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Health Coverage and Care for American Indians and Alaska Natives

Appendix A: Federal Medicaid Payments for Uncompensated Care at IHS Facilities in Arizona and California

Recently, CMS has approved Section 1115 waivers that include provisions designed to improve the financial viability of IHS- and tribally-operated facilities. Section 1115 of the Social Security Act authorizes the Secretary of HHS, at the request of a state, to waive certain requirements of federal Medicaid law to enable the state to experiment with different approaches to delivering or paying for services. Section 1115 also authorizes the Secretary to provide federal Medicaid matching funds for state costs that would not otherwise be matched under current rules, subject to an overall budget neutrality limit.

As of July 2011, almost half of the roughly 278,000 American Indians and Alaska Natives residing in Arizona were enrolled in the state’s Medicaid program.1 In 2010, Arizona made cutbacks in Medicaid eligibility and benefits to reduce state spending, closing enrollment for childless adults with incomes below 100% of the federal poverty level (FPL) and eliminating coverage of certain optional services such as adult dental care. As a result of these reductions, IHS- and tribally-operated facilities would no longer receive reimbursement for poor childless adults unable to enroll in the program due to the enrollment cap and optional services no longer covered by Medicaid. However, because the federal government pays 100% of the cost of covered services provided to American Indians and Alaska Natives through IHS- or tribally-operated facilities, the state would not realize any savings from the reductions in these services provided by these facilities to American Indians and Alaska Natives

In April 2012, CMS approved an amendment to Arizona’s existing section 1115 waiver that enables IHS- and tribally-operated facilities to continue to receive federal Medicaid funds for services provided to these childless adults and for these optional services, even though they are no longer covered by the state Medicaid program. Specifically, under the waiver, the federal government will pay IHS- and tribally-operated facilities for uncompensated care costs that stem from services provided to adults with incomes below 100% FPL who are no longer able to enroll in Medicaid and the provision of optional services that are no longer covered by the program to Medicaid-eligible individuals. According to the waiver approval, this “will enable the State to evaluate how this approach impacts the financial viability of IHS and 638 [tribal] facilities and ensures the continued availability of a robust health care delivery network for current and future beneficiaries.”2

In April 2013, a similar waiver amendment was approved in California that allows the state Medicaid agency to make supplemental payments to IHS facilities, including tribal facilities, to take into account the burden of providing care to certain uninsured adults and for optional services that are no longer covered by the state Medicaid program. The waiver approval states this will enable the state “to test the effects of the payments on the financial viability of IHS and 638 [tribal] providers and determine if Medicaid funding under the demonstration results in an increase in the volume of primary care services delivered to Medicaid beneficiaries, an increase in the capacity to deliver such services by participating providers.”3

Appendix B, Table 1

Nonelderly Uninsured American Indians and Alaska Natives (AIANs), 2009-2011
 State  Total Nonelderly AIANs Percent Uninsured Distribution of Uninsured by Income
Total Uninsured AIANs <139% FPL 139-400% FPL 400% FPL +
United States 2,279,100 30% 694,300 61% 33% 6%
Alabama 24,100 20% 4,800 56%
Alaska 91,400 40% 36,300 59% 33% 8%
Arizona 258,900 31% 80,200 65% 30% 5%
Arkansas 17,400 24% 4,100 49%
California 253,400 25% 63,500 59% 33% 8%
Colorado 45,000 29% 13,200 64% 31%
Connecticut 6,700 13%
Delaware 2,500 40%
District of Columbia
Florida 57,100 38% 21,800 57% 34% 9%
Georgia 20,900 32% 6,700 68% 31%
Hawaii 2,600 9%
Idaho 18,400 34% 6,200 69% 27%
Illinois 22,300 20% 4,600 67%
Indiana 12,300 31% 3,800 72%
Iowa 9,400 24% 2,200 61%
Kansas 22,200 26% 5,800 72% 27%
Kentucky 7,800 20% 1,600 82%
Louisiana 24,200 30% 7,300 59% 36%
Maine 6,900 15%
Maryland 15,600 24% 3,700 58%
Massachusetts 11,400 16%
Michigan 48,900 19% 9,100 65% 28%
Minnesota 53,100 23% 12,000 57% 32%
Mississippi 12,900 36% 4,700 57%
Missouri 19,300 21% 4,100 60%
Montana 58,600 47% 27,700 60% 31% 9%
Nebraska 16,100 37% 6,000 69% 28%
Nevada 25,200 33% 8,400 62% 31%
New Hampshire 2,600 21%
New Jersey 19,300 29% 5,600 57%
New Mexico 175,500 42% 73,600 60% 35% 5%
New York 59,200 23% 13,600 61% 30%
North Carolina 99,300 30% 29,700 64% 32%
North Dakota 33,200 36% 11,900 72% 22%
Ohio 19,500 19% 3,800 56%
Oklahoma 232,800 32% 74,500 57% 37% 6%
Oregon 46,200 30% 13,900 64% 30%
Pennsylvania 14,700 14% 2,100 62%
Rhode Island 3,900 16%
South Carolina 12,700 23% 2,900 69%
South Dakota 64,800 38% 24,700 73% 23%
Tennessee 13,600 30% 4,100 69%
Texas 116,400 30% 35,300 58% 36%
Utah 29,200 35% 10,300 69% 25%
Vermont
Virginia 22,500 26% 5,800 53%
Washington 85,900 26% 22,500 58% 35%
West Virginia 2,800 19%
Wisconsin 44,600 24% 10,700 57% 39%
Wyoming 12,600 32% 4,100 61% 32%
“–” = Sample size not sufficient for reliable estimate; totals may not sum to 100% due to rounding and sample size restrictionsAmerican Indian and Alaska Native includes people of Hispanic origin.Data include noninstituational, civilian nonelderly individuals ages 0-64.SOURCE: KCMU analysis of the 2009-2011 American Community Survey.

Appendix B, Table 2

Nonelderly Uninsured American Indian and Alaska Native Adults <100% FPL by State, 2009-2011
Grouped by Status of State Medicaid Expansion Decision as of September 30, 2013
Nonelderly Uninsured Adults <100% FPL Distribution of Nonelderly Uninsured Adults  <100% FPL
UNITED STATES                                               268,400 100%
MOVING FORWARD AT THIS TIME
Arizona 29,100 11%
Arkansas  –
California                                                  25,400 9%
Colorado                                                    4,800 2%
Connecticut  –
Delaware  –
District of Columbia  –
Hawaii  –
Illinois                                                    2,300 1%
Iowa  –
Kentucky  –
Massachusetts  –
Michigan                                                    3,700 1%
Minnesota                                                    3,900 1%
Nevada                                                    3,400 1%
New Jersey  –
New Mexico                                                  30,000 11%
New York                                                    4,500 2%
North Dakota                                                    4,200 2%
Oregon                                                    5,900 2%
Rhode Island  –
Vermont  –
Washington                                                    9,200 3%
West Virginia  –
Total                                               135,300 50%
NOT MOVING FORWARD AT THIS TIME
Alabama                                                    1,800 1%
Alaska                                                  13,300 5%
Florida                                                    7,700 3%
Georgia                                                    3,000 1%
Idaho                                                    2,700 1%
Indiana  –   –
Kansas                                                    2,600 1%
Louisiana                                                    2,500 1%
Maine  –   –
Mississippi  –   –
Missouri  –   –
Montana                                                    9,500 4%
Nebraska                                                    2,600 1%
New Hampshire  –   –
North Carolina                                                  13,800 5%
Ohio  –   –
Oklahoma                                                  26,200 10%
Pennsylvania  –   –
South Carolina                                                    1,700 1%
South Dakota                                                  11,200 4%
Tennessee                                                    2,400 1%
Texas                                                  12,700 5%
Utah                                                    4,800 2%
Virginia  –   –
Wisconsin                                                    4,000 1%
Wyoming                                                    2,000 1%
Total                                               133,100 50%
– = Sample size is not sufficient for a reliable estimate.American Indian and Alaska Native includes people of Hispanic origin.Data include noninstituational, civilian nonelderly individuals ages 0-64.SOURCES: Status of Medicaid expansion decision based on Centers for Medicare and Medicaid Services data available at: http://www.medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/Downloads/Medicaid-and-CHIP-Eligibility-Levels-Table.pdf. Uninsured data based on KCMU analysis of 2009-2011 American Community Survey.
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