Affordable Care Act and Purchased Health Services

Affordable Care Act and Purchased/ Referred Care aka Contract Health Services Terri Schmidt R.N. Director, Division of Contract Care Office of Resource Access and Partnerships Indian Health Service

Purchased/Referred Care aka Contract Health Services Is an integral part of Indian Health Service and Tribal Health Programs as PRC/CHS purchases health care services from private sector providers to support direct care facilities. PRC/CHS funding is limited by appropriations and regulations restrict PRC/CHS payment unless specific criteria are met. No accessible direct care facility; A member or descendant of a Federally recognized Tribe and live on a reservation; Reside in the CHS Delivery Area and be a member of the Tribe the CHS Delivery Area was established for; or, Reside in a CHS Delivery Area and meet close socioeconomic ties. PRC/CHS is the payer of last resort

Qualified Health Plans Cost Sharing and Minimum Essential Benefits All QHPs are required to provide 10 Essential Health Benefits (EHB) Ambulatory patient services, Emergency services, Hospitalization, Maternity and newborn care, Mental health & substance use disorder services including behavioral health treatment Prescription Drugs, Rehabilitative and habilitative services and devices, Laboratory services, Preventive and wellness services and chronic disease management, Pediatric services, including oral and vision. Cost sharing provisions under ACA only apply to services that are considered EHBs or covered services

Zero Cost-sharing Plan PRC/CHS Provider Referral Requirements Plan Member Limited to members of Federally Recognized Tribes, Alaska Native Corp. Shareholders and are at or under 300% poverty level In Network (Always the First Choice) A PRC referral is not needed for the patient to receive an EHB from an in-network non Indian health care provider. PRC/CHS Authorized referral is required to cover the cost of non EHBs or non covered services and balance of non EHB covered services up to the MLR for hospital based inpatient and hospital based outpatient services Out of Network A PRC/CHS Authorized referral is required to cover the cost of out of network charges

Limited Cost-sharing Plan PRC/CHS Plan Member Type of Provider Referral Requirements Limited to members of Federally Recognized Tribes, Alaska Native Corp. Shareholders with any level of income In Network A PRC referral or a referral from an urban Indian organization is required to avoid cost- sharing for EHBs. This referral needs to be authorized for all EHB services provided for during this episode of care. There is no cost to the patient or PRC program as long as the patient is referred through the PRC program. A QHP plan referral from the QHP primary care provider may be required. PRC staff need to confirm with the QHP and assist the Patient in acquiring this referral. Out of Network PRC/CHS authorized referral is required to cover costs not covered by the plan and any cost sharing or out of network charges that would otherwise be charged to the patient up to the MLR for hospital based inpatient and hospital based outpatient services.

Silver Plan with Cost Sharing Reductions Plan Member Type of Provider Referral Requirements For IHS beneficiaries who are not members of Federally Recognized Tribes, Alaska Native Corp Shareholders but are otherwise eligible for IHS and are below 250% FPL. Cost sharing reductions are based on income not Indian status. In Network A PRC referral authorized for payment is required for the PRC eligible patient to avoid any cost-sharing expenses after the QHP payment is made. In addition to the PRC referral authorized for payment, a referral from the QHP primary care provider may be required. To verify if an in-network plan referral is needed contact the patient s QHP primary care provider and confirm. If needed, assist the patient in acquiring the QHP referral to avoid any cost- sharing

Standard Plan Plan Member Type of Provider Referral Requirements For IHS beneficiaries who are not members of Federally Recognized Tribes, Alaska Native Corp Shareholders but are otherwise eligible for IHS In Network or out of Network A PRC referral authorized for payment is required for the PRC eligible patient to avoid any cost-sharing expenses after the QHP payment is made. In addition to the PRC referral authorized for payment, a referral from the QHP primary care provider may be required. To verify if an in-network plan referral is needed contact the patient s QHP primary care provider and confirm. If needed, assist the patient in acquiring the QHP referral to avoid any cost- sharing

Questions Terri Schmidt R.N. Director, Division of Contract Care Office of Resource Access and Partnerships IHS, HQ Terri.Schmidt@ihs.gov 301-443-4973