DEPARTMENT OF HEALTH  & HUMAN SERVICES  
Centers for Medicare & Medicaid Services  
7500 Security Boulevard,  Mail  Stop S2-26-12  
Baltimore, Maryland    21244-1850  
 SMD # 22-006  
RE: Additional Guidance on Section 9815 of  
the American Rescue Plan Act  of 2021  
December 27, 2022  
Dear State Medicaid Director:  
This State Medicaid Director  Letter  (SMDL) provides additional guidance  to states on section  
9815 of the American Rescue Plan Act of 2021 (ARP) (P.L. 117-2).  Section 9815 of the ARP  
amends the third sentence of section 1905(b) of the Social Security Act (Act) to make a 100 
percent  federal medical assistance percentage (FMAP)  temporarily available for Medicaid 
services received through certain Urban Indian Organizations (UIOs) and  certain  Native  
Hawaiian health care providers.  The Centers  for  Medicare & Medicaid Services (CMS)  
previously described this provision in State Health Official (SHO)  Letter #21-004, Temporary  
increases to FMAP under sections 9811, 9814, 9815, and 9821 of the ARP and administrative  
claiming for vaccine incentives (August 30, 2021).1 
This SMDL provides additional information about CMSs interpretation of section 9815 of the  
ARP by explaining: 1) which specific Native Hawaiian health care providers are referenced in  
section 9815 of the ARP; and 2) that the 100 percent FMAP available under section 9815 of the  
ARP for Medicaid services received through certain UIOs and certain Native Hawaiian health  
care providers is also available when these Medicaid services are provided  by other  health care 
providers pursuant to care coordination agreements with the qualifying providers, consistent with 
the guidance in SHO  Letter #16-002, Federal Funding for Services Received Through an 
IHS/Tribal Facility and Furnished to Medicaid-Eligible American Indians and Alaska Natives 
(February 26, 2016).2   
1.  Native Hawaiian Health Care Providers Referenced in Section 9815 of the ARP
Under section 9815 of the ARP, a state may receive 100 percent FMAP for its medical assistance  
expenditures for services received through a Native Hawaiian Health Center (as defined in  
section 12(4) of the Native Hawaiian Health Care  Improvement Act) or a qualified entity  (as  
defined in section 6(b) of such Act) that has  a  grant or contract with the Papa Ola  Lokahi under  
section 8 of such Act.   Under section 6(b) of the Native Hawaiian Health Care  Improvement  
1  SHO Letter #21-004 is available at:  https://www.medicaid.gov/federal-policy-guidance/downloads/sho-21-004.pdf.  
2  For specific details about  what a qualifying care coordination agreement includes, please see SHO Letter  #16-002  
which is available at: https://www.medicaid.gov/federal-policy-guidance/downloads/sho022616.pdf.   Page 2  State Medicaid  Director  
Act (NHHCIA), a qualified entity is a Native Hawaiian health care system (System).  42  
U.S.C.  11705(b). 
Section 8 of the NHHCIA (42 U.S.C.  11707), referenced at the end of section 9815 of the  
ARP, does not address  grants or contracts between Papa Ola  Lokahi and health care providers.  
Instead, section 8 of the  NHHCIA sets forth certain provisions and requirements for the  
Secretarys  grants or contracts made under this Act, meaning the NHHCIA.  Under the 
NHHCIA, the U.S. Department of Health & Human Services (HHS) makes grants or enters into 
contracts in two ways: (1) with Systems (to  provide comprehensive health promotion and 
disease prevention services as well as primary health services to Native Hawaiians pursuant to 
the authority in section 6 of the NHHCIA  (42 U.S.C.  11705)),3 and (2) with Papa Ola  Lokahi  
(for activities such as  coordinating, implementing  and updating  a Native  Hawaiian 
comprehensive health care master plan;  training; research; data  collection; coordination of health  
care programs  and services; and administration of  special project funds, pursuant to the authority  
in sections 4 and 7 of the NHHCIA, 42 U.S.C.  11703 and 11706).4   
While Systems are recognized and certified by Papa Ola Lokahi for purposes of receiving HHS  
funding under the NHHCIA (section 12(6)(F) of the NHHCIA, 42 U.S.C.  11711(6)(F)), the  
NHHCIA does not authorize HHS contracts or  grant awards to Papa Ola  Lokahi to provide  
health services or to provide health services through Systems.  The NHHCIA also defines  Native  
Hawaiian Health Centers (Centers) (section 12(4)  of the NHHCIA, 42 U.S.C.  11711(4)), and 
while Centers may be part of a System, the NHHCIA does not authorize HHS contracts or  grant  
awards to Centers directly.    
Because there are no health care providers with grants or contracts with Papa Ola  Lokahi to 
provide health services under section 8 (or any section) of the NHHCIA, CMS interprets  section  
9815 of the  ARPs phrase a qualified entity ... that has a grant or  contract with the Papa Ola  
Lokahi under section 8  of the NHHCIA  to refer to Systems that: (1) otherwise meet the  
definition of a System at  section 12(6) of the  NHHCIA (42 U.S.C.  11711(6)) (including that 
they  are  recognized and certified by Papa Ola  Lokahi under this NHHCIA  provision), and (2)  
have a  grant or contract  with HHS under section 6 of the NHHCIA (42 U.S.C.  11705) that  
meets the requirements in section 8 of the NHHCIA (42 U.S.C.  11707).  Thus, state  
expenditures on Medicaid services received through the five Systems that  have  grants from or  
3Under  42 U.S.C. 11705,  HHS  may make  grants to or enter into contracts  with qualified  entities  for  the purpose of  
providing comprehensive health  promotion  and disease prevention  services  as  well  as  primary  health  services  to  
Native Hawaiians.  Systems are  defined in 42 U.S.C.    11711(6)  to mean an entity  in  which Native Hawaiian  health  
practitioners  provide or arrange  for health care services,  significantly participate in the planning,  management,  
monitoring, and evaluation of health care services and that, among  meeting other requirements, is organized under  
the laws of Hawaii and certified by the  Papa Ola Lokahi.   Additionally,  per 42 U.S.C.  11705(d), the Secretary  may 
make a grant to, or hold a contract  with, not  more than 5  Systems  per fiscal  year.   The Health Resources and  
Services Administration  (HRSA)  administers the HHS programs that provide funding to Native Hawaiian providers  
under the NHHCIA.    
4  Under  42 U.S.C.   11706,  HHS  may  make grants to or  enter into contracts  with Papa Ola Lokahi for specified  
administrative purposes.  The  NHHCIA also provides  for grants or cooperative agreements  with Papa Ola Lokahi  
for the provision of scholarship assistance (42 U.S.C.  11709) which is  unrelated to the provision of health care  
services at issue in section 9815 of the ARP.   Page 3  State Medicaid  Director  
contracts with HHS under section 6 of the NHHCIA (42 U.S.C.  11705) will be matched at 100 
percent  FMAP under section 9815 of the  ARP. 
Separately, because HHS does not enter directly into contracts with, or provide grants to, Centers  
under the NHHCIA, CMS does not interpret section 9815 of the  ARPs  phrase has  a grant or  
contract with the Papa Ola Lokahi under section 8 of the NHHCIA to apply  to Centers.  Rather, 
CMS interprets section 9815 of the  ARP to authorize 100 percent FMAP for state expenditures  
on Medicaid services received through all Centers, as defined in section 12(4) of the NHHCIA  
(42 U.S.C.  11711(4)), regardless  of whether the  Center is part of a System that has a grant from 
or contract with HHS under section 6 of the  NHHCIA (42 U.S.C.  11705). When claiming 100 
percent  FMAP for Medicaid services  received through a Center, the state would need to attest  
that the provider  meets the definition of a Center  in section 12(4) of the  NHHCIA (42 U.S.C. 
 11711(4)).5 
In sum, CMS interprets section 9815 of the  ARP to authorize 100 percent FMAP for state  
expenditures on Medicaid services received through the following Native  Hawaiian health care 
providers: (1)  all Systems that meet the definition at 42 U.S.C.  11711(6) and have a  grant or  
contract with HHS under 42 U.S.C.  11705; and (2) all Centers as defined in 42 U.S.C. 
 11711(4), regardless of  whether the Center is part of  a System that has  a grant from or  contract 
with HHS under section 6 of the NHHCIA (42 U.S.C.  11705). 
States may  claim FFP under section 9815 of the  ARP retroactively back to April 1, 2021, 
provided that their claims are filed within the two-year claims  filing limit described in section  
1132 of the  Act.  
2.  Medicaid Services Received through Providers  Referenced in Section 9815 of the ARP 
Pursuant to a Care Coordination Agreement 
As discussed in SHO  Letter #21-004, CMS interprets the amendments to section 1905(b) of the  
Act made by section 9815 of the ARP to apply to Medicaid services received by  all  Medicaid  
beneficiaries through UIOs  with a grant or  contract with the  Indian Health Service (IHS) under  
title V of the  Indian Health Care  Improvement Act, and through  certain Native Hawaiian health  
care providers.6   
5  The term  Native Hawaiian  Health  Center (Center) is defined  in 42 U.S.C. 11711(4)  to mean a  public or private  
nonprofit  entity  organized under Hawaii state law  in  which Native Hawaiian health practitioners  provide or arrange 
for health services and  significantly participate in the planning,  management,  monitoring, and evaluation of health  
care services.  
6  As  explained in SHO  Letter #21-004,  based on the legislative  history of section 9815 of the  ARP, CMS has  
interpreted that provision  to apply  to expenditures  for Medicaid services received by all Medicaid beneficiaries  
through the providers listed in section  9815  of the  ARP.  CMSs longstanding interpretation of the pre-ARP language  
in section 1905(b)s third  sentence, under  which 100 percent FMAP for services received through IHS facilities  
(whether operated by IHS or by Tribes or Tribal organizations) is limited to Medicaid services received by  
American Indian and Alaska Native (AI/AN)  beneficiaries,  remains unchanged.   Page 4  State Medicaid  Director  
In  SHO Letter #16-0027 and subsequent Frequently Asked Questions (FAQ)8 that CMS issued in 
2017,  CMS explained that the 100 percent  FMAP  under section 1905(b) of  the Act is available  
for Medicaid services that are received through IHS/Tribal facilities because they  are furnished  
by non-IHS/Tribal providers pursuant to a  care coordination agreement  with an IHS/Tribal  
facility, if that care coordination agreement meets certain criteria outlined by  CMS in the 2016 
and 2017 guidance.  
As explained in SHO  Letter #16-002, amounts paid by the state  for Medicaid services provided 
in accordance with a qualifying care coordination  agreement are eligible for the 100 percent  
FMAP authorized under  section 1905(b) of the  Act. Section 9815 of the ARP amends section 
1905(b) of the Act to authorize 100 percent  FMAP for Medicaid services received through 
certain UIOs and  certain  Native Hawaiian health care providers, and does so by using language 
that is nearly identical to the language of the existing authority providing for 100 percent FMAP  
for Medicaid services  received through IHS/Tribal facilities.  Thus, the  guidance in SHO  Letter  
#16-002 explaining that 100 percent  FMAP is available for state expenditures on Medicaid  
services furnished by non-IHS/Tribal providers under a qualifying  care coordination agreement  
with an  IHS/Tribal facility  also applies with respect to state expenditures on Medicaid services  
furnished under  a qualifying care  coordination agreement with the providers listed in section  
9815 of the ARP.  
Consistent with SHO Letter #16-002, states can claim the 100 percent FMAP under section 9815 
of the ARP for their expenditures on Medicaid services furnished under a qualifying care  
coordination agreement only beginning with the date of execution of such an agreement.  In 
addition, states should keep in mind that the 100 percent  FMAP authorized under section 9815 of  
the ARP is limited to the eight fiscal quarters beginning April 1, 2021 and ending March 31, 
2023. 
Technical Assistance 
As explained in SHO letter  #21-004, section 9815 of the ARP temporarily changes the federal  
matching percentage that CMS pays to states for  certain Medicaid expenditures, but that section 
is silent about the payment rates states opt to pay to the health care providers listed in it.  States  
have the discretion to set and adjust Medicaid provider payment rates, consistent with section 
1902(a)(30)(A) of the Act, as long as the state payment rates are consistent  with efficiency,  
economy, and quality of  care  and are sufficient to enlist enough providers so that care  and 
services are available under the state plan  at least  to the extent that such care and services  are 
available to the general population in the geographic area.  States must comply with the  
provisions of section 1902(bb) of the Act when setting Medicaid payment rates for  Federally  
Qualified Health Center (FQHC) services  and Rural Health Clinic (RHC) services (as described  
in section 1905(a)(2) of the Act) that are furnished by  FQHCs and RHCs.  CMS is available to  
provide technical assistance to states that believe  adjusting their reimbursement rates to UIOs,  
Centers, or Systems is appropriate.  
7  SHO Letter #16-002 is available at: https://www.medicaid.gov/federal-policy-guidance/downloads/sho022616.pdf. 
8  The 2017 FAQs are available at:  https://wwwmedicaid.gov/federal-policy-guidance/downloads/faq11817.pdf.   Page 5  State Medicaid  Director  
We encourage states needing technical assistance to contact their CMS state lead, and  UIOs,  
Centers, and Systems needing technical assistance to contact their CMS Native American  
Contact.9  For more information or questions regarding this SMDL, please contact Kitty Marx, 
Director, Division of Tribal Affairs, kitty.marx@cms.hhs.gov.   
Sincerely,  
Daniel Tsai  
Deputy  Administrator and Director  
9  Native American Contacts:  https://www.cms.gov/files/document/cms-native-american-contact.pdf.