Health Coverage Options for American Indians and Alaska Natives

Version 2.0. May 2024. This information is intended only for the use of entities and individuals certified to serve as Navigators, certified application

counselors, or non-Navigator assistance personnel in a Federally-facilitated Marketplace. The terms “Federally-facilitated Marketplace” and “FFM,”

as used in this document, include FFMs where the state performs plan management functions. Some information in this manual may also be of

interest to individuals helping consumers in State-based Marketplaces and State-based Marketplaces using the Federal Platform. This material

was produced and disseminated at U.S. tax filer expense.

Health Coverage Options for

American Indians and Alaska

Natives

This job aid provides information and guidance that Navigators, Certified Application Counselors

(CACs), and Enrollment Assistance Personnel (EAPs) (collectively, assisters) need to know in

order to help American Indians and Alaska Natives (AI/ANs) understand their health coverage

options, including through the Marketplace, Medicaid, and the Children’s Health Insurance

Program (CHIP).

Table of Contents

Background and Key Terms .........................................................................................................2

Indian Health Care Programs .......................................................................................................2

Marketplace Coverage ..................................................................................................................3

Medicaid and CHIP Coverage ......................................................................................................5

AI/AN Income Calculation .............................................................................................................7

FFM Application Options ..............................................................................................................8

Employer-sponsored Coverage ....................................................................................................9

Additional Resources ..................................................................................................................10

Background and Key Terms

In the United States, there's a special government-to-government relationship between the

Federal Government and federally recognized Indian tribes. Additionally, in Alaska, Alaska

Native regional and village corporations were established under the Alaska Native Claims

Settlement Act (ANCSA).

The definition of AI/AN is different for the United States Census Bureau, eligibility for services

from the Indian Health Services (IHS), special benefits under Medicaid and CHIP, and for the

Marketplaces.

 For purposes of the special protections in the Marketplaces, an AI/AN is a member of a

federally recognized Indian tribe or a shareholder in an ANCSA corporation.

 For purposes of Medicaid and CHIP, an AI/AN is a member of a federally recognized

Indian tribe, an ANCSA shareholder, or any individual eligible to receive services from the

IHS.

AI/AN consumers have special benefits and protections in the Health Insurance Marketplace

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and under Medicaid and CHIP.

 Some benefits are available to members of federally recognized tribes or ANCSA

Corporation shareholders.

 Others are available to people of Indian descent or otherwise eligible for services from

the IHS [also known as an Indian hospital or Public Health Service (PHS)], a tribal

program, or an urban Indian health program.

A list of federally recognized tribes is available at BIA Tribal Leaders Directory, and a list of

village or regional corporations formed under ANCSA is available at Index of Regional Native

Corporations.

Indian Health Care Programs

Many AI/ANs currently receive health care from Indian health care providers, which include

health programs operated by the IHS, tribes and tribal organizations, and urban Indian

organizations. These health programs are sometimes called ITUs (IHS/ Tribal/Urban):

 I: The Indian Health Service. In 1955, the Federal Government established the IHS

under the Department of Health and Human Services (HHS) to provide health care to

people of Indian descent. The Affordable Care Act (ACA) reauthorized and made

permanent the Indian Health Care Improvement Act

, which is an underlying authority for

the IHS. A large portion of AI/AN consumers access health care through providers in the

Indian health care system, which may include tribal and urban Indian organizations.

However, the IHS isn't an insurance program. AI/ANs don't pay premiums and are usually

not charged for services provided in the facilities.

 T: Tribes and Tribal Organizations. Currently, the Indian health care system includes

44 Indian hospitals and nearly 570 Indian health centers, clinics, and health stations. A

large portion of these health facilities are managed by the tribes. When specialized

services aren't available at these sites, health services are purchased from public and

private providers through the Purchased/Referred Care Program, formerly known as the

Contract Health Services (CHS) Program.

 U: Urban Indian Organizations. Thirty-four urban programs also offer services ranging

from community health to comprehensive primary care in urban Indian communities.

When AI/ANs enroll in Centers for Medicare and Medicaid Services (CMS) programs, they can

continue to receive services from their local Indian health care provider or access services from

non-IHS providers. Indian health care providers can bill qualified health plan (QHP) issuers or

Medicaid/CHIP for services provided to their patients, and these revenues can be used to hire

health professionals, purchase equipment, and meet accreditation requirements.

 Indian health care providers also provide services to other individuals, such as persons of

Indian descent who are not members of their tribe, spouses of tribal members (if the tribe

has passed a resolution allowing them to receive services), children adopted by tribal

members, and non-Indian women who are pregnant with the child of an eligible Indian.

These individuals do not qualify for the special protections in the Marketplace but can

qualify for the Medicaid and CHIP protections.

Marketplace Coverage

AI/AN consumers may choose to enroll in private insurance through the Marketplace with

advance payments of the premium tax credit (APTC) and/or cost-sharing reductions (CSRs)

even though they get services from an I/T/U. The Marketplace may provide them with greater

access to providers and services while allowing them to remain eligible to access health care

services through the IHS.

Marketplace Protections

The Marketplace provides certain protections for AI/ANs:

 Special Enrollment Periods (SEPs)

iii

: Members of federally recognized tribes can enroll

in the Health Insurance Marketplace

throughout the year, not just during the annual

Open Enrollment period (OEP). Members may also change plans as often as once a

month.

 Zero cost sharing plan

: Members of federally recognized tribes with income between

100 percent and 300 percent of the federal poverty level (FPL) can enroll in a zero cost

sharing plan, which means these consumers won’t have to pay any out-of-pocket costs

such as copays, deductibles, or coinsurance when receiving care from Indian health care

providers or when receiving essential health benefits (EHB) through a QHP.

 In addition, there is no need for a referral from an Indian health care provider

when receiving EHB through the QHP.

 These consumers can enroll in a zero cost sharing plan at any metal level.

 Limited cost sharing plan

: Members of federally recognized tribes with income below

100 percent and above 300 percent of the FPL can enroll in a limited cost sharing plan,

which means no copays, deductibles, or coinsurance when receiving care from Indian

health care providers.

 A referral from an Indian health care provider to a QHP is required when

receiving EHB through the QHP to avoid copays, deductibles, or coinsurance.

 These consumers can enroll in a limited cost sharing plan at any metal level.

Members of federally recognized tribes are not exempt from QHP premiums. However, they

may qualify for APTCs to lower their premiums based on their income.

Note: For Plan Years 2021 and 2022, The American Rescue Plan Act of 2021 (ARP) makes the

premium tax credit (PTC) available to consumers with household income above 400 percent of

the FPL and caps how much of a family’s household income the family will pay towards the

premiums for a benchmark plan at 8.5 percent.

Eligibility Verification

To qualify for tribal member and ANCSA shareholder year-round enrollment and cost sharing,

consumers will need to provide documentation to the Marketplace. They can provide either of

the following:

 Enrollment or membership document from a federally-recognized tribe or the Bureau of

Indian Affairs (BIA). It must be on tribal letterhead or an enrollment/membership card that

contains the tribal seal and/or an official signature, or a Certificate of Degree of Indian

Blood (CDIB) issued by the BIA or a tribe, if the CDIB includes tribal enrollment

information.

 Document issued by an Alaska Native village/tribe, or an ANCSA regional or village

corporation acknowledging descent, affiliation, shareholder status, or participation in

village or Alaska Native community affairs. The document can also include a CDIB issued

by the BIA or tribe, if the CDIB includes ANSCA shareholder status or information

regarding membership in an Alaska Native village.

A list of some of the tribal documents an AI/AN consumer may need is available at

HealthCare.gov: American Indians and Alaska Natives.

When a consumer applies for Marketplace coverage, their eligibility results will explain how to

provide the documents. Documentation may be uploaded to the online application or mailed in

after submitting the application.

 When mailing in copies of tribal documents, applicants should indicate their application

number or include a copy of the letter received after submitting their online application.

This will help to ensure that the correct tribal documentation is linked with the correct

application.

 Individuals will have 90 days to submit their documents. If documentation is not submitted

within this timeframe, they will be notified that they will need to choose another plan until

tribal documents are provided.

Consumers may also need to provide information about the size of their household and how

much money they earn or receive if they want to apply for help paying for coverage through a

Marketplace.

Mixed Status Households

Members of households with a mixed AI/AN status have special considerations when applying

through the Marketplace.

If a federally recognized tribal member and non-tribal member enroll in the same Marketplace

plan, the tribal family member will not be able to use the special cost-sharing savings.

Therefore, federally recognized tribal members and non-tribal family members with an income

under 300 percent of the FPL should consider enrolling in separate plans if they want to take

advantage of all potential savings.

Members of households with a mixed AI/AN status may also choose to enroll on the same

Marketplace application. If all family members use the same application and one family member

on the application is eligible for the SEP, all family members will benefit from the SEP.

Therefore, non-tribal members applying on the same application as a tribal member requesting

an SEP can take advantage of this SEP. This is true even if different family members are

eligible for different Marketplace plans based on differing eligibility for lower monthly premiums

or out-of-pocket costs. In Marketplaces operated by states, this flexibility may vary.

Medicaid and CHIP Coverage

Medicaid and CHIP are available to AI/ANs. These programs provide better access to services

that a local Indian health clinic might not be able to provide.

Medicaid and CHIP Protections

Members of federally recognized Indian tribes and individuals who are otherwise eligible for

services from an Indian health care provider have the following Medicaid and CHIP protections:

 They do not have to pay Medicaid premiums or enrollment fees if they are eligible to

receive care from an Indian health care provider or through referral to a non-Indian

provider (such as PRC).

 They do not have to pay any cost sharing such as deductibles, coinsurance, or

copayments for any Medicaid service from any Medicaid provider if they have ever

received a service or referral from an Indian health care provider.

 Children who are AI/AN cannot be charged any premium, enrollment fee, copayment,

coinsurance, or deductible in CHIP.

Medicaid Eligibility Verification

When applying for Medicaid and CHIP, applicants may need to provide documentation of U. S.

citizenship. The following tribal documents can be used to show proof of U.S. citizenship:

 A document issued by a federally recognized tribe indicating tribal membership, such as

a tribal enrollment card

 A document issued by an Alaska Native village/tribe or an ANCSA corporation (regional

or village) acknowledging descent, affiliation, or shareholder status

 A certificate of degree of Indian blood issued by the BIA

 A tribal census document

 Any document indicating affiliation with the tribe

Medicaid and CHIP agencies may accept an individual’s self-attestation regarding Indian

status. If the Medicaid or CHIP agency requires documentation, this same list of tribal

documents or any of the following documents could be used to verify Indian status or eligibility

for services from an Indian health provider:

 Evidence the consumer has ever received or is eligible to receive services from an Indian

health provider or through referral from an Indian health provider.

 If the consumer is a California Indian, a document from the BIA or an Indian tribe showing

a person who is listed on the plans for distribution of the assets of Rancherias and

reservations located within the state of California under the Act of August 18, 1958, and

any descendant of such an Indian; or document showing trust interests in public domain,

national forest, or reservation allotments in California; or document showing a person is a

descendant of an Indian who was residing in California on June 1, 1852, if such

descendant is a member of the Indian community served by a local program of the IHS.

 Marriage certificate, if non-Indian spouses are made eligible for services through an

Indian health care provider, as a class, by an appropriate resolution of the governing

body of the Indian tribe or tribal organization, AND a document from the list above for

their eligible Indian spouse.

 If the consumer is eligible for services through an Indian health care provider only

because they are pregnant with the child of a member of an Indian tribe or a shareholder

of an Alaska Native corporation, a document from the list above for the member or

shareholder.

 If the consumer is an urban Indian, a document showing residency in an urban Indian

center, such as a rent statement, mortgage, utility bill, or voter registration card, AND an

enrollment or membership card/ID or document establishing that the individual:

 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;

 Is an Eskimo or Aleut or other Alaska Native;

 Is considered by the Secretary of the Interior to be an Indian for any purpose;

 Has been determined to be an Indian under regulations promulgated by the

Secretary.

AI/AN Income Calculation

In general, AI/ANs should not report AI/AN income that the IRS exempts from tax. Because

some types of income specific to AI/ANs are non-taxable, this income is excluded when

determining eligibility for Marketplace tax credits, cost-sharing reductions, Medicaid, and CHIP.

The following categories of income are generally excluded from an AI/AN’s MAGI:

 Distributions from ANCSA Corporations and Settlement Trusts

 Distributions from trust/reservation property

 Income from property and rights related to hunting, fishing, and natural resources

 Income from the sale and use of cultural/subsistence property

 Student financial assistance provided by the BIA and/or a tribe

 Income that falls within the IRS General Welfare Doctrine

 Any other income that is non-taxable according to federal law or IRS guidance

 Certain types of Indian trust income and resources are exempt from Medicaid estate

recovery rules. Medicaid estate recovery only applies to those age 55 and older who

receive long term care services, such as nursing home care.

NOTE: Per capita income from Indian gaming is not excluded when calculating income. It will be

counted toward eligibility and should be reported on a consumer’s application for coverage.

There might be instances where certain Indian income is taxable by the IRS but is excluded for

the purposes of Medicaid and CHIP. For example, an individual might sell Indian jewelry and

report that income to the IRS; however, if the jewelry has AI/AN cultural significance, it may not

be counted for Medicaid and CHIP eligibility. In general, the exemptions apply to income and

property that are connected to the political relationship between the tribes and the Federal

Government and property with unique AI/AN significance.

FFM Application Options

AI/AN consumers may complete eligibility applications for QHPs and Medicaid and CHIP

coverage through the FFMs by paper or online. They may also apply over the phone through the

FFM Call Center.

For both the paper and online applications, AI/ANs can attest to their tribal membership and will

need to submit proof of tribal membership/enrollment/ANCSA shareholder status within 90 days

of application.

There are two paper applications that AI/AN consumers can complete to apply for QHP

coverage through the FFMs.

 Application for Health Coverage (Individuals or Families) is intended for individuals

who don't want to apply for help paying for health insurance costs. Step 3 of this

application asks if a consumer or members of the consumer's household are AI/AN. If the

application is received outside of the annual OEP, the FFMs use the responses to this

question to determine whether the AI/AN consumer is eligible for an SEP.

 Application for Health Coverage & Help Paying Costs (Individuals or Families Who

Wish To Apply For Programs To Lower Costs) asks AI/ANs to complete Step 3 and

Appendix B of the application. The FFMs use the responses to the questions in Step 3

and Appendix B to determine whether the consumer is eligible for enrollment in a QHP

and for financial assistance as well as whether the consumer is eligible for Medicaid or

CHIP.

The online FFM application includes a question asking whether the applicant or household

members are AI/AN. Consumers who identify as AI/ANs should answer additional questions to

find out if they're eligible for special benefits under Medicaid and CHIP.

Employer-sponsored Coverage

The protections from cost sharing for AI/ANs that are included in the ACA are only available with

individual market health insurance coverage through a Marketplace. However, AI/ANs with

employer-sponsored coverage should not have to pay copayments or deductibles if they receive

care at an IHS or tribal facility because they do not charge cost sharing to eligible AI/ANs. The

employer-sponsored plan would not be required to reimburse the Indian health care facility for

the cost-sharing amount not paid by the AI/AN patient.

Consumers who are offered employer-sponsored coverage are not eligible for the PTC unless:

 The employer-offered coverage is "unaffordable" or does not meet minimum value,

 They decline the employer-sponsored coverage, and

 They enroll in individual market health insurance coverage through a Marketplace.

Additional Resources

 HealthCare.gov/american-indians-alaska-natives/

 Indian Health Service: IHS.gov/aca/faq/

 Administration for Native Americans (HHS): ACF.HHS.gov/ana/fact-sheet/american-

indians-and-alaska-natives-affordable-care-act-definitional-issues

 CMS Division of Tribal Affairs: CMS.gov/Outreach-and-Education/American-Indian-

Alaska-Native/AIAN

 National Indian Health Board Tribal Health Reform Resource Center:

NIHB.org/tribalhealthreform/

Health Insurance Marketplace

is a registered service mark of the U.S. Department of Health & Human Services.

Indian Health Care Improvement Act

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45 CFR § 155.420 (d)(8)

45 CFR § 156.410(b)(2)

45 CFR § 156.410(b)(3)

45 CFR § 155.350(c)(1)