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

January 25, 2013

 Kitty Marx

Director, Tribal Affairs Group

CMS

Robert Nelb

Project Officer, NM Waiver

CMS

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

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

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

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

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

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

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

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

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

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

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

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