The term “Enrollment Assister” refers to the wide variety of individuals Download the 2016 IRS Form 8965—Health Coverage Exemptions (PDF) and

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What is the Enrollment Assister This toolkit was designed as a resource for Enrollment Assister s in the field across Indian Country. Guided by best practices and experiences relayed by Enrollment Assister s across Indian Country, the contents of this toolkit are provided to he lp those serving Indian Country understand the pur pose of the enrollment process and how to engage community members effectively regarding Marketplace , Medicaid, Medicare, and Program ( CHIP ) enrollments . Who are Enrollment Assisters ? The term Enrollment Assister refers to the wide variety of individuals who are on – site at Indian Health Service (IHS) clinics , Tribal health facilities , and Urban Indian Organizations (I / T /U ) to assist American Indian and Alaska Native s ( AI/AN ) with enrolling in he althcare coverages thr ough the Marketplace or other government programs such as Medicaid, Medicare, and CHIP. These are but not limited to: Certified Application Counselors Navig ators Patient Benefits Coordinators Enrollment Assisters, of all titles, are integral to the Indian Health system, driving revenue and third party bill ing for the clinics they serve. Why Outreach and Education f or Indian Country ? The Patient Protection and Affordable Care Act (ACA), country and that all Americans would have access to quality, affordable, health care. To achieve its mission, the law created the Health Insurance Marketplace and mobilized a wide variety of consumer assistance resources. As a result of this mobilization, American Indians and Alaska Natives (AI/ANs) throughout Indian Country are now more aware of how th ey can get referred out faster, save Purchased Referred Care dollars for their hospitals/clinics, and the ability of third party insurance to bring resources into the Indian health system. However, with efforts underway to repeal and replace the ACA, work continues to expand the scope of Outreach and Education (O&E) into other concepts of health coverage , including : Medicaid expansion, s Health Insurance Program, Veteran benefits , and many health resourc es beyond the ACA . We must use lessons lear ned and best practices made in health education for Tribal communities to move forward despite a changing landscape. Enrollment Assisters and those who see the value of their work should continue to come together, share, and learn from each other to increa se health coverage for American Indians and Alaska Natives. For More Information Contact: Kristen Bitsuie Tribal Healthcare Reform Outreach and Education Program Associate Email: Phone: 202 – 507 – 4084

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#HealthyTribalCommunities #GetCoveredIndianCountry 1 What does the Patient Protection and Affordable Care Act (ACA) mean for American Indians/Alaska Natives (AI/AN s )? American Indians and Alaska Natives have specific health insurance benefits and protections in the Health Insurance Marketplace . Some benefits are available to members of federally recognized Tribes or Alaska Native Claims Settlement Act (ANCSA) Corporations. Others are available to people of Indian descent or who are otherwise eligible for services from an Indian Heal th Service or Tribal health facility . Special Marketplace protections and benefits for American Indians and Alaska Natives: The Health Insurance Marketplace benefits AI/ANs by providing opportunities for affordable health coverage. This coverage can be through a private health plan bought in the Marketplace or by signing up for Medicaid or the Health Insurance Program (CHIP). If the con sumer is a member of a federally recognized tribe : Purchasing private insurance in the Health Insurance Marketplace , they may not have to pay out – of – pocket costs like deductibles, copayments, and coinsurance. They can enroll in the Health Insurance Marketplace any month, not just during the yearly open enrollment period. If the consumer is an American Indian or Alaska Native or are otherwise eligible to receive services from a n Indian Health Service or Tribal health facility : They may have special c Insurance Program (CHIP) that make it easier to qualify for these programs. They may receive an exemption from the individual mandate to carry health insurance. If an eligible AI/AN d oes not most other people without health insurance must pay. The exemption is not automatic, so the consumer will have to claim an exemption from the penalty when filing taxes with the IRS. If a consumer enroll s in a private health insurance plan through the Health Insurance Marketplace : The consumers can get (or keep getting) services from the Indian Health Service , Tribal , or Urban Indian Organization clinic . These consumers can also get services from any providers on the Marketplace plan.

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#HealthyTribalCommunities #GetCoveredIndianCountry 2 The Marketplace is the one – stop shop for applying for health care coverage . It helps uninsured people find health coverage through a simple , single – stream line d application that will help you find out what consumers are eligible for today. The Marketplace offers: Private health insurance. Plans cover essential health benefits , pre – existing conditions , and preventive care . Lower costs through tax credits based on your household size and income. The consumer can preview plans available in their area right now, with prices based on income and household size. Most AI/ANs who apply may qualify for tax credits. Tax credits reduce the amount of the monthly premium. Special benefits for enrolled members of federally recognized Tribes including shareholders in Alaska Native Claims Settlement Act (ANCSA) Corporations. Members may enr oll in zero or limited cost sharing plan variations and are eligible for monthly enrollment in Marketplace plans. Medicaid and the Health Insurance Program (CHIP). These programs cover millions of families with limited income. If the consumer qualifies, the Marketplace will share the information with state agency and establish contact . Enrollment in Medicaid and CHIP is available year round to qual ified individuals. Continued use of the Indian Health System. If the individual consumer has health insurance, they will still be able to use their local IHS or Tribal health facility . Additionally, they will have access to more providers and services. T his insurance coverage may also extend to the family. Stand Alone Dental Plans. Dentistry for children under 19 years old is covered in all private Marketplace plans. However, tax credits and cost sharing reductions do not apply to adult Stand Alone Dental Plans.

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#HealthyTribalCommunities #GetCoveredIndianCountry 3 Four main types of Marketplace s. (Each state is required by law to have a Marketplace .) Federally – Facilitated Marketplace : States that have opted to have the Department of Health and Human Services (HHS) run its Marketplace and use . State – based Marketplace : States that run their own Marketplace and have their own Marketplace website. If you know your state specific website, you can visit to be directed to the right website. Federally – Supported State – Based Marketplace : These Marketplace s operate under the same conditions as State – Based Marketplace s, but the Marketplace interface through State – partnership Marketplace : States that run their own Marketplace in partnership with HHS. Additional Points: The consumer can also buy a plan outside the Marketplace and still be considered covered . However, if they buy a plan outside the Marketplace , they will not be eligible for premium tax credits or lower out – of – pocket costs based on their income. the zero or limited cost sharing protections through qualified health plan s (QHP) available on the Marketplace . An Individual is considered covered if they have: Medicare , Medicaid , CHIP , any job – based plan , any plan they bought themselves , COBRA , retiree coverage , TRICARE, VA health coverage , or some other kind of health coverage. IHS provides health care to eligible AI/AN , but it is not considered to be health insurance , so check the options for coverage in the Marketplace at . If the con sumer lives in a state that has expanded Medicaid they may be able to get affordable health care coverage as a childless adult. Qualification for Medicaid is based on income, household size, disability, family status and other factors. Eligibility for Medicaid differs by state. The ACA allowed states to have the option to their Medicaid eligibility levels, based on the Federal Poverty Levels (FPL) from 100% to 133%. If the consumer is eligible for job – based insurance, they can consider swi tching to a Marketplace plan. But, the consumer will not qualify for lower costs based on their income unless the job – based insurance is not considered affordable or does not meet minimum requirements . If the consumer has Medicare, considered covered and have to make any changes; Marketplace to buy a Medicare supplemental plan. against the law for someone to sell a consumer a Marketplace plan if they know the consumer has Medicare. For supplemental Medicare coverage, visit to learn more about Medicare Supplement Insurance (Medigap) and Medicare Advantage Plan options.

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#HealthyTribalCommunities #GetCoveredIndianCountry 4 1. Open Enrollment Period for Plan Year 2018 a. The final rule shortens the annual open enrollment period from three months to six weeks. The final rule implements the plan year 2018 open enrollment period to begin November 1, 2017 and run through December 15, 2017. The start date for health coverage for plan year 2018, is January 1, 2018. b. The shortened open enrollment period does not restrict American Indian and Alaska Natives (AI/ANs) and their dependents enrollment in the federal Marketplace. The Affordabl e Care Act (ACA) provides for AI/ANs to enroll in a qualified health plan (QHP) at any time of the year through monthly special enrollment periods (M – SEPs). 2. Special Enrollment Periods a. Special enrollment periods enable individuals who experience certain li fe events that involve a change in family status, such as marriage or loss of health insurance, to enroll in a QHP outside the open enrollment period for sixty days (thirty days for employer health plans). The final rule includes stricter requirements for special enrollment periods (SEPs) to curb eligibility self – attestation abuse. Beginning in June 2017, any individual enrolling in the Marketplace through a special enrollment period will need to submit additional pre – enrollment verification supporting docu mentation to verify eligibility. b. American Indian and Alaska Native enrollees will be required to provide Tribal membership documentation when applying for coverage. In the proposed rule, CMS promoted continuous coverage and discourages individuals from wa iting to enroll in health coverage when an illness occurs, however continuous coverage was not included in the published final rule. 3. Health Plan Network Adequacy a. The final rule requires that qualified health plan (QHP) issuers maintain a network suffici ent in number and types of providers to ensure enrollees have access to all services without unreasonable delay. Currently, CMS conducts network adequacy reviews using that have a sufficient network adequacy review process. CMS believes that states are best positioned to determine what constitutes an adequate network in their geographic area. This alteration could affect whether plans include an adequate number and range of providers in their network.

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#HealthyTribalCommunities #GetCoveredIndianCountry 6 Every year, the parameters of the Federal Poverty Level (FPL) increase based on the cost of living. Consumers and their f amilies need to understand where they fall on the FPL so they know whether they are eligible for federal subsidies on the Marketplace . Use the chart below to determine which Cost Sharing level and Advance Premium Tax Credits may apply to the consumer based on their income. Under the ACA some states have chose n their Medicaid programs to cover all people with household inc ome below a certain level. Other s tates have chosen not to expand, this is known as an expanded versus a non – expanded state. LIMITED COST SHARE PLANS (NO APTC ) ZERO COST SHARE PLANS PLUS APTC LIMITED COST SHARE PLANS PLUS APTCS LIMITED COST SHARE PLANS (NO APTC ) Number of People in Your Household Income under 100% FPL Income 100% to 300% FPL Income 301% to 400% FPL Income over 400% FPL 1 $0 — $1 2,060 $ 12,060 — $ 36,180 $3 6,181 — $ 48,240 $ 48,240 and up 2 $0 — $16, 240 $ 16,240 — $48, 720 $48, 721 — $64, 960 $ 64,960 and up 3 $0 — $20, 420 $ 20,420 — $6 1,260 $ 61,261 — $ 81,680 $ 81,680 and up 4 $0 — $24, 600 $ 24,600 — $7 3,800 $ 73,801 — $9 6,000 $ 96,0 00 and up 5 $0 — $28, 780 $ 28,780 — $86 ,3 40 $ 86,340 — $ 115,120 $ 115,120 and up 6 $0 — $32, 960 $ 32,960 — $9 8,880 $ 98,881 — $ 131,840 $ 131,840 and up Assister Tip: If a consumer falls below the 100% FPL levels, or 133% in an expanded state, Medicaid may be an option . Note: These amounts are higher for consumers in Alaska and Hawaii. FPL guidelines are updated and published yearly by the Department of Health & Human Services (HHS) in January or February. Medicaid and CHIP eligibility for the next year are bas ed on the new guidance, once it’s released.

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#HealthyTribalCommunities #GetCoveredIndianCountry 7 Below are the definitions of the Limited, and Zero Cost Sharing plans and the Advanced Premium Tax Credit for members of federally recognized Indian tribe s and Alaska Native Claims Settlement Act Corporation shareholders

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#HealthyTribalCommunities #GetCoveredIndianCountry 8 Although enrollment in Marketplace plans or Medicaid affords American Indians and Alaska Natives many options for low cost or free health coverage, the consumer may also decide to apply for an exemption from the individual shared responsibility payment. It is important to note that if the consumer was not enrolled in minimum essential coverage, they may be subject to an individual shared responsibility payment or fine unless they qualify for an exemption. American Indians and Alaska Natives may claim an exemption from the fine if they are : 1) Members of federally recognized T ribes (which includes Alaska Native Claims Settlement Act (ANCSA) Corporations Shareholders ) 2) Individuals who are eligible to receive services from an Indian Health Care Provider at IHS, T ribal , and urban Indian clinics. Remember! The consumer can and should still enroll in health coverage, even if they claim an exemption. enrolling in a Marketplace health plan, Medicaid, or CHIP. These coverag e options are still available to consumers. Consumers might qualify for certain protections under Medicaid or CHIP, or for lower costs on monthly premiums and no out – of – pocket costs on private insurance through the Marketplace . Note: The Marketplace paper application process will no longer be used as an option for applying for an exemption certification number. If you have attained an exemption certification but an exemption certification number is no longer required. However, t o claim the exemption the consumer must file the IRS form 8965 every year they want to claim an exemption. How to Claim the exemption on your federal income tax return 1. Download the 2 016 IRS Form 8965 Health Coverage Exemptions (PDF) and instructions (PDF) 2. On Part III of the form, enter the code for the Indian Exemption (Co documentation. 3. Be sure to include your completed Form 8965 when you file your tax return. (It is important to note that the consumer should maintain written documentation of their Tribal membership or eligibility for IHS service in event of an audit.) The consumer may choose to fill out Form 8965 themselves when submitting their taxes, or to use a qualified tax preparer to complete the form. However, tax preparer entities may charge a fee for this service.

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#HealthyTribalCommunities #GetCoveredIndianCountry 9 Over the past year the National Indian Health Board traveled throughout Indian Country to assist with enrolling American Indians & Alaska Natives (AI/AN) into numerous forms of affordable health coverages at a variety of Indian Health Service clinics, Trib al health facilities, and Urban Indian Organizations (I/T/U) . However, the work of outreach and education is not limited to these periods. Every day, enrollment Assister s throughout Indian Country are enrolling AI/AN s into Medicaid or the th Insurance Pr ogram (CHIP). I/T/Us play a crucial role with enrolling AI/ANs since AI/AN s receive their medical services at these facilities . Original Medicaid covers children, pregnant women, parents, seniors and individuals with disabilities. Some sta tes have expanded their Medicaid programs to cover all people with household incomes below a certain level . The serves uninsured children up to age 19 in families with incomes too high to qualify for Medicaid. E ach state has a CHIP program which works with its regional Medicaid program and states have broad discretion in setting their income eligibility requirements for their CHIP programs . American Indians and Alaska Natives have special protections under th e American Recovery and Reinvestment Act (ARRA) of 2009. The ARRA provides certain protections for AI/A N s who are enrolled in Medicaid or CHIP including paying for premiums or enrollment fees. Also, if AI/ANs receive care from an Indian health care provi der or through a referral to a non – Indian provider, they do not have to pay any cost sharing, such as deductibles, co – insurance, or co – payments. Outreach and Education in your community is important. In order to have an effective enrollment and retention of qualified AI/ANs in Medicaid or CHIP programs, it is essential to create events that tailored to the local community. Here are some ideas of how to implement Best Practice to enrolling American Indian and Alaska Natives into Medicaid and CHIP progra ms. When thinking about enrollment in Medicaid and CHIP, consider The Who, What, Where, Why and When of best practices for enrollments! 1) Who can enroll into Medicaid and CHIP programs? When we start thinking about enrolling AI/AN in Medicaid and CHIP programs, we have to understand who will be applying for and using these services. Some low – income people Families and children Pregnant women

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