DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland  21244-1850 
CMCS Informational Bulletin 
DATE:  October 4, 2021 
FROM:  Daniel Tsai, Deputy Administrator and Director 
Center for Medicaid and CHIP Services 
SUBJECT:  Further Extension of Grace Period Related to the Four Walls 
Requirement under 42 C.F.R.  440.90 for Indian Health Service and 
Tribal Facilities to Nine Months after the COVID-19 PHE Ends 
The Center for Medicaid and CHIP Services (CMCS) is issuing this CMCS Informational 
Bulletin (CIB) to announce that the Centers for Medicare & Medicaid Services (CMS) is further 
extending a grace period previously granted to Indian Health Service (IHS) facilities, including 
those facilities operated by Tribes and Tribal organizations under the Indian Self-Determination 
and Education Assistance Act (ISDEAA), Pub. L. No. 93-638.1 The grace period permits IHS 
and Tribal facilities to continue to claim Medicaid reimbursement under the clinic services 
benefit at 42 C.F.R.  440.90 (including at the IHS All Inclusive Rate (AIR)) for services 
provided outside of the four walls of the facility. On January 15, 2021, due to the urgent need 
to ensure continued access to services provided by IHS and Tribal facilities during the COVID-
19 public health emergency (PHE), and the need for states, IHS, and Tribes to focus limited 
resources on addressing the COVID-19 PHE, CMS issued a CIB extending the grace period from 
January 30, 2021 to October 31, 2021 (January 15, 2021 CIB), available on Medicaid.gov at 
https://www.medicaid.gov/federal-policy-guidance/downloads/cib11421.pdf. 
The ongoing burden of the COVID-19 PHE continues to place additional strain on state and 
Tribal resources and continues to impede states and Tribes ability to complete the work needed 
to make an informed decision about an option described in the January 15, 2021 CIB (referred to 
in that CIB as the Tribal FQHC option) and take steps to effectuate that option.2 Therefore, 
CMS is further extending this grace period for states and Tribal facilities to nine months after 
the COVID-19 PHE ends. CMS is also further extending the grace period for IHS-operated 
facilities for the same time period, to give IHS and states additional time to work toward a 
solution addressing compliance with the four walls requirement for IHS-operated facilities. 
1 In this document, we refer to facilities operated by Tribes and Tribal organizations under the ISDEAA as Tribal 
facilities. 
2 The Tribal FQHC option allows a Tribal facility to convert to FQHC status and states can adopt the IHS AIR as an 
Alternative Payment Methodology (APM) under section 1902(bb)(6) of the Social Security Act for any Tribal 
facilities that are FQHCs, in lieu of the prospective payment system rate. FQHCs are not affected by the four walls 
limitation so any services furnished outside the facility may be reimbursed at the IHS AIR.   CMCS Informational Bulletin  Page 2 
 
Additional information on the Four Walls requirement, the Tribal FQHC option, and the 
related grace period can be found in the January 15, 2021 CIB. 
 
Technical Assistance 
 
We encourage states needing technical assistance to contact their CMCS state lead and Tribes 
needing technical assistance to contact their CMCS Native American Contact. These CMS 
contacts are available to provide any additional technical assistance needed in determining 
whether to adopt the Tribal FQHC option discussed in the January 15, 2021 CIB. For more 
information about the four walls limitation and the grace period discussed in this CIB, please 
contact Kitty Marx, Director, Division of Tribal Affairs, kitty.marx@cms.hhs.gov.  
 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any 
way, unless specifically incorporated into a contract.  This document is intended only to provide clarity to the public 
regarding existing requirements under the law.