NCUIH Joins NIHB and 70 Organizations Calling on Congress to include $8 Billion for IHS in FY 2022 and Advance Appropriations

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On March 9, 2022, the National Council of Urban Indian Health (NCUIH) joined the National Indian Health Board (NIHB), and over 70 Tribal nations, Tribal and national Indian organizations, and friends of Indian health in sending a series of joint letters to Congress amid their final negotiations of an omnibus appropriations bill for Fiscal Year (FY) 2022. The recommendations for reauthorization outlined in the letter include:

  • No less than the House-passed level of $8.114 billion for the Indian Health Service (IHS) in the final Appropriations bill for FY 2022
  • Advance Appropriations for the Indian Health Service (IHS)

The House-passed funding level would be an increase of $1.88 billion over the FY 2021 enacted level. The Senate Appropriations Committee FY 2022 funding bill included $6.6 billion in Advance Appropriations for IHS FY 2023.

Letters to Congress:

 

Background and Advocacy

NCUIH has long advocated for larger investments in AI/AN health care and has called on Congress to strengthen their commitment to Indian Country with increased funding in the FY 2022 appropriations:

American Academy of Pediatrics Committee on Native American Child Health Seeking Nominees for Four Psychologists for Pediatric Consultation Visits

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The American Psychological Association (APA) recently issued an invitation for four (4) psychologist self-nominations to participate in the American Academy of Pediatrics (AAP) Committee on Native American Child Health (CONACH) pediatric consultation visits. The AAP CONACH develops policies and programs that improve the health of American Indian and Alaska Native (AI/AN) children and advocates for AI/AN child health. The CONACH also conducts pediatric consultations visits to Indian Health Services and Tribal health facilities. Psychologists selected will also participate in the APA Advisory Group, which consists of APA staff from multiple APA offices (Practice; Public Interest; Equity, Diversity, and Inclusion (EDI); and Advocacy; as well as representation from the Society of Indian Psychologists).

Nominees must submit the completed application materials to the APA Advisory Group (ohcf@apa.org) by Monday April 4, 2022. NCUIH encourages eligible UIO psychologists to apply because of the unique psychological needs of urban AI/AN children and the culturally focused care that UIOs provide the AI/AN community generally.  Questions should be e-mailed to ohcf@apa.org.

Background and Call to Action

In an effort to further the APA’s commitment to dismantle systemic racism, the CONACH offers expertise to individuals and groups concerned about the issues facing AI/AN children.  CONACH Committee members maintain contact with tribal, urban, and Indian Health Service (IHS) programs, and keep up with important changes, legislation, and regulations that affect AI/AN health in general and AI/AN child health. By participating in CONACH and pediatric consultation visits, psychologists will facilitate the development and expansion of integrating psychological practice in AI/AN communities to address social determinates of health and health inequities.

In order to strengthen representation, and come to solutions that are culturally appropriate, the APA is seeking four psychologist nominees who can meet the following needs and expectations:

  • Indigenous licensed pediatric/child psychologist and/or experience practicing in hospital or ambulatory practice settings serving AI/AN children and their communities
  • Familiarity and/or expertise with relevant government or clinical initiatives in tribal health, urban Indian health or IHS programs
  • Ability to meet deadlines and respond to issues and requests promptly
  • Excellent written and public speaking skills
  • Geographic representation from any state with significant AI/AN communities, and/or AI/AN heritage
  • Time to devote to the pediatric consultation visits that CONACH requires. The pediatric consultation visits typically require 3-4 days with travel over a weekend, depending on the location of the consultation visit. Typically, psychologists would participate in one pediatric consultation visit per year, but there may be two required for 2022. The first visit would occur in May of 2022. Travel to the consultation will be covered by APA. Due to evolving nature of the public health emergency, site visits may be held virtually.
  • Time to devote to participation in the APA Advisory Group which will meet for 1 hour quarterly.

NCUIH Submits Comments to DOI and DOJ on Executive Order on Improving the Public Safety and Criminal Justice for Native Americans and Addressing the Crisis of MMIP

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On March 17, 2022, the National Council for Urban Indian Health (NCUIH) submitted comments to the Department of Interior (DOI) and Department of Justice (DOJ) in response to their joint Dear Tribal Leader letter dated February 7, 2022 seeking stakeholder input related to the policy directives outlined in Executive Order (E.O.) 14053 – Improving Public Safety and Criminal Justice for Native Americans and Addressing the Crisis of Missing or Murdered Indigenous People (MMIP). NCUIH emphasized the importance of clear and consistent communication with urban Indian organizations (UIOs) regarding the Agencies’ future plans to incorporate UIOs into the policies, procedures, and projects set forth in E.O. 14053 and also encouraged the Agencies to establish an Urban Confer policy.

E.O. 14053 Impact on Urban AI/AN Communities

E.O. 14053, signed by President Biden on November 15, 2021, directs the federal government to ““to strengthen public safety and criminal justice in Indian Country and beyond, to reduce violence against Native American people, and to ensure swift and effective Federal action that responds to the problem of missing or murdered indigenous people.”  E.O. 14053 committed the federal government’s to “[c]onsistent engagement, commitment, and collaboration,” with AI/AN people and communities to “drive long-term improvement to public safety for all Native Americans.”  E.O. 14053 specifically directed the federal government to “build on existing strategies to identify solutions directed toward the particular needs of urban Native Americans,” because “approximately 70 percent of  American Indian and Alaska Natives live in urban areas and part of this epidemic of violence is against Native American people in urban areas.”  In addition, E.O. 14053 directed the federal government to “work closely with Tribal leaders and community members, Urban Indian Organizations, and other interested parties to support prevention and intervention efforts that will make a meaningful and lasting difference on the ground.”  To that end, in a November 15, 2021 memorandum, Deputy Attorney General Monaco directed DOJ’s Steering Committee to seek and consider the views of stakeholders including Urban Indian Organizations (UIOs).

The E.O. also included the following directions to various federal agencies to collaborate with urban AI/AN communities:

  • Section 4
    • Directs DOJ, DOI, and HHS to “sustain efforts to improve data collection and information-sharing practices, conduct outreach and training, and promote accurate and timely access to information services regarding crimes or threats against Native Americans, including in urban areas.”
    • Directs DOJ, DOI, and HHS to “develop a strategy for ongoing analysis of data collected on violent crime and missing persons involving Native Americans, including in urban Indian communities.”
    • Directs HHS to “evaluate the adequacy of research and data collection efforts at the Centers for Disease Control and Prevention and the National Institutes of Health in accurately measuring the prevalence and effects of violence against Native Americans, especially those living in urban areas.”
  • Section 5
    • Instructs HHS, “in consultation with the Secretary of the Interior and Tribal Nations and after conferring with other agencies, researchers, and community-based organizations supporting indigenous wellbeing, including Urban Indian Organizations,” to “develop a comprehensive plan to support prevention efforts that reduce risk factors for victimization of Native Americans and increase protective factors, including by enhancing the delivery of services for Native American victims and survivors, as well as their families and advocates

NCUIH’s Role

NCUIH has consistently advocated for urban AI/AN communities to be included when addressing public safety and MMIP in an effort to strengthen critical services provided by UIOs for AI/ANs.  In furtherance of that advocacy, NCUIH’s comments in response to the Dear Tribal Leader Letter highlighted the critical importance of UIOs in addressing and combating the epidemics of MMIP crisis and violent crime against AI/ANs. NCUIH made the following recommendations and requests to the DOI and DOJ:

  • NCUIH requests that the Agencies honor E.O. 14053 through consistent and clear communication with UIOs
  • NCUIH requests that the Agencies provide specific information regarding their future plans to incorporate UIOs into the policies, procedures, and projects set forth in E.O. 14053
  • NCUIH requests that Urban Indian Organizations receive formal notice of future consultations on E.O. 14053
  • NCUIH request that the Agencies establish an Urban Confer policy to set the necessary policies and procedures for direct and clear communication with UIOs

NCUIH also attended consultations on March 11, 2022, hosted by DOI, and March 17, 2022, hosted by DOJ, on behalf of the UIOs it represents.  In these consultations Chandos Culleen, NCUIH’s Director of Federal Relations, provided additional oral comments stressing the need for the Agencies to work with UIOs to address the crises of MMIP and violent crime against AI/AN people.  Mr. Culleen emphasized that these epidemics also affect urban AI/AN communities and that UIOs are already engaged in providing critical services to combat MMIP and violent crime.  UIOs are critical service providers who can help bridge Tribal, State, local, and Federal efforts to ensure that all AI/ANs are accounted for when combatting MMIP and public safety issues. NCUIH will continue to closely monitor and advocate for urban AI/ANs on this topic.

NCUIH Submits Comments to DOJ OVC on the Tribal and Victims Services Set-Aside

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On March 15, 2022 the National Council of Urban Indian Health (NCUIH) submitted comments to the Department of Justice (DOJ) Office for Victims of Crimes (OVC) in response to their December 13, 2021 correspondence seeking written comment on the Tribal Set-Aside from the Crime Victims Fund (Tribal Set-Aside) for Fiscal Year (FY) 2022. The Tribal Victim Services Set-Aside Formula grant program (TVSSA Program) is a key source of funding for American Indian/Alaska Native (AI/AN) communities working to enhance services for victims of crime, with over $532 million made available through FYs 18, 19, 20, and 21. NCUIH emphasized the critical services urban Indian organizations (UIOs) provide victims of crime and the importance of extending more funding opportunities for UIO.

NCUIH’s Role

Because many AI/AN victims of crime reside off reservations and because many seek care from Urban Indian Organizations (UIOs), NCUIH made the following specific comments, requests, and recommendations:

  • DOJ should provide Congress with technical assistance to support expansion of the Tribal Set-Aside and TVSSA Program to include UIOs.  Expansion of the percentage of the Tribal Set-Aside should be commensurate with inclusion of UIOs to ensure that funding to Tribes from the Tribal Set-Aside is not reduced.
  • OVC should formally invite UIOs to all future events in the TVSSA program consultation process.
    • OVC, and DOJ more broadly, should consider adopting an Urban Confer Policy.
  • OVC must ensure that all AI/ANs are served by its funding opportunities by expanding its definition of eligible awardees for all programs to the broadest extent permissible by law.

NCUIH will continue to closely follow the DOJ OVC policies and opportunities for AI/AN communities. NCUIH will also continue to advocate for more funding opportunities for UIOs that provide services to victims of crimes.

NCUIH Submits Comments to HRSA Advisory Committee on Infant and Maternal Mortality

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On March 10, 2022, the National Council of Urban Indian Health (NCUIH) submitted comments to the Health Resources Services Administration (HRSA) Advisory Committee on Infant and Maternal Mortality (ACIMM). The comments were submitted in advance of the ACIMM’s March 15-16 meeting focusing on program updates, race-concordant care, health of Indigenous mothers and babies, and the impact of violence on infant and maternal mortality. In the comments, NCUIH reiterated the need for an Urban Confer policy at the Department of Health and Human Services (HHS) and the importance of collaborating with urban Indian organizations (UIOs) for accurate data collection. NCUIH also recommended that the ACIMM include a Tribal and UIO representative among the ACIMM’s membership and create an ACIMM subcommittee on American Indian/Alaska Native (AI/AN) infant and maternal health disparities.

The Advisory Committee on Infant and Maternal Mortality

Formed in 1991, the ACIMM advises the Secretary of Health and Human Services (HHS) on department activities, partnerships, policies, and programs directed at reducing infant mortality, maternal mortality and sever maternal morbidity, and improving the health status of infants and women before, during, and after pregnancy. The ACIMM consists of public and private members and provides advice on how to coordinate governmental efforts to improve infant mortality, related adverse birth outcomes, and maternal health, as well as influence similar efforts in the private and voluntary sectors. With its focus on underlying causes of the disparities and inequities seen in birth outcomes for women and infants, the ACIMM advises the Secretary on the health, social, economic, and environmental factors contributing to the inequities and proposes structural, policy, and/or systems level changes.

American Indian and Alaska Native Infant and Maternal Mortality

According to HHS Office of Minority Health AI/ANs have almost twice the infant mortality rate as non-Hispanic whites. AI/AN infants are also 2.7 times more likely than non-Hispanic white infants to die from accidental deaths before the age of one year and AI/AN infants are 50 percent more likely to die from complications related to low birthweights as compared to the same group. AI/AN mothers are also disproportionately represented in maternal mortality. In 2019, AI/AN mothers were almost three times as likely to receive late or no prenatal care as compared to non-Hispanic white mothers.

NCUIH’s Role

NCUIH has engaged in extensive advocacy on behalf of AI/AN mothers and infants and for increased funding and support to the UIOs which provide maternal health, infant health, prenatal, and family planning services to AI/AN mothers and infants.  In its comments to the ACIMM, NCUIH made the following recommendations:

  • Advise the Secretary of HHS (Secretary) to lead the establishment of an Urban Confer policy to ensure that urban AI/ANs can provide pertinent guidance to HHS on department activities, partnerships, policies, and programs directed at reducing infant and maternal mortality, severe maternal morbidity, and improving the health status of infants and women before, during, and after pregnancy.
  • Advise the Secretary to collaborate with UIOs to gather accurate data on urban AI/AN infant and maternal health
  • Improve AI/AN representation on the ACIMM by including a tribal and UIO health provider representative on the ACIMM to complement the work of the standing IHS ex-officio member
    • NCUIH recommends that there be two seats, a Tribal and a UIO seat, so that ACIMM can receive a variety of viewpoints regarding the provision of health care to diverse AI/AN communities
  • Create an ACIMM subcommittee dedicated to addressing AI/AN infant and maternal health disparities

In addition to submitting comments, NCUIH attended the ACIMM’s session on the health of Indigenous mothers and babies.  During this session Alexandra Payan, NCUIH’s Federal Relations Associate, connected with several ACIMM members regarding their interest in improving AI/AN maternal and infant health.  NCUIH will continue to closely follow the ACIMM’s important work on AI/AN mothers and infants and seek opportunities for collaboration.

NCUIH Signs on to Letter Urging Reauthorization of Maternal, Infant, and Early Childhood Home Visiting Program with Tribal Set-Aside Increase

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Last week, the National Council of Urban Indian Health signed-on to a letter to Congress led by the National Home Visiting Coalition in support of the reauthorization of the Health Resources & Services Administration (HRSA) Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV). The recommendations for reauthorization outlined in the letter include:

  • Increase MIECHV funding over the next five years to reach more families and better support the workforce
  • Double the Tribal MIECHV set-aside from three to six percent
  • Continue to allow virtual home visits with model fidelity as an option for service delivery
Read the Full Letter

NCUIH Submits Written Testimony to House Interior Appropriations with FY23 Budget Requests for Urban Indian Health

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The National Council of Urban Indian Health (NCUIH) submitted written testimony for Tribal Public Witnesses to the House Appropriations Subcommittee on Interior, Environment, and Related Agencies regarding Fiscal Year (FY) 2023 funding for Urban Indian Organizations (UIOs). On January 28, 2022, the Subcommittee Chair and Ranking Member requested information from “Indian Country on issues and needs” that is used to develop the annual appropriations bill.

NCUIH advocated in its testimony for additional resources for the Indian Health Service and urban Indian Health.

In the testimony, NCUIH requested the following:

  • $48 billion for the Indian Health Service and $950 million for Urban Indian Health for FY23 (as requested by the Tribal Budget Formulation Workgroup)
  • Advance appropriations for IHS
  • UIOs be insulated from unrelated budgetary disputes through a spend faster anomaly so that critical funding is not halted

NCUIH reiterated, “The federal government owes a trust responsibility to tribes and AI/ANs that is not restricted to the borders of reservations. Funding for Indian health must be significantly increased if the federal government is, to finally, and faithfully, fulfill its trust responsibility.”

NEXT STEPS:

The testimony will be read and considered by the subcommittee as the appropriations process goes forward for FY23. The Subcommittee has not yet announced dates for the hearings on the FY 23 budget.

Department of Veterans Affairs Seeks Comments on Tribal Representation Expansion Project and Designation of Individuals to Represent AI/AN Veterans in VA Benefit Claims

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On February 14, the Department of Veterans Affairs (VA) released a notice of Tribal consultation regarding the VA’s Tribal Representation Expansion Project (T.REP). Through this consultation and an additional written comment period, VA is seeking comments on three general areas.  First, whether Tribal communities have access to representation for VA benefit claims.  Second, for Tribes that are underserved in terms of representation, VA is also seeking comments regarding whether their Tribal government is interested in collaborating with VA to designate an individual within the community as authorized to prepare, present, and prosecute VA benefit claims.  Third, VA is seeking comments and recommendations on any issues, concerns or processes Tribes believe should be addressed in T.REP to better ensure that it is successful in expanding access to representation for AI/N veterans on their benefit claims before VA.

In addition to these general areas, VA has posed the following seven questions to be addressed through written comments:

  1. Are Native American Veterans in your community receiving any Start Printed Page 8343 assistance in pursuing their VA benefit claims? Are they being represented before VA on their VA benefit claims? Who is providing those services? For example, those claims services may be provided by: (a) A person employed by the Tribal government; (b) a member of your Tribe or Tribal community; (c) a VA-recognized organization or a representative of a VA-recognized organization; or (d) an agent or attorney. Please provide details as to the extent of the assistance provided and whom we may credit if your Tribal community currently has access to benefit claims assistance and/or representation before VA.
  2. If Veterans within your Tribal community have access to representation for their VA benefit claims, do you consider the option(s) for representation to be culturally competent representation? Please explain.
  3. If Veterans and their families within your Tribal community are not being adequately represented on their VA benefit claims, is there someone employed by, or affiliated, with your Tribal government that is currently, or could be, positioned to serve Veterans? For example, such individual may currently be serving Veterans and their families as a Tribal Veterans Service Officer (TVSO) or as a Tribal Veterans Representative (TVR).
  4. Are there barriers to Veterans and their family members within your Tribal community in accessing representation on their VA claims? For example, barriers may include: (a) Location or environmental obstacles; (b) language difficulties; (c) cultural differences; (d) distrust of the Federal or State government; (e) difficulties in finding training; (f) difficulties in securing office equipment and internet services; or (g) other circumstances.
  5. Do you believe that your Tribal government may want to collaborate with VA to identify someone affiliated with your government to be authorized to represent Veterans and their families on benefit claims before VA?
  6. Are you interested in being contacted by VA’s Office of General Counsel to learn more about the project?
  7. Are there issues, concerns, or processes that should be addressed in T. REP so that the project functions effectively in support of access to representation for Native American Veterans within your Tribal government and/or community? If so, how do you recommend VA address those matters in this project?

VA will be holding a virtual tribal consultation session on March 23, 2022, from 3:00-5:00 p.m. (Eastern Time). Written comments may also be submitted to VA by March 30, 2022. Written comments may be submitted by email to tribalgovernmentconsultation@va.gov, as well as through other methods listed in the Federal Register Notice.  To access the virtual consultation session, participants must register by clicking here.

Background

There is an urgent need to ensure that all AI/AN veterans have access to the benefits they earned through their service.  According to a 2020 VA Report, AI/AN veterans served in the Pre-9/11 period at a higher percentage than veterans of other races.  Despite a distinguished record of service, VA’s statistics also show that AI/AN veterans were more likely to be unemployed, were more likely to lack health insurance, and were more likely to have a service-connected disability when compared to veterans of other races.  In addition, in Fiscal Year 2017, AI/AN veterans used Veterans Benefits Administration (VBA) benefits or services at a lower percentage than veterans of other races.

In 2017, VA amended its regulations governing recognition of organizations permitted to provide assistance on VA benefit claims in 2017 to permit the VA Secretary to recognize Tribal organizations in a similar manner as state organizations.  VA also amended its regulation to allow employees of Tribal governments to become accredited through recognized State organizations in a similar manner as a County Veterans’ Service Officer.  Despite a request that VA amend its regulations to also recognize UIOs, VA declined to do so.  VA stated that UIOs should consider applying for VA recognition as a regional or local organization.

VA’s T.REP represents VA’s most recent effort to ensure that AI/AN veterans and their families have access to appropriate representation in the preparation, presentation, and prosecution of their VA benefit claims. The aim of this program is to focus on Tribal communities that are being underserved in terms of representation. VA’s current T.REP focus is collaborating with Tribal governments to identify “an individual who is affiliated with their government, is of good character and reputation, and, who, after proper training on VA benefits, would be fit to be authorized by the VA General Counsel to represent on VA benefit claims.”  According to VA, if a tribal government identifies such a person “[t]he General Counsel then plans to use his discretionary authority, pursuant to 38 CFR 14.630, to specially authorize such individuals to prepare, present, and prosecute VA benefit claims before VA.”

Inclusion of UIOs in T.REP Would Benefit AI/ANs living in Urban Areas

NCUIH encourages UIOs to submit comments to VA by March 30, 2022 concerning T.REP, the needs of AI/AN veterans living in urban areas, and whether VA should consider including UIOs in T.REP.  AI/AN veterans living in urban areas face many of the same barriers to accessing competent representation in VA claims that AI/AN veterans face on reservations.  For example, VA cites cultural and language barriers as being two of the main deterrents for AI/AN veterans seeking representation on VA benefit claims.  AI/AN veterans living in urban areas also face cultural and language barriers when searching out representation on their claims.

Further, current estimates show that 67 percent of the veteran population identifying as AI/AN alone lives in metropolitan areas. UIOs currently serve six of the ten urban counties with the largest veteran AI/AN alone populations, including Maricopa County, Arizona; Los Angeles County, California; San Diego County, California; Bernalillo County, New Mexico; Oklahoma County, Oklahoma; and Tulsa County, Oklahoma. AI/AN veterans regularly prefer to see UIOs over other health care providers thanks to the provision of culturally competent care (including traditional healing services), community and familial relationships, shorter wait times, and shorter distance to travel.  Given the large portion of the AI/AN veteran population living in urban areas and UIOs’ ability to reach AI/AN veterans, inclusion of UIOs in T.REP would help VA accomplish its goal of “ensur[ing] that Native American Veterans and their families have access to responsible, qualified representation in the preparation, presentation, and prosecution of their benefit claims before VA.”

NCUIH Releases “2021 Policy Assessment: Setting Policy Priorities for 2022”

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The policy assessment informs urban Indian organization policy priorities in 2022, identifies HIV care needs, reviews COVID-19 funding disbursements, and addresses data accuracy needs.

NCUIH is pleased to announce the release of its 2021 Policy Assessment. NCUIH hosted five focus groups to identify Urban Indian Organization (UIO) policy priorities for 2022, as they relate to Indian Health Service (IHS)-designated facility types (full ambulatory, limited ambulatory, outreach and referral, and outpatient and residential). The focus groups were held on the following dates in 2021: November 18, 19, and 22. Information was also collected from UIOs via a questionnaire sent out on December 1, 2021. Together these tools allowed NCUIH to work with UIOs to identify policy priorities in 2022; identify HIV prevention, treatment, and care needs at UIOs; review disbursements of COVID-19 funding; and determine the accuracy of the data reported by the IHS National Data Warehouse (NDW). Of 41 UIOs, 25 UIOs attended the focus groups or participated in the questionnaire. This is the second year that NCUIH has conducted focus groups and sent a questionnaire to UIOs.

Overview

The COVID-19 pandemic renewed the focus on priorities such as funding for UIO facilities, funding for behavioral health, and funding transparency. Existing priorities also remain a key focus across the UIOs, especially increasing funding amounts for the urban Indian health line item, funding flexibility, and parity issues such as permanent 100% Federal Medical Assistance Percentage (FMAP).

Key findings from the discussions are as follows:

  • Overall Funding, Facilities and Infrastructure, and FMAP Parity Top Priority Lists for UIOs
  • Area Office Inconsistencies Affect Staffing, Funding, and Resources
  • UIOs Need Health IT Guidance from IHS to Reflect their Unique Systems and Cite Data Accuracy Concerns
  • UIOs Need Community Health Representatives (CHRs)
  • Contract Flexibility and Funding Security
  • Facility Funding Necessary for UIOs Amid the COVID-19 Pandemic
  • COVID-19 Pandemic and Vaccine Impacts on UIOs
  • Need for Permanent 100% FMAP for UIOs
  • UIOs Identified a Need for Additional HIV, Behavioral Health, and Substance Abuse Support
  • Special Diabetes Program for Indians (SDPI) Reauthorization Remains a Priority
  • NCUIH Services Benefit UIOs and Opportunities to Expand Identified

Read the 2021 Policy Assessment: Setting Policy Priorities for 2022

Past Resources

2020 Policy Assessment

2021 Policy Priorities

CMS Requesting Information on Access to Coverage and Care in Medicaid and CHIP

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Last month, the Centers for Medicare and Medicaid Services (CMS) issued a Request for Information (RFI) entitled Access to Coverage and Care in Medicaid and CHIP.  CMS is seeking input on topics related to healthcare access in Medicaid and the Children’s Health Insurance Program (CHIP).  This includes enrollment in coverage, maintaining coverage, and access to services and support. For the full list of questions included in the RFI click here. The comment deadline is April 18, 2021.  NCUIH urges UIOs to respond to this RFI to provide feedback to CMS regarding the barriers to access to coverage and care in Medicaid and CHIP in AI/AN communities.

CMS Strategic Vision for Medicaid and CHIP and Role of this RFI

This RFI is one of CMS’ first steps in developing a comprehensive access strategy for Medicaid and CHIP.  CMS has established three key areas for its strategic visions for Medicaid and CHIP: (1) coverage and access, (2) equity, and (3) innovation and whole-person care. CMS will use the feedback from this RFI to inform its future policy, monitoring, and regulatory approaches in all three key areas of the strategic vision.

CMS has set forth five objectives to be addressed in the RFI.

  1. Medicaid and CHIP reaches people who are eligible and who can benefit from such coverage.
    • CMS is interested in identifying strategies to ensure that individuals eligible for Medicaid and CHIP are aware of coverage options and how to apply for and retain coverage. Eligible individuals should be able to apply, enroll in, and receive benefits in a timely and streamlined manner that promotes equitable coverage.
  2. Medicaid and CHIP beneficiaries experience consistent coverage.
    • CMS is seeking input on strategies to ensure that beneficiaries are not inappropriately disenrolled and to minimize gaps in enrollment due to transitions between programs. These strategies are particularly important during and immediately after the COVID-19 Public Health Emergency (PHE) and can include opportunities that promote beneficiaries’ awareness of requirements to renew their coverage as well as states’ eligibility assessment processes, which can facilitate coverage continuity and smooth transitions between eligibility categories or programs (e.g., students eligible for school-based Medicaid services are assessed for Supplemental Security Income (SSI)/Medicaid eligibility at age 18, or youth formerly in foster care are assessed for other Medicaid eligibility after age 26).
  3. Whether care is delivered through fee-for-service or managed care, Medicaid and CHIP beneficiaries have access to timely, high-quality, and appropriate care in all payment systems, and this care will be aligned with the beneficiary’s needs as a whole person.
    • CMS is seeking feedback on how to establish minimum standards or federal “floors” for equitable and timely access to providers and services, such as targets for the number of days it takes to access services. These standards or “floors” would help address differences in how access is defined, regulated, and monitored across delivery systems, value-based payment arrangements, provider type (e.g., behavioral health, pediatric subspecialties, dental, etc.), geography (e.g., by specific state regions and rural versus urban), language needs, and cultural practices.
  1. CMS has data available to measure, monitor, and support improvement efforts related to access to services (i.e., potential access; realized access; and beneficiary experience with care across states, delivery systems, and populations).
    • CMS is interested in feedback about what new data sources, existing data sources (including Transformed Medicaid Statistical Information System [T-MSIS], Medicaid and CHIP Core Sets, and home and community based services (HCBS) measure set), and additional analyses could be used to meaningfully monitor and encourage equitable access within Medicaid and CHIP programs.
  2. Payment rates in Medicaid and CHIP are sufficient to enlist and retain enough providers so that services are accessible.
    • Section 1902(a)(30)(A) of the Social Security Act (the “Act”) requires that Medicaid state plans “assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area.” Section 1932 of the Act includes additional provisions related to managed care. Section 2101(a) of the Act requires that child health assistance be provided by States “in an effective and efficient manner….” CMS is interested in leveraging existing and new access standards to assure Medicaid and CHIP payments are sufficient to enlist enough providers to ensure that beneficiaries have adequate access to services that is comparable to the general population within the same geographic area and comparable across Medicaid and CHIP beneficiary groups, delivery systems, and programs. CMS also wants to address provider types with historically low participation rates in Medicaid and CHIP programs (e.g., behavioral health, dental, etc.). In addition, CMS is interested in non-financial policies that could help reduce provider burden and promote provider participation.

Need to Address Uninsured Rates Among American Indians and Alaska Natives

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 revenue for facilities like UIOs which provide healthcare to AI/ANs.  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.”  While UIOs had hoped to see an increase in Medicaid funds in light of Congress’ authorization for eight quarters of 100% Federal Matching Assistance Percentage for UIOs, this has so far failed to result in higher rates of reimbursement for UIOs.