• Health Insurance Issues
  • None of the work of National Assoc of Insurance Commissioners (NAIC) considers the special provisions for American Indians and Alaska Natives in the ACA.  This neglect is evident in the lack of meaningful protections for Indian health programs.

  • Comments on NAIC white paper did not include any proposals to address issues relating to contracting with Indian health programs (IHS, Tribal, Urban I//T/Us).

  • Network Adequacy-Exchanges will determine this (with Insurance Commissioners/Departments and federal oversight) and they could, but probably will NOT require contracting with Indian health programs if they don't understand its importance to Indian tribes.
  • Several states, notably Oregon, are moving forward with Medicaid reform based on coordinated care organizations.  
  • The Northwest Portland Area Indian Health Board, National Indian Health Board and the CMS Tribal Technical Advisory Group, have identified the issues that MCOs and IHPs need to address to establish a working relationship that allows for simplified contracting with Qualified Health Plans (QHPs).

  • The Addendum makes contracting easier and thereby offers many benefits.
  • The benefit to MCOs is access to a culturally appropriate primary care home for AIANs. 
  • The benefit to IHPs is access to specialists and other resources of the much larger MCOs. 
  • The benefit to our community members is they can continue to use their Tribe's health care program and their 'medical home.'


  • CMS Website in support of Managed Care and Long Term Support Services MLTSS
  • Under the state demonstrations to integrate care for dual-eligible individuals, CMS awarded 15 states contracts of up to $1 million each to design a program that covers primary, acute, long- term care, and behavioral health. According to a MacPac report  "It is likely that many of the 15 states will propose the capitated model or the managed FFS model, but the 15 states have the discretion to propose other models. To date, 26 states have posted demonstration proposals for comment on their state website or on the CMS website Coordinated Care."  

  • Washington State has indicated that Tribes will continue to receive fee for service payments and AIANs will not be automatically enrolled in a MCO.  Tribes are participating in the planning effort with an expectation that they will have the option to join integration efforts in the future.  See Community Catalyst Report and a letter to HHS from leading consumer groups with  concerns for consumers with Dual Eligible demonstrations.

State support for MCOs in health exchange plans, Medicaid programs, dual eligible projects and coordinated care organization development should ensure access to culturally appropriate health care services to AIANs in their own tribally or IHS operated health program.

Medicaid

Although states initially(1995) made no special accomodation for Indian health programs, Washington became the first to allow any AIAN to choose and approved payment to IHPs using the OMB/IHS encounter rate. AIANs could choose MCOs and if they made no choice and were assigned an MCO they could still 'opt out' and choose an IHP. Later AIANs who self-identifiied were auto assigned, by zip code, to IHPs.  

Washington State Medicaid has not required MCOs to contract with tribes. Kansas, after agreeing to meet with the states four tribes to mitigate damage to their programs, has become the first state to require an MCO to contract with the state's Indian health programs (and pay the encounter rate as well). In addition they require that managed care plans use an Indian Addendum


  • Indian Health Programs and Managed Care Providers in Exchange Health Plans.

  •   Will tribal citizens and other community members be able to utilize their own health programs when they access health insurance through health exchanges?

  •   Will Tribes be able to pay for (sponsor) their own citizens' and other community members health insurance and be assured those citizens can utilize their tribes' health program as part of the required use of managed care organizations?

  • Managed Care, Medicaid, Qualified Health Plans and Indian Health Programs
  • Managed Care is a requirement of Marketplace Plans and it is increasingly used in Medicaid.
  • Qualified Health Plans (QHPs)---is what managed care plans are called in the new Marketplaces.
  • QHPs contracting with Tribes is a still a work in progress as OE2 approaches (Oct 2014).
  • Indian QHP Contract Addendum  Key Documents
  • Oregon QHP NPAIHB Contract Review (September 25, 2013) highlights main issues in contracting with QHPs, 
  • Basic Health Option may be the best option for American Indians and Alaska Natives since Tribes and Indian Organizations have been unable to get needed regulations to sponsor Tribal members.
  • Basic Health not likely in Washington and specific funding ($500,000) not approved in 2014 supplemental budget (approved in House budget only).
Healthplanfinder lists QHPs that include the Port Gamble S'Klallam Health Programs as In-network providers
Suggested Citation: Website,  Health Care Reform for American Indians and Alaska Natives, Ed Fox, 2015
105 Maple Park Ave SE Olympia,WA 98501
Free and unlimited use granted, citation appreciated
edfox_phd@yahoo.com  360 790 1164
Free and unlimited use granted, citation appreciated
Contracting with Qualified Health Plans

The two contracting questions Tribes want answered is:

1.  Can an AIAN with an exchange-offered private health plan choose their Indian health program as their medical home?  


2.  Can an Indian health program utilize the managed care plan's provider network of specialists and hospitals without redundant tests and treatment plans?

There is no guarantee that Indian health programs (IHPs) will be included in Qualified Health Plans (QHP). Exchanges or Insurance regulators could require this, that is, they could make any IHP an available choice for AIANs eligible to use that program.  Federal and State regulators have no plans to do so in 2014 or 2015(federal).
New York Regulation
Oregon and Indian Addendum
Medicaid---Kansas, after agreeing to meet with the states tribes to mitigate damage to their programs, has become the first state to require an MCO to contract with the state's Indian health programs (and pay the encounter rate as well). In addition, Kansas requires that these managed care plans use the Indian Addendum developed by the TTAG/MMPC. See appendix H of the Kansas/CMS waiver.
 Arizona, like Oregon and California have offered to have Insurance plans meet with Tribes and IHS and Urban Programs on Contracting with QHPs
  • The Northwest Portland Area Indian Health Board, National Indian Health Board and the CMS Tribal Technical Advisory Group, have identified the issues that MCOs and IHPs need to address to establish a working relationship that allows for simplified contracting with Qualified Health Plans (QHPs).
  • This effort includes a Proposed Indian Health Program Addendum.

Oregon requires the use of the Indian Addendum if contracting with Tribe.
New York Regulation
  • Minnesota  Exchange  Legislation (2013) that includes a requirement that QHPs utilize the Indian Addendum in contracts with Indian health programs, beginning Jan 2015.
  • Washington State Medicaid Contracting 
  • Only the Community Health Plan of Washington has refused to contract (and use the Indian Addendum) with the Port Gamble S'Klallam Tribe 
  • Managed Care Plans agreeing to use Addendum:   Molina, Coordinated Care, Amerigroup, and United Health.
Tribes in Washington can now bill state and plans if their patients are enrolled in Medicaid Managed Care plans and Medicaid can still result in $368 encounter rate payments to Indian health programs.
2014 Self-Governance Tribes request for use of Indian Addendum