ITU Medicaid Managed Care Addendum / HealthChoice

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good afternoon and welcome to today's All Tribes call on the Medicaid managed care itu addendum sponsored by the tribal affairs division Center for Medicaid and CHIP services dmca I am lame to Allah ger with the position of tribal affairs and joining me on today's call is my colleague rachel ryan on april 25 2016 6 p.m. s released a final rule on managed care in medicaid in the Children's Health Insurance Program chip

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this rule incorporated the Indian protections in Section five thousand six to the american recovery and reinvestment act otherwise referred to as ARA the indian specific provisions in the final managed care role are located in the section standards for contracts involving indians being health care providers and Indians managed care entities in the final roll CMS committed to developing sub regulatory guidance through consultation on the use of the

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Medicaid and CHIP Indian managed care itu addendum the ITU addendum is intended to help facilitate contracts between indian health providers and managed care plans by identifying specific several specific provisions established in federal law that apply when contracting with indian health care providers for an oktoberfest 2016 and CMS all tribes call CMS and chain tribal

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input and advise on an informational bulletin that the Center for Medicare and Medicaid Services is developing that highlights the Indian specific provisions of the final roll we indicated on that call that we would hold a separate call on the ITU addendum CMS will then release the informational bulletin and the ITU addendum as a single on guidance together and after bone is called the IT of the link to the

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ITU addendum will be sent out to everyone who participated it's on our spotlight page at this time I would like to provide an overview of the purpose of the ITU addendum and walk through key provisions purpose similar to the standardized contract addendum use for the qualified health providers in the Medicare Part D program this addendum has been developed for Medicaid managed care entities to use when contracting

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with Indian healthcare providers through the clearance process this addendum was modified slightly from the model addendum for QHPs to be streamlined and consistent with the final manage Medicaid managed care role this is jinda ms not required that CMS received several comments according the development and issuance of a model addendum for this purpose to assist Medicaid managed care entities in including Indian healthcare providers in their networks we anticipate that the

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addendum will facilitate acceptance of network contracts by ITU providers we also anticipate that offering contracts that include the addendum will provide an image then managed care entities with an efficient way to establish contract relationship with ITU providers and ensure that American Indian and Alaska Natives can continue to be served by their Indian healthcare provider of choice Indian tribes are entitled to special protections and provisions under

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the federal law which are listed in the addendum the addendum also identifies several specific provisions that have been established in federal law that apply when contracting with ITU providers the use of this addendum benefits both medical managed care entities and the ITU providers by lowering the perceived barriers contracting assuring managed care entities comply with key federal laws that apply when contracting with ITU providers and minimizing potentials

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disputes next I'm going to walk through the key provisions in the addendum first of all we have defined both indian indian health care provider managed care plan consistent with the regulatory definition in the final roll next we have the cost sharing exemption for Indians no reductions in payment in this section we emphasize that American Indian Alaska Natives are exempt from cost-sharing and explain that managed care entities are

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prohibited from reducing payments to Indian healthcare providers these provisions were enacted with the american reinvestment recovery act of 2009 the next section describes the enrollee option to select an Indian healthcare provider as a primary healthcare provider we also emphasized American Indian Alaska Natives right to choose the indian health care provider regardless of whether that provider is in the managed care entities network this provision was also enacted with the

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american reinvestment recovery act of 2009 next managed care entities agreement to pay indian health care providers this provision requires managed care entities to pay indian health care providers regardless of whether the provider is in the managed care entities network next contract assurance that allows indian health care providers to limit who is eligible for items and services this section identifies that an Indian health care

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provider can limit who it provides services to under the Indian Health Care Improvement Act the next section explanation of applicable clickability of federal laws to indian health care providers this provision explains that certain federal laws are applicable the indian health care providers but not others those laws are listed in Appendix A to the addendum next section is the explanation that Indian healthcare

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providers are non taxable entities this section explains that managed care entities may not collect or require Indian healthcare providers to remit taxes the next section is an explanation that Indian healthcare providers are not subject to insurance requirements including professional liability insurance this provision of the addendum explains that Indian healthcare providers are subject to Federal Tort Claims Act are exempt for insurance requirements

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the next section is explanation concerning licensure accreditation exemption for Indian healthcare providers including professional staff and the facility this section explains that managed care entities may not subject Indian healthcare providers to state licensure and accreditation requirements the next section talks about view resolution and binding arbitration this section identifies that managed care entities may not subject Indian healthcare providers to binding

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arbitration in the event of a dispute between the managed care entity and the Indian healthcare providers the next section is a statement that federal law governs Indian healthcare providers are not subject to state law and medical quality assurance requirements these provisions explained that federal law governs in the event of a conflict and will prevail it also explains at section 8 05 the Indian Health Care Improvement Act applies to medical quality assurance

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requirements the next section explains the claims format the section requires managed care entities to process claims in accordance with section 206 H of the Indian Health Care Improvement Act next we talk about the payment of claims this provision requires managed care entities to pay the applicable payment rate whichever is higher hours and days of service this section of the intend m

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explains that the Indian healthcare providers may set its own hours and dates of operations next section is purchased and referred care requirement this section explains that the requirements for purchase and referred care prevail over the managed care entities requirements when purchased and referred here or used the next section discusses sovereign immunity the section advises that by contracting with the managed care entity the indian health care provider person

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waived sovereign immunity last section discusses endorsement the final provision of the indent advises against using indian health care provider names used to suggest official endorsements or preferential treatment of a specific managed care integy at this time I would like to open up the call for any questions and comments Joanne operator could you ask there any questions or comments no worries mrs. care really

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good ladies and gentlemen at this time I would like to remind everyone in order to ask a question or make a comment please you spread fire to the number one during a telephone keypad real pause for just a moment to the plaza to any western once again if you would like to ask a question or make a comment please press x 1 x 1 on your telephone keypad your first question or comment comes from the line of Miss Melanie for killin

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from Choctaw Nation your mind for pens go ahead with your question or comment thank you and thanks playing and Rachel for holding us all and I just wanted to fit on the record that we appreciate the work that's gone into this draft addendum and we did and we had a discussion with you all last week during P tags subcommittee and a strike free version with them recommended changes

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with was presented and I plan say for the record shop foundation sources that that strike through and got off the record but one of the items i wanted to mention specifically was with regards to spca coverage the section that refers to that and in the current draft pick it has a paragraph related to you indeed health service paragraph related to FTCA coverage for tribal organizations and I just wanted to

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we we've made some suggestive comments or changes to that section and the reason that we have is because we want to be clear that the coverage for ftp a related to either IHS or tribes it should be the same and and you should be stated is equally strongly in the in the tribal paragraph residue to the federal paragraph so and it's line to put that comment on the record and we've made it suggested change for that we understand

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that the that one of the differences is that we have a self determination or self-governance agreement and to assume those services from Indian Health Services and how we get FCPA coverage but we do believe the definitions of the beginning of the addenda would cover the definition of a tribal organization and for purposes of that so thank you again for hosting this call and thanks for receiving my comments Thank You Melanie

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k Melanie this is Rachel um I received a copy of the redline version but you have not submitted your recommended comments yet right we didn't miss that I'm not specifically Choctaw Nation I've also had to say that we please support the red line okay do you know all right thank you thank you yes once again I would like to remind everyone in order to ask if I should not make a comment please spread far and then I'm foot born

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on your telephone keypad sorry no further questions or comments from the phone lines at this time I would not like to have the conference back to today's presenters please continue and this is lame to villiger I was going to wrap up since I don't hear any more questions and we do appreciate the red line and the support for the redline version from Melanie thank you so as a final reminder tribal affairs is seeking

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written comments on the ITU addendum and those comments are due by close of business November 16 2016 please submit written comments to the tribal affairs at CMS HHS gov again please submit written comments to tribal affairs that's one word at CMS HHS gov thank you again for your participation rugged interruption mr. Williger yes yes

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ma'am we do have additional participants who are going to make a comment or ask a question I would like to kick them yes thank you comment thank you so your next question in our comment comes from the line of Devon's el-ro from national indian health you're my Nicole pencil ahead with your question or comment thank you hylian hi Rachel I just want to echo Melanie's comments and really thank CMS for taking the comments

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submitted by T tag and tries to heart with creating this managed care addendum I just want to recommend that you continue to work with the T tagging tribes in finalizing this hopefully at the end of this comment period nihd will be submitting some formal written recommendations but at the end of the comment period if you could also any additions or edits you make to the addendum you share those edits with P tag with tribes before the product is

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actually finalized thank you thank you devin your next question or comment comes from the line of Elliot millhollon from called the cops ball your line is open go ahead with a question or comment hi Lane Rachel again to echo dedham and Melanie's comments thank you to CMS for working on this addendum and for issuing separate regulatory guidance I think this the the managed care addendum will

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be quite an important tool for the IHS and tribes tribal organizations and urban programs in contracting with and entering into provider networks in managed care settings I would like to ask make make one comment and and ask 11 clarifying question if I could on the managed care addendum there is a section

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entitled purchase referred care requirement that then states I think very positively that the provider may make the provider which is really any health care provider may make referrals to other network providers and such referral shall be deemed to meet any coordination of care and referral obligation for the managed care plan and that's consistent with what CMS put out and its new managed care regulation and I think that will be that will go a long

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way to avoiding scenarios in which an individual Indian Medicaid managed care enrollee would have to seek primary care for example at an indian health care provider and then go see the same primary care at a managed care for about in network managed care provider simply in order to be referred up for to a specialist left that would create a burden on the individual medicaid and rly and also a burden on the Medicaid system in an unnecessary duplication

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care so we think that that that first sentence is very important um I think it's a second the the second two sentences of the second or third sentence is there are really designed to be kind of assist with purchase preferred care issues and to the extent system you know that's kind of looking at this again the tribal comments are graphed managed-care addendum the best that was provided to CMS entitled this section purchase

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referred care and I think that you know on further reflection really it should just be she just reference referral requirements as a you know purchased referred care programs or pair of last resort and should not really be implicated in referrals in managed care setting so it may be neater to simply remove those those those second or third sentences for that paragraph and simply

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have the paragraph reiterates the the deemed deemed to meet of provisions in the first Center um that's my comment my question and and you know I I think that some tribes will be submitting written comments and thank you very much for the reminder to do so the information about how they can do so one question I had was there was in at least the draft that tribes the some tribes had submitted to

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CMS that had included a provision which would have laid out the requirement that set out in the RF stimulus bill ah which states that certain trust related income from things like forestry or fisheries or other types of crust related income are not account for the purposes of determining how much income somebody has for Medicaid eligibility purposes so

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there was a provision that was included there in there in the so the tribal version that was initially submitted to CMS and that was that was emitted from the final draft it may have been omitted cause of the sense that met the managed care entities never have a role in making eligibility determinations we were not sure whether that was the case or not and so I guess that's our

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question to CMS have you been able to to confirm whether that's the case because to the extent they are assisting in enrollment they'll obviously be working with the state but he says that they're assisting and then you know in the enrollment process that's an important provision which really opens up Medicaid to a large larger number of individuals particularly in certain areas of the country Thank You Elliot for that question and you are actually correct managed care entities don't play any

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role in the Medicaid eligibility process and so that was the genesis behind removing that particular provision individuals that are enrolled in Medicaid and CHIP that that is a state function of single state agency function and then after they're ruled and Medicaid then they're either assigned or AA 'king into the plans and so that was the genesis of why that provision with taken out that I really appreciate your

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questions like if I think will be will be submitting for their comments in writing as well thank you we're looking forward to receiving us we have your next question or comment coming from the lying on Sarah Freeman from national indian go ahead with your question or comment to my eyes open all right Thank You Lena and Rachel mrs. Araz and I just wanted to add a kind of minor

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terminology additional comment I'm sure we'll be including them in in our written comments that are due to sickness as well thanks for all the information especially clarified a few of our questions but with regards to change in the terminology for an Indian healthcare provider that you have listed you know first in the purpose of the addendum that really sit so I guess just trying to figure out you know which are the facilities obviously they include I just entirely operate

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facilities but it just seems to not be clear what a network Indian healthcare provider Sabrina stick this reference to terminology and we want to make sure everyone on the same bored so this is my name could you step back and repeat your question on make sure I understand this yeah sorry about that so just with us it's not it's not much of a question for a comment but with regard to the terminology of the Indian healthcare providers that have been replaced Indian

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start have replaced provider I think we need a clarification on what a network indian health care provider agreement is so this is Rachel I can this might help so when we were reviewing the identity tag somebody actually pointed out that we had some somewhere along in the Edit process someone had done a word replace for provided ihc-p so what happened is that there were some places where it should have just said network provider

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in reference to a provider that within the managed care network and it got replaced with network ihc-p provider so we've tracked those states that down in the addendum and has corrected that does that fix your problem or am I not is that not address it yes it does thank you reach I wanted to make sure that that was big after family oh there's a really good catch and we all have gone a couple places but it was very confusing and we we do this is laying we really do appreciate all your your willingness to

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respond to this quickly on the tea cakes participation in this and that we're are looking for a quick response but we really are trying to get this guidance out so what can have that the informational bulletin in the ITU addendum kind of come out as a pair and you know now that we have a different administration it's really incumbent that we work to get these out as fast as possible i think that there'll be one more little round of clearance internally

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so I just want to warn you about that so we really appreciate your willingness to to turn this around and fairly quickly thank you your next question or a comment comes from the line of angela wilson from Cape River tribe your lines have been go ahead with your question or comment hi Lina and Rachel thanks formals in the call as well and

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certainly agree with all the comments what we're hearing on the phone from our colleagues out in Indian country and so we do appreciate the work of gchat as well just a quick comment really one of the significant barriers that we went into here in California you know Pitt River averages about 27,000 miles in months and transporting our patient to especially care outside of our managed care entity that we primarily work with

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which is partnership and when that happens in the cross over to the boundaries of another managed care entity part of the problems that we're running into is a credentialing process so when we all become all of us itu become we enroll with the state medicaid program we have to credential at that time and i guess you know my comment would be that that tribes should be able to credential with the state medicaid program and have that credentialing

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carry throughout all of all of the medicaid process whether it's on the managed care entity side or on the fee-for-service wyd the reason that this decision issue is when we're forced to do separate credentialing for every single of different managed care entity that process causes nificant barriers in third party reimbursement and attendant enter and also um access to care in certain cases when we're really trying to work hard to educate the managed care attitude about these referrals from the

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primary care provider so it is a administrative burden on the eye to use to have two separate separately credential with each managed care entity so that's just a come on online by in this is lame i'd like to respond to that because right now i know you're in california it always seems to be our pool of problem areas we are actually looking into that in that issue now and going over it with our general counsel and getting clarification so i think it's kind of a

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two-pronged problem it's not only is it happening to you on the ground there and we agree with you that it shouldn't but we've got to get the clarification and internally educate CMS internally and also within our regional offices so we've got a little bit of work cut out for us but we are we've heard about that issue and a lot of times we're also hearing from different regions that sometimes tribes are just agreeing to do things just to get into the network and

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so we're trying to get kind of a feel for how widespread this program it I mean this issue is whether it's not just in California or it's in other areas and maybe when Kitty Marx gets back we might have a discussion on maybe when we've seen some guidance to the states to remind them what that what the rules are because we're hearing that a lot more offshore assuring that some managed care organizations in California are doing like site visits and things to so we've

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learned alarming number of issues going along with the credentialing and licensing and i think that there's a general confusion on what the requirement is for fee for service and whether or not the managed care entities can apply an additional requirements on top of paper service so we're on that and i hope that we can get that resolved in your region soon so more to come on that but never stop bringing us all right thanks wayne appreciate it

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your next question or comment comes from the line of Carolyn gal Tom red cape indian still ahead with your question or comment your line is open good afternoon yes mrs. carolyn gooje with the red cliff and Blake superior oh gee boy in Wisconsin and I work within the purchase referred care department and our health center is going through on some some transitions and so when I look at this the Medicaid and CHIP managed care

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entities with this addendum for contracting I need to be able to find I need to get a 101 on this first off our health center I believe we have contracts with the state and we do have work with Medicaid Medicare so I'm not quite sure if I'm able to unfollowing you in as far as the purchase referred care we do need referrals for those that

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are referred outside of the facility so I'm trying to see on for my experience is when we do applications up with individuals for Medicaid the state will automatically put those individuals in a HMO or a managed care entity and it's out to the people then to go exempt themselves out of that managed care so

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is this am i following this is this is this what's happening it is this where what the focus of the group is I'm let me just a copy of a couple of questions in there let me address that in our final rule and also um as part of our guidance that we're hoping to really release with this itu addendum we want to kind of point out some options and four states and tribes to work together even CMS states and tribes to leave them

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together to figure out you know if they're going to mandate um indian individuals in managed care then maybe there are some things that they could do better we talked a little bit in our rule about algorithms and all and that's kind of like a foreign object but we're thinking like on the ground we've heard some practices I heard some from the telephone your world Indian Health Board that maybe you could put all the Indian healthcare programs into the plans and

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maybe the individual could be assigned by zip code and maybe that would eliminate the individuals wrong assignment to the wrong provider and there's been some other kind of strategy so we'd be happy to work with you in your particular date with your tribes figure out a strategy that maybe we can facilitate discussion and how they could do that better because we do understand that is a burden to be enrolled into a managed care plan when you're already

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using an Indian healthcare provider is your primary care provider so we do understand that we like to have a discussion offline with you and must like to hear you know any kind of best practices you can think of because we when we're all provisions out we want to like to be able to suggest to state strategies for making it better I appreciate that and yes I would like to have further dialogue with you on how we can do best practices I work best for

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the people that we serve I'm finna area so um I guess I could female q um and then try to start collaborating coordinating some of these records so I can understand so as I mentioned reverse your transition SATA how Spencer and I work with the trip to super camp I know that but this something that was just a fraction would you like me to provide my email now please yes that would be great

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but i'm just going to spell it out of this phonetic and la n e dot te r wi ll I ger at CMS hhs.gov all right let's thank your lane you're welcome we really do look forward to getting some strategies for this because we've been hearing

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about it at all of the consultations across the nation there are no further questions or comments from the whole night at this time I would not like Karen to conference back to today's presenters please continue thank you for everyone for taking time to participate in this call we really look forward to receiving your comments and again thank you for your willingness to submit them on such a short turnaround track but we really are trying to get this guidance out now we're in a new administration you know

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fresh not even 21 hours old we want to get as many things as possible we've been working hard on with you out as soon as possible so we look forward to receiving them thank you

ITU Medicaid Managed Care Addendum

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SMALL BUSINESS

SENIOR PRESCRIPTION COVERAGE

DENTAL COVERAGE

SENIOR VISION COVERAGE