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Tribes scramble to avoid $1 million in fines under Affordable Care Act

Diabetes patient Jay Littlewolf says he sought medical help for a diabetic ulcer at a Billings hospital after not receiving "adequate health care through the IHS in Lame Deer." He wants reimbursement from the IHS and sought Sen. Jon Tester's assistance.Photo/Larry Mayer, Gazette staff — Diabetes patient Jay Littlewolf says he sought medical help for a diabetic ulcer at a Billings hospital after not receiving “adequate health care through the IHS in Lame Deer.” He wants reimbursement from the IHS and sought Sen. Jon Tester’s assistance.
Photo/Larry Mayer, Gazette staff

BILLINGS – Montana’s Indian tribes, which until recently thought the Affordable Care Act would pass them by, could face fines exceeding $1 million for not offering insurance to employees.

Beginning in 2016, businesses with 50 or more full-time workers will have to offer at least a minimum amount of health insurance to employees. Those who don’t comply face tax penalties, and that includes tribal governments.

The requirement has been a surprise to tribes, said George Heavy Runner, Blackfeet Insurance Services health and wellness coordinator. As individuals, American Indians have the option of choosing not to follow Affordable Care Act rules. Many assumed tribal governments, which are sovereign, had that same option.

“We thought this was a ship kind of passing us by,” Heavy Runner said. “But it’s not just a ship passing through the night. We have been identified in this legislation, just not where we thought we would be.”

Tax penalties facing the Blackfeet Tribe for not complying could be as high as $1.1 million. Crow Tribal Chairman Darrin Old Coyote said the size of the fee depends on how many people a tribal government employs.

“If we don’t do the mandate, we’re going to be fined for the number of employees we have, and that number could be up to $1.5 million,” Old Coyote said. “We pay federal tax, and our employees pay federal tax and so we’re part of the large employer mandate.”

The tribes can avoid the fees by offering the insurance to their workers. Old Coyote said the Crow have hired a benefits manager to do just that.

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The change caught tribes off-guard because American Indians by treaty receive health care via the Indian Health Service on reservations. IHS is much maligned by tribal members for not providing adequate health care and for not covering services by specialists outside the IHS program.

Because IHS is limited, tribal members who work for their government would benefit from having other health care, Old Coyote said. The challenge is having a health care plan to offer by next year.

Suing to get off the employer mandate has already been tried. In February, Wyoming’s Northern Arapaho Tribe failed to convince a federal judge to block the employer mandate. The Northern Arapaho argued that subjecting tribes to the employer mandate was an oversight that overlooked treaty rights related to Indian health care, while also stating that tax credits and benefits granted to Indians under the Affordable Care Act would be denied.

Earlier this month, U.S. Sen. Steve Daines, R-Mont., and U.S. Rep. Ryan Zinke, R-Mont., announced a bill to exempt tribes from the employer mandate. Daines called the mandate a job killer for tribal governments, who wouldn’t hire as many employees if they had to pay significant penalties.

Other sponsors of the bill, such as Republican Sen. John Thune, of South Dakota, said it was unfair to exempt individual tribal members and not exempt tribal governments as well.

However, exempting tribes from the employer mandate won’t help the nagging problems with Indian health care, said a representative for Sen. Jon Tester, D-Mont.

“This bill does nothing to solve the underlying problem, which is crisis-level health disparities among Native Americans,” said Marnee Banks. “If we are serious about increasing access to quality health care in Indian Country, we will expand Medicaid and adequately fund the Indian Health Service.”

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IHS spending on Indian patients was $2,741 per person in 2013, according to the National Congress of American Indians, which asserts that IHS is severely underfunded. Medicaid spending, by comparison was $5,841.

The state of Montana is awaiting federal approval of the state’s plan to begin offering Medicaid to Montanans earning up to 138 percent of the federal poverty level.

Medicaid expansion would extend benefits to as many as 11,000 tribal members over the next four years, said Jon Ebelt of Montana’s Department of Public Health and Human Services. The program would benefit tribal health care in general, Ebelt said.

“Medicaid expansion revenue will be critical for building health infrastructure, expanding the workforce, and keeping health care providers in tribal communities,” Ebelt said. “Medicaid revenues will bring new funds to the programs and further investment in the Indian health system infrastructure and workforce. This is an opportunity to provide more health care services, create more jobs and employ more Native Americans in tribal communities.”

Old Coyote said he’s concerned that state benefits representatives won’t be able to clearly explain the expanded Medicaid program to some Crow Indians who speak Crow as their primary language. He’s asked the state to provide a benefits representative who is fluent in Crow.

Ebelt said the state is able to provide translation assistance if necessary and in determining an outreach plan with members of the Indian Health Service at Crow Agency.

Administration takes steps to ensure Americans signing up through the Marketplace have coverage and access to the care they need on January 1

Source: U.S. Department of Health and Human Services

Today, the Department of Health and Human Services (HHS) Secretary Kathleen Sebelius announced additional steps to help ensure consumers who are seeking health insurance through the Health Insurance Marketplace smoothly transition to coverage that best fits their needs. HHS continues to look for additional steps to take to make this process easier for consumers.

The steps taken today include:

Requiring insurers to accept payment through December 31 for coverage that will begin January 1, and urging issuers to give consumers additional time to pay their first month’s premium and still have coverage beginning Jan. 1, 2014.
Giving people enrolled in the federal Pre-existing Condition Insurance Plan (PCIP) the chance to extend their coverage through Jan. 31, 2014 if they have not already selected a new plan. PCIP is a transitional bridge program that provides people with health conditions who could otherwise be shut out of the insurance market or charged more because of their pre-existing condition quality, affordable health insurance until options become available in the Marketplaces. The additional month gives this vulnerable population additional time to enroll in a plan and ensure continuity of coverage.
Formalizing the previously announced decision giving individuals until December 23, instead of December 15, to sign up for health insurance coverage in the Marketplaces that would begin January 1.
Strongly encouraging insurers to treat out-of-network providers as in-network to ensure continuity of care for acute episodes or if the provider was listed in their plan’s provider directory as of the date of an enrollee’s enrollment.
Strongly encouraging insurers to refill prescriptions covered under previous plans during January.

“We are providing additional flexibility to consumers across the country to ensure they have access to coverage options that begin on January 1, 2014,” said Secretary Sebelius. “The Department is committed to providing consumers with the information they need to pick the coverage option that works for them and their families.”

Other ways the administration is working to provide consumers with a smooth transition to coverage include:

Working with health insurers on options to smooth this transition such as allowing people who come in after December 23 to get coverage starting January 1 or sooner than February 1;
Working with insurers and consumers to make sure that they know whether their doctor or prescriptions are covered before they choose a plan, and how to get care they need during the transition (e.g., receiving a drug not covered by your plan if your doctor deems it medically necessary);
Educating consumers who recently received cancellation notices about the possible option to extend their old policy or enroll in a new plan; and
Continuing outreach to consumers who began the application process through the Marketplace and experienced technical difficulties.

HHS is committed to meeting consumers where they are in the health coverage process, helping them access and shop for quality, affordable insurance.

Consumers with questions are encouraged to call the call center at 1-800-318-2596 or visit HealthCare.gov where they can Find Local Help.

Navigators help get Native Americans insurance

Associated Press

Insurance enrollment helpers are encouraging Native Americans to sign up for coverage under the nation’s new healthcare law, saying it will help them better access X-rays, mammograms, prescription drugs and trips to specialists not covered under Indian Health Service.

American Indians are exempt from the Affordable Care Act’s requirement that people carry insurance, but the law opens up resources that for years have been limited through IHS, said Jerilyn Church, executive director of the South Dakota-based Great Plains Tribal Chairmen’s Health Board.

“There’s a huge gap in access to services, so being enrolled in the marketplace is going to make a big difference in terms of accessibility to healthcare,” Church said.

The Indian Health Service, a branch of the U.S. Department of Health and Human Services, provides free healthcare to enrolled members of tribes, their descendants and some others as part of the government’s treaty obligations to Indian tribes dating back nearly a century.

Critics long have complained of insufficient financial support that has led to constant turnover among doctors and nurses, understaffed hospitals, sparse specialty care and long waits to see a doctor.

The Great Plains Tribal Chairmen’s Health Board received $264,000 in South Dakota and $186,000 in North Dakota to assist with Native American signups on the states’ reservations and urban areas.

The new law healthcare law will especially benefit people who seek treatment at urban Indian health clinics, which collectively are funded by just 1 percent of the IHS budget, said Ashley Tuomi, executive director of the American Indian Health and Family Services clinic in Detroit.

“Our resources are extremely limited, even more so than the tribes,” Tuomi said. “What we have within our walls is what we can offer for free.”

The clinic has seen a lot of patient interest in the healthcare marketplace, but “navigators” helping with signups have had to cancel many appointments because of continued issues with the federal healthcare.gov website, Tuomi said.

The Ponca Tribe of Nebraska has received about $38,000 in federal grant funds to encourage signups for tribal members scattered in 12 counties in Nebraska, two in Iowa and one in South Dakota.

The tribe’s IHS-contracted clinic in Omaha, Neb., has a medical doctor and two nurse practitioners, but the X-rays, specialists and prescriptions that are outsourced are not covered, said Jan Henderson, the tribe’s navigator project director. “And if they don’t have insurance, they have to pay for it themselves,” she said.

Tribes across the country get some federal money for referrals, but the small pools run out quickly, Henderson said.

She views the new healthcare law as a great step for Native Americans, but the greatest challenge is educating tribal members who are weary from decades of promises of improved healthcare.

“Education is very important in this right now to get people to be open to actually hearing about it,” Henderson said. “We hear a lot of people who say they don’t need this, they don’t want this.”