During the 2019 legislative session, the Montana Legislature passed House Bill (HB) 599, which allows community health aides to provide care under the Indian Health Service Community Health Aide Program in Montana. While there is still uncertainty around what CHAP and its implementation could look like in Montana, this report answers some frequently asked questions about the program.
What Is the Community Health Aide Program (CHAP), and Why Is it Important?
The Indian Health Service (IHS) established the Community Health Aide Program (CHAP) in rural Alaska in 1968 to increase access to quality health care in rural communities and Indian Country. CHAP does this by providing authority for mid-level behavioral, community, and dental health professionals, like community health aides, to work alongside licensed providers.[1]
In 2010, the U.S. Congress amended the Indian Health Care Improvement Act (IHCIA) to authorize the expansion of CHAP beyond Alaska.[2] The expansion of CHAP in Montana will increase opportunities to access health care across Indian Country. Nearly two-thirds of Montanans who are American Indian live in medically underserved counties, and Montanans who are American Indian are more likely than Montanans who are non-Indian to report barriers to accessing care.[3] Lack of access to care contributes to the lower health outcomes of Montanans who are American Indian, as compared to Montanans who are non-Indian, including a life expectancy that is, on average, 16 years shorter.[4] It is clear that Indian Country needs greater access to health care.
What Is the Indian Health Care Improvement Act (IHCIA)?
In 1976, the U.S. Congress passed the Indian Health Care Improvement Act (IHCIA), which provides the foundational legal authority for the provision of health care to American Indians and Alaska Natives.[5] Through the IHCIA, the U.S. Congress declared that it is the policy of the United States to fulfill its trust responsibilities and legal obligations to American Indians to:
This trust responsibility stems from the fact that, between 1778 and 1871, the United States negotiated nearly 400 treaties with tribal nations.[7] Through these treaties, tribal nations ceded control of millions of acres of their homelands to the United States.[8] In exchange for land, treaties created a legal obligation for the federal government to provide services like health care.[9]
The IHCIA also amended the Social Security Act of 1935 to allow reimbursement by Medicare and Medicaid for services American Indians and Alaska Natives receive in IHS and tribal health care facilities. This amendment made Medicaid and Medicare services more accessible to more people, particularly for those residing in remote and rural locations, where Medicaid and Medicare providers may not be located.[10] The IHCIA also provided states with a 100 percent federal reimbursement for Medicaid services provided through an IHS or tribal facility, meaning the state Medicaid program incurs no cost.[11]
In 2010, President Obama permanently extended the IHCIA when he signed the Patient Protection and Affordable Care Act into law.[12]
If CHAP Is a Federal Program, Why Did the Montana Legislature Pass HB 599?
The IHCIA requires state authorization for specific types of aides, like dental health aides.[13]
How Are CHAP Activities Funded?
CHAP requires a separate federal appropriation within the IHS budget. At this time, Congress has not funded CHAP expansion activities.[14] However, the state and tribal nations can provide resources once the federal Secretary of Health and Human Services has certified the program. Further, HB 599 amended the Montana Medicaid program to include services provided by a community health aide and directs the Montana Department of Public Health and Human Services to apply for a state Medicaid plan amendment through the federal Centers for Medicare and Medicaid Services.[15]
What Is a Community Health Aide, and What Type of Health Aides Are Included in the Montana CHAP?
A community health aide is a mid-level, community-based health-care provider. HB 599 specifies that, once certified, individuals may practice in the areas of dental health, behavioral health, and community health.[16] While the certification board (more below) will ultimately determine the scope of practice for each type of aide for each of the practice areas, this section gives examples of care that aides in the Montana CHAP could potentially provide.
Dental Health
Dental health aides provide a range of services, depending on their level of training and certification. Types of dental health aides included in the Montana CHAP are primary dental health aides, expanded function dental health aides, dental health aide hygienists, and Dental Health Aide Therapists (DHATs).[17]
Primary dental health aides largely provide oral health promotion and oral disease prevention education.[18] Expanded function dental health aides and dental health aide hygienists provide progressively more advanced care, such as dental cleanings. DHATs, which require the most advanced level of training, can typically provide some restorative care and can perform some basic dental surgery procedures.[19] However, HB 599 prohibits individuals from performing dental extractions or invasive procedures to teeth and gums.[20]
Behavioral Health
Depending on their level of training and certification, behavioral health aides provide a range of services, including assisting with case management, patient and community education, patient evaluation, treatment planning, and treatment activities. Types of behavioral health aides included in the Montana CHAP are behavioral health aides and behavioral health practitioners.
Behavioral health practitioners may, only under the general supervision of a licensed behavioral health professional, conduct routine screening, assessment, evaluation, and counseling of patients.[21] Behavioral health practitioners require a more advanced level of training than do behavioral health aides.
According to the IHS CHAP expansion timeline, no other state outside of Alaska has yet to expand the use of behavioral health services.[22]
Community Health
Community health aides are mid-level medical providers who can provide basic medical attention and clinical care. Depending on their level of training and certification, community health aides provide a range of services, including family planning, health education, and maternal and child health.[23] Types of community health aides included in the Montana CHAP are community health aides and community health practitioners. Community health practitioners require a more advanced level of training than do community health aides.
According to the IHS CHAP expansion timeline, no other state outside of Alaska has yet to expand the use of community health services.[24]
Who Has Certification Authority Over CHAP?
The federal Secretary of Health and Human Services, acting through IHS, establishes and maintains a CHAP certification board, which adopts certification standards for individuals to act as specific aides within the program, including those standards related to scope of practice, training, supervision, and continuing education.[25] While there is not yet a national certification board in place, the certification board could be comprised of medical, dental, and behavioral health professionals. Additionally, because the Alaska CHAP currently has its own area certification board, it is likely that the Montana CHAP will also require an area certification board.
Certification boards require community health aides to have successfully completed training that demonstrates their capacity to provide care.[26] HB 599 specifies that individuals may practice in a setting operated by IHS or a tribal health program, as long as the individual is certified by either a federal CHAP certification board or a federally recognized tribal nation that has adopted certification standards that meet or exceed the requirements of a federal CHAP certification board.[27]
How Is CHAP Different from the Community Health Representatives (CHR) Program?
Both CHAP and the CHR Program are IHS programs; however, they have key differences. First, they have different scopes of work. Community health aides are mid-level medical providers who can provide basic medical attention and clinical care, such as inserting stitches.[28] Community health representatives, on the other hand, provide health promotion and outreach to community members.[29] They do not provide clinical care.[30] Examples of activities performed by community health representatives include providing patients with transportation to health appointments, informal counseling, and social support.[31]
Second, they have different funding sources. The CHR Program receives its own designated funding.[32] CHAP requires federal appropriations. At this time, CHAP expansion activities are unfunded; however, IHS plans to work with tribal nations to develop the budget.[33]
How Does CHAP Expansion Impact Tribal Health Programs, Services, Functions, and Activities (PSFAs)?
It depends upon whether a tribal nation has contracted or compacted with IHS.
When contracting, tribal nations or organizations work with IHS to plan, conduct, and administer one or more individual programs, functions, services or activities (PFSAs), or portions thereof, that IHS would otherwise provide; therefore, tribal nations or organizations may need IHS approval to make changes to PFSAs.[34]
When compacting, tribal nations assume full funding and control over PSFAs, or portions thereof, that IHS would otherwise provide; therefore, tribal nations or organizations do not need IHS approval to make changes.[35]
Are Urban Indian Health Centers Included in CHAP?
No, urban Indian organizations are not authorized to implement CHAP under the IHCIA.[36]
What Is Next?
The following list is not exhaustive; however, the IHCIA requires IHS to:
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