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All Tribes Calls

The All Tribes Calls and Webinars are sponsored by the Centers for Medicare & Medicaid Services (CMS), Division of Tribal Affairs (DTA). All Tribes Calls and Webinars provide an opportunity for CMS to solicit input from Indian Health Services (IHS), tribal, and urban programs (I/T/U) on the implementation of or changes to CMS legislative and regulatory provisions impacting AI/AN beneficiaries in the operation of IHS, or Indian health programs in the Indian health program delivery system.  The topics for the calls will be identified and developed as the Affordable Care Act is implemented and information will be presented by subject matter experts using cleared materials.  Please plan to call in approximately fifteen minutes prior to the call and identify yourself by name and tribe.  There will be limited lines available so to the extent possible, please share a phone line.

The CMS calls are not considered consultation but rather technical listening. The purpose of the calls is to solicit input from IHS, Tribal, and urban programs on how the provision impacts AI/AN beneficiaries and the operation of the Indian health program delivery system.    After each call, CMS will make available a summary of the provision or provisions discussed and the major issues and questions asked on the call.    These summaries will be posted in the download section below.   In addition, DTA has established a mailbox for participants on the calls to submit additional questions, feedback, and suggestions for future topics to be discussed on the calls. That mailbox is tribalaffairs@cms.hhs.gov.

 

Tribal Medicare Chronic Care Management (CCM)

August 16, 2017

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The Centers for Medicare & Medicaid Services (CMS) is pleased to host a webinar entitled Tribal Medicare Chronic Care Management (CCM) on Wednesday, August 16th, 2017 from 3:00 – 4:00 pm, Eastern Time.

Intended Audience: Business Office, Patient Benefit Coordinators and Health Care Professionals responsible for time-intensive chronic care coordination and billing.

This webinar will provide an overview of the CMS Chronic Care Management program and will discuss the updated program with additional billing codes and requirements. Many IHS, Tribal and Urban Indian programs provide chronic care management services and don’t realize their program can receive Medicare Part B reimbursement.

CMS recognizes chronic care management as one of the critical components of primary care that contributes to better health and care for individuals, and holds promise for reducing overall health care costs. In January, 2015, CMS adopted a new service code to allow Medicare Part B payment for chronic care management services provided to Medicare and dual eligible beneficiaries who have two or more serious chronic conditions.

Medicare Part B eligible practitioners and suppliers can bill for at least 20 minutes of non-face-to-face clinical staff time directed by a physician or other qualified health professionals each month to coordinate care for beneficiaries who have two or more serious chronic conditions that are expected to last at least 12 months. In November, 2016, the Medicare Physician Fee Schedule was revised to enable reimbursement for more complex and time-intensive chronic care coordination effective January, 2017.

Technical Assistance and Outreach on Medicaid Billing and Payment for Services Provided Outside the Four Walls by IHS/Tribal Employees and Non-IHS Providers

August 9, 2017

On February 26, 2016, the Centers for Medicaid and CHIP Services (CMCS) issued a State Health Official (SHO) letter to states and Tribes providing guidance to update our policy on when 100% Federal Medical Assistance Percentage (FMAP) would be available for services furnished to Medicaid-eligible American Indians and Alaska Natives through facilities operated by IHS or Tribes. A copy of the Tribal SHO letter can be found at https://www.medicaid.gov/federal-policy-guidance/downloads/SHO022616.pdf.

On January 18, 2017, CMCS issued Frequently Asked Questions (FAQs) to address common questions related to provisions of the Tribal SHO letter relating to Medicaid billing and payments to non-IHS providers. The FAQs provided an explanation of the “four walls” limitation. Under CMS’ interpretation of its regulations at 42 CFR 440.90 and the underlying statute, “clinic services” must be provided at the clinic – i.e., within the “four walls” of the facility – unless the beneficiary is homeless. Under this interpretation, services furnished outside of the “four walls,” even services furnished by an off-site practitioner under a care coordination agreement consistent with the Tribal SHO, may not be billed at the outpatient facility all inclusive rate. Thus, services provided outside of the “four walls” of a clinic, by either Tribal employees or non-Tribal providers, would have to be billed at the Medicaid practitioner fee for service rate. A copy of the FAQs can be found at: https://www.medicaid.gov/federal-policy-guidance/downloads/faq11817.pdf.

The FAQs offered a solution to minimize the impact on Tribal clinics by explaining that Tribal programs would have the option to enroll as a Medicaid FQHC and could be paid at an Alternate Payment Methodology (APM) rate, such as the IHS OMB Medicaid outpatient rate, for services provided by Tribal employees or non-Tribal providers outside of the “four walls.”

The purpose of this call is to provide technical assistance and a better understanding of the process for Tribes interested in enrolling as Medicaid FQHCs. CMCS staff will provide a basic overview of the policy and to answer specific questions CMCS has received regarding the January 2017 FAQs.

If you have any questions regarding this call, please feel free to contact Kitty Marx, Director, Division of Tribal Affairs, IEAG, CMCS at kitty.marx@cms.hhs.gov.

CY 2018 Medicare Diabetes Prevention Program (MDPP) Model Expansion Proposed Rule

August 3, 2017

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On July 13, 2017, the Centers for Medicare & Medicaid Services (CMS) issued the Calendar Year (CY) 2018 Physician Fee Schedule (PFS) proposed rule that includes additional proposals to implement the Medicare Diabetes Prevention Program (MDPP) expanded model starting in 2018. CMS will accept comments on the proposed rule until September 11, 2017 and will respond to comments in the proposed rule. The proposed rule can be downloaded from the Federal Register at https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-14883.pdf.

The goal of the Medicare Diabetes Prevention Program is to prevent progression to type 2 diabetes in individuals with an indication of pre-diabetes. The clinical intervention consists of a minimum of 16 intensive “core” sessions of a Centers for Disease Control and Prevention (CDC) approved curriculum furnished over six months in a group-based, classroom-style setting that provides practical training in long-term dietary change, increased physical activity, and behavior change strategies for weight control. After completing the core sessions, less intensive follow-up meetings furnished monthly will help ensure that the participants maintain healthy behaviors. The primary goal of the expanded model is at least 5 percent weight loss by participants.

For more information, visit the MDPP webpage: https://innovation.cms.gov/initiatives/medicare-diabetes-prevention-program.

The purpose of this All Tribes’ Call is for CMS staff to provide a brief overview of the MDPP Model Expansion CY 2018 Proposed Rule. Consistent with the CMS Tribal Consultation Policy, CMS holds All Tribes’ Calls to provide an opportunity for Tribes to learn about proposed rules and ask questions. CMS looks forward to receiving Tribal feedback on this model expansion. However, please note that while we use this call to receive feedback, any comments regarding the current MDPP rule proposal must be submitted through the official comment process; submitted comments are reviewed and responded to as required by law.

Some of the highlights of new MDPP proposed rule includes:

  • Effective Dates of MDPP Services, Enrollment and Billing Privileges: The CY 2017 PFS established that MDPP services would be available on January 1, 2018. We propose to revise our policy to state that MDPP services would be available on April 1, 2018 in order to ensure that MDPP suppliers have sufficient time to enroll in Medicare after the effective date of the CY 2018 PFS final rule.
  • Diabetes Diagnosis during the MDPP Services Period: In the CY 2017 PFS, we established eligibility criteria for beneficiaries to receive the set of MDPP services, which excluded individuals with previous diagnosis of diabetes (with the exception of gestational). In this rule, we propose that if a beneficiary develops diabetes during the MDPP services period, this diagnosis would not prevent the beneficiary from continuing to receive MDPP services.
  • Ongoing Maintenance Sessions: We propose a two-year limit on ongoing maintenance sessions (assuming attendance and weight loss performance goals are met), making the total MDPP services period three years (consisting of one year of core and core maintenance sessions, followed by up to two years of ongoing maintenance sessions, depending on eligibility, as described below). We propose that MDPP beneficiaries must attend three sessions and maintain 5 percent weight loss at least once in the previous ongoing maintenance session interval to be eligible for additional intervals after the first.
  • Payment Structure: We propose a performance-based payment structure, which ties payment to performance goals based on attendance and/or weight loss.
  • Interim Preliminary Recognition: In this rule, we propose that an entity may be eligible to enroll in Medicare as an MDPP supplier if they have achieved CMS interim preliminary recognition, CDC preliminary recognition (if established), or CDC full recognition. Our intent with CMS interim preliminary recognition is to bridge the gap until any CDC preliminary recognition standards are established and to allow organizations who have met this standard to enroll in Medicare.
  • Beneficiary Engagement Incentives: We propose that an MDPP supplier may choose to provide in-kind patient engagement incentives to a MDPP beneficiary to assist the supplier in furnishing high quality services and engaging in health behavior change programs that lead to improved beneficiary health and reductions in Medicare spending.

FY 2018 Medicare Inpatient Prospective Payment System (IPPS) Proposed Rule and Request for Information (CMS-1677-P)

May 22, 2017

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On April 14, 2017, CMS issued a proposed rule to update the 2018 Medicare payment and polices that determine when patients are admitted into hospitals. This rule contains special provisions related to Indian Health Service (IHS) and tribal hospitals, such as a proposed low volume payment adjustment for Disproportionate Share Hospital (DSH) payments and Provider Based Status of IHS and tribal facilities.

As part of this rule, CMS is releasing a Request for Information (RFI) to find ways to improve and simplify the health care delivery system by reducing the burden for clinicians, providers, and patients while increasing quality of care and decreasing costs. CMS is soliciting ideas for regulatory, sub-regulatory, policy and practice, and procedural changes to better accomplish these goals. In response to the RFI, please provide clear and concise proposals that include specific examples with data.
 
The purpose of the All Tribes’ Call is for Medicare experts to present a brief overview of the rule, review the fact sheet and uncompensated care payments, describe the provider based proposals explained in the rule and how the proposals relate to conditions of participation, and then open up the call for questions.
CMS looks forward to feedback on the rule and RFI.

Comments to both the proposed pule and RFI are due by June 13, 2017.

Download the proposed rule

CMS has developed a fact sheet that discusses the major provisions of the rule.

More information about the rule

Tribal Consultation: Reimbursement Rate for Services Provided Outside of an IHS/Tribal Facility

December 15, 2016

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On February 26, 2016, CMS issued a State Health Official letter (SHO) expanding the circumstances under which services furnished to American Indian and Alaska Native (AI/AN) Medicaid beneficiaries could be considered to be “received through” an Indian Health Service (IHS) or Tribal facility. Under the updated policy, IHS/Tribal facilities may enter into written care coordination agreements with non-IHS/Tribal providers to furnish certain services for their patients who are AI/AN Medicaid beneficiaries. Those services provided per the care coordination agreements are eligible for federal matching funds at the enhanced federal matching rate (FMAP) of 100 percent.

Under the SHO, either the Tribal facility or the non-IHS/Tribal practitioner may bill Medicaid for services furnished by the non-IHS/Tribal practitioner. If the non-IHS/Tribal provider were to bill the state Medicaid program directly, the provider would be reimbursed at the rate authorized under the Medicaid state plan applicable to the provider type and the service rendered, not at the facility rate that the IHS/Tribal facility would receive. If the Tribal facility were to bill for the service, the Tribal facility would have to separately identify services provided by non-IHS/Tribal providers under the care coordination agreement that can be claimed as services of the Tribal facility from those that cannot. Services that can properly be claimed as services of the IHS/Tribal facility (“IHS/Tribal facility services”) are reimbursed at the facility rate authorized under the Medicaid state plan. Those services that do not qualify as “IHS/Tribal facility services” are reimbursed at the rate applicable under the Medicaid state plan to the provider type and service rendered.

Whether services furnished by non-Tribal providers can be billed as facility services depends on whether the Tribal facility is enrolled in the state Medicaid program as a provider of “clinic services” or as a Federally Qualified Health Center (FQHC). If the Tribal facility is enrolled in the state Medicaid program as a provider of “clinic services” under 42 CFR 440.90, the Tribal facility may not bill for the services furnished by a non-Tribal provider or Tribal employee at the facility rate for services that are provided outside of the facility. This is referred to as the ‘four walls’ limitation. Instead, the Tribal provider would bill for the services at the rate applicable to the non-Tribal provider and the service. (As noted above, the Tribal provider has the option to allow the non-Tribal provider bill to bill directly for the service rather than bill on the provider’s behalf). If the Tribal facility is enrolled in the state Medicaid program as an FQHC, the Tribal facility may properly claim payment for services furnished by the non-Tribal provider at the facility rate.

We understand that states may not have been paying for services provided by Tribal clinics in accordance with the ‘four walls’ limitation. In reviewing possible solutions that will minimize the impact on Tribal clinics, we have determined that the FQHC benefit provides the most flexibility since there is no Federal requirement that FQHC services be provided within the ‘four walls’ of the facility. In addition, section 1905(l)(2)(B)(iv) of the Social Security Act recognizes outpatient Tribal health programs as FQHCs. Pursuant to the Benefits Improvement and Protection Act (BIPA) of 2000, FQHCs must be paid no less than a rate developed based on 1999/2000 cost trended forward by the MEI. However, BIPA also permits states to establish higher payment rates under an alternative payment methodology (APM). In light of the unique nature of Tribal Health programs, CMS could support payment of the outpatient IHS/AIR for FQHC services under an APM.

To effectuate this change, Tribal Health programs should work with their Medicaid agencies to have their provider designation changed from clinic to FQHC. No other steps need be taken by the Tribal Health program. The state Medicaid agency will be required to submit a state plan amendment to designate payment for Tribal FQHC services at the IHS AIR as an APM. States will be given a grace period to consult with Tribes and to modify the state plan.

Medicare Diabetes Prevention Program

December 14, 2016

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The Medicare Diabetes Prevention Program (MDPP) expansion was announced in early 2016, when the Secretary of Health and Human Services determined that the Diabetes Prevention Program model test met the statutory criteria for expansion. The rule establishing the expansion was finalized in the Calendar Year 2017 Medicare Physician Fee Schedule (PFS) Final Rule that was published in November 2016.

The MDPP expanded model is a structured behavioral change intervention that aims to prevent the onset of type 2 diabetes among Medicare beneficiaries diagnosed with pre-diabetes. The MDPP expanded model is a CMS Innovation Center model test that has been expanded in duration and scope under section 1115A(c) of the Social Security Act and will be covered as an additional preventive service with no cost-sharing under Medicare. Beginning January 1, 2018, eligible beneficiaries will be able to access MDPP services in community and health care settings and provided by coaches who are trained community health workers or health professionals.

The 2017 PFS rule finalizes aspects of the expansion that will enable organizations, including those new to Medicare, to prepare for enrollment into Medicare as MDPP suppliers. Finalized policies include the definition of the MDPP benefit, beneficiary eligibility criteria, and supplier eligibility and enrollment criteria. Future rulemaking will address policies related to payments, virtual providers, and other program integrity safeguards.

The purpose of this All Tribes’ Call is for CMS staff to provide a brief overview of the MDPP Model Expansion. We are interested in hearing more about the Special Diabetes Program for Indians and receive feedback about the MDPP Model Expansion. CMS looks forward to receiving tribal feedback on this model expansion.

For more information, see this fact sheet about the Medicare Diabetes Prevention Program.

You can also listen to a recorded Medicare Learning Network webinar. Copies of the slides are available now at that link and a recording of the November 30 webinar will be available soon.

Indian Health Care Addendum for Contracting with Medicaid and CHIP Managed Care Entities

November 9, 2016

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On April 25, 2016, CMS released a final rule on managed care in Medicaid and the Children’s Health Insurance Program (CHIP). This rule incorporated the Indian protections in Section 5006 of the American Recovery and Reinvestment Act. The Indian-specific provisions in the final rule are located in the section, “Standards for Contracts Involving Indians, Indian Health Care Providers and Indian Managed Care Entities.”

In the final rule, CMS committed to developing sub- regulatory guidance through consultation on the use of Medicaid and CHIP Indian Managed Care (ITU Addendum). The ITU Addendum is intended to help facilitate contracts between Indian Health Care Providers (IHCPs) and managed care plans by identifying several specific provisions established in federal law that apply when contracting with IHCPs.

Per an October 5, 2016, CMS All Tribes Call, CMS obtained tribal input and advice on an Informational Bulletin that the Center for Medicaid & CHIP Services (CMCS) is developing that highlights the Indian-specific provisions of the final rule. We indicated on that call that we would hold a separate call on the ITU Addendum. CMCS will then release the Informational Bulletin and ITU Addendum as a single guidance.

The purpose of the All Tribes Call on the ITU Addendum is to provide an overview of the ITU Addendum and address any questions you may have. Download the ITU Addendum (PDF, 98 KB)

CMS looks forward to feedback on the ITU Addendum. Written comments can be submitted to tribalaffairs@cms.hhs.gov by close of business, November 16, 2016.

Indian Provisions in Medicaid Managed Care

October 5, 2016

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On April 25, 2016, the Center for Medicare & Medicaid Services (CMS) announced the publication of the final rule on managed care in Medicaid and the Children’s Health Insurance Program (CHIP).

CMS engaged closely with Tribes during the rulemaking process, and received many comments from Tribes and Tribal organizations, including comments on mandatory enrollment of AI/ANs in managed care and use of an Indian health care addendum for contracting with managed care entities. Because of these comments, CMS has committed to developing additional sub-regulatory guidance on this rule through consultation.

Medicare Access and Chip Reauthorization Act Of 2015 (MACRA) And The Merit-Based Incentive Payment System (MIPS) Proposed Rule

May 19, 2016

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The Centers for Medicare & Medicaid Services (CMS) released a proposed rule on April 27th, 2016, MIPs & APMs in Medicare-Fee-for-Service - CMS-5517-P, that is intended to align and modernize how Medicare payments are tied to the cost and quality of patient care for hundreds of thousands of doctors and other clinicians.

Medicaid Managed Care Final Rule

April 27, 2016

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On April 25, 2016, CMS published a final rule on managed care in Medicaid and the Children’s Health Insurance Program (CHIP), which incorporates the Indian protections in section 5006 of the American Recovery and Reinvestment Act (ARRA). CMS engaged with Tribes throughout the rulemaking process to ensure that the final rule is consistent with the ARRA protections for American Indians and Alaska Natives (AI/ANs). The final rule codifies the Indian managed care protections in section 5006 of ARRA, including those provisions that allow AI/ANs enrolled in Medicaid managed care plans to continue to receive services from an Indian health care provider and ensures Indian health care providers are reimbursed appropriately for services provided and addresses other tribal comments received.

 

Tribal State Health Official Letter on 100% FMAP for Service

March 8, 2016

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On February 26, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a letter to States and Tribes providing guidance to update our policy regarding the circumstances in which 100 percent federal funding would be available for services furnished to Medicaid-eligible American Indians and Alaska Natives through facilities operated by the Indian Health Service (IHS) or Tribes. A copy of the letter can be found at: https://www.medicaid.gov/federal-policy-guidance/downloads/sho022616.pdf

100 percent FMAP for services provided

September 16, 2015

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In this consultation, tribes and CMS discuss the scope of services provided under 100 percent FMAP.

100 percent FMAP for services provided

September 11, 2015

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In this consultation, Alaska and South Dakota tribes and CMS discuss the scope of services provided under 100 percent FMAP.

 

Minimum Information Required for Referrals to Qualified Health Plans

August 19, 2015

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In this consultation, tribes and CMS discuss the minimum information that non-Indian health care providers must provide to Indian health care providers before qualified tribal members can receive special cost sharing protections under the Affordable Care Act.

 

Grand-fathered Tribal FQHCs

July 29, 2015

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On July 8, 2015, The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule to update payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) and other programs, effective on or after January 1, 2016.  The rule is available at  https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-16875.pdf.

This All Tribes Call reviewed the proposed rule, including eligibility, certification and billing requirements, and transitioning to the new system for grandfathered tribal FQHCs.

In response to concerns raised by tribes and the CMS Tribal Technical Advisory Group, CMS proposed that tribal facilities grandfathered in as Medicare provider-based entities on or before April 7, 2000, and have a change of status from IHS operated to tribally operated and no longer meet Medicare hospital conditions of participation, may seek to become certified as grandfathered tribal FQHCs.

Under the authority in 1834(o) of the Affordable Care Act to “include adjustments…determined appropriate by the Secretary,” CMS  proposed that these grandfathered tribal FQHCs be paid the lesser of their charges or a grandfathered tribal FQHC PPS rate of $307, which equals the Medicare outpatient per visit payment rate paid to them as a provider-based department, as set annually by the IHS, rather than the FQHC PPS per visit base rate of $158.85, and that coinsurance would be 20 percent of the lesser of the actual charge or the grandfathered tribal FQHC PPS rate. These grandfathered tribal FQHCs would be required to meet all FQHC certification and payment requirements.

This FQHC PPS adjustment for grandfathered tribal clinics would not apply to a currently certified tribal FQHC, a tribal clinic that was not provider-based as of April 7, 2000, or an IHS-operated clinic that is no longer provider-based to a tribally-operated hospital. This provision would also not apply in those instances where both the hospital and its provider-based clinic(s) are operated by the tribe.

 

Medicaid Managed Care Proposed Rules

June 25, 2015

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On May 26, 2015, CMS issued proposed rules on Medicaid Managed Care, CHIP Delivered in Managed Care, and Revisions related to Third Party Liability (CMS -2390-P) to modernize Medicaid and the Children's Health Insurance Program (CHIP) managed care regulations.  This proposed rule is the first major update to Medicaid and CHIP managed care regulations in more than a decade. The proposed rules are intended to update managed care regulations to reflect changes in health delivery systems and to align regulations with other statutes, such as section 5006 of the American Recovery and Reinvestment Act (ARRA). Overall, this proposed rule supports the agency's mission of better care, smarter spending, and healthier people.

On June 25th, the Division of Tribal Affairs hosted an All Tribes' Call to provide an overview of the proposed rules, including the tribal specific provisions, and to respond to comments and questions. CMS is seeking advice and input on those provisions of the proposed rule regarding the requirements of section 5006 of ARRA and comments on how to facilitate a coordinated approach to care for AI/ANs enrolled in managed care and who receive services from their Indian health care providers (IHCP), including services provided through a referral to a specialty provider.  Also, we seek comment on the potential barriers to contracting with managed care plans and what technical assistance and resources should be made available to states, managed care plans, and IHCPs to facilitate these relationships.  There were 100 participants on the call.

The proposed rule is available at https://www.federalregister.gov/public-inspection and can be viewed at https://www.federalregister.gov starting June 1. The deadline to submit comments is no later than 5 pm on July 27, 2015.  We encourage you to submit written comments during the comment period as outlined in the Federal Register notice. Written comments that are submitted during the comment period will become part of the official rulemaking record. 

For more information about the proposed rule, please visit http://medicaid.gov/medicaid-chip-program-information/by-topics/delivery-systems/managed-care/managed-care-site.html

A copy of the power point presentation can be downloaded here: Medicaid Managed Care Proposed Rules

Institutions for Mental Diseases (IMD) Exclusion and what this means for Indian Country

June 9, 2015

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On June 9, 2015, SAMSHA and CMS held an All Tribes' Call to learn information about how Medicaid reimbursement might be available for mental health services provided to persons in residential treatment centers. Under the Medicaid laws, Medicaid payment is not allowed for services provided in Institutions for Mental Diseases (IMD) that have more than 16 beds. However, there are exceptions to this rule.  The call focused on the IMD exclusion, the exceptions, and what this means for Indian Country.

BACKGROUND: The Institutions for Mental Diseases (IMD) exclusion means that no Federal Medicaid funds are available for services provided either in or outside the facility for persons residing in IMDs. The IMD exclusion dates back to 1965 and is based on the States' responsibility to provide for and fund inpatient psychiatric services to its citizens. 

The IMD exclusion is limited to those entities that provide residential treatment to persons with mental illnesses or substance use disorders, and have more than sixteen beds. 

If the facility has less than 16 beds, the IMD exclusion does not apply and the facility can bill Medicaid for services provided to eligible Medicaid persons at any age.  For these facilities, room and board is not a reimbursable service unless they are licensed as an inpatient hospital or a Psychiatric Residential Treatment Facility (PRTF).

For IMD facilities that have more than 16 beds, there are two exceptions:

  • Medicaid coverage is allowed if the facility provides services to patients under age 21 (up to age 20) and is qualified as a psychiatric hospital, psychiatric unit of a general hospital, or PRTF.
  • Medicaid coverage is allowed if the facility is a hospital or nursing facility and provides services to patients age 65 and over

A copy of the power point presentation can be downloaded here: IMD Exclusion & what this means for Indian Country