1. American Indians and Alaska Natives in the Marketplace

2. Affordable Care Act: Benefits for Tribal Communities
Permanently reauthorizes the Indian Health Care Improvement Act (IHCIA) and strengthens the Indian Health Service’s role in health delivery.
Strengthens the IHS and ensures that AI/ANs will be able to continue to receive services from IHS, Tribes or Tribal organizations, and urban Indian organizations.
Health care services for American Indians and Alaska Natives is a key component of the federal government’s trust responsibility. Updating and permanently reauthorizing the Indian Health Care Improvement Act helps to fulfill this responsibility.
The law also strengthens the IHS by providing more options for health insurance, while American Indians and Alaska Natives can continue to receive health care through Indian health care providers.
IF ASKED:
The Affordable Care Act and the permanent reauthorization of the Indian Health Care Improvement Act makes special improvements for the health of those in Indian Country by expanding and creating programs not just in the Marketplace, but within the Indian Health System, such as loan repayment and recruitment programs for health professionals.

3. Definition of AI/AN
For purposes of Medicaid and CHIP, an AI/AN is a member of a federally recognized Tribe, an Alaska Native Claims Settlement Act (ANCSA) shareholder, or any individual eligible to receive services from IHS.
For purposes of the Marketplace, an AI/AN is limited to members of a federally recognized Tribe or ANCSA shareholders.
Now we’re going to go over a few terms that will be important as we discuss the CMS programs and Indian protections. First, it’s important to understand the definition of American Indian and Alaska Native is different for purposes of Medicaid and CHIP and for the Marketplace.
In the Marketplace, the definition of American Indian and Alaska Native only includes members of federally recognized tribes or Alaska Native shareholders. But the definition of American Indian and Alaska Native in the Medicaid and CHIP programs include members as well as persons of Indian descent or Indians residing in urban centers. This definition is consistent with the IHS criteria for eligibility to receive health services.

4. Special Protections for Indians
Congress enacted special protections in the Marketplace and in Medicaid based on the government to government relationship with Indian tribes.
Marketplace considers only TAXABLE AI/AN Monies
Does not consider trust settlement payouts, IIM account distributions, any other AI/AN monies not subject to federal income tax.
Casino earnings paid out to AI/AN are counted for Marketplace and Medicaid.
There are special protections for Indians when determining income eligibility in the Marketplace and Medicaid. For the Marketplace, the general rule is if you report something on your income tax return, you report it for Marketplace purposes.

5. The Marketplace One process to determine eligibility for
Marketplace health plans (QHPs)
Tax credits and cost sharing subsidies
Medicaid
Children’s Health Insurance Program (CHIP)
Offers choice of plans and levels of coverage
Insurance companies compete for business
The Marketplace sets up a one stop shop for determining eligibility for Qualified Health Plans on the Marketplace, tax credits, Medicaid, and CHIP.

6. Marketplace Establishment
Each State Can Decide To:
Create and run its own Marketplace
State Based Marketplace
Have a Marketplace established and operated by the federal government
Federally Facilitate Marketplace
Engage actively with the federal government in operating certain Marketplace functions
State Partnership Marketplace
Each state can choose how its Marketplace is run – either operated by the state, the federal government, or a combination of both, called a parternship.
A state has substantial flexibility in establishing a Marketplace that meets the needs of its citizens. States across the country received grants to establish Marketplaces. Marketplaces operated by the state is called a State Based Marketplace. A state may apply at any time to run its own Marketplace.
A state may also decide to have the federal government operate its Marketplace, called a Federally Facilitated Marketplace, or FFM. The Federal Government is now operating a Marketplace in those states that didn’t establish their own. In states where the Federal Government is operating a Marketplace, the state can opt to partner with the federal government, called a State Partnership Marketplace. This allows states to make recommendations for key decisions and help tailor a Marketplace to local needs and market conditions.
IF ASKED: To see the type of Marketplace in your state go to:

7. The Marketplace: Qualified Health Plans (QHPs)
A Qualified Health Plan (QHP) is an insurance plan certified by the Marketplace that will cover 10 Essential Health Benefits (EHB).
Each QHP Must follow established limits on cost-sharing
deductibles, copayments, and out-of-pocket maximum amounts
meets other requirements
As mentioned earlier, the Marketplaces offer comprehensive health coverage through Qualified Health Plans, or QHPs. A QHP is simply a health plan offered on the Marketplace. You may also hear it referred to as a “Marketplace health plan.”

8. The Marketplace: Essential Health Benefits (EHB)
Ten (10) Essential Health Benefits (EHB):
Outpatient care you get without being admitted to a hospital (ambulatory patient services)
Visits to the emergency room
Hospitalization
Maternity and newborn care
Mental health, behavioral health, and substance abuse treatment
Prescription drugs
Rehabilitative and habilitative services and devices (such as physical, occupational, or speech therapies that help improve skills for daily living)
Laboratory services
Preventive and wellness services and chronic disease management (such as screenings, check-ups, and monitoring and coordinating treatment)
Pediatric services (including oral and vision care)
All QHPs must cover the same set of items and health care services, these items and services are called essential health benefits (EHBs). They include doctor’s visits, hospitalizations, medications, and mental health and substance abuse treatment.

9. Special Protections for AI/ANs on the Marketplace
Special enrollment periods and the ability to switch plans monthly
Cost-sharing reductions in zero cost-sharing and limited cost-sharing at any level plan, depending on income
Ability to apply for an exemption from the individual shared responsibility payment
Remember, the definition of Indian in the Marketplace is different than for other CMS programs. For purposes of the Marketplace, an AI/AN is limited to members of a federally recognized Tribes or Alaska Native shareholders.
There are several protections in the Marketplace:
Special enrollment periods and the ability to switch plans monthly
Cost-sharing reductions in zero cost-sharing and limited cost-sharing at any level plan, depending upon income
Ability to apply for an exemption from the individual shared responsibility payment. Also known as the fee or tax penalty.

10. Special Protections: Special Enrollment Periods
Tribal members and Alaska Native shareholders have special enrollment periods (SEPs), which allow them to enroll in health coverage monthly, rather than only during the yearly Open Enrollment period.
In the Federal Marketplace, if one family member on the application is eligible for the SEP, all family members who apply on the same Marketplace application are eligible. This is true even if different family members are eligible for different Marketplace plans. However, a State Marketplace might process the SEP differently.
It’s important to remember that when we talk about Special Enrollment Periods and Cost Sharing Reductions, the definition of American Indian and Alaska Native is limited to Tribal members and Alaska Native shareholders.
Tribal members and Alaska Native shareholders qualify for SEPs, which means they’re eligible to change health plans once a month and not limited to changing plans during open enrollment like other consumers.
Check with your state’s website for more information about how they process SEPs for Tribal members and Alaska Native shareholders

11. Special Protections: Zero Cost Sharing Plans
Tribal members and Alaska Native shareholders with income between 100% and 300% of FPL:
May be able to enroll in a zero cost sharing plan which means no copays, deductibles or coinsurance when receiving care from Indian health care providers or when receiving Essential Health Benefits (EHBs) through a QHP.
In addition, there is no need for a referral from an I/T/U provider when receiving EHBs through the QHP.
The next special protection is cost sharing reductions, which includes copays, coinsurance, deductibles, and other similar charges. Again, remember that these special rules only apply to Tribal members and Alaska Native shareholders.
There are two types of plan variations that provide cost sharing reductions for Tribal members and Alaska Native shareholders: Zero cost sharing and limited cost sharing.
Tribal members and Alaska Native shareholders with income between 100% and 300% of FPL:
Can enroll in a zero cost sharing plan which means no copays, deductibles or coinsurance when receiving care from Indian health care providers or when receiving Essential Health Benefits (EHBs) through a QHP.
In addition, when receiving EHBs through the QHP, such as a Purchased or Referred Care referral, formerly known as Contract Health Services, there is no need for a referral from an I/T/U provider first.
Refer to the chart on the FPL slide or the handout for levels for your family.

12. Special Protections: Limited Cost Sharing Plans
Tribal members and Alaska Native shareholders with income below 100% and above 300% FPL:
Can enroll in a limited cost sharing plan which means no copays, deductibles or coinsurance when receiving care from Indian health care providers
Or when receiving EHBs through a QHP, will need a referral from an I/T/U provider to avoid cost sharing when receiving EHBs through a QHP.
Tribal members and Alaska Native shareholders with income below 100% and above 300% FPL:
Can enroll in a limited cost sharing plan which means no copays, deductibles or coinsurance when receiving care from Indian health care providers or when receiving EHBs through a QHP.
The difference between a zero and limited cost sharing plan is that in a limited cost sharing plan, an individual will need to get a referral from an I/T/U provider before receiving EHBs through a QHP to avoid paying co-pays, deductibles, or co-insurance.
Refer to the chart on the FPL slide or the handout for levels for your family.
IF ASKED ABOUT MEDICAID FPLS: Medicaid uses the current year’s FPL. Marketplace uses last year’s.
IF ASKED ABOUT MIXED HOUSEHOLDS (Indian and non-Indian households): For households with both Tribal members and Alaska Native shareholders and non-members, the family members who aren’t members or shareholders wouldn’t qualify for a zero cost sharing or limited cost sharing plan and would need to choose a separate QHP. If the family wants to stay in the same plan, then the family must decide if it wants to forgo the cost sharing savings.

13. Marketplace Plan Levels of Coverage: Metal Levels
This slide represents the different levels of coverage, what the plan pays on average, and what enrollees pay on average in addition to the monthly plan premium. These are an average cost of an individual under the plan and may not be the same for every enrolled person.
You could be responsible for a higher or lower percentage of the total costs of covered services for the year, depending on your actual health care needs and the terms or your insurance policy. But generally, plans with higher premiums, such as Platinum plans, have lower cost sharing; while plans with lower premiums, like Bronze or Silver plans, have higher cost sharing. Cost sharing includes costs like deductibles, co-insurance, and co-payments.
Those Tribal members and Alaska Native shareholders eligible for cost sharing reductions, might want to look at lower premium plans, such as the Bronze or Silver plans, to save money.
Tribal members and Alaska Native shareholders can enroll in a zero cost sharing or limited cost sharing plan, at any metal level.
Tribal members and Alaska Native shareholders who qualify for cost sharing reductions are not exempt from premiums.

14. Advanced Premium Tax Credits (APTC)
Tribal members and Alaska Native shareholders are not exempt from premiums.
You could be eligible for APTCs, if:
Buy health insurance through the Marketplace;
Don’t have coverage through an employer or government plan;
Are within 100% and 400% FPL
Tribal Premium Sponsorship
APTCs apply to people with income limits between 100% FPL and 400% FPL. If you qualify for APTCs, your premiums could be very low. But, if your income is below 100%, you don’t qualify for a tax credit to lower your premiums. And if you live in a state that hasn’t expanded Medicaid and you have income below 100%, you qualify for a limited cost sharing plan and do NOT get APTCs. Therefore, your tribe might want to consider Tribal Premium Sponsorship. Please contact your tribe to see if they are participating in this program.

15. Exemption from the Shared Responsibility Payment
Tribal members or Alaska Native shareholders, descendants, and other Indians eligible for services from an I/T/U, qualified for an exemption from the shared responsibility payment.
An exemption is claimed when you file your federal income tax return:
IRS form 8965, Part III, enter Code E – Indian exemption and check full year
People uninsured in 2019 and beyond will not be subject to a penalty.
If you don't have health coverage, you may have to pay a fee unless you have Minimum Essential Coverage or an exemption. Minimum Essential Coverage is the type of coverage an individual needs to have to meet the individual responsibility requirement under the Affordable Care Act. The fee is sometimes called the "penalty," "fine," "individual responsibility payment," or "individual mandate.“
However, if you don’t have to file taxes, then you don’t need an exemption.
If you do file taxes but you don’t have a certain level of health coverage (employer coverage, Medicare, Medicaid, CHIP, TRICARE, certain VA coverage, an individual policy, or a plan in the Marketplace) you may have to pay a fee with your tax return.
American Indians and Alaska Natives have an exemption from the shared responsibility payment and remember if you don’t file taxes then you don’t need an exemption.

16. Additional Resources Marketplace Resources
Call Center: hours a day. 7 days a week.
Details on special Marketplace protections and benefits for AI/ANs are located here:
Printed Tribal materials to share with your community: CMS Marketplace information center:
IHS information on the Affordable Care Act:
Information for Tribal leaders and Tribal health programs: National Indian Health Outreach and Education (NIHOE):
Additional Tribal outreach and education resources: CMS Division of Tribal Affairs:
Weekly Assister's Webinar:
IHS Q&A call for Affordable Care Act questions:
We know you may have questions after this presentation. This is a list of websites that have valuable information.
In addition, you can join the bi-weekly IHS Q&A call for Affordable Care Act questions. The calls are every other Tuesday. You can for more information about the calls.
You can also join the weekly assister’s webinar on Fridays from 2 to 3 eastern time. You can register for these calls at
These resources will help you stay up to date and stay involved because there are frequent changes to these policies.

17. Questions?
CONTACTS:
Division of Tribal Affairs Center for Medicaid & CHIP Services