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COVERED CALIFORNIA FOR
A
MERICAN INDIANS
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• ACA and Federal Trust Responsibility for American Indians
• Definition of “Indian”
• Provisions and Protections for American Indians
o Outreach Considerations
• Enrollment and American Indian Status Verification
• Provisions and Protections for American Indians in Medi-Cal
• MAGI and American Indian Income Exemptions
KEY POINTS
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• The government’s unique legal relationship with
American Indians is based on treaties, laws, and
Supreme Court decisions.
• Indian Health Service offers health care to American
Indians on or near Indian reservations and in some
Urban Indian communities.
• The special provisions for American Indians in the
ACA are part of the federal trust responsibility, and
are intended to protect American Indians and
modernize the Indian health delivery system.
ACA & FEDERAL TRUST RESPONSIBILITY
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• Permanent Reauthorization of the Indian Health
Care Improvement Act.
• Strengthens the Indian Health Service.
• Increases access to new health coverage options
and makes the Indian Health Service the Payer of
Last Resort.
ACA PROVISIONS FOR AMERICAN INDIANS
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The American Indian population in California is unique
and diverse. California has the largest population of
American Indians in the United States and is home to
723,225 American Indians. Translated into direct terms:
one in seven American Indians in the United States lives
in California.
California is also home to 110 Federally recognized
Tribes, over 50 non-Federally recognized Tribes, and
Urban Indian communities.
AMERICAN INDIANS IN CALIFORNIA
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WHAT IS THE DEFINITION OF “INDIAN”?
The definitions of the word “Indian” in the ACA and Covered California
differs from the definition used for delivery of other federally supported
health services to American Indians under Medicaid / Medi-Cal and
CHIP program and through the Indian Health Service (IHS).
Enrollment assistance personnel should know that the inconsistency
may result in confusion because the application for Covered California
and Medi-Cal are integrated and because many individuals may be
deemed as American Indian for one program and not for the other,
resulting in different eligibility outcomes.
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DETERMINING ELIGIBILITY FOR AMERICAN INDIANS
Covered California: American Indian provisions and
protections in Covered California are limited to a member
of a federally recognized Tribe.
Medi-Cal: American Indian provisions and protections in
Medi-Cal are inclusive of any American Indian who has
received (or is eligible to receive) services at a Tribal or
Urban Indian health program.
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FEDERAL HEALTH COVERAGE OPTIONS FOR AMERICAN
I
NDIANS
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NO HEALTH CARE EXPENSE FOR CERTAIN INCOME LEVELS
American Indians, who are members of a federally recognized Tribe, with a household income of less
than $70,650 for a family of four-classified as 300% of the federal poverty level-will not have cost
sharing (co-pays or deductible).
NO HEALTH CARE COSTS FOR MEDICAL CARE PROVIDED BY INDIAN HEALTH PROGRAMS
There is no cost sharing (co-pay or deductible) for American Indians, who are members of a
federally recognized Tribe, for any item or service received from an Indian Health
Program including Tribal and Urban Indian Organizations or through referral under contracted health
services, regardless of household income.
ENTITLED TO MONTHLY ENROLLMENT PERIODS
American Indians, who are members of a federally recognized Tribe, are entitled to enroll in/or
change plans once a month through Covered California. All other taxpayers are subject to the annual
open enrollment period.
NO REQUIREMENT TO HAVE COVERAGE
American Indians, who are members of a federally recognized Tribe, are exempt from the individual
mandate to maintain health care coverage beginning January 1, 2014. Any American Indians, who
have received or who are eligible to receive services through an Indian Health Program, are eligible
to apply for a Hardship Exemption from the individual mandate.
PROVISIONS AND PROTECTIONS FOR AMERICAN INDIANS IN
C
OVERED CALIFORNIA
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Outreach Considerations for No Requirement
to Have Coverage For American Indians
Accessing Exemption from Individual Mandate:
Members of a federally recognized Tribe can access the exemption through the
I.R.S. by applying on their annual tax return.
Any American Indian who has received (or is eligible to receive) services at a Tribal
or Urban Indian health program can apply for a Hardship Waiver through the
Federal Marketplace: www.HealthCare.gov
.
Once an exemption is received, the applicant will not have to pay a penalty for not
having health insurance. This is a lifetime exemption (unless Tribal eligibility status
changes). Further, the exemption does not prevent applicant from enrolling in
Covered California, Medi-Cal or other coverage programs.
OUTREACH CONSIDERATIONS
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PLAN OPTIONS
Plan Tier Non-Indian cost sharing Indian* cost sharing
Platinum 10% 0%
Gold 20% 0%
Silver 30% 0%
Bronze 40% 0%
Higher Premiums
Lower Premiums
Members of a federally recognized tribe: Zero cost sharing for any premium
Pay Premium NO cost sharing
Non-Indians: Lower premium means higher cost sharing
Pay Premium Pay cost sharing
*American Indians who are a member of a federally recognized tribe and who are at/under
300%FPL and/or receive services at an Indian health Program.
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Outreach Considerations for Monthly Enrollment Period
Provisions and Protections For American Indians
OUTREACH CONSIDERATIONS
Members of a federally recognized Tribe do not face the same open enrollment restrictions
as the general population. They have year round open enrollment and can switch health
plans and metal tiers up to once per month.
• Allows for unrestricted navigation between Indian Health Service coverage and
Covered California in order to access care not available at Indian health providers in
California, such as medical specialists and hospital and surgical care.
• Allows for unrestricted navigation between plan and tier levels to access different
premium levels providers networks based on medical need.
Monthly application and enrollment timelines to consider:
For applications received between the 1
st
– 15
th
of the month, enrollment will begin the
following month. For applications received after the 15
th
of the month, enrollment will be
delayed one additional month.
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American Indian Attestation Process in Covered
California Application
ATTESTATION PROCESS
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QUESTIONS THAT ASK AIAN STATUS Attachment A
STATUS QUESTIONS ATTACHMENT A
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QUESTIONS THAT ASK AIAN STATUS Attachment B
STATUS QUESTIONS ATTACHMENT B
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Examples of acceptable documentation:
How Is Federally Recognized Tribal Status
Verified By Covered California?
1. Tribal Identification
Card
3. Certificates of Degree
of Indian Blood (CDIB)
2. BIA Form
STATUS VERIFICATION
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How Is American Indian Status Verified By Covered
California?
Enrollee has 90 days to provide documentation that confirms Tribal enrollment.
Without proof, Covered California will remove American Indian benefits from
coverage.
CECs and Enrollment staff should have no issue in uploading documents as
part of the enrollment process as long as the documents are not retained by the
clinic related to the enrollment process. Should the clinic have other reasons
for retaining documents, and would do so in the normal course of business
[such as determining eligibility for IHS services], they will not run afoul of the
regulations or policies governing CECs.”
STATUS VERIFICATION
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Outreach Considerations for American Indian Enrollment
in Covered California
American Indians:
• Currently have access to free (or
significantly reduced cost) health care
through Tribal and Urban Indian health
programs.
• Are not required to maintain minimal
coverage (exempt from the individual
mandate).
By enrolling in Covered California:
• American Indian individual / family will be
covered for services that their Tribal or
Urban Indian health program does not
provide, such as medical specialists, tests,
emergency room visits, and hospital care.
• Community will have more IHS resources for
health care and Contract Health Services.
• Benefits include coverage for "10 Essential
Benefits".
OUTREACH CONSIDERATIONS
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American Indian’s are exempt from premiums and cost
sharing, including copays, coinsurance and deductibles
Eligibility: Any American Indian who has received (or is
eligible to receive) services at a Tribal or Urban Indian
health program.
Medi-Cal Provisions and Protections For
American Indians
MEDI-CAL PROVISIONS
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MAGI is used to determine eligibility for Covered California
subsidies and Medi-Cal expansion.
Some examples of taxable American Indian Income which
are excluded from MAGI are:
• Distributions or payment for tribal land.
• Distributions resulting from federally protected rights
specific to American Indians.
• Student financial assistance provided by the B.I.A.
Modified Adjusted Gross Income
MAGI
