How can American Indians and Alaska Natives get coverage under the ACA? Are there specific plan options for them?

No cost-sharing if income is up to 300% FPL

American Indians and Alaska Natives who apply for coverage via HealthCare.gov or a state-run exchange/Marketplace and who have an income of at least 100% and less than 300% of the federal poverty level do not have to pay cost-sharing (deductibles, copays, and coinsurance) on any Marketplace plan (note that in states that have expanded Medicaid, Medicaid is available to households with income up to 138% of the poverty level, so eligibility for subsidized Marketplace plans starts above that level rather than 100% of the poverty level. Note also that the prior year’s federal poverty level numbers are used to determine eligibility for Marketplace premium tax credits and cost-sharing reductions, including AI/AN cost-sharing reductions.

An AI/AN is also exempt from cost sharing for any health services received directly from IHS (Indian Health Service), Indian tribe, tribal organization, urban Indian organization or through the Contract Health Service program (Purchased/Referred Care Program, or PRC).

To qualify, you must be a member of a recognized Indian tribe, band, or nation, according to the Indian Healthcare Improvement Act, or a shareholder in an Alaska Native Claims Settlement Act corporation (ANCSA shareholders).³

Until late 2017, the federal government reimbursed insurers for the cost of providing $0 cost-sharing to eligible AI/AN enrollees. But that was part of the cost-sharing reduction (CSR) program, and CSR funding was cut off by the Trump administration in October 2017.⁴ The Center for Medicare & Medicaid Services (CMS) confirmed that funding to cover the elimination of cost-sharing for eligible AI/AN populations was eliminated along with the rest of the CSR program’s funding.

To be clear, American Indians and Alaska Natives are still eligible for $0 cost-sharing if their income doesn’t exceed 300% of the federal poverty level. (In the lower 48 states, that’s $74,580 for a family of three in 2024. The limits are higher in Alaska and Hawaii.⁵) But the federal government is no longer reimbursing insurers for providing that benefit. Insurers in most states have added the cost of CSR to premiums (typically, Silver-plan premiums) since 2018.

AI/ANs are also eligible for the same premium tax credits (premium subsidies) that are available to other Marketplace enrollees, including the subsidy enhancements under the American Rescue Plan and Inflation Reduction Act.

Year-round enrollment

During the open enrollment period for 2023 health coverage, 66,016 American Indians and Alaska Natives enrolled in coverage through the health insurance Marketplaces nationwide (excluding Idaho and DC, where data were not reported).⁶ But there are rolling monthly open enrollment periods throughout the year for AI/AN individuals who wish to enroll in the exchanges. They are not limited to enrolling during open enrollment, and can switch to a different plan as often as once per month.³

If an AI/AN household includes some members who are not AI/AN, the entire household can enroll in Marketplace coverage, utilizing the ongoing special enrollment period for AI/AN enrollees. But the other household members are not eligible for the zero cost sharing that’s available to AI/ANs with household income up to 300% FPL.³

Extra benefits for American Indians and Alaska Natives eligible for Medicaid or CHIP

American Indians and Alaska Natives who are eligible for Medicaid or CHIP have some special protections under federal law:

• There are no enrollment fees or cost-sharing (copays, deductibles, etc.) for AI/AN enrollees in Medicaid or CHIP,⁷ (The elimination of Medicaid cost-sharing is contingent on the person ever having received care from Indian Health Service, Tribal Health Service, Urban Indian Health Programs, or through a PRC Program.)³
• Some American Indians and Alaska Natives resources and federal payments³ aren’t counted as income when determining eligibility for Medicaid or CHIP.⁸

Improvements to existing services

The ACA also made the 1976 Indian Health Care Improvement Act permanent, which enhances and improves the Indian Health Service (IHS). AI/AN populations have access to free healthcare via IHS, but the services provided by IHS are not all-encompassing or available in all locations.⁹ So it’s not uncommon for people to also need care outside of the IHS system.

In addition, many people who qualify for tribal care live far from IHS facilities, making them an unrealistic option for health care. So even though AI/ANs can get care through IHS, it’s often beneficial to enroll in coverage through the exchange if they can afford to do so. AI/ANs who enroll in Marketplace coverage can continue to receive care from IHS facilities, but they also have access to providers who are in the Marketplace plan’s network.³

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.

1. “Health Coverage by Race and Ethnicity, 2010-2022” KFF. January 11, 2024. ⤶
2. “Native American Population by State, 2024” World Population Review. Accessed March 21, 2024 ⤶
3. “Health Coverage Options for American Indians and Alaska Natives” Centers for Medicare & Medicaid Services. Accessed March 1, 2024. ⤶ ⤶ ⤶ ⤶ ⤶ ⤶
4. “Administration’s Ending Of Cost-Sharing Reduction Payments Likely To Roil Individual Markets” Health Affairs. October 13, 2017. ⤶
5. “2023 Poverty Guidelines” US Department of Health & Human Services. Accessed March 1, 2024 ⤶
6. “2023 Marketplace Open Enrollment Period Public Use Files” (Sum of column BD, Rows 2-52, in the State Level Public Use File) Centers for Medicare & Medicaid Services. Accessed March 1, 2024 ⤶
7. “Medicaid and Indian Health” Centers for Medicare & Medicaid Services. Accessed March 1, 2024. ⤶
8. “American Indian and Alaska Native Trust Income and MAGI” Centers for Medicare & Medicaid Services. Accessed March 1, 2024. ⤶
9. “Frequently Asked Questions” Indian Health Service. Accessed March 21, 2024. ⤶