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

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

A: American Indians and Alaska Natives (AI/AN) benefit from the Affordable Care Act’s expanded coverage. In fact, 94 percent of American Indians/Alaska Natives have incomes that make them eligible for either Medicaid expansion or exchange subsidies. The bad news is that a significant percentage of their low-income uninsured population lives in states that have not yet expanded Medicaid (of the ten states with the largest Native American populations, four — Oklahoma, Texas, North Carolina, and South Dakota — have not yet expanded Medicaid).

No cost-sharing if income up to 300% FPL: Federal government no longer covers this cost, but insurers must still provide the benefit

Native Americans who apply for coverage in an ACA exchange and who have income below 300 percent of the Federal Poverty Level do not have to pay cost-sharing (deductibles, copays, and coinsurance). 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 be eligible as a Native American, you must be a member of a recognized Indian tribe, band, or nation, according to the Indian Healthcare Improvement Act.

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 percent of the poverty level (That’s $61,260 for a family of three in 2018). 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) for 2018, but most of the rate filings didn’t specifically address Native American cost-sharing benefits. Blue Cross Blue Shield of New Mexico did specifically add the cost of Native American cost-sharing benefits to premiums at all metal levels for 2018, while adding the cost of general CSR only to silver plan premiums. But insurers that didn’t add the cost of Native American CSR to their premiums are simply having to absorb that cost for 2018 (it’s a much smaller cost than general CSR, given the low percentage of exchange enrollees who qualify for Native American cost-sharing elimination).

Year-round enrollment

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. As long as they enroll by the 15th of the month, their coverage will be effective the first of the following month (there are two state-run exchanges — Massachusetts and Rhode Island — where enrollments can be completed as late as the 23rd of the month for coverage effective the first of the following month).

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 CHIP, and some Native American resources and federal payments aren’t counted when determining eligibility for CHIP.
  • Medicaid-eligible Native Americans who are eligible for or receive services from the Indian Health Service (IHS), tribally-run health plans, or urban Indian health programs (collectively known as I/T/U, referring to the overall Indian Health System) do not have to pay Medicaid premiums or enrollment fees. In addition, if they’ve ever used one of the I/T/U programs, they’re exempt from Medicaid cost-sharing (copays, deductibles, etc.). As with CHIP, some Native American resources and federal payments are not counted when determining eligibility for Medicaid.

Improvements to existing services

The ACA also made the 1976 Indian Health Care Improvement Act permanent, which enhances and improves the Indian Health Service. American Indians have access to free health care via IHS, but the services provided by IHS are not all-encompassing – which means that referrals to specialists outside of the program are common, and often not covered.

In addition, many people who qualify for tribal care live far from IHS facilities and are thus realistically uninsured. So even though Native Americans don’t face penalties for not complying with the individual mandate, and even though they can get care through IHS, it’s often beneficial to enroll in coverage through the exchange if they can afford to do so.


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. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.