IHS Initiates Listening Sessions for Tribal and Urban Indian Organization Leaders on Advance Appropriations Implementation

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On August 8, 2023, the Indian Health Service (IHS) sent a Dear Tribal Leader and Urban Indian Organization (UIO) Leader letter inviting Tribal and UIO leaders to participate in Agency-sponsored Listening Sessions to share information and solicit input on advance appropriations implementation. IHS will host two (2) identical Listening Sessions for Tribes and UIOs on August 17, 2023, and September 6, 2023. During the Listening Sessions, IHS will share additional information on implementation plans and strategies for advance appropriations, and seek Tribal and UIO input. The information discussed in these sessions will be used to prepare public-facing Frequently Asked Questions and other helpful materials.

Since advance appropriations was included in the final FY 2023 spending bill, the National Council of Urban Indian Health (NCUIH) has consistently requested that IHS host a Tribal Consultation and Urban Confer to ensure Tribes and UIOs are briefed on the implementation process and prepared for fund distribution. NCUIH recently met with IHS Director Roselyn Tso and emphasized the importance of hosting an Urban Confer before October 1, 2023. We look forward to continuing to engage with IHS to ensure successful implementation of advance appropriations for the whole IHS, Tribal, and UIO system.

The Advance Appropriations Implementation Listening Sessions will be on Thursday, August 17, 2023, 12:00-1:30 p.m., ET and Wednesday, September 6, 2023, 3:00-4:30 p.m., ET.

    • Click here to join the Thursday, August 17 Listening Session
    • Click here to join the Wednesday, September 6 Listening Session

Background on IHS Advance Appropriations

The FY 2023 Consolidated Appropriations Act (Public Law 117-328) included a total of $5.1 billion in FY 2024 advance appropriations for the Indian Health Service, including the urban Indian health line item. The full year funding level will be available for programs on Oct. 1, 2023, regardless of whether Congress enacts a continuing resolution or full year bill. Advance appropriations provide long overdue funding stability and predictability for the IHS. Congress will determine a final appropriations level for the IHS in the FY 2024 appropriations process and has the ability to significantly increase the IHS budget, in-line with the recommendations of the National Tribal Budget Formulation Workgroup, through additional discretionary appropriations.

NCUIH Advocacy

After tireless advocacy from the National Council of Urban Indian Health (NCUIH) and our partners across Indian Country, Congress included advance appropriations for IHS in the FY 2023 final spending bill to provide stable funding for FY 2024. The current advanced appropriation expires in FY 2025, and NCUIH is continuing its advocacy to secure advanced appropriations for IHS for future years. NCUIH endorsed the bipartisan, bicameral Indian Program Advance Appropriations Act (H.R.4832/S.2424) which was reintroduced by Sen. Lujan (D-NM), Sen. Mullin (R-OK), Rep. McCollum (D-MN-04), and Rep. Cole (R-OK-04) on July 24, 2023. This bill would authorize advance appropriations for several accounts under the Bureau of Indian Affairs and Bureau of Indian Education within the Department of Interior and IHS within the Department of Health and Human Services.

NCUIH has been advocating that advance appropriations be maintained for IHS until mandatory funding is achieved. On March 9, 2023, NCUIH CEO Francys Crevier (Algonquin), testified before and submitted public witness written testimony to the House Appropriations Subcommittee on Interior, Environment, and Related Agencies regarding FY 2024 funding and requested that advance appropriations for IHS be maintained. NCUIH also worked closely with Representatives Gallego and Grijalva on leading a Congressional letter to the House Committee on Appropriations for FY 2024, urging to maintain advance appropriations for IHS until such time that authorizers move IHS to mandatory spending. On April 4, 2023, a group of 12 Senators sent a letter to the Senate Interior Appropriations Committee with the same requests. Due to this advocacy, advance appropriations for IHS was maintained for FY 2025 in both the House and Senate Interior Appropriations proposed FY 2024 spending bills.

NCUIH Requests IHS Support Interoperability, Reimbursement for Health IT Modernization

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On June 9, 2023, the National Council of Urban Indian Health (NCUIH) submitted comments to the Indian Health Service (IHS) on Health Information Technology (HIT) Modernization in response to the February 6, 2023 joint Dear Tribal Leader and Urban Indian Organization Leader letter and the May 5, 2023 Tribal Consultation and Urban Confer on IHS HIT Modernization Resources. In its comments, NCUIH incorporates previous comments to IHS regarding the HIT modernization and Resource and Patient Management System (RPMS) replacement and again notes that the inclusion of urban Indian Organizations (UIOs) in the HIT Modernization process is consistent with, and required by, the federal government’s trust responsibility and the Indian Health Care Improvement Act and is also sound public health policy. 

Recommendations 

In its comments, NCUIH made the following specific requests, and recommendations to IHS: 

  • Incorporate necessary new capabilities in the modernized Electronic Health Record (EHR) solution. 
    • Ensure that the new EHR contains the full suite of EHR Capabilities. 
    • Supports the unique interoperability needs of UIOs by ensuring that the modernized EHR is either a complete EHR or a modular EHR that a UIO will be able to upgrade as it creates demand for new capabilities. 
  • Develop a timeline for IHS, Tribal, and UIO (I/T/U) facilities to use as a planning base to prepare for the transition to a new system and develop uniform training packages to assist I/T/U facilities in training their staff members on the new EHR. 
  • Take all necessary and practicable steps to secure funding for direct reimbursement of Tribal and UIO facilities for the cost of commercial off-the-shelf (COTS) EHR systems.

Background on NCUIH Work on IHS Health IT Modernization 

NCUIH has submitted several written comments to IHS on HIT Modernization. NCUIH also submitted written testimony to the House Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies regarding the Fiscal year (FY) 2024 funding for UIOs in which NCUIH requested increased funding for EHR Modernization. Specifically, NCUIH requested support for the IHS’ transition to a new EHR system for IHS and UIOs by supporting the President’s budget request of $913 million in FY 2024 appropriations. 

IHS Outlines Strategic Goals including Rapid Disbursement of Funds, for FY 2024 Advance Appropriations Implementation

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On July 19, 2023, the Indian Health Service (IHS) sent a Dear Tribal Leader and Urban Indian Organization Leader letter providing an update on the status of implementing the Fiscal Year (FY) 2024 advance appropriations provided to the IHS. To ensure the successful implementation of advance appropriations, the IHS has identified three strategic goals. Goal 1 aims to distribute FY 2024 advance appropriations for IHS, Tribal, and Urban Indian health programs as close as possible on or after October 1, 2023. Goal 2 aims to ensure regular engagement with Tribal Leaders, Urban Indian Organization (UIO) Leaders, and Congress so that all relevant stakeholders have a clear understanding of the Agency’s progress. Goal 3 aims to demonstrate the impact of advance appropriations to demonstrate the positive impacts.

IHS Strategic Goals for Advance Appropriations

The IHS’s first goal in implementing advance appropriations is to distribute the funds as soon as possible after October 1, 2023. To date, to achieve this goal, the IHS has taken the following steps:

  • Updating existing budget execution systems and internal timelines to allow funds to be distributed as quickly as possible. The IHS has confirmed that all financial systems will support the rapid distribution of funds.
  • Ensuring apportionments, which authorize the expenditure of funds, are prepared and approved timely by the IHS for submission to the Department of Health and Human Services (HHS) and Office of Management and Budget (OMB);
  • Partnering with all IHS Headquarters and Area Office staff involved in payments to Tribal Organizations and UIOs to ensure an effective process; and
  • Upon the enactment of a full year bill, the IHS will distribute any additional funds enacted by Congress as soon as possible after the passage of the bill.

The IHS’s second goal in implementing advance appropriations is to ensure regular outreach and engagement with Tribal Leaders, UIO Leaders, and Congress, so that all relevant stakeholders have a clear understanding of the Agency’s progress. To achieve this goal, the IHS is:

  • Making useful information about advance appropriations implementation available on the IHS Web site; 􀁸 Briefing Tribal Leaders and Urban Indian Organization Leaders on implementation progress during scheduled meetings and/or engagements. Conducting listening sessions, or Tribal Consultation and Urban Confer; and
  • Providing updates to Congress on the IHS’s progress toward implementation.

The IHS’s third goal in implementing advance appropriations is to demonstrate the positive impacts of advance appropriations, including:

  • Partnering with health programs operated by the IHS, Tribes, and UIOs to identify metrics for success, including success stories. The IHS is developing a plan to engage IHS, Tribal, and Urban Indian health programs on an ongoing basis to seek your input on how advance appropriations have improved your ability to provide high-quality health care services.
  • The IHS will complete an evaluation to assess the implementation, impact, and customer service satisfaction regarding the execution of advance appropriations.

Background on IHS Advance Appropriations

In FY 2023, the IHS received the first ever advance appropriation for the FY 2024 Budget. The FY 2023 Consolidated Appropriations Act (Public Law 117-328) included a total of $5.1 billion in FY 2024 advance appropriations for the Indian Health Service, which includes funding at the same level as FY 2023 enacted for nearly all IHS programs. The full year funding level will be available for these programs on Oct. 1, 2023, regardless of whether Congress enacts a continuing resolution or full year bill. Advance appropriations provide long overdue funding stability and predictability for the IHS.

NCUIH Advocacy

After tireless advocacy from the National Council of Urban Indian Health (NCUIH) and across Indian Country, advance appropriations for IHS was included in the FY 2023 final spending bill to provide stable funding for FY 2024. The current advanced appropriation expires in FY 2025, and NCUIH is continuing its advocacy to secure funding for IHS for future years. NCUIH endorsed the bipartisan, bicameral Indian Program Advance Appropriations Act (H.R.4832/S.2424) which was reintroduced by Sen. Lujan (D-NM), Sen. Mullin (R-OK), Rep. McCollum (D-MN-04), and Rep. Cole (R-OK-04) on July 24, 2023. This bill would authorize advance appropriations for several accounts under the Bureau of Indian Affairs and Bureau of Indian Education within the Department of Interior and IHS within the Department of Health and Human Services.

For FY 2024, NCUIH has been advocating that advance appropriations be maintained for IHS until mandatory funding is achieved. On March 9, 2023, NCUIH CEO Francys Crevier (Algonquin), testified before and submitted public witness written testimony to the House Appropriations Subcommittee on Interior, Environment, and Related Agencies regarding FY 2024 funding and requested that advance appropriations for IHS be maintained. NCUIH also worked closely with Representatives Gallego and Grijalva on leading a Congressional letter to the House Committee on Appropriations for FY 2024, urging to maintain advance appropriations for IHS until such time that authorizers move IHS to mandatory spending. On April 4, 2023, a group of 12 Senators sent a letter to the Senate Interior Appropriations Committee with the same requests. Due to this advocacy, advance appropriations for IHS was maintained for FY 2025 in both the House and Senate Interior Appropriations proposed FY 2024 spending bills.

Next Steps

NCUIH continues to engage with IHS to ensure the successful implementation of advance appropriations for the whole IHS, Tribal organization, and UIO system. NCUIH encourages IHS to host an Urban Confer before October 1, 2023, to ensure UIOs are briefed on the implementation process and are prepared for fund distribution.

NCUIH Submits Comments to CMS with Recommendations on Native American Access to Medicaid Services

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On July 3, 2023, the National Council of Urban Indian Health (NCUIH) submitted written comments and recommendations to the Centers for Medicare and Medicaid Services (CMS) Administrator, Chiquita Brooks-LaSure, in response to the May 2, 2023, request for comment on the CMS proposed rule regarding ensuring access to Medicaid services (CMS–2442–P).  NCUIH urged CMS to specifically consider how the proposed sections will advance the Nation’s efforts to fulfill its trust responsibility to provide services to maintain and improve the health of American Indians and Alaska Natives (AI/ANs).

NCUIH recommended that CMS take the following actions:

In its comments, NCUIH recommended that CMS ensure AI/AN representation on each state Medicaid Advisory Committee (MAC) and Beneficiary Advisory Group (BAG), ensure the rule does not impose additional burdensome reporting requirements on providers, engage with the Tribal Technical Advisory Committee (TTAG) to consider regulations or guidance to enforce the state consultation and confer requirements, and support 100% Federal Medical Assistance Percentage (FMAP) for Medicaid services provided at urban Indian organizations (UIOs) to ensure AI/AN Medicaid beneficiaries receive appropriate, quality culturally competent care. By extending this funding mechanism to cover all Medicaid services provided at UIOs, CMS can make substantial progress in reducing the existing barriers to healthcare access faced by urban Native populations.

Background on the Proposed Rule Ensuring Access to Medicaid Services (CMS–2442–P):

The proposed rule, Ensuring Access to Medicaid Services, includes both proposed changes to current requirements and newly proposed requirements that would advance CMS’s efforts to improve access to care, quality, and health outcomes, and better promote health equity for Medicaid beneficiaries across fee-for-service (FFS) and managed care delivery systems, including for home and community-based services provided through those delivery systems. These proposed requirements are intended to increase transparency and accountability, standardize data and monitoring, and create opportunities for states to promote active beneficiary engagement in their Medicaid programs.

Background on Medicaid and AI/ANs:

AI/AN people depend upon Medicaid to receive their healthcare coverage and services. In 2020, over 1.8 million AI/ANs were enrolled in Medicaid. According to a NCUIH analysis of American Community Survey (ACS) data, in 2019 Medicaid covered 1.3 million urban AI/ANs, including 30% of urban AI/AN adults under the age of 65. Medicaid and CHIP are important programs for addressing the significant disparities in insurance coverage which exist for AI/AN people.  For example, according to the Urban Institute, AI/AN children were uninsured at a rate of 8.9% in 2019, the highest rate for any ethnic group in the country.  AI/AN parents were uninsured at a rate of 18.7% in 2019, the second highest rate in the country. The Urban Institute reported that in 2019, AI/AN children remained more than twice as likely as white children to be uninsured and AI/AN were more than 2.5 times more likely to be uninsured than with white parents.

Medicaid is also an important source of funding for to support the operation of the Indian Health system, including UIOs who help serve the approximately 70% of AI/AN people who live in urban areas.  Medicaid remains the largest secondary source of funding for UIO clinics. In 2020, 33% of the total population served at UIOs were Medicaid beneficiaries, and 35% of the AI/AN population served at UIOs were Medicaid beneficiaries. As the Kaiser Family Foundation noted in 2017, “Medicaid funds are not subject to annual appropriation limits . . . since Medicaid claims are processed throughout the year, facilities receive Medicaid funding on an ongoing basis for covered services provided to AIANs.”  Because the Medicaid program receives Mandatory appropriations, Medicaid revenue is particularly essential for Indian health providers when IHS funding is reduced or interrupted by budgetary disagreements.

NCUIH Endorses Bipartisan, Bicameral Bill To Secure Advance Appropriations For Critical Indian Country Programs

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On July 24, 2023, Senators Lujan (D-NM) and Mullin (R-OK) and Representatives McCollum (D-MN-04) and Cole (R-OK-04) reintroduced the bipartisan, bicameral Indian Program Advance Appropriations Act (H.R.4832/S.2424). The bill would authorize advance appropriations for several accounts under the Bureau of Indian Affairs and Bureau of Indian Education within the Department of Interior and the Indian Health Service (IHS) within the Department of Health and Human Services. The bill would specifically provide advance appropriations for IHS, Contract Support Costs, Payments for Tribal Leases, Indian Health Facilities, Operation of Indian Programs, Operation of Indian Education, and several other critical Indian Services accounts.  The bill is sponsored by twenty-three Democrats and four Republicans. The bill has been endorsed by the National Congress of American Indians, the National Indian Health Board, and the National Council of Urban Indian Health (NCUIH).

“The National Council of Urban Indian Health is pleased to endorse the Indian Programs Advance Appropriations Act from Senators Lujan, Mullin and Congresswoman McCollum and Congressman Cole. This legislation is simple and essential. It would enable Congress to appropriate funding for the Indian Health Service, the Bureau of Indian Affairs, and the Bureau of Indian Education one year in advance- ensuring timely and sustained funding for essential programs and services that are vital to the well-being and prosperity of Native communities. The Act demonstrates a commitment to transparency and accountability, ultimately empowering our communities to thrive. I urge Congress to swiftly pass this bill, a significant step forward in supporting Native American health and education initiatives.” – Francys Crevier (Algonquin), CEO, NCUIH.

Next Steps

The bill was referred to the Senate Committee on Indian Affairs and the House Natural Resources Committee. The bill has been added to the NCUIH bill tracker and can be found here.

Background

After tireless advocacy across Indian Country, advance appropriations for IHS were included in the fiscal year (FY) 2023 final spending bill to provide stable funding for FY 2024. On July 19, 2023, the House Appropriations Committee released their FY 2024 Interior, Environment, and Related Agencies Appropriations Bill – maintaining advance appropriations for FY 2023 at $5.878 billion. Despite the victory in the final FY23 spending bill for IHS, other critical Indian country programs were not included in advance appropriations. It is paramount that all critical programs receive advance appropriations to ensure all American Indians and Alaska Natives have continuous access to the essential services many rely on.

Senate Interior Appropriations Bill Passes out of Committee with Advance Appropriations and a Modest Increase for the Indian Health Service

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The bill includes $7.27 billion for IHS, $2.6 billion less than the amount requested by the President.

On July 27, 2023, the Senate Appropriations Committee completed the markup of the Fiscal Year (FY) 24 Interior, Environment, and Related Agencies bill. The bill passed out of committee with a vote of 28-0 and will advance to the Senate floor for initial passage. The bill authorizes $7.27 billion for IHS— an increase of $218.6 million from FY23 but $2.68 billion below the President’s request. The FY24 budget also includes $92.4 million for Urban Indian health, which is $2 million above the FY23 enacted levels but $22.7 million under the House recommended amount and President Biden’s Request. Advance appropriations for IHS was maintained for FY25 and received an increase to $5.22 billion from $5.12 billion for FY24. Other key provisions include: $8 million to improve maternal health and $2.5 million for the Produce Prescription Pilot Program for Tribes and urban Indian organizations (UIOs) to increase access to produce and other traditional foods. A more detailed analysis follows below.

During the Full Appropriations Committee hearing, Chair of the Committee, Senator Patty Murray (D-WA) expressed the importance of protecting the Indian Health Service, “This bill plays a critical role in making sure we keep our promises to Tribes and deliver on key federal investments by sustaining funding for the Indian Health Service and providing new resources to support Tribal families, protect Tribal treaty rights, and more.” 


Line Item		 FY23 Enacted FY24 TBFWG Request FY24
President’s
Budget		 FY24 House Proposed FY24 Senate Proposed
Urban Indian Health $90,419,000 $973,590,000 $115,150,000 $115,150,000 $92,419,000
Indian Health Service $6,958,223,000 $50,996,276,000 $9,700,000,000 $7,078,223,000 $7,275,531,000
Advance Appropriations $5,129,458,00 Request is to expand advance appropriations to include all IHS accounts $5,129,458,00 $5,878,223,000 $5,228,112,000

Establishment of a UIO Interagency Workgroup

The bill also includes direction for IHS to establish a UIO Interagency Workgroup. The bill report reads, “Despite the excellent efforts of Urban Indian Organizations, AI/AN populations continue to be left out of many Federal initiatives. Therefore, the Committee directs the Indian Health Service to continue to explore the formation of an interagency working group to identify existing Federal funding supporting Urban Indian Organizations [UIOs] and determine where increases are needed, where funding is lacking, or what programs should be amended to allow for greater access by UIOs; to develop a Federal funding strategy to build out and coordinate the infrastructure necessary to pilot and scale innovative programs that address the needs and aspirations of urban AI/ANs in a holistic manner; develop a wellness centered framework to inform health services; and meet quarterly with UIOs to address other relevant issues. In addition to the Indian Health Service, the working group should consist of the U.S. Department of Health and Human Services, U.S. Department of Housing and Urban Development, U.S. Department of Agriculture, U.S. Department of Justice, U.S. Department of Education, U.S. Department of Veteran Affairs, U.S. Department of Labor, the Small Business Administration, the Economic Development Agency, FEMA, the U.S. Conference of Mayors, and others as identified by UIOs.”

The National Council of Urban Indian Health (NCUIH) has advocated for the creation of the UIO Interagency Workgroup as a key step to increasing support and resources to American Indians and Alaska Natives (AI/ANs) living in urban areas. On September 12, 2022, NCUIH submitted comments and recommendations to IHS regarding the formation of an Urban Interagency Workgroup with other federal agencies. The agency held an Urban Confer on July 13, 2022, in response to a letter sent to President Biden and Vice President Harris from several Senators, requesting the formation of such a workgroup. NCUIH will continue to work with House and Senate appropriators to ensure this language is included in the final appropriations bill.

Background and Advocacy

On March 9, 2023, President Biden released his budget request for FY24 which included $9.7 billion for IHS and proposed mandatory funding for IHS from FY 2025 to FY 2033 to the amount of $288 billion over-ten years as well as exempting IHS from sequestration. This mandatory formula would culminate in $44 billion for IHS in FY 2033, to account for inflation, staffing increases, long-COVID treatment, and construction costs. This move from discretionary to mandatory funding is essential as noted in the IHS Congressional Justification, “While the progress achieved through the enactment of advance appropriations will have a lasting impact on Indian Country, funding growth beyond what can be accomplished through discretionary spending is needed to fulfill the federal government’s commitments to Indian Country.” On March 17, 2023, IHS published their Fiscal Year (FY) 2024 Congressional Justification with the full details of the President’s Budget, which includes $115 million for urban Indian health – a 27% increase above the FY 2023 enacted amount of $90.42 million.

On July 18, 2023, the House of Representatives Appropriations Committee advanced the FY24 Interior Appropriations bill with $7.079 billion for IHS, an increase in FY25 advance appropriations for IHS to $5.8 billion, and $115.15 million for urban Indian health.

Full Funding, Maintain Advance Appropriations, and Mandatory Funding as Priorities

NCUIH requested full funding for urban Indian health for FY 2024 at $973.59 million for urban Indian Health in FY24 in accordance with the Tribal Budget Formulation Workgroup (TBFWG) recommendations. NCUIH also requested that advance appropriations be maintained for the Indian Health Service (IHS) until mandatory funding is achieved. The marked increase for FY24 is a result of Tribal leaders, over several decades, providing budget recommendations to phase in funding increases over 10-12 years to address growing health disparities that have largely been ignored.

On April 4, 2023, a group of 12 Senators sent a letter to the Senate Interior Appropriations Committee. The letter has bipartisan support and calls for support for Urban Indian Health based on the TBFWG’s recommendation and to maintain advance appropriations for IHS until such time that authorizers move IHS to mandatory spending. Representatives Gallego and Grijalva also led a Congressional letter to the House Committee on Appropriations for FY 2024 with the same requests.

On March 9, 2023, NCUIH CEO Francys Crevier (Algonquin), testified before and submitted public witness written testimony to the House Appropriations Subcommittee on Interior, Environment, and Related Agencies regarding FY 2024 funding. NCUIH requested full funding for IHS at $51.41 billion and Urban Indian Health for FY 2024 as requested by the TBFWG, maintain advance appropriations for IHS, and support of mandatory funding for IHS.

Bill Highlights

Indian Health Service: $7.27 billion

  • Bill Report, Pg. 119, “The Committee recommendation provides $7,275,531,000 for IHS for fiscal year 2024 discretionary funding, an increase of $248,042,000 to the enacted level and a decrease of $2,194,123,000 to the requested level.”

Urban Indian Health: $92.4 million

  • Bill Report, pg. 123, “The recommendation includes $92,419,000 for the Urban Indian Health program, $2,000,000 above the enacted level.”

Contract Support Costs $1 billion and Tribal 105(l) leases $149 million

  • Bill Report, pg. 124, “The Committee has continued language from fiscal year 2021 establishing an indefinite appropriation for contract support costs estimated to be $1,051,000,000 in fiscal year 2024.
  • Bill Report, pg. 124, “The recommendation includes an indefinite appropriation of an estimated $149,000,000 for the compensation of operating costs associated with facilities leased or owned by Tribes and Tribal organizations for carrying out health programs under ISDEAA contracts and compacts as required by 25 U.S.C. 5324(l).”
  • The Biden Administration included Contract Support Costs and Tribal 105(l) leases as mandatory costs. The Committee did not recommend the line items to be mandatory costs.
    • NCUIH along with 22 other Tribes and Native organizations advocated for these tribal sovereignty payments as mandatory in a letter to Congressional appropriators.

Dental Health: $254.7 million

  • Bill Report pg. 122, “The recommendation includes $254,729,000 for dental health, an increase of $6,631,000 above the enacted level. The Service is encouraged to coordinate with the Bureau of Indian Education [BIE] to integrate preventive dental care at schools within the BIE system.”

Equipment: $32.59 million

  • Bill Report, pg. 125, “The recommendation includes $32,598,000 for medical equipment upgrades and replacement, equal to the enacted level.”

Electronic Health Records: $217.6 million

  • Bill Report, pg. 88, “The Committee is aware there is a need for a new electronic health record system to improve the overall interoperability, efficiency, and security of the Service’s information technology system and provides $217,564,000 for this effort, equal to the enacted level”

Mental Health: $130.2 million

  • Bill Report, pg. 122, “The recommendation includes $130,155,000 for mental health programs, an increase of $2,984,000 above the enacted level.”

Alcohol and Substance Abuse: $266.8 million

  • Bill Report, pg. 122, “The recommendation includes $266,843,000 for alcohol and substance abuse programs, an increase of $403,000 above the enacted level. The bill also provides $11,000,000 for opioid abuse, described below.”

Produce Prescription Pilot Program: $2.5 million

  • Bill Report, pg. 120, “The bill maintains funding at fiscal year 2023 enacted levels for the Alzheimer’s program and Produce Prescription Pilot program.”

Maternal Health: $8 million

  • Bill Report, pg. 120, “The Committee recommendation supports funding for maternal health initiatives and provides an additional $1,000,000 for these efforts as noted above.”

Alzheimer’s Disease: $5.5 million

  • Bill Report pg. 120, “The bill maintains funding at fiscal year 2023 enacted levels for the Alzheimer’s program and Produce Prescription Pilot program.”

Purchased and Referred Care: $997.8 million

  • Bill Report pg. 123, “—The recommendation includes $997,755,000 for purchased/referred care, an increase of $1,000,000 above the enacted level.”

Senate Appropriations Committee Approves Labor-HHS Bill with Marginal Funding Increases for Indian Country

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On July 27, 2023, the Senate Appropriations Committee approved the fiscal year (FY) 2024 Labor, Health and Human Services, Education, and Related Agencies appropriations bill with a vote of 26-2. The bill authorizes $117 billion for the Department of Health and Human Services (HHS)- a 6% decrease from the FY23 enacted level and $27.2 billion below the President’s Budget request. Other key provisions include an increase of $3,000,000 for National Health Service Corps (NHSC) Loan Repayment Program, and maintained funding for the Good Health and Wellness in Indian Country (GHWIC) program, the Tribal Behavioral Health Grants, and the American Indian/Alaska Native (AI/AN) set-aside funding for AI/AN Suicide Prevention Initiative. A more detailed analysis follows below.

NCUIH Advocacy

On March 23, 2023, NCUIH submitted written testimony to the Senate Committee on Appropriations, Subcommittee on Labor, Health and Human Services. The testimony outlined NCUIH priorities to fulfill the Tribal Budget Formulation Workgroup’s Budget Request for the Indian Health Service and the urban Indian line item, maintain advance appropriations for IHS, 100% Federal Medical Assistance Percentage (FMAP), increase funding for the electronic health record modernization, ensure UIOs are appropriately included in relevant grant programs, appropriate $80 million for the Native Behavioral Health Resources Program, as well as reauthorize the Special Diabetes Program for Indians.

Bill Highlights

Centers for Disease Control and Prevention (CDC) – Decrease of $20 million

  • Bill Report, pg. 57: “The Committee recommendation provides a program level of $9,197,590,000 for the Centers for Disease Control and Prevention [CDC], which includes $55,358,000 in mandatory funds under the terms of the Energy Employees Occupational Illness Compensation Program Act [EEOICPA], and $1,186,200,000 in transfers from the Prevention and Public Health [PPH] Fund.”

Good Health and Wellness in Indian Country – Maintained funding

  • Bill Report, pg. 69: “The Committee’s recommended level includes $24,000,000 for Good Health and Wellness in Indian Country.”

National Institutes of Health (NIH) – Increase of $943 million

  • Bill Report, pg.88: “The Committee provides $49,224,000,000, an increase of $943,000,000, for the National Institutes of Health [NIH]”

Substance Abuse and Mental Health Services Administration

State Opioid Response Grants – Increase of $20 million

  • Bill Report, pg. 149: “State Opioid Response [SOR] Grants: The Committee provides $1,595,000,000 for grants to States to address the opioid crisis. Bill language provides $60,000,000 for grants to Indian Tribes or Tribal organizations. The Committee supports the 15 percent set-aside for States with the highest age-adjusted mortality rate related to substance use disorders, as authorized in Public Law 117–328. Activities funded with this grant may include treatment, prevention, and recovery support services. States receiving these grants should ensure that comprehensive, effective, universal prevention, and recovery strategies are prioritized to account for comprehensive services to individuals”
    • UIOs are not included

AI/AN Suicide Prevention Initiative – Maintained funding

  • Tribal set-aside: $3.9 million
  • Bill Report, pg. 142: “Suicide is often more prevalent in highly rural areas and among the American Indian and Alaskan Native populations. According to the CDC, American Indian/Alaska Natives [AI/AN] have the highest rates of suicide of any racial or ethnic group in the United States. In order to combat the rise in suicide rates among this population, the Committee recommends $3,931,000 for the AI/AN Suicide Prevention Initiative.”

Medication Assisted Treatment – Maintained funding

  • Tribal set-aside: $14.5 million
  • Bill Report, pg. 147, “The Committee includes $111,000,000 for medication-assisted treatment, of which $14,500,000 is for grants to Indian Tribes, Tribal organizations, or consortia.”

Tribal Behavioral Grants – Maintained funding

  • Bill Report, pg. 152, “SAMHSA has administered Tribal Behavioral Health Grants for mental health and substance use prevention and treatment for Tribes and Tribal organizations since fiscal year 2014. In light of the continued growth of this program, as well as the urgent need among Tribal populations, the Committee continues to urge the Assistant Secretary for SAMHSA to engage with Tribes on ways to maximize participation in this program.”
    • The bill provides $23,665,000 for the Tribal Behavioral Health Grants.

Health Resources and Services Administration (HRSA)

Community Health Centers – Maintained funding

  • Bill Report, pg. 36, “The Committee provides $1,858,772,000 for the Bureau of Primary Health Care. Programs supported by this funding include community health centers, migrant health centers, healthcare for the homeless, school-based, and public housing health service grants. The Committee continues to support the ongoing effort to increase the number of people who have access to medical services at health centers. Health centers play a vital role in ensuring access to primary care in underserved areas of the country, including urban, rural, and frontier areas. In addition, within the amount provided, the Committee provides up to $120,000,000 under the Federal Tort Claims Act [FTCA] (Public Law 102–501 and Public Law 104–73), available until expended. These funds are used to pay judgments and settlements, occasional witness fees and expenses, and related administrative costs. The Committee intends FTCA coverage funded through this bill to be inclusive of all providers, activities, and services included within the health centers’ federally approved scope of project.”

National Health Service Corps – Increase of $3 million

  • Bill Report, pg. 38, “The Committee provides $128,600,000 for the National Health Service Corps [Corps], an increase of $3,000,000 above the fiscal year 2023 enacted level. The Committee recognizes the success of the Corps program in building healthy communities in areas with limited access to care. The program has shown increases in retention of healthcare professionals located in underserved areas.”

Ending the HIV Epidemic – Maintained funding

  • Bill Report, pg. 37, “The Committee provides $157,250,000 within the health centers program for the Ending the HIV Epidemic initiative. The initiative provides funding to Health Centers in high-need jurisdictions to increase prevention and treatment services for people at high risk for HIV transmission, including Pre-Exposure Prophylaxis [PrEP] related services, outreach, and care coordination through new grant awards in areas currently served by health centers.”

Native Hawaiian Health Care – Maintained funding

  • Bill Report, pg. 37, “The Committee includes no less than $27,000,000 for the Native Hawaiian Health Care Program. Of the total amount appropriated for the Native Hawaiian Health Care Program, not less than $10,000,000 shall be provided to Papa Ola Lokahi for administrative purposes authorized under 42 U.S.C. 11706, including to coordinate and support healthcare service provision to Native Hawaiians and strengthen the capacity of the Native Hawaiian Health Care Systems to provide comprehensive health education and promotion, disease prevention services, traditional healing practices, and primary health services to Native Hawaiians.”

Center for Medicare and Medicaid Services

Tribal Health Care Reimbursements

  • Bill Report, pg. 162, “The IHS rate does not reimburse Tribal healthcare providers for the cost of chemotherapeutics provided by a physician in the office setting. This makes the provision of cancer treatment on Indian reservations unsustainable for Medicare patients and damages the ability of American Indians to access local cancer treatment. The Committee urges CMS to clarify reimbursement procedures and amounts for Part B oncology drugs dispensed at IHS facilities to ensure parity among IHS and non-IHS facilities.”

Office of the Secretary

Center for Indigenous Innovation and Health Equity – Maintained funding

  • Bill Report, pg. 203, “The Committee continues $4,000,000 to support the Center for Indigenous Innovation and Health Equity. The Committee recognizes the Center’s efforts to partner with institutions of higher education with a focus on Indigenous health research and policy among American Indians and Alaska Natives, as well as institutions of higher education with a focus on Indigenous health policy and innovation among Native Hawaiians/Pacific Islanders. The Committee encourages the Center to both continue and expand these efforts.”

National Cancer Institute

Alaska Native Colorectal Cancer

  • Bill Report, pg. 89, “The Committee is concerned the Alaska Native people are twice as likely to be diagnosed with colorectal cancer as the White population. A recent study shows that Alaska Natives have the world’s highest rate of colorectal cancer. Colorectal cancer often has no symptoms until later stage, but screenings help detect growth at earlier stages. These high rates have led the Alaska Native Tribal Health Consortium and the Alaska Native Medical Center to amend their guidelines to lower the screening age from 45 to 40 in order to detect early-onset colorectal cancer. The Committee encourages NCI to expand research efforts to reduce Alaska Native cancer disparities and improve outreach.”

Climate and Health: Maintained Funding

  • The Committee includes $10,000,000 for the program to provide guidance, data, and technical assistance to all States, local health departments, and additional assistance to Tribes and territories to identify possible health effects associated with a changing climate and implement health adaptation plans.

IHS Releases Office of Urban Indian Health Strategic Plan, Incorporates NCUIH Suggestions to Improve Data Accuracy and Facilitate Communication Efforts with Federal Partners and UIOs

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On June 5, 2023, the Office of Urban Indian Health Program (OUIHP) under the Indian Health Service (IHS) published a Dear Urban Leader Letter, regarding the release of the final 2023-2027 5-Year Strategic Plan (Plan). Prior to this release, the National Council of Urban Indian Health (NCUIH) submitted comments to the OUIHP on December 15, 2022, regarding the upcoming Plan. Several of NCUIH’s comments were reflected in the Plan. OUIHP hosted several Urban Confers and Tribal Consultations starting in December 2021 seeking input and recommendations from UIOs for revisions to the 2017-2021 OUIHP Strategic Plan.

Background

In 2017, the IHS developed an OUIHP Strategic Plan 2017-2021, pursuant to the Consolidated Appropriations Act, which described what the Agency hoped to achieve over the next 5 years.  The 2017-2021 Plan was based on the participation and feedback received from UIO Leaders, IHS staff, and other stakeholders. In fiscal year (FY) 2022, IHS evaluated the existing OUIHP Strategic Plan and made revisions and modifications to the new Plan for FY 2023-2027. According to the OUIHP, the Plan will be centered on five Strategic Pillars:

  • Provide effective, timely, and transparent communication;
  • Improve OUIHP’s operational oversight and management;
  • Leverage partnerships to expand UIO resources;
  • Improve data quality; and
  • Expand the infrastructure and capacity of UIOs.

NCUIH’s Role

NCUIH submitted a total of 4 comments to OUIHP regarding feedback on drafting of the Plan. NCUIH appreciates OUIHP for its efforts to meet various goals and objectives of the 2017-2021 Plan, for hosting several Urban Confers seeking UIO feedback on the new Plan, and for sharing each draft iteration of the new plan. However, NCUIH noted in each comment that there remains significant unmet goals and objectives from the 2017-2021 Plan which need continued attention and action.

NCUIH reiterated previous comments submitted in response to each draft of the Plan and also recommended that OUIHP include several key goals from the 2017-2021 Plan. Some recommendations NCUIH made in the 2023-2027 Plan included:

  • Improve communication at the Area Level
  • Improve area office consistency concerning oversight and management
  • Support equitable reporting of individuals who are visiting multiple sites within the I/T/U system as well as proper reporting of UIO patient identity
  • Review and modify the Implementation Plan annually
  • Include specific actionable items and timelines
  • Include UIOs to establish an annual on-site review process across IHS Areas through training and development
  • Ensure action items include actions to achieve the corresponding objective
  • Ensure that UIOs will be conferred within the process of evaluating the expansion of UIOs

NCUIH is pleased that OUIHP incorporated several of these recommendations into the development of the Plan across the different Strategic Pillars. For example, NCUIH’s recommendation on improving data accuracy by using appropriate data metrics to better reflect the effective use of federal funding was reflected in the Plan’s Strategic Pillar 4 to “Improve data quality” through the Strategic Pillar 4, Goal 2 that states that OUIPH “Partners with UIOs and other urban stakeholders to improve data accuracy and quality.” The Plan also includes the following two objectives: “Partner with NCUIH data workgroup and Tribal Epidemiology Centers to improve UIO data reporting; Work with UIOs to achieve 100% data mapping to the National Data Warehouse.” The Plan additionally includes NCUIH’s recommendation that OUIHP keep Strategic Pillar 1, Goal 3, Objective 3 from draft 2 “Facilitate communications with federal partners and UIOs on Urban Indian issues.”

NCUIH strongly believes that the Plan is an important vehicle to articulate leadership priorities, provide direction for program management functions, engage external partners and entities, and measure OUIHP’s progress towards meeting the goals and objectives contained in the Plan. NCUIH will continue to participate in the implementation and exercise of the Plan and inform UIOs of upcoming opportunities related to implementation of OUIHP’s Plan.

In a Divided Fiscal Climate, House Advances Interior Bill with Advance Appropriations and a Modest Increase for Indian Health Service

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The bill advanced to the Full Committee on Wednesday and includes $7.078 billion for IHS, $2.6 billion less than the amount requested by the President.

On July 18, 2023, the House Appropriations Subcommittee on Interior, Environment, and Related Agencies released the Committee Bill Report for the fiscal year (FY) 2024 budget with $115,156,000 for Urban Indian health. The bill appropriates $25.4 billion for Interior, Environment, and Related Agencies, which is $13.4 billion below the fiscal 2023 levels and $21.3 billion below the Biden Administration’s request.  However, the bill rescinds $9.37 billion in funding for programs established in  the Inflation Reduction Act, resulting in the final program level of $34.79 billion. Despite the sizeable cut to the Interior, Environment, and Related Agencies bill and reducing funding for nearly every account to below FY23 enacted levels, the Indian Health Service (IHS) received a 2.2% increase.

The report and bill were approved by the House Subcommittee on Interior on July 13, 2023 and approved with amendments by the full House Appropriations Committee on July 19, 2023. The bill authorizes $7.078 billion for IHS— an increase of $149 million from FY23 but $2.6 billion below the President’s request. Advance appropriations for IHS was maintained for FY25 and received an increase to $5.8 billion from $4.9 billion in FY24. Other key provisions include: $3 million for generators at IHS/Tribal Health Programs/Urban Indian Organizations (UIOs), $6 million for the Produce Prescription Pilot Program for Tribes and UIOs to increase access to produce and other traditional foods, as well as $35 million for Tribal Epidemiology Centers (TECs). A more detailed analysis follows below.

“While the proposed funding for Indian health by the House falls short of the full funding amount requested by the Tribal Budget Formulation Workgroup, NCUIH is grateful for the Committee’s commitment to securing funding for IHS with advance appropriations in Fiscal Year 2025 at the Fiscal Year 2024 enacted amount. We thank Chair Mike Simpson and Ranking Member Chellie Pingree for their continued efforts to ensure that Native lives are not at-risk because of funding disputes.” – Francys Crevier (Algonquin), CEO, National Council of Urban Indian Health (NCUIH).

Bi-Partisan Support for IHS Funding and Advance Appropriations in Bill Hearing

On July 19, 2023, the House Appropriations Committee completed the markup of the FY24 Interior, Environment, and Related Agencies bill.  The bill was passed out of committee 33 to 27 and referred to the House Floor.  The Majority Leadership will now work to schedule the bill for a vote on the House floor. They will also work with Senate Leadership to negotiate a final bill text for passage in both chambers. The Senate Appropriations Committee has scheduled a markup for the Senate FY24 Interior, Environment, and Related Agencies bill for July 27, 2023, at 10:30a.m.

During the Full Appropriations Committee markup, Representative Mike Simpson (R-ID-2) expressed his commitment to providing stable funding for IHS, “I am pleased that the bill provides a fiscal year 2025 advance appropriation for the Indian Health Service and it’s very important that we do that. I made a commitment from the start of this that we were not going to balance this budget on the backs of our Indian brothers and sisters, and we kept that commitment in this bill. It is a bipartisan commitment. We have a moral and a trust responsibility to the Indians of this country, and we need to make sure that we are trying to address that. We still have a long way to go, but we are moving in the right direction.”

“This is an extraordinarily good bill from a Native American standpoint. I was quite shocked; I go through these bills very carefully cause that’s a passionate area of interest. I want to thank all four current chairmen and the 3 former chairmen for working together. Chairman Simpson started us on this course of trying to begin to address many, many years of neglect and broken treaty responsibilities. The members on both sides of the aisle have been enormously helpful with this… in particular I want to thank the Chairman for keeping in advance appropriations for the Indian Health Service which is absolutely critical. There was a situation where whenever we had a government shutdown or differences, we shut down healthcare systems on reservations. It is the only healthcare system we have that gets almost all of its money from discretionary dollars. That was extraordinary,” – Representative Tom Cole (R-OK-4).

 “…I think we made great, great, strides and I am so excited about our opportunity with the Indian Health Service, which we know is in desperate need for federal assistance to get it in the place where people can continue to get their healthcare,” – Representative Rosa DeLauro (D-CT-3).

Line Item FY23 Enacted FY24 TBFWG Request FY24 President’s Budget FY24 House Proposed
Urban Indian Health $90,419,000 $973,590,000 $115,150,000 $115,150,000
Indian Health Service $6,958,223,000 $50,996,276 $9,700,000,000 $7,078,223,000
Advance Appropriations $5,129,458,00 $9,100,000,000 $5,129,458,00 $5,878,223,000

 

Background and Advocacy

On March 9, 2023, President Biden released his budget request for FY24 which included $9.7 billion for IHS and proposed mandatory funding for IHS from FY 2025 to FY 2033 to the amount of $288 billion over-ten years as well as exempting IHS from sequestration. This mandatory formula would culminate in $44 billion for IHS in FY 2033, to account for inflation, staffing increases, long-COVID treatment, and construction costs. This move from discretionary to mandatory funding is essential as noted in the IHS Congressional Justification, “While the progress achieved through the enactment of advance appropriations will have a lasting impact on Indian Country, funding growth beyond what can be accomplished through discretionary spending is needed to fulfill the federal government’s commitments to Indian Country.” On March 17, 2023, IHS published their Fiscal Year (FY) 2024 Congressional Justification with the full details of the President’s Budget, which includes $115 million for urban Indian health – a 27% increase above the FY 2023 enacted amount of $90.42 million.

Full Funding, Maintain Advance Appropriations, and Mandatory Funding as Priorities

NCUIH requested full funding for urban Indian health for FY 2024 at $973.59 million for urban Indian Health in FY24 in accordance with the Tribal Budget Formulation Workgroup recommendations. NCUIH also requested that advance appropriations be maintained for the Indian Health Service (IHS) until mandatory funding is achieved. The marked increase for FY24 is a result of Tribal leaders, over several decades, providing budget recommendations to phase in funding increases over 10-12 years to address growing health disparities that have largely been ignored.

On March 9, 2023, NCUIH CEO Francys Crevier (Algonquin), testified before and submitted public witness written testimony to the House Appropriations Subcommittee on Interior, Environment, and Related Agencies regarding FY 2024 funding. NCUIH requested full funding for IHS at $51.41 billion and Urban Indian Health for FY 2024 as requested by the Tribal Budget Formulation Workgroup (TBFWG), maintain advance appropriations for IHS, and support of mandatory funding for IHS.

NCUIH recently worked closely with Representatives Gallego and Grijalva on leading a Congressional letter to the House Committee on Appropriations for FY 2024. The letter has bipartisan support and calls for support for Urban Indian Health based on the TBFWG’s recommendation and to maintain advance appropriations for IHS until such time that authorizers move IHS to mandatory spending. On April 4, 2023, a group of 12 Senators sent a letter to the Senate Interior Appropriations Committee with the same requests.

Bill Highlights

Indian Health Service: $7.078 billion

  • Bill Report, Pg.2 : “The bill provides $2,582,452,000 for the Bureau of Indian Affairs (BIA), $1,399,504,000 for the Bureau of Indian Education (BIE), and $7,078,223,000 for the Indian Health Service (IHS) in funding available in fiscal year 2024.”

Urban Indian Health: $115 million

  • Bill Report, pg. 90: “The bill includes $115,156,000 for this program, which will help to expand access to urban Indian program care services.”

Mandatory Funding: Contract Support Costs and Tribal 105(l) leases

  • Bill Report, pg. 44: ” The Committee recommends an indefinite appropriation estimated to be $342,000,000 for contract support costs incurred by Indian Affairs as required by law and does not include the Administration’s mandatory proposal”
  • Bill Report, pg. 44 :” The Committee recommends an indefinite appropriation estimated to be $64,000,000 for Payments for Tribal Leases incurred by Indian Affairs as required by law and does not include the Administration’s mandatory proposal”
  • The Biden Administration included Contract Support Costs and Tribal 105(l) leases as mandatory costs. The Committee outlined in the bill report, “It does not include the Administration’s proposal to make these costs mandatory.”
    • NCUIH along with 22 other Tribes and Native organizations advocated for these tribal sovereignty payments as mandatory in a letter to Congressional appropriators.

Dental Health: $288 million

  • Bill Report pg. 88: “The recommendation includes $288,230,000 for the Dental Health program, including $8,844,000 for staffing at new facilities and $31,288,000 to expand access to dental care.”

Equipment: $42 million

  • Bill Report, pg. 91: “The recommendation continues $500,000 for TRANSAM and provides an increase of $10,264,000 above the fiscal year 2023 level for additional medical equipment at Federally and Tribally-operated healthcare facilities.”
  • Bill Report , pg. 91: “The recommendation directs IHS to continue to use at least $3,000,000 to purchase generators for IHS, Tribal Health Programs, and Urban Indian Organizations in areas impacted by de-energization events.”

Electronic Health Records:

  • Bill Report, pg. 88: “The bill reduces funding for the Electronic Record Health System below the 2023 level to fund the required new staffing increases and other patient care initiatives. The Committee recognizes the importance of this project but is concerned about the overall cost and schedule of the project. The bill continues language prohibiting IHS from obligating or expending funds to select or implement a new IT infrastructure system unless IHS notifies the Committee at least 90 days before such funds are obligated or expended.”

Mental Health: $130 million

  • Bill Report, pg. 89: “The Committee provides $130,864,000 for Mental Health, including $3,693,000 for staffing at new IHS facilities.”

Alcohol and Substance Abuse: $276 million

  • Bill Report, pg. 87: “The Committee provides $267,194,000 for this program, including $754,000 for staffing at new IHS facilities.”

Produce Prescription Pilot Program: $6 million

  • Bill Report,pg. 89: “The recommendation includes $6,000,000 for IHS to maintain, in coordination with Tribes and Urban Indian Organizations (UIOs), the pilot program to implement a produce prescription model to increase access to produce and other traditional foods among its service population.”

Tribal Epidemiology Centers: $35 million

  • Bill Report, pg. 89: “The Committee recognizes the importance of TECs which conduct epidemiology and public health functions critical to the delivery of health care services for Tribal and urban Indian communities. The recommendation includes $35,000,000 for TECs.”

Maternal Health: $10 million

  • Bill Report, pg. 89: “The recommendation includes $3,000,000 above the fiscal year 2023 level to improve maternal health. The Committee directs IHS to provide a briefing within 180 days of enactment of this Act on the use of funds including hiring and staff training.”

Alzheimer’s Disease: $6 million

  • Bill Report pg. 87: “The recommendation includes $6,000,000 to continue Alzheimer’s and related dementia activities.”

CMS Releases Medicaid Unwinding FAQs Document

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On May 12, 2023, the Centers for Medicare and Medicaid Services (CMS) released a frequently asked questions (FAQs) document regarding changes made to the Medicaid continuous enrollment condition under the Families First Coronavirus Response Act (FFCRA) by the Consolidated Appropriations Act 2023 (CAA, 2023). Key topics addressed in the FAQs include questions relating to the CAA, 2023 returned mail condition for states claiming the increased FMAP available under the FFCRA, reestablishment of premiums in Medicaid and CHIP, renewal requirements for individuals who receive Social Security Income, and Medicaid and CHIP agency capacity to share beneficiary data with enrolled providers to support renewals.

 These FAQs clarify other CMS guidance most recently released in the January 5, 2023 CMCS Informational Bulletin and January 26, 2023 State Health Official letter #23-002.

Background

On Thursday, December 29, 2022, Congress enacted the Consolidated Appropriations Act, 2023 (CAA, 2023). CAA, 2023 includes various Medicaid and Children’s Health Insurance Program (CHIP) provisions, including significant changes to the continuous enrollment condition at section 6008(b)(3) of the Families First Coronavirus Response Act (FFCRA) that took effect April 1, 2023. Under this section of the FFCRA, states claiming a temporary 6.2 percentage point increase in the Federal Medical Assistance Percentage (FMAP) have been unable to terminate enrollment for most individuals enrolled in Medicaid as of March 18, 2020, as a condition of receiving the temporary FMAP increase. Currently, states must, over time, return to normal eligibility and enrollment operations. States will have up to 12 months to initiate, and 14 months to complete, a renewal for all individuals enrolled in Medicaid, CHIP, and the Basic Health Program (BHP) following the end of the continuous enrollment condition— this process is commonly referred to as “unwinding”.

Under the Consolidated Appropriations Act 2023 (CAA, 2023) expiration of the continuous enrollment condition and receipt of the temporary FMAP increase will no longer be linked to the end of the Covid-19 public health emergency. The continuous enrollment condition ended on March 31, 2023. Beginning April 1, 2023, the FFCRA’s temporary FMAP increase will be gradually reduced and phased down and will end on December 31, 2023. Additionally, as of April 1, 2023, states have been able to terminate Medicaid enrollment for individuals no longer eligible.

Medicaid Unwinding and UIOs

During this unwinding, 12% of all AI/AN children and 6% of all AI/AN adults nationwide are expected to lose CHIP or Medicaid coverage. Urban Indian Organization (UIO) Medicaid beneficiaries may lose their Medicaid coverage as result of the unwinding. The National Council of Urban Indian Health (NCUIH) is helping to mitigate this. It released a Medicaid unwinding toolkit for UIOs in December 2022. On April 24, 2023, NCUIH, in collaboration with the Asian & Pacific Islander American Health Forum, the Coalition on Human Needs, The Leadership Conference on Civil and Human Rights, the National Association for the Advancement of Colored People, National Urban League, Protect Our Care, UnidosUS and 220 other organizations, sent a letter to the Department of Health and Human Services (HHS) Secretary Xavier Becerra. In it, the coalition of organizations called on the Administration to use the full extent of its authorities to safeguard Medicaid coverage and outlined specific steps the Administration can take to avoid wrongful terminations.

See NCUIH’s COVID-19 Public Health Emergency Medicaid Unwinding Toolkit for more information on Medicaid unwinding, its impact on UIO Medicaid beneficiaries and additional resources: https://ncuih.org/2022/12/05/resource-covid-19-public-health-emergency-medicaid-unwinding-toolkit-released/.