DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, MD 21244-1850 
 
CMCS Informational Bulletin 
 
Date:    November 28, 2016 
 
FROM:  Vikki Wachino, Director 
    Center for Medicaid and CHIP Services 
 
SUBJECT:   Strategies to Enroll American Indian and Alaska Native Families and Children in 
Medicaid and CHIP 
 
The purpose of this Informational Bulletin is to provide strategies and helpful information for 
states, Tribes, Tribal organizations, Indian health care providers, and application assisters to 
increase enrollment of American Indians and Alaska Natives (AI/ANs) into programs 
administered by the Centers for Medicare & Medicaid Services (CMS).   The first section of this 
Bulletin identifies strategies states can employ, in concert with Tribes and Indian health care 
providers. The second section outlines outreach and enrollment best practices for assisters and 
others working in or with Tribal communities.  
 
Background 
 
The Indian Health Service (IHS),1 a federal agency within the Department of Health and Human 
Services, has primary responsibility to provide health care to AI/ANs.  In addition, the Social 
Security Act requires that Medicare and State Medicaid programs provide payment for covered 
services furnished by IHS facilities (whether operated by IHS or by an Indian Tribe or Tribal 
organization). In addition, Congress enacted Indian specific provisions in other laws, such as the 
Childrens Health Insurance Program Reauthorization Act of 2009 (CHIPRA), the American 
Recovery and Reinvestment Act (ARRA) of 2009, and the Patient Protection and Affordable 
Care Act (ACA). These laws provide special protections for AI/ANs to remove barriers and 
ensure improved access and enrollment in Medicaid and the Childrens Health Insurance 
Program (CHIP).   
 
Even with these statutory provisions that address barriers to enrollment for AI/ANs, and despite 
major coverage gains subsequent to the implementation of the Affordable Care Act that have 
reduced rates of un-insurance to their lowest levels in our nations history, additional efforts to 
enroll AI/AN individuals are needed.  AI/ANs have  high rates of un-insurance in the United 
States.  For instance, in 2015, 21 percent of AI/ANs (down from 43 percent in 2013) were 
uninsured, nearly twice the rate for African Americans, and approximately 12 percent more than 
                                                           
1The IHS delivery system is comprised of hospitals and health centers operated by the IHS, Tribes and 
Tribal organizations under the Indian Self-Determination and Education Assistance Act, and Urban 
Indian organizations under title V of the Indian Health Care Improvement Act.  These providers are 
collectively referred to as Indian health care providers.   CMCS Informational Bulletin  Page 2  
the rate of non-Hispanic whites2. In addition, AI/ANs experience greater health disparities (e.g. 
diabetes and chronic liver disease) and higher mortality rates than other Americans.  For more 
information, please see https://www.ihs.gov/newsroom/factsheets/disparities/  
 
The opportunity for states to expand Medicaid coverage to adults earning up to 133 percent of 
the federal poverty level (FPL) has increased enrollment of AI/AN families and children who 
were previously eligible but not enrolled in Medicaid or CHIP. In addition, the ACA contained 
provisions that simplified and streamlined the enrollment and renewal process for Medicaid and 
CHIP coverage generally.  Specifically, states are now required to implement streamlined 
enrollment and renewal processes, greater outreach and availability of enrollment assistance, 
electronic data matching, and simplified verification procedures. 
 
Despite these eligibility and enrollment improvements, AI/ANs still encounter enrollment 
challenges due to remote geographic locations, lack of access to reliable internet and phone 
service, distrust of government programs, language and health literacy barriers, and cultural 
differences. Understanding the history of the Indian health care delivery system is a key 
component to successful enrollment of AI/ANs into a state Medicaid program or CHIP. Many 
AI/ANs believe they should not have to enroll in a State Medicaid program or CHIP because 
health care is viewed as a treaty right or federal obligation.  
 
However, enrollment in Medicaid and CHIP benefits AI/AN individuals, their families and their 
communities. Enrollment in Medicaid and CHIP helps reduce health disparities by providing 
AI/ANs with greater access to preventive and specialty care. Treatment of chronic care 
conditions on a continuous basis reduces the likelihood of AI/ANs facing unexpected or 
emergent care, and improves quality of life.  In addition, increasing enrollment of AI/ANs into 
Medicaid and CHIP improves the health status of Tribal members and strengthens Tribal 
communities.   IHS, Tribal, and urban clinics that enroll their patients can use the saved funding 
and resources on other uninsured patients.  Moreover, when Indian health care providers receive 
Medicaid and CHIP reimbursements for direct care services, more money is brought into the 
Indian health care system to hire doctors and nurses, purchase equipment, renovate facilities, and 
meet accreditation and certification standards. 
 
Part 1: Effective Enrollment Strategies for States 
 
There are a number of enrollment strategies that states may elect to provide expedited pathways 
to coverage and/or reduce administrative burdens.  For more information about these enrollment 
strategies, please visit https://www.medicaid.gov/medicaid-chip-program-information/by-
topics/outreach-and-enrollment/enrollment-strategies.html.  
 
We encourage states implementing these enrollment strategies to reach out to Indian health care 
providers located in their states. Please visit www.ihs.gov for more information and location of 
these Indian health care facilities.  
 
Tribal Access to State Medicaid Eligibility Portal: 
                                                           
2 AI/ANs who indicate the Indian Health Service or Tribal health program as their only source of health coverage do 
not have comprehensive coverage and are considered uninsured. 
 
  CMCS Informational Bulletin  Page 3  
Many states are able to conduct real-time eligibility determinations for some applicants, allowing 
eligibility workers to enroll patients in real time at the clinic and in the field. For that reason, 
Indian health care providers with direct access to a states Medicaid eligibility portal or those 
that have an eligibility or outreach worker onsite may be able to help patients get Medicaid 
coverage on the spot. Many Indian health care providers that conduct real-time eligibility 
determinations have seen an increase in Medicaid and CHIP enrollment of AI/AN families and 
children. 
 
Access to state portals for eligibility information results in effective outreach and enrollment 
because: 
  Using online applications and accessing state portals to see a persons Medicaid 
enrollment status streamlines and expedites the application process.  
  Outreach workers with portal access can help prospective, re-enrolling, or renewing 
beneficiaries more easily navigate the application and renewal process. 
  Outreach workers may be able to utilize mobile hot spots to assist families, located in 
remote Tribal communities, in applying for or renewing coverage in real time.  
  Outreach workers can connect individuals to other support services they may be eligible 
for beyond Medicaid or CHIP. This type of service in AI/AN communities can help forge 
trusting relationships between beneficiaries and organizations. 
 
Outstationing in Federally Qualified Health Centers (FQHCs) 
  Regulations at 42 CFR 435.904 require states to provide the opportunity for low-income 
pregnant women, infants, and children under age 19 to apply for Medicaid at outstation 
locations other than traditional eligibility offices, including FQHCs and DSH hospitals.  
Outstation locations must provide for the receipt and initial processing of Medicaid 
applications, including assistance in completing the application, providing information 
and referrals, obtaining documentation to complete processing of the application and 
conducting any necessary interviews. 
  Indian health programs operated by Tribes under P.L. 93-638 and urban Indian 
organizations are entitled to be treated as FQHCs by statute.  Providing state workers at 
outstation locations or entering into agreements with Indian health organizations to 
provide other arrangements for outstationing are effective strategies for enrolling AI/AN 
in their own communities. For more information, please the State Medicaid Director 
letter entitled: Outstationing in Tribal and Urban Indian Healthcare Facilities, located at 
https://www.medicaid.gov/Federal-Policy-Guidance/downloads/smd071901.pdf 
 
Tribal Medicaid Administrative Match 
 
Under Medicaid, states receive federal matching funds for certain activities related to the 
administration of their Medicaid programs. These activities can include, but are not limited to, 
outreach, application assistance, referrals, and coordination of covered medical services.   
 
Tribes and Tribal organizations may partner with state Medicaid agencies to administer the 
Medicaid program, and receive partial payment (Medicaid Administrative Match, or MAM) from 
 
  CMCS Informational Bulletin  Page 4  
the state for these activities. Under such a partnership, Tribes and Tribal organizations can certify 
their expenditures for Medicaid administrative activities authorized by an agreement with the 
state.  The agreement must provide that the state pass on to the Tribe no less than the federal 
matching funding that the state receives based on that certified public expenditure.   For 
example, a Tribal program could certify that it expended $80,000 on Medicaid administrative 
activities authorized under its agreement with the state, and would receive from the state no less 
than $40,000 in return.   Tribes should be cautious in entering into such partnerships, to ensure 
that any tribally-funded administrative activities supplement rather than supplant state-required 
activities. We note that costs can only be recognized as allowable Medicaid administrative 
expenditures only to the extent that the expenditures are consistent with the agreement between 
the tribe and the state, are claimed consistent with Federal allocation principles and are supported 
by documentation demonstrating that the expenditures were both allowable and allocable as 
Medicaid administrative costs.     
 
Under a Tribal MAM arrangement, payment to the Tribe for administrative activities performed 
on behalf of the state Medicaid agency would come from the state, pursuant to a written 
agreement between the Tribe and the state.  The agreement would define the activities that would 
be allowable (such as helping potential beneficiaries fill out Medicaid applications), and the 
applicable cost principles for determining certified expenditures.  The state would be able to 
submit claims for the Federal share of the expenditures certified by the tribe for such activities 
pursuant to the agreement.  Some states, such as Alaska, California, Montana and Oklahoma, 
have successfully partnered with their Tribes and Tribal organizations to implement Tribal MAM 
programs.  Please contact your state Medicaid office to see whether your Tribal program could 
participate in a Tribal MAM program. 
 
Express Lane Eligibility for Children 
 
Express Lane Eligibility (ELE) allows states to rely on findings for income, household size, or 
other factors of eligibility from "Express Lane" agencies to efficiently enroll and renew eligible 
children in Medicaid and CHIP, which can increase Medicaid and CHIP enrollment, reduce 
administrative burden for states and families, and simplify the renewal process.  States have 
flexibility in implementing ELE policies to best fit their circumstances, including identifying 
eligible ELE entities, such as the Supplemental Nutrition Assistance Program (SNAP), School 
Lunch programs, Temporary Assistance for Needy Families (TANF), Head Start, and the 
Women, Infant, and Children's programs (WIC).  Please visit our Express Lane Eligibility page 
at Medicaid.gov to learn more about states that have adopted strategies related to Tribal TANF 
and Head Start programs. 
 
 
Presumptive Eligibility 
 
Since 1997, states have had the option to use presumptive eligibility (PE) to enroll eligible 
pregnant women and children into Medicaid and CHIP without having to wait for their 
application to be fully processed.  Under PE, states authorize qualified entities, which can 
include health care providers, community-based organizations, schools, Tribes and Tribal 
organizations, and other entities to screen for Medicaid and CHIP eligibility based on 
 
  CMCS Informational Bulletin  Page 5  
preliminary information provided by the family and immediately enroll children and pregnant 
women who appear to be eligible.  
Under the ACA, all states are required to implement hospital PE for Medicaid.  IHS and Tribally 
hospitals can participate if they qualify under state plan requirements.  Through PE, hospitals are 
able to immediately enroll patients  children, pregnant women and other adults  who are likely 
eligible under a states Medicaid MAGI eligibility guidelines for a temporary period of time 
while a single streamlined application is completed and eligibility is determined.   
States can promote Medicaid and CHIP enrollment for AI/ANs by implementing hospital PE as 
well as adopting a broader PE policy for children and pregnant women.  Implementation of such 
policies will also help ensure AI/ANs have timely access to care while a final eligibility 
determination is made. IHS and Tribal hospitals interested in participating in PE, should contact 
the state Medicaid office or visit our Presumptive Eligibility page on Medicaid.gov.  
Continuous Eligibility for Children 
 
Since 1997, states have had the option to provide 12-months of continuous Medicaid and CHIP 
eligibility for children, guaranteeing a full year of coverage regardless of changes in family 
circumstances, such as income or household size, and eliminating moving in and out of 
coverage.  Guaranteeing ongoing coverage ensures that children get appropriate care, helps 
doctors and other health professionals develop relationships with children and their families, and 
reduces state administrative burden. Many states with significant Indian populations and Indian 
health care providers have adopted the state plan option for continuous eligibility.  For more 
information, please contact your state Medicaid office or visit 
https://www.medicaid.gov/medicaid/outreach-and-enrollment/continuous-eligibility/index.html. 
 
Part 2: Effective Enrollment Strategies for Indian Country 
 
The following strategies and best practices can be used by any enrollment assisters working in or 
with a Tribal community. 
Best Practices for Increasing Enrollment in Medicaid and CHIP for AI/AN Communities 
Varied Outreach Strategies  Enroll uninsured patients who receive services in emergency 
rooms and hospital clinics by using hospital presumptive 
eligibility.   
If patients are coming in for a medical appointment, provide 
easy access to information about programs they might be 
eligible for, such as Medicaid and CHIP. 
Use local radio stations and newspapers to run advertisements 
and public service announcements. Or, post informational 
flyers on community boards at local supermarkets and post 
offices where Tribal members gather.  
Share Medicaid and CHIP information at Tribal events and 
community activities, such as health fairs, powwows, cultural 
events, and schools.  
 
  CMCS Informational Bulletin  Page 6  
Best Practices for Increasing Enrollment in Medicaid and CHIP for AI/AN Communities 
Use culturally appropriate fact sheets and brochures and 
include a point of contact name, phone number and location. 
Call patients  make personal contact and build trust. 
Individuals will want to talk to a particular outreach person 
that they know and trust. 
Hand out business cards with name and contact information 
for application assisters. To help facilitate the enrollment 
process, some Tribal programs provide a list of documents or 
information they might need, such as social security numbers, 
monthly income, etc. Most of this information can be verified 
electronically, but by having these documents, the enrollment 
process may be faster and less confusing.   
Provide giveaway items as incentives, such as food, water 
bottles, hats, t-shirts, or coolers, to encourage individuals to 
apply. 
Have a staff person dedicated to helping families apply for 
childrens coverage. 
Technology in Outreach  Use Facebook, Twitter, a blog, or email blasts to a developed 
listserv to promote programs and provide information about 
renewal.  
Use social media to remind people to apply and renew.  
Internal Technological  State Medicaid agencies have the option to share AI/AN 
Infrastructure  Medicaid enrollment data with Indian health care providers as 
long as personal health information is protected. This 
searchable database can be used to target outreach and 
enrollment efforts, to track patient enrollment status, and to 
send reminders and contact patients about renewal.  
Provide laptops for outreach workers conducting application 
and renewal activities to allow workers to visit client homes 
and complete the application face-to-face. This addresses 
some clients transportation barriers and helps prevent clients 
from forgetting necessary paperwork or documentation. 
Help Beneficiaries Renew So  Inform individuals when renewal is required, and remind 
they do not have a lapse in  them what materials are necessary to complete the renewal 
Coverage  process.  
Track when patients are due for renewal (information is 
generally sent between 30 and 60 days prior to the end of the 
renewal cycle) using electronic spreadsheets or databases.  
When renewal is due, help patients fill out forms in-person to 
make the re-enrollment process as easy as possible.  
 
 
 
 
 
 
  CMCS Informational Bulletin  Page 7  
Best Practices for Cultural Competency and Working in Indian Country 
  
If you are new to working with Tribal communities, there are some cultural differences that are 
important to understand before you start your outreach efforts. We have summarized and 
highlighted a few helpful hints from the Culture Card developed by the Substance Abuse and 
Mental Health Services Administration. We encourage you to review the Culture Card for more 
detailed information. You can view the Culture Card here:  
https://store.samhsa.gov/shin/content/SMA08-4354/SMA08-4354.pdf.  
 
Dos   Donts 
Learn how the community refers to itself as a  Avoid stereotyping based on looks, language, 
group of people (e.g., Tribal name).   dress, and other outward appearances.  
Listen and observe more than you speak.   Avoid intrusive questions early in 
conversation.  
Learn to be comfortable with silence or long  Do not interrupt others during conversation or 
pauses in conversation by observing  interject during pauses or long silences.  
community members typical length of time   
between turns at talking.  
Casual conversation is important to establish  Do not stand too close to others and/or talk 
rapport, so be genuine and use self-disclosure  too loud or fast.  
(e.g., where you are from, general information 
about children or spouse, personal interests).  
Avoid jargon or slang. An AI/AN community  Be careful about pointing with your finger, 
member may nod their head politely, but not  which may be interpreted as rude behavior in 
understand what you are saying.   many Tribes.  
It is acceptable to admit limited knowledge of  Avoid frequently looking at your watch and 
AI/AN cultures, and invite people to educate  do not rush things.  
you about specific cultural protocols in their 
community. 
If you are visiting the home of an AI/AN  During a formal interview, if the person you 
family, you may be offered a beverage and/or  are working with begins to cry, support the 
food, and it is important to accept it as a sign  crying without asking further questions until 
of respect. Sharing food is a way of  they compose themselves and are ready to 
welcoming visitors, similar to offering a  speak.  
handshake.  
During formal interviews, it may be best to  Do not touch sacred items, such as medicine 
offer general invitations to speak, then remain  bags, other ceremonial items, hair, jewelry, 
quiet, sit back, and listen. Allow the person to  and other personal or cultural things.  
tell their story before engaging in a specific 
line of questioning.  
Be open to allow things to proceed according  Do not take pictures without permission.  
to the idea that things happen when they are 
supposed to happen.  
 
   
 
  CMCS Informational Bulletin  Page 8  
APPENDIX A: HELPFUL RESOURCES 
 
MEDICAID and CHILDRENS HEALTH INSURANCE PROGRAM (CHIP): Medicaid and the 
Children's Health Insurance Program (CHIP) offer free or low-cost health coverage for eligible 
children and other family members. These programs may be called by different names in your 
state.is a State-Federal program that offers health insurance to eligible individuals.  
 
Visit www.Medicaid.gov or visit https://www.medicaid.gov/medicaid-chip-program-
information/by-state/by-state.html and click on your state on the map for more information about 
each states Medicaid programs.   
 
Visit www.InsureKidsNow.gov, a website operated by the Centers for Medicare & Medicaid 
Services, provides information for: 
  Families seeking health insurance coverage for children and teens and families needing 
help locating a dentist 
  Organizations interested in getting involved in the Connecting Kids to Coverage National 
Campaign, a national outreach and enrollment initiative initially funded under the 
Children's Health Insurance Program Reauthorization Act (CHIPRA) and the Affordable 
Care Act, and now through the Medicare Access and CHIP Reauthorization Act 
(MACRA). 
 
CMS TRIBAL AFFAIRS:  
The CMS Tribal Affairs office has its own website, http://go.cms.gov/AIAN, which serves as a 
resource for AI/ANs Tribes, Tribal organizations, and Federal agencies. CMS Tribal Affairs 
develops and produces outreach and education resources, such as brochures, posters, training 
materials, webinars, and video and radio public service announcements (PSAs), to increase 
awareness and understanding of health insurance benefits available to AI/ANs.  Many of these 
materials are developed in collaboration with HHS, IHS, CMS Tribal Technical Advisory Group, 
and national Indian organizations.  For example, PSAs are developed monthly in the form of 
drop-in ads for Tribal newspapers and magazines translated in five native languages to air on 
Tribal radio stations (Zuni, Yupik, Navajo, Lakota, Ojibwe). We encourage Tribal communities 
to download these PSAs, print them in their local newspapers, newsletters, and play them on 
local radio stations or at outreach events. For more information about CMS Tribal Affairs 
outreach and education resources, please visit, http://go.cms.gov/AIAN-
OutreachEducationResources. 
 
Here are a few of CMSs most helpful fact sheets for Outreach and Enrollment:  
 
  Detailed fact sheet describing the protections for AI/ANs in the Medicaid 
o
program, Medicaid Basics https://www.cms.gov/Outreach-and-
Education/American-Indian-Alaska-Native/AIAN/Downloads/Medicaid-Basic-
Fact-Sheet.pdf  
 
  Detailed fact sheet describing the protections for AI/ANs in the Childrens Health 
o
Insurance Program, CHIP Basics  https://www.cms.gov/Outreach-and-
 
  CMCS Informational Bulletin  Page 9  
Education/American-Indian-Alaska-
Native/AIAN/Downloads/AIANCHIPFACTSHEET.pdf  
 
  Summary of the special protections available to AI/ANs as a result of the 
o
Affordable Care Act and the Indian Health Care Improvement Act, our AI/AN 
Special Protections Fact Sheet https://www.cms.gov/Outreach-and-
Education/American-Indian-Alaska-Native/AIAN/Downloads/AI-
ANSpecialProtections11902-N-FactSheet.pdf 
 
  Many AI/ANs may qualify for Medicaid because most Indian trust income is not 
o
counted when determining eligibility for Medicaid. This process for determining 
income eligibility is based on Modified Adjusted Gross Income (MAGI), AI/AN 
Trust Income and MAGI Fact Sheet https://www.cms.gov/Outreach-and-
Education/American-Indian-Alaska-
Native/AIAN/Downloads/AIANTrustIncomeandMAGI-FactSheet11903-N.pdf  
 
  Medicaid Estate Recovery requires state Medicaid programs to assess claims 
o
against the estates of some Medicaid beneficiaries who have died. Many AI/ANs 
are exempt from Medicaid Estate Recovery. This fact sheet explains how, 
Medicaid Estate Recovery Rules and Protections for Indians 
https://www.cms.gov/Outreach-and-Education/American-Indian-Alaska-
Native/AIAN/CMS_AIAN_Medicaid_Estate_Recovery_brochure_11905-
N_PrintReady.pdf  
 
  CMS developed a Tribal Glossary that explains commonly used health insurance 
o
terms in plain language and in a Tribal context, Tribal Glossary Brochure 
https://www.cms.gov/Outreach-and-Education/American-Indian-Alaska-
Native/AIAN/Downloads/Tribal-Glossary-Brochure.pdf  
 
  CMS developed a Tribal specific tip sheet for navigators and assisters working 
o
with AI/ANs, AI/AN Assisters Tips https://www.cms.gov/Outreach-and-
Education/American-Indian-Alaska-Native/AIAN/Downloads/AIAN-Assisters-
Tips.pdf 
 
 
Please see our Helpful Resources fact sheet for more resources: https://www.cms.gov/Outreach-
and-Education/American-Indian-Alaska-Native/AIAN/Downloads/AIAN-Resource-Links-
January-2016.pdf. 
 
NATIONAL INDIAN HEALTH OUTREACH & EDUCATION (NIHOE): www.tribalhealthcare.org  
NIHOE is a national partnership between Indian Health Service (IHS), the National Congress of 
American Indians (NCAI), and the National Indian Health Board (NIHB). Its website provides 
AI/AN consumer-oriented education materials and training tools to assist in enrollment of AI/AN 
families and children into the Marketplace, Medicaid and CHIP.