Health Director's view
  • The daily work of management does not stop while health care reform is implemented.
  • Preparations have been made to maximize revenue opportunities, clarify the mixed messages tribal communities hear,  implement plans, but with flexibility to adjust them.
  • Reminding the community that for most there is no change and for others the change will only occur with their approval as they work with our health program to make the most of HC reform.
  • Key elements of health care reform planning:

  • 1.  Staffing, support for current staff critically important---work with those who need help to send a message that you support all staff and high standards understanding change is difficult.
  • 3.  Business Office.  Learn how to work with CMS Medicare Medicaid progrms, health plans and providers to stay current (e.g., on credentialing, Medicare cost reports),  maximize revenues and keep strong relationships by paying bills promptly and invoicing likewise.
  • IT support all quality improvements and will eventually be required to work with health plans.
  • Our job is finding out which health insurance 'coverage' is best for our tribal members and their families (and for some tribes other community members).
  • Understanding can only come by educating about the 'knowns' and unknowns of health care reform-support will be needed if a change in course is required or resources needed for investments in staff, facilities or equipment.
  • 7. Organizational Change may be required as payment reform drives integration of services and delivery system changes.  
  • 8.  Working with NPAIHB and AIHC and other Tribes and federal and state partners.
  • 9.  Building the 2014 budget to maximize HC reform benefits-we will budget for 'insurance premium payments' and we will reduce our expected CHS expenditure estimate.  This 'new' budgeting reality will need close monitoring in the first year of sponsorship.


  • Managing Indian Health Programs(IHPs) Relationships with 
  • Managed Care Organizations (MCOs) (called Qualified Health Plans in the Health Benefits Exchange).

  • The goal 
  • State support for MCOs in health exchange plans, Medicaid programs, dual eligible projects and coordinated care organization development should ensure access to culturally appropriate health care services to AIANs that begins with primary care, but extends across the spectrum of health care services without diminishing the strong connections IHPs have to supportive social services.  

  • Medicaid

  • Although states initially(1995) made no special accomodation for Indian health programs, Washington became the first to allow any AIAN to choose an IHP and for payment using the OMB encounter rate.  AIANs could chooses MCOs and if they made no choice and were assigned an MCO they could still 'opt out' and choose an IHP.   Later AIANs who self-identifiied were auto assigned, by zip code, to IHPs.  This reasonable accomodation ended any work toward MCOs and IHPs working out arrangements to integrate their service networks.

  • Washington State Medicaid has not required MCOS to contract with tribes, but is considering this in 2013.  Two of these plans inquired about contracting with tribes, but went silent when asked to meet to discuss modifications to their standard contract.  Thankfully, unlike Oregon, New Mexico, Kansas and a number of other states, expansion of managed care is not being proposed in Washington in 2012. Kansas, after agreeing to meet with the states tribes to mitigate damage to their programs, has become the first state to require an MCO to contract with the state's Indian health programs (and pay the encounter rate as well).   In addition Kansas requires that these managed care plans use the Indian Addendum developed by the TTAG/MMPC. See appendix H of the Kansas/CMS waiver.


  • Dual Eligibles projects, Coordinated Care Organizations and Accountable Care Organizations.

  • Tribes should be included as states begin to build their coordinated care organizations or supports for dual eligibles. Simple contracting provisions could include the existing comprehensive services of IHPs.  This is not to say it is a simple task to develop new payment mechanisms, referral arrangements with MCOs, or to convince state regulators to do more than describe our programs as good ones---without any follow-up on suggestions to build these arrangements.

  • Health Benefit Exchange Health Plans

  • Tribes expect that the criteria for the Washington State Office of Insurance Commissioner's approval of health plans will include the requirement to contract with Indian health programs so any eligible American Indian or Alaska Native resident can choose an IHP as their primary care provider. 

  • Watch us build a Tribal Sponsorship Program to pay for Exchange-health plans as part of our CHS program's alternate resource support for insurance.
Suggested Citation: Website,  Health Care Reform for American Indians and Alaska Natives, Ed Fox, 2014
edfox_phd@yahoo.com  360 710 0728
105 Maple Park Ave SE Olympia,WA 98501
Free and unlimited use granted, citation appreciated
edfox_phd@yahoo.com  360 790 1164
105 Maple Park Ave SE Olympia,WA 98501
Free and unlimited use granted, citation appreciated
Staff Meeting 1 year prior to Launch
October 1, 2012
 October 4, 2014