Trump and CMS Issue Second Round of Changes to Healthcare Regulations

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On April 30, 2020, at President Trump’s direction, the Centers for Medicare & Medicaid Services (CMS) issued a second round of regulatory waivers and rule changes “to deliver expanded care to the nation’s seniors and provide flexibility to the healthcare system as America reopens. These changes include making it easier for Medicare and Medicaid beneficiaries to get tested for COVID-19 and continuing CMS’s efforts to further expand beneficiaries’ access to telehealth services.”

Many of CMS’s temporary changes will apply immediately for the duration of the Public Health Emergency declaration. The changes build on an array of temporary regulatory waivers and new rules CMS announced on March 30 and April 10. Providers and states do not need to apply for the blanket waivers and can begin using the flexibilities immediately. CMS also is requiring nursing homes to inform residents, their families, and representatives of COVID-19 outbreaks in their facilities. Below are the blanket waivers issued separated into categories:

  • New rules to support and expand COVID-19 diagnostic testing for Medicare and Medicaid beneficiaries:
    • Under the new waivers and rule changes, Medicare will no longer require an order from the treating physician or other practitioner for beneficiaries to get COVID-19 tests and certain laboratory tests required as part of a COVID-19 diagnosis. During the Public Health Emergency, COVID-19 tests may be covered when ordered by any healthcare professional authorized to do so under state law. A written practitioner’s order is no longer required for the COVID-19 test for Medicare payment purposes.
    • Pharmacists can work with a physician or other practitioner to provide assessment and specimen collection services, and the physician or other practitioner can bill Medicare for the services. Pharmacists also can perform certain COVID-19 tests if they are enrolled in Medicare as a laboratory, in accordance with a pharmacist’s scope of practice and state law. With these changes, beneficiaries can get tested at “parking lot” test sites operated by pharmacies and other entities consistent with state requirements.
    • CMS will pay hospitals and practitioners to assess beneficiaries and collect laboratory samples for COVID-19 testing, and make separate payment when that is the only service the patient receives.
    • CMS is announcing that Medicare and Medicaid are covering certain serology (antibody) tests. Medicare and Medicaid will cover laboratory processing of certain FDA-authorized tests that beneficiaries self-collect at home.
  • Additional highlights of the waivers and rule changes announced today:
    • CMS is giving providers flexibility during the pandemic to increase the number of beds for COVID-19 patients while receiving stable, predictable Medicare payments. For example, teaching hospitals can increase the number of temporary beds without facing reduced payments for indirect medical education. Inpatient psychiatric facilities and inpatient rehabilitation facilities can admit more patients to alleviate pressure on acute-care hospital bed capacity without facing reduced teaching status payments. Similarly, hospital systems that include rural health clinics can increase their bed capacity without affecting the rural health clinic’s payments.
    • Under current law, most provider-based hospital outpatient departments that relocate off-campus are paid at lower rates under the Physician Fee Schedule, rather than the Outpatient Prospective Payment System (OPPS). CMS will allow certain provider-based hospital outpatient departments that relocate off-campus to obtain a temporary exception and continue to be paid under the OPPS.
    • Long-term acute-care hospitals can now accept any acute-care hospital patients and be paid at a higher Medicare payment rate, as mandated by the CARES Act.
  • Healthcare Workforce Augmentation:
    • Beneficiaries may need in-home services during the COVID-19 pandemic, nurse practitioners, clinical nurse specialists, and physician assistants can now provide home health services, as mandated by the CARES Act. These practitioners can now (1) order home health services; (2) establish and periodically review a plan of care for home health patients; and (3) certify and re-certify that the patient is eligible for home health services
    • CMS is allowing physical and occupational therapists to delegate maintenance therapy services to physical and occupational therapy assistants in outpatient settings.
    • CMS is waiving a requirement for ambulatory surgery centers to periodically reappraise medical staff privileges during the COVID-19 emergency declaration
  • Prioritizing Hospitalization Services:
    • CMS is allowing payment for certain partial hospitalization services – that is, individual psychotherapy, patient education, and group psychotherapy – that are delivered in temporary expansion locations, including patients’ homes.
    • CMS is temporarily allowing Community Mental Health Centers to offer partial hospitalization and other mental health services to clients in the safety of their homes. Previously, clients had to travel to a clinic to get these intensive services.
  • Expansion of Telehealth in Medicare:
    • CMS is waiving limitations on the types of clinical practitioners that can furnish Medicare telehealth services. Prior to this change, only doctors, nurse practitioners, physician assistants, and certain others could deliver telehealth services. Now, other practitioners are able to provide telehealth services, including physical therapists, occupational therapists, and speech language pathologists.
    • Hospitals may bill for services furnished remotely by hospital-based practitioners to Medicare patients registered as hospital outpatients, including when the patient is at home when the home is serving as a temporary provider based department of the hospital.
    • Hospitals may bill as the originating site for telehealth services furnished by hospital-based practitioners to Medicare patients registered as hospital outpatients, including when the patient is located at home.
    • CMS previously announced that Medicare would pay for certain services conducted by audio-only telephone between beneficiaries and their doctors and other clinicians. CMS is broadening that list to include many behavioral health and patient education services. CMS is also increasing payments for these telephone visits to match payments for similar office and outpatient visits. This would increase payments for these services from a range of $14-$41 to $46-$110. The payments are retroactive to March 1, 2020.
    • As mandated by the CARES Act, CMS is paying for Medicare telehealth services provided by rural health clinics and federally qualified health clinics.
    • CMS is waiving the video requirement for certain telephone evaluation and management services, and adding them to the list of Medicare telehealth services. As a result, Medicare beneficiaries will be able to use an audio-only telephone to get these services.
  • In addition, CMS is making changes to the Medicare Shared Savings Program to give the 517 accountable care organizations (ACOs):
    • ACOs are groups of doctors, hospitals, and other healthcare providers, that come together voluntarily to give coordinated high-quality care to their Medicare patients. CMS is making adjustments to the financial methodology to account for COVID-19 costs so that ACOs will be treated equitably regardless of the extent to which their patient populations are affected by the pandemic. CMS is also forgoing the annual application cycle for 2021 and giving ACOs whose participation is set to end this year the option to extend for another year. ACOs that are required to increase their financial risk over the course of their current agreement period in the program will have the option to maintain their current risk level for next year, instead of being advanced automatically to the next risk level.
    • CMS is permitting states operating a Basic Health Program (BHP) to submit revised BHP Blueprints for temporary changes tied to the COVID-19 public health emergency that are not restrictive and could be effective retroactive to the first day of the COVID-19 public health emergency declaration.

In response to these changes Seema Verma, CMS Administrator, stated that “CMS’s changes will make getting tested easier” and the health care system “more accessible for Medicare and Medicaid beneficiaries.”

https://www.cms.gov/newsroom/press-releases/trump-administration-issues-second-round-sweeping-changes-support-us-healthcare-system-during-covid

IHS Announces Dissemination of Final $367 million in CARES Act funding with $20 million for UIOs

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On April 23, the Indian Health Service (IHS) announced its decision to distribute $20 million to Urban Indian Organizations (UIOs) in COVID-19 relief aid from the remaining CARES Act resources. These funds will be distributed through existing Indian Health Care Improvement Act (IHCIA) contracts by providing a one-time base amount for each UIO and an additional amount based on each UIO’s Urban Indian users. The announcement came in a Dear Tribal Leader and Urban Indian Organization Leader Letter (DULL) which announced the final allocation decisions for the agency’s remaining $367 million in CARES Act funding.

The DULL also announced a transfer of $125 million to the IHS Facilities Account for IHS and tribal health programs facilities. An additional $50 million will be allocated to IHS health programs and Tribal Health Programs for Community Health Representatives and Public Health Nursing, while $26 million will be set aside for Tribal Epidemiology Centers. The remaining funds will be used for IHS telehealth expansion, COVID-19 prevention, COVID-19 testing, cleaning of IHS facilities, and COVID-19 response and recovery messaging.

These funding allocations finalize the total use of CARES Act funding for IHS. The agency received $1.032 billion from this third wave of COVID-19 legislation. NCUIH continues to advocate for the resources UIOs need to combat COVID-19 by working with lawmakers and federal agencies.

Reps. Gallego, Mullin Introduce Bill Boosting Resources for Urban Indian Health Organizations

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https://rubengallego.house.gov/media-center/press-releases/icymi-reps-gallego-mullin-introduce-bill-boosting-resources-urban-indian

April 20, 2020
Press Release

WASHINGTON, DC – Rep. Ruben Gallego (D-AZ) and Rep. Markwayne Mullin (R-OK) introduced H.R. 6535 last week to expand Federal Tort Claims Act (FTCA) coverage to urban Indian health organizations, giving them a desperately needed boost in resources as they suffer shortages, closures, and financial hardship as a result of the COVID-19 pandemic.

The Indian Health System, commonly referred to as the ITU system, is made up of the Indian Health Service (IHS), Tribal health programs, and urban Indian organizations (UIOs). UIOs provide culturally competent care for the over 70 percent of American Indians and Alaska Natives who live in urban centers. H.R. 6535 would create parity within the ITU system by extending FTCA coverage to urban Indian organizations, who currently are forced to divert resources away from health care in order to foot exorbitant liability costs themselves.

“Urban Indian organizations, including Native Heath in my District, are on the front lines of this pandemic. Individual facilities are reporting skyrocketing costs in the hundreds of thousands and dangerous supply shortages. Three UIOs have already closed their doors as a result of the strain,” said Rep. Gallego, Chair of the Subcommittee for Indigenous Peoples. “We cannot afford to leave urban Indians without access to care during this public health crisis. My bill will both bring long overdue parity to urban Indian health providers and provide an infusion of desperate resources to an urban Indian health system on the brink.”

“Urban Indian Health Centers play a critical role in providing health care to Native Americans. Our bill ensures they are covered by the FTCA so that they won’t have to use their limited resources to cover costly liability bills. I want to thank Congressman Gallego for working with me on this legislation that will improve health care for Native Americans,” said Rep. Mullin.

The National Council for Urban Indian Health (NCUIH) said: We are extremely grateful for Congressman Gallego and Congressman Mullin’s leadership in introducing this legislation for a long-needed fix to the medical malpractice liability protection to ensure parity for Urban Indian Organizations (UIOs). A single UIO can pay as much as $250,000 annually, which could be spent providing health care for the American Indians and Alaska Natives. As all other Indian Health Care Providers are covered by FTCA and it is extended to Community Health Centers as well as volunteers, this legislative fix is needed now more than ever to ensure continuity of health care in a time when it’s needed most.

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NCUIH Joins National Native Organizations in COVID-19 Legislative Request

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(April 20, 2020) – Last week, NCUIH along with a coalition of National Native Organizations sent a letter to Members of both chambers of Congress outlining a joint COIVD-19 recovery legislative proposal for health, education, nutrition, and human services.

NCUIH, along with the National Congress of American Indians, National Indian Health Board, Self-Governance Communication & Education Tribal Consortium, National Association of Food Distribution Programs on Indian Reservations, Native Farm Bill Coalition, Intertribal Agriculture Council, National Indian Education Association, American Indian Higher Education Consortium, National Indian Child Welfare Association, and United South and Eastern Tribes Sovereignty Protection Fund, sent the legislative priorities as Congress negotiates the fourth major legislative package on coronavirus.

The proposal included, among other essential proposals, requests for Congress to:

  • Provide sufficient appropriations to IHS for Indian Health Care Providers as they face the pandemic on the frontlines, including:
    • Provide $1 billion for Purchased/Referred Care (PRC).
    • Provide $1.215 billion for Hospitals and Health Clinics.
    • Establish a $1.7 billion Emergency Third-Party Reimbursement Relief Fund for IHS, Tribal Programs, and Urban Indian Organizations.
    • Provide $85 million for equipment purchases and replacements.
    • Provide $161 million for Urban Indian Health.
    • Provide $1 billion for Sanitation Facilities Construction.
    • Provide $750 million for maintenance and improvement of Indian Health Service and Tribal facilities.
  • Authorize technical Medicaid and Medicare fixes including 100% FMAP for services provided at UIO facilities and technical amendments including Tribal and UIO access to the Strategic National Stockpile.
  • Clarify that the VA is authorized to reimburse UIOs for services provided to Native Veterans.

Letters

C-SPAN Clip: NIHB Chair Victoria Kitcheyan Discusses Indian Health Priorities for COVID-19

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APRIL 9, 2020 | CLIP OF VICTORIA KITCHEYAN ON NATIVE AMERICAN COMMUNITIES AND CORONAVIRUS

Clip Transcript

Call from: Michigan

Thank you so much for taking my call. I run an urban agency an urban indian center just south of Detroit called the American indian Services. We’re a mental health provider as well as a food provider. My question is, what is being done for the 75% of American Indians who live in cities? We’ve had a hard enough time just surviving because the State of Michigan has cut our budget repeatedly for the last 5 years. We’re trying to hang on and serve the American Indians in the cities. If people went home, the tribes would not be able to accommodate them. They would be bankrupt in weeks, so what’s going to be done for the Indian people living in the cities?

Victoria Kitcheyan

Thank you Faith for that question. The urban Indian organization, NCUIH, has been a champion in advocating for urban organizations and they were also included in the first funding package and, in fact, the urban indian priorities are something that cannot be forgotten because many of our tribal members live in urban areas and most recently the National Congress of American Indians and the National Indian Health Board signed on to a letter today advocating for the needs of the fourth funding package and in there the urban needs have also been advocated for. So, I understand your frustration and often the urbans are left out and so the federal agencies have to consult with the federally recognized tribes and they only have to concur with the urban organizations, but we cannot forget our relatives that are living in some of these most highly populated areas that need the resources just as much as we do on the reservation.

Udall, Senate Democrats Unveil COVID-19 “Heroes Fund,” $25,000 Proposed Pay Increase to Essential Workers and, Urban Indian Organizations and Tribal Workers on Frontlines of Pandemic Response

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https://www.indian.senate.gov/news/press-release/audio-udall-senate-democrats-unveil-covid-19-heroes-fund-25000-proposed-pay

AUDIO: Udall, Senate Democrats Unveil COVID-19 “Heroes Fund,” $25,000 Proposed Pay Increase to Essential Workers and Tribal Workers on Frontlines of Pandemic Response

COVID-19 “Heroes Fund” would give Tribal frontline workers equal access to proposed $25,000 premium for essential workers, implement $15,000 Essential Worker Recruitment Incentive to attract and secure frontline workforce needed to fight public health crisis

Udall’s remarks on the COVID-19 Heroes Fund begin at 11:38 here.

WASHINGTON—Today, U.S. Senator Tom Udall (D-N.M.) joined Senate Democratic Leader Chuck Schumer (D-N.Y.) and Senators Patty Murray (D-Wash.), Sherrod Brown (D-Ohio), Bob Casey (D-Penn.), and Gary Peters (D-Mich.) to unveil the COVID-19 “Heroes Fund,” Senate Democrats’ proposal to establish a pandemic premium pay to reward, retain, and recruit essential workers. Senate Democrats’ proposed “Heroes Fund” consists of two major components: a $25,000 premium pay increase for essential workers—including Tribal workers—equivalent to a raise of $13 per hour from the start of the public health emergency until December 31, 2020, and a $15,000 essential worker recruitment incentive to attract and secure the workforce needed to fight the public health crisis.

A summary of Senate Democrats’ COVID-19 “Heroes Fund” proposal can be found here.

“Essential frontline workers in New Mexico, Indian Country, and across America are risking their own health to protect ours, to care for our loved ones, and to keep our communities safe and running. We owe these heroes – the health care workers, first responders, law enforcement, grocery clerks, delivery workers, and many others – more than just words of gratitude: we must make sure they are paid what they deserve,” Udall said.

“Importantly, this proposal will give Tribal frontline workers equal access to these benefits, and includes the necessary flexibility to meet the unique needs of Native communities,” Udall continued. ”Because this crisis is hitting Indian Country especially hard: frontline workers in Native communities are stretched thin, and, due to severe federal underfunding, Indian Country has long struggled to recruit and retain workers in fields like health care and law enforcement. So this proposal is absolutely necessary for Indian Country and for all communities — to support the frontline workers who are doing incredible, life-saving work, and to secure the workforce that we need to keep our nation healthy and strong.”

Across New Mexico, Indian Country, and America, essential frontline workers—doctors, nurses, grocery store workers, transit workers, public safety personnel, and many more—continue to put themselves at risk on the front lines of the COVID-19 pandemic. Udall and Senate Democrats’ proposal would compensate these workers for their great personal sacrifices and tireless dedication while increasing the recruitment of additional workers for the front lines that will be needed in the months ahead.

Udall and Senate Democrats fought for workers-first provisions in the recently-passed CARES Act, the $2 trillion package includes key provisions to support New Mexico, including: direct payments to individual New Mexicans and a major expansion of unemployment benefits, badly-needed direct relief for small businesses, an emergency infusion of resources into hospitals and to support health care workers, and reimbursement for state and Tribal governments that have stepped up to address the crisis.

Udall and Senate Democrats also fought to ensure Tribes had equitable access to federal resources in the recently-passed CARES Act. They secured over $10 billion in resources for Tribes and Native communities to address their unique needs, including providing over $1 billion to the Indian Health Service and establishing an $8 billion Tribal Government Relief Fund.

Portions of the first wave of grants from the package have recently been released to New Mexico, while the Indian Health Service announced disbursement of $600 million of the over $1 billion in funds Udall helped secure from the CARES Act.

“Thousands of workers report to the frontlines of our nation’s pandemic response each and every day, placing themselves squarely in harm’s way to serve the needs of others,” said Leader Schumer. “Senate Democrats’ proposed ‘Heroes Fund’ would provide premium pay to these essential workers—the doctors and nurses, grocery store workers, transit workers, and more who are central to fighting this crisis—and would establish an incentive system to retain and recruit the workforce needed for the long months to come. Essential frontline workers sacrifice daily for our collective health and well-being, and Senate Democrats are fully committed to supplying these heroes the financial support they deserve.”

Listen to the audio of Udall’s remarks, beginning at minute 11:38, here.

A summary of Senate Democrats’ COVID-19 “Heroes Fund” proposal can be found here and below:

The COVID-19 “Heroes Fund” Summary

Senate Democrats’ Proposal for Pandemic Premium Pay to Reward, Retain, & Recruit Essential Workers

Essential frontline workers are the true heroes of America’s COVID-19 pandemic response.  Senate Democrats believe in providing premium pay to frontline workers during this pandemic to reward essential frontline workers, ensure the retention of essential workers who are working grueling hours on the frontlines of this crisis, and promote the recruitment of additional workers who will be needed in the months ahead.

As the Congress looks at a potential fourth COVID-19 bill, the following proposal is meant for consideration by Members of Congress, key stakeholders, and the American people. Senate Democrats’ proposal consists of two major components:

1. A $25,000 pandemic premium pay increase for essential frontline workers, equivalent to a raise of an additional $13 per hour from the start of the public health emergency until December 31, 2020.

2. A $15,000 recruitment incentive for health and home care workers and first responders to attract and secure the workforce needed to fight the public health crisis.

Structure of the Pandemic Premium Pay

To meet the goals of reward, retention, and recruitment, Senate Democrats propose a set dollar amount per hour with a maximum amount for the year, for a definite duration, and with an additional bonus for workers who sign up to do such essential work during this crisis.

Amount of Pay Premium. The proposal—

  • Uses a flat-dollar amount per hour premium model in order to ensure it is clear, simple, and lifts up particularly those workers making lower wages.
  • Would give each essential frontline worker $13/hour premium pay on top of regular wages for all hours worked in essential industries through the end of 2020.
  • Would cap the total maximum premium pay at $25,000 for each essential frontline worker earning less than $200,000 per year and $5,000 for each essential worker earning $200,000 or more per year.

Duration of Premium. The premium pay period—

  • Must be for a specified and clear duration of time to ensure workers can rely on it for their economic security and plan for needs like additional child care.
  • Should cover all hours worked by each essential frontline worker through December 31, 2020, or until the worker’s salary-based maximum premium pay is reached.

Premium Pay as a Recruitment and Retention Incentive.  In order to recruit the additional health care workers, home care workers, and first responders needed over the coming months, thef proposal—

  • Would provide a one-time $15,000 premium for signing on to do essential work.
  • Would limit eligibility for this incentive premium to essential health and home care workers and first responders that are experiencing severe staffing shortages impeding the ability to provide care during the COVID-19 pandemic.[1]

Premium Pay and Worker Incentives Delivery Mechanism

The proposal would fully federally-fund the premium pay and recruitment and retention incentive. We will continue to seek input on the specific mechanism for delivering the pay to workers, as well as the universe of “essential workers” to be covered. The new federal fund would partner with entities designated as an “eligible employer” – states, localities, tribes, and certain private sector employers – to issue the funds premium payments to eligible workers. Frontline federal employees would also be granted the new benefit of up to $25,000.

COVID-19 Heroes Fund. The new COVID-19 Heroes Fund would provide funds directly to eligible employer-partners so that they could distribute the premium payments.

  • Employers in industries engaged in “essential work” would apply to the Heroes Fund for funds to be used to add line-item premium pay to employees’ or independent contractors’ paychecks. The eligible employer would track these payments, provide payroll records demonstrating premium payments, and return any unspent funds to the agency.
  • No employer would be required to participate, but all would be strongly encouraged to and the program would be widely advertised.
  • An entity that contracts directly with the state, locality, Tribe, or the federal government (e.g., to provide care to people with Medicare and Medicaid coverage) would be considered a private sector employer, and employees of this entity who are designated as “essential” would be eligible for premium pay. Similarly, an eligible employer is also an individual who hires someone designated as “essential” through programs established through the State (e.g., self-directed care arrangements). This would help ensure coverage of the 2.2 million home health aides, direct service providers, and personal care workers who provide services to more than 12 million Americans.
  • Eligible employers would submit applications for the recruitment and retention incentive premium on a rolling basis.

Federal Workforce. The proposal would ensure all federal government essential frontline employees receive the same $25,000 premium pay benefit provided to other essential workers.[2]

  • Coverage should be expansive to capture all federal employees with public-facing positions.  This includes Title 5 employees and employees of all other federal personnel systems (e.g., employees of the Postal Service, TSA, VA, FAA, District of Columbia, and federally-funded Indian programs[3]).
  • The benefit would be limited to frontline and public-facing positions – employees who are not teleworking from their homes.

Additional Background and Commentary

Precedents. Disasters require exceptional flexibility in standard work schedules and assignments and often put first responders and other essential workers in dangerous situations. To ensure this critical workforce is compensated appropriately, there are precedents for funding hazard premium pay and worker incentives through a federal program.

FEMA, through the Robert T. Stafford Disaster Response and Emergency Assistance Act and the Disaster Relief Fund, is currently authorized to reimburse state, local, and tribal governments for straight-time and premium pay associated with disaster response. Extraordinary costs (such as call-back pay, night-time or weekend differential pay, and hazardous duty pay) for essential employees who are called back to duty during administrative leave to perform eligible Emergency Work are eligible for reimbursement in certain circumstances.

This authority has been used many times over the last few years to pay for personnel costs associated with enforcing curfews, facilitating evacuation routes, and restoring critical infrastructure. Past usage illustrates precedent for federal funding of critical state, local, and tribal employees performing essential response functions that keep our communities safe in times of disaster.

Essential Frontline Worker definitions. As mentioned above, the definition of essential frontline workers for purposes of both the premium pay increase and the recruitment-retention incentive will be the subject of debate. This proposal is not meant to exclude any worker from this conversation. Rather, we hope this proposal will encourage a discussion about how large and diverse this universe of workers truly is. Our goal is to make federal, state, tribal, local and private sector essential workers that are at risk eligible for this benefit.

Retroactive Pay. Workers who have been on the frontlines since the initial declaration of the Public Health Emergency on January 27, 2020, could receive a lump sum of backpay of $13 per hour for work before enactment. These workers would continue to receive the $13 per hour premium pay on top of regular wages moving forward, but these workers would still be subject to the maximum premium pay cap outlined above.

Additional Benefits for Essential Health and Home Care Workers and First Responders. The employers of frontline health and home care workers and first responders should be eligible to apply for a second round of premium pay funds of up to $10,000 as those workers continue to combat the virus.

Death Benefits. It is a deeply disturbing but unfortunate reality that some of our frontline workers are making the ultimate sacrifice to the nation through their work fighting COVID-19. Their families rightfully deserve to receive the full amount of the premium pay as a lump sum in addition to all other forms of death benefits.

Protections from Corporate Expense Shifting. Certain large corporations engaged in the provision of essential services and goods employ essential frontline workers who are deserving of premium pay. However, massive corporations should make investments in providing premium pay of their own accord before trying to participate in this program.

Protecting Workers and PPE. Senate Democrats have been fighting to give essential workers the protections and equipment they need to stay safe. The CARES Act provided billions of dollars for PPE, and Democrats have pushed the Administration to appoint a czar to handle all manufacturing and distribution of critical PPE. We must do more to ensure all frontline workers have the protective gear they need to perform their jobs safely, and we need a strong emergency temporary standard to protect all workers.

[1] The recruitment and retention incentive might need to cover a broader swathe of workers in Indian Country and other underserved areas that experienced high levels of essential frontline worker vacancies prior to the COVID-19 pandemic.

[2] Certain federal workers are entitled under current law to a maximum 25 percent hazard premium pay for exposure to hazardous substances, including virulent biologicals.  However, President Trump has failed to activate this policy for the federal workforce during the COVID-19 pandemic.

[3] Federally-funded Indian program employees include any employee who works for 1) program operated by an Indian Tribe under an Indian Self-Determination and Education Assistance Act “638” contract or compact; 2) a Tribal Controlled Schools Act “297” grant Bureau of Indian Education school; or, 3) an urban Indian organization operating under an Indian Health Service contract pursuant to Title V of the Indian Health Care Improvement Act.

Indian Health Service (IHS) Opioid Grant Pilot Program (OGPP)

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On April 3, 2020, the Indian Health Service (IHS) in a Dear Tribal Leader and Urban Indian Organization Leaders (DTLL/DUIOLL) announced that they will be creating a new Indian IHS Opioid Grant Pilot Program (OGPP). OGPP is being funded by the $10 million increase for the Alcohol and Substance Abuse Program budget line funding, authorized by The Consolidated Appropriations Act, 2019 (Public Law 116-6).

As an immediate step, IHS will publish a Notice of Funding Opportunity (NOFO) in the Federal Register this spring.  The NOFO will outline details of the eligibility criteria, objectives, and funding methodology.  In general, the IHS anticipates to award up to 18 grants: one grant opportunity open to each of the IHS Areas; three grant opportunities open to Urban Indian Organizations; and three grant opportunities open to highest priority IHS Areas with a targeted focus on Maternal & Child Health.

A component of the OGPP includes national management and administrative activities, including intensive programmatic technical assistance and support to grantees in developing, implementing, and evaluating their pilot program.

The OGPP was formed after considering the input from 26 letters and over 100 comments IHS received during the comment period on OGPP.

Letter to Tribal Leaders and Urban Indian Organization Leaders on IHS CARES Act Funding (April 3, 2020)

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Letter to Tribal Leaders and Urban Indian Organization Leaders on IHS CARES Act Funding (April 3, 2020)

The Indian Health Service announces the availability of, and distribution decisions for, $600 million in new resources appropriated in the recently enacted Coronavirus Aid, Relief, and Economic Security Act (CARES Act), Pub. L. No. 116-136, to address coronavirus (COVID-19) prevention, preparedness, and response in American Indian and Alaska Native (AI/AN) communities.

Policy Analysis: The Coronavirus Aid, Relief, and Economic Security Act (CARES Act)

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Washington, DC (March 27, 2020) – Today, the President signed the Coronavirus Aid, Relief, and Economic Security (CARES) Act, which is the third phase of legislation in response to the coronavirus pandemic. The CARES Act passed the House of Representatives today and cleared the Senate earlier this week.  The bill provides $1.032 billion to the Indian Health Service (IHS) in critically needed resources to support the Indian Health System during the pandemic, including expanded support for medical services, equipment, supplies and public health education for IHS direct service, tribally operated and Urban Indian Organizations; expanded funding for purchased/referred care; and new investments for telehealth services, electronic health records improvement, and expanded disease surveillance by tribal epidemiology centers.

Overview

Funding

Indian Health Service (IHS)

  • The bill provides $1.032 billion to the Indian Health Service (IHS) in critically needed resources to support the Indian Health System during the pandemic, including expanded support for medical services, equipment, supplies and public health education for IHS direct service, tribally operated and Urban Indian Organizations; expanded funding for purchased/referred care; and new investments for telehealth services, electronic health records improvement, and expanded disease surveillance by tribal epidemiology centers.
  • Not less than $450 million shall be distributed through Tribal shares and Urban Indian Organizations.

Center for Disease Control and Preventions

  • Provides for a total of $4.3 billion for program wide activities and support with no less than $1.5 billion to be made available to States, localities, territories, tribes, tribal organizations, UIOs, or health service providers to tribes. Activities include:
  • Surveillance, Epidemiology, Laboratory Capacity, Infection Control, Mitigation, Communications, Other Preparedness and Response Activities
  • Of this, at least $125 million is to be made available to tribes, tribal organizations, UIOs or health service providers to tribes.

Substance Abuse and Mental Health Services Administration (SAMHSA)

  • A total of $435 million is allocated for Health Surveillance and Program Support for SAMHSA. This includes prevention, preparation, and response to COVID-19.
  • No less than $15 million is to be allocated for tribes, tribal organizations, UIOs or health/ behavioral health service providers to tribes.

Health Resources and Services Administration (HRSA)

  • HRSA Rural Health is appropriated $180 million of which no less than $15 million is to be allocated for tribes, tribal organizations, UIOs, or health service providers to tribes to carry out telehealth and rural health activities.

Legislative Authorizations

Special Diabetes Fund for Indians (SDPI)

  • Reauthorizes SDPI at current funding levels through November 30, 2020. Allocates $25,068,493 for the period from October 1, 2020 to November 30, 2020.

Policy Analysis of House Coronavirus Relief Package

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NCUIH Legislative Alert:
Analysis of House Coronavirus Relief Package

Dear UIOs,

Yesterday, the House of Representatives released their latest piece of legislation in response to the novel coronavirus (COVID-19), entitled the Take Responsibility for Workers and Families Act. This bill includes major policy changes NCUIH and UIOs have been working towards, such as 100% FMAP and a fix for the Medicaid clinic “four walls” issue.

NCUIH supports this bill and asks that you please contact your Senators to support the inclusion of UIO-specific authorizing language and emergency supplemental appropriations provisions in the Senate’s coronavirus relief legislation. The Senate is currently working on its next draft of the third coronavirus bill and past drafts have not included authorizing language for 100% FMAP applicability to UIOs.

Below you will find a summary of the relevant provisions to UIOs. Some major pieces include:

The funds in the provisions highlighted below would remain available until September 30, 2021, unless otherwise noted. Provisions with specific references to urban Indian organizations (UIOs) appear highlighted.
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DIVISION A—THIRD CORONAVIRUS PREPAREDNESS AND RESPONSE SUPPLEMENTAL APPROPRIATIONS ACT, 2020

TITLE I—Agriculture, Rural Development, Food and Drug Administration, and Related Agencies

INDIAN HEALTH SERVICE (pages 72- 74)

  • The bill provides for a total of $1,032,000,000 for preparedness, response, surveillance, and health service activities for coronavirus, including for:
    • Urban Indian Organizations
    • Public Health Support
    • Electronic Health Record Modernization
    • telehealth and other IT upgrades
    • Purchased/Referred Care
    • Catastrophic Health Emergency Fund
    • Community Health Representatives
    • Tribal Epidemiology Centers
    • Other activities to protect the safety of patients and staff
  • Not less than $450,000,000 shall be distributed through Tribal shares and contracts with Urban Indian Organizations. Any remaining funding that is not distributed through Tribal shares or UIO contracts “shall be allocated at the discretion of the Director of the Indian Health Service.”
  • When these funds are transferred to tribes and tribal organizations under the Indian Self-Determination and Education Assistance Act (ISDEAA), they will be transferred on a one-time basis (non-recurring), are not part of the amount required by ISDEAA, and may only be used for the purposes of coronavirus preparedness, response, surveillance, and health service activities.
  • Funds may be used to supplement amounts otherwise available under the ‘‘Indian Health Facilities’’ account.
  • In order to use any of these funds to select core components appropriate to support the initial capacity of an Electronic Health Record system, the Committees on Appropriations of the House of Representatives and the Senate must be briefed 90 days in advance of executing a Request for Proposal for the components.
TITLE VIII—DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND RELATED AGENCIES

HEALTH RESOURCES AND SERVICES ADMINISTRATION (page 85)

PRIMARY HEALTH CARE

  • $1,300,000,000 for necessary expenses to prevent, prepare for, and respond to coronavirus, for grants and cooperative agreements under the Health Centers Program, as defined by section 330[1] of the Public Health Service Act, and for eligible entities under the Native Hawaiian Health Care Improvement Act, including maintenance of current health care center capacity and staffing levels.RYAN WHITE HIV/AIDS PROGRAM
  • $90,000,000 for the ‘‘Ryan White HIV/ AIDS Program’’ to prevent, prepare for, and respond to coronavirus through modifications to existing contracts and supplements to existing grants and cooperative agreements.[2]
  • Supplements shall be awarded using a data-driven methodology determined by the Secretary of Health and Human Services.

HEALTH CARE SYSTEMS

  • $5,000,000 to prevent, prepare for, and respond to coronavirus, for activities authorized under sections 127 and 1273 of the Public Health Service Act to improve the capacity of poison control centers to respond to increased calls and communications.
  • Of this amount, not less than $15,000,000 shall be allocated to tribes, tribal organizations, urban Indian health organizations, or health service providers to tribes.

RURAL HEALTH

  • $460,000,000 to prevent, prepare for, and respond to coronavirus, including telephonic and virtual care for the underinsured, and for continuation and expansion of telehealth and rural health activities under sections 330A and 330I of the Public Health Service Act and section 711 of the Social Security Act.
  • Not less than $15,000,000 of this amount shall be allocated to tribes, tribal organizations, urban Indian health organizations, or health service providers to tribes.

CENTERS FOR DISEASE CONTROL AND PREVENTION (page 87)
CDC–WIDE ACTIVITIES AND PROGRAM SUPPORT

  • Total of $5,500,000,000 to prevent, prepare for, and respond to coronavirus, domestically or internationally.
  • Not less than $2,000,000,000 of the amount provided shall be for grants to or cooperative agreements with States, localities, territories, tribes, tribal organizations, urban Indian health organizations, or health service providers to tribes, for such purposes including to carry out surveillance, epidemiology, laboratory capacity, infection control, mitigation, communications, and other preparedness and response activities.
  • Every grantee that received a Public Health Emergency Preparedness grant for fiscal year 2019 shall receive not less than 100 percent of that grant level.
  • Of this amount, not less than $125,000,000 of such funds shall be allocated to tribes, tribal organizations, urban Indian health organizations, or health service providers to tribes.
  • The Director of CDC may satisfy the funding thresholds above by making awards through other grant or cooperative agreement mechanisms.
  • $500,000,000 shall be for public health data surveillance and analytics infrastructure modernization.
  • That funds may be used for grants for the rent, lease, purchase, acquisition, construction, alteration, or renovation of non-Federally owned facilities to improve preparedness and response capability at the State and local level.
  • Funds shall remain available until September 30, 2024.

NATIONAL INSTITUTE OF ENVIRONMENTAL HEALTH SCIENCES (page 90)

  • $10,000,000 for worker-based training to prevent and reduce exposure of hospital employees, emergency first responders, and other workers who are at risk of exposure to coronavirus through their work duties.

SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION (page 93)
HEALTH SURVEILLANCE AND PROGRAM SUPPORT

  • Total of $435,000,000 to prevent, prepare for, and respond to coronavirus, for program support and cross-cutting activities that supplement activities funded under the headings ‘‘Mental Health’’, ‘‘Substance Abuse Treatment’’, and ‘‘Substance Abuse Prevention’’.[3]
  • Of this amount, not less than $15,000,000 shall be allocated to tribes, tribal organizations, urban Indian health organizations, or health or behavioral health service providers to tribes.
  • $60,000,000 of these funds shall be for services to the homeless population.
  • $50,000,000 of these funds shall be for suicide prevention programs.

CENTERS FOR MEDICARE & MEDICAID SERVICES (page 94)

  • For ‘‘Program Management’’, $550,000,000, to remain available until September 30, 2022 to prevent, prepare for, and respond to coronavirus, of which $100,000,000 shall be for necessary expenses of the survey and certification program, prioritizing nursing home facilities in localities with community transmission of coronavirus.

ADMINISTRATION FOR CHILDREN AND FAMILIES (pages 95-102)
LOW INCOME HOME ENERGY ASSISTANCE

  • $1,400,000,000 for ‘‘Low Income Home Energy Assistance’’

CHILDREN AND FAMILIES SERVICES PROGRAMS (pages 98-102)

  • Total of $5,202,000,000.
  • $2,500,000,000 for activities to carry out the Community Services Block Grant Act
  • $25,000,000 shall be available for grants to support the procurement and distribution of diapers through non-profit organizations
  • Each State, territory, or tribe shall allocate not less than xx percent of its formula award to non-profit organizations
  • $100,000,000 for carrying out activities under the Runaway and Homeless Youth Act

ADMINISTRATION FOR COMMUNITY LIVING (pages 102-103)
AGING AND DISABILITY SERVICES PROGRAMS

  • $1,205,000,000 total to prevent, prepare for, and respond to coronavirus
  • $1,070,000,000 shall be for activities authorized under the Older Americans Act of 1965
    • $200,000,000 for supportive services
    • $720,000,000 for nutrition services
    • $30,000,000 for nutrition services under title 19 VI
    • $100,000,000 for support services for family caregivers under part E of title III
    • $20,000,000 for elder rights protection activities

OFFICE OF THE SECRETARY (pages 104- 109)
PUBLIC HEALTH AND SOCIAL SERVICES EMERGENCY FUND

  • $6,077,000,000 for ‘‘Public Health and Social Services Emergency Fund’’, to remain available until September 30, 2024, to prevent, prepare for, and respond to coronavirus, domestically or internationally, including the development of necessary countermeasures and vaccines, prioritizing platform-based technologies with U.S.-based manufacturing capabilities, the purchase of vaccines, therapeutics, diagnostics, and necessary medical supplies, as well as medical surge capacity, workforce modernization, enhancements to the U.S. Commissioned Corps, telehealth access and infrastructure, initial advanced manufacturing, and related administrative activities 
  • The Secretary may take such measures authorized under current law to ensure that vaccines, therapeutics, and diagnostics developed from funds provided in this Act will be affordable in the commercial market
  • Products purchased with funds appropriated in this paragraph may be:
    • Deposited in the Strategic National Stockpile, at the discretion of the Secretary of Health and Human Services
    • Used for grants for the construction, alteration, or renovation of non-Federally owned facilities to improve preparedness and response capability at the State and local level
    • Used for the construction, alteration, or renovation of non-Federally owned facilities for the production of vaccines, therapeutics, and diagnostics where the Secretary determines that such a contract is necessary to secure sufficient amounts of such supplies
  • Not later than seven days after the date of enactment of this Act, and weekly thereafter until the Secretary declares the public health emergency related to coronavirus no longer exists, the Secretary shall report to the Committees on Appropriations of the House of Representatives and the Senate on the current inventory of personal protective equipment in the Strategic National Stockpile, including the numbers of face shields, gloves, goggles and glasses, gowns, head covers, masks, and respirators, as well as deployment of personal protective equipment during the previous week, reported by state and other jurisdictions
  • $100,000,000,000, to remain available until expended, to prevent, prepare for, and respond to coronavirus, to provide grants to public entities, not-for-profit entities, and Medicare and Medicaid enrolled suppliers and institutional providers, including for profit entities, to reimburse for health care related expenses or lost revenues directly attributable to the public health emergency resulting from the coronavirus
    • Grants shall be awarded in coordination with the Administrator of the Centers for Medicare & Medicaid Services and shall not be used to provide grants to reimburse for health care related expenses or lost revenues that have been reimbursed or are eligible for reimbursement from other sources
  • $4,500,000,000, to remain available until September 30, 2022, to prevent, prepare for, and respond to coronavirus, to reimburse the Department of Veterans Affairs for expenses incurred by the Veterans Affairs health care system to provide medical care to civilians

PUBLIC HEALTH EMERGENCY FUND (page 109)

  • $5,000,000,000 for the ‘‘Public Health Emergency Fund’’to remain available until expended, to prevent, prepare for, and respond to coronavirus, to be deposited into the Public Health Emergency Fund, as established under section 319(b) of the Public Health Service Act.
    • Funds appropriated under this heading in this Act may, at the discretion of the Secretary of Health and Human Services, be deposited in the Strategic National Stockpile

GENERAL PROVISIONS—TITLE I (page 127-133)
SEC. 10803.
(a) Funds appropriated in this title may be made available to restore amounts, either directly or through reimbursement, for obligations incurred by agencies of the Department of Health and Human Services to prevent, prepare for, and respond to coronavirus, domestically or internationally, prior to the date of enactment of this Act.
(b) Grants or cooperative agreements with States, localities, territories, tribes, tribal organizations, urban Indian health organizations, or health service providers to tribes, under this title, to carry out surveillance, epidemiology, laboratory capacity, infection control, mitigation, communications, and other preparedness and response activities to prevent, prepare for, and respond to coronavirus shall include amounts to reimburse costs for these purposes incurred between January 20, 2020, and the date of enactment of this Act.

[1] Sections 330(r)(2)(B), 330(e)(6)(A)(iii), and 330(e)(6)(B)(iii) shall not apply to funds provided under this heading in this Act.
[2] Under parts A, B, C, D, F, and section 2692(a) of title XXVI of the Public Health Service Act. Sections 2604(c), 2612(b), and 2651(c) of the Public Health Service Act shall not apply to funds provided under this heading in this Act.
[3] In carrying out titles III, V, and XIX of the Public Health Service Act.

 

DIVISION G—HEALTH POLICIES

TITLE I—MEDICAID

SEC. 70101. INCREASING FEDERAL SUPPORT TO STATE MEDICAID PROGRAMS DURING ECONOMIC DOWNTURNS.

SEC. 70102. LIMITATION ON ADDITIONAL SECRETARIAL ACTION WITH RESPECT TO MEDICAID SUPPLEMENTAL PAYMENTS REPORTING REQUIRE20
MENTS.

  • During the period that begins on the date of enactment of this section and ends the date that is 2 years after the last day of the emergency period, the Secretary of Health and Human Services shall not take any action (through promulgation of regulation, issue of regulatory guidance, or otherwise) to—
    • (1) finalize or otherwise implement provisions contained in the Medicaid Fiscal Accountability Regulation proposed rule published on November 18, 2019; or
    • (2)promulgate or implement any rule or provision similar to the provisions described in paragraph (1) pertaining to the Medicaid program established under title XIX of the Social Security Act[1] or the State Children’s Health Insurance Program established under title XXI of such Act[2]

SEC. 70103. AUTHORITY TO AWARD MEDICAID HCBS GRANTS TO RESPOND TO THE COVID–19 PUBLIC HEALTH EMERGENCY. (pages 254-268)

  • This section includes UIOs in the definition of “Indian tribe” for purposes of awarding home and community-based services (HCBS) grants. 
  • “Indian tribe.—The term ‘‘Indian tribe’’ means an Indian tribe, a tribal organization, or an urban Indian organization (as such terms are defined in section 4 of the Indian Health Care Improvement Act (25 U.S.C. 1603)), and includes a tribal consortium of Indian tribes or tribal organizations (as so defined).”
  • GRANTS TO INDIAN TRIBES.
    • During the COVID–19 public health emergency period, the Secretary may award grants to an Indian tribe in the same manner, and subject to the same requirements, as apply to a State, except as otherwise provided in this paragraph.
    • The bill includes information on the application, monthly grant payment amounts, tribal share of monthly HCBS expenditures, and the grant period.

SEC. 70105. COVERAGE AT NO COST SHARING OF COVID–19 VACCINE AND TREATMENT. (pages 269 – 274)

SEC. 70106. OPTIONAL COVERAGE AT NO COST SHARING OF COVID–19 TREATMENT AND VACCINES UNDER MEDICAID FOR UNINSURED INDIVIDUALS. (pages 275 – 276)

SEC. 70107. TEMPORARY INCREASE IN MEDICAID FEDERAL FINANCIAL PARTICIPATION FOR TELEHEALTH SERVICES. (pages 277 – 278)

SEC. 70108. EXTENSION OF FULL FEDERAL MEDICAL ASSISTANCE PERCENTAGE TO INDIAN HEALTH CARE PROVIDERS. (page 278)

  • Extends 100% FMAP to Urban Indian organizations,[3] Indian health care providers[4]
  • Provides a fix for the Medicaid clinic “four walls” issue.
  • The section reads:
    • Section 1905 of the Social Security Act (42 U.S.C. 1396d) is amended—
      • (1) in subsection (a)(9), by inserting ‘‘and including such services furnished in any location by or through an Indian health care provider (as defined in section 1932(h)(4)(A))’’ before the semicolon; and
      • (2) in subsection (b)—
        • (B) by striking ‘‘Indian Health Care Improvement Act)’’ and inserting ‘‘Indian Health Care Improvement Act), or through an urban Indian organization (as defined in section 4 of the Indian Health Care Improvement Act) pursuant to a grant or contract with the Indian Health Service under title V of the Indian Health Care Improvement Act’’.“

SEC. 70110. INCREASED FMAP FOR MEDICAL ASSISTANCE TO NEWLY ELIGIBLE INDIVIDUALS. (page 282 – 283)

SEC. 70111. RENEWAL OF APPLICATION OF MEDICARE PAYMENT RATE FLOOR TO PRIMARY CARE SERVICES FURNISHED UNDER MEDICAID AND INCLUSION OF ADDITIONAL PROVIDERS. (page 283- 290)

  • Includes FQHC

SEC. 70114. EXTENSION OF EXISTING SECTION 1115 DEMONSTRATION PROJECTS. (page 292- 295)

  • Upon request by a State, the Secretary of Health and Human Services shall approve an extension of the waiver and expenditure authorities for a demonstration project described in subsection (a) for a period up to and including December 31,2021, to ensure continuity of programs and funding during the emergency period.
EXPEDITED APPLICATION PROCESS.
  • The Federal and State public notice and comment procedures or other time constraints otherwise applicable to demonstration project amendments shall be waived to expedite a State’s extension request pursuant to this section.

SEC. 70118. EXTENSION OF THE COMMUNITY MENTAL HEALTH SERVICES DEMONSTRATION PROGRAM.

  • Extends program end date from May 22, 2020 to November 30, 2020.
[1] 42 U.S.C. 1396 et seq.
[2] 42 U.S.C. 1397aa et seq.
[3] As defined in section 4 of the Indian Health Care Improvement Act.
[4] As defined in section 1932(h)(4)(A) of the Social Security Act.
TITLE II—MEDICARE

SEC. 70201. COVERAGE OF THE COVID-19 VACCINE UNDER THE MEDICARE PROGRAM WITHOUT ANY COST-SHARING. (page 298-300)

SEC. 70202. HOLDING MEDICARE BENEFICIARIES HARMLESS FOR SPECIFIED COVID-19 TREATMENT SERVICES FURNISHED UNDER PART A OR PART B OF THE MEDICARE PROGRAM. (page 300-305)

SEC. 70204. ENHANCING MEDICARE TELEHEALTH SERVICES FOR FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS DURING THE EMERGENCY PERIOD. (page 305-308)

  • The Secretary shall pay for telehealth services that are furnished via a telecommunications system by an FQHC to an eligible telehealth individual SPECIAL PAYMENT RULE.—
  • The Secretary shall develop and implement payment methods that apply under this subsection to an FQHC that furnishes a telehealth service to an eligible telehealth individual during such emergency period.
  • Such payment methods shall be based on payment rates that are similar to the national average payment rates for comparable telehealth services under the physician fee schedule.
TITLE V—PUBLIC HEALTH POLICIES

Subtitle A—Improving Public Health and Medical Response
PUBLIC HEALTH DATA SYSTEM TRANSFORMATION. EXPANDING CDC AND PUBLIC HEALTH DE PARTMENT CAPABILITIES.—(page 417)

Subtitle B—Tribal Health (pages 435 – 443)
SEC. 70521. IMPROVING STATE, LOCAL, AND TRIBAL PUBLIC HEALTH SECURITY. (pages 435-442)

  • Includes urban Indian organizations’ as eligible entities and describes the determination of funding amount.
  • The Secretary shall award at least 10 cooperative agreements under this section

SEC. 70522. PROVISION OF ITEMS TO INDIAN PROGRAMS AND FACILITIES. (page 442)

  • Ensures that items (drugs, vaccines and other biological products, medical devices, and other supplies) from the Strategic National Stockpile are deployed to urban Indian organizations.

SEC. 319F–5. DISTRIBUTION OF QUALIFIED PANDEMIC OR EPIDEMIC PRODUCTS TO INDIAN PROGRAMS AND FACILITIES. (page 443)

  • Specifically includes urban Indian organizations
  • Secretary distributes qualified pandemic or epidemic products[1] to States or other entities, such products are distributed directly to health programs or facilities operated through an urban Indian organization

SEC. 70542. DIABETES PROGRAMS.

  • Extends Special Diabetes Program for Indians (SDPI) to November 30, 2020.
[1] As defined in section 319F–3(i)(7).