mmpc - National Indian Health Board

MEDICARE, MEDICAID, & HEALTH REFORM
POLICY COMMITTEE (MMPC)
FACE TO FACE MEETING
Tuesday, November 13, 2012
9:00am-5:00pm EST
KAISER FAMILY FOUNDATION, BARBARA CONFERENCE CENTER

MISSION STATEMENT
The Medicare, Medicaid and Health Reform Policy Committee (MMPC) is a
standing committee of the National Indian Health Board (NIHB). The committee
is chaired by a member of the NIHB Board of Directors. The primary purpose of
MMPC is to provide technical support to the Tribal Technical Advisory Group to
the Centers for Medicare and Medicaid Services (TTAG). TTAG is a group
codified by the American Reinvestment and Recovery Act of 2009 and is
composed of formally appointed representatives from each Indian Health
Service (IHS) Areas as well as from specific national Indian
organizations. TTAG advises the Centers for Medicare and Medicaid Services
(CMS) on Indian issues related to Medicare, Medicaid, the Children’s Health
Insurance Program (CHIP), and any other health care program funded (in whole
or part) by CMS. MMPC continues work on the Affordable Care Act (ACA) and
Indian Health Care Improvement Act (IHCIA) health policy issues, regulation
review and the development of draft positions with the greatest opportunities
and highest priority for the Indian Health System.
MMPC also acts as a national forum to identify, discuss, advise and act on issues
that will improve the health of American Indians and Alaska Natives. In this
capacity MMPC has the ability to pool expertise in Indian health care from
across the country in order to develop information and recommendations on
current issues. Implementation of components of the Indian Health Care
Improvement Act and the Patient Protection and Affordable Care Act that are
outside the jurisdiction of CMS are examples.
Membership in MMPC is open to individuals authorized to represent: a Tribe;
Tribal Organization; Urban Indian Program; or Indian Health Service (IHS). For
more information or to join the MMPC distribution list please contact Liz
Heintzman at lheintzman@nihb.org.

GENERAL INFORMATION
TABLE OF CONTENTS
MMPC FACE TO FACE AGENDA 1
MMPC ACTION PLAN, TASKS, & ASSIGNMENTS 3
MMPC OCTOBER TELECONFERENCE AGENDA NOTES 16
ACTIVE, NEW & ONGOING MMPC/TTAG ISSUES, STATUS, GOALS & NEXT STEPS
IRS SEPTEMBER MEETING NOTES 20
INDIAN ADDENDUM COMPANION PIECE 23
INDIAN ADDENDUM 30
TRIBAL CONSULTATION WITH HHS ON FFE/MEDICAID EXPANSION NOTES 35
NIHB COMMENT TO ALL INCLUSIVE REIMBURSEMENT RATE AGREEMENT 44
TSGAC COMMENT TO ALL INCLUSIVE REIMBURSEMENT RATE AGREEMENT 46
SUMMARY OF INDIAN SPECIFIC BENEFITS AND PROTECTIONS 50
CHART OF INDIAN SPECIFIC HEALTH CARE PROVISIONS 52
WHITE HOUSE LETTER FROM CRIHB & NPAIHB 53
AMENDMENT TO ACA REGARDING AI/AN DEFINITION 56
ENABLING EXCHANGES IMPLEMENT A STREAMLINED APPLICATION PROCESS PAPER 57
MEDICAID REPORT FROM CRIHB 73
DEAR TRIBAL LEADER REGARDING HHS CONSULTATION LETTER 123
TRIBAL CONSULTATION POLICY 124
TTAG FACE TO FACE PREPARATION ___
TTAG AGENDA 134
BEHAVIORAL HEALTH DOCUMENTS ___
HHS BLOCK GRANT REGULATIONS 137
NPAIHB COMMENTS TO IHS NATIONAL BEHAVIORAL STRATEGIC PLAN 150
NPAIHB COMMENTS FOR UNIFORM APPLICATION FOR MENTAL HEALTH BLOCK GRANT 154
NPAIHB COMMENTS ON TRIAL LAW & ORDER ACT OF 2010 158
GO THE EXTRA MILE INITIATIVE ___
EXECUTIVE DIRECTOR LETTER 161
GO THE EXTRA MILE FACT SHEET 162
ADDITIONAL ITEMS ___
LEGISLATIVE ACTION ALERT 165

Last Updated: November 12, 2012
Medicare, Medicaid, and Health Reform Policy Committee (MMPC)
Face to Face Meeting
Tuesday, November 13, 2012
9:00 AM-5:00 PM EST
Call in number: NIHB conference line: 1-866-303-3137
Passcode: 414526
AGENDA
Purpose: To review and provide updates and detailed discussion of 2012 MMPC Action Plan priorities and assignments.
Outcomes:
1. Continue work on the Affordable Care Act (ACA) and the Indian Health Care Improvement Act (IHCIA)
health policy issues, regulation review and development of draft positions with the greatest opportunities and
highest priority for the Indian health system;
2. Review strategies and process for advancing issues; and identified tasks and timeframes; and,
3. Prepare for TTAG November 14-15, 2012 Face to Face meeting.
9:00 am Welcome
Opening Prayer
Introductions
9:10 am Review of Agenda, Purpose of Meeting and General Housekeeping Items
9:30 am Regulations Review Update (MMPC Action Plan #5) (also see handout)
Review status of proposed comments
Upcoming regulations
10:00 am Prepare for Office of Personal Management (OPM) Guest Speaker-John O’ Brien, Director,
Healthcare & Insurance, OPM (also see handout)
10:10 am John O’Brien OPM (tentative time)
Kaiser Family Foundation/ Barbara Jordan Conference Center
1330 G Street, NW, Washington, DC 20005
Phone: (202) 347-5270; fax: (202) 347-5274
10:50 am Active, New and Ongoing MMPC/TTAG Issues, Status, Goals, and Next Steps
(Review of Current MMPC Action Plan and Strategies)
1. Update on IRS Issues (MMPC Action Plan #9)
a. Assignment of tax refunds
b. Treatment of Indian income under MAGI

Last Updated: November 12, 2012
2. Discussion on CCIIO Policy Issues (MMPC Action Plan # 6)
a. Status of internal clearance on Indian Addendum and companion piece
b. Timing on response to tribal comments on the Federally-facilitated exchanges.
3. Tribal Hospital EHR Charity Care Calculation (Myra Munson) (MMPC Action Plan #10)
4. Update on VA/IHS Draft Reimbursement Agreement (MMPC Action Plan #11)
5. Single Enrollment Form for Exchanges and Medicaid (MMPC Action Plan #6)
a. Request schedule and process for dealing with open issues, including how CMS is dealing
with process for vetting with other groups
6. Working with States on Exchanges and Medicaid Expansion (MMPC Action Plan #19) (also see
handout)
a. Status of letter to Tribes (development of a template from CMS) for outlining process at state
level for those Tribes not moving forward with Medicaid Expansion (Jim Roberts)
b. Need a process to ensure that Medicaid Expansion is addressed through the ACA Policy
Subcommittee; raise this at the TTAG meeting
c. State Waivers
7. Standard Operating Procedures (SOP) on the CMS Tribal Consultation Policy (MMPC Action Plan
#2)
a. needs to be reviewed by the TTAG Consultation Policy Subcommittee
8. Data Issues (MMPC Action Plan #28)
9. Consultation (MMPC Action Plan #2, 3, 4)
12:00 pm Lunch on Your Own
1:00 pm Continue Discussion of Active, New and Ongoing MMPC/TTAG Issues, Status, Goals, and Next
Steps
1:50 pm Prepare questions to ask Dr. Yvette Roubideaux
2:00 pm Dr. Yvette Roubideaux Q/A
3:00 pm Break
3:15 pm Prepare for TTAG Face to Face
Review TTAG Agenda
Prepare TTAG Talking Points
4:30 pm Additional Discussion Topics
5:00 pm Adjourn MMPC
Upcoming Calls/Meeting dates
Post-Election
Need for more active participation on TTAG subcommittee calls
Decision to dissolve or keep active/reorganize across state borders and behavior health
subcommittees
NIHB GO the EXTRA MILE Initiative
MMPC Teleconference Call-December 5, 2012, 2:00-4:00 PM EST
TTAG Teleconference Call-December 12, 2012, 2:30-4:00 PM EST

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MMPC: SUMMARY OF ISSUES, STRATEGIES & ASSIGNMENTS
UPDATED 10/9/12
(RECENT UPDATES IN RED AND HIGHLIGHTED IN YELLOW)
Please Note: This Summary of issues, assignments and strategies has been organized to follow the
general Goals and Objectives identified in the “draft” 2013-2018 CMS-TTAG AI/AN Strategic Plan.
I. CONSULTATION
Task/Issue Person(s)
1. Invites/Presentation at
MMPC/TTAG November
2012 Face-to-Face
meetings
NIHB
Liz Heintzman
Due Date/
Timeline
Action(s) Needed
Oct 2012 Finalize topics and
speakers for CMS Day;
plenary and workshops
Brief Summary of Next Steps and Follow-up
Notes/Comments
MMPC November 2012 Meeting:
1. Invite OPM
2. Review Data Report (request copy from Jim Crouch/Carol Korenbrat)
TTAG October 2012 Meeting – Additional Agenda Items/Topics:
1. Request updates from CCIIO on (1) status of internal clearance on
Indian Addendum and companion piece; and (2) timing on response
to tribal comments on the Federally-facilitated exchanges.
2. Request Schedule and Process for dealing with open issues on the
Single Enrollment Form for Exchanges and Medicaid including how
CMS is dealing with process for vetting with other groups.
3. Status of letter to Tribes (development of a template from CMS) for
outlining process at state level for those Tribes not moving forward
with Medicaid Expansion (Jim Roberts)
TTAG November 2012 Meeting:
1. Invite Gary Cohen
2. Invite OIG to report and present on Safe Harbors and Medicaid
Collections
3. Take final action on CMS TTAG Strategic Plan
4. Fuller discussion and update on working with States on Exchanges
and Medicaid Expansion
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2.
Task/Issue Person(s)
CMS Consultation
Policy
3. State/Tribal
Consultation
Jim Roberts
Myra Munson
MMPC
MMPC: SUMMARY OF ISSUES, STRATEGIES & ASSIGNMENTS
UPDATED 10/9/12
(RECENT UPDATES IN RED AND HIGHLIGHTED IN YELLOW)
Due Date/
Timeline
Action(s) Needed
On-going CMS Policy Finalized
November 2011
MMPC On-going Need to engage with
States and establish
process for Tribal
consultation
Brief Summary of Next Steps and Follow-up
Notes/Comments
Final CMS Consultation Policy released November 2011. There are some
substantive differences between the originally approved Tribal Consultation
Workgroup version and the final copies released by CMS. Talking points of these
issues and concerns were drafted for Tribal leaders to use for the all Tribes call
hosted by CMS on Friday, December 9th .
Draft letter has been developed to CMS on behalf of TTAG Co-Chairs regarding
Tribal recommendations on the process & timeline for revising the Consultation
policy. To be finalized by April 10, 2012.
Letter approved by TTAG and forwarded 4/11/12.
Standard Operating Procedures (SOP) being prepared by Kitty on the CMS Tribal
Consultation Policy (needs to be reviewed by the TTAG Consultation Policy
Subcommittee).
1. Monitor SPA’s
2. Tribes engage in planning efforts with States on Health Exchanges
3. Engage and monitor State legislative action
4. Medicaid Managed Care – Kansas Tribes’ Strategy.
7/24/12 Update:
13 States are going forward with State Exchanges.
HHS Secretary directed States to work with Tribes.
Only 4 States are actively working with Tribes (OR, RI, WA, and MN)
Only 3 States have formal Tribal consultation policies (OR, RI and WA)
Next Steps/Recommendations:
1. Have a Tribal TTAG Representative participate on monthly CCIIO calls on
State Exchanges.
2. Request updated list of State Exchange contacts.
3. Request CCIIO to report back on which States with establishment grants
have Tribal consultation policies.
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Task/Issue Person(s)
4. Tribal Consultation
Sessions on Federallyfacilitated
Exchanges
MMPC
Mim Dixon
MMPC: SUMMARY OF ISSUES, STRATEGIES & ASSIGNMENTS
UPDATED 10/9/12
(RECENT UPDATES IN RED AND HIGHLIGHTED IN YELLOW)
Due Date/
Timeline
July-August
2012
Action(s) Needed
Discuss strategy, review
talking points, and assign
people to speak to issues
Brief Summary of Next Steps and Follow-up
Notes/Comments
4. Have Area Health Boards reach out to Tribes and assist in communication.
5. 9/5/12 - Need a process to ensure that Medicaid Expansion is
addressed through the ACA Policy Subcommittee; raise this at the
next TTAG meeting in November 2012.
6. Need to develop a letter to Tribes on process of what needs to
happen at State level for those States not moving forward with
Medicaid Expansion; Work with CMS on a template.
HHS held 3 Tribal consultation sessions: July 26 (Washington, DC); August 7
(Anchorage, AK) and August 9 (Denver, CO)
Next Steps:
1. Conference call held 7/31/12. Additional talking points and strategy
developed for presentation at the August 7 & 9 th Consultations. Talking
Points to be circulated.
2. Request CCIIO to share information with Tribes/TTAG that is being
communicated with States.
3. Need clarify from IHS regarding their ability to pay premiums. (This may
require a technical fix.)
4. Comments forwarded on behalf of NIHB and TTAG (Sept 2012).
5. TTAG to request an update from CCIIO on the timing and response to
Tribal recommendations and comments.
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II. POLICY
Task/Issue Person(s)
MMPC: SUMMARY OF ISSUES, STRATEGIES & ASSIGNMENTS
UPDATED 10/9/12
(RECENT UPDATES IN RED AND HIGHLIGHTED IN YELLOW)
Due Date/
Timeline
Action(s) Needed
5. Regulation Review NIHB On-going Identify Regs
Coordinate & Submit
Comments
Track Responses
6. TTAG ACA Policy
Committee
NIHB On-going Conduct weekly
conference calls to
review issues
(Wednesdays 3-5 pm
eastern)
Brief Summary of Next Steps and Follow-up
Notes/Comments
NIHB to continue to provide CMS with on-going written Regulation Review and
Update Report on a bi-monthly basis.
Reg. Report, v.2.10 covering the time period through August 15, 2012 was
distributed. NIHB received new cycle of funding end of September 2012. Will
review the process and timeframes for continuing the on-going Reg. Report
on a bi-monthly basis.
10/9/12 - Upcoming Regs and Comments due as follows:
1. CMS #10003 Paperwork Reduction Request (Medicare coverage and
payment in a single form) – Due 11/6/212
2. OPM certification of Qualified Health Plans – Due 10/22/12
Current issues include:
1. Indian Addendum plus companion piece explaining Addendum.
(completed and forwarded to CCIIO) - TTAG to request an update from
CCIIO on the status of internal clearance..
2. Tribal Sponsorship
3. Other topics will be prioritized as high impact, high value topics.
4. Draft response to Data Elements for application to support eligibility
determinations for enrollment in exchanges, Medicaid and CHIP
5. TTAG to request schedule and process for dealing with open issues
on single enrollment form exchanges and Medicaid (including how
CMS is dealing with process for vetting with other groups.
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Task/Issue Person(s)
7. Strategy for ACA
Legislative Issues
following Supreme
Court Decision
8. Strategy for moving
forward on determining
eligibility for Health
Insurance Exchange
Applications (Definition
of Indian)
MMPC
Myra Munson
Jennifer Cooper
Elliott Milhollin
MMPC
ACA Policy
Committee
NIHB
NCAI
NCUIH
MMPC: SUMMARY OF ISSUES, STRATEGIES & ASSIGNMENTS
UPDATED 10/9/12
(RECENT UPDATES IN RED AND HIGHLIGHTED IN YELLOW)
Due Date/
Timeline
Action(s) Needed
July 2012 Consideration of possible
legislative fixes to ACA
On-going Need to monitor actions
being taken by CMS
Brief Summary of Next Steps and Follow-up
Notes/Comments
Following the Supreme Court decision that removed the penalty for States to
courage the Medicated Expansion, there may be a legislative fix and the MMPC
might want to develop a list of other items that would like to be included in any
legislation. The following issues were preliminary identified:
(a) definition of Indian; (b) CHSDA for purchasing services; (c) Section 206; (d)
Qualified Health Providers; ( e) dental health Section 119; and (f) other
technical corrections.
Next Steps:
1. Create MMPC workgroup to identify areas that need to be fixed and
develop technical corrections.
2. Develop a list of all the issues (Broad brush picture).
3. Fix when there is an opportunity.
TTAG formally submitted recommended questions to be included in the Exchange
applications to determine who is eligible for benefits and protections. This was
narrowed down to 1 question, but no feedback from CMS has been received.
No final rule has been published. There are concerns with waiting for definition and
that it might be narrowly defined. States are currently writing code and it could be
too late to address services for AI/AN.
Need to develop a broader strategy and next steps. (National organizations to
take the lead, NIHB, NCAI and NCUIH.)
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Task/Issue Person(s)
9. Strategy to engage
CMS & IRS Re: Health
Exchanges and
Medicaid Expansion
10. Tribal Hospital EHR
Charity Care
Calculation
Mim Dixon
Jim Roberts
Ron Allen
MMPC: SUMMARY OF ISSUES, STRATEGIES & ASSIGNMENTS
UPDATED 10/9/12
(RECENT UPDATES IN RED AND HIGHLIGHTED IN YELLOW)
Due Date/
Timeline
Action(s) Needed
On-going Continue to advance
priorities identified by
MMPC
Myra Munson On-going Respond to latest set of
questions from CMS
Brief Summary of Next Steps and Follow-up
Notes/Comments
IRS Representatives Jonathan R. Damm & Telly J. Meir, Tax Law Specialists, Office
of Indian Tribal Government met with the MMPC representatives at the face-to-face
meeting on 2/21/12; and again on 7/24/12. IRS issued final rule on May 23, 2012.
Many Tribal recommendations were rejected. MMPC inquired on practicial
implementation issues, including:
What is the process for implementation and how will they coordinate
with HHS?
How will they determine who is AI/AN?
How will Tribes be consulted? Tribes want an opportunity to be
consulted before a final decision is made.
IRS reps responded that a complicated flow chart to outline the process has been
developed; and they’re working within the timeframes established in the ACA. They
appreciate the need for on-going communication with Tribes; and IRS follows the
Dept. of Treasury’s consultation policy. They are also informally communicating
with Tribes through outreach in meetings and request for written comments.
Follow up:
1. Invite IRS reps to NIHB Annual Consumer Conference.
2. IRS urged Tribes to continue to communicate in writing on issues of key
concern and Tribal recommendations.
3. Tribes recommended that a TTAG subcommittee be identified to work with
IRS on these issues. (Send follow up email and/or letter with this
recommendation.) Meeting held with Christie Jacobs in Denver
during the ACC meeting.
4. Need to develop an IRS Outreach and Education Plan.
Conference calls are continuing. Technical Workgroup needs to re-write and finalize
response. Myra will finalize prior to the November 2012 TTAG meeting.
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11.
Task/Issue Person(s)
VA/IHS Draft
Reimbursement
Agreement
13. Coordination with OPM
on Multi-State
Exchange Plans
14. Coordination with OPM
on implementation
issues regarding FEHB
and FEGLI
MMPC
Stacy Bohlen
Elliot Milhollin
NIHB
MMPC
NIHB
NCAI
MMPC
MMPC: SUMMARY OF ISSUES, STRATEGIES & ASSIGNMENTS
UPDATED 10/9/12
(RECENT UPDATES IN RED AND HIGHLIGHTED IN YELLOW)
Due Date/
Timeline
Action(s) Needed
Brief Summary of Next Steps and Follow-up
Notes/Comments
On-going Need to Identify next 1. Alaska has finalized and entered into Agreements; some provisions are
steps for Advancing
different than the draft VA/IHS Reimbursement Agreement that was
Agreements between VA circulated for Tribal comment.
& IHS/Tribes
2. VA consultation held during NIHB ACC. The Tribal Self-Governance
Advisory Committee sent a follow up letter regarding comments on
Negotiation of Participating Tribal Health Program Agreements with Local
VA Facilities NIHB to send letter similar and to include clarification
regarding rates.
On-going On December 20, 2011, a small group of MMPC members met with OPM, including
Susan McNally, the Assistant Director of National Healthcare Operations, John
Cutler, the team leader for the Multi-State Plans Program, Kay Pestura, Deputy
Direct for National Healthcare Operations, and Florence Jackson, who works for Ms.
McNally and Ms. Pestura. OPM is not as far along as CCIIO in implementing
Exchange plans, and is in the beginning stages. They are in the pre-consideration
phase of rulemaking, and were unable to provide much in the way of specifics.
MMPC provided an overview of some of the most pressing issues, including
inclusion of ITU providers in any multi-state exchange plan, inclusion of the Indian
addendum, etc. Ms. McNally indicated that OPM is very interested in hearing from
Tribes on what they would like to see in a multi-state exchange plan.
On-going Continue outreach and The first effective date of coverage began May 1, 2012. Tribes, Tribal organizations
education efforts on and urban Indian organizations may also purchase FEHB coverage effective after
FEHB implementation. this date. OPM and NFC are also working with a Tribal Technical Work Group to
finalize operational details related to the program. This Work Group is comprised of
individuals from Tribes, Tribal organizations and urban Indian organizations of
various sizes and geographic locations. For more information, please see
www.opm.gov/tribalprograms
1. As of June 2012, OPM reported approximately 30 Tribes covering
approximately 3,000 Tribal employees are now covered. OPM is continuing to
provide training and detailed information regarding the roll-out of the FEHB
program implementation. They are also developing policy handbooks and draft
guidance. Final guidance will be completed when regulations are complete.
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Task/Issue Person(s)
15. Evaluation of ARRA
5006 Implementation
16.
MMPC Staffing and
Funding
Carmelita Skeeter
MMPC
Stacy Bohlen
Jim Roberts
(Budget
Subcommitte)
MMPC: SUMMARY OF ISSUES, STRATEGIES & ASSIGNMENTS
UPDATED 10/9/12
(RECENT UPDATES IN RED AND HIGHLIGHTED IN YELLOW)
Due Date/
Timeline
Action(s) Needed
On-going TTAG to recommend to
CMS to conduct an
evaluation of ARRA 5006
implementation.
On-going Seek both short and longterm
resources to support
MMPC efforts.
Brief Summary of Next Steps and Follow-up
Notes/Comments
2. Additional outreach and education with Tribes is needed. OPM plans to release
a Dear Tribal Leader letter in the near future to address some of the questions
and concerns raised during the initial trainings.
3. New guidance for Tribal employers was provided by OPM; identifies what types
of benefit packages have been included.
Recommend state-by-state evaluation; include survey with State Medicaid Directors,
Tribes, Regional Health Boards and other organizations.
1. Develop and prepare a budget identifying staffing and financial resources
needed, including:
a. Full time regulation review staff (short-term funding identified for
regulation review through September 2012)
b. Dedicated NIHB staff for coordination of MMPC/TTAG activities, including
staffing and facilitation.
2. Encourage IHS to build capacity and resources (IHS benefits from this work)
3. Seek private sector funding:
a. Identify potential foundation funding, e.g. Kellogg, Robert Wood Johnson,
etc. (Stacy)
b. Other outreach
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17.
III. LONG-TERM SERVICES AND SUPPORT
Task/Issue Person(s)
MMPC: SUMMARY OF ISSUES, STRATEGIES & ASSIGNMENTS
UPDATED 10/9/12
(RECENT UPDATES IN RED AND HIGHLIGHTED IN YELLOW)
Due Date/
Timeline
Action(s) Needed
Long Term Care MMPC On-going Continue to monitor
activities and resources
available under the
ACA/IHCIA.
Brief Summary of Next Steps and Follow-up
Notes/Comments
IHS LTC & Behavioral Health experts have been meeting regularly.
1. LTC Subcommittee is working with KAI regarding coordination of the upcoming
Long Term Care Support and Services Conference to be held March 21-23 in
Denver.
2. LTC Subcommittee is drafting comments in response to IHS Director, Dr.
Roubideaux’s January 6, 2012 Dear Tribal Leader letter requesting comments
on the recommendations from the previous LTC conference and report. Draft
comments have been shared with the MMPC. Comments were submitted on
March 16, 2012.
3. LTC Subcommittee is planning a conference call with Anita Yuskauskas to
discuss “Money Follows the Person” initiative. Conference call to be
scheduled with the Long-Term Care Committee.
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IV. OUTREACH AND EDUCATION
MMPC: SUMMARY OF ISSUES, STRATEGIES & ASSIGNMENTS
UPDATED 10/9/12
(RECENT UPDATES IN RED AND HIGHLIGHTED IN YELLOW)
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Task/Issue Person(s)
Due Date/
Timeline
Action(s) Needed
Brief Summary of Next Steps and Follow-up
Notes/Comments
18. Outreach and
MMPC On-going Regional Trainings NIHB/NCAI/NCUIH conducted a survey and gathering information for their website.
Education
Targeted groups include (1) tribal governments; (2) tribes as providers; (3) area
health directors; and (4) consumers. It was reported that all information must be
vetted by IHS. Information is currently being developed and area health boards; and
MMPC/TTAG is encouraged to provide their input on these educational materials.
Need TTAG involvement in identification of materials, projects and other
contractual work being developed.
19. Engaging with States
on Planning for Health
Exchanges (including
those not involved in
planning efforts.)
20.
State Associations
(and other related
Websites)
MMPC
NIHB
MMPC
Tyra Baer
On-going 1. Seek resources for
outreach and
education activities.
2. Establish Planning
Group for
Consultation
On-going Seek funding to provide
for posting of AI/AN
Issues.
1. Recommendations included:
a. Development of Toolkit for Tribal leaders, health providers, and community
beneficiaries.
b. Development of Navigators.
c. Have NIHB develop and complete a list of what is occurring at state level.
d. Request and identify a representative from each state to work with NIHB
on a standard format and process.
e. Post the Indian addendum on the R(e)form website.
f. Continue to share what is happening across states. AZ/NM have
established working group which include Tribes.
g. NIHB/NCAI are launching on a new website. Draft materials will be
presented the end of March 2012.
MMPC recommended that funding be sought to provide for AI/AN issues as part of
the State website for Health Exchange Planning.
Websites related to MMPC issues on NIHB website on MMPC link:
http://www.nihb.org/mmpc/
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Task/Issue Person(s)
21. Create TTAG project on
new payment
structures, I/T/U
analysis and outreach
to Tribes
22. Follow up with Office
of Innovation at CCIIO
RE: ACA provisions
that identify IHS
23. Waivers/Exemptions
for AI/AN from
Medicaid Cuts
24. Indian Eligibility in
State Basic Health
Plans
MMPC: SUMMARY OF ISSUES, STRATEGIES & ASSIGNMENTS
UPDATED 10/9/12
(RECENT UPDATES IN RED AND HIGHLIGHTED IN YELLOW)
Due Date/
Timeline
MMPC New Issue
July 2012
Action(s) Needed
Brief Summary of Next Steps and Follow-up
Notes/Comments
To be discussed and addressed MMPC Face-to-Face Meeting.
MMPC July 2012 CCIIO Office of Innovation participated at the July 25, 2012 TTAG meeting.
Issues to be clarified included:
Jim Roberts
Jim Crouch
On-going Re-convene Benefits
Options Workgroup
MMPC On-going Identify preliminary
comments for MMPC
review
1. What is the plan to put money into Indian Country for Projects in the
following three areas:
Tele-health
Behavioral health
Unique Providers
2. Need to ensure there is culturally appropriate evaluation criteria
included in the process.
Share WA State concept paper (NPAIH) and CRIHB’s work with California with the
Workgroup.
Request made to CMS to make available, upon requests by Tribes in States, all
pending waiver requests.
Waivers on posted on CMS website, but the documents are not accessible when
trying to access.
Need to review and determine Indian eligibility and how it will be defined in Basic
Health Plans.
HHS Secretary sent letter to state insurance commissioners to consult with Tribes
on Medicaid and Exchanges. Need to ensure that states are also consulting with
Tribes on BHPs that address that 133%-200% federal poverty level.
National Indian Health Board, MMPC Issues, Strategies & Assignments Page 11 of 13 10/9/12

Ref.
#
Task/Issue Person(s)
25. Medicaid
Administrative Match
(MAM)
26. Update Strategic Plan
27.
MMPC: SUMMARY OF ISSUES, STRATEGIES & ASSIGNMENTS
UPDATED 10/9/12
(RECENT UPDATES IN RED AND HIGHLIGHTED IN YELLOW)
Due Date/
Timeline
Action(s) Needed
MMPC On-going Need to develop
advocacy at State-level
Jim Roberts
Mim Dixon
MMPC
Nov 2012 NPAIHB taking lead on
the development of an
updated Plan
Behavioral Health Linda Frizzell On-going Continue to monitor
activities and resources
available under the
ACA/IHCIA.
Brief Summary of Next Steps and Follow-up
Notes/Comments
More education is needed for Tribal health programs. Need to work with CMS to
provide support for MAM agreements. MMPC recommended:
1. Hold Workshop at NIHB Annual Consumer Conference.
2. Conduct Regional Trainings
3. NIHB Area Association Meeting
1. Status of Draft Plan, and Schedule and Process for Completion (Subcommittee
has met in person and held several teleconferences)
2. Conducted interviews of CMS representatives and identified initiatives for TTAG
to consider.
3. Met with Michael Hash – CCIIO
4. Draft presented at NIHB Annual Consumer Conference in Sept 2012.
5. NIHB shared through their distribution lists, TTAG, MMPC and current
draft is out for 30 day comment. Comments due on October 30, 2012.
6. Final report to be presented for review at the November 2012 TTAG
meeting.
Recommendations:
Integrate Strategic Plan Issues into CMS Operations for easier tracking.
Conduct at least 1 TTAG meeting/annually at CMS Headquarters in
Baltimore.
The various HHS agencies responsible for implementation should assure that the
Indian health system and Indian people have a fair opportunity to benefit from ALL
behavioral health provisions in the new law.
Most recent work of Subcommittee has revolved around the Essential Health
Benefits package.
National Indian Health Board, MMPC Issues, Strategies & Assignments Page 12 of 13 10/9/12

Ref.
#
V. DATA
Task/Issue Person(s)
28. Data MMPC
Jim Crouch
MMPC: SUMMARY OF ISSUES, STRATEGIES & ASSIGNMENTS
UPDATED 10/9/12
(RECENT UPDATES IN RED AND HIGHLIGHTED IN YELLOW)
Due Date/
Timeline
Action(s) Needed
On-going Review on-going issues
regarding Policy and
Data
Brief Summary of Next Steps and Follow-up
Notes/Comments
TTAG letter was sent to CMS Acting Administrator Marilyn Tavenner on April
10, 2012 summarizing the concerns related to the implementation of the
National Data Hubs by CMS and recommendations.
Other recommendations:
1. Form Tribal/CMS Workgroup on Policy and Data Issues (CMS committed to
forming this Workgroup.)
2. Advise CMS Office of Enterprise Management on having appropriate AI/AN
identifiers and making data useful of AI/AN and I/T/U on CMS website being
developed
3. Medicaid data project ended June 30 to expand State data from 400 to 1,000
data elements with no Tribal consultation, but States will be submitting State
Plan Amendments to change their data and this will require Tribal consultation.
We need to prepare Tribes for this consultation and discuss enforcement with
CMS. States in the pilot project with Tribes include: WA, OR, CA, MN, AX, MI,
NM, NC and TX.
4. Health Disparities Data on a national basis for AI/AN. The IHS discontinued the
Trends reports in 2007 and the data from the last report is getting too dated to
be reliable.
5. Data report from Jim Crouch/Carol Korenbrot to be reviewed at the MMPC
November 2012 face-to-face meeting.
Need to continue tracking all these items 2-4 listed above.
National Indian Health Board, MMPC Issues, Strategies & Assignments Page 13 of 13 10/9/12

MMPC October 9, 2012 Teleconference Agenda Notes
Roll Call: Liz Heintzman, Myra Munson, Rhonda Butcher (IHS), Jennifer Cooper, John Stevens, Sam Ennis,
Mim Dixon, Trevelyn Cross, Jay Stiener, Doneg McDonough, Carmealita Skeeter, Phil Norrgard, Jessica
Imotichey, Elliot Milhollin, Jim Roberts, Anthony Yepa, Sherri Varner (IHS), Tammy Clay (IHS), Tom
Gordon, Carol Chicharello, Don Wright, John Rael, Judy Parker, Trevlyn Cross Jim Roberts, Ed Fox, Jessica
Imotichey, Gerald Moses, Dee Sabattus, Diddy Nelson, Valerie Davidson, Doneg McDonough, Sam Ennis,
Myra Munson, D’Shane Barnett, Mim Dixon, John Stephens, and Jim Crouch met with John Dann and
Christie Jacobs from IRS.
Facilitator: Cyndi Ferguson
1. Update on meeting with IRS during the NIHB ACC Conference
Items discussed:
To do List:
-Indian definition
-Identify a path to call on Treasury Secretary and HHS Secretary to collaborate together for IHS
essential coverage
-Advanced premium tax credit-can be split between health plan and dental plan?
-MAGI-resource exemptions are consistent with Medicaid’s
-Outreach-what will IRS be doing with the requirements/responsibilities and how related to
Indian country
-tribal representatives suggest that IHS database should be used for electronic identification for
coverage-Christi said those discussions are just starting now
-Organize a Tribal meeting during the NCAI Conference to be held in Sacramento later this
month*will report later (Jim Roberts and Ron Allen are setting this up)
-Provide recommendation to have Christi join in on TTAG ACA subcommittee call with Pete from
CCIIO
Questions still to be answered:
What extent can taxpayers assign a refund to someone else (prove the like-hood that tribe could
subsidize into the exchange)? Individual can apply 100% tax credit to purchase insurance in exchange or
use portion?

-Oregon has a provision in the insurance system to make the individual put 100% tax credit into
exchange for tribes to help sponsor payment to the health plan
-Christi said that IRS can’t pose a requirement because that is an Individual right
2. Update on Companion Piece to Indian Addendum
To Do List:
-Has been finalized and gone through CCIIO internal review process
-Oregon is making an addendum; and would like to use it if the federal addendum is not as
good; but if it is, want it to be the threshold
-Pete wants to have a meeting with insurance issuers with Tribal representation-
-Need tribal consultation after the review process
3. Update on TTAG Strategic plan:
To Do List:
-new version of the draft for 2013-2017; retained objectives from last one with additional items
TTAG presented at NIHB conference and distributed copies through NIHB distribution lists and
website, and shared with TTAG members of region and area health board; 30 day comment
period with comments due by October 30, 2012.
Plan to be finalized and formally approved by the TTAG during the November face-to-face
meeting.
-Incorporate any changes by November Face to Face TTAG meeting for adoption and
implementation by new election
*send another email to TTAG about commenting on strategic plan for next week
4. Update on Single Enrollment Form for Exchanges/Medicaid, including Tribal Sponsorship
-There is no reference for tribal sponsorship on application itself-no direct tie
-problem in explanatory: core item is wrong that AI/AN can qualify for extra tax credits if they
hold premiums in advance (no mention about cost sharing-got it backwards)
-enrollment form includes categories and subcategories if you are AI/AN
5. Update on Tribal Hospital EHR Charity Care Calculation

To do List:
-Myra will have draft by the 3 rd week; goal to have it done by November face to face meeting
6. Update on CMS/IHS Process for Electronic Verification Process
7. Medicaid expansion and exchange update
-reg. side on expansion-state questions wanting to know if they can go to 100% instead of 133%
-feedback won’t come back until after election
8. Update on VA Reimbursement Agreement Consultation
To Do List:
- Self advisory group sent a letter for Medicare reimbursement that only includes Medicare for
all in exclusive rates because of lower reimbursement rate
-VA said won’t use Medicaid for all in exclusive rates because it is a system issue and would be a
delay in processing Tribal claim; more quick to handle Medicare rates; concerned about error
rates/budget
*NIHB to see a similar letter as the Tribal Self-Governance Advisory Committee and to include
clarification regarding rates
*Myra Munson agreed to circulate the letter sent by Alaska representatives
Regulations Review and Update
RRAR updated through August, 15, 2012; circulated right before ACC
Upcoming Regulations and Comments:
Comment to CMS #10003—paperwork reduction request (Medicare coverage and payment into one
form; could pertain to section 206; need to look at what form means and what it could do for AI/AN,
due on Nov 6 th
OPM comment regarding certification of qualified health plans due October 22
To Do List and Items to Include for Next Meetings:
October 10 th TTAG call:
Request Update from CCIIO on (1) Status of Internal Clearance on Indian Addendum and
Companion Piece; and (2) Timing on Response to Tribal Recommendations and Comments on
the Federally-Facilitated Exchanges

-Request Schedule and Process for dealing with open issues on Single Enrollment Form for
Exchanges and Medicaid (including how CMS is dealing with process for vetting with other
groups)
-Status of letter to Tribes (development of CMS Template) for outlining process at state level for
those Tribes not moving forward with Medicaid Expansion-Jim Roberts
TTAG November Face-to Face Meeting
-Invite Gary Cohen
-Invite OIG to report and present on Safe Harbors and Medicaid Collections
-Take final action and approval of Strategic Plan
-Discussion on working with states on exchanges and Medicaid expansion
MMPC November Face-to-Face Meeting:
-Request Data Report from Jim Crouch/Carol Korenbrot and review/discuss findings
-Invite OPM (coordinate with Elliott)

Internal Revenue Service Meeting Notes
Denver, Colorado Meeting
September 25, 2012
Participants: Christie Jacobs, Jonathon Damm, IRS
Jim Roberts, Ed Fox, Jessica Imotochi, Gerald Moses, Dee Sabattus, Diddy Nelson,
Valerie Davidson, Doneg McDonough, Sam Ennis, Myra Munson, D’Shane Barnett, Mim
Dixon, John Stephens, Jim Crouch
1. Health Insurance Penalty Exemption Discussion
a. We covered definition issue and strategy to align. IRS not much to do here aligning ACA
with Medicaid. This is HHS.
o IRS seemed agree that the three statutory references to def. of Indian under ACA
are the same, including under IRC § 45(A)(c)(6).
o For IRS, their primary concern seemed to be, after comparing the ACA-referenced
definitions to the Medicaid reg., is that non-Federally recognized tribes would be
included under the Medicaid reg., if used.
b. Tax Penalty
o There may be administrative authority by Treasury Secretary and HHS Secretary to
grant IHS coverage as meeting “essential coverage” pursuant to Treasury regulation.
But it will take collaboration and agreement of both Secretaries. Doneg had citation
in Treasury reg....Section 5000(A)(f)(1)????
o This request would apply only to the tax penalty and not eligibility for the APTC.
o TTAG should draft a letter to this effect requesting that Secretaries act on this.
2. Identification of Indians: IHS data base of users
a. It was mentioned to IRS staff that the HIS-maintained database for users is an important
mechanism to more easily identify AI/AN
b. The fact that not all IHS eligibles are captured in the database should not mean that the HIS
database not be used.
c. Christy stated that “discussions are just starting on how this [identification of AI/AN] is going
to work.”
3. MAGI
a. Chart that IRS and CMS are working on this. They have created a chart with the Indian
exemptions for each of the programs. There are only one or two items that are not on the
IRS exemption list. Aside these, most exempt items for IRS & CMS are the same. If IRS
exempts Indian income, it will not collect information about the income that is exempt. The
two items still under discussion are:
i. Education costs and the BIA
ii. Per capita distributions
b. These items are also under discussion with regard to the General Welfare guidance that
Treasury is preparing with regard to Tribes and tribal members.
c. Follow up item: Can we get a copy of the chart?
4. Tribal Sponsorship/APTC items

a. RE: premium subsidies and applying full APTC for purpose of Tribal sponsorship. Up to
individual and IRS may not impose any requirements on how individual uses.
b. When asked whether APTC could be split between a medical plan and a dental plan, Christy
said she didn’t know. Doneg noted that HHS is responsible for issuing guidance re APTC for
pediatric dental plans.
c. Myra asked whether IRS could enter into assignment agreements whereby people who
accept tribal sponsorship for payment of health insurance premiums can have any
underpayment of premium tax credits paid to the sponsoring organization. IRS was not
enthusiastic about the chances of this happening because IRS only uses this for limited
situations and Christy thought the Tribe might not be the right kind of entity to qualify for
assignment of tax refunds.
d. John Stephens asked whether over or under recovery of APTC at the end of the year could
be moved to the following year’s taxes. Christie responded that they couldn’t let it ride to
the next year without interest. John was very effective in making the point that it will only
take one tax bill for one person to end tribal sponsorship. Jim Roberts commented that
Washington State was working with tribes on an aggregator model for tribal sponsorship,
but it may not work due to assignment of tax credits. He asked if IRS was working with
states on this. Christy said IRS isnot working with States.
e.
f. Follow up item: IRS is to send us the section of the tax code that applies to similar
assignment so that Tribal policy wonks can determine if there is some application here that
can be used for Tribal sponsorship.
5. IRS Form 1040
a. Christy indicated that IRS will want to consult with tribes on the question(s) put on Form
1040
b. We mentioned that TTAG submitted recommendations on a “single question” to ask
c. It seems we should resend the old TTAG recommendations to Christy/IRS, or send a revised
recommendation if preferred.
6. IRS Outreach & Education
a. IRS does plan to have special outreach to AI/AN, with an increase in outreach activities in
2013. IRS is tied into the overall O&E campaign of HHS. IRS not in position to conduct
outreach until final rules & decisions are in place.
b. Voluntary tax assistance centers. There are tribal sponsors for these centers now and IRS
expects to use them for ACA.
i. Follow-up Item: How can Tribes become Voluntary Tax Assistance centers if they
are not? Can IHS/Tribal benefits coordinators be trained to provide this assistance?
Non-tribal sites will need special training about tribal benefits and sponsorship; how
will this happen?
c. In IRS all training is now electronic. Christie recognizes the need for face-t0-face, small
group training for Tribes, but she says that the IRS needs to hear this from Tribes.
d. Follow-up item: Tribes should send letter to IRS Commissioner and Sec of Treasury with cc
to Christy.
e. Christie recommended that we stay in touch with her about such issues as they become
more clear in the coming months.
f. Who do we direct our advocacy to? Normally the Deputy Secretary is responsible for Tribal
issues however position is vacant (Aaron Kline left, but someone else checks in mailbox)

with a “interim/acting”. Can always direct information to IRS Commissioner, with copy to
Christie Jacobs.
g. John Stephens asked whether a person had to file taxes previously in order to apply for
APTC through the Exchange. Christy said she didn’t know the answer to that question.
7. Recommendation to form IRS-Tribal Workgroup
a. The Department of Treasury Tribal Consultation Policy is on their website on a Tribal page.
The Department of Treasury does not seem willing to have IRS Advisory Groups.
b. Christie will check with Pete Nakata to see if they can combine this effort. She didn’t seem
willing to do something different than the ACA Policy Subcommittee meetings that we have
with CCIIO. Christie preferred to site in on the CCIIO meetings and use that venue if she
needs to engage on Tribal issues. She will get back to us.

I. Purpose.
DRAFT EXPLANATION OF ADDENDUM
FOR INDIAN HEALTH CARE PROVIDERS TO NETWORK PROVIDER
AGREEMENTS OF HEALTH PLANS OFFERING PRODUCTS ON
HEALTH INSURANCE EXCHANGES
CMS has developed the attached Addendum for Indian Health Care Providers to promote
inclusion of Indian health care providers in qualified health plan (QHP) provider networks and
help health insurance issuers develop health plans that comply with the QHP certification
standards set forth in 45 CFR Part 156. Based upon a similar standardized contract addendum
used in the Medicare Part D program, this addendum has been developed for QHP issuers to use
when contracting with Indian Health Care Providers.
The federal government has a historic and unique relationship with American Indian and Alaska
Native (AI/AN) tribes. The purpose of this addendum is to further the aims of the Federal trust
responsibility by fostering participation of Indian health care providers in QHP networks, and
help issuers meet QHP certification standards, particularly with respect to network adequacy and
access to essential community provider participation. In adhering to QHP certification standards,
QHP issuers will need to reach out to Indian health care providers in many parts of the country.
It is anticipated that the addendum will assist health plans meet the “sufficient number and type
of provider” criterion required for QHP certification, and will facilitate acceptance of network
contracts by Indian health providers.
Most AI/AN people access care through their longstanding providers in the Indian health system.
As a result, an important consideration in evaluating network adequacy and essential community
provider accessibility will be the extent to which a QHP includes Indian providers in their
networks and whether it can assure that services to AI/AN consumers will be accessible without
unreasonable delay.
Offering contracts that include the Addendum will provide QHPs with an efficient and effective
way to establish network contract relationships with Indian Providers, and also ensure that
American Indian and Alaska Native consumers can continue to be served by their Indian
provider of choice. Indian tribes are entitled to special protections and provisions under Federal
laws, which are described further in Section II.
The addendum identifies specific provisions that have been established in Federal
law that apply when contracting with Indian Health Care Providers (i.e. I/T/Us). Use of this
Addendum benefits both QHPs and the Indian Providers by lowering the perceived barriers to
contracting, assuring QHP issuers comply with key Federal laws that apply when contracting
with Indian providers, and minimizing potential disputes. AI/ANs consumers will be better
served if their QHP encourages Indian providers to coordinate their care through the QHP
network.
8/7/12 DRAFT COMPANION TO ADDENDUM – PAGE 1

8/7/12 DRAFT COMPANION TO ADDENDUM – PAGE 2

II. Explanation of the Addendum for Indian Health Care Providers
1. Purpose of Addendum
Building on the success achieved in the Medicare Part D program, this Addendum for Indian
Health Care Providers has been developed for use in Exchange’s Qualified Health Plan
network contracts with Indian Health Care Providers. .
2. Definitions.
The definitions of terms used in the Addendum relate to federal laws.
3. Description of Health Care Provider.
This addendum can be used with different types of Indian health providers. This section gives
the opportunity to check the provider type that applies to the specific organization or facility
which is covered by the contract or agreement.
4. Cost-Sharing Exemption for Indians; No Reduction in payments.
Section 1402(d)(2) of the ACA provides that QHPs may not impose any cost-sharing on AI/AN
plan enrollees and may not reduce payments to an Indian Health Care Provider or contract health
services provider that would otherwise be due. The ACA directs the Secretary of HHS to
reimburse issuers for the increase in the actuarial value of the plan due to these costs.
5. Persons eligible for items and services from Indian Health Care Provider.
This section of the Addendum protects the QHP from charges of discrimination if the I/T/U
provider sees only people who are eligible IHS beneficiaries. Indian health programs are
generally not open to the public; they are established to serve AI/ANs, as provided in the IHCIA.
The applicable eligibility rules are generally set out in IHS regulations at 42 C.F.R. Part 136.
IHCIA §813 (25 U.S.C. §1680c) sets out the circumstances under which certain non-AI/ANs
connected with an AI/AN (such as minor children or a spouse) can receive services as
beneficiaries. IHCIA § 813 also authorizes services to certain other non-AI/ANs if carefully
defined requirements are satisfied.
6. Applicability of other Federal laws.
This section identifies a number of Federal laws that apply variously to IHS, Tribal health
programs, and urban Indian programs. These laws are briefly described here.
Anti-Deficiency Act, 31 U.S.C. §1341. This law applies to the Indian Health Service as a
Federal agency. It prohibits agency personnel from obligating the expenditure of Federal
funds in excess of appropriations made by Congress.
8/7/12 DRAFT COMPANION TO ADDENDUM – PAGE 3
Comment [A1]: Something to consider – in the
interest of brevity, should we just include a
description of selected provisions which require
clarification?
RESPONSE – If a summary of only certain
provisions is to be included, then perhaps only the
provisions listed in Section 6 could be included.

Indian Self-Determination and Education Assistance Act (ISDEAA), 25 U.S.C. §450 et
seq. This law directs the Secretary of HHS, at the request of an Indian tribe, to enter into
a contract or compact with a tribe, a tribal organization, or an inte- tribal consortium to
operate Federal health programs for Indians with the funds the Indian Health Service
would have otherwise used to carry out the program directly. It is through this law that
many Indian tribes and tribal organizations have taken over direct operation of health
programs from IHS.
Federal Tort Claims Act (FTCA), 28 U.S.C. §§2671-2680. This law waives the United
States’ sovereign immunity from suit with regard to the torts enumerated in the FTCA,
and is the exclusive remedy for suits against Federal agencies such as the Indian Health
Service. Congress extended the FTCA to cover Indian tribes and tribal organizations
operating Federal programs pursuant to contracts or compacts under the ISDEAA. 25
U.S.C. §450f note. Urban Indian organization health providers who acquire FQHC status
under Sec. 224 of the Public Health Service Act can acquire FTCA coverage pursuant to
the Federally Supported Health Centers Assistance Act. Since a claim under the FTCA is
the exclusive remedy for actions against Indian health care providers that are covered by
the FTCA, those entities are not required to obtain professional liability insurance.
Federal Medical Care Recovery Act (FMCRA), 42 U.S.C. §§2651-2653. This law
authorizes Federal agencies, including the Indian Health Service, to recover from a
tortfeasor (or an insurer of a tortfeasor) the reasonable value of health services furnished
to a tortfeasor’s victim. The right of recovery under the FMCRA extends to Indian tribes
and tribal organizations operating ISDEAA contracts and compacts. 25 U.S.C.
§1621e(e)(3).
Federal Privacy Act, 5 U.S.C. §552a and regulations at 45 C.F.R. Part 5b. This law and
its regulations apply to the IHS, and to Indian tribes, tribal organizations and urban Indian
organizations that operate Federally-funded health care programs. The Privacy Act
governs the use and disclosure of personally identifiable information about individuals
that is maintained in a federal records system.
Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2. These
regulations restrict disclosure and use of drug abuse patient records that are maintained in
connection with the performance of any federally assisted alcohol or drug abuse program.
The restrictions would apply to any such records maintained by the IHS, an Indian tribe,
tribal organization or urban Indian organization.
Health Insurance Portability and Accountability Act (HIPAA) regulations at 45 C.F.R.
Parts 160 and 164. These regulations restrict access to and disclosure of protected health
information maintained by the IHS, Indian tribes, tribal organizations and urban Indian
organizations.
Indian Health Care Improvement Act (IHCIA), 25 U.S.C. §1601 et seq. This law supplies
the comprehensive statutory framework for the delivery of health care services to Indian
people. It applies to all Indian health providers – the IHS; Indian tribes and tribal
organizations operating ISDEAA contracts and compacts from the Secretary of HHS; and
8/7/12 DRAFT COMPANION TO ADDENDUM – PAGE 4

urban Indian organizations that receive grants from IHS under Title V of the IHCIA.
Specific provisions of the IHCIA that would impact contracts between Indian health care
providers and QHPs are cited in various provisions of the Addendum.
7. Non-taxable entity.
Because of provisions in federal law, QHPs may not require Indian Health Care Providers to
collect or remit any federal, state or local taxes.
8. Insurance and indemnification.
The IHS, Tribes and Tribal Organizations and Urban Indian Organizations that qualify are
covered by the FTCA. Since a claim under the FTCA is the exclusive remedy for actions against
Indian health care providers that are covered by the FTCA, those entities are not required to
obtain professional liability insurance.
9. Licensure of Health Care Professionals.
This section safeguards a QHP from state licensing requirements for health care
professionals with respect to Indian providers. IHCIA §221 (25 U.S.C. §1621t) permits an
Indian tribe or tribal organization to employ a health care professional who is subject to licensure
if that individual is licensed in any state. Employees of the IHS obtain their “licensed in any
state” status through other Federal law.
10. Licensure of Provider, eligibility for payments.
This provision waives QHP requirements for State licensing of facilities. IHCIA §408 (25
U.S.C. §1647a) deems a health program operated by the IHS, an Indian tribe, tribal organization
or urban Indian organization to be licensed under state or local law if it meets all requirements
for such license regardless of whether it obtains such a license.
11. Dispute Resolution.
This provision provides that the Indian Health Care Providers agree to meet and confer to resolve
any dispute in good faith, and that any disputes that cannot be resolved in good faith will be
subject to the laws of the United States . The IHS and Tribes are generally not subject to State
laws, and may only be subject to binding arbitration if specifically authorized by law.
12. Governing Law.
Tribes are generally subject to Federal law. This provision states that the QHP agreement and
the addendum shall be governed by Federal law., and that nothing in the agreement shall subject
an Indian tribe, tribal organization, or urban Indian organization to State law to any greater
extent than State law is already applicable.
13. Medical Quality Assurance Requirements.
8/7/12 DRAFT COMPANION TO ADDENDUM – PAGE 5
Comment [A2]: Because of…..
Comment [A3]: Because of…..(federal law?)

Under federal law, There are privacy rules governing quality assurance for the I/T/U that must
be considered as requirements are imposed by the QHP. IHCIA §805 (25 U.S.C. §1675)
facilitates internal medical program quality reviews; shields participants in those reviews; and
restricts disclosure of medical quality assurance records. This provision applies to the IHS,
Indian tribes, tribal organizations and urban Indian organizations.
14. Claims Format.
An I/T/U may use a claims format offered by the QHP, or it may submit claims in a format that
is consistent with Medicare claims. IHCIA §206(h) (25 U.S.C. §1621e(h) prohibits insurance
carriers from denying a claim submitted by IHS, an Indian tribe or tribal organization based on
the format on which the claim is submitted if the format complies with the Medicare claims
format requirements.
15. Payment Rate.
IHCIA §206(a) and (i) (25 U.S.C. §1621e(a) and (i)) provides that the IHS, an Indian tribe, tribal
organization and urban Indian organization have the right to recover the reasonable charges
billed, or, if higher, the highest amount an insurance carrier would pay to other providers. This
Addendum provision states that a QHP must pay claims to the I/T/U according to IHCIA Section
206 except to the extent the Indian Health Care Provider expressly agrees in writing to accept rates or
amounts specified in [specify payment schedule here] as payment in full, except that such rates or
amounts may not be lower than the Qualified Health Plan pays to any of its other preferred or in-network
providers .
16. Hours and Days of Service.
QHP may not require the I/T/U to provide services at times they would not otherwise provide
services for the IHS beneficiaries. For example, some I/T/U clinics are open only a few days a
week and some do not provide 24-call.
17. Sovereign Immunity.
Becasuse tribes are soverign governments, This provision provides that nothing in the agreement
shall constitute a waiver of federal or tribal sovereign immunity from suit.
18. Endorsement.
IHS providers and employees are prohibited from officially endorsing any non-federal entity.
This provision ensures that no such endorsement is implied by signing the agreement.
8/7/12 DRAFT COMPANION TO ADDENDUM – PAGE 6
Comment [A4]: State the basis. Can we hook to
some federal provision?

Appendix A. I/T/U Programs in Each State
8/7/12 DRAFT COMPANION TO ADDENDUM – PAGE 7

1. Purpose of Addendum; Supersession.
DRAFT
Addendum for Indian Health Care Providers
The purpose of this Addendum for Indian Health Care Providers is to apply special terms and conditions
necessitated by Federal law and regulations to the agreement by and between ______________________
(herein "Qualified Health Plan") and ___________________________ (herein "Indian Health Care
Provider"). To the extent that any provision of the Qualified Health Plan's network provider agreement or
any other addendum thereto is inconsistent with any provision of this Addendum for Indian Health Care
Providers, the provisions of this Addendum for Indian Health Care Providers shall supersede all such
other provisions.
2. Definitions. (NOTE: NEED TO CHANGE THE ORDER TO BE ALPHABETICAL)
For purposes of the Qualified Health Plan's agreement, any other addendum thereto, and this Addendum
for Indian Health Care Providers, the following terms and definitions shall apply:
(a) "Qualified Health Plan" has the meaning given in Sec. 1301 of the Patient Protection and Affordable
Care Act (ACA), 42 U.S.C. §18021.
(b) Indian Health Care Provider" means a health program administered by the Indian Health Service
(IHS), a tribal health program, an Indian tribe or tribal organization to which funding is provided
pursuant to section 23 of the Act of June 25, 1910 (25 U.S.C. § 47(commonly known as the “Buy
Indian Act”)) or an urban Indian organization that receives funding from the IHS pursuant to Title V
of the Indian Health Care Improvement Act, Pub. L. 94-437, as amended (IHCIA).
(c) "Indian Health Service" means the agency of that name within the U.S. Department of Health and
Human Services established by IHCIA Sec. 601, 25 USC §1661.
(d) "Indian tribe" has the meaning given in IHCIA Sec. 4(14), 25 USC § 1603(14).
(e) The term "tribal organization" has the meaning given in IHCIA Sec. 4(26), 25 USC §1603(26).
(f) "Urban Indian organization" has the meaning given in IHCIA Sec. 4(29), 25 USC §1603(29).
(g) The term "Indian," has the meaning given in 45 C.F.R. 155.300(a).
(h) The term "contract health services" has the meaning given in IHCIA Sec. 4(5), 25 U.S.C. §1603(5).
(i) The term “Tribal health program” has the meaning given in IHCIA Sec. 4(25), 25 U.S.C. § 1603(25).
3. Description of Indian Health Care Provider.
The Provider identified in Section 1 of this Addendum for Indian Health Care Providers is (check
appropriate box):
/_/ The Indian Health Service (IHS).
/_/ An Indian tribe that operates a health program under a contract or compact to carry out programs of
the IHS pursuant to the Indian Self-Determination and Education Assistance Act (ISDEAA), 25 USC
§450 et seq.
/_/ A tribal organization that operates a health program under a contract or compact to carry out programs
of the IHS pursuant to the ISDEAA, 25 USC §450 et seq.
/_/ A tribe or tribal organization that operates a health program with funding provided in whole or part
pursuant to section 23 of the Act of June 25, 1910 (25 U.S.C. § 47 (commonly known as the Buy
8/7/12 DRAFT Addendum – Page 1
Comment [A1]: While the QHP issuer might also
be an MCO, the QHP is a commercial health
insurance product that is not governed by medicaid
requirements. The Medicaid definition is not
applicable in this context.

Indian Act), or urban Indian organization that receives funding from the IHS pursuant to Title V of
the Indian Health Care Improvement Act, Pub. L. 94-437, as amended (IHCIA)
/_/ An urban Indian organization that operates a health program with funds in whole or part provided by
IHS under a grant or contract awarded pursuant to Title V of the IHCIA.
4. Cost-Sharing Exemption for Indians; No Reduction in Payments.
If an Indian enrolled in a qualified health plan is furnished an item or service directly by the Indian Health
Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization or through referral under
contract health services –
(a) No cost-sharing under the plan shall be imposed under the plan for such item or service; and
(b) The issuer of the plan shall not reduce the payment to any such entity for such item or service by
the amount of any cost-sharing that would be due from the Indian but for subparagraph (a). .
ACA §1402(d) (2) (42 USC 18071(d)(2)).
5. Persons eligible for items and services from Indian Health Care Provider.
(a) The parties agree that the IHS is limited to serving eligible IHS beneficiaries, except under limited
circumstances pursuant to 42 CFR Part 136 and IHCIA Sec. 813, 25 USC §1680c.
(b) The parties agree that the Indian Health Care Provider that is an Indian tribe, a tribal organization, or
an urban Indian organization has the authority to limit its service population in accordance with the
following authorities:
(1) Sec. 813 of the IHCIA, 25 USC §1680c;
(2) 42 CFR Part 136; and
(3) The terms of the ISDEAA contract or compact or IHCIA grant or contract, as
applicable.
(c) No term or condition of the Qualified Health Plan's agreement or any addendum thereto shall be
construed to change, reduce, expand or alter the eligibility of persons for services of the Indian Health
Care Provider that is inconsistent with the authorities identified in subsection (a) or (b).
6. Applicability of Other Federal laws.
Federal laws and regulations affecting an Indian Health Care Provider, include but are not limited to the
following:
(a) The IHS as an Indian Health Care Provider:
(1) Anti-Deficiency Act 31 U.S.C. §1341;
(2) Indian Self Determination and Education Assistance Act (ISDEAA) ; 25 USC §450 et seq.;
(3) Federal Tort Claims Act (“FTCA”), 28 U.S.C. §§2671-2680;
(4) Federal Medical Care Recovery Act, 42 U.S.C. §§2651-2653;
(5) Federal Privacy Act of 1974 (“Privacy Act”), 5 U.S.C. §552a, 45 CFR Part 5b;
(6) Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2;
(7) Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 45C.F.R. Parts 160
and 164; and
(8) IHCIA, 25 U.S.C. §1601 et seq.
(b) An Indian tribe or a tribal organization that is an Indian Health Care Provider:
8/7/12 DRAFT Addendum – Page 2

(1) ISDEAA, 25 USC §450 et seq.;
(2) IHCIA, 25 USC §1601, et seq.;
(3) FTCA, 28 USC §§2671-2680;
(4) HIPAA, and regulations at 45 CFR parts 160 and 164.
(c) An urban Indian organization that is an Indian Health Care Provider:
(1) IHCIA, 25 USC §1601, et seq.;
(2) Privacy Act, 5 USC §552a and regulations at 45 CFR Part 5b; and
(3) HIPAA, and regulations at 45 CFR parts 160 and 164.
7. Non-taxable entity.
To the extent an Indian Health Care Provider is a non-taxable entity, such Provider shall not be required
by a Qualified Health Plan to collect or remit any Federal, State, or local tax.
8. Insurance and indemnification.
(a) Indian Health Service. The Indian Health Service is covered by the Federal Tort Claims Act (FTCA)
which obviates the requirement that IHS carry private malpractice insurance as the United States
consents to be sued in place of federal employees for any damages to property or for personal injury
or death caused by the negligence or wrongful act or omission of federal employees acting within the
scope of their employment. 28 U.S.C. §2671-2680. Nothing in the Qualified Health Plan's agreement
shall be interpreted to authorize or obligate any IHS employee to perform any act outside the scope of
his/her employment. The IHS shall not be required to acquire insurance, provide indemnification, or
guarantee that the Qualified Health Plan will be held harmless from liability.
(b) Indian Tribes and Tribal Organizations. An Indian Health Care Provider which is an Indian tribe or a
tribal organization shall not be required to obtain or maintain professional liability insurance to the
extent such Provider is covered by the Federal Tort Claims Act (FTCA) pursuant to Federal law
(Pub.L. 101-512, Title III, §314, as amended by Pub.L. 103-138, Title III, §308 (codified at 25 USC
§450f note); and regulations at 25 CFR Part 900, Subpt. M. Nothing in the Qualified Health Plan's
agreement or any addendum thereto shall be interpreted to authorize or obligate such Provider or any
employee of such Provider to operate outside of the scope of employment of such employee. Such
Provider shall not be required to acquire insurance, provide indemnification, or guarantee that the
Qualified Health Plan will be held harmless from liability.
(c) Urban Indian Organizations. To the extent an Indian Health Care Provider that is an urban Indian
organization is covered by the FTCA pursuant to section 224(g)-(n) of the Public Health Service Act,
as amended by the Federally Supported Health Centers Assistance Act, Pub.L. 104-73, (codified at 42
USC §233(g)-(n)) and regulations at 42 CFR Part 6, such Provider shall not be required to obtain or
maintain professional liability insurance. Nothing in the Qualified Health Plan's agreement or any
addendum thereto shall be interpreted to authorize or obligate such Provider or any employee of such
Provider to operate outside of the scope of employment of such employee. Such Provider shall not be
required to acquire insurance, provide indemnification, or guarantee that the Qualified Health Plan
will be held harmless from liability.
9. Licensure of Health Care Professionals.
(a) Indian Health Service. States may not regulate the activities of IHS-operated health care programs nor
require that IHS health care professionals be licensed in the State where they are providing services,
8/7/12 DRAFT Addendum – Page 3

whether the IHS employee is working at an IHS-operated facility or has been assigned to a health care
program of a tribe, tribal organization or urban Indian organization. The parties agree that during the
term of the Qualified Health Plan's agreement, IHS health care professionals shall hold state licenses
in accordance with applicable federal law, and that IHS facilities shall be accredited in accordance
with federal statutes and regulations.
(b) Indian tribes and tribal organizations. Sec. 221 of the IHCIA (25 U.S.C. §1621t) exempts a health
care professional employed by an Indian tribe or tribal organization from the licensing requirements
of the state in which such tribe or organization performs services, provided the health care
professional is licensed in any state. Sec. 408 of the IHCIA (25 U.S.C. § 1647a) provides that a
health program operated by an Indian tribe or tribal organization shall be deemed to have met a
requirement for a license under state or local law if such program meets all the applicable standards
for such licensure, regardless of whether the entity obtains a license or other documentation under
such state or local law. The parties agree that these federal laws apply to the Qualified Health Plan's
agreement and any addenda thereto.
(c) Urban Indian organizations. To the extent that any health care professional of an urban Indian
Provider is exempt from State regulation, such professional shall be deemed qualified to perform
services under the Qualified Health Plan Sponsor's agreement and all addenda thereto, provided such
employee is licensed to practice in any State. Sec. 408 of the IHCIA (25 U.S.C. § 1647a) provides
that a health program operated by an urban Indian organization shall be deemed to have met a
requirement for a license under state or local law if such program meets all the applicable standards
for such licensure, regardless of whether the entity obtains a license or other documentation under
such state or local law.
10. Licensure of Provider; eligibility for payments.
To the extent that the Indian Health Care Provider is exempt from State licensing requirements, such
Provider shall not be required to hold a State license to receive any payments under the Qualified Health
Plan's agreement and any addendum thereto.
11. Dispute Resolution.
In the event of any dispute arising under the Qualified Health Plan's agreement or any addendum thereto,
the parties agree to meet and confer in good faith to resolve any such disputes. The laws of the United
States shall apply to any problem or dispute hereunder that cannot be resolved by and between the parties
in good faith. Notwithstanding any provision in the Qualified Health Plan's agreement or any addendum
thereto to the contrary, the Indian Health Care Provider shall not be required to submit any disputes
between the parties to binding arbitration.
12. Governing Law.
The Qualified Health Plan's agreement and all addenda thereto shall be governed and construed in
accordance with Federal law of the United States. In the event of a conflict between such agreement and
all addenda thereto and Federal law, Federal law shall prevail. Nothing in the Qualified Health Plan's
agreement or any addendum thereto shall subject an Indian tribe, tribal organization, or urban Indian
organization to State law to any greater extent than State law is already applicable.
8/7/12 DRAFT Addendum – Page 4

13. Medical Quality Assurance Requirements.
To the extent the Qualified Health Plan imposes any medical quality assurance requirements on its
network providers, any such requirements applicable to Indian Health Care Providers shall be subject to
Sec. 805 of the IHCIA (25 U.S.C. §1675).
14. Claims Format.
Pursuant to Sec. 206(h) of the IHCIA (25 USC §1621e(h)), the Qualified Health Plan may not deny a
claim submitted by the Indian Health Care Provider based on the format in which submitted if the format
used complies with that required for submission of claims under Title XVIII of the Social Security Act or
recognized under section 1175 of such Act.
15. Payment of Claims.
The Qualified Health Plan shall pay claims from the Indian Health Care Provider in accord with Federal
law, including Sec. 206 of the IHCIA (25 U.S.C. §1621e), and Sec. 1402(d)(2)(B) of the ACA (42 U.S.C.
§18071(d)(2)(B)), except to the extent the Indian Health Care Provider expressly agrees in writing to the
rates or amounts specified in [specify payment schedule here] as payment in full, provided that such rates
or amounts shall not be lower than the Qualified Health Plan pays to any of its other preferred or innetwork
providers .
16. Hours and Days of Service.
The hours and days of service of the Indian Health Care Provider shall be established by such Provider.
At the request of the Qualified Health Plan, such Provider shall provide written notification of its hours
and days of service.
17. Sovereign Immunity.
Nothing in the Qualified Health Plan's agreement or in any addendum thereto shall constitute a waiver of
federal or tribal sovereign immunity.
18. Endorsement.
An endorsement of a non-Federal entity, event, product, service, or enterprise may be neither stated nor
implied by the IHS provider or IHS employees in their official capacities and titles. Such agency names
and positions may not be used to suggest official endorsement or preferential treatment of any non-
Federal entity under this agreement.
APPROVALS
For the Qualified Health Plan: For the Indian Health Care Provider:
____________________________________ __________________________________
Date ________________________________ Date ______________________________
8/7/12 DRAFT Addendum – Page 5
Comment [A2]: The base agreement will specify
the payment rate. Not sure what legal standing this
statement would have.

Notes from Tribal Consultation with HHS on Federally-facilitated Exchange (FFE)
and Medicaid Expansion
July 26 (Washington, DC), August 6 (Anchorage, AK), August 9 (Denver, CO), as well
as IHS consultation with tribes on ACA August 8 (Denver, CO)
Notes from Mim Dixon (with additions from Doneg McDonough shown in bold)
1. We now have agenda for FFE Tribal Consultation Sessions.
a. Jennifer Cooper put together talking points that tracked the agenda for DC
session and revised for Anchorage session.
- A revised version was prepared for the Denver session.
b. No real opportunity for written statements or comments unrelated to topics.
c. Morning about Medicaid Expansion.
2. FFE Developments
i. No real news about Medicaid Expansion alternatives.
ii. Administration is encouraging interest groups (Tribes, Hospital Assn) to
work together to pressure Republican governors and legislatures to adopt
ME.
a. TTAG’s ACA Policy Committee is meeting weekly to work on some issues.
Only agenda items identified to date are:
i. Addendum + Companion piece explaining addendum
ii. Tribal Sponsorship
iii. Network adequacy / contracting with I/T/U
iv. Other topics will be prioritized as high impact, high value topics
b. For Addendum and companion piece, Pete Nakahata has said process will
be: ACA Subcommittee – HHS Legal Counsel – Tribal Consultation – completion
in September.
- A session with the ACA Policy Committee on the Indian Addendum
was held during a break in the Denver consultation. Policy
Committee reviewed edits on documents from P. Nakahata. Final
1

edits on documents are due back from tribal reps to P. Nakahata by
8/14.
- P. Nakahata recommended that the topic for the 8/16 ACA Policy
Committee meeting will be tribal sponsorship.
c. CCIIO has a request for input on data elements pertaining to an “Indian
placeholder” to be included in the single application form being developed by
CMS for use by Exchanges.
i. Formal comments are due back to CMS on CMS-10439 by
September 4, 2012
- Jennifer Cooper agreed to prepare a draft response by
pulling from prior comments on this issue that were submitted
by NIHB/TTAG.
ii. A Webinar will be held on this issue on August 20 at 3:00 pm EDT
iii. An all tribes call is scheduled for September 7 at 1:00 pm EDT.
iv. TTAG asked that the whole process be explained to put AI questions
in context – not sure whether this will be ACA Policy Subcommittee or
another group.
v. TTAG had already submitted questions to use, but it doesn’t seem like
these are being referenced by CCIIO.
d. CCIIO has stated that monthly enrollment periods for AI/AN will have a cut-off
date of the 15 th of each month for enrollment beginning on the 1 st of the following
month. (People who apply on the 16 th wouldn’t be enrolled for 6 weeks.)
e. CCIIO has stated that termination of coverage requires 14 days notice.
f. According to CCIIO, ACA does not include IHS as ECPs, and therefore any
requirement for QHPs to contract with ECPs would not include IHS.
g. At the TTAG meeting, the website and data management folks spoke for the
first time and they said they are using open source computer software that allows
them to re-program quickly and easily to add elements over time. They seem to
grasp AI issues.
h. At MMPC meeting, IRS representatives said they expected that AI/AN
applying for waiver of penalty would only have to use self-attestation that they
2

are eligible for the waiver (i.e., they would not have to go through the Exchange
application process to determine their eligibility as AI/AN).
i. NPRM on AI/AN cost sharing waiver and how providers/QHPs will be paid by
Federal government for the amount of cost sharing they are not collecting from
AI/AN will be issued in August.
3. New Issues that came up at FFE Tribal Consultation in DC, July 26
a. Partnerships - Administration is encouraging Partnership arrangements with
states and it’s not clear whether Tribes need to be consulting with States or
Feds, or both. More work for Tribes and very confusing.
b. State Exchange Tribal Consultation Policies - States are not being required to
have Tribal Consultation Policy for Exchanges until they submit the package to
be certified (April 2013) – which means Tribes will not necessarily be consulted in
the decisions about Exchanges.
- Example: Essential Health Benefits
c. Indian questions on application - Amy Erhardt is working on the applications
and she said that waiver of cost sharing will only happen if applicant declares
that they want to be considered for an “Insurance Accessibility Program”.
i. The law says all AI are eligible for cost sharing waivers, even if they
don’t want one of the Insurance Accessibility Programs (Medicaid, CHIP,
Advanced Tax Credits).
ii. This is important because we don’t want MAGI calculated for people
who haven’t filed tax returns.
iii. This approached was not challenged in the DC meeting.
iv. New acronym: APTC/CSR (= Advanced Payment of Tax Credits and
Cost Sharing Reductions)
c. Navigators and In Person Assistance - (Holly Whalen is CCIIO point person
on this)
I. Looks like there will be competition for Navigator grants at federal level
– no set aside for Tribes.
ii. A second source of funding that can come from federal establish
grants, but is not identified in the law is “in-person assistance.”
3

d. CCIIO Philosophy - CCIIO is taking the approach that “where we start is not
where we finish”, in other words, they want to stand up the FFE as quickly as
possible and go back and correct things that aren’t working.
i. Tribes know from experience with CMS that it is better to get things right
the first time rather than going back and trying to fix things that are in
writing later.
ii. Too many people in CMS/HHS are referring to Tribes as “Stakeholders”
and not acknowledging the special legal/political status and governmentto-government
relationship
4. Additional information provided during teleconference
a. State Exchanges are expecting to decide on their QHP requirements for
network adequacy in September or October and they are looking to CCIIO for
guidance, including decisions about the FFE.
b. State Exchange Tribal Consultation
i. NM is moving forward on planning an exchange using a consultant, and
the Exchange will be housed in the NM Health Alliance. Tribal input has
been limited.
ii. AZ is planning a State Exchange.
c. Basic Health Programs
i. Only 3 states are expected to have BHP: WA, VT, RI
ii. CA has a BHP now, but they may drop it.
5. Next steps recommended in teleconference
a. Alaska Consultation, August 7
i. Val should invite Pete and other federal officials to lunch at ANMC and
include a tour of the facility and SCF outpatient services.
ii. Comments in Alaska should focus on network adequacy, including both
ANMC and village clinics.
iii. Participants should tell Pete that they realize that not many federal
officials could attend, but they are relying on him to communicate issues to
others, particularly those whose decisions are outside his control.
4

iv. Suggest that Medicaid/CHIP representative be at the table for
discussion of single application and data elements.
b. Doneg volunteered to take notes at Anchorage and Denver and distribute a
document to Tribes (through TSGAC and MMPC) with new issues that are
identified. Issues identified in Anchorage will be distributed quickly, so that they
can be included in the Denver consultation.
c. Denver Consultation, August 9
i. Diddy will organize a Tribal caucus on the evening of August 8
ii. Jim Roberts will facilitate the Tribal caucus
iii. MMPC and TSGAC will notify Tribes about the caucus date, time,
place.
iv. There is also a 3 hour time slot in the IHS consultation for ACA and the
following topics are recommended:
(1) How will IHS respond to sponsorship opportunity for people in
Direct Service Tribes?
d. Letter to Michael Hash to be sent by NIHB, TSGAC (and possibly TTAG) with
cc to Secretary to cover these topics: 1) referring to AI/AN and Tribes as
“stakeholders” is not consistent with CMS policy; and 2) need for greater
oversight on State Tribal consultation in Exchanges.
e. Second letter to Michael Hash with summary of issues that surfaced in the 3
FFE Tribal Consultation meetings and the Tribal positions on those issues.
6. Points made at the Anchorage and Denver tribal consultations with HHS on
FFE and Medicaid Expansion
a. CMS stated that the new (and ACA-intended mandatory) Medicaid
expansion to adults without dependent children with incomes up to
138% FPL will be considered a “voluntary” expansion group. As with
other voluntary expansion groups under Medicaid --
i. A state is able to cancel the expansion in the future.
ii. AI/AN-specific protections (e.g., ARRA premium and cost-sharing
protections) carry over to the expansion population, including –
- No premiums or cost sharing
- Ability to choose an I/T/U provider that is in plan network
5

- I/T/U provider receives their all-inclusive or FQHC rate
(either directly from the plan or Medicaid makes up the
difference between plan payment and the I/T/U’s rate)
iii. There is not a specific date by which a state has to inform CMS
that it intends to expand Medicaid. The standard State Plan
Amendments procedures apply.
b. Other changes to Medicaid called for under the ACA are to be
implemented whether or not a state exercises the Medicaid expansion
option.
i. Application of a uniform definition of income using the new
definition of modified adjusted gross income (MAGI)
ii. No asset test for non-long term care service eligibility
iii. Maintenance of effort requirements on income eligibility continue
through 2019 for children and through 2014 for others
c. The ACA-directed study of a Navajo “single state agency for Medicaid”
was referenced several times by CMS and IHS.
i. The initial draft of the study is due from the contractor
Econometrica to CMS by October 2013.
ii. A final report is due to Congress from CMS by early 2014
d. Determining “Indian” for Exchange and IRS-related provisions.
i. In response to the question “How will AI/AN prove that they don’t
have to have insurance”, CMS staff responded “Exchange will
have to issue a letter or other document to an AI/AN so they have
proof.”
- It seems that this answer needs further clarification, if not
revision.
ii. A follow-up question was asked: “what documentation is required
by an AI/AN to provide to the Exchange to prove being an AI/AN”.
CMS staff responded: “CMS needs more input from tribes.”
e. Certification standards applied to Qualified Health Plans offered through
an Exchange.
6

i. CMS stated on a couple of occasions that states have the ability to
apply additional standards on QHP than the minimum standards
established by CMS
- Imposing a requirement that all QHP’s in a state Exchange
must offer to contract with I/T/U would be allowable.
ii. CMS stated they would need to issue additional formal
regulations if the FFE were to impose additional requirements on
QHP, such as requiring a plan to offer to contract with each I/T/U.
- CMS staff also indicated that, while it is not certain and
they didn’t offer to include any AI/AN-specific provisions if
they do, it is likely that CMS will be issuing further formal
guidance on the FFE.
f. Who should tribes engage in tribal consultation with regarding Exchange
operations?
i. For state-based Exchanges, state officials.
ii. For strictly FFE, engage CMS but no explanation was given yet of
how tribes will engage CMS on state-specific issues that may
apply solely to one specific state FFE (versus the discussions
going on now between TTAG and CMS on the national FFE
design.)
iii. For Partnership exchanges, engage states on the specific
functions a state may decide to operate.
- Plan management (e.g., certification of QHP)
- Outreach and enrollment assistance (e.g., Navigator
program and “in-person assistance”)
g. Liability for tax penalty for certain IHS beneficiaries
- In response to questions, the IHS Director and CMS staff
acknowledged that some IHS beneficiaries who choose not to
purchase health insurance coverage and who do not meet the
definition of Indian under the IRC definition could be liable for the
tax penalty administered by the IRS for not having “creditable
coverage”.
h. Analysis of impact of Medicaid expansion on states
7

i. CMS rep. commented that an analysis is underway to determine
the impact on each state from exercising the new Medicaid
expansion option, but the analysis isn’t complete.
- It wasn’t clear if CMS or another party was doing the
analysis.
- CMS rep. noted that it looks as if the Medicaid expansion will
prove to reduce some/many state’s overall local
expenditures.
ii. CMS rep. cited statistics for a select number of states on the
reduction in the percentage of uninsured persons in the state
solely from a state exercising the new Medicaid expansion option
(up to 138%). The data source was not cited.
- Montana: 66%
- North Dakota: 67%
- South Dakota: 50%
- Oklahoma: 74%
- Arizona: 65%
i. For non-expansion states, in response to questions raised in
Anchorage and Denver --
i. CMS commented “We would be very interested in waiver
proposals” from states/tribes designed to expand Medicaid
coverage solely to AI/AN through I/T/U, possibly structured
similar to the approved approach for AI/AN-specific benefits in
Arizona.
ii. CMS is considering developing a template for states to use in
requesting a waiver to extend Medicaid coverage to AI/AN.
j. State Plan Amendment or waiver request to CMS
i. CMS emphasized that tribes in a state have the ability to request
tribal consultation directly with CMS if they are not satisfied with
the tribal consultation process and outcomes undertaken with the
state.
8

ii. New Mexico tribes raised concerns about the state’s tribal
consultation held with regard to their pending Medicaid waiver,
and they may wish to request the direct consultation with CMS.
k. IHCIA section 206 and “reasonable charges”
i. CMS and IHS were asked if an I/T/U’s FQHC or IHS all-inclusive
rates would meet the definition of “reasonable charges” under
section 206.
ii. The CMS and IHS reps did not know.
l. Outreach and Education Funding
i. Tribes and tribal organizations are eligible to apply for grants
under the Navigator program.
ii. Funding will be available under the “in-person assistance”
program for assisting individuals to enroll in Exchange and
Medicaid coverage.
- The lead CMS staff member / contact for the in-person
assistance program is Holly Whelan, Consumer Support
Group, CCIIO-CMS, holly.whelan@cms.hhs.gov
iii. Medicaid Administrative Match (MAM) remains an option for
states to be reimbursed by CMS for the costs of tribes
performing enrollment assistance.
- A question was raised as to how funding may be used /
time may be allocated between combined Medicaid and
Exchange eligibility assistance but a specific answer
was not given.
iv. $4 million in CMS CHIPRA funding for AI/AN-specific
education and outreach in 2013.
v. $32 million in CMS CHIPRA funding for general education and
outreach in 2013.
– Tribes and tribal organizations can apply for the
general CHIPRA funds.
9

IHS TRIBAL SELF-GOVERNANCE ADVISORY COMMITTEE
c/o Self-Governance Communication and Education
5060 Pacific Highway, Suite 101, Ferndale, WA 98248
Telephone (360) 380-1820 ~ Facsimile (360) 380-1981 ~ Website: www.tribalselfgov.org
October 5, 2012
Sent Via Fax Dr. Petzel: (202) 273-5787
Sent Via Email Dr. Roubideaux: Rene.Joseph@ihs.gov
Originals Sent Via USPS
Dr. Robert A. Petzel, M.D. Dr. Yvette Roubideaux, M.D., M.P.H., Director
Under Secretary for Health Indian Health Service
Department of Veterans Affairs Department of Health and Human Services
810 Vermont Avenue, NW Room 448, The Reyes Building
Room 800 801 Thompson Avenue
Washington, DC 20420 Rockville, MD 20852
RE: Negotiation of Participating Tribal Health Program Agreements with Local
VA Facilities: Need for Inclusion of Agreed Upon Payment Methodologies
Dear Dr. Petzel & Dr. Roubideaux:
On behalf of the Tribal Self-Governance Advisory Committee (TSGAC), we are writing to
provide comments on one component of the latest set of materials released by the Department
of Veterans Affairs (VA) regarding implementation of section 405(c) of the Indian Health Care
Improvement Act (IHCIA). We appreciate the opportunity last week during the National Indian
Health Board Annual Consumer Conference in Denver, Colorado to discuss with the VA, as well
as with the Indian Health Service (IHS), securing reimbursement for health care services
provided to eligible veterans by the IHS, Tribes and Tribal Organizations. The sessions were
helpful to the Tribal participants, and we are encouraged that the VA is moving forward with
establishing agreements with Tribal health programs without restricting participation to a small
number of Tribal organizations under a demonstration project. We remain concerned, though,
that the National Reimbursement Agreement between the VA and IHS has not been finalized
and executed.
The TSGAC has previously provided comments on various aspects of implementation of IHCIA
section 405(c) since the provision was enacted in March of 2010. (TSGAC letters to VA/IHS
dated April 4, April 18, and May 25, 2012.) We believe the successful implementation of section
405(c) will serve to: (1) improve access to health care services for our veterans by expanding
access and reimbursement at IHS and Tribal facilities; and (2) strengthen and improve the care
received by veterans through improved coordination of their care across VA, IHS and Tribal
facilities. We wish to acknowledge the apparent inclusion by the VA (as indicated in the VA’s
August 24, 2012 Dear Tribal Leader letter) of a number of items TSGAC had previously
recommended, particularly the exclusion of copayments for Tribally-provided services and the
inclusion of behavioral health care and long-term care services as reimbursable services.
In an earlier VA document titled “VA-IHS Draft Agreement – Reimbursement for Direct Health
Care Services: Summary” (Summary of Reimbursement Agreement dated March 2, 2012), it
stated that a number of items had been successfully negotiated between the VA and the IHS,

Letter: Dr. Robert Petzel, Under Secretary, VA & Dr. Yvette Roubideaux, Director, IHS
RE: Negotiation of Participating Tribal Health Program Agreements with Local
VA Facilities: Need for Inclusion of Agreed Upon Payment Methodologies
Page 2 of 4 October 5, 2012
including the payment methodologies to be used in the Participating Tribal Health Program
Agreements. The Summary of Reimbursement Agreement document stated:
Payment methodologies are proposed to be basically the same as what IHS
hospitals and clinics are reimbursed for now: Inpatient hospital services would be
based on Medicare payment methodologies specific to the type of rate already
received (IPPS, CAH, etc); Outpatient services would be based on the IHS all
inclusive rate for Medicare and Medicaid. Other specific rates will be spelled out in
the document.
In the April 5, 2012 “Final Consultation Draft” of the “Draft Agreement between the Department
of Veterans Affairs and Department of Health and Human Services Indian Health Service for
Reimbursement for Direct Health Care Services” (Draft National Reimbursement Agreement),
additional detail on the agreed upon payment methodologies was included. TSAGC endorses
section VII. Reimbursement for Direct Care Services, subsections A – F, of the Draft National
Reimbursement Agreement, as follows:
VII. REIMBURSEMENT FOR DIRECT CARE SERVICES
A. Except to the extent inconsistent with the rate methodology explained herein, VA
shall reimburse at rates based on Medicare payment methodologies for services,
including home and community based services, to Eligible AI/AN Veterans.
B. Inpatient Hospital Services. Except to the extent inconsistent with the rate
methodology explained herein, VA shall reimburse at rates based on Medicare
payment methodologies for services to Eligible AI/AN Veterans. The payment
methodology under this section applies to all inpatient services furnished by the
hospital, whether provided by part of a department, subunit, distinct part, or other
component of a hospital (including services furnished directly by the hospital or
under arrangements with contract providers who provide Direct Care Services
onsite in an IHS or Tribal health facility).
1. Payment for hospital services that the Medicare program would pay under a
prospective payment system (PPS) will be based on the applicable PPS. For
example, payment for inpatient hospital services shall be made per discharge
based on the applicable PPS used by the Medicare program to pay for similar
hospital services under 42 C.F.R. Part 412.
2. For hospitals that furnish inpatient services but are exempt from PPS and receive
reimbursement based on reasonable costs (for example, critical access hospitals
(CAHs)), including provider subunits exempt from PPS, payment shall be made
per discharge based on the reasonable cost methods established under 42
C.F.R. Part 413, except that the interim payment rate under 42 C.F.R. Part 413,
subpart E shall constitute payment in full.
3. The inpatient rates set forth above do not include inpatient physician services
and practitioner services. The inpatient physician and other practitioner services
shall be billed based on the Medicare fee schedule.

Letter: Dr. Robert Petzel, Under Secretary, VA & Dr. Yvette Roubideaux, Director, IHS
RE: Negotiation of Participating Tribal Health Program Agreements with Local
VA Facilities: Need for Inclusion of Agreed Upon Payment Methodologies
Page 3 of 4 October 5, 2012
C. Outpatient Hospital Services and Freestanding Clinic Services. VA shall pay for
outpatient and free standing clinics services to Eligible AI/AN Veterans at the all
inclusive rate approved each year by the Director of IHS, under the authority of
sections 321(a) and 322(b) of the Public Health Service Act (42 U.S.C. §§ 248
and 249(b)), Public Law 83-568 (42 U.S.C. § 2001(a)), and the Indian Health
Care Improvement Act (25 U.S.C. § 1601 et seq.). This rate is published annually
in the Federal Register under the title: Outpatient Per Visit Rate (Excluding
Medicare).
D. Federally Qualified Health Centers. For facilities reimbursed by Medicare at the
Medicare Federally Qualified Health Center Rate, VA shall pay for services to
Eligible AI/AN Veterans at the Medicare Federally Qualified Health Center rate.
E. Ambulatory Surgical Services. VA shall reimburse for services to Eligible AI/AN
Veterans at established Medicare rates for freestanding Ambulatory Surgery
Centers.
F. Inpatient Pharmacy Services/Outpatient Pharmacy Services/ Take-Home Drugs.
VA agrees to provide reimbursement for inpatient medications for Eligible AI/AN
Veterans receiving direct inpatient care in IHS and Tribal hospitals. For outpatient
medications, IHS, Tribes and VA agree to use the VA Consolidated Mail
Outpatient Pharmacy (CMOP) for routine/ongoing/regular prescriptions written for
Eligible AI/AN Veterans under this agreement. VA agrees to provide
reimbursement of the cost of medication dispensed for the provision of outpatient
emergent need prescriptions or other outpatient prescriptions requiring provision
to eligible patients to initialize or continue therapy before CMOP can provide. In
those instances, those prescriptions are to be limited to not more than a 14-day
(Alaska: 30-day) supply.
We would like to emphasize that the rates in subsections A through E – which parallel the
reimbursement methodologies in use today under Medicare for IHS, Tribe and Tribal health
programs – were established in order to cover the costs of care at these facilities to the eligible
beneficiaries. Any proposed reductions to these rates would result in revenues to the facilities
being below the costs of providing the care to the AI/AN veterans, which would not be
acceptable.
In closing, we strongly recommend, to the extent that participating Tribal health program
agreements with local VA facilities are put in place prior to the execution of a National
Agreement on Reimbursement for Health Care Services, that the above payment policies
contained in the Draft National Reimbursement Agreement be incorporated into each
participating Tribal health program agreement unless the participating Tribal health program
specifically requests that alternate payment policies be employed. We further recommend that
the payment methodologies contained in the Draft National Reimbursement Agreement be
retained in the final National Reimbursement Agreement.
We encourage the VA and IHS to finalize this agreement as soon as possible, after taking into
consideration the remaining issues identified in the previous TSGAC comment letters. We look

Letter: Dr. Robert Petzel, Under Secretary, VA & Dr. Yvette Roubideaux, Director, IHS
RE: Negotiation of Participating Tribal Health Program Agreements with Local
VA Facilities: Need for Inclusion of Agreed Upon Payment Methodologies
Page 4 of 4 October 5, 2012
forward to continuing to work with you. If you have any questions, you can reach me at (860)
862-6192; or via email: lmalerba@moheganmail.com.
Sincerely,
Chief Lynn Malerba, Mohegan Tribe
Chairwoman, TSGAC
cc: P. Benjamin Smith, Director, Office of Tribal Self-Governance, IHS
Stephanie E. Birdwell, M.S.W. Director, Office of Tribal Government Relations, VA
Stacy Bohlen, Executive Director, National Indian Health Board
TSGAC Members
TSGAC Technical Workgroup Members

October 17, 2012
Dr. Robert Petzel, M.D. Dr. Yvette Roubideaux, M.D., M.P.H., Director
Under Secretary Indian Health Service
Department of Veterans Affairs Room 448, The Reyes Building
810 Vermont Avenue 801 Thompson Avenue
Washington, D.C. 20420 Rockville, MD 20852
RE: National All Inclusive Reimbursement Rate Agreement
Dear. Dr. Petzel, and Dr. Roubideaux:
On behalf of the National Indian Health Board (NIHB), I respectfully submit the following
recommendation contained in this letter regarding the Department of Veterans Affairs’ (VA)
implementation of the reimbursement requirements under Section 405(c) of the Indian Health
Care Improvement Act (IHCIA). 1 Tribes see the implementation of reimbursement rates as a top
priority that remains to be fulfilled.
NIHB recommends that all Tribal facilities and Indian Health Service (IHS) operating
programs receive reimbursement from the VA for services provided to our Native
American Veterans based upon the Medicaid All-Inclusive rate rather than the Medicare
Fee Schedule cost reimbursement rate that is applicable to a Federally Qualified Health
Center (FQHC). This important issue will play a critical role in allowing AI/AN access to
quality health care, especially as Tribes enter into negotiations with the VA for terms and
conditions for reimbursement rates for ambulatory services.
In the April 5, 2012, “Final Consultation Draft” of the “Draft Agreement between the VA and
IHS for Reimbursement for Direct Health Care Services” (Draft National Reimbursement
Agreement), additional detail on the agreed upon payment methodologies was included. Included
was Section VII Reimbursement for Direct Care Services, which further articulated VA’s policy
that reimbursement would be based at the Medicaid All-Inclusive Rate for outpatient hospital
services. Initially, Tribes were pleased with the decision by VA to rely on the Medicaid All-
Inclusive Rate approved by the IHS Director and published in the Federal Register as the basis
of reimbursement.
1 Section 405(c) requires the VA to reimburse the IHS, an Indian Tribe or Tribal Organization “where services are
provided through the Service, an Indian Tribe or a Tribal Organization to beneficiaries eligible for services from the
[VA], notwithstanding any other provisions of law.”

P a g e | 2
Now there appears to be confusion among the Tribes about the rate of reimbursement that Tribal
health facilities and IHS will receive from the VA for services provided to AI/AN eligible
veterans. Tribes had the opportunity last month at the NIHB Annual Consumer Conference in
Denver, Colorado to discuss with the VA securing reimbursement for health care services
provided to AI/AN eligible veterans. Following these discussions and a brief period of tribal
consultations where the reimbursement rate was not an issue, the VA has now stated that the
reimbursement rate will be the Medicare Fee Schedule as opposed to the original understanding
by Tribes that the Medicaid All-Inclusive Rate would apply, which was contained in the VA’s
previously-published Draft Agreement with IHS.
Reimbursement rates vary by payer source. For example, the Medicaid reimbursement rate is
significantly higher than the Medicare FQHC rate for the same service. NIHB recommends that
the reimbursement rate under the VA Agreement for all tribal health facilities be based upon the
All-Inclusive Rate rather than the Medicare Fee Schedule reimbursement rate as an FQHC in
order to cover the costs of care at these facilities to the eligible beneficiaries. Any proposed
reductions in reimbursement rates could result in revenues to the facilities below the costs of
providing the care to the AI/AN veterans.
As you already know, many of the Alaska Tribal Health Programs (ATHPs) have collectively
negotiated and entered into agreements with the VA under which they will be reimbursed for
health care services provided to AI/AN veterans based on the Medicaid All-Inclusive Rate. This
historic agreement expands access to health care to Alaska’s veterans. Already, enrollment
efforts have been redoubled and the number of enrolled AI/AN veterans is increasing in Alaska.
Similar to the successfully negotiated agreements between ATHPs and the VA, NIHB believes
the Medicaid All-Inclusive Rate to be the appropriate reimbursement rate for all Tribes
throughout Indian Country.
I respectfully ask that you consider our recommendation outlined above, specifically that all
tribal health facilities and IHS receive the Medicaid All-Inclusive reimbursement rate from the
VA for services provided to eligible AI/AN veterans instead of the Medicare Fee Schedule rate
as an FQHC.
Thank you in advance for consideration of these recommendations as we jointly work to advance
the health status of AI/AN individuals and communities across the United States.
Yours in Health,
Cathy Abramson
Chairperson
National Indian Health Board

A BILL
To correct inconsistencies in the definitions affecting Native Americans under the Patient
Protection and Affordable Care Act.
Be it enacted by the Senate and House of Representatives of the United States of America in
Congress assembled,
SECTION 1. TECHNICAL CORRECTIONS RELATING TO THE DEFINITIONS OF
INDIAN IN PPACA.
IN GENERAL.—Title I of the Patient Protection and Affordable Care Act is amended—
(1) in section 1311(c)(6)(D), by striking ‘‘(as defined in section 4 of the Indian Health
Care Improvement Act)’’ and inserting ‘‘(as defined in section 447.50(b)(1) of title 42 of
the Code of Federal Regulations, as in effect on July 1, 2010)’’; and
(2) in section 1402(d)(1), by striking ‘‘(as defined in section 4(d) of the Indian Self-
Determination and Education Assistance Act (25 U.S.C." "450b(d)))’’ and inserting ‘‘(as
defined in section 447.50(b)(1) of title 42 of the Code of Federal Regulations, as in effect
on July 1, 2010)’’.
(3) in section 1501(b), by striking “MEMBERS OF INDIAN TRIBES. —Any applicable
individual for any month during which the individual is a member of an Indian tribe (as
defined in section 45A(c)(6)) and inserting ‘‘INDIANS.—Any applicable individual who
is an Indian (as defined in section 447.50(b)(1) of title 42 of the Code of Federal
Regulations, as in effect on July 1, 2010).”

a b c d
e
IHS & Medicaid Align
IHS Eligibility for
AI/ANs
Chart of Indian-specific Health Care Provisions
with Different Citations in Federal Law for Defining "Indian"
Medicaid:
Protections and
Benefits for AI/ANs
Monthly Enrollment
Periods for AI/AN's
Sec. 4 IHCIA
Affordable Care Act-related Provisions
Health Insurance Exchange-related Provisions
Cost-Sharing Protections for AI/AN's
Sec. 4(d) ISDEAA
No cost-sharing for
AI/ANs under 300%
FPL (at all providers)
No cost-sharing for
AI/ANs served by
I/T/U; payment of full
amount due to I/T/U
(without cost-sharing
reductions)
CMS stated in regulations these definitions "operationally mean the same
thing."
Exemption from
IRC tax penalties
for AI/ANs not
having "minimum
essential coverage"
IRC 45A(c)(6)
IRS stated informally in meetings these definitions are the same.
NPAIHB / TSGAC v. 1.1

California Rural Indian
Health Board
September 21, 2012
Valerie B. Jarrett, Senior Advisor
The White House
1600 Pennsylvania Avenue N.W.
Washington, DC 20500
Dear Ms. Jarrett and Ms. Gillette:
Jodi Gillette, Senior Policy Advisor
Native American Affairs
1600 Pennsylvania Avenue N.W.
Washington, DC 20500
Northwest Portland Area
Indian Health Board
The California Rural Indian Health Board (CRIHB) and the Northwest Portland Area Indian Health Board
(NPAIHB) are Tribal organizations organized under the Indian Self-Determination and Education Assistance
Act. 1 Our organizations represent health care issues of 63 federally-recognized Tribes in California, Idaho,
Oregon, and Washington. We are writing to you about a very important Affordable Care Act matter.
In just three months, States will be applying to the federal government for certification of their Health
Insurance Exchanges under the Affordable Care Act. One of the current activities for both State Exchanges
and the Federally-Facilitated Exchange is to create a single streamlined application for Medicaid, Child Health
Insurance Programs, and the individual Exchanges. The Administration’s goal of a short and simple application
that uses electronic data bases is at odds with regulatory guidance regarding identifying American Indians and
Alaska Natives (AI/AN) for the purposes of cost sharing waivers, special enrollment periods, and other
protections in Medicaid, CHIP and the Exchanges. It is imperative that the White House provide guidance on
this issue so that AI/AN who were intended to benefit from ACA are not left out.
Here is a short list of potential problems that could occur if the definition of Indian used by Exchanges is
different from the one used by Medicaid and CHIP:
An AI/AN child who is not allowed to enroll as tribal members until her 18 th birthday will not be
considered as AI/AN by Exchanges, although she would be considered AI/AN by Medicaid and CHIP.
An Alaska Native adult will not be considered AI/AN by Exchanges until his parent dies and he inherits
stock in an Alaska Native corporation. And his children will not be considered AI/AN by Exchanges
until he dies and his stock in an Alaska Native corporation is passed along to his children, even though
they qualify as AI/AN under Medicaid and CHIP.
1 As defined in the Indian Self-Determination and Education Assistance Act, P.L. 93-638, 25 U.S.C., Section 450(b) a Tribal organization
is a legally established governing body of any Indian tribe(s) that is controlled, sanctioned, or chartered by such Indian Tribe(s) and
designated to act on their behalf.

An American Indian child that may not have enough blood quantum to be enrolled in a Tribe will be
considered Indian under Medicaid. But not in Exchanges, because she lacks enough blood quantum to
be enrolled in either of her parent’s tribe.
An American Indian cannot enroll in his father’s tribe where tribal membership is passed from mother
to child in what has been called matrilineal descent, and therefore he would not be considered AI/AN
under Exchanges, even though he would qualify as AI/AN in Medicaid.
An individual who has been determined to be AI/AN by the federal Bureau of Indian Affairs and has a
Certificate of Indian Blood issued by that federal agency that is recognized by every other federal
agency, is not recognized as Indian by the Federally-facilitated Exchange or state-based exchanges.
A person enrolled in Medicaid as an AI/AN no longer meets the income criteria and does not purchase
health insurance because she gets her care from her Tribal health clinic and assumes that she is
exempt from tax penalties because she is AI/AN. However, IRS uses a different definition of AI/AN
than Medicaid uses, and she finds out later that she does have to pay a tax penalty.
The complications of Exchanges to administer and families to understand the varying definition of
Indian and the high level of churning that is anticipated for AI/AN families will disenfranchise AI/AN
families from participating in opportunities provided under the Affordable Care Act.
In each of these cases, the individuals could be living in a family that is considered AI/AN, in an AI/AN
community – perhaps even on a reservation, attending Indian schools funded by the federal government, and
receiving their health services at an Indian Health Service clinic or hospital. They could be considered AI/AN
for Medicaid, CHIP and every federal Indian program. And, still they would not be qualified for the special
protections for AI/AN in Health Insurance Exchanges according to the current interpretation of ACA by the
Department of Health and Human Services.
As a result of the differences in how Exchange rules are being written and how Medicaid and CHIP rules are
written, it is not possible to have a simple, streamlined application that relies on existing electronic data
sources. The application must ask at least three different questions to determine who qualifies as Indian
under the different programs. Those three questions take up a lot of space on an application which will be
used by a lot of people who are not AI/AN, and they will confuse a lot of people who are AI/AN. If Exchanges
use the same definition as Medicaid, CHIP and the Indian Health Service, they could use the electronic
registration data base from the IHS as part of the application process. However, the more restrictive
definition currently in use by Exchanges may require someone at every Exchange and at every Tribal
government site to process paperwork that shows that an individual has a tribal enrollment card. Ironically,
the ACA calls for self-attestation for almost every aspect of the application (except citizenship), and yet AI/ANs
may be expected to provide documentation instead of using self-attestation to prove that they are a member
of a Tribe or Alaska Native regional or village corporation. The Administration should be trying to make it
easier for underserved individuals to enroll in health insurance through Exchanges, not more difficult.
Operationally, it is going to be a nightmare to have different definitions of AI/AN for Medicaid, CHIP and
Exchanges. Personnel at call centers, navigators, in-person assisters, and individuals working in Indian health
clinics will have to explain to people why they are considered an Indian for one federally-funded program, but
not for another. Explaining the benefits of this new program will be difficult enough. As health care providers
bill Medicaid Plans and Qualified Health Plans, they will need to know whether cost sharing waivers apply for
some AI/AN and not for others.

As people have changes in employment, income and family size, they will churn between Medicaid to
Exchange coverage assuming that the same rules apply, only to find out later that they have been
disenfranchised as AI/AN from Exchanges.
This is a problem that can be solved easily by having Exchanges adopt the Medicaid definition of Indian and
use the same types of verification that Medicaid uses. We didn’t agree, but understood the view of lawyers
and others in HHS immediately after the law passed when they asserted that since there were three different
“definitions,” these problems couldn’t be fixed without a “legislative fix.” However, HHS formally, and IRS
informally, have agreed that the three statutory definitions have the same meaning. We know it is not likely
that Congress will amend the ACA to fix this problem in the next few months while the single, streamlined
applications are being designed. It is clearly time for the Administration to reconsider relying on a regulatory
correction.
There are many ways to justify aligning how these definitions are implemented to correspond to how the
agencies most responsible for administering programs for Indians determine who is Indian. The attached
paper discusses these. What is needed now is leadership at the highest levels to require that this problem is
solved immediately through the issuance of regulations or similar guidance that applies the Medicaid
definition of AI/AN to Exchanges.
We would like to meet with you to discuss this issue and offer assistance to resolve it. For questions, please
follow up with Jim Crouch, CRIHB Executive Director, at (916) 929-9761; or Jim Roberts, NPAIHB Policy Analyst,
at (503) 347-7664.
Sincerely yours,
Michelle Hayward, Chairperson Andy Joseph, Jr., Chairperson
California Rural Indian Health Board NW Portland Area Indian Health Board
Redding Rancheria Tribal Council Member Colville Tribal Council Member
Attachment: “Enabling Exchanges Implement a Streamlined Application Process: The Need for a Uniform
Operational Definition of Indian to Efficiently and Accurately Identify Individuals Who Are
Eligible for Special Benefits and Protections”

v.7, 2012‐09‐23a
Enabling Exchanges Implement a Streamlined Application Process:
The Need for a Uniform Operational Definition of Indian to Efficiently and Accurately Identify
Individuals Who Are Eligible for Special Benefits and Protections
1, 2
as American Indians and Alaska Natives
I. Executive Summary
As a component of carrying out the Federal government’s special trust responsibility 3 to Indian Tribes
and to American Indians and Alaska Natives (AI/ANs), the Patient Protection and Affordable Care Act 4 –
inclusive of the expansion and permanent reauthorization of the Indian Health Care Improvement Act –
authorized Indian-specific benefits and protections. The two health insurance exchange-related Indianspecific
provisions (i.e., monthly enrollment periods and additional cost-sharing protections) are available
only to AI/ANs enrolled in the individual market through an Exchange. 5 A third Indian-specific provision
in the Affordable Care Act exempts AI/ANs from tax penalties enforced through the Internal Revenue
Code (IRC) for not maintaining minimum essential coverage. 6
In indicating who is eligible for these Indian-specific benefits and protections, the Affordable Care Act
relies upon definitions of Indian found in three different, previously-existing federal laws. Each of these
definitions specifies that an Indian is “a member of an Indian tribe”, but there are slight differences in the
wording of what constitutes an “Indian tribe”. Given the nearly identical language across the definitions,
in the final rule for establishment of Exchanges issued by the Centers for Medicare and Medicaid Services
7, 8
(CMS) the two Exchange-related definitions were determined to “operationally mean the same thing.”
The Internal Revenue Service has not yet formally opined on the third, IRC-based definition of Indian. 9
In addition to the ACA-established special benefits and protections for AI/ANs, there are Indian-specific
cost-sharing protections under Medicaid that predate the ACA. 10 For purposes of determining eligibility
for the Indian-specific Medicaid cost-sharing protections, in 2010 CMS promulgated regulations at 42
C.F.R. § 447.50 that drew from a range of definitions in federal law (as a definition was not provided in
the law) to create a comprehensive definition of Indian. 11,
To ensure AI/ANs are able to access the Medicaid- and Exchange-related special benefits and protections
and Exchanges are able to efficiently and consistently make eligibility determinations, and given the
apparent agreement that the definitions of Indian applicable within the Exchange are operationally the
same, the primary issues remaining to resolve are 1) whether operational guidance will be issued to aid in
determining eligibility for Exchange-related Indian-specific benefits and protections and 2) whether any
operational guidance that is issued will apply a uniform operational definition of Indian for application
across both Medicaid and the Exchange.
We encourage Exchange officials to seek the flexibility that appears to be available from HHS to fashion
a uniform operational definition of Indian to be used across the Medicaid and Exchange-related
programs. 12, 13 This is particularly important given the complexity of “Indian” determinations and as the
Affordable Care Act mandated the creation of a streamlined eligibility determination process for
Medicaid and Exchange programs that relies upon a single application form. If it is ultimately determined
that applying a uniform operational definition of Indian to each of the Indian-specific benefits and
protections is not acceptable to HHS, we recommend that an existing set of guidance materials (namely,
the CMS Medicaid eligibility guidance for AI/ANs under 42 C.F.R. § 447.50) be used as the basis for
Northwest Portland Area Indian Health Board Page 1 of 16

Indian eligibility determinations, with the identification of specific exceptions to these rules when
necessary for any of the Indian-specific protections and benefits.
II. Focus of This Paper
v.7, 2012‐09‐23a
This paper is intended to address two core issues of concern. First, the reliance on three different sections
of federal law to define “Indian” under the Affordable Care Act has created confusion as to how an
Exchange will implement the definitions for the different ACA protections and benefits that they apply.
(Ironically, because the three definitions are actually nearly identical, the definitions themselves do not
create this confusion.) Second, the Center for Consumer Information and Insurance Oversight
(CMS/CCIIO), an agency within CMS with primary responsibility for ACA implementation, and the
Internal Revenue Service (IRS) need to utilize the knowledge and experience of agencies responsible for
implementing eligibility for Indian-specific health benefits prior to enactment of the ACA. The CMS
Center for Medicaid and State Operations (CMS/CMSO), which is responsible for Medicaid operations
including Indian-specific Medicaid protections, have developed regulations and materials to provide the
operational guidance to determine who is a “member of an Indian tribe” (which is the core element under
each definition of Indian) . An Exchange 14 will ultimately learn – as did CMS/CMSO – that they need
detailed guidance materials to assist Federal, Tribal and State officials in determining that a person falls
within the statutory definition of Indian. 15
If implementation guidance is not rooted in the CMS/CMSO’s Medicaid experiences, or if no
implementation guidance is provided beyond the definition itself, the results for American Indians and
Alaska Natives are very likely to be a significant number of AI/ANs not gaining access to the benefits and
protections for which they are eligible, as well as disruptions to an otherwise streamlined eligibility
determination and enrollment process. For an Exchange, the results would likely be greater costs and
longer processing times, as well as a heightened error rate among the Exchange staff and outside assisters.
Each of these results would run counter to the expressed goals of the Affordable Care Act. 16
This paper presents options for avoiding these potentially detrimental results when determining eligibility
for Indian-specific benefits and protections through an Exchange. We believe the options presented are
within the authority of an Exchange to implement, whether a state-based or Federally-facilitated
Exchange.
III. Background
After a great deal of interaction with tribes, in March of 2012 CMS issued guidance that the two
definitions of Indian that apply to Exchange-related protections are “operationally the same.” 17 This
should largely mitigate the confusion generated from having to apply two different sections of federal law
to determine who is eligible for the two Indian-specific protections available through an Exchange.
Under each definition, the core criterion is that an Indian is “a member of an Indian tribe.”
There is general acceptance that all tribes listed by the Bureau of Indian Affairs as Federally-recognized
tribes are included in the definition of Indian tribe. But this is not the sole determination of which entities
are included under “Indian tribe”, as that term is used in each of the statutory provisions cited in the ACA.
In fact, the plain language of these definitions includes no reference to Federally-recognized Tribes.
Instead, the three ACA-cited definitions include a list of entities – in fact the same list with the exception
of the words “pueblo” and “group” not being included in all of the definitions – which includes
Northwest Portland Area Indian Health Board Page 2 of 16

v.7, 2012‐09‐23a
“organized groups and communities,” including Alaska Native regional and village corporations. Because
it is not readily apparent from a simple read of the definitions which entities are included in the
description of “Indian tribes,” IHS and CMS both previously determined – for purposes of determining
eligibility for IHS services and for Indian-specific Medicaid protections, respectively – that detailed
guidance was necessary on which entities are included as “Indian tribes”, who is considered a “member”
of such Indian tribes, and what documentation serves to prove one’s status as an “Indian”.
It is important to point out that a basic principle of tribal sovereignty is that tribes can decide who their
members are. This is very similar to the United States government deciding who can be a U.S. citizen.
For the United States as well as for tribes, the definition of a citizen can change over time, 18 and there
may be differences between countries (and tribes) as to what qualifies an individual to be a citizen. For
some tribes, tribal membership confers at a specified age, such as 18. For other tribes, parents may apply
for membership for their children at time of birth. The eligibility guidance issued by IHS and CMS
accommodates such differences in tribal membership/citizenship procedures to ensure that all AI/AN
persons intended by Congress to be eligible for such Indian-specific benefits and protections are in fact
included.
To date, for purposes of implementing the Indian-specific Exchange-related provisions of the ACA, the
Department of Health and Human Services, and by extension CMS, has been reluctant to issue detailed
guidance on the implementation of these definitions, particularly guidance that applies a uniform
operational definition across the Medicaid and Exchange provisions. As expressed by HHS before it
determined that the various statutory provisions cited in the ACA were operationally the same, there was
concern that the ACA-specific definitions of Indian 19 might result in different benefits being available to
different individuals because the definitions might cover different individuals. Thus, HHS concluded that
its ability was constrained to apply in toto the operational guidance issued by CMS in the past, which
included individuals eligible under each of the definitions of who is Indian.
We understand there may be disagreements between the national tribal organizations and HHS on these
matters. For example, some of the specific categories used for determining eligibility for Medicaid
protections that are included under the CMS operational guidelines may be considered not to be within
the narrower ACA-cited definitions. But, we believe that any exclusions of eligibility categories that may
be required by HHS are identifiable, would be limited, and would enable the remainder of the CMS
guidance to be relied upon for purposes of determining eligibility through an Exchange-facilitated,
streamlined eligibility determination process.
Simultaneously, if determined necessary by HHS and the Administration to do so, a legislative fix could
be pursued with Congress in order to either solidify the application of a uniform operational definition or
to eliminate the need to include specific exceptions to a uniform operational definition.
IV. The ACA References Different Provisions of Federal Law in Defining Persons Eligible for
Indian-specific Benefits and Protections
In addition to the health insurance benefits made available to all Americans, including AI/AN, the
Affordable Care Act established additional benefits and protections that are specific to American Indians
and Alaska Natives. Table A presents (1) the Indian-specific protections and benefits contained in the
Northwest Portland Area Indian Health Board Page 3 of 16

v.7, 2012‐09‐23a
ACA, (2) the section of federal law referenced defining eligibility for the provision, and (3) the lead
implementing agency for the provision.
Table A: Indian-Specific Provisions of Affordable Care Act
Exchange-related Provisions IRS-related
Special Enrollment
Periods for AI/ANs
Cost-Sharing
Protections for AI/ANs
Section of ACA ACA § 1311(c)(6)(D) ACA § 1402(d)(1) and (2)
Section of federal
law cited that
defines eligibility
for Indian-specific
provision
Lead
implementing
agency
Section 4 of IHCIA:
“(D) special monthly
enrollment periods for
Indians (as defined in section
4 of the Indian Health Care
Improvement Act).”
Exchange (but with option of
deferring to HHS for
eligibility determinations)
Section 4(d) of ISDEAA: 21
“If an individual
enrolled in any qualified
health plan in the individual
market through an Exchange
is an Indian (as defined in
section 4(d) of the Indian
Self-Determination and
Education Assistance
Act (25 USC 450b(d)))…”
Exchange (but with option of
deferring to HHS for
eligibility determinations)
Exemption from
Penalty for Failing to
Maintain Minimum
Essential Coverage
ACA § 1501(b)) creating
IRC 20 § 5000A(e)(3)
Section 45A(c)(6) of the
IRC:
“[A]ny applicable
individual for any month
during which the individual
is a member of an Indian
tribe (as defined in section
45A(c)(6)”
Internal Revenue Service
Two of the Indian-specific protections (special monthly enrollment periods 22 and additional cost-sharing
protections 23 ) are available only to AI/ANs who are enrolled in the individual market through an
Exchange. An Exchange, whether operated by a state or state-established entity or by HHS, has the
responsibility for determining eligibility for these Exchange-related Indian-specific provisions, although
an Exchange may rely upon HHS for determinations of eligibility for the premium tax credits and costsharing
assistance as provided for under 45 CFR 155.302(c). A third provision (providing an exemption
from any penalties for AI/ANs who do not maintain minimum essential coverage) is to be administered
by the Internal Revenue Service, 24 We understand there will be coordination between determinations
made by HHS and those that IRS must make, however the mechanics of the working relationship are as
yet unknown to us.
Eligibility for the special monthly enrollment periods is defined in section 4 of the IHCIA. Eligibility for
the cost-sharing protections is defined in section 4(d) of the ISDEAA. Under both provisions, as well as
under the Internal Revenue Code-related definition, an “Indian” is defined as a person who is a member
of an Indian tribe.
Exchange-related Definitions of Indian (IHCIA and ISDEAA) “Operationally Mean the Same Thing”
Shown below is a combined definition of “Indian tribe” drawn from the definitions in the IHCIA and the
ISDEAA that are referenced in the Exchange-related provisions. The definition of Indian tribe from the
ISDEAA is shown verbatim, with any additional language from the IHCIA definition added and
highlighted in underline.
Northwest Portland Area Indian Health Board Page 4 of 16

Indian tribe means any Indian tribe, band, nation, or other organized
group or community, including any Alaska Native village or group or
regional or village corporation as defined in or established pursuant to
the Alaska Native Claims Settlement Act, which is recognized as
eligible for the special programs and services provided by the United
States to Indians because of their status of Indians. 25
v.7, 2012‐09‐23a
As is evident, the definition of an “Indian tribe” is nearly identical under each definition, with the
exception that the IHCIA definition includes the phrase “or group” in addition to the language contained
in the ISDEAA definition. This additional phrase creates no functional difference in meaning. It is
understood that the “or group” phrase was included in the IHCIA definition in an attempt to include
redundancies to assure that the definition is comprehensive and not misunderstood. 26
The position that these definitions are effectively and operationally the same is held by national tribal
organizations and advisory bodies, including the Tribal Technical Advisory Group to CMS (TTAG), the
National Congress of American Indians (NCAI), the National Indian Health Board (NIHB), the Tribal
Self-Governance Advisory Committee (TSGAC), and the Northwest Portland Area Indian Health Board
(NPAIHB), among others. 27 In addition to being the position of these tribal organizations, the opinion that
these two definitions “operationally mean the same thing” is held by the United States Government.
CMS included guidance in the Final Rule on the establishment of Exchanges released in March of 2012.
In the Final Rule, CMS noted:
[S]ince both the ISDEAA and IHCIA operationally mean the same thing,
there is uniformity among the definition of Indian for purposes of the
Exchange-related benefits described in this final rule. We accept that the
definitions of ‘‘Indian’’ as provided under section 4(d) of ISDEAA
(codified at 25 U.S.C. 450 et seq.) and section 4 of IHCIA (codified at 25
U.S.C. 1603) operationally mean the same thing: an individual who is a
member of an Indian tribe. In their definitions of an ‘‘Indian tribe,’’ both
of these acts have nearly identical language that refers to a number of
Indian entities (tribes, bands, nations, or other organized groups or
communities) that are included in this definition on the basis that they are
“recognized as eligible for the special programs and services provided by
the United States to Indians because of their status as Indians.” 28
An Exchange would be well within the boundaries of this guidance if the Exchange considered persons
who are eligible for the Exchange-related Indian-specific special monthly enrollment periods to be
eligible for the Exchange-related Indian-specific cost-sharing protections, and vice versa. As such, a
uniform operational definition could be fashioned to guide eligibility determinations for these Exchangerelated
provisions of the ACA.
IRC-related Definition of Indian: Providing an Exemption from Potential Tax Penalties
The definition of an Indian tribe found in Internal Revenue Code (IRC) § 45A(c)(6) (referenced in the
ACA for purposes of eligibility of Indians for the exemption from the penalty for not maintaining
minimum essential coverage) is also identical to that in the ISDEAA, with one exception.
Northwest Portland Area Indian Health Board Page 5 of 16

Indian tribe means any Indian tribe, band, nation, pueblo, or other
organized group or community, including any Alaska Native village or
group or regional or village corporation as defined in or established
pursuant to the Alaska Native Claims Settlement Act, which is
recognized as eligible for the special programs and services provided by
the United States to Indians because of their status of Indians. 29
v.7, 2012‐09‐23a
The IRC § 45A(c)(6) definition includes the word “pueblo”, as in “Indian tribe means any Indian tribe,
band, nation, pueblo, or other organized group…” (For reference, the phrase “or group” is also shown in
the definition above, although this phrase is only found in the IHCIA Sec. 4 definition.) To further
support the contention that these definitions are not in fact different, dropping the word pueblo from the
definition would not actually exclude pueblos. 30 This again makes the point that the differences among
the three definitions of Indian tribe referenced in the ACA are without meaning, especially when one
considers that the HHS regulations implementing the ISDEAA definition actually includes pueblos,
although they are not expressly referenced in the statutory definition. 31
The Internal Revenue Service has not yet formally issued an opinion on this issue. In different meetings
of the Medicare, Medicaid and Health Reform Policy Committee of the National Indian Health Board,
representatives of the IRS offered different approaches that IRS may take in consideration of who is
Indian for purposes of waiving the tax penalty. On February 21, 2012, IRS representatives indicated that
the IRS likely would accept a determination made by an Exchange as to who is “Indian” (in instances
when an individual is certified as being an Indian by an Exchange.) 32 If this position holds, a
determination by an Exchange of Indian status could be used to indicate eligibility for an exemption from
tax penalties under the ACA, if any. However, it is unrealistic to assume that every AI/AN who files
taxes will go to an Exchange to determine their eligibility for waiver of the tax penalty. Operationally, it
would be very expensive for Exchanges to provide this information for the 1.5 million AI/ANs who are
not expected to enroll in Exchange plans. Furthermore, the Bureau of Indian Affairs and Tribes have
been the designated entities to make these determinations long before ACA. The Exchange would only
make a determination if the individual provided the Exchange with documentation from either the BIA or
a Tribe, and that in turn only adds a layer of bureaucracy and works against the concept of “streamlining.”
At a later meeting on July 24, 2012, representatives of the IRS said that the IRS would likely use selfattestation
of Indian status on the tax forms as the basis for waiving the penalty.
V. Indian-specific Cost-sharing Protections under Medicaid
In 1997, Congress enacted protections for AI/ANs in the Balance Budget Act (BBA). 33 The provision
prevents a state from mandating an AI/AN enroll in a managed care entity if that entity is not an Indianspecific
entity. Under the BBA provision, an Indian is identified as a person meeting the definition in
34, 35
section 4(c) of the Indian Health Care Improvement Act of 1976 (25 U.S.C. 1603(c)).
In 2008, a second set of Indian-specific cost-sharing protections in the Medicaid program were enacted
through the American Recovery and Reinvestment Act of 2009 (ARRA of Recovery Act). 36 These
protections block the imposition of cost-sharing for AI/ANs for items or services furnished by Indian
health programs, as well prevent a reduction in the amount of payment to an Indian health program as a
result of no cost-sharing by AI/AN patients. But in contrast to the BBA and Affordable Care Act
examples, other than indicating that the provision is applicable to “Indians”, a specific definition of Indian
Northwest Portland Area Indian Health Board Page 6 of 16

v.7, 2012‐09‐23a
was not included in the Recovery Act nor was a reference to an existing definition of Indian in another
federal statute provided.
In order to provide guidance to states in determining eligibility for the Indian-specific Medicaid costsharing
protections under ARRA, HHS promulgated regulations at 42 C.F.R. § 447.50 (effective July 1,
2010) that drew from a range of definitions in federal law to create a single operational definition of
Indian. 37 This CMS regulatory guidance drew from the statutory definitions of Indian in the IHCIA, the
ISDEAA, and in the Snyder Act, which itself has no definition of Indian, but instead is viewed as broad
underlying authority for all Indian health programs and other services to AI/ANs. 38 In doing so, “Indian”
was defined to mean –
any individual defined at 25 USC 1603(c)[IHCIA Sec. 4(13)], 1603(f)
[IHCIA Sec. 4(28) , or 1679(b) [IHCIA Sec. 809(a)], or who has been
determined eligible as an Indian, pursuant to Sec. 136.12 of this part.
This means the individual:
(i) Is a member of a Federally-recognized Indian tribe;
(ii) Resides in an urban center and meets one or more of the following
four criteria:
(A) Is a member of a tribe, band, or other organized group of
Indians, including those tribes, bands, or groups terminated since
1940 and those recognized now or in the future by the State in which
they reside, or who is a descendant, in the first or second degree, of
any such member;
(B) Is an Eskimo or Aleut or other Alaska Native;
(C) Is considered by the Secretary of the Interior to be an Indian for
any purpose; or
(D) Is determined to be an Indian under regulations promulgated by
the Secretary;
(iii) Is considered by the Secretary of the Interior to be an Indian for any
purpose; or
(iv) Is considered by the Secretary of Health and Human Services to be
an Indian for purposes of eligibility for Indian health care services,
including as a California Indian, Eskimo, Aleut, or other Alaska Native.
To further facilitate the eligibility determination process, CMS issued guidance on the documentation that
may be provided to substantiate meeting the definition of Indian under 42 C.F.R. § 447.50.
Documentation that an individual is an Indian could include Tribal
enrollment and membership cards, a certificate of degree of Indian blood
issued by the Bureau of Indian Affairs, a Tribal census document, or a
document issued by a Tribe indicating an individual‘s affiliation with the
Tribe. The Indian health care programs and urban Indian health programs
are responsible for determining who is eligible to receive an item or
service furnished by their programs and so a medical record card or
similar documentation that specifies an individual is an Indian as defined
above could suffice as appropriate documentation. These documents are
examples of documents that may be used, but do not constitute an allinclusive
list of such documents. 39
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v.7, 2012‐09‐23a
In issuing this guidance, CMS commented, “We agree that administrative simplicity is very important.
Therefore, we have defined the term ‘Indian’ for purposes of the exemption from premiums and cost
sharing in broad terms that indicate the kinds of documentation that could support the application of the
exception.” 40
Although CMS did not issue a directive to states to apply § 447.50 uniformly for all Indian-specific
Medicaid protections, including the BBA protections, in practice it appears that states and their eligibility
workers may be applying a single definition of Indian for both sets of protections. 41 Given the more
extensive operational guidance issued by CMS and a definition that would not result in the exclusion of
persons for whom eligibility was intended, the definition of Indian promulgated by HHS under 42 C.F.R.
§ 447.50 appears to be the uniform definition relied upon for Medicaid purposes, including Medicaid
managed care.
VI. Multiple Definitions of Indian May Impede Health Reform Goals
Given the apparent agreement that the definitions of Indian applicable within the Exchange are
operationally the same, the primary issues to resolve are 1) whether operational guidance will be issued to
facilitate implementation of the Exchange-related Indian-specific benefits and protections and 2) whether
the definitions of Indian under Medicaid and the Exchange will be applied in a uniform manner or with
certain populations excluded under some definitions.
First, what might be the problems created by applying the definitions of Indian differently? In short,
applying the definitions of Indian differently may impede the central goals of health reform.
A central goal of the Affordable Care Act is the streamlining of eligibility determinations for federal
health insurance programs. 42 The creation of an Exchange serving each state 43 and the requirement that
“the Exchange must use a single streamlined application to determine eligibility and to collect
information necessary for: (1) enrollment… (3) cost-sharing reductions; and (4) Medicaid…” 44 are two
primary means for achieving the streamlining of eligibility determinations. 45 But if an Exchange were
required to apply different definitions of Indian when making eligibility determinations for Medicaid and
Exchange-related programs – even if those definitions had very little difference in practice – the efforts at
streamlining eligibility determinations could be significantly frustrated. Results of this would be likely to
include –
Increased inaccuracies in eligibility determinations: Enrollment staff, as well as AI/ANs
themselves, could become confused – and ultimately frustrated – if they are required to
understand obscure differences between the definitions. Without a thorough understanding of
any differences in the application of the definitions, instances of inaccurate eligibility
determinations being made are likely to increase. 46
Unwarranted application of tax penalties: If an AI/AN were determined to be eligible for IHS
services as an “Indian” (and therefor chose not to secure health insurance coverage), but was not
determined to be eligible as an “Indian” for the exemption from the requirement to secure
minimum essential coverage, this individual and his or her family could be subject to significant
tax penalties.
Interruption of streamlined process: Applying definitions differently will lead to individuals
needing to interact with Exchange/Medicaid eligibility staff and tribal offices on multiple
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v.7, 2012‐09‐23a
occasions as they navigate understanding the differences in the definitions and the different
documents that might satisfy one definition but not another.
Increased training necessary: If enforcement of multiple definitions of Indian were required to be
carried out by an Exchange, enrollment staff of an Exchange and individuals and organizations
involved in outreach to AI/AN 47 would need to be educated in the nuances under each definition
of Indian, including understanding the differences, if any, in documentation permitted to satisfy
each definition of Indian.
Increased and uncertain cost-sharing liabilities: AI/ANs determined to be “Indian” for purposes
of Medicaid will be afforded comprehensive Indian-specific cost-sharing protections under
Medicaid. However, if the same individuals’ income increases and the individuals are then
eligible for Exchange coverage and not Medicaid, they are likely to assume they are eligible for
the comprehensive Indian-specific cost-sharing protections through the Exchange. If the
Exchange determines that such individuals are not eligible for cost-sharing waivers on the basis
of AI/AN status, this will become very confusing to both the individuals and the QHP.
Uncertainty in the applicability of cost-sharing protections could result in significant liabilities to
the affected individuals without their having the slightest awareness of this discrepancy.
Uncertain application of cost-sharing protections within families by providers: Providers that
serve AI/ANs, and do not collect cost-sharing for the AI/ANs because of their status of being an
Indian for purposes of the Medicaid program, would need to understand that patients’ status as an
Indian – or the status of just some of the members of an AI/AN household – might have changed
when they secured health insurance coverage through an Exchange. The provider would then
need to collect cost-sharing from some or all members of a previously “Indian” household.
Reduced timeliness: The streamlined application process is being designed to rely, to the extent
possible, on electronic verification of application-related information. The lack of a single
operational definition would complicate (although not prevent) the use of automated databases
that may be available for verification purpose, such as using the IHS beneficiary roster.
Reduced involvement of AI/AN in insurance options: Even if the instances of an individual
being determined to be “Indian” for one Exchange-related provision and not for another were rare
(which we anticipate), this outcome would likely cast a shadow over AI/ANs involvement with
ACA implementation more generally. For instance, AI/ANs may be much more reluctant to
transition from the IHS-based coverage model to comprehensive Exchange coverage if they could
end-up subject to significant cost-sharing requirements under a different, potentially unknown
application of a definition of Indian.
Individually and collectively, these results would run directly counter to the central goal of the ACA to
expand access to affordable health insurance coverage for all Americans. And, these results could
seriously impede the specific policy declarations of the United States Congress contained in ACA §
10221(a) 48 for AI/ANs that:
Congress declares that it is the policy of this Nation, in fulfillment of its special
trust responsibilities and legal obligations to Indians—
Northwest Portland Area Indian Health Board Page 9 of 16

(1) to ensure the highest possible health status for Indians and urban Indians
and to provide all resources necessary to effect that policy;
…
(3) to ensure maximum Indian participation in the direction of health care
services so as to render the persons administering such services and the
services themselves more responsive to the needs and desires of Indian
communities;
…
VII. Addressing the Problem: Why a Uniform Operational Definition of Indian is Needed and
Potentially Permitted
v.7, 2012‐09‐23a
To ensure AI/ANs are able to access the Medicaid and Exchange-related special benefits and protections
that they are statutorily entitled to, and Exchanges are able to efficiently and consistently make accurate
eligibility determinations, it is critical that – to the greatest extent possible – a uniform operational
definition of “Indian” be employed.
For purposes of determining eligibility for ARRA-enacted Indian-specific Medicaid cost-sharing
provisions, HHS fashioned a single operational definition of Indian that was inclusive of the existing
definitions of Indian contained in federal law. In the same manner, fashioning such an operational
definition for purposes of the Medicaid and Exchange-related eligibility determinations would enable an
Exchange to carry-out the requirements established for an Exchange (e.g., to conduct a streamlined
eligibility determination process using a single application form) in an efficient and accurate manner.
More specifically, extending the 42 C.F.R. § 447.50 guidance that was developed for Indian-specific
Medicaid eligibility determinations as the uniform operational definition for both Medicaid and
Exchange-related eligibility determinations would provide such uniformity of definition.
In the Final Rule on the establishment of Exchanges which was promulgated on March 27, 2012, HHS
may have offered states the flexibility to apply such a uniform operational definition of Indian. 49
States Offered Flexibility in the Application and Verification of Definitions of Indian
In response to comments submitted to HHS regarding the definition of Indian and verification of an
individual’s status as an Indian, the following guidance was included in the preamble to the Final Rule:
We are maintaining the verification process described under § 155.350 in
this final rule. This verification is tied to a full exemption from costsharing,
which could involve a substantial expenditure for the Federal
government; consequently, we are specifying a more stringent process
for verification though we note that § 155.315(h) allows the Exchange
flexibility to modify this and other verification processes with HHS
approval. In addition, we note that the documentation process described
under § 155.350(c)(3) is similar to the documentation process utilized by
the IHS when determining eligibility for American Indians/Alaska
Natives who seek services at IHS facilities. 50 (Underline added.)
In this response, HHS indicated that verification of Indian status would be required (and a simple
attestation would not suffice), but the Exchange is afforded discretion in how it conducts the eligibility
verification.
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v.7, 2012‐09‐23a
The Final Rule response continued with the following, indicating that CMS recognizes that even the
definitions of Indian with the potentially greatest variance are still only “slightly different.”
The [Indian eligibility] standard for Exchanges is slightly different from the
[Indian eligibility] standard for such [IHS] services, however, which means that
the registration database for Indian Tribe, Tribal Organization, or Urban Indian
Organization programs may not be a one-to-one match. With that in mind, we are
working closely with the IHS and intend to work with States and tribes to
determine whether and how electronic data can support this process. 51
As referenced above, the definition used to determine eligibility for IHS services (which most closely
resembles the CMS § 447.50 Medicaid eligibility guidance) has the most inclusive definition of Indian,
and the Exchange-related definitions may be considered the most restrictive. 52 But still, these definitions
are considered only “slightly different”.
The language of 45 C.F.R. § 155.315(h) cited above which provides flexibility to Exchanges in
implementation of eligibility determination processes, reads as follows:
§ 155.315 (h) Flexibility in information collection and verification. HHS may
approve an Exchange Blueprint in accordance with § 155.105(d) or a significant
change to the Exchange Blueprint in accordance with § 155.105(e) to modify the
methods to be used for collection of information and verification of information
as set forth in this subpart, as well as the specific information required to be
collected, provided that HHS finds that such modification would reduce the
administrative costs and burdens on individuals while maintaining accuracy and
minimizing delay, that it would not undermine coordination with Medicaid and
CHIP, and that applicable requirements under § 155.260, § 155.270, paragraph
(i) of this section, and section 6103 of the Code with respect to the
confidentiality, disclosure, maintenance, or use of such information will be met. 53
(Underline added.)
As indicated, central to HHS approving a request by an Exchange for flexibility authorized under 45
C.F.R. § 155.315(h) is a determination that “HHS finds that such modification would reduce the
administrative costs and burdens on individuals while maintaining accuracy and minimizing delay, that it
would not undermine coordination with Medicaid and CHIP…” Given the number of definitions of
“Indian” involved and the nuanced differences across the definitions, the threshold requirements for
applying the § 155.315(h) authority would seem to be readily satisfied if an Exchange were to rely upon a
uniform operational definition of Indian, such as using the § 447.50 guidance from CMS, when
determining eligibility for the Medicaid and Exchange-related Indian-specific provisions.
A uniform operational definition would seem likely to result in –
Administrative costs on state Exchanges being lessened;
Paperwork burdens on individual AI/ANs being reduced;
The overall accuracy and consistency of eligibility determinations across Medicaid and ACArelated
provisions being increased;
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v.7, 2012‐09‐23a
Delays in accessing the special benefits and protections afforded AI/ANs through the Affordable
Care Act being reduced;
The seamless coordination between Medicaid and Exchange-related programs being furthered;
Participation by AI/ANs in the Exchange-related programs being heightened; and
Clarity across providers and QHPs in the application of Indian-specific benefits and protections
would be enhanced.
If it is ultimately determined that full uniformity across the application of the definitions of Indian to each
Indian-specific provision cannot be achieved, we strongly recommend that Exchanges use the CMS
guidance on eligibility and documentation provided under § 447.50 as the base for Indian-specific
eligibility determinations and identify specific exceptions (i.e., exclusions) from eligibility, as needed, for
any particular Indian-specific provision.
VIII. Conclusion
We encourage Exchange officials – whether operated by a state or HHS – to seek the flexibility that
appears to be available under the Affordable Care Act and its implementing regulations to fashion a
uniform operational definition of Indian to be used across the Medicaid and Exchange-related programs in
order to be able to carry-out a streamlined eligibility determination process using a single application
form, with the result being eligibility determinations conducted more efficiency and more accurately.
Previous eligibility guidance issued by CMS could be relied upon to implement the uniform operational
definition.
If it is determined that applying a single operational definition of Indian to each of the Indian-specific
benefits and protections is not agreed to by HHS, we recommend that an existing set of guidance
materials (namely the CMS Medicaid eligibility guidance for AI/ANs under 42 C.F.R. § 447.50) be used
as the basis for Indian eligibility determinations with specific exceptions to these rules identified where
necessary.
As stated previously, national and regional tribal organizations support the application of a uniform
operational definition of Indian for purposes of implementing the provisions of the Affordable Care Act.
These include NCAI, NIHB, TTAG, TSGAC and NPAIHB. 54 These organizations believe that providing
a uniform definition will ultimately lead to advances in the health status of AI/ANs by more effectively
matching available resources to the needs of eligible AI/AN individuals. We stand ready to continue to
work with state and federal Exchange officials to make the determination of Indian status an efficient and
effective process.
1 For a more detailed exposition of the issue of the definition of an Indian, see “Tribal Technical Advisory Group to
CMS, Analysis of and Comment on Definition of ‘Indian’ in Proposed Rules to Implement Provisions of the Patient
Protection and Affordable Care Act,” October 31, 2011, submitted to CMS and the IRS. (“TTAG Analysis”)
2
A separate paper will be prepared by Northwest Portland Area Indian Health Board (“NPAIHB”) discussing
verification materials for documenting Indian status.
3
The Indian Health Care Improvement Act (“IHCIA”), Pub. L. 94-347, was permanently reauthorized and amended
March 23, 2010, by § 10221(a) of the ACA. IHCIA § 103 reads, in part:
Congress declares that it is the policy of this Nation, in fulfillment of its special
trust responsibilities and legal obligations to Indians—
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v.7, 2012‐09‐23a
(1) to ensure the highest possible health status for Indians and urban Indians and
to provide all resources necessary to effect that policy;
(2) to raise the health status of Indians and urban Indians to at least the levels set
forth in the goals contained within the Healthy People 2010 initiative or
successor objectives;
(3) to ensure maximum Indian participation in the direction of health care
services so as to render the persons administering such services and the services
themselves more responsive to the needs and desires of Indian communities;
(4) to increase the proportion of all degrees in the health professions awarded to
Indians so that the proportion of Indian health professionals in each Service area
is raised to at least the level of that of the general population;
(5) to require that all actions under this Act shall be carried out with active and
meaningful consultation with Indian tribes and tribal organizations, and
conference with urban Indian organizations, to implement this Act and the
national policy of Indian self-determination;
(6) to ensure that the United States and Indian tribes work in a government-togovernment
relationship to ensure quality health care for all tribal members; and
(7) to provide funding for programs and facilities operated by Indian tribes and
tribal organizations in amounts that are not less than the amounts provided to
programs and facilities operated directly by the Service.
4
The Patient Protection and Affordable Care Act (Pub. L. 111-148) as amended by the Health Care and Education
Reconciliation Act of 2010 (Pub. L. 111-152), are collectively referred to herein as the “Affordable Care Act” or
“ACA”.
5
Health insurance exchanges (“Exchanges”) are to be available by October 1, 2013 in each State in order to allow
enrollment in new health insurance coverage options effective January 1, 2014. Exchanges are marketplaces for the
offering of health insurance coverage, mechanisms for determining eligibility for various government health
insurance programs, and vehicles for securing government assistance, if eligible, with covering all or a portion of the
health insurance plan monthly premiums.
6
ACA § 1501(b) / IRC § 5000A(e)(3).
7
See Federal Register, March 27, 2012, CMS, “Patient Protection and Affordable Care Act; Establishment of
Exchanges and Qualified Health Plans,” (CMS-9989-F), Vol. 77, No. 59, page 18346. (“Final Rule”) The
Department of Health and Human Services (HHS) and CMS did not opine on the definition of Indian pertaining to
the exemption from tax penalties afforded AI/ANs under ACA § 1501(b) as it falls within the Internal Revenue
Code. (See IRC § 5000A(e)(3).) CMS did determine that the two Exchange-related definitions (contained in the
IHCIA and the Indian Self-Determination and Education Assistance Act) “operationally mean the same thing.”
8
The position that these definitions are effectively and operationally the same is also held by numerous tribes and
tribal organizations, including the National Congress of American Indians (“NCAI”), the National Indian Health
Board (“NIHB”), the Tribal Technical Advisory Group to CMS (“TTAG”), the Tribal Self-Governance Advisory
Committee (“TSGAC”), and the Northwest Portland Area Indian Health Board (NPAIHB”), among others.
9
In a meeting of the Medicare, Medicaid and Health Reform Policy Committee of the National Indian Health Board
on February 21, 2012, IRS representatives indicated that the IRS likely would defer to the uniform determination
made by an Exchange as to who is “Indian” and as such qualifies for an exemption from tax penalties under the
ACA.
10
These cost-sharing protections for AI/ANs include those established under § 5006 of the American Reinvestment
and Recovery Act of 2009, Pub. L. 111-5 and those enacted as part of the Balanced Budget Act of 1997 (Social
Security Act § 1932(a)(2)(C).)
11
See 42 C.F.R. § 447.50, promulgated May 28, 2010. In particular, these regulations drew from the definitions of
Indian in the Snyder Act, the IHCIA, and the Indian Self-Determination and Education Assistance Act
(“ISDEAA”). A second set of Indian-specific Medicaid protections was enacted in the Balanced Budget Act of
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v.7, 2012‐09‐23a
1997. The provision amended section 1932(a)(2)(C) of the Social Security Act and is codified at 42 U.S.C. 1396u-
2(a)(2)(C), with regulations issued at 42 C.F.R. § 438.50(d)(2).
12
See discussion in the Final Rule at 77 Fed. Reg. 18383; and see 45 C.F.R. § 155.315(h) “Flexibility in information
collection and verification” at Final Rule, 77 Fed. Reg. 18455.
13
Again, the range of Indian-specific eligibility determinations include the cost-sharing and monthly enrollment
protections in the individual market through an Exchange, eligibility for Medicaid cost-sharing and managed care
protections, and the exemption from penalties for AI/AN not securing minimum essential coverage.
14
This issue is of concern under state-based Exchanges as well as the Federally-facilitated Exchange (FFE).
15 While these regulations and other materials demonstrate that the statutory definitions can be reconciled, mere
restatement of the statutory language is not sufficient to facilitate accurate eligibility determinations.
16 See Federal Register, Vol. 75, No. 148, August 3, 2010, Request for Comments, “Planning and Establishment of
State-Level Exchanges,” Section G. Enrollment and eligibility, Office of Consumer Information and Insurance
Oversight, HHS, page 45588, which includes “additional requirements to assist Exchanges by… simplifying and
coordinating enrollment in the Exchanges, Medicaid and the Children’s Health Insurance Program (CHIP).”
17 77 Federal Register 18346.
18
For example, on October 30, 2000, President Clinton signed into law H.R. 2883, the Child Citizenship Act of
2000. The new law, Public Law 106-395, amends the Immigration and Nationality Act (INA) to permit foreign-born
children — including adopted children — to acquire citizenship automatically and immediately if they meet certain
requirements, rather than having citizenship conferred only after an application process is completed. This law
became effective on February 27, 2001.
19
ACA § 1311(c)(6)(D) referring to section 4 of the IHCIA and codified at 25 U.S.C. 1603; ACA § 1402(d)(1) and
(2) referring to section 4(d) of the ISDEAA and codified at 25 U.S.C. 450 et seq.; and ACA § 1501(b)) creating
IRC § 5000A(e)(3) which refers to section 45A(c)(6) of the Internal Revenue Code.
20
The Internal Revenue Code.
21 The ISDEAA, Pub. L. 93-638.
22
The special monthly enrollment periods are described in 45 C.F.R. § 155.420(d)(8). An AI/AN may enroll in a
health plan or change from one health plan to another one time per month.
23
See ACA § 1402(d)(1) and (2). The additional cost-sharing protections are described in 45 C.F.R. § 155.300(a)
and (b)). Under ACA § 1402(d)(1), the cost-sharing protections encompass a waiver of all cost-sharing for an
AI/AN individual whose household income is not more than 300 percent of the Federal poverty level. Under ACA §
1402(d)(2), there is no cost-sharing for an AI/AN individual of any income level when furnished an item or service
directly or through referral by an Indian Health Care Provider. “Indian Health Care Providers” are comprised of the
Indian Health Service, Tribes and tribal organizations, and urban Indian organizations. Collectively, these entities
are also sometimes referred to as “I/T/U”. The Indian Health Service means the agency of that name within the U.S.
Department of Health and Human Services (“HHS”) established by IHCIA § 601 (25 USC §1661). The terms
“Indian tribe,” “tribal organization,” and “UIO” have the meaning given those terms in IHCIA § 4 (25 USC §1603).
The issuer of a health plan shall not reduce the payment to an Indian Health Care Provider by the amount of any
cost-sharing that would be due from an AI/AN but for this provision. The Secretary of HHS is to pay to the health
plan the amount necessary to reflect the increase in actuarial value of the plan required by reason of this provision.
24
The determination of eligibility for this exemption is not within the functions of an Exchange. The IRS has
responsibility for implementing this Indian-specific protection, which is found in IRC § 5000A(e)(3) and waives the
penalties for AI/ANs who do not maintain minimum essential coverage, although the IRS may rely upon an
Exchange’s determination of who is Indian for those individuals who have been determined to be “Indian” for
purposes of Exchange-related provisions.
25
Wording contained in IHCIA Sec. 4(14) and ISDEAA Sec. 4(d), except that the double underlined words (“or
group”) are only contained in IHCIA Sec. 4(14).
26
See TTAG Analysis, page 6.
27
TTAG October 2010; NCAI Res. # ABQ-10-080, November 2010, NIHB Res. 10-01, October 2010; TSGAC
February 2011; and NPAIHB, October 21, 2010.
Northwest Portland Area Indian Health Board Page 14 of 16

28 Final Rule, 77 Fed. Reg. 18346.
v.7, 2012‐09‐23a
29
Wording contained in IHCIA § 4(14), ISDEAA § 4(d), and IRC § 45A(c)(6), except that the underlined word
(“pueblo”) is only contained in IRC § 45A(c)(6) and the double underlined words (“or group”) are only contained in
IHCIA Sec. 4(14).
30
This is the result because pueblos are also considered to be Indian Tribes, nations, organized groups, and
communities recognized as eligible for the special programs and services provided by the United States to Indians
because of their status of Indians.
31
25 C.F.R. § 900.6 (HHS and Department of the Interior (―DOIǁ) Title I), 25 C.F.R. § 1000.2 (DOI Title IV), 42
C.F.R. § 137.10 (Title V). These regulatory definitions also include ―rancherias and colonies.
32
A significant percentage of American Indians and Alaska Natives that seek an exemption from the tax penalties
may not engage an Exchange as the AI/AN individuals may have determined not to pursue health insurance
coverage. For these individuals, it is assumed attestations would be made and/or documentation would be provided
directly to the IRS.
33
Public Law 105-33. The primary protection established is “A State may not require… the enrollment in a
managed care entity of an individual who is an Indian (as defined in section 4(c) of the Indian Health Care
Improvement Act of 1977 of 1976 (25 U.S.C. 1603(c)) unless the entity is one of the following [Indian
organizations] (and only if such entity is participating under the plan)… ”
34
For purposes implementing the protections afforded AI/AN in the Balanced Budget Act of 1997, see 42 C.F.R. §
438.50(d)(2).
35
In referencing subsection (c) of section 4 of the IHCIA, this definition of Indian is more restrictive than the
reference to “Indian” under the IHCIA for purposes of the special monthly enrollment period for AI/ANs enrolled in
the individual market through an Exchange (authorized under ACA § 1311(c)(6)(D)).
36
These cost-sharing protections for AI/ANs were established under § 5006 of the American Reinvestment and
Recovery Act of 2009, Pub. L. 111-5.
37
See 42 C.F.R. § 447.50, promulgated May 28, 2010.
38
The Snyder Act is the primary statute authorizing the Federal government to provide health care to Indians and
implementing the unique Federal obligations to Indians. It directs and authorizes HHS to “direct, supervise, and
expend such moneys as Congress may from time to time appropriate, for the benefit, care, and assistance of the
Indians throughout the United States” for the “relief of distress and conservation of health.” 25 U.S.C. § 13.
39
Medicaid Program; Premiums and Cost Sharing, 75 Fed. Reg., No. 103, pp. 30, 244, 30,248 (May 28, 2010).
40
Medicaid Program; Premiums and Cost Sharing, 75 Fed. Reg., No. 103, p. 30247.
41
For example, in a recent Section 1115 waiver application from the State of Kansas, a single operational definition
of Indian was applied to both sets of Indian-specific Medicaid protections.
42
Federal Register, Vol. 75, No. 148, August 3, 2010, Request for Comments, “Planning and Establishment of
State-Level Exchanges,” Section G. Enrollment and eligibility, Office of Consumer Information and Insurance
Oversight, HHS, page 45588.
43
ACA § 1311 and 45 C.F.R. § 155.100.
44
ACA § 1413(b) and 45 C.F.R. § 155.405(a). “CHIP” refers to the Children’s Health Insurance Program under
title XXI of the Social Security Act.
45
An additional approach to streamlining eligibility across federal programs is the implementation of a common
methodology (“modified adjusted gross income”) for determining household income, as authorized by ACA § 1401
/ IRC § 36B(d)(2)(B).
46
Conversely, as it appears to occur today under Medicaid, to simplify implementation a state or a subset of
Exchange/Medicaid eligibility staff in a state might default to applying one definition for all Indian-specific
purposes in a state. AI/ANs applying on one occasion or in one state may be found to be eligible whereas the same
AI/ANs would be found to be ineligible on another occasion or in another state, or vice versus.
47
Such as grantees under the Navigator program authorized under ACA § 1311(i) or “in-person assisters”. See 45
C.F.R. § 155.210.
Northwest Portland Area Indian Health Board Page 15 of 16

v.7, 2012‐09‐23a
48
Enacted through the passage of the ACA, Congress made the declarations of national Indian health policy in
IHCIA § 103.
49
See discussion in the Final Rule at 77 Fed. Reg. 18383; and see 45 C.F.R. § 155.315(h) “Flexibility in information
collection and verification” at Final Rule, 77 Fed. Reg. 18455.
50
Final Rule, 77 Fed. Reg. 18383.
51
Final Rule, 77 Fed. Reg. 18383.
52
An additional definition is used for purposes of determining eligibility for services through the Indian Health
Service, although this generally aligns with the guidance under 42 C.F.R. § 447.50.
53
Final Rule, 77 Fed. Reg. 18455.
54
NCAI Res. # ABQ-10-080, November 2010, NIHB Res. 10-01, October 2010; TTAG October 2010; TSGAC
February 2011; and NPAIHB, October 21, 2010.
Northwest Portland Area Indian Health Board Page 16 of 16

[Type text] [Type text] [Type text]
CALIFORNIA RURAL INDIAN HEALTH BOARD
ANALYSIS OF MEDICAID
PAYMENTS FOR
AMERICAN INDIANS &
ALASKA NATIVES
Centers for Medicare and Medicaid Services:
American Indian & Alaska Native Data Project
FEEDBACK DRAFT for the Tribal Technical Advisory Group
C M S T R I B A L A F F A I R S G R O U P
2012

Prepared by
James Crouch MPH Chair, CMS TTAG Data Subcommittee
and Carol Korenbrot PhD
California Rural Indian Health Board Inc.
Funded by
The Centers for Medicare and Medicaid (CMS) Tribal Affairs Group through the National Indian Health
Board pursuant to an award from the Indian Health Service (IHS), following an intra-departmental
delegation of authority (CMS IDDA-09-50 and IHS 2-RAP-09-0080-DA).
Please provide feedback to:
California Rural Indian Heath Board (CRIHB)
Phone: 916.929.9761
Fax: 916.929.7246
Email: carol.korenbrot@crihb.net

Contents
SUMMARY I
Findings .......................................................................................................................................................................................................... ii
Conclusions and Recommendations .................................................................................................................................................. iii
INTRODUCTION 1
Purpose of this Report .............................................................................................................................................................................. 2
METHODS 3
Data Sources ................................................................................................................................................................................................. 3
Medicaid-IHS Linked Person Summary File ............................................................................................................................... 3
Medicaid Inpatient, Prescription Drug and Other Services Claims Files ........................................................................ 3
Analysis Groups ........................................................................................................................................................................................... 4
IHS AIAN .................................................................................................................................................................................................... 4
Other AIAN ............................................................................................................................................................................................... 5
Whites (Non-Hispanic) ........................................................................................................................................................................ 5
Analysis Plan ................................................................................................................................................................................................. 6
Outcome of Analysis: Mean Total Payment per Medicaid Recipient ................................................................................ 6
Determinants of the Outcome .......................................................................................................................................................... 7
Statistical Adjustments ........................................................................................................................................................................... 15
FINDINGS 19
Payments for AIAN Medicaid Recipients ........................................................................................................................................ 19
Recipients with Fee-for-Service Medical Services ................................................................................................................. 19
Recipients in Medical Comprehensive Managed Care Plans (CMCP) ............................................................................. 28
Compiled Findings for All Analyses and Areas ........................................................................................................................ 32
Medicaid Paid Fraction of Total Health Care Costs of IHS Active Users ............................................................................ 37
IHS Calculated Health Care Costs for IHS Active Users ........................................................................................................ 37
Medicaid Fraction of IHS Active User Health Care Costs ..................................................................................................... 38
Medicaid Fraction Paid to IHS and Tribal Providers for IHS Active Users ................................................................... 39
CONCLUSIONS AND RECOMMENDATIONS ..................................................................................................................................... 41
IHS AIAN Payments Compared to Others ....................................................................................................................................... 41
Medicaid-enrolled IHS Active Users without IHS Program Medicaid claims .................................................................. 42
Medicaid-paid Fraction of IHS Active User Costs ........................................................................................................................ 42
REFERENCES 43

Summary
T
he Indian Health Service (IHS) provides only part of the health care needed by the American Indians and
Alaska Natives (AIAN) who rely on the IHS health care system because of the limited funding
appropriated to the agency by the federal budget. The largest alternate resource to IHS for the health
care funding of AIAN who rely on the IHS health care system is Medicaid. Medicaid pays for care received
not only at the IHS and tribally operated health care facilities, but from other providers when specialized or
emergency care is needed. The federal Medicaid program pays 100% of state Medicaid claims from IHS health
care system providers for IHS funded services provided to AIAN (IHS Program claims). Together with its
companion program, the Children’s Health Insurance Program (CHIP), Medicaid has grown to provide a
substantial but largely unknown fraction of the coverage of health care for the AIAN who use the IHS system.
The first objective of this report to determine whether Medicaid (including the Medicaid portion of CHIP not
operated by states alone) pays as much for the personal health care services of AIAN who rely on the IHS system
of health care providers (IHS AIAN) as it does for other Medicaid recipients. If the per capita amounts paid for
the IHS AIAN are comparable to those of others, then a basic measure of health care equity for AIAN served by
the IHS system has been achieved. If not then efforts are needed to achieve equity.
A second objective is to determine whether there are any Areas of the IHS health care delivery system, or
subgroups of AIAN who rely on the IHS system that do not have Medicaid payment levels as high as those of
other AIAN subgroups served by the IHS System. Where the payment levels for IHS AIAN are not as high as
those of others in an Area, it can be because IHS AIAN have more difficulties obtaining Medicaid paid care, or
because the state and IHS system provider need to work more closely to see that Medicaid claims are filed and
paid successfully. If IHS system providers do not file and collect claims for services provided to Medicaid
enrolled AIAN they serve, they are in effect substituting IHS funding for Medicaid funding of health care costs. In
this report, analyzing only the Medicaid data of the counties of the IHS Areas allows comparison of payments
across IHS Areas and using Medicaid data that has been linked with IHS registry data allows examination of
AIAN subgroups served by the IHS System.
A third objective of this report is to determine what fraction of the personal health care costs of the AIAN user
population of the IHS system is actually provided by Medicaid payments. The IHS has current data on the
Medicaid collections of the IHS and tribal facilities that they operate, but not the tribal facilities operated by
tribes. About one-third of the IHS system facilities are tribally-operated facilities. The IHS estimates that about
25% of the per capita costs of health care needed by AIAN they serve is paid by third-parties including Medicaid,
Medicare and private insurance. The AIAN survey data on which this calculation is based is now more than 20
years old, however. Medicaid payment data provides a way to update the Medicaid portion of the third-party
payment fraction. In addition it offers a way to estimate how much this Medicaid fraction varies across IHS
Areas. Determination of the fraction is critical because the IHS estimates that it provides only about 54% of the
per capita costs of health care needed by AIAN they serve. The extent to which the 25% fraction is too high,
underestimates the remaining unmet health care need of the AIAN, the extent to which the 25% fraction is too
low overestimates the unmet health care need. The IHS allocates new federal funds it receives to the IHS and
tribally-operated facilities based on its calculated estimates of the unmet health care need of the AIAN served by
the facilities.
To achieve the first two objectives, after excluding longterm care and institutionalized Medicaid recipients the
per capita payments for six different types of Medicaid recipients of the remaining medical, behavioral health

Summary
and dental services were analyzed with data from 2006. Medicaid recipients were classified depending on
whether they were under age 65 or not, enrolled all year in Medicaid or not, and whether they received only feefor-service
medical care or had any of their medical services in managed care. The payments for each type of
Medicaid recipient were risk-adjusted for differences between the IHS AIAN and comparison groups with
respect to age, sex, disability, and dual-enrollment with Medicare. Adjustments for differences among the
groups in morbidity were possible for those enrolled all year in Medicaid. The payments were also adjusted for
variation in health care prices across the IHS Areas.
To achieve the third objective, the unadjusted mean per capita payments were determined for all AIAN Medicaid
recipients who used IHS system providers in each Area, except those with institutionalized or longterm care.
These payments were divided by the IHS estimated per capita health care costs for a standard personal health
care service plan for AIAN in each IHS Area in 2006-2007 adjusted for differences in age, sex, health status, and
health care prices. These adjusted per capita health care costs indicated the different payment amounts
required in the different Areas from all payers combined to provide the AIAN in the Area the health care they
need.
Findings
The total amount of Medicaid funds paid for personal health care services in 2006 for 550,000 IHS AIAN
Medicaid enrollees living in the service delivery Areas of IHS and tribally operated facilities for paid personal
health care services was $ 2.05 billion. An additional $15 million was paid by other third-party payers (mainly
private insurance) to cover payments for the claims filed with Medicaid. Of those IHS AIAN Medicaid enrollees
496,000 were recipients of Medicaid paid services during the year full or restricted benefits. For the 472,000
recipients with full benefits $420 million was paid to IHS and tribally operated health care facilities or their
providers of Contract Health Service referral care.
Overall Medicaid risk-adjusted payments for personal health care services of IHS AIAN were higher than selfdeclared
AIAN who did not use the IHS health care system and of whites living in the same counties.
There were exceptions to the general finding in four of the 12 IHS Areas where risk-adjusted payments were
lower: In Aberdeen and Billings Areas the payments were lower for most types of Medicaid recipients analyzed
when compared to those of self-declared AIAN who did not use the IHS system or whites. In Albuquerque Area
the payments overall were lower for whites, but higher for self-declared AIAN. In Oklahoma Area the payments
were lower for self-declared AIAN, but higher for Whites.
The overall results did not depend on whether the payments were adjusted for differences in morbidity or not,
or whether IHS AIAN Medicaid recipients received their medical care in a fee-for-service or managed care
system. The medical care services that contributed most to fee-for-service payments for IHS AIAN was
outpatient care, rather than hospital care or prescription drugs. There were very little if any contribution of IHS
Program Medicaid claims for prescription drugs to the Medicaid payments for IHS AIAN outside of Bemidji Area.
One subgroup of AIAN served by the IHS system had much lower risk-adjusted payments than any other AIAN
or white comparison group. This group was that of AIAN who were identified as IHS Active Users in the IHS
data, and had Medicaid paid claims, but no Medicaid IHS Program paid claims. This group who constituted 33%
of the IHS AIAN Medicaid recipients consistently had lower payments across all IHS Areas. The lower payments
for IHS AIAN who were Active Users without IHS provider claims were found even among Medicaid recipient
types where differences in morbidity could be adjusted. The persistence of this affect across all IHS Areas and
Medicaid recipient types implied that IHS these AIAN were potentially receiving IHS services from IHS system
ii

Summary
providers that were either not being billed or paid or both. This would be substitution of limited IHS funding for
Medicaid covered care.
The ‘Medicaid fraction’ of health care costs needed by the IHS AIAN Active User population that is paid by
Medicaid (and Medicaid-CHIP) for personal health care costs is at least 25% in 9 of 12 IHS Areas, but varies
from 19% to 65% depending on the Area. Areas with the lowest fraction of about one-fifth are Nashville (19%)
and Oklahoma (21%). Aberdeen, California, Albuquerque, Portland and Bemidji Areas have mid-range fractions
of between a little more than one quarter and a little less than one-third (27% to 31%). Alaska and Billings are
in the middle of the Area rankings with a little more than one-third of the costs paid by Medicaid (34% to 38%).
It was found that very high Medicaid payments in the state of Arizona for AIAN contributes to the highest
Medicaid fractions found: nearly one half for Navajo and Phoenix Areas (46% and 49% respectively) and nearly
two-thirds (65%) in Tucson Area.
Conclusions and Recommendations
The findings reported here from 2006 support the general conclusion that in most Areas the IHS system
providers and the state Medicaid programs with which they interface in these Areas were as a whole are doing
well at billing and collection for services provided to AIAN Medicaid recipients in the IHS system.
In Aberdeen, Billings, Albuquerque and Oklahoma Areas, it is possible that either the IHS system or others who
provide Medicaid paid care could improve billing and collection. Alternatively, in Albuquerque Area the reason
that lower payments were found only compared to self-declared AIAN who do not use the IHS system could be
because these other AIAN have higher demands for health care when ill because they are not in the IHS system.
The morbidity risk-adjustment is only a partial adjustment for health status differences, because it depends on
the extent to which people use their Medicaid health care provider for completeness.
In every IHS Area there were IHS Active User Medicaid recipients for whom billing and collection could be
improved. This group with no IHS Program claims and such low risk-adjusted Medicaid payments that it is
likely that their IHS system providers are not billing or collecting for a portion of the care of these AIAN they
serve. In addition, IHS system providers were not billing or collecting for prescription drugs.
The IHS estimation of unmet need of the AIAN user population for health care funding needs to use more
recent Medicaid payment data and recognize higher levels of coverage of the health care costs by Medicaid and
Medicaid-CHIP programs, and the variation of the coverage across IHS Areas. Data like that analyzed in this
report but restricted to services included in the Federal Equivalent Health Benefit plan. Medicaid benefits vary
in the state programs, though more and more states are starting to provide only the mandatory services, and
dropping the optional benefits that made the services provided across states particularly variable.
iii

Introduction
The Indian Health Service (IHS) provides only part of the health care needed by the AIAN who rely on the IHS
health care system because of the limited funding appropriated to the agency by the federal budget process.
Funding of the agency has grown in recent years but has not caught up with the growth of the low income AIAN
population, the amount or kinds of specialized care needed, and the increases in health care costs. The IHS
estimates that they provide only 54% of the health care funds needed for the AIAN user population.
The largest and most important alternate resource to IHS for the health care funding of AIAN who rely on the
IHS system is Medicaid. Together with its companion program, the Children’s Health Insurance Program (CHIP),
Medicaid has grown to provide a substantial but largely unknown fraction of the coverage of health care for the
AIAN user population of the IHS system. Though the numbers of the user population enrolled in Medicaid and
CHIP has grown substantially over the years, it has been a challenge for IHS and tribally operated health care
facilities accustomed to annual appropriations of federal funds to bill and collect daily claims payments from
state Medicaid programs or private Medicaid managed care plans. Even with Medicaid coverage, it can also be a
challenge for AIAN to obtain the specialty medical care and non-medical services they need from providers
outside the IHS system when they are required.
There has been little reliable data on how much Medicaid funding has grown to cover care the Medicaid enrolled
user population of the IHS system of providers since a household survey of AIAN who rely on the IHS system
was conducted in 1987. While the IHS releases its estimates of total funds gathered from third-parties annually
for the facilities they operate, it is not known how this compares to what is collected at tribally operated
facilities, nor how it breaks down on a per capita basis.
We previously analyzed Medicaid MSIS online data for 2005 on paid claims to IHS system providers on a stateby-state
basis for 2005 (Crouch et al, 2009). That aggregate data could not be used to determine the per capita
funding, or portions of funds spent on IHS system and other providers. The data within states was often from
more than one IHS Area. We then analyzed data extracted from the MSIS data into analytical files for 2004 and
provided estimates of per capita payments for AIAN who had Medicaid (or Medicaid-CHIP) IHS Program claims
in each IHS Area (Crouch et al, 2010). This data could also be compared to per capita payments for AIAN who did
not have such claims and were likely not to have access to the IHS system. It could also be compared to per
capita payments for non-Hispanic Whites living in the same counties. But it could not be determined what the
total number of AIAN Medicaid enrollees who were users of the IHS system. The extent to which there were
AIAN users of the IHS system without Medicaid IHS Program claims paid was an important factor in
determining the potential amounts of funds that IHS system providers might not be collecting.
The data needed to reliably estimate what Medicaid (and Medicaid-CHIP) contribute to cover the health care
costs of AIAN who are users of the IHS system is Medicaid payment data linked to IHS registry data. With such
linked data it is possible to determine how per capita levels of payment for AIAN in the IHS system compare
with those for AIAN not in the system, and to what extent AIAN in the IHS system with Medicaid paid claims do
not have Medicaid IHS Program paid claims. Even more importantly, with Medicaid data linked to IHS registry
data it is possible to determine the fraction of total health care costs of the AIAN user population in the IHS
system is paid by Medicaid and Medicaid-CHIP programs.
1

Introduction
Reliable determination of the proportion of AIAN health care costs covered by this largest source of third-party
payments in the IHS system is critical. To determine how to allocate any new funds that it receives for health
care services among its system providers, the IHS calculates the unmet need for health care funds of the AIAN
user population of its system providers by subtracting from the total calculated need the amount of funding
provided by both the IHS and these alternate sources. The IHS uses data from that 1987 household survey of
AIAN to estimate that Medicaid, Medicare and other third party coverage provides to allocate new health care
funds to IHS and tribal facilities. Because of the relative unreliability of the aging household survey data, they
estimate that a fixed 25% of the health care funds needed at any given Service Unit in the system is provided by
third-party payers. They are unable to determine how this varies across the service delivery areas of the
various Service Units.
Purpose of this Report
The first objective of this report is to determine how much the Medicaid and Medicaid-CHIP programs pay for
the personal health care services of AIAN served by IHS provider system, and then compare those payment
levels to how much is paid for AIAN without access to the IHS system of care, and for non-Hispanic white people
living in the same counties. To achieve this objective it is necessary to understand how variation in enrollee
characteristics and Medicaid payment systems determine the differences in the Medicaid funds paid for the
three groups. Then adjusting for these determinants, we analyze how Medicaid payments for the three groups
vary across the IHS Areas for all three groups of Medicaid enrollees.
A second objective is to determine what fraction of the IHS Active User population with Medicaid paid claims,
does not have any IHS Program Medicaid paid claims and whether their per capita costs are lower than
expected compared to IHS Active Users with IHS Program Medicaid paid claims, and the other AIAN and white
comparison groups. If their Medicaid per capita payments are lower than the other groups after adjustments
for determinants of payment differences, this implies that the rest of their health care costs are not being paid to
IHS providers by Medicaid. To achieve this objective we divide the IHS system users with Medicaid paid claims
into those who were IHS Active Users without IHS Program Medicaid paid claims and those with IHS Program
Medicaid paid claims and determine how adjusted Medicaid per capita payments compare for the two groups
across the IHS Areas. We also compare how payments for IHS Active Users without IHS Program Medicaid paid
claims compare to those of the AIAN and white comparison groups not in the IHS system.
A third objective of this report is to determine what percent of health care funding needed for personal health
care services of AIAN calculated by the IHS is actually provided by the Medicaid and Medicaid-CHIP payments.
How reliable is the assumption based on 1987 data that as much as 25% of the health care costs are met by
Medicaid funds? How reliable is the assumption that the proportion of Medicaid paid health care coverage is
unvarying across the IHS Areas?
2

Methods
I
n this section we describe technical issues regarding the Medicaid and IHS linked data and its
analysis in this report. The term ‘Medicaid data’ in this report includes both Medicaid and CHIP
data in state Medicaid programs (M-CHIP), but not CHIP data for state-only CHIP programs.
Medicaid and M-CHIP data are combined because, 1) there are small numbers of AIAN found to
have CHIP coverage in the IHS Areas in our past studies (American Indian and Alaska Native Medicaid
Program and Policy Data, 2010); 2) there is no State-only CHIP program data uniformly collected by
Medicaid; and 3) Medicaid expansion CHIP program data is required of Medicaid state programs and
is included in Medicaid data. Those readers interested in separate Medicaid and M-CHIP data
specific to each IHS Area for 2006 presented in exactly the same format as we did for 2004 data in
2010, please see the separate companion document we prepared with the enriched (linked) data
used in this report: AIAN Medicaid Data Linked to Indian Health Service Data: Medicaid and CHIP
Enrollment, Service Use and Payments, 2011.
Data Sources
Medicaid-IHS Linked Person Summary File
In 2011 we linked the CMS federal Medicaid/CHIP (MAX) Person Summary File for Calendar Year
(CY) 2006 to IHS registration data from the IHS National Data Warehouse (NDW). The methods and
linkage, and the resultant contents of the data file created are described in Integrating Medicaid and
Indian Health Service Data, 2011. The MAX Person Summary Files included in the linkage were state
files for the 35 states with IHS Contract Health Service Delivery Area (CHSDA) counties.
Medicaid Inpatient, Prescription Drug and Other Services Claims Files
The CMS-IHS linked Person Summary File made in 2011 was merged with MAX Inpatient,
Prescription Drug and Other Services claims files for Calendar Year (CY) 2006 by MAX identification
numbers. Claims paid for services in Fee-for-Service (FFS) delivery of care systems, and for
premiums paid in capitated (CAP) systems were provided for services that occurred in CY2006.
Payments processed through May 2007 were included in the MAX claims files, however. In this way
adjustments for adjudicated claims or payments among multiple payers are likely to have been
resolved so that payments represent amounts as close to ‘final’ as possible. In addition diagnostic
information was provided with paid claims in FFS delivery of care systems, and with encounter
records in CAP managed care plan systems.
3

Analysis Groups
IHS AIAN
Methods
The linkage of IHS registry and Medicaid data files in 2011 resulted in three groups of Medicaid
enrollees who obtain services from IHS programs (‘IHS AIAN’), two of which had Medicaid claims
from Indian health program providers for IHS ‘covered’ services in 2006, and a third group of which
did not:
1. Medicaid Recipients with IHS Program Claims who are IHS Active Users
IHS AIAN in Group 1 are Medicaid enrollees with Medicaid claims from IHS or Tribal Indian (I/T)
healthcare providers in the state who have designated by the state/tribe/Indian provider as AIAN
whose Medicaid IHS Program claims for IHS ‘covered’ services are eligible for 100% matching funds
from the federal Medicaid program (100% FMAP).
IHS AIAN in Group 1 were found to be defined by the IHS as AIAN ‘Active Users’ in their data registry
system. These IHS Active Users have had a medical or dental visit from an Indian healthcare
provider within a period of three years. A ‘2006 IHS AIAN Active User’ had at least one visit to an
IHS, tribal or Urban Indian health program service provider between October 1, 2004 and
September 30, 2006.
Table 1. Analysis groups resulting from linkage of Indian Health Service (IHS) and Medicaid (MAX) data sources.
Analysis Groups Includes Definition
IHS AIAN
Other AIAN
Whites, Non-Hispanic
1. Medicaid
‘IHS Program’ Recipients
& IHS ‘Active Users’
2. Medicaid
‘IHS Program’ Recipients
3. IHS ‘Active Users’ who are
Medicaid Recipients
Medicaid
‘Racial AIAN’ Recipients not
included in the IHS AIAN
subgroups
Medicaid
‘Racial White Recipients
without Hispanic Ethnicity’
4
Medicaid Enrollees who meet both the
definition of IHS Program Recipients &
IHS Active Users in a given year
Medicaid Enrollees with
at least one paid claim
for an ‘IHS Program’ provided service
IHS Active Users had at least one medical
service from an IHS system provider in 3
years according to IHS, but there is no
Medicaid paid claim for an ‘IHS Program’
provided service in the year of analysis
Race code in the data is ‘AIAN’ either as
the only Race, or in addition to any other
Races, regardless of Hispanic Ethnicity
Race code in the data is ‘White’ as the
only Race, with no Hispanic Ethnicity

Methods
2. Medicaid Recipients with IHS Program Claims who are not IHS Active Users
IHS AIAN in Group 2 are Medicaid enrollees with IHS Program claims for IHS ‘covered’ services
from an I/T provider as in Group 1, but they were not found in the IHS data registry system as IHS
AIAN Active Users. These enrollees may not link as IHS Active Users because: 1) federal Medicaid
criteria for IHS Program users are not the same as IHS criteria for AIAN Active Users and these
enrollees meet the federal Medicaid criteria; 2) the method of the state Medicaid program for
meeting federal Medicaid criteria for IHS Program users subject to 100% FMAP is not sufficiently
specific; 3) not all IHS Active Users have a record in the IHS NDW (the number of 2006 IHS Active
Users in the NDW is 86% of the total 2006 IHS Active User count).
3. Medicaid Recipients without IHS Program Claims who are IHS Active Users
IHS AIAN in Group 3 were Medicaid enrollees with Medicaid claims (recipients) found to be defined
by the IHS as AIAN ‘Active Users’ in the IHS data registry system, but without any IHS Program
claims in the Medicaid data. These Medicaid enrollees may link to the IHS Active User data because:
1) they used an IHS or tribal health program at least once in 2004 or 2005, but not in 2006; 2) they
could have used an IHS or tribal health program in 2006 but the encounter did not result in a
Medicaid paid claim (perhaps because the IHS Program provider was a Medicaid managed care
network provider and received a payment from the managed care plan not Medicaid); or 3) they
could have used an Urban Indian health program which are included in IHS Active User
determination, but not Medicaid IHS Program use determination (only IHS and tribally operated
health programs are included in Medicaid determinations of claim payments eligible for 100%
FMAP).
Other AIAN
The ‘Other AIAN’ were Medicaid enrollees with a self-declared race code of “AIAN” who had
Medicaid claims, but did not have any IHS Program Medicaid claims and did not link to the IHS
Active User registry. Since these AIAN live in the counties of the service delivery areas of Indian
healthcare providers (IHS CHSDA Counties) they can be AIAN who do not meet the stricter criteria of
‘AIAN’ required by the local tribes or IHS Program provider to be able to receive IHS covered
services at no charge, or who do meet those criteria but do not choose to use an IHS or tribal health
program, or who require more specialized or institutional care not provided by the IHS Program or
its Contract Health Service system. These Medicaid enrollees may also have failed to link to the IHS
registry because of data limitations of the Medicaid and IHS data systems for a linkage (accurate and
complete data for Social Security Number, date of birth and gender).
Whites (Non-Hispanic)
A random sample cohort of Medicaid enrollees with a self-declared race code of “White” and no
“Hispanic” ethnicity code was constructed from the same counties of the IHS healthcare system as
the IHS AIAN groups (IHS CHSDA Counties). The sampling procedure is described in the 2011 report
Integrating IHS and Medicaid Data . For this analysis the White enrollees are restricted to Medicaid
recipients with Medicaid claims, since the AIAN groups had to have claims to be defined. Recipients
have used at least one Medicaid paid service. We selected White non-Hispanics as the reference
5

Methods
group for the statistical models used in this report to adjust for undetermined differences in
Medicaid programs across the IHS Areas at the county level, and measure adjusted Racial Disparities
in morbidity and Medicaid payments.
Analysis Plan
The questions to be answered by the analyses are, 1) What variables determine the mean total
payment per recipient for IHS AIAN, Other AIAN and Whites? and if those determinants are adjusted,
2) What are the adjusted mean payments for IHS AIAN across the 12 IHS Areas? And 3)How can
those mean payments be used to determine what Medicaid pays for IHS AIAN Active User health
care costs? In this Methods section we restrict the study groups in a systematic way step by step
making the analytical groups more homogeneous and more and more representative of the groups
we mean to compare. We then build models that adjust for determinants that affect large numbers of
recipients In Findings Section I we present the findings from those models that test for the effects of
potential determinants on the payment outcome. In Findings Section II we see how those effects
affect the fraction of the mean total payment per IHS Active User that is paid by Medicaid for the 12
IHS Areas.
Outcome of Analysis: Mean Total Payment per Medicaid Recipient
The analysis is governed by selection of the dependent – or outcome – variable used in the analyses
to measure payments. Particular care has been taken to target the Mean Payment per Person
measure that is most relevant to the goal that we were commissioned to investigate: identify the
contributions of characteristics of the IHS AIAN, state Medicaid programs and the IHS system of
healthcare to Medicaid program payments for medical, dental and behavioral health care of IHS
AIAN. Specific objectives are to determine how those characteristics vary for IHS AIAN across the
twelve IHS administrative areas, and how those characteristics differ for other AIAN and for whites
who also live in the counties of the IHS Areas.
Because of the varying role of private insurance in total payments for Medicaid claims in certain IHS
Areas (in particular, Nashville Area) we include Third Party Payments in the outcome measure for
the analyses and analyze the Total Payment to avoid bias in analyses across IHS Areas (Attachment
Table C.1). Third Party Payments for Medicaid and CHIP program claims can be paid in part by third
parties, rather than the Medicaid or CHIP programs themselves. Third Party Payments for Medicaid
program claims are mainly private insurance payments for Medicaid enrollees under age 65, and
Medicare payments for those over age 65.
Because of differences in systems of claims and payments for acute medical care in Fee-for-Service
(FFS) and capitated Comprehensive Managed Care Plans (CMCP, medical managed care plans), we
analyze results separately for these two groups. Within each group, however, we sum paid claims
and monthly premium (Capitated) paid claims for Prepaid Health Plans (PHP, behavioral health and
dental managed care plans) for both FFS and CMCP recipients, and Primary Care Case Management
6

Methods
(PCCM), for some enrollees in FFS medical care). Enrollees with total payments less than $1 were
excluded since claims with Medicaid payments of $0 and negative values (adjustments to prior paid
claims) were included in MAX data (Attachment Table C.3). Outlier values for Medicaid payments
(top 1%) were excluded because of the added skew to mean values while in practice these outliers
are usually relegated to reinsurance mechanisms of payment.
Determinants of the Outcome
Institutionalized and Longterm Care
Medicaid Enrollees in institutionalized and longterm care are excluded from analysis because their
care includes services related to living expenses that are not acute medical or dental care.
Longterm care and institutionalized enrollees include the elderly who need assistance for daily
living, as well as the developmentally disabled and longterm psychiatric inpatients. When payments
for longterm care and institutionalized enrollees are excluded from Total Payments, what remains
is the breadth of medical and dental care covered by Medicaid for acute medical episodes of care.
Total payments per enrollee for the Medicaid covered service are more than 10 times as high as the
medical and dental acute care services per enrollee (See Table 2). As a result, small differences in
institutionalized and longterm care payments can make large differences in mean Total Payment
per Enrollee. For example, when longterm and institutionalized care payments are included, the
mean payment for IHS AIAN is $4,314 (95% Confidence Limits, C.L. $4,274 and $4,354) which is
lower than the $4,785 mean payment for Whites (C.L. $4,758 and $4,812). But when longterm and
institutionalized care payments are excluded, the mean payment for IHS AIAN is higher $3,759 (C.L.
$3,725 and $3,794) than the $3,058 mean payment for Whites (C.L. $3,040 and $3,076).
Furthermore only 1% of IHS AIAN who are Medicaid enrollees use Medicaid covered longterm care,
while 5% of Whites do (calculated using numbers in Table 2). For IHS Area-specific mean Total
Payments per Enrollee including longterm and institutionalized care see Attachment Table C.1. For
numbers and payments for enrollees with longterm and institutionalized care in each Area see
Attachment Table C.2.
Table 2. Mean Medicaid and Third Party payments per Medicaid enrollee with and without institutionalized and
other long-term care for the main study groups. The lower and upper 95% Confidence Limits of each mean are
shown.
Analysis Groups*
Longterm & Institutional Care
IHS AIAN 8,337
Other AIAN 4,488
Whites, Non-Hispanic 64,831
Other Enrollees
Enrollees*
IHS AIAN 550,016
Other AIAN 176,046
Whites, Non-Hispanic 1,232,415
Medicaid Third Party Total
Mean +/- C.L. Mean +/- C.L. Mean +/- C.L.
$ 38,414 $ 308 $ 200 $ 13 $ 38,614 $ 308
$ 37,137 $ 892 $ 187 $ 58 $ 37,324 $ 894
$ 45,771 $ 1,818 $ 167 $ 38 $ 45,939 $ 1,819
$ 3,732 $ 34 $ 27 $ 5 $ 3,759 $ 35
$ 2,576 $ 66 $ 23 $ 3 $ 2,599 $ 66
$ 2,995 $ 17 $ 63 $ 8 $ 3,058 $ 18
7
Total Payment per Enrollee
*The state of Arizona could not be included because of the large numbers of enrollees in longterm care without data on
payments.

Enrollees with no Payments
Methods
Medicaid Enrollees with no Medicaid Payment are excluded from analysis, and thus the outcome
variable is Mean Total Payment per Recipient, not per Enrollee. Medicaid program payments
depend on whether an enrollee has a Medicaid paid service or not. Enrollees must have a Medicaid
paid claim to have any Medicaid payment regardless of whether that claim is paid to a provider for
a medical or dental service, or to a managed care plan for a monthly premium. Two of the IHS AIAN
subgroups in Table 1 were required to have at least one Medicaid paid claim by definition,
‘Medicaid Enrollees with IHS Program Claims’ (those who were IHS Active Users, and those who
were not). As a result the percent of IHS AIAN who had $0 Total Payments was 10%, while for the
two comparison groups Other AIAN and Whites, 13% of the Medicaid enrollees had $0 Total
Payments. Furthermore within IHS Areas the percents of IHS AIAN with $0 Total Payments varied
from a low of 1% in California to a high of 20% in Phoenix and Tucson (Attachment Table C.3). Thus
to avoid the bias created when analysis groups have varying proportions of enrollees with no
Medicaid paid claims, we exclude Medicaid Enrollees with $0 Total Payments. The enrollees who
remain are termed ‘Recipients’ of services by CMS we therefore analyze Total Payment per
Recipient for all analysis groups where a Recipient is a Medicaid Enrollee who receives at least one
paid service claim or one month’s premium paid for managed care. Operationally the enrollee
exclusion criterion technically was enrollees with Total Payments less than $1. Though all
payments in MAX data were rounded to the nearest dollar, there were some claims of less than $0
as a result of payment adjustments removing all Medicaid payments for the year.
Table 3. Mean Medicaid and Third Party payments per Medicaid enrollee of the main study groups with and
without enrollees with zero dollar total Medicaid payments for the year. The ‘Mean Payments per Enrollee’
excluding ‘Enrollees with Zero Dollar Payments for the year’ are the same as ‘Mean Payments Per Recipient.’ The
95% Confidence Limits are also shown.
Enrollees*
Mean +/- C.L. Mean +/- C.L. Mean +/- C.L.
Excluding Enrollees w ith Zero Dollar Payment for the year*
IHS AIAN 495,629 $ 4,141 $ 38 $ 31 $ 6 $ 4,172 $ 38
Other AIAN 153,452
Whites, Non-Hispanic 1,073,924
$ 2,956 $ 76 $ 26 $ 3 $ 2,982 $ 76
$ 3,437 $ 19 $ 72 $ 9 $ 3,509 $ 21
Including Enrollees w ith Zero Dollar Payment for the year*
IHS AIAN 550,016 $ 3,732 $ 34 $ 27 $ 5 $ 3,759 $ 35
Other AIAN 176,046
Whites, Non-Hispanic 1,232,415
$ 2,576 $ 66 $ 23 $ 3 $ 2,599 $ 66
$ 2,995 $ 17 $ 63 $ 8 $ 3,058 $ 18
8
Total Payment per Enrollee
Medicaid Third Party Total
*Enrollees have payments of zero (or negative) dollars if they receive no services, have no paid claims or premiums, or only
adjustments are made to previous payments. Enrollees with non-zero dollar payments for the year are known to be 'Recipients' of
Medicaid paid services during the year.
To determine the mean Total Payment per Enrollee for any group, all that need be done is multiply
the mean Total Payment per Recipient by the number of Recipients in the group and divided by the
total number of Enrollees in the group. This calculation is the same as multiplying the mean Total
Payment per Recipient times the percent of Enrollees who are Recipients (or 100% minus the
percent of Enrollees who are not Recipients). The proportions of Enrollees who are not Recipients

Methods
are in Attachment Table C.3, and the mean Total Payment per Recipient are provided for the
analysis groups in each IHS Area in Attachment Table C.4.
Enrollment for Less than 12 Months
Analyses are done separately for Medicaid Recipients enrolled the full 12 months of the year, and
those enrolled less than 12 months. The Mean Total Payment per Year for Recipients enrolled all 12
months of the year is greater than that for Medicaid Recipients enrolled less than 12 months because
of shorter time of coverage (Table 4). However when analyzed as Mean Total Payment per Month,
the payments for Medicaid Recipients enrolled less than 12 months is systematically larger. Reasons
offered for this bias found in many studies of program enrollees is that there is a ‘pent up demand’
for medical service in enrollees who start coverage during the year, and there is a high utilization at
end of life that occurs for enrollees who die during the year. Varying months of enrollment and
differences amounts of enrollment in managed care plans can affect this phenomenon. This
phenomenon was found to occur for IHS AIAN ($424 and $505 per Recipient per Month with nonoverlapping
95% Confidence Limits, C.L.) and Other AIAN ($310 and $410 per Recipient per Month
with non-overlapping C.L.), but was reversed for Whites ($379 and $371 per Recipient per Month
with non-overlapping C.L.) (Table 4). To avoid potentially unadjusted differences between the
groups behind the phenomenon, data for Medicaid Recipients enrolled 12 months is analyzed
separately from those enrolled less than 12 months. For IHS Area-specific values for the numbers of
recipients and Mean Total Payment per Year for Recipients enrolled 12 months and enrolled less
than 12 months see Attachment Tables C.5 and C.6.
Table 4. Mean Medicaid and Third Party payments per Medicaid recipient* divided between those enrolled all 12
months, and those enrolled less than 12 months for the main analysis groups. The 95% Confidence Limits are
also shown.
Analysis Groups Recipients* Mean +/- C.L. Mean +/- C.L. Mean +/- C.L.
Recipients* enrolled 12 months
IHS AIAN 271,509
Other AIAN 83,156
Whites, Non-Hispanic 588,629
Recipients* enrolled Less than 12 months
IHS AIAN 224,120
Other AIAN 70,296
Whites, Non-Hispanic 485,295
Recipients* enrolled 12 months
IHS AIAN 271,509
Other AIAN 83,156
Whites, Non-Hispanic 588,629
Recipients* enrolled Less than 12 months
IHS AIAN 224,120
Other AIAN 70,296
Whites, Non-Hispanic 485,295
Medicaid Third Party Total
$ 5,086 $ 57 $ 42 $ 10 $ 5,128 $ 58
$ 3,721 $ 120 $ 35 $ 5 $ 3,756 $ 120
$ 4,551 $ 31 $ 104 $ 15 $ 4,656 $ 34
$ 2,997 $ 47 $ 17 $ 4 $ 3,014 $ 47
$ 2,050 $ 84 $ 16 $ 3 $ 2,066 $ 85
$ 2,085 $ 19 $ 33 $ 4 $ 2,118 $ 19
$ 424 $ 5 $ 3 $ 1 $ 427 $ 5
$ 310 $ 10 $ 3 $ 0 $ 313 $ 10
$ 379 $ 3 $ 9 $ 1 $ 388 $ 3
$ 505 $ 10 $ 3 $ 1 $ 507 $ 10
$ 410 $ 23 $ 3 $ 1 $ 413 $ 23
$ 371 $ 5 $ 7 $ 1 $ 378 $ 5
9
Annual Payment per Recipient
Monthly Payment per Recipient
*Only enrollees who are recipients of services are included because analyses exclude enrollees with zero dollar Medicaid
payments.

Methods
Table 5. Mean Medicaid and Third Party Payments per Recipient* divided between those Less than 65 years of
age and 65 years or more for the main analysis groups. The 95% Confidence Limits are also shown.
Analysis Groups Recipients Mean +/- C.L. Mean +/- C.L. Mean +/- C.L.
Recipients* enrolled 12 months
IHS AIAN 254,278
Other AIAN 79,019
Whites, Non-Hispanic 528,997
Recipients* enrolled Less than 12 months
IHS AIAN 220,745
Other AIAN 69,131
Whites, Non-Hispanic 468,157
Recipients* enrolled 12 months
IHS AIAN 254,278
Other AIAN 79,019
Whites, Non-Hispanic 528,997
Recipients* enrolled Less than 12 months
IHS AIAN 220,745
Other AIAN 69,131
Whites, Non-Hispanic 468,157
Recipients* enrolled 12 months
IHS AIAN 17,228
Other AIAN 4,134
Whites, Non-Hispanic 59,521
Recipients* enrolled Less than 12 months
IHS AIAN 3,322
Other AIAN 1,034
Whites, Non-Hispanic 16,191
Recipients* enrolled 12 months
IHS AIAN 17,228
Other AIAN 4,134
Whites, Non-Hispanic 59,521
Recipients* enrolled Less than 12 months
IHS AIAN 3,322
Other AIAN 1,034
Whites, Non-Hispanic 16,191
Medical Fee-for-Service and Capitated Care
Medicaid Third Party Total
$ 5,008 $ 60 $ 33 $ 9 $ 5,041 $ 60
$ 3,656 $ 125 $ 30 $ 5 $ 3,686 $ 125
$ 4,440 $ 33 $ 98 $ 17 $ 4,538 $ 37
$ 2,979 $ 47 $ 15 $ 3 $ 2,993 $ 47
$ 2,038 $ 86 $ 14 $ 2 $ 2,052 $ 86
$ 2,048 $ 19 $ 29 $ 4 $ 2,076 $ 20
$ 417 $ 5 $ 3 $ 1 $ 420 $ 5
$ 305 $ 10 $ 2 $ 0 $ 307 $ 10
$ 370 $ 3 $ 8 $ 1 $ 378 $ 3
$ 499 $ 10 $ 2 $ 0 $ 502 $ 10
$ 407 $ 23 $ 3 $ 1 $ 411 $ 23
$ 363 $ 5 $ 6 $ 1 $ 369 $ 5
$ 6,230 $ 194 $ 178 $ 88 $ 6,408 $ 214
$ 4,964 $ 285 $ 137 $ 54 $ 5,102 $ 292
$ 5,540 $ 76 $ 158 $ 33 $ 5,698 $ 84
$ 4,208 $ 476 $ 148 $ 151 $ 4,356 $ 524
$ 2,919 $ 443 $ 161 $ 105 $ 3,080 $ 461
$ 3,165 $ 118 $ 165 $ 54 $ 3,330 $ 132
$ 519 $ 16 $ 15 $ 7 $ 534 $ 18
$ 414 $ 24 $ 11 $ 5 $ 425 $ 24
$ 462 $ 6 $ 13 $ 3 $ 475 $ 7
$ 846 $ 153 $ 21 $ 17 $ 867 $ 155
$ 557 $ 106 $ 26 $ 15 $ 583 $ 108
$ 597 $ 35 $ 35 $ 14 $ 632 $ 38
10
Less than 65 years of Age
Annual Payment per Recipient
Monthly Payment per Recipient
65 years of Age & Over
Annual Payment per Recipient
Monthly Payment per Recipient
Data is analyzed separately for recipients whose Medicaid paid medical care is provided Fee-for-
Service (FFS) and those whose is provided through a capitated Comprehensive Managed Care Plan
(CMCP). Much of Medicaid covered care has in recent years become managed by health care plans
to lower Medicaid payments. Even recipients in FFS medical care may have monthly capitated
premiums paid for Primary Care Case Management (PCCM), or behavioral or dental Prepaid Health
Plans (PHP). For enrollment of AIAN in CMCP, PHP and PCCM in the IHS areas see Integrating
Medicaid and Indian Health Service Data, 2011 .

Methods
When medical care is paid through monthly capitated premiums to CMCP, hospital care may or may
not be included. Thus hospital services may be paid FFS for CMCP enrollees. CMCP also vary in their
breadth of other optional Medicaid services covered as well. CMCP may or may not include
behavioral health or dental services. Enrollees in CMCP may or may not also have monthly
capitated premiums paid for behavioral or dental Prepaid Health Plans (PHP). Alternatively these
services not covered in CMCP plans may like hospital care be paid through FFS claims. When CMCP
recipients are not enrolled in a CMCP for all the months they are enrolled in Medicaid, they can also
have FFS claims for services.
In analyses of Medicaid payments it is thus important to adjust for the effect of capitated CMCP
payments in groups of Recipients. We thus analyzed Mean Total Payments for Recipients with 12
months enrollment but no CMCP (that is, 12 months of FFS care, which can also include PCCM, or
Dental or Behavioral Health PHP), or with any months of CMCP (Table 6). The numbers of
recipients with 12 months enrollment in Medicaid but less than 12 months enrollment in CMCP was
too small a group to be analyzed separately. The numbers of recipients for the IHS Areas are shown
in Attachment Table C.7 (all ages combined). The payments for recipients in only FFS medical care
in the IHS Areas are shown in Attachment Table C.8, and for those with any CMCP in Attachment
Table C.9. Values for the hospital, other medical, prescription drug and dental FFS payments, as well
as for PCCM, Dental and Behavioral Health PHP premiums are provided in Attachment Tables C.8
and C.9.
Table 6. Mean Medicaid and Third Party payments per Medicaid recipient enrolled 12 months divided into those
not enrolled in any Comprehensive (medical) Managed Care Plan (CMCP), those enrolled less than 12 months in
CMCP and those enrolled 12 months in CMCP for the main study groups. The 95% Confidence Limits for each
mean value are also shown.
Analysis Groups Recipients Mean +/- C.L. Mean +/- C.L. Mean +/- C.L.
Recipients not enrolled in medical managed care (CMCP)
IHS AIAN 237,019 $ 5,114 $ 64 $ 48 $ 12 $ 5,161 $ 65
Other AIAN 61,669
Whites, Non-Hispanic 371,592
$ 3,751 $ 134 $ 46 $ 7 $ 3,796 $ 134
$ 4,872 $ 46 $ 163 $ 24 $ 5,035 $ 53
Recipients enrolled less than 12 months in medical managed care (CMCP)
IHS AIAN 13,861 $ 4,886 $ 178 $ 6 $ 2 $ 4,892 $ 178
Other AIAN 4,784
Whites, Non-Hispanic 51,114
$ 3,576 $ 209 $ 14 $ 14 $ 3,589 $ 210
$ 3,594 $ 52 $ 13 $ 2 $ 3,607 $ 52
Recipients enrolled 12 months in medical managed care (CMCP)
IHS AIAN 20,629 $ 4,897 $ 119 $ 1 $ 0 $ 4,898 $ 119
Other AIAN 16,703
Whites, Non-Hispanic 165,923
Medicaid Third Party Total
$ 3,655 $ 326 $ 1 $ 1 $ 3,656 $ 326
$ 4,129 $ 26 $ 1 $ 0 $ 4,130 $ 26
11
Annual Payment per Recipient
While payments per recipient under age 65 are lower for every analysis group with CMCP when
compared to those with FFS medical care (Table 6), the differences are not large. What is striking is
the smaller proportions of AIAN in CMCP than Whites who live in the same counties. This we find
depends on the IHS Area (See Attachment Table C.9.) Over age 65, the numbers of AIAN Recipients
in CMCP is small for all groups, but particularly the AIAN groups (Table 6).

Restricted Benefits
Methods
Enrollees with Restricted Benefits were excluded from the analyses. Enrollees in certain Medicaid
enrollment categories are only eligible for a restricted portion of the full scope of medical benefits:
For example, women eligible only because they are pregnant (but not women who are eligible for
Medicaid or CHIP and become pregnant), certain groups of Medicare-Medicaid Dual eligibles,
enrollees in pharmacy only or other specially approved state ‘waiver’ programs. We found small
numbers of Medicaid enrollees with Restricted Benefits (Table 7), and therefore cannot do a
separate analysis for these enrollees. Adjusting analyses of the mean Total Payments per Person
for Restricted Benefits in the models described below had small if any effects. We therefore
excluded enrollees with Restricted Benefits from the analyses we present here.
Table 7. Mean Total Payments per Recipient for enrollees with 12 months Fee-for-Service (FFS) medical care
with or without managed care (PCCM, CMCP and Dental & Behavioral Health Prepaid Health Plans, PHP) paid
per Medicaid recipient with Full Benefits all 12 months or at least one month of Restricted Benefits for the main
study groups. The 95% Confidence Limits for each mean value are also shown.
Analysis Groups Recipients Mean +/- C.L. Mean +/- C.L. Mean +/- C.L.
Recipients not enrolled in medical managed care (Fee-For Service, FFS)
IHS AIAN 220,368 $ 5,035 $ 67 $ 37 $ 11 $ 5,073 $ 68
Other AIAN 57,865
Whites, Non-Hispanic 320,435
$ 3,683 $ 141 $ 39 $ 7 $ 3,722 $ 142
$ 4,840 $ 52 $ 160 $ 28 $ 5,000 $ 59
Recipients enrolled less than 12 months in medical managed care (CMCP)
IHS AIAN 13,666 $ 4,850 $ 179 $ 5 $ 2 $ 4,855 $ 179
Other AIAN 4,719
Whites, Non-Hispanic 49,932
$ 3,492 $ 200 $ 13 $ 14 $ 3,505 $ 200
$ 3,427 $ 50 $ 12 $ 2 $ 3,439 $ 50
Recipients enrolled 12 months in medical managed care (CMCP)
IHS AIAN 20,244 $ 4,821 $ 107 $ 1 $ 0 $ 4,821 $ 107
Other AIAN 16,435
Whites, Non-Hispanic 158,630
$ 3,609 $ 331 $ 1 $ 1 $ 3,610 $ 331
$ 3,950 $ 26 $ 0 $ 0 $ 3,951 $ 26
Recipients not enrolled in medical managed care (Fee-For Service, FFS)
IHS AIAN 16,648 $ 6,154 $ 188 $ 183 $ 91 $ 6,337 $ 210
Other AIAN 3,801
Whites, Non-Hispanic 51,056
$ 4,778 $ 294 $ 148 $ 59 $ 4,926 $ 303
$ 5,068 $ 84 $ 182 $ 38 $ 5,251 $ 94
Recipients enrolled less than 12 months in medical managed care (CMCP)
IHS AIAN 195 $ 7,413 $ 1,107 $ 63 $ 75 $ 7,476 $ 1,107
Other AIAN 65
Whites, Non-Hispanic 1,177
$ 9,680 $ 5,122 $ 51 $ 59 $ 9,731 $ 5,117
$ 10,647 $ 638 $ 32 $ 13 $ 10,680 $ 638
Recipients enrolled 12 months in medical managed care (CMCP)
IHS AIAN 385 $ 8,928 $ 3,033 $ 1 $ 1 $ 8,929 $ 3,033
Other AIAN 268
Whites, Non-Hispanic 7,288
Less than 65 years of Age
$ 6,464 $ 585 $ 2 $ 4 $ 6,466 $ 587
$ 8,024 $ 163 $ 5 $ 5 $ 8,029 $ 164
12
Annual Payment per Recipient
Medicaid Third Party Total
65 years of Age & Over

Medical Cost Index
Methods
Payments were adjusted using the Medical Cost Index used by the IHS in computing what it would
cost to provide equitable services across the 12 IHS Areas
(http://www.ihs.gov/NonMedicalPrograms/lnf/): This Medical Cost Index is calculated from the
Health Care portion of the Cost of Living Index (COLI) published by the Council for Community and
Economic Research (C2ER). Indices of regional differences of health care prices are published by
C2ER for select counties and metro-areas (www.coli.org/Method.asp).
Table 8. Indices of regional differences in health care costs for the IHS Areas calculated by IHS for 2009 using the
health care portion of the COLI of the Council for Community and Economic Research.
IHS Area
13
Health Care Cost
of Living Index
Scaled
Alaska 1.31
Portland 1.13
California 1.08
Aberdeen 1.02
Billings 1.01
Nashville 1.00
Navajo 0.99
Phoenix 0.99
Tucson 0.99
Bemidji 0.98
Albuquerque 0.97
Oklahoma 0.94
The Health Care portion of their COLI is designed to provide the best possible means to compare
cost of living differences in these areas based on the price of consumer goods and services, but the
index has a number of limitations. The data is voluntarily provided by designated organizations.
The C2ER states that all price data are obtained from sources deemed reliable and that the C2ER
stringently reviews all prices reported, and attempts to eliminate errors and noncompliance with
pricing specifications. Still they issue a disclaimer that, ‘no representation is made as to the complete
accuracy thereof.’ In addition there are certain definitional limitations such as that the health care
purchases priced are those appropriate for “professional and managerial households in the top
income quintile,” while Medicaid programs purchase for households in the lowest income quintile of
their state. Certainly the greatest limitation is that the price variation largely reflects variation in
urban health care prices, which is but an undetermined fraction of the health care purchased by
Medicaid for residents of the generally rural CHSDA counties of the IHS Areas.
We used the health care C2ER COLI because it was recommended that the IHS use the health care
COLI in the calculation of the IHS Federal Disparities Index by its Contract Health Service
workgroup. The workgroup of tribal and technical advisors to the IHS believed it was best available
index that could reflect macro differences in health care prices among regions. The determination
of the Health Care COLI for the 12 IHS Areas is done by the IHS.

Age and Sex
Methods
Medical care payments increase with age, and yet the differences in age of populations among AIAN
groups and between AIAN and Whites cannot be changed unless a Medicaid eligibility policy change
occurs affecting age groups differently. Age can be coded continuously (in years), or in intervals (5
or 10 year age cohorts). Usually an analytical definition is used to avoid unnecessarily large
numbers of interval groups: irregular intervals are used to define age groups with substantially
higher payments than the immediate younger group. We will test the use of a Continuous Age
variable and an analytical Interval Age Group variable. The adjustment that explains most of the
variation in the Mean Total Payment will be used in the Core Model.
Medical care payments are generally higher for women than men when the services include
reproductive care, and especially higher in Medicaid for women who are pregnant or give birth
during the year. Alternatives for gender determinants are 1) Male, Female pregnant, & Female non-
Pregnant; or 2) Male, Female, with adjustment for pregnancy and childbirth services in the Service
Coverage variables. The adjustment that explains most of the variation in the Mean Total Payment
will be used in the Core Model.
Disability as Basis of Medicaid Eligibility and Dual Eligibility with Medicare
Medical care payments are generally higher for blind or disabled individuals. We provided a list of
the blind and disabled eligibility categories for Medicaid and for Dual Eligibility with Medicare in
AIAN Medicaid Program and Policy Statistics: Summary Report, 2009 . The proportions of AIAN
Medicaid eligibles who are Disabled or Dual eligibles in each IHS Area are documented in AIAN
Medicaid Program and Policy Data, 2010 .
Risk Adjustment: Morbidity
Medical care costs rise as the number and severity of medical conditions increase. To determine if
there are differences in payments not related to illness requires adjusting costs for differences in the
morbidity burden among the study groups. This is possible with Medicaid claims tested Risk
Adjustment software systems (Winkelman and Dammler, 2008). We used the Adjusted Clinical
Groups® (ACG) system developed at The Johns Hopkins University to characterize the concurrent
morbidity burden in the AIAN and White Medicaid populations in our study for the time period of
the claims (http://www.acg.jhsph.org). With this software demographic, diagnostic and procedure
code combinations on 12 continuous months of claims and encounter records were reduced to a
fixed number of health status categories called Aggregated Diagnosis Groups.
The ACG system captures interrelationships between co-occurring morbidities that pose the greatest
demands for health care resources. ACG actuarial cells are based on Aggregated Diagnosis Groups
that are similar in terms of severity and likelihood of persistence of the health condition over time.
Diagnostic codes are assigned to one of the 32 clusters of Aggregated Diagnosis Groups. Since
individuals can have more than one diagnosis, they may have more than one Aggregated Diagnosis
Group. Individual diseases or conditions are placed into a single Aggregated Diagnosis Groups based
14

Methods
on five clinical dimensions: 1) Duration of the condition (acute, recurrent, or chronic); 2) Severity of
the condition (e.g., minor and stable versus major and unstable); 3) Diagnostic certainty (symptoms
versus documented disease); 4) Etiology of the condition (infectious, injury, or other); and 5)
Specialty care involvement (e.g., medical, surgical, obstetric, hematology). The Aggregated Diagnosis
Groups are then weighted and added so that a single ACG morbidity (risk) score is obtained by each
individual.
The ACG system provides an external standard sample of privately insured population in a managed
care plan for reference, but the system recommends use of an internal reference group to
standardize for unadjusted differences between Medicaid populations and provider claims and
privately insured managed care data. We used the random sample of non-Hispanic White Medicaid
recipients living in the same counties as the AIAN as the morbidity reference group.
The software is not recommended for use without a 12 month continuous claim history for
recipients, and therefore we did not apply it to recipients with less than 12 months enrollment. We
did not use the feature of the software that uses pharmacy data because we found that IHS AIAN in
the Medicaid data had much lower pharmacy payments than other which is likely due to access to
medications through their Indian healthcare providers, which Other AIAN and Whites do not have
(see Prescription Drug FFS data in the Findings section).
Statistical Adjustments
To adjust for the effects of determinants on mean total payments per recipient, we constructed
Generalized Linear Mixed Models of SAS statistical software (version 9.2) using the log-likelihood
function, assuming the gamma distribution of the dependent variable (Medicaid payments). We
have previously published studies using these methods with Medicaid claims data (Wong et al,
2006), including using the ACG risk adjustment (Korenbrot, Kao & Crouch, 2009).
Medicaid Enrollee Exclusions were: 1) enrollees with no known months of eligibility, 2) enrollees
with longterm or institutionalized care, 3) enrollees with ‘Restricted’ rather than ‘Full’ Medicaid
benefits, and 4) enrollees with no paid claims of $1 or more. Recipients remaining were then
grouped for analytical modeling as in Table 9:
15

Methods
Table 9. Findings for all six series are summarized at the end of the Findings Section. The results of Analyses 1
and 2 are presented in Figures in the Findings Section with detailed tables in Attachments F and G. All findings
from Analyses 3 to 6 are in Attachments H, I, J and K respectively.
1 2 3 4 5 * 6 *
FFS Medical
Morbidity
Adjustment
Capitated
Medical
No morbidity
adjustment
FFS Medical
No morbidity
adjustment
Capitated
Medical
No morbidity
adjustment
Analyses
Recipients Less than 65 years of Age Recipients Aged 65 & Over
12 months Enrollment
Any Months of Enrollment
16
12 months Enrollment
FFS Medical
Morbidity
Adjustment
Capitated
Medical
Any Months of Enrollment
FFS Medical
No morbidity
adjustment
The numbers of recipients in each analytical group are presented in Attachment C by state and IHS
Area. All recipients in Analysis 1 are included in Analysis 2, those in Analysis 3 are included in
Analysis 4, and those in Analysis 5 are included in Analysis 6.
Capitated
Medical
In Analyses 1, 2 and 5 recipients were enrolled in Medicaid 12 months, so the outcome was the
Adjusted Mean Total Payment per Recipient per Year and the models could be adjusted for
morbidity (Attachments E, F and I). In analyses 3, 4 and 6 the recipients could be enrolled less than
12 months in Medicaid and therefore the outcome was the Adjusted Mean Total Payment per
Recipient per Month and the models could not be adjusted for morbidity because there was not a 12
month continuous claims history for all recipients (Attachments G, H and J).
Within each of the 6 series of analytical models the study groups are nested within each of the 12
IHS Areas and adjusted for Age and Sex (interaction terms) and Medicaid Disability and Dual
Eligibility Status under age 65 (interaction terms). Morbidity adjustments were included for the
groups enrolled 12 months in Medicaid. The first set of study groups within each series of analyses
compares: IHS AIAN, Other AIAN and Whites. For further comparison the second set of study groups
within each series of analyses divides the IHS AIAN into, 1) those with IHS Program claims who are
also IHS Active Users, 2) those with IHS Program claims who are not also IHS Active Users, and 3)
those who are IHS Active Users but did not have any IHS Program claims – and includes Other AIAN
and Whites.
In the models, all effects of the adjustment and study variables were significant at the P

Methods
each recipient type across IHS Areas we calculated for each recipient type the difference between
the adjusted mean payment for IHS AIAN and a comparison group in each IHS Area as a percent of
the mean payment for IHS AIAN (Attachment Tables L.1, L.4). We then multiplied the relative
percent difference in the payment times the number of the IHS AIAN in that IHS Area, and
determined the weighted difference for the recipient type across the IHS Areas for the comparison
group (Attachment Tables L.2, L.5).
To obtain an overall measure for each IHS Area across the 6 analyses of all types of recipients, we
repeated the method using the same differences between the adjusted mean payment for IHS AIAN
and a comparison group in each IHS Area for each recipient type as the difference in percent of the
mean payment for IHS AIAN (Attachment Tables L.1, L.4). However we multiplied the relative
percent difference in the payment for each recipient type times the number of the IHS AIAN in that
recipient type, and determined the weighted difference for each IHS Area across all the recipient
types represented in that Area (Attachment Tables L.3, L.6).
17

Methods
Map 1. 12 IHS Areas: Contract Health Service Delivery Areas (CHSDA)
18

Findings
Findings
Payments for AIAN Medicaid Recipients
The total amount of Medicaid funds paid in 2006 for 550,000 IHS AIAN Medicaid enrollees living in the service
delivery Areas of IHS and tribally operated facilities for paid personal health care services was $ 2.05 billion
(Table 2). The personal health care services included Medical (including physician, clinic, outpatient, laboratory
and imaging, pharmacy), Behavioral Health and Dental Care services. An additional $15 million was paid by
other third-party payers (mainly private insurance) to cover payments for the claims filed with Medicaid. Of
those IHS AIAN Medicaid enrollees 496,000 were recipients of Medicaid paid services during the year.
Findings are presented here for the CHSDA counties of the IHS service delivery areas. The numbers of IHS AIAN
with Medicaid coverage in the separate states of each IHS service delivery area are not large enough to give
statistically reliable findings (the numbers and payments for AIAN in the counties of the IHS service delivery
areas of the states in the analytical subgroups are presented in Attachments F to I). One of the main reasons why
state numbers of IHS AIAN are not large enough is that not all states report IHS claims separate from other
claims (see American Indian and Alaska Native Medicaid Program and Policy Statistics: Summary Report 2009)
and when they do they do not capture all claims for IHS AIAN.
Recipients with Fee-for-Service Medical Services
Age, Sex, Disability & Morbidity Do Not Explain Differences in Payments
If left unadjusted for any determinants, the mean total payment for IHS AIAN recipients with FFS medical care
who are less than 65 years of age is only slightly higher than Whites ($5,104 compared to $4,960, or $144
difference), but much higher than Other AIAN ($3,670, or $1,436 difference) (Figure 1). The minimal actuarial
adjustment for age and sex differences increases the difference in payments between IHS AIAN and Whites
($7,052 compared to $6,369, or about $600) but not with Other AIAN ($7,052 compared to $5,567, or about
$1500). This effect is expected because the IHS AIAN have a younger age distribution than that of Whites and
therefore lower expected payments, but a similar age distribution to that of Other AIAN and therefore similar
expected payments. The mean adjusted payment increases for all three groups with the age adjustment because
payments for older more costly recipients are given equal weight with less costly younger recipients which
constitute the vast majority of the recipients in all three groups. This is how the statistical adjustment controls
for the differences in age distributions across the three groups.
Adjusting payments further for disability status, either because of Medicaid eligibility as a disabled enrollee, or
as a Medicare-Medicaid ‘Dual’ enrollee under age 65, increases the adjusted means and the differences in means
for all three groups (Figure 1). The mean total payment for IHS AIAN is much higher for Whites ($9,999
compared to $7,884, or a $2,115 difference) and for Other AIAN ($7,319, or a $2,680 difference). Again the
adjusted mean rises for all groups because the higher payments for the smaller groups of Disabled are given
equal weight with less costly but higher proportions of non-disabled recipients during the statistical
adjustment.
19

Findings
Figure 1. Adjustment of Mean Total Payment per Recipient for IHS AIAN, Other AIAN and Whites less than 65 years of age
enrolled 12 months with FFS medical care (successive adjustments for age and sex, disability, & morbidity). Payments include
FFS claims for medical services and either FFS claims or managed care plan premiums for non-medical services (behavioral
health or dental).
$10,000
$9,000
$8,000
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
$-
$5,104
$3,670
$4,960
$7,052
$5,567
$6,369
$9,999
The further adjustment for the variation in morbidity among the three groups reduces the differences between
IHS AIAN and Whites, and between IHS AIAN and Other AIAN, but substantial differences remain (Figure 1).
The mean total payment for IHS AIAN is higher for Whites ($5,865 compared to $4,689, or a $1,176 difference)
and for Other AIAN ($4,453, or a $1,412 difference). The morbidity scores for the low income Medicaid eligible
Whites (1.013 with 90% Confidence Limits, C.L., from1.011 to 1.015) were actually worse than those of IHS
AIAN (0.954 with 90% C.L. 0.949 to 0.959) and Other AIAN (0.880 with 90% C.L. 0.875 to 0.885). We
investigated whether the lack of diagnosis codes on claims paid to Indian health care providers could explain
the morbidity scores and found that it did not. More diagnosis codes per recipient were used to determine
morbidity for IHS AIAN recipients with Indian health care provider claims than for Whites or Other AIAN in all
Areas except Aberdeen Area (Attachment Tables D.1 and D.2).
Payments across IHS Areas still Vary Substantially after Adjustments
Fee-for Service payments are higher for IHS AIAN than Whites in two-thirds of the IHS Areas (Alaska, Bemidji,
Billings, California, Phoenix, Portland and Tucson Areas, Figure 2). But the payments are lower for IHS AIAN in
Aberdeen and Albuquerque Areas, and about the same for IHS AIAN and whites in Nashville and Oklahoma
Areas. The mean adjusted total payments for Whites in the Tucson Area are exceptionally low (less than $1000
per recipient) while payments for IHS AIAN are exceptionally high, so we investigated payments in Arizona
more closely.
20
$7,884
$7,319
Unadjusted Age*Sex Adjusted Disabled*Medicare,
Age*Sex Adjusted
$5,865
$4,453
$4,689
& Morbidity Adjusted
IHS AIAN
Other AIAN
Whites

Findings
Figure 2. Adjusted Mean Total Payment per Recipient for IHS AIAN, Other AIAN and Whites less than 65 years of age with FFS
medical care across 12 IHS Areas (adjusted for age and sex, and for Disability, Dual eligibility with Medicare, & Morbidity).
Aberdeen
Alaska
Albuquerque
Bemidji
Billings
California
Nashville
Navajo
Oklahoma
Phoenix
Portland
Tucson
$- $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000 $10,000
In the state of Arizona unadjusted payments are more than 7 times higher for IHS AIAN as for whites
(Attachment xx) which explains the much higher payments for IHS AIAN in Navajo, Phoenix and Tucson Areas
(Figure 2). When recipients in the state of Arizona are simply excluded from the adjusted analyses because of
the unusually high disparities in payments with whites, payments for IHS AIAN are higher in Phoenix but not
Navajo Area (Figure 3). All of Tucson Area is included in Arizona, and therefore no determination is possible for
IHS AIAN after excluding recipients in the state of Arizona. There were also too few Whites in FFS care in
Arizona to include them in further models with FFS recipients.
Figure 3. Adjusted Mean Total Payment per Recipient for IHS AIAN, AIAN and Whites less than 65 years of age with FFS
medical care across IHS Areas, excluding recipients in the state of Arizona (in Navajo, Phoenix and all Tucson Areas).
Aberdeen
Alaska
Albuquerque
Bemidji
Billings
California
Nashville
Navajo
Oklahoma
Phoenix
Portland
Tucson
$- $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000 $10,000
21
IHS AIAN
Other AIAN
Whites
IHS AIAN
Other AIAN
Whites

Findings
Payments are Higher for IHS AIAN with Medicaid IHS Program claims
When the IHS AIAN are divided into those with and without Medicaid IHS Program claims paid to IHS system
health care providers (I/T), payments are higher for IHS AIAN who had Medicaid IHS Program claims than those
who did not in all Areas but Nashville (Figure 4). Whether the IHS AIAN who had Medicaid IHS Program claims
were also IHS Active Users (Group 1) or not (Group 2), payments are higher than those of IHS Active Users who
did not have any Medicaid IHS Program claims (Group 3). The only distinction was that in the Navajo Area the
payments were much higher for IHS AIAN who had Medicaid IHS Program claims and were also IHS Active
Users (Group 1), but not for those with Medicaid IHS Program claims who were not also IHS Active Users
(Group 2). The much higher payments for IHS AIAN in Navajo Area were eliminated when all recipients in the
state of Arizona were excluded from analysis (Figure 5). In fact there were no Medicaid IHS Program claims for
AIAN who were not IHS Active Users when recipients from Arizona were excluded from the analysis.
Figure 4. Adjusted Mean Total Payment per Recipient for IHS AIAN in Figure 2 divided into: 1) IHS AIAN with IHS Program
claims who are IHS Active Users; 2) IHS AIAN with IHS Program claims who are not IHS Active Users; and 3) IHS AIAN who
are IHS Active Users with no IHS Program Medicaid claims. For comparison the Other AIAN and Whites of Figure 2 are shown.
Aberdeen
Alaska
Albuquerque
Bemidji
Billings
California
Nashville
Navajo
Oklahoma
Phoenix
Portland
Tucson
$- $2,000 $4,000 $6,000 $8,000 $10,000
22
1.IHS Program claims
& Active User
2.IHS Program claims
but Not Active User
3.IHS Active User with
no IHS Program claims
Other AIAN
Whites

Findings
Figure 5. Adjusted Mean Total Payment per Recipient for IHS AIAN in Figure 3 which excluded recipients in the state of
Arizona divided into the 3 IHS AIAN groups in Figure 4. Other AIAN and Whites of Figure 3 are also shown.
Aberdeen
Alaska
Albuquerque
Bemidji
Billings
California
Nashville
Navajo
Oklahoma
Phoenix
Portland
Tucson
$- $2,000 $4,000 $6,000 $8,000 $10,000
In all Areas except the Nashville Area, payments for IHS Active Users who did not have any Medicaid IHS
Program claims (Group 3) were lower or about the same (Alaska and Portland Areas) as those of Whites (Figure
4).
Payments for Outpatient Services had Largest Effect on Total Payments
We investigated whether there were payments for particular types of services that explained the higher
payments for IHS AIAN with IHS Program claims (Groups 1 and 2). The cleanest way to investigate this was to
successively exclude 1) clinic and physician outpatient payments (Figure 6), then 2) hospital payments (Figure
7), and finally 3) prescription drug payments (Figure 8). These three categories of services were uniformly
defined by the Medicaid data extraction process into separate MAX claims files.
Excluding outpatient clinic and physician payments (Figure 6) had the largest impact of the three general types
of service on reducing the differences in mean total payments per recipient between IHS AIAN with IHS
Program claims (Groups 1 and 2) and IHS AIAN Group 3 without IHS Program claims and Whites. The average
decline in adjusted mean payments for Group 1 was $2,960, Group 2 was $2,520, while that for Group 3 was
$680 and Whites was $750 (difference in values of Figure 6 and Figure 4). Particularly large differences remain
for Groups 1 and 2 for the Areas with Arizona state recipients (Navajo, Phoenix and Tucson Areas). For hospital
services the average decline in adjusted mean payments for Group 1 was $1068, Group 2 was $992, while that
23
1.IHS Program claims
& Active User
2.IHS Program claims
but Not Active User
3.IHS Active User with
no IHS Program claims
Other AIAN
Whites

Findings
for Group 3 was $600 and Whites was $737 (difference in values of Figure 7 and Figure 4). Prescription drugs
contributed the least to mean payments for AIAN (difference in values of Figure 8 and Figure 4). For
prescription drugs the average decline in adjusted mean payments for Whites was largest ($935) while for IHS
AIAN with IHS Program claims the values were lowest: Group 1 it was only $274 and Group 2 was $234. For IHS
AIAN with no IHS Program claims (Group 3) the amount was $548, more like that for Other AIAN ($400) than
Groups 1 and 2 or Whites.
Figure 7. Adjusted Mean Payment per Recipient excluding payments for outpatient visits to clinics, hospitals, or physicians’
offices. Compare with Figure 4 Adjusted Mean Total Payments per Recipient.
Aberdeen
Alaska
Albuquerque
Bemidji
Billings
California
Nashville
Navajo
Oklahoma
Phoenix
Portland
Tucson
$- $2,000 $4,000 $6,000 $8,000 $10,000
24
1.IHS Program claims
& Active User
2.IHS Program claims
but Not Active User
3.IHS Active User with
no IHS Program claims
Other AIAN
Whites

Findings
Figure 8. Adjusted Mean Payment per Recipient excluding payments for hospital stays. Compare with Figure 4 Adjusted Mean
Total Payments per Recipient, and Figure 6 Adjusted Mean Payment per Recipient excluding outpatient visits.
Aberdeen
Alaska
Albuquerque
Bemidji
Billings
California
Nashville
Navajo
Oklahoma
Phoenix
Portland
Tucson
$- $2,000 $4,000 $6,000 $8,000 $10,000
Figure 9. Adjusted Mean Payment per Recipient excluding payments for prescription drugs. Compare with Figure 4 Adjusted
Mean Total Payments per Recipient, and Figure 6 Adjusted Mean Payment per Recipient excluding outpatient visits.
Aberdeen
Alaska
Albuquerque
Bemidji
Billings
California
Nashville
Navajo
Oklahoma
Phoenix
Portland
Tucson
$- $2,000 $4,000 $6,000 $8,000 $10,000
25
1.IHS Program claims
& Active User
2.IHS Program claims
but Not Active User
3.IHS Active User with
no IHS Program claims
Other AIAN
Whites
1.IHS Program claims
& Active User
2.IHS Program claims
but Not Active User
3.IHS Active User with
no IHS Program claims
Other AIAN
Whites

Findings
Unadjusted mean payments for outpatient services to IHS and Tribal Program providers (Figure 10) for IHS
AIAN were about 60% of the total paid to all providers (Figure 9, see Table 9). For Group 1 the proportion was
58% ($1,800 out of at least $3100 per recipient), while for Group 2 the proportion was 62% ($1,530 out of at
least $2,487 per recipient). The types of outpatient services included in IHS Program services provided by IHS
and Tribal providers is more comprehensive than those included for all providers in ways that cannot be
equalized with MAX claims data. In the Billings Area outpatient service payments for IHS Program outpatient
services are so large that payments to IHS Program providers for IHS outpatient services actually exceed
payments to all providers for Outpatient Visit, Laboratory, Imaging, and Dental services (Table 9).
Figure 10. Unadjusted Mean Payment per Recipient for outpatient services including visits, laboratory and
imaging, and dental services. Compare with Figure 10 unadjusted Mean Payment per Recipient for IHS or Tribal
outpatient services.
Aberdeen
Alaska
Albuquerque
Bemidji
Billings
California
Nashville
Navajo
Oklahoma
Phoenix
Portland
Tucson
Outpatient Payments
to all Providers
$- $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000
The types of outpatient services provided by IHS Program Providers are more comprehensive than those
included here for all providers in ways that cannot be equalized with MAX data. In the Billings Area (Montana &
Wyoming states) these other outpatient services are so much broader that payments to IHS Program Providers
for IHS Program outpatient services actually exceed payments to All Providers for Outpatient Visit, Laboratory,
Imaging, and Dental services for the same recipients.
26
1.IHS Program claims
& Active User
2.IHS Program claims
but Not Active User
3.IHS Active User with
no IHS Program claims
Other AIAN
Whites

Findings
Figure 11. Unadjusted Mean Payment per Recipient for outpatient visits, laboratory & imaging, dental, and other IHS
outpatient services through IHS or Tribal clinics or hospitals. Compare with IHS AIAN Groups 1 and 2 in Figure 9.
Aberdeen
Alaska
Albuquerque
Bemidji
Billings
California
Nashville
Navajo
Oklahoma
Phoenix
Portland
Tucson
Outpatient Payments
to IHS & Tribal Programs
$- $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000
27
1.IHS Program claims
& Active User
2.IHS Program claims
but Not Active User

Findings
Table 10. Unadjusted Mean Fee-for-Service payments per IHS AIAN Recipient for Outpatient Visit, Laboratory, Imaging and
Dental services.
Outpatient Visit, Laboratory, Imaging, and Dental* Payments per IHS AIAN Recipient
Group 1.IHS Program claims
& Active User
IHS Program
All Providers Providers* All Providers
28
Group 2.IHS Program claims
but Not Active User
IHS Program
Providers*
IHS Area Unadjusted Mean Payments Difference Unadjusted Mean Payments Difference
Aberdeen $ 2,045 $ 1,330 $ 715 $ 1,471 $ 1,045 $ 426
Alaska $ 2,554 $ 554 $ 2,000 $ 2,140 $ 387 $ 1,753
Albuquerque $ 2,124 $ 1,191 $ 933 $ 1,453 $ 974 $ 479
Bemidji $ 2,437 $ 592 $ 1,845 $ 2,417 $ 1,105 $ 1,313
Billings* $ 1,202 $ 2,039 $ (837) $ 1,202 $ 1,724 $ (521)
California $ 2,026 $ 1,397 $ 629 $ 1,882 $ 1,052 $ 830
Nashville $ 1,688 $ 842 $ 846 $ 2,351 $ 530 $ 1,821
Navajo $ 4,827 $ 3,340 $ 1,486 $ 2,200 $ 2,200 $ -
Oklahoma $ 1,854 $ 943 $ 910 $ 1,935 $ 918 $ 1,017
Phoenix $ 6,892 $ 4,102 $ 2,790 $ 4,841 $ 3,318 $ 1,523
Portland $ 1,963 $ 1,791 $ 173 $ 1,809 $ 1,356 $ 453
Tucson $ 7,588 $ 3,470 $ 4,118 $ 6,143 $ 3,769 $ 2,374
Area Mean $ 3,100 $ 1,800 $ 1,300 $ 2,487 $ 1,530 $ 956
Recipients in Medical Comprehensive Managed Care Plans (CMCP)
Age, Sex, Disability & Morbidity Do Not Explain Differences in Payments for Recipients with
Managed Medical Care
If left unadjusted for any determinants, the mean total payment for IHS AIAN recipients with capitated medical
care in a Comprehensive Managed Care Plan (CMCP) who are less than 65 years of age is slightly higher for
Whites ($4,268 compared to $3,865, or about $400 difference), but substantially higher for Other AIAN ($3,426,
or $842 difference) (Figure 11). The minimal actuarial adjustment for age and sex differences increases the
difference in payments between IHS AIAN and Whites ($6,273 compared to $5,265, or about $1,000) but not
with Other AIAN ($6,273 compared to $5,398, or about $875). As with the FFS recipients not in CMCP plans, this
effect is expected because the IHS AIAN have a younger age distribution than that of Whites and therefore lower
expected payments, but a similar age distribution to that of Other AIAN and therefore similar expected
payments. Again, the mean adjusted payment increases for all three groups with the age adjustment because
payments for older more costly recipients are given equal weight with less costly younger recipients which
constitute the vast majority of the recipients in all three groups. This is how the statistical adjustment controls
for the differences in age distributions across the three groups.
Adjusting payments further for disability status, either because of Medicaid eligibility as a disabled enrollee, or
as a Medicare-Medicaid ‘Dual’ enrollee under age 65, increases the adjusted means but not the differences in
means for the groups (Figure 11). The mean total payment for IHS AIAN is about $1,000 higher for Whites
($7,439 compared to $6,490) and for Other AIAN ($6,479). Again the adjusted mean rises for all groups
because the higher payments for the smaller groups of Disabled are given equal weight with less costly but
higher proportions of non-disabled recipients during the statistical adjustment.

Findings
Figure 12. Adjustment of Mean Total Payment per Recipient for IHS AIAN, Other AIAN and Whites less than 65 years of age
enrolled 12 months with any months of enrollment in a Comprehensive Managed Care Plan (CMCP) (successive adjustments
for age and sex, & disability). Payments include capitated plan premiums for medical services and either FFS claims or
managed care plan premiums for non-medical services (behavioral health or dental).
$10,000
$9,000
$8,000
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
$-
$4,268
$3,865
$3,426
$6,273
$5,265
$5,398
$7,439
$6,490
$6,479
Unadjusted Age*Sex Adjusted Disabled*Medicare,
Age*Sex Adjusted
29
$5,743 $5,200
$5,050
& Morbidity Adjusted
IHS AIAN
Other AIAN
Whites
After the further adjustment for variation in morbidity among the three groups, the differences are reduced
between IHS AIAN and Whites, and between IHS AIAN and Other AIAN, but the differences remain that are as
large as the unadjusted Mean Total Payments (about $700 and $500 respectively, Figure 11). CMCP plan
members in all three groups had lower morbidity scores than their FFS counterpart groups in Figure 1. This
could be because managed care participants are healthier or because managed care plans provide premium
and encounter claims but not service claims. The morbidity scores for the low income Medicaid eligible Whites
(0.949 with 90% Confidence Limits, C.L., from 0.946 to 0.952) were actually worse than those of IHS AIAN
(0.863 with 90% C.L. 0.858 to 0.868) and Other AIAN (0.843 with 90% C.L. 0.835 to 0.851) (Attachment Tables
D1 and D2).
Payments across IHS Areas Vary Substantially for Recipients with Managed Medical Care
Among recipients with any enrollment in medical managed care plans (CMCP) in their 12 months of Medicaid
enrollment, mean total payments (including any FFS services) are higher for IHS AIAN than Whites in half of the
10 Areas with any CMCP plans (Bemidji, California, Phoenix, Portland and Tucson Areas, Figure 13). Nashville
which had lower payments for IHS AIAN who were not enrolled in any CMCP (Figure 2) is now joined by
Aberdeen, Albuquerque, Navajo and Oklahoma Areas which have lower payments for IHS AIAN than Whites.
Alaska and Billings Areas did not have AIAN or Whites in the counties of the IHS program service delivery areas
enrolled in CMCP plans.

Findings
Figure 13. Adjusted Mean Total Payment per Recipient for IHS AIAN, Other AIAN and Whites less than 65 years of age enrolled
12 months with any months of managed medical care in a CMCP across the IHS Areas (adjusted for age and sex, and for
Disability, Dual eligibility with Medicare, & Morbidity).
Aberdeen
Alaska
Albuquerque
Bemidji
Billings
California
Nashville
Navajo
Oklahoma
Phoenix
Portland
Tucson
$- $2,000 $4,000 $6,000 $8,000 $10,000
30
IHS AIAN
Other AIAN
Whites
Payments for Recipients in Managed Medical Care are Higher for IHS AIAN with Medicaid IHS
Program Claims
When the IHS AIAN recipients with any enrollment in medical managed care plans (CMCP) are divided into
those with and without Medicaid IHS Program claims paid to IHS system health care providers (I/T), payments
are higher for IHS AIAN who had Medicaid IHS Program claims than those who did not in all Areas but
Aberdeen (Figure 14). Whether the IHS AIAN who had Medicaid IHS Program claims were also IHS Active
Users (Group 1) or not (Group 2), payments are higher than those of IHS Active Users who did not have any
Medicaid IHS Program claims (Group 3). In Alaska, Billings and Nashville Areas there were no IHS AIAN with
Medicaid IHS Program claims who also were enrolled in medical managed care plans (CMCP). Albuquerque,
Bemidji and Oklahoma Areas joined the three Areas with recipients in the state of Arizona (Navajo, Phoenix
and Tucson Areas) to have much higher payments for IHS AIAN who had Medicaid IHS Program claims when
compared to IHS Active Users who did not have any Medicaid IHS Program claims. The payments were so much
higher for Bemidji, Oklahoma, Phoenix and Tucson that the scale in the figure was expanded to accommodate
adjusted mean total payments between $10,000 and $12,000 per recipient.

Findings
Figure 14. Adjusted Mean Total Payment per Recipient for the IHS AIAN with any months of managed medical care in a CMCP
in Figure 13 divided into three groups across 12 IHS Areas. Other AIAN and White results are shown as well. Note that the
scale was expanded to accommodate adjusted payments greater than $10,000 IHS AIAN with Medicaid IHS Program claims in
Bemidji, Oklahoma, Phoenix and Tucson Areas.
Aberdeen
Alaska
Albuquerque
Bemidji
Billings
California
Nashville
Navajo
Oklahoma
Phoenix
Portland
Tucson
$- $2,000 $4,000 $6,000 $8,000 $10,000 $12,000
31
1.IHS Program claims
& Active User
2.IHS Program claims
but Not Active User
3.IHS Active User with
no IHS Program claims
Other AIAN
Whites

Analysis
Group
Compiled Findings for All Analyses and Areas
Findings
Adjusted Mean Payments for IHS AIAN are Overall Higher
IHS AIAN generally had higher adjusted mean total payments than either Other AIAN or Whites for nearly all
types of Recipients analyzed, though the payments for IHS AIAN were only 4% to 9% higher than those of
Whites (depending on the type of Recipient, Table 11). The payments were 18% to 32% higher for four of six
types of Recipients when compared to Other AIAN. To obtain an overall measure for all types of Recipients in
the 6 analyses, we first determined the adjusted mean total payment for each type of IHS AIAN Recipient (Table
11) in each IHS Area (Attachment Table L.1). We then determined the difference between the adjusted mean
total payment for IHS AIAN with that of each type of Other AIAN and White Recipients in the IHS Areas
(Attachment Table L.1). The difference between the payment for the IHS AIAN and comparison group was
expressed as a percent of the payment for IHS AIAN. That percent difference in mean payments was multiplied
by the number of IHS AIAN in each Recipient and IHS Area to provide a weighted mean (average) of the relative
differences (Attachment Table L.2). The findings for the differences thus determined across the six types of
Recipients are presented in Table 11 and Figure 15. The findings across the 12 IHS Areas are presented in the
next section (Figures 16 and 17, Attachment Table L.3).
Table 11. Mean percent differences in the adjusted Mean Total Payments for IHS AIAN recipients compared to Other AIAN and
Whites for the 6 groups of recipients. See also Figure 15 and Attachment Table L.2.
Mean
Payment
Analyses
1 2 3 4 5 * 6 *
Differen
ce in
Means
Recipients Less than 65 years of Age Recipients Aged 65 & Over
12 months Enrollment Any Months of Enrollment 12 months Enrollment Any Months of Enrollment
FFS Medical
(220,368)
Capitated Medical
(34,490)
Mean
Payment
Differe
nce in
Means
FFS Medical
(336,888)
Mean
Payment
Differe
nce in
Means
Capitated Medical
(116,277)
Mean
Payment
32
Differen
ce in
Means
FFS Medical
(8,554)
Mean
Paymen
t
Differe
nce in
Means
Capitated
Medical
(1,759)*
Mean
Payment
IHS AIAN $ 5,976
$ 6,157
$ 848
$ 702
$ 8,609
$ 888
FFS Medical
(14,715)
Payments per Year Payments per Month Payments per Year Payments per Month
Differen
ce in
Means
Other AIAN 24% 25% -17% 32% -38% 18%
Whites 13% 9% 12% 4% 8% -21%
*There were insufficient numbers of recipients over age 65 in capitated medical care to analyze mean payments reliably.
Capitated
Medical
(3,884)*

Findings
Differences in adjusted mean total payments for IHS AIAN were 2% to 13% higher than those for Whites in five
of the six types of Medicaid Recipients analyzed (Table 11, Figure 15). Only in the analysis of Recipients age 65
and over in FFS medical care with any number of months of enrollment, was the payment lower. The adjusted
mean per capita payment for IHS AIAN of $888 per month was 21% lower than the payment for Whites. When
IHS AIAN payments were compared to those of Other AIAN, for four of the six types of Medicaid Recipients
analyzed the payments IHS AIAN payments were higher, while in two they were not. Payments 17% lower were
found for Other AIAN when compared to the adjusted mean of $848 per month for IHS AIAN Recipients under
age 65 with any number of months of enrollment in FFS medical care. Payments 28% lower than the adjusted
mean of $8,609 per year were found for Other AIAN when Recipients with 12 months of enrollment in FFS
medical care and aged 65 and over were analyzed.
Figure 15. Mean percent differences in the adjusted Mean Total Payments for IHS AIAN recipients compared to Other AIAN
(red bars) and Whites (grey bars) for the 6 analytical groups of recipients in Table 11.
50%
40%
30%
20%
10%
0%
-10%
-20%
-30%
-40%
-50%
Analysis
1 2 3 4 5 6
33
Other AIAN
Whites

Findings
Adjusted Mean Payments for IHS AIAN are Lower than Whites in Some IHS Areas
When the overall measure for the same adjusted mean total payments examined above by type of Medicaid
recipient, are calculated by IHS Area, the overall finding differs for four of the Areas: Aberdeen, Billings and
Oklahoma Areas had lower adjusted mean total payments for IHS AIAN compared to Other AIAN across the
different types of Recipient analyzed (Figures 16, Attachment Table L.3). Aberdeen, Billings and Albuquerque
Areas had lower adjusted mean total payments for IHS AIAN compared to Whites (Figures 17, Attachment Table
L.3). Findings for all other Areas tended to be higher mean payments.
Figure 16. Percent differences in the adjusted Mean Total Payments for IHS AIAN recipients compared to Other AIAN for the 6
analyses by IHS Area. Positive percent changes indicate the relative amount by which IHS AIAN payments were higher than
Other AIAN. Negative percent changes indicate that by which they were lower.
Aberdeen
Alaska
Albuquerque
Bemidji
Billings
California
Nashville
Navajo
Oklahoma
Phoenix
Portland
Tucson
-60% -40% -20% 0% 20% 40% 60%
Figure 17. Percent differences in the adjusted Mean Total Payments for IHS AIAN recipients compared to Whites for the 6
analyses by IHS Area. Positive percent changes indicate the relative amount by which IHS AIAN payments were higher than
Whites. Negative percent changes indicate that by which they were lower.
Aberdeen
Alaska
Albuquerque
Bemidji
Billings
California
Nashville
Navajo
Oklahoma
Phoenix
Portland
Tucson
-60% -40% -20% 0% 20% 40% 60%
*There are insufficient numbers of whites in the counties of the Tucson Area for a comparison to be made.
34

Findings
Adjusted Mean Payments for IHS AIAN without IHS Program Medicaid Claims are Lower than
Others
IHS AIAN who were Active Users but had not IHS Program Medicaid claims had substantially lower payments
than all other groups (Table 12). Payments for the three different subgroups of IHS AIAN created by the linkage
of data with the IHS registry system were analyzed in the same way as in Table 11 to arrive at an overall
measure that allowed comparison of IHS Active Users with no IHS Program Medicaid claims with the two
groups of IHS AIAN with IHS Program claims as well as Other AIAN and Whites (Attachment Table L.5). There
were sufficient numbers of IHS AIAN without Medicaid IHS Program claims under age 65 to allow analyses but
not over age 65, and therefore a total of 4 analyses were possible. The per capita payments for IHS AIAN Active
Users without IHS Program Medicaid claims were substantially lower for all types of Medicaid recipients when
compared to either IHS AIAN subgroup with IHS Program Medicaid claims (IHS Active Users with IHS Program
claims: 64% to 93% lower; and IHS Program claims only: 26% to 100%). Payments were substantially lower
than those of other AIAN who did not use the IHS system (11% to 30% depending on the type of Recipient), and
of whites living in the same counties (14% to 46% depending on the type of Recipient).
Table 12. Difference in Adjusted Mean Total Payment per Recipient for IHS AIAN Active Users (group 3) with no IHS
Program Medicaid claims of each type of Recipient analyzed compared to IHS AIAN groups IHS Program Medicaid claims
(groups 1 and 2), Other AIAN and Whites in each Area.
IHS Area Analysis Group
Recipie
nts
1
FFS Medical
(220,368)
Mean
Paymt
Differe
nce
Recipie
nts
Mean
Paymt
35
Analyses
2 3 4
Recipients Less than 65 years of Age
12 months Enrollment Any Months of Enrollment
Capitated Medical
(34,490)
Differe
nce
Recipie
nts
FFS Medical
(336,888)
Payments per Year Payments per Month
Mean
Paymt
Differe
nce
Recipie
nts
Capitated Medical
(116,277)
All Areas 1.IHS Claims & User -64% -76% -93% -71%
Mean
Paymt
Differe
nce
2.IHS Claims -52% -81% -100% -26%
3.IHS Active User 55670 $ 3,820
13951 $ 4,134 103859 $ 585
46931 $ 465
Other AIAN -16% -11% -30% -16%
Whites -27% -14% -32% -46%
When the overall measure was calculated by IHS Area across the 4 types of Medicaid recipients, only Nashville
Area was found to have overall higher payments (26% higher) for the IHS AIAN Active Users without IHS
Program Medicaid claims than for Other AIAN who did not use the IHS system (Figure 18, Attachment Table
L.6). Only Tucson was found to have substantially higher payments for the IHS AIAN Active User group than
Whites (13%, Figure 19). Nashville had only 1% higher payments than Whites, which is negligible. Oklahoma
Area had lower payments for the IHS AIAN Active User group than all four of the other groups but only 1% to
4% lower (Attachment Table L.6). Aberdeen Area also had lower payments that were only 1% to 9% lower than
the four other groups.

Findings
Figure 18. Percent differences in the adjusted Mean Total Payments for IHS AIAN recipients without Medicaid IHS Program
claims compared to Other AIAN for the 4 analyses under age 65. See Attachment Table L.6.
Aberdeen
Alaska
Albuquerque
Bemidji
Billings
California
Nashville
Navajo
Oklahoma
Phoenix
Portland
Tucson
-60% -40% -20% 0% 20% 40% 60%
Figure 19. Percent differences in the adjusted Mean Total Payments for IHS AIAN recipients without Medicaid IHS Program
claims compared to Other AIAN for the 4 analyses under age 65. See Attachment Table L.6.
Aberdeen
Alaska
Albuquerque
Bemidji
Billings
California
Nashville
Navajo
Oklahoma
Phoenix
Portland
Tucson
-60% -40% -20% 0% 20% 40% 60%
36

Findings
Medicaid Paid Fraction of Total Health Care Costs of IHS Active Users
IHS Calculated Health Care Costs for IHS Active Users
The IHS determined that the actuarially calculated benchmark (standardized) cost of a Federal Employee Health
Plan of personal medical services for the AIAN users at the IHS and tribal provider sites in the IHS Indian health
care service delivery system was an estimated $4,106 in 2006 (Table 13, 2007 calculations from the Federal
Employees Health Plan Disparities Index). Within each Area, for each IHS and tribal health care site they adjusted
how this benchmark amount would need to be increased or decreased (negative numbers are in parentheses in
Table 13) to purchase the care at that site using standard actuarial techniques. They then aggregated results at
the Area level.
Table 13. IHS determined differences in per capita costs of health care costs for IHS Users across IHS Areas and the expected
adjustments including Alternate Resource amounts. Amounts in parentheses (x) are negative reductions in expected costs of
care to IHS and tribal providers for costs of care of their IHS Active User population.
IHS Area
Benchmark Adjustments Adj Bnchmk Adjustments Adj Bnchmk
Cost per
IHS Active
User 2006
Economic
Adjustment
Health Status
& Poverty
Adjustment
37
Cost per
IHS Active
User
Alternate Resource
Adj aggregated for
Sites by Area
Cost per
IHS Active
User
Aberdeen $ 4,106 $ (189) $ 774 $ 4,691 $ (999) -21% $ 3,693
Alaska $ 4,106 $ 1,856 $ (131) $ 5,831 $ (1,396) -24% $ 4,435
Albuquerque $ 4,106 $ (202) $ 9 $ 3,913 $ (822) -21% $ 3,091
Bemidji $ 4,106 $ (101) $ 333 $ 4,338 $ (815) -19% $ 3,523
Billings $ 4,106 $ (128) $ 502 $ 4,480 $ (910) -20% $ 3,569
California $ 4,106 $ 488 $ (399) $ 4,195 $ (728) -17% $ 3,467
Nashville $ 4,106 $ 266 $ (263) $ 4,109 $ (678) -17% $ 3,432
Navajo $ 4,106 $ (597) $ 97 $ 3,606 $ (902) -25% $ 2,705
Oklahoma $ 4,106 $ (414) $ (170) $ 3,522 $ (687) -20% $ 2,834
Phoenix $ 4,106 $ 95 $ (10) $ 4,191 $ (806) -19% $ 3,385
Portland $ 4,106 $ 572 $ (259) $ 4,419 $ (770) -17% $ 3,649
Tucson $ 4,106 $ (278) $ 102 $ 3,930 $ (867) -22% $ 3,063
The $4,106 benchmark amount for the FEHP medical, dental, behavioral health? and vision care was adjusted
for the following:
Actuarial Adjustments for age and sex distribution of the AIAN user population of IHS and Tribal sites
Economic Adjustments for differences in health care costs (the COLI Index, see Methods Medical Cost
Index); Size (economies of scale of larger provider sites) and whether all hospital and specialty services are
purchased because of lack of access to an IHS or tribal hospital
Health and Poverty Adjustments for differences in health status (relative rates for the Areas for injuries and
poisonings, alcoholism, diabetes, heart disease, cancer); Area differences in birth rates; Area differences in
Percent of population over age 55; and Area and site differences in Poverty Rates among AIAN
After adjustments, the expected Benchmark cost per IHS Active User varied across the IHS Area varied
considerably from a low of $3,522 in Oklahoma Area to a high of %5,831 in Alaska Area.
The amount deducted for third party ‘Alternate Resources’ from the adjusted benchmark cost in each IHS Area
for FY2007 is shown in Table 13. The calculations included the estimate that Medicaid/CHIP, Medicare, Private
Insurance and other third party payers pay about 25% of the adjusted health care costs for IHS Active Users
across all IHS and tribal provider sites in the IHS Areas based on 1987 survey data. The Alternate Resources
include estimated collections to the IHS and tribal sites from the third party payers and payments made to other

Findings
providers for services needed by IHS and tribal site users. At sites without access to an IHS or tribal hospital the
amount deducted from the benchmark cost for Alternate Resources was higher because no hospital costs were
billable by IHS or tribal provider sites, and instead had to be purchased.
Medicaid Fraction of IHS Active User Health Care Costs
We can use the actual Medicaid (that is Total Medicaid and Third Party) payments for IHS AIAN enrollees in
2006 that are documented in the Medicaid-IHS linked data in this report to update the Medicaid/CHIP portion
of Alternate Resources paid in each Area per IHS Active User. Because IHS adjusted the expected benchmark
cost for each Area, the proper payment information to use is the Unadjusted Mean Payment per IHS AIAN
Recipient multiplied by the rate at which IHS Active Users in the IHS Registry were found to be Medicaid
enrollees, and then the rate at which the IHS AIAN Medicaid enrollees were found to be Recipients with
Medicaid paid claims (Table 14).
When we insert the Mean Total Payments for the appropriate IHS AIAN Medicaid recipients in the IHS analytical
framework (Attachment Table C.4 data inserted in column A of Table 14), we find that the Medicaid Alternate
Resources are higher than expected from the 1987 survey data, (Table 14 compared to Table 13).
Table 14. Calculation of the expected Medicaid Mean Total Payment per IHS Active User across IHS Areas as a percent of the
FDI Adjusted Benchmark (Column F, blue column from Table 13). Total payment includes the amounts paid by Medicaid/CHIP
and Third Parties for Medicaid enrollees with paid claims (recipients).
IHS Area
Unadjusted Mean
Total Medicaid
Payment per IHS
AIAN Recipient*
IHS Active Users
w ho are Medicaid
Enrollees (%)
IHS AIAN Medicaid
Enrollees w ho are
Recipients
(%)
38
IHS Active User
Recipients
(% of all IHS
Active Users)
Unadjusted
Mean Total
Medicaid
Payment
per IHS Active
User
FDI Adj Bnchmk
per IHS Active
User
Medicaid
Payments
(% of FDI Adj
Benchmark)
A B C D = B x C E = A x D F G=E/F
Aberdeen $ 3,024 44% 96% 42% $ 1,277 $ 4,691 27%
Alaska $ 6,575 37% 92% 34% $ 2,238 $ 5,831 38%
Albuquerque $ 3,162 39% 93% 36% $ 1,147 $ 3,913 29%
Bemidji $ 4,172 35% 92% 32% $ 1,343 $ 4,338 31%
Billings $ 4,078 39% 96% 37% $ 1,527 $ 4,480 34%
California $ 4,261 29% 99% 29% $ 1,223 $ 4,195 29%
Nashville $ 3,983 22% 88% 19% $ 771 $ 4,109 19%
Navajo $ 4,065 49% 84% 41% $ 1,673 $ 3,606 46%
Oklahoma $ 2,924 26% 95% 25% $ 722 $ 3,522 21%
Phoenix $ 5,757 45% 79% 36% $ 2,047 $ 4,191 49%
Portland $ 4,113 34% 94% 32% $ 1,315 $ 4,419 30%
Tucson $ 6,244 51% 80% 41% $ 2,548 $ 3,930 65%
*From Attachment C: Recipients Enrolled Any Number of Months in Medicaid (Attachment Table C.4)
The percent of all IHS Active Users who are Medicaid Recipients (column D) is the product of multiplying two
key rates of Medicaid participation determined from linked IHS and Medicaid data:

Findings
Percent of IHS Active Users who are Medicaid enrollees (column B). The Medicaid enrollment rate for IHS
Active Users was determined during the linkage of IHS Registry data to this Medicaid enrollee data (see
Methods and Table 2 in the 2011 report Integrating Medicaid and Indian Health Service Data).
Percent of IHS Active User Medicaid Enrollees who are Recipients of Medicaid Paid Services (column C).
The Medicaid participation rate of enrollees was determined by dividing the number of IHS AIAN Medicaid
enrollees that had paid claims of more than zero dollars in column A, by all the IHS AIAN Medicaid
enrollees (Attachment Table C.3).
When expressed as a percent of the FDI Adjusted Benchmark Costs, the Areas with lowest fractions of health
care costs paid by Medicaid for their IHS Active User population are Nashville (19%) and Oklahoma (21%)with
a Medicaid Fraction of about one-fifth ( Figure 15). Aberdeen, California, Albuquerque, Portland and Bemidji
Areas have mid-range fractions of between a little more than one quarter and a little less than one-third (27% to
31%). Alaska and Billings are in the middle of the Area rankings with a little more than one-third of the costs
paid by Medicaid (34% to 38%). And Navajo and Phoenix have Medicaid fractions of nearly one half (46% and
49% respectively). Tucson has the highest Medicaid paid fraction of nearly two-thirds (65%).
Figure 20. Medicaid Alternate Resources paid to all providers as percent of IHS calculated FDI benchmark health care costs
for IHS Active Users in each Area.
Nashville
Oklahoma
Aberdeen
California
Albuquerque
Portland
Bemidji
Billings
Alaska
Navajo
Phoenix
Tucson
19%
21%
27%
29%
29%
30%
31%
34%
38%
46%
49%
Medicaid Fraction Paid to IHS and Tribal Providers for IHS Active Users
Using the Medicaid IHS Program claims payment data for IHS AIAN Medicaid recipients we can calculate the
expected Mean Medicaid IHS Program Payment per IHS Active User to IHS and Tribal (I/T) providers. We
substitute the unadjusted Mean Medicaid IHS Program Payment per IHS AIAN Recipient for the Total Payment
in the calculations in Table 14 to obtain the percents in Figure 16.
When the outcomes are expressed as a percent of the FDI Adjusted Benchmark Cost, the Areas with I/T
providers with the lowest reported Alternate Resources for IHS Active User Medicaid enrollees are Nashville
(2%), Bemidji (4%), Oklahoma (4%) and California (6%), (Figure 15). For Portland, Albuquerque, and Aberdeen
Areas only 8% of all Medicaid payments are to IHS and Tribal providers for health care costs of their Active
Users, and Alaska Area is only 9%. Medicaid resources Billings (12%), Navajo (19%), Phoenix (21%), and
Tucson Areas (24%) have the highest relative Medicaid resources.
39
65%
0% 20% 40% 60% 80% 100%
Percent of FDI Benchmark Cost
All Providers

Findings
Figure 21. Medicaid Alternate Resources paid to I/T providers as percent of IHS calculated FDI benchmark health care costs
for IHS Active Users in each Area.
Nashville
Oklahoma
Bemidji
California
Portland
Albuquerque
Aberdeen
Alaska
Billings
Navajo
Phoenix
Tucson
2%
4%
4%
6%
8%
8%
8%
9%
12%
19%
21%
24%
0% 20% 40% 60% 80% 100%
Percent of FDI Benchmark Cost
40
I/T Providers

Conclusions and Recommendations
IHS AIAN Payments Compared to Others
There is no evidence on a national basis that Medicaid per capita payments for the AIAN user population of IHS
Programs (IHS AIAN) in 2006 are lower than for other Medicaid recipients. Overall in 9 of the 12 IHS Areas
Medicaid payments for personal health care services of IHS AIAN were as high as or higher than either selfdeclared
AIAN who did not use the IHS health care system and of whites living in the same counties. The
exceptions to the general finding in four IHS Areas were: In Albuquerque Area the per capita payments overall
were higher than those of self-declared AIAN who did not use the IHS system, but not higher than Whites. In
Oklahoma Area the payments were higher than for Whites, but not the AIAN who did not use the IHS system. In
Aberdeen and Billings Areas the payments were lower for most types of IHS AIAN Medicaid recipients analyzed
when compared to other AIAN or whites. For the Nashville Area the conclusion requires acknowledgment that
the Medicaid total payments are higher because Third Party payments for Medicaid claims were included in the
total per capita payment analyzed for all the IHS areas. In the Nashville Area the contribution to the total per
capita payment for Medicaid claims due to private insurance is substantial. Nashville Area also was unlike other
Areas in the large number of states that do not report any IHS Program claims. Nashville Area has many states
and counties, but many states have IHS system providers with small numbers of Active Users. These state
Medicaid programs when interviewed were more likely to acknowledge in 2010 they had no special activities to
identify IHS or tribal provider Medicaid claims (Korenbrot and Crouch, 2010).
In the Tucson, Navajo and Phoenix Areas the payments for the AIAN user population of IHS Programs were
highest, which was found to be attributable to the payment levels in the state of Arizona. When Medicaid
recipients in Arizona were excluded, the AIAN payments for Navajo and Phoenix Areas relative to other AIAN
and whites became more like those in other Areas (the Tucson Area is entirely within Arizona and could not be
analyzed with the exclusion of Arizona Medicaid recipients).
In making these comparisons, payments for six different types of Medicaid service recipients were analyzed.
Medicaid recipients were classified depending on whether they were under age 65 or not, enrolled all year in
Medicaid or not, and whether they received only fee-for-service (FFS) medical care or had any of their medical
services in managed care. The payments for each type of Medicaid recipient were risk-adjusted for differences
between the IHS AIAN and comparison groups with respect to age, sex, disability, and dual-enrollment with
Medicare. Adjustments for differences among the groups in morbidity were possible for those enrolled all year
in Medicaid, but not those enrolled less than a year. The payments were also adjusted for variation in health
care prices across the IHS Areas whether analyzed as mean payment per year for recipients enrolled all year, or
mean payment per month for when recipients were analyzed regardless of length of enrollment.
The findings were not found to depend on any particular type of Medicaid recipient analyzed. For any given
Area one or more of the recipient types the AIAN user population might have an adjusted mean per capita
payment higher or lower than a comparison group. One of the implications of this finding is that the overall,
results did not depend on whether the payments were adjusted for differences in morbidity or not, or whether
they received their medical care in a FFS or managed care system.
The IHS AIAN FFS per capita payments were dominated by outpatient services (including claims for clinic,
medical care practitioners, laboratory and imaging, and dental services). Inpatient payments were a small
41

Conclusions and Recommendations
proportion of overall payments. Prescription drug payments contributed little to the payments for IHS AIAN
compared to their contribution to payments for Other AIAN or whites. There were almost no payments for IHS
Program claims for prescription drugs outside of the Bemidji Area.
This evidence supports the general conclusion that in most Areas the IHS system providers and the state
Medicaid programs with which they interface in these Areas are as a whole are doing a well at billing and
collection for services provided to Medicaid enrolled users of the IHS system. In Aberdeen, Billings,
Albuquerque and Oklahoma Areas, however, it is possible that either IHS system or other providers who
provide care for these AIAN do not file as many claims, or are denied more claims for their care. It is also
possible that in Albuquerque Area the reason that lower payments were found only compared to self-declared
AIAN who do not use the IHS system is because these other AIAN have higher demands for health care when ill
because they are not in the IHS system. The morbidity risk-adjustment is only a partial adjustment for health
status differences, because it depends on people accessing their Medicaid health care provider over the year to
have information on health status to adjust.
Medicaid-enrolled IHS Active Users without IHS Program Medicaid claims
IHS Active Users with Medicaid claims but no IHS Program Medicaid claims had substantially lower payments
over all the recipient types analyzed. The per capita payments for this subgroup of IHS AIAN were substantially
lower for all types of Medicaid recipients analyzed than those of: 1) other IHS AIAN with IHS Program Medicaid
claims, 2) other AIAN who did not use the IHS system, and 3) whites living in the same counties. This was found
as an overall conclusion for all IHS Areas when the compared to the IHS AIAN with IHS Program Medicaid
claims. This was found for all but one IHS Area compared to other AIAN (Nashville) and for one IHS Area
compared to whites (Tucson). The payments were risk-adjusted and therefore it is not likely that they are
lower because these are healthier IHS AIAN than the other groups of IHS AIAN. This finding supports the
conclusion that IHS system providers may not be doing all the billing and collections of Medicaid for care they
have provided to their IHS user population.
Medicaid-paid Fraction of IHS Active User Costs
The fraction of health care costs needed by the IHS Active User population that is paid by Medicaid (and
Medicaid-CHIP) is 25% or more in 9 of 12 IHS Areas, but varied from 19% to 65% depending on the IHS Area.
Areas with the lowest fraction of about one-fifth are Nashville (19%) and Oklahoma (21%). Aberdeen,
California, Albuquerque, Portland and Bemidji Areas have mid-range fractions of between a little more than one
quarter and a little less than one-third (27% to 31%). Alaska and Billings are in the middle of the Area rankings
with a little more than one-third of the costs paid by Medicaid (34% to 38%). And Navajo and Phoenix have
Medicaid fractions of nearly one half (46% and 49% respectively). Tucson has the highest Medicaid paid
fraction of nearly two-thirds (65%).
When the amounts paid by Medicaid to IHS and tribal providers are separated out of the Medicaid fraction and
compared to the total health care costs of their user population, the Areas with the lowest reported Medicaid
fraction paid to IHS and tribal providers by Medicaid are Nashville (2%), Bemidji (4%), Oklahoma (4%) and
California (6%). For Portland, Albuquerque, and Aberdeen Areas only 8% the total health care costs needed by
their user population are paid to IHS and tribal providers by Medicaid, and in Alaska Area it is only 9%. Billings
(12%), Navajo (19%), Phoenix (21%), and Tucson Areas (24%) receive the highest Medicaid fractions.
42

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44

Dear Tribal Leader:
THE SECRETARY OF HEALTH AND HUMAN SERVICES
WASHINGTON, D.C. 20201
October 19, 20 12
The Department of Health and Human Services (HHS) has been a leader in the federal
government's efforts to improve its partnership with tribes. I am proud of our current
government-to-government relationship with tribes from across the country. HHS continuously
strives to find innovative and meaningful ways to work with you and your communities. One
mechanism to ensure this collaboration is our Tribal Consultation Policy (TCP).
At the very start of this administration, I requested your feedback and input with updating our
TCP. I then created a federal tribal workgroup to coordinate all of your comments and
recommendations. As a result of that work, in December 201 0, I signed the updated TCP. In
that revision, HHS committed to evaluating that policy every few years, and that is why I write
you today.
In accordance with that policy, HHS has conducted tribal consultation in a variety of ways over
the years, including: conference calls; direct correspondence to tribal leadership; meetings with
tribal leadership at the local, area, or national levels; and national and regional consultations.
Tribal leaders have indicated their agreement with current HHS policy, but we are always
looking to make improvements.
I am interested in your thoughts and views regarding our current TCP. I would appreciate it if
you would take the time to review and evaluate our TCP and provide your feedback on what is
working, what isn't, and what we can do to improve our activities to ensure meaningful tribal
consultation policy. This will greatly assist us in our evaluation of the policy. Here is the link to
our current policy for your review: http:ll~~ww.hhs.gov/intergovernmental/tribal/tcp.html.
I ask that you provide us with your feedback by submitting your comments by Friday,
December 7,2012. Comments can be sent to:
Stacey Ecoffey, Principal Advisor for Tribal Affairs
Office of Intergovernmental and External Affairs
U.S. Department of Health and Human Services
200 Independence Ave SW Room 620-E
Washington, DC 2020 1
Email: Consultation~,hhs.gov
If you have further questions or concerns please feel free to contact Stacey Ecoffey, Principal
Advisor for Tribal Affairs, via email at Stacev.Ecoffey@,hhs.aov or via phone at (202) 690-6060.
Thank you in advance for your contribution and commitment to a strong HIIS Tribal
Consultation Policy. 1 look forward to our continued partnership.
Gthleen Sebelius

Tribal Consultation Policy HHS
1. PURPOSE
The U. S. Department of Health and Human Services (HHS) and Indian Tribes share the goal to
establish clear policies to further the government-to-government relationship between the
Federal Government and Indian Tribes. True and effective consultation shall result in information
exchange, mutual understanding, and informed decision-making on behalf of the Tribal
governments involved and the Federal Government. The importance of consultation with Indian
Tribes was affirmed through Presidential Memoranda in 1994, 2004 and 2009, and an Executive
Order (EO) in 2000.
The goal of this policy includes, but is not limited to, eliminating health and human service
disparities of Indians, ensuring that access to critical health and human services is maximized,
and to advance or enhance the social, physical, and economic status of Indians. To achieve this
goal, and to the extent practicable and permitted by law, it is essential that Federally-recognized
Indian Tribes and the HHS engage in open, continuous, and meaningful consultation.
This policy applies to all Divisions of the Department and shall serve as a guide for Tribes to
participate in all Department and Division policy development to the greatest extent practicable
and permitted by law.
2. BACKGROUND
Since the formation of the Union, the United States (U.S.) has recognized Indian Tribes as
sovereign nations. A unique government-to-government relationship exists between Indian
Tribes and the Federal Government. This relationship is grounded in the U.S. Constitution,
numerous treaties, statutes, Federal case law, regulations and executive orders that establish
and define a trust relationship with Indian Tribes. This relationship is derived from the political
and legal relationship that Indian Tribes have with the Federal Government and is not based
upon race.
An integral element of this government-to-government relationship is that consultation occurs
with Indian Tribes. The Executive Memorandum titled “Tribal Consultation” reaffirmed this
government-to-government relationship with Indian Tribes on November 5, 2009. The
implementation of this policy is in recognition of this special relationship.
This special relationship is affirmed in statutes and various Presidential Executive Orders
including, but not limited to:
o Older Americans Act, P.L. 89-73, as amended;
o Indian Self-Determination and Education Assistance Act, P.L. 93-638, as amended;
o Native American Programs Act, P.L. 93-644, as amended;
o Indian Health Care Improvement Act, P.L. 94-437, as amended;
o Personal Responsibility and Work Opportunity Reconciliation Act of 1996, P.L.104-193;
o Presidential Executive Memorandum to the Heads of Executive Departments dated April 29,
1994;
o Presidential Executive Order 13175, Consultation and Coordination with Indian Tribal
Governments, November 6, 2000; and
o Presidential Memorandum, Government-to-Government Relationship with Tribal
Governments, September 23, 2004
o Presidential Memorandum, Tribal Consultation, November 5, 2009

o American Recovery and Reinvestment Act of 2009, P.L. 111-5, 123 Stat. 115 (Feb. 17,
2009).
o Children's Health Insurance Program Reauthorization Act of 2009, P.L. 111-3, 123 Stat. 8
(Feb. 4, 2009).
o Patient Protection and Affordable Care Act of 2010, P.L. 111-148, 124 Stat. 119 (Mar. 23,
2010).
3. TRIBAL SOVEREIGNTY
This policy does not waive any Tribal Governmental rights and authority, including treaty rights,
sovereign immunities or jurisdiction. Additionally, this policy does not diminish any rights or
protections afforded other American Indians or Alaskan Natives (AI/AN) or entities under Federal
law.
The special government-to-government relationship between the Federal Government and
Indian Tribes, established in 1787, is based on the Constitution, and has been given form and
substance by numerous treaties, laws, Supreme Court decisions, and Executive Orders, and
reaffirms the right of Indian Tribes to self-government and self-determination. Indian Tribes
exercise inherent sovereign powers over their citizens and territory. The U.S. shall continue to
work with Indian Tribes on a government-to-government basis to address issues concerning
Tribal self-government, Tribal trust resources, Tribal treaties and other rights.
Tribal self-government has been demonstrated to improve and perpetuate the government-togovernment
relationship and strengthen Tribal control over Federal funding that it receives, and
its internal program management. Indian Tribes participation in the development of public health
and human services policy ensures locally relevant and culturally appropriate approaches to
public issues.
4. POLICY
Before any action is taken that will significantly affect Indian Tribes it is the HHS policy that, to
the extent practicable and permitted by law, consultation with Indian Tribes will occur. Such
actions refer to policies that:
1. Have Tribal implications, and
2. Have substantial direct effects on one or more Indian Tribes, or
3. On the relationship between the Federal Government and Indian Tribes, or
4. On the distribution of power and responsibilities between the Federal Government and
Indian Tribes.
Nothing in this policy waives the Government’s deliberative process privilege. Examples of the
government’s deliberative process privilege are as follows:
5. The Department is specifically requested by Members of Congress to respond to or report
on proposed legislation, the development of such responses and of related policy is a part
of the Executive Branch’s deliberative process privilege and should remain confidential.
6. In specified instances Congress requires the Department to work with Indian Tribes on the
development of recommendations that may require legislation, such reports,
recommendations or other products are developed independent of a Department position,
the development of which is governed by Office of Management and Budget (OMB) Circular
A-19.
A. Each HHS Operating and Staff Division (Division) shall have an accountable process as

defined in Sections 8 and 9 of this policy to ensure meaningful and timely input by Indian Tribes
in the development of policies that have Tribal implications. If Divisions require technical
assistance in implementing these sections, the Office of Intergovernmental Affairs (IGA) can
provide and/or coordinate assistance.
B. To the extent practicable and permitted by law, no Division shall promulgate any regulation
that has Tribal implications, or that imposes substantial direct compliance costs on Indian Tribes,
or that is not required by statute, unless:
7. Funds necessary to pay the direct costs incurred by the Indian Tribe in complying with the
regulation are provided by the Federal Government; or
8. The Division, prior to the formal promulgation of the regulation,
a. Consulted with Indian Tribes throughout all stages of the process of developing the
proposed regulation;
b. Provided a Tribal summary impact statement in a separately identified portion of the
preamble to the regulation as it is to be issued in the Federal Register (FR), which
consists of a description of the extent of the Division's prior consultation with Indian
Tribes, a summary of the nature of their concerns and the Division's position
supporting the need to issue the regulation, and a statement of the extent to which
the concerns of Tribal officials have been met; and
c. Made available to the Secretary and to the Director of OMB any written
communications submitted to the Division by Tribal officials.
C. To the extent practicable and permitted by law, no Division shall promulgate any regulation
that has Tribal implications and that preempts Tribal law unless the Division, prior to the formal
promulgation of the regulation,
9. Consulted with Tribal officials throughout all stages of the process of developing the
proposed regulation;
10. Provided a Tribal summary impact statement in a separately identified portion of the
preamble to the regulation as it is to be issued in the FR, which consists of a description of
the extent of the Division's prior consultation with Tribal officials, a summary of the nature
of their concerns and the Division's position supporting the need to issue the regulation,
and a statement of the extent to which the concerns of Tribal officials have been met; and
11. Made available to the Secretary any written communications submitted to the Division by
Tribal officials.
D. On issues relating to Tribal self-governance, Tribal self-determination, Tribal trust resources,
or Tribal treaty and other rights, each Division shall make all practicable attempts where
appropriate to use consensual mechanisms for developing regulations, including negotiated
rulemaking.
5. PHILOSOPHY
Indian Tribes have an inalienable and inherent right to self-government. Self-government means
government in which decisions are made by the people who are most directly affected by the
decisions. As sovereign nations, Indian Tribes exercise inherent sovereign powers over their
members, territory and lands.
HHS has a long-standing commitment to working on a government-to-government basis with
Indian Tribes and to work in partnership with AI/ANs. Also, HHS is committed to enhancing the
collaboration among its Divisions to address Tribal issues and promoting the principle that each
Division bears responsibility for addressing Tribal issues within the context of their mission.

IGA is identified as the responsible HHS entity, located in the Immediate Office of the Secretary
(IOS) for monitoring compliance with EO 13175 and the Department Tribal Consultation Policy.
In addition, the Secretary has charged the Intradepartmental Council on Native American Affairs
(ICNAA) to meet regularly and no less then 2 times a year and to provide advice on all HHS
policies that relate to Indian Tribes as well as instances where HHS activities relate to Native
Americans. Regional consultation sessions have been developed as a systematic method to
regularly consult with Indian Tribes on HHS programs at field locations. The goal of these efforts
is to focus HHS on Tribal issues, to continue to enhance the government-to-government
relationship between Indian Tribes and the U.S., as well as to make resources of HHS more
readily available to Indian Tribes.
6. OBJECTIVES
0. To formalize the Administration’s policy that HHS seek consultation and the participation of
Indian Tribes in the development of policies and program activities that impact Indian
Tribes.
1. To establish a minimum set of requirements and expectations with respect to consultation
and participation throughout HHS management, the Office of the Secretary (OS) Division,
and Regional levels.
2. The need to consult may be identified by the Department or by an Indian Tribe(s). Any
time the Tribe(s) or the Department identifies a critical event the Department may initiate
any necessary consultation in accordance with this policy.
3. To identify events and partnerships that HHS would participate with Indian Tribe(s) and
Tribal/Indian Organizations that establish and foster partnerships with HHS which
complement and enhance consultation with Indian Tribes.
4. To promote and develop innovative consultation methods with Indian Tribes in the
development of HHS policy and regulatory processes.
5. To uphold the responsibility of HHS to consult with Indian Tribes on new and existing
health and human service policies, programs, functions, services and activities that have
Tribal implications.
6. To charge and hold accountable each of the HHS Operating Division Heads for the
implementation of this policy.
7. To be responsive to requests by an Indian Tribe(s) request for consultation and technical
assistance in obtaining HHS resources.
8. To charge the HHS Operating Divisions with the responsibility for enhancing partnerships
with Indian Tribes which will include, requests for technical assistance, access to programs
and resources, as well as collaborating with Tribal subject matter expertise.
9. To provide a single point of contact within HHS and its Operating Divisions for Indian Tribes
at the highest level which would have access to the IOS, the Deputy Secretary, and
Operating Division Heads. The Principal Advisor for Tribal Affairs and the Division Tribal
points of contact will be responsible for compliance with this policy and ensuring
timeframes identified in section 9 are met.
7. CONSULTATION PARTICIPANTS AND ROLES
0. Indian Tribes: The government-to-government relationship between the U.S. and
Federally recognized Indian Tribes dictates that the principal focus for HHS consultation is
Indian Tribes, individually or collectively.
1. Indian Organizations: At times it is useful that the HHS communicate with Indian
organizations to solicit Indian Tribe(s) advice and recommendations. The government does
not participate in government-to-government consultations with these entities; rather
these organizations represent the interest of Indian Tribes when authorized by those Tribes
These organizations by the sheer nature of their business serve and advocate Indian Tribes
issues and concerns that might be negatively affected if these organizations were excluded
from the process.

2. Office of Intergovernmental Affairs (IGA): IGA is responsible for Department-wide
implementation and monitoring of EO 13175 for HHS Tribal consultation. IGA serves as the
Department’s point of contact in accessing department-wide information. The single point
of contact within the IGA for Indian Tribes and other Tribal/Indian organizations, at a level
with access to all HHS Divisions, is the Principal Advisor for Tribal Affairs. As a part of the
IOS, IGA’s mission is to facilitate communication regarding HHS initiatives as they relate to
Tribal, State, and local governments. IGA is the Departmental liaison to States and Indian
Tribes, and serves the dual role of representing the States and Tribal perspective in the
Federal policymaking process, as well as, clarifying the Federal perspective to States and
Indian Tribes, including Tribal consultation.
3. Assistant Secretary for Finance and Resources (ASFR): ASFR is the lead office for
budget consultation for the overall departmental budget request.
4. HHS Divisions: The Department has numerous Staff Divisions and Operating Divisions
under its purview. Each of the these Divisions share in the Department-wide responsibility
to coordinate, communicate and consult with Indian Tribes on issues that affect these
governments. All Operating Divisions shall establish a Tribal consultation policy to comply
with the HHS Policy. All Divisions are responsible for conducting Tribal consultation to the
extent practicable and permitted by law on policies that have Tribal implications.
5. Intradepartmental Council on Native American Affairs(ICNAA): The ICNAA is
charged with: (1) develop and promote an HHS policy to provide greater access and
quality services for AI/AN/NAs throughout the Department; (2) promote implementation of
HHS policy and Division plans on consultation with Indian Tribes in accordance with
statutes and EOs; (3) promote an effective, meaningful AI/AN/NA policy to improve health
and human services for AI/AN/NAs; (4) develop a comprehensive Departmental strategy
that promotes self-sufficiency and self-determination for all Indian Tribes and AI/AN/NA
people; (5) promote the Tribal/Federal Government-to-government relationship on an
HHS-wide basis in accordance with EO 13175; and (6) operate in accordance with policy
and timeframes identified within ICNAA charter and as directed by the Secretary and the
ICNAA Executive Leadership.
6. Regional Offices: The ten (10) HHS Regional Offices share in the Department-wide
responsibility to consult, coordinate and communicate with Indian Tribes on issues that
affect Indian Tribes and HHS programs, services and resources available to Indian Tribes
through States. The Regional Directors are the Secretary’s immediate representatives in
the field for the HHS. Each of the Regional Office(s) shall conduct an annual regional Tribal
consultation meeting with Indian Tribes in their respective regions. Additional meetings
may be conducted if requested by the Regional Director or an Indian Tribe(s) within the
Region. Further, the Regional Directors will work closely with the respective Indian Tribes
and State Governments to assure continuous coordination and communication between
Tribes and States. The Regional Office Directors will promote and comply with this policy
and its timeframes identified in Section 9.
8. TRIBAL CONSULTATION PROCESS
An effective consultation between HHS and Indian Tribes requires trust between all parties which
is an indispensable element in establishing a good consultative relationship. The degree and
extent of consultation will depend on the identified critical event. A critical event may be
identified by HHS and/or an Indian Tribe(s). Upon identification of an event significantly affecting
one or more Indian Tribe(s), HHS will initiate consultation regarding the event. In order to
initiate and conduct consultation, the following serves as a guideline to be utilized by HHS and
Indian Tribes:
0. Identify the Critical Event: Complexity, implications, time constraints, and issue(s)
(including policy, funding/budget development, programs, services, functions and
activities).

1. Identify affected/potentially affected Indian Tribe(s)
2. Determine Consultation Mechanism – The most useful and appropriate consultation
mechanisms can be determined by HHS and/or Indian Tribe(s) after considering the critical
event and Indian Tribe(s) affected/potentially affected. Consultation mechanisms include
but are not limited to one or more of the following:
a. Mailings
b. Teleconference
c. Face-to-Face Meetings at the Local, Regional and National levels between the HHS
and Indian Tribes.
d. Roundtables
e. Annual HHS Tribal Budget and Policy Consultation Sessions.
f. Other regular or special HHS Division or program level consultation sessions.
A. Communication Methods: The determination of the critical event and the level of consultation
mechanism to be used shall be communicated to affected/potentially affected Indian Tribe(s)
using all appropriate methods and with as much advance notice as practicable. These methods
include but are not limited to the following:
3. Correspondence: Written communications shall be issued within 30 calendar days of an
identified critical event. The communication should clearly provide affected/potentially
affected Indian Tribe(s) with detail of the critical event, the manner and timeframe in
which to provide comment. The HHS frequently uses a “Dear Tribal Leader Letter” (DTLL)
format to notify individual Indian Tribes of consultation activities. Divisions should work
closely with the Principal Advisor for Tribal Affairs, IOS/IGA if technical assistance is
required for proper format and protocols, current mailing lists, and content.
4. Official Notification: Within 30 calendar days, and upon the determination the consultation
mechanism, proper notice of the critical event and the consultation mechanism utilized
shall be communicated to affected/potentially affected Indian Tribe(s) using all appropriate
methods including mailing, broadcast e-mail, FR, and other outlets. The FR is the most
formal HHS form of notice used for consultation.
5. Meeting(s): The Division shall convene a meeting, within 60 calendar days of official
notification, with affected/potentially affected Indian Tribe(s) to discuss all pertinent issues
in a national, regional, and/or local forum, or as appropriate, to the extent practicable and
permitted by law, when the critical event is determined to have substantial impact.
6. Receipt of Tribal Comment(s): The Division shall develop and use all appropriate methods
to communicate clear and explicit instructions on the means and time frames for Indian
Tribe(s) to submit comments on the critical event, whether in person, by teleconference,
and/or in writing and shall solicit the advice and assistance of the Principal Advisor for
Tribal Affairs, IOS/IGA.
7. Reporting of Outcome: The Division shall report on the outcomes of the consultation within
90 calendar days of final consultation. For ongoing issues identified during the consultation,
the Division shall provide status reports throughout the year to IOS/IGA and Indian
Tribe(s).
A. HHS Response to Official Tribal Correspondence: Official correspondence from an Indian Tribe
may come in various forms, but a resolution is the most formal declaration of an Indian Tribe’s
position for the purpose of Tribal consultation. In some instances, Indian Tribes will submit
official correspondence from the highest elected and/or appointed official(s) of the Tribe. HHS

will give equal consideration to these types of correspondence. Once HHS receives an official
Indian Tribe correspondence and/or resolution, the Secretary/Deputy Secretary and/or their
designee should respond appropriately. The process for official correspondence to Indian Tribes
is described below:
8. Correspondence submitted by Indian Tribes to HHS shall be officially entered into HHS
correspondence control tracking system and referred to the appropriate Division(s).
9. Acknowledgement of Correspondence: HHS and/or Divisions shall provide
acknowledgement to Indian Tribes within 15 working days of receipt.
10. Official Response to an identified critical event: HHS shall provide an official response to
Indian Tribes that includes: the Division head responsible for follow up, the process for
resolution of the critical event and timeline for resolution.
a. If an identified critical event is national in scope the Department shall to the extent
practicable respond to the request within 60 working days or less.
b. If a critical event is specific to a single Indian Tribe the Department shall to the
extent practicable respond to the request within 45 working days or less.
B. Policy Development through Tribal Consultation Process: The need to consult on the
development or revision of a policy may be identified from within HHS, an HHS Division or may
be identified by Indian Tribes. This need may result from external forces such as Executive,
Judicial, or Legislative Branch actions or otherwise. Once the need to consult on development or
revision of a policy is identified the consultation process must begin in accordance with critical
events and consultation mechanisms described above. HHS Divisions may request technical
assistance from IGA for the Tribal consultation process.
C. Schedule for Consultation: Divisions must establish and adhere to a formal schedule of
meetings to consult with Indian Tribes and their representatives concerning the planning,
conduct, and administration of applicable activities. Divisions must involve Tribal representatives
in meetings at every practicable opportunity. Divisions are encouraged to establish additional
forums for Tribal consultation and participation, and for information sharing with Tribal
leadership. Consultation schedules should be coordinated with IGA to avoid duplications or
conflicts with other national Tribal events. HHS Divisions should make every effort to schedule
their consultations in conjunction with the Annual Regional Tribal Consultation Sessions.
9. CONSULTATION PROCEDURES AND RESPONSIBLITIES
. Consultation Parties and Mechanisms- Consultation Occurs:
1. When the HHS Secretary/Deputy Secretary, or their designee, meets and/or
exchanges written correspondence with a Tribal
President/Chair/Governor/Chief/Principal Chief and/or elected/appointed Indian Tribal
Leader, or their designee to discuss issues concerning either party.
2. When an HHS Division Head, or their designee, meets or exchanges written
correspondence with an Indian Tribal representative designated by an
elected/appointed Tribal leader to discuss issues or concerns of either party.
3. When an HHS Regional Director, who is the Secretary’s representative in the field,
meets or exchanges written correspondence with an elected/appointed Indian Tribal
Leader, or their designee to discuss issues or concerns of either party.
4. When the Secretary/Deputy Secretary/HHS Division Head, or their designee, meets
or exchanges written correspondence with a Tribal representative designated by an
elected/appointed Indian Tribal leader to discuss issues or concern of either party.
A. Consultation Procedures
0. Tribal: Specific consultation mechanisms that will be used to consult with an Indian
Tribe(s) include but are not limited to mailings, meetings, teleconference and
roundtables.

a. An Indian Tribe(s) has the ability to initiate consultation, i.e. meet one-on-one
with an HHS Division Head or designated representative to consult on issues
specific to that Indian Tribe.
b. HHS Division Heads will initiate consultation to solicit official Indian Tribe(s)’
comments and recommendations on policy and budget matters affecting Indian
Tribe(s). These sessions at roundtables, forums and meetings will provide the
opportunity for meaningful dialogue and effective participation by Indian
Tribe(s).
c. National/Regional Inter-Tribal Forums: Other types of meetings and/or
conferences occur which may not be considered consultation sessions, but these
meetings may provide opportunities to share information, conduct workshops,
and provide technical assistance to Indian Tribes.
1. HHS: Consultation mechanisms that will be used to consult with Indian Tribe(s)
include but are not limited to mailings, meetings, teleconferences and roundtables.
HHS has various organizational avenues in which Tribal issues and concerns are
addressed. These avenues include the OS, the ICNAA, Regional Offices, and
Divisions.
1.
2. Office of the Secretary
a. The HHS National Tribal Consultation Sessions are designed to solicit
Indian Tribes’ health and human services priorities and program needs.
The Sessions provide an opportunity for Indian Tribes to articulate their
recommendations on budgets, regulations, policies and legislation.
i. Upon completion of consultation, HHS will document and notify
Indian Tribes on the proceedings, noting positions and following-up
on all issues raised that would benefit from ongoing consultation
with Indian Tribe(s) within 90 calendar days.
3. ICNAA
a. The ICNAA represents the internal HHS team providing consistent
direction across the Divisions for AI/AN/NA issues. One of the primary
responsibilities of ICNAA is to solicit Tribal input in establishing Tribal
policy and budget priorities and recommendations for Divisions.
The health and human service priorities established by Indian Tribes are
used to inform the development of the Divisions’ annual performance
goals and measures for improving health and human services, which are
linked to their budget requests.
4. Regional Offices
a. Regional Offices will work with the Indian Tribes and Indian organizations
within their respective regional area in facilitating the Tribal perspective
with HHS programs, services, functions, activities and planning Tribal
regional consultation sessions. HHS Divisions have various geographic
coverage, however all HHS Divisions, regardless of geographic location,
are intended to serve Indian Tribe(s) in their respective locations.
b. Regional Offices/Directors will work collaboratively with the HHS Division
lead regional representative in communicating and coordinating on issues
and concerns of Indian Tribes in those respective regions or areas.
c. Regional Offices/Directors will work collaboratively to facilitate Tribal-State
relations as they affect Indian Tribes in the delivery of HHS programs and
services.
d. Regional Tribal Consultation Sessions are held to solicit Indian Tribe(s)’
priorities and needs on health and human services. The sessions also

provide Indian Tribes with a regional perspective and shall be held, at
least but not limited to, annually with status reports to Indian Tribe(s) as
appropriate throughout the year, or at least biannually.
1. Regional Consultations will occur between February and April of
every year.
2. Regional Consultations shall be utilized as a venue for Divisions to
coordinate their consultation responsibilities in a manner that is
feasible and convenient for Indian Tribes.
3. Regional Offices/Directors will contact Indian Tribes and Indian
Organizations in their respective regions to assist in the planning of
the session. This will ensure inclusion of all perspectives and issues
for the session.
4. Protocol will ensure that the highest ranking official present from
each respective Indian Tribe is given the opportunity to address the
session first, followed by other elected officials, those designated by
official letter to represent their respective Indian Tribe and
representatives of Indian Organizations.
a. Official letter from the Indian Tribe designating a
representative must be presented to Regional Director before
the session begins.
5. Regional Offices/Directors will seek the assistance of Tribal Leaders
to assist with moderating the annual regional consultation session.
6. The official record of every regional session will be left open for 30
calendar days after the conclusion of the session for submission of
additional comments/materials from Indian Tribe(s)
7. Regional Offices/Directors will provide a summary no later than 45
calendar days after the consultation of the session.
5. HHS Divisions
a. Divisions will work collaboratively with the Indian Tribes on the
development of consultation meetings, one-on-one meetings, roundtables,
teleconferences and annual sessions.
b. Divisions will work collaboratively with Indian Tribes on developing and
implementing their respective Tribal Consultation Policy or Plan.
c. Divisions will coordinate with IGA on their respective consultation
activities in order to ensure that HHS and its Divisions are conducting
Tribal consultation coordinating in a manner that is feasible and conducive
to the needs of Indian Tribes.
d. Divisions will participate in both the Annual Tribal Budget and Policy
Consultation Session and Annual Regional Tribal Consultations with Indian
Tribes.
e. Divisions will work collaboratively to facilitate Tribal-State relations as
they affect Indian Tribes and AI/ANs in the delivery of HHS programs and
services.
2. States: In some instances the authority and program funding for HHS programs is
administered by the States on behalf of Indian Tribes. The Divisions will consult with
the Office of the General Counsel to determine whether these arrangements are
based on statutes, regulations, or policy decisions. If there is no clear regulatory or

statutory basis mandating that States administer the program on behalf of the
Tribe(s), the Division will consult with the affected Indian Tribe(s) as soon as
practicable to review alternate options.
If there is a statutory basis mandating that the State administer the program and
associated funding on behalf of the Indian Tribe(s) the Division will examine the
permissibility of encouraging or mandating a term requiring tribal consultation as a
condition of the State’s receipt of program funds. If such a term may be mandated
regarding State administered programs affecting Indian Tribes it should be
incorporated. If it is not permissible, the Division shall facilitate consultation between
the State and affected Tribe(s).
In addition, whenever practicable and permitted by law, the Division shall notify
Indian Tribes of funds administered by the State that the Division believes should be
allocated to Indian Tribes.
The Division shall also encourage the State to recognize that Indian Tribal members
are entitled to benefits provided to all State citizens and should be provided the same
access to State administered or funded services since Tribal members are citizens of
the State(s). To the extent possible, data shall be collected and reported about the
number of Tribal members served by the State with federal resources.
10. ESTABLISHMENT OF JOINT TRIBAL/FEDERAL WORKGROUPS AND/OR TASKFORCES
The need to develop or revise a policy may be identified from within the Division or by an Indian
Tribe(s). When new or revised national policy, regulations or legislation affects an Indian
Tribe(s), an Indian Tribe(s) or HHS may recommend the establishment of a workgroup and/or
task force. In response, HHS may establish such a workgroup and/or task force to develop
recommendations on various technical, legal, regulatory, or policy issues. In such cases, see
ADDENDUM 1 which outlines the process for establishing such aforementioned workgroups
and/or task forces.
11. HHS BUDGET FORMULATION
HHS shall consult with Indian Tribes throughout the development of the HHS Budget formulation
process to the greatest extent practicable and permitted by law. The Secretary shall require the
Divisions to include a process in their Tribal Consultation Policy/Plan that assures Tribal priorities
and needs and requests are identified and considered in the formulation of the HHS budget.
. HHS Annual Tribal Budget and Policy Consultation Session (ATBPCS): A
Department-wide Tribal budget and policy consultation session will be conducted annually
to give Indian Tribes the opportunity to present their budget and policy priorities and
recommendations to the Department as HHS prepares to receive the budget requests of its
Divisions. The session is convened in March of each year as a means for final input in the
development of the Department’s budget submission to OMB.
0. At a minimum, HHS conducts annually one ATBPCS to ensure the active participation
of Indian Tribes in the formulation of the HHS performance budget request as it
pertains to Indian Tribes, which will be held at the HHS Headquarters in Washington,
DC no later than March each year.
1. HHS will notify Tribes of the date of the consultation no later than 90 days prior to
the session.
2. The session will not exceed two days.
3. Each Operating Division Head/Deputy and budget officer will attend their agency’s
appropriate session(s).

4. Each Operating Division Head/Deputy will participate in other portions of the ATBPCS
that affect their respective division.
5. IGA/ASFR will provide a summary of the session to Indian Tribes no later than 30
calendar days after the session has concluded.
6. Within 90 calendar days IGA shall post the transcript of the ATBPCS with a summary
of the Indian Tribes’ issues/concerns presented at the session.
7. HHS will seek the assistance of Indian Tribal Leaders to assist with moderating the
ATBPCS. HHS will also contact Indian Organizations in the planning of the session in
order to ensure inclusion of all perspectives and issues.
8. Presentation protocol will ensure that the highest ranking official from each
respective Tribe is given the opportunity to address the session first, followed by
other elected officials, those designated by their elected official to represent their
respective Indian Tribes and representatives of Indian/Tribal Organizations.
. Official letter from the Indian Tribe designating a representative must be
presented to IGA before the session begins.
A. Performance Budget Formulation: HHS IGA will ensure the active participation of
Indian Tribes and Indian Organizations in the formulation and throughout the HHS
performance budget request as it pertains to Indian Tribes to the greatest extent
practicable and permitted by law.
B. Budget Information Disclosure: HHS provides Indian Tribes the HHS budget related
information on an annual basis: appropriations, allocation, expenditures, and funding levels
for programs, services, functions, and activities.
12. TRIBAL CONSULTATION PERFORMANCE AND ACCOUNTABILITY
HHS and its Divisions will measure and report results and outcomes of their Tribal consultation
performance to fulfill the government-to-government relationship with Indian Tribes.
Parts of the HHS mission and performance objectives are designed to address the health and
well-being of AI/ANs by providing for effective health and human services and by fostering
strong, sustained advances in the sciences underlying medicine, public health and social
services.
The Divisions shall utilize the Tribal Consultation Policy to address HHS’s mission and
performance objectives with respect to AI/ANs. HHS and its Divisions will follow the goals and
objectives of the seated Secretary and Administration.
Divisions and Indian Tribes will also promote a collaborative atmosphere to gather, share, and
collect data and other information to demonstrate the effective use of Federal resources in a
manner that is consistent with OMB performance measures and requirements. Divisions shall
consult, to the greatest extent practicable and permitted by law, with Indian Tribes before taking
actions that substantially affect Indian Tribes, including regulatory practices on Federal matters
and unfunded mandates.
13. EVALUATION, RECORDING OF MEETINGS AND REPORTING
The consultation process and activities conducted within the policy should result in a meaningful
outcome for the Department and for the affected Indian Tribes. To effectively evaluate the
results of a particular consultation activity and the Department’s ability to incorporate Indian
Tribes’ consultation input, the Department should measure, on an annual basis, the level of
satisfaction of the Indian Tribes.

0. Divisions should develop and utilize appropriate evaluation measures to assess Indian
Tribes’ responses to Department consultation conducted during a specific period to
determine if the intended purpose of the consultation was achieved and to receive
recommendations to improve the consultation process.
. The Divisions will maintain a record of the consultation, evaluate whether the
intended results were achieved, and report back to the affected Indian tribe(s) on the
status or outcome, including, but not limited to, the annual sessions conducted
below.
1. At a minimum, HHS Regional Directors will conduct an Annual Regional Tribal Consultation
to consult with Indian Tribes.
. These sessions shall provide an opportunity to receive the Indian Tribe’s priorities for
budget, regulation, legislation, and other policy matters.
a. Consultation Sessions shall include evaluation components for receipt of verbal and
written comments from participating Indian Tribes, HHS Divisions, and other invited
participants to obtain immediate feedback on the consultation process for the session
conducted.
b. The Divisions and the Regional Directors will report at each regional Tribal
consultation session regarding what substantive and procedural actions were taken as
a result of the previous Tribal consultation session and describe how HHS addressed
the consultation evaluation comments provided received by participants.
c. All national and regional consultation meetings and recommended actions shall be
formally recorded and made available to Indian Tribes.
d. Once the consultation process is complete, and any policy decision is finalized, all
recommended follow-up actions adopted shall be implemented and tracked by the
appropriate Regions and/or Divisions and reported to the Indian Tribes in the IGA
Annual Tribal Consultation Report.
e. Unless otherwise specified, the IGA Annual Consultation Report shall provide an
annual reporting mechanism for this purpose and all HHS Divisions are required to
participate in providing information for this report.
2. IGA will seek Tribal feedback to assist in measuring and evaluating the implementation and
effectiveness of this Policy. IGA will assess the Department Tribal Consultation Policy on an
ongoing basis and utilize comments from Indian Tribes and Federal participants to
determine whether amendment to the Policy may be required. If amendment is needed,
IGA will convene a Tribal-Federal workgroup.
3. Divisions are required to submit to IGA their fiscal year Tribal consultation information
within 90 calendar days from the end of the fiscal year. IGA shall compile the Division
submissions, and publish and distribute the information to the Indian Tribes within 60
calendar days from receipt of the Division reports. The IGA, Regional Directors and
Divisions shall also report the Department’s views on the level of attendance and response
from Tribal leaders during the Annual Tribal Budget and Policy Consultation Session and
the Annual Regional Tribal Consultation Sessions, including evaluative comments, and
provide advice and recommendations regarding the Tribal consultation process. The IGA
shall post on the HHS website, the IGA Annual Tribal Consultation Report, including the
evaluation results.
14. CONFLICT RESOLUTION
The intent of this policy is to promote partnership with Indian Tribes that enhance the

Department’s ability to address issues, needs and problem resolution. Agencies shall consult with
Indian Tribes to establish a clearly defined conflict resolution process under which Indian Tribes
bring forward concerns which have a substantial direct effect. However, Indian Tribes and HHS
may not always agree and inherent in the government-to-government relationship, Indian Tribes
may elevate an issue of importance to a higher or separate decision-making authority.
Nothing in the Policy creates a right of action against the Department for failure to comply with
this Policy.
15. TRIBAL WAIVER
Divisions shall review and streamline the processes under which Indian Tribe may apply for
waivers of statutory, regulatory, policy, or procedural requirements. Each Division shall, to the
extent practicable and permitted by law, consider any application by an Indian Tribe for a waiver
with a general view toward increasing opportunities for utilizing flexible approaches at the Indian
Tribal level when the proposed waiver is consistent with the applicable Federal policy objectives
and is otherwise appropriate. Each Division shall, to the extent practicable and permitted by law,
render a decision upon a complete application for a waiver within 120 calendar days of receipt,
or as otherwise provided by law or regulation. If the application for waiver is not granted, the
Division shall provide the applicant with timely written notice of the decision and the reasons
therefore. Waiver requests for statutory or regulatory requirements apply only to statutory or
regulatory requirements that are discretionary and subject to waiver by the Division.
16. EFFECTIVE DATE
This policy is effective on the date of the signature by the Secretary of Health and Human
Services.
This policy replaces the Tribal Consultation Policy signed on February 1, 2008, and it applies to
all Operating Divisions and Staff Divisions. Operating Divisions shall complete necessary
revisions to their existing Division consultation policy/plan to conform to the revised Department
Tribal Consultation Policy. Operating Divisions without a consultation policy shall utilize the
guidance of the OS policy until the development of their respective policy.
17. DEFINITIONS
0. Agency – Any authority of the United States that is an “agency” under 44 USC 3502(1)
other than those considered to be independent regulatory agencies, as defined in 44 USC
3502 (5).
1. Communication – The exchange of ideas, messages, or information, by speech, signals,
writing, or other means.
2. Consultation – An enhanced form of communication, which emphasizes trust, respect and
shared responsibility. It is an open and free exchange of information and opinion among
parties, which leads to mutual understanding and comprehension. Consultation is integral
to a deliberative process, which results in effective collaboration and informed decision
making with the ultimate goal of reaching consensus on issues.
3. Coordination and Collaboration – Working and communicating together in a meaningful
government-to-government effort to create a positive outcome.
4. Critical Events – Planned or an unplanned event that has or may have a substantial
impact on Indian Tribe(s), e.g., issues, polices, or budgets which may come from any level
within HHS.

5. Deliberative Process Privilege – Is a privilege exempting the government from
disclosure of government agency materials containing opinions, recommendations, and
other communications that are part of the decision-making process within the agency.
6. Executive Order – An order issued by the Government’s executive on the basis of
authority specifically granted to the executive branch (as by the U.S. Constitution or a
Congressional Act).
7. Federally Recognized Tribal governments – Indian Tribes with whom the Federal
Government maintains an official government-to-government relationship; usually
established by a Federal treaty, statute, executive order, court order, or a Federal
Administrative Action. The Bureau of Indian Affairs (BIA) maintains and regularly publishes
the list of Federally recognized Indian Tribes.
8. HHS Tribal Liaisons – HHS staff designated by the head of an HHS Division that are
knowledgeable about the Division’s programs and budgets, and have ready access to
senior HHS Division leadership, and are empowered to speak on behalf of that Division for
AI/AN/NA programs, services, issues, and concerns.
9. Indian – Indian means a person who is a member of an Indian tribe as defined in 25
U.S.C. 479a. Throughout this policy, Indian is synonymous with American Indian/Alaska
Native.
10. Indian Organizations: 1). Those Federally recognized tribally constituted entities that
have been designated by their governing body to facilitate DHHS communications and
consultation activities. 2). Any regional or national organizations whose board is comprised
of Federally recognized Tribes and elected/appointed Tribal leaders. The government does
not participate in government-to-government consultation with these entities; rather these
organizations represent the interests of Tribes when authorized by those Tribes.
11. Indian Tribe – an Indian or Alaska Native tribe, band, nation, pueblo, village, or
community that the Secretary of the Interior acknowledges to exist as an Indian tribe
pursuant to the Federally Recognized Indian Tribe List Act of 1994, 25 U.S.C. 479a.”
12. Intradepartmental Council on Native American Affairs (ICNAA) – Authorized by the
Native American Programs Act of 1974 (NAPA), as amended. The ICNAA serves primarily to
perform functions and develop recommendations for short, intermediate, or long-term
solutions to improve AI/AN/NA policies and programs as well as provide recommendations
on how HHS should be organized to administer services to the AI/AN/NA population.
13. Joint Tribal/Federal Workgroups and or/Task Forces – A group composed of
individuals who are elected Tribal officials, appointed by Federally recognized Tribal
governments and/or Federal agencies to represent their interests while working on a
particular policy, practice, issue and/or concern.
14. Native American (NA) – Broadly describes the people considered indigenous to North
America.
15. Policies with Tribal Implications – Refers to regulations, statutes, legislation, and other
policy statements or actions that have substantial direct effects on one or more Indian
Tribes, on the relationship between the Federal Government and Indian Tribes, or on the
distribution of power and responsibilities between the Federal Government and Indian
Tribes.
16. Self Government – Government in which the people who are most directly affected by
the decisions make decisions.

17. Sovereignty – The ultimate source of political power from which all specific political
powers are derived.
18. Substantial Direct Compliance Costs – Those costs incurred directly from
implementation of changes necessary to meet the requirements of a Federal regulation.
Because of the large variation in Tribes, “substantial costs” is also variable by Indian Tribe.
Each Indian Tribe and the Secretary shall mutually determine the level of costs that
represent “substantial costs” in the context of the Indian Tribe’s resource base.
19. To the Extent Practicable and Permitted by Law – Refers to situations where the
opportunity for consultation is limited because of constraints of time, budget, legal
authority, etc.
20. Treaty – A legally binding and written agreement that affirms the government-togovernment
relationship between two or more nations.
21. Tribal Government – An American Indian or Alaska Native Tribe, Band, Nation, Pueblo,
Village or Community that the Secretary of the Interior acknowledges to exist as an Indian
Tribe pursuant to the Federally Recognized Indian Tribe List Act of 1994, 25 USC 479a.
22. Tribal Officials – Elected or duly appointed officials of Indian Tribes or authorized inter-
Tribal organizations.
23. Tribal Organization – The recognized governing body of any Indian tribe; any legally
established organization of Indians which is controlled, sanctioned, or chartered by such
governing body or which is democratically elected by the adult members of the Indian
community to be served by such organization and which includes the maximum
participation of Indians in all phases of its activities: Provided, That in any case where a
contract is let or grant made to an organization to perform services benefiting more than
one Indian tribe, the approval of each such Indian tribe shall be a prerequisite to the
letting or making of such contract or grant.
24. Tribal Resolution – A formal expression of the opinion or will of an official Tribal
governing body which is adopted by vote of the Tribal governing body.
25. Tribal Self–Governance – The governmental actions of Tribes exercising self-government
and self-determination.
18. ACRONYMS
AI/AN: American Indian/Alaska Native
AI/AN/NA: American Indian/Alaska Native/Native American
ASFR: Assistant Secretary for Finance and Resources
BIA: Bureau of Indian Affairs
Division: Staff Division and/or Operating Division
EO: Executive Order
FACA: Federal Advisory Committee Act
FR: Federal Register
HHS: U.S. Department of Health and Human Services
ICNAA: Intradepartmental Council on Native American Affairs
IGA: Office of Intergovernmental Affairs
IOS: Immediate Office of the Secretary
NPRM: Notice of Proposed Rule Making
OMB: Office of Management and Budget
OS: Office of the Secretary
U.S.: United States
U.S.C.: United States Code

S/ Kathleen Sebelius December 14, 2010
_____________________________________________ ___________________
__
Kathleen Sebelius Date
Secretary
U.S. Department of Health and Human Services
ADDENDUM 1
1. Establishing Joint Tribal/Federal Workgroups and/or Tasks Forces:
Although the special “Tribal-Federal” relationship is based in part on the government-togovernment
relationship it is frequently necessary for HHS to establish Joint Tribal/Federal
Workgroups and/or Task Forces to complete work needed to develop new policies, practices,
issues, and/or concerns and/or modify existing policies, practices, issues, and/or concerns.
These Joint Tribal/Federal Workgroups and/or Task Forces do not take the place of Tribal
consultation, but offer an enhancement by gathering individuals with extensive knowledge of a
particular policy, practice, issue and/or concern to work collaboratively and offer
recommendations for consideration by Federally recognized Indian Tribes and Federal agencies.
The subsequent work products and/or outcomes developed by the Joint Tribal/Federal
Workgroup and/or Task Forces will be handled in accordance with this policy. These Workgroups
will be Federal Advisory Committee Act (FACA) compliant unless exempt.
1. Meeting Notices: The purpose, preliminary charge, time frame, and other specific tasks
shall be clearly identified in the notice. All meetings should be open and widely publicized
ideally through IGA or the Division initiating the policy.
2. Workgroups: membership should be selected based on the responses received from
prospective HHS Regions/Indian Health Service Areas as a result of the notice, and if
possible, should represent a cross-section of affected parties. HHS staff may serve in a
technical advisory capacity.
A. Participation:
1. Membership Notices: HHS shall seek nominations from Indian Tribes to participate in
taskforces and/or workgroups. The Secretary shall select workgroup members that
represent various regions and/or views of Indian Country. Membership of these
workgroups shall be in compliance with FACA unless the workgroup is exempt
2. Appointment of Alternates: Each primary representative may appoint an alternate by
written notification. In cases where an elected Tribal Leader (primary representative)
appoints an alternate who is not an elected official, and the primary member can not
attend a workgroup meeting, the alternate is permitted to represent the primary member
and will have the same voting rights as the primary member.
3. Attendance at Meetings: Workgroup members must make a good faith effort to attend all
meetings. Other individuals may accompany workgroup members, as that member
believes is appropriate to represent his/her interest, however FACA requirements will be
adhered to at meetings unless exempt
B. Workgroup Protocols: The workgroup may establish protocols to govern the meetings. Such
protocols will include, but are not limited to the following:

1. Selection of workgroup co-chairs, if applicable
2. Role of workgroup members
3. Process for decision-making (consensus based or otherwise)
4. Developing a Workgroup Charge. Prior to the workgroup formulation, the HHS will develop
an initial workgroup charge in enough detail to define the policy concept. The workgroup
may develop recommendations for the final workgroup charge for the approval of the HHS
Secretary, the IGA Director or the Division head.
C. Process for Workgroup Final Products: Once a final draft of the work product has been created
by the workgroup the following process will be used to facilitate Tribal consultation on the draft
work product:
1. Upon completion, the draft documents will be distributed informally to Indian Tribes and
Indian Organizations for review and comment and to allow for maximum possible informal
review.
2. Comments will be returned to the workgroup, which will meet in a timely manner to
discuss the comments and determine the next course of action.
3. At the point that the proposed draft policy is considered to be substantially complete as
written, the workgroup will forward the draft document to the HHS Secretary as final
recommendation for consideration.
4. The workgroup will also recognize any contrary comment(s) in its final report and explain
the reasoning for not accepting the comment(s).
5. If it is determined that the policy should be rewritten, the workgroup will rewrite and begin
informal consultation again at the initial step above.
6. If the proposed policy is generally acceptable to the HHS Secretary, final processing of the
policy by the workgroup will be accomplished.
D. Recommendations and Policy Implementation: All final recommendations made by the
workgroup should be presented to the Secretary. Before any final policy decisions are adopted
within HHS, the proposed policy shall be widely publicized and circulated for review and
comment to Indian Tribes, Indian Organizations, and within HHS. Once the consultation process
is complete and a proposed policy is approved and issued, the final policy shall be broadly
distributed to all Indian Tribes.

NORTHWEST
PORTLAND
AREA
INDIAN
HEALTH
BOARD
Burns-Paiute Tribe
Chehalis Tribe
Coeur d' Alene Tribe
Colville Tribe
Coos, Sui slaw &
Lower Umpqua Tribe
Coquille Tribe
Cow Creek Tribe
Cowl it? Tribe
Gmnd Ronde Tribe
Hoh Tribe
Jamestown S'Klaliam Tribe
Kalispcl Tribe
Klamath Tribe
Kootenai Tribe
Lower Elwha Tribe
Lummi Tribe
Makah Tribe
Muekleshoot Tribe
Nez Perce Tribe
Nisqually Tribe
Nooksack Tribe
NW Band of Shoshone Tribe
Port Gamble S'Klallam Tribe
Puyallup Tribe
QuileuteTribe
Quinault Tribe
Sam ish Indian Nation
Sauk-Suiattlc Tribe
Shoalwater Bay Tribe
Shoshone-Bannock Tribe
Siletz Tribe
Skokomish Tribe
Snoqualmie Tribe
Spokane Tribe
Squaxin Island Tribe
Stillaguamish Tribe
Suquamish Tribe
Swinomish Tribe
Tulalip Tribe
Umatilla Tribe
Upper Skagit Tribe
Wann Springs Tribe
Yakama Nation
2121 SW Broadway
Suite 300
Portland, OR 97201
(503) 228-4185
(503)228-8182 FAX
www.npaihb.org
SENT VIA EMAIL: Pam.Hyde@SAMHSA.hhs.gov; blockgrants@samhsa.hhs.gov
September 21,2012
Ms. Pamela S. Hyde, J.D.
Administrator
Substance Abuse and Mental Health Service Administration
1 Choke Cherry Rd.
Rockville, MD 20857
REF: Comments - Agency Information Collection Activities: Proposed
Collection; Comment Request for: Uniform Application for the Mental
Health Block Grant and Substance Abuse Block Grant FY 2014-2015,
Application Guidance and Instructions (OMB No. 0930-0168)­
Revision.
Dear Ms. Hyde:
The Northwest Portland Area Indian Health Board (NPAIHB) is a P.l. 93-638 Tribal
organization 1 that represents forty-three federally-recognized Tribes in the states of
Idaho, Oregon, and Washington. On behalf of our member Tribes, we are writing to
provide comments for the Agency Information Collection Activities: Proposed Collection;
Comment Request, published in the Federal Register, Vol. 77, No. 135, Friday, July 13,
2012, notices.
We understand the purpose of this notice is to comment on: information from reports
will have a practical utility; have accuracy of the agency's estimate of the burden of the
proposed collection of information; ways to enhance the quality, utility, and clarity of
the information to be collected; and ways to minimize the burden of the collection
techniques or other forms of information technology.
Before providing comment it is important for us to underscore our deep concern that
there is no mention of Tribal governments in the entire document. We note a "casual"
citation near the end of page 41434 and the reference to Native Americans on page
41435. The document overlooks the preferred reference and legislative term "American
Indians and Alaska Native (AI/AN)" and we urge SAMHSA to use the preferred term in
future publications. We are concerned that past comments we provided and issues
discussed at the SAMHSA Tribal Advisory Committee meetings are not adequately
addressed. These issues have also been raised in SAMHSA Tribal consultation sessions.
J As defined in the Indian Self-Determination and Education Assistance Act. P.L. 93-638. 25 U.S.C .• Section
45O(b) a Tribal organization is a legally established governing body of any Indian tribe(s) that is controlled.
sanctioned. or chartered by such Indian Tribe(s) and designated to act on their behalf.

It is unclear if this was just an oversight or a lack of understanding of the government to government
requirement. The proposed application requirements will have a direct impact of the ability of SAMHSA
to further its mission and services for Tribal communities.
Please note the following comments from a submission dated June 6, 2011 per SAMHSA's request.
Where these comment disregarded? We did not receive any feedback from the comments. These
comments were directed toward the information provided in the Federal Register, Vol. 76, No. 69,
Monday, April 11, 2011:
In regards to States following a four-step planning process conSisting of: (1) Assessing the
strengths and needs of the service system; (2) identifying the unmet service needs and
critical gaps within the current system; (3) prioritize the State planning activities, and; (4)
develop goals, strategies and performance indicators, there will be unintended
consequences for Tribal population unless:
1. Tribes are consulted to address the strengths and needs of the population they serve. It
would be impossible for a State to provide a comprehensive assessment of strengths
and needs of the service system without the assistance of Tribes in their respective
States.
Additionally, non-Medicaid encounter data from Tribal systems is often reported
directly to the Federal government, (via Indian Health Service), and is not included in
State databases. Furthermore, Tribal populations often do not access State services due
to historical discrimination and mistreatment, resulting in an unrealized "silent need".
2. The unmet service needs are difficult to identify. States have various methods for
gathering data, as do the 565 Federally Recognized Tribes. Currently, most policy for
service provision is driven from encounter data. This results in a fatal flaw - no valid
method to determine unmet service needs when there is no access or limited access to
behavioral health services. As noted in numerous publications, including the Report on
State Responses to the FY 2011 Block Grant Addendum on Health Care Reform, there is a
current shortage of behavioral health professionals. This shortage is projected to
amplify with the surge caused by the implementation of the Affordable Care Act, thus
the intense need to determine actual levels of need.
This Proposed Project needs to clearly define how population needs will be assessed for
people that do not have access to behavioral health services. There should be a specific
section that elaborates on a method to not only determine this for Tribal populations
but all rural populations as identified by the Health Professional Shortage Areas.
If this measure is not taken there will be a gross underestimate of service needs from
populations that are never "counted" until they self-terminate or suffer catastrophic
consequences.
3. States must be required to consult with Tribal representatives (specifically elected Tribal
leaders or individuals formally appointed to represent their Tribal government) for any
prioritization of State planning activities. Tribal populations will continue to be

underserved without this requirement.
4. Only Tribes know their population's attainable goals, strategies and performance
indicators that are culturally applicable. This responsibility is accepted by Tribes for
their constituents and not transferable. All Tribes, which have territories within State
boundaries, should be consulted for any development of goals and performance
indicators.
In regard to the paragraph Description of State's Consultation with Tribes, the following
comments are provided:
We would suggest some additional language to fortify the government to government
relationship that Tribes have with the Federal government. State relations history and
Tribes as noted by Administrator Hyde in the Alcoholism and Drug Abuse Weekly,
" ... (Tribes) neither consulted with nor are their needs addressed when the state gets the
dollars" ... , needs to be definitively improved and required.
While we have been advised that SAMHSA "cannot require" State to consult with Tribes,
there should be required reporting components in the State reports that tracks the
dollars spent. A suggested list of those components should at a minimum include:
• Name of Tribe(s)
• Date of Consultation
• Duration of Consultation (e.g. hours, days)
• List of Tribal Representatives
• Topic of Consultation
Required Topics of Discussion must include:*
Scope of service provision (amount and need)
Strategies for service provision
Utilization of services
Time frame for State implementation of Proposed Project
Involvement of "Dashboard" development (key performance indicators
Suicide prevention
- Technical assistance needs
Involvement of individuals and families
Use of technology
Collaboration
(* please note this is not an all inclusive list, more components could be required)
The list above should be strongly considered as a reporting requirement. Without such
a requirement, history and experience has clearly shown that Tribal populations will be
neglected/excluded from access to federal dollars that are appropriately designated for
the needs of American Indians and Alaska Natives (AI/AN).
Lastly, SAMSHA should require States to include official Tribal representatives (from all
Tribes in the State) to be a voting member of State Behavioral Health Advisory Councils
(council names may vary by State). This is critical, and important that each Tribe be
invited to name a representative for State level councils. It is not enough nor

November 14 -15, 2012 TTAG
FACE TO FACE MEETING
National Museum of the American Indian
4 th floor conference room
Fourth & Independence Avenue, SW
Washington, DC
AGENDA: Day 1 Wednesday – Nov. 14, 2012
9:00 – 9:15 Welcome Call to Order: Valerie Davidson, Chair, and Alaska Area Representative
Opening Prayer:
Roll Call: Liz Heintzman, Legislative Program Associate, NIHB
Introductions: Valerie Davidson, Chair
9:15 – 9:30 Report from Chair: Valerie Davidson, Chair
9:30– 9:45 Report from Secretary (TAB A): Richard Narcia, Phoenix Area Representative
- Approval of TTAG Face-to-Face Meeting minutes: July 25-26, 2012
9:45 – 10:15 CMS Leadership:
- Ajay Gupta, Senior Advisor to the Administrator
10:15 – 11:15 CMS Tribal Affairs Group Report (TAB B)
- Kitty Marx, Director, TAG/CMS
o Tribal Affairs Group Updates
o Determine 2013 TTAG Face-to-Face Meeting Dates
11:15 – 11:30 Break
NIHB Update:
- Stacy Bohlen, Executive Director, NIHB
- Jennifer Cooper, Legislative Director, NIHB
11:30– 12:00 Money Follows the Person Funding Opportunity
- Kitty Marx, Director, TAG/CMS
12:00 – 1:30 Lunch on your own
November 14-15, 2012 TTAG Face To Face Meeting
1

1:30 – 2:15 OIG: Update OIG Work Plan FY 2013 (TAB C)
- Talisha Searcy, Deputy Director for Evaluation Planning and Support Division,
Office of Evaluation and Inspections, OIG
- Maritza Hawrey, Audit Manager, Grants and Internal Audits, Office of Audit
Services, OIG
2:15-2:45 Final action and Approval of TTAG AI/AN Strategic Plan 2013 -2018
- Jim Roberts, Chair, TTAG Budget and Strategic Plan Subcommittee
- Mim Dixon, TTAG Technical Advisor, TSGAC
2:45 – 3:15 Subcommittee Reports (TAB D):
- Outreach & Education: Dr. Alec Thundercloud
- Long-Term Care: Judy Goforth Parker
- DATA : Jim Crouch
- Behavioral Health: Linda Frizzell
- CMS Tribal Consultation: Ron Allen
- ACA Policy Subcommittee: Jim Roberts
- Across State Borders: Donita Stephens
3:15 – 3:30 Break
3:30 – 4:00 CCIIO Update (TAB E)
- Lisa Wilson, CCIIO, CMS
4:00- 5:00 Update from the Center for Medicaid and CHIP (TAB F)
- Lane Terwilliger JD, LL.M., Technical Director, Div. of State Demonstrations &
Waivers, CMCS/CMS
5:00 Adjourn: Valerie Davidson, Chair
November 14-15, 2012 TTAG Face To Face Meeting
2

AGENDA: Day 2 Thursday – Nov. 15, 2012
9:00 Call to Order: Valerie Davidson, Chair, Alaska Area Representative
9:05 – 12:00 Other Subcommittee meetings
10:00 – 11:30 Data Subcommittee meeting at HHS, Room 335G
877-267-1577; Meeting ID: 7218
12:00 Adjourn TTAG Meeting
12:30 pm NIHOE Area & National Partnership Meeting
National Congress of American Indians
1516 P Street NW, Washington, DC
888-244-8150; password: 6989122
Future Meetings and Conference Calls:
Conference Calls: 2:30 - 4:00 PM
December 12, 2012: call in number 1-877-267-1577, meeting ID: 9925
January 9, 2013: call in number 1-877-267-1577. Meeting ID: TBD
March 13, 2013: call in number 1-877-267-1577. Meeting ID: TBD
April 10, 2013: call in number 1-877-267-1577. Meeting ID: TBD
May 8, 2013: call in number 1-877-267-1577. Meeting ID: TBD
June 12, 2013: call in number 1-877-267-1577. Meeting ID: TBD
August 14, 2013: call in number 1-877-267-1577. Meeting ID: TBD
September 11, 2013: call in number 1-877-267-1577. Meeting ID: TBD
October 9, 2013:call in number 1-877-267-1577. Meeting ID: TBD
December 11, 2013: call in number 1-877-267-1577. Meeting ID: TBD
Face to Face Meetings:
February : NMAI, Washington, D.C.
July : NMAI, Washington, DC
November :NMAI, Washington, DC
November 14-15, 2012 TTAG Face To Face Meeting
3

HHS Block Grant Regulations
Title 45 (Public Welfare and Human Services, General
Administration),
Part 96 (Block Grants), revised as of October 1, 1996
The text of the U.S. Department of Health
and Human Services (HHS) Block Grant
Regulations (Title 45, Part 96 of the Code
of Federal Regulations) is taken from
the U.S. Government Printing Office via GPO
Access//CITE: 45CFR96.
A listing of the sections to Subparts A-L
and Appendices A-B of the regulations
begins HERE. Text links to the Subparts and
Appendices begin HERE.
LIHEAP regulations are found at Subpart H.
Subparts A-F are also relevant to LIHEAP.
Text links to the Subparts and Appendices
Subpart A--Introduction
Subpart B--General Procedures
Subpart C--Financial Management
Subpart D--Direct Funding of Indian Tribes
Subpart E--Enforcement
Subpart F--Hearing Procedure

Subpart G--Social Services Block Grant
Subpart H--Low-Income Home Energy
Assistance Program
Subpart I--Community Services Block Grants
Subpart J--Primary Care Block Grants
Subpart K--Transition Provisions
Subpart L--Substance Abuse Prevention and
Treatment Program
Appendix A to Part 96--Uniform Definitions
of Services
Appendix B to Part 96--SSBG Reporting Form
and Instructions
Subpart D--Direct Funding of Indian Tribes
and Tribal Organizations | Top of Page
Sec. 96.40 Scope.
This subpart applies to the community
services, alcohol and drug abuse and mental
health services, preventive health and
health services, primary care, and lowincome
home energy assistance block grants.

[[Page 486]]
Sec. 96.41 General determination.
(a) The Secretary has determined that
Indian tribes and tribal organizations would
be better served by means of grants provided
directly by the Secretary to such tribes and
organizations out of the State's allotment
of block grant funds than if the State were
awarded its entire allotment. Accordingly,
where provided for by statute, the Secretary
will, upon request of an eligible Indian
tribe or tribal organization, reserve a
portion of a State's allotment and, upon
receipt of the complete application and
related submission that meets statutory
requirements, grant it directly to the tribe
or organization.
(b) An Indian tribe or tribal
organization may request direct funding
under a block grant program included in this
subpart regardless of whether the State in
which it is located is receiving funds under
the block grant program.
Sec. 96.42 General procedures and
requirements.
(a) An Indian tribe or tribal

organization applying for or receiving
direct funding from the Secretary under a
block grant program shall be subject to all
statutory and regulatory requirements
applicable to a State applying for or
receiving block grant funds to the extent
that such requirements are relevant to an
Indian tribe or tribal organization except
where otherwise provided by statute or in
this part.
(b) A tribal organization representing
more than one Indian tribe will be eligible
to receive block grant funds on behalf of a
particular tribe only if the tribe has by
resolution authorized the organization's
action.
(c) If an Indian tribe or tribal
organization whose service population
resides in more than one State applies for
block grant funds that, by statute, are
apportioned on the basis of population, the
allotment awarded to the tribe or
organization shall be taken from the
allotments of the various States in which
the service population resides in proportion
to the number of eligible members or
households to be served in each State. If
block grant funds are required to be
apportioned on the basis of grants during a
base year, the allotment to the Indian tribe
or tribal organization shall be taken from
the allotment of the State whose base year
grants included the relevant grants to the

tribe or organization.
(d) The audit required under the block
grant programs shall be conducted by an
entity that is independent of the Indian
tribe or tribal organization receiving grant
funds from the Secretary.
(e) Beginning with fiscal year 1983, any
request by an Indian tribe or tribal
organization for direct funding by the
Secretary must be submitted to the
Secretary, together with the required
application and related materials, by
September 1 preceding the Federal fiscal
year for which funds are sought. A separate
application is required for each block
grant. After the September 1 deadline,
tribal applications will be accepted only
with the concurrence of the State (or
States) in which the tribe or tribal
organization is located.
(f) A State receiving block grant funds
is not required to use those funds to
provide tangible benefits (e.g., cash or
goods) to Indians who are within the service
population of an Indian tribe or tribal
organization that received direct funding
from the Department under the same block
grant program for the same fiscal year. A
State, however, may not deny Indians access
to intangible services funded by block grant
programs (e.g., treatment at a community
health center) even if the Indians are

members of a tribe receiving direct funding
for a similar service.
[47 FR 29486, July 6, 1982, as amended at 52
FR 37966, Oct. 13, 1987]
Sec. 96.43 Procedures during FY 1982.
(a) This section applies to the fiscal
year beginning October 1,1981.
(b) A request for direct funding must be
received by the Secretary before the
Secretary has awarded all of the allotment
to the State involved. The application and
related submission may be submitted later
but must be submitted within 75 days after
the beginning of the quarter in which the
State qualified for block grant funds, (or
by August 20,1982 in the case of an Indian
tribe located in a State that has not
qualified for block grant funds in FY 1982)
except that the application and related
submission for the low-income
[[Page 487]]
home energy assistance program must be
submitted by December 15, 1981. A separate
request and application are required for
each block grant.
[47 FR 29486, July 6, 1982; 47 FR 43062,
Sept. 30, 1982]
Sec. 96.44 Community services.

(a) This section applies to direct
funding of Indian tribes and tribal
organizations under the community services
block grant.
(b) The terms Indian tribe and tribal
organization as used in the Reconciliation
Act have the same meaning given such terms
in section 4(b) and 4(c) of the Indian Self-
Determination and Education Assistance
Act (25 U.S.C. 450b). The terms also include
organized groups of Indians that the State
in which they reside has determined are
Indian tribes. An organized group of Indians
is eligible for direct funding based on
State recognition if the State has expressly
determined that the group is an Indian
tribe. In addition, the statement of the
State's chief executive officer verifying
that a tribe is recognized by that State
will also be sufficient to verify State
recognition for the purpose of direct
funding.
(c) For purposes of section 674(c)(2) of
the Act (42 U.S.C. 9903(c)(2)) an eligible
Indian means a member of an Indian tribe
whose income is at or below the poverty line
defined in section 673(2) of the Act (42
U.S.C. 9902(2)). An eligible individual
under section 674(c)(2) of the
Reconciliation Act (42 U.S.C. 9903(c)(2))
means a resident of the State whose income

is at or below the poverty line.
(d) An Indian tribe or tribal
organization will meet the requirements of
section 675(c)(1) (42 U.S.C. 9904(c)(1)) if
it certifies that it agrees to use the funds
to provide at least one of the services or
activities listed in that section.
(e) An Indian tribe or tribal
organization is not required to comply with
section 675(b) (42 U.S.C. 9904(b)) or to
provide the certifications required by the
following other provisions of the
Reconciliation Act.
(1) Section 675(c)(2)(A) (42 U.S.C.
9904(c)(2)(A));
(2) Section 675(c)(3) (42 U.S.C.
9904(c)(3)); and
(3) Section 675(c)(4) (42 U.S.C.
9904(c)(4)).
(4) Section 675(c)(11) (42 U.S.C.
9904(c)(11)).
(f) In each fiscal year, Indian tribes
and tribal organizations may expend for
administrative expenses--comparable to the
administrative expenses incurred by State at
the State level--an amount not to exceed the
greater of the amounts determined by:

(1) Multiplying their allotment under
section 674 of the Reconciliation Act (42
U.S.C. 9903) by five percent; or
(2) Multiplying the allotment by the
percentage represented by the ratio of
$55,000 to the smallest State allotment
(excluding territorial allotments) for that
fiscal year.
[47 FR 29486, July 6, 1982, as amended at 52
FR 37967, Oct. 13, 1987]
Sec. 96.45 Preventive health and health
services.
(a) This section applies to direct
funding of Indian tribes and tribal
organizations under the preventive health
and health services block grant.
(b) For the purposes of determining
eligible applicants under section 1902(d) of
the Public Health Service Act, a grantee
that received a grant directly from the
Secretary in FY 1981 under any of the
programs replaced by the preventive health
and health services block grant that was
specifically targeted toward serving a
particular Indian tribe or tribal
organization will be considered eligible if
the grantee is an Indian tribe or tribal
organization at the time it requests funds

under this part. Grantees that received
funds under formula or Statewide grants, and
subgrantees that received funds from any
program replaced by the preventive health
and health services block grant, are not
eligible.
Sec. 96.46 Substance abuse prevention and
treatment services.
(a) This section applies to direct
funding of Indian tribes and tribal
organizations under the substance abuse
prevention and treatment Block Grant.
(b) For the purpose of determining
eligible applicants under section 1933(d) of
the Public Health Service Act (42 U.S.C.
300x-33(d)) an Indian tribe or
[[Page 488]]
tribal organization (as defined in
subsections (b) and (c) of section 4 of the
Indian Self-Determination and Education
Assistance Act) that received a direct grant
under subpart I of part B of title XIX of
the PHS Act (as such existed prior to
October 1, 1992) in fiscal year 1991 will be
considered eligible for a grant under
subpart 2 of part B of title XIX of the PHS
Act.
(c) For purposes of the substance abuse
prevention and treatment Block Grant, an

Indian tribe or tribal organization is not
required to comply with the following
statutory provisions of the Public Health
Service Act: 1923 (42 U.S.C. 300x-23), 1925
(42 U.S.C. 300x-25), 1926(42 U.S.C. 300x-
26), 1928 (42 U.S.C. 300x-28), 1929 (42
U.S.C. 300x-29),and 1943(a)(1) (42 U.S.C.
300x-53(a)(1)). An Indian tribe or tribal
organization is to comply with all other
statutes and regulations applicable to the
Substance Abuse Prevention and Treatment
Block Grant.
In each case in which an Indian Tribe
receives a direct grant, the State is also
responsible for providing services to Native
Americans under the State's Block Grant
program.
[58 FR 17070, Mar. 31, 1993]
Sec. 96.47 Primary care.
Applications for direct funding of
Indian tribes and tribal organizations under
the primary care block grant must comply
with 42 CFR Part 51c (Grants for Community
Health Services).
Sec. 96.48 Low-income home energy
assistance.
(a) This section applies to direct
funding of Indian tribes under the low-

income home energy assistance program.
(b) The terms Indian tribe and tribal
organization as used in the Reconciliation
Act have the same meaning given such terms
in section 4(b) and 4(c) of the Indian Self-
Determination and Education Assistance Act
(25 U.S.C. 450b) except that the terms shall
also include organized groups of Indians
that the State in which they reside has
expressly determined are Indian tribes or
tribal organizations in accordance with
State procedures for making such
determinations.
(c) For purposes of section 2604(d) of
the Act (42 U.S.C. 8623(d)), an organized
group of Indians is eligible for direct
funding based on State recognition if the
State has expressly determined that the
group is an Indian tribe. A statement by the
State's chief executive officer verifying
that a tribe is recognized by that State
will also be sufficient to verify State
recognition for the purpose of direct
funding.
(d) The plan required by section
2604(d)(4) of the Reconciliation Act (42
U.S.C. 8623(d)(4)) shall contain the
certification and information required for
States under section 2605 (b) and (c) of
that Act (42 U.S.C. 8624 (b) and (c)). An
Indian tribe or tribal organization is not
required to comply with section 2605(a)(2)

of the Act (42 U.S.C. 8624(a)(2)).
(e) Where a tribe requests that the
Secretary fund another entity to provide
energy assistance for tribal members, as
provided by section 2604(d)(3) of the Act
(42 U.S.C. 8623(d)(3)), the Secretary shall
consider the following factors in selecting
the grantee: the ability of the other entity
to provide low-income home energy
assistance, existing tribal-State agreements
as to the size and location of the service
population, and the history of State
services to the Indian people to be served
by the other entity.

Need for Uniform Operational Guidance in Determining Eligibility
for Indian-specific Benefits and Protections under the Affordable Care Act
ISSUE:
The ACA includes three Indian-specific sections that provide special protections and benefits to AI/ANs. CMS
has determined that the two Exchange-related definitions (for Exchange cost-sharing and enrollment
protections) “operationally means the same thing.” 1 IRS has said informally that its definition section, which
protects against tax penalties being applied to AI/ANs for not maintaining minimum essential coverage, has
the same meaning as the definitions used for the Exchange.
CMS has opined that the eligibility standard for the Indian-specific provisions under the ACA are “slightly
different” from the AI/AN eligibility standards for IHS services. 2 In response to requests from States for
clarification about who an “Indian” is, CMS adopted Medicaid regulations that simplified the IHS eligibility
rules. See, 42 CFR 447.50.
OBJECTIVE:
Uniform operational guidance is needed, consistent with 42 CFR 447.50, regarding eligibility determinations
for Indian-specific benefits and protections under Medicaid and the Affordable Care Act through HHS and IRS
guidance or regulation.
RECOMMENDED ACTIONS:
1. Issue operational guidance from HHS and Treasury to assist Exchange enrollment staff and others as
necessary in determining eligibility for Indian-specific benefits and protections for Exchange and
Medicaid coverage;
2. Rely on the CMS regulations, 42 C.F.R. § 447.50, in order to permit a uniform application across
Medicaid, state and federal Exchanges and IRS (for the exemption for AI/ANs from the tax penalty for
not maintaining minimum essential coverage).
AUTHORITY:
It is well established that (1) the federal government has a trust responsibility to provide health care to
Indians, and (2) that laws for the benefit of Indians should be construed liberally in favor Indians.
As established under 45 C.F.R. § 155.315(h) Flexibility in information collection and verification, the Secretary
of HHS has discretionary authority to approve modifications to the methods used for the collection and
verification of information related to eligibility for enrollment through an Exchange and for eligibility for
Exchange insurance affordability programs. This authority may be exercised by the Secretary “provided that
HHS finds that such modification would reduce the administrative costs and burdens on individuals while
maintaining accuracy and minimizing delay, [and] that it would not undermine coordination with Medicaid
and CHIP…” As indicated below, these criteria would be met through the issuance and reliance on uniform
operational guidance.
TRIBAL SUPPORT FOR USING CMS’ MEDICAID REGULATIONS AS THE UNIFORM OPERATIONAL GUIDANCE
National and regional tribal organizations support the application of uniform operational guidance using the
CMS Medicaid regulation at 42 C.F.R. § 447.50 for purposes of implementing the Indian-specific provisions of
the Affordable Care Act. Resolutions of support were adopted by the National Congress of American Indians
(NCAI), the National Indian Health Board (NIHB), and the Tribal Technical Advisory Group to CMS (TTAG).
1 Exchange Establishment Final Rule, 77 Fed. Reg. 18346.
2 Exchange Establishment Final Rule, 77 Fed. Reg. 18383.
Page 1 of 2

POTENTIAL RAMIFICATIONS FOR FAILING TO ISSUE UNIFORM OPERATIONAL GUIDANCE:
Failure to issue uniform operational guidance will impede Exchange, Medicaid and IRS staff in making accurate
and consistent determinations of eligibility as well as delay or completely deny access for some AI/ANs to the
Indian-specific benefits and protections established under the Affordable Care Act.
Delayed eligibility for some AI/AN children: An AI/AN child who is not allowed to enroll as a tribal
member until her 18 th birthday may not be considered eligible for Exchange-related Indian-specific
cost-sharing and enrollment protections, despite being considered an AI/AN for purposes of IHS,
Medicaid and CHIP coverage.
Unwarranted application of tax penalties: If an AI/AN who is eligible and, in fact, is accessing IHS
services decides not to secure health insurance coverage, but is not (ultimately) determined to be
eligible as an “Indian” for the exemption from the requirement to secure minimum essential coverage,
this individual could be subject to significant tax penalties imposed under the ACA by the Internal
Revenue Service.
Reduced timeliness: The consolidated and streamlined Medicaid and Exchange application process is
intended to rely, to the greatest extent possible, on electronic verification of application-related
information. The lack of uniform operational guidance would complicate (although not prevent) the
use of automated databases that may be available for electronic verification, such as using the IHS
beneficiary roster, hamper coordination between Medicaid and Exchange eligibility, and likely increase
the administrative costs and burden on individuals.
Reduced accuracy in eligibility determinations: If guidance is not issued by CMS, or if the guidance
issued does not provide uniformity across the Indian-specific provisions in Medicaid, Exchange
coverage, and pertaining to the exemption from tax penalties, thereby requiring each Exchange to
identify any differences in eligibility standards under the various definitions, including understanding
the differences, if any, in documentation permitted to satisfy each definition of Indian, error rates for
eligibility determinations will increase.
Blocked access for some Alaska Natives: Some Alaska Native adults and children may not be
considered AI/AN by Exchanges until their parents die and they inherit stock in an Alaska Native
corporation; likewise, their children would not be considered AI/AN by Exchanges until they die and
the stock in an Alaska Native corporation is passed along to children even though the parent and the
children would qualify as AI/AN under Medicaid and other governmental services (e.g., IHS and BIA).
Reduced involvement of AI/AN in insurance options: Even if the instances of an individual being
determined to be “Indian” for one Indian-specific provision and not for another represent a relatively
small percentage of the total population (which we anticipate), this outcome would likely cast a
shadow over AI/ANs involvement with ACA implementation more generally. For example, AI/ANs may
be much more reluctant to consider transitioning from the IHS-based coverage model to
comprehensive Exchange coverage if there is a risk of ending-up subject to significant cost-sharing
requirements under a different, potentially unknown application of a definition of Indian.
For questions please contact Jim Roberts, Policy Analyst, (503) 228-4185 or email at jroberts@npaihb.org.
Page 2 of 2

Dear Tribal Representatives,
October 25, 2012
You are invited to join the National Indian Health Board (NIHB) on a bold journey to GO THE EXTRA MILE with NIHB. On
November 1, 2012, the first day of both American Indian Heritage Month and Diabetes Awareness month, NIHB will
launch its GO THE EXTRA MILE initiative, and we invite you to join us on this year-long journey. The kickoff event will
take place on November 1 st at 8 AM in front of the National Museum of American Indians in Washington, D.C., and you
are invited to join us for this event and walk a mile with us. If you are unable to join us, we encourage you to organize
your own community event on November 1 st to GO the EXTRA MILE and begin this journey by walking the first mile
together.
The GO the EXTRA MILE initiative is a result of the NIHB signing the CEO pledge, which is part of a national campaign to
encourage Executive Directors to commit to supporting and fostering a physically-active workplace. NIHB’s GO the
EXTRA MILE initiative achieves these goals by creating a workplace that supports physical activity for every member of
its staff. Through the GO THE EXTRA MILE with NIHB initiative, we will provide staff 30 minutes during the work day to
walk one mile each day for a year. We will aggregate these miles and “virtually” walk to each of the 12 Indian Health
Service Areas, either to an Area Indian Health Board or to a Tribal Partner in Areas that do not have a Board. We invite
you to join NIHB by signing the CEO pledge and participating in the November 1 st launch. You will have access to the
NIHB Go The Extra Mile website, which will include a toolkit, electronic mapping for your journey, and access to
information like “Hot Health Tips” from our partner, the Association of American Indian Physicians. More information is
also provided in the enclosed materials.
As you know, American Indians and Alaska Natives (AI/AN) have the highest age-adjusted prevalence of Type 2 diabetes
among all U.S. racial and ethnic groups and our People’s obesity rate is 39% for those 18 and older. Among AI/AN adults
18 and older, the percentage of inactive physical activity in 2010 was 53.9%, which was far from meeting federal physical
activity guidelines (at least 150 minutes or 30 minutes a day of moderate-intensity aerobic activity per week, i.e., brisk
walking). There is a correlation between physical activity and chronic diseases. The Diabetes Prevention Program clinical
trial, led by the National Institutes of Health, has shown that getting at least the recommended 30 minutes a day of
moderate physical activity and losing 5% to 7% of body weight can reduce the risk of developing type 2 diabetes by 58%
in people at risk. NIHB’s GO the EXTRA MILE is one small step toward supporting diabetes and obesity prevention for
AI/AN.
Remember, the journey for health is not a marathon, nor a sprint, but a relay that we, together, walk in order
to outsmart chronic diseases that threaten our health in Indian Country
We will be joined for the November 1 st kick off event by the Association of American Indian Physicians, American
Diabetes Association, Juvenile Diabetes Research Foundation, National Obesity Awareness Coalition, and the National
Coalition on Promoting Physical Activity. We hope to see you there and on the virtual road ahead, as we GO the EXTRA
MILE together.
Miigwech – Thank you,
Stacy A. Bohlen, Executive Director, NIHB

Introduction
NIHB to Launch a Workplace Fitness Program:
GO the EXTRA MILE!
October 25, 2012
The National Indian Health Board (NIHB) is excited to introduce our new healthy workplace initiative, GO the
EXTRA MILE. The goal of the NIHB GO the EXTRA MILE initiative is to create a healthier work
environment and promote employee health through providing staff members with thirty paid minutes each work
day to go for a walk. Along with the NIHB Executive Director, each staff member pledged to walk an
additional mile each day for an entire year. The GO the EXTRA MILE initiative stems from the CEO Pledge, a
project through the National Coalition on Promoting Physical Activity (NCPPA), which urges CEOs to pledge
their commitment to foster a healthy workplace. The NIHB GO the EXTRA MILE initiative is the newest
element of collaborated efforts within the National Physical Activity Plan.
The National Physical Activity Plan
The National Physical Activity Plan, the first, national comprehensive plan to support and encourage physical
activity among all Americans, was launched in 2010 through a 10 month collaboration between experts from
various, diverse fields. The plan comprises a wide range of public policy recommendations across eight broad
sectors. Through the National Physical Activity Plan, hundreds of organizations are working together to change
our communities in ways that will enable every American to be physically active. Its ultimate purpose is to
improve health, prevent disease and disability, and enhance quality of life.
The CEO Pledge
The National Coalition for Promoting Physical Activity (NCPPA) is a 501(c)(4) tax exempt organization that is
leading the implementation of the National Physical Activity Plan at the national level through The CEO
Pledge, which encourages every CEO in the United States to recognize physical activity as an important driver
of employee health. Studies of employee wellness programs consistently find that executive leadership is
critical to employee engagement. If employees believe that creating a culture of physical activity is an executive
priority, employees are more likely to be physically active.
The CEO Pledge states:
“For the betterment of my company, our employees, their families, and our country, I pledge to
improve employee health and wellness by providing opportunities and resources for physical
activity before, during or after the workday, and to enhance my own health and wellness by
engaging in regular physical activity.”
GO the EXTRA MILE Initiative

There is a strong correlation between obesity and diabetes—more than 80% of people with Type 2 diabetes are
overweight. With diabetes and obesity on the rise, every organization in the United States has an obligation and
responsibility to lead its community to a healthier future. Nowhere is this need more urgent than in Indian
Country. At nearly 16.1%, American Indians and Alaska Natives (AI/AN) have the highest age-adjusted
prevalence of Type 2 diabetes among all U.S. racial and ethnic groups. The obesity rate, which is determined by
having a body max index (BMI) of 30 or greater, is 39% for AI/AN 18 and older. Among AI/AN adults 18 and
older, the percentage of inactive physical activity in 2010 was 53.9%, which did not meet federal physical
activity guidelines (at least 150 minutes of moderate-intensity aerobic activity, i.e., brisk walking a week).
Mission
The NIHB recognizes this urgent need to advocate for physical activity as a preventive measure against chronic
diseases. NIHB would like to welcome Executive Directors from Area Indian Health Boards, Tribes, and other
Tribal organizations to join NIHB in recognizing this urgent need by signing the CEO Pledge and Go the
EXTRA MILE.
Goal
NIHB’s yearly goal is to encourage every NIHB employee to walk a mile every day (an additional mile separate
from daily routine) for a year. With 13 employees, the minimum yearly walking goal NIHB is aiming to achieve
is 4,745 miles. With these aggregated miles, NIHB will “virtually” walk to all Area Indian Health Boards and
the Midwest Alliance of Sovereign Tribes (Bemidji Area). The idea is to provide encouragement to Tribes and
Tribal organizations to GO the EXTRA MILE. Together, we can help transform our Tribal nation’s overall
health and wellbeing.
The Plan
As part of the CEO Pledge, NIHB has established a plan to implement exercise in the workplace.
Provide thirty paid minutes a day for staff to go for a walk.
Track and report miles daily.
Arrange healthy incentives for meeting team walking goals.
Coordinate community walks.
Update monthly the “GO the EXTRA MILE” website with physical activity events, exercise
information, and progress from NIHB and participating organizations.
Offer a toolkit to encourage other organizations to GO the EXTRA MILE.
One of NIHB’s primary areas of focus is to improve the health of AI/AN. Through exercise and diet, many
American Indians who suffer from this disease, can help mitigate the symptoms of diabetes through diet and

exercise. NIHB GO the EXTRA MILE initiative is just a small way that NIHB can demonstrate positive and
supportive workplace efforts to support diabetic employees, help prevent the onset of Type 2 diabetes through
added physical activity and enhance the quality of health for all employees.
Kick-off Launch
NIHB’s kickoff launch for the GO the EXTRA MILE is on November 1 st , 2012 at 8:00 am in front of the
National Museum of American Indians in Washington, D.C. November is Native American Heritage Month and
National Diabetes Awareness Month—the perfect time to start our new healthy initiative for promoting exercise
in the workplace.
It is not a marathon, or a sprint, but a relay that we, together, walk in order to outsmart chronic diseases that
threaten our health in Indian Country.

Wed. Nov 14 th : SDPI National Call-In Day
We Need Your Voice to Save the SDPI
November 14, 2012
The Special Diabetes Program for Indians (SDPI) provides critical programs that are helping our Tribal
communities address complications and burdens of diabetes. This critical program is set to expire unless
Congress acts to renew it. We need your help. On November 14 th - World Diabetes Day - please join NIHB
and Tribal communities from across the country in asking your Senators and Representatives to support renewal
of the SDPI this year! We need to make sure that Congress renews SDPI!
What You Can Do: Contact your Senate and House of Representative member on November 14 th and request
your Member to support renewal of SDPI.
• To determine your Representative and contact information, click here.
• To determine your Senators and contact information, click here.
• To be connected to a Senator or Representative via phone, call the Congressional Switchboard at
1-(800) 828-0498 or (202) 224-3121 and ask to be connected to your Senator or Representative and after
you are connected to the office, ask to speak with the Health aide.
Tell Your Representative:
• I am a constituent and calling to ask Senator ____ / Representative ____ to support a multi-year renewal
of the Special Diabetes Program for Indians this year.
• SDPI proves that federal investment in community-driven, culturally-appropriate prevention and
education programs can reduce a person’s risk of developing diabetes or of developing complications for
those who have diabetes.
• If SDPI is not renewed this year, critical diabetes prevention and education services will be eliminated
and the progress that has been made will be reversed.
• Thank you for your support of this critical program.
Questions: Please contact NIHB’s Senior Legislative Associate, Jeremy Marshall at (202) 507-4078.or
Jmarshall@nihb.org.

Background on the SDPI
Congress established the Special Diabetes Program for Indians (SDPI) in 1997 to address the growing epidemic
of diabetes in American Indian and Alaska Natives (AI/ANs) communities. AI/ANs have the highest rates of
type 2 diabetes in the United States, 2.8 times higher than the general population. The SDPI is currently funded
at $150 million per year through Fiscal Year (FY) 2013.
The program will expire in 2013 unless it is reauthorized.
To ensure uninterrupted funding for SDPI, it is crucial that Congress pass a reauthorization this year. SDPI
proves that federal investment in community-driven, culturally-appropriate prevention programs has immensely
positive results:
• Average blood sugar levels among the AI/AN population decreased a full percentage point (from 9.0
percent to 8.0 percent) between 1996 and 2011, translating into a 40% reduction in risks for many
complications.
• Average LDL (bad) cholesterol declined over 20 percent between 1998 and 2011, significantly lowering
the risk of cardiovascular complications.
• Between 1995 and 2006, the incidence rate of End Stage Renal Disease (ESRD) in AI/AN individuals
with diabetes fell by 27.7 percent – a greater decline than for any other racial or ethnic group - which
translates into millions of dollars in savings for Medicare, the Indian Health Service, and other third
party payers.

Future MMPC Meetings & Conference Calls:
2:00PM - 4:00 PM EST
Conference Call In Number: 866-303-3137
Pass Code: 414526
December 5, 2012
January 2013-TBD
March 6, 2013
April 3, 2013
May 1, 2013
June 5, 2013
August 7, 2013
September 4, 2013
October 2, 2013
December 4, 2013
Face to Face Meetings:
February 2013 TBD,Washington, D.C.
July 2013, TBD, Washington, D.C.
November 2013, TBD,Washington, D.C.
______________________________________________________________________________
Future TTAG Meetings & Conference Calls:
2:30PM - 4:00 PM EST
Call in number 1-877-267-1577
December 12, 2012: Meeting ID: 9925
January 9, 2013: Meeting ID: TBD
March 13, 2013: Meeting ID: TBD
April 10, 2013: Meeting ID: TBD
May 8, 2013: Meeting ID: TBD
June 12, 2013: Meeting ID: TBD
August 14, 2013: Meeting ID: TBD
September 11, 2013: Meeting ID: TBD
October 9, 2013: Meeting ID: TBD
December 11, 2013: Meeting ID: TBD
Face to Face Meetings:
February 2013: NMAI, Washington, D.C.
July 2013: NMAI, Washington, D.C.
November 2013: NMAI, Washington, D.C.

REGULATIONS REVIEW UPDATE
TABLE OF CONTENTS
FEDERAL REGISTER IDENTIFIER CMS 10445 1
DRAFT NIHB COMMENT CMS 10445 3
RRIAR V. 2.11 6
ACTIVE, NEW & ONGOING MMPC/TTAG ISSUES, STATUS, GOALS & NEXT
STEPS
BIO—JOHN O’BRIEN, DIRECTOR, HEALTHCARE & INSURANCE, OPT 47
NIHB COMMENTS ON DRAFT MULTI-STATE PLAN PROGRAM APPLICATION 48
DEAR GOVERNOR LETTER FROM SECRETARY SEBELIUS 55
ANALYSIS OF TRIBAL CONSULTATION POLICIES FOR HEALTH INSURANCE EXCHANGES 57
TRIBAL CONSULTATION FOR HEALTH INSURANCE EXCHANGES SURVEY QUESTIONS 75

Regulation Review and Impact Analysis Report
v. 2.11
-- DRAFT --
As of November 12, 2012
Attachments
- Table A: Listing and Status Report on Regulations Reviewed (through 11/9/2012)
- Table B: Summary and Analysis of Agency Notices and Regulations (through 8/15/2012)
- Table C: NIHB Recommendations and Evaluation of Agency’s Subsequent Actions (through 5/15/2012)

The purpose of the Regulation Review and Impact Analysis Report (RRIAR) is to identify and summarize key regulations issued by the Centers for
Medicare and Medicaid Services (CMS) pertaining to Medicare, Medicaid, CHIP, and health reform 1 that affect (a) American Indians and Alaska Natives
and/or (b) Indian Health Service, Indian Tribe and tribal organization, and urban Indian organization providers. Furthermore, the RRIAR includes a
summary of the regulatory analyses prepared by the National Indian Health Board (NIHB) 2 , if any, and indicates the extent to which the recommendations
made by NIHB were incorporated into any subsequent CMS actions.
In addition to this cover page, the report consists of three tables –
- Table A provides a status report on the RRIAR itself, listing the regulations included in the RRIAR to date, and the components of the analysis
provided under each. The regulations are organized in four sections: I. Medicaid; II. Medicare; III. Health Reform; and IV. Other.
- Table B lists key regulations issued by CMS, due dates for comments, a synopsis of the CMS action, and a summary of the analysis, if any,
prepared by NIHB.
- Table C identifies the recommendations made by NIHB pertaining to each regulation, if any, and evaluates the extent to which the
recommendations made by NIHB were incorporated into subsequent CMS actions.
Regulations with pending due dates for public comments –
2.d. Medicare Advantage and Part D Plan Applications (CMS-10237 and CMS-10137; comments due 11/13/2012; under review)
11.e. Medicare Advantage Quality Bonus Payment Demonstration (CMS-10445; comments due 11/16/2012; comments drafted)
60.d. Medicare Electronic Data Interchange Form (CMS-10164; comments due 11/16/2012)
84. Monthly State File of Dual Eligible Enrollees (CMS-10143; comments due 11/16/2012)
49.b. Medicare Credit Balance Reporting Requirements (CMS-838; comments due 11/16/2012)
85. Minimum Data Set for Medicaid Incentives for Prevention of Chronic Diseases (CMS-10444; comments due 11/19/2012)
83. Medicaid Statistical Information System (CMS-R-284; comments due 11/19/2012)
3.c. DME Certificate of Medical Necessity (CMS-846-849, 10125, 0126; comments due 11/23/2012)
88. Early Retiree Reinsurance Program Survey (CMS-10408; comments due 11/27/2012)
95. Indian Health Service Forms to Implement Privacy Rule (IHS-810, etc.; comments due 11/30/2012 approx.)
11.d. Medicare Bid Pricing Tool (CMS-10142; comments due 12/4/2012)
11.f. Medicare PDP Benefit Package Formulary (CMS-R-262; comments due 12/4/2012)
11.c. Outcome Measures for Quality Assessment in Medicare Advantage and Special Needs Plans (CMS-10451; comments due 12/26/2012)
11.g. Medicare Advantage Reporting Requirements (CMS-10261; comments due 12/26/2012)
94. Methodology for Designation of Frontier and Remote Areas (HRSA/no ref. #; comments due 1/4/2013)
4.b. Hospital Outpatient and Ambulatory Service Center Payment Systems (CMS-1589-FC; comments due 1/12/2013 approx.)
70.a. Medicare Physician Fee Schedule Rule (CMS-1590-FC; comments due 1/13/2013 approx.)
96. IHS New System of Records (IHS/no ref. #; comments due 12/13/2012)
Comments recently submitted by NIHB, TTAG and/or other tribal organizations–
80. Notice of Denial of Medical Coverage (or Payment) (CMS-10003: comments submitted 11/6/2012)
66. Requirements for Charitable Hospitals: Proposed Rule (IRS-130266-11; comments submitted 9/24/2012)
1 “Health reform” is inclusive of (1) the Patient Protection and Affordable Care Act (Pub. L. 111-148), incorporating by reference S. 1790 as reported by the
Committee on Indian Affairs of the Senate in December 2009 (containing amendments to the Indian Health Care Improvement Act, IHCIA), and as amended by
the Health Care and Education Reconciliation Act (HCERA; Public Law 111–152) (collectively referred to as “ACA”) and (2) the American Recovery and
Reinvestment Act of 2009 (ARRA, Pub. L. 111-5)
2 The analyses and recommendations may include those made by the Tribal Technical Advisory Group to CMS (TTAG) and other tribal organizations.
National Indian Health Board, Regulation Review and Impact Analysis Report Page 2 of 3 11/12/2012

64. Policy on Conferring with Urban Indian Organizations: Request for Comments (No ref #; comments submitted by ANTHC and NCUIH
9/23/2012)
65. Health Care Reform Insurance Web Portal Requirements (CMS-10320; submitted 9/13/2012)
Regulations under OMB (Office of Management and Budget) review –
92. Insurance Market Rules (CMS-9972-P; sent to OMB 11/8/2012)
31.d. Standards Related to Health Benefits (CMS-9980-P; sent to OMB 11/8/2012)
81. Part II--Regulatory Provisions To Promote Program Efficiency, Transparency, and Burden Reduction (CMS-1367-P; sent to OMB 8/2/2012)
Recent (final) rules issued –
71.a. Physician Fee Schedule, ESRD, Bad Debt, etc (CMS-1352-F; issued 11/9/2012)
52. Home Health Prospective Payment System Rate for CY2013 (CMS-1358;F; issued 11/8/2012)
44. Medicaid Payment for Primary Care Services and Charges for Vaccine Administration: Proposed Rule (CMS-2370-P; issued 11/6/2012)
1.b. MU EHR Incentive Payments--Stage 2 (CMS-0044-F; issued 9/4/2012; corrections issued 10/23/2012)
Contacts: Jennifer Cooper (JCooper@nihb.org); Liz Heintzman (EHeintzman@nihb.org)
National Indian Health Board, Regulation Review and Impact Analysis Report Page 3 of 3 11/12/2012

RRIAR
Ref.
#
1.a.
1.b.
Short Title/
Current Status of Regulation/
Title/
Agency
MU EHR Incentive Payments
ACTION: Proposed Final Rule
NOTICE: Medicare and Medicaid
Programs; Electronic Health
Record (EHR) Incentive Program
AGENCY: CMS
MU EHR Incentive Payments--
Stage 2
ACTION: Proposed Final Rule
NOTICE: Medicare and Medicaid
Programs; Electronic Health
Record Incentive Program Stage 2
AGENCY: CMS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/09/2012
File Code
CMS-0033-P F
CMS_ FRDOC_
0001-0520
CMS-0044-PF
CMS-0044-
CN2
Dates (Issue, Due, File,
Subsequent Action)
SECTION I: MEDICAID (AND DUAL
MEDICAID AND MEDICARE)
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Beginning on page 1 of 38
SECTION II: MEDICARE Beginning on page 9 of 38
Section III: Health Reform Beginning on page 23 of 38
Section IV: Other Beginning on page 36 of 38
SECTION I: MEDICAID (AND DUAL
MEDICAID AND MEDICARE)
Issue Date: 1/13/2010
Due Date: 3/15/2010
NIHB File Date: Pre-2/15/2010
Date of Subsequent Action, if any:
Issued Final Rule 7/28/2010;
issued correction 12/29/2010
Additional: NIHB/TTAG provided
analysis 2/03/2011; 5/23/2011;
7/05/2011; 12/14/2011
Issue Date: 3/7/2012;
Due Date: 5:00 pm, 5/7/2012
NIHB File Date: 5/7/2012
Date of Subsequent Action, if any:
Issued correction 4/18/2012;
issued Final Rule 9/4/2012;
issued correction 10/23/2012
Summary of Agency
action: √
NIHB analysis of
action: √
Summary of Agency
action: √
NIHB analysis of
action: [To be
entered.]
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included: √
Subsequent Agency action: √
Analysis of Agency action: √
NIHB recommendations included: To
be entered.
Subsequent Agency action: [To be
entered.]
Analysis of Agency action: [To be
conducted and entered.]
: regulation review complete : reg. currently under review : regulation release pending
Page 1 of 38

RRIAR
Ref.
#
1.c.
8.
9.
13.
Short Title/
Current Status of Regulation/
Title/
Agency
HIT Revised Standards--CMS
EHR Program
ACTION: Proposed Final Rule
NOTICE: Health Information Tech.;
Revised Standards, Implementation
Specs and Cert. Criteria for EHRs
AGENCY: ONC, HHS
Sec. 1115 Waiver Transparency
ACTION: Proposed Final Rule
NOTICE: Medicaid; Review/App.
Process for Sec. 1115 Demo’s
AGENCY: CMS
Med/Med Provider Survey
ACTION: Final Rule w/Comments
NOTICE: Medicare, Medicaid, and
CHIP Programs; Additional
Screening Requirements, App. Fee
AGENCY: CMS
Provider Complaint Filing
ACTION: Proposed Rule
NOTICE: Medicare & Medicaid
Providers & Suppliers to notify
beneficiaries of the right to file
written complaint with QIO
AGENCY: CMS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
HHS
RIN 0991-
AB82
Dates (Issue, Due, File,
Subsequent Action)
Issue Date: 3/7/2012
Due Date: 5:00 pm, 5/7/2012
NIHB File Date: None
Date of Subsequent Agency
Action, if any: Issued Final Rule
9/4/2012
CMS-2325-PF Issue Date: 9/17/2010
Due Date: 11/16/2010
NIHB File Date: 11/15/2010
Date of Subsequent Agency
Action, if any: Issued Final Rule
2/27/2012
CMS-6028-FC Issue Date: 9/23/2010
Due Date: 11/16/2010
NIHB File Date: 11/16/2010
Date of Subsequent Agency
Action, if any: 2/1/2011
Additional: NIHB provided
CMS-3225-P
RIN 0938-
AP94
examples of hardship 3/25/11
Issue Date: 2/2/2011
Due Date: 4/4/2011
NIHB File Date: 4/4/2011
Date of Subsequent Agency
action, if any: Sent Final Rule
to OMB for review 6/2/2011
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action: √
Summary of Agency
action: √
TTAG analysis of
action: √
Summary of Agency
action: √
NIHB analysis of
action: √
Summary of Agency
action: √
NIHB analysis of
action: √
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
TTAG recommendations included: √
Subsequent Agency action: √
Analysis of Agency action: To be
entered.
NIHB recommendations included: √
Subsequent Agency action: √
Analysis of Agency action: √
NIHB recommendations included: √
Subsequent Agency action: None as
of 5/31/2011.
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 2 of 38 11/12/2012

RRIAR
Ref.
#
16.a.
16.b.
17.
Short Title/
Current Status of Regulation/
Title/
Agency
New Medicaid Community First
Choice Option
ACTION: Proposed Final Rule
NOTICE: Community First Choice
Option
AGENCY: CMS
Medicaid HCBS Waivers
ACTION: Proposed Rule
NOTICE: Medicaid; State Plan
Home and Community-Based
Services, 5-Year Period for
Waivers, Provider Payment
Reassignment; Setting
Requirements
AGENCY: CMS
Assuring Access to Covered
Services
ACTION: Request for Information
NOTICE: Opportunities for
Alignment Under Medicaid and
Medicare
AGENCY: CMS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
CMS-2337-PF
RIN 0938-
AQ35
Dates (Issue, Due, File,
Subsequent Action)
Issue Date: 2/25/2011
Due Date: 4/26/2011
NIHB File Date: 4/26/2011
Date of Subsequent Agency
Action, if any: 5/7/2012
CMS-2249-P2 Issue Date: 5/3/2012
Due Date: 7/2/2012 (corrected)
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
CMS-5507-NC
Issue Date: 5/16/2011
Due Date: 7/11/2011
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: √
NIHB analysis of
action: √
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action: √
NIHB analysis of
action: √
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included: √
Subsequent Agency action: √
Analysis of Agency action: In
progress.
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included: No
recommendations submitted
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 3 of 38 11/12/2012

RRIAR
Ref.
#
20.
23.
26.
28.a.
Short Title/
Current Status of Regulation/
Title/
Agency
Assuring Access to Services
ACTION: Proposed Rule
NOTICE: Medicaid Program;
Methods for Assuring Access to
Covered Medicaid Services
AGENCY: CMS
Request for Approval of
Medicaid and CHIP Standard
Forms
ACTION: Request for Comment
NOTICE: Clearance for Medicaid
and CHIP State Plan, Waiver, and
Program Submissions
AGENCY: CMS
Medicaid Home Health
ACTION: Proposed Rule
NOTICE: Medicaid Program; Faceto-Face
Requirements for Home
Health Services; Policy Changes
and Clarifications Related to HH
AGENCY: CMS
Medicaid Eligibility Under ACA
ACTION: Proposed Final Rule
NOTICE: Medicaid; Eligibility
Changes Under the ACA
AGENCY: CMS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
CMS-2328-P
Dates (Issue, Due, File,
Subsequent Action)
Issue Date: 5/6/2011
Due Date: 7/5/2011
NIHB File Date: 7/5/2011 (filed
by ANHTC)
Date of Subsequent Agency
Action, if any:
CMS-10398 Issue Date: 7/1/2011
Due Date: 8/30/2011
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
CMS-2348-P Issue Date: 7/12/2011
Due Date: 9/12/2011
NIHB File Date: None
Date of Subsequent Agency
Action, if any: Issued Proposed
Rule on home health payment
rates 7/12/2011 (CMS-1353-P)
CMS-2349-PF Issue Date: 8/12/2011
Due Date: 10/31/2011
NIHB File Date: 10/31/2011
Date of Subsequent Agency
Action, if any: Issued Final
Rule 3/23/2012 (see 28.b.)
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: √
NIHB analysis of
action: √
Summary of Agency
action: √
NIHB analysis of
action: √ (Limited)
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action: √
NIHB analysis of
action: √
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included: √
(ANHTC recommendations)
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
None.
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
None.
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included: √
Subsequent Agency action: √
Analysis of Agency action: To be
completed.
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 4 of 38 11/12/2012

RRIAR
Ref.
#
28.b.
34.
40.
41.
Short Title/
Current Status of Regulation/
Title/
Agency
Medicaid Eligibility Under ACA
ACTION: Interim Final Rule
NOTICE: Medicaid; Eligibility
Changes Under the ACA
AGENCY: CMS
Presumptive Eligibility
ACTION:
NOTICE:
AGENCY: CMS
State Plan Pages
ACTION: Notice
NOTICE: Medicaid State Plan Base
Plan Pages
AGENCY: CMS
New Safe Harbors
ACTION: Notice of Intent to
Develop Regulations
NOTICE: Solicitation of New Safe
Harbors and Special Fraud Alerts
AGENCY: HHS OIG
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
Dates (Issue, Due, File,
Subsequent Action)
CMS-2349-IF Issue Date: 3/23/2012
Due Date: 5:00 pm, 5/7/2012
NIHB File Date: 5/7/2012
Date of Subsequent Agency
Action, if any:
CMS-[TBD] Issue Date: [TBD]
Due Date: [TBD]
NIHB File Date:
Date of Subsequent Agency
Action, if any:
CMS-179 Issue Date: 12/29/2011
Due Date: 2/14/2012
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
OIG–120–N Issue Date: 12/29/2011
Due Date: 5:00 pm, 2/27/2012
NIHB File Date: 2/27/2012
Date of Subsequent Agency
Action, if any: None as of
5/15/2012
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: √
NIHB analysis of
action: [To be
entered.]
Summary of Agency
action:
NIHB analysis of
action:
Summary of Agency
action: None.
NIHB analysis of
action: None.
Summary of Agency
action: √
NIHB analysis of
action: [To be
entered.]
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included: To
be entered.
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
[To be entered.]
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 5 of 38 11/12/2012

RRIAR
Ref.
#
43.
44.
46.
61.
Short Title/
Current Status of Regulation/
Title/
Agency
Medicaid Reimbursement for
Outpatient Drugs
ACTION: Proposed Rule
NOTICE: Medicaid Program;
Covered Outpatient Drugs
AGENCY: CMS
Medicaid Payment for Primary
Care Services
ACTION: Proposed Final Rule
NOTICE: Payment for Primary
Care Services under Medicaid
Program
AGENCY: CMS
Medicaid DSH and Definition of
Uninsured
ACTION: Proposed Rule
NOTICE: Medicaid Program;
Disproportionate Share Hospital
Payments--Uninsured Definition
AGENCY: CMS
Medicaid State Disallowance
ACTION: Final Rule
NOTICE: Medicaid and Children’s
Health Insurance Programs;
Disallowance of Claims for FFP and
Technical Corrections
AGENCY: CMS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
Dates (Issue, Due, File,
Subsequent Action)
CMS-2345-P Issue Date: 2/2/2012
Due Date: 5:00 pm, 4/2/2012
NIHB File Date: 4/2/2012
Date of Subsequent Agency
Action, if any:
CMS-2370-PF Issue Date: 5/11/2012
Due Date: 5:00 pm, 6/11/2012
NIHB File Date: None
Date of Subsequent Agency
Action, if any: Issued Final Rule
11/6/2012
CMS-2315-P
Issue Date: 1/18/2012
Due Date: 5:00 pm, 2/17/2012
NIHB File Date: 2/17/2012
Date of Subsequent Agency
Action, if any: None as of
4/30/2012
CMS-2292-F Issue Date: 5/29/2012
Due Date: None
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: √
NIHB analysis of
action: √
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action: √
NIHB analysis of
action: √
Summary of Agency
action: √
NIHB analysis of
action: None.
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included: √
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included: √
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 6 of 38 11/12/2012

RRIAR
Ref.
#
62.
65.
66.
Short Title/
Current Status of Regulation/
Title/
Agency
Medicaid State Disallowance
ACTION: Request for Comment
NOTICE: External Quality
Review Protocols
AGENCY: CMS
Health Care Reform Insurance
Web Portal Requirements
ACTION: Request for comment
NOTICE: Health Care Reform
Insurance Web Portal
Requirements
AGENCY: CMS
Requirements for Charitable
Hospitals
ACTION: Proposed Rule
NOTICE: Additional Requirements
for Charitable Hospitals
AGENCY: IRS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
Dates (Issue, Due, File,
Subsequent Action)
CMS-R-305 Issue Date: 5/31/2012
Due Date: 7/2/2012
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
CMS-10320 Issue Date: 8/15/2012
Due Date: 9/13/2012
NIHB (TTAG and ANTHC) File
Date: 9/13/2012
Date of Subsequent Agency
Action, if any:
IRS-130266-11 Issue Date: 6/26/2012
Due Date: 9/24/2012
NIHB File Date: 9/24/2012
Date of Subsequent Agency
Action, if any:
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action: √
NIHB analysis of
action: √
Summary of Agency
action: √
NIHB analysis of
action: [To be
entered.]
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
TTAG and ANTHC recommendations
included: [To be entered.]
Subsequent Agency action:
Analysis of Agency action:
TTAG / NIHB recommendations
included: [To be entered.]
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 7 of 38 11/12/2012

RRIAR
Ref.
#
83.
84.
85.
86.
Short Title/
Current Status of Regulation/
Title/
Agency
Medicaid Statistical Information
System
ACTION: Request for Comment
NOTICE: Medicaid Statistical
Information System
AGENCY: CMS
Monthly State File of Dual
Eligible Enrollees
ACTION: Request for Comment
NOTICE: Monthly State File of
Medicaid/Medicare Dual Eligible
Enrollees
AGENCY: CMS
Medicaid Incentives for
Prevention of Chronic Diseases
ACTION: Request for Comment
NOTICE: Minimum Data Set for
MIPCD Program Grantees
AGENCY: CMS
Community Health Accreditation
Program for Hospices
ACTION: Final Notice
NOTICE: Medicare and Medicaid
CHAP for Continued Deeming
Authority for Hospices
AGENCY: CMS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
Dates (Issue, Due, File,
Subsequent Action)
CMS-R-284 Issue Date: 8/15/2012
Due Date: 10/15 11/19/2012
NIHB File Date: Under review.
Date of Subsequent Action, if any:
Issued extension without change
10/19/2012
CMS-10143 Issue Date: 9/17/2012
Due Date: 11/16/2012
NIHB File Date:
Date of Subsequent Agency
Action, if any:
CMS-10444 Issue Date: 10/19/2012
Due Date: 11/19/2012
NIHB File Date: Under review
Date of Subsequent Agency
Action, if any:
CMS-3266-FN Issue Date: 10/19/2012
Due Date: None
NIHB File Date:
Date of Subsequent Agency
Action, if any:
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: To be entered.
NIHB analysis of
action:
Summary of Agency
action: [To be
entered.]
NIHB analysis of
action:
Summary of Agency
action: [To be
entered.]
NIHB analysis of
action:
Summary of Agency
action: [To be
entered.]
NIHB analysis of
action:
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 8 of 38 11/12/2012

RRIAR
Ref.
#
87.
2.a.
2.b.
Short Title/
Current Status of Regulation/
Title/
Agency
Medicare and Medicaid Quarterly
Listing of Program Issuances
ACTION: Notice
NOTICE: Medicare and Medicaid
Quarterly Listing of Issuances—
July through September 2012
AGENCY: CMS
I/T/U Addendum to Medicare
Prescription Drug Plans (PDP):
Revision of Current Collection
ACTION: Information Collection
NOTICE: Agency Information
Collection Activities: Proposed
Collection; Comment Request
AGENCY: CMS
I/T/U Addendum to Medicare
Prescription Drug Plans (PDP)
ACTION: Information Collection
NOTICE: Information Collection
Activities: Comment Request
AGENCY: CMS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
CMS-9075-N
CMS-10137
and CMS-
10237
CMS-10137
Dates (Issue, Due, File,
Subsequent Action)
Issue Date: 11/9/2012
Due Date: None
NIHB File Date:
Date of Subsequent Agency
Action, if any:
SECTION II: MEDICARE
Issue Date: 6/11/2010
Due Date: 8/10/2010
NIHB File Date: 8/10/2010
Date of Subsequent Agency Action,
if any: Issued revised “Medicare
PDP Sponsor contracts with
Revised I/T/U Addendum” pre-
1/13/2011
Additional: Issued revised 2013
contracts 7/1/2011 (see 2.b.)
Issue Date: 7/1/2011
Due Date: 8/30/2011
NIHB File Date: 8/30/2011
Date of Subsequent Agency
Action, if any:
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: To be entered.
NIHB analysis of
action:
Summary of Agency
action: √
NIHB analysis of
action: √
Summary of Agency
action: √
NIHB analysis of
action: √
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
From Review of 2011 Docs
NIHB recommendations included: √
Subsequent Agency action: √
Analysis of Agency action: √
NIHB recommendations included: √
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 9 of 38 11/12/2012

RRIAR
Ref.
#
2.c.
2.d.
3.a.
Short Title/
Current Status of Regulation/
Title/
Agency
Medicare Advantage and PDP
Data Requirements
ACTION: Request for Comment
NOTICE: Application for New and
Expanding Medicare Prescription
Drug Plans and Medicare
Advantage Prescription Drug (MA-
PD) Plans, including Cost Plans
and Employer Group Waiver Plans
AGENCY: CMS
Medicare Advantage and PDP
Plan Applications
ACTION: Request for Comment
NOTICE: Part C Medicare
Advantage and 1876 Cost Plan
Expansion Application
AGENCY: CMS
Medicare Part B Rates
ACTION: Final Rule
NOTICE: Medicare Program;
Payment Policies Under the
Physician Fee Schedule and Other
Revisions to Part B for CY 2011
AGENCY: CMS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
Dates (Issue, Due, File,
Subsequent Action)
CMS-10137 Issue Date: 7/6/2012
Due Date: 9/4/2012
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
CMS-10237
and CMS-
10137
CMS-2010-
0205-0002
Issue Date: 10/12/2012
Due Date: 11/13/2012
NIHB File Date: Under review.
Date of Subsequent Agency
Action, if any:
Issue Date: 7/13/2010
Due Date: 8/24/2010
NIHB File Date: None
Date of Subsequent Agency
Action, if any: Issued Final Rule
11/29/2010
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action: [To be
entered.]
NIHB analysis of
action: [To be
entered.]
Summary of Agency
action: √
NIHB analysis of
action: None.
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 10 of 38 11/12/2012

RRIAR
Ref.
#
3.b.
3.c.
4.a.
Short Title/
Current Status of Regulation/
Title/
Agency
DME Competitive Bidding
ACTION: Request for Comment
NOTICE: Durable Medical
Equipment, Prosthetics, Orthotics,
and Supplies (DMEPOS)
Competitive Bidding Program
AGENCY: CMS
Durable Medical Equipment
Certificate of Medical Necessity
ACTION: Request for Comment
NOTICE: DME Medicare
Administrative Contractor CMN and
Supporting Documentation
Requirements
AGENCY: CMS
Medicare Outpatient Rates
ACTION: Final Rule
NOTICE: Medicare Program:
Proposed changes to the Hospital
Outpatient Prospective Payment
System and CY 2011 Rates, etc.
AGENCY: CMS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
CMS-10169
CMS-846-849,
10125, and
10126
CMS-2010-
0205-0002
Dates (Issue, Due, File,
Subsequent Action)
Issue Date: 7/27/2012
Due Date: 8/27/2012
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
Issue Date: 9/24/2012
Due Date: 11/23/2012
NIHB File Date: Under review.
Date of Subsequent Agency
Action, if any:
Issue Date: 8/3/2010
Due Date: 8/31/2010
NIHB File Date: None
Date of Subsequent Agency
Action, if any: Issued Final Rule
11/24/2010
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action: [To be
entered.]
NIHB analysis of
action:
Summary of Agency
action: √
NIHB analysis of
action: None.
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 11 of 38 11/12/2012

RRIAR
Ref.
#
4.b.
5.
10.a.
10.b.
Short Title/
Current Status of Regulation/
Title/
Agency
Medicare Outpatient Rates
ACTION: Proposed Final Rule
NOTICE: Medicare Program:
Revisions to hospital outpatient
prospective and ambulatory
surgical center payment systems;
CY 2013 rates, etc.
AGENCY: CMS
PACE Information Request
ACTION: Request for Comment
NOTICE: Medicare and Medicaid;
Programs of All-Inclusive Care for
the Elderly (PACE)
AGENCY: CMS
ACO Standards
ACTION: Request for Comment
NOTICE: Medicare; Request for
Info. Regarding Accountable Care
Organizations (ACOs) and
Medicare Shared Saving Program
AGENCY: CMS
ACO Standards
ACTION: Proposed Final Rule
NOTICE: Medicare Program;
Shared Savings Program: ACOs
AGENCY: CMS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
CMS-1589-
PFC
CMS-2010-
0222-0001
CMS-R-244
Dates (Issue, Due, File,
Subsequent Action)
Issue Date: 7/30/2012
Due Date: 9/4/2012
NIHB File Date: None
Date of Subsequent Agency
Action, if any: Issued Final Rule
11/15/2012 (scheduled)
Due Date for Final Rule
Comments: 60 days (approx..
1/12/2013)
Issue Date: 7/30/2010
Due Date: 9/28/2010
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
CMS-1345-NC Issue Date: 11/17/2011
Due Date: 12/3/2011
NIHB File Date: None
Date of Subsequent Agency
Action, if any: 3/31/2011 (see
10.b.)
CMS-1345-P F Issue Date: 3/31/2011
Due Date: 5:00 pm, 6/6/2011
NIHB File Date: 6/6/2011
Date of Subsequent Agency
Action, if any: 11/2/2011
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action: √
NIHB analysis of
action: √
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action: See 10.b
below.
Analysis of Agency action:
NIHB recommendations included: √
Subsequent Agency action: √
Analysis of Agency action: √
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 12 of 38 11/12/2012

RRIAR
Ref.
#
11.a.
11.b.
11.c.
11.d.
Short Title/
Current Status of Regulation/
Title/
Agency
Revisions to PDP Requirements
ACTION: Proposed Final Rule
NOTICE: Medicare Program;
Proposed Changes to MA and the
Medicare PDP for Contract Year
2012 and Other Proposed Changes
AGENCY: CMS
Medicare Advantage and PDP
ACTION: Final Rule
NOTICE: Policy and Technical
Changes to Medicaid Advantage
and PDP for CY 2013
AGENCY: CMS
Quality in Medicare Advantage
and Special Needs Plans
ACTION: Request for Comment
NOTICE: Evaluation and
Development of Outcome
Measures for Quality Assessment
in MA Plans and SNPs
AGENCY: CMS
Bid Pricing Tool
ACTION: Request for Comment
NOTICE: BPT for Medicare
Advantage and Prescription Drug
Plans
AGENCY: CMS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
CMS-4144-F
CMS-4157-F
Dates (Issue, Due, File,
Subsequent Action)
Issue Date: 11/22/2010
Due Date: 1/11/2011 (changed
from 1/22/2011)
NIHB File Date: 1/11/2011
Date of Subsequent Agency
Action, if any: Issued Final Rule
4/15/2011
Issue Date: 4/12/2012
Due Date: None
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
CMS-10451 Issue Date: 10/26/2012
Due Date: 12/26/2012
NIHB File Date: Under review.
Date of Subsequent Agency
Action, if any:
CMS-10142
Issue Date: 10/5/2012
Due Date: 12/4/2012
NIHB File Date: Under review.
Date of Subsequent Agency
Action, if any:
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: √
NIHB analysis of
action: √
Summary of Agency
action: √
NIHB analysis of
action:
Summary of Agency
action: [To be
entered.]
NIHB analysis of
action:
Summary of Agency
action: [To be
entered.]
NIHB analysis of
action:
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included: √
Subsequent Agency action: √
Analysis of Agency action: √
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 13 of 38 11/12/2012

RRIAR
Ref.
#
11.e.
11.f.
11.g.
Short Title/
Current Status of Regulation/
Title/
Agency
Medicare Advantage Quality
Bonus Payment Demonstration
ACTION: Request for Comment
NOTICE: Medicare Advantage
Quality Bonus Payment
Demonstration
AGENCY: CMS
Plan Benefit Package and
Formulary Submission
ACTION: Request for Comment
NOTICE: PBP and Formulary
Submission for Medicare
Advantage and Prescription Drug
Plans
AGENCY: CMS
Medicare Advantage Reporting
Requirements
ACTION: Request for Comment
NOTICE: Part C Medicare
Advantage Reporting Requirements
and Supporting Regulations in 42
CFR 422.516(a)
AGENCY: CMS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
CMS-10445
CMS-R-262
Dates (Issue, Due, File,
Subsequent Action)
Issue Date: 9/17/2012
Due Date: 11/16/2012
NIHB File Date: Under review.
Date of Subsequent Agency
Action, if any:
Issue Date: 10/5/2012
Due Date: 12/4/2012
NIHB File Date: Under review.
Date of Subsequent Agency
Action, if any:
CMS-10261 Issue Date: 10/26/2012
Due Date: 12/26/2012
NIHB File Date: Under review.
Date of Subsequent Agency
Action, if any:
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: To be entered.
NIHB analysis of
action: To be entered.
Summary of Agency
action: [To be
entered.]
NIHB analysis of
action:
Summary of Agency
action: [To be
entered.]
NIHB analysis of
action:
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
TTAG / NIHB recommendations
included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 14 of 38 11/12/2012

RRIAR
Ref.
#
18.
19.
21.
Short Title/
Current Status of Regulation/
Title/
Agency
eRx Incentive Program
ACTION: Proposed Rule
NOTICE: Medicare Program;
Proposed Change to the Electronic
Prescribing Incentive Program
AGENCY: CMS
Value-Based Purchasing
ACTION: Final Rule
NOTICE: Medicare Program;
Hospital Inpatient Value-Based
Purchasing
AGENCY: CMS
Medicare Outpatient Rates and
Other Provider-Related Issues
ACTION: Proposed Final Rule
NOTICE: Medicare and Medicaid:
Hospital Outpatient Prospective
Payment; Ambulatory Surgical
Center; Hospital Value-Based
Purchasing Program, etc.
AGENCY: CMS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
CMS-3248-P
CMS-3239-F
CMS-1525-
PFC
RIN 0938-
AQ26
Dates (Issue, Due, File,
Subsequent Action)
Issue Date: 6/1/2011
Due Date: 7/25/2011
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
Issue Date: 5/6/2011
Due Date: None
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
Issue Date: 7/1/2011
Due Date: 8/30/2011
NIHB File Date: None
Date of Subsequent Agency
Action, if any: 11/1/2011; issued
correction 4/24/2012
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: √
NIHB analysis of
action: √
Summary of Agency
action: √
NIHB analysis of
action: √
Summary of Agency
action: √
NIHB analysis of
action: √
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included: No
comments/recommendations made.
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
None.
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 15 of 38 11/12/2012

RRIAR
Ref.
#
22.
24.
25.a.
Short Title/
Current Status of Regulation/
Title/
Agency
Medicare Physician Rates
ACTION: Proposed Rule
NOTICE: Medicare Program;
Payment Policies Under the
Physician Fee Schedule and Other
Revisions to Part B for CY 2012
AGENCY: CMS
Transportation Barriers Study
under Medicare for AI/AN
ACTION: Information Request
NOTICE: Analysis of Transportation
Barriers to Utilization of Medicare
Services by AI/AN Medicare Bene’s
AGENCY: CMS
Medicare Inpatient Rates
ACTION: Proposed Rule
NOTICE: Medicare; Hospital
Inpatient PPPS for Acute Care
Hospitals and the LTC Hospital
PPS and Fiscal Year 2011 Rates
AGENCY: CMS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
CMS-1524-P
RIN 0938-
AQ25
Dates (Issue, Due, File,
Subsequent Action)
Issue Date: 7/1/2011
Due Date: 8/30/2011
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
CMS-10399 Issue Date: 7/1/2011
Due Date: 8/30/2011
NIHB File Date: 8/30/2011
Date of Subsequent Agency
Action, if any: Issued Notice
12/14/2011; issued Notice
4/18/2012
CMS-1518-P
Issue Date: 4/19/2011
Due Date: 6/20/2011
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: √
NIHB analysis of
action: √
Summary of Agency
action: √
NIHB analysis of
action: √
Summary of Agency
action: √
NIHB analysis of
action: Partial.
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included:
None
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included: √
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
None.
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 16 of 38 11/12/2012

RRIAR
Ref.
#
25.b.
32.
49.a.
49.b.
Short Title/
Current Status of Regulation/
Title/
Agency
Medicare Inpatient Rates
ACTION: Proposed Final Rule
NOTICE: Medicare; Hospital
Inpatient and LTC PPS and FY
2013 Rates; Hospital GME
Payments; Quality Reporting
Requirements for ACS and others
AGENCY: CMS
Bundled Payments
ACTION: Request for
Applications
NOTICE: Bundled Payments for
Care Improvement Initiatives
AGENCY: CMS
Reporting and Returns of
Medicare Overpayments
ACTION: Proposed Rule
NOTICE: Medicare; Reporting and
Returning of Overpayments
AGENCY: CMS
Medicare Credit Balance
Reporting Requirements
ACTION: Request for Comment
NOTICE: Medicare Credit Balance
Reporting Requirements and
Supporting Regulations
AGENCY: CMS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
CMS-1588-PF
CMS-1588-
CN2 & CN3
CMS-1588-F2
Dates (Issue, Due, File,
Subsequent Action)
Issue Date: 4/24/2012
Due Date: 5:00 pm, 6/25/2012
NIHB File Date: None
Date of Subsequent Agency
Action, if any: Issued Final Rule
8/31/2012; issued correction
10/17/2012 and 10/29/2012
CMS-5504-N Issue Date: 8/25/2011
Due Date: 10/06/2011 and
11/18/2011
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
CMS-6037-P Issue Date: 2/16/2012
Due Date: 5:00 pm, 4/16/2012
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
CMS-838
Issue Date: 9/17/2010
Due Date: 11/16/2010
NIHB File Date:
Date of Subsequent Agency
Action, if any:
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of
Subsequent Agency
action: √
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action: [To be
entered.]
NIHB analysis of
action:
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 17 of 38 11/12/2012

RRIAR
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#
52.a.
52.b.
52.c.
57.
Short Title/
Current Status of Regulation/
Title/
Agency
Medicare Home Health Access
ACTION: Information Request
NOTICE: Surveys of Physicians
and Home Health Agencies to
Assess Access Issues for Specific
Med. Beneficiaries in ACA §3131(d)
AGENCY: CMS
Medicare Home Health Payments
ACTION: Proposed Final Rule
NOTICE: Medicare; Revisions to
Home Health Prospective Payment
System Rate Update for CY 2013,
Hospice Quality Reporting
Requirements, etc.
AGENCY: CMS
Medicare Hospice Wage Index
ACTION: Notice
NOTICE: Medicare Program;
Hospice Wage Index for FY 2013
AGENCY: CMS
Durable Medical Equipment
ACTION: Request for Comment
NOTICE: Durable Medical
Equipment, Prosthetics, Orthotics,
and Supplies Competitive Bidding
Program
AGENCY: CMS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
CMS-10429
and CMS-
10185
Dates (Issue, Due, File,
Subsequent Action)
Issue Date: 4/18/2012
Due Date: 6/18/2012
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
CMS-1358-PF Issue Date: 7/13/2012
Due Date: 9/4/2012
NIHB File Date: None
Date of Subsequent Agency
Action, if any: Issued Final Rule
11/8/2012
CMS-1434-N Issue Date: 7/27/2012
Due Date: 9/4/2012
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
CMS-10169 Issue Date: 5/7/2012; 7/27/2012
(revised)
Due Date: 7/6/2012; 8/27/2012
(revised)
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action: √
NIHB analysis of
action: None.
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 18 of 38 11/12/2012

RRIAR
Ref.
#
58.
59.
60.a.
Short Title/
Current Status of Regulation/
Title/
Agency
Medicare Hospital Conditions of
Participation
ACTION: Final Rule
NOTICE: Medicare and Medicaid
Programs; Reform of Hospital and
Critical Access Hospital Conditions
of Participation
AGENCY: CMS
Medicare Provisions to Promote
Efficiency
ACTION: Final Rule
NOTICE: Medicare and Medicaid
Provisions to Promote Program
Efficiency, Transparency and
Burden Reduction
AGENCY: CMS
Health Insurance Common
Claims Form--phase-out
ACTION: Comment Request
NOTICE: Agency Information
Collection Activities: Proposed
Collection; Comment Request
AGENCY: CMS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
Dates (Issue, Due, File,
Subsequent Action)
CMS-3244-F Issue Date: 5/16/2012
Due Date: None
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
CMS-9070-F Issue Date: 5/16/2012
Due Date: None.
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
CMS-1500
(version 08/05)
and CMS-
1490S
Issue Date: 5/29/2012
Due Date: 7/30/2012
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action: √
NIHB analysis of
action: None.
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 19 of 38 11/12/2012

RRIAR
Ref.
#
60.b.
60.c.
60.d.
Short Title/
Current Status of Regulation/
Title/
Agency
Health Insurance Common
Claims Form--phase-in
ACTION: Comment Request
NOTICE: Agency Information
Collection Activities: Proposed
Collection; Comment Request
AGENCY: CMS
Health Insurance Common
Claims Form
ACTION: Request for Comment
NOTICE: Health Insurance
Common Claims Form and
Supporting Regulations at 42 CFR
Part 424, Subpart C
AGENCY: CMS
Medicare Electronic Data
Interchange Form
ACTION: Request for Comment
NOTICE: Medicare EDI
Registration and Enrollment Form
AGENCY: CMS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
CMS-1500
(version 2/12)
CMS-1500
(02/12) and
CMS-1500
(08/05)
CMS-10164
Dates (Issue, Due, File,
Subsequent Action)
Issue Date: 5/29/2012
Due Date: 7/30/2012
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
Issue Date: 9/21/2012
Due Date: 10/22/2012
NIHB File Date: None.
Date of Subsequent Agency
Action, if any:
Issue Date: 9/17/2012
Due Date: 11/16/2012
NIHB File Date: Under review.
Date of Subsequent Agency
Action, if any:
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action: [To be
entered.]
NIHB analysis of
action:
Summary of Agency
action: [To be
entered.]
NIHB analysis of
action:
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action: 49
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 20 of 38 11/12/2012

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#
70.a.
70.b.
71.a.
Short Title/
Current Status of Regulation/
Title/
Agency
Medicare PFS Rule
ACTION: Proposed Final Rule
NOTICE: Medicare: Revisions to
payment policies under physician
fee schedule, DME, face-to-face
encounters, etc.
AGENCY: CMS
Medicare Fee-for-Service
Prepayment Medical Review
ACTION: Request for Comment
NOTICE: Medicare Fee-for-Service
Prepayment Medical Review
AGENCY: CMS
Medicare PFS Rule
ACTION: Proposed Final Rule
NOTICE: Medicare Program; End-
Stage Renal Disease Prospective
Payment System, Quality Incentive
Program, and Bad Debt Reductions
for All Medicare Providers
AGENCY: CMS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
CMS-1590-
PFC
Dates (Issue, Due, File,
Subsequent Action)
Issue Date: 7/30/2012
Due Date: 9/4/2012
NIHB File Date: None
ANTHC File Date: 9/4/2012
Date of Subsequent Agency
Action, if any: Issued Final Rule
11/16/2012 (scheduled)
Due Date for Final Rule
Comments: 60 days (approx..
1/13/2013)
CMS-10417 Issue Date: 9/21/2012
Due Date: 10/22/2012
NIHB File Date:
Date of Subsequent Agency
Action, if any:
CMS-1352-PF
Issue Date: 7/11/2012
Due Date: 5:00 pm, 8/31/2012
NIHB File Date: None
Date of Subsequent Agency
Action, if any: Issued Final Rule
11/9/2012
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: √
ANTHC analysis of
action: To be entered.
Summary of Agency
action: [To be
entered.]
NIHB analysis of
action:
Summary of Agency
action: √
NIHB analysis of
action: None.
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
ANTHC recommendations included:
To be entered.
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 21 of 38 11/12/2012

RRIAR
Ref.
#
71.b.
72.
73.
Short Title/
Current Status of Regulation/
Title/
Agency
Medicare Beneficiaries with End-
Stage Renal Disease
ACTION: Request for Comment
NOTICE: Evaluation of Patient
Satisfaction and Experience of
Care for Medicare Beneficiaries
with ESRD
AGENCY: CMS
Medicare Skilled Nursing Facility
Payments
ACTION: Notice
NOTICE: Medicare: Prospective
Payment System and Consolidated
Billing for Skilled Nursing Facilities
for FY 2013
AGENCY: CMS
Medicare Inpatient Psychiatric
Rates
ACTION: Notice
NOTICE: Medicare: Inpatient
Psychiatric Facilities Prospective
Payment System--Update for Fiscal
Year Beginning October 1, 2012
(FY 2013)
AGENCY: CMS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
CMS-10425
CMS-1432-N
Dates (Issue, Due, File,
Subsequent Action)
Issue Date: 9/21/2012
Due Date: 10/22/2012
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
Issue Date: 8/2/2012
Due Date: None
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
CMS-1440-N Issue Date: 8/7/2012
Due Date: None
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: [To be
entered.]
NIHB analysis of
action:
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action: √
NIHB analysis of
action: None.
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 22 of 38 11/12/2012

RRIAR
Ref.
#
78.
80.
81.
6.a.
Short Title/
Current Status of Regulation/
Title/
Agency
Hospice Services
ACTION: Final Rule
NOTICE: Requirements for Longterm
Care Facilities: Hospice
Services
AGENCY: CMS
Notice of Denial of Medical
Coverage (or Payment)
ACTION: Request for comment
NOTICE: Notice of Denial of
Medical Coverage (or Payment)
AGENCY: CMS, HHS
Efficiency, Transparency, and
Burden Reduction
ACTION: Proposed Rule
NOTICE: Part II--Regulatory
Provisions to Promote Program
Efficiency, Transparency, and
Burden Reduction
AGENCY: CMS, HHS
High-Risk Pool Eligibility
ACTION: Interim Final Rule
NOTICE: Pre-Existing Condition
Insurance Plan Program
AGENCY: OCIIO
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
Dates (Issue, Due, File,
Subsequent Action)
CMS-3140-F Issue Date: [Pending at OMB as
of 9/14/2012]
Due Date:
NIHB File Date:
Date of Subsequent Agency
Action, if any:
CMS-10003 Issue Date: 9/7/2012
Due Date: 11/6/2012
TTAG / NIHB File Date:
11/6/2012
Date of Subsequent Agency
Action, if any:
CMS-1367-P Issue Date:
[Pending at OMB since
8/2/2012]
Due Date:
NIHB File Date:
Date of Subsequent Agency
Action, if any:
OCIIO-9995-
IFC
Section III: Health Reform
Issue Date: 7/30/2010
Due Date: 9/28/2010
NIHB File Date: 9/28/2010
Date of Subsequent Agency
Action, if any: None as of
4/15/2012
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action:
NIHB analysis of
action: None.
Summary of Agency
action: √
TTAG / NIHB analysis
of action: [To be
entered.]
Summary of Agency
action:
NIHB analysis of
action:
Summary of Agency
action: √
NIHB analysis of
action: √
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
TTAG / NIHB recommendations
included: [To be entered.]
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included: √
Subsequent Agency action: none
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 23 of 38 11/12/2012

RRIAR
Ref.
#
6.b.
6.c.
7.a.
Short Title/
Current Status of Regulation/
Title/
Agency
Pre-Existing Condition Insurance
Plan Program
ACTION: Interim Final Rule
NOTICE: Pre-Existing Condition
Insurance Plan Program
AGENCY: CMS
Pre-Existing Condition Insurance
Plan Authorization
ACTION: Request for Comment
NOTICE: : PCIP Authorization to
Share Personal Health Information
AGENCY: CMS
ACA Exchange Rules
ACTION: Request for Comment
NOTICE: Planning and
Establishment of State-Level
Exchanges; RfC Exchange-Related
Provisions in Title I of the ACA
AGENCY: OCIIO
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
CMS-9995-
IFC2
Dates (Issue, Due, File,
Subsequent Action)
Issue Date: 8/30/2012
Due Date: 10/29/2012
NIHB File Date: None.
Date of Subsequent Agency
Action, if any:
CMS-10428 Issue Date: 9/21/2012
Due Date: 10/22/2012
NIHB File Date: None.
Date of Subsequent Agency
Action, if any:
CIIO-9989-NC
HHS-0S-2010-
0021-0001
Issue Date: 8/3/2010
Due Date: 10/4/2010
NIHB File Date: 10/4/2010
Date of Subsequent Agency
Action, if any: 7/15/2011 (see
7.b.)
Additional: Issued Tribal
Sponsorship and Indian
Addendum 4/13/11
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: [To be
entered.]
NIHB analysis of
action:
Summary of Agency
action: [To be
entered.]
NIHB analysis of
action:
Summary of Agency
action: √
NIHB analysis of
action: √
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included: √
Subsequent Agency action: √
(Partial previously √)
Analysis of Agency action: √
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 24 of 38 11/12/2012

RRIAR
Ref.
#
7.b.
7.c.
7.d.
Short Title/
Current Status of Regulation/
Title/
Agency
Establishment of Exchange/QHP
ACTION: Proposed Final/Interim
Final Rule
NOTICE: Establishment of
Exchanges/ Qualified Health Plans,
Part 1
AGENCY: HHS
Exchange: Eligibility
Determinations
ACTION: Proposed Final Rule
NOTICE: Exchange Functions:
Eligibility Determinations; Employer
Standards
AGENCY: HHS
Definition of Indian, Supplement
to CMS-9989, 9974, 2349, and IRS
REG-131491
ACTION: Proposed Rule
NOTICE: Cross-reg. response
AGENCY: HHS and Treasury
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
CMS-9989-PF
(with item 7.c.:
CMS-9974-F)
CMS-9974-PF
(see item 7.b:
CMS-9989-F)
CMS-9989-P,
CMS-9974-P,
CMS-2349-P,
and IRS REG-
131491 (see
7.b. and c.)
Dates (Issue, Due, File,
Subsequent Action)
Issue Date: 7/15/2011
Due Date: 10/31/2011
NIHB File Date: 10/31/2011
Date of Subsequent Agency
Action, if any: 3/27/2012; issued
correction 5/29/2012
Due Date for Interim Final Rule
Comments: 5:00 pm, 5/11/2012
Issue Date: 8/12/2011
Due Date: 10/31/2011
NIHB File Date: 10/31/2011
Date of Subsequent Agency
Action, if any: Issued Final Rule
3/27/2012
Issue Date: 8/12/2011
Due Date: 10/31/2011
NIHB File Date: 10/31/2011
Date of Subsequent Agency
Action, if any: Issued Final Rule
3/27/2012
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: √
NIHB analysis of
action: √
Summary of
subsequent Agency
action: √
Summary of Agency
action: √
NIHB analysis of
action: √
Summary of Agency
action: √
NIHB analysis of
action: √
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included: √
Subsequent Agency action: √
Analysis of Agency action: √
NIHB IF recommendations included:
None filed.
NIHB recommendations included: √
Subsequent Agency action: √
Analysis of Agency action: √
NIHB recommendations included: √
Subsequent Agency action: √ (partial)
Analysis of Agency action: Entered,
in part.
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 25 of 38 11/12/2012

RRIAR
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#
7.e.
7.f.
7.g.
12.a.
Short Title/
Current Status of Regulation/
Title/
Agency
Exchange: Cooperative
Agreements
ACTION: Request for comment
NOTICE: Cooperative Agreement
to Support Establishment of the
Affordable Care Act’s Health
Insurance Exchanges
AGENCY: HHS
Exchange: Blueprint Application
ACTION: Request for comment
NOTICE: Cooperative Agreement
to Support Establishment of the
Affordable Care Act’s Health
Insurance Exchanges
AGENCY: HHS
Exchange: General Guidelines
ACTION: Request for comment
NOTICE: General Guidance on
Federally-Facilitated Exchanges
AGENCY: HHS
Co-Op Plans (Sec. 1322 of ACA)
ACTION: Request for comment
NOTICE: Planning and
Establishment of Consumer
Operated and Oriented Plan
Program
AGENCY: OCIIO, HHS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
CMS-10424
CMS-10415
CMS (no
reference
number)
OCIIO-9983-
NC
RIN 0950-
AA19
Dates (Issue, Due, File,
Subsequent Action)
Issue Date: 5/18/2012
Due Date: 6/18/2012
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
Issue Date: 11/10/2011
Due Date: 1/10/2012
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
Issue Date: 5/16/2012
Due Date:
NIHB File Date: 6/18/2012
Date of Subsequent Agency
Action, if any:
Issue Date: 2/2/2011
Due Date: 3/4/11
NIHB File Date: None
Date of Subsequent Agency
Action, if any: See 12.b.
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action: √
NIHB analysis of
action: To be entered.
Summary of Agency
action: √
NIHB analysis of
action: √
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included: To
be entered.
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included: No
recommendations submitted (NIHB
issued paper prepared 4/12/11).
Subsequent Agency action: √
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 26 of 38 11/12/2012

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Ref.
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12.b.
14.
15.
27.a
Short Title/
Current Status of Regulation/
Title/
Agency
Co-Op Plans (Sec. 1322 of ACA)
ACTION: Proposed Final Rule
NOTICE: Establishment of
Consumer Operated and Oriented
Plan (CO-OP) Program
AGENCY: OCIIO, HHS
ACA Waivers for State
Innovation
ACTION: Proposed Final Rule
NOTICE: Application, Review, and
Reporting Process for Waives for
State Innovation Under Sec. 1332
AGENCY: CMS/Treasury
Delegation of Authority to CMS
ACTION: Notice / Effective
Immediately
NOTICE: Office of the Secretary:
Delegation of Authority; CMS
AGENCY: HHS
Risk Adjustment Standards in
ACA
ACTION: Proposed Final Rule
NOTICE: ACA; Standards Related
to Reinsurance, Risk Corridors and
Risk Adjustment
AGENCY: HHS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
OCIIO-9983-P
F
CMS-9987-PF
RIN 0938-
AQ75
FR 13553-01
76 FR 13618
DOCID:
fr14mr11-74
Dates (Issue, Due, File,
Subsequent Action)
Issue Date: 7/20/2011
Due Date: 5:00pm, 9/16/2011
NIHB File Date: 9/16/2011
Date of Subsequent Agency
Action, if any: 12/13/2011
Issue Date: 3/14/2011
Due Date: 5/13/2011
NIHB File Date: 5/13/2011
Date of Subsequent Agency
Action, if any: Issued Final Rule
2/27/2012
Issue Date: 3/14/2011
Due Date: None
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
CMS-9975-PF Issue Date: 7/15/2011
Due Date: 10/31/2011 (revised)
NIHB File Date: 9/27/2011
Date of Subsequent Agency
Action, if any: Issued Final Rule
3/23/2012; issued correction
5/17/2012
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: √
NIHB analysis of
action: √
Summary of Agency
action: √
NIHB analysis of
action: √
Summary of Agency
action: √
NIHB analysis of
action: No response
provided.
Summary of Agency
action: √
NIHB analysis of
action: √
Summary of
Subsequent Agency
action: √
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included: √
Subsequent Agency action: √
Analysis of Agency action: √
NIHB recommendations included: √
Subsequent Agency action: √
Analysis of Agency action: To be
entered.
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included: √
Subsequent Agency action: √
Analysis of Agency action: √
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 27 of 38 11/12/2012

RRIAR
Ref.
#
29.
31.a.
31.b.
31.c.
Short Title/
Current Status of Regulation/
Title/
Agency
Premium Subsidies and Tax
Credits
ACTION: Proposed Final Rule
NOTICE: Health Insurance
Premium Tax Credit
AGENCY: IRS, Treasury
Essential Health Benefits Bulletin
ACTION: Request for comment
NOTICE: Essential Health Benefits,
HHS Informational Bulletin
AGENCY: HHS
Preventive Health Services
ACTION: Interim Final Rule
NOTICE: Group Health Plans and
Health Insurance Issuers Relating
to Coverage of Preventive Services
AGENCY: HHS/IRS/DoL
Certain Preventive Services
ACTION: Advanced Notice of
Proposed Rule Making
NOTICE: Certain Preventive Health
Services under the ACA
AGENCY: HHS/ IRS/DoL
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
IRS REG-
131491
No reference
number
CMS-9992-
IFC2
CMS-9968-
ANPRM
Dates (Issue, Due, File,
Subsequent Action)
Issue Date: 8/12/2011
Due Date: 10/31/2011
NIHB File Date: 10/31/2011
Date of Subsequent Agency
Action, if any: 5/23/2012
Issue Date: 12/16/2011
Due Date: 1/31/2012
NIHB File Date: 1/31/2012
Date of Subsequent Agency
Action, if any: CMS issued FAQ
on EHB 2/17/2012
Issue Date: 7/19/2010; 8/3/2011
NIHB File Date: None
Date of Subsequent Agency
Action, if any: Issued Bulletin
2/10/2012
Issue Date: 3/21/2012
Due Date: 6/19/2012
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: √
NIHB analysis of
action: √
Summary of Agency
action: √
NIHB analysis of
action: √
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action: √
NIHB analysis of
action: None.
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included: √
Subsequent Agency action: √
Analysis of Agency action: To be
prepared and entered.
NIHB recommendations included: √
Subsequent Agency action: √ (partial)
Analysis of Agency action: To be
entered.
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 28 of 38 11/12/2012

RRIAR
Ref.
#
31.d.
33.
37.
38.
Short Title/
Current Status of Regulation/
Title/
Agency
Standards Related to Essential
Health Benefits
ACTION: Proposed Rule
NOTICE: Exchanges Part II—
Standards Related to Essential
Health Benefits; Health Insurance
Issuer and Exchange
Responsibilities
AGENCY: CMS
Citizenship Documentation
ACTION:
NOTICE:
AGENCY: CMS
Performance Metrics for
Medicaid and Exchange
Eligibility & Enrollment
ACTION:
NOTICE:
AGENCY: CMS
Appeals
ACTION:
NOTICE:
AGENCY: CMS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
CMS-9980-P
Dates (Issue, Due, File,
Subsequent Action)
Issue Date: [Pending at OMB as
of 11/8/2012]
Due Date:
NIHB File Date:
Date of Subsequent Agency
Action, if any:
CMS-[TBD] Issue Date: [TBD]
Due Date: [TBD]
NIHB File Date:
Date of Subsequent Agency
Action, if any:
CMS-[TBD] Issue Date: [TBD]
Due Date: [TBD]
NIHB File Date:
Date of Subsequent Agency
Action, if any:
CMS-[TBD] Issue Date: [TBD]
Due Date: [TBD]
NIHB File Date:
Date of Subsequent Agency
Action, if any:
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action:
NIHB analysis of
action:
Summary of Agency
action:
NIHB analysis of
action:
Summary of Agency
action:
NIHB analysis of
action:
Summary of Agency
action:
NIHB analysis of
action:
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 29 of 38 11/12/2012

RRIAR
Ref.
#
39.
42.
45.
47.
Short Title/
Current Status of Regulation/
Title/
Agency
Basic Health Program
ACTION: Request for Information
NOTICE: State Flexibility to
Establish a Basic Health Program
under the ACA
AGENCY: CMS
Employer Minimum Value
Standard
ACTION:
NOTICE:
AGENCY: CMS/DoL
Actuarial Value and Cost-Sharing
ACTION: Pre-Rule Bulletin
NOTICE: Draft Actuarial Value and
Cost-Sharing Reductions Bulletin
AGENCY: CMS
HSA Eligibility and IHS
Beneficiaries
ACTION: Proposed Rule
NOTICE: Health Savings Accounts
Eligibility and IHS Beneficiaries
AGENCY: Treasury/IHS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
Dates (Issue, Due, File,
Subsequent Action)
CMS-9980-NC Issue Date: 9/14/2011
Due Date: 5:00 pm, 10/31/2011
NIHB File Date: 10/31/2011
Date of Subsequent Agency
Action, if any: None as of
4/30/2012
CMS
RIN-0938-
ZB08
Notice 2012-14
Issue Date: [TBD]
Due Date: [TBD]
NIHB File Date:
Date of Subsequent Agency
Action, if any:
Issue Date: Post-2/24/2012
Due Date: None
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
Issue Date: 2/2012
Due Date: 4/30/2012
NIHB File Date: 4/30/2012
Date of Subsequent Agency
Action, if any:
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: √
NIHB analysis of
action: √
Summary of Agency
action:
NIHB analysis of
action:
Summary of Agency
action: √
NIHB analysis of
action: √
Summary of Agency
action: √
NIHB analysis of
action: √
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included: √
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included: √
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 30 of 38 11/12/2012

RRIAR
Ref.
#
48.
50.b.
51.
53.
Short Title/
Current Status of Regulation/
Title/
Agency
Medical Loss Ratio
Requirements
ACTION: Final Rule
NOTICE: Medical Loss Ratio
Requirements under the Affordable
Care Act--Notice Requirements
AGENCY: CMS
EHB and QHP Standards
ACTION: Proposed Final Rule
NOTICE: Data Collection to Support
Standards Related to Essential
Health Benefits; Recognition of
Entities for the Accreditation of
Qualified Health Plans
AGENCY: CMS
Student Insurance Coverage
ACTION: Final Rule
NOTICE: Student Health Insurance
AGENCY: CMS
Certificates of Exemption
ACTION:
NOTICE:
AGENCY: CMS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
Dates (Issue, Due, File,
Subsequent Action)
CMS-9998-F Issue Date: 5/16/2012
Due Date: None
NIHB File Date: None
Date of Subsequent Agency
Action, if any: Issued correction
5/17/2012
CMS-9965-PF Issue Date: 6/5/2012
Due Date: 7/5/2012
NIHB File Date: None
Date of Subsequent Agency
Action, if any: Issued Final Rule
7/20/2012
CMS-9981-F Issue Date: 3/21/2012
Due Date:
NIHB File Date:
Date of Subsequent Agency
Future
issuance
referenced in
CMS-9989-F
Action, if any:
Issue Date: [TBD]
Due Date:
NIHB File Date:
Date of Subsequent Agency
Action, if any:
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: √
NIHB analysis of
action: None.
Subsequent Agency
action: √
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action: √
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action:
NIHB analysis of
action:
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 31 of 38 11/12/2012

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#
54.
56.
63.
64.
Short Title/
Current Status of Regulation/
Title/
Agency
ESI Coverage Verification
ACTION: Notice
NOTICE: Employer-Sponsored
Coverage Verification: Preliminary
Informational Statement
AGENCY: CMS
Stop-Loss Insurance
ACTION: Request for Information
NOTICE: Request for Information
AGENCY: CMS/IRS/DoL
Health Care EFT Standards
ACTION: Interim Final Rule with
Request for Comment
NOTICE: Administrative
Simplification: Adoption of
Operating Rules for Health Care
Electronic Funds Transfers (EFT)
and Remittance Advice Trans.
AGENCY: HHS
Policy on Conferring with Urban
Indian Organizations
ACTION: Request for comment
NOTICE: Draft Policy on Conferring
With Urban Indian Organizations
AGENCY: IHS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
CMS
RIN: 0938-
ZB09
Dates (Issue, Due, File,
Subsequent Action)
Issue Date: [OMB approved
4/26/2012]
Due Date:
NIHB File Date:
Date of Subsequent Agency
Action, if any:
CMS-9967-NC Issue Date: 5/1/2012
Due Date: 7/2/2012
NIHB File Date: None
Date of Subsequent Agency
HHS
RIN 0938-
AR01
No reference
number
Action, if any:
Issue Date: 8/10/2012
Due Date: 10/9/2012
NIHB File Date: None.
Date of Subsequent Agency
Action, if any:
Issue Date: 7/16/2012
Due Date: 9/10/2012
NIHB File Date: None.
Comments filed by NCUIH and
ANTHC.
Date of Subsequent Agency
Action, if any:
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action:
NIHB analysis of
action:
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action: √
ANTHC and NCUIH
analysis of action: [To
be entered.]
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included: [To
be entered.]
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 32 of 38 11/12/2012

RRIAR
Ref.
#
65.
67.
68.
Short Title/
Current Status of Regulation/
Title/
Agency
Health Care Reform Insurance
Web Portal Requirements
ACTION: Request for comment
NOTICE: Health Care Reform
Insurance Web Portal
Requirements
AGENCY: CMS
State Consumer Assistance
Grants
ACTION: Request for Information
NOTICE: Revision of a currently
approved collection; Consumer
Assistance Program Grants
AGENCY: CMS
Security of Electronic Health
Information
ACTION: Request for comment
NOTICE: Health Insurance Reform:
Electronic Security Standards
AGENCY: CMS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
Dates (Issue, Due, File,
Subsequent Action)
CMS-10320 Issue Date: 8/15/2012
Due Date: 9/13/2012
NIHB File Date: 9/13/2012
Date of Subsequent Agency
Action, if any:
CMS-10333 Issue Date: 7/27/2012
Due Date: 9/25/2012
NIHB File Date: None.
Date of Subsequent Agency
Action, if any:
CMS-10149 Issue Date: 8/31/2012
Due Date: 10/30/2012
NIHB File Date: None.
Date of Subsequent Agency
Action, if any:
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: √
NIHB analysis of
action: √
Summary of Agency
action: √
NIHB analysis of
action:
Summary of Agency
action: √
NIHB analysis of
action:
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included: [To
be entered.]
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 33 of 38 11/12/2012

RRIAR
Ref.
#
69.
77.
88.
Short Title/
Current Status of Regulation/
Title/
Agency
Data Elements for Exchange
Application
ACTION: Request for Information
NOTICE: Data Collection to
Support Eligibility Determinations
for Insurance Affordability
Programs and Enrollment through
Affordable Insurance Exchanges,
Medicaid and Children’s Health
Insurance Program Agencies
AGENCY: CMS
Unique Plan Identifiers
ACTION: Final Rule
NOTICE: Adoption of a Standard
for a Unique Health Plan Identifier;
Addition to the National Provider
Identifier Requirements; and a
Change to the Compliance Date for
the ICD-10 Medical Data Code Sets
AGENCY: CMS
Early Retiree Reinsurance
Program Survey
ACTION: Request for Comment
NOTICE: Early Retiree
Reinsurance Program Survey of
Plan Sponsors
AGENCY: CMS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
CMS-10440
and CMS-
10438
CMS-0040-F
CMS-0040-CN
Dates (Issue, Due, File,
Subsequent Action)
Issue Date: 7/6/2012
Due Date: 9/4/2012
NIHB File Date: 9/4/2012
Date of Subsequent Agency
Action, if any:
Issue Date: 9/5/2012
Due Date: None
NIHB File Date: None
Date of Subsequent Agency
Action, if any: Issued correction
10/4/2012
CMS-10408 Issue Date: 9/28/2012
Due Date: 11/27/2012
NIHB File Date: Under review.
Date of Subsequent Agency
Action, if any:
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: √
NIHB analysis of
action: √
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action: [To be
entered.]
NIHB analysis of
action:
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included: √
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 34 of 38 11/12/2012

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Ref.
#
89.
90.
91.
Short Title/
Current Status of Regulation/
Title/
Agency
Notice of Benefit and Payment
Parameters for 2014
ACTION: Proposed Rule
NOTICE: Patient Protection and
Affordable Care Act Notice of
Benefit and Payment Parameters
for 2014
AGENCY: CMS
Adverse Benefit Determinations
ACTION: Guidance
NOTICE: Adverse Benefit
Determinations and Final Internal
Adverse Benefit Determinations for
Beneficiaries in Non-Federal
Governmental Health Plans
AGENCY: CCIIO
Waiting Period Limitation Under
Public Health Service Act
ACTION: Guidance
NOTICE: Guidance on 90-Day
Waiting Period Limitation under
Public Health Service Act
AGENCY: CCIIO
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
Dates (Issue, Due, File,
Subsequent Action)
CMS-9964-P Issue Date: TBD
Due Date:
NIHB File Date:
Date of Subsequent Agency
Action, if any:
CCIIO (no
reference
number)
CCIIO (no
reference
number)
Issue Date: 8/17/2012
Due Date: None
NIHB File Date:
Date of Subsequent Agency
Action, if any:
Issue Date: 8/31/2012
Due Date: 9/30/2012
NIHB File Date: None.
Date of Subsequent Agency
Action, if any:
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action:
NIHB analysis of
action:
Summary of Agency
action:
NIHB analysis of
action:
Summary of Agency
action:
NIHB analysis of
action:
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 35 of 38 11/12/2012

RRIAR
Ref.
#
92.
35.
36.
74.
Short Title/
Current Status of Regulation/
Title/
Agency
Health Insurance Market Rules
ACTION: Proposed Rule
NOTICE: Patient Protection and
Affordable Care Act Health
Insurance Market Rules
AGENCY: CMS
Medical Child Support
ACTION:
NOTICE:
AGENCY: CMS
Transitional Medical Assistance
ACTION:
NOTICE:
AGENCY: CMS
Beat Down Blood Pressure
Challenge
ACTION: Notice
NOTICE: Announcement of
Requirements and Registration for
Beat Down Blood Pressure
Challenge
AGENCY: ONC, HHS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
Dates (Issue, Due, File,
Subsequent Action)
CMS-9972-P Issue Date: [Pending at OMB as
of 11/8/2012]
Due Date:
NIHB File Date:
Date of Subsequent Agency
Action, if any:
Section IV: Other
CMS-[TBD] Issue Date: [TBD]
Due Date: [TBD]
NIHB File Date:
Date of Subsequent Agency
Action, if any:
CMS-[TBD] Issue Date: [TBD]
Due Date: [TBD]
NIHB File Date:
Date of Subsequent Agency
Action, if any:
ONC (no Issue Date: 3/23/2012
reference Due Date: None
number) NIHB File Date: None
Date of Subsequent Agency
Action, if any:
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action:
NIHB analysis of
action:
Summary of Agency
action:
NIHB analysis of
action:
Summary of Agency
action:
NIHB analysis of
action:
Summary of Agency
action: √
NIHB analysis of
action: None.
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 36 of 38 11/12/2012

RRIAR
Ref.
#
75.
76.
82.
93.
Short Title/
Current Status of Regulation/
Title/
Agency
Indian Tribal Government Plan
ACTION: Request for comment
NOTICE: Determination of
Governmental Plan Status
AGENCY: IRS
Tribal Self-Governance Program
ACTION: New-Limited
Competition
NOTICE: Funding Opportunity:
Tribal Self-Governance Program;
Planning Cooperative Agreement
AGENCY: IHS
HIPAA Rules
ACTION: Final Rule
NOTICE: Modifications to the
HIPAA Privacy, Security,
Enforcement, and Breach
Notification Rules
AGENCY: Office of Civil Rights,
HHS
New Freedom Initiative
ACTION: Request for Comment
NOTICE: New Freedom Initiative—
Web-based Reporting System for
Grantees
AGENCY: CMS
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
IRS REG-
133223-08
HHS-2012-
IHS-TSGP-
0001
HHS
RIN 0945-
AA03
Dates (Issue, Due, File,
Subsequent Action)
Issue Date: 3/8/2012
Due Date: 6/2012
NIHB File Date: None
Date of Subsequent Agency
Action, if any:
Issue Date: 8/8/2012
Due Date: 9/9/2012
NIHB File Date: None.
Date of Subsequent Agency
Action, if any:
Issue Date: [Pending at OMB
since 3/24/2012]
Due Date:
NIHB File Date:
Date of Subsequent Agency
Action, if any:
CMS-10161 Issue Date: 9/28/2012
Due Date: 10/29/2012
NIHB File Date: None.
Date of Subsequent Agency
Action, if any:
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action: √
NIHB analysis of
action: None.
Summary of Agency
action:
NIHB analysis of
action:
Summary of Agency
action: [To be
entered.]
NIHB analysis of
action:
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 37 of 38 11/12/2012

RRIAR
Ref.
#
94.
95.
96.
97.
Short Title/
Current Status of Regulation/
Title/
Agency
Methodology for Designation of
Frontier and Remote Areas
ACTION: Request for Comment
NOTICE: Methodology for Design.
of Frontier and Remote Areas
AGENCY: HRSA
Indian Health Service Forms to
Implement the Privacy Rule
ACTION: Request for Comment
NOTICE: IHS Forms to Implement
Privacy Rule (45 CFR Parts 160;
164)
AGENCY: IHS
IHS New System of Records
ACTION: Notice
NOTICE: Privacy Act of 1974
System of Records
AGENCY: IHS
Federal Employees Health
Benefits Program Coverage
ACTION: Interim Final Rule
NOTICE: Federal Employees
Health Benefits Program Coverage
for Certain Intermittent Employees
AGENCY: OPM
TABLE A: REGULATIONS INCLUDED TO DATE IN RRIAR TABLES B AND C
UPDATED THROUGH 11/9/2012
File Code
HRSA (no
reference
number)
IHS-810, 912-
1, 912-2, 913,
and 917
IHS (no
reference
number)
OPM
RIN 3206-
AM74
Dates (Issue, Due, File,
Subsequent Action)
Issue Date: 11/5/2012
Due Date: 1/4/2013
NIHB File Date: Under review.
Date of Subsequent Agency
Action, if any:
Issue Date: 10/2/2012
Due Date: 60 days (approx.
11/30/2012)
NIHB File Date: Under review.
Date of Subsequent Agency
Action, if any:
Issue Date: 10/29/2012
Due Date: 12/13/2012
NIHB File Date: Under review.
Date of Subsequent Agency
Action, if any:
Issue Date: [Approved by OMB
as of 11/6/2012]
Due Date:
NIHB File Date:
Date of Subsequent Agency
Action, if any:
In Table B--
Is the summary of
Agency action
included?
Is the NIHB analysis
included?
Summary of Agency
action:
NIHB analysis of
action:
Summary of Agency
action:
NIHB analysis of
action:
Summary of Agency
action:
NIHB analysis of
action:
Summary of Agency
action:
NIHB analysis of
action:
In Table C--
Is the list of NIHB
recommendations included?
Has the Agency taken subsequent
action?
Is an analysis of subsequent
Agency action included?
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
NIHB recommendations included:
Subsequent Agency action:
Analysis of Agency action:
: regulation review complete : regulation currently under review : regulation release pending
National Indian Health Board, Regulation Review and Impact Analysis Report Page 38 of 38 11/12/2012

Mr. John n J. O'Brien
Director, , Healthcare and Insuran nce
U.S. Offi ice of Person nnel Manage ement
1900 E Street, S NW, Room R 5532B B
Washing gton, DC 204 415-0001
Re: NIHB N Comm ments on Draf ft Multi-Stat te Plan Proggram
Applicaation
Dear Mr. . O'Brien:
On behal lf of the National
Indian n Health Bo oard
Office of f Personnel Managemen M t (OPM) Dra
comment ts are provid ded below as s well as in th
1 , I am wwriting
to suubmit
commments
on thee
U.S.
aft 2014 Muulti-State
Plaan
Program AApplication.
. Our
he attached ccomment
temmplate.
The Mul lti-State Plan n Program (Program) ( will w be criticcally
importtant
to ensurre
that Ameerican
Indians and a Alaska Natives N (AI/ /ANs) are ab ble to accesss
affordable health insurrance
througgh
the
Affordab ble Insurance e Exchanges s (Exchanges s). As discuussed
below, , AI/ANs haave
a federal right
to health care at no cost c to them through the e Indian Heaalth
Service, Tribes and Tribal progrrams,
and urban
Indian org ganizations (collectively
( , the I/T/U oof
the Indiann
health systtem).
Becauuse
of
this, they y are unlikely y to purchas se insurance products onn
the Exchannges
unless tthey
can conntinue
to receive
care at no cost to them m, and do so at the Indiaan
health carre
provider oof
their choicce.
If
they do not particip pate in the Exchanges, E AI/ANs willl
not be abble
to take aadvantage
oof
the
1 Establish
Del livered via electronic e traansmission
Octo ober 22, 20122
hed 40 years ag go, NIHB is an n inter-Tribal organization o thaat
advocates onn
behalf of Triibal
governmennts
for
the provisi ion of quality health h care to all American Indians and AAlaska
Natives. . NIHB is govverned
by a Booard
of
Directors consisting c of a representative
from each of
the twelve Inndian
Health SService
(“IHS” ”) Areas. Eachh
Area
Health Boa ard elects a rep presentative to o sit on the NIH HB Board of DDirectors.
In arreas
where theere
is no Area HHealth
Board, Tri ibal governme ents choose a representative who communnicates
policy information aand
concerns of the
Tribes in that area with h NIHB. Whe ether Tribes op perate their enntire
health caare
program tthrough
contraacts
or
compacts with IHS und der Public La aw 93-638, th he Indian Selff-Determinatioon
and Educattion
Assistancce
Act
(“ISDEAA A”), or continue e to also rely on o IHS for deli ivery of some, or even most, of their healthh
care, NIHB iis
their
advocate

premium tax credit assistance and cost-sharing exemptions Congress intended would be made
available to improve health care outcomes for AI/AN people.
To overcome this financial barrier to meaningful AI/AN access to the Exchanges, Tribal entities
may choose to pay all or part of the premiums on behalf of designated AI/AN individuals.
Tribes and Tribal organizations will be hesitant to do so unless the plans on the Exchanges are
open to allowing them to make aggregated premium payments on behalf of their members, and
the plans offer to include Indian health care providers in their provider networks. In addition,
based on the successful experience under the Medicare Part D Program, we have found the use
of a standard contract addendum that addresses Indian-specific issues to be critical to successful
contracting by health plans with Indian health care providers. Our comments focus on designing
the Program application criteria to ensure that the Multi-State Plans (MSPs) selected by OPM
will allow Tribal entities to implement this solution for AI/AN people.
Our comments request that the application criteria OPM establishes for the Program encourage
MSP applicants to (1) demonstrate how they will offer to include Indian healthcare providers in
their provider networks, (2) agree to use a standard contract addendum when contracting with
Indian health care providers, and (3) allow Tribes, Tribal organizations and urban Indian
organizations to make aggregated group payments of premiums on behalf designated individuals
to the MSPs. These requests are consistent with the guidance provided by CMS in its Final
Exchange Establishment Rule, “Patient Protection and Affordable Care Act; Establishment of
Exchanges and Qualified Health Plans,” 77 Fed. Reg. 18346 (March 27, 2012), and with ongoing
efforts by the CMS Center for Consumer Information and Insurance Oversight (CCIIO) to
draft and issue a standard Indian addendum, thereby facilitating and encouraging Qualified
Health Plans (QHPs) to contract with Indian health care providers. For OPM to foster these
three measures (i.e., MSP contracting with Indian health care providers, use of a standard Indian
addendum, and group payment of premiums on behalf of AI/ANs) is also fully consistent with
advancing the Federal trust responsibility.
OPM Has a Continuing Federal Trust Responsibility to Enable Meaningful AI/AN Access to
the Federal Health Care Programs It is Charged with Administering
The Federal government’s trust responsibility to provide health care services to Tribes originates
in treaties and other agreements between Tribes and the United States, and has been consistently
reaffirmed in numerous Acts of Congress, Executive Orders, regulations, and the ongoing course
of dealings between the Federal government and Indian Tribal governments. The most recent
reaffirmation of the unique responsibility was included in the 2010 amendments to the Indian
Health Care Improvement Act in which Congress declared:
“Congress declares that it is the policy of this Nation, in fulfillment
of its special trust responsibilities and legal obligations to Indians--
(a) to ensure the highest possible health status for Indians
National Indian Health Board Page 2 of 7 October 22, 2012

and urban Indians and to provide all resources necessary to effect
that policy . . .” 2 .
Although the Federal trust responsibility to provide health care to AI/ANs has been carried out in
recent years by the Indian Health Service (as well as Tribes and Tribal organizations, operating
under the Indian Self-Determination and Education Assistance Act (ISDEAA)), this
responsibility is not limited to the Indian Health Service. Rather, it applies to the Federal
government as a whole, and to each agency charged with administering federal health care
programs.
OPM has demonstrated itself as a model agency in administering the Federal trust responsibility
in its implementation of the Federal Employees Health Benefits (FEHB) program option for
Tribes. OPM's commitment to Tribal consultation and the resources required to getting the
program up and running and available to Tribes across the country is to be commended. We
hope that OPM will continue to administer the Federal trust responsibility in the Program with
the same level of commitment, Tribal consultation and collaboration it has demonstrated with the
FEHB program.
The Unique Nature of the Indian Health System Creates Barriers to Accessing Exchange
Benefits for American Indians and Alaska Natives
American Indians and Alaska Natives have a right to health care at no cost to them, and AI/ANs
who seek services from IHS and Tribal providers do not pay for those services directly.
Consistent with the Federal trust responsibility, Congress has enacted laws that ensure that
AI/ANs are not charged for participating in other federal health care programs. In Medicaid,
CHIP and the Exchanges 3 , for example, there are no deductibles or co-pays for AI/ANs.
Similarly, the ACA provides that AI/ANs are not subject to the penalties for failing to obtain
insurance.
Because AI/ANs can obtain care at no cost to themselves through the I/T/U, AI/ANs will be
hesitant to purchase health insurance through the Exchanges. Yet Congress clearly intended
Exchange coverage to be an additional vehicle for providing additional resources to the Indian
health care system, and Congress encouraged AI/ANs to participate in the Exchange program
when it exempted most AI/ANs from cost-sharing in the Exchanges.
The Congressional Budget Office (CBO) estimates that the premium exchange subsidies for
qualified individuals will total $1,017 billion over the 2012-2022 period. We estimate as many
as 510,000 AI/ANs will qualify for exchange subsidies as their family income falls between 138
and 400 percent of the Federal Poverty Level (FPL). These tax credits are only available through
the Exchanges.
2 25 U.S.C. § 1602.
3 All AI/AN who receive their care through an I/T/U or contract health services are not subject to cost-sharing
through the Exchanges. AI/AN with incomes below 300 percent of the Federal Poverty Level who receive care
from any other provider are similarly exempt from cost-sharing in the Exchanges.
National Indian Health Board Page 3 of 7 October 22, 2012

Access to this benefit is critically important to the Indian health system, as it will provide access
to the private insurance market that many AI/ANs could not otherwise afford, and create new
third party sources of revenues for I/T/U, which are chronically underfunded with federal
appropriated funds at only 55 percent of need. Without action by OPM and its sister agencies to
remove barriers to access Exchanges by AI/ANs, however, these benefits will likely remain
unclaimed by AI/AN people, and provide no relief to the chronic health care disparities between
AI/ANs and the general population.
OPM Has an Opportunity to Implement the Program to Reduce Barriers to AI/AN Access to
the Exchanges
OPM has a unique opportunity to further reduce impediments to AI/ANs’ timely access to
comprehensive health care services by lowering barriers to Exchange coverage by AI/ANs and in
the process create positive and lasting change in the health care of AI/AN people. As outlined
above, there are three critical steps for achieving this goal: (1) encourage MSPs to contract with
I/T/U; (2) facilitate the use of a standard Indian addendum when contracting with I/T/U; and (3)
require MSPs to accept aggregate payment of premiums on behalf of AI/ANs.
Tribal Sponsorship
Because AI/ANs have little incentive to purchase insurance products on the Exchanges when
they otherwise have a right to free care through the I/T/U system, many Tribes and Tribal
organizations may choose to pay all or part of the unsubsidized portion of the premium payment
on behalf of their members. In the final rule on Exchange establishment, CMS confirmed that an
“Exchange may permit Indian Tribes, Tribal organizations and urban Indian organizations to pay
aggregated QHP [Qualified Health Plan] premiums on behalf of qualified individuals…” 45
C.F.R. § 155.240(b). Similarly, in the Preamble to the Final Rule, CMS stated that “[w]e
encourage Exchanges to include this [Tribal Sponsorship] option as part of its consultation with
Tribal governments.” 77 Fed. Reg. 18310, 18338 (Mar. 27, 2012).
We understand that the MSPs selected by OPM will operate in accordance with the rules of the
Exchange in which they participate. For example, some Exchanges may permit premium
payments from plan enrollees to be made through the Exchange, while others (such as those
operated as Federally-facilitated Exchanges) will require payments to be made directly to the
QHPs themselves. But, as provided for the Affordable Care Act, all Exchange enrollees have the
right to make direct payments to QHPs. Likewise, OPM should ensure that any MSP selected
be willing to permit Tribal entities to make aggregate payments for sponsored AI/ANs in each
Exchange they operate.
Inclusion of I/T/U in MSP Provider Networks
Tribal entities are unlikely to make such premium payments on behalf of their members unless
their Tribal health facilities can fully participate as in-network providers in the MSP provider
networks. Although Section 206 of the Indian Health Care Improvement Act (IHCIA) allows
I/T/U providers to bill health plans for services provided to the plan’s enrollees whether or not
the I/T/U provider is in the plan’s network, it is preferable that the I/T/U be part of a plan’s
network. Section 408 of the IHCIA provides that Federal health care programs like the Multi-
National Indian Health Board Page 4 of 7 October 22, 2012

State Plan Program must accept I/T/Us as in-network providers on the same basis as any other
provider. Including I/T/U in MSP networks will facilitate coordination of care, minimize
duplication of services, and provide greater certainty to the I/T/U providers in the timeliness and
amount of payments. It will also significantly reduce the transaction costs that would be
involved for each I/T/U to enforce its right to payment under Section 206 of the IHCIA.
Accordingly, we request that OPM encourage plans that seek qualification as an MSP to offer to
contract with I/T/U providers in their service areas. Inclusion of I/T/U providers should be
central to demonstrating network adequacy for AI/AN people who are likely to have longstanding
relationships with these providers who provide culturally competent care.
The Draft 2014 Multi-State Plan Program Application (Application) requires MSPs to
“Describe provisions for adequate choice for enrollees who are American
Indians and for ensuring covered services from the Indian Health Service,
as applicable”
in demonstrating the adequacy of their provider networks. The Application also requires MSPs
to
“Describe your approach to ensuring compliance with 45 CFR 156.235,
regarding Essential Community Providers in your network.”
We are encouraged that OPM has proposed to ask potential MSPs to demonstrate their networks
will provide adequate choice for AI/AN enrollees and to ensure continued coverage of services
from the IHS. However, we believe this section of the application must be strengthened and
made more precise if it is to have the desired effect. First, we note that it should cover American
Indians and Alaska Natives, not just American Indians. Second, we note that health care services
to AI/ANs are not only provided by the IHS, but also by Tribes, Tribal organizations and urban
Indian organizations. Third, the only adequate choice for most AI/AN people is their local I/T/U
provider. In many cases in Indian country, the only alternative health care option for AI/AN
people is located hundreds of miles from Tribal population centers, leaving the I/T/U as the only
practical option available. Even in more densely populated areas of the country, the I/T/U offers
the only health care facility providing culturally competent care. Accordingly, because
"adequate choice" for AI/AN people means the I/T/U of their choice, this requirement should be
revised to explicitly require MSP applicants to describe provisions to offer to include I/T/U
providers in their provider networks.
To address these concerns, we recommend that the first of the two provisions above from the
Application be amended, as follows:
Describe provisions for adequate choice for enrollees who are American
Indians or Alaska Natives and for ensuring these enrollees have access to
covered services from the Indian Health Service, Tribal health programs,
and urban Indian health programs, as applicable.
We also note with approval that the draft application would require a plan to demonstrate
compliance with 45 CFR 156.235 regarding essential community providers. I/T/Us are essential
National Indian Health Board Page 5 of 7 October 22, 2012

community providers for purposes of the final Exchange rule, and a “sufficient number and
geographic distribution of essential community providers” must be included in any provider
network for that reason as well.
Use of a Standard Indian Addendum
One impediment for I/T/U providers may be the standard contract language an MSP requires.
Often, the standard contract language offered by health plans contains provisions that are
inconsistent with federal Tribal rights. For example, many such contracts will impose a
requirement that the provider demonstrate it has obtained sufficient insurance. I/T/Us are
generally covered by the Federal Tort Claims Act, however, and should not be required to spend
significant and unnecessary dollars purchasing private insurance that is duplicative of FTCA
coverage simply to enter into a provider contract. Likewise, when health plans are informed of
the applicability of various Indian-specific federal laws, their concerns are often addressed.
The attached Addendum for Indian Health Care Providers has been developed to preemptively
address these issues. It sets out federal laws that apply to provider contracts between I/T/Us and
QHPs. We believe that use of this Indian Addendum will benefit both the plans and the Indian
Health Care Providers by lowering perceived barriers to contracting, assuring compliance by the
MSPs with key federal laws protecting I/T/Us, and minimizing potential disputes.
HHS has recognized the merits of the use of such an Indian Addendum. In the preamble to the
Final Rule on Exchange Establishment, HHS stated that:
We recognize that furnishing QHP issuers with a standard Indian Addendum to a
provider contract may make it easier for QHP issuers to contract with Indian
providers. We note that QHP issuers may not be aware of the various Federal
authorities that govern contracting with Indian health providers, and such an
Addendum may lower the perceived barrier of contracting with Indian providers.
We plan to develop a template for contracting between QHP issuers and Tribal
health care providers. While we do not uniformly mandate that QHP issuers use
the template, we believe that QHP issuers will find it in their interest to adopt
such a template when contracting with Indian providers. We also note that
Exchanges may elect to direct QHP issuers to use the Indian Addendum when
contracting with Indian providers. 77 Fed. Reg. at 18423.
CCIIO, the agency tasked with developing guidance and regulations on the Exchanges, is
currently developing a standard Indian Addendum template. We further understand that CCIIO
is preparing additional guidance that would encourage health plans to offer to contract with I/T/U
using the Indian Addendum. We understand that this guidance may be released soon. We
encourage OPM to ensure that the evaluation criteria OPM sets for the MSPs require or at the
very least encourage plans in the strongest possible terms to offer to contract with I/T/U using
the Indian Addendum. For your reference, we have attached a copy of a guide to the Indian
Addendum we previously provided to CCIIO. Again, we strongly encourage OPM to make the
attached Indian Addendum a part of OPM's 2014 Multi-State Plan Program Application along
with the explanatory guide.
National Indian Health Board Page 6 of 7 October 22, 2012

The MSPs will be of particular importance to AI/ANs and I/T/Us across the country. Ultimately,
the MSPs will be available in every state, regardless of how a state implements their Exchange
and regardless of whether an Exchange is operated by a state or HHS. Consistent with that
Federal trust responsibility, we urge OPM to ensure that any plan that seeks MSP designation be
required to demonstrate how it will offer to contract with the I/T/U using the Addendum as a
condition for participation as an MSP.
Conclusion
The Multi-State Plan Program provides an important opportunity to ensure that AI/AN people
will be able to meaningfully participate in Exchange coverage options and take advantage of the
federal health care funding offered only through the Exchanges. As discussed above and in the
specific recommendations we have made in the attached comments template, we urge OPM to
administer this federal health care program in a way that incentivizes AI/AN participation in the
Exchanges while still allowing them to receiving culturally competent care at the I/T/U provider
of their choice. OPM can accomplish this by requiring the MSPs to offer to enter into network
provider contracts with I/T/Us using the attached Indian addendum, and to allow aggregate
payment of premiums by Tribal entities on behalf of qualified AI/AN individuals.
We appreciate the opportunity to provide comments on OPM's Draft 2014 Multi-State Plan
Program Application. We would like to have further consultation with OPM on the issues raised
in our comments and are available to provide additional information as may be necessary. You
may contact Jennifer Cooper, NIHB Legislative Director at jcooper@nihb.org for further
questions.
cc: Yvette Roubideaux, IHS
Stacy A. Bohlen, NIHB
Susan McNally, OPM
John Cutler, OPM
Gary Cohen, CMS
Peter Nakahata CCIIO
Sincerely Yours,
Cathy Abramson
Chairperson, National Indian Health Board
National Indian Health Board Page 7 of 7 October 22, 2012

November 12, 2012
Centers for Medicare and Medicaid Services
Office of Strategic Operations and Regulatory Affairs
Division of Regulation Development
Department of Health and Human Services
Attention CMS-10445 / OCN: 0938-New
Room C4-26-05
7500 Security Boulevard
Baltimore, MD 21244-1850
Submitted via regulations.gov
RE: Comments of CMS-10445; Survey regarding the Medicare Advantage Quality Bonus Payment
Demonstration
I write on behalf of the National Indian Health Board (NIHB) 1 , to the Centers for Medicare and Medicaid
Services (CMS) regarding the request for comments on CMS-10445 / OCN 0938-New pertaining to the
Paperwork Reduction Act (PRA) Notice on the survey of Medicare Advantage plans regarding the
Medicare Advantage Bonus Payment Demonstration published in the Federal Register on September 17,
2012 (Request for Comments). 2 We appreciate the opportunity to comment on the proposed survey.
We provide below a limited set of recommended additions to the survey.
Background
CMS-10445 requests comments on the survey to be conducted of Medicare Advantage Organizations
(MAOs) as part of an assessment of the MA Bonus Payment Demonstration.
Under the Affordable Care Act (ACA), beginning in 2012, all plans earning four or five stars in Medicare’s
Star Rating program will receive quality bonus payments (QBPs). As an extension of this legislation, CMS
launched the Medicare Advantage Quality Bonus Payment Demonstration, which accelerates the phasein
of QBPs by extending bonus payments to three-star plans and eliminating the cap on blended county
1 Established 40 years ago, NIHB is an inter-Tribal organization that advocates on behalf of Tribal governments for the provision
of quality health care to all American Indians and Alaska Natives. NIHB is governed by a Board of Directors consisting of a
representative from each of the twelve Indian Health Service (“IHS”) Areas. Each Area Health Board elects a representative to
sit on the NIHB Board of Directors. In areas where there is no Area Health Board, Tribal governments choose a representative
who communicates policy information and concerns of the Tribes in that area with NIHB. Whether Tribes operate their entire
health care program through contracts or compacts with IHS under Public Law 93-638, the Indian Self-Determination and
Education Assistance Act (“ISDEAA”), or continue to also rely on IHS for delivery of some, or even most, of their health care,
NIHB is their advocate
2 77 Federal Register 57090, Comment Request, Medicare Advantage Quality Bonus Payment Demonstration, CMS-10445,
September 17, 2012 (http://www.gpo.gov/fdsys/pkg/FR-2012-09-17/html/2012-22726.htm)
Draft NIHB Comments on CMS-10445 Page 1 of 3

enchmarks that otherwise would limit QBPs. Through this demonstration, CMS seeks to understand
how incentive payments impact plan quality across a broader spectrum of plans.
Through a contractor, CMS will conduct a survey of MAOs and as many as 10 case studies of MAOs to
supplement analyses of administrative and financial data for MAOs and environmental and literature
scans. CMS requires this information collection to evaluate the QBP demonstration and better
understand what impact the demonstration has had on MAO operations and their efforts to improve
quality. Researchers will use a survey questionnaire designed to capture information on how MAOs
perceive the demonstration and are planning for or implementing changes in quality initiatives and to
identify factors that help or hinder the capacity to achieve quality improvement and that influence the
decision calculus to make changes. For the case studies, researchers will hold a series of open-ended
discussions with MAO staff guided by a discussion protocol. The case studies will supplement the
information gathered from the survey and data analysis, providing context and details about successful
quality improvement activities.
Analysis
The CMS survey is required of MAOs and will guide CMS in designing quality improvement efforts and
requirements. The survey includes a question about the “main challenges to improving star ratings for
your contract”, and the survey includes a question as to whether quality improvement efforts are
focused on a particular population. The survey does not, though, explicitly query about the efforts
undertaken by MAOs to meet the needs of these particular populations. For instance, and a particular
concern for American Indians and Alaska Natives (AI/ANs), is whether MAOs seek to include culturally
and linguistically competent providers in their networks in order to meet the needs of AI/ANs.
Despite the remote locations of many AI/ANs, and compounded by the relatively low number of AI/ANs
in most MAO service areas, there is typically not a great deal of attention paid to addressing the access
needs of AI/ANs. Including a question in the survey seeking information on whether MAOs focus quality
improvement efforts on particular beneficiary populations should produce useful information, as the
survey currently does. But, the survey should also include a question soliciting information on what
efforts are undertaken to address the needs of these beneficiary populations. Doing so – gathering
information on whether MAOs make efforts to conduct quality improvement efforts with particular
populations as well as identifying what those efforts are – should: 1) provide useful information for
evaluating the Medicare Advantage Quality Bonus Payment Demonstration and 2) stimulate the MAOs
to pay greater attention to these beneficiary populations. Combined, the information will indicate
whether MAOs focus quality improvement efforts on AI/ANs and, if so, what those efforts are.
Recommendations
The proposed survey does seek information (in questions A2. and A2a.) on whether the MAOs focus
quality improvement efforts on particular beneficiary populations.
Recommendation: In question A2a. add the following two options –
Draft NIHB Comments on CMS-10445 Page 2 of 3

_________ American Indian or Alaska Native
_________ Persons with English as a second language
The proposed survey, though, does not include a question or provide an opportunity for survey
respondents to include information on efforts to match particular beneficiary populations with
particular providers that may be most responsive to these beneficiaries’ needs.
Recommendation: Re-label A3 as A4, and adjust all subsequent numbering. Insert the following
new questions as “A3.” and “A3a.”.
A3. Have you worked to contract with providers that have cultural and linguistic competencies
for the particular beneficiary populations you are targeting? _____ Yes ______ No
A3a. If yes, which ones?
_______ Federally-Qualified Health Centers
_______ Indian Health Services or other Indian health care providers
________ [ ]
_______ Other: ________________________________________
Thank you for your attention to these recommendations. We appreciate the opportunity to provide
comment on CMS-10445. We are available to provide additional information as may be necessary to
fully consider our recommendations.
Sincerely Yours,
Cathy Abramson
Chairman, National Indian Health Board
Cc: Marilyn Tavenner, Acting Administrator, CMS
Kitty Marx, Director of Tribal Affairs, CMS
Dr. Yvette Roubideaux, Director, IHS
Stacy Bohlen, Executive Director, NIHB
H. Sally Smith, Chairwomen, MMPC
Draft NIHB Comments on CMS-10445 Page 3 of 3

Dear Governor:
THE SECRETARY OF HEALTH AND HUMAN SERVICES
WASHINGTON, D.C. 20201
November 9,2012
Over the past two years, we have worked together as many of you began building your new
health insurance marketplaces. The hard work you have engaged in has laid the foundation for
providing access to quality affordable coverage for millions of Americans. Consumers in all
fifty states and the District of Columbia will have access to insurance through these new
marketplaces on January 1, 2014, as scheduled, with no delays.
This Administration is committed to providing significant flexibility for building a marketplace
that best meets your state's needs. We intend to issue further guidance to assist you in the very
near future. Funding is now available to you no matter where you are in the process of
establishing an Exchange and no matter whether you plan to run your own Exchange, partner
with another state, or work with the federal government. In response to your request, we
previously announced that states have until the end of2014 to apply for these federal funds and
have the flexibility to use such funds both for building Exchanges and for associated start-up
costs provided that a state's Exchange is not yet self-sustaining. The next application deadline
for Levelland Level 2 Exchange establishment grants is November 15,2012. I encourage you
to take advantage of these additional resources.
As the date approaches for submission of your Blueprint for Approval of State-based and State
Partnership Exchanges, we have heard from many states that additional time would allow you to
submit a more comprehensive, complete Blueprint application for your Exchange.
The deadline for a Declaration Letter for a State-based Exchange remains Friday, November 16,
2012. However, today, in order to continue to provide you with appropriate technical support if
you are pursuing a State-based Exchange, HHS is extending the deadline for State-based
Exchange Blueprint application submissions to Friday, December 14,2012. HHS will approve
or conditionally approve the State-based Exchanges for 2014 by the statutory deadline of January
1,2013.
Additionally, if you are pursuing a State Partnership Exchange, we will accept Declaration
Letters and Blueprint Applications and make approval determinations for State Partnership
Exchanges on a rolling basis. The final deadline for both the Declaration Letter and Blueprint
Application for State Partnership Exchanges that would be effective for 2014 has been extended
to Friday, February 15,2013. And states will be able to apply to run Exchanges in subsequent
years.

November 9, 2012
Page 2
We are committed to providing you with the flexibility, resources, and technical assistance
necessary to help you achieve successful implementation of your state's Exchange and look
forward to continuing to work with you as we implement the health care law.
Sincerely,
Kathleen Sebelius

Tribal Consultation for Health Insurance Exchanges
Survey Questions
Please take a few minutes to fill out this questionnaire for the Tribal Self Governance
Advisory Committee (TSAGC). In December 2012, States will submit their applications,
or “blueprints,” to create a State Health Insurance Exchange or to become partners with
the federal government in operating an Exchange. The federal government will ask
States to explain how they consulted with Tribes in their planning process. We want to
hear the perception of Tribes in every State, so we can compare it with what States are
reporting. If your Tribe is in more than one State, please fill out a separate
questionnaire for each State. We would like your response no later than December 20.
Thank you for assisting us.
1. Name of Tribe: __________________
2. Name of Person Responding to Survey: _______________________
3. Title of Person responding to survey: __________________________
4. E-mail address of person responding to survey: ___________________
5. State where Tribe is located: ___________________
If your Tribe is in more than one State, please fill out a separate questionnaire for
each State.
6. Which kind of Health Insurance Exchange are you expecting to have in your State:
a. State Exchange
b. Federally Exchange
c. Partnership (Federally-Facilitated Exchange with State taking on some
functions)
d. Don’t know
7. Has your Tribe been involved in Tribal Consultation on Exchanges?
a. Yes at the State level
b. Yes at federal level
c. Not involved at either the State or federal level

Tribal Consultation for Health Insurance Exchanges
Survey Questions Page 2
Follow up: What is the main reason you have not been involved?
8. If you wanted to be involved at the State level, do you have the name of a person
working for the State who you could contact?
a. Yes. Please give name: _______________________
b. No.
9. Please check any of the following which describe your State’s Tribal consultation
policy for health insurance exchanges:
a. State has a Tribal consultation policy for the Health Insurance Exchange and
Tribes helped to formulate the policy.
b. State does not have a Tribal consultation policy specifically for Health
Insurance Exchanges, but they have other policies for State government that
require Tribal consultation for planning Exchanges.
c. State is working on a Tribal consultation policy for the Exchange, but it has not
been finalized.
c. State does not have any Tribal consultation policies that cover Exchanges.
d. Don’t know.
10. Has your Tribe been invited to participate in any of the following:
a. Meetings to discuss Health Insurance Exchange planning with Tribes Y/N
b. Meetings to discuss Medicaid Expansion with Tribes. Y/N
c. Individual discussions with Health Insurance Commissioner. Y/N
d. Individual discussions with State planners for Exchange. Y/N
e. State workgroups set up to plan Health Insurance Exchanges. Y/N
f. Membership on the planning or governing body for Exchange. Y/N
11. Has your Tribe been involved in discussions with the State on any of the following
issues related to Health Insurance Exchanges:
a. Essential Health Benefits Y/N

Tribal Consultation for Health Insurance Exchanges
Survey Questions Page 3
b. Indian Addendum and Qualified Health Plan (QHP) networks Y/N
c. Eligibility and enrollment, including identification of American Indians and
Alaska Natives Y/N
d. Tribal sponsorship of premiums for individuals in Exchange Y/N
e. Payment to I/T/U for services provided to enrolled individuals Y/N
f. Design of website Y/N
g. Navigators and in-person assisters Y/N
h. Call centers Y/N
12. How much do you agree with the following Statements:
a. Our State interacts with Tribes as full partners during the design and
implementation of the Health Insurance Exchange.
Strongly agree/Agree/Disagree/Strongly Disagree/ No Answer
b. Tribal consultation on Exchanges has ensured that the Health Insurance
Exchange will meet the needs of Tribes in our State.
13. Other comments:
Strongly agree/Agree/Disagree/Strongly Disagree/ No Answer
Thank you.

Background
Analysis of Tribal Consultation Policies
For Health Insurance Exchanges
Mim Dixon
November 11, 2012
On September 14, 2011, Secretary of Health and Human Services (HHS) Kathleen
Sebelius sent a letter to each State governor regarding Tribal consultation on all health
and human services programs that are supported with federal funding, including Tribal
consultation in the development of health insurance exchange under the Affordable
Care Act (see Attachment A). The Secretary cited the Executive Order on Tribal
Consultation signed by President Obama in 2009, and the HHS Tribal Consultation
Policy. The letter states,
States must consult with Tribes to ensure the programs that they administer with
federal funding meet the needs of the Tribes in that state. Tribes should be
considered full partners by states during the design and implementation of
programs that are administered by states with HHS funding. The requirement of
states to consult with Tribes in the development of the Affordable Insurance
Exchanges is an example of how states can proactively include and partner with
Tribes during the planning stages of a program that has the potential to benefit
Tribal members greatly.
While this letter requires States with federal funding to consult with Tribes on the
development of Health Insurance Exchanges, it does not actually require that States
adopt a Tribal consultation policy for their Exchanges. At an HHS Tribal Consultation
on Federally-Facilitated Exchanges held in Washington, DC, on July 26, 2012, a Center
for Consumer Information and Insurance Oversight (CCIIO) representative stated that
the requirement for Tribal consultation would be considered in the certification process
in 2013 when CCIIO decides whether States have the readiness to implement
Exchanges.
Federal Funding for Exchange Planning
Every State except Alaska applied for and received an initial planning grant to consider
whether or not they would create an Exchange, with the understanding that the federal
government would create exchanges for States that did not create their own
Exchanges. States were then able to apply for Establishment Grants to do the work of
designing Exchanges. Level 1 and Level 2 Establishment Grants were available to
States.

Analysis of Tribal Consultation Policies For Health Insurance Exchanges
Tribes understood from the HHS Secretary’s letter to Governors that States with
federally-funded Planning Grants and Establishment Grants would be consulting with
Tribes in their respective States during the planning and implementation process.
Establishment Grant funding could be used for this purpose. However, this has not
happened in every State that received this federal funding.
Partnership Exchanges
CCIIO issued Blueprint for Approval of Affordable State-Based and State Partnership
Insurance Exchanges on August 14, 2012. It outlines ways that States that decide not
to operate their own Exchanges can assume some of the responsibilities for the
Federally-facilitated Exchange (FFE). States may take on functions related to plan
management, or consumer assistance, or both. States that want to take on these
functions must submit a “blueprint” to CCIIO by February 15, 2013. 1 CCIIO is expected
to make decisions in early 2013 2 , about the readiness of States to operate their own
Exchanges or to take on responsibilities in a Partnership Exchange.
Within the Partnership Exchanges, States could take responsibility for a number of
functions that have great interest for Tribes and Urban Indian programs, such as
certifying Qualified Health Plans with regard to network adequacy and essential health
benefits (EHB), as well as administration of the navigator program and in-person
assister program. Furthermore, States must be involved in the coordination of other
programs that they manage with federal funding -- Medicaid, Medicaid Expansion and
Child Health Insurance Programs (CHIP) — with the FFE for purposes of a single,
streamlined application, determination of eligibility, and enrollment. States are also
encouraged to run the re-insurance program that is required under the Affordable Care
Act (ACA) through 2016.
Tribal Consultation Approaches
The Indian Health Service (IHS), Tribes, and Urban Indian clinics (collectively called the
“I/T/U” or “Indian health programs”) have the experience and perspective to advise both
the federal government and state governments about how to structure policies and
procedures to be workable in the unique context of Indian health programs. Indian
health programs have a strong interest in making sure that all of the activities of both
state and federal Exchanges are carried out in a way that preserves the protections for
American Indians and Alaska Natives (AI/AN) and makes it easy for the Indian health
1 Original deadline of November 16 was extended by HHS on November 9 to February 15, 2012.
2 Originally, the federal government was to decide by January 1, 2013, whether states were ready to operate their
own Exchanges or participate in partnership arrangements. However, the deadline for states to submit their
blueprints was extended from November 15 until December 14. Therefore, it is assumed that HHS may not be able
to assess readiness by January 1, 2013, as originally intended.
2

Analysis of Tribal Consultation Policies For Health Insurance Exchanges
facilities to bill for services that they provide to people who are enrolled in Exchange
plans.
Some States have a better history of working with Tribes than other States where there
may be hostility over a variety of issues that may be unrelated to health care. In States
with good relations with Tribes, there may be state law that requires Tribal consultation
and provides the infrastructure to make it happen. In those States, there may also be a
state policy for Tribal consultation in the Medicaid program and cooperative efforts at
planning. However, in most States – even those with a history of good relationships
with Tribes-- the Exchange planning process is being conducted in the Department of
Insurance or by an off-shoot of that type of agency, which has had very little experience
working with Indian health programs. State Health Insurance Commissioners typically
are ignorant about Indian health programs and federal Indian law. Their focus is on
regulating insurance companies so that they do not lose money and fail to live up to
their contractual obligations.
Survey of State Exchange Consultation Policies and Approaches
In 2011, CCIIO provided to Tribes and to the Tribal Technical Advisory Group (TTAG),
an advisory group to the Centers for Medicare and Medicaid (CMS), a list of contact
people in each State that would serve as liaisons with the I/T/U. Starting in July 2012,
Tribal representative began contacting people on that list by e-mail to inquire about
whether or not their Exchange had a Tribal Consultation Policy. By that time, many
people had moved to other jobs, their e-mails were not working, and Tribal
representatives were referred as often as four different times to other people. In some
cases, there was no response to Tribal e-mails and no further names in State
government to pursue. Tribal representatives tried again to contact people in August,
September and October and were unable to make contact with anyone in the following
states: Alaska, Florida, Idaho, Kansas, North Dakota, Texas, and Wisconsin. One can
only assume that if this survey failed to make contact, then the I/T/U also could not use
the list provided by CCIIO to contact anyone involved in Exchange planning in those
States. Tribal representatives asked for an updated list of contacts from CCIIO in
September 2012, but have not yet received it at the time this report is written.
A summary of the findings from the States that responded to this survey is provided as
Attachment B. Only 3 of the 34 states with Tribes had a final, signed Exchange Tribal
Consultation Policy: Colorado, Minnesota, and Oregon. In addition, 6 States reported
that they were working with Tribes on an Exchange Tribal Consultation Policy that they
expected to have signed and completed by the November 16, 2012 deadline for the
State Exchange and Blueprint applications. These are: Arizona, California,
Connecticut, Mississippi, New York, and Washington.
3

Analysis of Tribal Consultation Policies For Health Insurance Exchanges
In a New Mexico and Utah, there are State Tribal consultation policies that cover a
broad range of health topics, including Medicaid. These are being used to guide State
Exchange planning activities. Utah has been consulting with Tribes about updating their
policies, but this process has not been finalized. Nebraska State officials report that
they are using the New Mexico policies as a template and adapting them for Nebraska.
While Oklahoma has returned its Establishment Grant funding is not planning an
Exchange, they note that the Oklahoma Health Care Authority, which runs the Medicaid
and CHIP program, has a Tribal Consultation Policy. As long as an Exchange or
Partnership is within State government and a separate quasi-governmental organization
has not been established to operate an Exchange, these States believe that their
existing policies apply to Exchange planning.
Another approach is being used by Rhode Island, which has one federally-recognized
Tribe. Instead of developing a formal Tribal Consultation Policy, they have chosen to
include the Tribal Health Director in a variety of State health advisory committees that
have already been established. They have documentation to submit to CCIIO that
describes discussions with the Tribal Health Director about Exchange planning issues.
Alabama is another State with one federally-recognized Tribe that seems to think a
formal Tribal Consultation Policy is unnecessary; however, they have put their
Exchange planning on hold until after the elections.
An additional 3 states responded to the survey saying that they are not establishing a
state Exchange and therefore not working on a Tribal Consultation policy: Louisiana,
Montana, and Wyoming. The survey response from Montana reported that the state
was advised by CCIIO that they would be handling Tribal Consultation for the FFE.
Timing of Tribal Consultation
Many States that have received Establishment Grants believe that they do not need to
have a Tribal Consultation Policy until they have state legislation or executive orders to
establish an Exchange, or until they apply to CCIIO for certification to operate an
Exchange or to assume Partnership functions in the FFE. Meanwhile they are going
forward with planning many details that are important to tribes.
For example, according to Reforum website (http://www.statereforum.org/stateprogress-on-essential-health-benefits)
by the end of July 2012, 7 states with Tribes had
formed workgroups on essential health benefits (EHB) (Alabama, Colorado,
Connecticut, Massachusetts, Minnesota, Mississippi, Nebraska, Nevada, and New
York). In addition, 3 States with Tribes had already enacted benchmark plan type
(Arizona, California, and Nevada). Other States with Tribes had conducted
assessments of benchmark plan options (Maine, Michigan, Mississippi, North Carolina
and New York.) Tribes need to be involved with these discussions and decisions
4

Analysis of Tribal Consultation Policies For Health Insurance Exchanges
because significant issues are at stake, including mental health parity, limitation in
number of visits, and having a separate plan for pediatric oral and vision services.
Consultation for Partnerships in FFE
In summary, 13 of the 34 states with Tribes have an approach to Tribal Consultation for
Exchange planning. Among the other 21 states, 10 did not receive Establishment
Grants and are, therefore, not likely to have state Exchanges or Partnerships in the FFE
(including 6 that did not respond to the survey).
Both the I/T/U and the federal government should be most concerned about the States
that received Establishment Grants with the clear direction to engage in Tribal
consultation and for which there is no evidence that this has been done. These include:
Iowa, Massachusetts, Maine, Michigan, North Carolina, Nevada, and South Dakota.
Idaho also received an Establishment Grant, but did not respond to the survey.
A number of these States indicated that they are still evaluating their options and have
not made a decision about what they will be doing, in most cases waiting until after the
election. This seems to be a rationale for not engaging Tribes in the planning process
and not developing policies, such as a Tribal Consultation policy. However, if they have
been using their Establishment Grant funding to do planning, they are likely to submit a
Blueprint for partnership in the FFE. These States may assume FFE functions related
to plan management, or consumer assistance, or both. If the federal government
approves their Partnership applications, these States will be making decisions that
affect the I/T/U without necessary consultation.
Attachments:
A. Letter to Governors from Kathleen Sebelius, HHS Secretary, September 14, 2011
B. Status of Tribal Consultation Policies
C. Issues for Tribal Consultation
5

Analysis of Tribal Consultation Policies For Health Insurance Exchanges
Attachment A
Dear Governor:
THE SECRETARY OF HEALTH AND HUMAN SERVICES WASHINGTON, D.C. 20201
September 14, 2011
Over the last two years, the Department of Health and Human Services (HHS) has taken a number
of steps to strengthen our partnership with American Indian and Alaska Native Tribal Nations. We
take seriously the federal government's obligation to help improve the health of American Indians
and Alaska Natives through the various health and human services programs administered by the
Department.
However, improving the health and well-being of Tribal nations is contingent upon understanding the
specific needs of Tribal communities. Tribal consultation is an essential tool in understanding these
unique needs and ensuring government to government relations. I am writing to you today to
encourage you to consult with Tribes as you administer health and human services programs that are
supported with federal funding.
HHS has made significant progress in strengthening our partnership with Tribes, and Tribal
consultation is one piece of our efforts to fulfill our responsibility to represent the best interests of
Tribes. Since President Obama signed an Executive Order on Tribal Consultation in 2009, HHS has
also updated its formal Tribal consultation policy. The updated policy includes the responsibility of
states to consult with Tribes when HHS has transferred the authority and funding for programs to
states that are intended to benefit Tribes. States must consult with Tribes to ensure the programs that
they administer with federal funding meet the needs of the Tribes in that state. Tribes should be
considered full partners by states during the design and implementation of programs that are
administered by states with HHS funding. The requirement of states to consult with Tribes in the
development of the Affordable Insurance Exchanges is an example of how states can proactively
include and partner with Tribes during the planning stages of a program that has the potential to
benefit Tribal members greatly. Consultations can identify strengths and barriers to Tribes accessing
these services and ensure that Tribes have the opportunity for greater health care coverage for their
members and employees.
I believe we share a vision of the future where our nation is strong and where every individual and
every community has the opportunity to reach their full potential. We can continue to strengthen
our partnership with Tribes and improve health and human service opportunities for all. Together,
we have the opportunity to build something great.
Kathleen Sebelius
6

Analysis of Tribal Consultation Policies For Health Insurance Exchanges
Attachment B
State Health Insurance Exchanges, Status of Tribal Consultation Policies, 10-18-12
Stat
e
Contact Polic
y?
7
Status
(latest status
report date)
Establishm
ent
Grant?
Type
Exchan
ge
Expecte
d
AK No FFE
AL Kathleen Healy
HIX
No FFE
Kathleen.healey@myalabama.gov establishme
nt on hold
until after
elections.
Only one
federallyrecognized
tribe seems
to be reason
for State not
to have
formal
policy.
(7/20/12)
AZ Donald Hughes
Expected to Yes
dhughes@az.gov (602-542-1334) be
completed in
October.
CA Jessica Abernethy
Working on Yes State
Jessica.abernethy@hbex.ca.gov
it. Check in
November
CO Myung Kim
yes CO Health Yes State
mkim@cohbe.org
Benefit
Exchange
Policy
Regarding
Consultation
with
Colorado’s
American
Indian
Tribes was
signed in
December
2011.
CT Julie Lyons Finalize Yes State

Analysis of Tribal Consultation Policies For Health Insurance Exchanges
Julie.Lyons@ct.gov (860-418-
6267)
Sept 27
FL No FFE
IA Angela Doyle Scar
Angela.DouyleScar@idph.iowa.go
v
no (9/18/12) Yes
ID Yes
KS No FFE
LA Carol Steckel
No LA is not No FFE
Carol.Steckel@LA.gov (337-233-
establishing
9627)
a state
based
exchange
and is
therefore not
working on a
Tribal
Consultation
Policy.
(7/9/12)
MA Kaitlyn Kenny
Kaitlyn.kenney@state.ma.us
(617-933-3030)
Yes State
ME Katrin P. Teel
No ME is
Yes
Katrin.Teel@maine.gov
reviewing its
(207-287-3531
options and
has not
developed
any policies
such as
Tribal
Consultation
Policies.
(10/19/12)
MI Chris Priest
No MI is waiting Yes
PriestC1@michigan.gov (517-335- until after
5178)
they have
established
legal
authority for
a statebased
exchange to
work on a
Tribal
Consultation
8

Analysis of Tribal Consultation Policies For Health Insurance Exchanges
MN April Todd-Malmlov
April.todd-malmlov@state.mn.us
(651-296-6025)
MS Liz Barnett
Liz.Barnett@mid.state.ms.us
MT Christa McClure
cmcclure@mt.gov (406-444-2041)
Policy.
(7/10/12)
Yes MN Health
Insurance
Exchange
Tribal
Consultation
Policy
signed
9/25/12
Working on
it (9/14/12)
No MT was
advised by
CCIIO that
they would
be handling
Tribal
Consultation
for FFE
(7/9/12).
9
Yes
Yes
No
FFE

Analysis of Tribal Consultation Policies For Health Insurance Exchanges
NB John Paul (JP) Sabby
JP.Sabby@nebraska.gov
(402-471-0344)
NC Jean Holliday
Jean.holliday@ncdoi.gov
10
Nebraska is
using NM
Tribal
Consultation
Policy as a
template
and
adapting it.
No decision
on
Exchange
until after
election. If
there is a
State
Exchange, it
will be
located
inside state
government
in Division of
Insurance.
Check back
in
November.
(10-18-12)
No NC has not
established
legal
authority
and
therefore no
legal entity
exists to
execute
Tribal
Consultation
Policy.
There is only
one
federallyrecognized
tribe (EBC)
and they
have been in
discussions
Yes
Yes

Analysis of Tribal Consultation Policies For Health Insurance Exchanges
ND
bout
Exchange.
(7/12/12).
No FFE
NM Priscilla Caverly
State HSD Yes
Priscilla.Caverly@ state.nm.us
has tribal
consultation
policy
signed
7/29/11.
State-Tribal
Collaboratio
n Act ,
SB196,
requires all
departments
of state
government
to have a
tribal
consultation
policy.
(7/10/12)
NV Jon Hager
jhager@exchange.nv.gov (775-
687-9926)
Yes
NY Lisa Sbrana
Tribal
Yes state
Lbs05@health.state.ny.us
consultation
(212-417-5293)
meeting
scheduled
for 10/30/12
OK Buffy Heater
No OK
No FFE
Buffy.heater@okhca.org
exchange
planning on
hiatus and
there is no
Tribal
Consultation
Policy,
although
Medicaid
(OHCA)
does have
one.
(7/13/12)
OR Rachel Oh Yes OR Health Yes state
11

Analysis of Tribal Consultation Policies For Health Insurance Exchanges
Rachel.oh@orhix.org Insurance
Exchange
Corporation
Tribal
Consultation
Policy
signed
RI Megan Hall
Megan.hall@faulknerconsultinggr
oup.com
12
4/2/12.
An
unsigned
Tribal
Consultation
Document
dated May
11, 2012,
outlines
processes
for tribalstate
communicati
on. State
has one
federallyrecognized
tribe
(Narraganse
tt). Tribal
health
director
serves on
Medicaid
Advisory
Committee.
Tribe is
invited to
attend public
meetings.
(7/15/12)
Yes state

Analysis of Tribal Consultation Policies For Health Insurance Exchanges
SD Eric Matt
Eric.matt@state.sd.us
No SD has not
yet decided
whether they
will have a
state
exchange.
No formal
Tribal
Consultation
Policy.
Convened
workgroup in
2011 with
tribal
representati
on.
Medicaid
Tribal
Consultation
group meets
quarterly
and they are
updated on
health
reform.
(7/11/12)
TX No FFE
UT Melissa Zito
Dept of
No FFE
mzito@utah.gov (801-712-9346)
Health Tribal
Consultation
Policy
signed
11/2/06.
Exchange
uses Utah
Indian
Health
Advisory
Board.
WA Brad Finnegan
Working on Yes State
Brad.finnegan@hca.wa.gov
it. Check in
November
WI No FFE
WY Tom Hirsig
No No state No FFE
Tom.hirsig@wyo.gov
exchange
and
13
Yes

Analysis of Tribal Consultation Policies For Health Insurance Exchanges
14
therefore no
work on
Tribal
Consultation
Policy.
(7/9/12)

Analysis of Tribal Consultation Policies For Health Insurance Exchanges
Attachment C
Issues for Tribal Consultation in Exchange Planning
Version 10/25/12
A. Qualified Health Plan (QHP) Networks and Essential Health Benefits
1. Require all QHPs to offer contracts to all I/T/U providers with an Indian
Addendum
2. Develop rules and processes to assure that AI/AN who are enrolled in a
QHP and referred through an I/T/U CHS program (and/or are below 300
percent FPL) are not charged a co-pay or deductible for services they receive
outside the I/T/U.
3. Essential Health Benefits
a. Review the scope and duration of services
b. Providers covered
B. Payment for Services Provided by I/T/U
c. Substitution of benefit categories from benchmark plan
d. Offering pediatric oral and vision services in the QHP versus
a separate plan
e. Compliance with Mental Health Parity and Addiction Equity
Act (MHPAEA)
1. Enforcement of Section 206 of the Indian Health Care Improvement Act
(IHCIA)
a. Assure that the I/T/U is paid in a sufficient and timely way for services
delivered to individuals who are enrolled in QHPs if the I/T/U is not a
network provider.
b. Create single point of contact for I/T/U facilities that have problems
collecting from QHPs, and a process for dealing with those issues.
2. Reimbursement for Waived Cost Sharing
a. Develop a process to assure that the I/T/U receives payment for the
co-pays and deductibles that are waived for AI/AN.
15

Analysis of Tribal Consultation Policies For Health Insurance Exchanges
b. Develop process to reimburse other QHP providers for waived cost
sharing for AI/AN.
C. Eligibility and Enrollment and Tribal Sponsorship
1. Eligibility
a. Identification of individuals who are eligible for special protections and
provisions as AI/AN in the eligibility process and at the provider level to
assure that deductibles and co-pays are waived.
b. Utilization of existing databases or development of new databases to
expedite eligibility determinations.
c. Deciding how additional documentation will be requested, submitted,
reviewed, and stored and how eligibility determinations will be made when
individuals are not included in approved data systems.
d. Develop the system to assure waiver of penalties for AI/AN without
Insurance and to communicate who is covered by this provision in the law.
2. Enrollment process
a. Enrollment process must accommodate special provision for AI/ANs in
Exchanges (monthly enrollment, waiver of cost sharing, exclusion of
certain sources of income).
b. As single point of enrollment, Exchanges must be able to identify
AI/AN for benefits and protections in Medicaid, Medicaid Expansion,
Child Health Insurance Programs, and Basic Health Plans, if there are
any in the State.
3. Tribal Sponsorship
4. Website
a. Allow tribes to decide which individuals they want to sponsor and
provide opportunity for aggregate payment of premiums.
b. Decide the terms and conditions of Tribal Sponsorship.
c. Allow I/T/U clinic addresses to be used for QHP mailing to enrolled
individuals.
16

D. FFE Data
Analysis of Tribal Consultation Policies For Health Insurance Exchanges
a. Design the website to include information specific to AI/ANs and the
I/T/U.
b. Test the website in Indian Country and in urban Indian clinics to make
sure it is culturally appropriate, easy to navigate to Indian health
information, and the information is presented in a way that is accurate and
easy accessible to consumers, as well as those assisting with enrollment.
5. Enrollment Assistance
a. Carve outs for navigator contracts for the I/T/Us, including an Indian
Addendum.
b. Provide other enrollment assistance funding, such as Medicaid
Administrative Match (MAM).
6. Call Centers
a. Decide whether it is most appropriate to have an Indian desk to handle
questions and resolve problems regarding AI/AN and I/T/Us, or whether
everyone who works at a call center should receive training about Tribes
in the State, the Indian health care delivery system and special provisions
in the law, regulations and systems for AI/AN.
b. Review scripts that are used in call centers to assure their accuracy for
AI/ANs and I/T/Us.
c. Provide appropriate back up for call center employees who are unable
to answer questions about AI/ANs and I/T/U and standards for timely
response.
d. Keep FAQs and review answers for accuracy.
1. Enrollment data
2. Federal data hub
a.IHS registration data
b. Other AI/AN data sets
3. Identifying AI/AN in FFE data and reports
a. For benefits and protections for AI/AN
b. For reimbursing cost sharing
17

Analysis of Tribal Consultation Policies For Health Insurance Exchanges
c. Performance metrics
d. Measuring effectiveness/barriers to enrollment of AI/AN
E. Outreach and Education
1. Provide outreach and education that is culturally appropriate.
2. Assure that AI/ANs know which QHPs have I/T/U providers in their
networks.
3. Inform consumers and providers about the special protections and
provisions for AI/AN.
18

John O'Brien
Director, Healthcare & Insurance
Office of Personnel Management (OPM)
John O'Brien is the Director of Health Care and Insurance at the Office of Personnel Management. In this position he
oversees the insurance programs for federal employees including the Federal Employees Health Benefit (FEHB)
program, which provides health insurance to over 8 million federal employees, retirees, and their dependents. In
addition, he leads the team implementing OPM's responsibilities under the Affordable Care Act (ACA). These include
the development of multi-state plans for state exchanges and allowing employees of tribes and tribal organizations to
purchase health and life insurance through the federal system.
From 2007 to 2009 he helped oversee the State of Maryland's unique all-payer hospital rate setting system as the
Deputy Director for Research and Methodology at the Maryland Health Services Cost Review Commission (HSCRC).
From 1997 to 2007 he was the Director of Acute Care Policy at the University of Maryland, Baltimore County (UMBC)
Hilltop Institute where his work focused on the management and oversight of Medicaid managed care plans. Mr.
O'Brien was a 2005 recipient of an Ian Axford Fellowship in Public Policy under which he studied health system
performance measurement in New Zealand. He has a Master Degree in Public Administration from Syracuse
University.

Centers for Medicare & Medicaid Services’ Tribal
Technical Advisory Group
American Indian and Alaska Native
Strategic Plan
2013 - 2018
This draft plan is being circulated for Tribal Leader and health director comments and
recommendations. An electronic copy is available at: www.nihb.org. Please submit
your comments by October 30, 2012 to Liz Heintzman at the National Indian Health
Board at EHeintzman@nihb.org. Thank you!
The 2013-2018 CMS-TTAG AI/AN Strategic Plan covers the time period from Fiscal Year 2013 to Fiscal Year
2017(FY2013-FY2017), which spans from October 1, 2013 to September 30, 2018. Recommendations contained in
the plan will also be used to inform budget requests for Fiscal Year 2012.

Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
CMS Tribal Technical Advisory Group
W. Ron Allen
Chairman, Jamestown S’Klallam Tribe
Tribal Self Governance Advisory Committee
Representative
Pearl Capoeman-Baller
Quinault Indian Nation
Portland Area Representative
James Crouch
Executive Director, California Rural Indian Health
Board, Inc.
California Area Representative
Valerie Davidson
Senior Director of Legal and Intergovernmental
Affairs, Alaska Native Health Consortium
Alaska Area Representative
Juana Majel-Dixon
Secretary, NCAI Executive Committee
National Congress of American Indians
Representative
Judy Goforth Parker, PhD
Administrator, Chickasaw Nation Division of Health
Oklahoma Area Representative
Carl Harper
Director, Office of Resource Access & Partnerships
Indian Health Service Representative
Rex Lee Jim
Vice-President, Navajo Nation
Navajo Area Representative
Grace Manuel
Legislative Council Member, Tohono O’odham
Nation
Tucson Area Representative
2
Richard Narcia
President, Board of Directors, Gila River Indian
Community
Phoenix Area Representative
Marlene Redneck
Northern Cheyenne Tribal Council
Billings Area Representative
H. Sally Smith
Chairman, Bristol Bay Health Area Health
Corporation
National Indian Health Board Representative
Carmelita Skeeter
Chief Executive Officer, Indian Health Care Resource
Center of Tulsa
National Council on Urban Indian Health
Representative
Donita Stephens
Finance Director, Choctaw Health Center
Nashville Representative
Alec Thundercloud, MD
Executive Director of Health, Ho-Chunk Nation
Bemidji Representative
Donald Warne, MD, MPH
Senior Policy Analyst, Great Plains Tribal Chairmen’s
Health Board
Aberdeen Representative
Albuquerque Representative
Vacant

Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Table of Contents
TABLE OF CONTENTS ..........................................................................................................1
DEDICATION .....................................................................................................................2
EXECUTIVE SUMMARY ............................................................................................... 3
INTRODUCTION..................................................................................................................4
GOALS AND OBJECTIVES FOR 2013-2018
Goal 1. Tribal Consultation ...........................................................................................................12
Goal 2. Policy Development and Implementation ......................................................................15
Goal 3. Long Term Services and Support ......................................................................................19
Goal 4. Outreach and Education ...................................................................................................22
Goal 5. Data for Evaluation ...........................................................................................................25
APPENDIX A: PLAN SUMMARY AND BUDGET ..........................................................................28
APPENDIX B: LEGAL BASIS FOR SPECIAL CMS PROVISIONS FOR AI/ANS .....................................40
APPENDIX C: CMS ORGANIZATION CHART .............................................................................62
APPENDIX D: COMMON TERMS & ACRONYMS .......................................................................63
ACKNOWLEDGEMENTS ........................................................................................................64
1

Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Dedication
This CMS American Indian and Alaska Native Strategic Plan
is dedicated to three colleagues whose contributions made the Tribal Technical
Advisory Group (TTAG) stronger and more effective.
Robert Dean Moore, Rosebud Sioux (1963 - 2010)
Tribal Council member for the Rosebud Sioux Tribe, Robert Moore was
the Aberdeen Area representative to the TTAG. Earlier in his career, as the
Indian Affairs staff member for former US Senator Tom Daschle, Robert
raised awareness of health disparities and the need for long-term care for
Tribal elders. He was a friend and warrior for all throughout Indian
communities.
Kristine Anne Locke (1950 - 2012)
Technical Advisor to the Tribal Self Governance Advisory Committee
(TSGAC) representative on the TTAG, Kris Locke brought technical
expertise, wisdom and experience to the process of defining values and
core principles, fostering team work among all participants, and providing
technical and program support for TTAG subcommittees. She worked
tirelessly on behalf of Tribes and American Indian and Alaska Native
people.
Elmer Brewster, MSW, MPH, Paiute (1949 - 2012)
A friend to all who knew him, Elmer Brewster was engaged with the TTAG
from its beginning, shared data and information about the costs of Indian
health care, advocated for payment systems that were inclusive, and
represented the Indian Health Service and the Indian health system
honorably.
2

Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Executive Summary
This is the third American Indian and Alaska Native (AI/AN) Strategic Plan for the Centers for
Medicare and Medicaid Services (CMS) by the Tribal Technical Advisory Group (TTAG). Update of
AI/AN Strategic Plan is urgently needed to address new opportunities and challenges of
implementing legislation passed since the last Plan was written, including:
American Recovery and Reinvestment Act of 2009 (ARRA)
Patient Protection and Affordable Care Act (ACA), which also amended and
permanently authorized the Indian Health Care Improvement Act (IHCIA)
AI/AN Strategic Plan has five goals that apply to all CMS programs, including Medicare, Medicaid,
CHIP, and Health Insurance Exchanges:
1. CMS engages in meaningful consultation with Tribes and works closely with the TTAG.
(Page 12)
2. CMS enacts and implements policy through regulation, guidance, review and
enforcement to align CMS programs to serve AI/ANs by improving enrollment processes,
assuring access to care, having efficient payment systems, and increasing the I/T/U capacity
to deliver integrated, comprehensive programs. (Page 15)
3. CMS improves and expands opportunities for development and delivery of Long Term
Services and Support throughout Indian communities. (Page 19)
4. Through outreach and enrollment activities, all I/T/U programs are fully informed about
CMS programs and AI/ANs know about benefits to which they are entitled. (Page 22)
5. Develop and improve CMS data systems to evaluate and expand the capacity of CMS to
serve American Indians and Alaska Natives. (Page 25)
Annual Plan budget is $5.5 million in 2013, $7.3 million in 2014, $7.4 million in 2015, and $4.5
million in the following 3 years. The higher amounts are needed in the next three years to prepare
for 2014 and on-going implementation to assure that AI/ANs benefit from ACA. Budget summary is
provided in Appendix A (Page 28).
AI/AN Strategic Plan serves as an important reference document through the inclusion of Appendix
B: Legal Basis for Special CMS Provisions for American Indians and Alaska Natives. (Page 39)
3

Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Introduction
New developments require strategic response
This is the third American Indian and Alaska Native Strategic Plan that the Tribal Technical Advisory
Group (TTAG) to the Centers for Medicare and Medicaid Services (CMS) has prepared to help guide
Centers for Medicare & Medicaid Services (CMS). The first one was issued for the period of 2005-2010,
and the second for the period of 2010-2015. There have been significant changes in the law and in CMS
since the most recent strategic plan was issued in 2009, including:
American Recovery and Reinvestment Act of 2009 (ARRA), P.L. 111-5, February 17, 2009.
Patient Protection and Affordable Care Act (ACA), P.L. 111-148, March 23, 2010, which also
permanently authorized the Indian Health Care Improvement Act (IHCIA) by Section 10221.
CMS Tribal Consultation Policy, signed Nov 17, 2011.
The Supreme Court of the United States decision on June 28, 2012, that upheld the ACA, but
created new challenges in the event that some states choose not to implement Medicaid
Expansion.
A prolonged period of an economic recession that has created pressures on State budgets
that affect Medicaid program funding and services.
Changes in direction by CMS to create a greater emphasis on payment related to quality,
integration of services, utilization of electronic methods for enrollment and care
management, and greater accountability.
This new American Indian and Alaska Native Strategic Plan for 2013-2018 is urgently needed to:
Get ready for 2014 when people will be able to enroll in the new Medicaid Expansion and
Health Insurance Exchanges.
Strengthen primary care networks to prepare for the managed care approaches across all
CMS programs by facilitating the integration of Indian health providers, utilizing them as
medical homes, acknowledging new provider types and services, and providing adequate
payment for services.
Build capacity for long term care through community based services and support in Tribal
communities.
Implement protections in the law for American Indians and Alaska Natives who enroll in
federally-funded health programs.
4

Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Create a partnership between CMS and Tribal governments that provides early discussions
of policy development and planning to assure the integration of CMS programs and Indian
health programs to create effective processes for enrollment, access to care, care
coordination, quality care, and adequate payment for services.
Reduce health disparities for American Indians and Alaska Natives which are among the
worst of any racial or ethnic group in our nation, a condition that can be improved through
better integration of the Indian health care system and CMS programs.
CMS programs must reduce health disparities
Federal funding for Medicaid, Medicaid Expansion, CHIP, Medicare, and Health Insurance Exchanges
is intended to reduce health disparities in our society. At every stage of their lifespan, American
Indians and Alaska Natives (AI/AN) have significantly worse health status than the rest of the nation.
A recent analysis of Medicaid data in one state 1 shows that infant mortality among AI/ANs was
twice the rate for the Medicaid population as a whole. Compared to the rest of the world, the
AI/AN infant mortality rate was higher in that State than such countries as Poland, Slovakia, Estonia,
Malaysia, Thailand, and Sri Lanka. Contributing factors included deaths due to Sudden Infant Death
Syndrome (SIDS) at a rate 3 times higher among Indians compared to the total Medicaid population,
deaths due to injuries at a rate 5 times higher among Indians, and a rate of deaths from
complications of pregnancy and delivery 50 percent higher than the total Medicaid population.
Medicaid data from the same state also provided an analysis of the risk factors that lead to poor
pregnancy outcomes. Compared to all pregnant women on Medicaid, Indian pregnant women were
2.7 times more likely to have a mental health diagnosis, 3.3 times the rate of alcohol and substance
abuse, a 70 percent higher rate of smoking, and a 30 percent higher rate of obesity.
CMS must assure that AI/ANs and Indian Health Service (IHS)/Tribal/and Urban Indian Organization
(I/T/U) users are accurately identified in records for Medicaid, Medicare and Health Insurance
Exchanges that can be used to calculate health disparities, as well as provide utilization data and
performance metrics. In the past IHS provided health status and health disparity information on a
nationwide basis for AI/ANs who are I/T/U users; however, that effort was discontinued in 2007.
According to the most recent reports from IHS, AI/ANs die at higher rates than other Americans
from tuberculosis (500 percent higher), alcoholism (514 percent higher), diabetes (177 percent
higher), unintentional injuries (140 percent higher), homicide (92 percent higher) and suicide (82
1 American Indian Health Commission for Washington State, Tribal Maternal and Infant Health Strategic Plan, 2010.
Analysis based on 8 years of data by Laurie Cawthon, MD, MPH, Manager of First Steps Data Base in Washington
State Department of Social and Health Services.
5

Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
percent higher). 2 Current data are needed to know whether interventions, such as enrollment in
CMS programs, are effective in changing health outcomes.
A number of factors contribute to persistent disparities in AI/AN health status. American Indians and
Alaska Natives have the highest rates of poverty in America, accompanied by high unemployment
rates, lower education levels, poor housing, lack of transportation and geographic isolation. All of
these factors contribute to insufficient access to health services. American Indians and Alaska
Natives continue to experience historical trauma from damaging federal policies, including those of
forced removal, boarding schools, and taking of tribal lands, and continuing threats to culture,
language, and access to traditional foods.
Historic and persistent under-funding of the Indian healthcare system has resulted in problems with
access to care, and has limited the ability of the Indian healthcare system to provide the full range of
medications and services that could help prevent or reduce the complications of chronic diseases.
CMS, IHS and Tribes must work together to help eliminate existing health inequalities. Together we
can and must strengthen the ability of Indian health programs to serve as the medical home for
AI/ANs, offering culturally competent care with a public health focus, while fulfilling their important
role as essential providers for Medicaid, Medicare, and Children Health Insurance programs and the
prospective Health Insurance Exchange plans. This plan offers CMS and TTAG a roadmap for making
that happen.
The Indian health care system is unique
The United States has acknowledged its special trust responsibility to provide health services to AI/ANs.
This responsibility is the direct result of treaties between the United States and Indian Tribes and of
executive orders, and has been reaffirmed by judicial decisions, executive orders, and Acts of Congress
(see Appendix B, p. 39).
The IHS was created in 1955 to assist the United States to fulfill its obligation to provide health care to
AI/ANs. Twenty years later, Congress enacted the Indian Self-Determination and Education Assistance
Act of 1975 (P.L. 93-638) to enable Tribes and Tribal Organizations to directly operate health programs
that would otherwise be operated by IHS, thereby empowering Tribes too design and operate health
programs that are responsive to community needs. Title V of the Indian Health Care Improvement Act
of 1976 (P.L. 94-437) (IHCIA) authorized federal funding for urban Indian organizations to provide health
services to AI/ANs, many of whom had been relocated to urban areas by federal relocation programs.
2 Website http://www.ihs.gov/Public Affairs/IHSBrochure/Disparities.asp. AI/AN data from 2004-2006 are
compared with U.S. All Races data for 2005.
6

Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Taken together, this complex healthcare delivery system is often referred to as the “I/T/U”
(IHS/Tribal/Urban) or Indian healthcare system. A year later, the Congress authorized IHS and tribal
health programs to bill Medicare and Medicaid, which expanded the resources available to them to
carry out the federal trust responsibility.
Today the Indian healthcare system includes 46 Indian hospitals (1/3 of which are tribally operated) and
nearly 630 Indian health centers, clinics, and health stations (80 percent of which are tribally operated).
When specialized services are not available at these sites, health services are purchased from public and
private providers through the IHS-funded Contract Health Services (CHS) program. Additionally, 34
urban programs offer services ranging from community health to comprehensive primary care.
The I/T/U utilizes a community-based public health model with many approaches that are not found in
typical American medical delivery systems. For example, the Indian health programs include public
health nursing, outreach workers, prevention services, and even building community water and
sanitation services. Indian health programs have pioneered new types of providers, such as community
health aides and dental health therapists, as well as new approaches to delivering services in remote
rural areas, including telehealth. Tribal governments manage a wide range of services, such as
substance abuse treatment, the U.S.D.A. nutrition programs for pregnant women, infants and children
(WIC), Senior Centers and elder nutrition sites, rabies vaccinations for dogs, and injury prevention
programs, to name just a few. Tribal programs tend to take a more holistic view and utilize indigenous
people who speak the local language and live in remote Tribal communities.
Not only does the Indian health system have to deal with health disparities, it’s important to note that
the system is also challenged with funding disparities. The IHS Federal Disparity Index (FDI) is used to
determine the level of funding for the Indian health system relative to its total need. The FDI compares
actual health care costs for an IHS beneficiary to those costs of a beneficiary served in mainstream
America. The FDI uses actuarial methods that control for age, sex, and health status to price health
benefits for Indian people using the Federal Employee Health Benefits (FEHB) plan, which is then used to
make per capita health expenditure comparisons. Based on this model it is estimated that Congress
provides direct appropriations to the Indian health system, on average, at approximately 60 percent of
its level of need. 3 It is these health and funding disparities that exacerbate the challenges in providing
health care for AI/AN people.
3 The IHS calculates funding needs for IHS and tribal health programs by “comparing [IHS] funding to the cost of
providing medical insurance for [AI/AN] users in a mainstream health insurance plan such as the Federal
Employees Health Plan (FEHP).” Indian Health Manual, Part 6, Chapter 4, Manual Exhibit 6-4-A. This methodology
is commonly referred to as the Federal Disparity Index (FDI). Available at:
http://www.ihs.gov/NonMedicalPrograms/lnf/
7

Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
The federal government reimburses States 100 percent for Medicaid services delivered to AI/ANs
through IHS and Tribal health programs. States are reimbursed for payments made to Urban Indian
Health Programs for Medicaid services provided to AI/ANs on the basis of the state-specific Federal
Medical Assistance Percentage (FMAP), which in 2013 varies from a minimum of 50 percent up to 73.43
percent. Many programs operated by the IHS and Tribes use a bundled rate approved by the Office of
Management and Budget (OMB) on an annual basis, called the “IHS Reimbursement Rate“ or the ”IHS
encounter rate.” These and other unique circumstances and billing practices are generally not well
understood outside the Indian health system. A summary of the legal basis for special CMS provisions
for American Indians and Alaska Natives has been updated and presented in Appendix B (page 39). The
lack of 100 percent FMAP to States for services provided in Urban Indian Health Programs has precluded
these programs from inclusion in the “IHS encounter rate” reimbursement methodology, and hinders
the recognition by States of the special obligations owed to urban Indians and Urban Indian Health
Programs under Federal law. There is much more work to be done to align the policies, programs, and
systems for billing for CMS services in order to ensure that AI/ANs have the health care coverage they
are entitled to receive.
Tribal consultation is required for CMS programs
The United States government has a unique legal and political relationship with American Indian and
Alaska Native Tribes. This special relationship recognizes Tribes as sovereign nations that retain the
inherent right to self-govern, and that interact with the United States on a government-to-government
basis. These rights are grounded in the U.S. Constitution and treaties, and are reinforced by judicial
precedent and Presidential Executive Orders that direct federal agencies to consult with Tribes on a
government-to-government basis. Tribal consultation is an open and continuous exchange of
information that leads to mutual understanding and informed decision making between federal
agencies and tribal governments. Tribal consultation should occur at the earliest possible point in the
policy formulation process, particularly whenever decisions would significantly impact Tribes, would
have a substantial compliance cost, or would result in new or changed policies. Both the Department of
Health and Human Services (HHS) and CMS have Tribal consultation policies, and CMS is developing
procedures to operate those policies. The CMS Tribal Consultation policy calls for an annual review and
revisions to update the policy.
The purpose of the first goal of this Strategic Plan is to ensure meaningful consultation with Indian
Tribes on policy and programmatic issues including, but not limited to eliminating health disparities of
Indians and ensuring access to critical health services, including those made available through Medicare,
Medicaid, CHIP, and Exchange Plans administered by CMS. The involvement of Tribes and the TTAG in
the development of CMS policy allows for culturally appropriate approaches resulting in greater access
8

Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
to CMS programs and positive outcomes for Indian people and the health programs operated by the
Indian Health Service, Tribes and Tribal Organizations, and urban Indian organizations.
Tribal Technical Advisory Group advises CMS
The Tribal Technical Advisory Group (TTAG) was started by CMS in 2004 as a policy advisory body. In
2009 ARRA Section 5006(e)(l), P.L. 111-5 established the TTAG in law, added new categories of
members, and reaffirmed its status as exempt from the Federal Advisory Committee Act (FACA), 5 U.S.C.
App. 2
TTAG has 18 members: elected tribal leaders (or their designated employees) selected from the 12
Areas of the IHS, as well as representatives from the National Congress of American Indians (NCAI), the
National Indian Health Board (NIHB), the Tribal Self-Governance Advisory Committee (TSGAC), the
Indian Health Service, and the National Council of Urban Indian Health (NCUIH). TTAG meetings,
subcommittees, and workgroups facilitate the exchange of information and perspectives on the
administration of CMS programs and their efficacy in Indian communities. TTAG meetings complement,
but do not supplant, tribal consultation processes that take place between CMS and individual Tribes.
Some of the recommendations from the TTAG have been implemented as CMS regulation and policy,
and later reaffirmed in federal law. While the TTAG has offered their advice to CMS on a wide range of
issues, the following are some of the significant achievements:
CMS Tribal Consultation Policy is adopted and training is provided for CMS employees to
implement it.
Native American Contacts (NACs) are designated for each Regional Office of CMS.
Medicaid Administrative Match may be made available by State Medicaid programs to Tribal
health programs to provide enrollment assistance.
Indian Addendum 4 developed for Medicare Part D to assure participation by I/T/U pharmacies
on terms appropriate to their governmental status and statutory protections.
Successful campaign is initiated to increase AI/AN enrollment in CHIP.
4 “Indian Addendum” refers to contract terms that are specific to IHS and tribal health programs that was
approved by CMS and that Medicare Part D pharmacy plans must include in preferred provider arrangements with
IHS and tribal health programs.
9

Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
On April 6, 2012, CMS approved Arizona’s request to amend its 1115 demonstration known as
the Arizona Health Care Cost Containment System (AHCCCS), which allows the State to offer
uncompensated care payments to Indian Health Service and tribal 638 facilities. Under the
amended demonstration, IHS and Tribal 638 facilities can begin to claim payments for
uncompensated care costs associated with services furnished to individuals with income up to
100 percent of the FPL.
CMS training is provided to I/T/U in each Area on an annual basis, supplemented by Medicine
Dish programs, All Tribes calls, a CMS Day at the NIHB Annual Consumer Conference, CMS
sponsorship of a Long Term Care Conference and a website.
Meaningful use of electronic health records rules are defined and promote I/T/U participation.
States are required to consult with Tribes and Tribal Organizations on Medicaid State Plans,
waivers and the development of health insurance exchanges.
Regulation tracking process is implemented for AI/AN and I/T/U issues.
CMS Tribal Affairs Group added staff to address issues.
Medicaid, CHIP, and Medicare enrollment, service and payment data for AI/AN have been
identified and reported .
Collaborative policymaking processes such as those demonstrated by TTAG improve the quality of
resultant decisions.
Organization of CMS AI/AN Strategic Plan
This plan is organized to provide a focus on the goals and objectives. Supporting documentation and
budget summaries are provided in appendices. There are five overarching goals in this plan that apply
to all CMS programs, including Medicare, Medicaid, CHIP, and Health Insurance Exchanges. These are:
Goal 1: CMS engages in meaningful consultation with Tribes and works closely with the TTAG.
Goal 2: CMS enacts and implements policy through regulation, guidance, review and
enforcement to align CMS programs to serve AI/ANs by improving enrollment processes,
assuring access to care, having efficient payment systems, and increasing the I/T/U capacity to
deliver integrated, comprehensive programs.
10

Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Goal 3: CMS improves and expands opportunities for development and delivery of Long Term
Services and Support (LTSS) throughout Indian communities.
Goal 4: All I/T/U programs are fully informed about CMS programs and AI/ANs know about
benefits to which they are entitled.
Goal 5: Develop and improve CMS data systems to evaluate and expand the capacity of CMS to
serve American Indians and Alaska Natives.
For each goal, a number of objectives are listed with tasks identified that are necessary to achieve each
objective.
Budgets for each of the tasks are estimates based on experience and have not been calculated based on
actual or projected costs. For items related to policy development, it is assumed that CMS staff is
already funded. It should be noted that the budgets do not consider the time and expenses of TTAG
members, alternates and their technical advisors who participate in TTAG meetings, subcommittee
meetings, teleconferences, and other activities.
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Goal 1: CMS will execute its federal trust responsibility to engage in meaningful consultation
with Tribes and work closely with the Tribal Technical Advisory Group.
Objective 1a – On an annual basis, CMS will engage the TTAG to evaluate and revise the CMS Tribal Consultation
Policy
Task 1: Evaluate and revise existing CMS Tribal Consultation Policy, in collaboration with the
TTAG and CMS Tribal Affairs Group (TAG), and provide an opportunity for Tribal consultation on
the policy.
Task 2: CMS will conduct an annual Tribal Consultation session separate and distinct from the
HHS Department-wide and Regional Tribal Consultation session.
Budget request: $75,000 per year
Task 3: In partnership with TTAG and IHS, CMS will develop a written annual report documenting
and evaluating consultation activities, which will be disseminated to partners in the first quarter
of each fiscal year. The report will assess both consultation processes and outcomes. This
detailed report will be used by TTAG to monitor and evaluate consultation processes and their
impact.
Budget request: $40,000 per year. These funds will be used to support tracking activities by
CMS and process evaluations carried out by a qualified tribal consultant/organization, and
review of the report with relevant stakeholders.
Objective 1b – In collaboration with the TTAG, CMS will develop mechanisms to involve Tribes in states that
have federally-facilitated exchanges and partnership exchanges to assure that I/T/U issues are
addressed in the planning, policies, structure, and operations of those exchanges.
Task 1: Beginning in 2012, CMS and TTAG will agree on a list of issues that could affect AI/AN
participation in health insurance exchanges and create workgroups that meet regularly to resolve
those issues prior to July 2013.
Objective 1c – Each year, CMS will provide financial and administrative support to facilitate the ongoing
activities of TTAG, and a sufficient budget to support TTAG activities included in the 2013-2018
Strategic Plan.
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Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Task 1: CMS will fully fund the Tribal Technical Advisory Group, including TTAG travel, per diem,
communication needs, basic staffing, and other related expenses for face-to-face meetings up to
three times per year. TTAG serves as a policy advisory body to CMS, providing expertise on
policies, guidelines, and programmatic issues affecting the delivery of health care for AI/ANs.
Budget request: $280,000 per year. Funds will be used to support the travel and per diem
expenses of TTAG members three times per year, occasional subcommittee meetings, and
the ongoing communication and professional technical assistance needed to support TTAG
meetings and activities.
Task 2: CMS will actively seek to recruit AI/ANs for key policy positions, particularly with regard
to Indian health care. CMS will develop a personnel succession plan to ensure consistent and
competent TAG staffing with expertise in the Indian healthcare system. The personnel succession
plan should include recruitment, training, and promotion strategies, particularly for AI/ANs,
including internships, cross-training opportunities for IHS employees, recruitment of AI/ANs to
serve as Native American Contacts (NACs) in regional offices, and/or providing executive
leadership training for AI/ANs in CMS.
Budget request: $25,000 per year for succession planning and recruiting as needed.
Task 3: The Tribal Affairs Group at CMS will report quarterly to TTAG activities and funding for
implementation of this Strategic Plan.
Task 4: CMS will retain at least 7 FTE personnel in their Tribal Affairs Group (TAG) who will
provide policy and administrative support to TTAG. CMS will hire and retain Native American
Contacts in each of its Regional Office locations.
Objective 1d – CMS personnel with the authority to make binding decisions will regularly participate in TTAG
meetings, the Annual DHHS Budget Consultation session, and DHHS regional tribal consultation
meetings and listening sessions.
Task 1: On an annual basis, the CMS Administrator, and/or CMS Center and Office Directors, will
participate in at least three face-to-face meetings with TTAG, along with other CMS officials with
pertinent expertise in the subject matter at hand.
Task 2: Key leadership from CMS Headquarters will attend annual DHHS regional tribal
consultation meetings and listening sessions.
Objective 1e – CMS will develop a set of standard operating procedures that will be used by the agency to guide
administrative decisions regarding Indian health policy.
Task 1: In recognition of the United States trust responsibility described in Appendix B (p. 39),
TTAG and the CMS Office of External Affairs will work collaboratively to develop a set of standard
13

Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
operating procedures that can be used by CMS to guide policy formation and Tribal consultation.
Such procedures should be based on values and principles that promote the federal trust
responsibility for health care and Tribal consultation.
Budget request: $40,000 for the first year to develop the standard operating procedures.
Funds will be used to support the completion of this task by a qualified consultant or Tribal
Organization, and any partner meetings needed to develop mutually agreed upon standard
operating procedures. An additional $15,000 per year is requested to monitor compliance
and evaluate the effectiveness of the standard operating procedures.
Examples of such values and principles include:
CMS recognizes that the tribal healthcare delivery system is politically, legally, and culturally
unique and that policies developed specifically for Indian healthcare can be designed to apply
only to Indian health programs, and will not be considered to set precedent for other types of
healthcare delivery system.
It is a well-settled canon of construction that federal laws enacted for the benefit of Indian Tribes
are to be given a liberal interpretation, and that doubtful expressions are to be resolved in favor
of Indian interests.
Absent express statutory prohibition, CMS shall engage in Tribal consultation and implement
Tribal recommendations made during such consultations, regarding any CMS policies and actions
that:
1. Have Tribal implications, or
2. Have substantial direct effects on
a. one or more Indian Tribes, or
b. the relationship between the Federal Government and Indian Tribes, or
c. the distribution of power and responsibilities between the Federal
Government and Indian Tribes.
CMS will develop enrollment strategies that maximize AI/AN participation in Medicaid, Medicare,
and CHIP, and health insurance exchanges, and will work collaboratively with I/T/Us to carry out
identified strategies.
14

Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Goal 2: CMS enacts policy through regulation, guidance, review and enforcement to align
CMS programs to serve American Indians and Alaska Natives by improving enrollment
processes, assuring access to care, having efficient payment systems, and increasing the I/T/U
capacity to deliver integrated, comprehensive programs.
Objective 2a – CMS will work with the TTAG to develop a global approach to funding enrollment assistance
provided by the I/T/U and eligibility determinations for all CMS supported programs.
Task 1: Evaluate the number of States that are using Medicaid Administrative Match (MAM) to
fund enrollment assistance at I/T/Us and the number of I/T/U programs that are receiving this
funding, and the best approaches to provide financial support (including expansion of MAM to
other I/T/Us and broadening the programs for which its funding can be used) for assisting AI/ANs
who use I/T/U programs to enroll in Medicaid, Medicaid Expansion, CHIP, qualified health plans
through the health insurance exchange, and other insurance and benefits (including those
provided by the Department of Veterans Affairs (VA), and other new approaches for simplifying
applications and approvals for enrollment within control of CMS.
Task 2: Develop mechanisms for the I/T/U to receive Navigator or other funding from the
federally-facilitated Exchanges, partnership exchanges and state exchanges.
Task 3: Consider alternative sources of funding for the I/T/U to assist AI/ANs to enroll in CMS
funded programs, including Medicaid, Medicare, CHIP, and qualified health plans offered through
exchanges, including special enrollments that may be offered to eligibles.
Task 4: Streamline systems to offer aggregate payment options and remove any barriers to
Tribes and others paying premiums for enrollment in federally-funded programs, including
Medicare, Basic Health Plans, and Health Insurance Exchanges.
Objective 2b – To maximize access to care and coordination of services for AI/ANs, CMS will work with the TTAG
to develop processes to assure that I/T/Us can choose to be network providers for managed care
organizations that deliver services with funding from Medicare, Medicaid, CHIP and Health
Insurance Exchanges.
Task 1: CMS will work with the TTAG to develop a prototype Indian Addendum that can be used
with managed care provider contracts in all programs of CMS to acknowledge the federal laws
that are specific to the I/T/U and that can affect provider contracts.
Task 2: CMS will adopt standards of network adequacy for managed care organizations that are
federally-funded (in whole or part) that require inclusion of I/T/Us as sources of care that are
geographically accessible and culturally appropriate.
15

Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Task 3: CMS will review programs, policies, and payment mechanisms and provide training and
technical assistance to assure that each I/T/U can be the medical home for the AI/ANs who use
its services.
Task 4: CMS will assure that all AI/ANs who are enrolled in a managed care organization through
Medicare, Medicaid, CHIP or Health Insurance Exchanges can be referred to specialty care by
I/T/U providers and that the laws and protections regarding deductibles and co-pays for AI/AN
are followed.
Objective 2c – CMS will assure that I/T/Us are paid for all services that are covered by CMS supported
programs and provided to any AI/AN who is enrolled in Medicaid, Medicaid Expansion, Basic
Health Plans, Medicare, and Health Insurance Exchanges.
Task 1: CMS will enforce the laws that assure that I/T/Us are paid for off-plan services delivered
by it or an I/T/U provider to an AI/AN enrolled in a federally funded program by
assuring that this requirement is included in contracts with managed care organizations
and preferred provider arrangements,
providing a point of contact for I/T/U programs that are not able to receive payment for
services that have been billed,
informing the managed care or preferred provider organization of its obligation to pay
for these services, and
cancelling or not renewing contracts with managed care or preferred provider
organizations or qualified health plans that do not abide by the applicable statutory and
contractual and requirements.
Task 2. CMS will sponsor a conference to engage Tribal technical advisors and others in a better
understanding of emerging payment approaches in Medicare and Medicaid, analyze how those
approaches may affect I/T/U participation and revenues, and share that information with I/T/U
management.
Budget: $120,000 in 2013.
Task 3: All CMS programs will review their payment policies for telehealth services and work
with the TTAG to update those policies to assure that I/T/Us can be paid for telehealth services.
Task 4: CMS will resolve the problem of paying for Medicaid serves for AI/AN youth who are
receiving treatment and/or enrolled in boarding schools in a state other than where their parents
are resident (A/K/A Across State Borders).
Task 5: CMS will create a workgroup across all CMS programs and with the TTAG to develop
criteria for I/T/U providers as distinct provider types for enrollment in Medicare and in State
16

Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Medicaid programs in order to achieve greater flexibility for services and distinct payment
methodologies.
Objective 2d – The CMS Office for Dual Eligibles will work with a subcommittee of the TTAG to assure that
I/T/Us can participate in new approaches for coordinating services to and associated payments
for people who are dually eligible for Medicaid and Medicare, and in some cases also eligible for
services from the VA.
Task 1: TTAG will form a subcommittee to work with the Office for Dual Eligibles on planning
new programs, enrollment policies, and payment approaches appropriate for I/T/Us.
Objective 2e – CMS and the TTAG will work together to assure that AI/AN continue to receive needed services
and the I/T/U continues to receive payment for those services In the context of States reforming
their Medicaid programs, creating new types of waivers, choosing whether to implement
Medicaid Expansion, and eliminating CHIP programs.
Task 1: CMS will provide information and technical assistance to Tribes and States to allow them
to adopt the principles and approaches used in the Arizona Medicaid waiver that preserves
services for AI/ANs.
Task 2: CMS will notify Tribes affected by State reforms to their Medicaid programs and consult
with Tribes as soon as practicable on State Medicaid reform proposals.
Task 3: CMS will, as a condition of approving any State reform proposal, require the State to
design its proposal to ensure continued AI/AN access to existing covered services and I/T/U
payment for those services.
Objective 2f – Offices within CMS that are responsible for enforcement and compliance will work with the TTAG
to develop approaches for assisting I/T/Us adhere to applicable laws and regulations, to develop
adequate compliance systems, and to resolve compliance issues.
Task 1: The CMS TAG will provide training on Indian health care delivery systems to offices
responsible for enforcement. Such training will include material regarding the unique legal and
regulatory environment in which I/T/Us carry out their programs.
Task 2: CMS will expedite consideration of recommendations regarding Safe Harbors submitted
by Tribes and Tribal Organizations to assure that there is appropriate coordination between
health care delivery systems without violations of the law.
Task 3: CMS will work with the TTAG to develop appropriate policies for compliance that
consider the budgets, size, location, and staffing of I/T/U programs and to develop tiered
standards that do not unreasonably take resources from direct patient care to comply with CMS
requirements for accountability.
17

Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Task 4: CMS will provide training, technical assistance, and funding for systems’ improvements
to I/T/Us to assist them to comply with policies with regard to disclosure and auditing.
Objective 2g– CMS will facilitate implementation of ARRA Section 5006 that authorizes American Indian
Medicaid Managed Care Entities.
Task 1: CMS will sponsor a meeting with Tribes, Tribal Organizations, urban Indian
organizations, and others to share information, provide technical assistance, and identify next
steps for implementing the creation of American Indian Medicaid Managed Care Entities under
Section 5006 of ARRA.
Budget request: $150,000 per year in 2014 and 2015.
Objective 2h – CMS will create internal processes and funding to facilitate partnerships with Tribes, Tribal
Organizations, and urban Indian organizations to work together on new policies and approaches
to better align CMS and I/T/U programs.
Task 1: CMS will substantively involve TTAG in administrative, regulatory, and legislative policy
questions before the notice of proposed rule-making (NPRM) and provide funding for a policy
analyst to track NPRMs, determine whether proposed rules are relevant to Indian health care,
provide information to the TTAG about the potential impacts of regulations, track TTAG
comments on NPRMs, and track final regulations to see if they have been responsive to TTAG
recommendations.
Budget request: $250,000 per year
Task 2. CMS will create better mechanisms to fund cooperative agreements with Tribes, Tribal
Organizations, and urban Indian organizations to provide policy analysis, outreach and education
to assist CMS to carry out its mission to improve the health status of AI/ANs through better
access to care and quality of care.
Task 3. The CMS Office of Legislation will work with Tribes, Tribal Organizations, and urban
Indian organizations on mutually beneficial legislation, including revisions to the Affordable Care
Act to clarify the definition of Indian and to address issues related to Medicaid Expansion that
were created by the Supreme Court decision.
Task 4. CMS will move the Tribal Affairs Group from the Office of Public Engagement to the
Office of the Administrator to more accurately reflect its role in policy development across all
CMS agencies.
18

Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Goal 3: Improve and expand the development and delivery of Long Term Services and
Support throughout Indian communities.
Objective 3a - Develop and maintain an interactive data base of current Long Term Services and Supports (LTSS)
provided by the Indian Health Service, tribal health programs, and urban Indian organizations
with contact information for the providers. Develop toolkits to assist other health programs to
evaluate options and develop similar programs. In addition, CMS working with IHS and the
Administration for Community Living (ACL) in HHS will provide technical assistance to I/T/Us
developing and taking advantage of these LTSS programs
Task 1: Working with ACL and IHS, CMS will develop and maintain a website that will serve as an
AI/AN LTSS portal to:
1. Facilitate a learning community for the sharing of knowledge and expertise among
I/T/U health programs by:
a. Posting lists of existing programs and contacts for each;
b. Posting technical assistance resources, information, and links;
c. Hosting web-based seminars and conference calls;
d. Posting inventory of State Medicaid Plans and waivers that address LTSS in
states where I/T/U programs are located and updating the inventory at least
annually;
e. Research and post “best practices” and models for successful LTSS programs,
including an analysis and description of prior Elder Care Initiative projects;
f. Providing information to I/T/Us about training and technical assistance
resources and potential funding opportunities.
2. Provide an actively moderated listserv that will make available:
a. A forum for communication among CMS, IHS, and ACL with I/T/Us as they
develop LTSS; and
b. A forum for communication and sharing among I/T/U programs
Budget request: $125,000 in 2013 and $100,000 per year in 2014 and 2015.
The website will identify current opportunities and barriers for operation and development of
LTSS communities where I/T/U programs operate, and present “best practices” or models of
successful LTSS programs in such locations and information about how I/T/U programs
participate in these LTSS programs.
19

Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Note: In 2011 AoA, IHS and CMS signed a Memorandum of Understanding (MOU) to establish a
coordinated effort between the agencies to develop methods and means for providing technical
support to I/T/Us in order to expand development and delivery of LTSS in Indian communities.
Task 2: CMS will work with the TTAG, IHS, and the Administration for Community Living to
develop technical assistance materials for I/T/Us that want to develop and take advantage of
these LTSS programs.
Objective 3b - CMS will develop an AI/AN LTSS Delivery Plan and a LTSS Roadmap (formerly Toolkit) for I/T/Us
to provide information and guidance to I/T/Us wishing to research the possibilities of
implementing LTSS programs in their communities.
Task 1: CMS will work with TTAG and IHS to
Assist I/T/Us to assess their current LTSSs and to identify internal and external barriers
to optimal operation and expansion;
Develop an AI/AN LTSS Service Delivery Plan containing strategies to overcome existing
administrative or regulatory policy barriers for the implementation of LTSS in Indian
communities, including practical guidance from I/T/Us that have already developed
certain services; and
Develop recommendations on how to engage States and CMS for financing LTSS in
Indian communities.
Task 2: Working with TTAG, IHS, and ACL, CMS will develop a searchable web tool (LTSS
Roadmap) as a part of the website development in Objective 3a for use by I/T/Us in the
development of LTSS programs. The Roadmap will include information on LTSS that are
accessible and/or covered under State Plans and waivers, and will include options available to
I/T/Us to overcome barriers and improve access to LTSS and financing.
Budget request: $150,000 per year in 2013, 2014, and 2015.
Objective 3c - Throughout the next five years, CMS and TTAG will work collaboratively to educate tribal leaders
about long term care program planning and implementation, particularly regarding services that
address the needs of elders, veterans, and persons with disabilities.
Task 1: CMS and TTAG will review annually documents that describe overarching principles and
talking‐points, regarding the importance of LTSS for AI/ANs in Indian communities and other
communities where I/T/Us are located and delivery by I/T/U programs, controlling the cost and
improving the quality of LTSS programs supported with Federal funds, including Medicare and
Medicaid.
Task 2: On a quarterly basis, CMS and TTAG will develop audience‐specific educational
materials for I/T/U leadership and staff that describe strategies to achieve increased access to
20

Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
LTSS in Indian communities and other communities in which I/T/U programs are located and
will disseminate these materials to tribal leaders and I/T/U staff.
Budget request: $100,000 per year. These funds will cover formative research, media
design, printing, and dissemination.
Task 3: On an annual basis, CMS will work with TTAG and IHS to identify existing meetings or
conferences that are attended by I/T/U leaders and staff, at which workshops or
presentations could be provided on LTSS services in Indian communities and other
communities in which I/T/U programs are located. When appropriate, experts in this field
will provide workshops or presentations.
Budget request: $100,000 per year. These funds will cover travel, per diem, and
registration expenses for CMS, Tribal and/or expert presentations at five or more national
meetings/conferences.
Task 4: ACL, IHS, and CMS will jointly develop and support an annual AI/AN LTSS Conference for
experts to provide education on LTSS and allow I/T/U LTSS programs to share their experiences,
showcase best practices, and enhance the LTSS’ learning network.
Budget request: $200,000 per year in 2013, 2014, and 2015. These funds will cover
conference planning, facility costs, speaker fees, travel, and registration expenses for a
national AI/AN LTSS conference.
Task 5: From 2013-2017, CMS will fund a resource center to build capacity for LTSS for 15
Tribes, by assisting them with planning and development grants, and providing teams of experts
to evaluate their existing LTSS, developing specific steps to integrate and expand necessary
LTSS, and providing program specific assistance in overcoming barriers to accomplishing the
steps.
Budget request: $300,000 in 2013; $1.5 million per year in 2014 and 2015
21

Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Goal 4: Every Indian Health Service, tribal and urban Indian health program is fully informed
about CMS programs and every American Indian and Alaska Native knows about the benefits
to which they are entitled.
Objective 4a – Maintain effective communications between CMS and Tribes and I/T/U health programs.
Task 1: CMS will work with the TTAG and its Outreach & Education subcommittee to design and
implement a communications plan each year that facilitates a better understanding of CMS
programs among I/T/U providers.
Budget request: $25,000 per year
Task 2: CMS will use national Indian organizations such as the National Indian Health Board
(NIHB), the National Congress of American Indians (NCAI), National Council of Urban Indian
Health (NCUIH), and the Tribal Self-Governance Advisory Committee (TSGAC) to share CMS
information with Tribal governments and I/T/U health programs via established communication
channels, such as newsletters, websites, e-mails, and meetings.
Budget request: $150,000 per year. Funds will be used to sponsor national and regional
Tribal Organizations to disseminate CMS information via established communication
channels.
Task 3: At the request of area and national Indian organizations, CMS will participate in tribal
meetings, such as: the CMS Day at the National Indian Health Board’s Annual Consumer
Conference; the annual meetings for the National Congress of American Indians, Tribal Self
Governance, Direct Service Tribes, and Urban Indian Clinics; meetings of Area Indian Health
Boards; and tribal consultation meetings.
Budget request: $150,000 in 2013, $175,000 in 2014, $175,000 in 2015. Funds will be used
for sponsorship and to support registration, exhibit costs, and travel expenses.
Task 4: CMS should contract with Area Indian Health Boards and other organizations of I/T/U
programs to publicize CMS trainings and provide travel assistance for tribal participation in
regional trainings.
Budget request: $240,000 in 2013, $240,000 in 2014, $250,000 in 2015. Funds will be used
by regional and national tribal organizations to publicize CMS meetings and facilitate tribal
participation in regional trainings.
22

Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Objective 4b – Provide information, training, and capacity building assistance to the I/T/U regarding CMS
programs.
Task 1: In collaboration with TTAG, CMS will develop and implement an annual training plan for
I/T/U providers using appropriate Information Technology (IT) communication systems, such as
webinars, Medicine Dish programs, YouTube videos, and other social media.
Budget request: $100,000 in 2013, $150,000 in 2014, $200,000 in 2015.
Task 2: CMS will hold 20 training meetings per year to provide information about Medicare,
Medicaid, CHIP, and Health Insurance Exchanges to I/T/U employees to improve their provision
of CMS services and increase enrollment of AI/AN beneficiaries.
Budget request: $750,000 per year. These funds will be used to contract with Area Health
Boards to hold annual trainings and meetings for I/T/U employees.
Task 3: CMS will develop, maintain, and update web based manual of CMS policies and guidance
that are specifically related to AI/AN and the I/T/U.
Budget request: $100,000 in 2013, $125,000 in 2014, and $150,000 in 2015.
Task 4: All Tribes Calls will be scheduled specifically for issues related to Indian healthcare at
least 6 times per year, with TTAG assisting in developing topics for the calls.
Budget request: $100,000 per year.
Task 5: CMS and its contractors will provide tribal-specific ICD-10 training in each of the 12 Areas
of the Indian Health Service, and other coding training as needed.
Budget request: $200,000 in 2013, $750,000 in 2014, $850,000 in 2015.
Objective 4c – Provide training and technical assistance for I/T/U programs to maximize enrollment of eligible
AI/ANs in Medicaid, Medicaid Expansion, Medicare, CHIP, and Health Insurance Exchanges.
Task 1: CMS will provide training and technical assistance to I/T/Us and States to improve access
to sustainable sources of compensation for I/T/Us to provide enrollment assistance to AI/ANs for
CMS programs, such as Medicaid Administrative Match (MAM), and Navigator funding for
Exchange enrollment.
Budget request: $100,000 per year.
Task 2: CMS will provide training and technical assistance to I/T/Us and States to increase
utilization by I/T/Us of electronic enrollment applications and determinations, and new
approaches to simplification of enrollment processes.
Budget request: $500,000 per year.
23

Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Task 3: CMS, in collaboration with TTAG, will develop a simple and practical handout for use by
I/T/U personnel, States, and other entities providing enrollment assistance to AI/ANs that
explains the special provisions they qualify for because of their status as AI/ANs in CMS
programs.
Budget request: $125,000 in 2013, $200,000 in 2014, $125,000 in 2015.
Objective 4d – Provide materials and marketing designed to inform American Indians and Alaska Natives about
CMS programs for which they may be eligible.
Task 1: CMS will develop, design, produce, and disseminate materials that are culturally
appropriate and effective in AI/AN communities, with an emphasis on the new Medicaid
Expansion and Health Insurance Exchanges, by:
Hiring graphic artists who are AI/AN
Developing a television campaign with AI/AN images and messages that are
appropriate for people using Indian health programs
Developing radio programs for tribal radio stations
Placing materials in effective communication channels
Translating materials as needed
Budget request: $500,000 per year.
24

Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Goal 5: Develop and Improve CMS data systems to evaluate and expand the capacity
of CMS to serve American Indians and Alaska Natives.
Objective 5a – CMS will create data systems that identify AI/AN appropriately to assure that they are provided
the benefits and protections under laws and regulations (such as waiver of co-payments and
deductibles) under Medicaid, CHIP, Basic Health Plans, and Health Insurance Exchanges.
Task 1: CMS and TTAG will create a joint workgroup on Data and Policy to assure that AI/AN
provisions of ARRA and ACA, as well as other laws and regulations, are implemented in
the eligibility and enrollment processes, including designating and implementing the
federal data hub for eligibility; to assure that computer systems used by providers flag
AI/AN cost sharing protections; and to appropriately designate AI/ANs for reporting and
performance metrics, including assessing levels of enrollment.
Task 2: Twice a year CMS will hold a day of meetings at CMS central offices in Baltimore for
TTAG Data and Policy Subcommittee members to exchange information with key CMS
staff in policy implementation, data systems, and innovations to understand the
changes that are occurring with the implementation of health care legislation and how
they could affect AI/AN enrollment and I/T/U provider participation in CMS programs.
Task 3: The attendees will make recommendations to the CMS TTAG regarding approaches
needed to change CMS and other data collection systems for implementation of health
care legislation and suggest topics on the effects on AI/AN and I/T/U for follow-up.
Task 4: Make the CMS data and any findings from the data systems available online, in
presentations at AI/AN and CMS conferences, and in reports, so that AIAN stakeholders
can use the data and findings.
Budget request: $150,000 per year for Objective 5a.
Objective 5b – Develop and improve data for AI/AN populations within and outside of the IHS healthcare
delivery system that can be used to evaluate CMS program enrollment, health care delivery,
outcomes, and payments across states and IHS Areas during the implementation of ACA, CHIPRA,
ARRA, and any subsequent health care policy changes.
Task 1: Establish baseline enrollment rates in CMS programs and federally facilitated Health
Insurance Exchanges for AI/ANs and monitor changes in the rates.
25

Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Task 2: Establish baseline usage indicators for CMS program health care services used by AI/ANs
and monitor changes in the usage.
Task 3: Determine health outcomes in CMS programs of care for AI/ANs.
Task 4: Establish baseline CMS program payments for health care for AI/ANs and monitor
changes in the payments.
Task 5: Make the evaluation data sets and findings available online, in presentations at AI/AN
and CMS conferences, and in reports, so that AIAN stakeholders can use the data and
findings.
Budget request: $300,000 per year for Objective 5b.
Objective 5c – Produce an AI/AN CMS Data Symposium on the impact of the implementation of ACA, CHIPRA,
ARRA, and any subsequent health care policy changes on AI/AN and I/T/U providers.
Task 1: CMS will sponsor a one-day Data and Policy Conference bringing together experts in
demographic, services ,and policy analysis from outside CMS to better understand the
impacts of the legislative health care reforms relevant to AI/AN and I/T/U providers.
Task 2: Conduct conference planning sessions with CMS staff, and secure the necessary
personnel, materials, facilities, and equipment to accomplish the tasks needed to plan,
prepare, and execute the Conference including making site arrangements for the event
and travel arrangements for speakers.
Task 3: Provide brief descriptions of three research projects that could be carried out using the
American Indian specific data developed to date that might have utility to Tribes, IHS
funded health providers, state Medicaid programs or Health Benefit Exchanges.
Task 4: Provide a technical writer for the symposium who shall prepare a draft Data Symposium
Summary report within 4 weeks after the event.
Task 5: Make summaries of the presentations available online and in a report, so that AI/AN and
CMS stakeholders can benefit from the data and findings.
Budget request: $50,000 for one conference.
26

Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Objective 5d – CMS and TTAG annually will update and review its AI/AN research and evaluation plan to better
track and evaluate CMS program services and policy impacts on AI/ANs and ITUs.
Task 1: CMS will work with the TTAG and its subcommittees, Tribal Epidemiology Centers, and
the HHS Health Research Advisory Committee for AI/ANs (HRAC) to update the plan to
identify additional data development and analysis work.
Task 2: Carry out additional data development and analysis activities that are of high impact or
of a time sensitive nature.
Budget request: $75,000 per year for objective 5d.
27

Draft Report: Currently being circulated for Tribal leader and health director review and comment. Please provide
comments by October 30, 2012 to Liz Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
APPENDIX A: PLAN SUMMARY AND BUDGET
Goal 1: CMS engages in meaningful consultation with Tribes and work closely with the Tribal Technical Advisory Group (TTAG).
Objectives & Tasks FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 FY 2018
Objective 1a – On an annual basis, CMS will engage the TTAG to evaluate and revise the CMS Tribal Consultation Policy
Task 1: Evaluate and revise existing CMS Tribal Consultation
Policy, in collaboration with the TTAG and CMS Tribal Affairs
Group (TAG), and provide an opportunity for Tribal
consultation on the policy.
Task 2: Conduct an annual Tribal Consultation session. 75,000 75,000 75,000 75,000 75,000 75,000
Task 3: Written annual report documenting and evaluating
consultation activities disseminated to partners in the first
quarter of each fiscal year to assess both consultation
processes and outcomes.
40,000 40,000 40,000 40,000 40,000 40,000
Objective 1b – In collaboration with the TTAG, CMS will develop mechanisms to involve tribes in states that have federal-facilitated exchanges and partnership
exchanges to assure that I/T/U issues are addressed in the planning, policies, structure, and operations of those exchanges.
Task 1: Beginning in 2012, health insurance exchanges
workgroups that meet regularly to resolve issues.
Objective 1c – Each year, CMS will provide financial and administrative support to facilitate the ongoing activities of TTAG, and a sufficient budget to support TTAG
activities included in the 2013-2018 Strategic Plan.
Task 1: CMS will fully fund the Tribal Technical Advisory Group. 280,000 280,000 280,000 280,000 280,000 280,000
Task 2: CMS will actively seek American Indians and Alaska
Natives to hire for key policy positions.
25,000 25,000 25,000 25,000 25,000 25,000
28

Draft Report: Currently being circulated for Tribal leader and health director review and comment. Please provide
comments by October 30, 2012 to Liz Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Task 3: The Tribal Affairs Group at CMS will report quarterly to
TTAG
activities and funding for implementation of this Strategic Plan
Task 4: CMS will retain at least 7 FTE personnel in the Tribal Affairs
Group.
Objective 1d – CMS personnel with the authority to make binding decisions will regularly participate in TTAG meetings, the Annual DHHS Budget Consultation session,
and DHHS regional tribal consultation meetings and listening sessions.
Task 1: On an annual basis, the CMS Administrator, the CPC
Director, the CMM Director, and the CMSO Director will
participate in at least 3 face-to-face meetings with TTAG, along
with other CMS officials.
Task 2: Key leadership from CMS Headquarters will attend
annual DHHS regional tribal consultation meetings and
listening sessions.
Objective 1e – By fiscal year 2013, CMS will develop a set of standard operating procedures that will be used by the agency to guide administrative decisions regarding
Indian health policy
Task 1: TTAG and the CMS Office of External Affairs will
develop standard operating procedures that can be used by
CMS to guide policy formation and Tribal consultation.
40,000 15,000 15,000 15,000 15,000 15,000
SUBTOTAL 460,000 435,000 435,000 435,000 435,000 435,000
29

Draft Report: Currently being circulated for Tribal leader and health director review and comment. Please provide
comments by October 30, 2012 to Liz Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Goal 2: CMS enacts and implements policy through regulation, guidance, review and enforcement to align CMS programs to serve AI/AN by
improving enrollment processes, assuring access to care, having efficient payment systems, and increasing the I/T/U capacity to deliver integrated,
comprehensive programs.
Objective 2a – CMS will work with the TTAG to develop a global approach to funding enrollment assistance provided by the I/T/U and eligibility determinations for all
CMS programs.
Task 1: Evaluate the number of States and Tribes using
MAM to fund enrollment assistance and other
approaches for assisting AI/AN who use I/T/U facilities
to enroll in CMS programs through the health insurance
exchange websites, and ways to simplifying
applications and approvals for enrollment.
Task 2: Develop mechanisms for the I/T/U to receive
Navigator or other funding from the Federallyfacilitated
Exchanges, the partnership exchanges and
the state exchanges.
Task 3: Consider alternative sources of funding for the
I/T/U to assist AI/AN to enroll in CMS funded programs,
including Medicaid, Medicare and dual eligibles.
Task 4: Streamline systems to offer aggregate payment
options and
remove any barriers to Tribes and others paying
premiums for enrollment in CMS programs.
Objective 2b – To maximize access to care and coordination of services for AI/ANs, CMS will work with the TTAG to develop processes to assure that the I/T/U can
choose to be network providers for managed care organizations that deliver services with funding from Medicare, Medicaid, CHIP and Health Insurance Exchanges.
Task 1: Develop a prototype Indian Addendum that
can be used with managed care provider contracts in all
CMS programs.
30

Draft Report: Currently being circulated for Tribal leader and health director review and comment. Please provide
comments by October 30, 2012 to Liz Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Task 2: Adopt network adequacy standards to include
I/T/U for managed care organizations funded through
CMS programs.
Task 3: Review programs, policies, payment
mechanisms and provide training and technical
assistance to assure that the I/T/U can be the medical
home for AI/AN who use their services.
Task 4: Assure that AI/AN who are enrolled in
managed care organization through CMS programs can
be referred to specialty care by I/T/U providers and
that the laws and protections regarding deductibles
and co-pays for AI/AN are followed.
Objective 2c – CMS will assure that the I/T/U is paid for all services provided that are covered by CMS programs for all AI/AN who are enrolled in Medicaid, Medicaid
Expansion, Basic Health Plans, Medicare, and Health Insurance Exchanges.
Task 1: CMS enforces the law that assures that the
I/T/U is paid for off-plan services by managed care
organizations with CMS funding.
Task 2: CMS will sponsor a conference to engage Tribal
technical advisors and others on emerging payment
approaches, analyze how those approaches may affect
I/T/U, and share that information.
Task 3: All CMS programs will review their payment
policies to assure that the I/T/U can be paid for
telehealth services delivered to AI/AN.
Task 4: CMS will pay for Medicaid serves for AI/AN
youth who are
receiving treatment and/or enrolled in boarding
schools in a different state from their parents (A/K/A
Across State Borders).
Task 5: CMS will create a workgroup across all agencies
and with the TTAG to develop criteria for I/T/U
providers as distinct provider types for enrollment in
Medicare and Medicaid.
120,000 0 0 0 0 0
31

Draft Report: Currently being circulated for Tribal leader and health director review and comment. Please provide
comments by October 30, 2012 to Liz Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Objective 2d – The Office for Dual Eligibles will work with a subcommittee of the TTAG to assure that there is integration of the Indian health system in new
approaches for coordinating services and payments for people who are eligible for Medicaid and Medicare, and in some cases also eligible for services from the VA.
Task 1: Workgroup on policy and data to implement
AI/AN provisions of ARRA and ACA on eligibility and
enrollment, federal data hub, and computer systems
used by providers to flag AI/AN cost sharing
protections, and performance metrics.
Objective 2e – CMS and the TTAG will work together to assure that AI/AN continue to receive needed services and the I/T/U continues to receive payment for those
services In the context of States reforming their Medicaid programs, creating new types of waivers, choosing whether to implement Medicaid Expansion, and
eliminating CHIP programs.
Task 1: Information and technical assistance to Tribes
and States to adopt principles and approaches used in
Arizona Medicaid waiver to preserve services for AI/AN.
Task 2: Notify Tribes about State Medicaid reforms and
consult with them.
Task 3: State Medicaid reform proposals approval
contingent on continued services for AI/AN from I/T/U,
and payment for those services.
120,000 0 0 0 0 0
Objective 2f – Offices within CMS that are responsible for enforcement and compliance will work with the TTAG to develop reasonable approaches for assuring that
I/T/U adheres to laws and regulations.
Task 1: Training on Indian health care delivery systems
to CMS offices responsible for enforcement.
Task 2: Expedite consideration of recommendations
regarding Safe
Harbors submitted by Tribes and Tribal Organizations.
Task 3: Develop appropriate policies for compliance
with tiered standards that consider the budgets, size,
location and staffing of I/T/U facilities.
32

Draft Report: Currently being circulated for Tribal leader and health director review and comment. Please provide
comments by October 30, 2012 to Liz Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Task 4: Training, technical assistance, and funding for
systems
improvement to the I/T/U to comply with policies on
disclosure and
auditing.
Objective 2g– CMS will facilitate ARRA Section 5006 that authorizes American Indian Medicaid Managed Care Entities.
Task 1: Sponsor a meeting on the creation of
American Indian Medicaid Managed Care Entities under
Section 5006 of ARRA.
0 150,000 150,000 0 0 0
Objective 2h – CMS will create internal processes and funding to facilitate partnerships with Tribes and Tribal organizations to work together on new policies and
approaches to better align CMS and I/T/U programs.
Task 1: Maintain funding for regulation review. 250,000 250,000 250,000 250,000 250,000 250,000
Task 2: Create better mechanisms to fund cooperative
agreements with Tribes and Tribal Organizations.
Task 3: The CMS Office of Legislation will work with
Tribes on mutually beneficial legislation, including
revisions to ACA to clarify the definition of Indian and
to address issues related to Medicaid Expansion.
Task 4: Move the CMS Tribal Affairs Group from the
Office of Public Engagement to the Office of the
Administrator.
SUBTOTAL 490,000 400,000 400,000 250,000 250,000 250,000
33

Draft Report: Currently being circulated for Tribal leader and health director review and comment. Please provide
comments by October 30, 2012 to Liz Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Goal 3: CMS Improves and expands the development and delivery of Long Term Services and Support (LTSS) throughout Indian communities.
Objective 3a - Develop and maintain an interactive data base of current Long Term Services and Supports (LTSS) provided by the Indian Health Service (IHS), tribal
health programs, and urban Indian health programs (I/T/U) with contact information for the providers. Develop tool kits to assist other health programs to evaluate
options and develop similar programs. In addition, CMS working with IHS and the Administration for Community Living (ACL) in HHS will provide technical assistance
to I/T/Us developing and taking advantage of these LTSS programs
Task 1: Working with ACL and IHS, CMS will develop
and maintain a
website that will serve as an AI/AN LTSS portal.
Task 2: CMS will work with the TTAG, IHS and ACL to
develop technical assistance materials for I/T/U.
125,000 100,000 100,000 0 0 0
Objective 3b - CMS will develop an AI/AN LTSS Delivery Plan and a LTSS Roadmap (formerly Toolkit) for Indian communities to provide information and guidance to
I/T/Us wishing to research the possibilities of implementing LTSS programs in their communities.
Task 1: Assist I/T/Us to assess their current LTSSs,
develop an AI/AN LTSS Service Delivery Plan, and
develop recommendations to engage States and CMS
for financing LTSS in Indian communities.
Task 2: Develop a searchable web tool (LTSS
Roadmap) as a part of the website development.
150,000 150,000 150,000 0 0 0
Objective 3c- Throughout the next five years, CMS and TTAG will work collaboratively to educate tribal leaders about long term care program planning and
implementation, particularly regarding services that address the needs of elders, veterans, and persons with disabilities.
Task 1: Annually review documents for I/T/U that
describe principles and talking‐points about the
importance of LTSS, controlling costs, and improving
quality.
34

Draft Report: Currently being circulated for Tribal leader and health director review and comment. Please provide
comments by October 30, 2012 to Liz Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Task 2: Quarterly development and dissemination of
audience‐specific educational materials for I/T/U
leadership and staff that describe strategies to achieve
increased access to LTSS in Indian communities.
Task 3: Annually identify existing meetings or
conferences attended by I/T/U leaders and provide
presentations there on LTSS services in Indian
communities.
100,000 100,000 100,000 100,000 100,000 100,000
100,000 100,000 100,000 100,000 100,000 100,000
Task 4: Support annual AI/AN LTSS Conference. 200,000 200,000 200,000 0 0 0
Task 5: Fund a resource center to build capacity for
LTSS for 15 Tribes.
300,000 1,500,000 1,500,000 0 0 0
SUBTOTAL 975,000 2,150,000 2,150,000 200,000 200,000 200,000
Goal 4: Every I/T/U facility is fully informed about CMS programs and every AI/AN knows about benefits to which they are entitled.
Objective 4a – Maintain effective communications between CMS and Tribes.
Task 1: Design and implement annual communications
plan that facilitates a better understanding of CMS
programs among I/T/U providers.
Task 2: CMS will use tribal organizations to share CMS
information with Tribes via established communication
channels.
Task 3: At the request of tribal organizations, CMS will
participate in tribal meetings.
Task 4: CMS should contract with Area Indian Health
Boards and other Tribal organizations to publicize CMS
trainings and provide travel assistance for Tribal
participation in regional trainings.
Objective 4b – Provide information, training and capacity building assistance to the I/T/U regarding CMS programs.
25,000 25,000 25,000 25,000 25,000 25,000
150,000 150,000 150,000 150,000 150,000 150,000
150,000 175,000 175,000 175,000 175,000 175,000
240,000 240,000 250,000 250,000 250,000 250,000
35

Draft Report: Currently being circulated for Tribal leader and health director review and comment. Please provide
comments by October 30, 2012 to Liz Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Task 1: Develop and implement annual training plan
for I/T/U providers using appropriate Information
Technology (IT) communication systems.
Task 2: Hold 20 training meetings per year to provide
information about CMS programs to I/T/U employees.
Task 3: Develop, maintain and update web based
manual of CMS policies and guidance specifically
related to AI/AN and the I/T/U.
Task 4: All Tribes Calls related to Indian healthcare at
least 6 times per year.
Task 5: Tribal-specific ICD-10 training in each of the 12
Areas of the IHS.
100,000 150,000 200,000 200,000 200,000 200,000
750,000 750,000 750,000 750,000 750,000 750,000
100,000 125,000 150,000 100,000 100,000 100,000
100,000 100,000 100,000 100,000 100,000 100,000
200,000 750,000 850,000 200,000 200,000 200,000
Objective 4c – Provide training and technical assistance for I/T/U facilities to maximize enrollment of eligible AI/AN in Medicaid, Medicaid Expansion, Medicare, CHIP
and Health Insurance Exchanges.
Task 1: Training and technical assistance to I/T/U and
States to identify enrollment assistance funding for
CMS programs.
Task 2: Training and technical assistance to I/T/U and
States to increase use of electronic enrollment
applications and determinations, and simplification of
enrollment processes.
Task 3: Develop a simple and practical handout for
enrollment assistance that explains the special
provisions for AI/ANs in CMS programs.
100,000 100,000 100,000 100,000 100,000 100,000
500,000 500,000 500,000 500,000 500,000 500,000
125,000 200,000 125,000 0 0 0
Objective 4d – Provide materials and marketing designed to inform AI/AN consumers about CMS programs for which they may be eligible.
36

Draft Report: Currently being circulated for Tribal leader and health director review and comment. Please provide
comments by October 30, 2012 to Liz Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Task 1: CMS will develop, design, produce and
disseminate create materials that are culturally
appropriate and effective in AI/AN communities, with
an emphasis on the new Medicaid Expansion and
Health Insurance Exchanges.
500,000 500,000 500,000 500,000 500,000 500,000
SUBTOTAL 3,040,000 3,765,000 3,875,000 3,050,000 3,050,000 3,050,000
Goal 5: Develop and improve CMS data systems to evaluate and expand the capacity of CMS to serve American Indians and Alaska Natives.
Objective 5a – CMS will create data systems that identify AI/AN appropriately to assure that they are provided the benefits and protections under law and regulations
(such as waiver of co-payments and deductibles) under Medicaid, Basic Health Plans, and Health Insurance Exchanges.
Task 1: Workgroup on policy and data to implement
AI/AN provisions of ARRA and ACA on eligibility and
enrollment, federal data hub, and computer systems
used by providers to flag AI/AN cost sharing protections,
and performance metrics.
Task 2: Twice a year CMS will hold a day of meetings at
CMS for TTAG Data and Policy Committee members to
exchange information with key CMS staff. Attendees will
make recommendations to the CMS TTAG and suggest
topics for follow-up. Presentations at AI/AN and CMS
conferences, and in reports.
150,000 150,000 150,000 150,000 150,000 150,000
Objective 5b – Develop and improve data for the AI/AN populations within and outside of the IHS healthcare delivery system that can be used to evaluate CMS
program enrollment, health care delivery, outcomes and payments across states and IHS Areas during the implementation of ACA, CHIPRA, ARRA and any subsequent
health care policy changes.
Task 1: Establish baseline enrollment rates for AI/ANs
and monitor
changes.
Task 2: Establish baseline usage indicators for AI/ANs
and monitor
changes.
37

Draft Report: Currently being circulated for Tribal leader and health director review and comment. Please provide
comments by October 30, 2012 to Liz Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Task 3: Determine health outcomes for AI/ANs in CMS
programs.
Task 4: Establish baseline CMS program payments for
health care for AI/AN and monitor changes.
Task 5: Make evaluation data sets and findings available
online, in presentations at AI/AN and CMS conferences,
and in reports.
300,000 300,000 300,000 300,000 300,000 300,000
Objective 5c – Produce an AI/AN CMS Data Symposium on the impact of the implementation of ACA, CHIPRA ARRA and any subsequent health care policy changes on
AI/AN and I/T/U providers.
Task 1: Sponsor AI/AN Data and Policy Conference.
Task 2: Conduct conference planning sessions with CMS
staff, and secure the necessary personnel, materials,
facilities and equipment to accomplish the tasks needed
to plan, prepare and execute the Conference including
making site arrangements for the event and travel
arrangements for speakers.
Task 3: Provide brief descriptions of three research
projects that could be carried out using AI/AN specific
data.
Task 4: Technical writer for the symposium shall prepare
Data Symposium Summary.
Task 5: Make summaries of the presentations available
online, and in a report.
50,000 0 0 0 0 0
Objective 5d – CMS and TTAG annually will update and review its AI/AN research and evaluation plan to better track and evaluate CMS program services and policy
impacts on AI/AN’s and ITU’s.
38

Draft Report: Currently being circulated for Tribal leader and health director review and comment. Please provide
comments by October 30, 2012 to Liz Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Task 1: CMS will work with the TTAG and its Sub
Committees, Tribal
Epidemiology Centers, and the DHHS Health Research
Advisory Committee
for AI/AN (HRAC) to update the plan to identify additional
data
development and analysis work.
Task 2: Carry out additional data development and
analysis activities that are of high impact or of a time
sensitive nature.
TOTAL
S
75,000 75,000 75,000 75,000 75,000 75,000
575,000 525,000 525,000 525,000 525,000 525,000
TOTALS 5,540,000 7,275,000 7,385,000 4,460,000 4,460,000 4,460,000
39

Draft Report: Currently being circulated for Tribal leader and health director review and
comment. Please provide comments by October 30, 2012 to Liz Heintzman at the
National Indian Health Board at EHeintzman@nihb.org.
Appendix B: Legal Basis for Special CMS Provisions for American Indians and Alaska Natives
I. Introduction
Carol Barbero, Esq. 5
Elliott Milhollin, Esq.
Hobbs, Straus, Dean and Walker, LLP
November 2012
There is a special relationship between the United States and Indian Tribes that creates a trust
responsibility toward Indian people regarding health care. The existence of this truly unique obligation
supplies the legal justification and moral foundation for health policy making specific to American
Indians and Alaska Natives (AI/ANs) – with the objectives of enhancing their access to health care and
overcoming the chronic health status disparities of this segment of the American population.
It is beyond question that the obligation to carry out the trust responsibility to Indians applies to all
agencies of the federal government – including the Centers for Medicare & Medicaid Services (CMS) –
as evidenced by Presidential Executive Orders and Special Memoranda. 6 Furthermore, with regard to
health care for AI/ANs, federal law assigns comprehensive duties to the Secretary of the Department of
Health and Human Services (HHS) in order to achieve the goals and objectives established by Congress
for Indian health. The trust responsibility, and laws enacted pursuant thereto, provides ample
authority for the Secretary – whether acting through the Indian Health Service (IHS), CMS, or other
agency of HHS – to take pro-active efforts to achieve the Indian health objectives Congress has
articulated.
5 The initial version of this Appendix D appeared in the first Strategic Plan submitted to CMS in 2005 by the CMS Tribal
Technical Advisory Group. In that submission, the author acknowledged the Northwest Portland Area Indian Health Board
(NPAIHB) and its member tribes for their generous support of the author’s earlier work which provided foundation for that
paper. That earlier paper, titled "The Federal Trust Responsibility: Justification for Indian-Specific Health Policy," was
presented at the National Roundtable on the Indian Health System and Medicaid Reform sponsored by the NPAIHB at the
Urban Institute on August 31, 2005. This Appendix D has been updated to reflect significant Indian-specific health policy
legislative and administrative actions that have occurred since it was originally drafted. The authors would like to thank the
United South and Eastern Tribes, Inc. for its generous support in updating this Appendix D.
6 See, e.g., Exec. Order No. 13175, 65 Fed. Reg. 67249 (Nov. 6, 2000) reprinted in 2000 U.S.C.C.A.N. at B77; White House
Memorandum for Heads of Executive Departments and Agencies, Nov. 5, 2009; Dep't of Health and Human Services Tribal
Consultation Policy (Dec. 14, 2010); Centers for Medicare and Medicaid Services Tribal Consultation Policy (Nov. 17, 2011);
Cramer v. United States, 261 U.S. 219 (1923).
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Draft Report: Currently being circulated for Tribal leader and health director review and
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National Indian Health Board at EHeintzman@nihb.org.
HHS and CMS both recognize this authority in their tribal consultation policy:
Since the formation of the Union, the United States (U.S.) has recognized
Indian Tribes as sovereign nations. A unique government-to-government
relationship exists between Indian Tribes and the Federal Government
and this relationship is grounded in the U.S. Constitution, numerous
treaties, statutes, Federal case law, regulations, and executive orders that
establish and define a trust relationship with Indian Tribes. This
relationship is derived from the political and legal relationship that Indian
Tribes have with the Federal Government and is not based upon race.
This special relationship is affirmed in statutes and various Presidential
Executive Orders … 7
While CMS often looks to the Social Security Act for authority, the historic and complex body of federal
Indian law and case law applies throughout the federal government to all agencies, including CMS. The
intent of this paper is to provide a brief summary of federal Indian law that is most relevant to current
and future regulations and guidance regarding participation of Indians and the Indian health system in
Medicare, Medicaid, Child Health Insurance Programs, and health insurance exchanges.
II. The United States has a Trust Responsibility to Indians
A. Origins of the trust responsibility to Indians
The federal trust responsibility to Indians, and the related power to exercise control over Indian affairs
in aid of that responsibility, is rooted in the United States Constitution – most significantly the Indian
Commerce Clause, the Treaty Clause, and the exercise of the Supremacy Clause. 8 The Constitution
contains no explicit language that defines the trust relationship. Rather, the parameters of the trust
responsibility have evolved over time through judicial pronouncements, treaties, Acts of Congress,
Executive Orders, regulations, and the ongoing course of dealings between the federal government
and Indian tribal governments.
7 Dep't of Health and Human Services Tribal Consultation Policy (Dec. 14, 2010), at 1; Centers for Medicare and Medicaid
Services Tribal Consultation Policy (Nov. 17, 2011), at 1.
8 Morton v. Mancari, 417 U.S. 535, 551-552 (1974) ("The plenary power of Congress to deal with the special problems of
Indians is drawn both explicitly and implicitly from the Constitution itself."); McClanahan v. Arizona State Tax Comm’n, 411
U.S. 164, 172, n.7 (1973); see also TASK FORCE No. 9, VOL. 1, AMERICAN INDIAN POLICY REVIEW COMM’N 31 (1976)
(explaining the origins of Constitutional power to regulate Indian affairs as flowing from Congress’s treaty making powers,
powers to regulate commerce with Indian tribes, and its authority to withhold appropriations); FELIX S. COHEN, HANDBOOK
OF FEDERAL INDIAN LAW 418-423 (2005); Reid Payton Chambers, Judicial Enforcement of the Federal Trust Responsibility to
Indians, 27 STAN. L. REV. 1213, 1215-1220 (1975).
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Draft Report: Currently being circulated for Tribal leader and health director review and
comment. Please provide comments by October 30, 2012 to Liz Heintzman at the
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The earliest formal dealings between the federal government and Indian Tribes were undertaken
through treaty-making. From the United States’ perspective, treaty objectives were essentially twofold:
cessation of hostilities to achieve and maintain public peace, and acquisition of land occupied by
tribal members. Tribes doubtless had a peace-making motive as well, but in return for the vast tracts
of land they relinquished to the more powerful federal government, Tribes also obtained the promise –
expressed or implied – of support for the social, educational, and welfare needs of their people,
including health care. These treaties/promises were the first expression of the federal government’s
obligation to Indian tribes.
The initial express recognition that a trust responsibility existed came from the courts. In the landmark
case of Cherokee Nation v. Georgia, 30 U.S, 1 (1831), Chief Justice John Marshall established the legal
foundation for the trust responsibility by describing Indian Tribes as “domestic dependent nations”
whose relationship with the United States “resembles that of a ward to his guardian.” Id. At 17. That
theme – and the duty of the federal sovereign to Indian Tribes – carried forward some 50 years later
when, in United States v. Kagama, 118 U.S. 375, 384 (1886), the Supreme Court acknowledged that
Tribes are under the protection and care of the United States:
From their very weakness and helplessness, so largely due to the course
of dealing of the federal government with them, and the treaties in which
it has been promised, there arises the duty of protection, and with it the
power [of protection]. 9
Through nearly two centuries of case law, the courts have extensively examined the parameters of the
trust responsibility to Indians, frequently in the context of whether the federal government has the
authority to perform an action and whether there are limitations on the exercise of Congressional
power over Indian affairs. While Congress has plenary authority over Indian matters through the
Constitution, the “guardian-ward” relationship articulated by Chief Justice Marshall requires that
federal actions be beneficial, or at least not harmful, to Indian welfare. This is not to say, however,
that the United States has always acted honorably toward Indians throughout its history. 10
Nonetheless, the fact that our government has failed in some instances to act in an honorable manner
9 See also Board of County Commissioners of Creek County v. Seber, 318 U.S. 705, 715 (1943) ("Of necessity the United
States assumed the duty of furnishing . . . protection [to Indian tribes] and with it the authority to do all that was required
to perform that obligation . . . .").
10 An example is unilateral abrogation of Indian treaties by Congress. See, e.g., Lone Wolf v. Hitchcock, 187 U.S. 553
(1903).
42

Draft Report: Currently being circulated for Tribal leader and health director review and
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toward Indians does not and should not absolve the more powerful sovereign from its responsibility to
carry out its obligations honorably.
B. “Indian” as a political rather than a racial classification: Indian-specific lawmaking and
the “rationally related” standard of review
In pursuit of its authority under the Constitution and the trust responsibility, Congress has enacted
Indian-specific laws on a wide variety of topics 11 as well as included Indian-specific provisions in
general laws to address Indian participation in federal programs. 12 In the landmark case of Morton v.
Mancari, 417 U.S. 535 (1974), the Supreme Court set out the standard of review for such laws – the
“rational basis” test. In Mancari, the Court reviewed an assertion by non-Indians that the application
of Indian preference in employment at the Bureau of Indian Affairs (as ordered in the Indian
Reorganization Act 13 ) was racially discriminatory under the then-recently amended civil rights law
which prohibited racial discrimination in most areas of federal employment.
11 See, e.g., Indian Health Care Improvement Act, 25 U.S.C. § 1601, et seq.; Indian Self-Determination and Education
Assistance Act, 25 U.S.C. §450, et seq.; Indian Education Act, 20 U.S.C. §7401, et seq.; Tribally Controlled Schools Act, 25
U.S.C. §2501, et seq.; Tribally Controlled College or University Assistance Act, 25 U.S.C. §1801, et seq.; Native American
Housing Assistance and Self-Determination Act, 25 U.S.C. §4101, et seq.; Indian Child Welfare Act, 25 U.S.C. §1901, et seq.;
Indian Child Protection and Family Violence Prevention Act, 25 U.S.C. §3201, et seq.; Indian Employment, Training, and
Related Services Demonstration Act, 25 U.S.C. §3401, et seq.
12 See, e.g., 42 U.S.C. §1395qq (eligibility of IHS/tribal facilities for Medicare payments); 42 U.S.C. §1396j (eligibility of
IHS/tribal facilities for Medicaid payments); 42 U.S.C. §1397bb(b)(3)(D) (assurance of CHIP services to eligible low-income
Indian children); Elementary and Secondary Education Act, as amended, 20 U.S.C. §6301, et seq. (funding set-asides
throughout this law for the benefit of children enrolled in the Bureau of Indian Affairs school system); Impact Aid Program,
20 U.S.C. §7701, et seq. (federal aid to public school districts for Indian children living on Indian lands); Carl D. Perkins
Vocational and Applied Technology Education Act, 20 U.S.C. §§2326 and 2327 (funding set-aside for Indian vocational
education programs and tribal vocational Institutions); Higher Education Act, 20 U.S.C. §1059c (funding for triballycontrolled
higher education institutions); Individuals with Disabilities Education Act, 20 U.S.C. §1411(c) (funding set-aside
for Bureau of Indian Affairs schools); Head Start Act, 42 U.S.C. §9801, et seq. (includes funding allocation for Indian tribal
programs and special criteria for program eligibility); Federal Highway Act, 23 U.S.C. §101, et seq. (1998, 2005, 2008 and
2012 amendments include funding set-asides for Indian reservation roads programs and direct development of regulations
through Negotiated Rulemaking with tribes); American Recovery and Reinvestment Act of 2009, P.L. 111-5 (Feb. 17, 2009)
(§5006 making amendments to the Social Security Act to provide various protections for Indians under Medicaid and CHIP,
discussed below); Patient Protection and Affordable Care Act, P.L. 111-148 (Mar. 23, 2010) (various Indian specific
provisions, discussed below).
13 25 U.S.C. §461, et seq. The Indian hiring preference appears at 25 U.S.C. §472.
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Draft Report: Currently being circulated for Tribal leader and health director review and
comment. Please provide comments by October 30, 2012 to Liz Heintzman at the
National Indian Health Board at EHeintzman@nihb.org.
While the Supreme Court’s civil rights jurisprudence has generally applied strict scrutiny when
reviewing classifications based on race, color, or national origin, 14 in Mancari the Court determined
that this test was not appropriate when reviewing an Indian employment preference law. Indeed, the
Court declared that the practice under review was not even a “racial” preference. Rather, in view of
the unique historic and political relationship between the United States and Indian Tribes, the Court
characterized the preference law as political rather than racial, and said that “[a]s long as the special
treatment [for Indians] can be tied rationally to the fulfillment of Congress’ unique obligation toward
the Indians, such legislative judgments will not be disturbed.” Id. At 555. The Court found that hiring
preferences in the federal government’s Indian service were intended “to further the Government’s
trust obligation toward the Indian tribes,” to provide greater participation in their own selfgovernment,
and “to reduce the negative effect of having non-Indians administer matters that affect
Indian tribal life” in agencies, such as the BIA, which administer federal programs for Indians. Id. At
541-542 (emphasis added). 15
Once the link between special treatment for Indians as a political class and the federal government’s
unique obligation to Indians is established, “ordinary rational basis scrutiny applies to Indian
classifications just as it does to other non-suspect classifications under equal protection analysis.”
Narragansett Indian Tribe v. National Indian Gaming Comm’n., 158 F.3d 1335, 1340 (D.C. Cir. 1998).
The Indian hiring preference sanctioned by the Court in Mancari is only one of the many activities the
Court has held are rationally related to the United States’ unique obligation toward Indians. The Court
14 The Supreme Court has interpreted Title VI to allow racial and ethnic classifications only if those classifications are
permissible under the Equal Protection Clause. Regents of Univ. of Cal. v. Bakke, 438 U.S. 265, 287 (1978). In this regard,
the Court has also stated that "all racial classifications, imposed by whatever federal, state, or local governmental actor,
must be analyzed by a reviewing court under strict scrutiny. In other words, such classifications are constitutional only if
they are narrowly tailored measures that further compelling governmental Interests." Adarand Constructors, Inc. v. Pena,
515 U.S. 200, 227 (1995).
15
Indian Preference provisions are not limited to the BIA, and have been applied in a variety of federal programs for the
benefit of Indians. Section 7 of the Indian Self Determination Act, for example, establishes a broad federal policy of
providing hiring, training, and contracting preferences for Indians in contracts or grants with Indian organizations across all
federal agencies. 25 U.S.C. § 450e(b). Indian preference provisions are also found in other statutes. See, e.g., 42 U.S.C. §
9839(h) (establishing an Indian hiring preference at American Indian Programs Branch of Head Start Bureau); 20 U.S.C. §
3423c(c) (establishing an Indian employment preference in the Office of Indian Education in the Department of Education).
See also Preston v. Heckler, 734 F.2d 1359 (9th Cir. 1984) (Indian Preference Act requires Secretary of HHS to adopt
standards for evaluating qualifications of Indians for employment in the Indian Health Service that are separate and
independent from general civil service standards).
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Draft Report: Currently being circulated for Tribal leader and health director review and
comment. Please provide comments by October 30, 2012 to Liz Heintzman at the
National Indian Health Board at EHeintzman@nihb.org.
has upheld a number of other activities singling out Indians for special or preferential treatment, e.g.,
the right of for-profit Indian businesses to be exempt from state taxation, Moe v. Confederated Salish
& Kootenai Tribes, 425 U.S. 463, 479-80 (1976); fishing rights, Washington v. Washington State
Commercial Passenger Fishing Vessel Ass’n, 443 U.S. 658, 673 n.20 (1979); and the authority to apply
federal law instead of state law to Indians charged with on-reservation crimes, United States v.
Antelope, 430 U.S. 641, 645-47 (1977). The Court in Antelope explained its decisions in the following
way:
The decisions of this Court leave no doubt that federal legislation with
respect to Indian tribes, although relating to Indians as such, is not based
upon impermissible racial classifications. Quite the contrary,
classifications singling out Indian tribes as subjects of legislation are
expressly provided for in the Constitution and supported by the ensuing
history of the Federal Government’s relations with Indians.
Antelope, 430 U.S. at 645 (emphasis added).
The courts continue to acknowledge the special political status of Indians and to uphold legislation
singling out Indians on that basis. See, e.g., Am. Fed’n of Gov’t Employees, AFL-CIO v. United States,
330 F.3d 513, 522-23 (D.C. Cir. 2003) (finding outsourcing preference for Indian-owned firms was
rationally related to the legitimate legislative purpose of promoting the economic development of
federally recognized Tribes and their members); United States v. Wilgus, 638 F.3d 1274, 1287-88 (10 th
Cir. 2011) (upholding exception to the Bald Eagle Protection Act for Indian tribal members to possess
eagle feathers).
III. Congress’s Recognition of the Federal Trust Responsibility in Health Laws
Since the early part of the 20 th century, Congress has enacted a number of laws that authorize, direct,
and fund the provision of health care services to Indian people. 16 Here we focus on the most
significant legislative enactments intended to ensure access of Indian people to federally-assisted
health care programs and to enhance the viability of Indian Health Service and tribal programs that
serve the Indian population.
A. The Indian Health Care Improvement Act
16 See, e.g., Snyder Act, 25 U.S.C. § 13; Johnson-O'Malley Act, 25 U.S.C. § 452; Transfer Act, 42 U.S.C. § 2001, et seq.
(transferred responsibility for Indian health to Public Health Service); annual appropriations to the Indian Health Service
included in the Interior and Related Agencies Appropriations Acts.
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Draft Report: Currently being circulated for Tribal leader and health director review and
comment. Please provide comments by October 30, 2012 to Liz Heintzman at the
National Indian Health Board at EHeintzman@nihb.org.
The Indian Health Care Improvement Act (IHCIA) 17 was originally enacted in 1976 as Public Law 94-437.
It brought statutory order and direction to the delivery of federal health services to Indian people. Its
legislative history catalogued the deplorable conditions of Indian health that demanded legislative
attention: inadequate and under-staffed health facilities; improper or non-existent sanitation facilities;
prevalence of disease; poor health status; inadequate funding; 18 low enrollment of Indians in
Medicare, Medicaid, and Social Security; serious shortage of health professionals, including Indian
health professionals; and the need for health care for Indian people who had moved from reservations
to urban areas. The legislation addressed each of these deficiencies through focused titles: Manpower;
Health Services; Health Facilities (including sanitation facilities); Access to Medicare and Medicaid;
Urban Indian Health; and a feasibility study for establishing an American Indian School of Medicine. 19
The IHCIA has been periodically reauthorized and amended since 1976. In 2010, the law was
comprehensively amended and authorized as a permanent law of the United States. 20
Throughout its history, the IHCIA has contained an unequivocal recognition of the United States’
responsibility to improve the health of Indian people, to provide federal health services to this
population, and to foster maximum Indian participation in health care program management. The
2010 amendments reiterated and reinforced these federal commitments through the following
provisions:
Congressional Findings
The Congress finds the following:
(1) Federal health services to maintain and improve the health of the Indians are consonant with and
required by the Federal Government’s historical and unique legal relationship with, and resulting
responsibility to, the American Indian people.
(2) A major national goal of the United States is to provide the resources, processes, and structure that will
enable Indian tribes and tribal members to obtain the quantity and quality of health care services and
17 25 U.S.C. §1601, et seq. The Indian Health Care Improvement Act was amended and permanently reauthorized by
Section 10221 of the Patient Protection and Affordable Care Act, P.L. 111-148 (Mar. 23, 2010).
18 The House Interior and Insular Affairs Committee noted that per capita spending on Indian health in 1976 was 25
percent less than the average American per capita amount. H.R. REP. No. 94-1026, pt. I, at 16 (1976), reprinted in 1976
U.S.C.C.A.N. 2652, 2655. According to the U.S. Commission on Civil Rights, IHS per capita spending for Indian medical care
in 2003 was 62 percent lower than the U.S. per capita amount. U.S. Commission on Civil Rights, Broken Promises:
Evaluating the Native American Health Care System (Sept. 2004), at 98.
19 The IHCIA was later amended to include formal establishment of the Indian Health Service as an agency of DHHS. Pub.
L. No. 100-713 (1988). The IHS establishment is codified at 25 U.S.C. § 1661.
20 Sec. 10221 of the Patient Protection and Affordable Care Act, P.L. 111-148 (Mar. 23, 2010).
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Draft Report: Currently being circulated for Tribal leader and health director review and
comment. Please provide comments by October 30, 2012 to Liz Heintzman at the
National Indian Health Board at EHeintzman@nihb.org.
opportunities that will eradicate the health disparities between Indians and the general population of the
United States.
(3) A major national goal of the United States is to provide the quantity and quality of health services which
will permit the health status of Indians to be raised to the highest possible level and to encourage the
maximum participation of Indians in the planning and management of those services.
(4) Federal health services to Indians have resulted in a reduction in the prevalence and incidence of
preventable illnesses among, and unnecessary and premature deaths of, Indians.
(5) Despite such services, the unmet health needs of American Indian people are severe and the health status
of the Indians is far below that of the general population of the United States. 21
Declaration of National Indian Health Policy
Congress declares that it is the policy of this Nation, in fulfillment of its special trust responsibilities and legal
obligations to Indians –
(1) to ensure the highest possible health status for Indians and urban Indians and to provide all resources
necessary to effect that policy;
(2) to raise the health status of Indians and urban Indians to at least the levels set forth in the goals contained
within the Healthy People 2010 initiative or successor objectives;
(3) to ensure maximum Indian participation in the direction of health care services so as to render the
persons administering such services and the services themselves more responsive to the needs and
desires of Indian communities;
(4) to increase the proportion of all degrees in the health professions and allied and associated health
professions awarded to Indians so that the proportion of Indian health professions in each Service are is
raised to at least the level of that of the general population;
(5) to require that all actions under this chapter shall be carried out with active and meaningful consultation
with Indian tribes and tribal organizations, and conference with urban Indian organizations, to implement
this chapter and the national policy of Indian self-determination;
(6) to ensure that the United States and Indian tribes work in a government-to-government relationship to
ensure quality health care for all tribal members; and
(7) to provide funding for programs and facilities operated by Indian tribes and tribal organizations in
amounts that are not less than the amounts provided to programs and facilities operated directly by the
Service. 22
It is important to note that these expressions of policy, obligation, and objectives apply to the federal
government as a whole. The Act reposes responsibility for their implementation in the Secretary of
Health and Human Services. While the Indian Health Service has first-line responsibility for
administering the Indian health system, the Secretary of HHS remains the official with ultimate
responsibility to see that programs are performed as directed and the objectives established by
Congress are achieved. Thus, the obligation to exercise the trust responsibility for Indian health, to
implement the expressed policies, and to achieve the stated goals extend to the Centers for Medicare
& Medicaid Services, as an agency of HHS.
B. Statutory Authority for Participation in Medicare and Medicaid
21 25 U.S.C. §1601.
22 25 U.S.C. §1602.
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Draft Report: Currently being circulated for Tribal leader and health director review and
comment. Please provide comments by October 30, 2012 to Liz Heintzman at the
National Indian Health Board at EHeintzman@nihb.org.
In the 1976 IHCIA, Congress amended the Social Security Act to extend to Indian health facilities the
authority to collect Medicare and Medicaid reimbursements. Prior to these amendments, the IHS, as a
federal agency, was not permitted to claim reimbursements from Medicare and Medicaid.
• Sec. 1880 23 made IHS hospitals (including those operated by Indian Tribes 24 ) eligible to collect
Medicare reimbursement.
• Sec. 1911 25 made IHS and tribal facilities eligible to collect reimbursements from Medicaid
• An amendment to Sec. 1905(b) 26 applied a 100 percent federal medical assistance percentage
(FMAP) to Medicaid services provided to an Indian by an IHS or tribally-operated facility.
Sections 1880 and 1911 were intended to bring additional revenue into the Indian health system in
order to address the deplorable condition of Indian health facilities, many of which were in such a poor
state they were unable to achieve accreditation. The application of a 100 percent FMAP to the
Medicaid-covered services provided by these facilities was made in express recognition of the federal
government’s treaty obligations for Indian health. The Committee of jurisdiction observed that since
the United States already had an obligation to pay for health services to Indians as IHS beneficiaries, it
was appropriate for the U.S. to pay the full cost of their care as Medicaid beneficiaries. 27 This action is
consistent with the status of AI/ANs as a political designation.
Through amendments to Sec. 1880 made in 2000, 2003 and 2010, IHS and tribal hospitals and clinics
are authorized to collect reimbursements for all Medicare Part A and Part B services. As health care
providers, IHS and tribal health programs are authorized to collect reimbursements under Medicare
Parts C and D, as well. 28
23 42 U.S.C. §1395qq.
24 Tribes and tribal organizations are authorized to operate IHS-funded hospitals and clinics through contracts and
compacts issued pursuant to the Indian Self-Determination and Education Assistance Act, 25 U.S.C. § 450, et seq.
25 42 U.S.C. §1396j.
26 42 U.S.C. §1396d(b).
27 H.R. REP. No. 94-1026, pt. III, at 21 (1976), as reprinted in 1976 U.S.C.C.A.N. 2782, 2796.
28
In fact, Congress expressly authorized the Secretary of HHS to issue standards to assure access by pharmacies operated
by the IHS, tribes and urban Indian organizations to the Medicare Part D prescription drug benefit (42 U.S.C. §1395w-
104(b)(1)(C)(iv)), and required the Secretary to establish procedures (including authority to waive requirements) to assure
participation by these pharmacies in the transitional assistance feature of the temporary discount drug program. 42 U.S.C.
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Draft Report: Currently being circulated for Tribal leader and health director review and
comment. Please provide comments by October 30, 2012 to Liz Heintzman at the
National Indian Health Board at EHeintzman@nihb.org.
C. Statutory Authority for Participation in CHIP
IHS and tribal health providers are authorized to collect payments when providing services to
individuals enrolled in the Children’s Health Insurance Program (CHIP). 29 To assure that low-income
Indian children who are CHIP-eligible are not overlooked, Congress, when creating the program in
1997, expressly required States to describe in their State plans the procedures they will use to assure
access for these children. 30
D. Indian-Specific Provisions Designed to Ensure Indian Access to Medicaid, Medicare and
CHIP
Since early 2009, Congress has added several significant provisions to Titles XIX and XXI of the Social
Security Act that give voice to the federal government’s unique responsibility to Indian people and the
need to remove barriers to their participation in Medicaid and CHIP, especially when AI/ANs eligible for
those programs receive services from Indian health providers. We highlight these actions below.
Proof of Citizenship for Medicaid Enrollment. In the Deficit Reduction Act of 2005 (DRA),
Congress directed that on and after July 1, 2006, persons who apply to enroll or renew
enrollment in Medicaid must provide documentary proof of identity and U.S. citizenship, and
identified the types of documents that would be acceptable proof. Indian health advocates
feared – correctly, as it turns out – that many AI/ANs would not possess sanctioned
documentation of their status as U.S. citizens. Recognizing the barrier this presented for Indian
access to Medicaid and CHIP, in 2009 Congress amended these requirements to designate
documents issued by a federally-recognized Indian Tribe evidencing an individual’s
membership, enrollment in, or affiliation with such Tribe as satisfactory evidence of U.S.
citizenship. 31 Significantly, Congress gave tribal documentation “tier I” status – the same as a
U.S. passport. Individuals presenting tribal affiliation documentation would not be required to
present any additional identity documentation.
§1395w-141(g)(5)(B). Congress added language in the Affordable Care Act to allow Indian patients to qualify for the
catastrophic coverage phase of the Part D program. 42 U.S.C. §1395w–102(b)(4)(C).
29 42 U.S.C. §2105(c)(6)(B); see also 25 U.S.C. §1647a.
30 42 U.S.C. §2103(a)(3)(D).
31 42 U.S.C. §1396b(x)(3)(B), as added by Sec. 211 of the Children’s Health Insurance Program Reauthorization Act of 2009
(P.L. 111-3) (Feb. 4, 2009).
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Draft Report: Currently being circulated for Tribal leader and health director review and
comment. Please provide comments by October 30, 2012 to Liz Heintzman at the
National Indian Health Board at EHeintzman@nihb.org.
This legislative action recognizes not only the historic reality that Indian people were the
original occupants of the North American continent, it also implements in the clearest possible
way the policy of maintaining a government-to-government relationship with Indian Tribes. It
also demonstrates respect for the sovereignty of Tribes both to determine tribal membership
and to issue legal documents. As a practical matter, amending the law to order acceptance of
tribal documentation underscores Congress’s recognition of its continued responsibility to
enact Indian-specific legislation when needed to assure full access to federal programs.
Medicaid Premium and Cost-Sharing Protections. Pursuant to an amendment to Medicaid
made in 2009, States are prohibited from imposing any premium or cost-sharing on an Indian
for a covered service provided by the IHS, a health program operated by an Indian Tribe, Tribal
Organization or urban Indian organization, or through referral under contract health services. 32
Disregard of Certain Indian Property from Resources for Medicaid and CHIP Eligibility. In 2009,
Congress amended the Medicaid and CHIP laws to exempt from the resources calculation
certain enumerated types of Indian property. Primarily, the excluded property is of a type that
flows to an individual Indian by virtue of his/her membership in a Tribe. 33
Medicaid Estate Recovery Protections. In an express endorsement of a provision in the CMS
State Medicaid Manual, in 2009 Congress statutorily exempted certain Indian-related income,
resources and property held by a deceased Indian from the Medicaid estate recovery
requirement. 34 The objective of the Manual and statutory protection was to remove a
disincentive to enrollment for Indian people eligible for Medicaid.
Special Indian-specific Rules for Medicaid Managed Care. In 2009, Congress removed several
barriers to full and fair participation of Indian people and Indian health providers in Medicaid
programs operated through managed care entities. This gave an Indian Medicaid enrollee the
option to select an Indian health program as his/her primary care provider, and directed that
32 42 U.S.C. §§1396o(j) and 1396o-1(b)(3)(vii), as added by Sec. 5006(a) of the American Recovery and Reinvestment Act
of 2009 (P.L. 111-5) (Feb. 17, 2009). In recognition of the trust responsibility, Indian children have been exempt from costsharing
in the CHIP program pursuant to regulation at 42 C.F.R. §457.535.
33 42 U.S.C. §§1396a(ff) and 1397gg(e)(1)(H), as added by Sec. 5006(b) of the American Recovery and Reinvestment Act of
2009 (P.L. 111-5) (Feb. 17, 2009).
34 42 U.S.C. §1396p(b)(3)(B), as added by Sec. 5006(c) of the American Recovery and Reinvestment Act of 2009 (P.L. 111-5)
(Feb. 17, 2009).
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Draft Report: Currently being circulated for Tribal leader and health director review and
comment. Please provide comments by October 30, 2012 to Liz Heintzman at the
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Indian health providers (IHS, tribal, and urban Indian organization programs) be paid at a rate
not less than that of the managed care entity’s network provider. 35 These changes were
needed to overcome the reluctance of managed care entities to admit Indian health providers
to their networks and to reimburse them for services provided to Indian Medicaid enrollees.
Authority for Tribal Medicaid Administrative Match. Federal funds may not be used to meet
State matching requirements, except as authorized by Federal law. In 2005, CMS issued a State
Medicaid Director letter that permits Indian Tribes and Tribal Organizations to certify funds
received under the Indian Self-Determination and Education Assistance Act as public
expenditures to be used as the non-Federal share of expenditures to fulfill State matching
requirements for administrative claiming activities under the Medicaid program. These
activities include, among other things, outreach and application assistance for Medicaid
enrollment and activities that ensure appropriate utilization of Medicaid services by Medicaid
beneficiaries.
E. Solicitation of Input from Indian Health Programs.
In recognition of the need to assure that impacts on the unique Indian health system by proposed
changes in Medicare, Medicaid, and CHIP are fully evaluated, Congress placed in the Social Security Act
a requirement for prior notice to and solicitation of input from IHS, tribal health programs, and urban
Indian organizations. On the federal level, this requirement is to be carried out by CMS through
maintenance of the Tribal Technical Advisory Group originally chartered by the agency in 2003. 36
States are required to solicit advice from IHS and tribal health programs and urban Indian organizations
within their borders prior to submission of any state plan amendments, waiver requests, and
demonstration projects to CMS. 37
35 42 U.S.C. §1396u-2(h), as added by Sec. 5006(d) of the American Recovery and Reinvestment Act (P.L. 111-5) (Feb. 17,
2009).
36 42 U.S.C. §1320b-24, as added by Sec. 5006(e)(1) of the American Recovery and Reinvestment Act (P.L. 111-5) (Feb. 17,
2009). The maintenance of the Tribal Technical Advisory Group does not substitute for government-to-government
consultation with tribes.
37 42 U.S.C. §§1396a(a)(73) and 1397gg(e)(1)(C), as added by Sec. 5006(e)(2) of the American Recovery and Reinvestment
Act (P.L. 111-5) (Feb. 17, 2009).
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Draft Report: Currently being circulated for Tribal leader and health director review and
comment. Please provide comments by October 30, 2012 to Liz Heintzman at the
National Indian Health Board at EHeintzman@nihb.org.
F. Cap on Rates Charged for Contract Health Services.
Modeling on the Medicare Provider Agreement provision that caps the amount a hospital can charge
for services purchased by the Department of Veterans Affairs, in 2003 Congress enacted a similar
limitation on the amount a Medicare participating hospital may charge for services purchased by
Indian health programs operated by the IHS, Tribes, and Tribal Organizations, and urban Indian
organizations (I/T/Us). As a condition for participation in Medicare, such hospitals must accept
patients referred by I/T/Us in accordance with the admission practices, payment methodology, and
payment rates set forth in Secretarial regulations, and may accept no more than the payment rates set
by the Secretary. 38 This statutory rate cap is often referred to by the shorthand “Medicare-like rates.”
In regulations issued by IHS and CMS in 2007, the maximum amount a Medicare hospital is permitted
to accept for a service purchased by an I/T/U is the applicable Medicare rate. 39
These statutory and regulatory actions are intended to enable I/T/Us to achieve greater economies for
the services they must purchase for their Indian patients with funds appropriated for contract health
services.
G. Indian-Specific Provisions Designed to Ensure Indian Access to the Health Insurance
Exchanges
The Patient Protection and Affordable Care Act (ACA) was enacted by Congress in 2010 in order to
reform the health insurance market and make health insurance more accessible and affordable for all
Americans. It imposes a responsibility on most Americans to acquire or maintain health insurance
coverage, and contains a number of provisions intended to strengthen health insurance consumer
protections and enhance the health care workforce. Congress included a number of provisions
designed to ensure that Indians could take advantage of the new reforms. We highlight several of
these below.
Exemption from Penalty for Failure to Comply with the Individual Mandate. Although Congress
designed the law to make nearly all Americans responsible for acquiring or maintaining
acceptable levels of health insurance coverage, Congress specifically exempted members of
Indian Tribes from the tax penalty for failure to obtain acceptable coverage. 40 This provision is
38 42 U.S.C. §1395cc(a)(1)(U), as added by the Medicare Modernization Act of 2003 (P.L. 108-173).
39 72 Fed. Reg. 30706 (June 4, 2007), adding Subpt. D to 42 C.F.R. Part 136, and adding §489.29 to 42 C.F.R. Part 489.
These regulations became effective on July 5, 2007.
40 26 U.S.C. §5000A(e)(3).
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comment. Please provide comments by October 30, 2012 to Liz Heintzman at the
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based on the theory that the United States is responsible for providing health care to Indians,
but it has failed to supply an acceptable package of benefits through the Indian Health Service.
Having failed in that responsibility, it would violate the trust responsibility to require Indians to
pay for non-IHS coverage or be assessed a tax penalty for failing to do so.
Cost-Sharing Protections for Indians Enrolled in a Health Insurance Exchange Plan. The
Affordable Care Act prohibits assessment of any cost-sharing for any service provided by an
Indian health provider to an AI/AN enrolled in an Exchange plan. Furthermore, no cost sharing
may be assessed by non-Indian health providers to an AI/AN enrolled in such a plan if the
individual receives services through an Indian health provider or through contract health
services. Indians with income below 300 percent of the Federal Poverty Level do not have cost
sharing in the private sector even if they do not have a referral from an Indian health provider.
The Secretary of HHS is responsible for paying the Exchange plan the additional actuarial cost
that results from these cost-sharing protections. 41
Special enrollment periods for AI/AN. The ACA provides special enrollment periods for AI/ANs
for health insurance exchanges. This is another measure to provide access to this important
source of funding for the I/T/U.
These provisions are designed to reduce the costs for AI/ANs to access the Exchange plans and to
provide incentives for them to do so, as well as to increase the likelihood that I/T/Us will receive
payments from health insurance exchange plans for services they provide to AI/Ans.
IV. Executive Branch Recognition of the Federal Trust Responsibility in Administering Federal
Health Programs
A. Executive Branch Administration of the Trust Responsibility
The Executive Branch is responsible for carrying out the federal trust responsibility to provide health
care to Indians. The federal government’s general trust duty to provide social services and its duty as a
trustee to protect and manage Indian trust property are different types of duties and thus are treated
differently by the courts. 42 Courts have generally been reluctant to impose liability for the federal
government’s failure to provide social services under the general trust relationship. 43 One notable
41 42 U.S.C. §18071(d).
42 Seminole Nation v. United States, 316 U.S. 286, 297 (1942).
43 See, e.g., Gila River Pima-Maricopa Indian Community v. U.S., 427 F.2d 1194 (Ct.CI. 1970), cert. denied. 400 U.S. 819
(1970).
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comment. Please provide comments by October 30, 2012 to Liz Heintzman at the
National Indian Health Board at EHeintzman@nihb.org.
exception is the case of Morton v. Ruiz 44 where the Supreme Court said the Bureau of Indian Affairs
erred in refusing to provide welfare benefits to unemployed Indians who lived off, but near, their
reservation. The Court reiterated that the “overriding duty of our Federal Government [is] to deal
fairly with Indians wherever located”, and that BIA’s failure to publish eligibility criteria through
Administrative Procedure Act regulations was not consistent with the “distinctive obligation of trust
incumbent upon the Government in its dealings” with Indians. 45
The IHCIA policy statements quoted above expressly recognize a trust responsibility to maintain and
improve the health of Indians, and establish a national policy to assure the highest possible health
status to Indians, as well as to provide all resources necessary to effect that policy. While currently
there may be no available mechanism to enforce these policies judicially, this does not make them
meaningless. They establish the goals, which the Executive Branch – particularly the Department of
Health and Human Services – must strive to achieve as it implements federal law. In fact, they justify –
indeed, require – the Executive Branch to be proactive and use its resources “to assure the highest
possible health status for Indians and urban Indians and to provide all resources necessary to effect
that policy.” 25 U.S.C. §1602(1). The Executive Branch has a dual duty – to carry out the policy
established by Congress in federal law, and to perform the United States’ trust responsibility to Indians
in accord with the Congressionally-established standard.
Indian people take the United States at its word when reading the policy statement in the IHCIA, and
have a right to expect its trustee to achieve the goal of assuring them the highest possible health
status. As stated by Justice Black in his lament over the U.S. breaking faith with Indians, “Great
nations, like great men, should keep their word.” 46
B. CMS Administration of the Trust Responsibility
As part of DHHS, and as an agency required to implement statutory provisions intended to benefit
Indian health, CMS should affirmatively advance policy objectives as set out by Congress in the IHCIA
when making Indian-related decisions in the Medicare and Medicaid programs. The trust responsibility
and the federal laws enacted to carry it out not only permit CMS to treat AI/ANs served by the Indian
44 415 U.S. 199 (1974).
45 Id. at 236. See also Chambers, note 2, supra, at 1245-46 (arguing that courts should apply the trust responsibility as a
"fairness doctrine" in suits against the United States for breach of a duty to provide social services).
46 Federal Power Comm'n v. Tuscarora Indian Nation, 362 U.S. 99, 142 (1960) (Black, J., dissenting),
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Draft Report: Currently being circulated for Tribal leader and health director review and
comment. Please provide comments by October 30, 2012 to Liz Heintzman at the
National Indian Health Board at EHeintzman@nihb.org.
health system as unique Medicare and Medicaid consumers entitled to special treatment, they require
it.
CMS shares the responsibility to carry out the policy goals established by Congress in the IHCIA. Both
the HHS and CMS tribal consultation policies recognize “the unique government to government”
relationship between the United States and Tribes, as well as the trust responsibility “defined and
established” by “the U.S. Constitution, numerous treaties, statutes, Federal case law, regulations, and
executive orders.” 47 One manifestation of this trust responsibility is CMS’s recognition that “CMS and
Indian Tribes share the goals of eliminating health disparities for American Indians and Alaska Natives
(AI/AN) and of ensuring that access to Medicare, Medicaid, the Children’s Health Insurance Program
(CHIP), and Exchanges is maximized.” 48 Through its consultation policy, CMS has committed to
consulting with Indian Tribes when developing policy that may affect Indians.
CMS has exercised its authority to administer federal health care programs and interpret the statutes
within its jurisdiction in a manner that assures access by Indian people and participation by the unique
Indian health delivery system. In recent decades, CMS (previously HCFA) has taken steps to carry out
the trust responsibility to Indians in its administration of the Medicare, Medicaid, and CHIP programs.
Each was a rational exercise of the agency’s authority and fully justified by the United States’ special
obligations to Indian Tribes.
A summary of these actions follows:
Authority for Tribal Facilities to Bill Medicaid at the Same Rate as IHS Facilities. In 1996,
through a Memorandum of Agreement with IHS, HCFA re-interpreted the term “facility of the
Indian Health Service” in Section 1911 (Medicaid) to allow a tribally-owned facility operated
under an ISDEAA agreement to elect designation as a “facility of the Indian Health Service.”
Previously, HCFA had interpreted the term “facility of the Indian Health Service” to include only
facilities actually owned or leased by IHS. The MOA enabled these tribally-owned facilities to
bill Medicaid at the annually-established Medicaid billing rates for IHS facilities and applied the
100 percent FMAP to Medicaid services provided by such facilities.
Exemption of IHS and Tribal Clinics from the Outpatient Prospective Payment System. In 2002,
the Director of the Center for Medicare agreed to continue the exemption of IHS and tribal
clinics from the Outpatient Prospective Payment System.
47 Centers for Medicare & Medicaid Services Tribal Consultation Policy (Nov. 17, 2011), at 1; U.S. Dep't of Health and
Human Services Tribal Consultation Policy (Dec. 14, 2010), at 1.
48 Centers for Medicare & Medicaid Services Tribal Consultation Policy (Nov. 17, 2011), at 2.
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Draft Report: Currently being circulated for Tribal leader and health director review and
comment. Please provide comments by October 30, 2012 to Liz Heintzman at the
National Indian Health Board at EHeintzman@nihb.org.
CMS has Broadly Defined the Hospital Services that are Subject to the Medicare-like Rates Cap.
In 2007, CMS issued regulations implementing Section 506 of the Medicare Modernization Act
to require all Medicare-participating hospitals to accept Medicare-like rates when providing
services to I/T/U beneficiaries. The final regulations broadly defined hospital and critical access
hospital services subject to the rule to include inpatient, outpatient, skilled nursing facilities,
and any other service or component of a hospital. 42 C.F.R. §136.30; 42 C.F.R. §489.29.
IHS and Tribal Facility Participation in Medicaid. The 1996 IHS/HCFA MOA incorporated the
regulatory policy that states must accept as Medicaid providers IHS facilities that meet state
requirements, but these facilities are not required to obtain a state license. 42 C.F.R. §431.110.
Thus, it applied this regulatory policy to tribally-owned facilities. Congress converted this policy
into law for all federally-funded health programs serving AI/AN in the 2010 amendments to the
Indian Health Care Improvement Act. 49
Cost-Sharing Protections for Indian Children in CHIP. In 1999, HCFA issued guidance, followed
by a proposed rule, that prohibits states from imposing any cost-sharing on AI/AN children
under CHIP, citing the unique federal relationship with Indian Tribes. This rule was
subsequently promulgated in final form. 42 C.F.R. §457.535. This HCFA regulation reflects the
agency’s interpretation of how best to carry out the statutory provision requiring states to
demonstrate how they will assure CHIP access for eligible Indian children. 42 U.S.C.
§1397bb(b)(3)(D). In 2000, HCFA announced that the policy prohibiting cost sharing for Indian
children under CHIP would be extended to Section 1115 Medicaid demonstration projects and
stated the agency would no longer approve Section 1115 projects that impose such costsharing.
66 Fed. Reg. 2490, 2526 (Jan. 11, 2001).
State-Tribal Consultation on Medicaid Programs. In 2001, CMS issued a policy statement that
requires states to consult with Tribes within their borders on Medicaid waiver proposals and
waiver renewals before submitting them to CMS. 50 Congress subsequently made this
consultation requirement statutory, adding State Plan Amendments and demonstration
49 25 U.S.C. §1647a.
50 Letter from Health Care Fin. Admin. To State Medicaid Directors (July 17, 2001)
http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/smd071701.pdf.
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Draft Report: Currently being circulated for Tribal leader and health director review and
comment. Please provide comments by October 30, 2012 to Liz Heintzman at the
National Indian Health Board at EHeintzman@nihb.org.
projects as requisite subjects of tribal consultation. 51 CMS informed the States of this
consultation requirement on several occasions and codified the 2001 policy statement. 52 In
May of 2012, CMS announced that it would not accept the waiver applications submitted by
New Mexico and Kansas until they met the tribal consultation requirements.
CMS Tribal Technical Advisory Group. In 2003, CMS chartered a Tribal Technical Advisory Group
comprised of tribal officials and tribal employees to advise the agency on Medicare, Medicaid,
and CHIP issues that impact Indian health programs. CMS’s foresight was met with approval by
Congress, which granted the TTAG explicit statutory status in 2009 and added representatives
of the IHS and urban Indian organizations to the TTAG’s membership. 42 U.S.C. §1320b-24.
Indian Health Addendum Required for Medicare Part D Pharmacy Contracts. When
implementing the Medicare Part D drug benefit, CMS recognized that special terms and
conditions in pharmacy contracts would be needed to assure that IHS, tribal, and urban Indian
organization pharmacies would be able to participate in the Part D program. The agency
requires Part D plans to include the CMS-approved text of an Indian Health addendum in
contracts offered to those pharmacies. 42 C.F.R. §423.120(a)(6). The addendum addresses
several aspects of federal law and regulations applicable to those pharmacies, such as Federal
Tort Claims Act coverage (obviating the need for privately-purchased professional liability
insurance). 53
Approval of Indian-specific State Medicaid Plan Provision. In April of 2012, CMS approved an
Arizona Medicaid waiver request through which several optional Medicaid services can
continue to be covered at IHS and tribal facilities, although they are otherwise discontinued
from coverage in the State’s plan. When these services are provided to Indian patients at IHS
and tribal facilities, the 100 percent FMAP continues to apply. This action is a significant
acknowledgement by CMS that it has the authority and the obligation to carry out its trust
responsibility for Indian health.
51 42 U.S.C. §§1396a(a)(73) and 1397gg(e)(1)(C), as added by Sec. 5006(e)(2) of the American Recovery and Reinvestment
Act (P.L. 111-5) (Feb. 17, 2009).
52 CMS SMD #09-003 (June 17, 2009); CMS SMDL #10-001 (Jan. 22, 2010); 77 Fed. Reg. 11678 (Feb. 27, 2012).
53
The text of the Addendum is included in the Medicare program's solicitation for applications for new cost plan
sponsors. See, e.g., "Medicare Prescription Drug Benefit, Solicitation for Applications for New Cost Plan Sponsors, 2012
Contract Year," at 131.
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Draft Report: Currently being circulated for Tribal leader and health director review and
comment. Please provide comments by October 30, 2012 to Liz Heintzman at the
National Indian Health Board at EHeintzman@nihb.org.
Carrying out the trust responsibility to Indians in these and other ways coincides with and compliments
CMS’s stated program objectives.
V. The Unique Nature of the Indian Health System
The IHS-funded system for providing health services to AI/ANs is one-of-a kind; it is unlike any other
mainstream health delivery system. In fact, the federal government created and designed the system
in use today for the specific purpose of serving Indian people in the communities in which they live.
Overall, the Indian health programs have a community-based approach and seek to provide culturallyappropriate
services. As demonstrated in this Plan, the IHS system was created for Indian people as a
political class, not as a racial group. These circumstances require unique rules and policies from CMS
to enable IHS-funded programs to fully access Medicare, Medicaid, and CHIP and to achieve the
agency’s health disparities elimination objective.
We outline below some of the unique circumstances of this health system and of Indian Tribes that
have been established or recognized by federal law and regulations:
Limited service population. The IHS health care system is not open to the public. It is
established to serve AI/AN beneficiaries who fall within the eligibility criteria established by the
IHS. See 42 C.F.R. §136.12. 54 The IHS estimates the service population served by IHS and
tribally-operated programs in more than 30 states is approximately 2.1 million AI/Ans.
No cost assessed to patients. IHS serves AI/AN beneficiaries without cost. For several years,
Congress reinforced this policy with language in the annual IHS appropriations act that
prohibited the agency to charge for services without Congressional consent. 55 IHS services at
no cost to the Indian patient remains IHS policy today. Some members of Congress have
described the IHS as a pre-paid health plan – pre-paid with land ceded by Tribes to the U.S.
government.
54 Under certain circumstances non-Indians connected with an Indian beneficiary (such as minor children and spouses)
can receive services as beneficiaries. Other non-Indians may receive services in carefully defined circumstances, but are
liable for payment. See 25 U.S.C. §1680c.
55 See, e.g., Pub. L. No. 104-134, 110 Stat. 1321-190 (April 26, 1996).
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Draft Report: Currently being circulated for Tribal leader and health director review and
comment. Please provide comments by October 30, 2012 to Liz Heintzman at the
National Indian Health Board at EHeintzman@nihb.org.
Indian preference in employment. Indian preference in hiring applies to the Indian Health
Service. 42 C.F.R. §136.41-.43. 56 Such preference also applies to tribally-operated programs
through the requirement that, to the greatest extent feasible, preference for training and
employment must be given to Indians in connection with administration of any contract or
grant authorized by any federal law to Indian organizations or for the benefit of Indians. 25
U.S.C. §450e(b).
Only Tribes have rights under ISDEAA. Indian Tribes (and Tribal Organizations sanctioned by
one/more Tribes) – and only those entities – can elect to directly operate an IHS-funded
program through a contract or compact from the Indian Health Service issued pursuant to the
Indian Self-Determination and Education Assistance Act (ISDEAA). 25 U.S.C. §450 et seq. The
tribal operator receives the program funds the IHS would have used and additional funding for
administrative costs. A tribal operator directly hires its staff and has the authority to re-design
the program(s) it offers.
Federal Tort Claims Act coverage. Pursuant to federal law, tribal health programs and their
employees are covered by the Federal Tort Claims Act (FTCA). 25 U.S.C. §450f, note. For this
reason, it is often unnecessary for Tribes to purchase liability insurance for the health services
they operate with federal funding.
Use of HHS personnel. To help staff their programs, Tribes and Tribal Organizations are
authorized by law to utilize employees of HHS under Intergovernmental Personnel Act
assignments and commissioned officers of HHS under Memoranda of Agreement. 25 U.S.C,
§450i.
Creation of specific health care providers. Federal law has created health care delivery
providers found only in the Indian health care system. See Community Health Representative
Program, 25 U.S.C. §1616; Community Health Aide Program (CHAP) for Alaska, 25 U.S.C. §1616l.
The Alaska Medicaid Plan reimburses Indian health programs for covered services provided by
CHAPs in Alaska. Through a 2010 amendment to the IHCIA, the Secretary is authorized to
implement a CHAP program for Tribes in the lower 48 states.
56 See also Preston v. Heckler, 734 F.2d 1359 (9th Cir. 1984) (upholding the Indian Health Service's Indian employment
preference).
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Draft Report: Currently being circulated for Tribal leader and health director review and
comment. Please provide comments by October 30, 2012 to Liz Heintzman at the
National Indian Health Board at EHeintzman@nihb.org.
IHS as payer of last resort. A longstanding IHS regulation makes IHS programs the payer of last
resort for eligible Indian beneficiaries, notwithstanding any state or local law to the contrary.
42 C.F.R. §136.61. Congress has made this payer of last resort status a statutory requirement
for IHS, tribal, and urban Indian organization programs. 57
IHS-specific Medicare and Medicaid reimbursement rates. On an annual basis, the IHS (in
consultation with CMS) establishes the rates at which Medicare outpatient and Medicaid
inpatient and outpatient services provided to eligible Indians shall be reimbursed to IHS
facilities. See, e.g.,77 Fed. Reg. 33470 (June 6, 2012). This is an all-inclusive encounter rate
which is unique to Indian health care. Tribal clinics may instead elect to bill for services as a
Federally Qualified Health Center (FQHC).
100 Percent Federal Medical Assistance Percentage. The cost of Medicaid covered services
provided to AI/ANs in IHS and tribal facilities are reimbursed to the States at 100 percent FMAP
in recognition that the responsibility for Indian health care is a federal obligation. Sec. 1905(b)
of SSA; 42 U.S.C. §1396d(b).
No U.S. right of recovery from Tribes. If an Indian Tribe (or a Tribal Organization sanctioned by
one/more Tribes) has a self-insured health plan for its employees, the United States is
prohibited by law from recovering from that plan the cost of services provided unless the
sponsoring Tribe/Tribal Organization expressly authorizes such recovery. 25 U.S.C. §1621e(f).
Indian Tribes are governments. Upon achieving federal recognition, an Indian Tribe is
acknowledged to be and is treated as a government by the United States. The U.S. deals with
Indian Tribes on a government-to-government basis that is recognized in Executive Orders and
consultation policies adopted by federal agencies. 58 Indian Tribes determine their own
governmental structure. They are not required to follow the U.S. model of separate legislative,
executive, and judicial branches.
57 25 U.S.C. §1623(b), as added by Sec. 2901(b) of the Affordable Care Act (P.L. 111-148) (Mar. 23, 2010).
58
See, e.g., Exec. Order No. 13175, "Consultation and Coordination with Indian Tribal Governments (Nov. 9, 2000) (issued
by President Clinton and subsequently endorsed by Presidents George W. Bush and Barack Obama); White House
Memorandum for Heads of Executive Departments and Agencies, Nov. 5, 2009 (President Obama endorsement); Dep't of
Health and Human Services Tribal Consultation Policy (Dec. 14, 2010); Centers for Medicare and Medicaid Services Tribal
Consultation Policy (Nov. 17, 2011).
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Draft Report: Currently being circulated for Tribal leader and health director review and
comment. Please provide comments by October 30, 2012 to Liz Heintzman at the
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State law does not apply. By virtue of the Supremacy Clause, state laws generally do not apply
to the IHS system. 59 The Supreme Court has recognized that Indian tribal governments are not
subject to state laws, including tax laws, unless those laws are made expressly applicable by
federal law. See, e.g., McClanahan v. Arizona State Tax Comm’n, 411 U.S. 1641 (1973). Indian
tribal governments are not political subdivisions of states. Tribal facilities and their employees
may not be required to have state licensure to perform their duties.
Federal trust responsibility. The United States has a trust responsibility to Indian Tribes
(described above).
Tribal sovereign immunity. Indian tribal governments enjoy sovereign immunity except vis-à-vis
the United States government, the superior sovereign. See, e.g., United States v. United States
Fidelity & Guaranty Co., 309 U.S. 506 (1940).
In sum, an Indian Tribe that has elected to directly operate its health care program can simultaneously
serve in several capacities: as a sovereign government; as beneficiary of IHS-funded health care; as a
direct provider of health care (including the right of recovery from third party payers); as administrator
of a health program with responsibilities for advising its patients about eligibility for Medicare,
Medicaid, and CHIP; and as a sponsor of a health insurance plan for its employees (and the payor
under such a plan if it is a self-insured plan). CMS must take these multiple roles into account and
fashion special policies to effectively implement Medicare, Medicaid, and CHIP in Indian communities
in ways that assure full access by Indian beneficiaries and IHS/tribal providers.
59 For example, Section 408 of the IHCIA provides that an entity operated by IHS, an Indian tribe, tribal organization or
urban Indian organization that meets state requirements for licensure must be accepted as a provider but is not required to
obtain a state license. 25 U.S.C. §1647a.
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Draft Report: Currently being circulated for Tribal leader and health director review and comment. Please provide
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APPENDIX C: CMS ORGANIZATION CHART
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Draft Report: Currently being circulated for Tribal leader and health director
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Appendix D: Common Terms & Acronyms
All agencies are in CMS unless otherwise indicated.
ACA Patient Protection and Affordable Care
Act (P.L. 111-148)
AI/AN American Indians and Alaska Natives
ACL Administration for Community Living (in
HHS)
ARRA American Recovery and Reinvestment Act
of 2009 (P.L. 111-5)
CCIIO Center for Consumer Information and
Insurance Oversight
CHS Contract Health Services, (IHS program to
purchase services)
CHIP Child Health Insurance Program
CHIPRA Children’s Health Insurance Program
Reauthorization Act of 2009 (P.L. 111-3)
CMCS Center for Medicaid and CHIP Service
CMM Center for Medicare Management
CMMI Center for Medicare and Medicaid
Innovation
CMS Centers for Medicare & Medicaid Services
CMSO Center for Medicaid and State Operations
DHHS Department of Health and Human
Services
FFE Federally-facilitated Exchange
FMAP Federal Medical Assistance Percentage
(for Medicaid)
FQHC Federally Qualified Health Centers
HHS Department of Health and Human
Services
63
I/T/U Health care services operated by the IHS,
Tribes and urban Indian clinics
IHCIA Indian Health Care Improvement Act (P.L.
94-437)
IHS Indian Health Service (federal agency in
DHHS)
LTSS Long Term Services and Support
MA Medicare Advantage (managed care plan)
MAM Medicaid Administrative Match
MOA Memorandum of Agreement
NAC Native American Contact in CMS Regional
Offices
NIHB National Indian Health Board
OGC Office of General Counsel
Part A Medicare inpatient coverage
Part B Medicare outpatient coverage
Part C Medicare managed care plans, also called
Medicare Advantage
Part D Medicare prescription drug benefit
TAG Tribal Affairs Group
TTAG Tribal Technical Advisory Group
Title XVIII Medicare, Social Security Act
Title XIX Medicaid, Social Security Act
Title XXI Children’s Health Insurance
Program , Social Security Act

Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Acknowledgements
This American Indian and Alaska Native Strategic Plan, 2013-2018 was developed by the CMS Tribal
Technical Advisory Group (TTAG) with assistance from the Northwest Portland Area Indian Health Board
(NPAIHB). Funding for this project was provided by CMS through an Interagency Agreement with the
Indian Health Service and a subcontract from the National Indian Health Board (NIHB).
This plan was developed over a period of six months, beginning in June 2012. The TTAG Strategic Plan
Subcommittee met in-person and by conference call to develop new goals, objectives, and tasks. TTAG’s
subcommittees for Tribal Consultation, Long Term Care, Data, and Outreach & Education provided
essential input related to their visions for future activities and outcomes. TTAG approved the plan for
nationwide tribal comment and review in September 2012.
This is the third AI/AN Strategic Plan developed by TTAG. Each plan has built on the work of the
preceding plan, although much of the background information in previous plans has been dropped from
this version to make it shorter. The first plan, for the period 2005-2010, was developed under the TTAG
Strategic Plan Chairmanship of Margaret Terrance, Nashville Area Representative to TTAG, and was
staffed by Mim Dixon, consultant. The second plan, for the period from 2010- 2015, was developed
under the TTAG Strategic Plan Subcommittee, chaired by the Honorable W. Ron Allen, Chair of the
Jamestown S’Klallam Tribe, and Tribal Self-Governance Advisory Committee representative to the TTAG.
The staff for the second plan included Craig Carter and Stephanie Craig Rushing from NPAIHB, as well as
Kitty Marx and Caitlin Wesaw who were then at NIHB.
TTAG would like to thank the many people in CMS who participated in interviews and provided their
insights for the development of this plan. While we are keeping their names and comments
confidential, we hope they will see the wisdom they shared reflected on these pages. Mim Dixon and
Jim Roberts staffed this plan, with assistance from Lisa Griggs (NPAIHB), Tyra Baer (NIHB), and Liz
Heintzman (NIHB).
Strategic Plan Subcommittee
W. Ron Allen, Tribal Chairman, Jamestown S’Klallam Tribe, Strategic Plan Subcommittee Chair
Jennifer Cooper, JD, National Indian Health Board
Jim Crouch, MPH, California Rural Indian Health Board
Valerie Davidson, JD, Alaska Native Tribal Health Consortium
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Draft Report: Currently being circulated for Tribal leader and health director
review and comment. Please provide comments by October 30, 2012 to Liz
Heintzman at the National Indian Health Board at EHeintzman@nihb.org.
Carol Korenbrot , PhD, California Rural Indian Health Board
Jim Lamb, Alaska Native Tribal Health Consortium
Liz Malerba, United South and Eastern Tribes
Elliott Milhollin, JD, Hobbs, Strauss Dean and Walker
Myra Munson, JD, MSW, Sonosky, Chambers, Miller and Munson
Raho Ortiz, Indian Health Service
Judy Goforth Parker, PhD, Chickasaw Nation
Jim Roberts, Northwest Portland Area Indian Health Board
Jay Steiner, JD, National Council for Urban Indian Health
Alec Thurdercloud, MD, Ho-Chunk Nation
65