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The Indian Addendum

The Indian Addendum. Ensuring Meaningful ITU Provider Access to Health Insurance Exchanges Presented by: Elliott Milhollin NIHB 28 th Annual Consumer Conference. Key AI/AN Exchange Benefits. Provide new revenue for Indian Health Programs

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The Indian Addendum

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  1. The Indian Addendum Ensuring Meaningful ITU Provider Access to Health Insurance Exchanges Presented by: Elliott Milhollin NIHB 28th Annual Consumer Conference

  2. Key AI/AN Exchange Benefits • Provide new revenue for Indian Health Programs • Allow billing of insurance for the Indian Health Program services • Reduce Contract Health Services expenditures by allowing billing of insurance plans for services supplied by CHS providers • Allow tribes to use federal health care dollars to pay premiums on behalf of members • Federal premium subsidies are available for low-income individuals on sliding scale up to 400% of the Federal Poverty Level (FPL) • Indians enrolled in Exchange plans would be exempt from all cost sharing when served by an I/T/U or CHS provider • Open enrollment periods

  3. How Would it Work? • Outreach and Education • Develop a premium payment model • Contract with Qualified Health Plans (QHPs) • AI/AN beneficiary receives services at an ITU or other in-network provider and the costs of those services are billed to the Plan. • AI/AN Cost-Sharing Exemption

  4. Network Provider Status • Unless ITU are offered contracts with Qualified Health Plans, AI/AN will have little incentive to participate • Section 408 of the Indian Health Care Improvement Act Requires federally funded plans like the Exchanges to offer to contract with ITU providers • Essential Community Provider definition includes tribal and urban programs

  5. What Does the Indian Addendum do? • Provides a comprehensive list of all of the federal laws applicable to contracting with I/T/U providers and sets them out all in one place • Becomes a standard contract provision in any contract between an I/T/U provider and a Qualified Health Plan • Reduces disputes between ITU and QHPs • Streamlines contracting between ITU and QHPs • Allows meaningful ITU provider access to Exchange plans

  6. Why we need an Indian Addendum • QHPs may be unfamiliar with ITU providers and with their federal rights and responsibilities • QHPs will likely contain standard contract language that may conflict with these rights • Without a standard Indian contract addendum, disputes may arise between QHPs and ITU providers as to federal requirements

  7. The Indian Addendum – Demonstrated Success • Modeled on the success of the Indian Addendum used in the Medicare Part D Prescription Drug Program • CMS regulations require Part D plan sponsors to offer network contracts to I/T/U pharmacies in their service areas with a standard Indian contract Addendum. 42 CFR 423.120 • This mechanism has proved to be efficient, effective and easy to use for both Part D plan sponsors and Indian health pharmacies; it is now a standard component of the Part D program.

  8. Key provisions in the Indian Addendum • No cost sharing payments for AI/AN served by I/T/Us and no reduction in payments to I/T/Us that would otherwise be due from the enrollee (ACA §1402(d)(2) (42 USC 18071(d)(2)) • IHS and I/T/Us may limit the population they serve 42 CFR Part 136 and Sec. 813 of the IHCIA, 25 USC §1680c • Federal Tort Claims Act coverage for IHS and extended by law to Indian tribes/tribal organizations and some urban Indian organizations, which precludes a plan from requiring acquisition of private malpractice insurance, a frequent provision in network contracts • Preservation of Sovereign Immunity

  9. Key provisions in the Indian Addendum • A comprehensive list of federal laws that are generally applicable to I/T/Us. • These include the Indian Self-Determination and Education Assistance Act, the Indian Health Care Improvement Act, the Federal Tort Claims Act, the Privacy Act, and the Health Insurance Portability and Accountability Act • Non-taxable status of I/T/Us • State licensing exemptions for providers. Sec. 221 and 408 of the IHCIA

  10. Key Benefits of the Indian Addendum • When specialty care is required, the Indian health program can better coordinate care by referring the patient to another in-network provider, avoiding red tape of being served by an out of network provider • The Indian health program can be assured of receiving payment for covered services they provide • The plans enrollment base will increase if Indian health programs have an incentive to enroll their Indian patients who do not have another form of insurance in an Exchange plan • Exchange plans benefit from having a wider network of providers to serve their Indian enrollees

  11. Request for Comments on Indian Addendum • HHS has requested comment on the “potential use of a standardized Indian heath provider contract addendum” • Comment period has been extended to October 31, 2011 • Proposed rule can be found at 76 Fed. Reg. 41866

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