NMICoA HC Medicaid Coaltion informal discussion comments

NMICoA Health Committee

Medicaid Coalition Discussion with

Centers for Medicaid and Medicare

August 14, 2012

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

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

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

Respectfully Submitted by

Erik Lujan
Volunteer Advocate