Melanie Knight, Secretary of State

1. National Tribal Health Reform Implementation Summit:Tribes as Employers & Sponsors Melanie Knight, Secretary of State

2. Background • On March 23, 2010, President Barack Obama signed into law H.R. 3590, the Patient Protection and Affordable Care Act (ACA) • H.R. 3590 included language that incorporated S. 1790, Indian Health Care Improvement Act Reauthorization (IHCIA) • IHCIA included Section 157, Access to Federal Insurance, which allows a tribe or tribal organization carrying out a program under the Indian Self-Determination and Education Assistance Act and an urban Indian organization carrying out a program under Title V of IHCIA to purchase coverage for its employees from the Federal Employees Health Benefits Program (FEHB)

3. Section 157 Access to Federal Insurance • Notwithstanding the provisions of title 5, United States Code, Executive order, or administrative regulation, an Indian tribe or tribal organization carrying out programs under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) or an urban Indian organization carrying out programs under title V of this Act shall be entitled to purchase coverage, rights, and benefits for the employees of such Indian tribe or tribal organization, or urban Indian organization, under chapter 89 of title 5, United States Code, and chapter 87 of such title if necessary employee deductions and agency contributions in payment for the coverage, rights, and benefits for the period of employment with such Indian tribe or tribal organization, or urban Indian organization, are currently deposited in the applicable Employee's Fund under such title.

4. Section 157 Access to Federal Insurance • Title 5, U.S. Code, Chapter 89 – relates to Health Insurance • Title 5, U.S. Code, Chapter 87 – relates to Life Insurance • Note that the access to Federal Employees Health Benefits (FEHB) does not include dental, vision, retirement, disability, long-term care

5. How will this Impact Indian Country? • Improved access to health care coverage and services for employees of Tribes, Tribal organizations, and urban Indian health programs • Potential for cost savings to the employer • Increased flexibility and variety in choice of plans for employees to purchase through FEHB • Could be utilized as a employment recruiting tool

6. How is Section 157 being Implemented? • Tribal Consultation was initiated through a joint Dear Tribal Leader on October 5, 2010 from Indian Health Service (IHS) and the U.S. Office of Personnel Management (OPM) • The joint letter included a questionnaire regarding current premium costs and how Tribes currently administer health insurance programs • Responses were submitted to IHS and OPM on November 5, 2010

7. How is Section 157 being Implemented? • OPM and IHS have convened various forums/presentations for Tribal input • 125 Tribes responded to the questionnaire and the data indicates: • 50 % of respondents currently pay higher health insurance premiums than those offered by FEHB • 25 % pay about the same, but plan to switch to FEHB because it offers better benefits • 25 % have lower premiums than those in FEHB; among this group, some will consider switching to FEHB for better benefits • Most tribes have a plan year based on the calendar year • OPM and IHS are currently developing plans/consultation to address the technical and operational issues involved with expanding the FEHB program into potentially 594 additional entities

8. Tribal Considerations • While the plain language of Section 157 does not limit FEHB plan access to employees “carrying out a program under the ISDEAA, or an urban Indian organization carrying out a program under Title V of the IHCIA,” it may be interpreted that way • Should it be interpreted in such a way, the administration of multiple health insurance programs would be extremely burdensome • Tribes have voiced support for following the plain language of Section 157

9. Tribal Considerations • Other considerations include: • Will the FEHB program be extended to employees of Tribally owned/operated enterprises? • Will the FEHB program be extended to elected/appointed officials? • How much control/participation will Tribes have in administering health coverage for their employees (enrollment assistance, customer support, etc.)? • What are the coverage options for terminated or retired employees?

10. Tribal Nations as Employers • In addition to FEHB implementation, several other provisions of the Affordable Care Act affect Tribal Nations as employers, some of which are dictated by the Tribe’s number of employees • Less than 50 employees = small employer • 50 employees or more = large employer

11. New Coverage Requirements for All Employer Plans • Cannot deny coverage to enrollees under the age of 19 with preexisting conditions (expands to everyone starting in 1/1/14) • Cannot have lifetime or annual limits for the dollar value of "essential health benefits" except that for plan years beginning before January 1, 2014, these plans may impose annual limits on "essential health benefits" to be defined by the Secretary of Health and Human Services as "restricted" • Strong restrictions on the use of rescissions (when insurance companies cancel policies)

12. New Coverage Requirements for All Employer Plans • Will be required to offer coverage of dependents who are children, until the date the child attains age 26, regardless of whether the child qualifies as a dependent for tax purposes, is married, or is a student ( before 2014 plan years, only if the adult child is not eligible for other employer-sponsored health plan coverage) • No discrimination based on health status • Elimination of excessive waiting periods • Development & utilization of uniform explanation of coverage documents and standardized definitions

13. “Grandfathered” Employer Plans • “If you like your health coverage, you can keep it” pledge led to the creation of “grandfathered” health plan rules • ACA provisions that do not apply to grandfathered plans: • Coverage for preventive health services without cost sharing • Independent appeals process • Ban on discrimination based on salary • Choice of primary care provider • Coverage protection for participants of clinical trials

14. Maintaining “Grandfathered” Status • To be grandfathered, an insured or self-funded health plan must have existed on March 23, 2010 • Grandfathered status is on a benefit package-by-benefit package basis (an employer can have some plans that are grandfathered, & others that are not) • Plans will lose their grandfathered status if they choose to make significant changes that reduce benefits, or increase costs, such as: • Eliminating all (or substantially all) benefits for a particular condition

15. Maintaining “Grandfathered” Status • Plans will lose their grandfathered status if they choose to make significant changes that reduce benefits, or increase costs, such as (CONTINUED): • Increase in % of a cost-sharing requirement, such as coinsurance, above the March 23, 2010 level   • Increase of a fixed-amount cost-sharing requirement, other than co-pays, (deductibles or out-of-pocket limits) that exceeds a set amount • Increase in co-pays by an amount that exceeds a set amount • Decrease in contribution rate by employer or employee organization that exceeds a set amount • Change in annual limits • Changing Insurance Companies (for a self-funded plan, this does not include changing plan administrators)

16. Special Provisions for Small Employers • Starting in 2014, small employers with less than 100 employees can shop in an Exchange which will offer a choice of plans that meet certain benefits and cost standards • Employers with fewer than 50 employees are exempt from new employer responsibility policies (they are not subject to assessments if their employees get tax credits through an Exchange) • Various Employer Tax Credits (not applicable to Tribal governments but may be applicable for not-for-profits)

17. Special Provisions for Large Employers • Starting in 2014, large employers will be subject to payments to the federal government for not offering “qualified” health insurance to their employees and dependents (the “play or pay” requirement) • Qualified coverage = comprehensive (paying at least 60 % of health care expenses) and affordable (costing less than 9.5 % of employees’ household incomes). • If an employer doesn’t provide qualified coverage AND if their employees purchase coverage through a state exchange, employers will have to make an “assessable payment” of up to $2,000 for every full-time employee beyond the first 30 employees

18. Helpful Resources • www.healthcare.gov • www.healthreform.kff.org • www.opm.gov • www.rwjf.org/healthpolicy

19. Questions/Comments?