Tribal Premium Sponsorship 
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.
  • Final estimate of $30,000 for 2014 budget will have a year-end balance of $15,000 to $18,000.
  • 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  remaining uninsured community members.

Goal of the 
Port Gamble S'Klallam Tribal Premium Sponsorship Program (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.  Those over 300% of FPL and spouses of an employee who has employer insurance are two uninsured groups.

  • 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 (progress in 2015) with Exchange health plans so health program can be paid for services provided (using Indian Addendum)

  • All tribal members (and other CHS eligibles) 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).
  • 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.
  • 5.  Who will remain insured and covered by CHS-mainly spouses of employed tribal members.

  • 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. 

  • What are the insurance options for the above....?
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
  • 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.
  •   4 Good reasons for limiting to 300%- and for most tribes 75- 80% of your 139-400% uninsured are between income levels 139- 300% of FPL.   

  •    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 cost.
  •   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.Don't Overestimate how many are eligible for your sponsorship program.  Not all eligibles will be enrolled, but don't underestimate the benefit of sponsorship as a part of 'coverage options.'

  • Advocacy (Ed Fox, Director, Health Services)
April 5, 2013 Community and Staff Pizza and Health Care Reform Meeting
  • Tribal Premium Sponsorship Programs TPSP) are the key to enrolling Tribal Community Members into Medicaid and Marketplace plans. Without a TPSP it is unlikely AIANs will acquire marketplace insurance.
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)
Free and unlimited use granted with citation.  360 790 1164
  • What we are telling our Port Gamble S'Klallam Community
  • 2.  We plan to aign health care reform with Tribe's Education, Employment, and Economic Development Goals.
  • 3.  Let us explore your coverage options-come see us!
Suggested Citation: Health Care Reform for American Indians and Alaska Natives, Ed Fox, 2015 Website.
  • Set up sponsorship program as part of the tribes' CHS/Purchased Referred Care program (PRC) 
  • 1. Have several staff trained as Navigators, Application Assisters, Sponsorship Representatives, (benefits counselors)
  • 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 including assistance with tax reconciliation in 2015
  • 5. Share experience with other tribes
  • Model Tribal Premium Sponsorship Program
  • Most tribes will set eligibility for CHS-eligibles only, not all 'active users,' not all tribal members (although considered by most).
  • 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 (15 to 1 for most tribes) than actual 'sponsored' enrollees with Marketplace insurance.

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

  •   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 for Medicaid, but not for Qualified Health Plan enrollment
  • QHPs are never retroactive, but Medicaid is to first of month automatically (and in some cases 90 days).
Powerpoints 2012-214 from Port Gamble S'Klallam
Newsletter Articles Oct 1, 2012 .......................  November 2012 ............................ and 1 year later   Oct 1, 2013 and 2 years later January 2014 and May 2015
  •   Timeline for Port Gamble S'Klallam 
  • May 25, 2013 Premium Sponsorship Program approved by Port Gamble S'Klallam Tribal Council 
  •   November 7, 2013 program enrollment began.
  •   Goal (estimated number eligible with goal of 100% 'take up'): 175 Medicaid, 50 Qualified Health Plans.
  •   May 13, 2014 update: 275 Medicaid (about 175 newly insured); 23 assisted with QHP enrollment 19 sponsored (most PGST tribal members) and assisted others purchase a QHP (not CHS eligible).
  •   Average annual premium increased from $500 to $1200 in 2015 with little change in covered population.
  •   Have we reached all uninsured? No, 100 likely still uninsured, but still eligible for CHS-now with more dollars for more services.
  • Narrative explaining the model that powers the NCAI calculator.
  • Don't overestimate the number eligible, but do not underestimate the benefit of having even one person enrolled in insurance.i
  • Why is Marketplace Enrollment, as expected, failing (less than 15% of eligibles enrolled) AIANs?   

  • Health Care is a trust responsibility between Tribes and the federal government and American Indians and Alaska Natives should not have to pay for health insurance.

  • Where is it succeeding?  Where Indian health programs guarantee there is no cost to patient.
  • It is not complicated:  Sponsorship & Outreach can overcome the complexity (and principled opposition to paying) that stops many AIANs from accessing health insurance at an extremely low cost(often with no cost sharing).
 Sponsorship NPAIHB October 22 2014
  • Sponsored patients are encouraged to continue their care with their Indian Health Program
  • There will be no cost sharing (including enrolled tribal members and descendents)  if they follow their CHS/PRC guidelines.
  •   # 1 question (question most commonly asked) asked is: 
  • I have insurance, can my spouse get tax credits? The answer is, NO.

  •   The spouse of an employee 'offered' employer sponsored insurance is typically (never) not eligible for tax credit in the exchange.

  •   They can purchase insurance in the exchange, but no tax credit is available until Congress fixes the "family glitch" ignores affordability of family coverage
  • Urban Institute's reform recommendations includes proposed elimination of family glitch.
Tribal Self-Governance Presentation on Tax Reconciliation,April 29,2015.
See others on tribal sponsorship success at
  • Tribal Council is the most important Advocate promoting Coverage Options.
  • 2013-2015 Port Gamble S'Klallam model sponsorship program described here (one that limits to 300% of FPL)had only 3 criteria:  6.

  • 1. CHS eligible, enrolled tribal member (not all tribes sponsor descendents)
  • 2. Eligible for tax credits (typically no spouse with employer insurance in family)
  • 3. Below 300% of Federal Poverty level; 

  • Note that for tribal members; only select bronze plans and only a plan that shows ZERO deductible as that indicates exchange recognizes a tribal member under 300% FPL is choosing plan.
  • See Joint IHS -Self Governance (below) for webinars on setting up sponsorship.

  • No Cost Sharing for 'enrolled tribal members' under 300% of FPL.
  • Limited Cost sharing for those over 300% reportedly problematic and subject of 2015 consultation.
  • Port Gamble has no problems with very very limited experience buying for those over 300%.
  • 2014 1st yr sponsorship-n=23.
  • 2015 estimate $28,000 in premiums for 21 enrollees, about $1,300 per person per year.
  • In 2015 Health Plans will pay more than $40,000 for the care of insured including over $20,000 to the Port Gamble S'Klallam Health program.
  • Estimated number of Tribal Patients eligible for typical sponsorship program described here (one that limits to 300% of FPL).

  • Washington  1,365
  • Oregon           593
  • Idaho              399

See extensive sponsorship training at: