American Indian Health Commission
for Washington State
AI/AN Qualified Health Plan Cost Sharing:
WA Referral and Payment
Presented By:
www.erblawfirm.com
[email protected]
360-220-1519
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Presentation Objective
Understand special Qualified Health Plan
(QHP) American Indian/Alaska Native cost
sharing provisions in the Patient Protection
and Affordable Care Act (ACA) and how they
intersect with:
(1) IHS rules for referrals and authorizations;
(2) Washington Administrative Code, Chapter
284-43.
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Presentation Outline
1. AI/AN QHP Cost Sharing Overview
2. CHS Referral vs. Authorization
3. Cost Sharing Example Scenarios
4. Office of the Insurance Commissioner
Complaint Process
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AI/AN Cost Sharing Overview
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Definition of Cost Sharing*
Share of costs covered by an individual’s
insurance that he/she pays out of his/her own
pocket with respect to essential health benefits
required in QHPs. This term generally includes:
 Deductibles
 Coinsurance
 copayments, or similar charges
*See 45 CFR 155.20
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Definition of Co-Insurance
Share of the costs of a covered health care
service, calculated as a percent (for example,
20%) of allowed amount for the service. An
individuals pays coinsurance plus any
deductibles he owes. For example, if the health
insurance or plan’s allowed amount for an office
visit is $100 and he’s met his deductible, his
coinsurance payment of 20% would be $20. The
health insurance or plan pays the rest of the
allowed amount.
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What is NOT Cost Sharing
Cost Sharing does NOT include
– premiums**
– balance billing amounts for nonnetwork providers, OR
– spending for non-covered services
*See 45 CFR 155.20
**BUT cost sharing in Medicaid and CHIP does
include zero premiums.
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What is NOT Cost Sharing (cont.)
Balanced Billing Defined*
When non-network provider bills you for
difference between provider charge and
allowed amount.
 Example: if provider charge is $100 and
allowed amount is $70, provider may
bill the patient for remaining $30.
*Source: healthcare.gov
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AI/AN QHP Cost Sharing
Two types of AI/AN QHP Cost
Sharing
(1)Limited cost-sharing
(2)No cost-sharing
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QHP Zero Cost Sharing
Protections for AI/AN
AI/AN enrolled in a QHP have no cost
sharing* if they are below 300% of Federal
Poverty Level (a household income of less
than $70,650 for a family of four and $34,470
for an individual).
See Section 1402(1)(2)(A), ACA, 42 U.S.C. 18071(d)(1)(A).
*no cost-share plans in WA are called Cost-Sharing Reduction (CSR)
Tier 2 plan variations. The tribal referral to a specialty care provider is
referred to as CSR Tier 3 plan variations
NOTE: For non-AI/AN, anyone (non AI/AN) between 138% and 250% depending on income within that range, their cost-sharing could be
reduced by a percentage
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QHP Limited Cost Sharing
Protections for AI/AN
AI/AN enrolled in a QHP, if they are above
300% of federal poverty level, have no cost
sharing when they receive an item or service
directly from an Indian health care provider
or from an Indian health care provider
through referral from through contract health
services.
See Section 1402(d)(2)(A), ACA, 42 U.S.C. 18071(d)(2)(A)
NOTE: AI/AN Cost-Sharing Reduction (CSR) Tier 2 and 3 plan variations.
The limited cost-sharing plans may benefit Tribal descendants,
however.
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Washington Health Insurance Issuers:
AI/AN Cost Sharing Requirements
Washington State requires all health
insurance issuers, including non-QHPs, to
ensure all AI/AN enrollees can receive medical
and behavioral health services from Indian
health care providers at the same cost they
would receive from a network provider/facility,
“even if the Indian health care provider is not
a contracted provider.”
See WAC 284-43-200(9), emphasis added.
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Washington Health Insurance Issuers:
AI/AN Cost Sharing Requirements Cont.
Issuers can limit payment to that
amount payable if the health service
were obtained from a network provider
or facility.
See WAC 284-43-200(9)
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Special Note on Out-of-Network I/T/U
Services and Closed Panel HMOs
Closed Panel HMO: a HMO in which physicians are
either employees of the HMO or belong to a group of
physicians who contract with it.
CCIO, without consultation with tribes, has informally
stated that an Closed Panel HMO may expect patient
to pay entire cost of visit (for all plan variations).
However, CCIO also stated an I/T/U has a right to be
paid by the insurance company under Section 206,
IHCIA.
See also RCW 43.71.065(1)(c)
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Contract Health Services*
Referral and Authorization
System
*Now referred to as “Purchase/Referred Care”
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CHS Referral vs. Authorization
In order to understand how AI/AN QHP
Cost Sharing works, it is important to
review/understand the difference between
Contract Health Services (CHS) Referrals v.
Authorizations.
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CHS REFERRAL ≠ CHS AUTHORIZATION
CHS REFERRAL*
CHS AUTHORIZATION*
Provides access to CHS
Provides authorization
in the IHS delivery
to make a payment for
system
services if certain
 Allows for QHP Cost
conditions are met:
Sharing
 Residency requirements
 does not authorize
 Notification requirements
payment for the medical
 Medical priority
care delivered
 Use of alternate
*IHS Circular 91-07
resources
*Indian Health Services
Manual, Ch. 3
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QHP Referral & Payment Examples
The following scenarios are taken from
examples provided by the Medicare,
Medicaid and Health Reform Policy
Committee, National Indian Health
Board, May 23, 2014.
AIHC is working with the Office of the
Insurance Commission and the
Washington Health Benefit Exchange to
tailor these examples to Washington
State.
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QHP Referral & Payment
Example 1: In-Network I/T/U Provider
Scenario: AI/AN goes to an in-network I/T/U
provider for a primary care visit.
 No plan referral or CHS referral is needed.
Patient pays no cost sharing for essential health
benefit (EHB).
 Plan pays provider the contracted amount with
no deduction for patient cost sharing.
 This scenario applies to both zero and limited
cost sharing plan variations.
*Source: Tables on Referrals and Payment Rates for Services for American Indians and Alaska
Natives Enrolled in Marketplace Plans, Medicare, Medicaid and Health Reform Policy Committee,
National Indian Health Board, May 23, 2014.
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QHP Referral & Payment
Example 2: Out-of-Network I/T/U Provider
Scenario: AI/AN goes to an out-of-network I/T/U provider
for a primary care visit.
 Plan may set rate for out-of-network cost sharing, but
patient exempt from paying cost sharing.
 If plan rules state no payment for out-of-network
providers without a plan referral, then I/T/U can still bill
plan for services provided under Sec. 206 of IHCIA, and
plan must pay amount without deducting cost-sharing
that would otherwise be charged to patient.
 Applies to both zero and limited cost sharing plan
variations.
*Source: Tables on Referrals and Payment Rates for Services for American Indians and Alaska
Natives Enrolled in Marketplace Plans, Medicare, Medicaid and Health Reform Policy
Committee, National Indian Health Board, May 23, 2014.
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QHP Referral & Payment
Example 3: In-Network Non-I/T/U Provider
Zero Cost Sharing
Scenario: AI/AN goes to non-ITU innetwork provider for primary or
specialty care.
 No CHS referral is needed for EHB services;
However, the plan may require a referral from a
primary care provider to a specialist.
 Patient pays no cost sharing.
 If service is non-EHB, CHS authorization required
in order for patient to avoid responsibility for any
costs.
*Source: Tables on Referrals and Payment Rates for Services for American Indians and
Alaska Natives Enrolled in Marketplace Plans, Medicare, Medicaid and Health Reform
Policy Committee, National Indian Health Board, May 23, 2014.
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QHP Referral & Payment
Example 4: In-Network Non-I/T/U Provider
Limited Cost Sharing
Scenario: AI/AN goes to non-ITU in-network
provider for primary or specialty care

CHS referral needed to avoid any co-pays or
deductibles for EHB services.

CHS referral may be issued before or after the
appointment.
*Source: Tables on Referrals and Payment Rates for Services for American Indians and Alaska
Natives Enrolled in Marketplace Plans, Medicare, Medicaid and Health Reform Policy Committee,
National Indian Health Board, May 23, 2014.
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QHP Referral & Payment
Example 5: Out-of-Network Non I/T/U
Providers
Scenario: AI/AN goes to a non-I/T/U out-ofnetwork provider for primary care or specialty
care
 If plan requires plan referral to go out-of-network
and patient has plan referral, there should be no
cost sharing for patient for EHB services
 If plan does not require a plan referral to go out-of
network, patient should have no cost sharing for
EHB services
 If plan does not pay for any out-of-network
providers, then CHS authorization is needed for
full amount
 Applies to both zero and limited cost sharing
variations
*Source: Tables on Referrals and Payment Rates for Services for American Indians
and Alaska Natives Enrolled in Marketplace Plans, Medicare, Medicaid and Health
Reform Policy Committee, National Indian Health Board, May 23, 2014.
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Office of the Insurance Commissioner
Complaint Process

I/T/Us and clients can take several actions (demand
letters, civil action, Indian Addendum, etc.) to
increase likelihood of issuer compliance with cost
sharing requirements.

One such action infrequently discussed is filing a
complaint with State of Washington’s Office of the
Insurance Commissioner (OIC).

Filling a complaint with OIC will assist tribes and
tribal organizations in seeing patterns/trends
among particular issuers not complying with cost
sharing and reimbursement requirements.
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Office of the Insurance Commissioner
Complaint Process (cont.)

I/T/Us can file a complaint online at
https://fortress.wa.gov/oic/onlineservices/Login.aspx
?module=CC
 In recognition of government-to-government
relationship between tribes and WA State, tribes and
I/T/Us may contact OIC tribal liaison, John Hamje at
[email protected] or (360)725-7262, to assist
with OIC complaint process.
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Resources
American Indian Health Commission for Washington State
(AIHC) – Indian Health Care Reform Manual http://www.aihcwa.com/aihc-health-policy-issues/indian-health-care-reformmanual-for-wa-state/
Washington Health Benefit Exchange, Sheryl Lowe, Tribal
Liaison, [email protected]
Tribal Self-Governance Health Care Reform Site
http://www.tribalselfgov.org/NEWSGCE/healthcare/Blog_page/he
althblog2.html
National Indian Health Board (NIHB) http://www.nihb.org
Northwest Portland Area Indian Health Board
http://www.npaihb.org/policy/policy_overview