Skip to Main Content

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

Interactive Map

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

 

Interactive Map

Map of the United States Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware Washington, DC Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachussets Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

State Placeholder

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

Back to Map

Alaska

Back to Map

Arizona

Back to Map

California

Back to Map

Colorado

Back to Map

Connecticut

Back to Map

Florida

Back to Map

Hawaii

Back to Map

Idaho

Back to Map

Illinois

Back to Map

Iowa

Back to Map

Kansas

Back to Map

Louisiana

Back to Map

Maine

Back to Map

Maryland

Back to Map

Massachusetts

Back to Map

Michigan

Back to Map

Minnesota

Back to Map

Mississippi

Back to Map

Montana

Back to Map

Nebraska

Back to Map

Nevada

Back to Map

New Mexico

Back to Map

New York

Back to Map

North Carolina

Back to Map

North Dakota

Back to Map

Oklahoma

Back to Map

Oregon

Back to Map

Rhode Island

Back to Map

South Carolina

Back to Map

South Dakota

Back to Map

Texas

Back to Map

Utah

Back to Map

Washington

Back to Map

Wisconsin

Back to Map

Wyoming