Centers for Medicare

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Centers for Medicare Medicaid ServicesTribal
Self-Governance Conference May 21, 2009
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CMS(Centers for Medicare Medicaid Services)
CMS Organizational Overview

• Department of Health and Human Services (DHHS)
• Administers Medicare, Medicaid and Childrens
  Health Insurance Program (CHIP)
• Serves over 90 million beneficiaries
• Annual Budget of over 415 billion
• CMS plays a key role in the overall direction of
  the U.S. health care system

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CMS AI/AN Beneficiaries

• AI/AN populations served by IHS 1.9 million
• AI/AN enrolled in
• Medicare 179,794
• Medicaid 793,835
• CHIP 26,744
• FY 2009, IHS estimates Medicare Medicaid
  reimbursements will exceed 750 million
• The revenues collected at each service unit
  varies from 15 to 50 of the service units
  hospital and clinics operating budgets

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10 CMS Regional Offices
CMS Organizational Overview
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CMS Resources to Assist Tribes

• At each CMS Regional office, there is a Native
  American Contact (NAC) who is available to
  provide technical assistance to Tribal programs
• The name and contact information for the NACs is
  available at the end of this handout
• Contact your NAC if your tribal program has
  questions about billing and reimbursements
  and/or questions about Medicare, Medicaid and
  CHIP beneficiary services

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CMS Resources to Assist Tribes

• NACs work with the Tribal Affairs Group, Office
  of External Affairs, CMS, located in Baltimore
• The Tribal Affairs Group serves as a liaison
  between the Agency and Tribal communities and
  other Federal Agencies in regards to AI/AN health
  and CMS programs.
• Director of TAG is Kitty Marx, who can be reached
  at kitty.marx_at_cms.hhs.gov

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CMS Training for Tribal Programs

• In FY 2009, the TAG, working with NACs and the
  IHS, will hold Area Trainings on Medicare,
  Medicaid, and CHIP issues
• Trainings begin in June 2009 check with your
  Area Office on date and location
• Agendas are developed to meet Area needs and
  include such topics as
• Medicare and Medicaid 101
• CHIPRA and ARRA provisions
• Area specific topics

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CHIPRA and Recovery Act

• Childrens Health Insurance Program
  Reauthorization Act (CHIPRA) reauthorizes the
  CHIP program for FY 2009 through FY 2013
• American Recovery and Reinvestment Act (Recovery
  Act) provides funding opportunities to jumpstart
  the economy, creates new jobs and addresses
  long-neglected needs
• The following is a summary of some of the
  provisions in CHIPRA and the Recovery Act that
  are specific to Indian heath programs and AI/AN
  beneficiaries

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CHIPRA and Indian Health

• Section 201 outreach and enrollment
• Provides for 100 million for all enrollment and
  outreach activities
• 80 million for outreach and enrollment grants to
  States and other eligible entities
• 10 million for national enrollment campaign,
  including outreach materials for Native Americans
• 10 million set aside for outreach to Indian
  children through grants to Indian Health
  providers and urban Indian organizations

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Section 202 Increased Outreach and Enrollment
of Indians

• Requires the Secretary to encourage States to
  take steps for enrollment of Indians into
  Medicaid and CHIP
• Includes outstationing eligibility workers
• Entering into State agreements with I/T/Us
• Requires CMS to take necessary steps to
  facilitate agreements between States and Tribes
• Exempts from a States 10 administrative cap for
  outreach enrollment activities of Indian
  children

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Section 211 Tribal Documentation

• Applies citizenship documentation requirements
  CHIP
• Effective July 2006, documentation from a
  Federally-recognized Tribe (such as a Tribal
  enrollment card or certificate of degree of
  Indian blood) is satisfactory evidence of
  citizenship and identity
• For Tribes located in States having an
  international border and whose membership
  includes non-U.S. citizens, the Secretary is to
  issue regulations, after Tribal consultation,
  identifying other forms of documentation
• Until such regulations are effective, Tribal
  enrollment/ membership documents for purposes of
  proving both citizenship and identity are
  sufficient

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Section 5006 of the Recovery Act Protections for
Indians under Medicaid/CHIP

• Exempts AI/ANs from Medicaid cost-sharing for
  services received directly or through I/T/Us
• Exempts Indian-specific property in determining
  Medicaid and CHIP eligibility
• Exempts Indian-specific property from Medicaid
  estate recovery

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Section 5006 (contd)

• Codifies in law the current FACA-exempt TTAG and
  adds one representative each for IHS and Urban
  Indian organizations
• Requires States to consult with Tribes on
  Medicaid and CHIP issues have a direct effect on
  Indian health programs
• Enhanced protections Indian health programs and
  for AI/ANs enrolled in Medicaid managed care

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CMS Tribal Consultation

• All Tribes Calls beginning Friday, June 5th
  through Thursday, July 2nd 200 400 PM ET
• Purpose of calls is to solicit tribal input on
  Recovery Act and CHIPRA
• Toll free number 1-888-455-5059, passcode
  Tribal Affairs
• July 10th Tribal Consultation Session to be
  held in Denver, immediately after Indian Health
  Summit, July 7-9th

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Key CMS LTC Community Based Programs

• 1915(c) Waivers (Home and Community Based
  Waivers)
• Deficit Reduction Act State Plan Options
• 1915(i) HCBS state plan option
• 1915(j) Self-directed personal care option
• Money Follows the Person (MFP) demo grants
• Program for All Inclusive Care for the Elderly -
  PACE

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HCBS Covered Services - both 1915(c) and 1915(i)

• Case Management
• Homemaker/chore
• Home health aide services
• Personal care
• Adult day health
• Habilitation
• Respite care

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HCBS Waivers (1915c)

• Provide community based long-term care and
  support as an alternative to institutional
  placement.
• Allow a State to waive certain provisions of the
  Social Security Act.
• Statewideness
• Comparability of services
• Income and resource requirements

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HCBS National Overview

• 284 HCBS Waiver Programs
• More than 1 million participants
• 21.2 Billion
• 7.5 of total Medicaid spending
• 24 of all Medicaid long-term services spending
• 67 of all Medicaid community service spending

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State Plan Option for Self-Directed Personal
Care DRA Section 1915 (j)

• States may opt to offer self-directed personal
  care services, including those offered by family
  members
• Provide items that increase independence or
  substitute for human assistance
• Planning, budgeting, spending and service
  delivery are individualized and directed by the
  person and those closest to him or her
• Incorporate participant direction into existing
  or new HCBS waivers.

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Money follows the Person

• Medicaid Demonstration program to transition
  individuals from institutional settings (e.g.
  nursing homes) to homes in their communities
• Individual has to be in an institutional setting
  for at least 6 months to qualify
• Population includes elderly, persons with
  physical disabilities, development disabilities,
  mental illness, dual diagnosed

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MFP Grants

• 29 States DC awarded MFP grants to transition
  35,000 individuals through 2011
• States with Tribal populations
• California, Connecticut, Iowa, Kansas, Louisiana,
  Michigan, Nebraska, New York, North Carolina,
  North Dakota, Oklahoma, Oregon, Washington,
  Wisconsin

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PACE Program of All-Inclusive Care for the
Elderly

• Designed to keep elders out of nursing home
  facilities
• Comprehensive Medical and LTC Services
• Adult Day health center, primary care and
  rehabilitation
• Integrated Team Management Care
• Integrated Medicare and Medicaid Financing

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Cherokee Elder Care

• Cherokee Elder Care is first PACE to be sponsored
  by a Tribe
• Not limited to Cherokee tribal members
• Must be 55 years or older
• Certified by state to need nursing home level of
  care
• Must live in a PACE service area
• eldercare.cherokee.org

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LTC options for Tribes

• Medicaid money must flow through the state
• Tribe(s) may explore an agreement with State
  agency
• Can waive statewideness and designate geographic
  area, ex., a Reservation
• Tribe(s) may tailor services and provider
  qualifications (can be specific to a tribe)
• 100 FMAP for some HCBS services under compacting
  - 638 Authority

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Accessing LTC services

• Eligible Tribal Members can apply to be
  consumers for benefits in their area.
• Qualified Tribal Providers can contract with the
  State or administering agency as a waiver
  provider or to perform certain administrative
  functions.
• Tribal Governments can perform a wide range of
  administrative functions re HCBS program
  operations on behalf of the State Medicaid
  Agency.

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CMS Native American Contacts

• Region I Boston (CT, ME, MA, NH, RI, VT)
  Nancy Grano
• [phone] nancy.grano_at_cms.hhs.gov
• Region II (NY, NJ, PR, Virgin Islands) Julie
  Rand
• [phone] julie.rand_at_cms.hhs.gov
• Region III Philadelphia (DE, DC, MD, PA, VA,
  WV) Tamara McCloy [phone]
  tamara.mccloy_at_cms.hhs.gov
• Region IV Atlanta (AL, NC, SC, FL, GA, KY, MS,
  TN) Dianne Thornton [phone]
  dianne.thornton_at_cms.hhs.gov
• Region V Chicago (IL, IN, MI, OH, WI) Pam
  Carson
• [phone] pam.carson_at_cms.hhs.gov

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CMS Native American Contacts

• Region VI Dallas (AR, LA, NM, OK, TX) Dorsey
  Sadongei
• [phone] eudora.sadongei_at_cms.hhs.gov
• Region VII Kansas City (IA, KS, MO, NE) Nancy
  Rios
• [phone] nancy.rios_at_cms.hhs.gov
• Region VIII Denver (CO, MT, ND, SD, UT, WY)
  Cynthia Gillaspie [phone]
  cynthia.gillaspie_at_cms.hhs.gov
• Region IX San Francisco (AZ, CA, HI, NV, Guam,
  Northern Mariana Islands, American Samoa)
  Rosella Norris
• [phone] rosella.norris_at_cms.hhs.gov
• Region X Seattle (AK, ID, OR, WA) Cecile
  Greenway
• [phone] cecile.greenway_at_cms.hhs.gov

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Questions?CMSOARRAQUESTIONS_at_CMS.HHS.GOVCMSCHIP
RAQUESTIONS_at_CMS.HHS.GOVFor more information
visit the CMS AI/AN Center www.cms.hhs.gov/cente
r/ir.asp