Updated Medicare CPT Codes and Payment for Additional COVID-19 Vaccine Doses

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On August 12, the Food and Drug Administration (FDA) amended the emergency use authorizations (EUAs) for the Pfizer-BioNTech and Moderna COVID-19 vaccines, authorizing the use of an additional dose in immunocompromised individuals. The new authorizations allow for a third dose to be given at least 28 days following the two-dose regimen of the same vaccine to those over the age of 18 (ages 12 and older for Pfizer-BioNTech) who are solid organ transplant recipients or have certain conditions that are an equivalent level of immunocompromise. After review, the Centers of Disease Control and Prevention (CDC) officially recommended that people with moderately to severely weakened immune systems receive the additional shot. CDC’s independent advisory panel, the Advisory Committee on Immunization Practices outlined clinical considerations regarding the additional dose. Urban Indians should talk to their healthcare provider about their medical condition, and whether getting an additional dose is appropriate for them.

Effective August 12, the Medicare CPT code for the Pfizer vaccine is 0003A and the CPT code for the Moderna vaccine is 0013A. CMS has also authorized payment for the administration of additional doses of the COVID-19 vaccine, which will be reimbursed at $40.

For more information on Medicare COVID-19 codes click here.

For more information on Medicare COVID-19 payments click here.

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HHS Statement on COVID-19 Booster Shots

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On August 18, The Department of Health and Human Services (HHS) released a statement on the Administration’s plan for COVID-19 booster shots for the American people. In the statement, medical experts observed that protection against COVID-19 wanes over time following initial doses of the vaccine, especially in those who are considered high risk or those who were vaccinated during the earlier phases of the vaccination rollout. HHS announced that a booster shot will be necessary to prolong vaccine protection against the virus and will begin offering booster shots this fall based on FDA and CDC evaluation:

“We are prepared to offer booster shots for all Americans beginning the week of September 20 and starting 8 months after an individual’s second dose. At that time, the individuals who were fully vaccinated earliest in the vaccination rollout, including many health care providers, nursing home residents, and other seniors, will likely be eligible for a booster. We would also begin efforts to deliver booster shots directly to residents of long-term care facilities at that time, given the distribution of vaccines to this population early in the vaccine rollout and the continued increased risk that COVID-19 poses to them.”

The statement also highlighted that more data is expected from the Johnson & Johnson (J&J) COVID-19 vaccine in the next few weeks. After data is collected, HHS will inform the public on a plan for the J&J booster shot as well.

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Native American Child Protection Act Now Includes Urban Indian Organizations

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The Senate held a legislative hearing on the NCUIH-endorsed Native American Child Protection Act. The bill includes two updates for UIOs that were advocated for by NCUIH and noted by Heidi Todacheene, Senior Advisor, Office of the Assistant Secretary for Indian Affairs at the Department of the Interior. In her testimony, Ms. Todacheene noted that the bill expands “services to be extended to the urban Indian organizations, and as you know those are critical services to help tribal communities, especially in places where American Indian, Alaskan natives don’t have access to some of the services on reservations.”

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Senators Smith and Cantwell Call on Appropriations Interior Subcommittee Leaders to Support $200.5 Million in Appropriations for UIOs

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On August 10, Senator Smith and Senator Cantwell sent a letter to Senator Merkley and Senator Murkowski, leaders of the Subcommittee on Interior, Environment, and Related Agencies, requesting their support for the $200.5 million for urban Indian health in the FY 2022 Interior, Environment, and Related Agencies Appropriations Act. The letter emphasized the historic underfunding and lack of facilities funding for UIOs, as well as health disparities in AI/AN communities that have been worsened by COVID-19. Senators Smith and Cantwell called the increase in funding a part of fulfilling of the government’s trust responsibility to urban Indians.

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Rep. Smith Advocacy Key to Increased Funding for Urban Indian Health

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On July 13, Congressman Adam Smith’s office published a press release regarding the historic funding increase for urban Indian organizations (UIOs) in the Fiscal Year (FY) 2022 Interior, Environment, and Related Agencies bill and highlighted the significance of UIOs, such as the Seattle Indian Health Board (SIHB), in both Native and non-Native communities. Due to Congressman Smith’s advocacy, the FY22 Interior Appropriations bill, which passed the House Appropriations Committee on July 1, includes $200.5 million for urban Indian health— $137,816,000 above the enacted level.

“Urban Indian organizations, such as the Seattle Indian Health Board (SIHB), play a pivotal role in providing health care for Native and non-Native communities across the country. They have been at the forefront of responding to the COVID-19 pandemic and supporting urban American Indians and Alaska Natives who are often marginalized in the traditional health care system,” said Congressman Smith. “This proposed increase in funding to urban Indian health organizations will strengthen clinics across the country, give them the tools to continue to combat the COVID-19 pandemic, and eliminate disparities and inequities in the health care system. The proposed increase in funding to Tribal Epidemiology Centers, including the Urban Indian Health Institute at SIHB, is long overdue to expand research and disease surveillance to improve health outcomes in American Indian and Alaska Native communities.”

NCUIH applauds Congressman Smith for being a champion of urban Indian health and fighting for equitable access to healthcare for American Indians and Alaska Natives both on and off the reservation.

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2021 Summer Legal Fellows Reflect on Time with NCUIH

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With the end of the summer comes the departure of our 2021 Summer Legal Fellows. With Bryn Whitney-Blum and Hayden Godfrey returning to their respective law schools, we asked them to reflect on their time with NCUIH. Please read their posts below. We wish them all the best as they complete their education!

My name is Bryn Whitney-Blum. I am a second-year law student at the George Washington University Law School, and I have a background in reproductive justice, maternal health, HIV/AIDS health care, and direct services. I applied to NCUIH as a legal fellow because of the unique opportunity to apply my interest in health equity and policymaking to serving urban Indian communities. The chance to advocate for a range of health care priorities within the framework of Indigenous sovereignty and justice set NCUIH apart from other internships, and I looked forward to applying my first year of legal education to congressional and federal policy.

At NCUIH, I learned about the incredible importance of persistent communication and advocacy in fulfilling the federal government’s trust responsibility to urban Indians. NCUIH’s policy team is full of powerhouse advocates, and after spending my summer working with this team I completely understand how NCUIH’s work has led to millions in federal funding and legislative support for UIOs. As a policy fellow, I researched and drafted comments to federal agencies, tracked legislation and policy, attended urban confer and Tribal consultations, and even got to meet with Department of Justice officials to follow up on comments I had submitted on Missing and Murdered Indigenous Persons. At this fellowship, I translated the skills and principles I gained from law school to substantive policy advocacy, and my experience at NCUIH has added meaning and motivation to my professional path as a public interest lawyer. I am so grateful to Sunny, Julia, Meredith, Sam, Al, Elaina, Jenna, Mary, and Francys for sharing their knowledge and passion with me, and I look forward to seeing all they will continue to achieve for urban Indian health.

Osiyo nigada! My name is Hayden Godfrey and I am a second-year law student at the University of Arizona James E. Rogers College of Law. I am Tsalagi and a federally enrolled citizen of the Cherokee Nation of Oklahoma. At Arizona Law, I am pursuing certification as a subject matter expert through our Indigenous Peoples Law and Policy program. I am also the President of the Arizona Law Chapter of the Native American Law Students Association (NALSA). The issues of sovereignty that impact our Tribal Nations are among the most critical issues that we face in Indian Country. Factors outside of our communities that seek to diminish our inherent nationhood threaten our very ways of life, preventing us from impactfully policing our communities, from protecting our friends and relatives from abduction or murder, and from attending to the health care needs of our Tribal members, among countless issues that arise out of broken trust obligations.

Through interviewing to become a Law Fellow with NCUIH, I felt that I would have an opportunity to devote the skills that I have honed through my legal studies to practically advocate for my Tribe and all others in our battles to improve the material conditions that we all suffer as the result of hundreds of years of genocidal Federal policy toward Indigenous people. Our fight for self-determination cannot reach its full potential until we have an Indigenous population that does not have to account for these historical traumas in our movement. NCUIH’s mission, being the only such organization that serves the 70 percent of AI/AN people who reside in urban areas, myself included in that statistic as an urban Indian, fell ideally into my desires to fulfill the needs of my own demographic so that we can be a stronger political force in the future. Our sovereignty and our means for protecting our own populations arise out of our political relationship with Congress, which is why it is more imperative now than ever to stand up for our political rights.

I spent Summer 2021 employed with NCUIH, where I worked with the policy team to address issues in federal Indian policy as they arose in legislation and regulation at the agency level. As a Summer Law Fellow with NCUIH, I spent my time drafting comments for regulatory agencies on regulations involving Urban Indian Organizations (UIOs), tracking and editing acts of legislation that impact Indian health, performing substantive legal and policy research on Medicaid reimbursement rates for Indian health providers, and other policy-related tasks involving Tribal communities or culturally sensitive questions. My background as an American Indian and citizen of my Tribe ultimately permitted me to answer sensitive questions that arose in a thoughtful manner that incorporated my own Indigenous understanding of the subject matter. In law school, I learned to formulate air-tight legal arguments, while at NCUIH, I learned to be an advocate for all Indigenous people in the United States. Without my experiences this summer at NCUIH, I would not have the same capacity to bring the professional skills that I have cultivated into my future in Indian policy and activism.

I will always carry the memories from this summer at NCUIH with me as I stride into the future. I have learned so much in such a short amount of time. I would like to thank Julia, Meredith, Sunny, and Francys for all that they have imparted during this all-too-short experience. They have been genuinely exemplary in their professionalism and zeal in their advocacy for communities much like my own. The passion and the drive that they bring into their activism will always remain with me in my own activism for the vulnerable communities whom we serve. I would accordingly like to express my gratitude for the privilege of serving Tribal communities this summer in our fight for equity, because I will derive my momentum from the passion that I have witnessed in you all. Wado.

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PRESS RELEASE: Bipartisan Padilla-Moran-Lankford NCUIH Amendment for Urban Indian Health Passes Senate

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The technical fix will be critical to improving health infrastructure for off-reservation American Indians and Alaska Natives.

FOR IMMEDIATE RELEASE – 8.2.21

Media Contact: National Council of Urban Indian HealthMeredith Raimondi, Director of Congressional Relations MRaimondi@ncuih.org 202-417-7781

Washington, D.C. (August 2, 2021) – On Monday, the Senate voted on amendments to the bipartisan infrastructure package including the Padilla-Moran-Lankford Urban Indian Health Amendment, which passed 90-7. The National Council of Urban Indian Health (NCUIH) has worked closely on a bipartisan basis for the past year on this technical legislative fix to support health care for tribal members who reside off of reservations. This amendment would allow existing resources to be used to fund infrastructure projects within the Indian health system.

“We applaud Senators Padilla, Moran, Lankford, Rounds, Smith, Feinstein, Schatz, and Schumer for their steadfast and tireless leadership on behalf of Indian Country. This technical fix will be critical to expanding health care infrastructure for Native communities who have been devastated by the COVID-19 pandemic. We also thank the National Congress of American Indians for their partnership in advocating for improved outcomes for all of Indian Country,” said Francys Crevier (Algonquin), CEO of NCUIH.

Next Steps

The Senate will continue to debate amendments to the bipartisan infrastructure plan. In the meantime, NCUIH will continue to advocate for $21 billion for Indian health infrastructure in the budget reconciliation package from the a joint letter led by the National Congress of American Indians (NCAI) on April 13, 2021.

Background

“Urban Indian Organizations (UIOs) are a lifeline to Native Americans living in urban areas across California,” said Senator Alex Padilla (D-CA). “Yet, UIOs are prohibited from using Indian Health Service funding for facilities, maintenance, equipment, and other necessary construction upgrades. During the pandemic, many UIOs couldn’t get approval for ventilation upgrades, heaters, generators, and weatherization equipment. Removing this unjust burden on UIOs is a commonsense fix and would allow them to improve the quality of the culturally competent care that they provide.”

“Oklahoma has the second-largest Urban Indian patient population and is proudly served in both Tulsa and Oklahoma City clinics. We should continue to improve health care access for our Urban Indian population and broaden the flexibility for Urban Indian Organizations’ use of facilities renovation dollars, in addition to those for accreditation, to meet patient needs,” said Senator James Lankford (R-OK).

“The impacts of COVID-19 will be with our Native communities for a long time to come. It is critical that the Indian Health Care Center of Santa Clara Valley and other UIOs be able to provide a safe environment for the families and patients we serve. We are extremely grateful for Senator Padilla’s leadership in rectifying a longstanding barrier preventing us from using existing funding to make urgent upgrades,” said Sonya Tetnowski (Makah), CEO of Indian Health Care Center of Santa Clara Valley, President of California Consortium for Urban Indian Health (CCUIH), and President-elect of NCUIH.

“It is time to live out this Country’s commitment to each other to live with respect for one another and in community. With this legislation, Friendship House in San Francisco will build a home village site for our urban Native Americans, so that our people may contribute to saving and enriching our homeland, which we must now all share and care for or lose. We greatly appreciate Senator Padilla’s leadership on this issue,” said Abby Abinanti (Yurok), President of the Friendship House Association of American Indians Board of Directors.

UIOs lack access to facilities funding under the general IHS budgetary scheme, meaning there is no specifically allocated funding for UIO facilities, maintenance, sanitation, or medical equipment, among other imperative facility needs. While the whole IHS system has made the transition to telehealth, negative pressurizing rooms, and other facility renovations to safely serve patients during the pandemic, restrictions in the relevant statutory text did not allow UIOs to make those transitions. Section 509 currently permits the IHS to provide UIOs with funding for minor renovations and only in order to assist UIOs in meeting or maintaining compliance with the accreditation standards set forth by The Joint Commission (TJC).

These restrictions on facilities funding under Section 509 have ultimately prevented UIO facilities from obtaining the funds necessary to improve the safety and quality of care provided to American Indian/Alaska Native (AI/AN) persons in urban settings. Without such facilities funding, UIOs are forced to draw from limited funding pools, from which they must also derive their limited funding for AI/AN patient services. This lack of facility funding for UIOs is a breach of the federal trust obligation to AI/AN health care beneficiaries, necessitating congressional action to include UIOs in future legislative measures for IHS facility funding.

In May, Congressman Ruben Gallego (D-AZ) and Congressman Don Bacon (R-NE) introduced the Urban Indian Health Facilities Provider Act (H.R. 3496) in the House of Representatives which expands the use of existing IHS resources under Section 509 of the Indian Health Care Improvement Act (IHCIA) (25 U.S.C. § 1659) to increase the funding authority for renovating, constructing, and expanding Urban Indian Organizations (UIO). Senators Alex Padilla (D-CA), James Lankford (R-OK) along with co-sponsors Moran (R-KS), Feinstein (D-CA), and Smith (D-MN) on the Senate Indian Affairs Committee introduced the identical Senate bill (S. 1797).

Last month, NCUIH testified before the House Natural Resources Subcommittee for Indigenous Peoples of the United States (SCIP) and the Senate Committee on Indian Affairs (SCIA) in support of the Urban Indian Health Facilities Provider Act (H.R. 3496 / S. 1797). Sonya Tetnowski (Makah Tribe), NCUIH President-Elect and Chief Executive Officer of the Indian Health Center of Santa Clara Valley, testified before SCIP and Robyn Sunday-Allen (Cherokee), NCUIH Vice President and CEO of the Oklahoma City Indian Clinic, testified before SCIA.

This fix is broadly supported in Indian Country and the National Congress of American Indians passed a resolution in June to “Call for Congress to Amend Section 509 of the Indian Health Care Improvement Act (IHCIA) to Remove Facility Funding Barriers for Urban Indian Organizations”.

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Revealing Vulnerability to COVID-19 in Urban American Indian and Alaska Native Communities

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Urban Native communities exist and thrive across this country, with 38 areas served by an Urban Indian Organization (UIO). These UIOs have been an indispensable source of culturally competent care to these communities during the COVID-19 pandemic as you can see in our previous post: Visualizing COVID-19: A Year in Urban Indian Organization Service Areas.

However, a lack of COVID-19 statistics continue to obscure the full burden that UIOs wrestle with. We know that cities are affected by COVID-19, but how are AI/AN communities affected within these cities?  A single count of cases across a county assumes that the extent of the pandemic is uniform within the county, but we know that’s not the case.  Especially in urban areas, neighborhoods and communities wildly vary in terms of resources, systemic deprivation, and the ability to resist natural disasters such as a pandemic.  

Resilience and vulnerability to natural disasters can be illustrated using the Social Vulnerability Index (SVI), a metric developed by the CDC and the Agency of Toxic Substances and Disease Registry. The SVI has been utilized for research in racial and geographic disparities in COVID-19 response, such as in Alabama, Los Angeles, and Louisiana and has also been used as a reference resource by public health departments. Research has shown that historically marginalized communities tend to live in areas of higher vulnerability, and areas of high SVI also have seen the most COVID-19 cases and deaths. Put together, this means that the full extent of the COVID-19 pandemic for the Urban AI/AN populations is not reflected in public county-level COVID-19 statistics. 

IS EVERYONE EQUALLY VULNERABLE WITHIN A CITY? 

Public health statisticians too often overlook urban AI/AN communities . And while AI/AN communities are often proportionately small when compared to the total population of the cities in which they live, great lessons can be learned from including them in analysis. AI/AN people do not live in an evenly dispersed pattern in most cities.  In fact, in many cities, they live concentrated in areas of disproportionately high social vulnerability, compared to the white population in the same city. This makes the presence of UIOs even more crucial, as they deliver life-saving services to areas of the highest need.

Urban AI/AN populations are more clustered in higher SVI census tracts than the white population in 30 out of 38 UIO service areas.  Further, in tracts that are extremely vulnerable – defined here as the top 10% most vulnerable tracts nationally – the concentration of AI/AN people is at least twice that of the local white population in 18 service areas.   

In the link below you will find an interactive map showing all 38 UIO service areas with information about the COVID-19 pandemic, the Urban AI/AN population, and the social vulnerability in each city. You can navigate this map by clicking on the black outline of any service areas to zoom in on summary statistics. Each map and chart can be magnified further by clicking on it. You can return to the main map by moving your cursor to the far right and clicking the home button or return to the prior page by clicking the arrow. You will also see a button on the main map with a glossary showing explaining all our methods and data sources used for this analysis.  Images may take a few moments to load. 

Clicking on a service area, the tool shows

  1. The county’s COVID-19 case and death count, illustrating that available COVID-19 statistics are coarse and uninformative for an urban setting.
  2. The urban AI/AN population is not equally spread across the service area. 
  3. Service areas and the neighborhoods within them vary in their level of vulnerability.  In many service areas the AI/AN population is more concentrated in areas that are more vulnerable to COVID-19.

These three points are illustrated in the red, green, and blue maps on each of the service area info-cards.

After selecting a service area, click the “SVI Graphics” button on the lower right and you will be navigated to statistics and visualizations about the relationship between SVI and service areas AI/AN population. Nearly all service areas show that more of the urban AI/AN population live in the most vulnerable tracts in their cities (Figure D).  Equally, in many UIO service areas, fewer AI/AN people live in the most resilient areas compared to the white population, forming a downwards-sloping distribution curve (Figure E).  In the most vulnerable areas, the ratio of AI/AN population to the same city’s white population is often high, representing the disproportionate vulnerability to disasters such as the pandemic (Figure F).

As an example of reading the figures and statistics, let us look at the Minneapolis/Saint Paul service area. As of April 14th, 2021, the area had 161,171 COVID-19 cases and 2,522 COVID-19 deaths cumulatively since the start of data collection (Figure A). These statistics are reported at the county level for Hennepin and Ramsey counties. But the Urban AI/AN community is not equally distributed across these counties (Figure B).  The Twin cities are wildly unequal in terms of community resources. Census tracts in the Minneapolis/Saint Paul service area range from among the most resilient in the country to the top 1% most vulnerable in the country.  The Urban AI/AN population tends to live in the more vulnerable tracts in this city (Figure C). Clicking on the “SVI Graphics” button will take you to an analysis showing the association between AI/AN-race and SVI in the Twin Cities. In this Metropolitan area there are 51 tracts that are in the top 10% most vulnerable in the nation. 21.7% of the local urban AI/AN population live in these most vulnerable tracts. Meanwhile only 4.5% of the city’s white population lives in those vulnerable tracts (Figure D). Figure E groups the census tracts into blocks of five, each approximately 1% of the service area, and orders them by their vulnerability. It then plots the percentage of the white and AI/AN populations that live in these tracts. You can see along the entire continuum of vulnerability in the Twin Cities, the AI/AN population is more likely to live in high-SVI neighborhoods and less likely to live in low-SVI areas than the white population.  Figure F shows the magnitude of this problem by measuring the ratio the concentration of AI/AN and white residents in areas of differing SVI. At some points (the 50 most vulnerable tracts) the AI/AN population is more than five times as concentrated in these areas than the white population.  Taken as a whole, these figures act as a corrective to county-level data, revealing a level of vulnerability to the virus that is not reflected in COVID-19 statistics. 

CONCLUSIONS 

In many urban areas, AI/AN people face additional vulnerability to the pandemic (and other disasters) simply because of where they live.  This compounds with the other challenges we know they face.  Explore the interactive map in other areas to see that this relationship holds across the country.  Relying on one county-level number for cases and deaths during to the pandemic effectively masks the vulnerabilities that AI/AN community’s face within those counties.  

Yet, due to a lack of accurate racial data on cases and deaths, county-level data is often the only thing key stakeholders see. It is more important than ever to push for accurate and reliable statistics for COVID-19 cases and deaths, particularly for racial minorities.  Efforts have already been made to collect and publish better statistics showing racial breakdown of COVID-19 cases and deaths.  Urban AI/AN communities need to ensure that they too are being counted.  Ensuring that more specific geographic and racial COVID-19 data is in the hands of those who rightfully own and can effectively utilize it is crucial to alleviate the burden faced by Urban AI/AN people.  As we have shown, even a proportionally “small population” can face a massively disproportionate burden in their home cities. This problem should be revealed and treated as a priority.  

By Alexander Zeymo & Andrew Kalweit, posted on Monday August 2, 2021

This post is supported by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award (NOFO OT18-1802, titled Strengthen Public Health Systems and Services through National Partnerships to Improve and Protect the Nation’s Health) funded by CDC/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS, or the U.S. Government.

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