100% FMAP for LTSS — Educate Your State

Receiving 100% Federal Medical Assistance Percentage (FMAP) for LTSS services provided to eligible patients through IHS or tribal programs can help tribes and states alike.


Real-Life Example: See how the Oneida Nation successfully negotiated with the state of Wisconsin to provide better care for tribal citizens.

Accessing More Federal Funding

  • Medicaid is a state-managed federal program that covers many long-term care services for eligible people who have limited income.
    • Costs are shared between the federal and state governments. Medicaid funding is based on the eligibility of patients and services, rather than on budget limits.
  • CMS pays each state a percentage of its total Medicaid expenditures. This percentage is the Federal Medical Assistance Percentage (FMAP).
  • FMAP varies by state, based on the state's per capita income. As a result, some states have a lower FMAP rate than others. For example, in 2015, Massachusetts had a high per capita income, so the state's FMAP was 50%, while the FMAP for Utah was about 70% due to a lower per capita income.
  • However, in all states, services provided to Medicaid-eligible AI/AN patients in IHS or tribal facilities can be reimbursed at 100% FMAP.
    • Since CMS reimburses these expenses at a rate of 100%, services provided to Medicaid-eligible Native American patients in IHS or tribal facilities cost your state nothing.
    • Non-Indians served at your facility can be reimbursed at the state's usual FMAP, not at 100% FMAP.
    • 100% FMAP provides a significantly higher Medicaid reimbursement for tribally provided services than for other state Medicaid services.
  • FMAP amounts are adjusted every 3 years.

A Win for Tribes and States

When you educate your state about the possibility of receiving 100% federal reimbursement for Medicaid services provided to eligible AI/AN patients in tribal facilities, you can open the door to helping both your tribe and your state access more federal dollars for health care.

With 100% FMAP, states receive a higher reimbursement from the federal government for a certain portion of their Medicaid services (the portion that is provided in tribal facilities to eligible AI/AN patients). And, because the federal government reimburses 100% of the costs of these services, the state does not have to pay anything. Tribal Medicaid services are "budget neutral" for the state.

Because the state achieves these savings, it can afford to reimburse these tribally provided Medicaid services at a higher (enhanced) rate. If those federal dollars are passed through to your tribe via an enhanced reimbursement rate with your state, your tribal facility will receive more resources to provide better care for tribal citizens. This partnership helps support better health for everyone.

Work with your state, and sit down with state representatives to explain how you can obtain federal reimbursement that benefits both the state and the tribe. Try to negotiate a reimbursement rate that will benefit both parties. Focus on these main points:

  • 100% FMAP is available for Medicaid services provided to eligible AI/AN patients in tribal or IHS facilities.
  • The state saves money because it doesn't have to pay its normal share for Medicaid services provided to these patients.
  • An enhanced reimbursement rate can increase tribal capacity to provide services while also benefiting the state.

By using 100% FMAP and an enhanced rate (such as the Medicare-like rate), the amount of federal funds coming to the state is increased. The tribe gets reimbursed for providing care and the state does not have to match funds.

Educating your state about these opportunities can take some time, but the benefits for both the state and the tribe can be substantial.

How to Become Eligible for 100% FMAP

To be eligible for 100% FMAP, your program must meet several requirements:

  1. LTSS must be explicitly included in a tribe's P.L. 638 contract or compact with IHS. When your tribe is negotiating its contract or compact, IHS must be made aware of your LTSS program.
  2. LTSS must be provided through the tribal health department, meaning the department either provides or oversees LTSS. You can either:
    • Have your tribal health center set up a funding agreement with the tribal aging program or department to provide LTSS, or
    • Move your LTSS program under that health department so that the department oversees the program
  3. The health program must bill the state Medicaid office for LTSS, since LTSS patients are ultimately patients of the health program.
    • The health program sends invoices to the state Medicaid office.
    • The health program must work to protect any LTSS-specific funding.
      • The state can only claim 100% FMAP for patients of tribal health programs.

Be aware that program directors can be protective of their programs. An LTSS program director may be reluctant to move their program between tribal departments. Often, you can address this by explaining that the move is necessary to be eligible for 100% FMAP and describing the ways in which the program could benefit from this eligibility.


For additional information about 100% FMAP, consult the following resources:

Page Last Modified:
04/15/2016 04:05 PM