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American Indians and Alaska Natives - Affordable Care Act Definitional Issues

Published: March 19, 2014
Fact Sheet
  • Definitions of the word Indian in the ACA are not consistent with the definition used for delivery of other federally supported health services to American Indian/Alaska Natives under Medicaid, Child Health Insurance Programs (CHIP), the Indian Health Services (IHS).  This inconsistency affects the ACA’s cost sharing (ACA §1402), special enrollment (ACA §1311), and tax penalty provisions (ACA §1501/Internal Revenue Code §5000A). 
  • Under the ACA, only members of federally recognized tribes and shareholders in Alaska Native regional or village corporations who purchase coverage through a state or federal Marketplaces are eligible to receive special protections and some exemptions from cost sharing. This definition of Indian is narrower than the definition used by IHS, Medicaid and CHIP, leaving out a significant population of American Indians and Alaska Natives that the ACA was intended to benefit and protect.
  • HHS has determined it does not have the administrative authority to align the inconsistent definitions under the ACA and that a legislative fix is necessary.
  • Examples of American Indian/Alaska Natives who are affected by ACA’s inconsistent definitions include California Indians who are entitled to IHS and Medicaid services as Indians but who are not treated as Indian under the ACA as well as Alaska Natives too young to have enrolled in ANCSA corporation because they have not yet become shareholders who are not treated as Indian under the ACA.
  • The definition of Indian used by IHS, Medicaid, and CHIP is found in 42 C.F.R. 447.50 (b) and includes individuals who: (1) are members of a federally recognized Indian tribe who reside in an urban center and meet one of four criteria, (2) are considered by the Secretary of the Interior to be an Indian for any purpose, or (3) are considered by the Secretary of Health and Human Services to be an Indian for purposes of eligibility for IHS services, including as a California Indian, Eskimo, Aleut, or other Alaska Native. 
  • By using the same definition of Indian for all federally funded health programs that rely on the same streamlined application (i.e., Medicaid, CHIP, and state and federal exchanges) and for avoiding ACA tax penalties, all American Indian and Alaska Natives will be treated equally consistent with the trust responsibility as well as improve their access to all available health programs.
  • American Indian and Alaska Native national and regional organizations support the implementation of all Indian-specific ACA provisions using the Medicaid definition at 42 C.F.R. 447.50 (b) for all federally funded health programs. Resolutions to this effect were adopted by the National Congress of American Indians (NCAI), the National Indian Health Board (NIHB), and the Tribal Technical Advisory Group to CMS (TTAG).