Position Statment NM Tribal Opposition to Centennial Care

Position Statement

New Mexico Tribal Opposition to Centennial Care

January 2013

Introduction:

On April 25, 2012, the State of New Mexico submitted its request for a Section 1115 Research and Demonstration waiver that would, if approved by CMS, result in a 100% Managed Care Organization (MCO) run Medicaid system. The state has named this plan Centennial Care.

Over the course of time, the state of New Mexico Human Services Department (HSD) has convened several meetings with I/T/Us (Indian Health Service/Tribal/Urban Health) to discuss the advantages of its plan. The I/T/Us opposed the plan, however. Despite repeated attempts to get HSD to collaborate with I/T/Us to redesign specific elements of the plan, the two entities reached what the I/T/Us considered an impasse. Because the plan was submitted over I/T/U objection to the Centers of Medicare and Medicaid (CMS) for review and approval, several tribal leaders called on the tribal consultation policy of the CMS to compel their involvement in tribal consultation regarding the waiver.

On January 23, 2013, CMS conducted the second of two tribal consultation sessions with the I/T/Us of New Mexico. At this session, HSD staff attended and remained stalwart in the design of Centennial Care as proposed. Similarly, the I/T/U’s maintained their opposition to the Centennial Care proposal. CMS has declared that the review team will take the positions of both sides under consideration and will work to make a decision regarding proposal.

Recommendations:

Although I/T/Us have different needs and different health delivery systems, the entities have compromised to narrow the redesign elements to the Centennial Care Plan to the following three points:

1. Eliminate requirement for Native Americans to be automatically or mandatorily enrolled in a Managed Care Organization. This is to ensure that Native American’s retain their right to choose their own health care system, including the choice to “opt in” to an MCO. However, only 15% of current NA Medicaid eligible individuals have chosen to “opt in” to an MCO.
2. Reject New Mexico’s proposal to eliminate the retroactive eligibility for Medicaid beneficiaries. CMS heard and responded to this concern and has tabled this request from the state. It will not be approved in the waiver this time, but remains a priority issue for I/T/Us.
3. Preserve the mechanism for payment of Medicaid claims for Fee For Service directly between the IHS/Tribal/Urban (I/T/U) and the State of New Mexico at the existing all inclusive OMB rate. Under the current system, when I/T/Us provide a service to a Medicaid eligible patient, the state’s fiscal intermediary makes payment promptly and in full. This system is working and working well. However, the position of the MCO as a “middle man” will create payment issues and administrative burdens that are likely to delay, limit or even eliminate the I/T/U’s ability to collect the Medicaid revenue owned.
4. Require that the protection against cost sharing for all Native Americans enrolled in New Mexico’s Medicaid program is clearly written in the state’s waiver; this is regardless of whether they seek care at an IHS or non-IHS facility. Currently, HSD indicates that this issue is “understood” in the application, but the tribes continue to request its clear delineation in the waiver.

The I/T/Us of the state of New Mexico have worked together to remain unified in opposition to the Centennial Care Plan. Further, the tribes have worked with NMICoA (New Mexico Indian Council on Aging), the Indian Health Service- Albuquerque Area Office (AAO) and the Albuquerque based Center for Law and Poverty to develop and communicate a holistic view and opinion of the potential negative impact of Centennial Care.

Overview of Negative Impact:

Centennial Care poses a significant threat to a health care delivery system’s ability to recover third party resources because it requires that the health system work through a Managed Care Organization (MCO) in order to be eligible for reimbursement for services delivered to Medicaid eligible individuals. The care provided today in I/T/U clinics will be shifted to MCO providers, which are located in urban areas, requiring our Native Americans to travel long distances for health care.

For example, in the Pueblo of Jemez, of the patients with some form of 3rd party coverage, 50% are Medicaid eligible. When Jemez health providers treat these patients, the Pueblo of Jemez is able to recover approximately $319/patient/visit, which is called the OMB (Office of Management and Budget) all inclusive rate. Through this process, which is called Fee For Service (FFS), the Pueblo of Jemez collects approximately $1,807,504 Medicaid reimbursements annually. With those funds, Jemez pays physicians and dentist salaries; procures physical therapy, behavioral health/substance abuse, optometry, podiatry and pediatrician services to be delivered in the Pueblo of Jemez, as both a matter of convenience and to provide a continuum of care for our population. This Medicaid reimbursement comprises approximately 73% of the total annual third party revenue. This scenario is similar for other tribally managed health systems.

Tribal health systems depend on that revenue to support a tribally developed health delivery system, as authorized under P.L. 93-638 Indian Self- Determination and Education Assistance Act. If tribes are required to work through an MCO to collect this third party resource, it stands to reason they will also have to assume the health care standards and methods required by the MCO. Tribal health representatives believe this poses a threat to tribal sovereignty. Further, relationships with existing state MCO contractors have resulted in delayed or nonpayment of submitted invoices and failure of the MCO’s to provide proper health care for our patients. Thus, tribes are reasonably concerned that under a 100% MCO Medicaid system, MCO’s will continue to deny or delay IHS and tribal claims, in whole or in part. This will cause I/T/Us to experience reductions in third-party collections, to devote greater administrative time and effort to claims processing and to provide even more extensive care coordination, where the MCO’s fall short. This is the experience of tribal health clinics, but they are not alone.

Regardless if a Native American receives health care through a tribal or Indian Health Service health center, the significant threat posed by the Centennial Care Plan remains the same. Recently, Richie Grinnell, IHS Albuquerque Area Director, put together the attached map to demonstrate how important Medicaid revenue is to the various service units (SU) across the state. With these Medicaid revenues, the Indian Health Service pays for the salaries of medical providers and support staff, purchases pharmaceuticals, supplements Contract Health Services, and supports facility infrastructure.

IHS has also had negative experiences with state MCO contractors. New Mexico has implemented 3 similar programs over the last 15 years and each of these implementations has resulted in a substantial negative impact to the cash flow to Indian Health Service (IHS) facilities, both tribal and federal.  100% of these managed care attempts for Native patients has resulted in lost revenue to IHS federal and tribal programs.

• In 1997, NM Medicaid began their Salud Managed Care programs and Native Americans were assigned to Salud Managed Care organizations that didn't have facilities in the tribal communities.  IHS federal facilities lost an estimated $2 million dollars in reimbursements in 1998 due to that change, but continued to provide the services to the patients.  
• In 2008, New Mexico awarded the statewide contract for behavioral health services to OptumHealth. IHS/Tribal facilities struggled to obtain contracts and payments from

Opturn.  By December, 2009, NM HSD issued OptumHealth a Letter of Direction requiring immediate payment to IHS/Tribal facilities. In March 2010, OptumHealth still owed federal IHS facilities over $900,000 that was significantly past due.

• A more recent example is the NM Coordinated Long-Term Care (COLTS) program implemented in 2009.  The financial systems of these COLTS contractors did not have the ability to track payments owed. IHS was asked to supply monthly reports to each of the Managed Care programs as to what was owed with upwards of $300,000 over 60 days past due for over a year.

Policy Issues:

Substantively, the following must be understood by law and policy makers.

New Mexico Centennial Care:

• Poses a direct threat to Tribal Sovereignty and other Federal Authorities. This plan was developed without proper tribal consultation as required under New Mexico’s State-Tribal Collaboration Act,  N.M.S.A. 11-18-3(C) (2009), which mandates the state to “make a reasonable effort to collaborate with Indian nations, tribes or pueblos in the development and implementation of policies, agreements and programs of the state agency that directly affect American Indians or Alaska Natives.” This plan’s design will make collection of this valuable 3rd party revenue so burdensome, that it will in fact limit the collection of that revenue.

• Limits access to Health Care for Native Americans, as many live in rural areas where MCO’s, who are bidding for the Medicaid business, do not have offices. When MCO’s do not have offices near tribal communities, their staff cannot become acquainted with the clients and the community. This limits the MCO’s ability to provide the required care coordination. You may be interested to know that one tribal community, Ramah, was directly affected by such a situation. In that case, the MCO assigned providers in Farmington to Ramah patients.  

• Does not result in significant cost savings to the State for health care to Native Americans. NM is paid 100% of federal funds, called FMAP, for services delivered to Native Americans at Indian Health Service connected facilities; this includes tribally managed health centers. Put simply, this means that all tribal and IHS facilities that bill Medicaid for services that Native Americans receive are reimbursed with 100% federal funds, instead of a federal-state shared basis like non-IHS facilities. 

Under Centennial Care, for every Medicaid eligible patient, including the Native American, who is enrolled with an MCO, New Mexico Medicaid Assistance Division (MAD) will pay the MCO upwards of $1700/patient/month (this is the rate paid to the state’s Behavioral Health MCO). This amount is called a per patient per month (PMPM) or capitated rate. This will be paid monthly regardless of whether the patient utilizes or has access to the MCO’s services. This means that the MCO will get a monthly payment from the state for the Native American Medicaid eligible patient, PLUS the FMAP. Clearly, there is no savings to the state when a Native American enrolls into an MCO.

• Is culturally inappropriate to the Native American population of New Mexico. Unfortunately, HSD made no effort to review health outcome data from the I/T/U health systems prior to developing the Centennial Care Plan. As a result, critical health data was not passed onto MCO’s and is not reflected in the service delivery plans designed by the MCO’s in response to the state’s RFP. Therefore, I/T/Us have no confidence that the MCO’s can train their care coordinators to properly respond to tribal patients and community needs in an effective manner. Further, the health systems proposed by the MCO’s will reflect the best interest of the MCO, including profitability. I/T/U’s are less concerned with profit, and more concentrated on appropriate health care delivery and generating funds to cover the cost of that system of care.

The I/T/Us of the state of New Mexico respectfully request that you consider their position and that you use your significant influence as an elected official to communicate their position to CMS. The request is that CMS either incorporate the three point redesign identified by the I/T/Us into the waiver, or deny the entire Centennial Care waiver proposal.

Should you have questions or require additional information, please contact any one of the following individuals:

Evelyn Blanchard, Organizer
New Mexico Center on Law and Poverty
evelyn@nmpovertylaw.org

Maria Clark, Director
Pueblo of Jemez Health and Human Services
Maria.clark@jemezpueblo.us

Erik Lujan, Health Committee Volunteer
New Mexico Council on Aging
Elujan78@gmail.com

Quela Robinson, Staff Attorney
New Mexico Center on law and Poverty
quela@nmpovertylaw.org

April Wilkinson, Program Specialist
Pueblo of Jemez
lwilkinson@jemezpueblo.org

Anthony Yepa, Director
Kewa Health Corporation
ayepa@kp-hc.org