Centennial Care Workgroup Meeting Notes: J. Weinberg

Centennial Care Workgroup Meeting Friday, June 22, 2012
9:30 a.m. Traditions Offices

Attendee List:
Gary Tenorio, Michael Bird, Mary F. Tenorio, Patricia Coriz, Anthony Yepa, Lisa Maves, Dave Panana, Quela Robinson, Erik Lujan, Diego Calabaza, Robin M. Clemas, Sara Schultz

SPECIAL GUEST:
Julie Weinberg, Director, NMHSD Medical Assistant Division; Alicia Smith, Consultant, Merce; Theresa Belanger, NA Liasion, HSD/Medical Assistant Division

DISCUSSION
MINUTES:
	Meeting started with an opening prayer.
Gary	We have here today, with us Ms. Weinberg from the State, Alicia Smith and Theresa Belanger. Proceeded with introductions of all those present. As the new tribal entity, the Health Corporation, we have jumped into fire with Centennial Care. The waiver and now we are talking points. We are about sharing information and educating ourselves, our fellow tribes and our fellow co-workers. Therefore inviting the workgroup members to be in attendance today. We don't have tribal leaders but out workers are here. We are aware of what could happen with our without the waiver. In my written testimony I have reminded the State and CMS of the Federal protections for the federal laws that have been passed by Congress. That there are no mandatory enrollment to MCO's, no co-pays and there is provisions in the Healthcare Improvement Act. We also believe the 1115 Waiver was incomplete and hope that much of our questions will be answered or at least talked about today. There are assessments, benchmarks, teir 1, teir 2, 3's , capitation rates and this thing called the budget neutrality. And our major issues about the tribal communication and understanding as economically poor and huge. Health disparities that I read, native will be a big eligibility population for Medicaid. We hear and read different things regarding the volunteer retraction of the State. What are the real reasons for the state’s retraction waiver and what are new things that will be added, deleted or changed? Also, what are the State's plans if Obama care is struck down or the decisions being made by the Supreme Court? What consultations will be in place with the Tribes if the exchanges go through into effect? I know there is a lot of unknowns, however, I want to let you know that KPHC maintains the Federal Laws effect in the Indian Health, Tribal and the urban settings. The tribal consultations are directives from CMS to the State and various provisions of the Centennial Care dramatically effect in the how health care is provided in Indian lands. We ask that we talk and be partners especially in the implementation and phases of whatever systems we end up with. And I thank you for coming and hope to have more discussions with you and your staff.
Ms. Weinberg	Thank you again for having us here and our pleasure to be here. I appreciate that some of you came from a fair distance. We have had, with a lot of people in this room and some are new, many discussions about Centennial Care and have answered questions about Centennial Care for awhile now. I'm trying not to debate on where we start on this. Should we start answering the questions you had Mr. Tenorio? My opening is I too look forward to a partnership as we go forward with our changes to the Medicaid program. The intentions of these changes are to improve health outcomes for all people in the State of New Mexico, including Native Americans. Both in cities and out in their own lands. We are concerned too about disparities that exist among Native Americans in terms of ability to access care and health status. The idea behind Centennial Care as we look at the needs of Native Americans throughout the State. Our goals are to improve health status to improve access care but to not interrupt the relationship between Native Americans and their tribal providers or the Indian Health Service providers. And hopefully to enhance access to services to urban Indians who are in Albuquerque, Santa Fe and other small cities around the State. That truly is the intent of Centennial Care and at the same time we expect to be able to better manage the cost of the program so that we continue to have a very robust benefit package, strong eligibility, no changes, no eligibility cuts, no provider rate cuts and our full very robust benefit package, we want to continue that.
Gary	Shared that he wanted to let the group know that he had designated Mr. Yepa to facilitate this meeting.
Anthony	Shared that we are a newly found corporation, called the Kewa Pueblo Health Corporation. When the Centennial Care hit the new corporation then we started looking at some of the existing partners that we have in our tribal communities thus we came up with a work group. It's not our work group, it's a work group comprised of several other communities that were directly affected by it, Acoma namely, Jemez and then we have had some other partners with the poverty centers as well as the council for aging. We had a bigger work group last week bringing up the nuts and bolts of the waiver. We try to stay away basically from the political side of things. We do not speak for any tribal leaders. What we wanted to do today, again the corporation is committed but we invited our partners here to listen and also ask some of the more technical questions that we may not be coming up with. This is an informal meeting and start talking about some of the issues that were more geared to us. I know that bringing things up to this point and time, the waiver has been retracted by the State and we also have copies of your letters that you have written. We are not going to beat the consultation issue to death here, what we want to do is start looking at the salient points that the waiver has in place. We'll go to page 29 is what we would like to tend to in terms of what some of the issues are. That's mainly the block grant issue. I know that it's general.(block grant description) I know that there's some pilot projects being looked at. I know that you have had some meetings with Jemez and Laguna. I think that for the Board Members of the Corporation that are here, we wanted to see what are your plans, what amounts are we talking about, what is the process, how do we engage in such a thing, what is the infrastructure development of a tribe who wants to play the game of being an MCO or an MCO like Corporation, how do we go about achieving that because I think, publicly, some comments have been made that there will be no additional MCO's. Then again you have those crazy group of people who you call Native Americans out there that keep coming up with their Federal Laws, that keep coming up with we are exempt, we've had fee for service, you didn't consult with us. That's our first question.
Ms. Weinbergh	Let me sure I understand your questions. Given our discussions on block grants and perhaps sub-capitation, capitated models. How do we go about doing that and how do we envision that? A couple of things that we heard when we were getting input to our concept before we even wrote the concept paper was, first of all, that Tribes often have providers or a group of providers that they use to coordinate care. We also heard that Tribes, a lot from the 638's, that they wanted to have more control over how they deliver the care instead of just having this pass in addition to this pass through that payments that we get we send through the Federal. The 638, 100% where we're like a pass through mechanism to the feds. We did a lot of thinking about it and one of the things that occurred to us is that there is a strong desire also for Pueblo's, Tribes to want to be a Managed Care organization themselves. With a Managed Care organization, there's a lot of legal stuff that has to happen and you have to have enough reserved dollars and financing to bare the risk. Because what the Managed Care organization does is they basically accept certain amount of risk regarding their monetary risk towards the payments they get and how much their going to have to spend on their enrollees. We thought about that and didn't think that the Tribes and the Pueblos were at a point where they could bare risk and we talked about we have these managed care organizations that we'll have that can bare risk. We designed and determined was that we would work to help . We would use the MCO's to work to help managed care organizations. The tribes to become, eventually, perhaps a risk baring entity. But before that, the way to do that was, we thought one way to do that was to create a sub-capitation model. What that means is that, when a managed care organization takes on the responsibility for an enrollee they get a certain payment per month, their PMPM. What we thought was that one way that the Tribes could start working towards all of the various kinds of things they need to know and do and be able to do to be a MCO was work under a sub-capitated model where they could get a lump sum payment on a monthly basis for their members that they serve and in return take on the responsibility of delivering a package of care for that member. It doesn't have to be the physical health care, it doesn't have to be the acute care that the 638 or the IHS providers provide now. There's a lot of other services that I know the tribes want to be able to deliver to their members. Care coordination comes to mind. There's outside of just that basic, ‘I need to see a doctor’, getting the treatment and then getting a prescription. We call that a sub-capitation for an array of services. From that, maybe you'll start on a smaller scale and from that if the facility or the group felt confident like we want to take responsibility for this aspect of acute care treatment we work with the MCO's to have sub-capitation on. The beauty of it is the MCO's are the official risk barer and you all would bare some kind financial risk for sure in that sometimes that payment may not be as much as the cost of the care delivering but over the course of time it tends to even out. We do a good actuary. That's the other thing you can leverage with those managed care organizations as actuaries or with us since we have an actuary. We want an actuary sound payments not just something that sounded good but some that we would understand members needs. We have a pretty good idea of your members claim history and from there we would establish this monthly rate. That's one way that we thought that would be really exciting, for instance Jemez, Kewa, and we talked to Navajo Nation. As one way to start those tribes that are entrepreneurial about their health system to start that road and get that learning and experience. The block grant is slightly different. It is sort of not based on an individual's risk. It would be a lump sum of money that again would come through the MCO because we contract with them. We pay them for the care of all our Medicaid members and then we would direct them to work with whatever interested Pueblo, tribe or health center on that and develop an agreement that basically says for this we're going to pay you this sum of money and you will be responsible for delivering these kinds of services. The MCO's would also be there to help with the technical assistance under either model. These are just two models. Under either model the health corporation, the tribe, learning how to do it, giving them the advise and the benefit of having these kinds of contractors is they got a broad experience. They know some of the things that work in a general way. Each pueblo is unique, the Native American needs are high for healthcare but they have experience for health care in a general way and some experience with very high needs membership as well. They would be there for that and we would require them to provide that technical assistance. Another thought is if a Tribe, Health Corporation or pueblo wanted to start a care coordination business, a team of care coordinators and I know a number of people have heard be say before, that, to us, makes complete sense. Because the tribe, the pueblo, know the members in their community and understand their needs. They are the culturally competent people to talk to these members and help them access the care they need and be sure that they are taking their meds right and all the other stuff. If a tribe is not there yet but wants to do that, again, we'd tell the MCO's that you must help this tribe learn how to develop and build a care coordination system for their members. Be sure that their getting that full package of care that they need and the assistance they need. It's not just a doctor or a nurse doing the exam. At least maintaining their health status to not getting sicker or improving their health status in the long run. Also, I see that as a very important part of prenatal care for members so you have good healthy children coming into the world who can really succeed in such a challenging environment. That was our big general ideas and those are just 3. I have stated before, we are open to other ideas. We will have these managed care contractors who we can leverage to help pueblos and tribes to help develop their health infrastructure and their health care delivery expertise in that very broad way. Not just doctors and nurses but your community healthcare representatives. There's many opportunities that the tribes that we've talked to see in terms of things that they want to do for their community.
Anthony	Taking that thought, I think what we want is at least, verbally you saying that, but something in writing to say that this is what we're going to do. Because right now in the waiver plan we don't see that in such as black and white. Yes we will work with the tribes to see if they can do just what you said, maybe a sub-capitated rate or maybe a blended rate or maybe even the block grant route or the pilot project, but at least we want to see it in writing. That it is open for discussion and then we can react to it. Because as it stands now, yes you do have your 638's and tribal communities, you do have that capability, the infrastructure, the capital, the intelligence capital in some sense where it's going to be needed. All of us, tribal, are at different levels because we had that conversation last week. We have that whole broad spectrum but yet at the same time I think that as long as there is ability and capability we should do study on this. We have had some conversations among tribes and we've also had conversations with some of the MCO's already. It's scary to take that risk but at the same time I think that in some sense we already are MCO's with the way we operate with the Federal Government now. Because we have to allocate CHS, we (Jemez, KEWA) only get a certain amount of money. So in some sense we are pro's in that area in terms of assuming risk. But we also recognize how many we are ignoring in terms of maybe preventive care and we don't have a say so in that. This is where I'm saying the Federal Law comes in and says "CHS, this is how you provide that service," "IHS, this is how you provide that service," you sign that 638 contract so, we have those kinds of challenges. When Mr. Tenorio writes his letters to your organization as well as to anybody, we are dictated by the Federal Government in our 638 contracts as to how, when and how much. We have to provide that service. If the Federal Law and Order Act comes into play that also is going to be a challenge in terms of behavioral health, suicide, depression screening, etc. Those kinds of things are going to be mandated in there and even mandates how much that person should receive. That is going to be the Coordinator up in Washington, DC. It gets definitive to that point, it gets descriptive to those points, then we're arguing with IHS that the State wants us to do this thing but we just need to explore all the options. Yes, we've even looked at the Oklahoma blended rate. In some sense we're meshed with IHS in terms of a lot of the care and I'm not seeing as much description in terms of residential and inpatient care. Yet we are getting questioned about the incarceration rate and the adult incarceration. What do we do with them? So those are some of our challenges. How do we blend it in with what we are talking about here today? We all have our own internal and external forces that are forcing us to do certain things but yet, somewhere we have to figure out how to do this. What we are asking from you is to make sure that it is put in writing. Make sure that we are offered the opportunity and if we can work around some of the capital that is required of the infrastructure that is developed and required for an MCO, then yes, we are welcome to that. We want to be partners in that. We have a Board that is capable of bringing in the partners to help us direct and manage such a thing. Ms. Weingberg stated that is exciting. Anthony proceeded to state that if we can get some of that commitment from the State because we are going to be a major part of the Medicaid population. 10-15 years ago we were 9% of the State's population but we were 35% of the Medicaid population. Right now we are 10% of the State's population but between 18-21% of the Medicaid population. The millions that you are referring too, we see it going to Presbyterian, Lovelace but they never came out here. We're partners but we can't even talk with them and we're having the denial disputes on payments. Where does that put us? We have to take another approach and start working with your organization in terms of a waiver to see how we can look at the entrepreneurial side yet at the same time not forget that the patient care is going to be paramount.
Ms. Weinbergh	I couldn't agree with you more. We recognize there have been problems. Many problems with our current Managed Care Organizations. We are determined in the contracts to be sure there are very strong language in there on payments. Where they will pay and on some of the things we've already discussed in terms of their cooperation and their technical assistance to the Pueblos and Tribes who are looking to try some very unique and exciting approaches to health care in their communities. We couldn't agree. When you're talking about the RTC's, I thought, yes the RTC is important and we need them as a step to get people back into their communities and live healthy. We have a strong behavioral health component in the plan. It will be hard. It will not be easy to do this but the goals and desires of any of the Tribes and Pueblos in the State will mesh and we'll be happy to get you that letter. We'll mesh with this programs design to be more flexible. I'm committed to all of the people in the State of New Mexico and my program at the State feels the same way. We're ready to sit down and get you that language and we are ready to figure out what exciting things we can do to improve people's lives.
Anthony	That is one of our first questions and the second questions is the segway into just what you're talking about in terms on contracts. Even though some of may elect to become "a blended sub-cap or some kind of managed care organization as a tribe," however for those that are just waiting to see what's going to happen and the State ends up with the 3 MCO's I think that a lot of them are not thinking about the Federal protections that are in place. I know that the Northwest, State of Washington and maybe even Wisconsin, some others already have what we call and Indian Addendum to the MCO contracts. What that Indian Addendum does it does reflect upon a lot of the No Pay, Prompt Payment Act, etc. The provisions in the Indian Healthcare Improvement Act in terms of credentialing all those federal protections that we have listed. The compacting tribes have written a letter to CMS indicating that if the exchange comes into play; CMS we want you to go ahead and tell the state's that the Indian Addendum should be included in all the contracts. From what I'm reading, it appears to us that we both have our issues with CMS. We are independently going to CMS for things. We have that relationship with CMS but it appears to us that they are going to allow the States to either say yes or no to that Indian Addendum. What we are saying is we are strongly encouraging that that be considered. Ms. Weinberg stated that they would look at that and that she was not aware of anything like that. If anybody has a copy they requested for one. Michael stated that they are happy to share their knowledge. Anthony stated that the Indian Addendum is already in effect at the State of Washington and possibly in Wisconsin. There's already history with states doing that and it does not only effect any of us that are only 638's, that it also effects the other tribes and pueblos who are going to need that in there. Because, unknowingly they are part of the federal protections that are already in place. It does afford any Indian Tribe at all levels of ability and capability and infrastructure to have that in place. So we are acknowledging that if you can go ahead and do that and at least sit down with us and we can explain all of those protections. Not only will it be good for you but it will also be good for us and I also know that it will be good when you are going to set up those contracts with the Lovelace's, the Blues, because their corporate office are in Nashville, Washington, DC who know nothing of Indian Tribes/Pueblos. If we can have that in place, in writing, because their attorneys are going to be the ones to negotiate these things with you, that if we can have that as a consideration, I know, that CMS is sending it back to the State's, then I think we'll be ok.
Michael	I know you were on a national conference call on Wednesday and there was some discussion about all the things that are going on in New Mexico. Would you share that with everyone?
Ms. Weinbergh	That was a webinar that the National Academy for State Health Policy NASHP asked me to talk about how states were getting ready for a Medicaid expansion and note that we'll talk about that sometime next week. We talked about we're expecting 130,000 - 170,000 new enrollees under Medicaid expansion. Over the course of the first 5 years of the expansion and how we were calculating that number. How we calculated that number and we tried to identify our uninsured and that's all technical. They asked me to talk about what we're doing in terms of trying to improve access for Native Americans into care, especially what we are doing for Native Americans thinking about access. Of course my concern is we have a lot of folks in the tribes and the nations that are not aware that they are eligible for Medicaid. So that was an important thing we had to do, especially with the expansion coming on. We'll have more people who are not aware and it was key. How Centennial Care was designed to help address some of the high needs of people that will come into the Medicaid program under expansion. The idea of a model of integrated care where the whole person is addressed, not we don't have MCO's for physical health and person's long term care needs and the behavioral health. Talked about the opportunities that we were just talking about now and about those that the managed care organizations would be a good way to leverage to help the tribal communities the opportunities to be there to improve their own health care delivery systems. If they had transportation provider already in place we would require the funding that the MCO's contract with that. Where they wanted to develop more capacity we were going to require the MCO's to provide the TA and then the financing to pay those services. We also talked about the fact that the Managed Care that by Native Americans being enrolled in Managed Care that they would not be limited to IHS contract provider budgets. That they would really have access to a larger array of providers. If they were accessing the provider through the contract budget, if they are on Medicaid they should be accessing it through the Medicaid provider, but if they need someone who is not a contract provider the Managed Care organizations would be able to provide a broad access to more care that person would need. The other idea was about expanding use of Tele-health and leveraging our program here in New Mexico at UNM Project Echo as a way to expand access to specialize care. I was at a meeting at Project Echo that I learned they do trainings for CHR or CHW's. Persons get trained and they go out into their communities where they are CHR's or CHW's. They get constant updated education so they're always in touch. I know that Project Echo is working with a number of either IHS facilities or Tribes on expanding access. It's really that it trains the providers to provide care for complex conditions that normally someone may have to travel hundreds of miles just to get. I talked about the fact that half our Specialist in New Mexico are in the Bernalillo, Albuquerque metro area and yet half of our population is not in that area, that means that the rest are scattered about and Project Echo and Tele-health and leveraging technology is key to also improving access to care across the nation. That is what we were talking about in terms of Native Americans and Centennial Care.
Anthony	The Centennial Care and Waiver on page 7, I think it talks about refugees and undocumented aliens remaining in fee for service, is that still standing?
Ms. Weinberg	Yes, that's still the case. Simply because they get very limited eligibility. They get eligibility for a short span of time on that so you can't manage care for a person who has eligibility to cover a specific time frame. An undocumented person who needs care here they get a period of time that was for the emergency or the birth of a child. A very limited benefit by time and set medical necessities so they get treated for whatever the condition is
Anthony	I'm referencing that question with understanding that currently under the Phase I of the MCO and what we have gone through the past 5 years that the Natives are still 85% Fee For Service. Having said that, if the waiver does go as where it will mandatorily enroll the Natives into and MCOs, what are the transition plans? What is the plan especially for the 1950 b & c waivers for the Colts? What's in the planning for that?
Ms. Weinbergh	That's a very important question and a good question. We are very much concerned about that transition. From the current system to the new system especially for people who are not use to using the managed care, being a member of the managed care organization. So yes there will be very intensive outreach and education to all of our members. We need to be sure it's culturally competent education to our Native American enrollees about what managed care means to them. What their responsibilities will be which would be choosing a plan and making sure it's the plan they want with the Dr's they like. Also understand, if that's what they want go to IHS facilities or to their 638 facilities that's all still available for them. It can be their PCP and that there will never be any obstruction to accessing services from ITUs . When you were asking me that I was thinking, there's a good important opportunity for the department to collaborate with the Tribes and the MCOs. Or at least come together and figure out what are the best ways? Who are the best people to do the outreach? And educate the Native American communities about that. I think that's a very important opportunity. We can't do it without you all.
Comment/Question from Dave Panana, -jemez	You've talked about the MCOs , contracts and what you're going to hold MCOs accountable for to the Tribes. I know it's been brought up several times regarding the Tribes wanting to be a part of the process. When you talk about contracts, the RFP process, etc., I think this is one of the main reasons the why the Tribes want to meet at the table. Your saying that a lot of technical assistance, etc., is going to be provided by the MCOs but that's coming from you. Once we actually start implementing in 2014 will that actually happen? It's not written down in contract. What do we have to go back to the MCOs and say well this is what we were promised yet it's not actually written down. For instance IT assistance training, I think we're all at different levels and we're looking out for one another. I think Jemez will be fine but we're wanting to make sure that everybody else is going to be fine as well and receive the assistance and training that they're going to need. And we talk about the PMPM, what is that going to look like? We have specific examples and the current MCOs right now, where they know we are up here as last resort? They know if they're going to say no we're not going to pay and we're going to foot the bill. We go back to the same, taking risk and that's what the MCOs are able to do. That's what we're going already. Nobody's going to pay for it. We're going to pay for it. We're going to pay for it through our CHS funds that we receive through the Government. That's the reason why we have our Benefits Coordinator working so hard to try and get people that we can onto different programs to be able to help supplement those funds. Different facilities are already barring those risks. We have systems to go through and handle that. On one end, again we've already talked about where we have a whole spectrum of facilities where their just starting up. Others are well into it and have been playing the game, understanding the game and I think that's why we have real issues and hesitation. Again, we've said straight out, that there's no trust. In order to build trust we have to see it in writing, we would like to see that contract. We would like to see what it specifically states and what the MCOs responsibilities, if it goes in that direction, would be to the Tribes and how would we be able to interact with the MCOs? What leverage would we have as Tribes to be able to say "no."
Comment/Question from group member-Erik Lujan	I'm going to piggy back on what David is saying. What your describing, true the MCOs, the description of that today is very different one than what we are familiar with. On unfettered access to care, no interference with receiving or accessing to services the patient needs; that has never been including with any of my own private health insurances that I have, that's never been the case in the managed care organization. In an approval position they retain the ability to approve and deny what's cover, what is not covered, when it's covered, who provides that care. I'm trying to picture how retaining an IHS provider as your PCP is going to change MCOs ability to approve or deny the care that PCP recommends for that patient. I don't understand or have no concept of how that's going to work. Because generally a primary care provider will make a recommendation. Say something isn't available in the primary care facility, the MCO still has the ability to approve or deny that regardless of how much they are receiving on a monthly basis to provide that care to bare that risk. We've not seen unfettered access to care.
Ms. Weinberg	I hear what you're saying. I think unfettered and gate keeping are different, I'm talking about PCP. Right now our managed care organization have very few requirements where when a PCP says you need to go see so and so about this, there's very few requirements for referral. I checked it because someone brought that up to me a couple of months ago and I checked to see what our managed care organizations do. It's very, very narrow but I was surprised what they do require for referral to access a certain specialty care. One of the things about Medicaid is that we, under federal law, the services that we pay for have to be medically necessary. That is where you might run into those, in terms of durable medical equipment applies, etc.. Both of your points are very important and I think that if there is a pattern of denials or we start seeing a lot of grievances from members, those are the kinds of things we would need to know. If the services are medically and there is not an acceptable alternative to that service, which most cases we don't get a lot of grievances or being denied access to services.
Comment/Question from group member. Lisa, Jemez	I think people go away. I think that's what we anticipate happening, you're not going to get a lot of grievances. You're going to get people who give up. You're going to get patients who give up.
J. Weinberg	Then we have to work as care coordinators. That's why we want to put this system together so that we have people paying attention to the people who are really in need of these services and if the people don't have whatever it takes inside of a person to put up that fight then we have advocates in all the communities for those people. If they are being denied care inappropriately then we know about it at the State. That kind of language is certainly in our contracts, you can't deny care just to save money. One of the things that we'll be able to do under Centennial Care, hopefully and the idea is by having fewer waivers to manage and fewer contractors to manage we will be able to be much more on top and prompt on the bad behavior or inappropriate behavior contrary to the contract. I don't disagree with you I think we've all been in positions with managed care organizations over the years where we feel like services were denied. Managed care organizations have evolved. The view on the whole health care system and the way it's paid for and what services are delivered is evolving and we're hoping to tap into that evolution under Centennial Care so that the MCOs start to understand. We're at that time where the world is shifting and I know you’re skeptical about it. We should have a self help this skepticism about it and that's where the contract comes in. David, as far as your concerns, you brought up a lot of things that made me think about some things I want to take back. I can't sit here and offer some ideas until I met them with my leadership. For sure we have offered to the IHS and Tribal 638's a review of contract language regarding prompt payment. Question posed: At what level was that? I mentioned it on Tuesday when we were in Albuquerque and I also told Sandra Winfrey & Reo Pernell & the Navajo Area Leadership, Mr. Thompson
Comment/Question for work group member	March 30th we had a meeting with Navajo Area IHS and Albuquerque Area IHS to discuss this. They asked that we review this contract.
Ms. Weinberg	I said yes, we want your input on that.
Anthony	This is where I'm talking about. Rather than reacting to what is already in place, we are being proactive. Our Kewa position is, bring that Indian addendum into it from the beginning before you even negotiate with the 3 MCOs. That those 3 things are considered, discussed and as David is saying, we be part of that design as you use it in your waiver design in the implementation that we have. Have us have a chair, in that roundtable when you're sitting down with 3 MCOs. My next question will be on budget neutrality.
Ms. Weinberg	The way that our PE will work is there will be a contract attached to that RFP. There will be very little room for negotiation with the bidders. They will see that as that they know their bidding on that. We are working on that contract language now so we're going to go back and look at these addendums that we were talking about. We fully anticipated before that ever gets out on the street that we were going to supply our proposed language and that we were going to start to come up with our proposed language based on all the conversations and consults that we've heard over the past year and get input and feedback that way. With the addendum, we have to look at it & I can't promise that we'll do that, but we're very interested in it but if that was the route we were going we would still come to you all and ask your input. We can't guarantee everything you input but it's going to get in there.
Anthony	The thing that we want to emphasize; first, that it's already part of the design that we are a player in the table as your setting up these agreements with whoever it may be and the second part, as Mike has indicated earlier, that if you ask us we are in a dilemma where we're looking at a broader picture in terms of us working with CMS and with the State and also with our Federal partner, meaning the Indian Health Service. But I think they work for the Executive Branch, the United States so they are mum on a lot of things, whereas we’re not mum on a lot of things. What we do offer is, if our concerns are these Federal protections and if other states have already adopted it and accepted it that doesn't mean you're taking everything from it. But at least you have something that has been approved in Washington, Wisconsin and Oregon. Mike stated, if you want to do it right then you have the opportunity to follow our recommendations and our lead in terms of what needs to be done. Anthony, but that will get into what Lisa and Dave are talking about and we can address all of the enrollment issues in there from the beginning because the 2703 planning grant and the amendment talks about those issues; assessments, telephone calls for the behavioral health models, etc. Those things we can bring up. If you look at our questions that you have copies of that's almost everything that we came up with that are technical issues in the waiver. If those are answerable then I think a lot of it will work. What I'm saying is that on the care coordination, we applaud it and we have it in writing from Mr. Tenorio's testimony, that we do applaud the care coordination piece of Centennial Care because we have trouble with it ourselves. The CHS issue care coordination, yes they get frustrated with us. We're the front line people, we know when they get upset because we didn't pay for their CHS and we don't see them again. We can bring up a lot of things on our side that realistically that we can, in some sense, teach the MCOs because we've been there. We are the champions in getting a certain amount of money and do the best you can with it plus the federal rules that come into play. The care coordination part, yes, we already are staffing our services with that in mind because we're already looking at CHS and I think we need a care coordinator out of the CHS budget. Those kinds of things, you made us realize a lot of things here, internally, ourselves. We may disagree with you on a lot of things but it also helps us look at ourselves too. Question 4 is budget neutrality and along with that on page 45 it talks about the FMAP for Native factor in. Is that factored in, in the calculation that your coming up with (the FMAP reimbursement)?
Ms. Weinberg	Budget neutrality is based on the calculated trend on cost of the program from a certain point going forward through the 5 years of the waiver. A demonstration waiver that we've asked for and what that means is that we're assuring, we have to give assurances to the feds. This is a new tool for me. The budget neutrality is, we say if we did nothing different then this is how much the program will cost over 5 years based on a base year to start the calculation. But what we're saying to the feds is your letting us do this we're going to guarantee that there will be this much savings or it's not going to cost you any more then that trend line cost. We're estimating, not guaranteeing, we're estimating the savings to be this much because the Federal Government, for services not supplied in an IHS or other Tribal facility pays about 70% of the medical cost of our Medicaid program here in the State of New Mexico. So Feds are very interested in us doing something that isn't going to cost them anymore. We're presenting to them is that budget. That's what budget neutrality is. We have 5 years to achieve that budget neutrality so we could actually spend. We don't have to achieve this all the same things up front, we may need to spend a little more upfront to watch the savings start to accrue later on in the program. It's basically saying it's not going to cost you more Federal Government as a matter of fact we think it's going to cost less.
Gary	Based on what you just shared, with the 5 year trend. When we were coming up with this provision, the budget neutrality to the feds. What was the factors used to come up with that?
Theresa/Alicia	As far as the trend goes, we used 2010 as a base year because that's the last year for which the State has all of its claims in. So we've got a record of everything that was spent in that year. Then we trended forward using the President's Medicaid trend rate. That will be a point of negotiation with the Federal Government because they will want to argue for a lower trend rate and the State will want to argue for a higher trend rate. And where that ultimately comes out would be a matter of probably one of the more serious parts of the negotiation with the Federal Government. That part of the negotiation doesn't get done with CMS it gets done with OMB. The only other point, just to reemphasize, because I think it's really important about 1115 waiver as opposed to the B n C waiver under which Colts now operates. Under those waivers you have to show cost effectiveness every year of the waiver. As Julie said, the nice thing about the 1115, it give us all an opportunity to invest some dollars upfront. In early years, for example to build a strong care coordination system or to build some additional health care infrastructure so we can achieve savings in the out years that's one of the values for going that long period of time with the budget.
Anthony	In your negotiations and now that you've mentioned OMB, OMB is going to bring up the all inclusive rate that has been reimbursed to the State on the 100% FMAP. How is that calculation going to effect the States negotiation with OMB? It's the question that I had on page 45. How is that factored in? How much are you going to get in direct reimbursement from the State for the Native care that is 100% pass through?
Ms. Weinberg	I don't know if I can answer that question here. Anthony, is that a good question though. Ms. Weinbergh, yes it is. Because I don't know the actuary or who developed it I can certainly get back to you on that
Anthony	Okay, but that's a major point that we need to factor in because the State claims in a lot of the information sent out-that they've spent 96 million dollars no Native care. But when we start calculating our stuff, it's more than that so that's where the logic comes in. The Federal Government reimburses the State and gives them an administrative percentage on top of that to deal with this group of people. The State does make money off serving natives, so we’re saying rather than going from the State to Lovelace then down to Tribal why couldn't we do a direct line to make it administratively easier for all of us. It's a thought that I want to impose to you.
Ms. Weinberg	Let me clarify a couple of things. I don't disagree that it seems kind of silly for us to be the conduit for the 100% federal reimbursement. Because we're the single State agency for the Medicaid program that's how it works. When a tribal member gets a service at IHS the MCOs make the payment. This is the complicated part, we reimburse the MCOs the 100% and then we ask the feds for the 100%. That's how that works. There are services that are paid for Native Americans that are not delivered by an ITU.(facilities). Those we get the match depending on, sometimes, the category of eligibility of the person's in or the service that was delivered. So there is some State general fund that does go to cover certain health services for Native Americans when it's delivered outside the all inclusive. We get 50% Federal match for our administrative cost for running the program. My salary is matched 50% by the feds. If we have to contract with someone that's matched also. For the most part 50%. Some contractor that runs the MMIS or Medicaid Information System that's more of a blended rate. It gets ridiculously complicated to do this and it takes some very smart people, full FTE's figure out what amounts we can claim from the Federal Government at which federal matching rates. I don't disagree, it's silly to do it that way and it's very complicated and then they come and audit us.
Erick	Could that be something that could be made into a pilot project? Having that 100% pass through to one of these tribes as an experiment or as one of these pilot projects we're talking about? Is that allowed in the 1115 waiver?
Ms. Weinberg	We didn't ask for it. That's a financing question but I think that the problem is that if it's for a Medicaid enrollee to cover Medicaid services then we end up getting stuck in the middle because we're the single State agency. The problems with that is all the reporting. There would definitely be some intense reporting issues.
Alicia/Theresa	Erick, could you clarify for me when you say a pilot on the 100%. Erick, I'm not really sure what I mean by that. It's just a big process and we've been talking about it for 5 or 6 years and it keeps being blown over as not even a consideration because of how big it is. Well it's so big because it's such a big deal, it's such a big process. Why don't we have somebody take a look at it and see if we can streamline that service that way it's not such a big deal. You guys save money, tribes get paid at the front end and everybody is happy. Everybody gets more services. Ms. Weinberg, you mean it doesn't go through the MCOs? The payment comes directly and doesn't go through the State? Erick, yes, it doesn't even go through the State. Why are we talking 4 or 5 administrative levels? You could take that right out.
Group member/Lisa Jemez	It also raises another question regarding one of your answers to Mr. Yepa's question earlier today about sub capitation and block grant ideas. Where funding is passed through the MCO. There wasn't really indication as to what degree of that funding passed from the State to the MCO to the Tribe. Is that some small fraction, is that 50% pass through?
Anthony	No, I think the question to her is that if there is a blended rate, a sub cap rate. She was offering the options that are available. What we want to assure is that it's in writing to where we work up to something, where we have a direct negotiation. Perhaps our direct contract with the State on a MCO type like thing but that will have to be done. But she was offering the possibility of one of the three MCOs doing a sub cap to do parts of, some of the requirements from the waiver.
Group member/Lisa	I understand, but what percentage of that funding is going to reach you?
David Panana	It's going to be based on the services that the facility provides. Correct?
Ms. Weinberg	I think your right David. It depends on the package your contemplating that you're going to be delivering and the tricky part will be to figure out if we're going to be dealing with any of those OMB rate services, then the match gets really messy. It can get to be a major headache but I agree with you David.
David	I agree with Erick and you're talking about administrative work and match and again going back to Jemez specifically, there already doing a lot of what your trying to suggest. Your trying to accomplish with rural communities, with Tribal communities and in essence we're trying to help. You need us to help you reach your goals and what your trying to do with the Centennial Care concept paper, Medicare organization. Again, we're already doing this so why would the administrative payments go to you all when we're the ones doing the work. It's the same thing that we keep talking about on the front end. It's almost the same thing were talking about with the MCOs. Why are we paying the MCOs when were the ones doing the run around? You talked about earlier, there's going to be more hands on it's not going to be over the phone which I think in the Centennial Care paper you did, it does state that. You are going to need our help in rural communities. The only way that you're going to achieve that is that the MCOs put a warm body in our facilities and I don't think that's going to happen. Some of that funding should be coming to us, directly. Because we are a big part of this process. You’re putting it out there as a concept but some of the tribes and some of the facilities but its far past the concept. We're doing it.
Alicia/Teresa/Group	PMPM and OMB rate are pretty far apart. Those things are pretty distant from each other. OMB is a fixed rate. Ms. Weinberg, I understand. We're talking about the difference between what the rate the MCO will be getting per person. What the Tribe under a sub capitation or a block grant would be receiving. If I understand you correctly you're talking about a 100%. That's the first percentage that I've heard this morning.
Anthony	I think the actuary studies, the economist that you need to hire just to understand this business it's going to be part of that discussion. All I'm saying is, think about it, put it in place and we would like to see it. I'm only thinking what the sub capitation rate or blended rate is going to be. So in the 5 years your projecting $452 million. Right? In savings, that's been put out there by your publicist or whomever. In this it's also saying you're trying to achieve those savings but then you have contraposing or competing organizations saying that there's a Hilltop Report. Have you heard of that? Ms. Weinbergh, yes. Anthony, so there claiming $40 million, $30 million. Is there some reason? What is that about?
Ms. Weinberg	The Hilltop Report was done early on, I think in the prior administrations effort to star working on implementing health care reform. To tell you the truth I have not been down in the details of implementing health care reform because I've been down in the details of trying to do a Medicaid program. Which of course is linked to health care reform in a number of ways but I'm not down to the details of the bigger picture of all the details outside Medicaid. We had actually some issues with the Hilltop Report as I recall and we being the department and whatever the Hilltop used is one thing. But this is based strictly on our Medicaid expenditures and the trend, the Executives, the President budget uses for the cost increase and the cost they project in Medicaid. It's strictly based on our Medicaid experience and some of our projections on where we're going to see some of the savings and the lower expenditures within the program.
Alicia/Theresa	Hilltop is about trying to predict the impact of healthcare reform. This is about trying to predict the impact of Medicaid and I think that's part of the difference.
Anthony	In some instances they are related but in some sense there not. The other thing that I think we’re thinking about the block grant issue, the money issue. As a liaison person you're saying $452 million. I know you're looking at probably only 3 month retro coverage, these kinds of strategies to same Medicaid funds. I don't know what went on with your discussions to come up with the waiver but wouldn't it have been a lot easier if you promulgated and said here's $452 million we're going to save why don't you tell us what it is. That way we don't have to mess with what the thinking was?
Ms. Weinberg	We didn't want to do that, we didn't want to cut programs and we didn't want to cut benefits. That's not what we're about. We're saying we can't afford to continue to do the model that we have now for a variety of reasons. One of them is the idea that our Managed Care organization is all paid. Mostly fee for service though. There's this pervasive incentive for providers to see you a lot so they can get paid. Vast majority of them there are no incentives in place except what's in the heart of the provider. We have a system that if we continue as it is we'll drive us all into the poor house, the whole State into the poor house because we can't afford it. We can't afford for services to be delivered just so we can get a payment without any interest in the outcome for the member and that goes for all of us. It goes well beyond Medicaid. It goes to me and you guys are doing some real exciting things in Jemez. You're taking a very whole community approach to health care. That's where the world is going and that's what we're starting to do under Centennial Care. The goal is how do we keep this robust program and afford it and be sure that people actually get better and that health status in all communities in the State that Medicaid serves improves.
Michael	I've been at this a long time and I've seen managed care come and go. I've seen administrations come and go. The other administration was the Richardson administration but here's the thing from my perspective and that is that it really goes back to social determinants of health in Indian communities. Medicaid is not going to change that and it's really incompetent upon the communities to embrace that and make that change. What you have here is representative of a lot of communities who have embraced that. Who recognize that they have to be responsible for their own health care, their own community, their own members and they're wanting to do that. But what we have are bureaucratic systems in place which are more attuned to doing things that they always have. More concerned about quantity versus quality and in many cases what your doing is shifting money. You look at State Health Department and Medicaid and you're going to put money in managed care organizations. It enhances and improves the bottom line for those MCOs but it doesn't do anything for the people and the programs that are actually in communities that actually have some influence and can make a difference in improving health conditions in their own communities. The MCOs don't have that. There not invested in the same way that people coming from the community are. There's is the bottom line, how much revenue are we generating (I'm not saying there good people). The other thing, on a larger scale is you've got large institutions in the State like the University of New Mexico and many others who generate all kinds of revenue in the name of Indians. We need to shift that whole dynamic. It needs to be the communities that are generating their own proposals together that we shift the gain so that were hiring, were contracting with UNM, send us a few professors out here. We can teach them a few things and maybe they can be helpful rather than them bringing in a few Indian people because their commitment is not to the community by in large. Their community is to UNM and the MCOs are committed to their own MCO. Your part of a State bureaucratic system. Under the last administration we saw all these political appointees, all these departments and the budget went up. Did that really improve anybody's care in the Indian community? Somebody show me, given all the monies gone to UNM, given all the monies gone to state, given all the monies gone to IHS. Can somebody demonstrate to me that there's been a significant improvement in our communities. I can't see it. Until we have the resources and until we have people who are sincere and committed to the health and well being of our community and our people and help us build our capacity, build our infrastructure it's not going to change. I'm not convinced we're better off now than 100 years ago. The point is, the Tribal communities who are ready and willing to take this on have to be resourced. So there has to be a fundamental shift in government . This administration that you represent and who you work for, the Governor needs to acknowledge and recognize that there are Indians in this State. The right this is to engage us. Not ignore us, not try and by pass us, everybody's been doing that including some other people in the last administration. If you want to do it right these are the people that you need to be talking too and who are successful at it. They have skill and knowledge and they can tell you what their experience has been with managed care organizations.
Ms. Weinberg	I don't disagree with a lot of what you said. I appreciate these discussions and I appreciate the frankness of these discussions. The Medicaid program (HSD) will be talking. We're going to continue to talk because we want change and we support change and improve care. And improve the lives of people and Medicaid can do that but of course we're limited. We're not a social program in terms of what you were talking about, that there's a lot of social determinants. Health is a determinant. Whether somebody can get a job and hold a job and that we want change for. The Secretary is really interested in that too. She's interested in people being able to function in the world and there are health issues that prevent that that's something within Medicaid that we can address or start to begin to address.
Group member/Quela	I had an eligibility question. Following off of Michael's comment, I think having a stakeholder and tribal involvement in the RFP process so that we can make sure that Managed care companies will be required to report on things like outcome, provider networks, access to care and making sure all of that check list is met before those contracts go out. Where we'd like to be able to offer assistance. We have a lot of expertise in that. If we're moving forward with this we want to make sure that we're actually getting them out. We haven't been able to data on that before. That's one thing we'd like to engage. Another question I have on that is on page 4 of the waiver, it's a chart illustrating populations that are going to be affected by Centennial Care waiver and populations that won't. There's some indication here for pregnant woman up to 185% FPL, for working disabled currently at 250, the waiver will apply to those below 138% FPL. So a couple of associated questions are that in 2014, is the Centennial Care waiver seeking to raft down eligibility to 138 or is this due to the expiration maintenance effort and is it planning to reduce eligibility for those categories? Does that mean that Centennial Care, for example won't apply to pregnant woman between 138 and 135? And working disabled people between 138 and 250?
Ms. Weinberg	So the thinking is that 2014, given the Affordable Care Act as it stands, that person's above or at 138 and above will be on the exchange and that's the adults. So the adults will be on the exchange where they qualify beyond the exchange. Group member Quela: So the State won't maintain eligibility for pregnant woman between 138 and 250? Ms. Weinberg, pregnant woman up to 185. There's a rule in the ACA that requires us that for woman up to 185 we are still responsible for their pregnancy related services. There's a group of woman which they only qualify for pregnancy related services and we're still responsible for that. Group member Quela: But it won't be full Medicaid? Ms. Weinberg, I'm not sure that the decision has been fully made on that because there's issues that if their on the exchange and they get pregnant and their up to 185, Medicaid would have to cover the pregnancy part of it and there's all that churn. Group member Quela: Adults up to 138 except for pregnant woman? Ms. Weinberg, yes, pregnant woman are different. Group member: What about the working disabled individuals currently up to 250? Will they have to go to the exchange? Ms. Weinberg, yes they would go to the exchange if they qualify. Group member: After 2014 do the expiration maintenance above the State won't maintain that. They won't be sent to the exchange? Ms. Weinbergh, that is the thinking now as illustrated in the waiver.
	Some of these are State plan amendments. Will that be a State plan amendment coming out of Centennial Care or will that be a separate process at the end of the maintenance effort?
Ms. Weinberg	State plan amendments, I really don't know. State plan amendments are State plan amendments. Group member: I guess my question is, is the authority to end the program and put these people on the exchange , is that due to maintenance effort or is that something that's being sought? Ms. Weinberg, I don't know. I don't know how to answer that.
Anthony	On any amendments, you will let the Tribes know? Ms. Weinberg, on State plan amendments? Anthony, yes.
Ms. Weinberg	We will notice the Tribe and Pueblos, the IHS and the ITU's on any State plan amendments. We do that 60 days prior to our submission.
David Panana	I know we talked about the whole contract, the RFP's and Tribes being able to review and get it out. Is it going to be e-mailed? How long are the Tribes going to be able to review it and send in their comments back? Do you know what the process is?
Ms. Weinberg	It's probably going to be a very tight process, a tight time wise process. I'm not sure exactly how we would get it out.
Theresa/Alicia	Tribes will have influence on the language that's being used in those contracts.
Ms. Weinberg	The consultations, the formal ones and the informal workgroups, I'd say a lot of what's in the concept paper and the waiver, Native Americans reflect what we heard here. We will certainly take your comments extremely seriously whether we take them all or change anything. I can't guarantee but we will take them and seriously consider them.
Alicia/Theresa	If you've got specific contract language that you would like us to consider, it would really be helpful, send it to us. Because it's going to be easier for all of us if we can look at it and we can say this makes a lot of sense, let's get this in and you can see when you review the documents. You've got your language in there. I know we've encouraged many of you before to send us stuff.
Anthony	In all fairness to the State, I've made this an open comment. We have had some concerns on issues but out of the 22 Tribes, if only 3 Tribes put anything in writing then how is that going to look for us as Tribes? So I say if you do have anything, put it in writing and if you do send something up put it in writing because we weren't at the Tuesday meeting or a lot of people aren't here. Once we see it on paper then we can print it out and address it. The important thing is some assurances from you in our communications then I think that is good. Going back to the Kewa questions on CSA's, how do we work with the MCOs by being designated as core service agency? I think we're designated because we're 638 as a core service agency,right ?
Ms. Weinberg	I may not be able to answer this one today. Let me make sure that I fully understand it.
Anthony	Just answer our questions and I think it would address a lot of the issues that a lot of Tribal people will have. Do you know why the MCOs and maybe the pharmaceutical companies are silent on your plan?
Ms. Weinberg	The MCOs all want to bid. Anthony, do they come from all over the place. Ms. Weinberg, some that are not here in New Mexico, yes.
Anthony	Not that we are and should be part of the State's contracting but going back to what Dave is saying, as long as we verbalize and put it in writing to you I think what your discussions should be with the MCOs I think this is what you're asking for because it's easier to yell from the audience and say this is what we want. The rest of us, maybe we just have a certain focus on it. But I think everything should be done in writing and with the Tribes, I don't think you're getting that response from some of our political groups. We're over here trying to be the political group on behalf and educate the others to what we're trying to do. We may be over stretching but we're just trying to educate and inform not only our partners but also the Indian Health Service.
Ms. Weinberg	We welcome it and you're in put in writing. It's helpful for us too. It's hard to take the notes.
Anthony	One of the things that we had discussed was, is it possible, in your view, a joint CMS and State meeting? What are your thoughts on that? CMS and the State being at the same table to deal with Native issues.
Ms. Weinberg	I think it's a good thing. We'd have to have very good solid goals and concerns. I think there would have to be a good solid purpose for it to have that. They talk to us and make sure that we're doing what we're suppose to doing in terms of our agreement with them on a variety of things regarding the Native American communities.
Alicia/Theresa	I think that would be a very helpful meeting. We've tried to get CMS to come here to be able to take them around the State. They keep telling us they have no travel budget.
Gary	That's a discussion that Anthony and I were having. Why can't we get the State and CMS to come and meet with the Corporation, jointly. Even extend invitations out to the other Tribes. Ms. Weinberg, I like the idea.
Anthony	Because a lot of CMS/State issues are questioned. Where’s the letter from you, Julie, saying that you were going to have another round of consultations.
Ms. Weinberg	Back in late 2010 we were required to put into our State plan a tribal consultation policy that came out of ARA. In the late summer of 2010 we sent a letter to all the tribes, pueblos and to the government showing them what we were going to propose as a State plan amendment. I was reviewing when we did send the amendment in and we got no responses back. According to what we wrote to the feds, I'm not involved in the detail to all of that, but the people who do that are very detailed. They said they sent out the proposed language on such and such date and we gave them 60 days for response. We got no response, we submitted it and the SPA (State Plan Amendment) was approved. And that is the official agreement between the Medicaid program and the Federal Government. On tribal consultation it is not the State statue tribal consultation. In the letter I was referring to the fact that under our State plan consultation agreement with the Federal Government we needed to properly notify the Pueblos, tribes and the ITUs. And because of the confusion between consultation and consultation and State and Federal we had the technicality where the ITU use to not get notified. So we re-notified both the Tribes and notified the ITUs of out intent to submit the waiver. We asked the Federal Government, CMS to not consider what we had submitted as the formal waiver. We had that 60 day window but we decided to also get additional public input and that's what we're doing. The consultation requirement that we're meeting that we are doing that caused the letter to be written in the first place. The one in the State plan which is a written notification. That's the consultation in the State plan and it's on Amendments to the State plan, changes in our regulations that would affect Native Americans. It says specifically Native Americans. Anthony, and the impact and the design and the implementation part (on natives), it does say that. That's why we're thinking, is what caused it (retraction) Ms. Weinberg, it was a technical oversight that caused us to write that letter to be sure that we do it right.
Group member/Quela	What are the dates? The starting day and the 60 days. June 7th was the kick off of the 60 days and 30 days for public input and you'll resubmit around August 6th. Anthony, so it goes into August?
Ms. Weinberg	Yes. The Tribes have 30 days from the date of the letter to respond formally if you want to do that. Anthony, do you have any parting comments? Ms. Weinberg, let's just keep talking and lets figure out some great things to do together under Centennial Care. I look forward to your suggestions and language for contracts. Anthony, and let's do it in writing. Don't verbally say it to Julie. Michael, we'd be happy to contract with any of the 3 MCOs for services.
Anthony	Your plan forces the issues to look at ourselves too. If Indian Health Service is doing such a good job then why did the disparities continue? We're not only thinking about changing things from the State but that's why the Tribe contracted. Now that we've contracted then it's the responsibility of these guys here to change whatever he's talking about and putting it in play. So I'm looking at the Board members here and you're job is no longer easy. Now you have assumed that responsibility and we do have some accountability and responsibility in terms of making sure that we have each avenue covered as far as this plan is concerned. Our issue, sometimes we're confused ourselves. Even the consultation part, we've been harping it as a work group for 10 days. Gary and I said enough of the consultation issue, we need to start looking at what going to happen here. In the Supreme Court decision, do you have any political insight on the Affordability Care Act? Where that may fly? And what does it do for all of that we're discussing here? Because I want the Board to understand. What happens if it doesn't go?
Ms. Weinberg	I don't know the answer to that. I attended a seminar in late April about it and someone whose very smart and understands the Supreme Court and the constitution and expanded for a long time about the actual issues and the arguments that were made on each issues. This person and a number of other people who are Supreme Court watchers and understand believe that the Medicaid expansion will stand. And they were making no predictions on anything else. Just because the Medicaid expansion stands, will the Congress fund it? An MPR, Nina Totanparg, whose been on the Supreme Court , she never predicts so I'm not predicting either. As far as Centennial Care goes , that's going forward because we're going to have Medicaid of some kind on January 1 2014 and as I said before we can't afford to continue the way we continue. We can't afford it in every sense of the word. We're talking monetary work, health work, the whole picture. We need to deliver health and pay for health care differently. For you all and your efforts, I hope you can do great things and I look forward where Medicaid can partner and help you do great things. We want to be there. But Centennial Care and the change in the way we pay for delivered services has to change, that has to go.
David Panana	Your tribal leader letter gave us until 11 to submit comments.
Group member	That 30 day for tribes to respond, was that established by the 2010 tribal consultation policy that you wrote earlier?
Ms. Weinberg	Yes it says the tribe has 30 days to respond. They may have counted in mailing time.
Anthony	I want to thank those of you that were here today. If you have any questions, there's a blog that Erick has. Your welcome to look at our blog. Our stuff as a work groups is in there. The work group meeting notes are also in there from last Friday. Again you have to understand that we do have some issues. You're talking about consultation with the Tribes, we have consultation issues with our own leaderships too. Hopefully we have the Corporation to help us out with some of the things that we're doing here and it expedites a lot of the paradigm shift or even anything that we want to talk to you about. It's a lot quicker going the way that we have, the Kewa Corporation set up and it's going to be quicker then Jemez because there's is still being worked on in terms of expediency with their Governor.
Ms. Weinbergh	Thank you for having us and thank you for the good discussion. I learned a lot.
Gary	Again, I want to thank you for coming. We look forward to working with the State Medicaid program and let's work on getting CMS and sit down with the State and us and see if we can go forward with this. I know we have a short turn around but as long as we have our inputs in there and considerations I think things will work out. With the Tribes and the Pueblos that are represented here I encourage you to go back to your leadership to have it in writing. Let's start doing that process instead of giving the verbal comments, let's start being proactive in this whole initiative. We need to start taking ownership to our healthcare and other things. Meeting adjourned.