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American Indians will soon feel the effects of the Affordable Care Act

ST. IGNATIUS — A major goal of the Affordable Care Act (ACA) is to put American consumers, including American Indians, back in control of their health care needs.

Proponents of the ACA say it puts into place comprehensive health insurance reforms that will hold insurance companies more accountable, will lower health care costs, will guarantee more health care choices, and will enhance the quality of health care for all Americans.

The ACA, also known as Obamacare, also includes the permanent reauthorization of the 1996 Indian Health Care Improvement Act (IHCIA), which extends current law and authorizes new programs and services within the Indian Health Service (IHS).

The term “Obamacare” was originally used by political opponents of the national health insurance effort as a negative connotation, however President Barack Obama turned the tables on the effort and whole-heartedly embraced the name for the signature legislation of his presidency.

The IHCIA, the cornerstone legal authority for the provision of health care to American Indians and Alaska Natives, was made permanent when President Obama signed the bill on March 23, 2010, as part of the Patient Protection and Affordable Care Act.

The authorization of appropriations for the IHCIA had expired in 2000, and while various versions of the bill were considered by Congress since then, the act now has no expiration date.

The Affordable Care Act
The ACA ensures new rights and benefits to all American Indians and Alaska Natives.

• Affordable health exchanges
Affordable insurance exchanges are designed to make buying health coverage easier and more affordable. Through an exchange, individuals and small businesses can purchase health insurance coverage. This will give them the ability to comparison shop and choose the affordable insurance option that is right for them.

• No cost sharing or co-payments
Certain American Indians and Alaska Natives who purchase health insurance through the exchange do not have to pay co-pays or other cost-sharing if their income is under 300 percent of the federal poverty level, which is roughly $66,000 for a family of four ($83,000 in Alaska).

• Value of health services cannot be taxed
The value of health services and benefits from IHS-funded health programs or tribes will be excluded from an individual’s gross income – meaning, this service cannot be taxed.

• Medicaid expansion
Health insurance reform expands Medicaid coverage to individuals with incomes up to 133 percent of poverty level (about $30,000 for a family of four). This provides more American Indians and Alaska Natives an opportunity for coverage.

It also expands the opportunity for Indian health programs, like the Confederated Salish and Kootenai Tribes’ Tribal Health and Human Services Department, to collect third-party reimbursements for health care it provides to patients covered by private insurance, Medicare, Medicaid, Healthy Montana Kids, etc.

• Closing the donut hole
For individuals who have Medicare Part D drug coverage, IHS, a tribe or tribal organization, or an urban Indian organization, spending will count toward the annual out-of-pocket threshold in the donut hole as of January 1, 2011.

Starting in 2011, individuals with this coverage received a 50 percent discount on brand-name drugs in the donut hole and will pay less for their generic Part D drugs in the donut hole.

By 2020, the coverage gap will be closed, meaning there will be no more “donut hole,” and individuals will only pay 25 percent of the costs of their drugs until they reach the yearly out-of-pocket spending limit.

• Reimbursements from third parties
Third party reimbursements from Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and private insurance help IHS fund needed health care services. The provisions of the new law improves reimbursements and strengthen these programs which will also benefit Indian health programs.

Reauthorization of the Indian Health Care Improvement Act
The IHCIA was made permanent with the 2010 passage of the ACA. The IHCIA now has no expiration date and guarantees access to health care for all American Indians and Alaska Natives.

The version of the IHCIA signed into law permanently extends provisions and authorizes new programs to facilitate the delivery of health care services, such as the following

• Expanded IHS services, including mental and behavioral health
The law gives IHS authority to establish expanded health care services such as mental and behavioral health treatment and prevention, long-term care services, dialysis services, facilitation of care for Indian veterans, and urban Indian health programs.

• Increasing clinician recruitment and retention in tribally operated health programs
This section of the law exempts a health care professional employed by a tribally operated health program from state licensing requirements if the professional is licensed in any state (as is the case with IHS health care professionals). It also encourages health professionals to join or continue in an Indian health program and to provide services in rural/remote areas in which a significant portion of Indians reside.

• Access to federal insurance
The IHCIA allows a tribe or tribal organization carrying out a program under the Indian Self-Determination and Education Assistance Act and an urban Indian organization carrying out a program under Title V of IHCIA to purchase coverage for its employees from the Federal Employees Health Benefits Program.

• Ends charges for CHS-referred care
Under the IHCIA, Contract Health Service (CHS) referred patients cannot be billed for any deductibles, fees, or co?pays for CHS-referred care.

With this protection, providers will not have further recourse against IHS patients for services authorized by the IHS under CHS.

• Establishes IHS as an agency of the Public Health Service
IHCIA expands the authorities of the IHS director to: facilitate advocacy for the development of appropriate Indian health policy; and promote consultation on matters related to Indian health.

These provisions are a significant step in acknowledging the importance of the government-to-government relationship between the U.S. and tribes and give the IHS director broader responsibilities for advising the Secretary of Interior on matters related to Indian health, and to collaborate and coordinate with other agencies and programs of the Department of Health and Human Services (HHS).

• Develops a plan to improve behavioral health training and community education
Under IHCIA, IHS is required within five years of enactment to develop a new plan to increase the staff providing behavioral health services by at least 500 positions, of which at least 200 will be devoted to children, adolescents, and families. The plan will be implemented when funding for the program is available.

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