Last week, the Centers for Medicare and Medicaid Services (CMS) issued its final rule updating Medicaid regulations that aim to make it easier for low-income older adults and people with disabilities to get help with their Medicare costs. The new final rule on “Streamlining Medicare Savings Program Eligibility Determination and Enrollment” simplifies the burdensome processes for applying to, and verifying income and assets for, the Medicare Savings Programs (MSPs) across states.  

The agency notes that only about half of the people eligible for MSPs are currently enrolled, so reducing the paperwork burden and streamlining the enrollment rules will help many older adults get the financial help that MSPs offer. The changes are designed to  help the millions of people who currently have MSPs retain coverage during redeterminations and renewals, especially our Elders who we have seen dropped from coverage. 

Under the final rule, many recipients of supplemental security income (SSI) will now be enrolled automatically into the most comprehensive form of MSP coverage: the Qualified Medicare Beneficiary (QMB) eligibility group, which covers Medicare premiums and cost sharing.  According to CMS, this should ease the burden on MSP applicants and enrollees to provide documentation of income and assets and should ensure QMB enrollment for people with Part A premiums is effective when Medicare entitlement begins.  

Learn more about the new rule in CMS’s press release. 

On September 8, Deputy Administrator and Director of the Center for Medicaid and CHIP Services (CMCS), Dan Tsai, published a CMCS informational bulletin (CIB) announcing the further extension of the “four walls” grace period to February 2025. CMS’s current interpretation of the clinic benefit regulations provided in 42 C.F.R. § 440.90 prohibits Medicaid reimbursement for “clinic services” provided outside of the four walls of a facility. Without this grace period, the current interpretation prevents access to care, including home visits, telehealth, and other necessary outpatient services. The bulletin clarifies that this grace period extension applies to Tribal, IHS-operated, and state facilities.    

The CIB notes the period of unwinding after the COVID-19 public health emergency has increased workloads and potentially complicated a Tribe’s decision about the Federally Qualified Health Center (FQHC) option presented by CMCS in a CIB published on January 15, 2021. CMCS suggested pursuing FQHC status for facilities as a potential solution because the CMS clinic benefit regulations which create the “four walls” rule do not apply to FQHCs. The bulletin also echoed what Mr. Tsai shared at the last TTAG Face-to-Face meeting in July: this extension is meant to signal the agency’s intention to resolve the four walls issue and to give CMS time to work through the complex regulatory impact of such a change and the statutory barriers that exist. 

On August 30th and August 31st, the Indian Health Service (IHS) Tribal Self-Governance Advisory Committee (TSGAC) held an in-person meeting in Washington, DC. The TSGAC provides an opportunity for Tribal leaders and federal officials to engage on IHS programs, services, and issues with particular focus on strengthening Tribal self-governance. This most recent meeting featured updates and discussions about Fiscal Year 2024 appropriations, IHS’s unobligated funds, and IHS’s standing on the Government Accountability Office’s High Risk List.    

National Indian Health Board (NIHB) Director of Budget and Appropriations, Tyler Scribner, presented an analysis of the 2024 Fiscal Year Appropriations legislative outlook. Mr. Scribner discussed the significance of Continuing Resolutions given that the FY 2023 will end on September 30th. Passing a Continuing Resolution would keep the government funded beyond September 30. Fortunately, most of the IHS budget has IHS advance appropriations, so even if a government shutdown were to occur, these functions of IHS would continue.  

IHS Director of Office of Finance and Accounting, Jillian Curtis, IHS’ unobligated funds. IHS shared that the Purchased/Referred Care (PRC) Program makes up 16% of prior year unobligated balances. Ms. Curtis shared that part of the root cause for these unobligated balances is the suspension of services during the COVID-19 public health emergency, which lessened referral activity. Congress is concerned about this issue as well, especially as they look to make funding decisions for FY 2024. To manage these unobligated funds, IHS has developed a Status of Funds Dashboard which displays funding balances in real time. IHS is also currently both leading an agency-wide effort to identify causes and solutions for unobligated funds and reviewing unobligated funds by location to update plans for their management. IHS Deputy Director Benjamin Smith also shared that IHS will soon announce Tribal consultation to revise the medical priorities list, which impacts PRC eligibility, to strengthen IHS’ focus on prevention services.  

The importance of creating a path off the Government Accountability Office’s (GAO) High Risk List was another topic of discussion at the latest TSGAC meeting. The High Risk Report is compiled by the GAO at the start of every Congress to address shortcomings from agencies that “provide critical services.” The GAO first included IHS in its High Risk Report in 2017.  Executive Director of Self-Governance Communication and Education Tribal Consortium (SGCETC), Jay Spaan, shared updates from the GAO Tribal and Indigenous Advisory Committee (TIAC) on the High Risk List. Spaan shared that removing IHS from the List is a priority for the TIAC, and it will also be the focus of multiple upcoming meetings for the committee. The TSGAC highlighted that the GAO understanding Tribal sovereignty is essential as TIAC efforts continue.  

The meeting closed with reflections from Smith that the close of this fiscal year is going to be “extremely busy” and communicated the IHS leadership’s willingness and enthusiasm to work towards “meaningful results because we know the Indian Health Service is here to stay.” 

As of last week, the House and Senate are both back on Capitol Hill. Speaker Kevin McCarthy planned for House lawmakers to pass the defense funding bill, but the votes were not there. Now, the plan is to pass a continuing resolution instead. On September 12th, the Speaker announced an impeachment inquiry into President Joe Biden. The inquiry will be conducted by the House Judiciary Committee, Ways and Means Committee, and Oversight Committee. The Senate was making progress on the minibus, but the unanimous consent request to package the three bills together was blocked, meaning the bills may be considered individually rather than together. Both chambers left last week without accomplishing much, let’s hope this week is different. 

In August, the Indian Health Service (IHS) released three notices proposing to expand the Purchased/Referred Care Delivery Areas (PRCDAs) for seven Mid-Atlantic Tribes,  the Confederated Tribes of Grand Ronde, and the Spokane Tribe of Indians. Each of these Delivery Area expansions increases the number of Tribal members who are eligible for PRC payment of services but does not increase the funding for these PRC programs.  

The Purchased/Referred Care (PRC) Program can pay for medical or dental services delivered outside of IHS and Tribal health facilities if a Tribal member can meet requirements relating to residency, notification, medical priority, and alternate resources. PRC is an impactful program because it can help fill gaps when Tribal members have difficulty accessing direct care from IHS and Tribal facilities that are far away, unable to offer necessary emergency or specialty care, or are over their capacity. 

Generally, to be eligible for PRC, a Tribal member must live in a county that contains or shares a border with a reservation—though there are exceptions. After consultation, the Secretary of Health and Human Services can modify the boundaries of PRCDAs. New PRCDA designations must take into account factors, including how many Tribal members would be newly included or excluded and impacts on funding.  

In the Mid-Atlantic region proposal, the seven separate PRCDAs for the Pamunkey Indian Tribe, Chickahominy Indian Tribe, Chickahominy Indian Tribe—Eastern Division, Upper Mattaponi Tribe, Rappahannock Tribe, Inc., Monacan Indian Nation, and Nansemond Indian Tribe would combine to create one collective PRCDA. IHS estimates that this redesignation will make a further 1006 Tribal members eligible for PRC. The proposal for the Confederated Tribes of Grande Ronde would expand the PRCDA to now include Clackamas County, which is estimated to grant eligibility to 179 more Tribal members. For the Spokane Tribe of Indians, the revised PRCDA would add Spokane County and Whitman County, making approximately 480 Tribal members newly eligible for PRC.  

It is important to note that while these redesignations make more people eligible, none of these changes come with an increase in funding for the PRC programs. There are limits on the capacities of PRC in part because IHS is chronically underfunded and already serves as the payor of last resort to help make up for this shortage of funding. To this end, PRC requires people to seek funding from alternative resources such as Medicare, Medicaid, or other insurance options to be eligible for payment of services. 

Comments on these PRCDA expansions are open until August 31 for the Mid-Atlantic Tribes, September 6 for the Confederated Tribes of Grande Ronde, and September 8 for the Spokane Tribe of Indians. Commenting on these notices from IHS is an opportunity to exercise Tribal sovereignty and engage in the management of health systems in Tribal communities. See the Federal Register notices linked above for more information on how to comment.