Generic Guidelines Policies - Health Care Reform for American ...

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1


__________

TRIBE


TRIBAL
PREMIUM
SPONSORSHIP PROGRAM

POLICIES and PROCEDURES

October

16
, 2013





Photo by Earl Hooper



October

16
, 2013


Acknowledgements;
Port Gamble S’Klallam Tribe,
Swinomish Tribe and input from in
-
person
visits with Confederated
Tribes of the Colville Reservation, Tulalip, Makah Nation, Quinault
Nation, Lummi Nation, Nisqually and Muckleshoot Tribe
s
.











2



TRIBAL PREMIUM SPONSORSHIP PROGRAM

................................
................................
........................

3

INTRODUCTION

................................
................................
................................
................................

3

Purpose

................................
................................
................................
................................
................................
..............

3

TERMS OF PARTICIPATION

................................
................................
................................
................

3

RESPONSIBILITIES

................................
................................
................................
..............................

4

Segregation of FUNDS FOR SPONSORSHIP OF PREMIUMS

................................
................................
...

5

CoverOregon, Healthplanfinder, YourhealthIdaho,

Healthcare.gov

................................
....................

5

Special Provisions
-

ACA

................................
................................
................................
....................

5

T
RIBES
P
AYING
P
REMIUMS

................................
................................
................................
................................
...........

6

E
SSENTIAL
C
OMMUNITY
P
ROVIDERS

................................
................................
................................
.........................

6

T
HIRD
P
ARTY
P
AYER

................................
................................
................................
................................
......................

6

I
NDIAN
A
DDENDUM

................................
................................
................................
................................
.........................

6

N
AVIGATORS

................................
................................
................................
................................
................................
......

7

E
STABLISHMENT OF
N
ETWORK
A
DEQUACY FOR
C
ERTIFICATION OF
QHP
S

................................
..................

7

V
ERIFICATION OF
I
NDIAN
S
TATUS

................................
................................
................................
..............................

7

Eligibility

................................
................................
................................
................................
..........

7

Plan Choice

................................
................................
................................
................................
......

7

Monthly enrollment option for enrolled tribal members

................................
................................
....

8

Alternate Resources

................................
................................
................................
..........................

8

Alternate Resource (includes TPSP) Policy & Procedure

................................
................................
......

8

Medicaid
................................
................................
................................
................................
...........

9

Medicare, Medicare A, Medicare B, Medicare C, Medicare D

................................
...............................

9

Private Insurance

................................
................................
................................
..............................

9

Contract Health Service Program

................................
................................
................................
.......

9

CONTRACT HEALTH SERVICES DELIVERY AREA

................................
................................
................

10

CONTRACT HEALTH SERVICES

................................
................................
................................
.........

10

Emergency

................................
................................
................................
................................
.....

10

E
-
Sign

................................
................................
................................
................................
.............

10

TRIBAL PREMIUM SPONSORSHIP DELIVERY AREA IS THE SAME AS THE CHS DELIVERY AREA (CHSDA)

.

10

PERSONS T
O WHOM CHS WILL BE PROVIDED

................................
................................
...................

10

Funds Available

................................
................................
................................
..............................

11

Services

................................
................................
................................
................................
..........

11

TRIBAL PREMIUM SPONSORSHIP/ CONTRACT HEALTH SERVICE ELIGIBILITY REQUIREMENTS

..............

11

Contract Health Services Establishment of Residence for Contract Health Services Eligibility

11

Documentation

................................
................................
................................
...............................

12

Eligibility

................................
................................
................................
................................
........

12

NOT TPSP
Eligible
-
CHS Eligible

................................
................................
................................
.......

12





3



TRIBAL

PREMIUM

SPONSORSHIP PROGRAM



The
__________ Tribe
Will Purchas
e Health Insurance for Contract Health Service Eligible
Unin
sured Community Members who are Eligible for Tax Subsidies in the new Health
Benefits Exchange (Marketplace).


Official Launch Date,
_____________ 2014
,



Vision of the Program: To Connect Tribal Members and Their Families to the Health
Insurance
Coverage th
at is Most Appropriate for Them, The Tribe, and
the Health Services
Department Program


INTRODUCTION

Purpose




This
Tribal Premium Sponsorship

Program
policy

consolidates the policy, procedures, and
guidance for the effective management of the Indian Health Service (IHS) Contract Health
Services (CHS) Program and
the
TPSP

program.


The authority to manage the operation of
the
TPSP

Program is delegated to the g
reatest degree possible to the Health Director,
working with the Contract Health Services Officer.

TERMS OF PARTICIPATION


There are additional participant requirements above those typical for Indian Health Service,
IHS, Contract Health Service, (CHS), pr
ogram’s to participate.




Information about income and verification

of income (could be simply self
-
attestation) or verification of IRS provided income from 2013 tax filing
.



All Uninsured who do not have employer sponsored health care insurance.

o

You can’t d
rop coverage and expect
Tribal Premium Sponsorship

without
prior
verification of eligibility for subsidies and the KTPS
.



Expanded eligibility depends on funding and continued successful cooperation of
the terms of participation



4



Update Income Information.



R
espond to requests for information from Tribal Staff, State or Federal agencies



Agree to work with sponsorship representative.



Agree to apply for financial assistance to pay health insurance.



Agree to apply full tax credit to premium

RESPONSIBILITIES



Hea
lth Services Director,
The Director, will:

Establish general policies regarding the
administration of the
TPSP

program in the IHS for the first year in coordination with the
Health Advisory Committee as appeals are addressed




Establish standards of performance




Assess the performance of the
TPSP

program
.




Assess the long
-
term purpose and direction of the program

and its contribution to
CHS program

to ensure maximum effectiveness of the program in meeting the health
needs of Indian people.




Formulate long
-
term plans and objectives for t
he future development of the TPSP

program.




Provide staff assistance in matters of general policies and procedures.




Prepare budget justification for the total
TPSP

program.




Financial controls. Ensure funding and financial controls follow tribal requirements.




Promptly and appropriately respond to
TPSP

appeal denials by Health Advisory
Committee appeal.




Establish an
d implement a manageme
nt control system for the T
P
S
P
.





Develop and establish policies and methods for the direction, control, review, and
evaluation of the
TPSP

programs.




Maintain records for planning and for controlling funds as required.



5




Promptly and
appropriately respond to
TPSP

appeal denials


Segregation of

FUND
S

FOR SPONSORSHIP OF PREMIUMS


Funds for premiums shall be segregated in a fund or money market account (until time of
start of payments, December 2013)
.


CoverOregon, Healthplanfinder, Yourh
ealthIdaho
, Healthcare.gov

The marketplace for the purchase of health plans and determination
of
and access to federal tax credits.

Delegation of Authority

Health Services Department will set up all financial arrangements for the payment of sponsored
community members.


Tax Subsidy

The sponsored eligible will work with tribal in
-
person assister or navigator to access 100% of the subsidy
(based on their income)
to be applied

toward the premium payment

to health plan (carriers)
.

Tax Reconciliation

The I
RS will determine any tax liability or refund necessary from changes in income over the course of
enrollment in a QHP.
The TPSP Health fund will pay any IRS tax obligations (reconciliation). The Tribal
member or sponsored person will be reimbursed unless

there is an admission of misreporting of income.

Tax Refund for use in subsequent year’s sponsorship


Community members participating in the
TPSP

are required to deposit
any
premium tax credit
reconciliation
tax

refund in the
TPSP

Trust Fund
, money market

account, or reserve

if they wish to
participate in future sponsorship years.


Special Provisions
-

ACA

Affordable Care Act Provisions Relevant to American Indians/ Alaska Natives


The Affordable Care Act includes specific provisions relevant to American I
ndians and Alaska Natives (AI/ANs)
purchasing coverage in Exchanges, including the following:






AI/ANs with household incomes below 300 percent of the federal poverty level who are
enrolled in a Qualified Health Plan (QHP) offered through the individual

market Exchange will not have to pay
any cost
-
sharing;

no deductible, no copays, no other cost sharing.






If an AI/AN is enrolled in a QHP and receives services directly from IHS, Indian tribe, tribal
organization, urban Indian organization or through

the Contract Health Service program, the individual will not
have to pay any cost sharing for those services;






Exchanges are to provide special monthly enrollment periods for AI/ANs; and



6



Members of Indian tribes

and descendants (essentially anyone w
ho has access to IHS)

are
exempt from the individual responsibility payment for not complying with the requirement
to maintain essential insurance coverage.


T
RIBES
P
AYING
P
REMIUMS


Exchanges may permit Indian tribes, tribal organizations, and urban Indian

organizations to pay the QHP
premiums for qualified individuals, subject to terms and conditions set by the Exchange.

We recognize that some Exchanges may wish to work with tribal governments to facilitate payment on behalf
of enrollees, including aggreg
ated payment. We encourage Exchanges to include this option as part of its
consultation with tribal governments.


E
SSENTIAL
C
OMMUNITY
P
ROVIDERS


In the final rule, the definition of an essential community provider is taken from section 1311 of the
Affordable Care Act.

The definition identifies essential community providers as providers that serve predominantly low
-
income,
medically underserved ind
ividuals and cites providers defined in section 340B of the Public Health Service
Act.1

• Includes urban Indian organizations and tribal organizations’ outpatient clinics.

• Exchanges may identify additional providers as essential community providers base
d upon local needs.

1.
42 U.S.C. § 1396r
-
8 (Section 1927 of the Social Security Act)


T
HIRD
P
ARTY
P
AYER


The Indian Health Care Improvement Act (IHCIA) provides that all Indian health providers have the right to
recover from any third party payers, including insurance companies:






Up to the reasonable charges billed for providing health services; or






If higher, the highest amount the insurer would pay to other providers to the extent that the
patient or another provider would be eligible for such recoveries.

In the final rule preamble, we note that section 206 of IHCIA applies to all third party paye
rs, including QHPs.

I
NDIAN
A
DDENDUM


Addendum developed by Tribes will be part of any contract with Qualified Health Plans (if at all possible).


I
N
-
PERSON
A
SSISTERS

The
_______

Tribe will continue to access the Medicaid Administrative Match program to p
ay for 50% (or 75% if
allowed) of the cost of enrollment activities for the Medicaid program (and initial screening for both Medicaid
and Marketplace insurance).
MAM does not reimburse for enrollment in Marketplace Qualified Health Plans.
In addition
,

t
ribal staff will complete necessary training to become in
-
person assisters

and sponsorship
representatives
.



7

N
AVIGATORS


Tribal Navigator funding is for enrollment in Marketplace Insurance plans. Subject to final rules the TPSP will
access all permissible
funding to reimburse for enrollment in tribally purchased marketplace insurance
through the
state health insurance exchange Marketplace
.

See in
-
person assisters and tribal sponsorship
representatives.


E
STABLISHMENT OF
N
ETWORK
A
DEQUACY FOR
C
ERTIFICATION O
F
QHP
S


The
_______

Tribe will work to ensure that ______

County has network adequacy

for Qualified Health Plans
serving

American Indians and Alaska Natives so they can access an Indian Health Program of their choice.

V
ERIFICATION OF
I
NDIAN
S
TATUS


If an
applicant attests that he or she is an Indian, the Exchange must verify Indian status.

The Exchange must rely on any electronic data sources that are available to the Exchange and have been
approved by HHS for this purpose. If approved data sources are unavailable, an individual is not represented in
the source, or the source is not reasonab
ly compatible with an applicant’s attestation, the Exchange must
follow inconsistency procedures.
Where permitted authorize
d

staff will attest to tribal membership for
_______

tribal members.


Hardship Exemption

CHS business office will work with all patie
nts to ensure they obtain exemption from the penalty assessed for
not having health insurance.


Eligibility

CORE Eligibility

1.

All members of household with income between 139 and 300% of poverty

2.

All uninsured whose insurance has a subsidy of greater than
50% at the time of
enrollment (with a one year guarantee of support from the Tribe).


Expanded Eligibility (depending on availability of funds0

1.

Some otherwise not eligible may be covered with Tribal funds should funding
become

available.

2.

Expanded eligibili
ty depends on funding and continued successful cooperation of the
terms of participation

Plan Choice

1.

The Sponsorship Program only supports the purchase of the bronze option in the Marketplace for
enrolled tribal members.



8

2.

The Sponsorship Program does not su
pport the choice of a catastrophic program since subsidies are
not available under this plan choice.

3.

A decision will be made by November 1, 2013 about whether or not the TPSP has a ‘preferred’ qualified
health plan and whether or not it has the option to o
nly recommend and pay for that plan.

Monthly enrollment option

for enrolled tribal members


1.

TPSP

does not support changes in health plans
, but on a case by case basis can
approve one change in a calendar year.

2.

American Indians

who are enrolled in a federal
ly recognized tribe

do have the option
to
change plans once a month, but
TPSP

will not approv
e discretionary changes in
plans without
prior
approval of the program.

3.

Exercising a change is permitted, but tribal funds
are only

approved for a second plan
in a

single calendar year by the Health Services Director upon review of circumstances
that required the change in plans.


Alternate Resources

Contract Health Services Non
-
Compliance with Applying for Alternate Resources Policy


Purpose
:

To outline the
process for Contract Health Services members who do not follow through
with applying for alternate resources. Alternate resources may include, but are not limited
to, Medicare, Medicaid, Vocational Rehabilitation

and the new Marketplace Qualified Health
Pl
ans
.


Eligibility
:

Any person covered by Contract Health Services.


Policy:

The
___________

Tribe requires all Contract Health Services eligible individuals to apply for
alternate resources to help off
set the cost of health care for the program.


Alternate Resource (includes
TPSP
)
P
olicy & P
rocedure


1.

Eligible persons need to follow through with applying for alternate resources if asked to
do so by the
Contract Health Services office including the
TPSP
.


2.

Staff in the Contract Health Services office
will be available to assist the eligible member
with the
TPSP

application process.



9


3.

The
TPSP

eligible

member
is required to direct the Health Plan Finder to provide
duplicate communication
to the CHS office address. The
TPSP

member
may use the
CHS
office’s

mailing address to have the staff assist with any information requests from
alternate resources to ensure continuation of coverage.


4.

Members who do not follow through on applying for alternate resources will receive a
termination letter from the Contract
Health Services office.


5.

Members who do not update their income information
will face potential termination
from the program, but an official review and notification will be conducted.



6.

The member will have an additional 30 days (as of the date of the termination letter) to
finalize the application process for the alternate resource they are eligible for. Failure to
complete the application process within the 30 days will result in termin
ation of the
members Contract Health Services benefits.


7.

The
patient

will not be eligible for Contract Health Services coverage until a complete
application for alternate resources has been submitted to the Contract Health Services
office.


8.

Any charges incurred for any health related care during the uncovered time period would
be the
client’s

responsibility.


Medicaid

Medicaid has no cost to the Health Services Department and is the required option for
uninsured u
nder 139
% of poverty.

Medica
id eligibles are not eligible for subsidies in the
Marketplaces.

Medicare, Medicare A, Medicare B, Medicare C, Medicare D

Medicare insurance is the required primary insurance for eligibles with wrap around
payments for costs not covered by Medicare.

Privat
e Insurance

Some

cases may require the purchase of private insurance outside the Health Path Finder
exchange.

Contract Health Service Program

See CHS manual. The
TPSP

is a part of the CHS program and all CHS rules apply.




10

CONTRACT HEALTH SERVICES DELIVERY

AREA

The geographic areas within which
CHS will be made available.


CONTRACT HEALTH SERVICES


Health services paid by the IHS that are provided to eligible AI/ANs by non
-
IHS public or
private providers (e.g., dentists, physicians, hospitals).


CONTRACT HEALTH SERVICES ELIGIBLE,
TRIBAL PREMIUM SPONSORSHIP

ELIGIBLE



A person as defined in as being eligible for CHS thus eligible for the
Tribal Premium
Sponsorship

Program

Emergency


Any medical condition for which immediate medical attention is nec
essary to prevent the
death or serious impairment of an individual’s health.


E
-
Sign


The electronic equivalent of a hand
-
written signature requiring user authentication and
verification, such as a digital certificate, smart card, or biometric methods. On
June 30,
2000, Congress enacted the “Electronic Signatures in Global and National Commerce Act,”
(E
-
SIGN) to expand the use of electronic records and signatures in interstate and foreign
commerce and ensure the validity and legal effect of contracts entere
d into electronically.
E
-
SIGN ensures that contracts and purchase orders entered into electronically will be legally
effective and valid, and that consumers who enter into contracts electronically have the
same protections they have when contracting in th
e “brick and mortar” world.

TRIBAL PREMIUM SPONSORSHIP

DELIVERY ARE
A IS THE SAME AS THE CHS
DELIVERY AREA (CHSDA)


All approved Contract Health Service Delivery Areas (CHSDA) are specified in 42 CFR
§136.22 and may be changed only in accordance with the Ad
ministrative Procedures Act (5
U.S.C. 553).

PERSONS TO WHOM CHS WILL BE PROVIDED


Tribal Premium Sponsorship

Eligible follows
CHS Eligibility
.



11


Authority

The CFR, Title 42 Part 136 is the appropriate citation for all correspondence to providers
and AI/AN patients. This IHM chapter should not be cited as the authority for making
decisions on eligibility or payment denials.

Funds Available

There is no autho
rity to authorize payment for

the insurance premium

under the
TPSP

program unless funds are made available by the Tribe.

Services

Beyond
Qualified Health Plan
-
provided service
-

Follow CHS Policy

payment allowed.

TRIBAL PREMIUM SPONSORSHIP
/ CONTRACT HEALTH

SERVICE ELIGIBILITY
REQUIREMENTS

Contract Health Services Establishment of Residence for Contract Health Services
Eligibility

P
URPOSE
:


To verify permanent residence for persons wanting to establish eligibility for Contract
Health Services benefits.


P
OLICY
:

The Port Gamble S’Klallam Tribe requires all persons who are trying to establish eligibility
for Contract Health Services benefits to provide proof of permanent residence
.


P
ROCEDURE


1.

Eligible persons need to follow through with providing valid pro
of of permanent
residence in
CHSDA.

2.

Proof of permanent residence includes: proof of being registered with the
Tribal

Housing
Authority, documents in the person’s name mailed to the address of residence, and or a
signed affidavit from the homeowner, within
the service area, the eligible person is living
with.


Failure to provide valid proof of residence will result in denial of eligibility for the C
ontract
Health Services program and
TPSP
.



12

Documentation



An AI/AN claiming eligibility for CHS has the
responsibility to furnish the CEO or the Tribal
program with documentation to substantiate the claim.


Eligibility


The definition of eligibility for CHS shall be consistent with Title 42 CFR § 136.23. If local
rules and Title 42 CFR §136.23 conflict, F
ederal regulations prevail. To be eligible for CHS
an individual must:


1.

Be eligible for direct care as defined in 42 CFR §136.12;

2.

Reside within the U.S. on a Federally
-
Recognized Indian reservation; or

3.

Reside within a CHSDA and;

4.

Be a membe
r of the Tribe or Tribes located on that reservation; or

5.

Maintain close economic and social ties with that Tribe or Tribes.

NOT
TPSP

Eligible
-
CHS Eligible

Not Health Plan Eligible:



Spouse
Dependents of an employee with employer

sponsored insurance.



Children and spouses are typically not eligible for subsidies so they are not eligible
for the TPSP.

They can purchase Marketplace plans on their own, but without subsidy