Valerie Davidson, vice president of the Alaska Native Health Consortium, provides an overview of Federal Health Reform and the Indian Health Care Improvement Act and its potential impact the Native health system. The presentation was presented at the Sept. 2, 2010 Alaska Health Provider Forum.

1. Patient Protection and
Affordable Care Act:
Health Reform &
Indian Health Care Improvement
Act
Alaska Native Tribal Health Consortium
September, 2010

2. Outline
• Alaska Tribal Health System intro
• Indian Provisions in main bill
• Indian Health Care Improvement Act
• Implications
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3. Indian Health Service
• Provides health care in recognition of government
to government relationship between Tribes and the
U.S. to members of federally recognized Tribes
and their descendents
• 3.3 million American Indians/Alaska Natives
(AI/AN) in 561 federally recognized Tribes.
– 229 Tribes in Alaska
– 135,000 Alaska Natives (projected 163,000 by 2015)
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4. Alaska Tribal Health System
• Transition to tribally provided care
• Voluntary affiliation of 30 Alaskan tribes and
tribal organizations providing health
services to Alaska Natives/American
Indians (7,000 employees)
• Each is autonomous and serves a specific
geographical area
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5. Alaska Tribal Health Compact
• Alaska Native Tribal Health • Ketchikan Indian Community
Consortium - 229 • Knik Tribal Council
• Aleutian Pribilof Is. Assn - 13 • Kodiak Area Native Assn - 11
• Arctic Slope Native Assn - 8 • Maniilaq Assn - 12
• Bristol Bay Area Health Corp - 34 • Metlakatla Indian Community
• Chickaloon • Mount Sanford Tribal
Consortium - 2
• Chugachmiut - 7 • Norton Sound Health Corp-20
• Copper River Native Assn - 5 • Seldovia Village Tribe
• Council of Athabascan Tribal • Southcentral Foundation
Governments - 10 • SouthEast Alaska Regional
• Eastern Aleutian Tribes Tribal Health Consortium - 18
• Native Village of Eklutna • Tanana Chiefs Conference - 42
• Eyak • Yakutat Tlingit Tribe
• Kenaitze Indian Tribe • Yukon Kuskokwim Health Corp
- 58
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6. Medical Care Service Levels
• 180 small community primary care centers
• 25 subregional mid-level care centers
• 4 multi-physician health centers
• 6 regional hospitals
• Alaska Native Medical Center tertiary care
• Referrals to private medical providers and
other states for complex care
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7. Opportunities for Tribes &
Tribal Organizations
• Express authority to participate in grant
programs
– Workforce Grants
– Maternal and Child Home Visitation
• Children and expecting at risk for poor child and
maternal health
• Grants through states for 5 years
• 3% set-aside for I/T/U ($45M)
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8. Opportunities for Tribes &
Tribal Organizations
• Express Lane Agencies
– I/T/U can enroll AI/ANs in Medicaid and
CHIP (Denali KidCare)
• Medicare Part B Services
– Extends authority of I/T/Us to bill for these
services retroactively to January 1, 2010
• Payor of Last Resort
– extends rule by extending it to other federal
programs (ie. VA, etc.)
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9. Access and Workforce
• Interagency Access to Health Care in AK Task
Force
– Develop strategies to improve federal beneficiary health
care in Alaska within 180 days
– Membership
• Health & Human Services
• Centers for Medicare & Medicaid Services
• Indian Health Service
• TRICARE
• Army
• Air Force
• Veterans Administration
• Veterans Health Administration
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10. Individual Indian Provisions
• Exemption from penalty for individual
mandate for health insurance
• AI/AN health benefits from tribes excluded
from income for tax purposes
• Cost Sharing under an Exchange Program
– No cost-sharing for AI/ANs who receive their
care through I/T/U or through Contract Health
– No cost-sharing for AI/ANs up to 300% FPL
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11. Indian Health Care
Improvement Act
Reauthorization

12. Indian Health Care Improvement Act
• Included in the Patient Protection and Affordable
Care Act (Health Reform), P.L. 111-148 as Title X,
Part III, Section 10221
• Incorporates Senate Bill 1790 as reported out of the
Senate Committee on Indian Affairs, except:
– Removed
• IHS scholarship tax exemption (these will remain taxable)
• 100% Reimbursement for Medicare services for IHS facilities
(remains at 80%)
– Added
• Dental Health Aide Therapy Clarification
• Abortion provision that prohibits the use of federal IHS
appropriations for abortions.
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13. Indian Health Care Improvement Act
• Permanent authorization; effective March
23, 2010
• Recognizes the federal government’s
“special trust relationship and legal
obligations to Indians”
• Not an appropriation bill
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14. IHCIA Major Provisions
• Title I: Workforce
• Title II: Health Services
• Title III: Facilities
• Title IV: Access to Health Services
• Title V: Urban Indians
• Title VI: IHS Organizational
• Title VII: Behavioral Health
• Title VIII: Miscellaneous
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15. Title I – Workforce
• Sec. 112 – Health Professional Chronic Shortage
Demonstration Program
– IHS authority to fund demo programs to address chronic
shortages of health professionals.
– Includes training and support of alternative provider types,
such as CHA/Ps. Should also apply to DHATs. (See also
sec. 5304 of PPACA which authorizes 15 grants for demo
projects for training of alternative dental health providers).
• Sec. 113 – Exemption from Licensing Fees
– Exempts tribal employees from licensing fees to the same
extent as IHS employees.
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16. Title I – Workforce
• Sec. 121 – Community Health Aide Program
– Authorizes national expansion
– Dental Health Aide Therapy (DHAT) limitations
• Limits scope of service consistent with ADA settlement
• Retains Alaska-only DHAT authority, but also allows
IHS facilities where mid-level or DHAT is allowed by
state law.
• If other federal law authorizes mid-level dental practice,
then IHS facilities not restricted.
• Requires quality study.
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17. Title II– Health Services
• Sec. 205 – Other Authority for Provision of Services
– Authorizes I/T/TOs to operate four types of programs:
• Hospice Care
• Long-term Care
• Assisted Living
• Home- and Community-based Care
• Sec. 206 – Reimbursement from Certain Third
Parties
– Authority to recover “reasonable charges billed” for
services provided to insured non-eligible individuals.
– Allows T/TOs to collect from tortfeasors (e.g., auto
insurer).
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18. Title II– Health Services
• Sec. 212 – Cancer Screenings
– Authorizes “other cancer screenings” beyond
mammography.
• Sec. 213 – Patient Travel Costs
– Includes “qualified escort” as authorized cost.
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19. Title II – Health Services
• Sec. 214 – Epidemiology Centers
– Designates Epidemiology centers as “public
health agency” under HIPAA allowing them
greater access to data and health information.
• Sec. 221 – Licensing
– Extends “licensed in any state” exemption
allowed for certain federal health care
professional employees to tribal employees.
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20. Title II – Health Services
• Sec. 226 – Contract Health Services
Administration and Disbursement Formula
– Opens current CHS distribution formula for
reevaluation via 3 step process:
• Step 1. GAO Report on CHS program
• Step 2. IHS-tribal consultation to determine whether
current distribution formula should be modified
• Step 3. If Secretary determines it necessary, a
Negotiate Rulemaking Committee may be
established to develop new distribution formula.
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21. Title III – Health Facilities
• Sec. 301 – Health Care Facilities Priority System
– Requires IHS, in consultation with T/TOs, to establish
a priority system allowing nomination of new projects
every 3 years.
• Grandfathers in projects listed in FY 2008 budget request.
• Area Distribution Fund as a possible approach to meet unmet
need for construction of health facilities.
• Sec. 309 – Federally Owned Quarters
– Authorizes T/TO to elect to directly operate and
establish rental rates for federally-owned staff quarters
and directly collect rents based on local rates.
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22. Title III – Health Facilities
• Sec. 311 – Other Funding, Equipment, and
Supplies for Facilities
– Authorizes other federal agencies to transfer funds for
the “planning, design, construction, and operation of”
health care and sanitation facilities to HHS/IHS.
– Requires HHS/IHS to establish new regulations for
“planning, design, construction, and operation of”
Indian health care and sanitation facilities.
– Applies the HHS/IHS regulations to the transferred
funds.
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23. Title IV – Access to Health Services
• Sec. 401 – Treatment of Payments under SSA
– Adds Children’s Health Insurance Program (in addition
to Medicaid & Medicare) as source I/T can collect
from.
– Provides greater flexibility for T/TOs in use of funds
collected under this section.
• Sec. 402 – Purchasing Health Care Coverage
– Allows T/TO/Us to use federal funds to purchase
health benefits coverage for beneficiaries.
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24. Title IV – Access to Health Services
• Sec. 404 – Outreach and Enrollment in SSA
and Other Health Benefit Programs
– Grants and contracts for I/T/U to conduct
outreach and enrollment activities for Indians.
– May be used to pay beneficiary premiums or
cost sharing.
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25. Title IV – Access to Health Services
• Sec. 405 – Sharing Arrangements with Federal
Agencies
– Allows Secretary to enter into arrangements with DoD
and DVA to share facilities and services.
– Directs DoD and DVA to reimburse I/T/TO for
services provided to DoD/DVA beneficiaries
notwithstanding any other provision of law.
• Sec. 407 – Eligible Indian Veteran Services
– Authorizes I/Ts to pay co-pays to DVA for services
provided to IHS beneficiaries.
– Provision was needed to facilitate arrangements for
Indian veterans to receive care from DVA providers in
I/T facilities. 25

26. Title IV – Access to Health Services
• Sec. 408 – Nondiscrimination in Qualifications for
Reimbursement
– Makes I/T/U programs eligible to participate in any
federal health care program without requiring state
licensure as long as such programs meet the applicable
state standards.
• Sec. 409 – Access to Federal Insurance
– Allows T/TO/Us operating any ISDEAA program (not
just IHS) to purchase insurance coverage for their
employees through the FEHB program.
• Sec. 410 – General Exceptions
– Exempts certain insurance products from being
considered 3rd-Party Payer under IHCIA, e.g., AFLAC.
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27. • Title V – Urban Indian Health
– Grants Urban Indian programs broader program
authority.
– Requires IHS to “confer” with urban Indian
programs.
• Title VI – IHS Organizational
– Some enhancements to authorities and
responsibilities of IHS Director.
– Establishes Office of Direct Service Tribes.
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28. Title VII – Behavioral Health
• Title VII replaces current law’s substance abuse
programs.
• Greatly expands behavioral health authorities:
– Comprehensive behavioral health Prevention and
Treatment
– Indian Women Treatment
– Indian Youth Program
– Inpatient MH Facilities
– FASD programs
– Child Sexual Abuse Prevention and Treatment
– Domestic and Sexual Violence Prevention and
Treatment
– Behavioral health research
– Indian Youth Suicide Prevention 28

29. Title VIII – Miscellaneous
• Sec. 805 – Confidentiality of Medical QA
Records
– Allows for peer reviews to be conducted within
Indian health programs without compromising
confidentiality of medical records.
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30. Title VIII – Miscellaneous
• Sec. 813 – Health Services to Ineligible
Persons
– Allows T/TO to make a determination to
provide services to non-beneficiaries.
– If T/TO makes this determination, services to
non-beneficiaries are deemed provided under
the ISDEAA agreement and FTCA applies.
– Non-Service providers in IHS/tribal hospitals
receive FTCA coverage when provided services
under this section.
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31. Title VIII – Miscellaneous
• Sec. 822 – Shared Services for Long-Term Care
– Expressly authorizes IHS to provide, or enter into
ISDEAA agreements, for the delivery of long-term care
to Indians:
• Home and Community Based services
• Hospice care
• Assisted living and other residential services
• Sec. 826 – Annual Budget Submission
– Directs the President to include in the annual IHS
budget request amounts that reflects changes due to
inflation (CPI) and increase in user population.
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32. Title VIII – Miscellaneous
• Sec. 827 – Prescription Drug Monitoring
– Requires HHS to establish a prescription drug
monitoring program at I/T/U facilities.
– Report due to Congress 18 months after enactment.
• Sec. 828 – Tribal Health Program Option for
Cost Sharing
– Allows Title V tribal health programs to charge
beneficiaries for services.
– Unclear whether this applies to Title I programs.
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33. Title VIII – Miscellaneous
• Sec. 831 – Traditional Health Care Practices
– Excludes these services from FTCA coverage.
• Sec. 832 – HIV/AIDS Prevention and
Treatment
– Establishes a new Director of HIV/AIDS
Prevention and Treatment within IHS to
coordinate the agency’s efforts on this issue.
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34. Overall Implications
Individuals
• More services may be available through the
I/T/U
• More opportunities for coverage
• More options for care
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35. Overall Implications
Providers
• More insured individuals
• Need for education and enrollment
• Marketing need due to options for care for
insured
• More opportunities to expand care
• More collaboration with non-tribal partners
• More opportunities for health workforce
training
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36. Questions?
Valerie Davidson, Senior Director
Legal & Intergovernmental Affairs
Alaska Native Tribal Health Consortium
4000 Ambassador Drive, CADM
Anchorage, AK 99508
vdavidson@anthc.org
Phone 907-729-1900
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