Improving health outcomes for eligible AI/AN children, youth, and families enrolled in Medicaid and the Children’s Health Insurance Program

To: Tribal Child Welfare Agencies, Child Care programs, Head Start, and Tribal Home Visiting

Dear Colleagues,

Quality and accessible health care is critical to supporting the children, families, and communities that the Administration for Children and Families (ACF) serves. We know that state Medicaid and the Children’s Health Insurance Program (CHIP) agencies are critical sources of care for American Indians and Alaska Natives (AI/AN). I am excited to share that the Centers for Medicare & Medicaid Services (CMS) recently made several announcements impacting care for AI/AN populations, including updates related to flexibility to cover traditional health care practices through Medicaid as well as new guidance regarding coverage requirements for eligible children and youth enrolled in Medicaid and CHIP.

Importance of Medicaid and CHIP in AI/AN Communities

More than one million AI/ANs are enrolled in Medicaid and CHIP. Far more are eligible for coverage, including many of the individuals served through ACF-funded programs. Medicaid and CHIP are jointly financed by the federal government and states, and they are administered by states within broad federal guidelines. States are prevented from imposing Medicaid premiums or any other Medicaid cost sharing on AI/AN Medicaid beneficiaries.

States that have an Indian Health Service, tribal, or urban Indian organization (ITU) facility located in their state must establish a process for the State Medicaid Agency to obtain advice and input on State Plan Amendments (SPA) or waivers with Tribal implications.[1] [2] States describe the process for seeking advice from ITUs through a Tribal consultation SPA.[3]

Coverage of Traditional Health Care Practices

In October, CMS announced that they approved section 1115 (a) demonstration amendments that allow, for the first time ever, Medicaid and CHIP coverage of traditional health care practices provided by ITUs. These amendments apply to tribal communities in Arizona, California, New Mexico, and Oregon, and also serve as a framework for other states interested in submitting similar proposals.[4]

EPSDT and ACF grant recipients

In September, CMS released new guidance in the form of a State Health Official letter entitled Best Practices for Adhering to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Requirements.[5] This guidance is intended to support states as they work to strengthen their implementation of EPSDT requirements to help ensure improved health outcomes for children and youth enrolled in Medicaid and CHIP. Though each state may take a tailored approach, EPSDT requires comprehensive and preventive health care services (medical, dental, mental health, and specialty services) for eligible children under age 21 who are enrolled in Medicaid or CHIP be provided.

There are many services that states can elect to include as part of the EPSDT benefit to address risk factors for adverse experiences such as child welfare involvement and youth homelessness. These services can be helpful as part of a broader strategy to reduce the overrepresentation of AI/AN children and youth in the child welfare system, as well as the disproportionate rates at which AI/AN children, youth, and families experience other adverse social and health outcomes. A few examples included in the new guidance are highlighted below:

Care coordination or care management, depending on a child’s needs

Non-Emergency Medical Transportation (NEMT)

Improving Care for Children in or Formerly in Foster Care

The updated EPSDT guidance from CMS also includes a dedicated subsection specific to improving care for children in or formerly in foster care. This guidance can serve as a powerful tool in better serving AI/AN children and youth in the child welfare system and addressing disparate outcomes throughout the child welfare process, including in entry into out-of-home care and exits from care. It encourages state Medicaid agencies to work with the state child