Negotiations over Medicaid expansion in states heavily populated by Native Americans have prompted the CMS to propose fully funding medical services that are often not available at tribal healthcare facilities.
The agency is looking to provide a 100% federal match rate for primary and specialty healthcare services that are purchased from private healthcare providers because they are not available at Indian Health Service or tribal healthcare facilities.
This can include hospital and outpatient care, as well as physician, laboratory, dental, radiology, pharmacy and transportation services.
Currently, the CMS has reimbursed standard Medicaid matching rates for these services. That payment averages 57% across states.
The idea about changing coverage comes as Alaska, the most recent state to expand Medicaid, wrestles with how to pay for it, CMS Medicaid Chief Vikki Wachino said last week during AHIP's Medicaid conference. Alaska has the largest share of the U.S.'s American Indian and Alaska Native population, with nearly 15% residing there, according to federal data.
"When we looked at (Alaska's proposal), we realized that issues Alaska had are faced by many of the 34 states with significant tribal populations," Wachino said.
Alaska's size and the distance between an individual's home community and nearest location of medically necessary services makes travel a barrier to care, said Sarana Schell, a spokeswoman for Alaska Department of Health and Social Services.
South Dakota also recently noted it would be more likely to expand if the CMS fully funded purchased or referred care services.
The implications of CMS' proposal would be huge, Native American policy experts say. IHS funding, around $4 billion annually for approximately 2.2 million people, is limited and must be appropriated by Congress each fiscal year. The IHS estimates the agency spends $3,099 per capita on its beneficiaries. The total U.S. population expenditure is $8,097.
Money now used to bring in specialists could instead expand services at IHS facilities, according to Devin Delrow, a program manager for the National Indian Health Board, a Washington, D.C.-based not-for-profit that represents tribal governments on healthcare issues.
For years, the agency has fully covered Medicaid enrollees' services provided within an IHS or tribal facility, including instances when a specialist is brought in to see patients.
Approximately 5.1 million individuals self-identify as American Indian or Alaska Native, and as many as 41% live in poverty according to the Kaiser Family Foundation. Prior to expansion, Medicaid was already covering 1 in 3 non-elderly American Indians and Alaska Natives.
American Indians and Alaska Natives are more likely to be overweight or obese than the average population. As a result, they have significant problems with diabetes and cardiovascular disease, and experience frequent mental distress, according to the Kaiser Family Foundation. The suicide rate for American Indian and Alaska Native adolescents and young adults is 2½ times higher than the national average.
On Tuesday, the CMS posted more specific proposals for comment. The response deadline is Nov. 17.
Most of these states with the largest Native American populations are in the Western and central part of the country.
The CMS has been actively collecting comments, meeting with tribes in each state, as well as hosting an all-tribes teleconference and a listening session last month.