February 24, 1998  
Dear State Official:  
This is one in a series of letters to States providing guidance on the new 
Children's Health Insurance Program (CHIP), which was enacted as part 
of the Balanced Budget Act of 1997 (BBA). This letter provides 
guidance to States on consultation with Indian Tribes and organizations 
and on using CHIP funds to benefit Indian children.  
Consultation with Indian Tribes and Organizations 
The President has directed all Federal Departments to engage in meaningful 
consultation with Federally recognized American Indian and Alaska Native 
(AI/AN) Tribes in order to ensure that the rights of these sovereign Tribal 
governments are fully respected. In addition to consulting with Federally-
recognized Tribes, the Department encourages consultation with other 
Indian Tribes and organizations before taking actions that affect these 
governments and/or the Indian people residing within a State. Such 
consultation should be conducted in a meaningful manner. The Department 
of Health and Human Services uses this definition of meaningful 
consultation:  
Consultation is an enhanced form of communication which 
emphasizes trust, respect and shared responsibility. It is an open and 
free exchange of information and opinion among parties which 
leads to a mutual understanding and comprehension. Consultation is 
integral to a deliberative process which results in effective 
collaboration and informed decision making.  
We are requesting that the State official responsible for CHIP consult with 
Federally recognized Tribes and other Indian Tribes and organizations in the 
State (such as regional Indian health boards, urban Indian health 
organizations, non-Federally recognized Tribes, and units of the Indian 
Health Service) on development and implementation of the CHIP State Plan.  This consultation process should be used in addition to the general public 
involvement process the State uses for CHIP. Prior to consultation, the State 
and Indian participants should establish a framework for the consultation 
process, determine the issues to be discussed, and decide how timely 
feedback will be provided to the Indian participants. (See Attachment for 
recommended consultation process and key issues).  
Using CHIP Funds to Benefit Indian Children 
As indicated in the attachment, American Indian/Alaska Native (AI/AN) 
children are more likely to experience many serious health conditions and 
have significantly less access to affordable health insurance and health care 
than other Americans. Under the law establishing the new program, Indian 
children are eligible for CHIP on the same basis as other children in the 
State in which they reside, regardless of whether or not they may be eligible 
for or served by IHS-funded care. (See attached question and answer.) In 
addition, the law specifically requires that each State describe in its CHIP 
State plan the procedures to be used to ensure the provision of child health 
assistance to targeted low-income AI/AN children in the State. Given the 
compelling health care needs of Indian children and these provisions, the 
Department encourages States to implement the CHIP program, in 
consultation with Tribes and Indian organizations, in a creative and flexible 
manner to allow Indian children to benefit from Title XXI to the maximum 
extent possible under the law.  
To facilitate enrollment in regular Medicaid or CHIP, States may target 
outreach to reservation, urban, and other communities with high 
concentrations of low-income Indian people. States may use Title XXI's 
limited administrative funds in these communities for outreach to families 
with children likely to be eligible for benefits under Title XXI or other 
public or private health programs, to inform these families of the State 
program, and to assist them in enrolling their children when appropriate. 
Given the large numbers of low-income uninsured children in Indian 
communities, targeting outreach to such communities is part of an effective 
outreach strategy.   States may also use Title XXI administrative funds to target low-income 
AI/AN communities for health services initiatives to improve the health of 
low-income children. In addition to Title XXI services, such health services 
initiatives could include health education, school health programs, and direct 
services (such as newborn screenings). These activities can assist Indian 
children, both those eligible and ineligible for Title XXI, if they promote the 
public's health in a targeted county, community, or school in which all 
children are equally eligible to benefit from the initiative. Please note that 
expenditures for health initiatives, outreach, administrative costs, and other 
child health assistance are subject to the 10 percent limit specified in section 
2105(c)(2)(A) of the law.  
We hope that the outreach efforts, health services initiatives, and other 
aspects of the CHIP program, developed in consultation with Tribes and 
Indian organizations, will help your State achieve the goal of providing 
access to health care for all vulnerable children. A list of contact people for 
American Indian and Alaska Native issues is included on the attachment. 
They, along with HCFA and HRSA Regional Office CHIP staff are 
available to assist you with the consultation process and with efforts to use 
CHIP funding to assist American Indian and Alaska Native children. Thank 
you for your continued efforts on this important program.  
Sincerely, 
 
Sally K. Richardson, Director Claude Earl Fox, M.D., M.P. 
Center for Medicaid and State Operations  
Acting Administrator Health Care Financing Administration 
Health Resources and Services Administration 
 
 
Attachment  
cc:  
HHS Regional Directors   HCFA Regional Offices  
PHS Regional Offices  
Ms. Lee Partridge, American Public Welfare Association  
Ms. Jennifer Baxendell, National Governors' Association  
Ms. Joy Wilson, National Conference of State Legislatures  
Ms. Cheryl Beversdorf, Association of State and Territorial Health Officials 
Ms. Mary Beth Senkewicz, National Association of Insurance 
Commissioners  
ATTACHMENT  
INDIAN CHILDREN AND CHIP (CHILDREN'S HEALTH INSURANCE 
PROGRAM)  
HEALTH CARE NEEDS OF INDIAN CHILDREN 
The health care needs of Indian children are compelling. The Indian 
population has a greater proportion of children (33 percent younger than age 
15, compared with 22 percent for the U.S. population of all races) and a 
higher birth rate (26.6 live births per 1,000 population, compared with 15.9 
per 1,000 for U. S. all races). In recent years, both maternal and infant 
mortality rates for Indian people have been reduced to levels comparable to 
those of the U.S. population generally. However, teen pregnancy is much 
higher, with 45 percent of Indian mothers under age 20 at the birth of their 
first child, compared with 24 percent of U.S. mothers of all races. In 
addition, a much greater proportion of Indian people continue to live below 
the Federal poverty level (1990 Census shows 31.6 percent of Indians 
residing in the 35 States with Indian reservations had incomes below the 
Federal poverty level -- a rate 2.4 times the comparable rate for Americans 
of all races). Poverty, geographic isolation, and substance abuse contribute 
to the much higher Indian child mortality rates due to causes such as 
accidents, homicide, suicide, SIDS, viral hepatitis, meningitis, pneumonia, 
and influenza, compared with other American children. Indian children have 
high rates of hospitalization and ambulatory medical visits for conditions 
such as respiratory system diseases, infectious and parasitic diseases, 
digestive system diseases, injuries and poisonings. 
   Very few Indian people have access to or can afford private health 
insurance. Many living on reservations depend upon IHS-funded health care. 
IHS per capita spending is only one third the amount spent on health care by 
the average American. IHS direct care, and IHS-funded Tribal and urban 
Indian health programs provide mostly primary care services. IHS funds 
used to pay other health care providers for specialty care are extremely 
limited, estimated to meet only about 60 percent of the need for such 
services.  
Approximately half or more of Indian people live off reservations in other 
rural and urban areas and often lack access to affordable, culturally 
appropriate care. IHS is able to fund 33 urban Indian programs for a total of 
only about $25 million. Many of these urban programs are only able to 
provide limited behavioral health services and information and referral 
rather than comprehensive services, leaving many unmet needs. Thus, CHIP 
presents a unique opportunity to maximize the potential for Federal and 
State funds to help fill some of the large gaps in health care for uninsured, 
low-income Indian children by expanding the provision of child health 
assistance in an effective and efficient manner.  
 
ELIGIBILITY OF INDIAN CHILDREN FOR CHIP 
In the fourth set of Title XXI questions and answers, issued November 26, 
1997, by the Health Care Financing Administration, we answered a 
question regarding the eligibility of Indian children for CHIP as follows:  
 
Question: Are American Indian/Alaska Native children eligible 
for the Children's Health Insurance Program?  
Answer: Yes, American Indian/Alaska Native children are eligible for CHIP 
on the same basis as other children in their State. Children, both Indian and 
non-Indian, may be eligible for CHIP if they meet State eligibility standards 
based on the definition of "targeted low-income child" in Section 2110(b) of 
the law. The eligibility of Indian children for CHIP is not affected by the fact 
that they may also be eligible for or are recipients of health care services 
funded by the Indian Health Service (IHS). Section 2105(c) (6)(B) of the law  specifically exempts programs operated or financed by IHS from the 
requirement to prevent duplication between CHIP and other federally 
operated or financed health programs. Finally, Section 2102(b)(3)(D) of the 
law requires each State to describe, in its CHIP State plan, the procedures to 
be used to ensure the provision of child health assistance to targeted low-
income children in the State who are American Indians or Alaska Natives.  
 
CONSULTATION PROCESS AND KEY ISSUES 
The consultation process should address the conceptual development of 
the CHIP plan, eligibility standards and methodology, outreach and 
coordination, and procedures to be used to ensure the provision of child 
health assistance to targeted low-income children in the State who are 
Indians. Key issues for consultation include: geographic areas to be 
served; income and resource standards; coordination of coverage with 
IHS-funded care; participation and reimbursement of IHS/Tribal/urban 
Indian health care providers; the role of traditional Indian healing; 
premiums and cost sharing; outreach, eligibility, and referral; criteria for 
deciding whether to provide Medicaid and/or private health insurance 
coverage; categories of additional services and other benefits; measurable 
goals related to health status and health demographics for Indian 
children; and criteria for and design of health services initiatives.  
CONTACTS FOR AMERICAN INDIAN/ALASKA NATIVE ISSUES  
 
Health Care Financing Administration  
Region 1:  
Craig Schneider 617-565-4483  
(Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, 
Vermont)  
 
Region 2:  
Carol Conciatori 212-264-3889   (New Jersey, New York, Puerto Rico, Virgin Islands)  
 
Region 3:  
Carol Messick 215-596-0580  
(Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, 
West Virginia)  
 
Region 4:  
Carol Langford 404-562-7412  
(Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, 
South Carolina, Tennessee)  
 
Region 5:  
Lucille Rinaldo 312-353-9842  
(Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin)  
 
Region 6: 
E. Dorsey Sadongei 214-767-3570 (Arkansas, Louisiana, New 
Mexico, Oklahoma, Texas)  
 
Region 7:  
Cheryl Chapman 816-426-2011  
(Iowa, Kansas, Missouri, Nebraska)  
 
Region 8:  
Peggye Wilkerson 303-844-6336, X345, Jean Fleury 303-844-6336, 
X346  
(Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming)  
  Region 9:  
Ron Reepen 415-744-3601, Sue Castleberry 415-744-3597  
(Arizona, California, Hawaii, Nevada, Pacific Islands)  
 
Region 10: Dennis Sexton 206-615-2398  
(Alaska, Idaho, Oregon, Washington)  
 
Washington, DC: Lloyd Bishop 202-690-8501,  
Inter-Governmental and Tribal Affairs Group  
 
Health Resources and Services Administration Rockville, MD  
June Horner 301-443-2964  
Indian Health Service Rockville, MD  
Michael D. Mahsetky 301-443-7261,  
William C. Vanderwagen, M.D. 301-443-3024  
Health and Human Services/Intergovernmental Affairs Washington, DC