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CMS Division of Tribal Affairs
Important information for our tribal partners

Opportunities for Promoting Work and Community Engagement Among Medicaid Beneficiaries

On January 11, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a State Medicaid Director Letter (SMDL) announcing a new policy designed to assist states in their efforts to improve Medicaid enrollee health outcomes through incentivizing work and community engagement among non-disabled, non-elderly adult Medicaid beneficiaries who are eligible for Medicaid on a basis other than disability. The SMDL indicates that CMS will support state efforts to test incentives that make participation in work or other community engagement a requirement for continued Medicaid eligibility or coverage for certain adult Medicaid beneficiaries in demonstration projects authorized under section 1115 of the Social Security Act (the Act). These demonstration applications are subject to the full federal review process, the public review process, and transparency requirements, including those described in regulations at 42 C.F.R. Part 431, subpart G.

A copy of the SMDL can be viewed by following this link, and Frequently Asked Questions accompanying the SMDL can be viewed here,

CMS received several requests for Tribal Consultation from Tribes located in states that have proposed work and community engagement requirements. CMS held consultation with those Tribes and heard Tribal concerns that work and community engagement requirements as a condition of eligibility for Medicaid could serve as a barrier to enrollment of American Indian and Alaska Native (AI/AN) beneficiaries in Medicaid. Through Tribal Consultation, Tribes requested CMS to require states to exempt AI/ANs from work and community engagement requirements. Unfortunately, we are constrained by statute and are concerned that requiring states to exempt AI/ANs from work and community engagement requirements could raise civil rights issues.

However, as indicated in the SMDL, States will be required to comply with Tribal Consultation requirements. The SMDL provides examples for states and tribes to consider on how AI/ANs can meet the work and community engagement requirements, such as through enrollment in tribal work programs or through exemptions specific to tribal communities under the SNAP and TANF work requirements.

CMS is committed to honoring the special relationship between Tribal governments and the Federal government. To that end, CMS has scheduled an All Tribes’ Call to provide an overview of the SMDL that outlines some options for states to consider in promoting work and community engagement requirements among Medicaid beneficiaries. CMS staff will be available to answer any questions you might have regarding the SMDL.

Please contact Kitty Marx, Director, Division of Tribal Affairs, Intergovernmental External Affairs Group, Center for Medicaid and CHIP Services, CMS, with any questions or concerns by phone, (410) 786-8619, or via e-mail,

An Update on the Hospital Acquired Conditions (HAC)Reduction Program

The Centers for Medicare & Medicaid Services (CMS)/Division of Tribal Affairs recently hosted a webinar on An Update on The Hospital Acquired Condition (HAC) Reduction Program.

Section 3008 of the Affordable Care Act established the Hospital-Acquired Condition (HAC) Reduction Program to encourage hospitals to reduce hospital acquired conditions. Beginning with Fiscal Year 2015 discharges, the CMS HAC Reduction Program is required to reduce payments by one percent to hospitals that rank at or below the 25th percentile with respect to meeting HAC quality measures.

The webinar provided updated information regarding low census adjustments. CMS finalized and adopted the new Winsorized z-score methodology for the FY 2018 HAC Reduction Program. 

More information on the program can be found at:

CMS Informational Bulletin on Indian Provisions in the Medicaid Managed Care Rule

The Center for Medicaid and CHIP Services (CMCS) issued an Informational Bulletin on the Indian provisions of the final Medicaid and the Children’s Health Insurance Program (CHIP) managed care regulation. The purpose of this Informational Bulletin is to summarize the relevant provisions into one document, clarify current statute and regulation regarding mandatory enrollment of Indians into managed care, and provide sample language for an Indian Addendum that can be offered to managed care plans on a voluntary basis when executing network provider agreements with Indian health care providers (IHCPs). In addition to the Informational Bulletin, CMCS also released a Model Medicaid and CHIP Managed Care Addendum for IHCPs.2:30-5

The Informational Bulletin and the Addendum can be viewed here:

CMS Informational Bulletin on Enrollment

The Center for Medicare & Medicaid Services (CMS) released an Informational Bulletin that provides strategies and helpful information for states, Tribes, Tribal organizations, Indian health care providers, and application assisters to increase enrollment of American Indians and Alaska Natives (AI/ANs) into programs administered by CMS.

The bulletin describes specific strategies for states, such as Tribal Access to State Medicaid Eligibility Portals, out stationing of eligibility workers at Tribal FQHCs, Tribal Medicaid Administrative Match, express lane eligibility for children, presumptive eligibility, and continuous eligibility to increase enrollment of AI/ANs. Specific strategies for Tribes to use are described as best practices and include suggestions such as making personal contact and building trust, holding enrollment events at tribal powwows or other cultural events, and using social media and radio stations to improve outreach and education efforts.

The Informational Bulletin is available on at