Pueblo of Jemez reponse to Tribal Consultation on Centennial Care

Tribal Consultation

New Mexico Human Services Department (HSD)

March 20, 2012

Indian Pueblo Cultural Center

The Pueblo of Jemez opposes the NM Medicaid modernization plans as detailed in the Centennial Care concept paper, issued February 21, 2012.

The Centennial Care concept paper is presented under the guise of “ensuring care of New Mexicans for the next 100 years, but its resultant product is to reduce costs by limiting medical services and care coordination to all New Mexicans. Specific to Native Americans, those same limitations are imposed, along with a direct threat by the state to tribal sovereignty and authority. This assessment is based on the following:

1. Threat to Tribal Sovereignty and Authority

PART I: P.L. 93-638 law authorizes tribal nations to contract their shares of health care funds that would have been spent by the IHS on their individual tribal membership. This law authorizes individual tribal nations to then determine and design the best health care system for that tribal population. Most tribes use a series of surveys, health data and expenditure analysis, prevalence data and a number of other health measures to determine the shape and scope of their tribal health system, for which the tribe then conducts financial planning. A part of that financial planning includes 3rd party revenue collection.

NM HSD’s Centennial Care concept paper poses a direct threat to the intent of PL 93-638 and tribal sovereignty in the following ways:

• The State describes a fully MCO run Medicaid system for the state. Although there is a recommendation in the Native Americans section that the MCOs selected by the state be required “to contract with the IHS and or 638 clinics as part of their network…” (27), there is no indication as to the timeframe or the scope of the relationship. Thus, there is no confidence that the tribal health clinics will immediately be made an integral part of the health care of our Medicaid eligible tribal members.
• The Centennial Care paper indicates that when a Medicaid eligible individual applies for Medicaid, he/she must select a health plan (MCO). This means that the individual automatically goes into the MCO “system” because fee for service, which is the practice utilized by tribal health clinics, will no longer be an option.
• The MCO’s will stratify our Medicaid eligible population and conduct care coordination through the MCO’s designated system. Following the state’s plan, our patients, in the interim while the MCO is attempting to develop effective tribal contracts and coordination, will be taken out of our tribal system.
• The Centennial Care paper describes the state’s intent to eliminate the “opt-out” provision for tribes, similar to what has occurred with other MCO’s in the state (CoLTS). Under this scenario, the tribe cannot proceed with its own determined care coordination on behalf of the patient, but must stick with the MCO directed care.

PART II: In 2000, the Indian Health Care Improvement Act was amended to include Public Law 106–417, also called the ‘‘Alaska Native and American Indian Direct Reimbursement Act of 2000’’. This act allows for direct billing of medicare, medicaid, and other third party payors, and to expand the eligibility under such program to tribes and tribal organizations. The ACA of 2010 contained the reauthorization of the Indian Health Care Improvement Act (IHCIA), not only confirming, but also expanding tribal authority to plan and design tribal health systems and to direct bill CMS for reimbursement.

• Under the state plan, the selected MCO’s will stratify our Medicaid eligible population and conduct care coordination from there through the MCO’s designated system.
• Based on the description, it is a very real concern that Indian health programs could find themselves without an ability to collect from any source for services rendered at tribal health clinics for Medicaid eligible patients.
• This would leave the Indian health programs with not only a loss of potential new revenues, but also an actual reduction in revenues from prior levels (where such claims had previously been paid by Medicaid).

• Medicaid makes up approximately 70% of our annual 3rd party revenue.
• The Pueblo of Jemez uses Medicaid as a 3rd party resource to supplement the cost of care for our patients through our tribally designed health system.
• The loss or reduction of this significant resource would negatively affect our tribal health care delivery system either by preventing us from maintaining current service level, which is partially supported by Medicaid reimbursements, or by preventing us from expanding our billable service delivery.
• Such an outcome would be directly counter to the Congressional intent in enacting IHCIA and Public Law 106–417: Alaska Native and American Indian Direct Reimbursement Act of 2000 (Exhibit A).
• Even if a tribe were immediately brought into the MCO via contract, it has been the experience of tribes working with MCO’s in the state that new MCO’s do not pay in a timely manner in the general in the first year of business.
• The state’s plans for a “proliferation of patient centered medical and health homes” (pg. 14) would bring tribes into the care coordination system, but are considered long range plans. The Centennial Paper describes the MCO’s as being initially responsible for basic care coordination and health homes being developed over the next several years.
• The state’s plan is culturally inappropriate to the Native American population of this state.
• Tribal health clinics already offer a “health home” to our tribal members.
• Under the state model, care coordination would begin through an initial phone interview with an MCO employee. This is concerning primarily because technology assessment of the state indicate that the population with the least amount of telephone access are rural New Mexicans, specifically Native Americans.
• Clients will go through a “stratification of risk”, which the Centennial Care paper indicates will be based on “evidence based, best practices”. Tribal data concerning standards of care and improved health outcomes are not included as part of the MCO consideration, though they are part of the tribe’s consideration for care coordination.
• Further, the state’s plan indicates that after the initial phone interview, the client will then be assigned a “risk group care coordinator” who will complete a comprehensive assessment. Based on the description of the need to interview family members and care givers, this interview will require a face to face visit.
• Many of our tribal communities use English as a second language. Communicating health concerns, discussing medical terminology, diagnosis, treatments plans and family dynamics is most effectively done by our tribal clinic based benefits coordinators, not the MCO.
• This is an area that current MCOs have struggled with and which will simply not be attainable under the proposed MCO run Medicaid model.
• In fact, our tribal benefits coordinators are providing the intensive care coordination for the existing MCOs in the state for our tribal members.
• Finally, at the point the MCOs shift the care coordination responsibility to the health home site, the Centennial Care paper does not indicate if and how the MCOs will be required to properly reimburse the tribes for that care coordination service. It appears that moving forward, as it occurs with current MCO relationships, the percentage of the capitation rate that the MCO’s receive for care coordination will not be passed on the entity actually conducting that coordination.
• The Pueblo of Jemez offers both State and Tribal remedies:
• State Remedies
1. Mini-Grants: The Centennial Care paper describes that the state will establish two pilot site projects. One is to develop health homes in pilot sites in Albuquerque, and the other is related to developing bundled rates for hospital stays. This urban location of the first pilot project is out of touch with NM, which is primarily rural.

By the January 2014, the Pueblo of Jemez, like many other tribal health centers will have its own provider network, operating very much along the same lines as a managed care entity.

Therefore, the Pueblo of Jemez proposes that the state issue mini-grants to tribal health entities to establish tribal health homes as pilot sites in the first year of this modernization effort. The tribal health homes would fully participate as partners in the state’s plans for Medicaid modernization, including:

1. Tribal sites will receive IT infrastructure on par with the other pilot sites for access to such things as the Medicaid Management Information System, which the state pays for existing MCOs;
2. Tribal sites will have access to the consolidated credential and re-credentialing processes;
3. Tribal sites will have access to (if desired) the state’s contract Third Party Administrator;
4. Tribal sites will direct bill for Medicaid.
1. The state must retain the “opt out” provision for tribes for all state- MCO relationships.

These first two remedies to alleviate many concerns related to tribal sovereignty, protect direct reimbursements to tribes and ensure culturally appropriate health care delivery.

3. Tribal Participation must be required in the development of the RFP’s for the MCO’s and on the selection committee of the MCO’s.
4. Tribal Subject Matter Experts (SME) must participate in selection or evaluation of proposed evidence based, best practices identified as applicable to Native American populations.
5. There must be equitable tribal representation on the governing board that will provide direction and oversight to the state’s Modernized Medicaid system.
3. Tribal Remedy
1. CMS Tribal Consultation (Exhibit B): Unlike any other population in the State of New Mexico, tribes have the option to work directly with CMS. Specifically, under the CMS Tribal Consultation Policy, signed into effect in November 2011: “…consultation must occur on an ongoing basis so that Indian Tribes have an opportunity to provide meaningful and timely input on issues that may have a substantial direct effect on Indian Tribes.” (page 3) If the State of New Mexico continues, as planned to seek CMS authorization and waivers to implement its Medicaid Modernization as described in the Centennial Care document, the tribes are within their authority to dispute the matter directly to CMS; tribes may request that CMS facilitate mediation between the tribes and the state, and deny any waiver request from the state that diminishes tribal sovereignty or attempts to limit federal law.