1. American Indians and Alaska Natives in the Marketplace

2. Overview What we will cover today:
Historical Background and the Indian Health System
Medicaid protections for American Indians and Alaska Natives (AI/ANs)
Marketplace protections for AI/ANs under the Affordable Care Act (ACA)
Medicare under the ACA
Today we’ll briefly touch on the historical background and the Indian health system and how the Affordable Care Act benefits tribal communities, then move on to the special protections for American Indians and Alaska Natives in CMS programs like Medicaid, the Marketplace, and Medicare.
When discussing the special protections on the Marketplace, it is always important to remember that American Indians and Alaska Natives can continue to receive health care services from the Indian Health Service, tribe, or urban Indian organization even if they purchase a health care plan on the Marketplace.

3. Historical Background
Federally recognized tribes and the federal government have a historical government-to-government relationship based on U.S. treaties, laws, Supreme Court cases, Executive Orders, and the U.S. Constitution.
As part of this unique relationship, the federal government provides health care, social services, housing, education, and other services to AI/ANs, through federal agencies such as the Department of Health & Human Services (HHS), Department of the Interior, and the Department of Education.
There is a special government-to-government relationship between the federal government and federally recognized tribes based on U.S. treaties, laws, Supreme Court cases, Executive Orders, and the U.S. Constitution.
Because of this special relationship between the federal government and the tribes, the Marketplace, Medicaid and Medicare contain special protections for Indians.

4. Federally Recognized Tribes and AI/AN Population in the U.S.
What is considered a federally recognized tribe in the U.S.?
A federally recognized tribe is any Indian or Alaska Native tribe, band, nation, Pueblo, village, or community that the Department of the Interior (DOI) acknowledges as an Indian tribe, including Alaska Native regional and village corporations.
How many AI/AN people live in the U.S.?
According to the U.S. Census, there are 5.2 million people in the U.S. who identify themselves as AI/AN, either alone or in combination with one or more other races. Approximately, 2 million receive services from the Indian health system.
There are 566 federally recognized tribes in the U.S. Although tribes are located in 34 states, American Indians and Alaska Natives reside in every state.
IF ASKED: You may see the full list of federally recognized tribes by visiting the Bureau of Indian Affairs Tribal Directory and the list of Alaska Native corporations available from the Alaska Department of Resources. The links to those lists are included on the second to last slide of this presentation.

5. The Indian Health Care System
The Indian Health Service (IHS) (I), Tribes and Tribal organizations (T), and urban Indian organizations (U) are the three components of the Indian health care system.
45 Indian hospitals
Over 600 Indian health centers, clinics, and health stations, including urban programs
When specialized services aren’t available at these sites, health services may be purchased from public and private providers through the Purchased/Referred Care Program, formerly known as Contract Health Services.
A large portion of American Indian and Alaska Native consumers access health care through providers in the Indian health care system, which includes the Indian Health Service, tribes or tribal organizations, and urban Indian organizations, often referred to as ITUs.
There are currently 45 Indian hospitals and over 600 Indian health centers, including urban programs. A large portion of these facilities are managed by tribes.
When specialized services aren’t available at these sites, health services may be purchased from public and private providers through the Purchased/Referred Care Program, formerly known as Contract Health Services.

6. CMS Programs CMS administers the following programs: Medicare Medicaid
Children’s Health Insurance Program (CHIP)
The Health Insurance Marketplace
The Centers for Medicare and Medicaid Services administers several programs that impact Indian health.
CMS BACKGROUND – IF ASKED:
Medicare and Medicaid were signed into law in Medicare is the federal health insurance program for people who are 65 or older. Medicare also covers some younger people with disabilities and people with End-Stage Renal Disease, which is permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD. The different parts of Medicare help cover specific services. Part A covers Hospital Insurance, such as inpatient hospital stays. Part B covers Medical Insurance, including outpatient medical care. Part C covers Medicare Advantage Plans, which are private health plans offered through contract that cover both Parts A, B, and often prescriptions. And, Part D covers prescription drugs. Visit for more information about how and when to change plans.
While the Medicaid program was created in 1965, the Children’s Health Insurance Program was signed into law in Both are joint state-federal health programs that help with medical costs for certain low income children and adults. Medicaid eligibility is different depending on whether the state has chosen to expand its Medicaid program. We’ll go into more detail about who is eligible for Medicaid in a few slides.
The Marketplace is designed to expand access to affordable health care by creating a place where consumers can compare health options.
By enrolling in CMS programs, American Indians and Alaska Natives benefit by having greater access to services that may not be provided by local ITUs, and the tribal communities benefit through increased resources to ITUs.

7. 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.

8. 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.

9. Benefits for Tribal Communities: Medicaid
CHIPRA/ARRA Protections
Documentation/Enrollment
Cost Sharing, Income/Resource Protections, Managed Care Protections/Estate Recovery
Individuals can apply and enroll in Medicaid at any time
In the last few years, several key pieces of legislation have made important changes and created protections for Indians in Medicaid and CHIP.
The Children’s Health Program Reauthorization Act, known as CHIPRA, made changes to require States to accept tribal documents as proof for both citizenship verification and identity. The State must accept any document from a tribe that indicates enrollment or affiliation with federally recognized Tribes and identifies the individual applicant. Essentially, making tribal documents equivalent to a US passport for verification purposes.
The American Recovery and Reinvestment Act, or ARRA, provided key protections for Indians under Medicaid that we will cover later in this presentation including, cost sharing exemptions, income and resource exclusions, managed care protections and protections for Indian specific properties from estate recovery.
Medicaid does not have “open enrollment periods” and applicants can apply at any time and if eligible, receive Medicaid coverage. In some cases, if the individual incurred medical bills in the 3 months prior to enrollment, retroactive coverage may be provided.

10. Benefits for Tribal Communities: 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
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.

11. Application and Eligibility
Streamlined Application
Eligible for Qualified Health Plan or
Medicaid/ CHIP
Submit Streamlined Application to the Marketplace
Verify and Determine Eligibility
Enroll in
Marketplace
Qualified Health Plan
The first step in getting health coverage is submitting an application, which you can see highlighted red here on this slide. You can apply online at by phone, by mail, or in person.
You’ll hear the application referred to as a “streamlined application,” which means it allows you to apply for either the Marketplace or the Medicaid and CHIP programs at the same time. And it’s also used to calculate advanced payments of the premium tax credit and cost-sharing reductions to help pay for coverage purchased through the Marketplace.
Once you submit an application to the Marketplace, your application is verified by a data services Hub between the Social Security Administration, the IRS, Homeland Security, and other approved data sources for verification.
At this time, there is no electronic verification for tribal members and Alaska Native shareholders who want to take advantage of cost sharing reductions or special enrollment periods. Instead, these individuals must verify tribal membership or shareholder status by submitting paper documentation within 90 days of application.
IF ASKED ABOUT STATE BASED MARKETPLACES: This application is used by the Federally-facilitated Marketplace. States operating their own Marketplace have the option of using the single application or developing an alternative application. IF ASKED ABOUT THE PAPER APPLICATION: It is available on healthcare.gov. Consumers have the option to complete either the paper or online application
IF ASKED ABOUT FILE TYPES: Submitting in one of the following file types will ensure successful upload: pdf, jpg, jpeg, gif, tiff, bmp, png. If you still have trouble uploading the documents, the files may be too large. In that case, you should try converting the files to pdf versions or submit copies of the documents by mail. If you mail in your documents, be sure to include your application number.
IF ASKED WHAT TRIBAL DOCUMENTS TO SUBMIT FOR THE MARKETPLACE:
A document issued by a federally recognized tribe indicating tribal membership, such as a tribal enrollment card, and includes tribal seal and/or an official signature
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 (CDIB) issued by the Bureau of Indian Affairs, if the CDIB includes tribal enrollment information
Supported by Data Services Hub
Submit Tribal Documentation w/in 90 days
Online
By Phone
By Mail
In Person
Premium Tax Credit
Cost-sharing Reductions
Tribal SEPs
Enroll in
Medicaid/CHIP

12. Why Does Household Income Matter?
You will be asked to report your household income on the application. This will help determine which CMS programs you are eligible for. You’ll see “100% FPL” or “400% FPL” in several different places throughout this presentation, outreach materials, and on healthcare.gov. These numbers are based on the national federal poverty level as determined annually by the federal government. Eligibility for many programs is based on percentage of the federal poverty level and where your income falls on that scale.
For example, if you have a family of three and your household income is below $26,321, or 133% of the federal poverty level, you may be eligible for Medicaid in a state that has chosen to expand Medicaid. Or, if you’re a member of a federally recognized tribe or an Alaska Native shareholder living alone with a household income of less than $35,010, you qualify for a zero cost sharing plan on the Marketplace. We’ll get into more detail about zero cost sharing plans later on in the presentation.
You may also see 138% of the federal poverty level used interchangeably with 133% because by law, Medicaid expanded up to 138% with a 5% disregard. But for simplification, Medicaid uses 133%.
IF ASKED: Keep in mind that Medicaid uses the current year’s FPL numbers, while the Marketplace bases their income determinations on last year’s. So if you apply for Medicaid in 2015, you’ll need to check with your state for the most up-to-date federal poverty levels or visit
IF ASKED: The new year’s FPLs are usually released in late January, and implemented sometime during the second quarter.

13. Streamlined Application: Verification of Indian Status
Benefit from the special protections in the Marketplace!
Use the streamlined application to indicate you are a Tribal member or Alaska Native shareholder.
For the Marketplace verification of Indian status is done through a paper documentation process.
In order to be eligible for cost-sharing reductions and monthly special enrollment period, tribal members and Alaska Native shareholders must demonstrate membership in a federally recognized tribe or Alaska Native Corporation (regional or village).
On the on-line application, there is a drop down list of federally recognized Indian tribes and Alaska Native corporations.
At this time, there are no approved electronic data sources available to support tribal verification.
To take advantage of the cost sharing reductions or special enrollment periods, verification of tribal membership is required and must be submitted within 90 days of application. You can upload your tribal documents or submit copies by mail.
IF ASKED QUESTIONS ABOUT ELECTRONIC VERIFICATION:
CMS has assessed the availability of electronic data from IHS and the Bureau of Indian Affairs, and determined that the data collected by these agencies do not contain the data elements necessary to verify Indian status as defined in the law. CMS will not utilize an electronic data source for the verification of Indian status to determine eligibility in the Federally-facilitated Marketplace pertaining to cost-sharing exemptions and monthly special enrollment periods.
IF ASKED ABOUT FILE TYPES: Submitting in one of the following file types will ensure successful upload: pdf, jpg, jpeg, gif, tiff, bmp, png. If you still have trouble uploading the documents, the files may be too large. In that case, you should try converting the files to pdf versions or submit copies of the documents by mail. If you mail in your documents, be sure to include your application number.
Documents accepted:
Tribal identification card
BIA Forms
Certificate of Indian Blood

14. Application and Eligibility
Medicaid Protections for AI/ANs
Eligible for Qualified Health Plan or
Medicaid/ CHIP
Submit Streamlined Application to the Marketplace
Verify and Determine Eligibility
Enroll in
Marketplace
Qualified Health Plan
After you apply using the streamlined application, you’ll be directed to either your state’s Medicaid or CHIP program or the Health Insurance Marketplace, depending on your income and other information you included on your application.
First, we’ll talk about Medicaid and CHIP. It’s important to understand the Medicaid and CHIP program and its protections for American Indians and Alaska Natives. If you don’t qualify for Medicaid or CHIP, you may qualify for health insurance on the Marketplace.
Supported by Data Services Hub
Submit Tribal Documentation w/in 90 days
Online
By Phone
By Mail
In Person
Premium Tax Credit
Cost-sharing Reductions
Tribal SEPs
Enroll in
Medicaid/CHIP

15. Medicaid: Who is Covered?
Mandatory Categorically Needy Groups - Required by Statute
Children and Families
Pregnant Women
Disabled and Aged Individuals
Optional Categorically Needy Groups – State Option
Childless adults, age , below 133% FPL in Medicaid Expansion states
Every state is required to cover certain groups of people, these are considered the mandatory categorically needy groups that are required by statute and include Children and Families, Pregnant Women, and Disabled and Aged individuals.
States must provide the full range of Medicaid services to elderly, disabled, pregnant women, and children covered by Early Periodic Screening, Diagnostic and Treatment, or EPSDT
States may also determine additional benefits and additional groups, including the new Medicaid expansion group. As you can see in this slide, Medicaid expansion includes individuals between ages 19 and 64, below 133% of the federal poverty level, in states that have chosen to expand Medicaid, also known as “expansion states”

16. Medicaid Expansion Reaches Many Different Groups of People
The Medicaid expansion: Potential for coverage for millions of uninsured Americans
Parents of children covered by Medicaid and CHIP
Parents of children who have grown and left home
Women that states now only cover while they are pregnant
Older people but still too young for Medicare
Younger people just starting out on their own
Individuals who are not yet in poor enough health to qualify based on disability
This slide shows all the different groups of people included in Medicaid expansion. Expansion often refers to “childless adults” but as you can see here, expansion covers more than just children adults.

17. 28 States and DC Will Expand Medicaid for 2015
Expanding
Medicaid
Not expanding
Medicaid to date
This map shows which states have chosen to expand Medicaid so far.
States in green have chosen to expand Medicaid, while those in blue have not.
You can see that about half of the states in Indian Country have expanded Medicaid.
Keep in mind that states can choose to expand Medicaid at any time. The federal government pays no less than 90% of the program costs to expand, depending on when states make that decision. DE DC
So far, 28 states and DC are expanding Medicaid to low-income adults in 2015 – discussions continue to evolve.

18. AI/AN Medicaid and CHIP Protections
Provides special protections for AI/ANs to increase access to health coverage through:
Medicaid and/or CHIP (ARRA Protections)
Resource Exemptions/Income Exclusions
Cost Sharing Exemptions
Estate Recovery Protections
Managed Care Protections
States/Tribal consultation
Although there is a big focus on the Health Insurance Marketplace, it’s important to remember the special protections in Medicaid and CHIP that also help increase access to healthcare for American Indians and Alaska Natives. The Affordable Care Act also created Medicaid expansion, which not all states have elected to do. But even if your state has not expanded Medicaid, the protections created in the American Recovery and Reinvestment Act, or ARRA, still apply.
These protections include:
Most Indian income won’t be counted when determining eligibility based on income for Medicaid and CHIP programs
No cost sharing for any service under Medicaid for individuals who have used I/T/Us
Protection of money and property derived from Indian resources from recovery by the estate of individuals who received Medicaid long term care services
American Indians and Alaska Natives enrolled in Managed Care in Medicaid or CHIP can go to an Indian health care provider even if the provider is not in the network and the provider must be paid their customary rate for those services
States must seek advice from I/T/Us before submitting changes to their programs that may have an impact on Indians or Indian health programs and States must consult with federally-recognized tribes before submitting Medicaid/CHIP Waiver requests.

19. AI/AN Medicaid and CHIP Protections
Certain types of Indian income and resources are not counted when determining Medicaid or CHIP eligibility:
Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties
Payments from natural resources, farming, ranching, fishing, leases, or profits from Indian trust land (including reservations and former reservations)
Money from selling things that have Tribal cultural significance, such as Indian jewelry or beadwork
And finally, certain types of Indian income and resources are not counted when determining Medicaid or CHIP eligibility, which are listed here.
IF ASKED ABOUT MEDICAID ESTATE RECOVERY: Medicaid Estate Recovery applies to Medicaid beneficiaries over the age of 55 and is only an option when Medicaid pays for Long Term Supports and Services (LTSS), such as care at nursing home facilities. Estate Recovery allows the State to recover some money and assets from beneficiaries who have received LTSS. However, some tribally related money and assets are excluded, just like when determining your income level for Medicaid eligibility. The types of income that are excluded for both eligibility determination, listed here, and Medicaid Estate Recovery, are similar.

20. AI/AN Medicaid and CHIP Protections
AI/ANs have the following Medicaid and CHIP protections:
Do not have to pay premiums or enrollment fees and can enroll at any time
No cost sharing in Medicaid if have ever used an I/T/U and no cost sharing for any AI/AN in CHIP.
These special protections are often referred to as “ARRA Protections” because they are as a result of the American Recovery and Reinvestment Act of We often discuss these protections when we talk about the Affordable Care Act because if you don’t qualify for health insurance on the Marketplace, you may be eligible for Medicaid coverage, even though the protections are part of the ACA.
First, Indians enrolled in Medicaid or CHIP do not have to pay premiums or enrollment fees.
Second, if they have ever received care from an Indian health care provider or through an I/T/U referral to a non-Indian provider, they do not have to pay any cost sharing, such as deductibles, co-insurance, or co-pays.

21. Benefits for Tribal Communities: Medicaid
100% FMAP for Medicaid-covered services provided through Indian Health and Tribal 638 facilities.
I/T/U Providers must be able to enroll in Medicaid and facilities are exempt from local licensure by the State as long as they substantially meet provider requirements.
Medicaid provides additional Benefits for tribal communities:
States are reimbursed 100% for Medicaid services provided through IHS and Tribal 638 facilities and do not have to pay a “share” of the cost of care like they do for other individuals. This 100% reimbursement is referred to as FMAP, or Federal Medical Assistance Percentage, which is the percent the federal government pays the state for certain Medicaid services.
There is no cost sharing allowed for American Indians and Alaska Natives in CHIP.
Indian health facilities are not subject to local licensure by the State but must meet licensing standards and health professionals must be licensed and in good standing in at least one state.
These are all benefits that Congress has enacted to encourage American Indian and Alaska Native enrollment in Medicaid and CHIP programs and participation by providers as well.

22. Application and Eligibility
Marketplace Protections for AI/ANs
Eligible for Qualified Health Plan or
Medicaid/ CHIP
Submit Streamlined Application to the Marketplace
Verify and Determine Eligibility
Enroll in
Marketplace
Qualified Health Plan
As you can see here, we started at the streamlined application, followed by verifying eligibility, then, based on the information you include in the application, coverage by either Medicaid and CHIP or the Marketplace. If you don’t qualify for Medicaid or CHIP, you may be eligible to purchase a Qualified Health Plan on the Marketplace. The Affordable Care Act provides American Indians and Alaska Natives with special protections in the Marketplace.
Supported by Data Services Hub
Submit Tribal Documentation w/in 90 days
Online
By Phone
By Mail
In Person
Premium Tax Credit
Cost-sharing Reductions
Tribal SEPs
Enroll in
Medicaid/CHIP

23. The Marketplace It’s a way to shop for health coverage
An individual or family can explore every QHP in the area
Using one application, you can learn all the programs for which you qualify
Most people receive help paying premiums
90% of people who were uninsured will qualify for savings on health insurance
It offers clear options with apples-to-apples comparisons
All health insurance plans in the Marketplace present their price and benefit information in plain language
The Marketplace is:
A way to shop for health coverage
A way to help most people with help paying premiums
And a way to offer clear options with apples-to-apples comparisons

24. 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
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:

25. 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.”

26. 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.

27. 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.
We’ve been referencing the special protections for American Indians and Alaska Natives in the Marketplace.
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

28. Special Protections: Special Enrollment Periods
For consumers who change their plan or enroll in a new QHP between the 1st and 15th day of any month, the effective date of coverage will be the first day of the following month.
If the consumer changes plans and enrolls in a new health plan between the 16th and the last day of any month, the coverage effective date will be the first day of the second following month.
Even though Tribal members and Alaska Native shareholders can change plans once a month anytime during the year, you still should be aware of the potential coverage gap that can happen when switching plans.
This is best illustrated by going through an example. If you change plans on May 15th, your current coverage will continue through May 31st and your new coverage will begin June 1st, meaning you won’t have any day of the month without coverage, also known as a “coverage gap.” However, if you change plans on May 16th, your current coverage will expire on May 31st, but your new coverage might not take effect until July 1st, resulting in a 30-day coverage gap.
Either way, the best way to avoid a coverage gap is to consult with your current plan and the plan you want to enroll in about the best process for changing plans to avoid coverage gaps. 

29. Special Protections: Zero Cost Sharing Plans
Tribal members and Alaska Native shareholders with income at or below 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 at or below 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.
In 2014, 300% FPL is above
A single consumer household income of $35,010 or less (for consumers in Alaska: $43,763)
A two-person family household income of $47,190 or less (for consumers in Alaska: $58,988)
A three-person family household income of $59,370 (for consumers in Alaska: $74,213)
Refer to the chart on the FPL slide or the handout for levels for your family.

30. Special Protections: Limited Cost Sharing Plans
Tribal members and Alaska Native shareholders with income 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 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.
In 2014, 300% FPL is above
A single consumer household income of $35,010 or less (for consumers in Alaska: $43,763)
A two-person family household income of $47,190 or less (for consumers in Alaska: $58,988)
A three-person family household income of $59,370 (for consumers in Alaska: $74,213)
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.

31. 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.

32. 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.
However, if your income is below 100% FPL, you don’t qualify for APTCs. There is an outstanding issue as to whether Tribal members and Alaska Native shareholders with income below 100% FPL residing in states not expanding Medicaid can still qualify for cost sharing reductions. Current regulations do not allow cost sharing reductions unless you qualify for APTCs even though there is a Special Rule for Indians prohibiting cost sharing for those with incomes at or 300% FPL. This issue is currently under review.
It is also possible for your tribe to pay for your premium through a Tribal Premium Sponsorship program. Please contact your tribe to see if they are participating in this program.
Add a question: I have health insurance through my tribal employer or (Medicare), can I purchase health insurance through the Marketplace and qualify for APTCs and cost sharing reductions?

33. Exemption from the Shared Responsibility Payment
If you don't have health coverage in 2014, 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.

34. Indian Exemption
Tribal members, ANCSA or Alaska Native shareholders, descendants, and other Indians eligible for services from an I/T/U, may qualify for an exemption from the shared responsibility payment
We call this the “Indian Exemption.” This means that Tribal members, Alaska Native or ANCSA shareholders, descendants, and other Indians eligible for services from an I/T/U, may qualify for an exemption from the shared responsibility payment

35. Indian Exemption There are two ways to apply for the Indian exemption:
Apply to the Marketplace for an exemption from the tax penalty through the mail
Must submit Tribal documentation
Will receive an Exemption Certificate Number (ECN)
File IRS form 8965, Part I, enter ECN
File for the Indian exemption when completing your federal tax return
File IRS form 8965, Part III, enter Code E – Indian exemption and check full year
There are two ways to apply for the Indian exemption:
Apply to the Marketplace for an exemption from the tax penalty through the mail
Must still submit tribal documentation
Will receive an Exemption Certification Number
Can report the same number on your tax return every year.
Indicate they qualify for the Indian exemption when you file your 2014 federal tax return.
Don’t have to submit documentation but must be able to produce tribal documentation
Remember, even if you get an exemption, you can still enroll in a Qualified Health Plan on the Marketplace.
IF ASKED ABOUT THE CHANGE: We’ve seen a recent change to how the Indian Exemption will work in this coming year. On September 18, 2014, the Secretary announced at the Secretary’s Tribal Advisory Committee that individuals eligible to receive services from an Indian Health Service, tribal, or urban Indian health program provider would also be able to claim an exemption from the shared responsibility payment through the tax filing process starting with the 2014 tax year. This benefit was previously only available to members of federally recognized tribes (including ANCSA shareholders).
IF ASKED ABOUT THE PENALTY: The penalty in 2014 is calculated one of 2 ways. If you or your dependents don’t have insurance that qualifies as Minimum Essential Coverage you'll pay whichever of these amounts is higher:
1% of your yearly household income above the tax filing threshold, $10,150 for an individual. The maximum penalty is the national average premium for a bronze plan, OR
$95 per person for the year ($47.50 per child under 18). The maximum penalty per family using this method is $285.
IF ASKED ABOUT MINIMUM ESSENTIAL COVERAGE: individual market policies, job-based coverage, Medicare, Medicaid, CHIP, TRICARE , VA.
IF ASKED ABOUT THE IRS FORMS: A link to the draft form: Instructions on how to fill out the form:

36. Key Points
Federally recognized tribes and the federal government have a unique relationship. The federal government has a responsibility to provide members of federally recognized tribes with health care.
By enrolling in Medicaid or a Marketplace QHP, AI/ANs benefit by having greater access to services that may not be provided by your local ITU. Using non-Tribal health care resources can increase the resources available to others in your Tribal community.
Here are some important points to remember from this presentation.

37. Key Points
Eligible AI/ANs have certain protections and exemptions under Medicaid, CHIP, and the Marketplace.
For Medicaid and CHIP, AI/ANs are exempt from cost sharing and certain Indian income is excluded in determining eligibility
For the Marketplace, Tribal members and Alaska Native shareholders have special monthly enrollment periods and zero or limited cost sharing
All AI/ANs have the ability to apply for an exemption from the individual shared responsibility payment
Whether an AI/AN enrolls in Medicaid, CHIP or the Marketplace, or applies for an exemption, AI/ANs can continue to get services from an ITU at no cost.

38. 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.

39. Additional Resources Medicaid Children’s Health Insurance Programs
Information on State Medicaid programs is located at
To find out information about specific State Medicaid programs go to:
Children’s Health Insurance Programs
Information on Children’s Health Insurance Programs is located at:
Partner Lists
List of Federally Recognized Tribes:
Tribal Directory:
List of ANCSA corporations:
Here are other valuable resources for Medicaid, the Children’s Health Insurance Programs (CHIP) and Partner lists

40. Questions?
CONTACTS:
Division of Tribal Affairs Center for Medicaid & CHIP Services Native American Contact, Region __