The Tribal Self-Governance Advisory Committee (TSGAC) is pleased to provide a user-friendly Tool Kit for Tribal Sponsorship to assist Tribal leaders and Health Staff by providing a step-by-step list of key tasks that should be considered in determining and establishing a Tribal Sponsorship program. This information was developed by a team of Tribal health and technical experts, including representatives who have successfully implemented Tribal Sponsorship programs. We hope that the following information and “best practices” will be helpful for Tribes/Tribal organizations to use in considering whether or not to establish a Tribal Sponsorship program.
What is a Tribal Sponsorship program?
The ACA provides an opportunity for any Tribe to establish a Tribally-Sponsored program to purchase health insurance coverage for their uninsured Tribal members through a Health Insurance Marketplace (“Tribal Sponsorship”). The Indian Health Care Improvement Act specifically authorizes that Tribes may use funds made available under the Indian Self-Determination and Education Assistance Act (ISDEAA) to purchase health insurance, such as coverage through a Marketplace, for Tribal members.
What are the benefits of a Tribal Sponsorship program?
A Tribal Sponsorship program provides for expanded access to health care for the Tribal member enrollee as well as increased resources available to the Tribal health program. For those formerly uninsured Tribal members who now have insurance under the Marketplace, Tribes can reduce expenditures for services authorized through Purchase and Referred Care (PRC) by accessing substantial federal premium and cost-sharing assistance provided through the Marketplace.
What should a Tribe consider before making a determination about whether to initiate a Tribal Sponsorship program?
A Tribe should carefully study and collect information regarding their uninsured Tribal population, including:
Gathering data on number of uninsured Active Users;
Analyzing available health plan options and selecting the preferred plan(s);
Creating a simplified table illustrating the net premium sponsorship costs for (potentially) eligible persons; and,
Estimating enrollment targets and staffing levels;
Identifying funding requirements;
Identifying Policies and Procedures; and,
Establishing terms and conditions for Individual Enrollment Agreements and entering into Agreements with the participating Tribal members.
A toolkit has been prepared to assist Tribes in completing these tasks.
Can a Tribe include specific provisions under the Individual Enrollment Agreement for the Tribal Sponsorship program that directs the Tribal member to utilize Tribal facilities?
Yes. A Tribe has the authority to establish policies under the Tribal Sponsorship program, such as directing Tribal Sponsorship enrollees to utilize Tribal and IHS health providers. Requiring Tribal members who are under the Tribal Sponsorship program to utilize participating Tribal health providers and programs will not only save PRC funds, but will provide increased revenues to a Tribal health care facility and program which can then be used to expand health services.
Gather data on number of uninsured Active Users. One option is to run a report (or request that the Indian Health Service (IHS) run a report) through the Resource and Patient Management System (RPMS) or other patient billing record system to pull current data on the insurance status of Active Users, by Tribal status. These data can be supplemented by estimating the income distribution of uninsured Active Users by accessing statewide Census data on uninsured Americans Indians/Alaska Natives (AI/ANs) (which can be obtained through the Census Bureau MDAT online tool (https://link.edgepilot.com/s/1e4a7e27/LFUqHAKFN0ea3ysVDvkgQw?u=https://data.census.gov/mdat/) and then applied to a Tribe’s (e.g., Service Unit) Active User figures). Ultimately, understanding the number / percentage of Active Users who meet a Tribe’s specific eligibility criteria might require establishing a pilot program under which uninsured Tribal members and other Active Users are screened.
Analyze health plan options available on the Marketplace and select the preferred plan(s) for bronze level, silver level, or gold level coverage. In the attached sample plan review, potential elements of a plan review are shown, most of which can be researched through the Marketplace website (e.g., through HealthCare.gov). In addition, contact the health plan(s) and negotiate the preparation of an aggregate invoice (from the health plan) and an aggregate payment mechanism (by the Tribal Sponsor).
Attachment B: Plan Review Sample
Evaluate the possibility of securing payment at the OMB encounter rate (i.e., the Office of Management and Budget / IHS all-inclusive rate) for covered services provided to Marketplace plan enrollees, including Tribal Premium Sponsorship program (TPSP) enrollees. To receive payment at the OMB encounter rate from Marketplace plans, a Tribe operating a Tribal clinic must: (1) participate in Medicaid as a federally qualified health center (FQHC); (2) have (and agree to) the option under the State Plan to receive payment at the OBM encounter rate, rather than the standard FQHC rate under Medicaid; and (3) negotiate with Marketplace plan issuers to secure payment at the OMB encounter rate.
Create a simplified table illustrating the net premium sponsorship costs for (potentially) eligible persons. Base premium costs on the plans identified under “Select preferred plan(s)” that have been identified in item #2 above. Use the Premium Sponsorship Table as a tool for establishing eligibility criteria
Attachment C: Sample Premium Sponsorship Table
Determine eligibility criteria for the Tribal Premium Sponsorship Program (TPSP), using the Premium Sponsorship Table as one guide. It often is useful to designate initial eligibility criteria for “Phase I” and then evaluate and adjust (and possibly expand) eligibility for the TPSP over time based on actual program results. Labeling the eligibility criteria as “Phase I” communicates that the TPSP is in its initial development and that these criteria and other program elements are open to modification over time based on actual program outcomes.
Attachment D: Tribal Sponsorship Through a Marketplace
A Sponsoring Tribe might wish to establish eligibility criteria based on factors such as:
Household income;
Fixed maximum number of Sponsored individuals under the TPSP;
Maximum aggregate premium sponsorship costs under the TPSP;
Active User status;
PRC eligibility (residing in CHSDA);
Enrolled Tribal member of Sponsoring Tribe;
Residing or not residing in tribal jurisdictional service area;
Dependents of enrolled Tribal member of Sponsoring Tribe;
Complexity and/or cost of medical services needed;
Need for PRC-funded services.
Sponsoring Tribes will need to ensure that program eligibility and expenditures are consistent with applicable laws.
NOTE: The Affordable Care Act limited eligibility for premium tax credits (PTCs) to Marketplace enrollees with a household income between 100% and 400% of the federal poverty level (FPL). However, for 2021 and 2022, the American Rescue Plan Act (ARP), enacted in March 2021, expanded PTC eligibility to Marketplace enrollees with a household income higher than 400% FPL and reduced the amount of the required household contribution to Marketplace plan premiums for PTC-eligible enrollees (effectively providing more generous tax credits to these individuals). The Inflation Reduction Act, enacted in August 2022, extended these provisions through 2025.
As such, Tribes operating a TPSP might want to consider allowing eligible individuals with a household income higher than 400% FPL to participate in the TPSP.
For Direct Service Tribes, review of general eligibility criteria with the IHS Area Office likely will be an element of the Title I contracting process. Within the general eligibility criteria, the Tribe might wish to phase-in eligibility by establishing eligibility for a subset of the general eligibility criteria in Phase I, an additional subset in Phase II, etc.
For Self-Governance Tribes, Tribes should include in contracts, compacts, or other funding agreements with IHS a general statement that notes the intention to use some Indian Self-Determination and Education Assistance Act (ISDEAA) or other funds available to the Tribe for Sponsorship of Tribal members.
A second data request to the IHS might be necessary to obtain Active User data that best match the proposed eligibility criteria.
In Attachment P: Cost-Benefit Analysis Tool (Excel), Attachment P – PDF version, a model is presented that assists Tribes in generating an estimate of the financial impact from enrolling different groups. The series of worksheets were developed by the Tribal Education and Outreach Consortium (TEOC), a collaboration of several Area Health Boards and individual Tribes with the aim of fostering Tribal capacity to access new health care resources for Tribal members and other IHS beneficiaries. The worksheets include instructions on the use of the Cost-Benefit Analysis tool.
Conducting a comprehensive cost-benefit analysis as provided for in this tool—or other similar tools—is not a requirement prior to initiating a TPSP.
A Tribe might choose to limit an analysis to a subset of potential enrollees. The Tribe might subsequently authorize enrollment of up to a set maximum number of enrollees, providing the Tribe an opportunity to limit uncertainty and risk, and to monitor actual results (i.e., actual costs versus actual net increase in health care resources).
Based on the number of uninsured Active Users and the eligibility criteria, project enrollment in the TPSP and identify staffing levels required to achieve this enrollment level. For a “Fast Track” start, set the initial enrollment target at a fixed number (such as 200) that represents no more than 10% of total potential eligible individuals. Based on how fast you would like to achieve this level of enrollment, set staffing level assuming enrollment staff can conduct two enrollments per day, once fully-trained.
See Attachment E: Enrollment and Premium Projections for a display of staffing and enrollment, by month, for a Tribe with a target enrollment of 700 individuals.
Based on enrollment and staffing level projections, estimate the projected funding needed for premium payments and administrative costs. Refer to information on average premium costs prepared under “Create a Premium Sponsorship Table” above.
Attachment E: Enrollment and Premium Projections
For Self-Governance Tribes, funding may be reallocated across program line items. For Direct Service and Title I contracting Tribes, a proposal must be submitted to the IHS for the Tribe to establish a TPSP program officially and reallocate funding from PRC, H&C, and/or general third-party revenues to this new TPSP program.
Attachment F: Sample Pre-Award Letter
Attachment G: Sample TPSP Language
Using samples from other Tribal Premium Sponsorship Programs, create a TPSP-specific Individual Enrollment Agreement that incorporates the Tribe’s policy decisions and that specifies the rights and responsibilities of TPSP enrollees and the Sponsoring Tribe.
Attachment H: Sample Individual Enrollment Agreement
Create a tool for Tribal enrollment staff to ensure enrollment in the intended health plan.
Attachment I: Sample Health Plan Enrollment Flow Diagram
Access the online CMS training modules to gain understanding of Marketplace rules and processes.
Attachment J: Generic-Steps for Accessing Marketplace Assister Training
Attachment K: 2023-quick-reference-guide-computer-requirements
Attachment L: 2023-quick-reference-guide-assister-training
Attachment M: Q & A on CAC Program
Attachment N: Joint Initiative Marketplace-Medicaid Enrollment Assisters Q&A