Provisions for American Indian and Native Alaskan Populations FAQ
- Does the special cost-sharing rule applicable to Indians apply to all metal tiers or is the requirement satisfied if one of the tiers has zero cost-sharing for Indians?
Section 1402(d) of the ACA provides that an eligible Indian enrolled in "any qualified health plan" is entitled to the elimination of all cost-sharing. Indian eligibility for no cost-sharing is determined without regard to the metal tier of the QHP.
- If a carrier (and its affiliates) offers both HMO and PPO products on the public exchange, must each of the HMO and PPO products offer the zero cost-sharing options for Indians?
Yes. Eligible Indians are entitled to enroll in any QHP without cost-sharing, regardless of the AV metal level or product type
- What are the special benefits and protections for AI/AN in the Marketplace?
Members of federally recognized Tribes and shareholders in Alaska Native Regional and Village corporations have the following benefits and protections under ACA:
- They do not have to pay cost-sharing for plans purchased on the Marketplace.
- They can apply the tax credits that are based on the second lowest cost silver plan to any plan on the Marketplace, including lower cost bronze plans, without losing their cost-sharing protections.
- They can enroll or change plans each month.
- They are exempt from the individual mandate, which means they do not have a tax penalty if they do not have insurance coverage.
In Marketplace plans, descendants who are not enrolled in Tribes do not qualify as AI/AN, and, therefore, they have no special Indian status or protections.
- What do AI/AN have to do to avoid cost‐sharing after they sign up for Marketplace insurance?
In the enrollment process, the individual will be given an opportunity to establish their Indian status (this requires answering questions and submitting documentation). After meeting the requirements for Indian status, individuals will be offered variations of plans that are only for Indians. Each plan offered on the Marketplace will have two Indian plan variations that are based on the individual’s:
Zero cost-sharing plan variation – for people who are below 300 percent FPL. There is no cost-sharing for EHBs provided in I/T/U* facilities or through network providers.
Limited cost-sharing plan variation – for people who are above 300 percent FPL or who chose not to have their income determined. There is no cost-sharing for EHBs provided in I/T/U facilities, but they must get a referral from Contract Health Service (CHS) to avoid cost-sharing with any other provider.
If a person is receiving a service that is not included in the 10 Essential Health Benefits (EHBs), then they would have to pay cost-sharing, unless Contract Health Services (CHS) issues an authorization to pay for those services.
* I/T/U is a common acronym for Indian health facilities: (“I”) Indian Health Service, (“T”) Tribally operated facility/program, and (“U”) Urban Indian clinic.
The answers provided are not meant to be a substitute for legal advice.