Medicare and Medicaid: CMS and State Efforts to Interact with the Indian Health Service and Indian Tribes
Published: 2008-07-11T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: By law, facilities funded by the Indian Health Service (IHS) may retain reimbursement from Medicare and Medicaid without an offsetting reduction in funding. Ensuring that IHS-funded facilities enroll individuals in--and obtain reimbursement from--Medicare and Medicaid can provide an important means of expanding the funding for health care services for the population served by IHS. The Centers for Medicare & Medicaid Services (CMS), the agency within the Department of Health and Human Services (HHS) that administers Medicare and oversees states' Medicaid programs, is required by Executive Order and HHS policy to consult with Indian tribes on policies that have tribal implications. This requirement is in recognition of the unique government-to-government relationship between the 562 federally recognized Indian tribes and the federal government. GAO was asked to (1) describe interactions between CMS and IHS, (2) examine mechanisms CMS uses to interact and consult with Indian tribes, (3) examine mechanisms that selected states' Medicaid programs use to interact and consult with Indian tribes, and (4) identify barriers to Medicare and Medicaid enrollment and efforts to help eligible American Indians and Alaska Natives apply for and enroll in these programs. GAO reviewed documents, interviewed federal and state officials, and visited a judgmental sample of Indian tribes and IHS-funded facilities in six states.
section_title: What GAO Found
paragraphs: CMS and IHS have interacted to (1) provide support to IHS-funded facilities and tribes in their access to Medicare and Medicaid and (2) address broader policy and regulatory concerns regarding these programs. Their interactions to provide support have included education and technical assistance; the agencies also have interacted to obtain input from tribal representatives on program operations. On broader policy and regulatory concerns, CMS and IHS have worked on policy initiatives aimed at ensuring that existing health care policies meet the needs of IHS-funded facilities and the populations they serve. CMS and IHS have had mixed success identifying whether proposed CMS regulatory changes would affect IHS-funded facilities or their populations and thus warrant IHS review. CMS has been working to improve its identification of such regulations. CMS has used two key mechanisms--tribal liaisons and an advisory board--to interact with representatives from Indian tribes, and it has relied primarily on annual regional sessions sponsored by HHS as its mechanism to consult with Indian tribes. Tribal liaisons in CMS's central and regional offices generally served as the point of contact for tribal representatives. CMS's tribal advisory board, which is meant to complement but not replace consultation, has provided the agency with advice on policies affecting the delivery of health care for American Indians and Alaska Natives. CMS has used annual HHS regional consultation sessions as the primary basis for consulting with Indian tribes. However, consulting with tribes is an inherently difficult task, in part because of the variation in tribes' size, location, and economic status. Further, these HHS regional sessions--which generally lasted 1 to 2 days and covered all HHS programs--have offered limited time for consultation and discussion. The six state Medicaid programs we reviewed have used at least one of three mechanisms--tribal liaisons, advisory boards, and regular meetings--to interact and consult with Indian tribes. Five of the six states reported having policies in place that governed the interactions between the state's Medicaid program and Indian tribes, with most of these policies establishing guidelines for how consultation should be conducted. Five states reported consulting with tribes about changes to their Medicaid programs. American Indians and Alaska Natives have faced several barriers to Medicare and Medicaid enrollment despite efforts to assist them with the application process. Many of these barriers are similar to those experienced by other populations, such as transportation and financial barriers. To help eligible American Indians and Alaska Natives enroll in Medicare and Medicaid, almost all of the IHS-funded facilities we visited had staff who assisted patients with the application process, including helping them complete and submit applications, and collecting required documentation. In commenting on a draft of this report, CMS noted that it was appreciative of GAO's review of CMS activities related to interactions with IHS and tribes.

section_title: Letter
paragraphs: The United States recognizes each of the more than 560 federally  recognized Indian tribes as sovereign nations within its borders. These  tribes, which are located in over 30 states, vary greatly in population,  economic status, and land ownership, and have a unique government-to- government relationship with the federal government. According to  federal law, this unique relationship includes a responsibility for the  provision of health care to American Indians and Alaska Natives. The  Indian Health Service (IHS), an agency within the Department of Health  and Human Services (HHS), provides or arranges for the provision of  health care services for American Indians and Alaska Natives. In fiscal  year 2007, IHS provided or arranged health care services for  approximately 1.5 million American Indians and Alaska Natives. Services  are provided through IHS-funded facilities, including those operated by  IHS and those operated by tribes, or purchased from other public and  private providers—referred to as contract health services.
IHS is funded through appropriations, which in fiscal years 2006 and 2007  were approximately $3.0 billion and $3.2 billion, respectively. In addition  to federal appropriations, IHS-funded facilities can seek reimbursement  for services they provide to individuals enrolled in Medicare, the federal  health insurance program for elderly and disabled individuals, and for  those enrolled in Medicaid, a joint federal and state health financing  program for certain low-income families and low-income individuals who  are aged or disabled. Reimbursement from Medicare and Medicaid can  increase the amount of funds available to IHS-funded facilities because by  law they can retain reimbursement from these programs without an  offsetting reduction in their appropriated funding. In fiscal year 2007, IHS  reported approximately $677 million in reimbursement from Medicare and  Medicaid; however, facilities vary greatly in the total reimbursement  obtained from these programs. For example, our prior work found that  Medicaid reimbursement across 12 IHS-funded facilities ranged from   2 percent to 49 percent of the total direct medical care budgets of these  facilities, and that facilities with higher reimbursement had additional  funds to hire staff and purchase equipment and supplies. As a result,  ensuring that eligible American Indians and Alaska Natives are enrolled in  Medicare and Medicaid, and that IHS-funded facilities obtain  reimbursement for services provided to these enrolled individuals, can  provide an important means of expanding the funding for health care  services available to this population.
Changes to Medicare and Medicaid can affect the enrollment of American  Indians and Alaska Natives in these programs and the ability of IHS-funded  facilities to claim reimbursement for enrolled individuals. Interactions  between Indian tribes, IHS, and the Centers for Medicare & Medicaid  Services (CMS), the agency within HHS that administers Medicare and  oversees states’ Medicaid programs, can help prevent policy changes from  having unforeseen effects on tribes and IHS-funded facilities. For example,  if changes in a Medicaid program’s delivery system—such as moving to a  system of managed care—are discussed with tribes and IHS officials, then  consequences—such as IHS-funded facilities not being part of managed  care systems—may be avoided. Recognizing the unique status of Indian  tribes, a 1998 Executive Order required a specific type of interaction  between federal agencies and Indian tribes, called consultation, which  required federal agencies to have an effective process to ensure  meaningful and timely input by tribal officials in the development of  regulatory policies that have tribal implications. In 2005, HHS adopted a  tribal consultation policy, under which every agency within HHS shares  the responsibility to coordinate, communicate, and consult with Indian  tribes. Thus, CMS is required to consult with Indian tribes on program  issues that have tribal implications. In contrast, states are not subject to  the Executive Order or HHS’s tribal consultation policy. However, CMS  has encouraged state Medicaid programs to consult with tribes when  making changes to their Medicaid programs. Moreover, some states have  policies requiring consultation between the state Medicaid program and  Indian tribes.
Given the importance of CMS programs to American Indians and Alaska  Natives, you asked us to examine the interactions between the Medicare  and Medicaid programs with IHS-funded facilities. This report   (1) describes interactions between CMS and IHS, (2) examines  mechanisms CMS uses to interact and consult with Indian tribes,   (3) examines mechanisms that selected states’ Medicaid programs use to  interact and consult with Indian tribes, and (4) identifies barriers to  enrollment in Medicare and Medicaid and efforts to help eligible American  Indians and Alaska Natives apply for and enroll in these programs.
To describe interactions between CMS and IHS, we interviewed officials  from both agencies. Specifically, within CMS, we interviewed officials  from its central office and 9 of its 10 regional offices who have  responsibility for coordinating issues related to Indian tribes and IHS, as  well as other CMS officials, including officials knowledgeable about  interactions between CMS and IHS. Within IHS, we interviewed  headquarters officials involved in interacting with CMS, including those in  the Office of Resource Access & Partnerships. We also interviewed  officials in each of IHS’s 12 area offices identified by IHS executives as  being the most knowledgeable about Medicare- and Medicaid-related  issues. (See app. I for a map of the locations covered by the IHS area  offices and the CMS regional offices.) In our interviews, we asked CMS  and IHS officials about their interactions with the other agency. During the  interviews we obtained information about the development and review  process for regulations and how CMS and IHS interact to identify  proposed CMS regulations that may affect IHS-funded facilities. To  supplement this information, we interviewed officials from the HHS Office  of the Executive Secretariat, which is responsible for determining which  agencies within HHS should have the opportunity to review a regulation.  We also interviewed officials from the HHS Office of Tribal Affairs about  HHS activities related to American Indians and Alaska Natives that involve  IHS and CMS. Additionally, we reviewed relevant CMS and IHS  documentation to supplement information obtained during our interviews.
To examine mechanisms that CMS uses to interact and consult with Indian  tribes, we reviewed information obtained during our interviews with the  CMS and HHS officials noted above. We also interviewed tribal  representatives to obtain their opinions about interactions with CMS.  During the course of our interviews with CMS and HHS officials, we asked  them about past and present interactions, including consultations, with  tribes. We conducted site visits in 3 of the 12 IHS areas from September  through November 2007. We selected these 3 areas to represent a mix in  terms of geographic location, level of reliance on contract health services,  and the entities operating the facilities (IHS or tribes). (See app. II for  more detailed information about the methodology for our site visits.)  During our site visits we met with tribal leaders or designated officials  from 14 tribes, and interviewed them regarding their interactions with  CMS and elicited their opinions about CMS’s consultation with Indian  tribes. To better understand CMS’s consultation activities, we reviewed  CMS’s involvement in HHS regional consultation sessions. To do this, we  interviewed HHS officials from the four HHS regional offices that  corresponded to the location of the tribes we visited and reviewed  agendas and reports from these regions’ consultation sessions. We  interviewed over 15 additional tribal representatives, including officials  from area health boards—who serve as the voice for tribes in their area on  health-related issues—and tribal representatives who are members of  CMS’s Tribal Technical Advisory Group (TTAG), an advisory board  created to inform CMS about issues affecting the delivery of health care to  American Indians and Alaska Natives served by CMS programs. Finally, we  observed several TTAG meetings and reviewed relevant documentation,  such as minutes, from prior TTAG meetings.
To examine mechanisms that selected states’ Medicaid programs use to  interact and consult with Indian tribes, we interviewed Medicaid officials  in the six states that corresponded to the location of the 14 tribes we  visited. We asked these officials about interactions and consultations  between the state Medicaid program and Indian tribes in the state. We also  reviewed relevant documentation, such as state policies that govern  interactions with tribes. Additionally, we used information gathered from  our interviews with tribal leaders and other tribal representatives.
To identify barriers to enrollment in Medicare and Medicaid and efforts to  help eligible American Indians and Alaska Natives apply for and enroll in  these programs, we used information obtained from our interviews with  CMS, IHS, and state officials as well as tribal representatives. Additionally,  during our site visits, we interviewed officials at 25 IHS-funded facilities,  13 of which were operated by IHS and 12 of which were operated by  tribes. During these interviews, we asked officials about barriers to  Medicare and Medicaid enrollment, enrollment assistance provided, and  outreach activities. We also interviewed officials from the Social Security  Administration (SSA), the federal agency responsible for Medicare  enrollment, about barriers to Medicare enrollment and the agency’s  outreach activities. In addition, we conducted a literature review about  barriers related to enrolling in Medicare and Medicaid. Where available,  we reviewed relevant documentation to supplement the information found  during our interviews.
The information from the six state Medicaid programs provides insight  about the interactions and consultations between state Medicaid programs  and Indian tribes, but it cannot be generalized to other states. Additionally,  the information we obtained from tribal representatives cannot be  generalized to all 562 federally recognized tribes. We conducted our work  from December 2006 through July 2008 in accordance with generally  accepted government auditing standards.
subsections: section_title: Background
paragraphs: The federal government recognizes 562 Indian tribes, which are located in  33 states, and vary greatly in size, economic status, and land ownership.  According to the Bureau of Indian Affairs, the tribes range in size from  villages in Alaska that have fewer than 50 members to tribes with over  240,000 members. The economic status of tribes also varies, ranging from  those with unemployment rates that are more than 90 percent to those  with unemployment rates that are below 10 percent. Some tribes also have  significant economic opportunities for tribal members, including  employment or payments provided to tribal members. With regard to land  ownership, reservation lands ranged from 16 million acres to less than 100  acres.
Overall, American Indians and Alaska Natives living in IHS areas have  lower life expectancies than the U.S. population as a whole and face  considerably higher mortality rates for some conditions. For American  Indians and Alaska Natives ages 15 to 44 living in those areas, mortality  rates are more than twice those of the general population. American  Indians and Alaska Natives living in IHS areas have substantially higher  rates for diseases such as diabetes, as well as a higher incidence of fatal  accidents, suicide, and homicide.
subsections: section_title: IHS Provision of Health Care
paragraphs: IHS arranges for the provision of health care to American Indians and  Alaska Natives who are members of federally recognized tribes.  Specifically, in 2007, IHS funded health care delivered to approximately   1.5 million American Indians and Alaska Natives. IHS consists of a system  of more than 650 IHS-funded facilities organized into 12 geographic areas  of various sizes. Within the 12 areas, direct care services are generally  delivered by IHS-funded hospitals, health centers, and health stations.  Tribes have the option of operating their own direct care facilities. Thus,  direct care is provided by IHS-funded facilities that are either IHS operated  or tribally operated. Services not available through direct care at IHS- funded facilities may be purchased by the facilities through arrangements  with outside providers; these services are referred to as contract health  services.
Eligibility requirements for direct care and contract health services differ.  In general, all American Indian and Alaska Native tribal members are  eligible to receive direct care at IHS-funded facilities free of charge. To be  eligible for contract health services, however, American Indians and  Alaska Natives must reside within a contract health services delivery area  that is federally established and either (1) reside on a reservation within  the area or (2) belong to or maintain close economic and social ties to a  tribe based on such a reservation. IHS-funded facilities will not authorize  or pay for contract health services for individuals who are eligible to  obtain such services through other sources, such as Medicare or Medicaid.
section_title: Medicare and Medicaid
paragraphs: Medicare finances health services for approximately 44 million elderly and  disabled individuals and consists of several different components, namely:    Medicare Part A, Hospital Insurance—which helps cover inpatient care  in hospitals. There is typically no premium for Part A.
Medicare Part B, Medical Insurance—which covers doctors’ services,  outpatient care, and certain other services, such as physical and  occupational therapy and medical supplies. In 2008, the monthly premium  for Part B is $96.40 for most individuals.
Medicare Part C, or Medicare Advantage—which provides coverage for  Medicare Parts A and B services through private health plans.
Medicare Part D, or Prescription Drug Coverage—a voluntary insurance  program for outpatient prescription drug benefits. Most Medicare drug  plans charge a monthly premium. However, beneficiaries eligible for both  Medicare and Medicaid (dual-eligibles) are generally not required to pay a  premium, and certain low-income beneficiaries are eligible for premium  subsidies.
IHS has the authority to pay Medicare Part B premiums on behalf of  individuals eligible to receive direct care, although the agency has not yet  utilized that authority. Some Indian tribes pay the Medicare Part B or   Part D premiums of their members.
American Indians and Alaska Natives may also be eligible for health care  benefits under Medicaid, a joint federal-state program that finances health  care for certain low-income children, families, and individuals who are  aged or disabled. Generally, the federal government and the states share in  the cost of the Medicaid program. However, the federal government pays  100 percent of the Medicaid program’s cost to provide services to  American Indians and Alaska Natives at IHS- or tribally operated facilities.
section_title: IHS Funding
paragraphs: In fiscal year 2007, Congress appropriated approximately $3.2 billion for  IHS, which included funding for the provision of direct care at IHS-funded  facilities, contract health services, and other functions. In addition to IHS’s  federal appropriation, IHS-funded facilities can be reimbursed by other  payers, including Medicare and Medicaid, for the services the facilities  provide. IHS-funded facilities are allowed to retain reimbursements  without an offsetting reduction in their IHS funding. Thus, revenues from  Medicare and Medicaid can increase the financial capacity of IHS-funded  facilities to provide needed medical services.
According to IHS data, the amount of Medicaid and Medicare  reimbursement that IHS has collected has increased over time (see fig. 1).  In fiscal year 2007, IHS reported approximately $516 million in Medicaid  reimbursement and $161 million in Medicare reimbursement, for a total of  $677 million. These data do not account for all collections by IHS-funded  facilities because tribally operated facilities are not required to report such  information.
section_title: Federal Consultation Requirements
paragraphs: In recognition of the unique government-to-government relationship  between the federal government and Indian tribes, federal agencies are  required by Executive Order to consult with Indian tribes on “policies that  have tribal implications.” The order states that “ach agency shall have  an accountable process to ensure meaningful and timely input by tribal  officials in the development of regulatory policies that have tribal  implications.” The order defines policies that have tribal implications as  regulations, legislative comments or proposed legislation, and other policy  statements or actions that have substantial direct effects on one or more  Indian tribes, on the relationship between the federal government and  Indian tribes, or on the distribution of power and responsibilities between  the federal government and Indian tribes.
On January 14, 2005, HHS adopted a tribal consultation policy that  formalized HHS’s requirement to consult with Indian tribes in policy  development. HHS’s policy defines consultation as: “An enhanced form of  communication, which emphasizes trust, respect and shared  responsibility.” In addition, the HHS policy explains that consultation is  “integral to a deliberative process, which results in effective collaboration  and informed decision making with the ultimate goal of reaching  consensus on issues.” Under the HHS tribal consultation policy, every  agency within HHS, including CMS, shares in the departmentwide  responsibility to coordinate, communicate, and consult with Indian tribes.  Among other things, the HHS tribal consultation policy specifies that each  of the 10 HHS regions should have an annual consultation session to  solicit information on Indian tribes’ priorities and needs related to health  and human services. Within CMS, issues related to American Indians and  Alaska Natives are coordinated by the agency’s Tribal Affairs Group and  by designated Native American Contacts (NAC) in each of its 10 regional  offices.
section_title: State Consultation Requirements
paragraphs: While the Executive Order establishes clear requirements for federal  agencies to consult with Indian tribes, in general, states determine how to  interact, and whether to consult, with the tribes in their states. However,  CMS has provided guidance to state Medicaid programs that encourages  the programs to consult with tribes and be as responsive as possible to  their issues and concerns when making changes to state Medicaid  programs. While states have flexibility in making many changes to their  Medicaid programs, some changes require states to obtain a waiver of  certain Medicaid requirements. Specifically, the Social Security Act  authorizes the Secretary of HHS to waive certain federal Medicaid  program requirements under certain conditions. CMS guidance indicates  that evidence of consultation with the tribes is one criterion that CMS will  use during its review of proposed state Medicaid program changes that  require a waiver of Medicaid requirements.
section_title: CMS and IHS Have Interacted to Provide Support as Well as Address Broader Policy and Regulatory Concerns
paragraphs: CMS and IHS have interacted to provide support to IHS-funded facilities  and Indian tribes in accessing Medicare and Medicaid as well as to address  efforts associated with broader policy and regulatory concerns regarding  the two programs. With regard to support, CMS and IHS have interacted to  educate staff from IHS-funded facilities and American Indians and Alaska  Natives about Medicare and Medicaid. Additionally, CMS has assisted IHS- funded facilities with Medicare and Medicaid billing procedures and other  concerns. CMS and IHS also have worked to obtain input from tribal  representatives through an advisory board and consultation sessions. At a  broader policy level, CMS and IHS have worked together on policy  initiatives aimed at ensuring that existing health care policies meet the  needs of IHS-funded facilities and the populations they serve. CMS’s  regulatory process—the process through which CMS issues regulations— can necessitate the review of approximately 140 major rule-making  documents on a yearly basis. Thus, it has provided an important, but  challenging, opportunity for CMS and IHS to identify regulatory changes  that may affect American Indians’ and Alaska Natives’ eligibility for  Medicare and Medicaid or these programs’ reimbursements to IHS-funded  facilities.
subsections: section_title: CMS and IHS Have Interacted to Provide Education and Assistance as Well as to Obtain Input from Tribal Representatives
paragraphs: CMS and IHS have interacted to educate IHS-funded facility staff and  American Indians and Alaska Natives about the Medicare and Medicaid  programs. The following are examples of such activities:    CMS and IHS have interacted to train staff from IHS-funded facilities on  Medicare and Medicaid program topics. For example, in August 2007, the  two agencies held a training session in the Aberdeen IHS area titled  “Working Together – CMS, Tribes and the Aberdeen Area.” The session  included presentations by both CMS and IHS officials on strategies to  increase Medicare and Medicaid enrollment, changes to contract health  service payments, and other topics.
In 2007, CMS, IHS, and tribal officials coordinated tribal stops on the  Medicare prevention tour, a nationwide CMS outreach effort that involved  a bus traveling to different venues to encourage Medicare beneficiaries to  utilize the preventive services covered by Medicare, such as cancer and  diabetes screenings. Through CMS’s coordination with IHS and tribes, the  CMS Medicare prevention bus visited approximately 15 tribal locations  across five different CMS regions.
CMS has also educated IHS staff about Medicare Part D. For example,  CMS has held multiple training sessions in each of the 12 IHS areas to  educate IHS-funded facility staff about the Medicare Part D program and  encourage American Indians and Alaska Natives to enroll in the program.
Additionally CMS and IHS interactions have included assistance intended  to maximize IHS-funded facilities’ collection of Medicare and Medicaid  reimbursement. Many of these activities have included helping facilities  become providers for Medicare and Medicaid, as well as assisting with  billing and other concerns. Examples include the following:    CMS has assisted IHS-funded facilities in becoming Medicare and  Medicaid providers, which is necessary to bill these programs. IHS  officials from the Bemidji area told us that CMS officials provided  instructions to IHS-funded facilities on how to sign up to participate in  Medicare and Medicaid. Additionally, in 2007, CMS helped an IHS-operated  health center and its satellite clinics to qualify as provider-based facilities,  which would allow the facilities to bill Medicare Part A and potentially  increase their Medicare reimbursement.
CMS has provided technical assistance to IHS to resolve billing concerns.
For example, CMS and IHS officials corrected a problem with the IHS  electronic billing system that according to CMS officials, had resulted in  some IHS-funded facilities being underpaid for certain Medicare services.
A CMS official helped IHS-funded facilities navigate the CMS survey  process, a process through which facilities are inspected for compliance  with federal quality standards.
Finally, CMS and IHS have interacted to ensure that they obtain input from  tribal representatives. For example, CMS and IHS have interacted through  CMS’s TTAG, an advisory board created to inform CMS about issues  affecting the delivery of health care to American Indians and Alaska  Natives served by CMS programs. Specifically, the IHS area offices helped  identify and appoint tribal representatives to serve on the TTAG.  Additionally, both CMS and IHS officials have attended TTAG meetings  and participated in TTAG subcommittees, which focus on specific  Medicare- or Medicaid-related issues. CMS and IHS officials also have  interacted through annual HHS regional tribal consultation sessions, held  in each region as part of HHS’s implementation of its tribal consultation  policy. In addition to participating in the consultation sessions, CMS and  IHS officials may work together to plan the sessions. For example, in the  Chicago region, CMS regional and IHS Bemidji area officials served on the  planning committee that organized the consultation session.
section_title: CMS and IHS Have Interacted about Specific Policies, but Have Had Mixed Success Identifying CMS Regulations Warranting IHS Review
paragraphs: With regard to specific policy issues, CMS and IHS have interacted on  issues related to Medicare Parts B and D; they also jointly issued  regulations to limit the amount that IHS-funded facilities must pay  hospitals for contract health services, as shown in the following examples.
Medicare Part B: CMS and IHS have been determining which American  Indians and Alaska Natives are eligible for an exemption from financial  penalties incurred for late enrollment into Medicare Part B. This  exemption, referred to as equitable relief, is granted to individuals who did  not initially enroll because of erroneous information provided by a  government agency. In this case, IHS, while operating under specific  interagency agreements with CMS, told some individuals not to enroll in  Medicare Part B because, at the time, IHS was unable to bill Medicare   Part B.
Medicare Part D: During the implementation of Medicare Part D, CMS  and IHS worked to ensure that IHS-funded facilities would be able to bill  and receive reimbursement from prescription drug plans. This required  special provisions to enable tribally operated facilities to enter into  contracts with prescription drug plans, while retaining tribal sovereignty.
Contract health services: In 2007, CMS and IHS jointly issued a  regulation requiring hospitals that receive Medicare funds to accept rates  based on Medicare as full payment for contract health services provided to  eligible American Indians and Alaska Natives. Termed Medicare-like  rates, this regulation prevents hospitals from accepting fees from IHS- funded facilities in excess of what Medicare would pay.
With regard to regulations, CMS and IHS have had mixed success  identifying CMS regulatory changes that have the potential to affect IHS- funded facilities and their populations and thus warrant IHS review. IHS  officials reported reviewing and commenting on CMS regulations  addressing Medicare payment issues, Medicaid managed care, and  Medicare Part D, noting that CMS made changes to these regulations in  response to their comments. For example, IHS informed CMS that  regulations implementing a new payment methodology for reimbursing  outpatient facilities under Medicare would adversely affect IHS-funded  facilities because a number of facilities would have to hire new staff to  implement the payment system. As a result of this interaction, CMS  exempted IHS-funded facilities from the new payment methodology. In  contrast, IHS officials also reported three examples where they did not  have an opportunity to review CMS regulations prior to the public  comment period. One regulation had the potential to affect Medicaid  prescription drug reimbursement for IHS-funded facilities, while the other  two regulations had the potential to affect Medicaid enrollment for  American Indians and Alaska Natives by requiring documentation of U.S.  citizenship and affected tribes’ access to federal funds that could be used  for Medicaid outreach.
Multiple opportunities exist for CMS and HHS to identify regulations that  are important for IHS to review (see fig. 2). However, identifying such  regulations can be challenging, as shown below.
CMS: The Tribal Affairs Group has an opportunity to review all draft  proposed regulations and notify IHS about regulations it determines are  relevant to the agency. However, Tribal Affairs Group officials explained  that the large number of regulations (approximately 140 regulatory  documents a year), coupled with the size of their staff, means that they  have difficulty doing more than a cursory review of the regulations.
HHS: Responsible for sending proposed regulations to affected agencies,  HHS staff use their judgment to determine which HHS agencies should be  provided regulations for review. However, the HHS staff making the  determination may not have expertise on IHS and thus might not foresee  the potential effect a regulation could have on American Indians’ and  Alaska Natives’ eligibility for Medicare and Medicaid or these programs’  reimbursements to IHS-funded facilities. HHS officials told us that they  make these determinations by reviewing regulations and looking for key  legislative terms, such as “Indian,” to determine which agencies should be  involved in the review. However, it is not clear that the HHS staff  consistently used certain key terms, as the three proposed regulations that  IHS reported not having the opportunity to review each contained the  word “Indian.”
If regulations are not identified by CMS or HHS, then IHS may identify  proposed CMS regulations that could affect its facilities or service  population by reviewing quarterly CMS updates listing regulations and  major policy changes under development. IHS may also review the Unified  Agenda of Federal Regulatory and Deregulatory Actions, a semiannual  listing of the regulatory actions that federal agencies—including CMS—are  developing or have recently completed.
Recognizing the difficulties associated with identifying a regulation that  could affect IHS and the tribes, CMS has been working to develop and  implement additional procedures aimed at improving these efforts. In  particular, the CMS Tribal Affairs Group has been working to obtain  information from IHS to compile a profile of the types of providers  available in tribal locations, which would assist CMS in determining the  regulations that could have tribal implications. Additionally, CMS staff  with responsibility for overseeing the regulations process have begun  asking the staff who draft a regulation whether it affects tribes. If a  potential tribal effect is identified, then CMS will indicate, on a cover sheet  transmitting the regulation to HHS, that IHS should be provided the  regulation for review.
section_title: CMS Has Used Two Key Mechanisms to Interact, and the Annual HHS Regional Sessions to Consult, with Indian Tribes
paragraphs: CMS has used two key mechanisms—tribal liaisons and an advisory  board—to interact with Indian tribes and has relied primarily on the  annual HHS regional consultation sessions as its mechanism for  consultation. CMS tribal liaisons have provided assistance and obtained  input from tribes through activities such as participating in conferences  and training sessions, visiting Indian reservations, and providing technical  assistance and written guidance. The composition, meeting schedule, and  organizational structure of CMS’s tribal advisory board—the TTAG—also  has provided an opportunity for CMS to obtain input from tribal  representatives. With regard to consultation activities, CMS has relied on  annual HHS regional consultation sessions as the primary mechanism to  ensure input from tribal officials in the development of regulatory policies,  although CMS officials noted that they have also held consultation  meetings with individual tribes. However, consulting with over 560 tribes  is an inherently difficult process, primarily because of complexities such  as considering the needs and priorities of individual tribes. Tribal  representatives’ opinions on the effectiveness of CMS’s consultation with  Indian tribes and the agency officials involved varied considerably.
subsections: section_title: CMS Has Used Tribal Liaisons and an Advisory Board as Its Mechanisms to Interact with Indian Tribes
paragraphs: CMS has used two key mechanisms to interact with representatives from  Indian tribes, namely (1) tribal liaisons, who generally serve as tribal  representatives’ points of contact within CMS and provide assistance with  Medicare and Medicaid, and (2) an advisory board, which provides input  to CMS about issues affecting the delivery of health care to American  Indians and Alaska Natives.
subsections: section_title: Tribal Liaisons
paragraphs: CMS tribal liaisons are located in both CMS central and regional offices. In  its central office, the CMS Tribal Affairs Group had four staff who served  as the points of contact for tribal-related issues; these staff provided  assistance to tribes and tribal representatives and coordinated issues  within CMS. Formed in November 2006, the Tribal Affairs Group has  served many functions, including (1) serving as an internal resource for  CMS staff, educating staff about the needs and priorities of American  Indians and Alaska Natives; (2) coordinating the creation of informational  materials on CMS programs, such as Medicare and Medicaid, for tribal  communities; and (3) representing CMS in communications with Indian  tribes and tribal representatives. In addition, the Tribal Affairs Group has  served as an advisor to the CMS Administrator, reporting directly to his  office and briefing him or his deputy approximately eight times per year  about issues raised by tribal representatives.
In addition to the CMS Tribal Affairs Group, each CMS regional office has  had a designated official, the NAC, who serves as a liaison between the  agency and Indian tribes in the region. Key roles of the NAC have  included providing training about CMS programs to Indian tribes in the  region; helping address tribal concerns, including assisting tribes and IHS- funded facilities in solving problems and obtaining answers to questions  that arose; and serving as a CMS information source on American Indians  and Alaska Natives. Except for two regions, the NAC role was a part-time  responsibility, with the percentage of time spent on NAC-related duties  ranging from 20 to 50 percent. In the remaining regions—Denver and  Seattle—the NAC positions are full-time because these staff have  additional responsibilities as the lead NACs who coordinate activities  across all CMS regions and because there are a significant number of  tribes within these two regions. The NAC officials have coordinated their  efforts with the CMS central office through monthly conference calls with  the Tribal Affairs Group.
The CMS Tribal Affairs Group and NACs have interacted, or coordinated  other CMS staff’s interactions, with tribal representatives using several  methods, including participating in conferences and training sessions,  visiting Indian reservations, and providing technical assistance and written  guidance to Indian tribes (see table 1).
Tribal representatives with whom we spoke had varying opinions on the  effectiveness of the CMS tribal liaisons. For example, a few tribal  representatives we spoke with praised the efforts of the CMS Tribal Affairs  Group staff; one representative noted that the Tribal Affairs Group is a  critical link between Indian tribes and CMS, while other representatives  noted the group’s responsiveness to tribal concerns. Additionally, some  tribal representatives mentioned specific interactions with the NAC, such  as the NAC’s working with the tribe to resolve issues with the state  Medicaid program. However, some tribal representatives raised concerns  about the liaisons’ lack of decision-making authority.
section_title: Advisory Board
paragraphs: In addition to liaisons, CMS has received input from tribal representatives  through an advisory board. Specifically, in 2003, CMS created an advisory  board, the TTAG, to provide it with expertise on policies, guidelines, and  programmatic issues affecting the delivery of health care for American  Indians and Alaska Natives served by Medicare, Medicaid, or other health  care programs funded by CMS. Interactions between CMS officials and the  TTAG are meant to complement, but not replace, consultation between  CMS and Indian tribes. The TTAG was created to increase understanding  between CMS and Indian tribes.
The TTAG has been an important vehicle for CMS to obtain input from  tribal representatives. (See table 2 for a description of the TTAG.) The  agenda for TTAG meetings has been formulated jointly by tribal  representatives and CMS officials, allowing for both CMS and tribal  priorities to be discussed. The TTAG’s composition, schedule, and  structure have provided an opportunity for CMS to obtain input from tribal  members. For example:    The TTAG has members from each IHS area and TTAG members gather  information and views about CMS policies from tribes nationwide.  Specifically, seven of the eight TTAG area representatives we spoke with  indicated that they solicited information and obtained input from regular  meetings with tribes in their area, often through the area health board or  its equivalent. Similarly, the TTAG representatives from two of the three  Washington, D.C.–based tribal associations indicated that they received  input from regular meetings with the membership or from the board of  their associations.
The TTAG generally has met monthly, which provides an opportunity for  tribal representatives and CMS to discuss issues as they arise. For  example, in February 2007, TTAG members were able to have a timely  discussion with CMS about tribal representatives’ concerns that a  proposed regulation would prevent tribes and tribal organizations from  collecting federal matching funds for Medicaid-related administrative  activities, such as outreach. As a result of tribal representatives’ concerns,  the regulation was revised prior to issuance.
The TTAG’s subcommittee structure has allowed tribal representatives  and CMS officials to conduct in-depth analysis, work, and dialogue on  Medicare and Medicaid topics that are a priority for CMS, American  Indians and Alaska Natives, or both. Subcommittees have focused on  topics such as the availability of CMS data on Medicare and Medicaid  enrollment and service use among American Indians and Alaska Natives,  outreach and education, and long-term care.
The TTAG and CMS have worked together on a number of issues. For  example, the TTAG worked with CMS and IHS officials to develop a  strategy to (1) educate Indian tribes and their members about the  Medicare Part D benefit and (2) assist IHS-funded facilities in contracting  with the program’s prescription drug plans. Additionally, the TTAG  created a strategic plan to outline a path for CMS to take over a 5-year  period to resolve high-priority issues related to health care for American  Indians and Alaska Natives.
section_title: CMS Efforts to Consult with Indian Tribes Have Relied Primarily on HHS Annual Regional Consultation Sessions
paragraphs: CMS has used the annual HHS regional consultation sessions as its main  mechanism to consult with the 562 federally recognized Indian tribes; CMS  is required by Executive Order and HHS policy to consult with Indian  tribes about policies that have tribal implications. HHS designed the  regional consultation sessions to (1) solicit Indian tribes’ priorities and  needs on health and human services programs and (2) provide an  opportunity for tribes to articulate their comments and concerns on health  and human services policy matters related to CMS and HHS. However,  consulting with so many tribes is an inherently difficult task, in part  because of the variation in the size, location, and economic status of the  Indian tribes. Differences in the priorities of tribal participants may also  make it difficult to have discussions that are meaningful for all  participants.
The HHS regional consultation sessions have offered limited time for  consultation and discussion, as the sessions have generally occurred in the  spring and lasted 1 to 2 days. Specifically, a review of a sample of eight  consultation session agendas found that the time devoted to discussion of  CMS-related issues ranged from less than 30 to 90 minutes. Additionally,  since the consultation sessions only occurred once a year, they may not  allow for meaningful discussions in a timely manner, as CMS makes policy  changes throughout the year.
While the consultation sessions have been open to all tribes, the number of  tribes that have participated is relatively small. According to HHS,  representatives from 100 tribes attended a 2006 HHS regional consultation  session and representatives from 152 tribes attended a 2007 session; this  equates to approximately 18 percent and 27 percent of federally  recognized tribes, respectively. Several HHS officials noted that tribal  attendance at the consultation sessions has varied, depending on the  location of the session, which generally differed each year. Additionally,  tribal participation in the sessions may be hindered by the amount of  notice provided regarding the date of the sessions. The amount of notice  tribes were given about the date of the regional consultation session  ranged from 3 to 8 weeks across the four HHS regions we reviewed.
In addition to the CMS-related discussions at the HHS consultation  sessions, CMS officials have held consultation meetings with individual  tribes or smaller groups of tribes. For example, CMS has consulted with  the Navajo Nation about Medicaid issues the tribe has faced since its  reservation is located across three states. Additionally, in January 2008,  CMS officials traveled to Washington State to consult with the state’s  Medicaid program and Indian tribes about a proposed amendment to  Washington State’s Medicaid program that would stipulate how tribes in  Washington state can receive federal reimbursement for Medicaid  administrative activities.
Tribal representatives had varying opinions on the effectiveness of the  CMS and HHS consultations, including varying perspectives on the agency  officials involved and the format of the consultation sessions. One tribal  representative commented that leaders in CMS attend the meetings and  are willing to share information, while another tribal representative  commented that the officials who attend the sessions are not able to make  decisions. Additionally, a third tribal representative explained that high- level officials who can make decisions attend the consultation sessions,  but that these officials do not have the necessary information to answer  questions. This variation may be due, at least in part, to regional  differences in participation. Regarding the format of the consultation  sessions, one tribal representative commented that the regional  consultation sessions were fairly effective at identifying the issues that  should be raised at the national level. However, a few tribal  representatives commented that the HHS regional consultation sessions  were too short and thus did not allow for meaningful tribal input or  dialogue.
section_title: Selected States’ Medicaid Programs Have Used Multiple Mechanisms to Interact and Consult with Tribes
paragraphs: The six state Medicaid programs we reviewed have used at least one of the  following three mechanisms to interact and consult with Indian tribes:  tribal liaisons, advisory boards, and regularly scheduled meetings. Most of  the states also reported having policies in place that provided a  mechanism to govern their interactions, including consultations, with the  Indian tribes. Most of the state Medicaid programs reviewed reported  consulting with Indian tribes about changes to their Medicaid program.  Tribal representatives’ opinions on state Medicaid program’s consultation  practices varied.
subsections: section_title: Medicaid Programs Have Used Mechanisms, Such as Tribal Liaisons, and State Policies to Interact and Consult with Indian Tribes
paragraphs: The six state Medicaid programs we reviewed have used at least one of  three mechanisms to interact and consult with Indian tribes: (1) tribal  liaisons—who serve as the tribes’ primary contact with the states on  issues related to Medicaid; (2) advisory boards—which, among other  things, inform the state about Medicaid issues affecting American Indians  and Alaska Natives; and (3) other regularly scheduled meetings—which  states and tribes used to discuss Medicaid issues and identify  opportunities for collaboration, technical assistance, and consultation.  Additionally, five of the six states we reviewed had policies in place that  provided a mechanism to govern interactions, including consultations,  between the state Medicaid program and Indian tribes.
subsections: section_title: Tribal Liaisons
paragraphs: All six state Medicaid programs have used at least one designated tribal  liaison in their interactions, including consultations, with tribes about  issues related to Medicaid. In addition to serving as a communication and  coordination link between tribes and state Medicaid programs, some state  tribal liaisons also have provided input on state Medicaid policies affecting  American Indians and Alaska Natives and training and technical assistance  to tribes on Medicaid (see table 3). Additionally, tribal liaisons have been  involved in consultations with Indian tribes. For example, one of New  Mexico tribal liaisons oversees the Medicaid program’s consultations with  Indian tribes, while a Wisconsin tribal liaison helps to coordinate an  annual tribal consultation session.
Tribal representatives we spoke with had varying opinions on the effect  tribal liaisons have had on interactions between the tribes and state  Medicaid programs. For example, representatives from a Montana tribe  reported that interactions with the state Medicaid program’s tribal liaison  resulted in changes to the state’s Medicaid application. Specifically, after  the tribe explained to the tribal liaison that the length of the application  was a barrier to American Indians and Alaska Natives enrolling in  Medicaid, the state simplified its Medicaid application. Additionally,  individuals representing selected tribes in Arizona told us that the  establishment of a tribal liaison position in that state’s Medicaid program  has improved tribes’ ability to provide input on health policy issues and  resulted in progress regarding those issues. In contrast, representatives  from a Minnesota tribe noted that working with the state is difficult even  though there is a tribal liaison. Similarly, while officials from a Southwest  tribe noted the importance of tribal liaisons, they also expressed concern  that tribal liaisons are sometimes kept out of decision making.
section_title: Advisory Boards
paragraphs: Three of the six state Medicaid programs—Arizona, New Mexico, and  Utah—reported using advisory boards to interact, and in some cases  consult, with Indian tribes. For example, Utah has utilized an advisory  board to determine if proposed state Medicaid policy or program changes  have tribal implications and thus require additional consultation with the  advisory board or other tribal representatives.
The Medicaid programs described using two types of advisory boards to  interact with the Indian tribes: (1) Indian advisory boards, which address a  broad array of issues affecting the provision of health care to American  Indians and Alaska Natives, and (2) Medicaid advisory boards, which  address issues affecting all Medicaid beneficiaries, including American  Indians and Alaska Natives. Specifically, one state Medicaid program  (Arizona) reported using Indian advisory boards; one program (New  Mexico) reported using its Medicaid advisory board, which includes tribal  representation; and one program (Utah) reported using both.
While both types of advisory boards are mechanisms for interactions  between the state and tribal representatives, the composition of the  advisory boards varied. Specifically, the Indian advisory boards included  numerous tribal representatives, while there were fewer tribal  representatives on the Medicaid advisory boards. For example, the Utah  Indian advisory board, which meets monthly, includes appointed  representatives from all of the Utah tribes as well as the state’s tribal  liaison, other state and tribal officials, and IHS staff. In comparison, Utah’s  Medicaid advisory board has one individual to represent the seven tribes  in the state. New Mexico’s Medicaid advisory board has two tribal  representatives who may also serve on a subcommittee on tribal issues.
section_title: Meetings
paragraphs: Four of the six state Medicaid programs (Arizona, Minnesota, New  Mexico, and Wisconsin) reported holding regularly scheduled meetings to  interact, and in some cases consult, with Indian tribes. The frequency of  these meetings ranged from bimonthly to annually, and states reported  discussing issues such as the Medicaid budget and reimbursement. For  example, New Mexico officials reported holding an annual meeting to  consult with tribal representatives about pertinent Medicaid policy and  program changes and the Medicaid program’s budget prior to the state  legislative session. A Wisconsin official reported that the state’s bimonthly  meetings with tribal health directors focus on specific issues, such as  increasing Medicaid reimbursements for tribally operated facilities and  accessing federal matching funds for tribal Medicaid expenditures.
Tribal representatives’ assessments of the value of the regularly scheduled  meetings with the states varied. For example, representatives from one  tribe, which participates in quarterly meetings with officials who oversee  Minnesota’s Medicaid program, said that the meetings were successful in  helping address tribal needs. However, representatives from two  Wisconsin tribes noted that the number of tribes involved and the brevity  of the annual meetings with the state made discussing specific issues  difficult. Tribes also reported that location was a factor that contributed to  the success of these meetings. Specifically, representatives from  Wisconsin and Minnesota tribes indicated that holding meetings in  convenient locations affects tribal participation and increased the  meetings’ effectiveness, respectively.
section_title: Policies
paragraphs: Five of the six states we reviewed—Arizona, Minnesota, New Mexico,  Wisconsin, and Utah—reported having policies in place that govern the  interactions, and in most cases consultations, between their states’  Medicaid programs and Indian tribes. The states had two types of policies  governing interactions with Indian tribes: (1) governor’s orders, which  specify that all state agencies should interact with Indian tribes on a  government-to-government basis and provide for consultation between the  state and Indian tribes, and (2) tribal consultation policies, which establish  guidelines that state agencies, including Medicaid agencies, should use to  consult with Indian tribes. Specifically, one state (Minnesota) reported  having a governor’s order, two states (Utah and Wisconsin) reported  having tribal consultation policies, and two states (Arizona and New  Mexico) reported having both. The four states’ tribal consultation  policies established guidelines with varying degrees of specificity for how  consultation between the Medicaid agency and Indian tribes should be  conducted. Table 4 provides an overview of the guidelines in the four  states’ consultation policies.
section_title: Most States Reviewed Reported Consulting with Indian Tribes about Medicaid Changes
paragraphs: Most of the state Medicaid programs we reviewed reported consulting  with Indian tribes in their state when making changes to their Medicaid  programs. Specifically, four states (Minnesota, New Mexico, Utah, and  Wisconsin) reported consulting with Indian tribes on any Medicaid  program changes that they believed affected Indian tribes, and one state  (Montana) reported consulting only on Medicaid program changes that  required a waiver. The remaining state—Arizona—reported that it has not  consulted with Indian tribes about Medicaid program changes. States  used a variety of mechanisms to consult with Indian tribes, such as  regularly scheduled quarterly meetings with tribal health directors and  advisory boards.
The states reported consulting with Indian tribes about a variety of topics.  For example, New Mexico officials reported an extensive consultation  process with tribes about a new Medicaid program for coordinated long- term services. These consultations resulted in changes to the program,  including requiring the program’s managed care plans to have tribal  liaisons. Additionally, Minnesota noted that it consulted with Indian tribes  about changing the process by which Medicaid eligibility determinations  are made for children in foster care and adoption assistance programs.
Tribal representatives’ opinions on state Medicaid program’s consultation  practices varied. For example, representatives from one Wisconsin tribe  noted that consultation was not hurtful but was also not helpful. They  explained that consultation provides opportunities to interact directly with  agency officials and voice concerns but does not necessarily lead to  changes in agency processes. In contrast, representatives from a  Minnesota tribe provided examples of specific actions the Medicaid  program took as a result of consultation. A representative from a  Minnesota tribe noted that consultation was effective when there was a  personal relationship with state officials. However, representatives from  several tribes in Montana reported that consultation did not occur. For  example, representatives from one Montana tribe noted that rather than  consulting with tribes about changes to the Medicaid program, the state  informed tribes after changes had already been made.
section_title: American Indians and Alaska Natives Have Faced Several Barriers to Medicare and Medicaid Enrollment Despite Efforts to Assist with the Application Process
paragraphs: American Indians and Alaska Natives have faced several barriers to  Medicare and Medicaid enrollment despite efforts to provide assistance  with the application process. While two of the barriers to Medicare and  Medicaid enrollment are associated with the unique status of the tribal  community, most of the enrollment barriers faced by American Indians  and Alaska Natives are similar to those experienced by other  populations—such as individuals with low incomes. Efforts to enroll  American Indians and Alaska Natives have focused on providing  assistance with the Medicaid and Medicare application processes. For  example, almost all of the IHS-funded facilities we visited had staff who  help patients complete and submit Medicare and Medicaid applications.  Many organizations, including CMS and IHS, have conducted outreach to  educate American Indians and Alaska Natives about the programs.
subsections: section_title: American Indians and Alaska Natives Have Faced Barriers Enrolling in Medicare and Medicaid
paragraphs: American Indians and Alaska Natives have faced barriers to Medicare and  Medicaid enrollment (see table 5). Two of the barriers are unique to the  tribal community. First, some officials we spoke with reported that some  American Indians and Alaska Natives believe they should not have to  apply for Medicare or Medicaid because the federal government has a duty  to provide them with health care as a result of treaties with Indian tribes.  Second, American Indians and Alaska Natives may not see a personal  benefit to enrolling in Medicare or Medicaid because they have access to  free health care at IHS-funded facilities regardless of whether they enroll.
Other barriers were similar to those faced by other populations. For  example, similar to low-income populations, American Indians and Alaska  Natives have experienced transportation and financial barriers, as well as  barriers related to limits on access to communication devices, such as  telephones and regular mail delivery. While similar to the barriers faced by  other populations, some officials believed that there are some distinct  aspects to the barriers faced by American Indians and Alaska Natives. For  example, application processes, such as the Medicaid requirement to  provide documentation of U.S. citizenship, may be especially difficult for  American Indians and Alaska Natives as this population was traditionally  not born in a hospital. As a result, some officials reported that some  American Indians and Alaska Natives, particularly those who are elderly,  do not have an official record of their birth.
section_title: Enrollment Efforts Have Focused on Assisting American Indians and Alaska Natives with Applying for Medicare and Medicaid
paragraphs: Efforts to enroll eligible American Indians and Alaska Natives in Medicare  and Medicaid generally have focused on providing assistance with the  application process. Specifically, almost all of the IHS-funded facilities we  visited offered patients assistance with applying for Medicare and  Medicaid. The assistance included helping complete and submit  applications, collecting and possibly certifying required documentation,  translating application information into tribal languages, and offering  these services through home visits. Facility staff generally identified  patients needing application assistance through their patient registration  process, which is the process through which patients sign in for their  medical appointments. For example, facility registration staff used  information about a patient’s age, employment status, and existence of  health insurance to determine whether the patient might qualify for  Medicare or Medicaid and thus should be referred to a patient benefit  coordinator for assistance (see fig. 3). In addition to the patient  registration process, some facilities also generated reports listing  individuals who were potentially eligible for, but not enrolled in, Medicare  or Medicaid. For example, one facility indicated that it generated monthly  reports of (1) individuals aged 65 and older who did not have Medicare  and (2) individuals aged 19 or younger without health insurance and thus  potentially eligible for Medicaid. This same facility also generated reports  of individuals who were age 64 to alert patient benefit coordinators that  these individuals may soon be eligible for Medicare.
Facilities we visited used staff—referred to as patient benefit  coordinators—to provide Medicare and Medicaid application assistance.  Among the facilities offering assistance, the number of patient benefit  coordinator positions ranged from one to eight; hospitals generally had a  higher number of patient benefit coordinator positions.
American Indians and Alaska Natives may also receive application  assistance directly from Medicaid or Medicare eligibility staff. State or  county Medicaid eligibility staff worked at or traveled to four of the IHS- funded facilities we visited to provide application assistance and conduct  on-site eligibility determinations; these eligibility staff were located at two  of the facilities full-time, that is, 5 days a week. State or county Medicaid  eligibility staff were also located at, or traveled to, tribal offices on three of  the reservations we visited. Specifically, one of the reservations had a  satellite Medicaid eligibility office, which was open 5 days a week and  housed several county Medicaid eligibility staff. The second reservation  had a staff member on-site 5 days a week, while a staff member was  available on the third reservation 2 days a week. Additionally, a few of the  tribes we visited had the authority to determine Medicaid eligibility for at  least some tribal members and therefore had additional Medicaid  application assistance available at the tribal office where eligibility  determinations occurred. Finally, staff from SSA, the federal agency  responsible for Medicare enrollment, provided Medicare application  assistance at some IHS-funded facilities. Specifically, staff from two of the  IHS-funded facilities we visited indicated that SSA office staff visited their  facilities at least monthly, while staff from a third IHS-funded facility  indicated that SSA staff came to a building nearby at least monthly.
Many organizations, including CMS and IHS, have conducted outreach to  educate the tribal community about Medicare and Medicaid and encourage  those in the community to apply. For example, beginning in May 2005,  there was a concerted effort by CMS, IHS, and SSA to educate and enroll  American Indians and Alaska Natives in the Medicare Part D prescription  drug benefit, including training for patient benefit coordinators in each  IHS area and informational materials, such as posters and fact sheets,  targeted to the tribal community. In 2007, CMS and the TTAG released an  outreach video, to be used at IHS-funded facilities, which emphasizes the  community benefit to enrollment in Medicare and Medicaid. Additionally,  in 2007, IHS published a poster and brochure to educate American Indians  and Alaska Natives about existing federal and state health benefit  programs, such as Medicare and Medicaid. Other outreach efforts  targeted to the tribal community included radio advertisements, which a  few of the state Medicaid programs we reviewed reported using, and  newspaper or newsletter articles, which some IHS-funded facilities  reported using. Finally, several of the IHS-funded facilities we visited  provide information about Medicare and Medicaid at facility-based or  community health fairs and events at schools, senior centers, or other  community venues.
section_title: Agency and State Comments and Our Evaluation
paragraphs: We provided copies of a draft of this report to HHS and provided the six  states we reviewed (Arizona, Minnesota, Montana, New Mexico, Utah, and  Wisconsin) with copies of the portion of the report related to state  Medicaid programs’ mechanisms for interacting and consulting with  Indian tribes. HHS provided us with written comments from CMS (see   app. III). We also received technical comments from CMS and three of the  six states (Arizona, Montana, and New Mexico), which we incorporated as  appropriate.
In written comments, CMS noted that it was pleased that our findings  highlight a number of activities that CMS engages in with IHS and  commented that the report reinforces the benefit of the multiple processes  CMS has put in place in working with IHS and the tribes. CMS  acknowledged that it is working to improve its process for identifying  whether proposed regulatory changes would affect IHS-funded facilities  and the populations they serve. CMS noted that its regulations also affect  programs directly operated by tribes, which have broader authority than  IHS in operating programs and facilities such as nursing homes. We agree  with CMS about the potential impact of its regulations on tribally operated  programs and facilities, and we encourage the agency to consult with  tribes when developing its regulations as required by Executive Order and  HHS’s tribal consultation policy.
As agreed with your offices, unless you publicly announce the contents  earlier, we plan no further distribution of this report until 30 days after its  issue date. At that time, we will send copies of this report to the  Administrator of the Centers for Medicare & Medicaid Services and the  Director of the Indian Health Service. We will also provide copies to others  upon request. In addition, the report will be available at no charge on the  GAO Web site at http://www.gao.gov.
If you or your staffs have any questions about this report, please contact  me at (202) 512-7114 or kingk@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. GAO staff who made major contributions to this report are  listed in appendix IV.
section_title: Appendix I: Locations of Indian Health Service (IHS) Areas and Centers for Medicare & Medicaid Services (CMS) Regions
section_title: Appendix II: Methodology for Selecting IHS Areas, Facilities, and Tribes Visited
paragraphs: We used a two-tiered approach to selecting facilities and tribes for site  visits, which included selecting 3 of the 12 IHS areas and then selecting  facilities and tribes within those 3 areas. Based on this approach, we  interviewed officials from 25 IHS-funded facilities and leaders (or  designated officials) from 14 tribes.
In the first tier, we selected three IHS areas to represent a mix in  geographic location, the entities operating the facilities (IHS or tribes),  and the level of reliance on contract health services. Table 6 shows the  characteristics of the areas selected.
In the second tier, we selected facilities within the three IHS areas. When  selecting facilities, we considered recommendations from CMS and IHS  officials and tribal representatives, the type of facility (for example,  hospital or health center), and whether it was IHS or tribally operated. We  also used pragmatic considerations, such as distance between facilities, to  guide our selections. See table 7 for the characteristics of the 25 facilities  in which we interviewed officials. For each facility visited, we requested  interviews with the leaders of the tribe primarily served by the facility. We  were able to interview leaders or designated officials from 14 tribes—7  from the Bemidji area, 5 from the Billings area, and 2 from the Navajo  area. Because of the judgmental nature of our sample, information  obtained from the facilities and tribal leaders cannot be generalized.
section_title: Appendix III: Comments from the Department of Health and Human Services
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the contact named above, Carolyn Yocom, Assistant  Director; Krister Friday; Elayne Heisler; Kevin Milne; Michelle Rosenberg;  and Elijah Wood made key contributions to this report.