Medicaid Work Rules Don't Apply to Native Americans. They Could Still Lose Coverage

This story was originally published by KFF Health News.

Two months before the deadline to implement new Medicaid work requirements, states had yet to receive detailed guidance from federal health officials on how to exclude Native Americans from those rules, leading to a patchwork of eligibility checks that pose challenges for qualified enrollees trying to keep their health insurance.

President Donald Trump's One Big Beautiful Bill Act excluded Native Americans from having to meet the work requirements to keep their Medicaid eligibility. But the rules issued by the Centers for Medicare & Medicaid Services (CMS) didn't provide a standardized system to help states identify Native Americans who should be excluded, leaving states to figure it out for themselves.

Native leaders fear the limited guidance will mean a repeat of the Medicaid "unwinding" in 2023, when states resumed checking qualifications for eligibility after a Covid-era pause. An estimated 850,000 Native Americans lost coverage by May 2024, often for paperwork reasons.

The latest carve-out for American Indians and Alaska Natives also left out some Indigenous people, such as Native Hawaiians.

"I'm nervous. I'm extremely nervous," said James Burns, who oversees the Eastern Band of Cherokee Indians' Medicaid managed-care program in the Qualla Boundary, the tribe's sovereign land in western North Carolina. "When you look at any state that's rolled out Medicaid work requirements, the unintended consequences have been vast, and that's what we don't want to happen."

CMS published its guidance on work requirements in June, instructing states to use data they already have before potentially asking Native enrollees for additional records. But the rule didn't set a standard process for states to prove Native American status, allowing states to raise the threshold for proof higher than federal requirements.

The rule also didn't require states to share data with tribes, coordinate with Native health providers, or advise on managed-care plans like the one Burns oversees. Managed-care programs contract with the state to provide Medicaid benefits and connect patients to providers when they need care.

In July, a tribal advisory group for CMS recommended that the agency require states to allow Native Americans to self-attest to their eligibility as the standard proof. The group also wanted CMS to require states to share their Medicaid eligibility data with tribal health programs to catch when tribal citizens are mistakenly kicked off Medicaid. The National Council of Urban Indian Health pushed for similar guidance.

Native leaders expect additional guidance to come, said A.C. Locklear, CEO of the National Indian Health Board, which advocates for federally recognized tribes. But Locklear said that if CMS waits until December to issue more specific guidance on the exemption, states will have already determined their own processes. CMS did not respond to KFF Health News' questions about whether it planned to provide more guidance.

"There's 30-plus states who are independently repurposing their administrative processes for this, and they really all happen in a vacuum," Locklear said. "That's why it's really important for CMS to provide guidance."

Falling Through the Cracks

KFF Health News asked 14 states how they would apply the exemption and found that they plan to ask tribal citizens to prove their status in different ways.

Arizona, Colorado, Montana, Nevada, New Mexico, and Washington plan to let enrollees identify their tribal status on their Medicaid application forms. The Arizona Health Care Cost Containment System, the state's Medicaid agency, will continue to allow tribal members to self-identify, then will confirm their status through the state's data on services received through the Indian Health Service or tribally run health centers.

South Dakota linked its claims system to identify people served by IHS, according to the state Department of Social Services. Oklahoma relies on a data-sharing agreement with tribes dating to 2022, according to Cherokee Nation Health Services. North Carolina requires a tribal enrollment card, a tribal census record, or confirmation from the Eastern Band of Cherokee Indians' Tribal Option managed-care program.

"There's still going to be folks that fall through the cracks," said Locklear, a citizen of the Lumbee Tribe of North Carolina.

In North Carolina, 3,400 Native Medicaid enrollees are verified as eligible for the exemption from the work requirement, health department spokesperson Summer Tonizzo said, and those enrollees will be automatically exempted. But the state doesn't know how many more people might be eligible for an exemption through tribal citizenship.

And Native Americans who don't live in states where their tribes are based may face challenges in affirming their status. About 87% of Native people live outside of what the U.S. Census Bureau calls tribal statistical areas, such as reservations, according to 2020 data.

A Navajo Nation citizen living in Connecticut, for example, may have a difficult time being identified by the state because it doesn't have a close working relationship with the tribe based in the southwestern U.S., said Liz Malerba, director of policy and legislative affairs for the United South and Eastern Tribes. She's a citizen of the Mohegan Tribe in Connecticut.

Most states didn't say how many Native enrollees they had verified as exempt from the work requirement. Several said they don't track tribal affiliation, noting that ethnicity questions that would show Native status on applications are optional. In a comment on CMS' work requirements guidance, the National Council of Urban Indian Health warned CMS that "not all states collect data on their American Indian and Alaska Native residents."

States, Tribes Prepare for Workload

The Eastern Band of Cherokee Indians' health system has spent five years building its managed-care program, which is the only tribal-run Medicaid managed-care program in the nation, said Gwynneth Wildcatt, a director with the Cherokee Indian Hospital Authority, who sits on North Carolina's Medicaid Beneficiary Advisory Council. All Medicaid enrollees in that tribe who need exemptions have them, thanks to that program, Wildcatt said.

A close connection with the state has made verifying its citizens for work requirement exemptions simple for the tribe, Wildcatt added, because its program is already integrated into the state Medicaid system. She's a citizen of the tribe.

In Montana, Native people who self-declare their tribal status for the work requirements won't be required to provide additional proof, said Jon Ebelt, a spokesperson for the state Department of Public Health and Human Services.

The state has one of the highest percentages of American Indian and Alaska Native residents in the nation and began work requirement checks in July. It's one of four states, alongside Nebraska, Arkansas, and Georgia, that are doing those scans ahead of the January 1 federal deadline. Iowa begins its program on December 1.

But Native leaders said Montana officials hadn't clearly communicated how Medicaid enrollees could prove their Native status when those checks began. The state saw one of the nation's sharpest declines in enrollment during the Medicaid unwinding as people struggled to navigate a backlogged system. Most enrollees who lost coverage did so due to paperwork problems, which rippled through Native communities.

Jason Smith, a citizen of the Confederated Salish and Kootenai Tribes who leads the Montana Consortium for Urban Indian Health, said clinics serving Indigenous patients are still working to reenroll members who lost Medicaid during that time.

Smith said the state has done a good job addressing tribal priorities while implementing work requirements. But he's still concerned about whether its system is ready to handle the workload of the new mandates. As of September, Montana still hadn't hired the number of workers officials estimated are needed to handle the workload. And federal data shows Montanans can face long waits on the state's helpline.

"Have they improved their communication and outreach?" Smith said. "Will people be there answering phones? It will take time to see."

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