Ohkay Owingeh Resolution and supporting Documents

Ohkay Owingeh

Position Paper

For CMS

State of New Mexico Centennial Plan

Ohkay Owingeh opposes the New Mexico Medicaid plan detailed in the Centennial Care Concept paper.

Centennial Care is presented by the State of New Mexico as a means to ensure Health Care for New Mexicans for the next century.  The consequences of these plans will reduce costs by limiting medical services and care coordination to all New Mexican residents.

Native Americans specifically will be imposed the same limitations’ which would include a direct threat to tribal sovernty and authority by the state.

I.      THE DIRECT THREAT OF AUTHORITY AND SOVEREIGNTY FOR OHKAY OWINGEH IS POSED BY THE CENTENNIAL CARE PLAN.

Ohkay Owingeh tribal member’s choice of health service has always been the Indian Health Service.  PL 93-638 law authorizes Ohkay Owingeh (individual Tribal Nations) to contract our shares of health care funds that would have been spent by the IHS on our individual tribal members.  This law authorizes Ohkay Owingeh (individual Tribal Nations) to determine and design the best health care system for our tribal population.  Ohkay Owingeh uses surveys, health data, expendable analysis, prevalence data, and a number of other health measures provided by IHS to determine the shape and scope of our health system (IHS). Ohkay Owingeh then assists in formal financial planning of IHS.  Part of the planning includes 3rd party revenue collecting inclusive of Medicaid reimbursements.

           A.        STATE TRIBAL GOVERNMENT TO GOVERNMENT

RELATIONSHIP

Senate Bill 196 (State Tribal Collaboration Act) requires that the state hold consultations with tribes in respect to all issues concerning or affecting Native Americans in New Mexico.  Since the elimination of the Office of American Indian Health and its Directors, the state has failed to live up to its responsibilities.  The State of New Mexico has failed to have consultations with New Mexico Tribes when the options of improved Medicaid services and cost savings became available.  Listening sessions with the tribes were not consultations.  New Mexico Medicaid plan had been finalized prior to these so called consultations.  Comments, concerns or objections of the Centennial Care Plan were not documented and submitted in the application.  If meaningful consultations had been conducted by the state with the tribes there would have been comments on the proposed Centennial Care Plan.  The documents would have been submitted in the application.  The information and the documents would have provided CMS with an understanding of the concerns of New Mexico tribes.  The changes would then have been addressed and engaged with the tribes directly and submitted in the application.  It is with this the Ohkay Owingeh and other tribal leaders request to have CMS hear our objections and our following requests:

OPT IN EXEMPTION CENTENNIAL CARE

Ohkay Owingeh (tribal leaders) request an exemption from New Mexico’s proposed mandate to include tribal Medicaid enrollees in the Centennial Care Plan’s managed care program.  We ask that individual tribal members have the choice to either opt in or out of Centennial Care Plan.

Given the relationship among the tribes, the Indian health system, and the federal government, Ohkay Owingeh and tribal leaders ask by what authority can The State of New Mexico mandate fundamental changes in the delivery of health care to our people and Native Americans residing in New Mexico.  Even though the Centennial Care Plan requires MCO’s to contract with I/T/U’s.  The I/T/U’s are under legal obligations to contract with MCO’s and federal law still requires New Mexico to pay for any services rendered to Native individuals in any Indian health system facility.  Even if New Mexico were able to compel the participation of Ohkay Owingeh tribal members in managed care the waiver does not effectively address the issues of our members who receive services from IHS clinics, 638 compact health facilities, and contract health services (CHS). Congress, through legislation enacted over decades, has created a multifaced health care system for tribal communities, a system that includes IHS and tribal health facilities.

Ohkay Owingeh has never received data on how the New Mexico State’s plan for managed care of our tribal members in Ohkay Owingeh will produce better health care outcomes.  Concerns with PCP’s will reside in urban communities which may be as far as 200 miles away.  Ohkay Owingeh tribal members are comfortable with IHS, they will not be able to accommodate an MCO to obtain their health care.  Our experience with Salud and other providers was that once they were enrolled you never heard from them or the services they provided were limited.  There were always delays in obtaining permission for services.  What was sad was how services were denied by PCP’s who they had never seen.  The ability for Ohkay Owingeh tribal members to opt in if the feel that their health care needs will be met is paramount.

    B.     MAINTENANCE OF THE FEE FOR SERVICE OPTION

Ohkay Owingeh requests that the Centennial Care Plan retain the traditional FFS option to compensate IHS clinics and other Indian health systems facilities for the services they render.  About 85 percent of the Ohkay Owingeh Medicaid population is FFS.  The proposed managed care system will shift the financial burden from the state to the tribes and CHS.  As much as 70 percent of revenue will leave the Indian health system as a result of the Centennial Care Plan.   Will the MCO be receiving payment when providers in the Indian Health System deliver service?.  The state at this present time allows FFS for undocumented aliens and refugees but not for American Indian individuals.  It is very difficult and time consuming when payment is being secured by middlemen.

    C.     END RETROACTIVE ELIGIBILITY

Ohkay Owingeh (tribal leaders) request that the Centennial Care Plan exempt Ohkay Owingeh tribal members (Native Americans) from the proposed termination of retroactive eligibility.  If the State of New Mexico eliminates retroactive eligibility, a huge burden for individuals may result.  If individuals are not CHS eligible they may face huge debt which will go to collections.  Paying for the cost of denial of retroactive eligibility will shift the financial burden from the state to the tribes or CHS.

In concluding, if the State of New Mexico can not accommodate Ohkay Owingeh (tribal leaders) with these three requests, then on behalf of Ohkay Owingeh we recommend that the New Mexico 1115 waiver proposal be rejected in its entirety.

Ohkay Owingeh believes that tribes should be afforded the opportunity to select Native Americans to represent them in the Native Advisory Board and the Native American Technical Advisory Sub Committee.

Ohkay Owingeh leadership concur with all our native brothers and their concerns and objections and issues with the proposed New Mexico Centennial Care Plan.

Ohkay Owingeh also supports the comments, issues, and suggestions of the panel of the tribal advisement.  April Wilkinson, Eric Lujan, Anthony Yepa, Quela Robinson


Sincerely



Governor Marcelino Aquino
Ohkay Owingeh

 

 

 

 

 

 

 

Info 15th HHS Annual Budget Consultaiton

for more information email me at nahainformation@gmail.com

 

 

The attached letter invites you to the 15^th U.S. Department of Health and Human Services (HHS) Annual Tribal Budget Consultation (ATBC) which will take place from March 6 to March 8, 2013, in the Great Hall of the Hubert H. Humphrey Building at 200 Independence Avenue, SW, Washington, DC as well as to our 2013 Annual Regional Tribal Consultations held across the country.  As in previous years, HHS will continue to work with you to improve the consultation process.  The Department understands the importance of hearing from tribes on national crosscutting issues, regional perspectives, as well as tribal-specific concerns.  Below you will find a brief description of the ATBC as well as details for the Regional Tribal Consultation sessions.  HHS will begin hosting planning calls for the ATBC on Wednesday, January 23 at 3:00p.m. EST.  Additional details are included in the enclosure.

 

15^th U.S. Department of Health and Human Services (HHS) Annual Tribal Budget Consultation (ATBC)

The consultation session will provide a forum for tribes to collectively share their views and priorities with HHS officials on national health and human services funding priorities and recommendations for the Department’s FY 2015 budget request.  We hope the consultation will provide a venue for a two-way conversation between tribal leaders and HHS officials on program issues and concerns that will lead to recommended actions. The schedule for this year’s consultation is as follows:

 

·         Tribal Resource Day: Wednesday March 6, 2013

The session is designed to give an overview of the programs, grants, and services that the Department provides to tribes.  This session is particularly helpful for newly-elected tribal leaders or others who want a comprehensive introduction to HHS.  We will also include an overview and training focused specifically on how the Affordable Care Act affects tribes.

·         One-on-one meetings with HHS Divisions: Thursday, March 7, 2013

Building off of the success of last year’s one-on-one sessions, we will once again be providing tribes’ time for one-on-one meetings to share their specific health and human service issues with HHS officials. This session will occur from 8:00 am to noon.  Officials from various HHS agencies will be available to listen and add to the conversation.  For this specific portion of the consultation we ask that you pre-register so that all tribes have an opportunity to meet with HHS representatives.  Please note that the amount of time that you are allotted to meeting with individual HHS officials will be determined by the volume of requests.  To pre-register for one-on-one meeting time, please email your request, and include the agency/agencies you would like to meet, to consultation@hhs.gov.

·         Annual Budget Consultation: Thursday, March 7 and Friday, March 8, 2013

At 1:30 p.m. on Thursday, March 7, 2012, we will begin the consultation session.  HHS will identify specific issues on which we would like to consult with tribes and will send them to you in the next few weeks so that you can prepare your thoughts, ideas, and recommendations.

 

2013 Annual Regional Tribal Consultations (RTC)

In addition to the ATBC, the Department will again host Regional Tribal consultation sessions to address how the Department can continue to improve our outreach and coordination and to discuss programmatic issues and overall concerns with tribes.  Regional sessions will include one-on-one time with the Regional Directors, as well as a tribal resource day similar to the session held during the ATBC. Additional details are included in the enclosure. Below are the dates for the consultations.

 

 

 Dates and Locations

·         February 6-7, 2013 Arlington, VA (Region 1, 2, 4, and 6)

·         March 26 – 28, 2013 Phoenix, AZ (Region 9)

·         April 2 – 4, 2013 Denver, CO (Region 7 & 8)

·         April 10 – 12, 2013 Tulsa, OK (Region 6 and 7)

·         April 22 -24 , 2013 Minneapolis, MN (Region 5)

·         May 14 – 16, 2013 Seattle, WA (Region 10)

·         Navajo Area Date TBD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Meeting regarding CMSs response to tribe's position regarding Centennial Care.

From the Center on Law and Poverty:

I write with an invitation to participate in a critical strategy meeting.  It is anticipated that within a very short period the Centers on Medicare and Medicaid Services (CMS) will make its decision regarding approval/non-approval of the state’s request for an 1115 Waiver to implement the Centennial Care Plan.  This decision will have major impact on tribal healthcare.  In meetings with both CMS and the state’s Human Services Department (HSD), the tribes have clearly stated their many objections to the plan’s design and implementation which have been communicated in direct discussion, numerous position papers and tribal resolutions.  Over the last several days tribes have called up our congressional delegation to protect their interests and on Monday state legislators, Representatives Clahchischillie, Jeff, Louis and Madalena sent a letter to the delegation supporting the tribes’ position.

 

Over many months the New Mexico Center on Law and Poverty has been acting in a supportive role to the tribal effort through the work of our health care attorneys and organizing personnel.  We want to continue to help as much as we can.  We believe that a meeting of representatives of the major tribal groups, Apache, Navajo and Pueblo, is needed so that a unified position can be endorsed that will give direction to all involved.  In addition, questions regarding the Native American response in the event that CMS gives approval to the state’s request need to be addressed, e.g. can we agree on a common response, is there legal recourse to an unfavorable decision, and if so, what are the legal resources that can be brought to bear.  The many people who have been involved in this effort over these many months are fully cognizant of the long-lasting effect of CMS’ decision and what it means for the future development of tribal health care systems. 

 

Initially we planned to have a meeting at our offices in Albuquerque but Ken reminded us that Friday, February 1, is Indian Day at the state legislature and the Apache, Navajo and Pueblo leaders would be there to address the Legislature at 11:00am.  so instead the meeting will be held in Santa Fe on Friday.  We will meet in the House majority leader’s conference room on the first floor following the leaders’ addresses to the Legislature.  The purpose of the meeting is to determine what can be done right now to convince CMS to respond to the tribes’ requests and to consider how we might coordinate our efforts to assure that the tribes secure their rights to determine the design and capacity of their health care systems.  Your participation in the meeting is crucial to the discussions because of your expert knowledge of the issues involved which needs to be shared with the leadership.  The synoptic information you can provide will be important to the decisions that need to be made regarding immediate and future response.  Look forward to seeing you on Friday.

Memorandum

    To: Regis Pecos

From:    April Wilkinson , Program Specialist, Pueblo of Jemez; Quela Robinson, Staff Attorney, NMCLP; Erik Lujan, Policy Analyst, New Mexico Indian Council on Aging

    Re:     Centennial Care Waiver
Date:    January 30, 2013

---

1. Background

On April 25, 2012, the State of New Mexico submitted its request for a Section 1115 Research and Demonstration waiver that would, if approved by CMS, result in a 100% Managed Care Organization (MCO) run Medicaid system. The state has named this plan Centennial Care.

The state of New Mexico Human Services Department (HSD) has convened several meetings with I/T/U’s (Indian Health Service/Tribal/Urban Health) to discuss the advantages of its plan. The I/T/U’s have vehemently and consistently opposed this plan. Despite repeated attempts to get HSD to collaborate with I/T/Us to redesign specific elements of the plan, the two entities have reached what the I/T/Us consider to be an impasse. Because the plan was submitted over I/T/U objection to CMS for review and approval, several tribal leaders have called on the tribal consultation policy of the CMS to compel their involvement in tribal consultation regarding the waiver.

On January 23, 2013, CMS conducted the second of two tribal consultation sessions with the I/T/Us of New Mexico. At this session, HSD staff attended and remained stalwart in the design of Centennial Care as proposed. Similarly, the I/T/U’s maintained their opposition to the Centennial Care proposal. CMS has declared that the review team will take the positions of both sides under consideration and will work to make a decision regarding this proposal,  but continues to pressure tribal leadership into delineating and accepting special terms and conditions as compromise positions. A final decision is anticipated from CMS within the next seven to fourteen days. Swift action is needed to prevent a decision from CMS on this piece of the waiver until further consultation can be held between the tribes and CMS.

2. The impact of Mandatory Managed Care and/or “Opt-out” provision for Native Americans under the Centennial Care Waiver
1. All of New Mexico’s previous attempts at mandatory managed care for Native Medicaid recipients have resulted in lost revenue to I/T/U’s
   New Mexico has implemented 3 mandatory managed care programs over the last 15 years and each of these implementations has resulted in a substantially negative impact to the cash flow to Indian Health Service (IHS) facilities, both tribal and federal:
1. In 1997, NM Medicaid began their Salud! Managed Care programs and Native Americans were automatically assigned to Salud! Managed Care organizations that didn't have facilities in tribal communities.  I.H.S. federal facilities lost an estimated $2 million dollars in reimbursements in 1998 due to this policy, but continued to provide the services to the patients.  
2. In 2008, New Mexico awarded the statewide contract for behavioral health services to MCO OptumHealth. IHS/Tribal facilities struggled to obtain contracts and payments for services from Optum.  By December 2009, New Mexico issued OptumHealth a Letter of Direction requiring immediate payment to IHS/Tribal facilities. As of March 2010, OptumHealth still owed federal IHS facilities over $900,000.
3. A more recent example is the NM Coordinated Long-Term Care (CoLTS) program implemented in 2009.  The financial systems of CoLTS contractors did not have the ability to track payments owed to providers. IHS was asked to supply monthly reports to each of the MCO’s as to what was owed with upwards of $300,000 over 60 days past due for over a year.
2. New Mexico’s I/T/U’s will once again lose revenue under mandatory managed care
   In the Pueblo of Jemez, of the patients with some form of 3rd party coverage, 50% are Medicaid eligible. When Jemez health providers treat these patients, the Pueblo of Jemez is able to recover approximately $319/patient/visit, which is called the OMB (Office of Management and Budget) all inclusive rate. Through this direct payment process, which is called Fee For Service (FFS), the Pueblo of Jemez collects approximately $1,807,504 Medicaid reimbursements annually. With those funds, Jemez pays physicians and dentist salaries and procures physical therapy, behavioral health/substance abuse, optometry, podiatry and pediatrician services to be delivered in the Pueblo of Jemez, as both a matter of convenience and to provide a continuum of care for our population. This Medicaid reimbursement comprises approximately 73% of the total annual third party revenue that we stand to lose under a managed care scheme.
   
   If a Native American receives health care through a tribal or Indian Health Service health center, the significant threat posed by the Centennial Care Plan remains the same. Recently, Richie Grinnell, IHS Albuquerque Area Director, documented the Medicaid revenue generated by various service units (SU) across the state. In FY12, over $85 million dollars was generated from serving more than 360,000 people. With these Medicaid revenues, the Indian Health Service pays for the salaries of medical providers and support staff, purchases pharmaceuticals, supplements Contract Health Services, and supports facility infrastructure.
   
3. An “opt-out” solution permits the state and MCO’s to profit from un-provided care
   Under managed care, for every Medicaid eligible patient, including the Native American, who is enrolled with an MCO, the state will pay the MCO upwards of $1700/patient/month (this is the rate paid to the state’s Behavioral Health MCO). This amount is called a per-patient per-month (“PMPM”) or “capitated” rate. This amount is paid monthly regardless of whether or not the patient utilizes or has access to the MCO’s services. In fact, the state Centennial Care contracts with the MCO’s indicate that MCO’s will share fifty percent (50%) of any profit generated in excess of three percent (3.0%) with HSD. Profits that only increase when the PMPM rate is not spent on providing services.
   
   The state has not provided any information about how Native Americans will be identified or enrolled in managed care, how the provision of services will be tracked, or how these individuals will be provided with information about dis-enrollment or how to opt out of their MCO. When MCO’s do not have offices near tribal communities, their staff cannot become acquainted with the clients and the community. This limits the MCO’s ability to provide the education or care coordination required to enroll and provide services to beneficiaries. One tribal community, Ramah, was directly affected by such a situation. In that case, the MCO assigned providers in Farmington to Ramah patients. Allowing beneficiaries to voluntarily choose the MCO and provider that is best for them (the “opt-in”) is the only way to ensure informed consent and that care will actually be provided.
3. Current position of New Mexico tribal leadership on Centennial Care
   Although I/T/Us have different needs and different health delivery systems, the entities have compromised to narrow the redesign elements to the Centennial Care Plan to the following three points:
   
1. Eliminate requirement for Native Americans to be automatically or mandatorily enrolled in a Managed Care Organization. This is to ensure that Native American’s retain their right to choose their own health care system, including the choice to “opt in” to an MCO. However, only 15% of current NA Medicaid eligible individuals have chosen to “opt in” to an MCO.
2. Preserve the mechanism for payment of Medicaid claims for Fee For Service directly between the IHS/Tribal/Urban (I/T/U) and the State of New Mexico at the existing all inclusive OMB rate. Under the current system, when I/T/Us provide a service to a Medicaid eligible patient, the state’s fiscal intermediary makes payment promptly and in full. This system is working and working well. However, the position of the MCO as a “middle man” will create payment issues and administrative burdens that are likely to delay, limit or even eliminate the I/T/U’s ability to collect the Medicaid revenue owed. This becomes an administrative nightmare when I/T/U’s are forced to seek recovery from the state every time that an MCO fails to pay the entire OMB rate (the state is required under the federal American Recovery and Reinvestment Act of 2009 to make I/T/U’s whole).
3. Require that the protection against cost sharing for all Native Americans enrolled in New Mexico’s Medicaid program is clearly written in the state’s waiver; this is regardless of whether they seek care at an IHS or non-IHS facility. Currently, HSD indicates that this issue is “understood” in the application, but the tribes continue to request its clear delineation in the waiver
4. Potential issues for further discussion with CMS

New Mexico tribal and pueblo leadership demand further consultation with CMS. To that end, several ideas for further discussion evolved from the January 23rd meeting. They are not by any means an exhaustive list and will require further vetting with leadership and CMS before they can be called any expression of tribal intent or compromise positions:

1. A demonstration project within Centennial Care as it relates to Native Americans to “test pilot” the initiative before we expose 100% of the Native American population and 100% of the I/T/Us to a full managed care system. The 15% of Native Americans currently enrolled in Medicaid managed care would be one possibility for the pilot population, or I/T/U’s could identify an appropriate population representative of the state’s composition.
2. A single I/T/U’s or group of I/T/U’s could become a managed care organization serving the entire Native American population.
3. I/T/U’s will receive part of the PMPM capitated rate provided to MCO’s for any administrative or care coordination services provided in addition to the OMB rate for services.
4. I/T/U’s will work with the state to develop a tribal specific contract for use with all clauses of contracts between the state and MCO’s impacting Native Americans, and for tribes and MCO’s to use when contracting with each other.

 

NM HIX Consumer Focused Navigator Committee

Interested in information on the NM Health insurance Exchange?  Wondering how and when it will start working?  This group does an outstanding job of educating consumers on how the NMHIX is going to affect all New Mexicans.  Paige is extremely knowledgeable about the NMHIX.



The Next Consumer-Focused Navigator Committee Meeting will be held on
FRIDAY, FEBRUARY 1st at 9:00 AM – 11:00 AM at the UNITED WAY BUILDING,  2340 Alamo Ave. SE, 1st Floor, Room 100,
 Albuquerque, NM 87106. Please note the change in location for the meeting, as the ACLU/SWLC building’s conference room remains under construction.

We had an incredibly productive Navigator Committee Meeting last week, with a wonderful discussion on community needs for New Mexico’s Navigator and In-Person Assister program. The group decided to continue that its discussion of consumer needs by specifically addressing what a “No-Wrong Door” Policy would look like in New Mexico, generally, and for particular communities, more explicitly. Accordingly, our agenda for the February 1st Meeting is as follows:

1. Update on New Mexico’s implementation of the Exchange, Navigator Program, and In-Person Assister Funding
2. Navigator Capacity Survey Distribution and Results
3. Ideas from Other States – Colorado Exchange Navigator Program
4. What Would a No-Wrong Door Policy Look Like In New Mexico?

           a.          Do different groups have different no-wrong-door access to benefits needs?
            b.          What is fiscally and practically feasible?
            c.          What aspects of the no-wrong-door health care/other benefits policy access are “must-haves”
    5. Reporting on consumer need, no wrong-door policy requests to the to the DIO/HIA.
Our Conference Call Number is:

Conference Dial-in Number: (605) 475-4000
         Participant Access Code: 658369#
Subscriber PIN code: 693195#
To complete the survey on Navigator Capacity and Need, please go to - https://www.surveymonkey.com/s/CRL2KFB
As an out-growth of the Health Care For All Coalition, we have organized the Consumer-Interest Navigator Committee Meeting to brainstorm consumer-supportive policies, lists of possible programs with Navigator capacity, and advocacy points to assist the state in developing the best consumer-friendly Navigator system for New Mexicans. If you think of other individuals who should be a part of this discussion, please let me know.

Paige



Paige Duhamel
Healthcare Staff Attorney
Southwest Women’s Law Center
1410 Coal Avenue SW
Albuquerque, NM 87104
Telephone:     505-244-0502
Facsimile:       505-244-0506
pduhamel@swwomenslaw.org

Senator Udalls office correspondence with Jemez

From Jemez:

 

 

Fern-

Thank you so much for your response. I have a tendency to be very straight forward, so I apologize if this seems a bit blunt:

1.       We want our tribal people to retain their “right to choose” their health care system and provider, not be mandatorily enrolled with an MCO. We are uncompromising on this point.
2.       What we want to work with the state, though. We see the state’s position and wand to find points of compromise. In fact, the four points, you detailed in your email was an act of compromise. Our original list contained nearly 10 items.
To that end, we are suggesting a demonstration project within Centennial Care as it relates to Native Americans to “test pilot” the initiative before we expose 100% of the Native American population and 100% of the I/T/Us to a system that we are trying to indicate is simply not going to work in Indian Country. Truthfully, we are not confident it will work in rural NM as a whole, but we are focused on our NA population.
3.       From that demonstration project and during the pilot year, we want to develop with the state a tribal specific contract- this could be for tribes to engage the selected state MCO’s or for a tribal specific MCO, which the state identifies as for I/T/Us to work with.

 

There is just a two part clarification that is important in response to your email below:

MCO’s do not align with tribal health systems-

We would be considered a provider by an MCO under Centennial Care, yes, and that is the problem. It is unreasonable to expect an MCO to not act like an MCO when it comes to tribal health centers. It will cycle our claims and care coordination through the same system of scrutiny as it would any claim from any health center. On its face, that seems reasonable. However, when you think about the fact that the MCO has specific standards of care, specific provider manuals, federal and state compliance requirements which MCO’s generally defer responsibility for to the affiliated facility and a myriad of other check points that make an MCO an MCO, you have to acknowledge that this does not align or make sense to align with a tribal health system. Now. Compound that by 5 MCOs- we would have to engage each of them.

Tribal health systems in contrast are working in rural, racially homogenous populations (in general) and with Indian Health Service in the design of shared standards of care, provider credentialing and privileging, etc.

Our systems of care, our health outcomes, our existing managed care coordination and system- all of these were not considered when Centennial Care was created. An MCO overlay on our system is an “accident waiting to happen”.

 

When (emphasis added) MCOs pay, yes, they would pay the OMB rate, but the MCO is then just passing thru the 100% FMAP the state receives from the feds, while the MCO retains the full PMPM (per patient/month) capitated rate for services for the Native American who was automatically enrolled in that MCO. However, that MCO will not be providing any services, because the NA is going to the tribal health centers. The tribal health centers are providing the services. I say this to point out that this is NOT a money saving venture, as proposed by the state.  Our elected officials must understand that.

Bottom line- Organizations of every sector get into business together for mutual benefit. In fact, Jemez is a provider under and MCO that we sought out (Lovelace), because it worked in the best interest of our business model.

From the comments above, it is clear that the benefit is to the MCO, the administrative burden is to the I/T/Us and the risk is to the NA client who can easily fall through the cracks in this system. It is happening today with the existing MCOs that the state is supposed to be managing.

Sorry for the long answer. Please let me know if you need any additional information.

April

 

 

From: Goodhart, Fern (Tom Udall) 
Sent: Tuesday, January 29, 2013 7:17 AM
To: April L. Wilkinson

 

Very helpful April, thanks.

 

Given this points:

 

1.      Eliminate requirement for Native Americans to be automatically or mandatorily enrolled in a Managed Care Organization. This is to ensure that Native American’s retain their right to choose their own health care system, including the choice to “opt in” to an MCO. However, only 15% of current NA Medicaid eligible individuals have chosen to “opt in” to an MCO.

2.      Reject New Mexico’s proposal to eliminate the retroactive eligibility for Medicaid beneficiaries. CMS heard and responded to this concern and has tabled this request from the state. It will not be approved in the waiver this time, but remains a priority issue for I/T/Us.

3.      Preserve the mechanism for payment of Medicaid claims for Fee For Service directly between the IHS/Tribal/Urban (I/T/U) and the State of New Mexico at the existing all inclusive OMB rate. Under the current system, when I/T/Us provide a service to a Medicaid eligible patient, the state’s fiscal intermediary makes payment promptly and in full. This system is working and working well. However, the position of the MCO as a “middle man” will create payment issues and administrative burdens that are likely to delay, limit or even eliminate the I/T/U’s ability to collect the Medicaid revenue owned.

4.      Require that the protection against cost sharing for all Native Americans enrolled in New Mexico’s Medicaid program is clearly written in the state’s waiver; this is regardless of whether they seek care at an IHS or non-IHS facility. Currently, HSD indicates that this issue is “understood” in the application, but the tribes continue to request its clear delineation in the waiver.

 

It’s my impression at the current time that all providers in NM (including tribal providers) would be considered part of an MCO, so that tribal members can continue to go to any provider they choose. That retroactive eligibility is likely. That the OMB rate is the default rate for tribal providers. And we can definitely request that cost sharing for Native Americans be clearly written into the terms and conditions.

 

If CMS approves the Centennial Care waiver, we can also request language to evaluate: the coordination of care under Centennial Care for Native Americans, an assessment of the cultural competence of care coordinators, and prompt payment to assure no negative fiscal impact on tribes under this model.

 

Anything else to include for consideration in terms and conditions?

 

Thank you for your thoughtful review of the application regarding the needs of tribal members.

 

Best,

Fern

What really happened today 1/28/13

There was a lot of confusion as to wether or not there was a teleconference today and with whom it was with.

 

 What I have been able to find out about the teleconference: 1) there is not one scheduled; 2) last in a conversation with Regis (NM Legislative council services), Kim Posich (Center on Law and Poverty) commented that he would like to put together a teleconference with the congressional delegation and tribal leadership. Apparently Regis thought that it was already arranged.

Then last week, Kim did mention that Regis would convene the NM legislators to converse with the congressional delegation.   Regis asked me (Evelyn) to write a letter for the NM legislators to sign and which would be sent to the congressional delegation. That was done and in the letter there was a statement that informational statements were being prepared by tribal personnel and advocates and that this information would be sent directly by those individuals which is what was asked for in emails to you, April, Anthony and Maria. The addresses for recipients were not organized and there was question about Udall and Grisham. 

What I can discern about what is happening today is: 1) no teleconference 2) we still need to get the statements into the congressional delegation. Here is a list that I can put together from correspondence. Let’s call a meeting to work out our organizational structure so that we are assured that everyone gets the same info all the time. 

 

Evelyn

 For those Tribal Programs and Advocates with position papers here is the list of individuals to send them to

 

Senator Udalls office

fern_goodhart@tomudall.senate.gov

Michael_Lopez@tomudall.senate.gov

 

NM Legislative Council Service

regis.pecos@nmlegis.gov

 

Senator Heinrichs office

katie.richardson@mail.house.gov

Sandra.Wilkness@heinrich.senate.gov

JanelleFrederick@heinrich.senate.gov

 

congresswoman Michelle Lujan Grisham

Tiffany.Fiser@mail.house.gov

Deborah.armstrong@mail.house.gov

NMICOA HC comments for CMS/Congression teleconference on 01/28/13

January 25, 2013

 Kitty Marx

Director, Tribal Affairs Group

CMS

Robert Nelb

Project Officer, NM Waiver

CMS

 Members of the New Mexico Indian Council on Aging Health Committee (NMICoA) were present at the Centers for Medicare and Medicaid Services (CMS)/Tribal Consultation meeting at the Albuquerque Bureau of Indian Affairs (BIA) Building on January 23, 2013.  We had assumed that this meeting was between CMS and the Tribal leaders and their representatives including Tribal health organizations and programs.  We thought that the presence of NM Human Services Department (HSD) and Medical Assistance Division (MAD) were not necessary at the meeting.  The presence of Managed Care Organization (MCO) representatives was also unnecessary and we question who invited them, certainly not the Tribes.

We presented a brief commentary regarding the concerns of Pueblo Seniors since the inception of CoLTS (Coordination of Long Term Services) in late 2008 and its phase-in during 2009.  This mandated automatic enrollment of our Pueblo seniors into managed care.  Seniors were told to choose between two contracted MCO’s:  Amerigroup or Evercare.  Patients who did not select one were assigned by algorithm. 

Initial concerns of the NMICoA Health Committee were expressed at a meeting with HSD Secretary Pam Hyde, Rep. Carolyn Ingrahm, Aging and Long Term Services (ALTS) Secretary Cindy Padilla and Indian Affairs Department (IAD) Secretary Alvin Warren.  These concerns included the lack of Government-to-Government consultation with loss of Tribal sovereignty when the state mandate to enroll Native seniors encroached on Tribal boundaries.  It was the consensus of the Committee members that Pueblo seniors were right to question the State Mandate.  The Pueblo seniors felt that this mandate should have been from their Pueblo Governors after meaningful discussion and consultation with the NM Governor and HSD.  No such discussion or consultation has taken place to date.  The Pueblo seniors and Health Committee also believe federal protections and the federal/tribal relationship overrides the state Tribal relationship.

The Health Committee also identified specific examples of patients having difficulty accessing care when contracted transportation companies (Logisti-care and Access-to-Care) both located out-of-state did not orient clients in the use of the 1-800 system.  This was problematic because many patients did not have land lines or cell phones.  Further, sub-contractors were, in many cases, unable to locate reservation dwellings of patients, thereby leaving patients to find alternative means to find access to clinics, hospitals or other relevant services. 

The use of the algorithm to enroll patients in some instances even had a married couple enrolled separately with the husband in Amerigroup and the wife in Evercare.  This couple could not understand why one had easier access to certain services and the other had different value added services.

Issues with the Personal Care Option (PCO) were also expressed, with problems arising with lack of timely communication by service coordinators, lack of local providers and, in some cases, lack of oversight of the PCO and its employees by the MCO and HSD.  In one instance, a non-tribal PCO and Non-Tribal PCO worker violated their contract when the PCO worker absconded with a Pueblo senior’s personal property and traditional clothes.  One of those items, a traditional drum, was found listed for sale on eBay.  This problem was reported to the MCO and its Quality Assurance Department as well as the HSD’s quality assurance manager.  No resolution of this problem has been completed after four months.

Continuity of Care issues have also plagued the CoLTS Program.  For example, if Pueblo seniors are referred for services outside the Indian Health delivery system, patients are lost to follow-up. Pueblo seniors referred for specialty services often lack post-discharge services because of lack of coordination between non-Native providers and Native providers.  In some cases, medicines are not available at an Indian facility and the patient is unable to fill the prescription unless they return to the discharging facility, possibly several hours away.  Many modern medications may not be available at Indian facilities, since communication between the Indian and non-Indian pharmacies has not been updated.

These are but a few of the many problems arising from mandated managed care enrollment of Pueblo seniors into CoLTS program.  We have seen NO definitive date or proof that mandated care has diminished health disparities in Pueblo Country.    

The Health Committee understands the lack of understanding of the CoLTS program with Pueblo seniors mandated into MCO’s.  Centennial Care is now proposing mandated inclusion of pueblo seniors into MCO’s!  This will only increase problems, most likely by a multiple of five. 

As in our commentary of January 23, 2013, at the CMS/Tribal meeting, we stand in opposition to the 1115 Research and Demonstration waiver, Centennial Care Plan.  This plan violates the American Reinvestment and Recovery Act (ARRA), Patient Protection and Affordable Care Act (PPACA) and Indian Health Care Improvement Act (IHCIA) exemption of mandatory MCO enrollment.  The waiver seeks authorization to violate Federal Law on behalf of Tribal governments without their consent. 

The NMICoA Health Committee also objects to Centennial Care proposing to eliminate the fee-for-service reimbursement program to HIS and Tribal providers.  The Health Committee also does NOT support the elimination of presumptive (retroactive) eligibility.   

We understood that CMS officials at the January 23, 2013 meeting would take these concerns back to the Baltimore CMS officials for further deliberation until which agreement by Tribes/Pueblos/Nations of NM occurred to make New Mexico’s 1115 waiver more agreeable to all parties concerned and involved in this impactful process.