Insurance regulators from states with American Indian and Alaska native tribal communities say the communities need help with untangling Patient Protection and Affordable Care Act (PPACA) red tape.

Regulators talked about the tribal communities’ PPACA headaches earlier this week in Chicago, at a session of the American Indian and Alaska Native Liaison Committee. Members of the committee, which is part of the National Association of Insurance Commissioners (NAIC), met at the NAIC’s summer meeting.

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Drafters of PPACA refer repeatedly to tribal communities and the need to improve Native Americans’ access to health care and health coverage.

Native Americans who are members of federally recognized tribes can sign up for coverage through the PPACA public health insurance exchange system at any time of the year, not just during the open enrollment period or through a special enrollment period.

Any tribal member who has household income at or below 300 percent of the federal poverty level gets automatic access to cost-sharing reduction subsidies that reduce out-of-pocket payments for in-network covered services to zero.

A tribal member can use access to Indian Health Service (IHS) coverage to qualify for an exemption from having to have minimum essential coverage, and the public exchange managers have made special efforts to market to tribal members. 

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In one county in Arizona, plan issuers must make Summaries of Benefits and Coverage (SBCs) available in Navajo.

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But regulators say tribes are having huge, little-acknowledged problems with PPACA compliance, and not getting much noticeable help from Washington with untangling knots.

For a look at what regulators are seeing, based on documents in a board meeting packet, read on. 

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1. The United States has negotiated treaties with the tribes that call for the country to pay members’ medical expenses.

Many tribal leaders are uncomfortable with the idea that they or their members need to make changes because of PPACA, because the United States treats the tribes as separate nations and has declared, in treaties, that it will provide health care and other necessities for the tribes’ members.

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Disintegrating dollar

2. The Indian Health Service (IHS) system is underfunded, and tribes have separate, poor, complicated health care delivery systems.

In theory, IHS-funded facilities should be able to provide care for tribal members, especially on reservations, but regulators note in a draft of a letter aimed at members of Congress that the IHS system gets only about 60 percent of the funding needed to provide the care promised.

In practice, regulators said during a meeting in Phoenix in March, how a particular tribe handles health care depends on factors such as the location of its land, the number of members, and access to revenue streams.

Marguerite Salazar, the Colorado insurance commissioner, said the IHS funding for the tribes in her state usually runs out by May in a typical year. She said tribal health care providers often have problems with knowing how to apply for government aid they are eligible for.

Lisa Reid of New Mexico said another problem is that some tribal health care providers do not want to be in general health plan provider directories, because they can get reimbursed at network rates without being in plan networks. But tribal members are reluctant to sign up for plans when they see no tribal health care providers are in the directories.

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Piggy bank with a tightened belt

3. Tribal employers say applying the PPACA employer mandate to them is a terrible idea, for many reasons.

Many tribal employers have not been providing health benefits, in part because their many low-wage employees already qualify for IHS health care services.

PPACA lets most of those employees apply for health coverage with no cost-sharing requirements through the PPACA public exchange system.

Tribal employers contend that they are governmental employers, and, legally, employers governed by laws of nations separate from the laws of the United States.

If the federal government applies the PPACA employer mandate to those tribal employers, it will be ignoring their status as governmental entities outside the usual U.S. legal framework, regulators say.

Applying the employer mandate to tribal employers will also force them to spend large sums of cash to provide bare-bones coverage that will prevent the covered employees from getting access to better, zero-cost-sharing coverage through the exchange system, regulators say.

State regulators said tribal officials have tried to talk to officials at the U.S. Department of Health and Human Services (HHS) and the Internal Revenue Service (IRS) about the issue and gotten the answer, “Well, that’s what the law says.” 

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Image: TS/Jeffrey Collingswood