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Summit Report Update
Tribal Health Programs as Providers in the Exchange
Issue Statement
Health insurance exchanges under the Affordable Care Act (ACA) will offer services for
American Indian/Alaska Natives (AI/AN) through qualified health plans (QHPs). Federal laws
and rules do not explicitly require QHPs to contract with Tribal and urban Indian health care
programs (“Indian Health Care Providers”). ACA only requires QHPs to contract with “… a
sufficient number and geographic distribution of essential community providers, where
available, to ensure reasonable and timely access to a broad range of such providers for lowincome, medically underserved individuals in the QHP's service area, in accordance with the
Exchange's network adequacy standards.”
AIHC will work with the Washington Health Benefit Exchange (WHBE) Board and Office of
Insurance Commissioner (OIC) to ensure that AI/AN enrollees have culturally appropriate access
to Tribal and urban Indian health programs (after referred to as ”Indian Health Care Providers”1)
that are consistent with Indian Care Improvement Act (IHCIA) requirements. Specifically,
AIHC will recommend that the WHBE and OIC require health carriers wanting to be certified as
QHPs to (1) offer network contracts to all Indian Health Care Providers in their service area; and
(2) utilize the Health and Human Services (HHS) “QHP Model QHP Addendum for Indian
Health Care Providers” to ensure that QHPs comport with IHCIA federal requirements.
Next Steps
Based on the AIHC Executive Committee’s February 1, 2012, Level 2 Establishment Grant
meeting, the following steps were considered:
1. After WHBE issues its revised “Guidance for Participation in the Washington Health
Benefit Exchange” document, the AIHC should send a letter to all of Washington’s
Tribes and two urban Indian health programs that describes the OIC/WHBE QHP
contracting requirements with Indian Health Care Providers.
2. The AIHC Executive Committee should consider convening one or two videoconference
meetings with the Tribes and urban Indian health programs to discuss the OIC/WHBE
QHP contracting requirements with Indian Health Care Providers. The videoconference
would be designed to have a live question and answer session.
3. The AIHC Executive or Policy Committee should consider what actions to take on
supporting Tribes to negotiate payment with QHPs that are consistent IHCIA Section 206
payment requirements.
1
Indian Health Care Provider means a health program administered directly by the Indian Health Service (IHS) or operated by
an Indian tribe or tribal organization under the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) or
by an urban Indian organization that operates a health program under Title V of the Indian Health Care Improvement Act (25
U.S.C. §§ 1651 et seq.)
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The AIHC Negotiating Team met with Beth Berendt, OIC Deputy Commissioner, on May 20,
2013, to discuss next steps (see Exhibit 1). OIC committed to holding an All-Filers meeting
with Tribal and AIHC representatives and WHBE representatives. Beth indicated at that time
OIC would not be getting final network contracts from potential QHPs until the middle of July
and that QHPs would be likely continuing to develop their networks until the start of open
enrollment beginning October 1, 2013. Given OIC resource constraints, OIC could not commit
to holding an All-Filers meeting until the middle to end of September.
On August 7, 2013, the AIHC Executive Committee’s Negotiating Team set forth the following
next steps to ensure the QHPs offered contracts to Indian Health Care Providers in their service
area:
1. Have the OIC schedule an All-filers meeting with representatives from the health carriers
whose QHPs were approved; tribes; WHBE; OIC; and AIHC. This meeting will
hopefully occur before mid-September.
2. AIHC wants one Washington Indian Addendum for contracting between tribes and QHP
carriers. In the interim, we can accept having two OIC-approved Model Indian Addenda
– (1) the November 2012 HHS draft Addendum that AIHC submitted in December 2012
to the OIC and interested health carriers; and, (2) the final CMS Model Addendum.
The AIHC Executive Committee has directed Heather Erb and Roger Gantz to develop a
Washington QHP Indian Health Care Provider Addendum. The Washington Addendum would
be based on the HHS November 2012 draft addendum that Tribes had approved with certain
modifications.
Leslie Wosnig will be work with Molly Nollette, Beth Berendts OIC replacement, to schedule
the Tribal All fillers meeting.
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Summit Report Update
Health Exchange and Tribes as Premium Sponsors-Indian Access &
Enrollment in The Exchange: Medicaid Expansion &
Tribal Outreach/Education
Indian Access & Enrollment in the Exchange
The AIHC Grant Team developed the “AIHC Get Covered Workgroup.” The primary purpose
of this workgroup is to provide technical support to tribes, UIHPs, and the Washington Health
Benefit Exchange (WHBE) for AI/AN accessing health care coverage through Washington
Healthplanfinder.
The AIHC advocated for and succeeded in ensuring that all tribes and
UIHPs will have the ability to have their own WHBE certified tribal assisters. The AIHC also
sought from the WHBE an extension of the 90-day requirement for AI/AN to verify enrollment
in a federally-recognized tribes for purposes of accessing their benefits and protections under the
Affordable Care Act. The WHBE has agreed to extend the 90-day requirement on a case-bycase basis and upon meeting certain requirements. The AIHC is currently working to develop a
Tribal Assister training and outreach program.
Tribal Sponsorship
The AIHC Grant Team, which includes the AIHC Get Covered Workgroup, has continued to
provide ongoing support to the Exchange and the tribes in the development and design of the
mechanics/operations of tribal premium sponsorship including how tribes and urban indian
health programs (UIHP) can initiate participation in the program and how the payment process
will work. The Get Covered Workgroup is currently developing educational premium
sponsorship materials for tribes and UIHPs.
Tribal Outreach & Education re Medicaid Expansion and the Exchange
Since January 2013, the AIHC has delivered numerous training workshops to each of the 29
tribes and 2 urban Indian organizations (see Attachment X for specific events and participation
data). Over 114 tribal representatives have participated in these workshops, many on a regular
basis. AIHC conducted five webinars: Comprehensive Overview of the Affordable Care Act,
Qualified Health Plans, Affordable Care Act Basics, Serving Urban Indians Under the
Affordable Care Act, and Tribal Premium Sponsorship. In collaboration with the Northwest
Portland Indian Area Health Board, the AIHC has also provided seven comprehensive on-site
workshops covering Indian-specific issues under the Affordable Care Act and continuous
updates on evolving provisions. AIHC has posted to the AIHC website previously recorded
webinars and helpful information and tools for tribal leaders, clinic administration, and AI/AN
individuals.
*See www.aihc-wa.com for recording of webinars and other helpful tribal health care reform
tools.
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PUBLIC HEALTH CAPACITY: THREATS AND OPPORTUNITIES, PANDEMIC
THREATS, PREPARATION AND RESPONSE
Primary Categories of Recommendations
A. Acknowledging American Indians and Alaska Natives a s a “priority population” for disease
outbreaks, epidemics and pandemics
B. Improving cross-jurisdictional communication between Tribes, local health jurisdictions, and
DOH
C. Improving vaccine distribution practices to Tribes
D. Increasing understanding and recognition of tribal sovereignty
A. Priority Population
Breakout Participants’ Recommendations
o DOH, AIHC and Tribes - continue to develop vaccine distribution systems that assure timely
and adequate access of vaccines for Tribes during public health emergencies
o AIHC and Tribes - follow up with IHS, to advocate for Federal recognition of Tribes as
priority populations for all future pandemics; this work should be immediate, to proactively
prepare for future emergencies
o Each Tribe - develop processes for defining and serving priority populations within their
service population (for example, elders, home-bound individuals, etc.)
o AIHC - provide Tribes with examples of best practices and Tribal public health codes
(Jamestown S’Klallam Tribe is an example of a Tribe that has developed a public health
code)
Work Completed
o AIHC Staff Consultant participated in the planning committee for the 2013 Tribal Public
Health Emergency Preparedness Conference. AIHC Staff Consultant developed and
presented a breakout session titled “Strategies for Effective Vaccine Distribution to Tribes
During Public Health Emergencies. The breakout session was attended by Tribal, IHS, and
Local Health representatives. Topics discussed included priority populations, developing
effective systems, and others.
B. Cross-Jurisdictional Communication
Breakout Participants’ Recommendations
o AIHC - take inventory to assure all Washington Tribes have active bidirectional interfaces
from their EHRs to the Washington State Immunization Information System
o Tribes – develop a mechanism to assure that tribal members who are incarcerated and in
other institutional settings receive care and access to immunizations during emergencies
o AIHC and DOH – develop a mechanism to keep the Tribal PHEPR contact list updated, at
least annually
o AIHC – schedule regular meetings for Tribes to share PHEPR knowledge and work together
to address needs
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Work Completed
o AIHC Staff Consultant submitted updated Tribal PHEPR contact list to DOH
o AIHC Staff Consultant participated in the 2013 10th Annual NWTEMC Emergency
Management Conference and presented at a breakout session on: Lessons Learned Using
Videoconferencing Technology
C. Vaccine Distribution
Breakout Participants’ Recommendations
o DOH – develop an After Action Report that outlines lessons learned during the Pertussis
epidemic of 2012 and includes feedback from all 29 Tribes and the two Urban Indian
Organizations
o DOH – simplify documentation for accessing the State Pharmaceutical Cache
Work Completed
o AIHC Staff Consultant coordinated the purchase of mobile emergency vaccine distribution
supplies for Tribes and Urban Indian Organizations
o AIHC Staff Consultant developed a project proposal for improving strategies for effective
vaccine distribution to Tribes during public health emergencies and submitted to DOH a
request for funding; this will help document lessons learned from Pertussis epidemic, Tribes’
preferences for emergency vaccine distribution pathways, and other
D. Tribal Sovereignty
Breakout Participants’ Recommendations
o AIHC – conduct an assessment of all Tribes to determine the status of cross-jurisdictional
relations, including the effectiveness of Healthcare Coalitions for Tribes and relationships
with Local Health Jurisdictions
o AIHC – facilitate a process to gather Tribes’ recommendations on the PHEPR funding
distribution formula
o AIHC – share models of Tribal public health codes and best practices
Work Completed
o AIHC Staff Consultant invited Chris Williams, Acting Director, DOH Public Health
Emergency Preparedness and Response Program to attend an AIHC meeting to discuss
funding formula issues with AIHC delegates; Mr. Williams has agreed to attend the October
2013 AIHC meeting
o Negotiations are in process to determine final scope of work for AIHC’s PHEPR Technical
Assistance contract
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Continuing the Journey of Improving AI/AN Maternal and
Infant Health through Collaboration and Partnerships
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Continuing coordinating and collaborating MIH work with PRAMS, Home Visiting, WIC,
Immunizations, and Healthy Communities to integrate work with MIH Strategic Plan goals
in mind. Attending PRAMS, Home Visiting, and Immunizations meetings as AIHC MIH
representative to make sure that our work is collaborative and cohesive, and to use those
additional opportunities to encourage MIH disparities work from several different
perspectives; to network with other Tribal leaders surrounding MIH disparities issues
Met with Native American Women’s Dialogue on Infant Mortality (NAWDIM-Leah Tanner,
Shelley Means, and Cammie Goldhammer) to discuss potential areas of collaboration and
support
Met with Global Alliance to Prevent Prematurity and Stillbirth (GAPPS) to share information
about our AIHC MIH initiatives in progress, and to hear about other organizations work
related to this topic
Met with Governor’s Committee on Health Disparities-provided overview of MIH
Disparities project
Assisted in contacting Tribes regarding participation in Tribal Maternal and Child Home
Visiting Conference
Participated in Healthy Communities Tribal Leadership meeting in Auburn
The Maternal and Infant Health Work Group convened in March and made recommendations
for a MIH Work Group Project to sustain MIH disparities improvements.The top two choices
were Maternal and Child Home Visiting and Breast Feeding Support. The ultimate decision
for this year’s project was determined to be: assisting in researching Home Visiting models,
noting pros and cons and possible adaptations for a model that would work in Tribal
Communities. The Work Group will also assist in education, outreach, and other areas of
need yet to be fully determined.
Plans are being drafted now (for approval by the AIHC delegates) for continuing the
Maternal and Infant Health Disparities work in 2013-2014 (implementing the MIH Strategic
Plan) including working on the Maternal and Child Home Visiting Project
Initial visits (first of 3) have been conducted with 5 Tribes/Tribal Organizations for the WIC
Project.
Met with Dr. Tom Weiser of the Portland Area Indian Health Board, to discuss the WIC
Project.
Made a site visit to the Yellow Hawk Tribal Clinic to meet with staff and learn about their
model of pregnancy care.
Attended a Maternal Child Health Epidemiology Conference in Nashville, TN.
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Tribal Health Care Worker Immunizations
This project addresses health disparities issues by focusing on two objectives identified in
recommendations made by the THIW convened in 2011. The objectives identified are:
1. Improve the immunization rates for Tribal health care employees in Washington State;
and
2. Improve utilization of Tribal immunization information systems (i.e., RPMS or Child
Profile) to support health care worker vaccination.
Four key components
1. Identify health care work immunization best practices, policy development, and potential
local solutions;
2. Conduct assessment on Tribal health care workers’ knowledge, attitudes, and practices;
3. Identify strategies, including how evidence-based strategies can be utilized, to address
immunization barriers; and
4. Make strategic recommendations.
The AIHC conducted a survey to learn about 1) the knowledge, attitudes, and practices of health
care workers and 2) the organizational and administrative practices and policies regarding
immunizations. The purpose of collecting this data was to identify barriers, opportunities and
strategies to improve public heath practice and programs. The project is funded by CDC and is
part of the ACA’s Collaborative Agreement to improve health care employee immunization rates.
The AIHC completed its report including challenges and lesson learned and recommendations in
March 2013.
Challenges and Lessons learned
 AIHC should consider developing data collection protocols for future work.
 AIHC explored entering into an agreement with the Northwest Portland Area Indian
Health Board, but the timing to enter into an agreement should have been at the inception
of the project. AIHC should consider developing a data sharing agreement for future
work.
Recommendations
1. Research the implications of the 29% of the health care workers (respondents)
choosing not to be immunized against the flu on patients’ immunization rates,
employee absenteeism, and the relationship to other health care workers’
immunization rates.
2. Perform a comprehensive review and analysis focused on long term solutions for
sustainable health care worker immunizations policies, including:
a. Heath care worker incentives
b. What works and what does not
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c. Standards of care/practice
d. What is in the Tribes’ H1N1 (or other novel flu virus or outbreak) emergency
plan related to employee immunizations
e. Recruitment/screening requirements for hiring providers to include
immunization attitudes/beliefs
f. Tracking of health care worker immunizations records and systems
g. Follow up with clinics willing to share policies
h. Follow up on requests for examples of employee immunization policies to be
shared via AIHC’s website
3. Review data to identify connection to other immunization issues. For example, health
care worker flu vaccine hesitancy to other specific individual immunizations, such as
MMR, (re: rubella) due to its implication for pregnant women and babies (birth
defects).
4. Perform a review and assessment of tribal access to data and tracking systems for
employee immunization programs, whether it is mandatory or not.
5. Develop communication plan to share the Immunizations Report and data, including:
a. How to reach targeted audience, may be multiple audiences (providers, Tribal
Leaders, staff, Tribal/Urban Community)
b. Messaging needs to be specifically framed to the target audience
c. Presentation to Tribes, Urbans, AIHC, NPAIHB, ATNI, etc.
6. Develop educational materials regarding health care worker hesitancy.
a. Ensure all materials are culturally appropriate and community driven
b. Address the myths
c. Develop a primer for ongoing learning for health care providers
d. Develop a template for immunization information that can be customized by
Tribes and Urbans.
e. Emphasize the positive aspect of immunizations protecting patients and
families.
7. Inform Tribes and Urbans of opportunities for quality improvement projects to
improve immunization rates.
8. Develop a collaborative approach for planning and partnerships to convene an
immunization summit to review, identify goals, and develop strategies regarding:
a. Ten Year Continuum and carry work forward
b. Top 5 strategies to address disease outbreak identified by Tribes
c. Continue Tribally-driven approach and collaborative values
d. Identify technology needs.
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9. Develop AIHC process and protocol for data gathering for Tribal surveys addressing
Tribal IRB processes, data sharing agreements, and a comprehensive review of Tribal
needs to ensure quality surveillance and to insure value is added for Tribes.
Next Steps
1. Identify funding to support the above recommendations.
2. Continue to convene THIW to ensure communication and engagement with 29 Tribes
and two Urbans.
3. Establish a long-term work plan from the recommendations.
4. Develop a communication plan as part of the work plan.
5. Develop partnerships to support, plan and convene immunization summit.
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Healthy Communities: Tribal Leaders’ Approaches to Improving Indian Health
Background
The American Indian Health Commission (AIHC) has facilitated the development of a
Tribal/Urban Indian-driven Healthy Communities framework. The framework focuses on a
comprehensive prevention strategy integrating Native and western knowledge to reduce risk
factors for chronic disease among American Indians and Alaska Natives (AI/AN) in Washington
State. This model utilizes a Policy, Environment, Systems (PES) change approach and
incorporates cultural appropriate strategies designed for Tribal and Urban Indian Communities.
What are the Benefits and Uses of the Framework?
 It provides a culturally appropriate Healthy Communities framework to take action to prevent
and reduce chronic disease, and ultimately reduce health disparities.
 It provides a framework that can be adapted to meet the needs of specific Tribal and Urban
Indian Communities.
 It helps build the capacity and competencies to prepare Tribes and Urban Indian
Communities to be able to develop Healthy Communities’ initiatives using a policy,
environment, and systems (PES) change approach.
 It helps prepare Tribes and Urban Indian Programs to access Healthy Communities funding
within the state, private, and federal funding landscape.
Healthy Tribal and Urban Indian Leadership Advisory Committee
A Tribal and Urban Leadership Advisory Committee was convened to provide leadership and
guidance to staff in the development of a Healthy Communities framework. Their guidance was
critical to ensure cultural relevancy and long term support of the project.
Framework makeup
1. Interviews with Tribal and Urban Leadership Advisory Board Members
2. Literature review
3. Survey of Tribes and Urban Indian Programs
4. Training and competencies
5. Tribal and Urban Indian engagement
6. Tribal and Urban Indian Leader’s approaches to improving health
7. Definitions, language, and assumptions
8. The Backbone of the Framework: Definition, Vision, and Values
9. Comprehensive tool: Healthy Communities Matrix: Vision, Goals (desired outcomes),
Indicators, Strategies)
10. Identified other significant and emerging factors
11. Identified Unique Tribal and Urban Indian healthy communities-competencies
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Next Steps
Report and Framework present to AIHC delegates on September 13, 2012 for approval.
Leadership Advisory Committee Meeting on September20, 2013.
Convene Workshop for Tribes and Urban Indian Communities.
 A one-day workshop has been scheduled for September 25, 2013.
Tribal Leadership and Community Engagement
 Identify venues to seek Tribal Leadership audience.
 Convene regional meetings to share the framework and get feedback from the
communities.
Sustainability
 Garner support of the framework from AIHC delegates and Tribal Leadership.
 Find collaborative partners.
 Identify and apply for funding to pilot the framework.
 Utilize components of the framework in current projects.
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Maternal Infant Early Childhood Home Visiting
The Tribal-Urban Indian Maternal Infant Child Home Visiting (T-U MIECHV) is a TriballyUrban Indian driven project to identify maternal infant-child health needs and capacity in Tribal
and Urban Indian communities. The purpose is to support healthy development of AI/AN
children and families in Washington State. The AIHC facilitated the project, a partnership with
the Department of Early Learning.
Two groups were established: 1) Tribal/Urban Indian Maternal Infant Early Childhood Home
Visiting Coalition (T-U MIECHV Coalition and 2) T-U MIECHV plus Partners. Participants
included Tribes, UIHOs, Tribal MIECHV grantees, State and Federal partners, and HV programs
and advocates.
Activities based up Strategic Direction and Work plan
1. The T-U MIECHV Coalition developed the strategic direction and workplan.
2. The AIHC administered a Survey Monkey questionnaire entitled, American Indian
Health Commission for Washington State HV Services for Mothers and Children. There
was a 90% response rate.
3. Eight key questions were developed through the guidance of the T-U MIECHV Coalition
and in partnership with DEL to better understand needs and capacity of Tribes and
UIHOs for HV services.
4. The AIHC used a Roadmap Exercise as a method to gather information during facilitated
sessions held at Spokane NATIVE project, Tulalip Tribe, Yakima Tribe, and at Little
Creek Casino during the One Day Conference on HV.
5. The AIHC and T-U MIECHV convened a one day conference as a Day of Learning: How
Home Visiting Builds Resilient Children and Families. The event was co-sponsored by
the DEL, DOH-Office of the Secretary, DOH-WIC Nutrition Program, United Indians of
all Tribes, and South Puget Sound Inter-Tribal Agency.
6. Tribal MIECHV grantees that are receiving and implementing research projects through
HHS-Administration of Children and Families have provided guidance based upon their
recent experience.
7. Based on the project activities, a report including challenges and lessons learned and
recommendations has been prepared and will be presented to the AIHC delegates on
September 13, 2013 for approval.
Challenges and Lessons learned
1. There is a lack of knowledge about the benefits of HV in Tribal and Urban Indian
communities. As the project evolved, it became clear that an outreach, education and
training component would be useful to clearly communicate the benefits of HV to engage
Tribes and Urban Programs in the project.
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2. Lack of Funds for Tribal and Urban Indian HV programs. It is difficult to ask Tribes and
UIHOs to allow staff involvement in a project that doesn’t currently have funding
available.
3. Methodology for Information Gathering and Established Protocols
The AIHC has identified the need to establish standardized protocol for information
gathering to include involvement of an IRB as a policy as a result of the HV and other
similar projects. This will increase AIHC’s capacity for future assessment work and
increase the level of engagement and ability to collect more detailed information.
4. No two Tribal communities are the same. It is important to note this when discussing
culturally appropriate program designs. The models need to be flexible to meet the needs
of the people in each unique community. Also, it is important to note that there are
differences between Tribal and Urban Indian communities. This was apparent in T-U
MIECHV coalition discussion and forum responses.
5. The AIHC and Thrive by Five engaged in initial discussions regarding engagement of
Tribes and UIHOs in Thrive by Five’s work with rural communities. They have also
begun discussing a readiness assessment that Thrive by Five is working on. AIHC is
interested in continuing that relationship to learn more about the assessment and whether
it could be adapted for AIHC’s use with Tribes and UIHOs.
Report Recommendations
1. Continue T-U MIECHV Coalition monthly meetings.
2. Continue T-U MIECHV Coalition and Partners quarterly meetings.
3. Develop Outreach and Education tools about benefits of HV. Provide training regarding
Resiliency to Historical and Intergenerational Trauma.
4. Provide training regarding ACEs and strengthening families.
5. Collaborate with AIHC to UW and DSHS “Cradleboard to Career” conveners to discuss
to explore the possibility of sharing expertise or if there are leveraging opportunities in
program and/or system development.
6. Further develop partnership with Thrive by Five to develop Tribal and UIHOs Readiness
framework.
7. Develop and conduct a HV Services and Readiness Assessment Survey.
8. Develop Engagement plan to include regional presentations to Tribes and UIHOs
regarding HV.
9. Merge the efforts of T-U MIECHV Coalition and DEL with the MIH workgroup and
DOH to leverage resources and efforts.
10. Provide Webinars/Education on Tribal/Indigenous HV Models: Family Spirit and others
identified by AIHC’s T-U MIECHV coalition and/or the MIH Workgroup.
11. Support and provide technical assistance to pilot a promising practice HV model and
evidence-based model with cultural adaptations.
12. Collaborate with AIHC to UW and DSHS “Cradleboard to Career” conveners to discuss
to explore the possibility of sharing expertise to leveraging opportunities in program
and/or system development.
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13. Present Report and Findings to key DEL staff—September 9, 2013.
Next Steps
1. Present Report and Findings to the American Indian Health Commission Delegates for
comments and final approval—September 13, 2013.
2. Present Report and Findings to the Director of the Department of Early Learning and key
stakeholders—Oct 7, 2013.
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