Tribal Programs response to Streamline Application and Consultation session

GENERAL COMMENTS AND SPECIFIC STREAMLINE APPLICATION COMMENTS

By TRIBAL WORKGROUP

General comments on the streamlined application for Medicaid, Health Exchange (Marketplace), Medicare Savings Plan, Supplemental Nutrition Assistance Program (SNAP), Cash Assistance and Low Income Home Energy Assistance Program (LIHEAP) based on the comments made by Native American  workgroup comprised of Kewa Pueblo Health Corporation, Santo Domingo, Zia and Acoma CHRs as a follow-up to the Tribal Consultation meeting held on August 29, 2013.   

1. The Affordable Care Act of 2010 requires a simple and streamlined application for Insurance (Insurance Exchange/Marketplace) and Medicaid and CHIP.  The State of New Mexico is violating the ACA and all previous statements, planning information and documentation presented in tribal consultation presentations by announcing a Separate application for the Insurance Exchange or Marketplace. Under the ACA, an applicant need only apply once and eligibility for the Marketplace, Medicaid and CHIP will be determined.  States must provide one single application and have an interface between the two programs so that a person can apply for either one and get enrolled in the Right Coverage. The State has previously announced ‘no wrong door’ access to coverage and now we have opened up ‘another door’. The ACA envisions a method for an electronic match system to verify applicant records including the IRS.

The State is to meet the Eligibility process and all the requirements under 42 CFR 435, Subpart J for processing applications, determining and verifying eligibility and furnishing Medicaid.  An alternative application developed by the State should follow section 1413(b)(1)(B) of the ACA and approved by the Secretary which may be no more burdensome than the streamlined application developed by the Secretary. Our comments and recommendations below will expose the cumbersome and conflicting statements in the design of the State’s application.

2. The State of New Mexico has ignored the Indian Protections in its Streamlined Application by not offering ‘choices’ and/or ‘options’ available to Native Americans under the ACA, IHCIA and acceptance in the implementation of the Indian provisions.  An example would be section 1932 of the Social Security Act which identifies requirements for Medicaid managed care plans to explain reasons for denying a request for a service or denying payment for a service already received and is to include information on beneficiary protections related to appealing a denial of coverage or payment. This application does not have such language, notice or description of such denials or appeals process. (rules on the content of written denial notice are in 42 CFR 438.404)
3. Outreach and Enrollment is required under ACA to vulnerable and underserved populations who are eligible for Medicaid as a condition of federal funding. The State is to meet all the requirements of 42 CFR 435, Subpart M relative to the Coordination of eligibility and enrollment between Medicaid, CHIP, Exchanges and other insurance affordability programs. This requirement is not being met by the State. The State of New Mexico is working in silos with the Exchange and Medicaid enrollment with no communication and no Medicaid enrollment funding for those newly eligible for coverage and those living in rural areas and are of racial and ethnic minorities. As Essential Community Providers, the Indian Health and Tribal Health Centers should be PE determiners and NOT only Hospital based facilities. The identification of a Native American or “Indian” should be identified in the Application if the “Indian” is ‘Indian Health Service Enrolled’ at existing Indian Health Service or Tribal facilities.
4. Identified ‘Indians’ have certain ‘Indian’ income which is NOT counted for Medicaid and CHIP eligibility including money from use of Indian land and trust rights and money from items of cultural and traditional value. The application makes not reference of opportunity to accommodate or include excluded income statements.
5. All the ‘Assistance Programs’ as called in the Application should be designed as complete self-contained and stand-alone sections, color coded, with separate and distinct symbols and with self –controlling electronic edits in each mandatory field. There are no time dates for approvals by the various sub-agencies and tracking lists to be monitored by the applicant or advocate. This is an application for enrollment to become eligible for ‘Assistance Programs’ and not for confusing Enrollment advocates and applicants.  The application is to be simplified not 16 pages to confuse and frustrate applicants from enrolling.

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Specific Streamline Application comments, suggestions and recommendations by sections as presented by the State of New Mexico:

Page 1- The statement is made that if an applicant does not qualify for Medicaid the application will automatically forwarded to the Exchange.  The Native American has a choice (not automatically enrolled) to enroll in the Exchange and this language and planned separate Exchange application will not be the correct statement nor action for this section. In Bold letters have this statement of Native American has options and are exempt from the individual mandate BEFORE getting started with the application.  

Recommend a ‘yes’ or ‘no’ box to allow for native to have an ‘option’ to enroll in Exchange.

Recommend symbols for each program, color coded, and electronic edits in each mandatory field with agency addresses or expected application approval time frames.

Section 2- Recommend simple language on ‘authorized representative or guardian’.  Also include a special section for Medicaid.  Not clear on what benefits/programs applicant is applying for.

Section 3- make Race and Ethnicity field mandatory and not optional. Include alien and immigrants. Combine last two columns on taxes as both are same question. Redo the entire statements at the bottom of grid as the language is confusing, not proper English, conflicting statements and do spell check.  Recommend an address or website to send information if you want to keep this verbiage.

Section 5- Define treatment facility- rehab, detox, institution-state hospital, Define PACE and under Other- include short term/long term facilities.

The question on ‘anyone receiving SSI’ the State should already know this based on existing State data base that should be shared among sub-agencies.

What is the legal purpose of ‘is anyone a victim of Family Violence’ question?

The question of ‘anyone in the household pregnant?  Who? Move this question to Section 9.

On the question of ‘how many babies expected from this pregnancy and due date ‘. Delete from application as 3 month retro coverage is in place.

On the question of ‘Name of Father of the unborn’?  Leave out in application and is requested in another section of application.

On the question of ‘Freedom of Choice for home and community based services waiver’?  Define and move to Nursing home section.

Section 6 – narrow the column on hours worked. Increase the ‘Income from’ column.  Under ‘other income’ section define and include exclusion of ‘Indian income NOT counted’ such as use of Indian land and trust rights, per cap, money from cultural and traditional value.  Where are the Indian protections noted in the application such as cost sharing exemptions, resource and estate recovery protections, managed care protections? How will ISD office know of such protections and how will such ISD staff be trained?

Section 7- Include a section to ‘income statements’ that can be made by Indian applicants declaring their income as some do not file taxes.

Section 8- This section has legal implications on allowing HSD rights to collect child support from absent parent. There is coordination needed between tribal courts and state courts on this section.

Section 9 – this is an Exchange question. Separate application and why? Move Section 5 to Section 9 and combine.

Section 11- Offer another  box for the Federally required ‘opt in ‘ option for Natives after changing the Application date to October 1, 2013 on top of this section and rewording and defining benefits and categories on the introductory language.  Another box for FFS as Natives can ‘opt in’ to both Medicaid and Exchange programs.

No need for a Stop Sign if you have self-contained and complete sections for each program.

Section 12 – this is same questions for QMB and institutional application.

Section 13- Define on top as introduction that his section is for Food stamps, SNAP/TANF.

What is the purpose for round trip mileage for dependent care?

Court ordered child support needs more space and sporadic support notation has no available field.

Best description of Rent type has a box for- Homeless. Replace Homeless with Owned home. Public housing should include type of house and conditions.  The Utilities is already asked for in section 14. Add cell phone to telephone box.

Section 14 – ask for Receipts as payment documents.

Section 15- has smorgasbord of questions for food stamps, workforce enforcement, fleeing felons, veterans, tribal TANF.  Reassign to the self-contained sections that we are recommending after you define purpose and need of these questions.

Section 16 –Signatures.

Reword, redefine, have paralegals not attorneys review this section with those who have knowledge of Indian law. HSD is given ample authority on release of information, ‘proof of things’, limited authority to send applicant information to unknown agencies, payback to HSD for unauthorized benefits, explanation of benefits in native language is never done, Estate Recovery (Federal laws protections in place for residents living on federal lands), assignment of all rights to HSD with no explanations.  

After going through this confusing application the last statement states ‘to withdraw your application for any program, initial the box of the program and it give the applicant a list including NMHIX.  All Native applicants can ‘opt in’ nor are they mandatorily required to enroll.

Recommend assign signatures to each self-contained section.

Section 17- states ‘we will help you fill out a voter registration application’ at ISD.  Is there someone at these offices to assist?  Recommend a box to be check off for those already registered.

Employer Coverage Form can be done by employers.