Tribal Health Programs in the Office of Medicaid and Health Care Policy
Commissioner Davidson’s commitment to improving relationships between the Department of Health & Social Services, the Tribes, and the federal government has reinvigorated the role of the Tribal Health Program. On August 31st, U.S. Health & Human Services Secretary Sylvia Burwell announced that the Centers for Medicare and Medicaid Services (CMS) will be updating its policy on the availability of 100% federal claiming activities related to transportation and referrals for Indian Health Service beneficiaries who receive care at a Tribal Health facility. This announcement elevated the importance of this statewide commitment. Improved working relations between the state, federal and tribal entities will result in improved health outcomes for Alaskans with the added benefit of state general fund savings.
The Tribal Health Program within the Department focuses on Medicaid services provided through Tribal Health Organizations (THO) statewide. This program was created after a major Departmental reorganization in 2002. The Tribal Health Program staff is responsible for collaborating across divisions, ensuring Tribal Health Organizations are key participants with the Department delivering health care to the Alaska Native Medicaid population. The program has two full-time dedicated staff located in both Juneau and Anchorage, and is assisted by several other programs within the Division of Health Care Services.
The Tribal healthcare delivery system is complex and unique. Rather than providing one service or specialty, each THO provides a wide range of services in their region. These services include hospital, behavioral health, dental, long-term care, targeted case management, community health aides, etc. This array of Medicaid services cross several programs within divisions of the Department. In the past, division specific programs were focused on one service area, created gaps in service and coordination with providers and/or key staff outside their program’s area. This process did not accommodate the uniqueness of the tribal health system and often resulted in conflicting rules and regulations.
The Alaska Medicaid program partners with other state agencies in the operation of mental health, substance abuse and home and community based waiver services. The state emphasizes the importance of supporting development of tribal infrastructure in these areas by funding staff to work on projects targeted to the tribes. Current projects include developing a behavioral health system for rural Alaska, combining the resources of mental health and substance abuse programs into a consolidated structure.
Supporting the health care needs of elders is a growing concern of the tribes and the state. Recent efforts support tribal development of nursing facilities in Kotzebue and Bethel, as well as increasing community based care options in the village.
To improve the health status of Alaska Natives, the Department and the Tribal Health Care System target enrollment of Medicaid eligible children under age 21 to ensure that they receive access to early and periodic screening and diagnosis to ascertain physical and mental defects and treatment to correct or ameliorate the defects and chronic conditions found through the Early & Periodic Screening, Diagnostic & Treatment (EPSDT) program. Also, because the expansion included pregnant women as well as children at higher income levels, the tribal health programs gained substantial new income as their beneficiaries are younger than other populations and have the highest birth rate.
Medicaid payments to tribal health care providers have increased substantially over the years. For example, in State Fiscal Year (SFY) 1991 payments to tribal providers were $9.6 million, in SFY05 payments exceeding $180 million, and exceeded $250million in SFY15. The increase in payments to the tribal health care system providers has been due to improved reimbursement, maximization of billing, service expansions and aggressive enrollment of Alaska Natives in program expansions. Training and outreach is also provided periodically in many of the major hubs around the state on claiming and reimbursement support.
When Alaska implemented the State Child Health Insurance Program in 1998 a grant from the Robert Wood Johnson Foundation was used to target effective outreach and enrollment to the Alaska Native community. The creation of outreach positions was funded in each tribal organization, and culturally appropriate materials were developed for the native community.
Additionally, to assist outreach activities the Tribal Health Program facilitates eligibility access to Tribal Health Organizations that have approved agreements with the state. This access enables approved THO staff to monitor Medicaid application status of recipients the Tribes and Tribal Health Organizations have assisted in applying for Medicaid. This person also frequently assists the prioritizing of application approval when there is an urgent medical need.
Overall, the Tribal Health Program acts not only as a liaison to the Tribal Health Organizations across the state, the program also liaisons with each division and program within the Department that works with the Tribes with a focus on health organizations that provide medical services covered by Medicaid. Further, since the rural areas are a combination of both health and social service providers, the Tribal Health Program works with social service organizations as well.
- Tribal Health Program impact of Medicaid Reform – and how our office facilitates the process from ideas to putting things into practice…
The ongoing partnership with Tribes and the Tribal Health Organizations on Medicaid Reform initiatives enhances the communication and shared responsibilities for Medicaid reform and improving health outcomes for tribal health beneficiaries. Through collaborating with Tribal Health Organizations, expertise and resources can be leveraged in a way that better informs the decision making process and capitalizes on shared and specialized knowledge and experience. The state and the tribes can solicit guidance from federal authorities and independent contractors and, as partners, maximize the tools available to analyze options and evaluate outcomes. With the federal government creating new opportunities for innovation through waivers and other policy options, and with the current demands due to budget realities in the state, affordable sustainable health care requires strong partnerships as we move forward. The state recognizes the benefits across the state to all Alaskans, especially in rural areas, from the provision of health services by tribal health. Partnerships, like those cultivated by the collaboration between tribes and the tribal health program, are critical to ensuring the state has a sustainable health care system all Alaskans can depend on.
- How our office works directly with tribes to facilitate delivery and reimbursement for services across the Medicaid spectrum for the full age range of beneficiaries…
The tribal health model provides a platform for, and has a common interest in, building a sustainable system with quality measures in place that promote economy, efficiency, and improved outcomes. From the high level view of designing coordinated care models for beneficiaries, to the detailed work of solving claims and eligibility issues, our office supports, collaborates, and consults with Tribal Health Organizations to effectively address access, experience, and funding for the tribal health care program.