Senator Bingaman's health policy analyst interested on pueblos comments on Medicaid

Hi everyone,

We’ve recently spoken with Sandra Wilkness, the new health policy analyst replacing Frederick Isasi in Senator Jeff Bingaman’s office, about the state of the Medicaid redesign and health care reform in New Mexico. When we explained our issues with Centennial Care, she stated that she wasn’t familiar with the issue of moving Native Americans into managed care and that she hadn’t heard anything from the tribes or pueblos. She was said that she’s very interested in hearing about these issues, and it would be good to keep her in the loop about whatever you contact CMS with. They might have some pull with CMS. She can be contacted by email at sandra_wilkniss@bingaman.senate.gov, or by phone in the DC office at (202) 224-5521.

Best,

Quela

Comments from Jemez Pueblo re: CMS 1115 waiver tribal consultation guidance

The Pueblo of Jemez does not believe that NM Medicaid met the requirements described in your email because the submitted application does not contain documented proof. It also does not contain responses from the tribal governments, only a few discussion notes.

The Pueblo of Jemez also believes that that the Centennial Care Plan submitted by the State of New Mexico should be identified by CMS as a policy that has tribal implications and a substantial direct effect on Indian Tribes or on the relationship between Tribes and the Federal Government, specifically Medicaid funding, thus compelling tribal consultation.
According to the (CMS) Tribal Consultation policy: “…policies with Tribal Implications refers to regulations, statutes, legislation, and other policy statements or actions that have substantial direct effects on one or more Indian Tribes, on the relationship between the Federal government and Indian Tribes, or on the distribution of power and responsibilities between the Federal government and Indian Tribes.”

Therefore, we submitted the attached letter to CMS formally requesting tribal consultation. Now, I want to make sure that everyone knows- Jemez in no way intended to “go ahead” of the other tribes. Instead, we just wanted a formal letter to be submitted so that CMS is compelled to respond. In that way, we can delay the approval of the Centennial Care waiver request and buy time for other tribes and tribal organizations to get their tribal leaders to formally weigh in. This is also reflected in the attached letter.

Unfortunately, we worker bees cannot exercise the right to consultation, only tribes/tribal leaders can. It is our opinion that time is of the essence and that some formal request needed to be submitted to CMS. We are hopeful that there are similar letters to CMS coming from tribal governments across the state.

CMS Guidance letter on Tribal Consultation for 1115 Waivers from July 2001

Subject: CMS Guidance letter on Tribal Consultation for 1115 Waivers from July 2001

CMS guidance requirements for states submitting 1115 waivers. The link is here:

http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/smd071701.pdf



Therefore, in reviewing all Section 1915 and Section 1115 waiver requests submitted after October 1, 2001 CMS will look to see that
1. All Federally-recognized Tribal Governments maintaining a primary office and/or major population within that State are notified in writing at least 60 days before the anticipated submission date of the State's intent to submit a Medicaid waiver request or waiver renewal to CMS.
2. The notification describes the purpose of the waiver or renewal and the anticipated impact on Tribal members. The description of the impact need not be Tribal specific if the impact is similar on all Tribes.
3. The notification also describes a method for appropriate Tribal representatives to provide official written comments and questions within a time frame that allows adequate time for State analysis, consideration of any issues that are raised, and time for discussion between the State and Tribes responding to the notification.
4. Tribal Governments were allowed a reasonable amount of time to respond to the notification. A minimum of 30 days is considered reasonable.
5. States, if requested by the Tribal Governments, provide an opportunity for an in-person meeting with Tribal representatives. A State does not need to have separate meetings with each Tribe, but may conduct one or more joint meetings with Tribes to discuss issues.

CMS will look to see that States have utilized these guidelines by looking at copies of correspondence sent by the State to the Tribal Governments notifying them of the State's intent to request a waiver or waiver renewal. Copies of any correspondence submitted by Tribal governments, and a discussion summary from any formal State-Tribal consultation meeting(s) as described in number 5 above, will also aid CMS's review of the proposed waiver or renewal request.

Thank you center on law and poverty for the information

Albuquerque journal article regarding MAC

From today's abq Journal:

Medicaid Plan Under Attack

By Winthrop Quigley / Journal Staff Writer on Fri, May 18, 2012


SANTA FE – New Mexico hospitals are worried about losing millions of dollars in revenue. Tribal officials are worried about losing sovereignty and money. Advocates are worried the poor will lose services.
Dozens of health care providers, Medicaid beneficiaries, insurance company officials and representatives of state and tribal governments and nonprofit agencies on Thursday aired those concerns about the state Human Services Department. Specifically, they were talking about HSD’s 104-page application to the federal government, submitted in late April, to overhaul New Mexico’s $3.9 billion Medicaid program, which serves 560,000 people.
Even though about two thirds of Medicaid funds are provided by the federal government, HSD officials say the program is expected to consume about 16 percent of the state’s general fund this fiscal year, up from 12 percent last year. Such growth could force cuts in other state services, they say.
HSD says its plan, called the Centennial Care waiver, will streamline administration of Medicaid, improve quality of care, allow more people to receive services and reduce costs by $453 million over five years. HSD started outlining its overhaul conceptually last June but the first public input on the resulting application occurred at Thursday’s Medicaid Advisory Committee meeting.
Participants generally praised HSD’s plans to help Medicaid recipients get better care through better patient education and programs to coordinate care among several providers. State officials were not able to provide many of the implementation details audience members were seeking.
New Mexico Hospital Association president Jeff Dye estimated one proposed change could cost Albuquerque’s major hospital systems $48 million a year in lost revenue. The state’s Department of Children, Youth and Families issued a statement opposing the change to what is known as retroactive eligibility because it would interrupt health care over administrative hiccups.
Today, people eligible for Medicaid who haven’t enrolled are allowed to enroll retroactively after they’ve started receiving care. Not allowing them to do so would leave hospitals with unpaid bills. CYFD said recipients are often removed from the rolls because of administrative problems that can be quickly resolved, but recipients, most of them children, lose care in the meantime.
Jemez Pueblo Gov. Joshua Madalena and Roselyn Begay of the Navajo Nation Division of Health both opposed plans to require Indians to receive Medicaid benefits through managed care organizations. Today Medicaid provides fee-for-service payments for Indians’ care.
Earlier HSD proposals would have allowed Indians to opt out of managed care, but officials said Thursday the waiver application requires tribal Medicaid beneficiaries to be enrolled in managed care programs.
Begay said managed care organizations would not provide adequate service on remote reservation lands. Madalena said Jemez’s own health system delivers care using fee-for-service payments to supplement costs.
He blasted state officials for failing to include pueblo representatives on the Medicaid Advisory Committee and said the state did not adequately consult with sovereign tribal nations.
“Outreach to Native American communities does not constitute consultation,” Madalena said.
Jim Jackson of Protection and Advocacy Inc. asked if the state would surrender saved money to the federal government or use it to improve and expand care. “There are still a lot of crucial details not spelled out yet,” he said.
Medicaid director Julie Weinberg told the Journal in an interview, “If we can bend the cost curve and do things we haven’t been able to do, I’m just speculating, but it gives us an opportunity for the department to invest in health care in Medicaid. We don’t want to make a decision on what we want to spend money on now.”
Providers and health plan officials said they don’t have the tools they need to execute some of the state’s quality improvement ideas.
New Mexico Primary Care Association executive director David Roddy said many primary care providers don’t have a way to coordinate care for patients and don’t have the information about patients they need.
Mary Eden of Presbyterian Health Plan said insurers have claims data but only medical providers have patient records necessary to improve care. Joie Glenn of the New Mexico Association for Home and Hospice Care said there are 18,000 people waiting for long-term care services through Medicaid but no one knows what needs those people have or even if some of them are still alive.
Dye said hospitals would have trouble collecting proposed copayments of up to $50 when Medicaid recipients use emergency rooms for non-emergency conditions and that the copayment would do little to reduce inappropriate emergency room use.
Dale Tinker of the New Mexico Pharmacists Association applauded a proposed $3 copayment for brand-name prescriptions when generics are available, but Doris Husted of the Arc of New Mexico warned that many generics do not perform as well as brand name drugs, especially psychiatric medications.
HSD said it will form working groups to hammer out details and differences. The agency said it hopes to have federal approval of its application this summer.
— This article appeared on page A1 of the Albuquerque Journal

MAC special meeting re: Centennial Care

At today's meeting there were a few new points brought up regarding, duel eligibles, Small fee for service component, in home health aids, reduction in the waiting list for HCBS, but nothing big in the way of changes that will effect tribes.

Navajo MAC committee member did again express Navajos' objection to the mandatory enrollment into managed care and the loss of fee for service/opt out category for Native Americans

Several other MAC committee members did express need for more outreach/education/consultation to tribal communities.

Governor from Jemez read a statement about lack of consultation, the rights of pueblos and tribes as sovereign nations, and the lack of a pueblo representative on the MAC. Many MAC committee members agreed and seconded his statement. I would like to thank the Governor for his words on behalf of the Pueblos.

Oportunity to Testify before the Legislature

I received a call this afternoon from Michael Hely with the NM Legislative Council Services expressing desire for myself and/or other members of the Work Group to testify before the legislature HHS committee on June 25th regarding HSDs consultation process surrounding the development and implementation Centennial Care. We will be given an hour for a presentation and Q&A from legislature. So we need to come up with people to present I can present major points but I think we will need a tribal leader there to enforce the lack of consultation points and someone within a tribal health program.

Any volunteers?

Erik

RFP Media release on the Health Insurance Exchange

HSD Email Logo
Susana   Martinez                                                                                                               
Governor
 
Sidonie Squier
Secretary
 
Media   contact: Matt Kennicott (505) 827-6236 or (505) 819-1402
matt.kennicott@state.nm.us <mailto:matt.kennicott@state.nm.us>  
 
May 10, 2012
For Immediate Release
 
HSD   Selects Contractor to Assist in Exchange Development
 
SANTA FE -   The New Mexico Human Services Department (HSD) has selected, through a   competitive RFP process, Leavitt Partners to assist with grant applications,   technical aspects, and overall development of a state based health insurance   exchange (HIX) for New Mexico.
 
"This is a good step forward for   New Mexico as we continue to develop a state based exchange," said Human   Services Department Secretary Sidonie Squier. "The firm brings first-hand   knowledge of how to build and operate an exchange. I look forward to working   with the top notch talent and expertise that Leavitt Partners will bring to   the table during the course of this engagement."
 
"New Mexico's   commitment to establishing a market-driven insurance exchange demonstrates a   willingness to apply a state solution to a long-standing problem," said Mike   Leavitt, founder and chairman of Leavitt Partners.  "We look forward to   working with Secretary Squier and her team."
 
The contract   period will begin immediately and will last for the next twelve months.   Leavitt Partners will be assisting HSD with the main components of developing   a state based health insurance exchange. Leavitt Partners will be assigned the   following tasks:
   
·         Developing a strategic   plan and implementation activities to include further stakeholder   consultation, health insurance market reforms, and business operations of the   exchange
·         Assist with the   planning and development of an application for grants to the US Department of   Health and Human Services (HHS)  
·         Assist with the   development of rules, regulations, and policy governing the HIX  
·         Assist in preparing   reports and materials required by HHS pursuant to the Level 1 grant award  
During the New Mexico engagement, Leavitt Partners will leverage the   experience they've had in other states with similar challenges to help develop   the best path forward.
 
About Leavitt Partners
   
Leavitt Partners is a health intelligence business. Its Health Insurance   Exchange Intelligence Team advises states, health insurance payers, technology   vendors and trade organizations. The team includes individuals who have led   significant portions of the federal government's health financing and   regulatory system, as well as those who have been on the cutting edge of state   health system reform. This deep background in understanding the policy issues,   technical requirements and infrastructure associated with operating an   exchange provides critical support for exchange development.
   
###
 
 
   
------------------------------------------
Matt Kennicott  
Communications Director | New Mexico Human Services Department | Office of   the Secretary
O: (505) 827-6236 | M:(505) 819-1402

Upcoming Meetings/events

As most of the Workgroup members have agreed the time for complaining about of lack of consultation with the NM Human Services Department is over,  however there are still a number of opportunites for colaboration with non-Tribal entities.  The HSD is also keeping the Legislature, other departments and MCOs, providers, in the dark about the details of the 1115 Demonstration and research waiver, "Centennial Care"

May 17, 2012 Medicaid Advisory Committee (MAC) Santa Fe NM, State Library 9AM- 12PM

May  24, 2012 NMICoA Health Committee Regional Meeting Taos Pueblo, Senior Center 10AM-12PM

May 29, 2012 UNMH Discussion on alternatives to "Centennial Care" with CEO Steve McKernan UNMH
Time 9AM Location TBA

June 8th Tribal workgroup Stradegy session at Kewa Health Corp.

June 25th Legislative interim Committee LHHS
Santa Fe Round House
Room 307
2:00 PM

Mr Joseph Ray from NAIL will be taking my place on the Agenda as I will be out of Town
Governor from Jemez is going to speak about Lack of Tribal involvment and Consultation with HSD
I still need a Tribal Program/Clinical Director, Healthboard member to speak about affects on Tribal health programs.  I also want to get as many Native Americans recipients of Medicaid and Tribal Leaders there as possible



I will continue to add meeting info as I receive it.

Comments from Jemez

I have three bits of information to share with the group:

First, Ken Reid asked if there are any Governors that are available to address health care issues at the upcoming meeting of MAC. Right now, our Governor, Joshua Madalena, plans to attend the meeting on the 17th. Are there any other Tribal Leaders coming?

***Special MAC Meeting on Thursday May 17,2012 at the Garrey Carruthers State Library from 9:00 am to 11:00am. The sole purpose of this meeting is for MAC Members to provide comment on the New Mexico Centennial Care Section 1115 Demonstration Waiver.

Next, Governor Madalena has also agreed to send a formal request for tribal consultation to CMS regarding  the Centennial Care Plan. We are developing this right now. Once this is complete, we will send a copy to the group. We have revised our position paper, as well, so I will get that out to you.

Finally, Jemez had yesterday what can be described as a “robust” discussion with Julie Weinberg, Alicia Smith and Teresa Ballenger. The discussion initially focused on the tribal vs state position regarding the Centennial Care Plan. In the end, we were all clear that the State intends to push forward, and we (tribes) intend to speak directly with CMS and challenge it, so no change.

However, an interesting opportunity was presented by Alicia Smith. She indicated that though the waiver application has been submitted, negotiations will be 6 months or more. She asked if we would be interested in developing an alternative plan for Native Americans. When we asked if that plan will be submitted as an amendment to the current application, the answer was possibly. So, I explained that I would bring the request to the workgroup to discuss.

I think that at the end of the “robust” discussions, the State reps felt that we (tribes) have valid and compelling issues that will influence the decision making with CMS. We did ask them to amend the submitted application now, indicating that Native Americans will retain their “opt out” status while we work through this. That is just not going to happen.

My thinking is that they are going to have to come up with an alternative for NA’s anyway for many reason, but one is I believe that CMS will ask that they get back to the table with the tribes. I want us to be part of any development of any program for NA’s. Of course, once we decide if this is an idea we want to pursue, we can meet and brainstorm and then meet with the State with our ideas. We will have to get to agreement before the State will modify the State application to CMS.

I want to notify you all now that the State made reference for how Jemez could be identified as a pilot sight, etc. Our team indicated that we want a policy change at the State level, not for the State to do for one tribe. We were clear that the workgroup made up of many diverse tribal reps intends to push forward together.

I hope we do continue to push forward together. Please let the group know your thoughts.  I look forward to hearing from you.

April

Comments from Mr. Wayne Lahi

May 4, 2012

At this morning meeting there was a lot of very good dialog and participation. We had some new players, which is good. I would like to share my comments and thoughts to this process that we are undertaking.

Communication:

·         To the tribal leaders on this topic for unity and voice as one. Several tribes are submitting their position papers individually. More leverage as a group.

·         Educating Communities which is going to impact them.

·         There has to be representation, if the leadership are unable to attend, that written designation letters be drawn appointing their representatives. State and Federal only recognize leadership for discussion and input. Nothing against tribal leaders however they generally don’t stick with the topic at hand, and voice other matters. Which in my opinion sends mixed messages and has an appearance as griping session(s).

Implementation:

·         I am aware it is very difficult and/or next to impossible to develop a single position paper with input from all tribes. As stated in yesterday’s meeting “Who is going to lead?” As stated above submission of individual positions separately does not signify unity. Would it better to read one position paper? Are these positions saying the same thing or are they specifically addressing their own concerns?

·         I would think that tribal resolution from each tribe to support “only” one support letter, with input from all tribes, would have clout.

Tribes:

·         Larger tribes have a bigger voice than much smaller tribes.

·         Urban’s are the largest population which is also going to get impacted by this. How are they going to be counted or represented? As with other tribes which are developing their position papers, what about the urban population?

·         There should be representation from AIPC and AAIHB at these sessions.

·         Navajos, Jicarilla and Mescalero are undoubtedly looking out for themselves.

Tribal MCO’s

·         This would greatly benefit tribes that are managing their own healthcare through P.L. 93-638 etc. What would it take to be identified as an MCO?

·         Are current tribal health center big enough to qualify as an MCO?

·         Would services be open to native Americans or to everyone?

·         Would services be offered to patients with some sort of alternate resources? What about the ones that don’t?

·         Agreements would need to be developed with much larger health facilities i.e. Lovelace etc. for services that cannot be provided at the tribal health facilities.

State:

·         The state has developed Centennial Care for implementation and my perspective is that we should have started this a while back.

·         As stated that CMS will make the final decision regarding this. Again, it would only make sense to submit a “Single” position paper endorsed by all tribes instead of individually. As stated “It only makes sense to read one document” instead of many.

I am in support of want needs to happen and will do my part. These are my thoughts that I would like to share.

Thanks you

Meeting notes from May 3rd Strategy session

NMICoA Health Committee

Notes on Medicaid Modernization Strategysession

Kewa Health Corporation

May 3, 2012

Mr. Yepa group discussion leader

Group gave Introductions

Anthony Yepa KHC
Colinda Garcia Acoma
Paul Fragua Jemez
Ana Jaramillo Isleta
Erik Lujan NMICoA Health Committee
Ron Lujan NMICoA Health Committee
Leonard Montoya Ohkay Owengeh
Joseph Ray NAIL Laguna

Other members present, I apologize I donot have a copy of the sign in sheet.

State Corporation commission has nojurisdiction over Tribes due to Sovereignty unique to Kewa Corp.  They have their own bylaws own employeepolicies.

Section 1115 research and demonstrationWaiver “Centennial Care” was submitted by the State of NM on April 25^thto CMS.  Language is similar to conceptpaper. The Waiver can be found on the NMHSD website www.hsd.state.nm.us 

The state has sent first pitch to CMS,HHS hearings happened last week many tribes had one on one visits with HHSdelegation. Kewa comments were mostly on Centennial Care, telling momma and dadthat our sister, the state, is not following Federal Laws.  We as tribes do have a right to go directlyto CMS; we also need to work with the state on some of these things.

Our basic presentations was okay Statego over some of the federal laws are already in place (ARRA, IHCIA, PL 93-638,Public Health Service Laws, Snyder Act)

Health care is and will always be afederal relationship/responsibility. 

IHCIA allows for 638/CHS funds to beused on dialysis and Long Term care. Congress spells out what tribes can use funding for. All of theseprovisions are what provides us with the legal basis for providing services inour own communities.  Hardest part forState and MCOs to understand.  One majorpart of ARRA is that we cannot be mandated into an MCO, but on page 21 (Waiver)tells you that there will be mandatory enrollment in an MCO.  This will create conflict for ourcommunities, if all the tribes have different positions then they’ll enjoy that(State) because nobody was together, we are here because we at least feel thatwe should be speaking in one voice, on the same page, we may have differentideas on how to approach.

 Kewa main message to CMS/HHS was thatthe state is not acknowledging Federal laws they are going to go ahead andignore the ARRA where it says we do not have to enroll in MCOs.

 At the same time there are some goodthings about Centennial Care but it takes planning to figure out. Waiver opensthe door for Tribes to be MCOs.  TheFederal requirements for federally operated facilities are coming out soon.

Time for Philosophical discussions astribes is over i.e., no consultation, the horse is out of the barn, the statehas thrown the first punch it’s now up to us to either give a counter punch orride the storm out.

Comment: Health committee has been following the MCO argument since 2008 CoLTSmandated that everyone be included in MCO, 180 degrees form Salude start of the Opt out category, elders asked whyis state telling us what to do not Tribes. Overall umbrella for Health care isthe Federal government they are obligated through stated federal laws and we feelthat the state is sort of infringing on that sovereign status that Tribes haveby saying that you are going to me mandate to join whatever MCO we decide.  CoLTS inclusion into Centennial Care willmake elders start at ground zero again with a new MCO. We are here to figureout the next steps that Tribes need to take together.

Comment: Paul Fragua 10 yrs on Jemez health board

Need to take action since the waiver hasalready been sent.  United approach isneeded.  Around HHS table was triballeadership and only they were allowed to speak. I have been in health carefield for 10 years yet am not allowed to speak. There are many people who workon these subjects that should be allowed to speak.  Difficult to get/keep Tribal leadershipinformed on the every changing subject of healthcare.  How do we gather all the tribes and differentgroups, AIPC NMICoA so that we do have a unified voice? And then take toHHS/CMS how do we get our leadership informed to take this message to State andCMS.

When it came to long term care Jemezwanted to start a PACE (program of all-inclusive care of elders) but found outdue to State regulations we couldn’t do it no matter how much we were preparedfor it.

How are we going to proceed?

How many tribes have taken action or whois taking the lead. 

Those are probably those who are 638already, other are still IHS direct services tribes will defer to IHS; theycannot speak on behalf of the Tribes.

 IHS needs to come up to par, and developcomparable health plans.

How do we package communication piecesand showcase programs that work.  Bringon trends on self governance for those who are direct service tribes, to showhow Waiver will eventually impact them. They might not be heading towards 638 now but maybe in the future they willand they need to support this effort now so that they will be able to takeadvantage in the future. 

Dollar bill example, start with onedollar and show how much goes to administration at each delivery.

Wayne Lahi:  IHS vs. 638 how many are still directservices now.  Will IHS will be around inthe future, with how many tribes are “638”ing more services I don’t know.  Most tribes are taking ownership of healthcare, Santa Fe Hospital Service Unit, Santo Domingo taking shares out.  IHS services based on out of hospital, andTribes are basing on community. 

 Change in leadership big issue, not alltribes are not represented, Tribal leaders spend half of their time beingorientated on their official duties.  Idon’t see my tribe represented (Zuni) we have a service unit.  National poverty levels big impact on healthcare. Funding from IHS to tribes is based on population and needs to bereviewed because when congress appropriates funds they go mostly to Area officeadministration, before it gets down to tribes they take their shares.  What comes to tribes and 638 facilities ispractically nothing. Populations rise and fall but funding does not follow theusers, and if you look at the mechanisms there patients are counted once, theyshould be counted every time they come in for services.   If we are going to be looking at this fromthe Tribal perspective then we need to be looking at the funding cost is toohigh compared to funding from IHS. 

 All tribal leaders need to be involvedbecause that’s really gonna make it happen resolutions.  Leadership need to be educated, as well ascommunities. This is too big for just this group to handle alone. Need to comeup with a document to say how to get from point A to B.

 Leonard Montoya:  No matter what tribe we came from we all camefrom IHS.  As IHS s revenue began toshrink so did services, then Tribes started taking ownership and left the restwith less resources and turned us against each other and IHS.  IHS doesn’t do a good job of informingTribes.  Now we are trying to fight theState, 50% of Tribes are still with IHS, but even the 638 tribes are still withIHS because of Inpatient funds.  We stillneed to protect IHS because of those inpatient reimbursements.  We need to push IHS to provide more services.

 IHS was at consultations but commentswere not taken by state, State decisions are impacting IHS.  Centennial Plan is no different than Salud,we are wasting time going back, and we need to take what worked from Salud.

 Anthony Yepa: It’s all aboutcommunication, we are talking about unified leadership coming from all of you,but if you look at the biggest tribe it’s the urban so just keep that in mind.People do pay attention to population size. Politicians look at these things. We need to have one position from AIPC, we need authorization fromsomebody or it doesn’t matter. The game plan needs to be getting anauthorization through AIPC by a resolution, saying that as pueblos we all agree.  We need to get on the Agenda, talk to HealthCommittee. Get a resolution in one statement from all tribes to CMS.  After that demand a meeting with CMS, becausethey are open to that.  They need to knowthat we know what we are talking about. Let those who understand go to CMS tocommunicate directly.  We may not all bein agreement with every little provision of the new law but we all need toacknowledge that we have commonalities with each other on what should. 

Ron Lujan:  Work with Ten Southern and Eight Northern governor’sorganizations get them to understand the concepts of Centennial care digest theinformation and get them to take it to AIPC. We discussed it after the March 20^th meeting with Acoma andSanta Ana, lets develop a position paper leading to a resolution for AIPC fromgrassroots up, then the overall AIPC can make an informed vote.

Yepa: position papers have gone out,been shared within this group including the elders position from NMICoA HC andcenter on Law and Poverty.  That’s who westarted, sooner or later, the leadership will say “oh I need to take it to mycouncil” someone (leadership, State) needs to make a decision.  PPACA implementation is just around thecorner.

 Erik Lujan: State Tribes have untilJanuary 2013 to make the decisions on Centennial care, the RFPs for MCOs willhave to be accepted and signed off on and implementation will have to start, wehave until then to come up with a response to what “we want” versus “what theygive us”

 Yepa: Jemez and Kewa will probably bethe ones to start and carry the issue.

Wayne: Urban are mixed between NM andAll Tribes nationwide.  We need to lookat economic issues surrounding urban and how are those people going to beenrolled and represented.  State and Fedsonly listen to Tribal Leaders. Leaders don’t focus on subject matter. We needdesignation letters for experts to take part in discussions.

Yepa: it takes time and energy to do these things to go to all theseplaces.  There are good things incentennial Care like the “Medical Homes” concept, but right now we are lookingat the bigger picture, like sovereignty issues and Fed law.  Implementing Centennial Care is going to be abig issue with reenrollment finding new providers, etc. we have people who knowwhat’s going on and what the hardships for individuals are going to be (CHR,social workers, business offices).  Thirdparty payments are crucial how will the changes affect us.

Paul Fragua: Are there some major pointsthat all the Tribes can agree on, so that we can move forward with a resolutionand discussions with CMS?  I like to setthis up with history how we got here, starting with Snyder Act.  Take all position papers and make a commonpaper out of all of them so that we can take to the overall Organizations.  This is going to take a lot of work who is goingto take the lead on project and then who takes to the organizations?  We need a couple of champions withinleadership to push position into governing organizations, councils.

Leonard Montoya: We are creating atribal resolution from Ohkay Owengeh with the councils support to take to EightNorthern.  Then they take message fromthat same group to AIPC  that way if theleadership says “I need to take it back to my council we can say no yourcouncil already know and approves”. 

Paul Fragua: our position paper wasdeveloped by staff not the heath board, I want to look at it so that I can takeit to Council and then to Ten Southern. 

Leonard Montoya: the State has beenmeeting individually with Tribes hoping that separately they don’t know what weare talking about, so they have a chance to meet with a tribal leader who maynot know a lot about Medicaid and Health Care. This they can get a leader to sign off and show support. By educatingthe leaders we can stop this from happening

Yepa: the Law is on our side PublicHealth Law, Social Security 18&19, PPACA, ARRA, 

What are most tribes in agreement with?

Tribal Specific details need to be addedthen.

Colinda Garcia: Part of the challenge isall the issues and concepts we are raising on how to move forward are all goodhowever who is going to do this?  Andbring to the Councils and AIPC.  We allhave vested interest in how and what the State is going to do but we don’t haveany action steps in place.  The state hasalready sent the waiver it is going to happen while we are still talking aboutit.  How are we going to continue to movewithout these meetings taking place? 

Yepa: talk is over its time to act, butwho among us is legitimized to do this? Without April leading the last effort the work group probably would nothave happened, so who is going to carry this? I can come up with information but until my health board Okays it I cant act.

Ron Lujan:  what about the mini block grants can weaccess funds to help push this group forward?

Erik Lujan: not in the time frame we arelooking those will be available only after the MCOs have been chosen and theRFPS are approved

Yepa: We need to look at outside organizations too like what the MedicaidCoalition, we have common issues to see how they can we help.  Timing is not right yet for grants.

Ron Lujan:  We need a plan for after (the resolution andtalks with the State and CMS) like having a Carve out for Native Americans totake advantage of 100% FMAP or having our own MCO. 

Yepa: that was one of our points butthat is a larger problem that we can’t change currently.  The block grants are vague in the Waiverintentionally because they are just a concept or an example; they don’t evenknow how they are going to structure them or who is going to administer them.

Erik Lujan:  The State wants the MCO’s to develop andimplement the Block Grants and then decided who gets the grants.  We need to know which MCO would be willing towork with us on our terms.

Ron Lujan: we are going to Taos topresent Centennial care to Elders, they asked for us to educate them on thechanges.

Yepa: You can know everything you haveto trust and rely on others to help. 

Erik Lujan: one of the main points isthat the Opt out needs to remain in place, that will give us (Tribes) the timeto develop our own programs the way we want them, even after Centennial caregoes into implementation, that way we still control the money, and where we gofor service, so that we can develop into an MCO or Medical Homes. That willgive us time to gather information from HSD from CoLTS and developcomprehensive programs. We don’t know if the MCO is the best route or if itwould be better to have our own insurance plan we just don’t have the data fromthe State. We need more time.  Keepingthe opt category and maybe even expanding it will give us the time to decidewhat is best for our communities.

Paul Fragua:  I think that’s one of those major points thatwe can all agree on, it’s a high priority

Yepa:  Opt out is now called “freedom ofChoice”, 80% are still opted out. It’s allowed because of the ARRA laws.  Going back to Colinda’s statement, who isgoing to carry this?

Paul Fragua: We need a simple documentnow then add on specifics later, something that I can take to Eight NorthernTen Southern and AIPC.

Ron Lujan:  We presented at Acoma to educate members onCentennial Care, there response was we are going to have a community meeting toaddress this topic and we would like you to come and present what you presentedto us.  We need that Tribal communitylevel involvement.

Yepa: We need to give them a “Chinese Menu” of what to do because smallertribes might not have experts.

Ron Lujan:  What about legal aspects have a lawyer lookat it from all perspectives

Jemez and Kewa responses were from thatlegal view, and the State has a lot of the position papers on theirwebsite.  There is nothing on the websitefrom about 80% of the Tribes

Fed and State look at that and saythat’s not enough to make a change.

Back to the “Who” who is going to leadand carry this group we are all invested in this we all have to report back toour tribes.  Who is going to lead?  We all have knowledge of some parts oraspects we all need to work together. State and Feds are not going to listen tojust one or two tribes.

Yepa: I am volunteering to start a paperand go from there.

Erik: I am willing to help with thisproject, and use outside organizations to help

Paul Fragua:  Time wise we need to move quickly so that wecan get resolution from AIPC to CMS. I’d rather do something now then nothingbecause once it’s done it will be harder to undo.

Yepa: we need a single argument

Colinda: option to speak with AIPC toschedule a general conversation with Bill Brooks from CMS Dallas on what we cando next? We will have to designate a spokesman. 

Joe Ray: Education of Tribal Leaders isvery important to help communities

Ron Lujan:  Are the Liaisons hiding information, they arevery secretive.

Colinda: I think that they do know butcan’t say or have been directed not to share information.

Wayne Lahi: Tribes did voice oppositionbut did they back it up with a written statement. I am really for what we aredoing here but who is going to lead, continue to push and then back theposition or resolutions that this workgroup is proposing

Navajo is concern because they are a bigplayer, they know that already and they have expressed that they are forCentennial Care, they want to go along with the State, and they are looking atbecoming an MCO.  IHS is in the same boatas the rest of us, but they cannot speak out/for the tribes that they stillserve.

We all need to go back to ourcommunities and tell them, councils and leadership what we have been talkingabout.

The State says that they are havingseparate programs that are going to be doing outreach and education to eligibleindividuals; we need to stay on top of these efforts. 

Health Insurance Exchange (HIX) willserve those low income individuals who are over 18 and under 65 previously inthe SCI program, they will have to purchase Health Insurance through theExchange.  The HIX will use income levels(Federal Poverty Level FLP) to dictate the level of subsidies given to pay forinsurance premiums.  Ex. Under 100% FPLconsumer pays 0-10% of premium over 300% of FPL consumer pays 60-75%.  SCI (1915 waiver) will be incorporated intoCentennial Care. 

We can’t forget about the Federalobligation, if it is a federally subsidized program then why are our peoplethen having to pay premiums. That was part of our position paper (NMICoA HC)that if the feds are paying for services on reservation, why is the statehaving to be part of the funding stream.

 (Diagram of FMAP funding was made)

 FED (HHS)->(CMS) ->State(HSD)-> MCO-> IHS->provider

Administration fees are taken each timeit passes hands.

Less money 

 Fed (HHS)-> CMS-> IHS/638providers

100% FMAP

 PM/PM Salud $290 CoLTS $1700 avg.Behavior Health $190 goes to MCO every month regardless if consumers go useservices.

 Centennial Care $350

 MCO get money and will hold $ as long asthey can (Delay denies payments)

We need Documentation on how funding isused from HSD and MCOs.

As a group we need to start gatheringour own data so i.e. Medicaid enrollment, income levels, servicesneeded/provided.

 Ron Lujan explained Staff modeled HMO,(Presbyterian, Lovelace) PM/PM was given capitation, and sub capitationpayments were much smaller.  Some providerswill not accept Medicaid patients because out of network sub capitation was toosmall.

From community side we have not receivedthis information about Centennial Care; we need to push for our communities tobe educated, because they do not understand. What can we do what has worked? We (Acoma) have educational meetings at senior centers, or open healthboard meetings, go to Health Benefits coordinators at ISD or IHS.  It takes reading and then translatinginformation in a way that everyone can understand.

 How do we communicate?

We can sponsor a facebook page? Orpublish a blog so that we can all access the information and comment. That wayif we find a new piece of information we can share it.  If there is part of the waiver that isbeneficial you can share it.

 Once the draft is complete what’s next,who take it to Tribes.

We will draft it and then the workgroupwill view and comment then,

Workgroup members will take to TenSouthern and Eight Northern, the AIPC.

Group Adjourned.

White Board Notes

BOARD

“Freedom of Choice” on Centennial Care

Centennial Care Waiver for NM wasalready sent April 25^th

1)      Generalconcepts/agreements

a.      Fed Laws                                                                    (AllTribes)

b.     Agreement ofprovisions/recommendation                 (SomeTribes)

c.      Special or unique to ______Tribes                             (TribalSpecific)

2)      Whois going to Draft? Create Facebook/Blog?

Jemez will take to 10 southern

Ohkay Owengeh will take to 8 northern

Colinda will take to Chandler

NMICoA Health Committee (elders) position

The NMICoA is a grassroots organization representing the Native American elders and disabled of the 19 Pueblos and the 2 Apache Nations of New Mexico (NM).  NMICoA is dedicated to enriching the lives of elders and disabled through education, information and advocacy of senior and disabled rights.  Under the direction of the late President Archie Chavez, the Health Committee was formed in response to increasing confusion among elders concerning changes in the delivery of healthcare services via the Coordination of Long Term Services (CoLTS) program.  The NMICoA Health Committee has been mandated to analyze the current Native American healthcare delivery system, in order to educate elders on the services and benefits available through State and Federal programs. Recently, the Health Committee has been analyzing the National Healthcare reform and the state of NM’s plans for redesign of Medicaid and the development of a Health Insurance Exchange.

In full cooperation with Pueblo communities the Health Committee has contributed this position paper to the Tribal Leadership of the Pueblo of Acoma, and hopes to continue working to elevate the education and health of Tribal Communities.

After careful consideration of New Mexico’s healthcare re-modification proposal, the NMICoA Health Committee believes the current plan does not present a viable solution to healthcare disparities within New Mexico’s Native American communities. The NMICoA Health Committee has the following comments regarding NM Human Services Departments’ Centennial Care concept paper as it affects Native Americans. The “Opt out” Fee For Services category must remain intact for Tribal members.  It is our belief that the State mandate for all Native Americans to be included into Managed Care Organization (MCO) directly challenges Tribal sovereignty, Tribal self-determination and self-governance.  As Sovereign Nations, it is the right of each tribal government to deal directly with the Federal government of the United States; Tribes are not required to accept State law that inhibits this “Government to Government” relationship.  Federal law prohibits Native Americans from being mandated to join an MCO.   According to federal regulations(PPACA), Native Americans are also exempt from proposed Cost Sharing, a promise that we hope the State will honor.

As the State of NM and the Federal Government develop Health Care Reforms, the State should allow for specific Native American Health plans to be incorporated into the designated New Mexico MCOs, which would allow Native Americans to choose a health plan tailored to each Tribe’s geographic region and access to care.  Exemptions from cost sharing should also be part of these plans, especially for rural Native American who access emergency rooms and urgent care after hours, which may require expensive co-pays that are difficult (the Pueblo of Acoma currently has a 50% unemployment according to recent US Census data) if not impossible for many Native Americans to pay out of pocket. 

The Federal and State Governments need to develop networks at both regional and local levels that will work with “opted-out” individuals in areas with no MCO presence on Reservations or in rural areas. Considering the development of health networks, the State should give preference to, invest in, develop, and train existing Tribal programs working on reservation providing Medicaid type services instead of contracting non-reservation based providers.  By developing the ability for Tribes to become healthcare providers, employment and infrastructure on reservations will grow.  The Federal Government needs to increase outreach and understanding of public law 93-638 pertaining to Self Governance of Governmental services so that Tribal providers can take full advantage of Federal funding. Funding meant for Native Americans should go directly to Tribal programs such that 100% of the Federal Medical Assistance Percentage (FMAP) funds are used appropriately in IHS and tribal 638 facilities.  With new funding sources Tribes could develop local Non-medical Transportation, which would cut down on costs associated with care and maintenance of transport vehicles.  Additionally, by using new funding sources current Tribal funding can be used on those Tribal members not eligible for services under Social Security. 

The NMCoA Health Committee believes that consultation sessions between Tribal officials and the State government needs to be more than one informational session with all Tribes participating to be meaningful. The State needs to understand that they are negotiating with Sovereign Nations that, much like foreign governments, have their own unique cultures and protocols. It is inappropriate to host a meeting where Tribal government is absent and declare this a “Tribal Consultation”. The State needs to go to each Tribe individually to better understand the unique needs of each community as well as the available infrastructure.  In previous sessions the State of NM has held a statewide consultation, where all Tribes were invited, yet only one Governor and a few Tribal representatives were ever in attendance (August 2011).  Instances like these do not constitute meaningful consultations or collaboration with all Tribes.   

Regarding the development of a New Mexico Health Insurance Exchange by the Office of Health Care Reform, the NMICoA Health Committee has the following comments: Starting with the Snyder Act of 1921, the Federal Government is mandated to provide “cradle to grave” health care for Native Americans. This mandate takes precedence over the State of NM’s inclusion of Native Americans into the proposed Health Insurance Exchange. It is the responsibility of the United States Government to provide health insurance or comparable health care packages to Native Americans, honoring the Snyder Act and its promises to the Native people of North America. Tribes should negotiate with the Federal Government directly, and vice versa.

The Indian Health Care Improvement Act (IHCIA), part of the Patient Protection and Affordable Care Act (PPACA) signed in 2010, gave Tribes the right, under Section 405, to create or invest in a private health insurance plan, or to purchase insurance through a national Health Insurance Exchange.  To our knowledge, IHS has not made any progress in developing a comparable benefits package for all Tribes or creating Long Term Care Services by 2014 as mandated in the IHCIA. Tribes should develop their own health insurance plan where funding by the Federal Government pays for premiums, co-payments and healthcare.  Those Tribes with smaller populations should be allowed to use Federal Funding to contract with a private insurance provider or to purchase private insurance for its community members.  If Tribes are unable to create their own, or contract with private insurance, then the Federal Government should create a nationwide Exchange or Option for Native Americans in which Native Americans are exempt for cost sharing.  As it stands, Centennial Care would do away with this Opt-Out program, and does not allow Tribes to create an independent, creative and culturally appropriate health care package for their people.

Health care reform has many components and options, including: Medical Health Homes, Money Follows the Person and Community First.  A similar component to these programs is the idea of Health Navigators, or Coordinators, who would help individuals navigate the healthcare system to determine eligibility for Medicare and Medicaid, or select an insurance package appropriate to their needs.  The Office of Health Care Reform (OHCR) has proposed that a special Native American Health Navigators office be created to help tribal members with eligibility and purchasing health insurance from exchanges.  The NMICoA Health Committee believes that Native American Tribes should be allowed to develop the Health Navigator’s office proposed by the State of NM Office of Health Care Reform.  The Tribes should also have direct input to develop the special Native office within the OHCR. The Pueblos should have a member designated by the All Indian Pueblo Council (AIPC), on any governing board proposed by the OHCR. Public Law 93-638, as well as the IHCIA, allows for Tribes to enter into Shared Agreements with Federal and State Agencies.  Having members on a governing board would ensure compliance with Public Law 93-638, the IHCIA and Executive Order 13175, all of which are relevant to Tribal involvement in the development of the Health Insurance Exchange.

It is the opinion of this Committee that the New Mexico State Human Services Department and their consultants did not actively include the individuals who are enrolled in Medicaid, namely the 19 Pueblo and 2 Apache Nations in the State, in the creation of the existing Medicaid modernization proposal.  The Health Committee believes that despite a consultation held on March 20, 2012, a meaningful consultation was not appropriately achieved because not all Tribal leadership was present at the consultation sessions described in the Centennial Care concept paper. We demand that more consultation sessions be called in which all Tribal Governors are present and the above recommendations made by the NMICoA Health Committee are addressed.

Zia Pueblo talking points on Medicaid Modernization

Pueblo of Zia

Talking Points

Medicaid Modernization Tribal Consultation

March 20, 2012

·         The Pueblo of Zia is looking forward to full implementation in the Affordable Care Act.  Specifically we support the full implementation of Medicaid Expansion, the Health Insurance Exchange Plan, and the entire Indian Health Care Improvement Act which is permanently reauthorized through the Affordable Care Act.

·         Cost Cutting Issues

o   From 2014 to 2019, the Federal government will pay between 100% and 93% of the cost of covering these newly-eligible individuals. After 2019, the Federal Medical Assistance Percentage (FMAP) will be 90 percent for these Medicaid health service costs, with States contributing 10%.

o   The FMAP for AI/AN served by the Indian Health Service (IHS) and Indian tribes and tribal organizations will remain at 100 percent.

·          The Medicaid expansion under the ACA is projected to generate new funding to serve AI/AN. A portion of the new Medicaid revenues will flow to Indian health programs and a portion will offset Contract Health Service expenditures.

·         These provisions along with the creation of a Health Insurance Exchange Plan in New Mexico will greatly expand the number of constituents that the State will be responsible for.

·         The Pueblo of Zia agrees with the State that this is a great opportunity to look at enhancing the health service delivery system for American Indians in New Mexico. This includes the modernization of the Medicaid Program.

·         Centennial Care is meant to be the States attempt at Modernization. The Pueblo of Zia shares the concerns of the other Tribes in this room.

·         The Pueblo of Zia is a direct service tribe. Meaning we receive our services directly from the IHS. We are concerned about the impact of the new program on the IHS.

·         We heard that the HSD will require the MCO to develop contracts with the IHS and Tribally run facilities, but we need more participation in that process. We need to be assured that the contracts are in place prior to Centennial Care going live. The IHS is highly dependent on the Medicaid reimbursements and therefore the Pueblo of Zia is dependent on these reimbursements.

·         The Pueblo of Zia does not support any mandatory requirement that puts the responsibility of health services in the hands of the state. We have a direct relationship with the Federal Government and resist any attempt of the state to insert itself in to that relationship.

·         The Plan must be conducive to the needs of American Indians on and off the reservation. And work efficiently with the Indian Health Service and tribally run programs.

·         The Pueblo of Zia feels the Plan would be most effective if the pieces of medical, behavioral and long-term care services are consolidated. In the past, the separation of services has created the effect of splitting the patient.

·         Finally, The Pueblo of Zia wants to ensure that existing Medicaid protections for American Indians remain in place and that the IHS, tribally run facilities and urban Indian organizations are included in health plan provider networks under Medicaid and HIE plans.