DEPARTMENT OF HEALTH & HUMAN SERVICES 
Health Care Financing Administration 
  
                                     7500 Security Boulevard 
Baltimore, MD 21244-1850 
 
                  SMDL #01-025 
 
              July 19, 2001 
 
            
            Dear State Medicaid Director: 
 
This is one in a series of letters regarding American Indian and Alaska Native (AI/AN) 
health policy issues and the Medicaid program.  This letter follows up on the 
outstationing letter (enclosed) you received from the Centers for Medicare and Medicaid 
Services (CMS), formerly the Health Care Financing Administration, regarding the 
requirement that states provide pregnant women and children opportunities to apply for 
Medicaid at locations other than welfare offices, such as Federally Qualified Health 
Centers (FQHCs) and disproportionate share hospitals (DSH).  This letter describes how 
your states may work with Federally-recognized Tribes and Urban Indian health care 
facilities to ensure these requirements are being met at Tribal facilities operating under an 
agreement with the Indian Health Service in accordance with the Indian Self-
Determination and Education Assistance Act (Public Law 93-638), and FQHCs and DSH 
hospitals operated by Tribes or Urban Indian organizations. 
 
The outstationing letter discussed the requirements for states to establish outstation 
locations at DSH hospitals and FQHCs participating in the state's Medicaid program, 
unless CMS approves an alternate plan that includes other sites and at least some DSH 
hospitals and FQHCs.  FQHCs meet specific definitions described in section 1905 
(l)(2)(B) of the Social Security Act.  The letter further specifies that the FQHC definition 
also "includes an outpatient program or facility operated by a tribe or tribal organization 
under the Indian Self-Determination Act or an urban Indian organization receiving funds 
under title V of the Indian Health Care Improvement Act for the provision of primary 
care services."  Also, please be aware that Section 708 of the Medicare, Medicaid, and 
State Children's Health Insurance Program Benefits Improvement and Protection Act of 
2000 (BIPA) adds new entities to the list of those qualified to make Medicaid 
presumptive eligibility determinations for children.  These new entities include agencies 
that determine eligibility for Medicaid for the State's Children's Health Insurance 
Program or certain elementary and secondary schools including those operated or 
supported by the Bureau of Indian Affairs, a state or Tribal child support enforcement 
agency or an organization that is providing emergency food and shelter under the Stewart 
B.McKinney Homeless Assistance Act. 
 
 
 
 
  Page 2  State Medicaid Director 
 
Many AI/ANs who are eligible for Medicaid have chosen not to apply for Medicaid 
because of distance, language, and cultural barriers. States may use properly trained  
Tribal members or other trained individuals who are not state employees to perform 
outstationing services in a Tribal or Urban Indian facility.  A trained Tribal member or 
other trained individual performing the permissible outstationing services onsite at the 
Urban Indian health care facility, Tribal FQHC or other sites added by BIPA could help 
to overcome these barriers and increase Medicaid enrollment.  Outstationing a Tribal 
member or other trained individual at a Tribal facility may also help overcome Tribal 
reluctance to having a state employee outstationed on Tribal lands.   
 
Also, as a result of the December 19, 1996 Memorandum of Agreement (MOA) between 
CMS and the Indian Health Service, states may claim 100 percent federal medical 
assistance percentage (FMAP) for expenditures made for Medicaid services provided to 
Medicaid eligible AI/ANs by any Tribal facility operating under an agreement pursuant 
to the Indian Self-Determination and Education Assistance Act (Public Law 93-638).  
However, the MOA does not allow for 100 percent FMAP for states at Urban Indian 
health care facilities because they do not operate under the authority of Public Law 93-
638.  Expenditures for the administrative functions of taking and processing Medicaid 
applications in Urban Indian facilities are reimbursed at the 50 percent Federal financial 
participation rate applicable to administrative expenditures.  
 
We encourage you to work with the Tribal FQHCs, Urban Indian health care facilities 
and other appropriate facilities in your states to ensure the outstationing requirements are 
being met in a manner that is mutually acceptable. 
 
If you have any questions or would like technical assistance regarding this letter, please 
contact the Native American Contact (NAC) in the appropriate CMS Regional Office.  A 
list of the NACs is enclosed.  You will receive a copy of a letter to the Tribal Leaders in 
your state transmitting this letter. 
 
We look forward to working with you in the future on this and other efforts.  
 
            Sincerely, 
 
            /s/ 
 
            Penny R. Thompson 
                                                                        Acting Director 
 
 
Enclosures 
 
 
 
 
 
 
 
 
  cc: 
 
CMS Regional Administrators 
 
 
CMS Associate Regional Administrators  
    for Medicaid and State Operations 
 
Lee Partridge 
Director, Health Policy Unit 
American Public Health Services Association 
 
  Joy Wilson 
Director, Health Committee 
National Conference of State Legislatures 
 
Matt Salo 
Director of Health Legislation 
National Governors' Association 
 
Sally Smith 
Chairperson 
National Indian Health Board 
 
Michael Trujillo, MD 
Director 
Indian Health Service 
 
Merle Boyd 
Chair 
Tribal Self-Governance Advisory Committee 
Indian Health Service 
 
James Mason 
Acting Director, Intergovernmental Affairs 
Indian Health Service 
 
Brent Ewig 
Association of State and Territorial Health Officials 
 
Susan Masten 
President 
National Congress of American Indians 
 
Barbara Namias 
President 
National Council of Urban Indian Health  
                                                     Native American Contacts 
 
Region I - Boston          Irv Rich 
DHHS/CMS            (617) 565-1247     (617) 565-1083 fax 
John F. Kennedy Federal Bldg., Rm 2325 
Boston, Massachusetts 02203-0003      Irich@hcfa.gov 
(Region I:  Maine, New Hampshire, Vermont, Massachusetts, Connecticut, Rhode Island) 
_____________________________________________________________________________ 
 
Region II - New York             Carol Conciatori          
DHHS/CMS            (212) 264-3889     (212) 264-6814 fax 
26 Federal Plaza, Room 3811       Cconciatori@hcfa.gov 
New York, New York 10278-0063           Joel Truman         
              (212) 264-3926     (212) 264-6814 fax 
                                                                              Jtruman@hcfa.gov 
 (Region II: New York and New Jersey) 
______________________________________________________________________________ 
 
Region III - Philadelphia        Tamara McCloy 
DHHS/CMS            (215) 861-4220     (215) 861-4280 fax 
3535 Market Street, Room 3100 
Philadelphia, Pennsylvania 19104      TMcCloy@hcfa.gov 
(Region III:  Pennsylvania, Virginia, West Virginia, Maryland, Delaware) 
______________________________________________________________________________ 
 
Region IV - Atlanta          Carol Langford 
DHHS/CMS            (404) 562-7412    (404) 562-7483 fax 
The Atlanta Federal Center 
Suite 4T20            Clangford@hcfa.gov 
61 Forsyth Street 
Atlanta, Georgia 30303-8909 
(Region IV:  Kentucky, Tennessee, North Carolina, South Carolina, Florida, Georgia, Alabama, 
Mississippi) 
______________________________________________________________________________ 
 
Region V - Chicago          Pam Carson    
DHHS/CMS            (312) 353-0108   (312) 353-1787 fax 
233 N. Michigan Ave., Suite 600      Pcarson@hcfa.gov  
Chicago, Illinois 60601        Ruth Hughes  
              (312) 353-1670   (312) 353-1787 fax 
              Rhughes@hcfa.gov 
(Region V:  Minnesota, Wisconsin, Michigan, Ohio, Indiana, Illinois) 
______________________________________________________________________________ 
 
Region VI - Dallas          Dorsey Sadongei 
DHHS/CMS            (214) 767-3570   (214) 767-0270 fax 
1301 Young Street, Room 833 
Dallas, Texas 75202          Esadongei@hcfa.gov 
(Region VI:  Texas, New Mexico, Oklahoma, Arkansas, Louisiana) 
______________________________________________________________________________   
Region VII - Kansas City        Sharon Taggart 
DHHS/CMS            (816) 426-3406   (816) 426-3851 fax 
Richard Bolling Federal Bldg.      Staggart@hcfa.gov 
601 East 12 Street, Room 227     
Kansas City, Missouri 64106-2808 
(Region VII:  Iowa, Nebraska, Missouri, Kansas) 
________________________________________________________________________ 
 
Region VIII - Denver         Jim Lyon 
1600 Broadway, Suite 700        (303) 844-7114  fax 303 844-7054 
Denver, Colorado 80202        Rlyon@hcfa.gov 
(Region VIII:  Montana, North Dakota, South Dakota, Wyoming, Colorado, Utah) 
________________________________________________________________________ 
 
Region IX - San Francisco        Jean Fleury 
DHHS/CMS            (415) 744-3509       (415) 744-3517 fax 
75 Hawthorne Street          Jfleury@hcfa.gov 
5th Floor 
San Francisco, CA 94105-3903       
(Region IX:  California, Nevada, Arizona, Hawaii) 
________________________________________________________________________ 
 
Region X -Seattle          Ernie Kimball 
DHHS/CMS            (206) 615-2428      (206) 615-2363 fax 
2201 Sixth Ave., Room 911        EKimball@hcfa.gov 
Seattle, WA 98121-2500         
(Region X:  Washington, Oregon, Idaho, Alaska)