On October 28, 2022, the Partnership for Medicaid (Partnership) sent a letter to House and Senate leadership urging that several Medicaid policy proposals be prioritized as Congress considers an end-of-year health care package. In the letter, they requested that Congress seek to include legislation that would extend 100% Federal Medical Assistance Percentage (FMAP) for urban Indian organizations (UIOs) and Native Hawaiian Health Systems for another two years. After advocacy from the National Council for Urban Indian Health (NCUIH), the American Rescue Plan Act (ARPA) authorized 8 fiscal quarters of 100% FMAP to UIOs, which is set to expire in just 3 months.

• Partnership for Medicaid Letter to Congress on Medicaid Priorities in an End of Year Legislative Package

Full Letter Text

Dear Leader Schumer, Speaker Pelosi, Minority Leader McConnell, and Minority Leader McCarthy:

On behalf of the Partnership for Medicaid (Partnership), thank you for your continued commitment to the Medicaid program. Our member organizations are eager to collaborate with you to build upon efforts to sustain and strengthen Medicaid.

The Partnership – a nonpartisan, nationwide coalition made up of organizations representing clinicians, health care providers, safety net plans, and counties –appreciates initiatives from Congress throughout the COVID-19 pandemic to bolster the Medicaid program and support the health care safety net. Your continued attention has not only allowed the program to meet the needs of millions of Americans during a public health crisis but has also reinforced the importance of investing in Medicaid now to protect and sustain its promise for the future.

As the Congress considers an end-of-year health care package, the Partnership urges lawmakers to prioritize policy proposals to strengthen Medicaid and ensure its stability for underrepresented populations who rely on this critical program. Congress should seek to include legislation that would:

• building on provisions included in the FY 2022 Continuing Resolution, create a permanent and sustainable Medicaid financing solution for Puerto Rico and other territories;
• permanently ensure that all pregnant individuals on Medicaid and the Children’s Health Insurance Program (CHIP) keep their health coverage during the critical first year postpartum;
• provide one year of continuous eligibility for children covered by Medicaid and CHIP;
• appropriately fund the Medicaid program in a manner that supports states to set competitive rates necessary for garnering equitable access for Medicaid, as undervaluing Medicaid payments—and consequently, the patients Medicaid serves—perpetuates systemic barriers to health and health care and worsens health disparities;
• invest in and improve access to Medicaid home-and community-based services (HCBS) and mental health services, including for children, while strengthening the direct care workforce;
• provide Medicaid coverage to eligible, justice-involved individuals 30 days prior to release;
• extend the 100 percent federal medical assistance percentage (FMAP) for Urban Indian Organizations and Native Hawaiian Health Systems for another two years;
• make permanent Medicaid’s Money Follows the Person program and the Protection Against Spousal Impoverishment.
• permanently fund CHIP; and
• close the Medicaid coverage gap for Americans living in states that have yet to expand Medicaid and still lack access to health insurance

Taken together, these proposed improvements to Medicaid and CHIP represent an opportunity to stabilize and expand access to health care and long-term services and supports for millions of low-income Americans, from older adults, people with disabilities, children, pregnant and postpartum individuals, and their families, and more.

Furthermore, for Medicaid issues legislatively tied to the public health emergency, we urge Congress to proceed with caution when applying imminent, static sunsets to policies stakeholders rely upon to help mitigate COVID-19’s ongoing impact. For example, Congress should create a predictable, evidence-informed wind down of the enhanced FMAP and continuous coverage provisions included in the Families First Coronavirus Response Act that provides sufficient guardrails to protect beneficiaries while also reflecting the trajectory of the COVID-19 pandemic.

We remain grateful for your leadership and commitment to the Medicaid program and the populations it serves. If you have questions or seek any additional information, please contact Jonathan Westin at the Jewish Federations of North America, First Co-Chair of the Partnership for Medicaid at Jonathan.Westin@jewishfederations.org.

Sincerely,

America’s Essential Hospitals
American College of Obstetricians and Gynecologists
American Dental Education
Association American Network of Community Options and Resources (ANCOR)
Associations of Clinicians for the Underserved
Catholic Health Association of the United States
Children’s Hospital Association
Easterseals
Jewish Federations of North America
National Association of Counties
National Association of Pediatric Nurse Practitioners
National Association of Rural Health Clinics (NARHC)
National Council for Mental Wellbeing
National Council of Urban Indian Health
National Health Care for the Homeless Council
National Rural Health Association

About the Partnership for Medicaid

NCUIH is a member of the Partnership for Medicaid, which is a nonpartisan, nationwide coalition of organizations representing clinicians, health care providers, safety-net health plans, and counties. The goal of the coalition is to preserve and improve the Medicaid program. Members of this coalition include:

• American Academy of Family Physicians
• American Academy of Pediatrics
• American College of Obstetricians and Gynecologists
• American Dental Association
• American Dental Education Association
• American Health Care Association
• American Network of Community Options and Resources
• America’s Essential Hospitals
• Association for Community Affiliated Plans
• Association of Clinicians for the Underserved
• Catholic Health Association of the United States
• Children’s Hospital Association
• Easterseals
• The Jewish Federations of North America
• Medicaid Health Plans of America
• National Association of Community Health Centers
• National Association of Counties
• National Association of Pediatric Nurse Practitioners
• National Association of Rural Health Clinics
• National Council for Mental Wellbeing
• National Council of Urban Indian Health
• National Health Care for the Homeless Council
• National Hispanic Medical Association
• National Rural Health Association

Background and NCUIH Advocacy on Medicaid

100% FMAP for UIOs

FMAP refers to the percentage of Medicaid costs covered by the federal government, which will be reimbursed to the states. Permanent authorization or an extension of the 100% FMAP for UIOs provision will further the government’s trust responsibility to American Indians/Alaska Natives (AI/ANs) by increasing available financial resources to UIOs and support them in addressing critical health needs of AI/AN patients. In March of 2021, Congress enacted ARPA which authorized eight fiscal quarters of 100% FMAP coverage for UIOs. Congress did this in part to increase the financial resources available to UIOs and support the provision of critically needed health services to urban AI/ANs during the COVID-19 pandemic. Unfortunately, with only 3 months until the provision expires, most UIOs have not received any increase in financial support because many states have not increased their Medicaid reimbursement rates to UIOs, citing short-term authorization concerns.

There has been strong support for the expansion of 100% FMAP to UIOs across Indian Country and NCUIH has tirelessly advocated to permanently fix this parity issue. The National Congress of American Indians and the National Indian Health Board passed resolutions along with NCUIH in support of extending 100% FMAP to UIOs. Additionally, there has been longstanding bipartisan congressional support, with over 17 pieces of legislation having been introduced since 1999 on this issue. NCUIH recently sent a letter to the House Committee on Energy and Commerce leadership requesting a markup on the Improving Access to Indian Health Services Act (H.R. 1888), which would establish permanent 100% FMAP for services provided to AI/ANs Medicaid beneficiaries at UIOs.

NCUIH and Partnership for Medicaid Priority: Medicaid Unwinding

After the COVID-19 Public Health Emergency (PHE), states will resume normal operations, which includes processing eligibility renewals and ending coverage for individuals no longer eligible for Medicaid and Children’s Health Insurance Program (CHIP) in a process known as “unwinding.” The Partnership for Medicaid advocates for protections against the potential loss of coverage for millions of Medicaid beneficiaries at the end of the PHE. NCUIH recently released a Medicaid unwinding toolkit for UIOs as they prepare for changes in Medicaid coverage. This document outlines the impact of Medicaid unwinding on AI/ANs and the steps UIOs can take to assist their patients with their coverage, such as working with their state, Tribes, federal agencies, and their community.

• NCUIH COVID-19 Public Health Emergency Medicaid Unwinding Toolkit

On September 20, 2022, The National Council of Urban Indian Health (NCUIH) sent a letter to Chair Frank Pallone and Ranking Member Cathy McMorris Rodgers on the House Committee on Energy and Commerce requesting a markup on the Improving Access to Indian Health Services Act (H.R. 1888). This bill would establish permanent 100% Federal Medical Assistance Percentage (FMAP) for services provided to American Indian/Alaska Native (AI/AN) Medicaid beneficiaries at urban Indian Organizations (UIOs).  The American Rescue Plan (ARP) authorized 8 fiscal quarters of 100% FMAP to UIOs. However, the ARP provision expires in less than 5 months, and UIOs are not seeing the benefit of this provision. States are generally not increasing their Medicaid reimbursement rates to UIOs, resulting in states seeing the 100% FMAP savings intended to go to UIOs.

Full Letter Text

Dear Chair Pallone and Ranking Member McMorris Rodgers,

On behalf of the National Council of Urban Indian Health (NCUIH), the national advocate for health care for the over 70% of American Indians and Alaska Natives (AI/ANs) living off-reservation and the 41 Urban Indian Organizations (UIOs) that serve these populations, we write to request the markup of H.R. 1888. This bill would permanently establish a 100% federal matching rate, also known as the Federal Medical Assistance Percentage (FMAP), for Medicaid services provided at UIOs.  This bill would also permanently expand Medicaid coverage to include clinical services provided outside of a clinic by an Indian Health Service (IHS) facility, a tribe or tribal organization, or UIO.

Extending FMAP to UIOs

FMAP refers to the percentage of Medicaid costs covered by the federal government, which will be reimbursed to the states. In 1976, Congress passed the Indian Health Care Improvement Act (IHCIA) which amended the Social Security Act to add Section 1911. Section 1911 authorized reimbursement by Medicaid for services provided to AI/AN Medicaid beneficiaries at Indian Health Service (IHS) and Tribal health care facilities.1 In addition,  ICHIA amended section 1905(b) of the SSA to set the FMAP at 100% for Medicaid services received through an IHS facility, whether operated by IHS or by an Indian Tribe. When Congress first authorized 100% FMAP for the Indian healthcare system in 1976, it did so because it recognized that “Medicaid payments are . . . a much needed supplement to a health care program which has for too long been insufficient to provide quality health care to” AI/ANs and because “the Federal government has treaty obligations to provide services to Indians, it has not been a State responsibility.”2 Unfortunately, the IHCIA amendments to the SSA were not inclusive of UIOs, meaning that services provided at UIOs were not eligible for 100% FMAP under IHCIA’s authority.

In March of 2021, Congress enacted the American Rescue Plan Act of 2021 (ARPA). Section 9815 of ARPA authorized eight (8) fiscal quarters of 100% FMAP coverage for Medicaid services at provided UIOs. Congress intended Section 9815 in part to increase the financial resources available to UIOs and support the provision of critically needed health services to urban AI/ANs during the COVID-19 pandemic. However, the ARPA’s 100% FMAP extension to UIOs ends in less than 6 months, and UIOs have generally not seen any increased financial support because of this extension. Unfortunately, states are not increasing their Medicaid reimbursement rates to UIOs, citing the short-term authorization for the UIO 100% FMAP extension as a reason not to increase their reimbursement rates.

On March 23, 2021, the House Committee on Energy and Commerce held a legislative hearing on the Affordable Care Act, which included H.R. 1888. At the hearing, Representative Raul Ruiz emphasized that there is no sound policy reason for excluding UIOs from eligibility for 100% FMAP and advocated for the Committee to pass this critical piece of legislation to address this longstanding issue.  There has been strong support for the expansion of 100% FMAP to UIOs across Indian Country. For example, both the National Congress of American Indians and the National Indian Health Board have passed resolutions in support of extending 100% FMAP to UIOS. Additionally, there has been longstanding bipartisan congressional support for extending 100% FMAP to UIOs, with over 17 pieces of legislation having been introduced since 1999 on this issue.

The federal government has a trust responsibility to provide “[f]ederal health services to maintain and improve the health of the Indians.3 The federal government owes that duty to all AI/ANs, no matter where they live, and Congress has declared it the policy of the United States “to ensure the highest possible health status for Indians and urban Indians and to provide all resources necessary to effect that policy.”4 Permanent 100% FMAP for UIOs will further the U.S. government’s trust responsibility to AI/ANs by increasing the available financial resources to UIOs and supporting them in addressing the critical health needs of their AI/AN patients. We request the markup of H.R. 1888 to honor this trust responsibility and progress the health of all AI/AN people, regardless of their location. Thank you for your attention to this urgent matter.

FMAP Background

FMAP refers to the percentage of Medicaid costs covered by the federal government, which will be reimbursed to the states. In 1976, Congress passed the Indian Health Care Improvement Act (IHCIA) which authorized reimbursement by Medicaid for services provided to AI/AN Medicaid beneficiaries at IHS and Tribal health care facilities. This set FMAP at 100% for Medicaid services received through an Indian Health Service (IHS) facility, whether operated by IHS or by an Indian Tribe.

Congress first authorized 100% FMAP for the Indian healthcare system in 1976 because it recognized that “Medicaid payments are . . . a much needed supplement to a health care program which has for too long been insufficient to provide quality health care to AI/ANs.” However, UIOs were not included in this IHCIA authorization as an oversight, meaning that services provided at UIOs were not eligible for 100% FMAP.

ARPA FMAP Provision and Permanent 100% FMAP for UIOs

In March of 2021, Congress enacted the ARP, which authorized two years of 100% FMAP coverage for Medicaid services provided at UIOs. Congress did this in part to increase the financial resources available to UIOs and support the provision of critically needed health services to urban AI/ANs during the COVID-19 pandemic. However, ARPA’s 100% FMAP extension to UIOs expires in less than 6 months, and states are generally not increasing their Medicaid reimbursement rates to UIOs, citing short-term authorization as a reason not to increase their reimbursement rates. H.R. 1888 would remedy this problem and establish a permanent 100% FMAP rate for services provided at UIOs to ensure they can continue providing critical health services to their AI/AN patients.

This bill would also permanently expand Medicaid coverage to include clinical services provided outside of a clinic by an IHS facility, Tribe, tribal organization, or UIO. This has been a critical priority identified by Indian Country to ensure that services provided through an Indian health care program are eligible for reimbursement at the IHS all-inclusive rate, no matter where that service is provided.

Support for 100% FMAP to UIOs

On March 23, 2021, the House Committee on Energy and Commerce held a legislative hearing on the Affordable Care Act, which included H.R. 1888. At the hearing, Representative Raul Ruiz emphasized that there is no sound policy reason for excluding UIOs from eligibility for 100% FMAP and advocated for the Committee to pass this critical piece of legislation to address this longstanding issue.  Additionally, there has been longstanding bipartisan congressional support for extending 100% FMAP to UIOs, with over 17 pieces of legislation having been introduced since 1999 on this issue.

 There has also been strong support for the expansion of 100% FMAP to UIOs across Indian Country. For example, both the National Congress of American Indians and the National Indian Health Board passed resolutions along with NCUIH in support of extending 100% FMAP to UIOs.

The federal government has a trust responsibility to provide health services to maintain and improve the health of all AI/ANs, no matter where they live.  Congress has also declared it the policy of the United States to ensure the highest possible health status for AI/ANs and to provide all resources necessary to do so. H.R. 1888 is a critical piece of legislation that would further the federal government’s trust responsibility to AI/ANs by increasing the available financial resources to UIOs to better address the critical health needs of their patients and ultimately bolster the entire Indian Health system.

Next Steps

NCUIH will continue to advocate for the markup of H.R. 1888 and provide updates on its movement within Congress.