Medicare and Medicaid
CMS and State Efforts to Interact with the Indian Health Service and Indian Tribes Gao ID: GAO-08-724 July 11, 2008By law, facilities funded by the Indian Health Service (IHS) may retain reimbursement from Medicare and Medicaid without an offsetting reduction in funding. Ensuring that IHS-funded facilities enroll individuals in--and obtain reimbursement from--Medicare and Medicaid can provide an important means of expanding the funding for health care services for the population served by IHS. The Centers for Medicare & Medicaid Services (CMS), the agency within the Department of Health and Human Services (HHS) that administers Medicare and oversees states' Medicaid programs, is required by Executive Order and HHS policy to consult with Indian tribes on policies that have tribal implications. This requirement is in recognition of the unique government-to-government relationship between the 562 federally recognized Indian tribes and the federal government. GAO was asked to (1) describe interactions between CMS and IHS, (2) examine mechanisms CMS uses to interact and consult with Indian tribes, (3) examine mechanisms that selected states' Medicaid programs use to interact and consult with Indian tribes, and (4) identify barriers to Medicare and Medicaid enrollment and efforts to help eligible American Indians and Alaska Natives apply for and enroll in these programs. GAO reviewed documents, interviewed federal and state officials, and visited a judgmental sample of Indian tribes and IHS-funded facilities in six states.
CMS and IHS have interacted to (1) provide support to IHS-funded facilities and tribes in their access to Medicare and Medicaid and (2) address broader policy and regulatory concerns regarding these programs. Their interactions to provide support have included education and technical assistance; the agencies also have interacted to obtain input from tribal representatives on program operations. On broader policy and regulatory concerns, CMS and IHS have worked on policy initiatives aimed at ensuring that existing health care policies meet the needs of IHS-funded facilities and the populations they serve. CMS and IHS have had mixed success identifying whether proposed CMS regulatory changes would affect IHS-funded facilities or their populations and thus warrant IHS review. CMS has been working to improve its identification of such regulations. CMS has used two key mechanisms--tribal liaisons and an advisory board--to interact with representatives from Indian tribes, and it has relied primarily on annual regional sessions sponsored by HHS as its mechanism to consult with Indian tribes. Tribal liaisons in CMS's central and regional offices generally served as the point of contact for tribal representatives. CMS's tribal advisory board, which is meant to complement but not replace consultation, has provided the agency with advice on policies affecting the delivery of health care for American Indians and Alaska Natives. CMS has used annual HHS regional consultation sessions as the primary basis for consulting with Indian tribes. However, consulting with tribes is an inherently difficult task, in part because of the variation in tribes' size, location, and economic status. Further, these HHS regional sessions--which generally lasted 1 to 2 days and covered all HHS programs--have offered limited time for consultation and discussion. The six state Medicaid programs we reviewed have used at least one of three mechanisms--tribal liaisons, advisory boards, and regular meetings--to interact and consult with Indian tribes. Five of the six states reported having policies in place that governed the interactions between the state's Medicaid program and Indian tribes, with most of these policies establishing guidelines for how consultation should be conducted. Five states reported consulting with tribes about changes to their Medicaid programs. American Indians and Alaska Natives have faced several barriers to Medicare and Medicaid enrollment despite efforts to assist them with the application process. Many of these barriers are similar to those experienced by other populations, such as transportation and financial barriers. To help eligible American Indians and Alaska Natives enroll in Medicare and Medicaid, almost all of the IHS-funded facilities we visited had staff who assisted patients with the application process, including helping them complete and submit applications, and collecting required documentation. In commenting on a draft of this report, CMS noted that it was appreciative of GAO's review of CMS activities related to interactions with IHS and tribes.
GAO-08-724, Medicare and Medicaid: CMS and State Efforts to Interact with the Indian Health Service and Indian Tribes
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Report to the Committee on Finance, U.S. Senate:
United States Government Accountability Office:
GAO:
July 2008:
Medicare and Medicaid:
CMS and State Efforts to Interact with the Indian Health Service and
Indian Tribes:
CMS and State Interactions with IHS and Tribes:
GAO-08-724:
GAO Highlights:
Highlights of GAO-08-724, a report to the Committee on Finance, U.S.
Senate.
Why GAO Did This Study:
By law, facilities funded by the Indian Health Service (IHS) may retain
reimbursement from Medicare and Medicaid without an offsetting
reduction in funding. Ensuring that IHS-funded facilities enroll
individuals in”and obtain reimbursement from”Medicare and Medicaid can
provide an important means of expanding the funding for health care
services for the population served by IHS. The Centers for Medicare &
Medicaid Services (CMS), the agency within the Department of Health and
Human Services (HHS) that administers Medicare and oversees states‘
Medicaid programs, is required by Executive Order and HHS policy to
consult with Indian tribes on policies that have tribal implications.
This requirement is in recognition of the unique government-to-
government relationship between the 562 federally recognized Indian
tribes and the federal government.
GAO was asked to (1) describe interactions between CMS and IHS, (2)
examine mechanisms CMS uses to interact and consult with Indian tribes,
(3) examine mechanisms that selected states‘ Medicaid programs use to
interact and consult with Indian tribes, and (4) identify barriers to
Medicare and Medicaid enrollment and efforts to help eligible American
Indians and Alaska Natives apply for and enroll in these programs. GAO
reviewed documents, interviewed federal and state officials, and
visited a judgmental sample of Indian tribes and IHS-funded facilities
in six states.
What GAO Found:
CMS and IHS have interacted to (1) provide support to IHS-funded
facilities and tribes in their access to Medicare and Medicaid and (2)
address broader policy and regulatory concerns regarding these
programs. Their interactions to provide support have included education
and technical assistance; the agencies also have interacted to obtain
input from tribal representatives on program operations. On broader
policy and regulatory concerns, CMS and IHS have worked on policy
initiatives aimed at ensuring that existing health care policies meet
the needs of IHS-funded facilities and the populations they serve. CMS
and IHS have had mixed success identifying whether proposed CMS
regulatory changes would affect IHS-funded facilities or their
populations and thus warrant IHS review. CMS has been working to
improve its identification of such regulations.
CMS has used two key mechanisms”tribal liaisons and an advisory
board”to interact with representatives from Indian tribes, and it has
relied primarily on annual regional sessions sponsored by HHS as its
mechanism to consult with Indian tribes. Tribal liaisons in CMS‘s
central and regional offices generally served as the point of contact
for tribal representatives. CMS‘s tribal advisory board, which is meant
to complement but not replace consultation, has provided the agency
with advice on policies affecting the delivery of health care for
American Indians and Alaska Natives. CMS has used annual HHS regional
consultation sessions as the primary basis for consulting with Indian
tribes. However, consulting with tribes is an inherently difficult
task, in part because of the variation in tribes‘ size, location, and
economic status. Further, these HHS regional sessions”which generally
lasted 1 to 2 days and covered all HHS programs”have offered limited
time for consultation and discussion.
The six state Medicaid programs we reviewed have used at least one of
three mechanisms”tribal liaisons, advisory boards, and regular
meetings”to interact and consult with Indian tribes. Five of the six
states reported having policies in place that governed the interactions
between the state‘s Medicaid program and Indian tribes, with most of
these policies establishing guidelines for how consultation should be
conducted. Five states reported consulting with tribes about changes to
their Medicaid programs.
American Indians and Alaska Natives have faced several barriers to
Medicare and Medicaid enrollment despite efforts to assist them with
the application process. Many of these barriers are similar to those
experienced by other populations, such as transportation and financial
barriers. To help eligible American Indians and Alaska Natives enroll
in Medicare and Medicaid, almost all of the IHS-funded facilities we
visited had staff who assisted patients with the application process,
including helping them complete and submit applications, and collecting
required documentation.
In commenting on a draft of this report, CMS noted that it was
appreciative of GAO‘s review of CMS activities related to interactions
with IHS and tribes.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-724]. For more
information, contact Kathleen M. King at (202) 512-7114 or
kingk@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
CMS and IHS Have Interacted to Provide Support as Well as Address
Broader Policy and Regulatory Concerns:
CMS Has Used Two Key Mechanisms to Interact, and the Annual HHS
Regional Sessions to Consult, with Indian Tribes:
Selected States' Medicaid Programs Have Used Multiple Mechanisms to
Interact and Consult with Tribes:
American Indians and Alaska Natives Have Faced Several Barriers to
Medicare and Medicaid Enrollment Despite Efforts to Assist with the
Application Process:
Agency and State Comments and Our Evaluation:
Appendix I: Locations of Indian Health Service (IHS) Areas and Centers
for Medicare & Medicaid Services (CMS) Regions:
Appendix II: Methodology for Selecting IHS Areas, Facilities, and
Tribes Visited:
Appendix III: Comments from the Department of Health and Human
Services:
Appendix IV: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Types of Interactions between CMS Tribal Liaisons and Indian
Tribes:
Table 2: Description of the CMS TTAG:
Table 3: Examples of Duties Performed by Tribal Liaisons:
Table 4: Highlights of Guidelines Established by State Tribal
Consultation Policies:
Table 5: Description of Barriers American Indians and Alaska Natives
Have Experienced Enrolling in Medicare and Medicaid:
Table 6: Selected Characteristics of IHS Areas Visited:
Table 7: Characteristics of IHS-Funded Facilities Visited:
Figures:
Figure 1: IHS Medicare and Medicaid Reimbursement, Fiscal Years 1998
through 2007:
Figure 2: Points in CMS Regulation Development Process When IHS Can Be
Informed about a Proposed Regulation:
Figure 3: Example of How Facilities Use the Patient Registration
Process to Identify Patients Needing Medicare or Medicaid Application
Assistance:
Abbreviations:
CMS: Centers for Medicare & Medicaid Services:
HHS: Department of Health and Human Services:
IHS: Indian Health Service:
NAC: Native American Contacts:
SSA: Social Security Administration:
TTAG: Tribal Technical Advisory Group:
United States Government Accountability Office:
Washington, DC 20548:
July 11, 2008:
The Honorable Max Baucus:
Chairman:
The Honorable Charles E. Grassley:
Ranking Member:
Committee on Finance:
United States Senate:
The United States recognizes each of the more than 560 federally
recognized Indian tribes as sovereign nations within its
borders.[Footnote 1] These tribes, which are located in over 30 states,
vary greatly in population, economic status, and land ownership, and
have a unique government-to-government relationship with the federal
government. According to federal law, this unique relationship includes
a responsibility for the provision of health care to American Indians
and Alaska Natives. The Indian Health Service (IHS), an agency within
the Department of Health and Human Services (HHS), provides or arranges
for the provision of health care services for American Indians and
Alaska Natives.[Footnote 2] In fiscal year 2007, IHS provided or
arranged health care services for approximately 1.5 million American
Indians and Alaska Natives. Services are provided through IHS-funded
facilities, including those operated by IHS and those operated by
tribes, or purchased from other public and private providers--referred
to as contract health services.
IHS is funded through appropriations, which in fiscal years 2006 and
2007 were approximately $3.0 billion and $3.2 billion, respectively. In
addition to federal appropriations, IHS-funded facilities can seek
reimbursement for services they provide to individuals enrolled in
Medicare, the federal health insurance program for elderly and disabled
individuals, and for those enrolled in Medicaid, a joint federal and
state health financing program for certain low-income families and low-
income individuals who are aged or disabled.[Footnote 3] Reimbursement
from Medicare and Medicaid can increase the amount of funds available
to IHS-funded facilities because by law they can retain reimbursement
from these programs without an offsetting reduction in their
appropriated funding.[Footnote 4] In fiscal year 2007, IHS reported
approximately $677 million in reimbursement from Medicare and
Medicaid;[Footnote 5] however, facilities vary greatly in the total
reimbursement obtained from these programs. For example, our prior work
found that Medicaid reimbursement across 12 IHS-funded facilities
ranged from 2 percent to 49 percent of the total direct medical care
budgets of these facilities, and that facilities with higher
reimbursement had additional funds to hire staff and purchase equipment
and supplies.[Footnote 6] As a result, ensuring that eligible American
Indians and Alaska Natives are enrolled in Medicare and Medicaid, and
that IHS-funded facilities obtain reimbursement for services provided
to these enrolled individuals, can provide an important means of
expanding the funding for health care services available to this
population.
Changes to Medicare and Medicaid can affect the enrollment of American
Indians and Alaska Natives in these programs and the ability of IHS-
funded facilities to claim reimbursement for enrolled individuals.
Interactions between Indian tribes, IHS, and the Centers for Medicare &
Medicaid Services (CMS), the agency within HHS that administers
Medicare and oversees states' Medicaid programs, can help prevent
policy changes from having unforeseen effects on tribes and IHS-funded
facilities. For example, if changes in a Medicaid program's delivery
system--such as moving to a system of managed care--are discussed with
tribes and IHS officials, then consequences--such as IHS-funded
facilities not being part of managed care systems--may be avoided.
Recognizing the unique status of Indian tribes, a 1998 Executive Order
required a specific type of interaction between federal agencies and
Indian tribes, called consultation, which required federal agencies to
have an effective process to ensure meaningful and timely input by
tribal officials in the development of regulatory policies that have
tribal implications.[Footnote 7] In 2005, HHS adopted a tribal
consultation policy, under which every agency within HHS shares the
responsibility to coordinate, communicate, and consult with Indian
tribes. Thus, CMS is required to consult with Indian tribes on program
issues that have tribal implications. In contrast, states are not
subject to the Executive Order or HHS's tribal consultation policy.
However, CMS has encouraged state Medicaid programs to consult with
tribes when making changes to their Medicaid programs. Moreover, some
states have policies requiring consultation between the state Medicaid
program and Indian tribes.
Given the importance of CMS programs to American Indians and Alaska
Natives, you asked us to examine the interactions between the Medicare
and Medicaid programs with IHS-funded facilities. This report (1)
describes interactions between CMS and IHS, (2) examines mechanisms CMS
uses to interact and consult with Indian tribes, (3) examines
mechanisms that selected states' Medicaid programs use to interact and
consult with Indian tribes, and (4) identifies barriers to enrollment
in Medicare and Medicaid and efforts to help eligible American Indians
and Alaska Natives apply for and enroll in these programs.
To describe interactions between CMS and IHS, we interviewed officials
from both agencies. Specifically, within CMS, we interviewed officials
from its central office and 9 of its 10 regional offices who have
responsibility for coordinating issues related to Indian tribes and
IHS, as well as other CMS officials, including officials knowledgeable
about interactions between CMS and IHS.[Footnote 8] Within IHS, we
interviewed headquarters officials involved in interacting with CMS,
including those in the Office of Resource Access &
Partnerships.[Footnote 9] We also interviewed officials in each of
IHS's 12 area offices identified by IHS executives as being the most
knowledgeable about Medicare-and Medicaid-related issues. (See app. I
for a map of the locations covered by the IHS area offices and the CMS
regional offices.) In our interviews, we asked CMS and IHS officials
about their interactions with the other agency. During the interviews
we obtained information about the development and review process for
regulations and how CMS and IHS interact to identify proposed CMS
regulations that may affect IHS-funded facilities. To supplement this
information, we interviewed officials from the HHS Office of the
Executive Secretariat, which is responsible for determining which
agencies within HHS should have the opportunity to review a regulation.
We also interviewed officials from the HHS Office of Tribal Affairs
about HHS activities related to American Indians and Alaska Natives
that involve IHS and CMS. Additionally, we reviewed relevant CMS and
IHS documentation to supplement information obtained during our
interviews.
To examine mechanisms that CMS uses to interact and consult with Indian
tribes, we reviewed information obtained during our interviews with the
CMS and HHS officials noted above. We also interviewed tribal
representatives to obtain their opinions about interactions with CMS.
During the course of our interviews with CMS and HHS officials, we
asked them about past and present interactions, including
consultations, with tribes. We conducted site visits in 3 of the 12 IHS
areas from September through November 2007.[Footnote 10] We selected
these 3 areas to represent a mix in terms of geographic location, level
of reliance on contract health services, and the entities operating the
facilities (IHS or tribes).[Footnote 11] (See app. II for more detailed
information about the methodology for our site visits.) During our site
visits we met with tribal leaders or designated officials from 14
tribes, and interviewed them regarding their interactions with CMS and
elicited their opinions about CMS's consultation with Indian tribes. To
better understand CMS's consultation activities, we reviewed CMS's
involvement in HHS regional consultation sessions. To do this, we
interviewed HHS officials from the four HHS regional offices that
corresponded to the location of the tribes we visited and reviewed
agendas and reports from these regions' consultation sessions.[Footnote
12] We interviewed over 15 additional tribal representatives, including
officials from area health boards--who serve as the voice for tribes in
their area on health-related issues--and tribal representatives who are
members of CMS's Tribal Technical Advisory Group (TTAG), an advisory
board created to inform CMS about issues affecting the delivery of
health care to American Indians and Alaska Natives served by CMS
programs. Finally, we observed several TTAG meetings and reviewed
relevant documentation, such as minutes, from prior TTAG meetings.
To examine mechanisms that selected states' Medicaid programs use to
interact and consult with Indian tribes, we interviewed Medicaid
officials in the six states that corresponded to the location of the 14
tribes we visited.[Footnote 13] We asked these officials about
interactions and consultations between the state Medicaid program and
Indian tribes in the state. We also reviewed relevant documentation,
such as state policies that govern interactions with tribes.
Additionally, we used information gathered from our interviews with
tribal leaders and other tribal representatives.
To identify barriers to enrollment in Medicare and Medicaid and efforts
to help eligible American Indians and Alaska Natives apply for and
enroll in these programs, we used information obtained from our
interviews with CMS, IHS, and state officials as well as tribal
representatives. Additionally, during our site visits, we interviewed
officials at 25 IHS-funded facilities, 13 of which were operated by IHS
and 12 of which were operated by tribes. During these interviews, we
asked officials about barriers to Medicare and Medicaid enrollment,
enrollment assistance provided, and outreach activities. We also
interviewed officials from the Social Security Administration (SSA),
the federal agency responsible for Medicare enrollment, about barriers
to Medicare enrollment and the agency's outreach activities. In
addition, we conducted a literature review about barriers related to
enrolling in Medicare and Medicaid. Where available, we reviewed
relevant documentation to supplement the information found during our
interviews.
The information from the six state Medicaid programs provides insight
about the interactions and consultations between state Medicaid
programs and Indian tribes, but it cannot be generalized to other
states. Additionally, the information we obtained from tribal
representatives cannot be generalized to all 562 federally recognized
tribes. We conducted our work from December 2006 through July 2008 in
accordance with generally accepted government auditing standards.
Results in Brief:
CMS and IHS have interacted to (1) provide support to IHS-funded
facilities and Indian tribes in accessing Medicare and Medicaid and (2)
address efforts associated with broader policy and regulatory concerns
regarding the two programs.
* With regard to support, CMS and IHS have interacted to educate staff
from IHS-funded facilities and tribal members about Medicare and
Medicaid, and CMS has assisted these facilities with Medicare and
Medicaid billing procedures and other concerns. CMS and IHS have
interacted to ensure that they obtain input from tribal representatives
at meetings and other sessions designed to inform CMS about issues
affecting the delivery of health care for American Indians and Alaska
Natives.
* With regard to broader policy and regulatory concerns, CMS and IHS
have interacted on policy initiatives aimed at ensuring that existing
health care policies meet the needs of IHS-funded facilities and the
populations they serve. CMS and IHS have had mixed success identifying
CMS regulatory changes that have the potential to affect IHS-funded
facilities and their populations and thus warrant IHS review. However,
identifying such regulatory changes can be challenging because of
factors such as the high volume of CMS regulations. For this reason,
CMS has been working to develop and implement additional procedures to
identify whether a regulation could affect IHS and the tribes.
CMS has used two key mechanisms--tribal liaisons and an advisory board-
-to interact with representatives from Indian tribes, and it has relied
primarily on annual regional sessions sponsored by HHS as its mechanism
for consulting with Indian tribes.
* CMS has tribal liaisons in its central and regional offices who
generally served as the points of contact for tribal representatives.
These liaisons have provided assistance and obtained input from tribes
through activities such as visiting Indian reservations and providing
technical assistance and written guidance to Indian tribes.
* CMS has a tribal advisory board, which includes tribal
representatives from each IHS area and three Washington, D.C.-based
tribal associations. While the advisory board is meant to complement
but not replace consultation, its composition, meeting schedule, and
organizational structure have provided an opportunity for CMS to obtain
input from tribal representatives.
* CMS's efforts to consult with Indian tribes have relied primarily on
participating in the annual HHS regional consultation sessions.
However, consulting with so many tribes is an inherently difficult
task, in part because of the variation in the size, location, and
economic status of the Indian tribes. Additionally, these HHS regional
sessions--which generally lasted 1 to 2 days and covered all HHS
programs--have offered limited time for consultation and discussion.
The six state Medicaid programs we reviewed have used at least one of
three mechanisms to interact and consult with Indian tribes: tribal
liaisons, advisory boards, and regularly scheduled meetings. All six
state Medicaid programs reported using at least one designated tribal
liaison who served as a communication and coordination link between
tribes and the program and provided training and technical assistance
to Indian tribes. Three of the six state Medicaid programs reported
using advisory boards to interact, and in some cases consult, with
Indian tribes. For example, Utah used an advisory board to determine if
proposed changes to the state Medicaid program had tribal implications
and thus required additional consultation with tribal representatives.
Four of the six state Medicaid programs also reported having regularly
scheduled meetings with tribal representatives to discuss Medicaid
issues; the meetings ranged in frequency from bimonthly to annually. In
addition to these mechanisms, five of the six states we reviewed also
reported having policies in place that provided a mechanism to govern
their interactions--including consultations--with Indian tribes. Most
states reported consulting with tribes when making changes to their
Medicaid programs. For example, New Mexico officials reported that
consultations with tribes resulted in revisions to a long-term care
program, such as requiring the use of tribal liaisons.
American Indians and Alaska Natives have faced several barriers to
Medicare and Medicaid enrollment despite efforts to assist them with
the application process. Some of these barriers to enrollment were
associated with the unique status of the tribal community. For example,
one barrier was the belief among some American Indians and Alaska
Natives that they should not have to apply for Medicare or Medicaid
because the federal government has a duty to provide them with health
care. Other enrollment barriers were similar to those experienced by
other populations, such as lack of transportation, financial barriers,
and limited access to telephones and other communication devices.
Efforts to help eligible American Indians and Alaska Natives enroll in
Medicare and Medicaid generally have focused on providing assistance
with the application process. Almost all of the IHS-funded facilities
we visited had staff who assisted patients with applying for Medicare
and Medicaid, including helping them complete and submit applications,
and collecting required documentation. In some cases, this application
assistance was available directly from Medicaid or Medicare eligibility
staff who worked at, or traveled to, IHS-funded facilities. Many
organizations--including CMS and IHS--have conducted outreach efforts
to educate the tribal community about Medicare and Medicaid and
encourage individuals to apply. For example, in 2007, CMS released a
video, to be used at IHS-funded facilities, which emphasized the
community benefit to enrollment in Medicare and Medicaid.
In commenting on a draft of this report, CMS noted that it was
appreciative of our review of its activities related to interactions
with IHS and tribes. Technical comments from CMS, Arizona, New Mexico,
and Montana were incorporated as appropriate.
Background:
The federal government recognizes 562 Indian tribes, which are located
in 33 states, and vary greatly in size, economic status, and land
ownership.[Footnote 14] According to the Bureau of Indian Affairs, the
tribes range in size from villages in Alaska that have fewer than 50
members to tribes with over 240,000 members.[Footnote 15] The economic
status of tribes also varies, ranging from those with unemployment
rates that are more than 90 percent to those with unemployment rates
that are below 10 percent. Some tribes also have significant economic
opportunities for tribal members, including employment or payments
provided to tribal members. With regard to land ownership, reservation
lands ranged from 16 million acres to less than 100 acres.
Overall, American Indians and Alaska Natives living in IHS areas have
lower life expectancies than the U.S. population as a whole and face
considerably higher mortality rates for some conditions. For American
Indians and Alaska Natives ages 15 to 44 living in those areas,
mortality rates are more than twice those of the general population.
American Indians and Alaska Natives living in IHS areas have
substantially higher rates for diseases such as diabetes, as well as a
higher incidence of fatal accidents, suicide, and homicide.
IHS Provision of Health Care:
IHS arranges for the provision of health care to American Indians and
Alaska Natives who are members of federally recognized tribes.
Specifically, in 2007, IHS funded health care delivered to
approximately 1.5 million American Indians and Alaska Natives. IHS
consists of a system of more than 650 IHS-funded facilities organized
into 12 geographic areas of various sizes. Within the 12 areas, direct
care services are generally delivered by IHS-funded hospitals, health
centers, and health stations.[Footnote 16] Tribes have the option of
operating their own direct care facilities. Thus, direct care is
provided by IHS-funded facilities that are either IHS operated or
tribally operated. Services not available through direct care at IHS-
funded facilities may be purchased by the facilities through
arrangements with outside providers; these services are referred to as
contract health services.
Eligibility requirements for direct care and contract health services
differ. In general, all American Indian and Alaska Native tribal
members are eligible to receive direct care at IHS-funded facilities
free of charge.[Footnote 17] To be eligible for contract health
services, however, American Indians and Alaska Natives must reside
within a contract health services delivery area that is federally
established and either (1) reside on a reservation within the area or
(2) belong to or maintain close economic and social ties to a tribe
based on such a reservation.[Footnote 18] IHS-funded facilities will
not authorize or pay for contract health services for individuals who
are eligible to obtain such services through other sources, such as
Medicare or Medicaid.
Medicare and Medicaid:
Medicare finances health services for approximately 44 million elderly
and disabled individuals and consists of several different components,
namely:
* Medicare Part A, Hospital Insurance--which helps cover inpatient care
in hospitals. There is typically no premium for Part A.
* Medicare Part B, Medical Insurance--which covers doctors' services,
outpatient care, and certain other services, such as physical and
occupational therapy and medical supplies. In 2008, the monthly premium
for Part B is $96.40 for most individuals.[Footnote 19]
* Medicare Part C, or Medicare Advantage--which provides coverage for
Medicare Parts A and B services through private health plans.
* Medicare Part D, or Prescription Drug Coverage--a voluntary insurance
program for outpatient prescription drug benefits. Most Medicare drug
plans charge a monthly premium. However, beneficiaries eligible for
both Medicare and Medicaid (dual-eligibles) are generally not required
to pay a premium, and certain low-income beneficiaries are eligible for
premium subsidies.
IHS has the authority to pay Medicare Part B premiums on behalf of
individuals eligible to receive direct care, although the agency has
not yet utilized that authority.[Footnote 20] Some Indian tribes pay
the Medicare Part B or Part D premiums of their members.
American Indians and Alaska Natives may also be eligible for health
care benefits under Medicaid, a joint federal-state program that
finances health care for certain low-income children, families, and
individuals who are aged or disabled. Generally, the federal government
and the states share in the cost of the Medicaid program. However, the
federal government pays 100 percent of the Medicaid program's cost to
provide services to American Indians and Alaska Natives at IHS-or
tribally operated facilities.
IHS Funding:
In fiscal year 2007, Congress appropriated approximately $3.2 billion
for IHS, which included funding for the provision of direct care at IHS-
funded facilities, contract health services, and other functions. In
addition to IHS's federal appropriation, IHS-funded facilities can be
reimbursed by other payers, including Medicare and Medicaid, for the
services the facilities provide.[Footnote 21] IHS-funded facilities are
allowed to retain reimbursements without an offsetting reduction in
their IHS funding. Thus, revenues from Medicare and Medicaid can
increase the financial capacity of IHS-funded facilities to provide
needed medical services.
According to IHS data, the amount of Medicaid and Medicare
reimbursement that IHS has collected has increased over time (see fig.
1). In fiscal year 2007, IHS reported approximately $516 million in
Medicaid reimbursement and $161 million in Medicare reimbursement, for
a total of $677 million. These data do not account for all collections
by IHS-funded facilities because tribally operated facilities are not
required to report such information.
Figure 1: IHS Medicare and Medicaid Reimbursement, Fiscal Years 1998
through 2007:
This figure is a multiple line graph showing IHS medicare and medicaid
reimbursement, fiscal years 1998 through 2007. The X axis represents
the fiscal year, and the Y axis represents the dollars (in millions).
The lines represent medicare, medicaid, and total.
Fiscal year: 1998;
Medicare: $82;
Medicaid: $207;
Total: $289.
Fiscal year: 1999;
Medicare: $87;
Medicaid: $270;
Total: $357.
Fiscal year: 2000;
Medicare: $109;
Medicaid: $283;
Total: $392.
Fiscal year: 2001;
Medicare: $115;
Medicaid: $316;
Total: $431.
Fiscal year: 2002;
Medicare: $109;
Medicaid: $375;
Total: $485.
Fiscal year: $2003;
Medicare: $119;
Medicaid: $418;
Total: $537.
Fiscal year: 2004;
Medicare: $129;
Medicaid: $446;
Total: $575.
Fiscal year: 2005;
Medicare: $136;
Medicaid: $472;
Total: 609.
Fiscal year: 2006;
Medicare: $142;
Medicaid: $464;
Total: $606.
Fiscal year: 2007;
Medicare: $161;
Medicaid: $516;
Total: $677.
[See PDF for image]
Source: IHS.
Note: Data do not account for all collections by IHS-funded facilities
because tribally operated facilities are not required to report such
information.
[End of figure]
Federal Consultation Requirements:
In recognition of the unique government-to-government relationship
between the federal government and Indian tribes, federal agencies are
required by Executive Order to consult with Indian tribes on "policies
that have tribal implications."[Footnote 22] The order states that
"[e]ach agency shall have an accountable process to ensure meaningful
and timely input by tribal officials in the development of regulatory
policies that have tribal implications." The order defines policies
that have tribal implications as regulations, legislative comments or
proposed legislation, and other policy statements or actions that have
substantial direct effects on one or more Indian tribes, on the
relationship between the federal government and Indian tribes, or on
the distribution of power and responsibilities between the federal
government and Indian tribes.
On January 14, 2005, HHS adopted a tribal consultation policy that
formalized HHS's requirement to consult with Indian tribes in policy
development. HHS's policy defines consultation as: "An enhanced form of
communication, which emphasizes trust, respect and shared
responsibility." In addition, the HHS policy explains that consultation
is "integral to a deliberative process, which results in effective
collaboration and informed decision making with the ultimate goal of
reaching consensus on issues." Under the HHS tribal consultation
policy, every agency within HHS, including CMS, shares in the
departmentwide responsibility to coordinate, communicate, and consult
with Indian tribes. Among other things, the HHS tribal consultation
policy specifies that each of the 10 HHS regions should have an annual
consultation session to solicit information on Indian tribes'
priorities and needs related to health and human services. Within CMS,
issues related to American Indians and Alaska Natives are coordinated
by the agency's Tribal Affairs Group and by designated Native American
Contacts (NAC) in each of its 10 regional offices.[Footnote 23]
State Consultation Requirements:
While the Executive Order establishes clear requirements for federal
agencies to consult with Indian tribes, in general, states determine
how to interact, and whether to consult, with the tribes in their
states. However, CMS has provided guidance to state Medicaid programs
that encourages the programs to consult with tribes and be as
responsive as possible to their issues and concerns when making changes
to state Medicaid programs.[Footnote 24] While states have flexibility
in making many changes to their Medicaid programs, some changes require
states to obtain a waiver of certain Medicaid requirements.
Specifically, the Social Security Act authorizes the Secretary of HHS
to waive certain federal Medicaid program requirements under certain
conditions.[Footnote 25] CMS guidance indicates that evidence of
consultation with the tribes is one criterion that CMS will use during
its review of proposed state Medicaid program changes that require a
waiver of Medicaid requirements.[Footnote 26]
CMS and IHS Have Interacted to Provide Support as Well as Address
Broader Policy and Regulatory Concerns:
CMS and IHS have interacted to provide support to IHS-funded facilities
and Indian tribes in accessing Medicare and Medicaid as well as to
address efforts associated with broader policy and regulatory concerns
regarding the two programs. With regard to support, CMS and IHS have
interacted to educate staff from IHS-funded facilities and American
Indians and Alaska Natives about Medicare and Medicaid. Additionally,
CMS has assisted IHS-funded facilities with Medicare and Medicaid
billing procedures and other concerns. CMS and IHS also have worked to
obtain input from tribal representatives through an advisory board and
consultation sessions. At a broader policy level, CMS and IHS have
worked together on policy initiatives aimed at ensuring that existing
health care policies meet the needs of IHS-funded facilities and the
populations they serve. CMS's regulatory process--the process through
which CMS issues regulations--can necessitate the review of
approximately 140 major rule-making documents on a yearly basis. Thus,
it has provided an important, but challenging, opportunity for CMS and
IHS to identify regulatory changes that may affect American Indians'
and Alaska Natives' eligibility for Medicare and Medicaid or these
programs' reimbursements to IHS-funded facilities.
CMS and IHS Have Interacted to Provide Education and Assistance as Well
as to Obtain Input from Tribal Representatives:
CMS and IHS have interacted to educate IHS-funded facility staff and
American Indians and Alaska Natives about the Medicare and Medicaid
programs. The following are examples of such activities:
* CMS and IHS have interacted to train staff from IHS-funded facilities
on Medicare and Medicaid program topics. For example, in August 2007,
the two agencies held a training session in the Aberdeen IHS area
titled "Working Together - CMS, Tribes and the Aberdeen Area." The
session included presentations by both CMS and IHS officials on
strategies to increase Medicare and Medicaid enrollment, changes to
contract health service payments, and other topics.
* In 2007, CMS, IHS, and tribal officials coordinated tribal stops on
the Medicare prevention tour, a nationwide CMS outreach effort that
involved a bus traveling to different venues to encourage Medicare
beneficiaries to utilize the preventive services covered by Medicare,
such as cancer and diabetes screenings. Through CMS's coordination with
IHS and tribes, the CMS Medicare prevention bus visited approximately
15 tribal locations across five different CMS regions.
* CMS has also educated IHS staff about Medicare Part D. For example,
CMS has held multiple training sessions in each of the 12 IHS areas to
educate IHS-funded facility staff about the Medicare Part D program and
encourage American Indians and Alaska Natives to enroll in the program.
Additionally CMS and IHS interactions have included assistance intended
to maximize IHS-funded facilities' collection of Medicare and Medicaid
reimbursement. Many of these activities have included helping
facilities become providers for Medicare and Medicaid, as well as
assisting with billing and other concerns. Examples include the
following:
* CMS has assisted IHS-funded facilities in becoming Medicare and
Medicaid providers, which is necessary to bill these programs. IHS
officials from the Bemidji area told us that CMS officials provided
instructions to IHS-funded facilities on how to sign up to participate
in Medicare and Medicaid. Additionally, in 2007, CMS helped an IHS-
operated health center and its satellite clinics to qualify as provider-
based facilities, which would allow the facilities to bill Medicare
Part A and potentially increase their Medicare reimbursement.[Footnote
27]
* CMS has provided technical assistance to IHS to resolve billing
concerns. For example, CMS and IHS officials corrected a problem with
the IHS electronic billing system that according to CMS officials, had
resulted in some IHS-funded facilities being underpaid for certain
Medicare services.
* A CMS official helped IHS-funded facilities navigate the CMS survey
process, a process through which facilities are inspected for
compliance with federal quality standards.
Finally, CMS and IHS have interacted to ensure that they obtain input
from tribal representatives. For example, CMS and IHS have interacted
through CMS's TTAG, an advisory board created to inform CMS about
issues affecting the delivery of health care to American Indians and
Alaska Natives served by CMS programs. Specifically, the IHS area
offices helped identify and appoint tribal representatives to serve on
the TTAG. Additionally, both CMS and IHS officials have attended TTAG
meetings and participated in TTAG subcommittees, which focus on
specific Medicare-or Medicaid-related issues. CMS and IHS officials
also have interacted through annual HHS regional tribal consultation
sessions, held in each region as part of HHS's implementation of its
tribal consultation policy. In addition to participating in the
consultation sessions, CMS and IHS officials may work together to plan
the sessions. For example, in the Chicago region, CMS regional and IHS
Bemidji area officials served on the planning committee that organized
the consultation session.
CMS and IHS Have Interacted about Specific Policies, but Have Had Mixed
Success Identifying CMS Regulations Warranting IHS Review:
With regard to specific policy issues, CMS and IHS have interacted on
issues related to Medicare Parts B and D; they also jointly issued
regulations to limit the amount that IHS-funded facilities must pay
hospitals for contract health services, as shown in the following
examples.
* Medicare Part B: CMS and IHS have been determining which American
Indians and Alaska Natives are eligible for an exemption from financial
penalties incurred for late enrollment into Medicare Part B.[Footnote
28] This exemption, referred to as equitable relief, is granted to
individuals who did not initially enroll because of erroneous
information provided by a government agency. In this case, IHS, while
operating under specific interagency agreements with CMS, told some
individuals not to enroll in Medicare Part B because, at the time, IHS
was unable to bill Medicare Part B.[Footnote 29]
* Medicare Part D: During the implementation of Medicare Part D, CMS
and IHS worked to ensure that IHS-funded facilities would be able to
bill and receive reimbursement from prescription drug plans. This
required special provisions to enable tribally operated facilities to
enter into contracts with prescription drug plans, while retaining
tribal sovereignty.
* Contract health services: In 2007, CMS and IHS jointly issued a
regulation requiring hospitals that receive Medicare funds to accept
rates based on Medicare as full payment for contract health services
provided to eligible American Indians and Alaska Natives.[Footnote 30]
Termed Medicare-like rates, this regulation prevents hospitals from
accepting fees from IHS-funded facilities in excess of what Medicare
would pay.[Footnote 31]
With regard to regulations, CMS and IHS have had mixed success
identifying CMS regulatory changes that have the potential to affect
IHS-funded facilities and their populations and thus warrant IHS
review. IHS officials reported reviewing and commenting on CMS
regulations addressing Medicare payment issues, Medicaid managed care,
and Medicare Part D, noting that CMS made changes to these regulations
in response to their comments. For example, IHS informed CMS that
regulations implementing a new payment methodology for reimbursing
outpatient facilities under Medicare would adversely affect IHS-funded
facilities because a number of facilities would have to hire new staff
to implement the payment system.[Footnote 32] As a result of this
interaction, CMS exempted IHS-funded facilities from the new payment
methodology. In contrast, IHS officials also reported three examples
where they did not have an opportunity to review CMS regulations prior
to the public comment period. One regulation had the potential to
affect Medicaid prescription drug reimbursement for IHS-funded
facilities, while the other two regulations had the potential to affect
Medicaid enrollment for American Indians and Alaska Natives by
requiring documentation of U.S. citizenship and affected tribes' access
to federal funds that could be used for Medicaid outreach.[Footnote 33]
Multiple opportunities exist for CMS and HHS to identify regulations
that are important for IHS to review (see fig. 2). However, identifying
such regulations can be challenging, as shown below.
* CMS: The Tribal Affairs Group has an opportunity to review all draft
proposed regulations and notify IHS about regulations it determines are
relevant to the agency. However, Tribal Affairs Group officials
explained that the large number of regulations (approximately 140
regulatory documents a year), coupled with the size of their staff,
means that they have difficulty doing more than a cursory review of the
regulations.[Footnote 34]
* HHS: Responsible for sending proposed regulations to affected
agencies, HHS staff use their judgment to determine which HHS agencies
should be provided regulations for review. However, the HHS staff
making the determination may not have expertise on IHS and thus might
not foresee the potential effect a regulation could have on American
Indians' and Alaska Natives' eligibility for Medicare and Medicaid or
these programs' reimbursements to IHS-funded facilities. HHS officials
told us that they make these determinations by reviewing regulations
and looking for key legislative terms, such as "Indian," to determine
which agencies should be involved in the review. However, it is not
clear that the HHS staff consistently used certain key terms, as the
three proposed regulations that IHS reported not having the opportunity
to review each contained the word "Indian."
If regulations are not identified by CMS or HHS, then IHS may identify
proposed CMS regulations that could affect its facilities or service
population by reviewing quarterly CMS updates listing regulations and
major policy changes under development. IHS may also review the Unified
Agenda of Federal Regulatory and Deregulatory Actions, a semiannual
listing of the regulatory actions that federal agencies--including CMS-
-are developing or have recently completed.
Figure 2: Points in CMS Regulation Development Process When IHS Can Be
Informed about a Proposed Regulation:
This is a flowchart discussing points in CMS regulation development
process when IHS can be informed about a proposed regulation.
[See PDF for image]
Source: GAO analysis of CMS regulation process, January 2008.
Note: This figure highlights the steps in the regulations development
process that are related to opportunities for IHS to be informed about
a proposed regulation. However, it does not depict all steps in the CMS
regulation development process. For example, it does not include steps
related to the Office of Management and Budget's review of regulations.
[End of figure]
Recognizing the difficulties associated with identifying a regulation
that could affect IHS and the tribes, CMS has been working to develop
and implement additional procedures aimed at improving these efforts.
In particular, the CMS Tribal Affairs Group has been working to obtain
information from IHS to compile a profile of the types of providers
available in tribal locations, which would assist CMS in determining
the regulations that could have tribal implications. Additionally, CMS
staff with responsibility for overseeing the regulations process have
begun asking the staff who draft a regulation whether it affects
tribes. If a potential tribal effect is identified, then CMS will
indicate, on a cover sheet transmitting the regulation to HHS, that IHS
should be provided the regulation for review.
CMS Has Used Two Key Mechanisms to Interact, and the Annual HHS
Regional Sessions to Consult, with Indian Tribes:
CMS has used two key mechanisms--tribal liaisons and an advisory board-
-to interact with Indian tribes and has relied primarily on the annual
HHS regional consultation sessions as its mechanism for consultation.
CMS tribal liaisons have provided assistance and obtained input from
tribes through activities such as participating in conferences and
training sessions, visiting Indian reservations, and providing
technical assistance and written guidance. The composition, meeting
schedule, and organizational structure of CMS's tribal advisory board-
-the TTAG--also has provided an opportunity for CMS to obtain input
from tribal representatives. With regard to consultation activities,
CMS has relied on annual HHS regional consultation sessions as the
primary mechanism to ensure input from tribal officials in the
development of regulatory policies, although CMS officials noted that
they have also held consultation meetings with individual tribes.
However, consulting with over 560 tribes is an inherently difficult
process, primarily because of complexities such as considering the
needs and priorities of individual tribes. Tribal representatives'
opinions on the effectiveness of CMS's consultation with Indian tribes
and the agency officials involved varied considerably.
CMS Has Used Tribal Liaisons and an Advisory Board as Its Mechanisms to
Interact with Indian Tribes:
CMS has used two key mechanisms to interact with representatives from
Indian tribes, namely (1) tribal liaisons, who generally serve as
tribal representatives' points of contact within CMS and provide
assistance with Medicare and Medicaid, and (2) an advisory board, which
provides input to CMS about issues affecting the delivery of health
care to American Indians and Alaska Natives.
Tribal Liaisons:
CMS tribal liaisons are located in both CMS central and regional
offices. In its central office, the CMS Tribal Affairs Group had four
staff who served as the points of contact for tribal-related issues;
these staff provided assistance to tribes and tribal representatives
and coordinated issues within CMS.[Footnote 35] Formed in November
2006, the Tribal Affairs Group has served many functions, including (1)
serving as an internal resource for CMS staff, educating staff about
the needs and priorities of American Indians and Alaska Natives; (2)
coordinating the creation of informational materials on CMS programs,
such as Medicare and Medicaid, for tribal communities; and (3)
representing CMS in communications with Indian tribes and tribal
representatives. In addition, the Tribal Affairs Group has served as an
advisor to the CMS Administrator, reporting directly to his office and
briefing him or his deputy approximately eight times per year about
issues raised by tribal representatives.
In addition to the CMS Tribal Affairs Group, each CMS regional office
has had a designated official, the NAC, who serves as a liaison between
the agency and Indian tribes in the region.[Footnote 36] Key roles of
the NAC have included providing training about CMS programs to Indian
tribes in the region; helping address tribal concerns, including
assisting tribes and IHS-funded facilities in solving problems and
obtaining answers to questions that arose; and serving as a CMS
information source on American Indians and Alaska Natives. Except for
two regions, the NAC role was a part-time responsibility, with the
percentage of time spent on NAC-related duties ranging from 20 to 50
percent.[Footnote 37] In the remaining regions--Denver and Seattle--the
NAC positions are full-time because these staff have additional
responsibilities as the lead NACs who coordinate activities across all
CMS regions and because there are a significant number of tribes within
these two regions. The NAC officials have coordinated their efforts
with the CMS central office through monthly conference calls with the
Tribal Affairs Group.
The CMS Tribal Affairs Group and NACs have interacted, or coordinated
other CMS staff's interactions, with tribal representatives using
several methods, including participating in conferences and training
sessions, visiting Indian reservations, and providing technical
assistance and written guidance to Indian tribes (see table 1).
Table 1: Types of Interactions between CMS Tribal Liaisons and Indian
Tribes:
Type of Interaction: Conferences and training sessions;
Examples: * CMS has sponsored a day at the National Indian Health
Board's Annual Consumer Conference, during which staff from the Tribal
Affairs Group and NACs participate in sessions about CMS programs. For
example, the 2007 conference featured sessions on understanding
Medicaid, Medicare and Medicaid outreach, and advising IHS and tribal
providers on how to navigate Medicare and Medicaid;
* In 2007, the Tribal Affairs Group began producing monthly educational
sessions on Medicare and Medicaid topics pertinent to IHS-funded
facilities. The sessions are broadcast over satellite dishes provided
to some IHS-funded facilities and on the internet. Topics of past
sessions include introductions to Medicare and Medicaid and Medicare
Part D reimbursement;
* In August 2007, CMS staff, including CMS tribal liaisons, provided
training in the Aberdeen IHS area to increase overall understanding of
the Medicare and Medicaid programs. The training was attended by over
200 people, including representatives from 13 Indian tribes.
Type of Interaction: Site visits;
Examples: * During a 2007 visit to a North Carolina tribe, the CMS
Atlanta Region NAC discussed an issue related to youth treatment
facilities that the tribe was having with the state Medicaid program;
* During the CMS Kansas City Region NAC's visits to tribes in the
region, she meets with the tribal councils, health officials, or both
to update them on CMS program changes and discuss her role as the NAC;
* During a 2004 visit to a Nebraska tribe, a CMS NAC and other CMS
program staff provided guidance to the tribe on how its medical
provider could become a Medicare-certified provider.
Type of Interaction: Technical assistance;
Examples: * CMS tribal liaisons have provided or coordinated the
provision of technical assistance to Indian tribes and tribally
operated facilities on topics including Medicaid eligibility, becoming
a Medicare-participating provider, and Medicare and Medicaid billing;
* The CMS Tribal Affairs Group worked with another CMS official to
assist a tribally operated facility in recovering Medicare funds for
over 4 years worth of claims that were underpaid because of an error in
IHS's electronic billing system. Additionally, CMS worked with IHS
staff to correct the program and ensured that other IHS-funded
facilities were notified about the possibility of past underpayment;
* In 2007, the Kansas City NAC coordinated technical assistance
regarding Medicaid reimbursements for pharmaceuticals and related
licensure requirements for IHS-funded facilities. As a result of this
assistance, pharmacies at IHS-funded facilities in Kansas will be able
to enroll as Medicaid providers and get reimbursed on a fee-for-service
basis for pharmaceuticals, including refills.
Type of Interaction: Written guidance;
Examples: * In 2006, the Dallas Region NAC distributed a letter to
tribal leaders on how tribes can be reimbursed for payments made to
Medicare Part D prescription drug plans on behalf of tribal members;
* With the help of the NAC, the Administrator of the CMS Kansas City
regional office sent a letter to tribal leaders in the region
describing an option that groups, such as tribes, have for paying the
Medicare Part B premiums for their members.
Source: GAO analysis of CMS and tribal information.
[End of table]
Tribal representatives with whom we spoke had varying opinions on the
effectiveness of the CMS tribal liaisons. For example, a few tribal
representatives we spoke with praised the efforts of the CMS Tribal
Affairs Group staff; one representative noted that the Tribal Affairs
Group is a critical link between Indian tribes and CMS, while other
representatives noted the group's responsiveness to tribal concerns.
Additionally, some tribal representatives mentioned specific
interactions with the NAC, such as the NAC's working with the tribe to
resolve issues with the state Medicaid program. However, some tribal
representatives raised concerns about the liaisons' lack of decision-
making authority.
Advisory Board:
In addition to liaisons, CMS has received input from tribal
representatives through an advisory board. Specifically, in 2003, CMS
created an advisory board, the TTAG, to provide it with expertise on
policies, guidelines, and programmatic issues affecting the delivery of
health care for American Indians and Alaska Natives served by Medicare,
Medicaid, or other health care programs funded by CMS. Interactions
between CMS officials and the TTAG are meant to complement, but not
replace, consultation between CMS and Indian tribes. The TTAG was
created to increase understanding between CMS and Indian tribes.
The TTAG has been an important vehicle for CMS to obtain input from
tribal representatives. (See table 2 for a description of the TTAG.)
The agenda for TTAG meetings has been formulated jointly by tribal
representatives and CMS officials, allowing for both CMS and tribal
priorities to be discussed. The TTAG's composition, schedule, and
structure have provided an opportunity for CMS to obtain input from
tribal members. For example:
* The TTAG has members from each IHS area and TTAG members gather
information and views about CMS policies from tribes nationwide.
Specifically, seven of the eight TTAG area representatives we spoke
with indicated that they solicited information and obtained input from
regular meetings with tribes in their area, often through the area
health board or its equivalent.[Footnote 38] Similarly, the TTAG
representatives from two of the three Washington, D.C.-based tribal
associations indicated that they received input from regular meetings
with the membership or from the board of their associations.
* The TTAG generally has met monthly, which provides an opportunity for
tribal representatives and CMS to discuss issues as they arise. For
example, in February 2007, TTAG members were able to have a timely
discussion with CMS about tribal representatives' concerns that a
proposed regulation would prevent tribes and tribal organizations from
collecting federal matching funds for Medicaid-related administrative
activities, such as outreach. As a result of tribal representatives'
concerns, the regulation was revised prior to issuance.[Footnote 39]
* The TTAG's subcommittee structure has allowed tribal representatives
and CMS officials to conduct in-depth analysis, work, and dialogue on
Medicare and Medicaid topics that are a priority for CMS, American
Indians and Alaska Natives, or both. Subcommittees have focused on
topics such as the availability of CMS data on Medicare and Medicaid
enrollment and service use among American Indians and Alaska Natives,
outreach and education, and long-term care.
Table 2: Description of the CMS TTAG:
TTAG: Composition;
Description: * TTAG members: An elected tribal leader (or designated
employee with authority to act on his or her behalf) from each of the
12 IHS areas and a representative from three Washington, D.C.-based
tribal associations.[A];
* Technical advisors: Individuals selected by the TTAG members who have
expertise in Medicare, Medicaid, and tribal issues.
TTAG: Meeting schedule;
Description: * Generally monthly;
* Meetings occur in-person approximately three times a year and through
conference calls during the other months.
TTAG: Organizational structure;
Description: * A chair and co-chair are elected annually by the 12 IHS
area representatives;
* Subcommittees are created to focus on particular Medicare and
Medicaid topics affecting American Indians and Alaska Natives;
the subcommittees include TTAG representatives, their technical
advisors, and employees from CMS and IHS.
Source: GAO analysis of the CMS TTAG, April 2008.
[A] The three Washington, D.C.-based tribal associations are the
National Congress of American Indians, the National Indian Health
Board, and the Tribal Self-Governance Advisory Committee.
[End of table]
The TTAG and CMS have worked together on a number of issues. For
example, the TTAG worked with CMS and IHS officials to develop a
strategy to (1) educate Indian tribes and their members about the
Medicare Part D benefit and (2) assist IHS-funded facilities in
contracting with the program's prescription drug plans. Additionally,
the TTAG created a strategic plan to outline a path for CMS to take
over a 5-year period to resolve high-priority issues related to health
care for American Indians and Alaska Natives.
CMS Efforts to Consult with Indian Tribes Have Relied Primarily on HHS
Annual Regional Consultation Sessions:
CMS has used the annual HHS regional consultation sessions as its main
mechanism to consult with the 562 federally recognized Indian tribes;
CMS is required by Executive Order and HHS policy to consult with
Indian tribes about policies that have tribal implications.[Footnote
40] HHS designed the regional consultation sessions to (1) solicit
Indian tribes' priorities and needs on health and human services
programs and (2) provide an opportunity for tribes to articulate their
comments and concerns on health and human services policy matters
related to CMS and HHS. However, consulting with so many tribes is an
inherently difficult task, in part because of the variation in the
size, location, and economic status of the Indian tribes. Differences
in the priorities of tribal participants may also make it difficult to
have discussions that are meaningful for all participants.
The HHS regional consultation sessions have offered limited time for
consultation and discussion, as the sessions have generally occurred in
the spring and lasted 1 to 2 days.[Footnote 41] Specifically, a review
of a sample of eight consultation session agendas found that the time
devoted to discussion of CMS-related issues ranged from less than 30 to
90 minutes.[Footnote 42] Additionally, since the consultation sessions
only occurred once a year, they may not allow for meaningful
discussions in a timely manner, as CMS makes policy changes throughout
the year.
While the consultation sessions have been open to all tribes, the
number of tribes that have participated is relatively small. According
to HHS, representatives from 100 tribes attended a 2006 HHS regional
consultation session and representatives from 152 tribes attended a
2007 session; this equates to approximately 18 percent and 27 percent
of federally recognized tribes, respectively. Several HHS officials
noted that tribal attendance at the consultation sessions has varied,
depending on the location of the session, which generally differed each
year. Additionally, tribal participation in the sessions may be
hindered by the amount of notice provided regarding the date of the
sessions. The amount of notice tribes were given about the date of the
regional consultation session ranged from 3 to 8 weeks across the four
HHS regions we reviewed.
In addition to the CMS-related discussions at the HHS consultation
sessions, CMS officials have held consultation meetings with individual
tribes or smaller groups of tribes.[Footnote 43] For example, CMS has
consulted with the Navajo Nation about Medicaid issues the tribe has
faced since its reservation is located across three states.
Additionally, in January 2008, CMS officials traveled to Washington
State to consult with the state's Medicaid program and Indian tribes
about a proposed amendment to Washington State's Medicaid program that
would stipulate how tribes in Washington state can receive federal
reimbursement for Medicaid administrative activities.
Tribal representatives had varying opinions on the effectiveness of the
CMS and HHS consultations, including varying perspectives on the agency
officials involved and the format of the consultation sessions. One
tribal representative commented that leaders in CMS attend the meetings
and are willing to share information, while another tribal
representative commented that the officials who attend the sessions are
not able to make decisions. Additionally, a third tribal representative
explained that high-level officials who can make decisions attend the
consultation sessions, but that these officials do not have the
necessary information to answer questions. This variation may be due,
at least in part, to regional differences in participation. Regarding
the format of the consultation sessions, one tribal representative
commented that the regional consultation sessions were fairly effective
at identifying the issues that should be raised at the national level.
However, a few tribal representatives commented that the HHS regional
consultation sessions were too short and thus did not allow for
meaningful tribal input or dialogue.
Selected States' Medicaid Programs Have Used Multiple Mechanisms to
Interact and Consult with Tribes:
The six state Medicaid programs we reviewed have used at least one of
the following three mechanisms to interact and consult with Indian
tribes: tribal liaisons, advisory boards, and regularly scheduled
meetings. Most of the states also reported having policies in place
that provided a mechanism to govern their interactions, including
consultations, with the Indian tribes. Most of the state Medicaid
programs reviewed reported consulting with Indian tribes about changes
to their Medicaid program. Tribal representatives' opinions on state
Medicaid program's consultation practices varied.
Medicaid Programs Have Used Mechanisms, Such as Tribal Liaisons, and
State Policies to Interact and Consult with Indian Tribes:
The six state Medicaid programs we reviewed have used at least one of
three mechanisms to interact and consult with Indian tribes: (1) tribal
liaisons--who serve as the tribes' primary contact with the states on
issues related to Medicaid; (2) advisory boards--which, among other
things, inform the state about Medicaid issues affecting American
Indians and Alaska Natives; and (3) other regularly scheduled meetings-
-which states and tribes used to discuss Medicaid issues and identify
opportunities for collaboration, technical assistance, and
consultation.[Footnote 44] Additionally, five of the six states we
reviewed had policies in place that provided a mechanism to govern
interactions, including consultations, between the state Medicaid
program and Indian tribes.
Tribal Liaisons:
All six state Medicaid programs have used at least one designated
tribal liaison in their interactions, including consultations, with
tribes about issues related to Medicaid. In addition to serving as a
communication and coordination link between tribes and state Medicaid
programs, some state tribal liaisons also have provided input on state
Medicaid policies affecting American Indians and Alaska Natives and
training and technical assistance to tribes on Medicaid (see table 3).
Additionally, tribal liaisons have been involved in consultations with
Indian tribes. For example, one of New Mexico tribal liaisons oversees
the Medicaid program's consultations with Indian tribes, while a
Wisconsin tribal liaison helps to coordinate an annual tribal
consultation session.
Table 3: Examples of Duties Performed by Tribal Liaisons:
Roles and duties performed: Providing input on state policies;
Examples: * The liaison in Montana presented a report in January 2007
to the Medicaid agency identifying barriers tribes faced in obtaining
Medicaid coverage. The liaison also researched ways that tribes could
obtain additional Medicaid funding, which were communicated to tribes
in a November 2006 letter;
* The Utah tribal liaison reported advising the governor's office, Utah
legislature, and Utah congressional members about public health policy,
including Medicaid, and its implications for American Indians in Utah.
Roles and duties performed: Technical assistance and training;
Examples: * The New Mexico tribal liaison reported working with the
tribes on issues such as Medicaid billing issues, provider enrollment,
payment policies, and eligibility;
* The Minnesota tribal liaison also reported providing training and
technical assistance to the tribes on issues such as Medicaid billing;
* The Wisconsin tribal liaison reported having a lead role in ensuring
that Medicaid program staff are trained on tribal perspectives and
cultural issues.
Source: GAO analysis of six states' information.
[End of table]
Tribal representatives we spoke with had varying opinions on the effect
tribal liaisons have had on interactions between the tribes and state
Medicaid programs. For example, representatives from a Montana tribe
reported that interactions with the state Medicaid program's tribal
liaison resulted in changes to the state's Medicaid application.
Specifically, after the tribe explained to the tribal liaison that the
length of the application was a barrier to American Indians and Alaska
Natives enrolling in Medicaid, the state simplified its Medicaid
application. Additionally, individuals representing selected tribes in
Arizona told us that the establishment of a tribal liaison position in
that state's Medicaid program has improved tribes' ability to provide
input on health policy issues and resulted in progress regarding those
issues. In contrast, representatives from a Minnesota tribe noted that
working with the state is difficult even though there is a tribal
liaison. Similarly, while officials from a Southwest tribe noted the
importance of tribal liaisons, they also expressed concern that tribal
liaisons are sometimes kept out of decision making.
Advisory Boards:
Three of the six state Medicaid programs--Arizona, New Mexico, and
Utah--reported using advisory boards to interact, and in some cases
consult, with Indian tribes. For example, Utah has utilized an advisory
board to determine if proposed state Medicaid policy or program changes
have tribal implications and thus require additional consultation with
the advisory board or other tribal representatives.
The Medicaid programs described using two types of advisory boards to
interact with the Indian tribes: (1) Indian advisory boards, which
address a broad array of issues affecting the provision of health care
to American Indians and Alaska Natives, and (2) Medicaid advisory
boards, which address issues affecting all Medicaid beneficiaries,
including American Indians and Alaska Natives. Specifically, one state
Medicaid program (Arizona) reported using Indian advisory boards; one
program (New Mexico) reported using its Medicaid advisory board, which
includes tribal representation; and one program (Utah) reported using
both.
While both types of advisory boards are mechanisms for interactions
between the state and tribal representatives, the composition of the
advisory boards varied. Specifically, the Indian advisory boards
included numerous tribal representatives, while there were fewer tribal
representatives on the Medicaid advisory boards. For example, the Utah
Indian advisory board, which meets monthly, includes appointed
representatives from all of the Utah tribes as well as the state's
tribal liaison, other state and tribal officials, and IHS staff. In
comparison, Utah's Medicaid advisory board has one individual to
represent the seven tribes in the state. New Mexico's Medicaid advisory
board has two tribal representatives who may also serve on a
subcommittee on tribal issues.[Footnote 45]
Meetings:
Four of the six state Medicaid programs (Arizona, Minnesota, New
Mexico, and Wisconsin) reported holding regularly scheduled meetings to
interact, and in some cases consult, with Indian tribes.[Footnote 46]
The frequency of these meetings ranged from bimonthly to annually, and
states reported discussing issues such as the Medicaid budget and
reimbursement. For example, New Mexico officials reported holding an
annual meeting to consult with tribal representatives about pertinent
Medicaid policy and program changes and the Medicaid program's budget
prior to the state legislative session. A Wisconsin official reported
that the state's bimonthly meetings with tribal health directors focus
on specific issues, such as increasing Medicaid reimbursements for
tribally operated facilities and accessing federal matching funds for
tribal Medicaid expenditures.
Tribal representatives' assessments of the value of the regularly
scheduled meetings with the states varied. For example, representatives
from one tribe, which participates in quarterly meetings with officials
who oversee Minnesota's Medicaid program, said that the meetings were
successful in helping address tribal needs. However, representatives
from two Wisconsin tribes noted that the number of tribes involved and
the brevity of the annual meetings with the state made discussing
specific issues difficult. Tribes also reported that location was a
factor that contributed to the success of these meetings. Specifically,
representatives from Wisconsin and Minnesota tribes indicated that
holding meetings in convenient locations affects tribal participation
and increased the meetings' effectiveness, respectively.
Policies:
Five of the six states we reviewed--Arizona, Minnesota, New Mexico,
Wisconsin, and Utah--reported having policies in place that govern the
interactions, and in most cases consultations, between their states'
Medicaid programs and Indian tribes.[Footnote 47] The states had two
types of policies governing interactions with Indian tribes: (1)
governor's orders, which specify that all state agencies should
interact with Indian tribes on a government-to-government basis and
provide for consultation between the state and Indian tribes, and (2)
tribal consultation policies, which establish guidelines that state
agencies, including Medicaid agencies, should use to consult with
Indian tribes. Specifically, one state (Minnesota) reported having a
governor's order, two states (Utah and Wisconsin) reported having
tribal consultation policies, and two states (Arizona and New Mexico)
reported having both.[Footnote 48] The four states' tribal consultation
policies established guidelines with varying degrees of specificity for
how consultation between the Medicaid agency and Indian tribes should
be conducted. Table 4 provides an overview of the guidelines in the
four states' consultation policies.
Table 4: Highlights of Guidelines Established by State Tribal
Consultation Policies:
State: Arizona;
Guidelines: * Consultation meetings can be scheduled upon request;
* If the Medicaid program identifies a policy likely to have a
significant impact on Indian tribes, then it should provide timely
written notice to tribal leaders soliciting feedback and
recommendations;
* At the request of tribal officials, the Medicaid program should
provide additional information either verbally or in written
correspondence.
State: New Mexico;
Guidelines: * Consultation can be initiated by the state or by tribal
leaders;
* The state and tribes may engage in direct consultation, establish a
work group, or both;
* The state and tribes shall meet annually to consult on health and
human services issues.
State: Utah;
Guidelines: * The state will initiate consultation following a request
from a tribe(s);
* The consultation process will include, but is not limited to;
- an initial meeting to present the intent and broad scope of the
policy to the state's Indian advisory board;
- discussions with the advisory board to understand the specifics and
impact of a proposed policy;
- open meetings for all interested parties to receive information and
provide comment;
- a presentation by tribal representatives of their concerns about the
proposed policy;
- continued meeting until concerns have been fully discussed, and;
- a written response from the state as to the action on tribal
concerns;
* When possible, the state will provide 90 days' notice of a proposed
policy by making a presentation to the Indian Advisory Board and
sending a formal letter to tribal leaders.
State: Wisconsin;
Guidelines: * Annual consultation meeting shall be scheduled with the
agenda, date, and location being jointly determined by the state and
tribal leaders;
* Additional consultation meetings shall be scheduled as deemed
necessary by either the state or a majority of tribal leaders;
* The state is responsible for drafting an annual implementation plan
that shall include (1) a list of programs and services available to
tribes; (2) a description of new initiatives, programs, and policies
affecting tribes; (3) priority issues for resolution with the tribes;
(4) the procedures to be used to consult with tribes; and (5) an
evaluation process.
Source: GAO analysis of state consultation policies, January 2008.
[End of table]
Most States Reviewed Reported Consulting with Indian Tribes about
Medicaid Changes:
Most of the state Medicaid programs we reviewed reported consulting
with Indian tribes in their state when making changes to their Medicaid
programs.[Footnote 49] Specifically, four states (Minnesota, New
Mexico, Utah, and Wisconsin) reported consulting with Indian tribes on
any Medicaid program changes that they believed affected Indian tribes,
and one state (Montana) reported consulting only on Medicaid program
changes that required a waiver.[Footnote 50] The remaining state--
Arizona--reported that it has not consulted with Indian tribes about
Medicaid program changes.[Footnote 51] States used a variety of
mechanisms to consult with Indian tribes, such as regularly scheduled
quarterly meetings with tribal health directors and advisory boards.
The states reported consulting with Indian tribes about a variety of
topics. For example, New Mexico officials reported an extensive
consultation process with tribes about a new Medicaid program for
coordinated long-term services. These consultations resulted in changes
to the program, including requiring the program's managed care plans to
have tribal liaisons. Additionally, Minnesota noted that it consulted
with Indian tribes about changing the process by which Medicaid
eligibility determinations are made for children in foster care and
adoption assistance programs.
Tribal representatives' opinions on state Medicaid program's
consultation practices varied. For example, representatives from one
Wisconsin tribe noted that consultation was not hurtful but was also
not helpful. They explained that consultation provides opportunities to
interact directly with agency officials and voice concerns but does not
necessarily lead to changes in agency processes. In contrast,
representatives from a Minnesota tribe provided examples of specific
actions the Medicaid program took as a result of consultation. A
representative from a Minnesota tribe noted that consultation was
effective when there was a personal relationship with state officials.
However, representatives from several tribes in Montana reported that
consultation did not occur. For example, representatives from one
Montana tribe noted that rather than consulting with tribes about
changes to the Medicaid program, the state informed tribes after
changes had already been made.
American Indians and Alaska Natives Have Faced Several Barriers to
Medicare and Medicaid Enrollment Despite Efforts to Assist with the
Application Process:
American Indians and Alaska Natives have faced several barriers to
Medicare and Medicaid enrollment despite efforts to provide assistance
with the application process. While two of the barriers to Medicare and
Medicaid enrollment are associated with the unique status of the tribal
community, most of the enrollment barriers faced by American Indians
and Alaska Natives are similar to those experienced by other
populations--such as individuals with low incomes. Efforts to enroll
American Indians and Alaska Natives have focused on providing
assistance with the Medicaid and Medicare application processes. For
example, almost all of the IHS-funded facilities we visited had staff
who help patients complete and submit Medicare and Medicaid
applications. Many organizations, including CMS and IHS, have conducted
outreach to educate American Indians and Alaska Natives about the
programs.
American Indians and Alaska Natives Have Faced Barriers Enrolling in
Medicare and Medicaid:
American Indians and Alaska Natives have faced barriers to Medicare and
Medicaid enrollment (see table 5). Two of the barriers are unique to
the tribal community. First, some officials we spoke with reported that
some American Indians and Alaska Natives believe they should not have
to apply for Medicare or Medicaid because the federal government has a
duty to provide them with health care as a result of treaties with
Indian tribes. Second, American Indians and Alaska Natives may not see
a personal benefit to enrolling in Medicare or Medicaid because they
have access to free health care at IHS-funded facilities regardless of
whether they enroll.
Other barriers were similar to those faced by other populations. For
example, similar to low-income populations, American Indians and Alaska
Natives have experienced transportation and financial barriers, as well
as barriers related to limits on access to communication devices, such
as telephones and regular mail delivery. While similar to the barriers
faced by other populations, some officials believed that there are some
distinct aspects to the barriers faced by American Indians and Alaska
Natives. For example, application processes, such as the Medicaid
requirement to provide documentation of U.S. citizenship, may be
especially difficult for American Indians and Alaska Natives as this
population was traditionally not born in a hospital. As a result, some
officials reported that some American Indians and Alaska Natives,
particularly those who are elderly, do not have an official record of
their birth.
Table 5: Description of Barriers American Indians and Alaska Natives
Have Experienced Enrolling in Medicare and Medicaid:
Barrier: Barriers unique to American Indians and Alaska Natives: Belief
in a federal responsibility to provide health care;
Description: Barriers unique to American Indians and Alaska Natives: A
belief that the federal government has a responsibility based on
treaties with Indian tribes to provide health care for American Indians
and Alaska Natives and therefore they should not have to apply for
Medicare or Medicaid.
Barrier: Barriers unique to American Indians and Alaska Natives: Belief
that enrollment provides limited personal benefit;
Description: Barriers unique to American Indians and Alaska Natives: A
lack of understanding of the benefit of enrolling in Medicare and
Medicaid because of the availability of free healthcare at IHS-funded
facilities.
Barrier: Barriers faced by American Indians and Alaska Natives as well
as other populations: Complex application process;
Description: Barriers unique to American Indians and Alaska Natives:
Includes the length of the application; the need to go to eligibility
offices; and documentation requirements, such as proof of income and
citizenship.
Barrier: Barriers faced by American Indians and Alaska Natives as well
as other populations: Cultural;
Description: Barriers unique to American Indians and Alaska Natives:
Includes American Indians and Alaska Natives' reluctance to pursue
enrollment if initially denied, aversion to revealing personal
information required for application, and reluctance to apply for
Medicaid because of requirements for seeking child support.
Barrier: Barriers faced by American Indians and Alaska Natives as well
as other populations: Financial;
Description: Barriers unique to American Indians and Alaska Natives:
Includes premiums requirements that are associated primarily with
Medicare Part B and D enrollment and concerns about losing assets
because of Medicaid estate recovery requirements.[A].
Barrier: Barriers faced by American Indians and Alaska Natives as well
as other populations: Lack of knowledge about the programs;
Description: Barriers unique to American Indians and Alaska Natives:
Includes a lack of awareness about the programs' existence, the
differences between the programs, and their requirements for
eligibility.
Barrier: Barriers faced by American Indians and Alaska Natives as well
as other populations: Language;
Description: Barriers unique to American Indians and Alaska Natives:
Includes limits to understanding, speaking, or reading English.
Barrier: Barriers faced by American Indians and Alaska Natives as well
as other populations: Limited access to communication devices;
Description: Barriers unique to American Indians and Alaska Natives:
Includes a lack of access to reliable and regular mail delivery and
phone service.
Barrier: Barriers faced by American Indians and Alaska Natives as well
as other populations: Mistrust of government;
Description: Barriers unique to American Indians and Alaska Natives: In
addition to just a general mistrust of the government, also includes
concerns about prejudice, racism, and mistreatment by government
officials.
Barrier: Barriers faced by American Indians and Alaska Natives as well
as other populations: Transportation;
Description: Barriers unique to American Indians and Alaska Natives:
Includes a lack of reliable transportation options, including public
transportation services, and the need to travel long distances to
eligibility offices.
Source: GAO analysis, April 2008.
[A] Estate recovery is the requirement that state Medicaid programs
seek to collect from the estate of a deceased Medicaid beneficiary the
amounts paid on the individual's behalf for certain Medicaid-covered
services, such as nursing facility services. While not totally exempt
from Medicaid estate recovery, CMS has instituted certain protections
on the estates of American Indians and Alaska Natives.
[End of table]
Enrollment Efforts Have Focused on Assisting American Indians and
Alaska Natives with Applying for Medicare and Medicaid:
Efforts to enroll eligible American Indians and Alaska Natives in
Medicare and Medicaid generally have focused on providing assistance
with the application process. Specifically, almost all of the IHS-
funded facilities we visited offered patients assistance with applying
for Medicare and Medicaid.[Footnote 52] The assistance included helping
complete and submit applications, collecting and possibly certifying
required documentation, translating application information into tribal
languages, and offering these services through home visits. Facility
staff generally identified patients needing application assistance
through their patient registration process, which is the process
through which patients sign in for their medical appointments. For
example, facility registration staff used information about a patient's
age, employment status, and existence of health insurance to determine
whether the patient might qualify for Medicare or Medicaid and thus
should be referred to a patient benefit coordinator for assistance (see
fig. 3). In addition to the patient registration process, some
facilities also generated reports listing individuals who were
potentially eligible for, but not enrolled in, Medicare or Medicaid.
For example, one facility indicated that it generated monthly reports
of (1) individuals aged 65 and older who did not have Medicare and (2)
individuals aged 19 or younger without health insurance and thus
potentially eligible for Medicaid. This same facility also generated
reports of individuals who were age 64 to alert patient benefit
coordinators that these individuals may soon be eligible for Medicare.
Figure 3: Example of How Facilities Use the Patient Registration
Process to Identify Patients Needing Medicare or Medicaid Application
Assistance:
This figure is a flowchart showing an example of how facilities use the
patient registration process to identify patients needing medicare or
medicaid application assistance.
[See PDF for image]
Source: GAO analysis of IHS-funded facility information, January 2008/
[End of figure]
Facilities we visited used staff--referred to as patient benefit
coordinators--to provide Medicare and Medicaid application assistance.
Among the facilities offering assistance, the number of patient benefit
coordinator positions ranged from one to eight; hospitals generally had
a higher number of patient benefit coordinator positions.
American Indians and Alaska Natives may also receive application
assistance directly from Medicaid or Medicare eligibility staff. State
or county Medicaid eligibility staff worked at or traveled to four of
the IHS-funded facilities we visited to provide application assistance
and conduct on-site eligibility determinations; these eligibility staff
were located at two of the facilities full-time, that is, 5 days a
week.[Footnote 53] State or county Medicaid eligibility staff were also
located at, or traveled to, tribal offices on three of the reservations
we visited.[Footnote 54] Specifically, one of the reservations had a
satellite Medicaid eligibility office, which was open 5 days a week and
housed several county Medicaid eligibility staff. The second
reservation had a staff member on-site 5 days a week, while a staff
member was available on the third reservation 2 days a week.
Additionally, a few of the tribes we visited had the authority to
determine Medicaid eligibility for at least some tribal members and
therefore had additional Medicaid application assistance available at
the tribal office where eligibility determinations occurred.[Footnote
55] Finally, staff from SSA, the federal agency responsible for
Medicare enrollment, provided Medicare application assistance at some
IHS-funded facilities. Specifically, staff from two of the IHS-funded
facilities we visited indicated that SSA office staff visited their
facilities at least monthly, while staff from a third IHS-funded
facility indicated that SSA staff came to a building nearby at least
monthly.
Many organizations, including CMS and IHS, have conducted outreach to
educate the tribal community about Medicare and Medicaid and encourage
those in the community to apply. For example, beginning in May 2005,
there was a concerted effort by CMS, IHS, and SSA to educate and enroll
American Indians and Alaska Natives in the Medicare Part D prescription
drug benefit, including training for patient benefit coordinators in
each IHS area and informational materials, such as posters and fact
sheets, targeted to the tribal community. In 2007, CMS and the TTAG
released an outreach video, to be used at IHS-funded facilities, which
emphasizes the community benefit to enrollment in Medicare and
Medicaid.[Footnote 56] Additionally, in 2007, IHS published a poster
and brochure to educate American Indians and Alaska Natives about
existing federal and state health benefit programs, such as Medicare
and Medicaid.[Footnote 57] Other outreach efforts targeted to the
tribal community included radio advertisements, which a few of the
state Medicaid programs we reviewed reported using, and newspaper or
newsletter articles, which some IHS-funded facilities reported using.
Finally, several of the IHS-funded facilities we visited provide
information about Medicare and Medicaid at facility-based or community
health fairs and events at schools, senior centers, or other community
venues.
Agency and State Comments and Our Evaluation:
We provided copies of a draft of this report to HHS and provided the
six states we reviewed (Arizona, Minnesota, Montana, New Mexico, Utah,
and Wisconsin) with copies of the portion of the report related to
state Medicaid programs' mechanisms for interacting and consulting with
Indian tribes. HHS provided us with written comments from CMS (see app.
III). We also received technical comments from CMS and three of the six
states (Arizona, Montana, and New Mexico), which we incorporated as
appropriate.
In written comments, CMS noted that it was pleased that our findings
highlight a number of activities that CMS engages in with IHS and
commented that the report reinforces the benefit of the multiple
processes CMS has put in place in working with IHS and the tribes. CMS
acknowledged that it is working to improve its process for identifying
whether proposed regulatory changes would affect IHS-funded facilities
and the populations they serve. CMS noted that its regulations also
affect programs directly operated by tribes, which have broader
authority than IHS in operating programs and facilities such as nursing
homes. We agree with CMS about the potential impact of its regulations
on tribally operated programs and facilities, and we encourage the
agency to consult with tribes when developing its regulations as
required by Executive Order and HHS's tribal consultation policy.
As agreed with your offices, unless you publicly announce the contents
earlier, we plan no further distribution of this report until 30 days
after its issue date. At that time, we will send copies of this report
to the Administrator of the Centers for Medicare & Medicaid Services
and the Director of the Indian Health Service. We will also provide
copies to others upon request. In addition, the report will be
available at no charge on the GAO Web site at [hyperlink,
http://www.gao.gov].
If you or your staffs have any questions about this report, please
contact me at (202) 512-7114 or kingk@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. GAO staff who made major contributions to
this report are listed in appendix IV.
Signed by:
Kathleen M. King:
Director, Health Care:
[End of section]
Appendix I: Locations of Indian Health Service (IHS) Areas and Centers
for Medicare & Medicaid Services (CMS) Regions:
Figure:
This figure is a map showing locations of Indian Health Service (IHS)
areas and Centers for Medicare Services (CMS) regions.
[See PDF for image]
Source: GAO-08-90 and information from CMS.
Note: Data on counties in the IHS areas are as of June 2007.
[End of section]
Appendix II: Methodology for Selecting IHS Areas, Facilities, and
Tribes Visited:
We used a two-tiered approach to selecting facilities and tribes for
site visits, which included selecting 3 of the 12 IHS areas and then
selecting facilities and tribes within those 3 areas. Based on this
approach, we interviewed officials from 25 IHS-funded facilities and
leaders (or designated officials) from 14 tribes.
In the first tier, we selected three IHS areas to represent a mix in
geographic location, the entities operating the facilities (IHS or
tribes), and the level of reliance on contract health
services.[Footnote 58] Table 6 shows the characteristics of the areas
selected.
Table 6: Selected Characteristics of IHS Areas Visited:
Factors considered: Geographic location;
Bemidji: Michigan, Wisconsin, and most of Minnesota;
Billings: Montana and Wyoming;
Navajo: Parts of Arizona, New Mexico, and Utah.
Factors considered: Percentage of facilities operated by tribes[A];
Bemidji: 89;
Billings: 14;
Navajo: 28.
Factors considered: Reliance on contract health services[B];
Bemidji: Moderate;
Billings: High;
Navajo: Low.
Source: GAO analysis of IHS data.
[A] Includes hospitals, health centers, and health stations.
[B] Determined based on contract health services dollars as a
percentage of total clinical care dollars for fiscal year 2003.
[End of table]
In the second tier, we selected facilities within the three IHS areas.
When selecting facilities, we considered recommendations from CMS and
IHS officials and tribal representatives, the type of facility (for
example, hospital or health center), and whether it was IHS or tribally
operated. We also used pragmatic considerations, such as distance
between facilities, to guide our selections. See table 7 for the
characteristics of the 25 facilities in which we interviewed officials.
For each facility visited, we requested interviews with the leaders of
the tribe primarily served by the facility.[Footnote 59] We were able
to interview leaders or designated officials from 14 tribes--7 from the
Bemidji area, 5 from the Billings area, and 2 from the Navajo area.
Because of the judgmental nature of our sample, information obtained
from the facilities and tribal leaders cannot be generalized.
Table 7: Characteristics of IHS-Funded Facilities Visited:
IHS area: Bemidji;
Facility type: Hospital;
Operating body: IHS: 1;
Operating body: Tribe: 0.
IHS area: Bemidji;
Facility type: Health center;
Operating body: IHS: 1;
Operating body: Tribe: 7.
IHS area: Billings;
Facility type: Hospital;
Operating body: IHS: 3;
Operating body: Tribe: 0.
IHS area: Billings;
Facility type: Health center[A];
Operating body: IHS: 2;
Operating body: Tribe: 2.
IHS area: Billings;
Facility type: Health station;
Operating body: IHS: 1;
Operating body: Tribe: 0.
IHS area: Navajo;
Facility type: Hospital;
Operating body: IHS: 3;
Operating body: Tribe: 1.
IHS area: Navajo;
Facility type: Health center;
Operating body: IHS: 2;
Operating body: Tribe: 2.
Source: GAO summary of information on 25 facilities.
[A] On one reservation, we spoke with officials from the Tribal Health
and Human Services Department, which oversees the tribe's health
centers, instead of staff from the actual facilities. Although the
tribe operates more than one health center, the facilities' operations
are centralized. Therefore, for purposes of this report, we counted
this tribe's facilities as a single health center.
[End of table]
[End of section]
Appendix III: Comments from the Department of Health and Human
Services:
The Secretary Of Health And Human Services:
Washington, DC 20201:
June 24, 2008:
Kathleen King:
Director, Health Care:
U.S. Government Accountability Office:
Washington, DC 20548:
Dear Ms. King,
Enclosed are the Department's comments on the U.S. Government
Accountability Office's (GAO) draft report entitled, "Medicare and
Medicaid: CMS and State Efforts to Interact with the Indian Health
Service and Indian Tribes" (GAO-08-724).
The Department appreciates the opportunity to review and comment on
this draft before its publication.
Sincerely,
Signed by:
Jennifer R. Luong:
for:
Vincent J. Ventimiglia, Jr.:
Assistant Secretary for Legislation:
Attachment:
Department Of Health & Human Services:
Centers for Medicare & Medicaid Services:
Administrator:
Washington, DC 20201:
Date: June 24, 2008:
To: Kathleen King:
Director, Health Care:
Government Accountability Office:
From: Kerry Weems:
Acting Administrator:
Signed by:
Kerry Weems:
Subject: Government Accountability Office (GAO) Draft Report: "Medicare
And Medicaid I and State Efforts to Interact with the Indian Health
Service and Indian Tribes" (GAO-08-724)
The Centers for Medicare & Medicaid Services (CMS) appreciates the
opportunity to respond to GAO's draft report entitled, "Medicare And
Medicaid: CMS and State Efforts to Interact with the Indian Health
Service and Indian Tribes." CMS has focused on developing a process
where the Indian Health Service (IHS) and Tribal programs can learn
more about Medicare, Medicaid, and the State Children's Health
Insurance Program (SCHIP) and on reinforcing ways in which Tribes can
provide input into the policy development; specifically through the
regulations process.
We were pleased to see GAO highlight a number of activities that CMS
engages in with IHS in support of the Department of Health and Human
Services' (HHS) strategic goals related to increasing the availability
and accessibility of health care service, as well as addressing the
needs, strengths, and abilities of vulnerable populations. Some of the
CMS activities recognized by the GAO include: annual IHS area training
sessions, tribal stops in the Medicare prevention tour, and training in
the implementation of Medicare Part D. Additionally, as referenced in
the report, CMS sponsors an annual CMS Day during the National Indian
Health Board Consumer Conference; conducts a monthly TV and Web-based
broadcast called Medicine Dish; provides technical assistance to
individual Tribes and facilities through the CMS regional office
network of Native American Contacts; develops outreach materials
specific to the needs of the American Indian and Alaska Native
beneficiary populations; and works closely with the CMS Tribal
Technical Advisory Group through a series of monthly conference calls
and face- to-face meetings with CMS' program staff. The CMS Tribal
Affairs Group (TAG), put into place in 2007, is the central point of
contact for CMS' activities related to IHS and Tribes. One of the key
initiatives undertaken by the TAG is providing annual training to CMS'
staff to enhance CMS' ability overall to work more effectively with IHS
and Tribal Governments.
The GAO report contains no recommendations as to areas CMS can improve
upon in our work with IHS and Tribes, but expresses that CMS has mixed
success in identifying whether proposed regulatory changes would affect
IHS-funded facilities and the populations they serve. As the report
notes, we are working to improve this process. However, regulations
issued by CMS not only impact the IHS-funded facilities, they also
impact programs directly operated by Tribes outside of IHS Medicare and
Medicaid authorities. We are becoming more familiar with these programs
as we work more directly with Tribes. Tribes have broader authorities
than IHS in operating programs such as Federally Qualified Health
Centers, Assisted Living Facilities, Nursing Homes, and Home and
Community Based Services. CMS is committed to continually seeking ways
in which we can work more effectively with both the IHS and Tribes in
meeting all provider needs; and in this way increasing access to
Medicare, Medicaid, and SCHIP services for the populations they serve.
The CMS is appreciative of GAO for its review of CMS' activities
related to our interactions with IHS and Tribes. This report reinforces
the benefit of the multiple processes CMS has put into place in working
with the IHS and Tribes; assisting them to become more knowledgeable of
Medicare, Medicaid, and SCHIP, with the goal of increasing access to
CMS' program services for the American Indian and Alaska Native
beneficiary populations. Understanding that CMS programs are important
to the sustainabIlity of health care services for these vulnerable
populations, we are committed to continually improving our interactions
with IHS and with Tribes.
[End of section]
Appendix IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
Kathleen M. King, (202) 512-7114 or kingk@gao.gov:
Acknowledgments:
In addition to the contact named above, Carolyn Yocom, Assistant
Director; Krister Friday; Elayne Heisler; Kevin Milne; Michelle
Rosenberg; and Elijah Wood made key contributions to this report.
[End of section]
Footnotes:
[1] A federally recognized Indian tribe is an Indian or Alaska Native
tribe, band, nation, pueblo, village, or community that the Secretary
of the Interior acknowledges to exist as an Indian tribe pursuant to
the Federally Recognized Indian Tribe List Act of 1994, 25 U.S.C. §
479a.
[2] To be eligible for IHS services, an individual must be a person of
American Indian or Alaska Native descent as evidenced by such factors
as tribal membership, living on tax-exempt land, owning restricted
property, participating actively in tribal affairs, or other relevant
factors. The most common standard applied for eligibility for IHS
services is that the individual is an enrolled member of a federally
recognized tribe.
[3] IHS-funded facilities can also seek reimbursement from other
sources, such as private health insurance.
[4] See 25 U.S.C. §§ 1621f, 1645 (2000).
[5] These data do not account for all collections by IHS-funded
facilities because tribally operated facilities are not required to
report such information.
[6] GAO, Indian Health Service: Health Care Services Are Not Always
Available to Native Americans, GAO-05-789 (Washington, D.C.: Aug. 31,
2005).
[7] See Executive Order 13084, 63 Fed. Reg. 27,655 (May 19, 1998). The
1998 Executive Order was replaced by Executive Order 13175, issued on
November 6, 2000. According to this order, policies that have tribal
implications include regulations, legislative comments or proposed
legislation, and other policy statements that have substantial direct
effects on one or more Indian tribes, on the relationship between the
federal government and Indian tribes, or on the distribution of power
and responsibility between the federal government and Indian tribes.
See 65 Fed. Reg. 67,249 (Nov. 9, 2000).
[8] We did not speak with officials from one region (Philadelphia)
because there are no federally recognized Indian tribes in that region.
[9] IHS's Office of Resource Access & Partnerships works with external
organizations and other federal agencies to increase access and
resources and to develop partnerships aimed at improving the health
status of American Indians and Alaska Natives.
[10] The three IHS areas we visited were (1) Bemidji, which includes
Michigan, Wisconsin, and most of Minnesota; (2) Billings, which
includes Montana and Wyoming; and (3) Navajo, which includes portions
of Arizona, New Mexico, and Utah.
[11] In selecting these areas, we also considered other factors, such
as whether we had visited the area previously and experts' views on the
relationship between tribes and states in the area.
[12] The four HHS regional offices were Chicago, Dallas, Denver, and
San Francisco. HHS has the same regional office structure as CMS.
[13] The six states are Arizona, Minnesota, Montana, New Mexico, Utah,
and Wisconsin.
[14] To identify the number of states with tribal locations, we
analyzed the 2008 list of Indian Entities Recognized and Eligible To
Receive Services (see 73 Fed. Reg. 18,553 (Apr. 4, 2008)). We excluded
one state on this list (Indiana) because it did not have reservations
or trust lands.
[15] See Department of the Interior, Bureau of Indian Affairs, American
Indian Population and Labor Force Report 2003 (Washington, D.C.: 2003).
[16] A health station is a facility, physically separated from a
hospital or health center, where primary care physician services are
available on a regularly scheduled basis but for less than 40 hours a
week.
[17] Under IHS regulations, an individual is eligible for direct care
if the individual is regarded as an American Indian or Alaska Native by
the community in which he or she lives, as evidenced by factors such as
tribal membership, enrollment, residence on tax-exempt land, ownership
of restricted property, active participation in tribal affairs, or
other relevant factors. In certain very limited circumstances,
individuals who are not American Indians or Alaska Natives may be
eligible for direct care services. 42 C.F.R. § 136.12 (2007).
[18] In most cases, a contract health service delivery area consists of
the county or counties in which a reservation is located, as well as
any counties it borders.
[19] Medicare Part B premiums are higher for individuals with incomes
above a certain level and a late payment penalty is assessed for
individuals who do not apply before the enrollment deadline.
Additionally, state Medicaid programs pay some or all of the premium
for certain low-income individuals.
[20] IHS does not currently have the authority to pay individuals'
Medicare Part D premiums.
[21] IHS has had the authority to bill Medicare and Medicaid since
1976.
[22] See Executive Order 13175, 65 Fed. Reg. 67,249 (Nov. 9, 2000).
[23] Although there is a designated NAC in each of the 10 CMS regions,
the NAC in the Philadelphia region is not involved as there are no
federally recognized Indian tribes in that region. CMS has the same
regions as HHS.
[24] CMS provided this guidance through a state Medicaid directors
letter issued November 9, 2006.
[25] For example, the Secretary may waive certain federal Medicaid
requirements and authorize Medicaid expenditures for experimental,
pilot, or demonstration projects that are likely to assist in promoting
Medicaid objectives. See Social Security Act § 1115. The Secretary can
also waive Medicaid requirements in order to allow long-term care
services to be delivered in community settings. See Social Security Act
§ 1915(c).
[26] CMS provided this guidance through a state Medicaid directors
letter issued July 17, 2001.
[27] A provider-based facility is a facility that is owned and operated
by a separate inpatient facility, such as a hospital.
[28] Specifically, an individual may face a late enrollment penalty for
Medicare Part B in the form of an increased premium of 10 percent for
each 12-month period that the individual was eligible for, but did not
enroll in, the program.
[29] IHS received the authority to bill Medicare Part B in 2001.
[30] See 72 Fed. Reg. 30,706 (June 4, 2007).
[31] This regulation will likely make it less expensive for IHS to
purchase contract health services from hospitals.
[32] IHS-funded facilities are generally paid per encounter, regardless
of the specific medical services provided; this is referred to as the
all-inclusive rate. Given this, IHS-funded facilities may not have
sufficient and qualified staff to submit claims under a methodology
that pays on the basis of specific medical services.
[33] See (1) Medicaid Program; Prescription Drugs, 71 Fed. Reg. 77,174
(Dec. 22, 2006); (2) Medicaid Program; Citizenship Documentation
Requirements, 71 Fed. Reg. 39,214 (July 12, 2006); and (3) Medicaid
Program; Cost Limit for Providers Operated by Units of Government and
Provisions To Ensure the Integrity of Federal-State Financial
Partnership, 72 Fed. Reg. 2,236 (Jan. 18, 2007).
[34] As of March 2008, the Tribal Affairs Group had four staff members.
[35] In 2007, the Tribal Affairs Group had as many as five staff.
However, because of an agency hiring freeze, an employee who left the
group in November 2007 has not been replaced as of March 2008.
[36] Although there was a designated NAC in each of the 10 CMS regions,
the NAC in the Philadelphia region was not involved, as there are no
federally recognized Indian tribes in that region.
[37] For the remaining percentage of their time the NACs perform
varying functions, including serving as Medicare or Medicaid program
staff and organizing CMS outreach and education efforts.
[38] Area health boards are generally associations created to advocate
for health-related issues on behalf of the tribes they represent.
[39] See Medicaid Program; Cost Limit for Providers Operated by Units
of Government and Provisions To Ensure the Integrity of Federal-State
Financial Partnership, 72 Fed. Reg. 29,748 (May 29, 2007). Congress
imposed a moratorium on this rule delaying its implementation until May
25, 2008. See Pub. L. No. 110-252, § 7001, 122 Stat. 2323.
[40] While subject to the HHS consultation policy, CMS has been working
with the TTAG to adopt its own consultation policy. In April 2007, the
TTAG submitted a draft policy to CMS for its review. As of June 2008,
the draft policy was under HHS review.
[41] Although there are 10 HHS regions, there are only 7 consultation
sessions each year because, at the request of tribes, 3 HHS regions
(Atlanta, Boston, and New York) do a combined consultation session.
These three HHS regions are included in the Nashville IHS area.
Additionally, another HHS region (Philadelphia), which is also in the
Nashville IHS area, does not have any federally recognized tribes.
[42] We reviewed consultation session agendas for the Chicago, Dallas,
Denver, and San Francisco regions, as well as the combined consultation
session for the HHS regions that compose the Nashville IHS Area. For
some regions we reviewed agendas from multiple years.
[43] CMS officials will also participate in the annual HHS Budget
Consultation, which is intended to give Indian tribes the opportunity
to present their budget priorities and recommendations to HHS.
[44] While states are not subject to the Executive Order on consulting
with Indian tribes, states may have their own policies governing
consultation with Indian tribes.
[45] Additional tribal representatives may participate in meetings of
this subcommittee, which are open to the public.
[46] In addition to its regularly scheduled meetings, Arizona and New
Mexico officials reported holding ad hoc meetings with tribal
representatives. One other state, Montana, also reported holding
meetings with tribal representatives on an ad hoc basis.
[47] The remaining state, Montana, reported that its state legislature
passed a bill in 2003 that instructed the state to develop a government-
to-government relationship with the tribes.
[48] Among the four states with tribal consultation policies, one state
(Arizona) had a policy specific to its Medicaid program, while the
consultation policies in the remaining three states were for the larger
department under which the Medicaid program operates.
[49] Such changes are either made through an amendment to the state's
approved Medicaid plan or through a waiver of certain Medicaid program
requirements.
[50] CMS guidance indicates that evidence of consultation with tribes
is a criterion that CMS will use during its review of states' waiver
requests.
[51] The state indicated, however, that tribes have been invited to
attend general community forums at which proposed waiver requests have
been discussed.
[52] The two facilities we visited that did not offer such assistance
were both satellite clinics of larger facilities, where such assistance
was available.
[53] All four facilities were located in the Navajo IHS area;
specifically, two were in New Mexico, one was in Arizona, and one was
in Utah.
[54] Two reservations were located in Montana, which is part of the
Billings IHS area, while the third was located in Minnesota, which is
part of the Bemidji IHS area.
[55] Only tribes that operate their own Temporary Assistance for Needy
Families program, a cash assistance program for needy families with
children, are able to obtain the authority to make Medicaid eligibility
determination decisions and generally only for the population covered
by their Temporary Assistance for Needy Families program.
[56] The video is entitled Our Health, Our Community: Medicare,
Medicaid and SCHIP Outreach to American Indians/Alaskan Natives.
[57] The brochure is entitled Make the Most of Your Benefits: Be
ResourceSmart. IHS also published a reference guide for IHS-funded
facility staff entitled How to Assess & Enroll Patients in Alternate
Resources, which provides an overview of existing federal and state
health benefit programs and steps to determine a patient's potential
eligibility for a program.
[58] In selecting areas, we also considered other factors, such as
whether we had visited the area previously and experts' views on the
relationship between tribes and states in the area.
[59] While IHS-funded facilities may see patients from multiple tribes,
we were interested in the tribe that primarily receives services at a
given facility.
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