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How can Native Americans get coverage under the ACA? Are there specific plan options for them?

How can Native Americans get coverage under the ACA? Are there specific plan options for them?

How can Native Americans get coverage under the ACA? Are there specific plan options for them?

American Indians and Alaska Natives (AI/AN) benefit from the Affordable Care Act’s expanded coverage. Most American Indians/Alaska Natives are eligible for either expanded Medicaid or premium tax credits (subsidies) in the Marketplace/exchange.1 Some states still haven’t expanded Medicaid under the ACA, but nine of the ten states with the largest Native American populations2 — all but Texas — have expanded Medicaid.

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

Native Americans 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).

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.”

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 Native American 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. CMS confirmed that funding to cover the elimination of cost-sharing for eligible Native Americans was eliminated along with the rest of the CSR program’s funding.

To be clear, Native Americans are still eligible for $0 cost-sharing if their income doesn’t exceed 300% of the 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 Hawaii4). 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, 53,826 Native Americans and Alaska Natives enrolled in coverage through HealthCare.gov.5 But there are rolling monthly open enrollment periods throughout the year for Native Americans 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/ANs. 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 Native Americans eligible for Medicaid or CHIP

Native Americans 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 Native Americans enrolled in Medicaid or CHIP,6 (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 Native American resources and federal payments3 aren’t counted as income when determining eligibility for Medicaid or CHIP.7

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).3 AI/ANs have access to free health care via IHS, but the services provided by IHS are not all-encompassing. 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.

Footnotes

  1. Health Coverage by Race and Ethnicity, 2010-2022” KFF. January 11, 2024. 
  2. US States With The Largest Native American Populations” World Atlas. Accessed March 1, 2024. 
  3. Health Coverage Options for American Indians and Alaska Natives” Centers for Medicare & Medicaid Services. Accessed March 1, 2024.       
  4. 2023 Poverty Guidelines” US Department of Health & Human Services. Accessed March 1, 2024 
  5. 2023 Marketplace Open Enrollment Period Public Use Files” Centers for Medicare & Medicaid Services. Accessed March 1, 2024. 
  6. Medicaid and Indian Health” Centers for Medicare & Medicaid Services. Accessed March 1, 2024. 
  7. American Indian and Alaska Native Trust Income and MAGI” Centers for Medicare & Medicaid Services. Accessed March 1, 2024. 

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