Tribal Technical Advisory Group:

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					Tribal Technical
Advisory Group:
      An Update

  Workgroup Activities

            April 6, 2005

                Prepared by:
    The Tribal Technical Advisory Group
       National Indian Health Board
                        Medicaid Administrative Match Subcommittee

The issue Medicare Administrative Match (MAM) has been pending since July 2002. Tribal
governments are concerned about the lack of Medicaid outreach efforts in Indian country. A way
in which to address this is for them to enter into MAM Agreements with states allowing tribes to
perform outreach activities in tribal communities and be reimbursed in the same manner as
states. MAM agreements involve the use of intergovernmental transfers for funding of the state
share of Medicaid expenditures by entities other than the state itself. The law provides for the use
of transfers between units of government for this purpose, within certain limits and from certain
sources, as an exception to the general prohibition against provider related donations. CMS must
ensure these other entities are units of government. Tribal governments are considered units of
government in Centers for Medicare and Medicaid Services (CMS) regulation. However, Tribal
Self Determination authorities extend tribal status to tribal organizations carrying out program
activities authorized by resolutions from tribal governments. Tribal organizations are not
mentioned in CMS regulation as units of government. CMS has prepared a decision
memorandum, which proposes criteria as to when and which tribal organizations can participate
in MAM. Tribal Technical Advisory Group (TTAG) members have requested they review the
decision memo that is before the CMS Director for signature. They want to ensure that direction
provided in the memo will be acceptable and workable in Indian country as this will have broad
national implications.

Through a series of several conference calls and in-person meetings, the Subcommittee is
working closely to examine all possible avenues to resolve this issue in a mutually acceptable

Current Workgroup members:
TTAG: Jim Crouch, California Rural Indian Health Board Executive Director (CO-CHAIR),
Jim Roberts, Myra Munson, Shulamit Decktor, Thomas Maynor, MD, Andy Schneider
CMS: Wanetah Wilkins,( CO-CHAIR) Ed Grendon, Jim Frizzera, Dorothy Dupree, Ernie
Kimball, Linda Brown, Camille Blake (OGC)
IHS: Kitty Marx, Gerald Moses, Jessica Imotichey
                              Medicare-Like Rate Subcommittee

The Medicare Modernization Act (MMA) includes a provision (Section 506) that requires
hospitals that participate in the Medicare program to accept Medicare-like rates as payment in
full when providing services to eligible persons under the Indian Health Service (IHS) and
tribally operated Contract Health Service (CHS) program. The new law will provide IHS and
tribal CHS programs with similar benefits to those enjoyed since the mid-1980s by the
Departments of Defense, Veterans Affairs, and Transportation. Indian health programs will now
benefit from Medicare’s bargaining power when buying care for their non-Medicare patients.

The Medicare-Like Rate Subcommittee was organized to assist the CMS and the IHS in the
development of regulations in order to implement Section 506 of the MMA. The Subcommittee
held their first meeting in June 2004 to develop an outline of items that needed to be included in
the regulations. This information was discussed over a number of conference calls between July
and August 2004. A draft copy of the Section 506 regulations was provided to the TTAG and
CMS at the September 22-23, 2004 TTAG meeting. It was hoped that the regulations could be
finalized and published for public comment prior to the effective date of the provision,
December 4, 2004; or a date specified by the Secretary, but no later than one year after
enactment of the MMA.

Since September 2004, both IHS and CMS have cleared the Section 506 regulations through
their internal review process and the regulations have been submitted to the Department for their
review and approval. Members of the Medicare-like Rate Subcommittee have been advised that
the Department’s Office of General Counsel has cleared the Section 506 regulations and that
they have now been submitted to the Office of Management and Budget (OMB) for their review
and approval. It is anticipated that this review could take as long as 90 days. Upon OMB’s
approval of the Section 506 regulations, the IHS will then be required to publish the new
regulations in the Federal Register for a minimum of 15 days. It is anticipated that this process
could easily take as long as 30 days. In light of the above, it is anticipated that the regulations
will not become effective until at least September 2005.

Current Workgroup members:
TTAG: Ed Fox, Executive Director, Northwest Portland Area Indian Health Board; Mickey
Peercy, Executive Director, Operations & Management, Choctaw Nation; Jim Lamb, Director,
Patient Financial Services, Alaska Native Medical Center
MMPC: Myra Munson; Carol Barbero; Jim Roberts; Phil Norgaard
CMS: Dorothy Dupree; Sue Burris; Ed Gill; Larry Stevenson
IHS: Harry Rosenzweig, Kitty Marx; Jessica Imotachy, Clayton Old Elk; Elmer Brewster;
Brenda Jeanotte-Smith; Sarah Soule (BCBSNM); Inge Zamora (BCBSNM; Rhonda Nichols
                            Outreach and Education Subcommittee

The new Medicare Part D drug benefit will be in effect on January 1, 2006. The Outreach and
Education (O&E) subcommittee of the TTAG is currently working with CMS and IHS to
establish at least two trainings in each Area of the IHS to inform the appropriate tribal and IHS
audiences regarding what it will take to help Indian people and the IHS/Tribal/Urban (I/T/U)
pharmacies they utilize access the new benefit.

The IHS, through an interagency agreement with CMS, is receiving $310,000 to facilitate a
national Indian outreach and education training effort. The O&E Subcommittee is recommending
that Awareness training on Part D is to be scheduled in the IHS Areas in late May/early June
2005, to provide background information and timeline information for the preparation and
implementation of Part D. A second training will be scheduled in the Fall of 2005, providing
more specifics on Plan sponsor participation in Indian country, including enrollment process,
plan premiums and selection, formularies and appeals process.

The TTAG notes problems inherent within Part D legislation, will hinder access to this new
benefit for Indian health beneficiaries. . They are advising CMS on how to better address these
concerns including:

      Outreach and education funding to truly penetrate and saturate Indian country with the
       information and assistance necessary to enroll eligible Indian beneficiaries and connect
       them with a Prescription drug plan that contracts with their I/T/U pharmacy or local
       community pharmacy
      Better educate private sector Prescription Drug Plans (PDPs) who have little, if any,
       experience with the unique aspects the Indian health care system
      Had significant input in the development of contract addenda that will recognize the
       unique status of Indians and Indian tribes including the federal trust responsibility for
       Indian health care
      Provide early education effort to minimize an expected potential significant drop in State
       Medicaid reimbursement to I/T/U pharmacies for most patients over 64 ends on January
       1, 2006 due to the dual eligible population shift to Medicare.
      Furthermore, each tribe will have to navigate through this very complex change without
       additional resources. Despite these formidable challenges, the O&E subcommittee will
       continue to work with CMS and IHS to help tribes prepare.

Current Workgroup members:
TTAG: Robert Newcombe, Alamo Navajo School Board (CO-CHAIR), Joe Crittenden, Ken
Daugherty, Valerie Davidson, Mickey Peercy, Anselm Roanhorse, Mim Dixon, Kris Locke
CMS: Rodger Goodacre (CO-CHAIR), Ernie Kimball, Patricia Barrett, Linda Brown, Brenda
Denman (Region VI), Andrea Yost, Dorothy Dupree, Priya Helweg, Nancy Rios (Region VII)
IHS: Balerma Burgess, Kitty Marx, Captain Robert Pittman, Elmer Brewster, Carol Littlefield,
Hickory Star, Jessica Imotichey
                                  Strategic Plan Subcommittee

The TTAG is to develop a Strategic Plan for CMS to more effectively work with and reach out to
American Indians and Alaska Natives (AI/AN). The development of this of the Plan will occur
in three parts.

Part 1 is currently being developed and will provide strategies to address three of the most
pressing issues facing CMS as viewed by Tribal leadership: 1) improve the capacity of CMS to
develop policies that work in Indian Country; 2) implement the Medicare Modernization Act
(MMA) of 2003; and 3) Medicaid reform.

The leadership and staff in CMS have an enormous task ahead with the implementation of
sweeping changes to Medicare and anticipated revisions to Medicaid. To make these changes
and other policies work for American Indians and Alaska Natives, CMS must develop greater
capacity to understand the Indian health system and needs. Tribes also need to understand CMS
programs and their important role relative to Indian health. Working together, CMS and Tribes
can strengthen the ability of Indian health facilities to serve as the medical home for AI/AN that
offers culturally competent care, while fulfilling the role of essential providers of Medicaid,
Medicare and State Child Health Insurance Programs (SCHIP) services.

For this plan to be focused and useful, complex issues are presented in a simplified and brief
manner. The intent is to present objectives and action steps that provide strategic direction. It is
anticipated that CMS will work with the TTAG to more fully develop the concepts and
implement them over the next five years. Some of the action steps can be accomplished with
effective leadership, without requiring any additional funding. Others will require additional
resources, which are estimated in the appendix to this plan.

This CMS AI/AN Strategic Plan is consistent with the Mission, Vision, Goals and Objectives of
CMS. The final section of the Part 1 Plan shows the crosswalk between the CMS broader
objectives and the more specific AI/AN objectives in this plan. Thus, this document will provide
an action plan to accomplish mutual goals of CMS and Indian Country.

In the process of developing this plan, we talked with more than 25 people working for CMS in
all the Centers and many of the offices, at various levels in the organization. They were
extremely generous with their time to explain how CMS works and to provide perspectives about
issues important to Tribes and the Indian Health Service. There is no doubt that CMS staff are
professional, hardworking, compassionate, caring, committed individuals who want their efforts
to result in better health care for CMS beneficiaries. Many of the insights and recommendations
in this plan were gleaned from those individuals who want to find a better way to serve
American Indians and Alaska Natives.

Current Workgroup members:
TTAG: Maggie Terrance, (Chair), Jim Crouch, Kathy Hughes, Valerie Davidson, Kris Locke,
Mim Dixon, Amy Sagalkin, JT Petherick, Jim Roberts, Ed Fox
CMS: RJ Ruff, Dorothy Dupree, Linda Brown, Priya Helweg, Ernie Kimball
IHS: Elmer Brewster and Jessica Imotichey

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