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Breaking Good: Obamacare in Indian Country

By B.L. Azure

Health Insurance Marketplace
One goal of the Affordable Care Act is to control costs of private insurance and health care. The Health Insurance Marketplaces (HIM) are one tool the law uses to create a more transparent, accessible insurance market.

Health Insurance Marketplaces are designed to make buying health coverage easier and more affordable. They will allow individuals, including American Indians and small businesses to compare health plans, get answers to questions, find out if they are eligible for tax credits for private insurance or health programs like the Healthy Montana Kids and enroll in a health plan that meets their needs.

What is a Health Insurance Marketplaces?
A HIM is a one-stop marketplace where consumers can choose a private health insurance plan that best fits their needs. Using the Health Insurance Marketplace consumers will be able to:
   • Look for and compare private health plans
   • Get answers to questions about your health coverage options
   • Find out if you’re eligible for health programs like Medicaid and Healthy Montana Kids, or tax credits that make coverage more affordable
   • Enroll in a health plan that meets your needs

What are the benefits of the Health Insurance Marketplaces?
The Health Insurance Marketplaces offer consumers choice and clout through competition among insurance companies:
   • Insurance companies will compete for business on a level playing field.
   • Individual consumers and small businesses will be able to easily compare qualified health plans to choose the plan that is right for them.
   • Small business owners will be able to offer their employees’ health insurance that meets their needs, and some will be eligible for a tax credit for coverage purchased for employees through the Health Insurance Marketplace.

Through the HIM, American Indians and Alaska Natives will be able to find out if they are eligible for programs to make insurance more affordable, such as advance payments of the premium tax credit, cost-sharing reductions, or health programs like Medicaid and Healthy Montana Kids.

States are required to work with Indian Nations to make sure that the implemented exchange will meet the needs of tribal citizens.

Tribal leaders may want to work with states to make sure that tribal citizenship is verifiable, to ensure that statutes are being followed including the required monthly enrollment opportunity, and that HIM staff members are prepared to answer questions specific to American Indians and Alaska Natives.

All states have until January 1, 2013, to create a state-based HIM that the U.S. Department of Health and Human Services approves as fully or conditionally operational.

If not approved, the federal government will assume responsibility for running a health insurance exchange in the state.

Many states have already received federal grant funding for initial exchange development plans; a requirement of this funding is that the state consults with Indian Nations.

ST. IGNATIUS — On March 23, 2010 President Barack Obama put his pen to the parchment to sign the Affordable Care Act it into law. A year ago the conservative United States Supreme Court upheld Constitutionality of the ACA, also known as Obamacare. Despite political gaming by Republicans wanting to scuttle the ACA, it is the law of the land and people need to be prepared to adhere to its mandates.

Beginning October 1, people can began shopping for health insurance at Health Insurance Marketplaces that were formally referred to as Health Care Exchanges for coverage that will become effective January 1, 2014.

Some of the ACA mandates are slightly different in Indian Country due to federal trust responsibility articulated in treaties between sovereign Indian Nations and the United States, as well as subsequent laws, policies and regulations related to the delivery of health care to pre-America Americans.

The latest buttress in the sovereign government-to-government relationship was the ACA permanently reauthorizing the Indian Health Care Improvement Act that is specific to American Indians and Alaska Natives.

However, the whole foundation has historically been on shaky political terra firma due to the U.S. Congress appropriation process that has woefully underfunded the need. President Obama has increased funding but it still falls well short — meeting only about 50 percent of the need.

So ready or not it is a new and brighter day healthcare-wise in Indian Country but it will take time to get used to the less-turbulent change in the weather.

“Acquiring health insurance for Indian people has not been something that has been routinely done in Indian Country because of the belief and assumption that the Indian Health Service was the sole provider of health care for Indian people,” said Confederated Salish and Kootenai Tribes Tribal Health and Human Services Director Kevin Howlett. “However, the Indian Health Services has been historically under funded and the result is needed medical care is often not available because individual Indians do not have any other coverage. Obamacare provides Indian people with access to affordable health insurance through the Health Insurance Marketplace, and depending upon individual or family incomes many of the insurance premiums in most cases will be minimal.”

In Montana the Health Insurance Marketplace will offer insurance through three private companies: Blue Cross Blue Shield, PacificSource and the Montana Health Co-op. All insurances sold through the Health Insurance Marketplace will provide comprehensive coverage that, among other things, includes doctor visits, emergency services, maternity care and prescription drugs. People cannot be denied insurance coverage due to pre-existing conditions.

Within the Health Insurance Marketplace the insurance companies will provide four levels of insurance coverage based on premium level and co-pay: Platinum, Gold, Silver and Bronze. There are various income based tax credits that apply that can greatly reduce the premium charge to nothing, next to nil to very affordable.

There are exemptions to the individual mandate for Shared Responsibility Payment of the ACA for some people who choose not to purchase health care insurance.

In Indian Country you are exempt if you are enrolled members of federally recognized Indian Nations. Descendants eligible for health care through Indian Health Service are eligible for a hardship exemption process that the Secretary of the Department of Health and Human Services Kathleen Sebelius authorized this past June. Indian Health Service is currently finalizing the process and application and it will be available IHS clinics and hospitals, tribal health clinics and urban Indian centers. The hardship waiver is considered an extension of the federal government’s trust responsibility.

Also exempt are people with employer funded health insurance, ala CSKT employees; those who have purchased individual insurance on their own; people on Medicaid and Medicare; those covered by Healthy Montana Kids and the Department of Veterans Affairs; and those who would have to spend more than 8 percent of their household income on the least expensive qualifying health care insurance plan.

Enrolled American Indians are also not restrained by the once a year enrollment period that is applicable to the rest of the population. They can enroll throughout the year and coverage would begin approximately six weeks after enrollment. People can enroll via an application submitted online, by phone, by mail or in person.

“It is very important that Indian people take advantage of the opportunity to access affordable quality health care insurance that heretofore has been unavailable in Indian Country,” Howlett said. “It can provide families with a sense of security that they can cover the cost of comprehensive quality medical services. It is equally important here on the Flathead (Reservation) so that Tribal Health clinics can recoup the cost of providing health care by being able to bill the insurance (policy) of the individual.”

It is that third-party billing ability that has allowed Tribal Health to expand its services, build new and/or remodel and expand existing clinics.

The revenue generation has also meant the creation of well-paid health care professional employment opportunities. The construction of the Polson THHS Clinic resulted in the creation of 40 new positions with an average salary of $60,000 per year.

The third-party revenues also helps stretch limited IHS and Contract Health Services funds to better serve those who really have no other coverage alternative due to low or none-existent incomes.

The revenue also makes Tribal Health a major contributor to the local and area economy. The Confederated Salish and Kootenai Tribes as a whole are the lifeblood to the local economy as well as a big kick to immediate area economy outside of the Flathead Reservation.

Tribal Health Patient Advocate staff has been and will be receiving the appropriate training to become certified Health Insurance Marketplace navigators that will assist people through ACA mandate process.

For more information on the ACA in Indian Country, visit website:

Additional information is available at the Montana Health Co-op website:

Also visit website: and

The Affordable Care Act is a complex, complicated and heretofore not well-explained or well-understood law. More clarification and explanatory information is now coming out the floodgates nationally, in Montana and in Indian Country. There continues to be kinks and clarifications that are getting worked out and addressed in the organic law.

In the coming weeks more comprehensive information will be published that explains Obamacare, its nuances, its requirements and application in Indian County.

Tribal Health in conjunction with Gary Neumann, Native American Liaison with the Montana Health Co-op, will be conducting community informational meetings throughout the Flathead Reservation in the upcoming months. The particulars are presently being hammered out.

Tribal Health Director Kevin Howlett and Gary Neumann will be on the agenda the Fall Quarterly this Friday to bring people up to speed on the ACA’s application in the Flathead Nation.

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