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. 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. 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. 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. 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. 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. 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. 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.