Tribal Premium Sponsorship
  • Sponsorship Policies developed by the Port Gamble S'Klallam Tribe are available for use/adaption by tribes.
  • Policies are recommended for larger tribes---IRS, general welfare regs like written policies too!.
  • TPSP Program Began:  July 1, 2013

  • TPSP began its enrollment on November 7 
  • 1. CHS-eligibles who:
  • 2. Qualifiy for tax subsidies in exchange 
  • 3. Income is under 300% FPL-that's just three criteria to determine eligibility.
Timeline for the Port Gamble S'Klallam TPSP:

  • Fall 2012  Developed Initial Program proposal
  • Present a draft proposal to council in January 2013.
  • October 1, 2012 Health Care Reform Staff Meeting so staff can prepare for community input
  • Februrary  2013 Community Mtg
  • December 2012 Approve Budget for 2013
  • January - March 2012 Develop Eligibility Guidelines
  • ​June 2013  Approve Program (and budget)
  • July 1, 2013 Program Launch Date
  • July 1 to October 1 Community Members can review their eligibility, view options while they help the TSP program estimate costs.
  • September 2013 Appointments for enrollment
  • October-December 2013 Application Assistance
  • January 2013 set aside $240,000 for proposed 2014 Health Insurance Trust Fund ($200,000 to $300,000) to be approved for 2014 budget.
  • Trust Fund now money market account with just $150,000 needed for all costs of program.
  • January 2014 Coverage Begins
  • Monthly reports on Insurance payments to health program
  • July, 2014 consider changes to eligibility based on revenues from new payors (insurance) and CHS savings.  Estimate the cost of insuring any remaining uninsured community members.

Goal of the 
Port Gamble S'Klallam Tribal Premium Sponsorship Program ( use edfoxphd password) (TPSP)

  • Ensure that a Tribally-defined set of community members is 'connected' to the most appropriate coverage for their families. 

  • CHS program enhanced to provide more services for all CHS eligibles and those who may still not have health insurance in 2014.

  • Added resources used to address Tribal Council's Priority Goal on Prevention

  • It is likely in 2014 many more will have health insurance coverage, but some may not change anything and still depend on the clinic and CHS program without insurance coverage.

  • Sign contracts with Exchange health plans so health program can be paid for services provided (using Indian Addendum)

  • All tribal members and their families will have expert application assistance at their disposal beginning July 1, 2013 we can determine likely eligibles.

  • Tribal financial support program will have certain conditions of participation (e.g., provide income and insurance information, agree to update, use our health services program).

  • Enrollment in new health insurance coverage begins October 1, 2013 and actual coverage January 1, 2014.
  • We needed to determine (we did not know) how many will be eligible for financial assistance from the Tribe for the purchase of health insurance but we will examine:

  • 1.  How many are uninsured patients of the clinic (100-200)
  • 2.  How many community members are uninsured, but not currently patients of the clinic
  • 3.  Who is underinsured-some coverage, but not the best value for what they or their employer are paying.
  • 4.  Who is paying too much (for example more than 10% of their income) for insurance.

  • Estimates of the number of the above will be refined,  but it is between 50 and 200, not the 200 and 500 persons originally estimated. This is the group who may receive financial assistance to become fully insured.

  • What are the insurance options for the above....?
ACA Income Categories spreadsheet.
  • 139% Medicaid threshold WA and OR and lower threshold for exchange plans and subsidies
  • 300% upper limit for no-cost sharing for AIANs in exchange health plans
  • 400% upper limit for subsidies and reduced rate insurance (for elders)
February 1, 2012 Ready for Reform Meeting with Washington Tribes (18 tribes,  attendance 75)
October 1, 2012 Health Services Department Health Care Reform Meeting Agenda
Tribal Council, November 27, 2012 Sponsorship Update (w corrections)
February 1, 2013 Community and Staff Pizza and Health Care Reform Meeting
  • Sponsorship will cover all uninsured CHS-eligible and Exchange-eligible PGST tribal members (adults) under 300% of poverty because cost sharing exemptions make plan choice easy and very affordable and a great value (Children  will be Apple Health/CHIP).  A high value plan at the cost of the Bronze Plan.
  • The sponsorship program considers the tribal employee health benefits in planning, but it operates separately from decisions on that program that are develop by Human Resources Dept.
  • Don't Overestimate how many are eligible for your sponsorship program.
  • Our first estimate was 195 uninsured eligilble and $425,288 in premiums we may end the year with 50 enrolled and just $75,000-$100,000 in premiums.
  • Second estimate, 120, $300,000 in premiums.
  • After several more estimates we currently expect 50 eligible for the program with premium costs from $120,000 to $160,000 including $20,000 reserve for tax reconciliation (we will reimburse any tax bill for IRS due to tax credit overpayment).
  • Remember a spouse of an employee 'offered' insurance is typically not eligible for tax credit in the exchange-you can still buy insurance, but no tax credit.
  • As of mid-January 2013 it appears 'take-up' will be lower than expected with only 20 insured on April 1, 2014, but an expected 35 to 40 by November 15 open enrollment.
  • Premium Sponsorship Program approved by Port Gamble S'Klallam Tribal Council on May 25, 2013
  • Sign-up began November 7, 2013
  • Goal (estimated of number eligible with goal of 100% 'take up'):  175 Medicaid, 50 Qualified Health Plans.
  • April 4, 2014 update: 245 Medicaid (about 2/3 newly insured); 19 QHP 
  • Have we reached all uninsured?  No, 125 still listed as no known insurance! An apparent increase in uninsured, but likely improved reporting.
April 5, 2013 Community and Staff Pizza and Health Care Reform Meeting
  • Tribal Premium Sponsorship Programs are the key to enrolling Tribal Community Members into Medicaid and Marketplace plans. Without a TPSP it is unlikely AIANs will acquire marketplace insurance.
1.  NCAI Marketplace Calculator Excel 2013
2.  User Guide for NCAI calculator
3.  Narrative of calculator logic model.

This calculator gives you an estimate of how many of your program's CHS-eligibles are uninsured AND are under 300% of federal poverty level AND an estimate of premiums AND potential for payments for medical care.
May 9, 2013 Sponsorship Meeting, Seattle
  • Since February 1, 2012 the Port Gamble S'Klallam Tribe has hosted meetings with other NW tribes, with community, council, and department staff.  
  • See PowerPoints below.
  • Feb 1, 2012
  • Oct 1, 2012
  • Feb 1, 2013
  • May 9, 2013
  • Oct 30, 2013
  • Feb 4, 2014 (cancelled)
  • HHS reports on Premiums September 2013
  • Port Gamble S'Klallam first two sponsored were young men with premiums of $28 per month and $98 per month.
105 Maple Park Ave SE Olympia,WA 98501
Free and unlimited use granted, citation appreciated
edfox_phd@yahoo.com  360 790 1164
 Page updated March 20, 2014
2013
2012
  • Private insurance will cover our first sponsored tribal member who, like many other eligibles, is young, healthy and whose insurance is gained at low cost to the tribe.
  • His health insurance began January 1, 2014!
  • What we are telling our Port Gamble S'Klallam Community
  • 2.  Align health care reform with Tribe's Education, Employment, and Economic Development Goals.
  • 3.  Let health program help you complete the OMB/ HHS/IRS (Indian)Exemption (lifetime exemption for ever having to pay a penalty for not having insurance) Form-
  • We plan to complete these after April 1, 2014-not a high priority winter 2014 as we work hard to ensure our community members who are not 'enrolled tribal members' make their insurance decisions before March 31, 2014 deadline.
Suggested Citation: Health Care Reform for American Indians and Alaska Natives, Ed Fox, 2014 Website.
  • Set up sponsorship program as part of the tribes' CHS/Purchased Referred Care program (PRC) 
  • 1. Have several staff become Navigators, Application Assisters, Sponsorship Representatives
  • 2. Set up process to pay first and ongoing payments(easy to pay with bank routing #)
  • 3. Amend CHS policy to add 'sponsorship'  
  • 4. Plan for customer service of insurance
  • 5. Share experience with other tribes
  • Model Tribal Premium Sponsorship Program
  • In the first year, 2014, most tribes will set eligibility for CHS-eligibles only, not all 'active users,' not all tribal members.
  • Set limit at 300% of FPL (see below for reasons why).
  • Buy Bronze plan only for Tribal Members-- they will have no cost share if under 300% & since benefits are the same for all metallic levels you don't need to 'upgrade' to buy lower cost sharing-that comes with tribal membership.
  • Buy Silver plans for non-enrolled descendents who are CHS -eligibles and under 250% of FPL they will have reductions in cost sharing (not exempt).

  • No cost sharing includes no deductible, no point of service copays and you do not pay a % of bill from hospitals or specialists.  Insurance plans pay 100% to these providers and the HHS Secretary is liable for the value of the exemption.​
• 5 reasons to set upper limit for sponsorship at 300% of FPL in the first year of sponsorship.

  •  1. There is no cost sharing for enrolled AIANs at this level of income, no deductible, no copays and no cost sharing (% of bill to pay). 

  • 2. At 300% and above the 'subsidy' or tax credit is much less than at lower levels-for older folks the tax credit, when transferred to a bronze plan make insurance free or extremely low cots.

  • 3. The benefit of sponsorship is far more than the cost at this level. Likely return on investment is 1.75 to 1 to over 2 to 1 at 300% and 4 to 1 at the 200% of federal poverty level.

  • 4. Minimize chance of full tax reconcilation that is assessed when income exceeds 400% FPL.

  • 5.  Many states set upper limit for children on Medicaid or CHIP at 300% of FPL (always more than 138%)

  • A Tribal Premium Sponsorship Program may be the best Medicaid Outreach Program
  • Why?  

  • It is "new," it generates interest in more tribal and community members, and it aligns with non-Indian marketing and media coverage.

  •   A well-designed Tribal premium sponsorship program will result in signing up far more Medicaid enrollees (9 to 1 for most) than actual 'sponsored' enrollees with Marketplace insurance.

  •   As community members are screened for coverage eligibility far more will find they are eligible for Medicaid under Medicaid expansion.


  •   Medicaid is "Golden" Why?

  •   ​Broadest Definition of Indian 

  •   Encounter Rate for Tribal IHS programs

  •   Less complexity and contracting uncertainty compared to Qualified Health Plans.

  •   Medicaid Administrative Claiming available
  • Estimate your cost and benefit of a tribal premium sponsorship program with NCAI calculator. (refresh to restart)
  • 1. Enter Area of IHS 
  • 2. Choose State 
  • 3. Your program 
  • 4. Specific Facility