TSGAC Packet - July 2019

Tribal Self-Governance Advisory Committee July 15 – 16, 2019

Tribal Self-Governance Advisory Committee July 15 – 16, 2019 Contents Save the Date …………………………………………………………………………………… 4 Agenda …………………………………………………………………………………………… 5 Committee Membership ……………………………………………………………………….. 6 Tribal Caucus Topics ………………………………………………………………………....... 7 Letter from ANHC to IHS Re: Use of Emergency Funds Fiscal Year 2018 IHS Director’s Emergency Fund Use CSC Workgroup Meeting TSGAC Meeting Summary from April 2019 ………………………………………………… 8 Workgroup Assignments List ………………………………………………………………….. 9 TSGAC Correspondence for 2018 – 2019 ………………………………………………...... 10 Dear Tribal Leader Letters & IHS Correspondence ……………………………………….. 11 Updates to IHS Senior Leadership Team Developing an Opioid Grant Program Draft Community Health Aide Program Policy Tribal Consultation for the IHS Sanitation Deficiency System All of Us Research Program TSGAC Comments Submitted from April 30, 2019 through July 5, 2019 ………….……. 12 Comments and Recommendations for Funding ISDEAA 105(l) Leases Comments on MISSION Act Strategic Plan Comments on the State of South Dakota’s 1115 Demonstration Application Comments in Response to IHS National CHAP Interim Policy Consultation

SAVE THE DATE TSGAC 4

Tribal Self-Governance Professionals Workshop and

Self-Governance Strategy Session September 9 - 12, 2019

Ak-Chin Indian Community Maricopa, Arizona

Register by August 1 to be entered in a drawing to win a $150 gift card to the Ak-Chin Harrah’s Spa. www.tribalselfgov.org

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AGENDA TSGAC

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IHS TRIBAL SELF-GOVERNANCE ADVISORY COMMITTEE c/o Self-Governance Communication and Education P.O. Box 1734, McAlester, OK 74501 Telephone (918) 302-0252 ~ Facsimile (918) 423-7639 ~ Website: www.Tribalselfgov.org

INDIAN HEALTH SERVICE TRIBAL SELF-GOVERNANCE ADVISORY COMMITTEE AND TECHNICAL WORKGROUP QUARTERLY MEETING Monday, July 15, 2019 (8:30 am to 5:00 pm) Tuesday, July 16, 2019 (8:30 am to 5:00 pm) Embassy Suites Washington DC - DC Convention Center 900-10th Street NW Washington, DC 20001 Phone: (202) 739-2001

AGENDA Monday, July 15, 2019 (8:30 am to 12:00 pm) Meeting of IHS Tribal Self-Governance Advisory Committee and Technical Workgroup 8:30 am

Meeting of Technical Workgroup Welcome Invocation Introductions

8:45 am

Opening Remarks Terra Branson, Director, Planning, Grants & Self-Governance, Muscogee (Creek) Nation and TSGAC Technical Workgroup Tribal Co-Chair Jennifer Cooper, Director, Office of Tribal Self-Governance, IHS and TSGAC Technical Workgroup Federal Co-Chair

9:00 am

Medicaid Legislative Priorities Doneg McDonough, TSGAC Technical Advisor

9:30 am

Update from Outreach to Jeannie Hovland Jay Spaan, Executive Director, Self-Governance Education & Communication Tribal Consortium • Update on recent discussions regarding Title VI

10:00 am

105(l) Lease Calculation of Need • Group discussion on potential estimation of need for 105(l) Lease costs.

10:30 am

Preparation of Talking Points for TSGAC Meeting

11:30 am

Lunch (Provided)

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IHS TSGAC & Technical Workgroup Quarterly Meeting July 15-16, 2019 – AGENDA

Monday, July 15, 2019 (1:00 pm to 5:00 pm) Meeting of IHS Tribal Self-Governance Advisory Committee (TSGAC) 1:00 pm

Tribal Caucus Facilitated by: Marilynn “Lynn” Malerba, Chief, Mohegan Tribe, and Chairwoman, Indian Health Service (IHS) Tribal Self-Governance Advisory Committee (TSGAC) • Fiscal Year 2018 IHS Director’s Emergency Fund Use, Alberta Unok, Alaska Native Health Board • Implementation of the VA Mission Act • Opioid Funding Consultation • CSC Policy

2:00 pm

Meeting Called to Order Welcome Invocation Roll Call Introductions – All Participants & Invited Guests

2:15 pm

TSGAC Opening Remarks Marilynn “Lynn” Malerba, Chief, Mohegan Tribe, and Chairwoman, IHS TSGAC RADM Michael D. Weahkee, Principal Deputy Director, IHS

2:30 pm

TSGAC Committee Business •

Approval of Meeting Summary (April 2019)

2:45 pm

Office of Tribal Self-Governance Update Jennifer Cooper, Director, Office of Tribal Self-Governance, IHS

3:15 pm

Indian Health Service Budget Update Ann Church, Acting Director, Office of Finance and Accounting, IHS Melanie Fourkiller, Policy Analyst, Choctaw Nation • Fiscal Year 2020 Appropriations

3:45 pm

Patient Protection and Affordable Care Act (ACA) Implementation Update Cyndi Ferguson, Self-Governance Specialist/Policy Analyst, SENSE Inc. Doneg McDonough, Consultant, TSGAC

4:15 pm

Office of Information Technology Update (OIT) Maia Z. Laing, HHS Optimization Team, Office of the Chief Technology Officer, Immediate Office of Secretary, HHS • HIT Modernization Work Update • Recommendations to Secretary Azar for Funding

4:40 pm

Facilities Appropriations Advisory Board (FAAB) Update Dr. Charles Grim, Secretary of Health, Chickasaw Nation (Invited) • FAAB Recommendation on Sanitation Deficiency System Guidance • Other FAAB Updates

5:00 pm

Recess until July 16, 2019

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IHS TSGAC & Technical Workgroup Quarterly Meeting July 15-16, 2019 – AGENDA

Tuesday, July 16, 2019 (8:30 am – 5:00 pm) Meeting of IHS Tribal Self-Governance Advisory Committee (TSGAC) and Technical Workgroup with RADM Michael D. Weahkee, Principal Deputy Director, IHS 8:30 am

Welcome and Introductions Marilynn “Lynn” Malerba, Chief, Mohegan Tribe, and Chairwoman, IHS TSGAC RADM Michael D. Weahkee, Principal Deputy Director, IHS

8:45 am

Updates from Advisory Committees and Consultations:  105(l) Leases Update for FY2018 and 2019 Ann Church, Acting Director, Office of Finance and Accounting, IHS • Total expenses for FY2018 (See TSGAC Letter October 2018) • Current FY2019 expenses • Calculation and future estimates workgroup  National Community Health Aide Program Tribal Consultation Christina Peters, Tribal Community Health Provider Project Director, Northwest Portland Area Health Board Minette C. Galindo, Public Health Advisor, Division of Behavioral Health, Office of Clinical & Preventive Services, IHS • Update and timeline for current policy recommendations • TSGAC recommendations  National Tribal Advisory Committee on Behavioral Health Theresa Galvan, Navajo Nation CAPT Andrew Hunt, Acting Deputy Director, Division of Behavioral Health, Office of Clinical & Preventive Services, IHS • Status Update on NTAC Recommendations • IHS Action on the NTAC Recommendations  National Institute of Health – All of Us Initiative Marilynn “Lynn” Malerba, Chief, Mohegan Tribe, and Chairwoman, IHS TSGAC  Opioid Funding Consultation CAPT Andrew Hunt, Acting Deputy Director, Division of Behavioral Health, Office of Clinical & Preventive Services, IHS

10:45 am

Legislative Update Geoff Strommer, Partner, Hobbs, Strauss, Dean and Walker • Update on the Opioid MDL Litigation & Texas v. United States ACA case Brett Weber, Congressional Relations Coordinator & Shervin Aazami, MPH, Policy Analyst, National Indian Health Board • House Task Force Update, FY 20 Appropriations, & SDPI Reauthorization

11:30 am

Lunch - TSGAC Members’ Executive Session with IHS Principal Deputy Director

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IHS TSGAC & Technical Workgroup Quarterly Meeting July 15-16, 2019 – AGENDA

1:00 pm

Update from Intradepartmental Council on Native American Affairs Michelle Sauve, Acting Director, ICNAA • Recent ICNAA agenda items • HHS Regional Consultation Update

2:00 pm

Joint TSGAC and IHS Principal Deputy Director Discussion • Use of the IHS Director’s Emergency Fund • Contract Support Cost Policy – status of pending decision • Behavioral Health Grants Tribal Consultation – status • Pharmacy Benefits Management (PBM) Claims Update • HHS/IHS Tribal Consultation Changes • SFC/SDS Consultation • IHCIF Fund – Workgroup to identify true need for IHS • Other Issues

3:45 pm

Closing Remarks Marilynn “Lynn” Malerba, Chief, Mohegan Tribe, and Chairwoman, IHS TSGAC RADM Michael D. Weahkee, Principal Deputy Director, IHS

4:00 pm

TSGAC Technical Workgroup Session • Assignments and follow up

5:00 pm

Adjourn TSGAC Meeting

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Committee Membership TSGAC

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IHS TRIBAL SELF-GOVERNANCE ADVISORY COMMITTEE c/o Self-Governance Communication and Education P.O. Box 1734, McAlester, OK 74501 Telephone (918) 302-0252 ~ Facsimile (918) 423-7639 ~ Website: www.tribalselfgov.org

TSGAC Membership July 5, 2019 Area

Member

Status Primary

Alaska

Diana Zirul Tribal Council Member Kenaitze Indian Tribe Gerald “Gerry” Moses Senior Director Alaska Native Tribal Health Consortium

Alternate

Richard Aspenwind Governor Pueblo of Taos

Primary

Raymond Loretto, DVM Governor Pueblo of Jemez

Alternate

Jane Rohl Tribal Council Secretary Grand Traverse Band of Ottawa & Chippewa Indians

Primary

Jennifer Webster Councilwoman Oneida Nation

Alternate

Michael Corcoran Chippewa Cree Tribe

Primary

TBD Confederated Salish & Kootenai Tribes

Alternate

Danny Jordan Self-Governance Coordinator Hoopa Valley Tribe

Primary

Robert Smith Chairman Pala Band of Mission Indians

Alternate

TBD Spirit Lake Nation

Primary

TBD Winnebago Tribe of Nebraska

Alternate

Albuquerque

Bemidji

Billings

California

Great Plains

Contact Information alaskadi@pentc.com

gmoses@anthc.org

governor@taospueblo.com

Raymond.loretto.dvm@jemezpueblo.org

jane.rohl@gtbindians.com

jwebste1@oneidanation.org

cbfdistrict@gmail.com

rsmith@palatribe.com

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Nashville

Marilynn “Lynn” Malerba* Chief Mohegan Tribe of Connecticut

Primary

Casey Cooper CEO Eastern Band of Cherokee Indians Hospital

Alternate

Myron Lizer Vice President Navajo Nation

Primary

Dr. Jill Jim Executive Director Navajo Nation Department of Health

Alternate

John Barret, Jr. Chairman Citizen Potawatomi Nation (Proxy: Kasie Nichols)

Primary

Justin Wood Principal Chief Sac and Fox Nation

Alternate

Jefferson Keel Lt. Governor Chickasaw Nation

Primary

Gary Batton Chief Choctaw Nation of Oklahoma (Proxy: Melanie Fourkiller)

Alternate

Joey Whitman Councilman Gila River Indian Community

Primary

Delia Carlyle Council Member Ak-Chin Indian Community

Alternate

W. Ron Allen Tribal Chairman/CEO Jamestown S’Klallam Tribe

Primary

Tyson Johnston Vice President Quinault Indian Nation

Alternate

Daniel L.A. Preston, III Councilman

Primary

lmalerba@moheganmail.com

TSGAC Chairwoman

Navajo

Oklahoma 1

Oklahoma 2

Phoenix

Portland

Tucson

Casey.Cooper@cherokeehospital.org

myronlizer@navajo.nsn.gov

Jill.jim@nndoh.org

Kasie.nichols@potawatomi.org

justinwood@sacandfoxnation-nsn.gov

lt.gov@chickasaw.net

mfourkiller@choctawnation.com

joey.whitman@gilariver-nsn.gov

dcarlyle@ak-chin.nsn.us

rallen@jamestowntribe.org

tjohnston@quinault.org

Daniel.preston@tonation-nsn.gov

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Tohono O’odham Nation Anthony J. Francisco, Jr. Councilman Tohono O’odham Nation

Alternate Anthony.francisco@tonation-nsn.gov

TSGAC Technical Workgroup Area

Member

Status Tech Rep

Alaska

Brandon Biddle Alaska Native Tribal Health Consortium Alberta Unok Deputy Director Alaska Native Health Board

Tech Rep

Albuquerque

Shawn Duran Pueblo of Taos

Tech Rep

Bemidji

John Mojica Mille Lacs Band of Ojibwe

Tech Rep

Candice Skenandore Oneida Nation

Tech Rep

Billings

Dustin Whitford Chippewa Cree Tribe

Tech Rep

California

John Robbins Hoopa Valley Tribe

Tech Rep

Great Plains Nashville

Contact Information bbiddle@anthc.org

aunok@anhb.org

SDuran@taospueblo.com

john.mojica@millelacsband.com

cskena10@oneidanation.org

dustin@cct.rockyboy.org

hvtsgjrobbinsjr@gmail.com Tech Rep

Martha Ketcher United South and Eastern Tribes

Tech Rep

Navajo

Theresa Galvan Navajo Nation

Tech Rep

Oklahoma 1

Jeremy Arnette Citizen Potawatomi Nation

Tech Rep

Oklahoma 2

Melissa Gower Chickasaw Nation Division of Health

Tech Rep

Terra Branson Muscogee (Creek) Nation

Tech Rep

Phoenix

Karen Fierro Ak-Chin Indian Community

Tech Rep

Portland

Jennifer McLaughlin Jamestown S’Klallam Tribe

Tech Rep

mketcher@usetinc.org

Theresa.galvan@nndoh.org

jarnette@potawatomi.org

Melissa.Gower@chickasaw.net

tbranson@mcn-nsn.gov

KFierro@ak-chin.nsn.us

jmclaughlin@jamestowntribe.org

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Tucson

Veronica Geronimo Tohono O’odham Nation

Tech Rep veronica.geronimo@tonation-nsn.gov

Federal Representatives Area

Member

Status

Contact Information

Jennifer Cooper OTSG Director

OTSG Rep

jennifer.cooper@ihs.gov

HQ

Jeremy Marshall Policy Analyst

OTSG Rep

jeremy.marshall@ihs.gov

Tamara Clay Policy Analyst

OTSG Rep

tamara.clay@ihs.gov

Alaska

Lanie Fox Director, Office of Tribal Programs

Area Rep

lanie.fox@ihs.gov

Albuquerque

Russel Pederson Director, OEHE Agency Lead Negotiator

Area Rep

russel.pederson@ihs.gov

Bemidji

Chris Poole Agency Lead Negotiator

Area Rep

chris.poole@ihs.gov

Billings

Bryce Redgrave Executive Officer

Area Rep

bryce.redgrave@ihs.gov

California

Travis Coleman Contracting Specialist

Area Rep

travis.coleman@ihs.gov

Great Plains

Dan Davis Federal Liaison

Area Rep

daniel.davis@ihs.gov

Nashville

Ashley Metcalf Agency Lead Negotiator

Area Rep

ashley.metcalf@ihs.gov

Navajo

Dee Hutchison Executive Officer

Area Rep

daalbaaleh.hutchison@ihs.gov

Oklahoma

Lindsay King Agency Lead Negotiator

Area Rep

lindsay.king@ihs.gov

Phoenix

Randall Morgan Director, Office of Tribal Self-Determination

Area Rep

randall.morgan@ihs.gov

Portland

Jason Davis Financial Analyst

Area Rep

jason.davis@ihs.gov

Tucson

Mark Bigbey Agency Lead Negotiator

Area Rep

mark.bigbey@ihs.gov

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Additional Technical Representatives Area

DC

Member

Status

Contact Information

C. Juliett Pittman SENSE Incorporated

SENSE, Inc.

pitt@senseinc.com

Cyndi Ferguson SENSE Incorporated Doneg McDonough Devin Delrow Director of Federal Relations, NIHB

cyndif@senseinc.com SENSE, Inc. Health Reform NIHB

d.mcdonough@yahoo.com ddelrow@nihb.org

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Tribal Caucus Topics TSGAC 7

Alaska Tribal Health Compact C/O Alaska Native Health Board 4000 Ambassador Drive, Suite 101 Anchorage, AK 99508 ______________________________________________________________________ June 19, 2019 RADM Michael Weahkee IHS Principal Deputy Director Mail Stop: 08E37A 5600 Fishers Lane Rockville, MD 20857

Dear Admiral Weahkee: The Co-Signers of the Alaska Tribal Health Compact 1 write with concerns regarding the use of certain Headquarters discretionary funds meant to be available for tribal emergencies and management initiatives for agency personnel costs. While these funds may be discretionary, they do have dedicated purposes that do not include agency worker’s compensation payouts or other personnel costs. Yet, both of these accounts were used exactly for that purpose in 2018. Our concern is that diversion of these funds leads to less sums available for tribal shares and the purposes Congress intended.

Specifically, the Headquarters PSFA Manual describes the purpose of the Director’s Emergency Fund (Budget Line Item 101) as follows: The Emergency Fund provides the Office of the Director (OD) with a limited reserve to address some of the emergencies involving IHS facilities and IHS/Tribal delivery of health services. The funds are not intended for administration, maintenance, construction, or for any other purposes that are not related to emergencies within IHS facilities or the delivery of IHS/Tribal health services.

(Emphasis added.) Additionally, “All undistributed funds are held in reserve until fiscal year end. Any remaining balances at the end of the fiscal year are made available for Tribal shares.” According to this direction, these funds are clearly not meant for agency administrative costs, such as worker’s compensation.

Instead, they are to be available for tribal emergencies. Given the recent experiences of our Co-Signers, including the challenges faced when trying to receive distributions from the fund for true emergencies, such as the largest earthquake to hit Southcentral Alaska since 1964, flooding or other natural disasters that are sure to worsen with climate change, we are especially concerned with this agency misuse of funds.

1

Alaska Native Tribal Health Consortium, Aleutian Pribilof Islands Association, Arctic Slope Native Association, Bristol Bay Area Health Corporation, Chickaloon Village Traditional Council, Chugachmiut, Copper River Native Association, Council of Athabascan Tribal Governments, Eastern Aleutian Tribes, Native Village of Eklutna, Native Village of Eyak, Kenaitze Indian Tribe, Ketchikan Indian Community, Knik Tribal Council, Kodiak Area Native Association, Maniilaq Association, Metlakatla Indian Community, Mt. Sanford Tribal Consortium, Norton Sound Health Corporation, Seldovia Village Tribe, Southcentral Foundation, SouthEast Alaska Health Consortium, Tanana Chiefs Conference, Yakutat Tlingit Tribe, Yukon Kuskokwim Health Corporation, representing 229 Tribes.

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Second, the PSFA Manual states the purpose of the Management Initiatives fund (Budget Line Item 105) is to provide the Director with funds “to meet a range of special, immediate initiatives/obligations, such as”: 1. Special meetings with Tribes which are covered through reimbursements, i.e. Regional Consultation Meetings; 2. Medical consultants and Traditional Medicine consultants; 3. Meeting facilitators and speakers; 4. Congressional requests for special studies; 5. IHS Strategic Planning Activities; 6. Special investigative studies and financial audits (CFO/CIO); 7. Tribal/Urban health work groups and other special work groups; and 8. Executive Leadership Development Program Again, “[a]ny monies remaining in this fund at the end of the fiscal year will be made available for Tribal shares.” While this fund provides for a range of needs, personnel costs are not one of those items.

However, the FY 2018 expenditures included funds for an MOU with HHS for support for two positions, funds for an inter-agency agreement with HRSA for the detail of a HRSA employee (i.e. direct compensation costs), Human Resources and Worker’s Compensation labs for the California Area, a contract for A-123 payroll data analytics services, and again Workmen’s Compensation. All in all, these personnel expenditures totaled over $800,000 of an account that only has an approximate $2 million balance. In other words, nearly 40% of the account in FY 2018 was used for agency personnel needs instead of the designated purposes.

These accounts may be discretionary, but they are not intended to account for the agency’s failure to adequately budget for its personnel costs. We ask that the agency take heed of the guidance provided by the PSFA Manual when making distributions from these accounts in FY 2019 and ensure these funds are only used for their intended purposes or distributed as tribal shares. We look forward to having a chance to address these concerns with you in person in August.

Sincerely,

ATHC Co-Lead Negotiator, Natasha Singh Tanana Chiefs Conference

ATHC Co-Lead Negotiator, Diana L. Zirul Tribally-Elected Leader, Kenaitze Indian Tribe

Cc: Christopher Mandregan, Acting Deputy Director for Management Operations, IHS Evangelyn Dotomain, Acting Director, AANHS Aaron Lane, Alaska Agency Lead Negotiator, IHS

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Open Items: B-1A and B-1B

INDIAN HEALTH SERVICE FY 2018 Director's Emergency Fund As of September 30, 2018 Approved FY18 Allowance Nashville Area - generators required in response to hurricanes Albuquerque Area - flood remediation at the Santa Fe Indian Hospital California Area - air purifiers related to wildfire response Nashville Area - flood remediation for Saint Regis Mohawk Tribe All Areas - Yearend Distribution Workmen's Compensation

67,500 539,500 71,093 11,424 3,003,847 262,652 Available

Balance 3,956,016 3,888,516 3,349,016 3,277,923 3,266,499 262,652 0 0

FY 2018 Management Initiatives As of September 30, 2018 Approved FY18 Allowance Memorandum of Understanding (MOU) with HHS/Office of Intergovernmental External Affairs (OIEA) in Support of Two Positions Inter-Agency Agreement (IAA) with HHS/National Institutes of Health (NIH) for Center for Information Technology (CIT) Hosting and Storage Services IAA with HHS/Health Resources & Services Administration (HRSA) for detail of S. Linde Travel Costs Contract for Subject Matter Expertise on Indian Health Care Improvement Fund Formula, Level of Need Funded, and the Headquarters Tribal Shares Database Indian Health Care Improvement Fund Workgroup Meetings: Logistics and Reimbursement of Travel for Primary Tribal Representatives Logistics for Indian Health Care Improvement Fund and Purchased/Referred Care InPerson Consultation Sessions 15th Annual Direct Service Tribes National Meeting California Area - Human Resources and Workers' Compensation Labs Contract for A-123 Payroll Data Analytics Services Portland Area - Chief Executive Officers Quality Leadership Materials Oklahoma City Area - IHS Leadership Training, Travel, and Administrative Costs Contract for Evaluation of the Community Health Representatives Program Headquarters Office of Technology Business Intelligence Dashboard Development Contract for Subject Matter Expertise on Improvement for Patient Services, Quality, and Safety Metrics Additional funds for Three-day Workplace Accountability Certification Course for Area Quality Managers Joint Commission Accreditation Training at the 2018 IHS Partnership Conference Additional funds for Accreditation Services for IHS Hospitals Workmen's Compensation Available

98,171

Balance 2,049,512 1,951,341

19,893

1,931,448

154,095

1,777,353

12,514 75,868

1,764,839 1,688,971

79,947

1,609,024

14,244

1,594,781

46,841 4,145 65,577 2,500 13,450 149,415 600,000

1,547,940 1,543,795 1,478,218 1,475,718 1,462,268 1,312,853 712,853

200,000

512,853

1,426

511,427

6,500 15,859 487,000

504,927 489,068 2,068 2,068

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NORTHWEST PORTLAND AREA INDIAN HEALTH BOARD Burns-Paiute Tribe Chehalis Tribe Coeur d’Alene Tribe Colville Tribe Coos, Siuslaw, & Lower Umpqua Tribe Coquille Tribe Cow Creek Tribe Cowlitz Tribe Grand Ronde Tribe Hoh Tribe Jamestown S’Klallam Tribe Kalispell Tribe Klamath Tribe Kootenai Tribe Lower Elwha Tribe Lummi Tribe Makah Tribe Muckleshoot Tribe Nez Perce Tribe Nisqually Tribe Nooksack Tribe NW Band of Shoshoni Tribe Port Gamble S’Klallam Tribe Puyallup Tribe Quileute Tribe Quinault Tribe Samish Indian Nation Sauk-Suiattle Tribe Shoalwater Bay Tribe Shoshone-Bannock Tribe Siletz Tribe Skokomish Tribe Snoqualmie Tribe Spokane Tribe Squaxin Island Tribe Stillaguamish Tribe Suquamish Tribe Swinomish Tribe Tulalip Tribe Umatilla Tribe Upper Skagit Tribe Warm Springs Tribe Yakama Nation

SUBMITTED VIA EMAIL June 3, 2019 RADM Michael D. Weahkee Principal Deputy Director Indian Health Service 5600 Fishers Lane, Mail Stop: 08E86 Rockville, MD 20857 RE:

Request for Update on Next CSC Meeting

Dear RADM Weahkee: The last Contract Support Costs (CSC) Workgroup meeting took place in April 2018, during the Tribal Self-Governance Annual Conference in Albuquerque.

Since that time, IHS has not provided an update to the CSC Workgroup on when the next CSC Workgroup meeting will take place. Please provide an update as soon as possible.

I look forward to your response and to IHS’s collaboration with the CSC Workgroup in honor of the government-to-government relationship.

Sincerely,

Andy Joseph, Jr., NPAIHB Chair Colville Business Council Vice Chair cc: IHS CSC Workgroup members

2121 S.W. Broadway Suite 300 Portland, OR 97201 Phone: (503) 228-4185

Fax: (503) 228-8182 www.npaihb.org

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Meeting Summary TSGAC

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April 24 - 25, 2019 Tribal Self-Governance Advisory Committee (TSGAC) Summary

Attendance: Quorum present for TSGAC Area

Member

Alaska

Gerald “Gerry” Moses Senior Director Alaska Native Tribal Health Consortium Diana Zirul Tribal Council Member Kenaitze Indian Tribe Ian Chisholm Pueblo of Jemez Jennifer Webster Councilwoman Oneida Nation

Albuquerque Bemidji

Billings California Great Plains Nashville

Navajo Oklahoma 1

Oklahoma 2 Phoenix Portland

Tucson

Kenny Baker Spirit Lake Nation Marilynn “Lynn” Malerba* Chief Mohegan Tribe of Connecticut Theresa Galvan Navajo Nation Kasie Nichols Citizen Potawatomi Nation Kay Rhoads Principal Chief Sac and Fox Nation Melanie Fourkiller* Choctaw Nation of Oklahoma W. Ron Allen Tribal Chairman/CEO Jamestown S’Klallam Tribe Daniel L.A. Preston, III Councilman Tohono O’odham Nation

Present X

X

X X

X X

X X X

X

X Phone, for a portion of the meeting

*Chief Batton provided a letter to TSGAC requesting Melanie Fourkiller serve as his

proxy when he is unable to attend TSGAC.

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TSGAC Committee Business Kenny Baker from the Great Plains Region made a motion to accept the minutes from the October 2018 minutes with edits identified by the committee and Diana Zirul seconded the motion. The motion passed.

Opening Statement RADM Chris Buchanan, Principal Deputy Director of the Indian Health System (IHS), presented opening remarks. Specifically, Buchanan made the following remarks: •

IHS continues its commitment to working with tribal nations, tribal organizations, and urban Indian organizations.

•

IHS received appropriations for the rest of fiscal year (FY) 2019. The total discretionary budget authority for IHS is $5.9 billion ($266 M increase). The IHS will soon announce a new tribal consultation and urban confer regarding the special behavioral health pilot program designed to provide opioid treatment and recovery service.

•

IHS realized significant improvements to the quality of care by developing and implementing a strategic plan and establishing the IHS Office of Quality.

Additionally, the IHS has also implemented a new standardized credentialing and privileging software.

•

Mr. James Driving Hawk was appointed as the Director of the IHS Great Plains Area.

Mr. Darrell LaRoche is the new Director of the Office of Clinical and Preventative Services (OCPS).

Office of Tribal Self-Governance (OTSG) Update

Jennifer Cooper, Director, Office of Tribal Self-Governance, IHS General Overview of Discussion Director Cooper provided an overview of personnel changes. Filling area lead negotiator positions is an increasing priority and, overall, recruitment is going to be a top priority for the next three months. Another priority is to finalize the funding 8b announcement for the FY 2019 Self-Governance Planning and Negotiation

Cooperative Agreements and recruitment for the objective review committee will begin soon. OTSG has been working diligently to improve their process and timeliness of communication.

Action Items Identified • •

Encourage participation in the objective review committee.

Follow up on OTSG progress on formalizing ALN selection process.

Patient Protection and Affordable Care Act (ACA) Implementation Update

Doneg McDonough, Consultant, TSGAC General Overview of Discussion Mr. McDonough provided an update on the agreement between the TSGAC and the IHS regarding the Affordable Care Act/Indian Health Care Improvement Act (ACA/IHCIA) activities. Mr. McDonough presented data collected from a survey conducted with the National Indian Health Board (NIHB) and the National Congress of American Indians (NCAI) about the ACA and its impact on tribes. After reviewing the information that was recently rereleased by Centers for Medicare and Medicaid Services (CMS) regarding market place coverage and cost-sharing protections for American Indians and Alaska Natives, TSGAC sent a letter to the Tribal Technical Advisory Group (TTAG) at the CMS containing suggestions on improving the information available on the website.

Key Questions and Responses Q: TSGAC requested some data regarding third-party coverage. Have you received any follow up to that?

A: No, I have not seen updated data.

Action Items Identified • • •

Follow up on recommendations made to TTAG. Letter from IHS to tribes asking them to update their National Data Warehouse (NDW) uploads, so that the information available is complete.

Once the NDW is updated, obtain a report showing active user insurance status.

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Office of Information Technology Update (OIT)

Mitchell Thornbrough, Acting Director, Office of Information Technology, IHS General Overview of Discussion Mr. Thornbrough gave an update on the new structure of the Information Systems Advisory Committee (ISAC) and the new ISAC charter, which is open for public comment until May 9. There are now 14 standing members that include CIO, NIHB, DSTAC, TSGAC, National Council of CMOs, National Council of Executive Officers, National Council of Informatics, National Council of Nurse Leadership, ISCC, Area Directors, Chief Information Security Officer, Chief Health Information Officer, Deputy Director of Quality, and the Director of Division of Facility Operations in the OEHE. There are also twelve at-large members (one from each area). He also provided an update on the research modernization project, and the IHS HIT modernization effort.

The Modernization Committee has met twice and has a full meeting on April 24. The overall project is on track to meet deliverables. Thirteen site visits have been completed, and there are three site visits remaining. In response to a data request, the Project received 1,300 responses. Data indicated that there is around 95% agreement that the RPMS infrastructure needs an overhaul.

The final modernization project report should be released in September.

Key Questions and Responses Q: How many of the 1,300 responses were tribal and how many were federal staff?

A: From memory, I want to say 10 to 12 percent is the tribal response rate.

Q: Are most of the responses from facilities or individual users?

A: The survey went out to individual users, so we are measuring their affiliation. About 10 to 12 percent of the responses were submitted from tribal locations. There is a small percent of unidentified respondents.

Q: Are the at-large area members of the ISAC tribal representatives?

A: Yes. Q: Was the charter in a Federal Register Notice?

A: It went out for public notice.

Q: Is there any way we can get a copy?

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A: Yes. We sent it out to all ISAC membership.

Action Items Identified • •

•

Encourage participation in the ISAC. Obtain report from NDW detailing the percentage and numbers of patients that were covered by third-party. Area and site-specific data should be grouped by the provider (e.g., Medicare, Medicaid, private insurance).

Follow up on request for IHS to a send letter to all sites (federal, tribal, etc.) explaining why the data is needed and asking them to update their information regularly.

Texas v. United States and Opioid Litigation Update

Geoff Strommer, Partner, Hobbs, Straus, Dean & Walker General Overview of Discussion Mr. Strommer provide an update on Texas v. United States. On December 14, 2018, a judge in the western district of Texas issued a decision striking down the ACA. The court interpreted legislation enacted in the previous session of Congress that eliminated the individual mandate of the ACA as rendering the entire statute unconstitutional. If the court’s decision is upheld, it will not only strike down the ACA but also the reauthorization of the Indian Healthcare Improvement Act (IHCIA) and all of the Indian provisions in the statute. It is likely that the case will go to the Supreme Court.

An amicus brief has been filed on behalf of many tribal nations and tribal organizations from around the country. The main argument of the brief is that if the court finds that the ACA is unconstitutional, the court should apply the Doctrine of Severability to sever IHCIA and Indian provisions.

The United States is going to file its brief by May 1st.

Recent Efforts and Discussion regarding Re-Vitalization of the ICNAA

Jeannie Hovland, Deputy Assistant Secretary, Native American Affairs, Commissioner, Administration for Native Americans and Co-Chair, Intradepartmental Council on Native American Affairs, U.S. Department of Health and Human Services RADM Michael D. Weahkee, Principal Deputy Director, IHS 8e

General Overview of Discussion Commissioner Hovland and RADM Weahkee provided an update on efforts to revitalize ICNAA. They had their first meeting in February and will meet again in May. ICNAA was established under the Native American Programs Act (NAPA). Congress intended to utilize ICNAA to foster communication and collaboration within HHS. The Commissioner of ANA will chair ICNAA, and the vice chair will be the Director of the IHS, and within HHS the council consists of the operation division heads. They are developing policy, programs, and addressing concerns collaboratively. Michelle Suave is serving as the Executive Director for the ICNAA while they seek to fill this role.

NAPA also includes a definition for Native Americans. The definition for Native Americans as members of state and federally recognized tribes, Native urban organizations, Native non-profits, Native Hawaiians, and Pacific Islanders including Northern Mariana Islands, America Samoa, and Guam.

Director Weahkee mentioned that ICNAA is structured in a way where they are completely separate from Intergovernmental and External Affairs Office at HHS. Jack Kalavritinos and Stacey Ecofee are running the STAC program and will to continue to be the outward facing liaison with tribes. ICNAA is meant to function more as an inward facing group. Commissioner Hovland and RADM Weahkee stated that they are open to suggestions for agenda items and offered to keep TSGAC informed of ICNAA activities moving forward.

TSGAC members were pleased to hear that the ICNAA is being revitalized and made several suggestions for items that the ICNAA can focus attention, including: • Advocating for the expansion of self-governance within HHS. • Advocating for the transition of funding for Indian programs from the discretionary side of the federal budget to the mandatory side.

• Exploring and encouraging implementation of methods to streamline interagency communication, collaboration, and resource exchange in a manner to better serve Native communities.

• Continuing to support interagency MOAs and MOUs. • Encouraging support from federal agencies for the increased flexibility of usage of resources at the local level within legal and ethical parameters Key Questions and Responses Q: Can you provide some background on how decided to separate ICNAA from the Office of Intergovernmental and External Affairs (IEA)?

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A: An important factor to point out is that IEA continues to be on ICNAA’s executive council. So, there will be robust participation from the IEA on ICNAA. The decision was driven by finances and the need to separate functions. We are having discussions about how to ensure that there are communication and collaboration between ICNAA and STAC.

Legislative Update

Caitrin Shuy, Director of Congressional Relations, National Indian Health Board Ms. Shuy provided an update on some of the things NIHB is working on legislatively, Medicaid amendments, and upcoming conferences. Specifically, •

The partial government shutdown was extremely detrimental to tribal communities. NIHB is working diligently on advocating for legislation that would provide an advance appropriation for IHS. Ms. Shuy clarified the differences between forward-funding, advance appropriations, and mandatory appropriations.

•

Securing mandatory appropriations for IHS is a long-term goal of NIHB.

•

NIHB has also been working on the bill introduced by Senator Tester that would authorize the formation of a VA tribal advisory group.

•

NIHB is holding off on legislative language regarding Medicaid bill until the Washington State Dental Therapy Program litigation is resolved. It will affect how some of the definitions of the bill are written. Additional support in the Senate is needed.

•

NIHB has two conferences coming up: May 13th - 17th in Albuquerque and September 16th - 20th in Pechanga.

•

Ms. Shuy also announced that she recently accepted a political appointment within HHS’ budget office.

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Department of Veteran’s Affairs (VA) – Office of Community Care

Stephanie Birdwell, Director, Tribal Government Relations, VA Kristin J. Cunningham, PMP, Executive Officer to the Deputy Under Secretary for Health for Community Care Ms. Cunningham provided an overview of the Office of Community Care and discussed the implementation of the MISSION Act. A detailed presentation is available at: https://www.tribalselfgov.org/wp-content/uploads/2019/04/2-OCC-for-Tribal-HEalth042419.pptx An Executive Order on a National Roadmap to Empower Veterans and End Suicide can be found at: https://www.tribalselfgov.org/wp-content/uploads/2019/04/Executive-Order-on-aNational-Roadmap-to-Empower-Veterans-and-End-Suicide-_-The-White-House.pdf TSGAC participants expressed concern that the time frame for submitting comments on implementation of the MISSION Act needs to be extended. Ms. Birdwell and Ms. Cunningham stated they would take the concern back to VA leadership and will request an extension of the time frame.

National Tribal Advisory Committee on Behavioral Health

Theresa Galvan, Navajo Nation The National Tribal Advisory Committee (NTAC) on Behavioral Health acts as an advisory body to the Division of Behavioral Health and to the Director of the Indian Health Service, with the aim of providing guidance and recommendations on programmatic issues that affect the delivery of behavioral health care for American Indian and Alaska Natives.

NTAC Leadership: • Tribal Co-Chair: Ms. Theresa Galvan (Navajo Nation) • Federal Co-Chair: Ms. Miranda Carman (IHS Division of Behavioral Health) Membership: The NTAC consists of one primary and one alternate representative from each of the 12 IHS areas. Members are nominated by IHS Area Directors, in consultation with Tribal leaders. All nominees must be elected Tribal leaders or a designee selected

by Tribal leaders.

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Ms. Galvan provided an overview of the current work of the NTAC and highlighted a number of NTAC’s priorities. To start, Ms. Galvan noted that NTAC recently convened in Alpine, CA as part of a joint meeting with SAHMSA and is working with IHS to identify the next meeting date. RADM Weahkee echoed the importance of establishing the next meeting date and hopes the committee will be able to convene in June 2019.

Among other priorities, Ms. Glavan highlighted funding levels, the mechanism through which funding is delivered, the difficulty identifying the appropriate Area Project Officer, and the minimal progress of a contracted marketing group. Specifically, • •

• • •

•

$51.2 M is available for behavioral health funding but some Congress designated set-asides totaling $10.7 M. NTAC has 3 vacancies—Nashville, Billings, and Albuquerque—and it is a priority to get those seats filled.

Regarding Area Project Officers, NTAC believes there are so many of them that it is confusing for Tribal programs to identify who to contact.

2018 Appropriations bill encouraged behavioral health funding to be transferred to Tribes through ISDEAA agreements.

NTAC wants all funding to be provided directly to Tribes, Tribal Organizations, and Urban Centers rather than external entities doing work within Native communities.

NTAC is concerned that the marketing group under contract is not making enough progress.

RADM Weahkee also noted that IHS intends to take the recommendations from NTAC and release those publicly for consultation. RADM Weahkee introduced Andy Hunt as the Acting Deputy Director for Behavioral Health.

A TSGAC participant asked Ms. Galvan for further explanation on reinvesting into tribal grant and program awards. Under NTAC recommendations, there is not a specific mention that the funding should go directly to Tribes through ISDEAA contracts and compacts and eliminate the grant piece of the fund disbursement. Ms. Galvan stated the main priority is to have more of the funding go directly to Tribes and not to be funneled through grants management. Several other TSGAC participants echoed the importance of the funding to be delivered through contracts and compacts and highlighted various reasons why this is important.

The letter from NTAC to RADM Weahkee can be found at:

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https://www.tribalselfgov.org/wp-content/uploads/2019/04/NTAC-Recommendation-to-RADMWeahkee-3-2019.pdf

Indian Health Service Budget Update

Ann Church, Acting Director, Office of Finance and Accounting, IHS (Invited) Melanie Fourkiller, Policy Analyst, Choctaw Nation Ms. Church provided an update for fiscal year 2019 and the fiscal year 2020 budget proposal. To start, Ms. Church noted that IHS recently received news that the services apportionments were approved. As such, funds for the 3rd quarter are being distributed now. A few key highlights from the presentation include: •

•

•

The enacted fiscal year (FY) 2019 budget includes a total discretionary budget authority of $5.8 billion, which is $266 million above the enacted FY 2018 funding level.

The budget includes three accounts: o Services: $4.1 billion o Facilities: $879 million o Contract Support Costs: $822 million CSC remains an indefinite discretionary appropriation.

•

$115 million for staffing and operating costs of newly‐constructed healthcare facilities.

•

The period of availability is changed for a majority of Services funds. Funds previously available for one FY are now available for two FYs, expiring on September 30, 2020. No changes to funds available until expended (no‐year funds). Ms. Church noted this is not advance appropriations authority but does provide some benefit to help mitigate the effects of CRs or a shutdown.

•

The Fiscal Year (FY) 2020 Budget requests a total discretionary budget authority of $5.9 billion, which is $392 million above the FY 2019 annualized continuing resolution level.

Ms. Church provided a presentation that can be found at: https://www.tribalselfgov.org/wp-content/uploads/2019/04/3-IHS-BudgetUpdate_IHS-Tribal-Self-Gov-Committee-Mtg_Apr-25-2019.pdf 8j

•

Ms. Fourkiller provided an update on the fiscal year 2021 budget committee. The committee recently met and selected Andy Joseph, Bruce Pratt, and Victor Joseph are the co-chairs for the budget formulation committee. The committee was also successful in coming together for an agreed upon message and budget amount.

The National Tribal Budget Formulation Workgroup’s Recommendations on the Indian Health Service Fiscal Year 2021 Budget can be found at: https://www.nihb.org/docs/04242019/307871_NIHB%20IHS%20Budget%20Book_ WEB.PDF

TSGAC Members’ Joint Discussion with IHS Principal Deputy Director

Chief Malerba and RADM Weahkee General Overview of Discussion •

RADM Weahkee reiterated an offer to put together a 105(l) lease technical workgroup to determine cost estimates.

•

Chief Malerba shared concerns that the Department of Justice (DOJ) is not supporting the rule of law regarding the ACA and the IHCIA. TSGAC is looking to leadership from the Department of Health and Human Services (HHS) and IHS to provide technical assistance to the DOJ. RADM Weahkee provided an update regarding attempts to obtain approval to go outside of the department and communicate with the DOJ directly concerning the potential detriment to Tribes and the IHS if the ACA is struck down.

•

TSGAC membership reminded Director Weahkee that advance appropriation authority is a priority. RADM Weahkee shared that Ms. Anne Church recently accompanied Department of the Interior (DOI) Officials on a visit to the Department of Veterans Affairs (VA) to learn how they implement advance appropriations.

•

The Broken Promises report released by the U.S. Commission on Civil Rights was discussed regarding how the report can be utilized to move our mutual agenda forward and highlight funding issues.

•

TSGAC requested an update on contract support cost policy. IHS officials commented that a contract support cost policy update should be available at the next quarterly meeting.

8k

•

TSGAC membership requested an update about pharmacy management benefit claims.

•

The Presidential Task Force on Protecting Native American Children was discussed.

RADM Weahkee explained efforts taken by the IHS to ensure that similar issues do not occur in the future. IHS employees are required to undergo No FEAR Act training, which is completely focused on whistleblower protections. However, a reprisal is still a concern by employees who report incidents. Part of the medical quality assurance review is to discover where incident reports are being dropped and if they are reaching management level. The IHS recently purchased an incident reporting system. They are also setting up headquarters governance structures with the standup of the new Office of Quality. They have a quality assurance/risk management workgroup or advisory group at the headquarters level that will review all concerns that are sexual assault or child abuse related.

Key Questions and Responses Q: How do we utilize the Broken Promises report to move our agenda forward and highlight funding issues? Can you leverage the report (Broken Promises) in any way?

A: I think the opportunities come in our conversations that will be coming up with the OMB about the budget. We can highlight it as part of our internal education and advocacy work.

Q: How are contract support costs recommendations going to be implemented? Are we reinstating the 97/3 methodology?

A: RADM Weahkee is hopeful that when we meet a quarter from now, we will have some movement on this and three or four of our other active consultations. TSGAC can expect dear tribal leader letters for all of these long-standing open consultation items.

Q: Does that include the PRC chapter changes in your consultation policy?

A: Yes, it does - PRC, SDS, mental health services funding.

Q: Have we assessed whether OGC should file a lawsuit to preserve the statute of limitations while we work through a settlement to get paid for past claims as well as the current claims system getting fixed?

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A: We are trying to work through the current issues. We have talked about it, but it has not gone that far yet to do that. We will talk about it some more with senior leadership if that is what we want to do.

Q: Have you identified an IHS pediatrician to be on the Presidential task force?

A: We do have an IHS pediatrician on the task force. Although we did not have a role in the selection, she was selected, I believe, by DOJ. We were asked if we support her participation in the task force, which we do. She came from our Navajo Area and is assigned to the Shiprock Service Unit.

Q: Have you given thought to internal systems to address incidents of this nature in a way that will prevent this from happening in the future?

A: One of my principal jobs is to create an environment and a culture within the agency that is supportive of our employees and promotes transparency and promotes reporting when there is a concern.

Action Items Identified • • • • •

Request update on progress made by IHS to develop a budget formulation to be implemented in the instance Congress authorizes advance appropriations Continue to encourage HHS and IHS leadership to encourage the DOJ to uphold the Indian Health Care Improvement Act Continue to advocate for an exemption for Tribes from Medicaid block grants.

Continue to seek updates on pharmacy management benefits claims Support recruitment of area lead negotiators.

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Workgroup Assignments List TSGAC 9

IHS TRIBAL SELF-GOVERNANCE ADVISORY COMMITTEE c/o Self-Governance Communication and Education P.O. Box 1734, McAlester, OK 74501 Telephone (918) 302-0252 ~ Facsimile (918) 423-7639 ~ Website: www.tribalselfgov.org

Technical Workgroup Assignment Matrix Updated: July 9, 2019 Technical Workgroup Co-Chairs: Terra Branson, Tribal Co-Chair Jennifer Cooper, Federal Co-Chair

Assignment 1.

Develop and include in IHS SelfGovernance Policy protocols for selfgovernance negotiations, including but not limited to expectations for information and document sharing and protocol for proper communication with Tribal leadership. Review with TSGAC. (see April 10, 1997 letter to TSGAC from previous IHS Director).

Person(s) Responsible Jennifer Cooper SGCE

Date Task Originated July 21, 2016

Mickey Peercy Rhonda Farrimond Melanie Fourkiller Cyndi Ferguson Terra Branson Shawn Duran Alberta Unok

9/15/17: Will be included for update on October, 2017 Quarterly Meeting agenda.

[SG Negotiations issue – whether IHS ALNs should accept provisions (at Tribal option) that have been previously negotiated in other Compacts/FAs, to the extent applicable to that Tribe.]

Develop TSGAC Comments to the SG Congressional Report.

3.

Develop TSGAC letter to NIH – support of the Tribal Report on “All of Us”

4.

Work with OTSG staff on updating the 2002 Headquarters PSFA Manual.

5.

White paper, re: CSC on CHEF reimbursements.

Develop White Paper on proposal to move IHS funds from Interior to LaborHHS Appropriations Subcommittee

6.

7.

8.

SGCE Letter to the Appropriations Committee, re: 105(l) Leasing for FY19 and future Invite VA OAA to the TSGAC meeting when additional information is available about Expansion of the loan program and GME project.

Other issues and recommendations remain regarding Title V implementation.

7/20/17: This group agree to review the ALN Handbook and make recommendations moving forward.

1997 IHS Director Letter

2.

Status

Melanie Fourkiller Carolyn Crowder SGCE Unassigned.

October 27, 2016

Jennifer Cooper SGCE Cyndi Ferguson Kasie Nichols Melanie Fourkiller Terra Branson

March 29, 2017

Melanie Fourkiller Kasie Nichols Caitrin Shuy Terra Branson SGCE

October 4, 2018

Terra Branson

October 4, 2018

1

March 29, 2018

March 29. 2018

October 4, 2018

10/4/18: OTSG agrees to provide additional direction for TSGAC Action.

Pending next report sent out for Tribal Consultation 4/26/19: There is an NIH consultation scheduled ahead of the NCAI MidYear Conference.

Though the report discussed is not yet available.

10/4/18: OTSG will update workplan and report back to TSGAC.

On hold until CSC Policy matter is decided by IHS. 4/26/19: Add to the Strategy Session agenda for discussion.

This may have been completed. Melanie and Jay will confirm.

On hold until additional updates are available

9a

9.

10.

11.

12.

13.

14.

15.

16.

Convene Medicaid Legislative workgroup to further develop strategy for TSGAC Invite ICNAA Acting Director, Michelle Suave, to the next TSGAC Meeting Response to the IHS DTLL dated March 12, 2019 re: 105(l) Leases • Include recommendation for technical workgroup. Candice Skenandore and Lee Olson volunteered for the workgroup.

Written Testimony for the HHS FY2021 Annual Tribal Budget Consultation Record Formal request to extend the comment period on the MISSION Act improvement questions.

Response to the April 16th VA letter on the MISSION Act Joint NIHB/TSGAC Letter to ICNAA regarding future agenda items, Title VI briefing, and meeting with advisory committee chairs.

Joint SGAC/TSGAC letter to Secretary Azar re: elevation of ANA Commissioner to Assistant Secretary

Doneg McDonough

April 25, 2019

Met 5/30/19 via teleconference.

Terra Branson

April 25, 2019

Completed.

Terra Branson

April 25, 2019

Completed.

SGCE

April 25, 2019

Completed.

Terra Branson

April 25, 2019

Completed.

Melissa Gower

April 25, 2019

Completed.

Devin Delrow Terra Branson

April 25, 2019

On hold pending additional information.

Cyndi Ferguson Terra Branson Devin Delrow

April 25, 2019

On hold pending additional information.

2

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TSGAC Correspondence TSGAC 10

6/20/19

6/7/19

6/7/19

5/24/19

4/30/19

4/30/19

3/29/19

12/21/18

12/19/18

11/13/18

2.

3.

4.

5.

6.

7.

8.

9.

10.

Date Sent/ Received

1.

Ref. #

Senate Appropriations Committee House Appropriations Committee

Ms. Stacey Ecoffey, Principal Advisor for Tribal Affairs, Office of Intergovernmental and External Affairs, U.S. Department of Health and Human Services (HHS)

The Honorable Jean Hovland Deputy Assistant Secretary for Native Americans Commissioner – Administration for Native Americans Chair – Intra-departmental Council on Native American Affairs

W. Ron Allen, TTAG Chairman

RADM Weahkee, Principal Deputy Director, IHS

Jennifer Cooper, Director, OTSG

Administrator Seema Verma Centers for Medicare and Medicaid Services

U.S. Department of Veterans Affairs VACO/OTGR Attn: Clay Ward

RADM Michael D. Weahkee Principal Deputy Director Indian Health Service

Mr. Jack Kalavritinos, Director Office of Intergovernmental Affairs U.S. Department of Health and Human Services

Addressed To

Advance Appropriations for the Indian Health Service

Opportunities to Enhance HHS’ Tribal Consultation Policy – TSGAC Comments

Joint TSGAC and SGAC Invitation to Tribal Self-Governance Advisory Committee Meeting (1/23/19) and Expansion of Tribal Self-Governance in HHS

TSGAC letter to TTAG regarding Rereview of Summary of Benefits and Coverage documents

105(l) Leases

Self-Governance National Indian Health Outreach and Education” (2018-2019)

State of South Dakota’s 1115 Demonstration Application, “Improving Indian Health in South Dakota”

VA Mission Act

IHS National CHAP Interim Policy Consultation

HHS STAC

Topic/Issue

Joint TSGAC/NIHB Letter Requesting Hearing

TSGAC Formal Comments on HHS Tribal Consultation Policy

Request to meet with TSGAC to discuss the expansion of Self-Governance in HHS and other top IHS priorities.

TSGAC recommendations.

TSGAC Formal Comments and Recommendations

Transmittal of Semi-Annual Report

TSGAC Formal Comments

TSGAC Formal Comments

TSGAC Formal Comments

TSGAC Nomination of Melanie Fourkiller as Member-at-Large

Action(s) Needed

Summary of IHS Tribal Self-Governance Advisory Committee (TSGAC) Correspondence Year: 2015-2018 Response Received

11/9/18

11/6/18

11/1/18

10/31/18

10/17/18

10/17/18

10/11/18

9/18/18

9/14/18

12.

13.

14.

15.

16.

17.

18.

19.

Date Sent/ Received

11.

Ref. #

RADM Weahkee, Acting Director, IHS

Chief Malerba, TSGAC

Kitty Marx Tribal Affairs Group, Office of External Affairs, CMS

The Honorable Robert Wilkie, Secretary U.S. Department of Veterans Affairs

RADM Weahkee, Principal Deputy Director, IHS

Jennifer Cooper, Director, OTSG

Chairman W. Ron Allen, TTAG Chairman

RADM Weahkee, Principal Deputy Director, IHS

The Honorable Gene L. Dodaro Comptroller General of the United States U.S. Government Accountability Office

Addressed To

Sanitation Deficiency System (SDS) Guide Tribal Consultation

RADM Weahkee, Acting Director, IHS

Tribal Technical Advisory Group (TTAG) Appointments

Request that VA Establish a Tribal Advisory Committee

Request for Fiscal Year (FY) 2018 105(l) Leasing Expenditures and Estimates

Self-Governance National Indian Health Outreach And Education”

Review of CMS/CCIIO Presentation to QHP Issuers and State Insurance Regulators on Indian-Specific CostSharing Protections and Preparation of Summary of Benefits and Coverage (SBC) Documents

Summary Letter from October 2018 Meeting

GAO-18-652, “Indian Health Service: Considerations Related to Providing Advance Appropriation Authority

Topic/Issue

Formal TSGAC comments.

IHS Responses to the July 17-18, 2018 TSGAC Quarterly Meeting

Official TSGAC re-appointment of TTAG Representatives

TSGAC requests the formation of a Tribal Advisory Committee

TSGAC requests that IHS provides a full accounting of the reprogrammed and appropriated funds utilized to fulfill all of the FY2018 requests for 105(l) leases.

Transmittal of Final Report (2017-2018)

Recommendations to TTAG (regarding conveyance to CMS/CCIIO)

TSGAC Summary of Main Issues and Recommendations

Joint Letter from TSGAC, NIHB, SGCETC, and NPAIHB to provide some comments following the release of GAO-18-652, Indian Health Service: Considerations Related to Providing Advance Appropriation Authority, and to request that GAO create a Tribal Advisory Committee.

Action(s) Needed

Letter received from IHS on September 19, 2018 with responses to issues raised during the July 2018 TSGAC meeting.

Response received from IHS on 3/18/2019.

Response Received

Summary of IHS Tribal Self-Governance Advisory Committee (TSGAC) Correspondence – 2015-2018

8/20/18

8/20/18

8/16/18

8/10/18

8/10/18

8/1/18

21.

22.

23.

24.

25.

Date Sent/ Received

20.

Ref. #

IHS Consultation

VADM Jerome M. Adams, M.D., M.P.H. Office of the Surgeon General, HHS RADM Weahkee, Acting Director, IHS

ADM Brett P. Giroir, M.D. Office of the Assistant Secretary for Health

Alex M. Azar II, Secretary, HHS

Mick Mulvaney, Director Office of Management and Budget

The Honorable Robert Wilkie, Secretary U.S. Department of Veterans Affairs

Kathleen Klink, MD, FAAFP Acting Deputy Chief Academic Affiliations Officer Veterans Health Administration

Karen Sanders, MD Acting Chief Academic Affiliations Officer Veterans Health Administration

Jennifer Cooper, Director, OTSG

RADM Weahkee, Acting Director, IHS

Addressed To

IHS Behavioral Health Funding

Updates to Indian Health Service (IHS) Tribal Consultation Policy

Delivering Government Solutions in the 21st Century, Reform Plan and Reorganization Recommendations

Inclusion of Purchased and Referred Care (PRC) in Veterans Affairs and Indian Health Service Reimbursement Agreements

Implementation of Indian Specific Provisions of the VA Mission Act

Support of the Great Plains Tribal Chairmen’s Health Board’s (“Board”) Efforts to Assume Management of Sioux San Hospital

Topic/Issue

TSGAC formal comments.

TSGAC/DSTAC Request to form Joint IHS/Tribal Workgroup

TSGAC comments regarding Commission Corps.

TSGAC official comments and recommendations.

TSGAC request to engage further on the provision of the Act. Invitation extended to attend the October 2018 meeting.

Official TSGAC support of Board.

Action(s) Needed

Letter received from IHS on September 19, 2018 with responses to issues raised during the July 2018 TSGAC meeting.

Letter from VA received 10/25/18. VA stated that it has several efforts underway that improve care coordination with community providers and it will assist in addressing TSGAC’s concerns. In addition, the VA welcomes the opportunity to establish a workgroup to ensure that care coordination will be effectively implemented. TSGAC was asked to provide the VA with the names of both Tribal leaders and technical workgroup members to participate on the workgroup. The VA would like to convene the first meeting of the workgroup in January through a conference call. Recommendations due 12/13/18.

Letter received from IHS on September 19, 2018 with responses to issues raised during the July 2018 TSGAC meeting.

Response Received

Summary of IHS Tribal Self-Governance Advisory Committee (TSGAC) Correspondence – 2015-2018

7/27/18

7/26/18

7/6/18

6/22/18

6/12/18

5/18/18

4/19/18

4/17/18

4/17/18

4/11/18

27.

28.

29.

30.

31.

32.

33.

34.

35.

Date Sent/ Received

26.

Ref. #

Chairman W. Ron Allen, TTAG Chairman

RADM Weahkee, Acting Director, IHS

RADM Weahkee, Acting Director, IHS

RADM Weahkee, Acting Director, IHS

Jennifer Cooper, Director, OTSG

RADM Weahkee, Acting Director, IHS

RADM Weahkee, Acting Director, IHS

RADM Weahkee, Acting Director, IHS

IHS Consultation

Jennifer Cooper, Director, OTSG

IHS Consultation

Addressed To

Recommendations for Improved Communication on Special Rule for Family Policies to AI/AN Marketplace Applicants to Prevent Loss of Comprehensive Indian-Specific CostSharing Protections

Exemption of Indian Health Service (IHS) Beneficiaries from Medicaid Work and Community Engagement Requirements

Follow-up Items from Tribal SelfGovernance Advisory Committee Meeting, March 28-29, 2018

Self-Governance National Indian Health Outreach and Education” (2017-2018)

Recommended Revision to the Contract Support Cost (CSC) Policy

Unpaid and Underpaid Third Party Benefits from Private Insurers

Office of Environmental Health & Engineering Updates

Response to the IHS May 18, 2018 Dear Tribal Leader Letter (DTLL) initiating Tribal consultation on changes to the Indian Health Manual; PRC Chapter

Request for ACA/IHCIA National Outreach and Education Funding (FY2019)

Section 105(l) Lease Funding “Dilemma”

Topic/Issue

Recommendations to TTAG (regarding conveyance to CMS)

Opposition to Medicaid Work requirements and strongly disagree with the interpretation by the Office of Civil Rights

Summary of Issues Discussed

Transmittal of Semi-Annual Report

TSGAC Formal Comments in response to IHS Dear Tribal Leader Letter dated 4/13/18

TSGAC follow up on the matter of the pattern of violation of the Indian Health Care Improvement Act (IHCIA) with regard to payment from some private insurers.

TSGAC concerns with the recent announcement of the Small Ambulatory Program (SAP) awards.

TSGAC official comments.

Request for on-going funding of $300,000 for FY2019.

TSGAC formal comments.

Action(s) Needed

Letter received from IHS on July 6th with responses to issues raised during the March 2018 TSGAC meeting.

Letter received from IHS on July 6th that the comment deadline has been extended until August 6th.

Project was funded in September 2018.

Letter received from IHS on September 19, 2018 with responses to issues raised during the July 2018 TSGAC meeting.

Response Received

Summary of IHS Tribal Self-Governance Advisory Committee (TSGAC) Correspondence – 2015-2018

4/5/18

4/5/18

4/4/18

3/9/18

3/1/18

2/22/18

2/14/18

2/5/18

1/8/18

37.

38.

39.

40.

41.

42.

43.

44.

Date Sent/ Received

36.

Ref. #

CMS Regulations.gov

RADM Weahkee, Acting Director, IHS P. Benjamin Smith Jennifer Cooper Liz Fowler

RADM Weahkee, Acting Director, IHS

HHS Consultation.gov

W. Ron Allen TTAG Chair

CMS Regulations

RADM Weahkee, Acting Director, IHS

CAPT Mark Rives IHS

RADM Weahkee, Acting Director, IHS

Addressed To

Medicare Program; Contract Year 2019 Policy and Technical Changes to the Medicare Advantage, Medicare Cost Plan, Medicare Fee-for-Service, the Medicare Prescription Drug Benefit Programs, and the PACE Program (CMS4182-P)

Concerns about Inconsistencies in the IHS Funding Agreement Negotiation Process

TSGAC Support for IHS Advance Appropriations

TSGAC Delegate to 20th Annual HHS Budget Consultation Session

Review of Summary of Benefits and Coverage (SBC) Documents

Comments on Standards Related to Reinsurance, Risk Corridors, and Risk Adjustment (CMS-10401/OMB control number 0938-1155)

TSGAC Representatives to the Community Health Aide Program (CHAP) Workgroup

Information Systems Advisory Committee (ISAC) Charter

Consultation on Recommended Revision to the Contract Support Cost (CSC) Policy

Topic/Issue

Official TSGAC comments

TSGAC request to IHS to inquire with GAO and ask them for a progress report on efforts to draft a report on the use of advance appropriations authority for healthcare programs across the Federal government, including problems encountered, any estimates of cost savings, and applications to the IHS. TSGAC concerns about the current disagreement between IHS and a new SelfGovernance Tribe regarding the timing and responsibility of the IHS to distribute Title V payments.

Appointment of Melanie Fourkiller

TSGAC report and recommendations on SBCs to coordinate the efforts of the TSGAC and the TTAG with an aim to secure needed revisions to the preparation and review of SBCs.

Submission of TSGAC formal comments.

Official appointment of TSGAC representatives

TSGAC Comments and Recommendations

TSGAC Recommendations

Action(s) Needed

March 27, 2018 Letter received from RADM Weahkee addressing issues and concerns raised during the January 2018 TSGAC Quarterly Meeting.

Response Received

Summary of IHS Tribal Self-Governance Advisory Committee (TSGAC) Correspondence – 2015-2018

DTLLs from IHS TSGAC 11

DEPARTMENT OF HEALTH & HUMAN SERVICES

Public Health Service

Indian Health Service Rockville MD 20857

JUN 19 2019

Dear Tribal Leader and Urban Indian Organization Leader: I am writing to update you on new appointments and updates to the Indian Health Service (IHS) senior leadership team.

Deputy Director for Field Operations I am pleased to share that I have appointed Mr. Christopher Mandregan, Jr., a Tribal member of the Aleut Community of St. Paul, Alaska, to serve as the new IHS Deputy Director for Field Operations. In this capacity, Mr. Mandregan will oversee the 12 IHS Areas, which include IHS and tribally managed Service Units, Urban Indian Organization health programs, and the IHS Office of Environmental Health and Engineering. He will also provide management oversight and expertise in formulating policies, goals, and strategies related to program operations and resource allocation.

Mr. Mandregan began his career with the IHS in 1986. In 1996, he was appointed as the Executive Officer for the IHS Alaska Area, responsible for administrative support services for the Area. In 1998, he accepted the position of Alaska Area Director, where he was responsible for the Federal portion of the health care system for Alaska Natives and for conducting Government-to-Government relationships with Tribes on behalf of the HHS Secretary.

Mr. Mandregan returned to IHS Headquarters in February 2019 to serve as Acting Deputy Director for Management Operations and succeeds Rear Admiral Kevin Meeks, a member of the Chickasaw Nation, now retired, after 32 years of service with the IHS. (Acting) Deputy Director for Management Operations Effective with Mr. Mandregan’s appointment, Rear Admiral Chris Buchanan, current IHS Deputy Director, will also serve as Acting Deputy Director for Management Operations at IHS Headquarters until a permanent replacement is selected.

Chief Information Officer and Director, Office of Information Technology I am also pleased to announce the appointment of Mr. Mitchell Thornbrugh, an enrolled member of the Muscogee Creek Nation, as the permanent Chief Information Officer and the Director of the IHS Office of Information Technology. As Director, Mr. Thornbrugh is responsible for advising IHS senior leadership on all aspects of information resource management and technology and ensuring IHS compliance with information technology laws, regulations, and policies.

Mr. Thornbrugh previously served as the Chief Operations Officer for the Cherokee Nation Hastings Hospital. While there, Mr. Thornbrugh streamlined administrative services, improved inventory management, led the implementation of a commercial electronic health record, and

11a

– Tribal Leader and Urban Indian Organization Leader

managed the transition and organizational change to a centralized revenue cycle team.

Mr. Thornbrugh also served as the Chief Information Officer for Cherokee Nation Hastings Hospital from 2005 to 2009, and has been a long-time member of the IHS Information Systems Advisory Committee (ISAC).

Please join me in welcoming these individuals to these leadership roles. As we strengthen IHS management and operations, I am confident that we will continue to make progress in achieving our mission to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level.

Sincerely, / Michael D. Weahkee / RADM Michael Weahkee, MBA, MHSA Assistant Surgeon General, U.S. Public Health Service Principal Deputy Director

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DEPARTMENT OF HEALTH & HUMAN SERVICES

Public Health Service

Indian Health Service Rockville MD 20857

JUN 19 2019

Dear Tribal Leader and Urban Indian Organization Leader: I am writing to initiate Tribal Consultation and Urban Confer on developing an Indian Health Service (IHS) Opioid Grant Program to distribute the Fiscal Year (FY) 2019 opioid funding.

The Consolidated Appropriations Act, 2019 (Public Law 116-6), provided a $10 million increase in the Alcohol and Substance Abuse Program budget line to better combat the opioid epidemic by creating a Special Behavioral Health Pilot Program (SBHPP), modeled after the Special Diabetes Program for Indians.

The explanatory statement further instructs the IHS that the SBHPP be developed in coordination with the Substance Abuse and Mental Health Services Administration to award grants for: 1) supporting the development, documentation, and sharing of locally designed and culturally appropriate prevention, treatment, recovery, and aftercare services for mental health and substance use disorders in American Indian and Alaska Native communities, and 2) providing services and technical assistance to grantees to collect and evaluate performance of the program.

During the formal Tribal Consultation and Urban Confer sessions, I invite you to provide feedback on the following: • • • •

Which priorities need to be considered in developing grant program objectives and goals to address opioid prevention, treatment, and recovery?

What are the associated national outcomes with each of the priorities identified?

How can the IHS demonstrate effectiveness using data and evaluation methods?

What distribution formula or methodology should be utilized in the selection and award process?

To frame these sessions, the IHS Division of Behavioral Health (DBH) will host learning sessions that will share the summary of previous opioid listening sessions and further explain grant distribution options currently in use within the IHS Office of Clinical and Preventive Services. To find proposed dates and locations of Tribal Consultation and Urban Confer sessions, please visit https://www.ihs.gov/dbh/consultationandconfer/.

I encourage you to participate in following virtual Tribal Consultation and Urban Confer sessions that will be hosted by the IHS DBH, in partnership with the IHS Opioid Coordinating Group, and the Heroin, Opioids, and Pain Efforts (HOPE) Committee through August 1, 2019: Virtual Tribal Consultations • • •

Monday, June 24, 2019 from 3:00 p.m. - 5:00 p.m. (ET) Adobe Connect: https://ihs.cosocloud.com/vtc Conference Call-in line: (800) 832-0736; Room Number *4571119 #

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– Tribal Leader and Urban Indian Organization Leader

Virtual Tribal Consultations • • •

Tuesday, July 9, 2019 from 2:00 p.m. - 4:00 p.m. (ET) Adobe Connect: https://ihs.cosocloud.com/vtc Conference Call-in line: (800) 832-0736; Room Number *4571119 #

Virtual Urban Confer • • •

Wednesday June 26, 2019 from 2:00-4:00 p.m. ET Adobe Connect: https://ihs.cosocloud.com/vtc Conference Call-in line: (800) 832-0736; Room Number *4571119 #

Written comments will be accepted through the duration of the Tribal Consultation and Urban Confer comment period. The deadline to provide comments is Thursday, August 1, 2019.

Send comments by e-mail to:

consultation@ihs.gov or urbanconfer@ihs.gov Subject Line: IHS FY 2019 Opioid Grant Funds

Send comments by postal mail to:

RADM Michael D. Weahkee Principal Deputy Director Indian Health Service 5600 Fishers Lane, Mail Stop: 08E86 Rockville, MD 20857 Attention: IHS FY 2019 Opioid Grant Funds

I look forward to your input and recommendations on developing an IHS Opioid Grant Program to address the opioid epidemic.

Thank you for your support and partnership in addressing important behavioral health issues in the communities we serve. If you have questions about the process for submitting a comment on the FY 2019 Opioid Grant Funding Tribal Consultation and Urban Indian Organization Confer, please directly contact Ms. Michele Muir-Howard, DBH, IHS, by telephone at (301) 443-2038, or by e-mail at michele.muir-howard@ihs.gov.

Sincerely, / Michael D. Weahkee / RADM Michael Weahkee, MBA, MHSA Assistant Surgeon General, U.S. Public Health Service Principal Deputy Director

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PROFESSIONAL SERVICES DRAFT- COMMUNITY HEALTH AIDE PROGRAM POLICY Sec. 1.

2.

3.

4.

Introduction Definitions Responsibilities Effective Date

1. INTRODUCTION A. Purpose. To implement, outline, and define a National Community Health Aide Program (CHAP) consistent with the structure of the Alaska CHAP with regard to community based provider selection, culturally tailored care and curriculum, competency based education, and the inclusion of health aides as part of a team of healthcare providers focused on providing effective, efficient, and patient centered care.

B. Scope. This policy applies to the National CHAP and covers those programs operating outside of Alaska. It is not applicable to the Alaska CHAP or its standards and procedures or to Urban Indian Organizations because they are not authorized by law to implement CHAPs. 1 C. Background. The CHAP was established under the Snyder Act to address significant unmet needs during an epidemic in Alaska. Over the years, it expanded to systematically train community health aides and practitioners, and maintain a system of certifying community health aides that have completed training and are competent to provide health care, health promotion and disease prevention services in rural Alaska. In 1992, Congress made CHAP a permanent program in Alaska and, in 2010, it expressly permitted the IHS to develop a national CHAP to promote the achievement of the health status objectives in the Indian Health Care Improvement Act (IHCIA). These objectives are broad in scope and address virtually every aspect of health care, including access, delivery, and status. Specialized training in medical, dental and behavioral health care and certification furthers those objectives by creating opportunities for health aides to focus their training and practice on particular health issues and delivery strategies. In 2016, the Indian Health Service (IHS) consulted with Tribes and Tribal Organizations on expanding the CHAP, and in 2018, 1

The CHAP TAG did not feel it was necessary for IHS to list that the National CHAP was not applicable to Urban Indian Organizations and should only reference the IHCIA as the authority since they feel that certification is separate from the employing organization. IHS kept this language to assist IHS staff in clarifying that the National CHAP applies to Tribes and Tribal Organizations outside of Alaska, but not to Urban Indian Organizations.

DRAFT - FOR COMMENT ONLY

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PROFESSIONAL SERVICES DRAFT- COMMUNITY HEALTH AIDE PROGRAM POLICY formed the CHAP Tribal Advisory Group (CHAP TAG) to begin expanding the CHAP outside the State of Alaska.

D. Authorities. 2 1. Snyder Act, 25 U.S.C. § 13 2. Transfer Act, 42 U.S.C. § 2001 3. Indian Health Care Improvement Act, 25 U.S.C. § 1616l(d) 4. Indian Self Determination and Education Assistance Act, 25 U.S.C. §§ 5301 et seq.

5. Indian Health Service Tribal Consultation Policy, Circular No 2006-01 6. U.S. Department of Health and Human Services Tribal Consultation Policy E. Policy. It is the policy of the IHS that: 1. All CHAP providers certified by the Alaska Community Health Aide Program Certification Board (Alaska CHAPCB) who wish to provide services in a program outside of Alaska and any CHAP provider certified by a federal CHAP Area Certification Board (ACB) but wants to provide services in another area must submit a copy of their certification to the receiving ACB for review and approval prior to being certified in that Area. 3

2

The CHAP TAG recommended to IHS to also include the entire Indian Health Care Improvement Act and the Public Health Service Act, 42 U.S.C. § 254a to provide a more complete picture of the authority and potential flexibility available to those charged with implementing this program. IHS included the primary authorities that implement the national CHAP. 3 The CHAP TAG requested to IHS to include tribally approved CHAP certification or licensure by a governmental authority. CHAP TAG basis for this recommendation is that federal policy recognizes the legitimacy of tribal programs and this recognition should also be included in this policy. IHS should defer not to the state in this policy and the policy should uphold the sovereignty of each Tribal Nation and IHS’s trust responsibility with respect to the ISDEAA. IHS did not agree with the CHAP TAG’s recommendation to include non-federal licensing or certification entities because this would constitute an expansion of the CHAP program beyond what is authorized in the IHCIA. The IHCIA requires federal certification, as evidenced from the Alaska Area CHAP. The IHCIA did not authorize a national CHAP with expanded authority beyond what is permitted in the Alaska Area.

DRAFT - FOR COMMENT ONLY

11f

PROFESSIONAL SERVICES DRAFT- COMMUNITY HEALTH AIDE PROGRAM POLICY 2. Tribes outside of Alaska may carry out a CHAP, including those that include dental health aide therapists (DHAT) service, by amending their Indian Self Determination and Education Assistance (ISDEAA) Title I and Title V agreements.

3. If Tribes or Tribal Organizations outside of Alaska include a CHAP as a program, service, function, or activity (PSFA) in their ISDEAA contract or compact, the individuals working under their CHAP must be certified by the Alaska CHAPCB or other federal ACB. 4. Nothing in this policy shall restrict the ability of the Service, an Indian tribe, or a tribal organization to participate in any program or to provide any service authorized by any other federal law.

5. At the time of drafting of this policy, IHS has not received additional funding and is not providing funding for the expansion of the CHAP outside of Alaska; however, Tribes and Tribal Organizations may propose to redesign or re-budget a PSFA in their ISDEAA agreement subject to any other applicable requirements to include this program. At the time of drafting of this policy, there is no IHS funding associated with the CHAP at the Headquarters, Area, or service unit level.

6. DHATs shall practice only in states that authorize the use of DHAT services if a Tribe or Tribal Organization seeks to include a CHAP as a PSFA in Title I and Title V ISDEAA contract or compact. DHATs must meet the federal training requirements for certification. 4 7. DHATs and Community Health Aides (CHAs) will be authorized to provide services in IHS operated health programs once the Office of Personnel

4

The CHAP TAG recommended that IHS not include this statement as they work with Congress to change the IHCIA for this requirement. The CHAP TAG also recommended that, if the IHS feels it is critically important to address this issue in the circular despite the likely delay in providing federal funding for the program, to notify its own officials as they review a Tribe’s proposal to include CHAP in their ISDEAA contract or compact of the existing requirements, IHS draft the provision more narrowly to more closely reflect the limitations implicit in this section. The CHAP TAG believes it unlikely that Congress intended with this provision to extend regulatory authority to states not already covered by Public Law No. 83-280. The IHS did not change this language since it is federal legal requirement, not a state requirement. It is critically important to notify IHS officials as they review a Tribe’s proposal to include CHAP in their ISDEAA contract or compact that the DHATs must be in a state that authorizes their use before it may be included in the ISDEAA contract or compact.

DRAFT - FOR COMMENT ONLY

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PROFESSIONAL SERVICES DRAFT- COMMUNITY HEALTH AIDE PROGRAM POLICY Management series and classification of position descriptions are approved.

This requirement does not apply to ISDEAA Title I and Title V Tribes.

8. IHS operated health programs will not fill any vacancy for a licensed dentist with a DHAT. ISDEAA Title I and Title V Tribes are not subject to this restriction.

9. Behavioral Health Aides (BHAs) may be utilized in IHS operated health care programs using existing Office of Personnel Management (OPM) approved position description for mental health specialists (OPM Series 0181 Psychology Technician and/or GS 0186 Social Service Aid) or other approved positions that may be established.

10. Expansion of CHAP will comply with the IHCIA and not reduce funding amounts of the Alaska CHAP. 11. The NCB is a federal board comprised of tribal and federal representatives.

12. The ACBs are federal boards and their membership must include at least one federal representative appointed by the respective IHS Area Director.

13. In the absence of an ACB, an IHS Area Director must consult with Area Tribes and will seek consensus of a majority of Area tribes or Tribal organizations to enter into a relationship with another IHS Area that has an ACB or with the Alaska CHAPCB for the purposes of certifying its CHAP providers. In the absence of consensus, IHS Area Directors will reserve the right to make the final decision. 5 14. While ACBs are federal boards and comprise the NCB, an IHS Area Director may partner with Tribes or Tribal Organizations to carry out the support for the operation and maintenance of the ACB.

2. DEFINITIONS This section provides background on the terms used in this policy. This section does not provide policy direction and should be used as a reference point for language in the policy.

5

The CHAP TAG recommended that IHS seek consensus and approval of Tribes in the area before partnering with another area to form a regional ACB. IHS reserves the right to make the decision on how to best meet the needs of the area when consensus is not met.

DRAFT - FOR COMMENT ONLY

11h

PROFESSIONAL SERVICES DRAFT- COMMUNITY HEALTH AIDE PROGRAM POLICY

A.

Academic Review Committees (ARC). Specialized body of practitioners representing the behavioral, primary, oral health, and other relevant fields that reports and makes recommendations to the Area Certification Boards (ACB) regarding the training standards for all CHAP provider types.

B.

Area. Refers to one of the twelve (12) IHS service Areas: Alaska, Albuquerque, Bemidji, Billings, California, Great Plains, Nashville, Navajo, Oklahoma City, Phoenix, Portland, and Tucson.

C.

Certification Boards.

1. CHAP National Certification Board (NCB). The NCB is a federal board chaired by the IHS Chief Medical Officer (CMO) or his or her delegate and will be comprised of Federal and Tribal representatives from each ACB. Functions of the NCB and board composition are addressed in the charter and procedures.

2. CHAP Area Certification Boards (ACBs). The ACBs are federal boards and their membership must include at least one federal representative appointed by the respective IHS Area Director. The ACB establishes board composition in its charters and develops the procedures of each respective board to certify individuals as their respective provider types.

D.

Community Health Aide Program (CHAP). The program provides for the education and training of Tribal community health providers who work as part of a team with other health professionals to provide health care, health promotion, and disease prevention services. CHAP includes three provider types listed below: 1. Behavioral Health Aide. Refers to a behavioral health aide I, II, III, and practitioner except when a level is specified. The specific roles and responsibilities of each level, will be defined in the National CHAP Standards and Procedures and other applicable ACB requirements.

2. Community Health Aide. Refers to community health aide I, II, III, IV, and Practitioner, except when a level is specified. The specific roles and responsibilities of each level, will be specified in the National CHAP Standards and Procedures and other applicable ACB requirements.

DRAFT - FOR COMMENT ONLY

11i

PROFESSIONAL SERVICES DRAFT- COMMUNITY HEALTH AIDE PROGRAM POLICY 3. Dental Health Aide. Refers to a primary dental health aide level I-II, expanded function dental health aide level I-II, dental health aide hygienist, and DHAT except when the level is specified. The specific roles and responsibilities will be specified in National CHAP Standards and Procedures and other applicable ACB requirements.

E. Standards and Procedures.

1. National CHAP Standards and Procedures. Adopted in part from the Alaska CHAPCB Standards and Procedures to outline the minimum program standards for all CHAP provider types operating outside of Alaska. The National CHAP Standards and Procedures include, but are not limited to, the minimum training, training equivalency, supervision, and scope of practice requirements.

2. Area Standards and Procedures. At a minimum, the Area Standards and Procedures include the National CHAP Standards and Procedures and may have additional supplemental requirements above and beyond the national standards that are specific to the cultural considerations of the region, community specific needs, as well as the health care delivery system. 6 3. RESPONSIBILITIES A. IHS CMO. Chairs the NCB. Consults with the CHAP Tribal Advisory Group to request initial membership for the NCB. Accepts nominations of tribal representatives to serve on the NCB. Appoints members of the NCB. NCB members shall not represent the interest of any professional association and will be comprised of representatives from across IHS Areas. The IHS CMO will make a good faith effort to ensure that the membership of the Board reflects the diversity of the geographic areas served, and includes tribal practitioners and tribal administrators with relevant expertise.

B. IHS Area Directors. Consults with Area Tribes to appoint members of the ACB and to the NCB. Provides ACB members with direction to establish board composition in its charters and to develop the procedures of each respective board. Certifies CHAP 6

The CHAP TAG recommended to the IHS that ACBs should be allowed to adopt standards and procedures that vary from the national standards and procedures. IHS agrees that ACBs may adopt standards and procedures above and beyond the minimum requirements of the national standards and procedures but may not alter below those requirements. The CHAP TAG further recommended that the skill and qualification levels would be addressed in a CHAP’s scope of practice. IHS agrees that the scope of practice should be tailored to the individual CHAP only if the minimum training standards have been met by all CHAPs as addressed in the national CHAP and as is the process in the Alaska CHAP.

DRAFT - FOR COMMENT ONLY

11j

PROFESSIONAL SERVICES DRAFT- COMMUNITY HEALTH AIDE PROGRAM POLICY providers based on recommendations from ACBs. Approves and signs individual certification documents for CHAP providers. Appoints a federal representative to serve on the ACB. C. Federal ACB Representative. Appointed by an IHS Area Director. Provides recommendations to the IHS Area Director based on discussions of the ACB on individuals who have met the CHAP training standards and should be certified to practice.

D. NCB. Establishes National CHAP Certification Standards and approves the national CHAP minimum training standards for all CHAP provider types for the ACBs to utilize to ensure consistency across IHS areas.

1. Specifies baseline requirements and scope of practice for all CHAP provider types, including community health aides and practitioners, dental health aides (including primary dental health aides, expanded functions dental health aides, dental health aide hygienists, and dental health aide therapists), and behavioral health aides and practitioners.

2. Conducts review of CHAP operations to ensure consistency across all IHS Areas every three years.

3. Convenes ACBs periodically to review National CHAP Standards and Procedures.

4. Determines what will constitute equivalent training of providers as authorized in the IHCIA. 5. Maintains annual records of ACB actions regarding certification of CHAP providers. The IHS will maintain a database and make it accessible to tribal contractors and compactors to encourage them to extend reciprocity in appropriate circumstances.

E. Area and/or Regional Certification Boards (ACBs).

1. Maintains records of certifications of individuals certified by the Alaska or other ACB who work in the area or areas under the jurisdiction of that ACB and maintains a record of all CHAP providers certified, denied, recertified, revoked,

DRAFT - FOR COMMENT ONLY

11j

PROFESSIONAL SERVICES DRAFT- COMMUNITY HEALTH AIDE PROGRAM POLICY and approved after appeal who work in the area or areas under the jurisdiction of that ACB. 2. Creates procedures that detail terms, chairmanship, quorum, meetings, duties, and transition functions.

3. Ensures National CHAP Standards and Procedures established by the NCB, as well as any additional requirements set forth by the ACB for its applicable provider type, are met before certifying individuals for all CHAP provider types identified in 2.D. 4. Certifies CHAP providers. Certification is approved and executed when an IHS Area Director or their federal designee’s signature is included on the certification document. Once completed a copy of the certification is sent to the NCB. 5. Adopts Area specific curriculum, consistent with the National CHAP Standards and Procedures established by the NCB, as needed, to ensure Area specific needs are met.

6. Ensures the National CHAP Standards and Procedures and the respective Area curriculum are culturally tailored and accessible to Area Tribal members.

7. Ensures the portability of health aide certification across Areas.

8. Certifies the Area curriculum for each CHAP provider type on at least a three (3) year recurring cycle.

9. ACB members shall not represent the interests of any professional organizations.

F. Academic Review Committees (ARC).

1. Conducts an independent review of the curriculum to ensure its alignment with the current health needs of American Indians and Alaska Natives.

2. Develops recommendations to the NCB through the ACB on curriculum.

3.

ARC members shall not represent the interests of any professional organizations.

DRAFT - FOR COMMENT ONLY

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PROFESSIONAL SERVICES DRAFT- COMMUNITY HEALTH AIDE PROGRAM POLICY 4. EFFECTIVE DATE This Circular becomes effective on the date of signature and will be superseded by the permanent policy once approved by the IHS Director.

DRAFT - FOR COMMENT ONLY

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DEPARTMENT OF HEALTH & HUMAN SERVICES

MAY 24 2019

Public Health Service Indian Health Service Rockville MD 20857

Dear Tribal Leader: I am writing to update you on the Tribal Consultation for the Indian Health Service (IHS) Sanitation Deficiency System – A Guide for Reporting Sanitation Deficiencies for American Indian and Alaska Native Homes and Communities (commonly known as the “SDS Guide”).

By letter dated July 2, 2018, I initiated Tribal Consultation on proposed updates to the SDS Guide, which is used to establish the processes by which IHS Areas collect and report the current sanitation deficiencies affecting American Indian and Alaska Native (AI/AN) homes and communities. At the request of Tribes, I extended the comment period through September 14, 2018, to provide additional time for comments. During the comment period, 41 responses were received that included 71 unique comments on the SDS Guide. I want to thank the Tribes and Tribal Organizations that took the time to review and provide comments on the document.

On March 20, 2019, the IHS Office of Environmental Health and Engineering (OEHE) met with the IHS Facilities Appropriation Advisory Board (FAAB) in Rockville, Maryland, to discuss the results of the Tribal Consultation and to receive feedback on the finalization of the SDS Guide. At the meeting, the IHS OEHE provided the FAAB with a summary of the comments received, and the FAAB requested additional time to review the comments in detail. Following the meeting, two conference calls were held to discuss the comments and proposed responses. I want to thank the FAAB members for their active engagement and feedback.

A summary of the comments received during Tribal Consultation and how the IHS incorporated them into the updated SDS Guide can be found under the Links header at https://www.ihs.gov/dsfc/resources/. IHS based these responses on a thorough review of the statutory requirements, program policy, and input from the FAAB. The comments are provided with limited modifications to remove identifying information and to group similar comments together.

The IHS OEHE plans to issue the updated SDS Guide for use in the 2020 SDS reporting cycle. The updated SDS Guide will be posted under the Documents header at the above-stated link by September 30, 2019.

If you have additional questions, please contact RADM Mark Calkins, Director, Division of Sanitation Facilities Construction, IHS, by telephone at (301) 443-1046 or by e-mail at mark.calkins@ihs.gov.

Sincerely, /Michael D. Weahkee/ RADM Michael D. Weahkee, MBA, MHSA Assistant Surgeon General, U.S. Public Health Service Principal Deputy Director

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May 24, 2019

Dear Tribal Leader and Urban Indian Organization Leader: In accordance with the HHS Tribal Consultation Policy, the National Institutes of Health (NIH) is announcing a series of Tribal Consultation and Listening Sessions on the All of Us Research Program.

The All of Us Research Program, part of NIH, was established to accelerate health research and medical breakthroughs to enable an era of precision medicine for all. Precision medicine is an approach to disease treatment and prevention that seeks to maximize effectiveness by taking into account individual variability in environment, lifestyle, and biological makeup. With the great promise this program represents for strategically addressing health challenges, it is our intent to respectfully engage with Tribal Nations to facilitate the inclusion of American Indian and Alaska Native (AI/AN) populations in this program.

NIH will take part in several upcoming 2019 HHS Regional Consultations to discuss the All of Us Research Program in-person with Tribal leaders: June 18 from 2:30-5:00 p.m. in Sacramento, California; July 16 from 2:30-5:00 p.m. in Washington, D.C.; and August 21 from 2:30-5:00 p.m. in Denver, Colorado. We also encourage you to participate in an upcoming special in-person consultation event on June 24, 2019, at the Nugget Casino and Resort in Sparks, Nevada, preceding the National Congress of American Indians’ 2019 Mid-Year Conference and Marketplace. Mr. Eric Dishman, Director of the All of Us Research Program, Dr. Aaron Payment, Chairperson of the Sault Ste. Marie Tribe of Chippewa Indians and Chair of the NIH Tribal Advisory Committee, and other NIH and All of Us leadership will be in attendance to listen and substantively incorporate your input. If you and your designee(s) are unable to participate in these in-person sessions, and/or if you prefer to comment in writing, we welcome written testimony submitted to AOUTribal@nih.gov by August 31, 2019.

In addition to the four consultations above, the program also invites you to join listening sessions throughout the summer, starting with the United South and Eastern Tribes (USET) Semi Annual Meeting on June 18 at 10:00 a.m. in Nashville, Tennessee. Additional opportunities to participate in listening sessions will be posted on the All of Us Tribal Engagement website as details become available. We welcome you to subscribe to our listserv to receive email updates on agendas, new listening sessions, and other information relevant to Tribal Nations (please use the “Subscribe” button found on our website: https://allofus.nih.gov/all-us-tribal-engagement).

These consultations are in direct response to advice we have received to explore and discuss ways the All of Us Research Program can develop meaningful, culturally appropriate

11n

collaborations with AI/AN populations. The goal for these events is to facilitate information exchange and provide an opportunity for Tribal and Urban Indian Organization leadership to have meaningful input as All of Us identifies priorities and opportunities around the inclusion of AI/AN populations in the research program while also implementing the appropriate protections to comply with tribal research oversight and laws.

To help assist with your preparation for this consultation, All of Us is offering the following resources: • Framing Letter • Tribal Collaboration Working Group Report “Considerations for Meaningful Collaboration with Tribal Populations” • Informational webinar about the All of Us Research Program: the 60-minute webinar, which will include an overview and Q&A session, will be hosted on June 3, 2019 from 3:00-4:00 p.m. (ET) and will be available for on-demand viewing after the event.

These and additional resources are available at the All of Us Research Program’s Tribal Consultation webpage at: https://allofus.nih.gov/all-us-tribal-engagement.

We look forward to participating, listening, and learning from each of you. If you have additional questions about this event, please contact the All of Us Research Program Tribal Engagement team by calling or texting (240) 515-5317 or by email at AOUTribal@nih.gov.

Sincerely yours,

Francis S. Collins, M.D., Ph.D. Director

11o

TSGAC Products TSGAC 12

IHS TRIBAL SELF-GOVERNANCE ADVISORY COMMITTEE c/o Self-Governance Communication and Education P.O. Box 1734, McAlester, OK 74501 Telephone (918) 302-0252 ~ Facsimile (918) 423-7639 ~ Website: www.tribalselfgov.org

Electronically Submitted to consultation@ihs.gov April 30, 2019 RADM Michael D. Weahkee, MBA, MHSA Assistant Surgeon General, U.S. Public Health Service Principal Deputy Director Indian Health Service U.S. Department of Health and Human Services 5600 Fishers Lane Rockville, MD 20857 RE:

Comments and Recommendations for Funding Indian Self-Determination Education and Assistance Act 105(l) Leases

Dear RADM Weahkee: On behalf of the Indian Health Service’s (IHS) Tribal Self-Governance Advisory Committee (TSGAC), I write to provide a response to your March 12, 2019 “Dear Tribal Leader and Urban Indian Organization Leader Letter” about funding 105(l) lease requirements. During the SelfGovernance Annual Consultation Conference and the recent TSGAC meeting, we discussed the Committee’s growing concern associated with IHS’s requirement to fund leases under section 105(l) of the Indian Self-Determination and Education Assistance Act (ISDEAA) and the actions taken to fund Fiscal Year (FY) 2018 lease expenses.1 TSGAC is concerned that last year’s practice of reprogramming funds from other IHS accounts or funding intended for inflation costs or other purposes erodes the base budgets of Tribes.

This deprives Tribes and IHS operated programs of badly needed resources to meet the health care needs of American Indian and Alaska Native (AI/AN) patients. A better solution is needed to address this ongoing and growing concern. Therefore, I propose the following recommendations: (1) Request supplemental appropriations for FY 2019 105(l) leases.

A better solution than reprogramming would be to seek a supplemental appropriation from Congress. Appropriators are aware that recent litigation has created an unforeseen and significant new cost, and that IHS needs a bridge to a permanent, long-term solution. Since the magnitude of these costs, even in FY 2019, are difficult to predict, TSGAC recommends that IHS acknowledge this fact in its supplemental appropriation request to Congress, so appropriators may provide such sums as may be necessary for obligation through the end of FY 2019.

(2) Find other sources of funding for FY 2019 105(l) leases.

TSGAC is still unclear if the action taken in FY2018 adheres to ISDEAA’s requirement to pass all congressional increases through ISDEAA agreements. Therefore, TSGAC recommends that most, if not all, of the funding comes from the Headquarters administrative funds rather than Tribal shares. In the past, IHS has held Tribes harmless when faced with a deficit of even 1

25 U.S.C. § 5324(l).

12a

Letter – RADM Michael D. Weahkee, MBA, MHSA Re: Comments and Recommendations on ISDEAA, 105(l) Leases

April 30, 2019

greater magnitude. In FY 2014, faced with a projected contract support cost shortfall of $48 million, IHS proposed that “half of the reprogramming would be accomplished with Headquarters funds and half would be accomplished with Area funds.” Ultimately, IHS had to reprogram $25.1 million, with approximately 80% of that from Headquarters in order to minimize impacts on Direct Service Tribes and Tribal providers. IHS should exhaust all other funds to avoid reductions in direct health care service funds.

(3) Convene a technical workgroup to create a methodology to estimate 105(l) funding needs.

Since the level of need to fund 105(l) is extremely difficult to predict, TSGAC believes a technical workgroup should be established under a standing IHS committee or workgroup to develop a policy to assist the Agency to estimate its on-going 105(l) funding needs. This workgroup should have representation from each IHS Area, TSGAC, the Facilities Appropriations Advisory Board, and the Direct Service and Contracting Tribes Advisory Committee. TSGAC has already identified two potential representatives for this workgroup and is ready to submit those nominations upon your announcement to establish the technical workgroup.

(4) Request a separate and indefinite appropriation specifically for 105(l) Leases.

This recommendation is intended to discourage any discussions and considerations to reprogram current IHS funding which would be unacceptable to Tribes. We expect the IHS and Congress to honor the trust responsibility and protect the IHS appropriation in order to fund current services and program increases. The best solution to resolve these issues is for the IHS to pursue a separate and indefinite appropriation for 105(l) lease payments similar to the appropriation for Contract Support Cost (CSC) payments for ISDEAA agreements. An indefinite appropriation would save IHS and Congress from the impossible task of identifying specific amounts needed in a given year to fully fund 105(l) leases.

As the past two years have shown, predicting the activity of hundreds of Tribes and Tribal organizations is simply not feasible, and will result in more painful reprogramming. Section 105(l) lease costs share much in common with CSCs: the legal mandate to pay in full, the difficulty in projecting the full need, and their central role in health program administration. A separate, indefinite appropriation for 105(l) leases is just as much a Federal obligation to pay under the ISDEAA as is CSC. This issue is very important to the TSGAC. If you have any questions about our comments and recommendations to fund 105(l) leases, please feel free to contact me at: lmalerba@mohegantribe.com. Thank you.

Sincerely,

Marilynn “Lynn” Malerba Chief, Mohegan Tribe Chairwoman TSGAC cc:

Jennifer Cooper, Director, Office of Tribal Self-Governance, IHS TSGAC and Technical Workgroup Members

12b

IHS TRIBAL SELF-GOVERNANCE ADVISORY COMMITTEE c/o Self-Governance Communication and Education P.O. Box 1734, McAlester, OK 74501 Telephone (918) 302-0252 ~ Facsimile (918) 423-7639 ~ Website: www.tribalselfgov.org

Submitted via email to: tribalgovernmentconsultation@va.gov

June 7, 2019

U.S. Department of Veterans Affairs VACO/OTGR Attn: Clay Ward 810 Vermont Ave. NW, Ste. 915a Washington, DC 20420 RE:

Comments on MISSION Act Strategic Plan

Dear Mr. Ward: On behalf of the Indian Health Service’s (IHS) Tribal Self-Governance Advisory Committee (TSGAC), I write to provide a response to your April 16, 2019, Dear Tribal Leader Letter providing an opportunity to submit comments on the Veteran’s Affairs (VA) Strategic Plan to meet the health care demands in consultation with a variety of stakeholders, as required by the MISSION Act. The TSGAC appreciates that the VA recognizes that Native American Veterans have an important role in shaping the future of VA health care.

We offer the following comments on our most important issues: 1. American Indian/Alaska Native (AI/AN) Veterans Co-Pays Currently, AI/ANs who seek health care services at a VA facility are assessed co-payments.

This practice does not align with the Federal trust responsibility to provide health care to all AI/ANs. IHS and Tribal Health Providers (THP) are the payor of last resort (section 2901(b) of the Affordable Care Act) whether or not there is a specific agreement in place for reimbursement. Therefore, neither the Native Veteran nor the Indian health system should be responsible for any co-payments. The TSGAC recommends the discontinuation of the practice of collecting co-payments from AI/AN Veterans.

2. VA Accept Tribal Provider Credentialing To ensure care coordination is effective and efficient, the TSGAC recommends the VA accept provider credentialing from THPs. 3. Health Information Exchange TSGAC has had several conversations with the VA and recommended the VA consider inclusion in local health information exchanges which THPs in that area utilize. Again, we recommend local VA health care facilities work with their local THPs to ensure health information can be exchanged at the local levels through health information exchanges.

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Letter – U.S. Department of Veterans Affairs RE: Comments on MISSION Act Strategic Plan June 7, 2019 4. Graduate Medical Education (Tribal Medical Residency Programs) The Indian health care system, consisting of facilities and programs operated by IHS, Tribes, Tribal Organizations and Urban Indian Health Programs, serve a great number of AI/AN Veterans, and often extend services to non-Native Veterans through partnerships with VA. These Indian health programs have significant workforce challenges due to most facilities being located in rural and/or remote locations. The HHS Health Resources and Services Administration (HRSA) automatically designates IHS, Tribally-operated and Urban Indian Health programs as Health Professionals Shortage Areas (HPSAs) and Medically Underserved Area and Medically Underserved Population (MUA/MUP) for these reasons.

TSGAC was very encouraged to review the provisions of the recent VA Mission Act, specifically Section 403 which included a “Pilot Program on Graduate Medical Education and Residency.”

This new pilot includes facilities operated by Tribes, Tribal Organizations and IHS as “covered facilities” for purposes of the program and requires such facilities have a priority in placement of residents.

There are several THPs that have Tribal medical residency programs and we have had several conversations with VA officials regarding this provision. The TSGAC recommends that these conversations continue about how the Office of Academic Affiliations (OAA) envisions implementing the pilot, and how IHS and Tribes can be involved early in the planning to ensure that any regulations or policy that may be developed in the future for the pilot work optimally in Indian Country.

5. Reimbursement to Tribal Health Facilities for Specialty Care Services Provided Outside the Tribal Health Facility (PRC Reimbursement) In addition to providing primary health care services, IHS and THPs utilize provider networks to provide specialty services (or other services not directly provided by IHS/THPs to AI/AN Veterans. The networks are critical in providing care to Veterans living in rural and remote areas. The VA currently reimburses IHS and THPs for care they directly provide under the IHS/VA Memorandum of Understanding (MOU). Despite the payor of last resort requirements that are included in Federal policy, the VA has not provided reimbursement for PRC specialty and referral care provided through IHS/THPs. Practically, if a Veteran receives care directly from IHS and THPs, the VA reimburses.

However, if a referral is needed for specialty care (or other services not directly provided by IHS/THPs), the VA only pays for the specialty service if the Veteran goes back to the VA health system and gets another referral by a VA provider. The PRC program authorizes Indian health care facilities to purchase services from a network of private providers. The payor of last resort statute and regulations require that all other sources of obtaining health services be exhausted prior to receiving care through the PRC program. These services may include primary or specialty care that is not available at an IHS and/or Tribal health care facility.

Because the assessment and referral conducted by the IHS/THP provider is not accepted by VA, this requires an additional consultation by a VA provider resulting in more time for the patient and additional federal funds for redundant assessments. There are often additional challenges with coordination of care between the VA or VA providers and the initial IHS/THP

12d

Letter – U.S. Department of Veterans Affairs RE: Comments on MISSION Act Strategic Plan June 7, 2019 provider that made the referral. In certain instances, this level of care may be directly available and provided under the current reimbursement agreements and reimbursed by the VA. However, because the mix of direct versus purchased care varies across the Indian health system, some IHS or Tribal health programs may purchase more care from outside providers, which is currently uncompensated by VA. This can result in inconsistent coordination and quality of care to the Native Veteran.

As a result, THPs are choosing to, with consent of the Veteran, refer out for specialty treatment or other medically necessary health services without VA involvement and absorbing that cost so Veterans can be treated in a complete and timely manner. The impact to Veterans that do go back to the VA is delayed treatment and results in a different level/standard of care for AI/AN veterans. The bottom line is that, in the best interest of the Veteran, THPs that run their own health programs are often forced to absorb the costs when they refer Veterans out for third party care rather than sending them back to the VA for the referral. Since health care systems (IHS, THP, VA) all utilize Medicare Like Rates, and all other resources such as Medicare, Medicaid and private insurance are required to be collected by the contracted provider prior to IHS/THP payment, the cost would remain approximately the same to VA to reimburse IHS/THPs for PRC services.

To date, the VA-IHS/THPs MOUs have proven to be successful in facilitating patient care and has been the least administratively burdensome approach for all parties, most importantly AI/AN veterans. However, the Indian Health Care Improvement Act (IHCIA) Section 405(c) has not been fully implemented. The current national agreement and, by default, nearly all THP agreements do not include reimbursement for Purchased/Referred Care (PRC).

IHCIA Section 405 (c) states - Sharing arrangements with Federal agencies Reimbursement - The Service, Indian tribe, or tribal organization shall be reimbursed by the Department of Veterans Affairs or the Department of Defense (as the case may be) where services are provided through the Service, an Indian tribe, or a tribal organization to beneficiaries eligible for services from either such Department, notwithstanding any other provision of law. 25 U.S. Code § 1645(c) PRC consists of purchased health care that is provided through IHS/THPs. Reimbursement for specialty care provided through PRC is essential to ensure that Native Veterans receive the best care possible. Nationally, only one in thirteen visits is an inpatient visit, but Veterans often need additional services which cannot be provided directly by an IHS Service Unit or THP. The TSGAC recommends the VA include PRC in future IHS/THP reimbursement agreements so that there is no further rationing of health care provided by IHS and THPs to Native veterans and other eligible AI/ANs in the system. This would ensure the IHCIA is fully implemented and ensure the VA fully reimburses for services provided by IHS/THPs as required in Section 405(c) of the IHCIA. 6. Establishment of VA/Tribal Care Coordination Workgroup TSGAC has discussed with the VA several times about the formation of a VA/Tribal workgroup to address care coordination issues and the VA gave the Committee a commitment to develop the workgroup and have the first call in January 2019. To date, we have not heard anything

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Letter – U.S. Department of Veterans Affairs RE: Comments on MISSION Act Strategic Plan June 7, 2019 about the formation of this workgroup. We again recommend that the VA establish this very important workgroup as soon as possible.

In closing, we appreciate the opportunities to provide these comments. These issues are very important to the TSGAC. If you have any questions about our comments and recommendations, please feel free to contact me at lmalerba@mohegantribe.com. Thank you.

Sincerely,

Marilynn “Lynn” Malerba Chief, Mohegan Tribe Chairwoman TSGAC cc:

Jennifer Cooper, Director, Office of Tribal Self-Governance, IHS TSGAC and Technical Workgroup Members

12f

IHS TRIBAL SELF-GOVERNANCE ADVISORY COMMITTEE c/o Self-Governance Communication and Education P.O. Box 1734, McAlester, OK 74501 Telephone (918) 302-0252 ~ Facsimile (918) 423-7639 ~ Website: www.Tribalselfgov.org

Submitted Electronically: Seema.verma@cms.hhs.gov May 23, 2019 Administrator Seema Verma Centers for Medicare and Medicaid Services Department of Health and Human Services 200 Independence Ave SW Washington, DC 20101 RE:

Comments on the State of South Dakota’s 1115 Demonstration Application, “Improving Indian Health in South Dakota”

Dear Administrator Verma: On behalf of the Tribal Self-Governance Advisory Committee (TSGAC) to the Indian Health Service (IHS), I am writing to submit comments to the Centers for Medicare and Medicaid Services (CMS) regarding South Dakota’s proposed new 5-year section 1115 demonstration to “reimburse Federally Qualified Health Centers (FQHCs) in the demonstration with 100% Federal Financial Participation (FFP) for services provided to American Indians.”

The waiver proposes to create a new alternative service delivery model that is represented as increasing access to primary care services for American Indians and Alaska Natives (AI/ANs) from FQHCs and Urban Indian programs. However, the waiver does not change the FQHC system or create a new delivery or payment model that does not already exist today. All the waiver does is increase federal financial participation (FFP) by allowing South Dakota to claim 100% FFP for services provided to AI/ANs by FQHCs and Urban Indian programs. Most importantly, nothing in the waiver indicates that the savings to the State from 100% FMAP claiming be used to increase access to services for AI/ANs—for example, by building the infrastructure of Indian health facilities or by funding an expansion of Medicaid eligibility.

As a result, the TSGAC requests that CMS not approve South Dakota’s waiver. It does not promote the objectives that Congress intended when providing 100% Federal Medical Assistance Percentage (FMAP) for services received through Indian Health Service (IHS) and Tribal health facilities under section 1905(b) of the Social Security Act (SSA). The waiver is not necessary since South Dakota already operates an “alternative service delivery model” through its existing structure of FQHC providers. AI/ANs can already access services at FQHCs. Approval of the waiver would not create a service delivery model that does not exist today, or increase access to such services.

The waiver only creates a new financing scheme that would allow the State to claim 100% FFP/FMAP for services provided by non-Tribal FQHCs and shifts this cost to the federal government.

In fact, in a recent CMS response to a section 1115 waiver demonstration proposed by the State of North Carolina, CMS took the position that the 100 percent FMAP rule could not be waived by a

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TSGAC Comments on State of South Dakota’s 1115 Demonstration Application May 23, 2019

Section 1115 waiver. CMS stated, “Section 1115(a)(i) waiver authority extends only to provisions of section 1902 of the Act, and does not extend to provisions of section 1905 of the Act, such as section 1905(b).” It would not—and does not—now appear to be supportable for CMS to waive portions of SSA section 1905.

It is important to acknowledge that the TSGAC supports the State of South Dakota continuing to work with Tribes in order for the State to claim 100% FFP/FMAP for services to eligible AI/ANs “received through” facilities of the IHS; however, this should be done under the existing CMS State Health Official letter (SHO #16-002) and apply to individuals eligible for IHS services as defined at 42 C.F.R. Part 136. And, we believe that this authority should be exercised for the purpose of strengthening the Tribal and IHS health systems in order to provide improved access to care for AI/ANs. The TSGAC also supports the expansion of 100% FMAP to those Urban Indian Health Programs that are funded under the Indian Health Care Improvement Act (IHCIA) (however, not as a part of this waiver).

Congress Intended 100% FMAP to Support IHS Facilities In 1976, Congress amended the Social Security Act to authorize the IHS and Tribes to bill Medicaid, a provision that Congress described “as a much-needed supplement to a health care program which for too long has been insufficient to provide quality health care to the American Indians.”1 Section 1905(b) of the SSA requires the federal government to match state expenditures at the FMAP rate, including 100% FMAP for state expenditures on behalf of “IHS eligible” Medicaid beneficiaries for covered services “received through” an IHS facility, whether operated by the IHS or by a Tribe or Tribal organization (as defined in section 4 of the Indian Health Care Improvement Act).2 Congress authorized 1905(b) to supplement inadequate IHS appropriations as part of the federal trust responsibility and, at the same time, recognized that “it would be unfair and inequitable to burden a State Medicaid program with costs which normally would have been borne by the Indian Health Service.”3 By providing 100% FMAP for services “received through” IHS and Tribal facilities, Congress ensured that states would not have to bear any such costs. Section 1905(b) allows Congress to provide critical resources to the Indian health system while not shifting this responsibility to the states.

At the same time, Congress stipulated that the Medicaid funding received by the IHS and paid for entirely by the federal government under 1905(b) is to be utilized to make facility improvements necessary to achieve compliance with Medicaid standards as prescribed in State Medicaid Plans.

Initially, the Act required that Medicaid and Medicare payments be placed into a special fund for improvements of IHS facilities [§ 401(c)(1)]. Subsequent amendments to the IHCIA now allow Tribal health programs to bill Medicaid directly and eliminate the use of the special fund. However, the requirement that funds be used to maintain and improve facilities to achieve compliance with Medicaid standards—among expanded uses of the reimbursements from improvements to reduce health deficiencies—still exists in current law. The IHCIA further stipulates that reimbursements received from Medicare, Medicaid, or CHIP shall be credited to the IHS operating unit generating

1

House Report No. 94-1026-Part III at 21 (May 12, 1976), reprinted in U.S.C.A.A.N. 2796.

Sec. 1905(b) of SSA; 42 U.S.C. § 1396d(b).

3 Senate Report 94-133, Indian Health Care Improvement Act. 2

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TSGAC Comments on State of South Dakota’s 1115 Demonstration Application May 23, 2019

these resources and be used for such purposes needed for maintaining compliance with the standards of the federal programs described above.4 CMS’ long-standing interpretation of section 1905(b) is that 100% FMAP is available for amounts expended for services under the following circumstances: 1) The service must be furnished to a Medicaid-eligible AI/AN; 2) The service must be a “facility service”; 3) The service must be furnished by an IHS/Tribal facility or by its contractual agent as part of the facility’s services; and 4) The IHS/Tribal facility must maintain responsibility for the provision of the service and must bill the state Medicaid program directly for the service.

CMS’ recent reinterpretation of 1905(b) permits a wider scope of services for which states can claim 100% FFP/FMAP.5 However, services must still be linked to an IHS/Tribal facility. Under CMS’ new interpretation, Medicaid services provided to AI/ANs that are “received through” a Tribal provider, but are delivered by a non-Tribal provider under a written care coordination agreement, can qualify for 100% FFP/FMAP. The purpose of CMS’ revised policy interpretation of 1905(b) is to enable IHS facilities to expand the scope of services they are able to offer to their AI/AN patients while ensuring coordination of care in accordance with best medical practice standards.

It was the intent of Congress to provide 100% FMAP so as not to burden the states with the federal responsibility to pay for the cost of care “received through” IHS facilities, and to provide additional resources for making improvements in IHS facilities in order to achieve compliance with the applicable conditions and requirements of Medicaid. As a result, the Tribal 100% FMAP rule must only be made available for services received through the Indian health system. Only in this way can CMS ensure that federal funds flowing into the Indian health system will achieve and maintain compliance with the Medicaid conditions of participation as Congress intended. For this reason, the TSGAC strongly objects to the State’s proposal to establish an “alternative” delivery system to serve AI/ANs that is divorced from the Indian health providers but nonetheless is funded by the Tribal 100% FMAP rule for Indian health facilities.

The South Dakota demonstration waiver would provide significant additional Medicaid funds to the State with no guarantee that these resources be used to support the Indian health system or address IHS/Tribal facility deficiencies, as Congress intended. The waiver states that it is intended to increase access to services for AI/ANs who do not have convenient access to IHS providers in the State. But the waiver does not actually provide additional access to providers, or additional resources to Indian health providers. AI/ANs already have access to FQHCs and Urban Indian programs in the State. The waiver does not increase their access to FQHC or Urban Indian clinics.

Nor does the waiver provide any new resources for FQHCs or Urban Indians clinics to serve AI/ANs. The waiver would appear to reimburse FQHCs under the State’s standard cost-based reimbursement methodology. There is nothing in the waiver stipulating that any additional resources would be provided for expanded care to AI/ANs. Billing by Urban Indian clinics is not even mentioned.

4

25 U.S.C. § 1641.

CMS State Health Official Letter #16-002 (Feb. 26, 2016), Federal Funding for Services “Received Through” an IHS/Tribal Facility and Furnished to Medicaid-Eligible American Indians and Alaska Natives, https://www.medicaid.gov/federal-policy-guidance/downloads/sho022616.pdf.

5

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TSGAC Comments on State of South Dakota’s 1115 Demonstration Application May 23, 2019

All of the cost savings in the waiver would flow directly to the State, and there is no assurance that any resources would flow back to the Indian health system, or make any improvements in the facilities of the IHS in order to achieve compliance with the applicable conditions and requirements of Medicaid, as Congress intended when it amended the Social Security Act sections 1905(b) and 1911(xx).

Budget Neutrality CMS requires states to demonstrate that projects authorized under section 1115 of the SSA are budget neutral. A budget neutral demonstration project requires that Medicaid costs to the federal government must not be greater than what the federal government’s Medicaid costs would likely have been absent the demonstration. The South Dakota demonstration waiver simply states that budget neutrality to the federal government is satisfied by claiming that these costs are the responsibility of the federal government under the federal trust responsibility citing the IHCIA’s Declaration of National Indian Health Policy (25 U.S.C. § 1602) as the authorization for 1905(b).6 While the TSGAC does not disagree with South Dakota’s foundational principle that the federal government has a duty and obligation to fund the health needs of AI/ANs, we note that the State conflates the Declaration with the authorization for 100% FMAP. The IHCIA is not the authorizing statute for 100% FMAP; it is the Social Security Act. Because of this, the requirements of the SSA, which authorizes 100% FMAP, would still mandate that covered services be “received through” an IHS facility.

South Dakota further reasons that there would not be increased federal expenditures than what would otherwise have been spent, since the federal government would be responsible under the “federal trust doctrine” and 1905(b) to pay all of the costs for Medicaid-eligible services at the FQHC facilities. South Dakota’s proposed demonstration effectively would allow 100% FFP/FMAP for services rendered by FQHC providers eligible under the demonstration—with no requirement that covered services be “received through” IHS facilities. This will increase the costs of Medicaid services, which would no longer be linked to a requirement that they be “received through” IHS facilities, and result in increased Medicaid expenditures to the federal government.

When Congress authorized the IHS and Tribal facilities to participate in Medicaid as a new class of provider, it did not negate a state’s existing obligation to provide Medicaid services to all eligible individuals, including AI/ANs as citizens of a state. Prior to the enactment of 1905(b), states paid the state share of Medicaid for all AI/ANs, whether served by Tribal or non-Tribal facilities. Section 1905(b) did not alter that, but it did provide 100% FMAP to offset the cost to states of authorizing a new class of providers to bill Medicaid, as well as to direct additional resources to the chronically underfunded IHS. The change outlined in this demonstration would contradict this principle.

Conclusion The TSGAC commends the State in identifying health disparities experienced in Indian country in the State of South Dakota and its commitment to exploring innovative ways of addressing these disparities. Unfortunately, the proposed waiver will not achieve its stated aim of reducing health disparities for AI/ANs, in large part because of a failure to reach a mutually agreeable approach supported by the State and Tribes.

6

See page 13 of the waiver.

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TSGAC Comments on State of South Dakota’s 1115 Demonstration Application May 23, 2019

As a result, we urge CMS not to approve this demonstration waiver since it will simply allow the State to claim additional cost savings with no direct benefit to the Indian health system and it fails to meet the budget neutrality requirements for 1115 waivers. In fact, this waiver will result in additional Medicaid expenditures to the federal government by allowing all Medicaid services provided to AI/ANs by non-Tribal FQHCs to be claimed at 100% FFP/FMAP. We hope that our comments and recommendations are not construed as an unwillingness to support efforts by the State of South Dakota, or any other state, to improve access to health care for AI/ANs. Our comments are intended to uphold the federal trust responsibility and to ensure that resources associated with 100% FMAP continue to be invested in maintaining and improving the Indian health system in order to better serve the health care needs of AI/ANs. If you have any questions or wish to discuss these comments further, please contact me at (860) 862-6192 or via email at lmalerba@moheganmail.com. Thank you.

Sincerely,

Marilynn “Lynn” Malerba Chief, The Mohegan Tribe of Connecticut Chairwoman, Tribal Self-Governance Advisory Committee cc:

Kitty Marx, Director, Division of Tribal Affairs/IEAG/CMCS Devin Delrow, Director of Policy, National Indian Health Board Jennifer Cooper, Director, Office of Tribal Self-Governance, IHS TSGAC Members and Technical Workgroup

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IHS TRIBAL SELF-GOVERNANCE ADVISORY COMMITTEE c/o Self-Governance Communication and Education P.O. Box 1734, McAlester, OK 74501 Telephone (918) 302-0252 ~ Facsimile (918) 423-7639 ~ Website: www.Tribalselfgov.org

Submitted via email to: consultation@ihs.gov

June 7, 2019

RADM Michael D. Weahkee Principal Deputy Director Indian Health Service 5600 Fishers Lane, Mail Stop: 08E86 Rockville, MD 20857 ATTENTION: IHS National CHAP Consultation RE: IHS National CHAP Interim Policy Consultation Dear RADM Weahkee: In response to the May 8, 2019 Indian Health Service (IHS) Dear Tribal Leader Letter (DTLL) and on behalf of the IHS Tribal Self-Governance Advisory Committee (TSGAC), I submit the following comments on the IHS draft National Community Health Aide Program Policy (CHAP Policy).

The CHAP is pivotal to improving the health care for our people. The CHAP recognizes Tribal sovereignty, provides for cultural community-based care, and assists to overcome provider recruitment and retention barriers by growing providers from within Tribal communities that understand the history, culture and language of their patients. CHAP nationalization holds great promise for the future health care delivery system for Indian Country. As Tribes know which care models work best in their communities, TSGAC supports flexibility for Tribes to choose how to adopt and implement CHAP. BACKGROUND In 2010, with the permanent reauthorization of the Indian Health Care Improvement Act (IHCIA), Congress charged the Secretary with the nationalization of the successful CHAP to Tribes outside of Alaska. Alaska has operated a CHAP for over 60 years.

CHAP services have proven to be a sustainable, effective, and culturally acceptable method for delivering health care. The success of the CHAP in Alaska has been to understand the role of the communities and its recognition to build on these strengths to develop the program.

The nationalization of the CHAP must be based in Tribal community values, priorities, and be reflective of the communities served. States all over the US have been passing legislation that will allow for the utilization of Dental Health Aide and Dental Health Aide Therapists (DHA/Ts) as part of the CHAP. While state legislation is not necessary to

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TSGAC Letter RE: Comments on CHAP June 7, 2019

utilize Community Health Aides and Community Health Practitioners (CHA/Ps) or Behavioral Health Aides and Behavioral Health Practitioners (BHA/Ps), due to language in the IHCIA, IHS believes that state legislation is necessary if Tribes wish these oral health providers to be eligible for reimbursement and in their annual funding agreements as part of their CHAP program. However, state legislation is not needed if Tribes wish to include these oral health providers outside of a CHAP program.

Following the Tribal Consultation in late 2016, IHS formed a CHAP Technical Advisory Group (TAG) and in February 2018 IHS and CHAP TAG began meeting to develop this draft CHAP Policy that will address expansion of CHAP to tribes in the lower 48 states.

DRAFT CHAP POLICY COMMENTS AND RECOMMENDATIONS The TSGAC makes the following comments and recommendations on the CHAP Policy: 1. Strengthen language in Sections 3(A), 3(E)(9), and 3(F)(3) barring members of the National Certification Board (NCB), Area Certification Boards (ACB), and Academic Review Committees (ARC) from representing the interest of professional organizations.

The TSGAC fully supports the inclusion of language that NCB/ACB/ARCs shall not represent the interests of any professional association or organization in Sections 3(A), 3(E)(9) and 3(F)(3) in the CHAP Policy. Professional associations are charged with protecting their professions, and not always in the interest of patient care. This has been demonstrated numerous times by the American Dental Association (ADA) and the State Dental Associations, most notably when they sued the Alaska Tribes to try to block DHATs from practicing in Alaska, when they lobbied to keep DHATs out of the national CHAP expansion, and as they continue to actively block or restrict tribes from accessing DHATs through state legislative activity. The proposed language is critical to preserving the integrity of the CHAP providers, especially DHATs, to provide recourse for the NCB, ACBs, and ARCs that find themselves with members that are not upholding their charge of representing the interest of Tribal health programs, and to ensure that the needs of tribes and Tribal health programs are central to the decisions of these certification and academic review bodies.

The TSGAC requests that the following language be added to sections 3(A), 3(E)(9), and 3(F)(3): NCB/ACB/ARC members shall not represent the interest of any professional association or organization. They shall carry out the mission of the IHS to raise the physical, mental, social and spiritual health of American Indians and Alaska Natives to the highest level and the missions of the Tribes served.

2. Remove language related to Urban Indian Organizations from Section 1(B).

The TSGAC disagrees with language excluding applicability of the CHAP Policy to Urban Indian Organizations (UIO) in Section 1(B). DHATs are required to be authorized by states in order for this provider type to be utilized as part of the CHAP. Some states have included UIOs in their state DHAT legislation. UIOs are an important part of the

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TSGAC Letter RE: Comments on CHAP June 7, 2019

Indian health system of care. Relocation policies, economic depression in rural areas, and other factors have led to large and robust AI/AN populations in urban centers. Even in urban areas, AI/AN individuals struggle with lack of access to care and report a preference to receive care at UIOs. Furthermore, there is no specific language in Section 119(d) of the IHCIA that excludes UIOs from hiring and using CHAP providers as part of the national program.

For these reasons, the TSGAC recommends that “Urban Indian Organizations” be deleted from Section 1(B). Additionally, there could be opportunities through partnerships with tribes for UIOs to utilize these providers and expand access to care to the urban communities they serve.

3. Add additional authorities to Section 1(D).

The TSGAC agrees with the CHAP TAG recommendations and supports broadening the authorities section to include additional statutory authorities so that the national CHAP benefits from a more complete legal framework.

TSGAC also requests inclusion of a citation to IHCIA in its entirety, or at least the provisions that address Federal health goals and objectives and the role of training and supporting health professionals, as well as the inclusion of the “Public Health Service Act, 42 U.S.C § 254a.” The Public Health Service (PHS) Act provides general authority for PHS agencies, including the IHS, to engage in a variety of health education, coordination and innovative health delivery activities. Section 254(a) permits “sharing specialized healthcare resources,” including personnel, space and equipment, which can be extremely helpful in rural areas where that level of coordination is essential to successful delivery of healthcare services.

4. Add language in Section 1(E)(1) to recognize Tribally licensed CHAP providers in the CHAP Policy.

TSGAC requests the inclusion of Tribally-licensed CHAP providers in the CHAP Policy, aligning with the request made by the CHAP TAG. The CHAP Policy, as written, does not provide any recognition of those Tribal programs, Tribal sovereignty, or any guidance for how they can be incorporated into a CHAP once the Federal infrastructure is in place.

Federal Indian law recognizes the legitimacy of Tribal programs and this recognition should also be included in this CHAP Policy. TSGAC understands that IHS initially disagreed based on its interpretation of what is authorized by the IHCIA. However, the Alaska program was developed under the authority of the Snyder Act, which applies equally to all services for AI/AN. While the IHCIA requires the IHS to maintain the Alaska CHAP, it does not preclude IHS or a Tribe from developing CHAP under preexisting authorities. There should be language recognizing the existing infrastructure

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TSGAC Letter RE: Comments on CHAP June 7, 2019

that was built in Areas prior to the development of this CHAP Policy and recognition of Tribal sovereignty.

TSGAC requests the revision of CHAP policy Section 1(E)(1) to incorporate the underlined language below: All CHAP providers certified by the Alaska Community Health Aide Program Certification Board (Alaska CHAPCB) who wish to provide services in a program outside of Alaska and any CHAP provider certified by a Federal CHAP Area Certification Board (ACB) or by a Federally recognized Tribe or Tribal Organization’s governing body, a Tribal board, that has adopted certification standards, but wants to provide services in another area, must submit a copy of their certification to the receiving ACB for review and approval prior to being certified in that Area.

TSGAC also requests that this language be included in Section 1(E)(3): If Tribes or Tribal Organizations outside of Alaska include a CHAP as a program, service, function, or activity (PSFA) in their ISDEAA contract or compact, the individuals working under their CHAP must be certified by the Alaska CHAPCB or other Federal ACB or, with the approval of the Tribe or Tribal Organization’s governing body, a Tribal board.

This requested revisions fully resolve the IHS’s concern that Federal certification standards be respected in CHAP expansion, because in this revision those Federal standards serve as a minimum floor, addressing potential concerns about quality, but Tribes are provided with an opportunity to adopt additional criteria that are consistent with cultural values or local needs and conditions. The requested revision is also consistent with the promotion of Tribal self-determination in ISDEAA, since the Tribal licensing authorities could choose to implement, as a minimum standard, Federal program requirements, but adapt them as appropriate for the particular Tribal setting.

5. Remove language from Section 1(E)(6) highlighting the need for state authorization for the use of DHATs in CHAPs. Section 1(E) 6 states that “DHATs shall practice only in states that authorize the use of DHAT services if a Tribe or Tribal Organization seeks to include a CHAP as a PSFA in Title I and Title V ISDEAA contract or compact. DHATs must meet the Federal training requirements for certification.” It is unnecessary to call out this portion of the IHCIA, §1616l (d)(3)(A), as the relevant section is included in Section 1(D). Additionally, Tribes and Tribal health programs are not generally subject to state law and without further explanation, this language could cause confusion. The TSGAC requests removal of language from Section 1(E)(6) highlighting the need for state authorization for the use of DHATs in CHAP.

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TSGAC Letter RE: Comments on CHAP June 7, 2019

6. Maintain language in section 1(E)(13) that requires consensus of a majority of Area Tribes to enter into relationships with another IHS Area for the purposes of certification of providers.

Section 1(E)(13) states that, “In the absence of an ACB, an IHS Area Director must consult with Area Tribes and will seek consensus of a majority of Area Tribes or Tribal organizations to enter into a relationship with another IHS Area that has an ACB or with the Alaska CHAP Certification Board (CHAPCB) for the purposes of certifying its CHAP providers.” TSGAC requests that Tribes be treated as participants in the expansion of the CHAP program, in addition to consultation, in their respective Areas.

Requiring a consensus is an imperfect but good way to ensure that IHS Area Directors have sufficient buy-in and partnership with the Area Tribes in expanding CHAP. 7. Remove language in section 1(E)(13) that allows IHS Area Director to make final decision without a consensus from Tribes.

Section 1(E)(13) further states that “In the absence of consensus, IHS Area Directors will reserve the right to make the final decision.” The TSGAC is concerned that the assertion that the Area Director reserves the right to make the decision on how to best meet the needs of the Area when consensus is not met could mean that CHAP in some Areas is implemented without necessary input from the Area Tribes. This is not in keeping with the spirit of CHAP, which is necessarily an organic, Tribally-based, community program. Tribes are in the best position to understand the health, oral health, and mental health needs of their communities. The CHAP was developed in Alaska to meet the specific needs of the AI/AN communities because the current system was failing their population. We must use the opportunity of expanding CHAP nationally to break down the various barriers perpetuated by the current system. The TSGAC recommends that the language in Section 1(E)(13) allowing IHS Area Directors to make a final decision be deleted.

In closing, please accept these comments with our sincere request to work together with IHS, in the spirit of its partnership to increase access to healthcare for our citizens through the successful implementation of the draft CHAP Policy. We look forward to IHS responses to our requests. Should you have questions or require additional information, please do not hesitate to contact me at (860) 862-6192 or via email at lmalerba@moheganmail.com. Thank you.

Sincerely,

Marilynn “Lynn” Malerba Chief, Mohegan Tribe Chairwoman TSGAC

cc:

Jennifer Cooper, Director, Office of Tribal Self-Governance, IHS TSGAC and Technical Workgroup Members 12p