26. 

Another 122,000 children in our state are no longer being denied coverage because of their pre-existing conditions. In 2014, no one with a pre-existing condition will be denied coverage; that’s at least 420,000 New Mexicans. And seniors and people with disabilities in New Mexico saved more than $17 million on prescription drug costs since the law was enacted. 

And there is more to come. We won’t feel the full effects of the law until 2014, when some 30  million more Americans will get health care coverage either because they will qualify for Medicaid or can purchase health insurance through the new health insurance exchanges. These are marketplaces that will be set up in every state so Americans can comparison shop to find the most affordable health care plan. 

According to the Bureau of Labor Statistics, by improving our nation’s health care safety net we will be creating millions of new jobs. New Mexico Voices for Children projects that 30,000 to 38,000 health sector positions will be created in our state. Our health care sector will be bolstered with an influx of $8 billion to $10  billion, according to one study. 

These dollars will help pay New Mexico doctors, nurses and other providers, and cover the cost of laboratory tests, medications and visits to health clinics. 

On the other hand, according to the nonpartisan Congressional Budget Office, repealing the law would add $109 billion to our deficit over the next decade, and dig us an even deeper hole in the following 10 years. Repeal would include rolling back controls on the unsustainable rise in Medicare costs and reducing intake of revenues further straining our economy.

What will we have to do in order to fully benefit from the ACA?

First, our state needs to continue developing its health insurance exchange. Nearly half of working New Mexicans do not have access to health insurance through their employers. Through the exchange, individuals and small businesses will both be able to shop for insurance and determine whether they qualify for federal subsidies or tax credits to help pay premium costs.

Second, we should fully participate in the Medicaid expansion. As many as 170,000 low-income New Mexicans would become eligible for Medicaid; the federal government will cover 100 percent of the cost of expansion for the first three years and more than 90 percent of the cost after that. 

Implementing health care reform will not only help make us a healthier nation, but it will also strengthen our economy and put money in our pockets. Let’s stop bickering over ACA and instead prepare to fully reap its benefits.

BIz journals New Article "Medicaid expansion wouldn't hit NM general fund"

http://www.bizjournals.com/albuquerque/news/2012/08/16/report-medicaid-expansion-wouldnt.html

Report: Medicaid expansion wouldn't hit NM general fund
New Mexico Business Weekly by Dennis Domrzalski, Reporter
Date: Thursday, August 16, 2012, 10:59am MDT

New Mexico Voices for Children says the state could expand Medicaid with no net expense to the general fund.

New Mexico could expand its Medicaid program to cover low-income adults with no net expense to the state’s general fund, says a new report by New Mexico Voices for Children.

The state’s Human Services Department has estimated that expanding Medicaid to cover adults who earn up to 138 percent of the federal poverty level would require as much as $496 million in new general fund revenue. However, that total would be covered by state taxes on the new federal Medicaid money that would come into the state. That federal money would be subject to the state’s 4 percent insurance premium tax and to the gross receipts tax when Medicaid benefits are paid by insurers to health care providers, said the study by the children’s health care advocacy organization.

It’s estimated that up to 150,000 New Mexicans would be eligible for Medicaid under the proposed expansion.

The June 28 U.S. Supreme Court decision that upheld the federal Affordable Care Act gave states the option to not participate in Medicaid expansion. Gov. Susana Martinez has not decided whether New Mexico would participate in the expanded program.

Under the ACA, the federal government would pick up 100 percent of the cost of new Medicaid enrollees for the first three years of the expansion. After the seventh year, the federal share would drop to 90 percent.

More than 530,000 New Mexicans currently receive Medicaid services.

News article Las Crusus Sun "Leaders hash out future of Medicaid for Navajos"

http://www.lcsun-news.com/new_mexico-news/ci_21324012/leaders-hash-out-future-medicaid-navajos

Leaders hash out future of Medicaid for Navajos
By Jenny Kane jkane@daily-times.com
Posted:   08/16/2012 01:00:00 AM MDT



SHIPROCK &mdash: Stanford Washburn, 53, was ready to tell the story of his deteriorating heart to the Legislative Health and Human Services Committee on Wednesday.
He was going to tell the committee about how his condition, cardiomyopathy, leaves him vulnerable to a heart attack at any time.
He was going to tell them about how he has no transportation from his home, a storage shed, to the hospital and how he walks six miles to town for every appointment.
He was going to tell them about how he once had to hitchhike to the hospital in Farmington to get a pacemaker, and then how he had to hitchhike back after the procedure.
He was going to tell them, but then he had a heart attack just before the meeting.
"We think he's going to be okay," said Sovereign Hager, Washburn's attorney from the DNA People's Legal Services in Shiprock.
Washburn's story led assembled leaders into a day-long discussion Wednesday about how the state might better provide comprehensive health care to American Indians.
The conversation focused on the potential to expand the state's Medicaid program, a possibility since the Supreme Court upheld the Affordable Care Act in June.
Gov. Susana Martinez, who was in Farmington on Wednesday, and the Legislature both are under pressure from organizations statewide to expand or not expand Medicaid to about 200,000 low-income New Mexicans. Neither has led on to what decision might be in the works.
"There's a fine line in the sand that says, "We're not going to go there,'" said Rep. Miguel Garcia (D-Albuquerque).
Studies already are in the works to determine how Medicaid expansion beginning in 2014 would affect the state and the Navajo Nation.
Studies shared Wednesday were positive, though not always believable, committee members said.
A study by New Mexico Voices for Children found that the state would generate more than $1 billion in new tax revenue by 2020. It also would generate between 32,000 and 38,000 jobs by the same time, the study said.
"We're selling this as an economic boost, but there's a lot of issues here," said Rep. Dennis Kintigh (R-Roswell).
Kintigh also questioned how the Navajo Nation intended on figuring out Medicaid expansion for the tribe when it is stretched across three states, New Mexico, Arizona and Utah.
All could pass different policies.
"The Navajo Nation already is assessing the expansion of health care," said Gayle Din Chacon, surgeon general for the Navajo Nation.
Currently, about 30,000 Navajo in New Mexico are enrolled in the state's Medicaid program. About 50,000 are enrolled in Arizona's program, and 1,000 in Utah's.
Many more, however, are eligible and are not taking advantage of the services offered.
"A lot of these people don't know these services are available to them," said Quela Robinson, an attorney for the New Mexico Center on Law and Poverty.
The committee considered increasing outreach to low-income New Mexicans, particularly those living in rural areas. Many of them do not have access to mainstream media and technology.
"If the state chooses to do this, I want to make sure that everyone that qualifies gets it," said Sen. Sander Rue (R-Albuquerque).
The state has much research to do on the outcome of expanding its Medicaid program, as does the Navajo Nation, but it was clear Wednesday parties statewide are interested in collaborating to better the system.
"If we don't do a lot of planning, there's going to be a lot of collateral damage," said David Foster, chairman of the Health Care Committee for the Association of Commerce and Industry of New Mexico

NMICoA HC Medicaid Coaltion informal discussion comments

NMICoA Health Committee

Medicaid Coalition Discussion with

Centers for Medicaid and Medicare

August 14, 2012

The Health Committee of the New Mexico Indian Council on Aging (NMICoA) has followed NM Human Services Department (HSD)’s Centennial Care waiver proposal to the Centers for Medicare and Medicaid (CMS) since it’s unveiling earlier this year. The Health Committee has these following concerns and issues with HSD’s attempts to have its 1115 waiver accepted by CMS.

• HSD has not been transparent in properly informing and involving Tribes and Pueblos to input grassroots solutions and networking to inform HSD about possible problems incurred with developing strategic health planning from a unilateral perspective. The government to government process is still not evident in meetings attended by members. Discordant information was presented at the NM Primary Care Association meeting and UNM Cancer Center meeting sponsored by the Navajo Nation.
• HSD does not understand the sovereign status of Tribes and Pueblos of NM and the Federal responsibility
• HSD needs to review Federal-Tribal policy and understand Tribes and Pueblos should be funded directly for their members who are enrolled in Medicaid
• This allows a 100% Federal Medical Assistance Percentage (FMAP) funding for natives to obtain medical services at Indian Health Services (IHS), 638 facilities but more importantly, Non-Tribal network providers who provide services not available at IHS/638 facilities.
• Carve out of Medicaid funding to Tribes/Pueblos should be considered such that local facilities and service providers can benefit patients with in –house; case management, care coordination, transportation, personal care, respite care in a more intergraded fashion.
• The health committee believes that the opt-out category should still be intact and the choice to enroll in Managed Care should remain with the individual Medicaid enrollee.
• In the past, with the institution of the Salud program, Native Americans were mandatorily enrolled in Managed care. This experience resulted in a loss of revenue to IHS and 638 facilities and confused the Native population. Currently approximately 80 % of Native Americans enrolled in Salud still opt-out of managed care in the face of enrollment efforts by the state and MCO’s
• The State of NM needs to present information to be consulted on to Governors/Tribal Leaders, at least ten days (10) prior to consultation sessions and submission of plans, amendments, proposals, waivers in order to give tribes proper time to analyze State documents to give informed input and comments in consultation sessions.
• Managed care organizations need to involve Tribes/Pueblos early in the proposal process to allow Native programs and providers the opportunity to be included in strategic planning
• The Health Committee also stands by its support of Tribal leadership and does not accept the State mandate for enrolling Natives into managed care.
• Tribes and Pueblos should be allowed to develop their own system of care management which includes all on and off reservation providers which provide primary and secondary services. The State should allow Tribal/Pueblo programs and providers to be in these case managed systems with HSD collaboration to provide technical assistance such as getting billing, coding and reimbursement services, integrative systems need to be developed to track clinical, behavioral health and long term care services needs and documentation of non-duplication by service providers, and patients are not inappropriately utilizing Medicaid services.
• After the last Tribal Consultation session between the State and NM Tribes, Tribes asked that HSD exclude them from mandatory inclusion in to Managed Care for one year. This will allow the State of NM to develop, implement and streamline Centennial Plan for the rest of the population. This will also give Tribes additional time to analyze their’ own options for health care delivery. If after one years’ time, the Tribes decide, based on Health outcomes data, to be incorporated into Centennial Care they may choose to.
• The US Supreme Court’s decision to up hold the PPACA except for the Medicaid Expansion is a concern for Tribes in NM. If Governor Martinez decides not expand Medicaid for NM’s low income individuals it will have a great effect on the Tribal Health Programs. NM Native Americans make up between 22%-26% of the Medicaid population with many individuals eligible but not yet enrolled. That number will grow with expansion and help many individuals obtain needed healthcare. This is another instance where the State of NM will make a decision without Consultation with Tribes. Given the Government to Government relationship what will happen if Tribes want to Expand Medicaid and the State of NM chooses not to?

In conclusion the Health Committee still believes the opt-out category should remain intact and if patients choose to enroll in managed care, it should be a personal choice. The State needs to understand Tribal Protocol from the Tribal/Pueblo perspective and honor these protocols when meeting on reservation lands. The Tribes/Pueblos need to revisit the consultation process in order to achieve meaningful outcomes.

Respectfully Submitted by

Erik Lujan
Volunteer Advocate

Impact of Republican "Ryan Budget" will have on Medicaid and Medicare by congressional districts

This information was forwarded to me by the National Committee to Preserve Social Security and Medicare (NCPSSM) www.ncpssm.org

The link below was produced by the Democrats in the Energy and Commerce Committee in the House. It breaks down the impact of the Ryan budget for every congressional district (CD) in the country.


http://democrats.energycommerce.house.gov/index.php?q=page/district-by-district-impact-of-republican-medicare-plan-and-medicaid-cuts

Very helpful information regarding how valuable Medicaid is to NM communities

Alternate plan from Roxane Bly

Hi there!  This is a very rough draft of an alternative to the mandatory managed care that is proposed in the Centennial Care plan.  I'd be interested in any feedback you all might offer.  I don't feel strongly about pushing forward with this idea, but I do feel it's critical that we offer some type of alternative rather than simply stating our opposition. 

My thinking is that we could consider piloting (in one maybe two counties) a partially capitated managed care model that would continue the Fee For Service structure for primary care while capitating payments for specialty care. 


I'm attaching a summary evaluation report of the Sooner Care model (Oklahoma's Medicaid program) which I think is also really helpful when formulating compelling arguments in opposition to the mandatory managed care proposal outlined in Centennial Care. 


Anyway, hope this might of use to some of you and am interested in any feedback you might offer.

Please comment on the Draft document on this site or email Roxane

Roxane.bly@gmail.com or the Blog nahainformation@gmail.com

ABQ Journal Article "Money at Root of N.M. Caution Over Medicaid"

Money at Root of N.M. Caution Over Medicaid
By Winthrop Quigley / Journal Staff Writer on Tue, Aug 7, 2012





In the 12 years I’ve covered health policy for the Journal, the one unchanging and undiminished concern of insurance companies, public officials, hospital administrators and many doctors, nurses and business leaders has been New Mexico’s large number of people who lack health insurance.
The federal Affordable Care Act offers New Mexico the chance to eliminate the problem at a relatively low cost to the state. You would think that after fretting about the uninsured for so many years our state’s political leaders would be jumping at the chance finally to bring health care coverage to an estimated 400,000 to 500,000 people who lack insurance.
They are not jumping.
It’s not as if they’ve suddenly decided that having as much as a quarter of our state’s population going uninsured is a good thing. They know what we’ve always known: Uninsured people are in worse health than insured people; unhealthy people are less productive; uninsured people seek care eventually, and when they do it costs more to treat them; uninsured people can’t pay their medical bills in full so the cost of their care is shifted to everyone who pays taxes or insurance premiums.
They know that uninsured people die younger.
They know that many of the state’s uninsured are working adults who earn so little they can’t afford their share of employer-provided insurance. Some work intermittently, at seasonal or temporary jobs, or at one or several part-time jobs. Many work in small businesses that don’t offer health insurance.
They also know that perhaps 200,000 of the people counted as uninsured could get and afford coverage. They just choose not to do it.
New Mexico is being offered a sweet deal to solve the problem.
The uninsured who can afford coverage will either buy insurance or pay the feds a tax or penalty, call it what you will. The federal government will give subsidies to qualifying small businesses and individuals to help.
Uncle Sam is willing to give New Mexico more than $6 billion from 2014 through 2020 to cover our lowest-income adult population through an expanded Medicaid program. All we have to do is tell Washington we’ll take their money, then put up 10 percent of the cost starting in 2017, about $500 million over the first three years of expansion.
The federal government swears it will continue in perpetuity to pay 90 percent of our cost of expanding Medicaid to more adults.
The health policy people and many of the state budget experts I talk with call this a no-brainer decision. Why not pay $500 million to get more than $6 billion in federal money? There certainly is a case to be made that an injection of $6 billion-plus into our economy from any source would stimulate economic activity. Sure, we would rather get $6 billion from new business startups and expansions, but that isn’t being offered. Medicaid expansion is.
New Mexico’s hesitation seems to be budgetary in nature. Our state has been blessed over the years with a lot of really smart tax and budget officials, elected and nonelected. When some of these people say they are not sure about this, we are well-advised to pay attention.
The feds have always been generous to New Mexico when it comes to Medicaid. Today, the state picks up only about 30 percent of the cost of covering beneficiaries, most of whom are low-income children, disabled adults and the elderly. Even at that, Medicaid is expected to account for about 16 percent of state general fund spending this fiscal year, up from 12 percent last year. Expanding Medicaid to all low-income adults would cost the state nothing for the first three years, then perhaps $167 million a year more for three years starting in 2017, which is as far as state officials are prepared to forecast.
Will the state have that extra money? Where will it come from? What if the state has promised low-income adults Medicaid coverage only to find in 2021 or thereafter that the federal government no longer wants to pay 90 percent of the cost of covering them? Can we pick up the higher cost then?
This isn’t an academic issue. Budget shortfalls forced the state to cut $40 million from Medicaid spending in 2004. New Mexico has always worked to avoid cutting eligibility and benefits. Usually we save money by making it a nuisance for beneficiaries to sign up and by cutting payments to providers. At some point, we may have to copy other states, like Nebraska, which removed 16,000 children from Medicaid in 2004.
If $40 million was a problem in 2004, can we expect $167 million in 2017 to be easy?
The budget people I know aren’t cruel, and they are far from stupid. They believe it is cruel and stupid to make promises they can’t keep. They want to be sure how deep the pool is before they make the state of New Mexico jump.
UpFront is a daily front-page news and opinion column. Comment directly to Winthrop Quigley at 823-3896 orwquigley@abqjournal.com. Go to www.abqjournal.com/letters/new to submit a letter to the editor.
— This article appeared on page A1 of the Albuquerque Journal

NM HSD Tribal Consutlation "Centennial Care" presentation 07/30/12

There is the link to the Presentation that HSD gave to tribal leaders at the last Tribal consultation at Dancing Eagle Casino.  The document is also on HSD's main Site www.hsd.state.nm.us



http://www.hsd.state.nm.us/Medicaid%20Modernization/index.html

ABQ Journal Article "Medicaid a Broken System That Can’t Withstand More Pressure"

A different look at Medicaid.

http://www.abqjournal.com/main/2012/08/05/opinion/medicaid-a-broken-system-that-cant-withstand-more-pressure.html


Medicaid a Broken System That Can’t Withstand More Pressure
By Joe Montes / N.M. State Director, Americans for Prosperity on Sun, Aug 5, 2012
 
Carol Vliet was 53 years old when she discovered her cancer had returned and spread to her brain, liver, kidneys and throat. With her life on the line, she turned to her primary care physician, who had monitored her health for the past two years.
But shortly after consulting with her doctor, she was devastated to learn that his practice was no longer accepting Medicaid patients. She would have to go elsewhere for treatment.
Unfortunately, Carol’s predicament isn’t unique among those covered by Medicaid. Over the years, Medicaid patients have suffered from dropped coverage, denied care and poorer health outcomes – sometimes placing patients in worse situations than those encountered by the completely uninsured.
Ultimately, Medicaid is a broken program.
When politicians speak of Medicaid, it’s often in glowing terms. Sen. Jeff Bingaman recently said in a statement that Medicaid stands to “improve the quality of life for many New Mexicans” and, when part of Medicaid was reauthorized, New Mexico Rep. Martin Heinrich called it “the change the American public wants and the change our children deserve.”
But if these politicians had to live with Medicaid, they’d certainly get a reality-check. Being covered under Medicaid isn’t a picnic.
One of the primary difficulties with Medicaid coverage is that fewer health care providers are accepting Medicaid patients. The New England Journal of Medicine published a study last year that showed that two-thirds of children on Medicaid are denied appointments to deal with serious medical conditions (compared with 11 percent of privately insured children).
Now nearly three in 10 physicians across the nation will not accept Medicaid patients.
Doctors aren’t refusing to take Medicaid patients out of cruelty. Many have admitted to feeling guilty over refusing these patients and have put off denying care for as long as possible. But, ultimately, accepting Medicaid has been costing health care providers just too much.
Currently, Medicaid reimburses doctors only 55 percent compared with private insurers. Moreover, those payments are often below the actual costs of providing the health care (meaning physicians lose money on every Medicaid patient).
This simply is not sustainable for any length of time.
Even for those patients who can find doctors that accept Medicaid insurance, studies have shown that they often receive worse care than those with private insurance and even, sometimes, those who are uninsured. A study published by the University of Virginia found that the mortality rate among surgical patients on Medicaid is 97 percent higher than those with private insurance and 13 percent higher than those uninsured.
If this is life with Medicaid currently, we have to ask ourselves – what will life be like if New Mexico implements the Medicaid expansion called for in President Obama’s health care reform? How many more doctors will decide to close their doors to all Medicaid patients when more than 200,000 new enrollees are added to the program in our state? How many more Carol Vliets will it take before our politicians see that Medicaid can’t withstand the strain of additional enrollees served by a diminishing pool of medical professionals?
Additionally, as more and more Americans join Medicaid, the costs for states and the federal government skyrocket.
And while some call this expansion the “deal of a decade,” because the federal government would pay the full cost for the first three years, either way, the average taxpayer is paying for it. Keep in mind, the same source of money on the federal level is the same source of money on the state level: the taxpayer.
New Mexico’s portion after the initial three years of Medicaid expansion could exceed $200 million.
Expanding a broken, overstretched program is not the right policy for New Mexico. Instead of breaking budgets and subjecting more New Mexicans to a broken health care system, Gov. Susana Martinez should pressure Washington for real, patient-centered reform.
This just simply isn’t “the change our children deserve.”
Americans for Prosperity is national conservative political advocacy group that promotes economic freedom.

NHELP "50 Reasons Medicaid Expansion is Good for Your State"

Here is a very informative document regarding the Medicaid Expansion

NHELP
National Health Law Program

50 Reasons Medicaid Expansion is Good for Your State
Prepared by Jane Perkins
August 2, 2012
http://www.healthlaw.org/images/stories/2012_08_02_50_reasons.pdf

Medicaid Expansion and States
: 1. The Medicaid Expansion is an exceptionally generous deal for the states. States will receive 100% federal funding for the expansion population for the first three years, to be gradually reduced to 90% thereafter. Between 2014 and 2022, a fully implemented Medicaid Expansion will cover 17 million lower-income people while increasing direct state Medicaid spending by only 2.8% more than if health reform had not been enacted.
1 These figures do not reflect savings that will be produced elsewhere as the ACA is implemented (see below). When these savings are factored in, states are expected to save an estimated $101 billion from 2014-2019.2
2. The Medicaid Expansion will generate savings for some states’ Medicaid programs. Between 2014 and 2019, a few states will save money by making the Expansion: HI, ME, MA, and VT. Other states will experience an increase of less than 1% in their state Medicaid spending, including AZ, DE, DC, NY, ND, SD, WI and WY.3
3. The Medicaid Expansion will help free up state and local spending that now goes to uncompensated care. State and local governments help offset the cost of care that is provided to uninsured patients who cannot afford to pay—paying an estimated 30% of the cost of uncompensated care. The ACA will roughly halve state spending on uncompensated care, generating savings of $26-$52 billion.4
4. The Medicaid Expansion will reduce state spending on mental health services for lower-income, uninsured patients. This includes spending on state mental hospitals, hospital emergency rooms and community health clinics. This spending has been growing over time, with state and local governments covering 42% of the cost of state mental health expenditures by 2009.5 Full Medicaid Expansion is estimated to save between $11 and $22 billion in funds states will otherwise spend on mental health programs from 2014-2019.6
5. The Medicaid Expansion will enable states to continue using health care provider assessments as part of their state matching funds. Although federal Medicaid funding to states is open-ended (i.e. a state entitlement), it is limited by a states’ ability to raise its matching share. Some states have taken advantage of federal provisions that place assessments on hospitals and other health care providers that are then used to match (and draw down additional) federal dollars.7 Without the Medicaid Expansion, hospitals and other providers may be unwilling or www.healthlaw.org 2 unable to pay these assessments, resulting in the loss of federal funds and a negative impact on state and local governments. 　
unable to pay these assessments, resulting in the loss of federal funds and a negative impact on state and local governments.

6. The Medicaid Expansion will avoid costs associated with transitions and churning. As individuals change jobs or fall in and out of work, income and eligibility for health insurance coverage fluctuate. Medicaid Expansion will provide stability in coverage; for example, individuals whose income moves them above 100% of the poverty line can remain in Medicaid and thus with the same providers.8 Stability in coverage means lower administrative costs. Stability in coverage improves continuity of care and the health care provider’s ability to provide good care.9 The ACA includes numerous options for state Medicaid programs to improve continuity of care; expansion will allow the affected populations to take advantage when a state elects these options.10
7. The Medicaid Expansion will keep residents’ federal taxes flowing into the State. Almost every state resident pays federal taxes, and federal dollars will fund the Medicaid Expansion. Taxpayers residing in states that do not implement the Expansion will be paying out dollars to states that do expand, states like CA, CT, CO, DC, MN, MO, NJ, WA, which have already obtained approval for Medicaid Expansions.11
8. The Medicaid Expansion could help avoid work force flight. States could lose valuable members of the work force, as some low-income working adults will move to states that are making Medicaid coverage available.

9. The Medicaid Expansion will attract managed care to the state. Medicaid managed care companies are experiencing some of the fastest growth among U.S. managed care firms. They are aggressively seeking to move into states that implement the Medicaid Expansion, as states have been actively seeking to move more of their Medicaid populations into managed care.12 States that do not implement the Medicaid Expansion will lose this population group as part of their business and bargaining strategy.
10. The Medicaid Expansion will have a deep and broad impact on the state economy. New federal Medicaid dollars will travel through the state economy, improving employment, labor income, and capital income. New federal dollars will turn over multiple times in the state economy (for example, from physician to employee to grocer).
13
11. The Medicaid Expansion will generate revenue. State and local revenues will increase when state residents pay income, sales, and other taxes generated by the federal funding for the Medicaid Expansion, which in some states will offset much, perhaps all, of the additional costs.14 These increased state income taxes are a major factor in the Arkansas Department of Human Services’ estimate that the Expansion will save the state $372 million in the first several years.15 Medicaid Expansion and Health Care Providers:
12. The Medicaid Expansion will help hospitals caring for a disproportionate share of low-income and uninsured people. Many community and public hospitals have been receiving enhanced federal funding, called Medicare and Medicaid disproportionate share hospital (DSH) funding, to compensate them for some of
www.healthlaw.org 3 　
the costs associated with treating large numbers of the uninsured. On the assumption that the number of uninsured people will fall dramatically beginning in 2014 when the individual mandate and Medicaid Expansion take effect, the ACA decreases DSH payments.16 In states that do not expand Medicaid, the need for uncompensated care may remain relatively stable, while the amount of DSH funds that can be used to subsidize some of that care will fall substantially. This may result in severe financial hardship for hospitals, meaning that they will increase costs to paying patients or provide less uncompensated care.
13. The Medicaid Expansion will reduce use of costly hospital departments. Uninsured people often cannot find a regular source of care and depend on hospital emergency departments for emergency and non-emergency care. Emergency room care is expensive. By contrast, once people get Medicaid, they use the hospital emergency department at the same rate as people who have private insurance for both emergency and non-urgent care. As with the privately insured, most of the Medicaid visits to the emergency room are for urgent or serious issues.
17 Fewer people in ERs means less waiting time for people with real emergencies, which includes everyone regardless of income.
14. The Medicaid Expansion could help safety net and low-profit margin hospitals keep their emergency departments open. From 1990 to 2009, the number of hospital emergency departments in non-rural areas declined by 27%.
18 Medicaid funding for uninsured patient care could help emergency departments open.
15. The Medicaid Expansion will be a source of revenue for hospitals, regardless of what the Independent Payment Advisory Board decides. The ACA establishes the Independent Payment Advisory Board, which must propose measures to reduce Medicare spending in years when spending growth will outpace target growth rates. The proposals cannot ration care, raise revenue by increasing beneficiary cost-sharing or reducing services, and until 2019 cannot reduce some provider (e.g. hospital) payment rates.
19 In years when the targets are not met, the IPAB’s proposals to reduce Medicaid spending could mean that hospitals will face even deeper cuts in states that do not implement the Medicaid Expansion.
16. The Medicaid Expansion will benefit community health centers. Federally funded health centers are the main source of primary care for medically underserved populations. The Expansion will enable these centers to expand capacity to serve the uninsured as well as those newly covered by Medicaid. Fully implemented by the states, the Medicaid Expansion will allow health centers to reach approximately 19.8 million new patients. Without the Expansion, health centers’ new patient care capacity will be reduced by nearly 27%, a 5.3 million drop in new patients.
20 Medicaid Expansion and the Residents of the State:
17. The Medicaid Expansion will significantly reduce the number of uninsured adult residents, particularly in southern states, where, on average, a 50% reduction will occur.
21
18. The Medicaid Expansion will help stop the deterioration in health access that nonelderly adults have been experiencing over the last decade. Their likelihood www.healthlaw.org 4 of having a usual source of care and having an office visit have all declined while the likelihood of having an emergency room visit has increased. Nonelderly adults were 66% more likely to report having unmet medical needs in 2010 compared to 2000. Uninsured adults experienced the most dramatic declines. By comparison, children experienced increased coverage through Medicaid and CHIP over the decade and by the end of the decade were more likely to have a usual source of care and office visits.22 　
of having a usual source of care and having an office visit have all declined while the likelihood of having an emergency room visit has increased. Nonelderly adults were 66% more likely to report having unmet medical needs in 2010 compared to 2000. Uninsured adults experienced the most dramatic declines. By comparison, children experienced increased coverage through Medicaid and CHIP over the decade and by the end of the decade were more likely to have a usual source of care and office visits.22

19. The Medicaid Expansion will reduce adult death rates. In states that have already expanded Medicaid, mortality rates have been reduced significantly. Death rates were the greatest among adults between the ages of 35 and 64 years, people of color, and residents of low-income counties. Adults also experienced significant reductions in delays getting health care due to cost. Comparable states that did not expand Medicaid did not have similar results.23 A report in Tennessee concludes that expanding Medicaid coverage to 225,000 people would save 9 lives in the state every week for the next 10 years.24
20. The Medicaid Expansion will improve the financial security of the state’s residents. Tracking of Oregon’s Medicaid expansion to uninsured adults found the coverage reduces by 40% the probability that people report having to borrow money or skip payments on other bills because of Medicaid expenses. It decreases by 25% the probability that they will have unpaid medical bills sent to a collection agency.25
21. The Medicaid Expansion could reduce the growing role of health debt as a cause of personal bankruptcy. The financial security brought about by the Medicaid Expansion can lead to reductions in bankruptcies. Medical debt factors into fully 62% of all bankruptcies-up from contributing to 46% of bankruptcies in 2001.26
22. The Medicaid Expansion will allow access to health services for the state’s residents working in low pay jobs. Medicaid Expansion will provide access to health care for these workers. If these individuals remain uninsured, the costs of their illnesses and injuries will continue to be shifted onto privately insured state residents. As Congress noted when it enacted the ACA, this "cost shift" is now raising family health insurance premiums, on average, by over $1,000 per year.27
23. The Medicaid Expansion will help ensure a healthier workforce for employers of low-wage workers, including states that are employing large numbers of low wage state employees. Improved health decreases absenteeism, which in turn increases productivity.28
24. The Medicaid Expansion will provide coverage for working persons who lose their jobs through no fault of their own and cannot afford to continue with their employer-based insurance coverage because the COBRA premiums are unaffordable.29
25. The Medicaid Expansion is critical for women. Compared with other countries (e.g. Germany, Australia, France, Canada, UK), more women in the U.S. report that they cannot get care because of cost. Fully 77% of uninsured women aged 19-64 experienced cost-related access problems.30 In 2010, 55 percent of the 19 million currently uninsured women in the U.S. had incomes low enough to qualify for coverage under the Medicaid Expansion.31 The Expansion will produce a significant reduction in the number of uninsured women aged 16-64 in each of www.healthlaw.org 5 　
the 50 states.32 Expansion will offer a strong benefit package to women because it will include at least all of the benefits offered in the exchanges, including maternity and preventive services and family planning benefits.33 26. The Medicaid Expansion will avoid discrimination against people with mental health disabilities. When it enacted the Expansion, Congress included a provision that requires newly eligible individuals to receive mental health and substance use services at parity with other benefits.34
27. The Medicaid Expansion will help individuals with mental illness. Approximately one in six currently uninsured adults with income below 133% of poverty has a severe mental illness. Many others have less serious mental health conditions.35
28. The Medicaid Expansion will help homeless individuals. Half of the newly eligible individuals have incomes at 50% or less of the poverty line. Many of these very-low income people are homeless, and approximately ¼ of them have a serious mental illness.36 Medicaid Expansion will mean more comprehensive care for these individuals, allowing them to obtain chronic care management and preventive services. Medicaid will allow the state to leverage numerous service options, such as health homes, to provide these new beneficiaries with care management services linked to supportive housing.37
29. The Medicaid Expansion will help the LGBT community. Unemployment and poverty are higher for LGBT individuals than for the general U.S. population (an estimated 14% of LGBT individuals earn less than $10,000 per year, compared to 6% of the general population).38 As a result, a significant proportion of LGBT adults will be likely benefit from the Medicaid Expansion.
30. The Medicaid Expansion will link adults with chronic and disabling conditions to health care, including individuals who do not qualify for Medicare because of that program’s two-year disability waiting period.
39
31. Medicaid Expansion will allow access to health services for low-income Veterans, covering about 650,000 of the 1.3 million currently uninsured Vets. Texas, Florida and California have the most uninsured veterans, with the highest number in Texas.40
32. The Medicaid Expansion, while targeted to adults, will actually help children. In the typical state, parents lose eligibility for Medicaid when their incomes reach just 63% of the federal poverty line (approximately $12,000 for a family of three in 2012). Medicaid Expansion will increase coverage for parents; thus, their health status is expected to improve. When parents and caretakers are insured, their children are more likely to be insured and to make more effective use of their coverage. Coverage of parents also improves continuity of children’s coverage and reduces the likelihood of breaks in coverage.41 Children coming onto Medicaid will be eligible for the program’s tailored child health benefit package, Early and Periodic Screening, Diagnosis and Treatment.42
33. The Medicaid Expansion will ensure that low-income parents are not punished when they move more fully into the workforce. By contrast, in states that do not expand, low-income parents may avoid increasing their work time because they need to maintain Medicaid coverage for their children.

34. The Medicaid Expansion will increase access to and use of health care by people of color. If implemented as written, the ACA is expected to cover 32 million www.healthlaw.org 6 Americans. Half of the 32 million will come into the health care system through Medicaid, and three out of four of those individuals are people of color.43 　
Americans. Half of the 32 million will come into the health care system through Medicaid, and three out of four of those individuals are people of color.43

35. The Medicaid Expansion will reduce healthcare costs by reducing health disparities. Between 2003 and 2006, more than $200 billion could have been saved in direct medical care expenditures if racial and ethnic health disparities did not exist. Since the lack of insurance is a contributing factor causing health care disparities, expanding Medicaid to provide insurance can save money.

36. The Medicaid Expansion will help slow the spread of HIV/AIDS by allowing individuals to obtain testing and initiate treatment sooner, which can help prevent the transmission of HIV. Currently, nearly 30% of people with HIV are uninsured, and up to 59% are not in regular care.44 Existing programs for low-income people with HIV/AIDS, while effective, have been increasingly strained as their budgets decrease while demand grows. For example, nine states currently have waiting lists for joining an AIDS Drug Assistance Program (ADAPs). Most low-income people living with HIV have to wait until the onset of a life-threatening opportunistic infection to qualify for Medicaid on the basis of disability. Expanding Medicaid to individuals living with HIV, but who have not yet progressed to AIDS, will not only keep those individuals healthier longer, but will help reduce the number of new infections in the future.
37. The Medicaid Expansion will ensure that 11.5 million people—the poorest of the poor—are
not left out in the cold. Under the ACA, individuals with incomes below 100% of the federal poverty line will not be able to obtain premium tax support for insurance products available through the exchange.
45 These individuals are likely to remain uninsured if states do not expand Medicaid.46
38. The Medicaid Expansion will provide tailored coverage for lower-income people, including coverage that is particularly relevant to adults and couple, such as family planning services and supplies, and to individuals with chronic conditions, such as prescriptions and home health care.47
39. The Medicaid Expansion will ensure that enrollees help pay for their health care while maintaining affordability, by allowing nominal copayments for individuals with incomes below the poverty line while capping cost-sharing at five percent of monthly income.48
40. The Medicaid Expansion means jobs. The Expansion would bring over 7500 jobs to Tennessee in 2014 alone;49 in Maryland, 9,122 jobs in FY 2014 alone (and nearly 27,000 jobs in FY 2020).50 Following the increase in the federal Medicaid matching rate in the American Recovery and Reinvestment Act, one estimate from Illinois found the Medicaid program supported as many as 385,742 jobs and generated wages as high as $15.8 billion during FY 2009 alone.51 Medicaid Expansion and Efficiency and Fairness:
41. The Medicaid Expansion is an efficient way to cover this group of low-income individuals. The Expansion merely requires addition of a new coverage group to Medicaid’s existing market-based benchmark coverage options. It does not require a new insurance program to be designed and a new bureaucracy to be
www.healthlaw.org 7 created. Addition of this population group will increase the bargaining power of the state with health plans and providers. 　
created. Addition of this population group will increase the bargaining power of the state with health plans and providers.

42. The Medicaid Expansion will extend a highly successful health insurance program that every state has aggressively implemented over the years. Every state has extended eligibility and/or services beyond the minimum coverage requirements of the federal law. At this point, more than 60% of current Medicaid funding covers optional population groups and services that no state is required to cover. In some states, the uptake of optional spending has been particularly dramatic, for example: 76.5% of expenditures in North Dakota are attributable to optional spending; 74.7%, in Ohio; 74% in Wisconsin; 69.4% in Iowa.52
43. Medicaid is efficient. The per enrollee cost growth in Medicaid (6.1%) is lower than the per enrollee cost growth in comparable coverage under Medicare (6.9%), private health insurance (10.6%), and monthly premiums for employer-sponsored coverage (12.6%).53
44. The Medicaid Expansion and ACA will produce cost savings to states even as individuals who are currently eligible but not enrolled in Medicaid come forward to enroll. Some states are concerned that the federal government will not really be paying the entire bill in the first three years because individuals who are already eligible for Medicaid will take advantage of the coverage "welcome mat" and "come out of the woodwork" to enroll. The states will receive their regular federal matching funding for these already-eligible individuals. The estimates of state costs (see #1 above) already include the costs associated with these potential new enrollees who are currently eligible. Equally important, the welcome mat effect will occur whether or not the state implements the Expansion. Beginning in 2014, the opportunity for uninsured people to purchase health insurance with federal subsidies will drive adults to insurance exchanges to obtain the health insurance, and upon arrival, their eligibility for Medicaid will automatically be determined—whether or not the state has expanded Medicaid.

45. The Medicaid Expansion represents fiscal responsibility and shared responsibility between state and federal government. It will be more efficient for all of the federal taxpayers who live in the state if individuals between 100-133% of the poverty line are covered through Medicaid rather than the exchange. The Congressional Budget Office has determined that the per capita cost of covering this population in the exchange will be $5,926 in 2019, as compared with $1,826 through Medicaid Expansion.54 Using these numbers, a state leaving the 100- 133% group to exchange coverage instead of a Medicaid Expansion would effectively be arguing that the Federal government should pay $5,926 per person, to save the state from paying $182.60 – the state’s 10% share of the $1,826 Medicaid cost. That leaves the government paying $5,926 instead of $1,643.40 – the Federal government’s 90% share of the Medicaid cost.
46. The Medicaid Expansion will mean that states’ spending of state and federal dollars for state program upgrades will not have been wasted. Beginning in April 2011, states could receive significantly enhanced federal matching funds (90% instead of the usual 50% administrative matching rate) to upgrade their eligibility systems and make them ready for the 2014 expansions. The majority of states have approved (19 states) or submitted plans (10 states) to overhaul or build
www.healthlaw.org 8 1 January Angeles, Center on Budget and Policy Priorities, How Health Reform’s Medicaid Expansion will Impact State Budgets (July 12, 2012) (discussing CBO estimates). 2 The Lewin Group, a frequent consultant to state Medicaid programs, estimates savings of $101 billion. See The Lewin Group, Patient Protection and Affordable Care Act (PPACA): Long Term Costs for Governments, Employers, Families and Providers (June 8, 2010) (Working Paper #11); see also Matthew their systems.55 If a recipient state refusing now to implement the Expansion, it will have made an inefficient use of taxpayer funds.
47. The Medicaid Expansion merely echoes what a number of states had already
obtained Medicaid funding to do. States have already obtained approval from the federal government to expand their Medicaid programs to uninsured adults—at the current, rather than Expansion, federal matching rates. By 2008, 18 states had already received federal permission to extend this coverage, including Arizona, Idaho, Indiana, Maine, Michigan, Tennessee and Utah.56
48. Successes in the states illustrate the value of the Medicaid Expansion. The success of health reform in Massachusetts demonstrates that making health care coverage available for most everyone, as would be accomplished by full implementation of the ACA—i.e. with the Medicaid Expansion—is the key to successful reform. The Commonwealth Care program provides health care insurance without premiums to all adults up to 150% of the poverty level. Combined with other aspects of health reform in Massachusetts, this has resulted in 439,000 more Massachusetts residents having health care coverage compared to before reform, with 98.1 % of residents now having coverage, the highest rate in the country.57 Medicaid Expansion and the Law:
49. State law may require the State to implement the Medicaid Expansion. For example, an Arizona law requires the Director of the State Medicaid program to ensure that sufficient funds are available to provide Medicaid benefits to "all persons" whose incomes are at or below the federal poverty, to be supplemented "as necessary, by any other available sources including … federal monies."
58 An Alaska law says that "[a]ll residents of the state for whom the Social Security Act requires Medicaid coverage are eligible to receive medical assistance" under Title XIX of the Social Security Act.59
50. It is the law. While the Supreme Court found that a state could not be "coerced" into implementing the Expansion, its full remedy was to "limit[] the financial pressure the Secretary may apply to induce States to accept the terms of the Medicaid Expansion."60 Thus, the Expansion population is still listed in the Medicaid Act as a group that the state "must" cover.61

Continued comments Centennial Care and consultation

Continuing on my comments on the Tribal Consultation on July 30th at Dancing Eagle Casino:

Having searched the HSD website again today I still have not beena ble to find the new version on the 1115 Waiver "Centennial Care" or the presentation that HSD presented to Tribal Leaders last Monday.  Of course Sec. Squir and Julie Wienberg did say that the waiver would not be avaliable to view by the public until after they submitted it to CMS in mid August.

Going off the limited inforamation that we do have from the slide presenation I will start with slide 2 :
Opperational/ Implemenation Time Line

According to the slide HSD submitted the Waiver on April 25, 2012 to CMS and will submit updated by mid August 2012?  This is where I have and issue with HSD.  For those of you that do not know there was a couple of news articles regarding the Waiver submission to CMS and the fact that both NM and Kansas wrote to CMS asking them to volunteeraly resend their waivers because they will have a hugh affect on Tribes and that they needed to have more tribal consultation.  I am looking for my copy on this letter if any one has it please forward to me or post it.  We first heard this from non-native health advocates and then confirmed it from a member of US HHS Sec Sebelius STAG.

Since these articles and statments were made public HSD has stated on several instances that "NO CMS DID NOT REJECT the WAIVER" and then "WE are voluntarily pulling back the waiver to get more PUBLIC input" and " WE DID NOT resend the waiver".  I would not question HSD as much if they were just honest about the situation.  The following letter is a respone to Govenor Madalena from Jemez Pueblo regarding the Waiver

My thoughts on State Tribal Consultation at Dancing Eagle hosted by Laguna Pueblo

Frist of all I would like to Thank Governor Luarkie for hosting the consultation, and the Governors/ Representative for attending and speaking clearly on behalf of Pueblos and Tribes.  I also would like to thank all of the other attendees for showing that we, Native American Indians, are not just going to smile and whatever the State chooses to give us.

the following is the comment paper written on behalf of the New Mexico Indian Council on Aging's Health Committee by Dr. Ron Lujan:

State Tribal Consultation and Collaboration

Dancing Eagle Casino

Pueblo of Laguna

July 30, 2012

The Health Committee of the New Mexico Indian Council on Aging (NMICoA) has followed NM Human Services Department (HSD)’s Centennial Care waiver proposal to the Centers for Medicare and Medicaid (CMS) since it’s unveiling earlier this year.  The Health Committee has these following concerns and issues with HSD’s attempts to have its 1115 waiver accepted by CMS.

·         HSD has not been transparent in properly informing and involving Tribes and Pueblos to input grassroots solutions and networking to inform HSD about possible problems incurred with developing strategic health planning from a unilateral perspective. The government to government process is still not evident in meetings attended by members.  Discordant information was presented at the NM Primary Care Association meeting and UNM Cancer Center meeting sponsored by the Navajo Nation.

·         HSD does not understand the sovereign status of Tribes and Pueblos of NM and the Federal responsibility

o   HSD needs to review Federal-Tribal policy and understand Tribes and Pueblos should be funded directly for their members who are enrolled in Medicaid

o   This allows a 100% Federal Medical Assistance Percentage (FMAP) funding for natives to obtain medical services at Indian Health Services (IHS), 638 facilities but more importantly, network providers who provide services not available at IHS/638 facilities.

o   Carve out of Medicaid funding to Tribes/Pueblos should be considered such that local facilities and service providers can benefit patients with case management, care coordination, transportation, personal care, respite care in a more intergraded fashion.

o   The health committee believes that the opt-out category should still be intact and the choice to enroll in Managed Care should remain with the individual Medicaid enrollee.

o   In the past, with the institution of the Salud program, Native Americans were mandatorily enrolled in Managed care.  This experience resulted in a loss of revenue to IHS and 638 facilities and confused the Native population. Currently approximately 80 % of Native Americans enrolled in Salud still opt-out of managed care in the face of enrollment efforts by the state and MCO’s

·         Managed care organizations need to involve Tribes/Pueblos early in the proposal process to allow Native programs and providers the opportunity to be included in strategic planning

·         The Health Committee also stands by its support of Tribal leadership and does not accept the State mandate for enrolling Natives into managed care.

·         Tribes and Pueblos should be allowed to develop their own system of care management which includes all on and off reservation providers which provide primary and secondary services. The State should allow Tribal/Pueblo programs and providers to be in these case managed systems with HSD collaboration to provide technical assistance such as getting billing, coding and reimbursement services, integrative systems need to be developed to track clinical, behavioral health and long term care services needs and documentation of non-duplication by service providers, and patients are not inappropriately utilizing Medicaid services.

In conclusion the Health Committee still believes the opt-out category should remain intact and if patients choose to enroll in managed care, it should be a personal choice.  The State needs to understand Tribal Protocol from the Tribal/Pueblo perspective and honor these protocols when meeting on reservation lands.  The Health Committee also believes that All Indian Pueblo Council (AIPC) resolution allows them to represent Pueblo elders and disabled members on matters of elder healthcare.

Respectfully,

Dr. Ron Lujan

For the NMICoA Health Committee

Now, having attended this and other consultations regarding this topic (Centennial Care) by the NM HSD, I have the following Statements, comments, questions:

How can these sessions be considered meaning full when Tribes have no advanced viewing of the material?  After searching HSD Web Site I have not found a current copy of the waiver or a copy of the Slide presentation that was given on on June 30, 2012.  How are Tribes who did not attend suppose to make informed decisions on Centennial Care without viewing these two Documents?

The waiver information that is posted on the HSD web site is the one that was submitted (and later resented) to CMS in February 2012.  The slide presentation that was given to Tribal leaders had a lot of new material  that is not part of the February version of the Waiver. 

I share Governor Madalena's sentiment regarding the state referencing data, that does not include Tribal data, that shows we have the worse health disparities and outcomes. 

All Tribes are still opposed to the Mandatory inclusion into Managed Care, the opt out category being taken away, charging co pays for any Medicaid Service regardless of where medicine is obtained, and getting rid of the prior quarter coverage.  The State believes that Enrolling Native American Indians in Managed care will elevate their health, but even though we have asked many times for the Data supporting the claims, NM HSD has not provided this information.  That is a claim being use across the country to advocate for managed care but there is no evidence that being enrolled in and MCO improves the individuals health, it does decrease state spending and increases MCO profits.

Even though the State HSD has come up with several new ideas to help entice Tribes into accepting Centennial Care, they still have not done their homework,  many of the incentives like, mini block grants, and paying a PM/PM for services provided by IHS and 638 facilities, would require Federal approval, IHS direct services Tribes would not be able to take advantage of them. 

These are just  a few of the concerns I have that we all should be taking into count.

I will be posting more comments and questions regarding Centennial Care as I analyze the current documents.