Background:

Medicaid reimbursement for services for American Indians and Alaska Natives.

The Indian Health Service (IHS), part of the federal Department of Health and Human Services, is the federal agency with primary responsibility for fulfilling the United States’ trust obligation to provide health care for American Indians and Alaska Natives. The IHS and tribes have developed a system of hospitals, clinics, field stations, and other programs to fulfill the federal trust responsibility and meet the health care needs of American Indians and Alaska Natives. Washington’s tribal health delivery system provides care to American Indians and Alaska Natives residing in both rural and urban areas. Twenty-eight of the 29 tribes have clinics that provide medical or behavioral health services. In addition, there are two urban Indian health clinics in Seattle and Spokane that provide care to urban American Indians and Alaska Natives.

Under Medicaid, the federal government matches state expenditures on behalf of American Indians and Alaska Natives at 100 percent of the Federal Medical Assistance Percentage for covered services received through an IHS and tribal health care facility. States, however, are reimbursed for payments made to non-IHS or non-Indian health providers for Medicaid services provided to American Indians and Alaska Natives based on the state's normal match rate.

In February 2016 the federal Centers for Medicare and Medicaid Services (CMS) issued an update to its payment policy affecting federal funding for Medicaid enrollees who are American Indians and Alaska Natives. Among the changes, CMS will allow a service to be considered to have been received through an IHS and tribal health care facility when an IHS and tribal health care facility practitioner requests the service from a non-IHS or non-tribal provider, who is also a Medicaid provider, in accordance with a care coordination agreement. This change in policy makes the services eligible for a 100 percent federal match.

Governor's Indian Health Council.

The 2018 Supplemental Operating Budget established the Governor's Indian Health Council (Health Council). The Health Council was directed to address policies with tribal implications, facilitate training for state agency leadership and staff, and provide oversight of contracting and performance of service coordination agencies and service contracting entities. The Health Council submitted its report to the Governor and the Legislature in December 2018. The report recommended establishing the Governor's Indian Health Advisory Council, establishing an account for appropriations of new state savings, providing funding for Health Care Authority staff to partner with tribes to achieve the new state savings, and partnering with tribes to cover the expenses of the Advisory Council to complete the first Indian Health Improvement Advisory Plan.

Summary of Bill:

The Governor's Indian Health Advisory Council.

The Governor's Indian Health Advisory Council (Advisory Council) is established. The voting members of the Advisory Council are:

one representative from each tribe;
the chief executive officer of each urban Indian organization;
one member from each of the two largest caucuses of the Washington State House of Representatives;
one member from each of the two largest caucuses of the Washington State Senate; and
one member representing the Governor's Office.

The nonvoting members of the Advisory Council are:

one member from the executive leadership team of the Health Care Authority (Authority); the Department of Children, Youth and Families; the Department of Commerce; the Department of Corrections; the Department of Health; the Department of Social and Health Services; the Office of the Insurance Commissioner; the Office of the Superintendent of Public Instruction; and the Washington Health Benefit Exchange;
the chief operating officer of each Indian Health Service (IHS) area office and service unit;
the executive director of the American Indian Health Commission; and
the executive director of the Northwest Portland Area Indian Health Board.

The Advisory Council must establish the Reinvestment Committee. The voting members of the Reinvestment Committee are every Advisory Council member who represents a tribe or urban Indian organization. The nonvoting members of the Reinvestment Committee are every Advisory Council member who represents a state agency, the IHS area office or service unit, the American Indian Health Commission, and the Northwest Portland Area Indian Health Board.

The Advisory Council is responsible for adopting the biennial Indian Health Improvement Advisory Plan (Advisory Plan) prepared by the Reinvestment Committee by November 1st of each odd-numbered year. It also must provide oversight of the Indian Health Improvement Reinvestment Account (Reinvestment Account) to ensure that expenditures are consistent with the Advisory Plan. The Advisory Council must address policies or actions that have tribal implications that are not able to be resolved at the agency level. The Advisory Council must also facilitate better understanding among its members of the Indian health system, American Indian and Alaska Native health disparities and historical trauma, and tribal sovereignty and self-governance. In addition, the Advisory Council must provide oversight of the contracting and performance of service coordination organizations or service contracting entities to address their impacts on services to American Indians and Alaska Natives and relationships with Indian health care providers.

The Advisory Committee may appoint technical advisory committees to address specific issues and concerns. The Authority must provide administrative and clerical assistance to the Advisory Council and its committees.

The Indian Health Improvement Advisory Plan.

The Reinvestment Committee must prepare and amend the Advisory Plan to: (1) raise the health status of American Indians and Alaska Natives in Washington to at least the levels set forth in the goals contained in the federal Healthy People 2020 initiative; and (2) help the state, the IHS, tribes, and urban Indian organizations improve delivery systems for American Indians and Alaska Natives.

The Advisory Plan must include an assessment of Indian health and Indian health care in the state; specific recommendations for programs, projects, or activities; and review the ways that the programs, projects, or activities that have received investment from the Reinvestment Account have or have not achieved the objectives. In addition, the Advisory Plan must include recommended Reinvestment Account expenditure amounts and priorities. The types of programs, projects, and activities that the Advisory Plan may address include:

tribally operated facilities providing evaluation, treatment, and recovery services for opioid use disorder, other substance use disorders, mental illness, or specialty care;
increased access to quality, culturally-appropriate, trauma-informed specialty services;
a third party administrative entity to provide, arrange, and make payment for services for American Indians and Alaska Natives;
expansion of suicide prevention services;
expansion of traditional healing services;
development of a community health aide program;
health information technology capability within tribes and urban Indian health organizations to assure the technological capacity to promote best practices, coordinate care, provide interoperability with state claims and reportable data systems, and support patient-centered medical home models;
support for care coordination by tribes and other Indian health care providers;
expanded support for tribal and urban Indian epidemiology centers; and
other health care services and public health services that contribute to reducing health inequities and increasing access to quality, culturally-appropriate health care for American Indians and Alaska Natives.

The Indian Health Improvement Reinvestment Account.

The Reinvestment Account is established. Receipts from new state savings and other appropriated money shall be deposited into the Reinvestment Account, less the Authority's administrative costs. "New state savings" is defined as savings to the State General Fund that are achieved through recent federal authority to provide 100 percent federal match for services provided to American Indians and Alaska Natives who are enrolled in Medicaid when those services are provided by a non-IHS or tribal provider according to a care coordination agreement. The new state savings is reflected as the difference between the 100 percent federal match actually received for the service and the match that the state would have otherwise received for the service.

Funds from the Reinvestment Account shall fund projects, program, and activities authorized by the Advisory Plan. Only the Director of the Authority may authorize expenditures from the Reinvestment Account and an appropriation is not required.

Legislative Findings and Intent.

Legislative findings are made regarding the nation's policy toward the health status of Native Americans and Alaska Natives, the health disparities that affect American Indians and Alaska Natives as a result of historical trauma and inadequate federal funding, the opportunity to shift the cost of care from the state to the federal government and the need for incentives to the tribes to take on the activities needed to shift the funds, and the federal government's intent to help improve delivery systems for American Indians and Alaska Natives. Legislative intent is declared to be to: (1) establish the policy of the state to provide quality care to American Indians and Alaska Natives, implement national policies of self-determination, and achieve the highest possible health status for American Indians and Alaska Natives; (2) establish the Governor's Indian Health Advisory Council; (3) establish the Reinvestment Account; (4) appropriate and deposit new state savings into the Reinvestment Account; and (5) require funds in the Reinvestment Account to be spent only on costs for projects, programs, or activities identified in the Advisory Plan.