Health Insurance Marketplace Protections 

for American Indians and Alaska Natives

Marketplace Protections:

The Marketplace provides special benefits for AI/ANs, but some are limited to 

members of federally recognized tribes and Alaska Native Claims Settlement 

Act (ANCSA) corporation shareholders.

 Special Enrollment Periods (SEP): Tribal members and ANCSA 

shareholders can enroll in the Health Insurance Marketplace throughout 

the year, not just during the yearly Open Enrollment period. Non-tribal 

members applying on the same application as a tribal member can take 

advantage of the SEP.

 Tribal members and ANCSA shareholders with incomes between 

100% and 300% of FPL:

◊	 May be able to enroll in a zero cost sharing plan, which means no 

copays, deductibles, or coinsurance when receiving care from Indian 

health care providers or when receiving Essential Health Benefits 

(EHBs) through a QHP.

◊	 There is no need for a referral from an Indian health care provider 

when receiving EHBs through the QHP.

 Tribal members and ANCSA shareholders with incomes below 100% 

and above 300% FPL:

◊	 Can enroll in a limited cost sharing plan, which means no copays, 

deductibles, or coinsurance when receiving care from Indian health 

care providers.

◊	 Will need a referral from an Indian health care provider to avoid cost 

sharing when receiving EHBs through a provider outside the Indian 

health system.

 Tribal members and ANCSA shareholders can enroll in a zero cost 

sharing or limited cost sharing plan at any metal level, including less 

expensive bronze plans. 

Tribal members and ANCSA shareholders who qualify for cost sharing 

reductions are not exempt from premiums. However, they may qualify for 

Advance Premium Tax Credits depending on income. All AI/ANs can apply for 

an exemption from the shared responsibility payment (tax penalty/fee) that 

others must pay when they file their taxes if they don’t have health insurance.

Medicaid and CHIP Protections:

All AI/ANs have the following Medicaid and CHIP protections: 

 Do not have to pay premiums or enrollment fees.

 If they receive care from an Indian health care provider or through referral 

to a non-Indian provider, they do not have to pay any cost sharing, such as 

deductibles or copayments. 

The Health Insurance 

Marketplace benefits 

American Indians and Alaska 

Natives (AI/ANs) by providing 

increased opportunities for 

affordable health coverage 

through a Qualified Health 

Plan (QHP) bought in the 

Marketplace, through 

Medicaid, or the Children’s 

Health Insurance Program 

(CHIP). 

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@CMSGov 

#CMSNativeHealth
 Local Indian health care providers may be able to provide a letter to their beneficiaries to verify eligibility for these 

protections.

 Certain types of Indian income and resources are not counted when determining Medicaid or CHIP eligibility. 

For example: 

◊ Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties

◊ Payments from natural resources, farming, ranching, fishing, leases, or profits from Indian trust land (including

reservations and former reservations)

◊ Money from selling items that have tribal cultural significance, such as Indian jewelry or beadwork

NOTE: Per capita income from Indian gaming is not excluded and should be reported.

The ECN is valid for a lifetime, but it must be reported 

if required to file an income tax return to avoid a shared 

responsibility payment (tax penalty/fee). If an individual 

does not have an ECN, he or she must file for the Indian 

exemption when completing his or her federal income 

tax return every year to avoid the shared responsibility 

payment (tax penalty/fee). Even if an individual applies 

for an exemption from the fee, he or she can also apply 

for QHPs on the Marketplace, or for Medicaid and CHIP 

programs, and still receive services from an Indian health 

care provider. 

Indian Exemption:

AI/ANs, including individuals who are otherwise eligible 

for services through an Indian health care provider, 

can now apply for an exemption from the shared 

responsibility payment (tax penalty/fee) in two ways. 

1. Apply when filing a federal income tax return through

self-attestation or by providing an Exemption Certificate 

Number (ECN).

 Self-attestation

◊ Do not need to submit documentation because

an individual can self-attest that they or a

member of their tax household are eligible for

an exemption

◊ Should retain the same documentation as if

filing for an exemption through the Marketplace

(see Step 5 of the exemption application)

◊ Must be able to produce this documentation if

audited by IRS

 Provide an ECN (the number received from the 

Marketplace contractor)

◊ Keep this number, because it will need to be

provided every year when filing taxes

◊ Because an individual has proven eligibility for

an ECN, he or she will not need to produce

tribal or eligibility documentation in case of an

IRS audit

2. Apply through the Marketplace by completing an

exemption application and mailing it with supporting 

documentation. 

 Must submit documentation of membership in a 

federally recognized tribe/ANCSA corporation, or 

eligibility for services through an Indian health care 

provider (see Step 5 of the exemption application)

 Will receive an ECN.

Forms to apply for the Indian exemption on the 

Marketplace are available for downloading at:

http://marketplace.cms.gov/getofficialresources/

publications-and-articles/tribal-exemption.pdf

For more information, visit: www.healthcare.gov/tribal

Contact Info:

@CMSGov #CMSNativeHealth www.healthcare.gov/tribal

CMS Product No. 11902-N, October 2015