State-Tribal Leadership Consultation Centennial Care March 20, 2012 All Indian Pueblo Cultural Center in Albuquerque _____________________________________________________________________________________

Notes

Governor of Pueblo of Picuris Serious problem with alcoholism in their community. Need to focus on this issue, not only for Native people for all who have these social problems. Pueblo of Zuni Full opposition to elimination of the opt out for their community basically because of their location. It is hard to get health care providers outside their reservation. Also, the emergency facilities have lost a lot of tribal members. Substance abuse is also a very critical area. Currently they have difficulty with transportation issues with contracting with the providers. Need more local providers. They dont have quality of road care and transportation services and cannot locate them in an appropriate amount of time. Cultural healers, there is a misunderstanding from tribe to tribe. Licensed or non-licensed we need that implemented for tribal members. Want better care for their communities. Pueblo of Zuni needs a more understanding for the Tribal members that have the Medicaid benefits because they misunderstand what they really have. Pueblo of Santa Clara - We dont have all of our members registered with Medicaid. Will there be enough medical facilities to handle an increased enrollment? Also they have an adult day care center that was approved. It is crucial to have third-party billing with Medicaid and the state. There are a lot of substance abuse issues and their Systems of Care are providing assistance. In regards to Emergency Use many people use ERs because there are not enough providers that people can see otherwise. Pueblo of Santo Domingo In response to the concept paper, health care for Native Americans (NA) has historically been through the federal government (gave a brief history). There are federal protections for NAs in federal laws. Under the Indian Health Care Improvement Act there is no mandatory participation for NA to enroll in managed care nor is there a requirement for those to buy health insurance. No premium on cost sharing for services. There are special rules for Indian enrollees. IHS and Tribal 638s get reimbursed at the highest reimbursement rates. No cost sharing should be required at Indian facilities or outside facilities. Healthcare is a federal responsibility for NAs. Need to follow federal laws before Centennial Care is implemented in this state. Patient center medical homes are a good idea. Fee for Service (FFS) has to remain. FFS shows that other states in the past that rural and frontier area have limited MCO facilities. MCOs have had their own challenges in rural and frontier areas. Pueblo of Santo Domingo (Kewa Pueblo) has a written statement that they will be leaving with the state.

Joe Garcia Ohkay Owingeh Head Tribal Councilman It is important for State of NM recognizes the relationship that tribes have with the federal government, which is to provide adequate health care. In this case, NM does not understand that relationship. Example: several different organizational levels that the tribes here in NM have. 1) Direct Service Tribes (majority). 2) 638 contracting. 3) selfgovernance side where IHS contracts and takes care of the health care for the tribe. The federal law that is in place, and NM goes forward with Centennial Care, the state will be in violation of federal law. They should have the option to go to tribal facilities. Reduce costs not about cost reduction, but rather about providing quality services. (Mr. Garcia misunderstood the point about education thought the state was talking about actually educating health care in the schools). Workgroups did not represent all of NM tribes. In reference to the opt out issue, is this an opportunity to discuss or is the state just moving forward. If moving forward, there will be problems. Does HSD have a written policy for state tribal consultation? (HSD provided the written document later in the meeting.) Ohkay Owingeh Pueblo will be providing a written document. Pueblo of Laguna A statement from Pueblo of Laguna was read Opposes mandatory participation in Managed Care Organizations (MCOs.) In the past there have been access issues. Tribal members have the right to choose their own providers. Medicaid program should meet the needs of our Tribal members. The Pueblo opposes cost sharing on NA beneficiaries. NA Medicaid beneficiaries should not incur out of pocket expenses. The Pueblo of Laguna would be interested in a partially capitated model. Pueblo of Jemez Lt. Governor Supports the reduction of the state budget, however, not by this plan. Support Medicaid Modernization. They worked hard for the Public law 638. The Pueblo 638 relies on the third-party billing to operate. 70% of their third party revenue is from Medicaid. The Pueblo believes they will see a negative effect through this plan. Pueblo of Jemez has quality and quantity of health care. Supports statements made about under the affordable care act, not mandated to participate in managed care. In reference to co-pays, many elders live on a budget, and cant afford a co-pay, especially for the emergency room. Urgent Care facilities are not available 24/7. IHS facilities are not available 24/7. Co-pays are pretty high and cant afford that. Pueblo of Jemez is comfortable with what they have. Strongly oppose Medicaid Modernization. Urges Secretary Allison to go back to Governor Martinez and have her re-consider and have Tribal Communities op out. Julie Weinberg, HSD Medicaid Director Clarified some issues/misunderstandings. The state will be requiring the MCOs to contract with IHS and Tribal 638s and get the OMB rate. Also we are going to pursue exempting NA from the two co-payments that we have proposed (prescriptions/ER), outside of the NA facilities to exempt tribal members from those co-payments. The state agrees that our contractors must do better with tribal health facilities are reimbursed promptly. The state understands that has been a problem and getting corrected now and hope not to have that problem in Centennial Care. In regards to Senate Bill 196 Julie clarified we are HSD and we do have a policy. Acoma Pueblo Opt out for NA must remain intact. The State mandate for all NAs into MCOs directly changes the tribal sovereignty. NAs are also exempt from proposed cost-sharing. NAs should have health plans. Acoma Pueblo has developed networks at both regional and local. State should give preference to develop training instead of contracting with MCOs. Consultation processes needs to be

more than one informational session. State needs to go to each tribe individually. In regards to the Health Insurance Excahange (HIX), federal mandate to provide cradle to grave health care for NAs takes precedence over the State of NM HIX. Tribes should negotiate with Federal Govt. directly. Fed government should create an exchange for NAs. Urges all leaders to take this back to their councils and give real feedback to the state. Vice-President of Navajo Nation (NN) NN believes that Navajo members who reside in NM the federal government is required to provide quality health care. Concern is related to costs. With additional layer of bureaucracy takes more administrative costs. Beneficiaries need to be explained the changes proposed. This need to be done in Navajo, and explained clearly. In reference to the status of working document, the NN is concerned that NM is indicating that they are moving forward without true consultation without technical assistance to NA communities. Revise plans to exempt tribal members from cost sharing. MCOs should not make a profit off of the NA enrollees. Bundles and profits. Comprehensive Holistic package. NN recommends the NN as a pilot project for a Medicaid feasibility state. Tribal representation is not adequate for consultation in the concept paper. NN did not have representation on policy making/decision making. NN recommends at least one NN on the policy committee. NN recommends the Medical Assistance Division (MAD) includes Tribal members in the development of the RFP. Stakeholder involvement information has been limited. NN recommends implement with all stakeholders to ensure the development enhances the NN position. Gilbert Suazo Sr., Lt. Governor Taos Pueblo Taos pueblo has health issues/problems just like any other community. The responsibility of the federal government and what it is supposed to do for NA people. Taos has had Tribal 638 for years and now going into self governance. Lacking facilities, like nursing homes for elders, treatment centers for substance abuse, more active preventive care programs. Always goes back to the federal governments responsibility, providing free healthcare for Indian people, along with education and protection of Tribal lands. Whole process has been misunderstood. Now the state is getting involved and it is being mandated that all people go into an MCO. This is not the right approach for sovereign tribes who practice self determination and self governance. Questions how much discussion there has been with IHS and Tribal Governments in trying to put into place a health care process. IHS needs to be a prominent figure in trying to figure out health care for NA people. Unless there is a more thought out plan for Tribal governments this will lead to a more misunderstood and complex process. Federal government may move further away from its trust responsibility in providing health care for its NA people. Not sure what the states motives are. Where they are coming from? More government to government discussion needs to take place and with the IHS at the table. Taos Pueblo will provide a written statement. Some of the tribal efforts being made are underway to try to improve the treatment of their Indian people who need health care and for social problems. Manuel Cristobal Pueblo of Santa Ana Opposition to the Medicare/Medicaid reformat. Appeal to all Indian pueblo council for a tribal resolution. This is medical genocide. Picuris Pueblo At this point they are working on a facility to incorporate with the pueblo of Taos. Facility with 8 northern pueblo leadership. In the future would like to see these insurance policies incorporated into this facility, to promote and make it grow. Insurance policies should be honored to

participate in all facilities having to do with their health. Medicaid needs to be incorporated into this treatment facility. All Indian Pueblo Council (AIPC) Chairman Youve heard the concerns, many concerns. We come to the table with hopes that we can continue to serve our people. Continue to give them hope that within our communities we are all healthy. Yes, there are many times when we can all sit around the table about how we are going to change things, how we are going to implement, how you invite NA leadership to the table to consult. Many times, once the day is over, where does that go? How often do we see followup of that implementation. How often do we see those leaders come back to tribal leadership to further explain the different policies and procedures, for something as big as this, health care? Each and every leader here are very concerned. Health care is always the number issue one on their list. Health care is always what has been asked about leadership. We need to continue to have further dialogue and discussion for leadership to fully understand. Urges NA leaders to go back to their councils and explain what these changes are going to be. Tomorrow is the AIPC meeting and they will discuss this issue. There is a big difference between Collaboration and Consultation. Ken Lucero Zia Pueblo Great to see this many people, tribal leaders participating in this consultation. Zia is looking forward for full implementation of the Affordable Care Act (ACA). Support full implementation of Medicaid on the federal level. Cost cutting issues with Centennial Care (CC) Indian Improvement Act and ACA from 2014 to 2019 pay 100% to 91%, after 2019 FMAP will be 90%. For NA population you will not realize any significant savings. FMAP for NA will remain at 100%. Medicaid expansion through ACA will have new funding for NA. CC is states attempt at modernization and Pueblo of Zia has same concerns as others leaders here today. Need to have more participation with MCOs and their current health care providers. Does not support mandatory opt in provision. Will resist any plan the state moves forward with on this issue. Supports consolidation of behavioral health services. Protections for NA need to remain in place. Who was participating in the work group? Ohkay Owingehs representative wasnt joined in until February. _________________________________________________________________________________ Public Input Ron Lujan Havent had response to questions from January 2011 meeting with Brian Moore and Matt Kennicott Havent had response to OHCR meeting last year We need to re-assess all of this and go back to the federal obligation that is supposed to be providing health care for NA people. 80% to 90 % of NA have maintained their opt out status.

Wayne Lehi -

Generic vs. brand name drugs? IHS and Tribal 638 use one source for prescriptions. Needs to be conclusive evidence that generic is better than brand. Diabetes issues will be impact. Also impact ability to bill pharmacy sales. (Julie Weinberg clarified that the state is not going to apply the $3 co-pay when getting prescription from IHS or Tribal 638 facility. We are also looking an equivalent, not better.)

Steve Boon (Lt. Governor, Pueblo of Zuni) passed to Mark Martinez Mark Martinez Reimbursements to tribal programs is of concern. FFS goes to outcomes. How is that going to deter? How far is the process with CMS? If we are already far in the process with CMS, what are we doing here?

Julie Weinberg The state has not submitted the waiver yet. The State hopes to by the end of April. Once the waiver is submitted it is just the beginning of the conversation with CMS. Once submitted it is not written in stone at that point. Quela Robinson Center on Law and Poverty Opposed to any out of pocket costs for anybody in Medicaid, specifically NAs due to the trust.

Cheryl Hunt Pueblos of Acoma Isleta and Laguna Long-term care issues that the communities are faced with. Grandparents taking care of grand kids, adults taking care of their elders, etc. She doesnt see the community dealing with issues that support taking care of elderly. Would like to see more emphasis on long-term care facilities.

Dave Pueblo of Jemez Centennial Care (CC) poses a direct threat of tribal sovereignty o State described full MCO run system. Although there is a requirement for MCO to work with all tribal providers, but there is no timeframe. o At the start of MCOs there have been issued with timely payments, care coordination, etc. o Claim MCOs will improve disparities, but no proof. o CC paper indicated when a Medicaid eligible individual must select a health plan. Automatically goes into MCO system, no FFS. Patients in interim while developing contracts with MCO will be taken out of pueblo system. o Pueblo of Jemez has both state and federal remedies. State must retain opt out provision. Tribal participation must be required for RFPs Tribal subject matter must participate in proposed evidence based applicable to NA populations

Must equitable tribal reps. to provide direction and oversight in modernized system. Tribal remedy tribes have the option to work directly with CMS, under federal tribal consultation. If NM continues to implement this plan, the Tribes are within their authority to dispute directly to CMS. To date, NM HSD does not accurately reflect input from various tribal stakeholders.

Rick Vigil Local Collaborative 18 Been involved in arena of cost containment, 2009 to 2012. In terms of behavioral health network, have been working with planning council. Council has now sanctioned combining behavioral health and physical health. Have to recognize the sovereignty of each nation. Also each nation needs to recognize the needs in each community. Quality is key to customer service. Native American protection plan went to CMS and nothing has happened with it. This is a system that is so complex that we need to take this CC plan to each of the NA communities.

Florine Gutierrez Behavioral Health Director of Santa Clara Pueblo Concerns about ACA. ACA is a good idea, grandiose idea. However, knowing that there are not enough providers in the US for mental health and medical facilities is of concern. Even those who have coverage and are being turned away. Providers are not picking up new patients. Where do they go? Indian Health you need to stand up to your obligations to the Indian people. You cant pull yourself away just because of ACA. You have to be there for the tribes to provide assistance, services, technical assistance. Services are diminishing and there are cuts through IHS. There are vacancies in Indian Health. IHS needs to work with the Tribes and tell them how this is going to work to make it better. True Tribal Consultation it is a government to government relationship. It is not getting a group of tribal leaders in one forum and expecting them to be able to make a decision. They have a tribal council they have to answer to. It takes time for true consultation. All these comments, whether written or verbal will they be available for review?

Leonard Montoya, Ohkay Owingeh With the CC putting in place, NAs are still depending on IHS to provide services. How is IHS going to be part of this? Doesnt see through the CC plan how this is going to directly impact IHS facilities.

Hopes the State hears that the majority of the tribes do not support this plan, and takes it into consideration.

Julie Weinberg clarified that the CC plan will not change one bit how NAs use services through the IHS or Tribal 638 facilities. MCOs will partner with the tribal facilities.

Picuris Pueblo Governor Feels this has been a very successful meeting. Suggest to the state, that this does not stop here. He would like to have a position paper come to his office in reference to this meeting. State input, tribal input and where we go from here. The position paper would be a vehicle to be used later on for collaboration.