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Tribal Refinancing

On February 26, 2016, the Centers for Medicare and Medicaid Services (CMS) released State Health Official (SHO) letter #16-002 updating its policy regarding circumstances in which 100% federal funding is available for services to Alaskan Native/American Indian (AN/AI) “received through” facilities of the Indian Health Service (IHS), including Tribal health organizations.
As outlined in the SHO letter, care coordination agreements (CCAs) between tribal and non-tribal providers are required to claim the enhanced federal match. Since February 2016, the department has been working with a lead point of contact at the Tribal Health Organizations (THOs) to initiate care coordination agreements (CCAs) with non-tribal organizations. While many tribal and non-tribal providers have existing purchased/referred care agreements in place, the State Health Official (SHO) letter #16-002 requires additional elements, such as shared electronic health records on valid referrals for Alaska Native/American Indian (AN/AI) recipients. Currently, the State of Alaska is the only state in the nation refinancing claims at this level since the State Health Official (SHO) letter #16-002 was released.

History of Advocating for 100% Federal Funding:

Alaska continually works with federal officials to secure the maximum federal funding possible for Medicaid services delivered to Alaska Natives/American Indians (AN/AI) through tribal facilities. In the early 1990s the state worked with Region X in Seattle to convince the Center for Medicaid and Medicare Services, formerly Health Care Financing Administration (HCFA) that the 100% federal matching should be made available to tribally owned and leased facilities. 

Until 2016, services delivered by a non-tribal provider to an Alaska Native/American Indian (AN/AI) Medicaid recipient were supported with 50% state funding and 50% federal funding (or the appropriate match based on the recipients Medicaid eligibility such as expansion, Title XIX, or XXI which are between 50-95%). The Department worked diligently with leadership at Center for Medicaid and Medicare Services to ensure states could receive 100% federal funding for all services provided to Alaska Native/Alaska Indian (AN/AI) Medicaid recipients, even if those services were delivered by a non-tribal provider.

On February 26, 2016, CMS issued State Health Official letter #16-002 revising CMS payment policy for services provided to Medicaid-eligible AI/AN beneficiaries “received through” an IHS/Tribal facility, and expanded the scope and nature of services that qualify for the 100% Federal Medical Assistance Percentage (FMAP).  This information elevated the importance of the statewide commitment to continue to improve relations between states, federal and tribal entities for improving health outcomes for Alaskans with the added benefit of state general fund savings. Federal Claiming Allowances Under Center for Medicaid and Medicare Services State Health Official (SHO) Letter #16-002:

In order to meet the new federal guidance which allows the state to receive 100% federal match for paid services when a tribal health organization refers an Alaska Native/American Indian (AN/AI) Medicaid recipient to a non-tribal provider, each of the following conditions must be met:
  • A care coordination agreement exists between the non-tribal provider and the tribal health organization;
  • The tribal health organization requests services from the non-tribal health provider;
  • The tribal health organization remains the patient’s primary care provider; and
  • The non-tribal provider transmits information to the tribal health organization regarding the services delivered to the Alaska Native/American Indian (AN/AI) recipient.
To assist the state in accessing the 100% federal match, the Department started working with Alaska Native Tribal Health Consortium (ANTHC) to perform outreach with providers to sign care coordination agreements (CCAs) with each of the tribal health organizations (THOs). All responsibility for acquiring the federal funds rests with the state once the care coordination agreements (CCAs) are in place. The Department developed new processes to ensure that all other requirements in addition to the care coordination agreements (CCAs) are met including verification of referrals and exchange of records. Through these efforts the state can then collect 100% federal match on all eligible paid claims without disruption to provider claim processing or reimbursement.  Providers who sign care coordination agreements (CCAs) will submit claims as usual and will receive the same reimbursement for eligible services provided.

Care Coordination Agreements

Care Coordination Agreements (CCAs) are formally established between Tribal Health Organizations (THOs) and non-tribal providers for specific referral services provided to Alaska Natives/American Indians (AN/AI) eligible for Medicaid. Several staff in the Tribal Health Unit work in conjunction with staff at the Alaska Native Tribal Health Consortium (ANTHC) to track and maintain an active list of Care Coordination Agreements (CCAs) from across the State.
To obtain the maximum level of refinancing and gain initial savings, the Department initially focused on transportation services including emergent and non-emergent, and inpatient hospital services. Since then, other services involving high dollar claims with low volume utilizers such as residential treatment programs, skilled nursing and pharmacy services have also been included in the initiative. As a result, majority of the Tribal Health Organizations (THOs) and over a hundred non-tribal providers have signed Care Coordination Agreements (CCAs) and are incorporated in the tribal refinancing efforts each quarter. Participation from Tribal Health Organizations (THOs) and non-tribal providers continue to increase every quarter due to the partnership between the Tribal Health Unit and Alaska Native Tribal Health Consortium (ANTHC). 
Primary point of contact for Care Coordination Agreements (CCAs) at Alaska Native Tribal Health Consortium (ANTHC):
Margie Bezona
Tribal Care Coordination & Planning Director

Referral Verifications

The Tribal Refinancing process includes various steps. This requires the participation and collaboration of Tribal Health Organization (THO) partners and multiple divisions within the Department of Health. Each quarter the tribes with signed Care Coordination Agreements (CCAs) are sent Referral Verification Lists (RVLs) for services provided by non-tribal providers. The Referral Verification Lists (RVLs) are specific to the service area of each Tribal Health Organization (THO) and include paid claims that fit certain criteria. Once the requirements of the State Health Official (SHO) Letter #16-002 are verified, internal analysis of paid claims is conducted by the Tribal Health Unit to determine which claims to submit for additional federal match. 
The table below shows the total referrals requested by the Department from the Tribal Health Organizations (THOs) and the percentage of referrals verified each quarter:

​Quarter Ending ​Total # of Referrals Requested ​Total # of Verified Referrals ​Total # of Unverified Referrals ​Percentage
of Verified Referrals

of Unverified Referrals

​12.31.16 ​1696 ​544 ​1152 ​32% ​68%
​03.31.17 ​2446 ​546 ​1900 ​22% ​78%
​06.30.17 ​1729 ​273 ​1456 ​16% ​84%
​09.30.17 ​4636 ​108 ​3553 ​23% ​77%
​12.31.17 ​4936 ​1042 ​4161 ​21% ​84%
​03.31.18 ​5036 ​1077 ​3969 ​21% ​79%
​06.30.18 ​4599 ​1029 ​3587 ​22% ​78%

Tribal Refinanced Savings

The Tribal Refinancing target savings are established each fiscal year during Legislative Session by political officials.  The table below shows the target savings by fiscal year and the savings achieved by the Department:
​Fiscal Year ​Target Savings
​Achieved Savings
​2017 ​$32 ​$34.7
​2018 ​$42 ​$44.7
​2019 ​$94 ​$25.9
​Totals ​$168 ​$105.3 (as of first quarter)
Note: For FY19, the reported figure is total savings as of 10/17/2018.