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American Indians and Alaska Natives – Affordable Care Act and IHS/Contract Health Services

Published: March 19, 2014
  • A person does not lose eligibility for IHS services if they sign up for Medicaid, Medicare, plans purchased on an Exchange or other health coverage and may continue to use their Tribal or IHS clinic if they choose.  An individual using such clinic should inform the clinic that they have insurance so that such clinics can receive payment for services they provide.
  • Current IHS eligibility guidelines do not require individuals to sign up for Medicaid or to enroll in a Marketplace plan in order to be eligible for IHS direct care.  The eligibility guidelines for contract health services (CHS) do require individuals to sign up for alternate resources if they are eligible for them before contract health service funds can be used.  However, CHS does not require people to pay insurance premiums in order to acquire alternate resources.
  • If a person receives services that are not included in the ten Essential Health Benefits (EHBs), they have to pay cost sharing unless CHS issues an authorization to pay for those services.
  • There is a difference between CHS referrals and CHS authorizations.  CHS referrals are required under the ACA so that Indians enrolled in limited cost sharing plans do not have cost sharing if they go to a provider other than IHS, Indian, Tribal, or Urban Indian facility  (I/T/Us).  This referral should not obligate the CHS program to pay for the services that are provided. Under the ACA, a referral does not have to restricted to people who live in the CHS Delivery Area (CHSDA), and referrals can be provided to Indians who live out of state.  CHS authorizations authorize the provider to bill the CHS program as the last payer.  For authorizations, CHS rules apply and typically may only be used by people who live in the CHSDA and may be limited by the CHS budget  and priority system.
  • If a person is an IHS beneficiary, or eligible to be an IHS beneficiary, they qualify for a hardship exemption to the otherwise applicable tax penalty for not having insurance.  To obtain such exemption, an individual must file an application through the Marketplace.
  • Non-Indian women are eligible for IHS services during pregnancy and post-partum care if the father of the child is Indian.  During the time they are eligible for IHS services, they are also eligible for the IHS-beneficiary hardship exemption.  After the post-partum eligibility period, they must notify the Marketplace that their status has changed and the hardship exemption will end.
  • Other non-Indians eligible for the IHS-beneficiary hardship exemption include children, adopted children and foster children living in a household of an Indian.