State Tribal Relations on Health Care

The United States recognizes Indian tribes as sovereign nations. This unique government-to-government relationship between the tribes and the federal government is grounded in:

  • The U.S. Constitution
  • Treaties
  • Statutes
  • Federal case law
  • Regulations
  • Executive orders

Executive Order 13175 requires federal agencies to engage in meaningful consultation with tribes. States are also held to certain requirements in their relationships with tribes, detailed on this page.

See the interactive map below for the State Plan Amendments (SPAs) required for each state.

On This Page

What is section 5006 of ARRA (Section 1902 (a) (73) of the SSA)?

What are section 1115 waivers (42 CFR 431.408(b))?

What are the Exchanges (45 CFR. Part 155)?

State-Tribal Consultation: Best Practices

Interactive Map

Legislation

What is section 5006 of ARRA (Section 1902(a) (73) of the SSA)?

The Social Security Act (SSA) allows states to impose enrollment fees, premiums, cost-sharing, and similar charges on some Medicaid participants.

However, section 5006 of the ARRA:

  • Prevents states from imposing Medicaid premiums or any other Medicaid cost-sharing on Indian applicants and participants who have used the Indian health system
  • Requires states to seek advice on Medicaid and Children’s Health Insurance Program (CHIP) matters from designees of Indian health programs and urban Indian organizations in the state when matters affect Indians
  • Requires states to describe the process used for seeking advice from Indian health programs and urban Indian organizations

 

What are section 1115 waivers (42 CFR 431.408(b))?

Section 1115 of the SSA allows certain Medicaid requirements of the SSA to be waived for experimental, pilot, or demonstration projects. States can use section 1115 waivers to test health care services that promote the objectives of Medicaid and CHIP.

These waivers can influence policy-making at the state, tribal, and federal levels by introducing new approaches.

CMS requires states to consult with tribes before submitting waiver requests. States that already have tribal consultation plans or have included tribes in their state plans may follow established tribal consultation processes. For any state that does not have an established process, the section 1115 transparency regulations explain time frames and processes.

 

What are the Exchanges (45 CFR Part 155)?

Americans now have access to Affordable Insurance Exchanges (Exchanges), state-based competitive marketplaces where individuals and small businesses can choose from and purchase the same affordable insurance choices as members of Congress.

Exchanges make it easy for consumers to:

  • Compare health plans
  • Get answers to questions about coverage options
  • Find a health plan that meets their needs
  • Determine if they are eligible for advance payments of premium tax credits and cost sharing reductions, or health programs like CHIP (small businesses are only eligible for the small business tax credit)

States operate as one of the following Exchange models:

  • State-based Exchange (SBE)
  • Partnership State Exchange (SPE)
  • Federally-facilitated Exchange (FFE)

To complete the Exchange application, the Exchange, in consultation with the tribes, must have a tribal consultation policy that has been submitted to HHS and an outreach plan for populations including tribal communities. As part its approval decision, the state should post the tribal consultation plan (excluding test data) of its Exchange application on the state website within 10 business days.

Blueprint for Approval of Affordable State-Based and State Partnership Insurance Exchanges

CCIIO Letters to Governors of States that received Conditional Approval to Establish a State-Based Exchange

 

State-Tribal Consultation: Best Practices

To share information about effective state-tribal consultation on healthcare, CMS conducted guided discussions in Minnesota, Oregon, and Washington. These states possess CMS-approved State Plan Amendments and established histories of successful consultation practices. State and tribal participants in Medicaid and CHIP consultations identified the strengths and weaknesses of current consultation processes in each location.

 

Back to Map

Alabama

Alabama

Alabama State Plan Amendment (SPA)

Alabama State Plan Amendment
 

Back to Map

New York

Alaska

Alaska State Plan Amendments (SPAs)

Alaska State Plan Amendment


Back to Map

Arizona

Arizona

Arizona State Plan Amendment(PDF)s (SPAs)

Arizona State Plan Amendment(PDF)

 

Back to Map
 

California

California

California State Plan Amendments (SPAs)

California State Plan Amendment
 

Back to Map

Colorado

Colorado

Colorado State Plan Amendment (SPA)

Colorado State Plan Amendment
 

Back to Map

Connecticut

Connecticut

Connecticut State Plan Amendment (SPA)

Connecticut State Plan Amendment
 

Back to Map

Florida

Florida

Florida State Plan Amendment (SPA)

Florida State Plan Amendment
 

Back to Map

Hawaii

Hawaii

Hawaii State Plan Amendment (SPA)

Hawaii State Plan Amendment
 

Back to Map

Idaho

Idaho

Idaho State Plan Amendment (SPA)

Idaho State Plan Amendment

Back to Map

Illinois

Illinois

Illinois State Plan Amendment (SPA)

Illinois State Plan Amendment
 

Back to Map

Iowa

Iowa

Iowa State Plan Amendment (SPA)

Iowa State Plan Amendment
 

Back to Map

Kansas

Kansas

Kansas State Plan Amendment (SPA)

Kansas State Plan Amendment
 

Back to Map

Louisiana

Louisiana

Louisiana State Plan Amendment (SPA)


Louisiana State Plan Amendment
 

Back to Map

Maine

Maine

Maine State Plan Amendment (SPA)

Maine State Plan Amendment
 

Back to Map

Maryland

Maryland

Maryland State Plan Amendment (SPA)

Maryland State Plan Amendment
 

Back to Map

Massachusetts

Massachusetts

Massachusetts State Plan Amendment (SPA)

Massachusetts State Plan Amendment
 

Back to Map

Michigan

Michigan

Michigan State Plan Amendment (SPA)

Michigan State Plan Amendment
 

Back to Map

Minnesota

Minnesota

Minnesota State Plan Amendment (SPA)

Minnesota State Plan Amendment
 

Back to Map

Mississippi

Mississippi

Mississippi State Plan Amendment(PDF) (SPA)

Mississippi State Plan Amendment
 

Back to Map

Missouri

Missouri

Missouri State Plan Amendments (SPAs)

Missouri State Plan Amendment

 

Back to Map

Montana

Montana

Montana State Plan Amendment (SPA)

Montana State Plan Amendment
 
 

Back to Map

Nebraska

Nebraska

Nebraska State Plan Amendment (SPA)

Nebraska State Plan Amendment
 

Back to Map

New Mexico

New Mexico

New Mexico State Plan Amendment (SPA)

New Mexico State Plan Amendment
 

Back to Map

New York

New York

New York State Plan Amendment(PDF) (SPA)

New York State Plan Amendment(PDF)
 

Back to Map

Nevada

Nevada 

Nevada State Plan Amendments (SPAs)

Nevada State Plan Amendment
 

Back to Map

North Carolina

North Carolina

North Carolina Plan Amendment (SPA)

North Carolina Plan Amendment
 

Back to Map

North Dakota

North Dakota

North Dakota State Plan Amendment (SPA)

North Dakota State Plan Amendment
 

Back to Map

Oklahoma

Oklahoma

Oklahoma State Plan Amendment (SPA)

Oklahoma State Plan Amendment
 

Back to Map

Oregon

Oregon

Oregon State Plan Amendment (SPA)

Oregon State Plan Amendment
 

Back to Map

Rhode Island

Rhode Island

Rhode Island State Plan Amendments (SPAs)

Rhode Island State Plan Amendment

 

Back to Map

South Carolina

South Carolina

South Carolina State Plan Amendment (SPA)

South Carolina State Plan Amendment
 

Back to Map

South Dakota

South Dakota

South Dakota State Plan Amendment (SPA)

South Dakota State Plan Amendment
 

Back to Map

Texas

Texas

Texas State Plan Amendment (SPA)

Texas State Plan Amendment
 

Back to Map

Utah

Utah

Utah State Plan Amendment (SPA)

Utah State Plan Amendment
 

Back to Map

Virginia

Virginia

Virginia State Plan Amendment (SPA)

Virginia State Plan Amendment
 

Back to Map

Washington

Washington

Washington State Plan Amendment (SPA)

Washington State Plan Amendment
 

Back to Map

Wisconsin

Wisconsin

Wisconsin State Plan Amendment (SPA)

Wisconsin State Plan Amendment
 

Back to Map

Wyoming

Wyoming

Wyoming State Plan Amendments (SPAs)

Wyoming State Plan Amendment
 

Back to Map

Page Last Modified:
12/01/2021 08:00 PM