`DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland 21244-1850 
 
Center for Medicaid and State Operations 
                     
SMDL#: 10-001 
ARRA #: 6 
 
January 22, 2010 
 
Re:  ARRA Protections for Indians in Medicaid and CHIP 
 
Dear State Medicaid Director: 
 
This letter is one of a series that provides guidance on the implementation of the American 
Recovery and Reinvestment Act of 2009 (Recovery Act), Public Law 111-5.  Section 5006 of the 
Recovery Act provides protections for Indians in Medicaid and the Childrens Health Insurance 
Program (CHIP).  The amendments made by this section were effective on July 1, 2009.  This 
letter provides a brief overview to assist States with implementation of these new provisions for 
Indians in your programs. 
 
Section 5006 of the Recovery Act provides certain premium and cost-sharing protections under 
Medicaid and exemption for certain Indian-specific property from consideration in determining 
Medicaid eligibility and from Medicaid estate recovery.  It also provides certain Medicaid 
managed care protections for Indian health programs and Indian beneficiaries and establishes 
new requirements for consultation on Medicaid and CHIP with Indian health programs.  The new 
provisions are described in greater detail below.  
 
Premium and Cost-Sharing Protections Under Medicaid 
 
The Social Security Act (the Act) allows States to impose enrollment fees, premiums, cost- 
sharing and similar charges under certain conditions on Medicaid participants under title XIX 
and CHIP participants under title XXI of the Act.  The Medicaid provisions are at section 1916 
of the Act for nominal premiums and cost-sharing and at section 1916A of the Act for alternative 
premiums and cost-sharing, as authorized by the Deficit Reduction Act of 2005 (DRA), Public 
Law 109-171.  CHIP provisions can be found at section 2103(e) of the Act.  
 
Section 5006(a) of the Recovery Act amends sections 1916 and 1916A of the Act, to preclude 
States from imposing Medicaid premiums or any other Medicaid cost sharing on Indian 
applicants and participants served by Indian health providers and to assure that Indian health 
providers, and providers of contract health services (CHS) under a referral from an Indian health 
provider, will receive full payment.  These provisions apply to the Medicaid program.  Premiums 
and cost-sharing exemptions for Indians under CHIP are not affected.  These provisions became 
effective July 1, 2009.  Specifically, section 5006(a):  
  Page 2  State Health Official 
 
  Exempts Indians from payment of enrollment fees, premiums, or similar charges if they 
are furnished an item or service by an Indian health care provider; Indian Health Service 
(IHS); an Indian Tribe, Tribal Organization, or Urban Indian Organization (I/T/U)) or 
through referral under CHS.  We consider this condition to be met if the individual meets 
the definition of Indian below. 
  Exempts Indians from payment of a deductible, coinsurance, copayment, or similar 
charge for any item or service covered by Medicaid if the Indian is furnished the item or 
service directly by an Indian health care provider, I/T/U or through CHS. 
  Prohibits any reduction in payment that is due under Medicaid to the I/T/U or to a health 
care provider through referral under CHS for furnishing an item or service to an Indian.  
The State must pay these providers the full Medicaid payment rate for furnishing the item 
or service.  Their payments may not be reduced by the amount of any enrollment fee, 
premium, deduction, copayment, or similar charge that otherwise would be due from the 
Indian.   
 
Definitions 
 
For purposes of ensuring compliance with the cost-sharing provisions under the Recovery Act, 
CMS will use the following definitions in reviewing State plans: 
 
  Indian Health Care Provider means a health care program, including CHS, operated by 
the IHS or by an Indian Tribe, Tribal Organization, or Urban Indian Organization 
(otherwise known as an I/T/U) as those terms are defined in section 4 of the Indian 
Health Care Improvement Act (25 U.S.C. 1603). 
  Indian means an individual, defined at title 25 of the U.S.C. sections 1603(c), 1603(f). 
1679(b) or who has been determined eligible, as an Indian, pursuant to 42 C.F.R. 136.12 
or Title V of the Indian Health Care Improvement Act,  to receive health care services 
from Indian health care providers (IHS, an Indian Tribe, Tribal Organization, or Urban 
Indian OrganizationI/T/U) or through referral under Contract Health Services.  
 
State Medicaid programs are encouraged to work closely with I/T/Us and Contract Health 
Services programs within the State to implement the exemption of Indians from Medicaid 
enrollment fees, premiums, or other similar charges and for exemption from deductibles, 
coinsurance payments, copayments, or similar charges.  In addition, States are encouraged to 
inform non-I/T/U providers who participate in CHS about the absence of cost-sharing.   
 
Exemption of Certain Property from Resources for Medicaid and CHIP Eligibility 
 
Section 5006(b) of the Recovery Act amends the Medicaid statute by adding section 1902(ff) of 
the Act and the CHIP statute by adding section 2107(e)(1)(C) of the Act to require States to 
exclude certain types of Indian-specific property from being considered as resources when 
determining Medicaid or CHIP eligibility for an individual who is an Indian.  These resource 
exclusions became effective July 1, 2009. 
 
In general, the Recovery Act requires States to exclude resources in two categories:   
  Page 3  State Health Official 
 
  Property connected to the political relationship between Indian Tribes and the Federal 
government; and  
  Property with unique Indian significance.   
 
The following resources must be excluded: 
 
1.  Property, including real property and improvements, that is held in trust, subject to 
Federal restrictions, or otherwise under the supervision of the Secretary of the Interior; 
located on a reservation, including any federally-recognized Indian Tribes reservation, 
pueblo, or colony, including former reservations in Oklahoma, Alaska Native regions 
established by the Alaska Native Claims Settlement Act and Indian allotments on or near 
a reservation as designated and approved by the Bureau of Indian Affairs of the 
Department of the Interior. 
2.  For any federally-recognized Tribe not described in paragraph (1), property located 
within the most recent boundaries of a prior Federal reservation. 
3.  Ownership interests in rents, leases, royalties, or usage rights related to natural resources 
(including extraction of natural resources or harvesting of timber, other plants and plant 
products, animals, fish, and shellfish) resulting from the exercise of federally-protected 
rights. 
4.  Ownership interests in or usage rights to items not covered by paragraphs (1) through (3) 
that have unique religious, spiritual, traditional, or cultural significance or rights that 
support subsistence or a traditional lifestyle according to applicable Tribal law or custom. 
 
Enclosed is additional guidance on consideration of income and conversion of resources for 
Medicaid eligibility of Indians.  It is important to note that section 5006(b) did not change the 
treatment of income for Medicaid or CHIP eligibility purposes.  Income that was protected under 
previous laws or rules will be protected still and income that was counted under previous laws or 
rules will be counted still. 
 
Continuation of Current Protections for Certain Indian Property from Medicaid Estate Recovery 
 
Section 5006(c) of the Recovery Act amends section 1917(b)(3) of the Act to specify in the Act 
that certain Indian income, resources, and property are exempt from Medicaid estate recovery.  
These provisions have been in the State Medicaid Manual since April 1, 2003 and can be found 
at section 3810.A.7. 
 
The specific income, resources, and property exempted from Medicaid estate recovery for 
Indians include: 
 
1.  Certain income and resources (such as interests in and income derived from Tribal land 
and other resources currently held in trust status and judgment funds from the Indian 
Claims Commission and the U.S. Claims Court) that are exempt from Medicaid estate 
recovery by other laws and regulations. 
2.  Ownership interest in trust or non-trust property, including real property and 
improvements:  Page 4  State Health Official 
 
a.  Located on a reservation (any federally-recognized Indian Tribes reservation, 
pueblo, or colony, including former reservations in Oklahoma, Alaska Native 
regions established by Alaska Native Claims Settlement Act and Indian 
allotments) or near a reservation as designated and approved by the Bureau of 
Indian Affairs of the U.S. Department of the Interior; or 
b.  For any federally-recognized Tribe not described in (a), located within the most 
recent boundaries of a prior federal reservation. 
c.  Protection of non-trust property described in (a) and (b) is limited to 
circumstances when the property passes from an Indian (as defined in section 4 of 
the Indian Health Care Improvement Act (25 U.S.C. section 1603)) to one or 
more relatives (by blood, adoption, or marriage), including Indians not enrolled as 
members of a Tribe and non-Indians, such as spouses and step-children, that their 
culture would nevertheless protect as family members; to a Tribe or Tribal 
Organization; and/or to one or more Indians; 
3.  Income left as a remainder in an estate derived from property protected in section 2 
above, that was either collected by an Indian, or by a Tribe or Tribal Organization and 
distributed to Indian(s), as long as the individual can clearly trace it as coming from the 
protected property. 
4.  Ownership interests left as a remainder in an estate in rents, leases, royalties, or usage 
rights related to natural resources (including extraction of natural resources or harvesting 
of timber, other plants and plant products, animals, fish, and shellfish) resulting from the 
exercise of federally-protected rights, and income either collected by an Indian, or by a 
Tribe or Tribal Organization and distributed to Indians(s) derived from these sources as 
long as the individual can clearly trace it as coming from protected sources; and. 
5.  Ownership interests in, or usage rights to, items not covered by 1-4 above that have 
unique religious, spiritual, traditional, and/or cultural significance or rights that support 
subsistence or a traditional life style according to applicable Tribal law or custom. 
 
New Statutory Requirements Regarding Indians, Indian Health Care Providers, Indian Managed 
Care Entities in Medicaid, and CHIP Managed Care Programs 
 
Section 5006(d) of the Recovery Act adds a new section 1932(h) to the Medicaid statute and 
section 2107(e)(1)(J) to the CHIP statute, which will apply consistent rules governing the 
treatment of Indians, Indian health care providersI/T/Us, and Indian Managed Care Entities 
(IMCEs) in a State Medicaid or CHIP managed care program.  The term Indian Managed Care 
Entity (IMCE) means a managed care entity that is controlled by the IHS, a Tribe, Tribal 
Organization, or Urban Indian Organization, or a consortium, which may be composed of one or 
more Tribes, Tribal Organizations, or Urban Indian Organizations, and which may also include 
the IHS.  The new statutory provision expressly recognizes that an IMCE may restrict its 
enrollment to Indians in the same manner as Indian health programs may restrict the delivery of 
services to Indians.  
 
Indians who are eligible for Medicaid or CHIP may elect to enroll in managed care entities for 
this purpose, including primary care case management (PCCM) programs on a voluntary basis.  
They may be enrolled on a mandatory basis under a Medicaid or CHIP waiver or in an I/T/U 
managed care entity.  Page 5  State Health Official 
 
 
Under section 5006(d), all contracts with Medicaid and CHIP managed care entities, which 
include Medicaid and CHIP managed care organizations (MCOs) and PCCMs, must: 
 
  Permit any Indian who is enrolled in a non-Indian MCE and eligible to receive services 
from a participating I/T/U provider, to choose to receive covered services from that I/T/U 
provider, and if that I/T/U provider participates in the network as a primary care provider, 
to choose that I/T/U as his or her primary care provider, as long as that provider has 
capacity to provide the services; 
  Require each managed care entity to demonstrate that there are sufficient I/T/U providers 
in the network to ensure timely access to services available under the contract for Indian 
enrollees who are eligible to receive services from such providers; 
  Require that I/T/U providers, whether participating in the network or not, be paid for 
covered Medicaid or CHIP managed care services provided to Indian enrollees who are 
eligible to receive services from such providers either (1) at a rate negotiated between the 
managed care entity and the I/T/U provider, or (2) if there is no negotiated rate, at a rate 
not less than the level and amount of payment that would be made if the provider were 
not an I/T/U provider; and 
  Provide that the managed care entity must make prompt payment to all I/T/U providers in 
its network as required for payments to practitioners in individual or group practices 
under federal regulations at 42 CFR sections 447.45 and 447.46. 
 
The Centers for Medicare & Medicaid Services intends to issue forthcoming regulations to 
address the application of the requirement for sufficient I/T/Us in States where there are few or 
none available. 
 
Under prior provisions of law, I/T/U providers that receive reimbursement as federally qualified 
health centers (FQHCs) pursuant to a contract from a managed care entity also receive a 
supplemental payment from the State to make up the difference between the amount the 
managed care entity pays and what the I/T/U FQHC would have received under the State Plan.   
 
The new provision provides a supplemental payment from the State to all I/T/U providers for 
services furnished to managed care enrollees, whether the provider is an FQHC or not, and 
without regard to whether the provider has a contract with the managed care entity.   The 
supplemental payment must make up the difference between the amount paid by the managed 
care entity and the applicable rate under the State plan.   
Consultation on Medicaid, CHIP, and Other Health Care Programs Funded under the Act 
Involving Indian Health Programs and Urban Indian Organizations 
 
Section 5006(e) of the Recovery Act codifies in statute, at section 1902(a)(73) and section 
2107(e)(1)(C) of the Act, the requirement for the Secretary of Health and Human Services 
(HHS) to maintain a Tribal Technical Advisory Group (TTAG) within CMS.  The TTAG, 
initially established in accordance with a charter dated September 30, 2003, is now required to 
include a representative of IHS and a representative of a national Urban Indian Organization. 
  Page 6  State Health Official 
 
Additionally, effective July 1, 2009, certain States are required to utilize a process for the State 
to seek advice on a regular, ongoing basis from designees of the Indian health programs and 
Urban Indian Organizations concerning Medicaid and CHIP matters having a direct effect on 
Indians, Indian health programs or Urban Indian Organizations.  The consultation process must 
be followed by any State in which one or more Indian health programs or Urban Indian 
Organizations furnish health care services, even if no federally-recognized Indian Tribes are 
located within the State.  These States are required to specifically solicit such advice prior to the 
States submission of any Medicaid or CHIP State plan amendment, waiver request, or proposal 
for a demonstration project likely to have a direct effect on Indians, Indian health programs, or 
Urban Indian Organizations.  The consultation may include the appointment of an advisory 
committee or a designee of these IHS (including those programs operated by federally-
recognized Tribes under P.L. 93-638 authority) and Urban Organizations to the State medical 
care advisory committee required by Federal regulations at 42 CFR 431.12, both, or another 
method.  Also, enclosed is the Medicaid State plan template that a State must use for a State plan 
amendment in order to document its process for such consultation.  CMS is sharing, in draft, the 
SPA template under the guidelines of the Paperwork Reduction Act (PRA) currently under OMB 
review.  Until the PRA process is completed, States are not obligated to use the recommended 
template.  After CMS obtains the necessary PRA clearance number from OMB, States will be 
required to complete the SPA template.   
 
Previously, CMS has provided guidance on the consultation process with federally-recognized 
Indian Tribes, which may be found in the July 17, 2001, State Medicaid Director Letter, 
requiring State consultation with federally-recognized Indian Tribes for waivers.  The letter will 
be revised to address additional requirements in Section 5006(e) of the Recovery Act.  The 
above-referenced letter can be found on the CMS Web site at: 
http://www.cms.hhs.gov/smdl/downloads/smd071701.pdf .    
 
Examples of changes that would have a direct effect on Indians, Indian health programs, or 
Urban Indian Organizations include Medicaid or CHIP changes (submitted through State plan 
amendments, proposed waivers, waiver extensions, waiver amendments or waiver renewals) that 
are more restrictive for eligibility determinations, changes that reduce payment rates or changes 
in payment methodologies to I/T/U providers or for services reimbursed to I/T/U providers, 
reductions in covered services, changes in consultation policies, and proposals for 
demonstrations or waivers that may impact Indians or I/T/U providers. 
 
Implementation 
 
This guidance is offered in order to assist States in planning for application of these provisions. 
Additional guidance will be forthcoming on this issue, and CMS will work with States to help 
them implement these provisions in a manner that is consistent with the statute.  
 
In keeping with the HHS Tribal consultation policy and the new provisions in the Recovery Act, 
CMS collaborated and consulted with the TTAG and IHS to solicit advice on implementing these 
provisions.  The Tribal Affairs Group and the Center for Medicaid and State Operations, within 
CMS, jointly hosted two All Tribes Calls on June 5 and 12, 2009, to consult on implementation 
of section 5006 of the Recovery Act.  Two face-to-face consultation meetings were held in  Page 7  State Health Official 
 
Denver on July 8 and 10, 2009, to solicit advice and input on these provisions from federally-
recognized Tribes, Indian health providers, and Urban Indian Organizations.  An All States Call 
was held on June 10, 2009, with the State Medicaid and CHIP programs to describe the CMS 
Tribal consultation process on the Recovery Act provisions and to solicit feedback and questions 
from States.   
 
Contact Information 
 
We hope you find this information helpful in your efforts to implement the provisions of the 
Recovery Act.  If you have questions regarding this guidance, please send an email to 
CMSOCHIPRAQuestions@cms.hhs.gov or contact Ms. Victoria Wachino, Director, Family and 
Childrens Health Programs Group, who may be reached at (410) 786-5647. 
 
            Sincerely, 
 
            /s/ 
 
            Cindy Mann 
            Director 
            Center for Medicaid and State Operations 
 
Enclosures 
 
cc: 
 
CMS Regional Administrators 
 
CMS Associate Regional Administrators 
Division of Medicaid and Childrens Health 
 
Ann C. Kohler 
NASMD Executive Director 
American Public Human Services Association 
 
Joy Wilson 
Director, Health Committee 
National Conference of State Legislatures 
 
Matt Salo 
Director of Health Legislation 
National Governors Association 
 
    Page 8  State Health Official 
 
Debra Miller 
Director for Health Policy 
Council of State Governments 
 
Christine Evans, M.H.P. 
Director, Government Relations 
Association of State and Territorial Health Officials 
 
Alan R. Weil, J.D., M.P.P. 
Executive Director 
National Academy for State Health Policy 
 
Dr. Yvette Roubideaux 
Director 
Indian Health Service 
 
Valerie Davidson 
Chairman 
Tribal Technical Advisory Group 
 
Stacy Bohlen 
Executive Director 
National Indian Health Board 
 
    Page 9  State Health Official 
 
Additional Guidance for Consideration of Income and Resources for           
Medicaid Eligibility of Indians 
 
In order to be eligible for Medicaid or the Childrens Health Insurance Program (CHIP), an 
individual must have countable income and resources at or below the maximum amounts 
established by the State plan.  The following rules, in accordance with Federal regulations at 42 
CFR 435.601(b), generally apply to eligibility for Medicaid and CHIP:  
 
  Income is defined for Medicaid and CHIP purposes as anything that an individual 
receives (e.g., wages, self-employment income, interest, dividends, Social Security 
payments) that the individual can use to pay for the familys basic necessities. 
  Resources are defined as cash or anything an individual owns (e.g., checking or savings 
accounts, real estate, personal property, stocks, bonds) that the individual can convert to 
cash to pay for the familys basic necessities. 
  Any income not spent during the month of receipt is considered as resources in the 
following months.  It is counted or excluded as a resource depending on the form that it 
takes (e.g., cash, checking account, stocks, property).   
  Certain types of income and resources are not counted for Medicaid and/or CHIP 
eligibility, such as the home property in which the family lives.   
 
If an individual does not have the legal right, authority, or power to liquidate resources or to use 
income or resources that the individual owns, that income or resource is not counted for 
Medicaid or CHIP eligibility because the individual is not free to access and spend it.   
 
  For example, if an Indian has a restricted Individual Indian Money (IIM) Account with 
money held in trust for the individuals use, but that individual must be authorized by 
someone else to access the money, and that access may be denied, the money in the IIM 
is considered to be inaccessible and so is excluded from consideration as a resource for 
Medicaid or CHIP eligibility. 
 
Resources include an individuals right to harvest or extract natural resources from land that the 
individual owns or for which the individual has an ownership interest (e.g., mineral rights, 
fishing rights, timber rights).  If the individual cannot sell those rights or that ownership interest, 
or those rights or that ownership is specifically excluded by statute, those resources are not 
accessible and are not counted for Medicaid or CHIP eligibility.   
 
  For example, if a Tribe holds rights to extract natural resources from a geographical area, 
those rights are not owned by any individual and cannot be sold by any Tribal member, 
even if an individual exercises those rights to extract and sell natural resources from the 
property (e.g., oil, gas, gravel, timber).  Therefore, the mineral/timber rights are not 
counted as a resource for any Tribal members Medicaid or CHIP eligibility. 
 
If a resource is sold or exchanged, the proceeds are still considered resources, not income.  
Therefore, if natural resources (e.g., gravel, timber, fish, oil) are sold by the owner of the 
property or by the owner of rights for use of that geographical area, the money received from that 
sale is also considered as a resource in the determination of Medicaid or CHIP eligibility.   Page 10  State Health Official 
 
However, if the rights for use of the natural resources are excluded as a resource (such as 
because the individual cannot sell the ownership interest), the money received for the sale of 
natural resources extracted or harvested from that area is also excluded as a resource during the 
month of receipt.  If the individual retains money from the sale of the natural resources and does 
not spend it, the money is considered for Medicaid or CHIP resource eligibility in the months 
following the month of receipt depending on the form the money takes (e.g., countable in a 
checking account or cash, excludable in certain property such as a home).  If the individual sells 
the resource and then spends the money or uses it to purchase another resource that is also 
considered exempt under Medicaid and CHIP rules, eligibility may not be affected.   
 
  For example, if a Tribal member or Tribe exercises federally-protected mineral rights and 
sells minerals extracted in that designated area, money received from the sale of the 
minerals is not income but is considered to be an excluded resource in the month that the 
money is received. 
  If the money from the sale of the minerals is not spent by the end of the month it is 
received (e.g., to pay for the familys food or other personal or business expenses), the 
money is either counted or excluded as a resource based on the type of resource in which 
the money is retained after the month of receipt.   
o  For example, if the money is deposited and retained in the individuals checking 
account, it is counted as a resource along with all other money in the checking 
account after the month the money is received.  If the money is spent to purchase 
a car and the States Medicaid program excludes motor vehicles as a resource, it 
is excluded from consideration as a resource for Medicaid or CHIP eligibility.  
 
Certain types of Tribal per capita payments and other types of Tribal income are excluded from 
consideration as income per Public Law 98-64 (the Per Capita Act) and 45 CFR section 
233.20(a)(4)(ii)(e).  This law and implementing regulations specify that per capita distribution of 
all funds held in trust by the Secretary of Interior for members of an Indian Tribe are excluded 
from consideration as income and resources for federal means-tested public benefits programs 
(e.g., Medicaid and CHIP).   
 
However, also according to Public Law 98-64, local Tribal funds that a Tribe distributes to 
individuals on a per capita basis, but which have not been held in trust by the Secretary of 
Interior (e.g., Tribally managed gaming revenues), are not excluded from income and resources.  
Therefore, those funds are considered as countable income in the month of receipt.  Any per 
capita payments from gaming revenues that are retained after the month of receipt are counted or 
excluded based on the type of resource in which the money is retained. 
 
  For example, if a Tribal member receives a quarterly check from the Tribe as the 
individuals per capita payment from the casino owned by Tribe, the money is considered 
as the individuals countable income in the month that the check is received. 
  Any money from a per capita casino payment that the individual still has after the month 
of receipt is counted or excluded based where the money is.  If it is retained in a 
countable resource (e.g., cash, checking or savings account), it is counted for Medicaid 
and CHIP eligibility.  If it is converted to an excludable resource (e.g., personal property 
like a refrigerator), it is excluded for Medicaid and CHIP eligibility.  Page 11  State Health Official 
 
 
DRAFT                     DRAFT 
  
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT 
 
State: 
 
1.4 State Medical Care Advisory Committee (42 CFR 431.12(b))  
There is an advisory committee to the Medicaid agency director on health and medical care 
services established in accordance with and meeting all the requirements of 42 CFR 431.12.  
 
Tribal Consultation Requirements  
Section 1902(a)(73) of the Social Security Act requires a State in which one or more Indian 
Health Programs or Urban Indian Organizations furnish health care services to establish a 
process for the State Medicaid agency to seek advice on a regular, ongoing basis from designees 
of Indian health programs, whether operated by the Indian Health Service (IHS), Tribes or Tribal 
organizations under the Indian Self-Determination and Education Assistance Act (ISDEAA), or 
Urban Indian Organizations under the Indian Health Care Improvement Act (IHCIA) 
Consultation is required concerning Medicaid matters having a direct impact on these Indian 
health programs .  Please indicate below whether the State, as part of its consultation process, 
appoints an advisory committee or appoints a designee of the Indian health programs and Urban 
Indian Organizations to the State medical care advisory committee, both of these, or something 
else.  
 
__/ State appoints a tribal advisory committee.  
__/ State appoints a designee of the IHS, Tribes or Tribal organizations operating health 
programs under the ISDEAA, and/or Urban Indian organizations operating health programs 
under the IHCIA to the State medical care advisory committee.  
__/ Other. Specify:  
__/ Not applicable because the State does not have at least one Indian Health Program or Urban 
Indian Organization furnishing health care services.  
 
TN No: Approval Date Effective Date _____  
 
Supersedes TN No.  
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Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.