State Tribal Relations on HealthCare

Government-To-Government Relationship

Since the formation of the Union, the United States (U.S.) has recognized Indian Tribes as sovereign nations. A unique government-to-government relationship exists between Indian Tribes and the Federal government and this relationship is grounded in the U.S. Constitution, numerous treaties, statutes, Federal case law, regulations and executive orders that establish and define a trust relationship with Indian Tribes. The federal government honors this unique relationship by adhering to Executive Order 13175, requiring federal agencies to engage in meaningful tribal consultation with tribes. As a result of the Executive Order, the Department of Health and Humans Services and the Centers for Medicare & Medicaid Services each have a tribal consultation policy.


State-Tribal Consultation Requirements

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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 Requirements

Depending on the nature of the policy at issue, states are subject to varying levels of soliciting advice or tribal consultation requirements.  Section 5006 of the American Recovery and Reinvestment Act (ARRA) (Section 1902(a)(73) of the Social Security Act (SSA)), section 1115 Transparency Regulations (42 CFR 431.408(b)) and Regulations for Exchanges under section 1311 of the Affordable Care Act (ACA) hold the states to certain requirements.   Please click on the Interactive Map to find copies of the State Plan Amendments (SPAs) required under section 5006.  The map will be populated with more information as it becomes available.


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

The SSA allows states to impose enrollment fees, premiums, cost-sharing, and similar charges on some Medicaid participants. However, section 5006 of the ARRA provides certain protections for Indians that preclude states from imposing Medicaid premiums or any other Medicaid cost-sharing on Indian applicants and participants who have used the Indian health system. Section 5006 also establishes new requirements for states to seek advice on Medicaid and CHIP matters.  Specifically, states must seek advice from designees of Indian health programs and urban Indian organizations in the state when Medicaid and CHIP matters have a direct effect on Indians, Indian health programs or urban Indian programs. States are also required to describe the process for seeking advice from Indian health programs and urban Indian organizations in the Medicaid and CHIP State Plans. 


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

Section 1115 of the SSA allows the Secretary of Health and Human Services to waive certain Medicaid requirements of the SSA for experimental, pilot, or demonstration projects. Section 1115 waivers are vehicles that states can use to test new or existing ways to deliver and pay for health care services that promote the objectives of the Medicaid and the Children’s Health Insurance Program (CHIP). These waivers can influence policy-making at the State, Tribal, and Federal level by introducing new approaches that can be models for other states and lead to programmatic changes nationwide. CMS issued regulations requiring states to obtain advice and input from stakeholders and specifically required states to consult with federally-recognized tribes in the state prior to submitting section 1115 waiver requests.  States that already have included tribes in their State Plan or that have tribal consultation plans or accords may follow their established processes for tribal consultation.  If a state does not have an established process, the section 1115 transparency regulations detail time frames and a process to meet the requirement.


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 guiding consultation with Tribes. They also have an established history of successful State-Tribal consultation practices. State and Tribal participants in Medicaid and CHIP consultations identified the strengths and weaknesses of these current consultation processes in each location.

A summary of best practices from Minnesota, Oregon, and Washington, as well as findings from each individual state, can be downloaded below.


What are the Exchanges (45 CFR Part 155)?

Starting January 1, 2014, Americans will have access to Affordable Insurance Exchanges (Exchanges), State-based competitive marketplaces where individuals and small businesses will be able to purchase private health insurance and have the same affordable insurance choices as Members of Congress. Exchanges will begin operating in 2014 and will make it easy for consumers and small businesses to compare health plans, get answers to questions, and enroll in or offer to their employees a health insurance plan that meets their needs.  Individuals will be able to find out if they are eligible for advance payments of premium tax credits and cost sharing reductions, or health programs like the Children’s Health Insurance Program (CHIP); small businesses will only be eligible for the small business tax credit for coverage purchased for employees through the Exchange.

An Exchange can help individuals:

  • Look for and compare health plans based on price, benefits, cost-sharing and quality.
  • Get answers to questions about your health insurance coverage options.
  • Find out if you’re eligible for private insurance tax credits or cost-sharing reductions or public insurance programs that make coverage more affordable.
  • Enroll in a health plan that meets your needs and budget.

In 2014, consumers in all States will have access to health insurance coverage.  States will operate as one of the following Exchange models:

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

To complete the Exchange application, the Exchange, in consultation with the Federally-recognized Tribes, must have developed and implemented a Tribal consultation policy or process, which has been submitted to HHS and the Exchange must have an outreach plan for populations including Federally-recognized Tribal communities. As part of a State’s Approval or Conditional Approval decision, States should post its Tribal-consultation plan (excluding test data) of a State’s Exchange Application on the appropriate State website within ten (10) business days of an Approval or Conditional Approval decision.

Link to CCIIO Blueprint for Approval of Affordable State-Based and State Partnership Insurance Exchanges:

Link to CCIIO Letters and News Releases website to see letters to Governors of States that received Conditional Approval to Establish a State-Based Exchange:

Page Last Modified:
02/11/2020 06:24 PM