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:  September 8, 2023 
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 February 11, 2025 
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. On October 4, 2021, 
due to the continuing burden of the COVID-19 PHE, CMS issued another CIB further extending 
the grace period for states and IHS and Tribal facilities to nine months after the COVID-19 PHE 
ends, available on Medicaid.gov at https://www.medicaid.gov/federal-policy-guidance/
downloads/cib10421.pdf. Because the COVID-19 PHE ended on May 11, 2023, this extension 
of the grace period is scheduled to expire on February 11, 2024.  
Although the COVID-19 PHE is now over, the process for returning to regular Medicaid 
eligibility operations following the March 31, 2023 expiration of the Medicaid continuous 
enrollment condition under section 6008(b)(3) of the Families First Coronavirus Response Act 
(FFCRA), commonly referred to as unwinding, is straining state and Tribal resources, and is 
expected to do so well into 2024.  This higher volume of work and focus on unwinding could 
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 
1 In this document, we refer to facilities operated by Tribes and Tribal organizations under the ISDEAA as Tribal 
facilities.  CMCS Informational Bulletin  Page 2 
 
FQHC option) and take steps to effectuate that option, if preferred by states and Tribes.2 In 
consideration of these factors, and because CMS is reviewing the clinic benefit regulation and 
the associated four walls requirement, CMS is further extending this grace period for states and 
Tribal facilities for twelve additional months. This will extend the four walls grace period end 
date to February 11, 2025. 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. 
 
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 and the October 4, 2021 CIB. 
 
For more information about the four walls requirement and the grace period discussed in this 
CIB, please contact Kitty Marx, Director, Division of Tribal Affairs, kitty.marx@cms.hhs.gov.  
 
 
2 Under the Tribal FQHC option, a Tribal facility enrolls in Medicaid as a Federally qualified health center (FQHC). 
Nothing in federal Medicaid law prevents FQHCs from claiming Medicaid payment for Medicaid FQHC services 
provided outside of the four walls of the FQHC. If consistent with section 1902(bb)(6) of the Social Security Act, 
states can adopt the IHS AIR as an alternative payment methodology (APM) for Medicaid-covered FQHC services 
provided by Tribal facilities that are FQHCs, in lieu of the prospective payment system rate.  
 
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.