October 13, 2022

In This Week's Washington Report

Action Item: Senate Ratifies Kigali Amendment in Win for Environmental Health

Action Item: Congress Passes Temporary Government Funding Measure

Action Item: Upcoming Marketplace and Medicare Open Enrollment

Action Item: CDO Window Application Extended

News From Capitol Hill

Senate Ratifies Kigali Amendment in Win for Environmental Health

The United States became the 138^th country to ratify the Kigali Amendment to the Montreal Protocol when the Senate voted to ratify the amendment on September 21, 2022. The amendment is a legally binding agreement to phase out the manufacture and use of a category of potent greenhouse gasses called hydrofluorocarbons. These manmade compounds are refrigerants and used in the manufacture of air conditions and refrigerators. Unfortunately, hydrofluorocarbons contribute to climate change because the chemicals trap heat when released into the atmosphere. Because hydrofluorocarbons are much more potent than carbon dioxide, climate advocates have called for a worldwide phaseout. 

The United States had already begun its phaseout of hydrofluorocarbons due to the 2020 American Innovation and Manufacturing Act. This law gave the Environmental Protection Agency the authority to regulate the production and use of these chemicals. However, ratification of the Kigali Amendment will build momentum and aid with international enforcement of the phaseout. 

Kigali amended the Montreal Protocol, which is an over 30-year-old international treaty to phase out numerous chemicals that contributed to the hole in the ozone layer. The Montreal Protocol is seen as an international environmental health success story because of the speedy and universal adoption of the treaty (all 197 United Nations member states adopted the Protocol within 14 years). Advocates are hopeful that Kigali will replicate that success in phasing out hydrofluorocarbons worldwide.

For more information, contact Environmental Health Programs Director Brett Weber at bweber@nihb.org.

Congress Passes Temporary Government Funding Measure

Congress passed a funding package that was signed into law on Friday, September 30 - one day before the start of federal fiscal year (FY) 2023, averting a government shutdown and keeping the government operating through December 16, 2022. Often referred to as a Continuing Resolution or CR, the measure passed the Senate with a strong bipartisan vote (72-25), while the House vote of 230-201 was mostly along party lines and hinted of funding battles ahead after the midterm elections and in the next Congress.

The Indian Health Service (IHS) is level-funded for the duration of the CR, except for an increase provided for costs of staffing and operating facilities that were opened, renovated, or expanded in FY 2022 and 2023. IHS is expected to continue its policy from FY 2020 of providing the full prior-year base Secretarial amount to Tribal health programs with performance periods starting within the CR period. Tribes and Tribal Organizations with ISDEAA agreements should connect with IHS directly on timing and complete any FY 2023 funding agreements so that funds can be made available. 

Formula-based program funding will likely not be distributed until Congress enacts a final FY 2023 appropriation and the IHS completes distribution decisions. Programs operated by the IHS, including contracts to Urban Indian Organizations, are expected to receive level-funding prorated for the duration of the CR. 

In addition to these funding inequities within the IHS budget, there exist inequities in relation to other federal healthcare programs. Hardships imposed on these programs by CR and government shutdowns are well documented by the Government Accountability Office, as are the benefits of advance appropriations. Advance appropriations help reduce these hardships by committing, at least one year in advance, to appropriating a full annual budget, available at the start of the fiscal year, regardless of any CR or government shutdown.  

According to the Congressional Research Service, IHS is the only major federal provider of health care that is solely funded through regular appropriations on an annual basis. In 27 years, IHS has only once (in FY 2006) received full-year appropriations by the start of the fiscal year. Other federal health care providers, such as the Veterans Health Administration, receive the majority of their funding through advance appropriations, and a number of health programs, including Medicare and Medicaid, receive mandatory funding, which is controlled outside of appropriations acts. 

In essence, Congress protects healthcare for seniors through mandatory funding and protects veterans through advance appropriations, yet continues to tolerate leaving Tribes vulnerable to stopgap funding and government shutdowns. This inequity is discriminatory and it needs to stop. A simple proposal for FY 2024 is right in front of Congress and it does not cost one extra dime. 

What comes next, and what you can do 

Although Members of Congress have gone home until after the midterm elections, the House and Senate Appropriations Committees are busy preparing for inevitable negotiations on final FY 2023 appropriations bills. House Majority and bipartisan Senate leadership have signaled a desire to complete negotiations and enact a final omnibus appropriations bill before the current CR expires on December 16. It is unclear yet whether House Minority leadership will agree to that timeline or prefer to extend the CR into the new year if midterm elections flip party control of the House. 

When the negotiations begin, advance appropriations for IHS will be on the table. This past July, Senators Leahy (D-VT) and Merkley (D-OR) released the FY 2023 Interior, Environment, and Related Agencies appropriations bill containing FY 2024 advance appropriations for IHS. The bill guarantees a full-year appropriation at the start of FY 2024 that is at least equal to the amounts appropriated for FY 2023 with the exception of funding provided for Electronic Health Records, Sanitation Facilities Construction, and Health Care Facilities Construction. 

The Leahy-Merkley proposal for IHS advance appropriations is not perfect but it is consistent with NIHB Resolution 14-03 and the 2022 NIHB Legislative and Policy Agenda and is an incremental step towards full mandatory funding for IHS. 

If enacted, the Leahy-Merkley proposal provides a level-funding floor for the FY 2024 IHS budget but is not the last word on the matter. Just as with advance appropriations for veterans, Congress can add funding to the IHS budget during the regular FY 2024 appropriations process as more accurate estimates of FY 2024 needs are developed. 

Strong and sustained pressure from Tribal leaders to their Members of Congress is still needed. Here are two things you can do: 

1. In June, NIHB and the National Congress of American Indians (NCAI) issued a Call to Action, providing templates and talking points for letters and phone calls to Members of Congress. Consider taking these actions if you have not already done so, and, even if you have, consider reminding those Members that this issue remains a top priority. 
2. In August, the NIHB and the NCAI issued a Call to Action seeking Tribal testimony on the impacts of government shutdowns on the delivery of IHS programs. Allies in Congress are asking for your stories to help get their colleagues on board. Members of Congress frequently ask, “Why do Tribes need Advance Appropriations?” and “How do funding disruptions harm Tribal nations and their people?” Sharing stories with NIHB and NCAI through this survey will help NIHB and NCAI to effectively better advocate for advance appropriations in Congress. Consider filling out the survey if you have not already done so. Or, if you would prefer, you can email your stories directly to Ciara Johnson, NIHB Congressional Relations Associate, at cjohnson@nihb.org. 

Other News and Events

Upcoming Marketplace and Medicare Open Enrollment

Marketplace open Enrollment starts Tuesday, November 1, 2022, however, you must enroll in a Marketplace plan by Thursday, December 15, 2022 for coverage that starts January 1, 2023. If you are ineligible for health care insurance through Medicaid, the Marketplace may be able to offer you an alternative form of health care coverage.

If you or someone you know has been thinking about signing up for health insurance, now is the time to sign up through the Marketplace. Because the public health emergency is still in effect, it is more important now than ever to have health insurance. American Indians/Alaska Natives (AI/ANs) continue to lead the country in preventative efforts against COVI-19, however other diseases and illnesses, such as the common flu, can still become severe. With the cold winter months coming and flu season just around the corner it is important to take preventative measures and enroll in health insurance for yourself and your loved ones. To see if you are eligible for a plan through the Marketplace, please click here. 

Medicare open enrollment will begin on October 15, 2022 and will continue until December 7, 2022. If you or someone you know over the age of 65 or someone who has a disability is interested in health insurance, Medicare might be right for you. Now more than ever it is important to keep our elders and vulnerable community members safe from disease and illness. Enrolling in a health care plan through Medicare can not only provide access to critical resources needed to prevent sickness, but it can also help families save money when accessing routine services. To see if you are eligible for Medicare, please click here. 

CDO Application Window Extended

The certified designated organization (CDO) application window typically runs from June 1 to August 31, annually. To support organizations in FFM states during the Unwinding period, the Marketplace will extend the current CDO application window to November 1, 2022, and will open another CDO application window once the Medicaid Unwinding begins.

These application window extensions will enable eligible organizations in FFM states to apply to become a CDO, which will provide access to FFM and Medicaid Unwinding technical guidance, training materials, and consumer support resources such as the Complex Case Help Center (CCHC).

CMS invites new applicant organizations who want to become a CDO for Plan Year 2023 to apply during CMS’ Open Season, which has been extended to November 1, 2022.

Any organization operating in an FFM state seeking to provide certified application counselor (CAC) enrollment assistance to consumers for Plan Year 2023 must apply to become a CDO and enter into an agreement with CMS if they are not a current CDO.

CDOs are a vital component of the assister community. In the FFM, CDOs oversee CACs, who are annually trained and able to help consumers seeking health coverage options through the Marketplace. For an overview of the CDO Program and resources that walk users through the CDO application, please visit:

• CDO Program Information – information about who can become a CDO and CDO role responsibilities.
• CDO Application Information – information about who should apply and how to apply during CMS’ Open Season.
• Submit a CDO Application – link to the CDO application web form.
• CDO Application Demonstration Video (Transcript) (Slides) - video demonstration of CDO application completion.
• CDO Application FAQs – frequently asked questions (FAQs) about application submission, post-application submission, and troubleshooting guidance.
• CDO Application User Guide - a systematic, detailed guide to completing your organization’s CDO application.

Only organizations that complete the two steps below by November 1, 2022, and receive a CDO ID from CMS can certify staff or volunteers as federally certified application counselors (CACs) to provide enrollment assistance services.

To apply to become CDO:

1. Access and complete the CDO application at: https://mats.secure.force.com/CDOApplication/. CMS will review your application and send a determination email with your application status. Please allow up to 10 business days for this review.
2. If CMS approves your application, you must access the CDO Organizational Maintenance Web Form (link provided in approval email) and submit a signed CMS-CDO agreement. CMS will then review your signed agreement and send a determination email. If CMS approves your agreement, you will receive a Welcome Packet email with a unique CDO ID. Please allow up to five business days for this review.

For questions or updates, you can email CACQuestions@cms.hhs.gov. Please include your organization’s name and address in the body of your email.