Washington, DC, August 14, 2026 — The National Council of Urban Indian Health (NCUIH) has released a new resource, Medicaid is Changing, outlining upcoming changes to Medicaid under the One Big Beautiful Bill Act (OBBBA) and the protections in place for American Indian, Alaska Native, and Urban Indian beneficiaries. 

Starting in 2027, most Medicaid enrollees will face new work requirements, more frequent eligibility redeterminations, and new cost-sharing charges for some expansion adults. Indians, Urban Indians, California Indians, and individuals otherwise determined eligible for the Indian Health Service are exempt from these changes.

As of August 2026, some states have already begun implementing these changes ahead of the national deadline. UIOs and patients should confirm their state’s specific timeline with their state Medicaid agency.

What Is the AI/AN and Urban Indian Medicaid Exemption?

Indians, Urban Indians, California Indians, and individuals otherwise determined eligible for the Indian Health Service are exempt from the OBBBA’s new Medicaid work requirements, six-month redetermination cycle, and cost-sharing changes. This exemption is written into the statute itself.

What the Exemption Protects

• No Work Requirement: No work, school, or volunteer hour requirement to keep Medicaid. (OBBBA § 71119(a))
• 12-Month Renewal: The current 12-month renewal cadence is retained, rather than the new 6-month redetermination cycle. (OBBBA § 71107)
• Cost-Sharing Protection: No new cost sharing for services at an Indian health care provider or through qualifying referred care. (ARRA § 5006, 42 U.S.C. § 1396o(j))
  • Note: This protection applies specifically to care received at an Indian health care provider or through a qualifying referral from one. It does not extend to cost sharing for Medicaid services received elsewhere.

Call to Action

Primary Ask: Ensure Proper Implementation of the AI/AN and Urban Indian Medicaid Work Requirement Exemption

States may not yet have sufficient information to reliably identify everyone who qualifies for the AI/AN exemption before outreach occurs, creating a risk of misidentification or confusing notices. HHS and CMS should issue binding guidance so states apply the AI/AN exemption automatically, ensuring implementation does not create new barriers for AI/AN and Urban Indian people.

Ongoing Priority: Preserve and Maintain All Existing Medicaid Resources for the Indian Health System

Cuts to Medicaid place a heavier burden on states and can force Indian health care providers to reduce essential services. Preserving Medicaid resources is critical to ensuring AI/AN and Urban Indian beneficiaries can access necessary care and to fulfilling the trust responsibility.

Frequently Asked Questions

Do American Indian and Alaska Native people have to comply with the new Medicaid work requirements?

No. AI/AN and Urban Indian Medicaid beneficiaries are statutorily exempt from the OBBBA’s community engagement and work requirements.

Will AI/AN Medicaid beneficiaries have their eligibility checked every six months?

No. The exemption preserves the current 12-month Medicaid renewal cycle for AI/AN and Urban Indian beneficiaries. 

Will AI/AN people face new Medicaid cost-sharing charges?

No. Federal law already prohibits cost sharing for services furnished to Indians through Indian health programs, and this protection remains in place under the OBBBA.

When do the OBBBA Medicaid changes take effect?

As of August 2026, the new work requirements and six-month redeterminations are already in effect in Nebraska and Montana, with Arkansas notifying enrollees ahead of a January 1, 2027 compliance start and Iowa following in December 2026. All other states must comply by January 1, 2027.

Who is covered by the AI/AN and Urban Indian Medicaid exemption?

Indians, Urban Indians, California Indians, and individuals otherwise determined eligible for services from the Indian Health Service.

Additional Medicaid Implementation Resources

NCUIH has developed resources to help Urban Indian Organizations (UIOs) and patients prepare for Medicaid implementation and respond when applicable American Indian and Alaska Native protections may not be recognized correctly.

Protecting Medicaid Coverage for American Indian and Alaska Native Patients: Implementation Guide for Urban Indian Organizations

A practical two-page guide to help UIO staff prepare for Medicaid implementation, establish local response procedures, and respond when a patient receives a Medicaid work or renewal notice that may not apply to them.

Got a Medicaid Work or Renewal Notice?

A one-page patient handout explaining what to do after receiving a Medicaid work or renewal notice and how to get help determining whether federal AI/AN protections may apply.

Questions or implementation problems? Contact policy@ncuih.org.

On March 3, 2025, the National Council of Urban Indian Health (NCUIH) joined 30 national and state level provider groups, health plan associations, and patient advocacy groups in signing on to the Medicaid Health Plans of America (MHPA) letter to the Chairs and Rankings Members of the Senate Finance and House Energy & Commerce Committees, expressing strong support for the importance of Medicaid and the Children’s Health Insurance Program (CHIP).

Medicaid provides health coverage to more than 80 million Americans, including working families, children, seniors, and people with disabilities. It plays a key role in ensuring that people have access to doctors, hospitals, and treatment when they need it. In 2023, approximately 2.7 million Native people were enrolled in Medicaid across the United States, according to American Community Service data. Medicaid is a major source of health care funding, particularly for Urban Indian Organizations (UIOs), which provide essential healthcare services to Native people living in urban areas. The letter emphasizes the importance of Medicaid and CHIP as a source of funding for critical safety net facilities and encourages Congressional leadership to continue in a tradition of bipartisan support for these vital programs.

NCUIH remains committed to working with policymakers to support a strong Medicaid program.

Read the letter here.

Full Letter Text

March 3, 2025

The Honorable Mike Crapo, Chairman, Committee on Finance, U.S. Senate
The Honorable Brett Guthrie, Chairman, Energy and Commerce Committee, U.S. House of Representatives The Honorable Ron Wyden, Ranking Member, Committee on Finance, U.S. Senate
The Honorable Frank Pallone, Ranking Member, Energy and Commerce Committee, U.S. House of Representatives

Dear Congressional Leaders,

As a coalition of stakeholders serving individuals relying on the Medicaid and Children’s Health Insurance Programs (CHIP), we write to convey the critical importance of these programs, and to encourage you to continue to strengthen both in the years to come. The flexibility, efficiency and positive impact of Medicaid in every state across the country is a hallmark of how federal-state partnerships can deliver results tailored to local needs.

As you know, Medicaid serves a broad spectrum of Americans across all walks of life, including children, mothers, the aged, blind and disabled, individuals with substance use disorder (SUD), persons with mental health conditions and mental illness, and low-income individuals, all of whom depend on the program to provide them with access to health care services and life-saving treatments.

Medicaid shines as a bright example of what can be accomplished when the Federal government works with state partners to deliver for the American people. The flexibility and accountability of the program enables efficient coverage for over 79 million individuals in 50 states and the District of Columbia, as of October 2024. The Medicaid program allows states the ability to tailor their programs to meet the needs of their unique populations, while creating efficiencies and innovations that might not be possible in other delivery systems.

With the ability to design their own programs, states have leveraged the Medicaid program to ensure access to care for our most vulnerable populations; populations that would have no other source of insurance coverage. Individuals with disabilities rely on the Medicaid program to receive long-term services and supports, both at in person nursing facilities and through home and community-based services, allowing them to find employment and serve as active members of their communities. Medicaid plays a key role in providing mental health and SUD services, as 40% of the nonelderly adult Medicaid population (13.9 million enrollees) had a mental health condition or SUD in 2020. And more than 37 million children receive health coverage through Medicaid and CHIP, representing 47.4% of overall Medicaid and CHIP program enrollment. Nearly two out of every three adult women enrolled in Medicaid are in their reproductive years, and Medicaid currently covers about 42% of all births in the United States. Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit keeps children healthy and provides them with critical behavioral health services. EPSDT is also a benefit with strong bipartisan support that was recently strengthened by the Safer Communities Act.

In addition to the vulnerable populations covered by Medicaid, it is a crucial source of coverage for many safety net facilities and the clinicians relied on by patients in these settings. Insurance coverage through Medicaid ensures that our safety net facilities, including rural hospitals, health centers, mental health centers, nursing homes, critical access hospitals, and others, remain open and can provide primary and specialty care services, as well as 24/7 emergency care, to the communities surrounding them. Without comprehensive Medicaid coverage these facilities may be forced to close, and millions of people would need to travel hundreds of miles to access a health care facility to receive necessary care from trusted clinicians.

It is vital that Medicaid and CHIP continue to receive strong support from the Federal government, so that the program can continue to serve mothers, children, the aged, blind and disabled, individuals with SUD, persons with mental health conditions and mental illness, and low-income Americans, all who depend on the program to stay healthy and to receive life-saving treatments. Interruptions in health coverage, even temporary, have been shown to lead to a deterioration of 2 health conditions which later leads to higher costs for payers, challenging the sustainability of the program and making it more difficult for Americans depending on Medicaid to continue to work and contribute as members of their communities. Further, reductions in Medicaid funding could lead to hospital closures and reduced access to healthcare providers in rural and underserved areas, that are already struggling to meet the needs of their populations. Medicaid and CHIP have historically received bipartisan support, and we respectfully encourage you to continue this tradition, in order to strengthen and enhance this vital program serving millions of Americans across the country.

We sincerely thank you for your consideration and remain available to work with you and your colleagues to continue to meet the needs of the American people through a flexible, accountable, and efficient Medicaid program.

Respectfully,

National
Advocates for Community Health
Alliance of Community Health Plans
Allies for Independence
American Academy of Pediatric Dentistry
American Association of Nurse Practitioners
American Association on Health and Disability
American Dental Association
American Nurses Association
Association for Community Affiliated Plans
Association of Clinicians for the Underserved (ACU)
CommunicationFIRST
Federation of American Hospitals
Institute for Exceptional Care
Lakeshore Foundation
Medicaid Health Plans of America (MHPA)
National Association of Community Health Centers
National Association of Pediatric Nurse Practitioners
National Disability Rights Network (NDRN)
National Health Care for the Homeless Council
National MLTSS Health Plan Association
The National Council of Urban Indian Health

State
Access Living (Illinois)
Coalition of New York State Public Health Plans (New York)
Kentucky Association of Health Plans (Kentucky)
Local Health Plans of California (California)
Michigan Association of Health Plans (Michigan)
Minnesota Association of County Health Plans (Minnesota)
National Council on Independent Living (District of Columbia)
Ohio Association of Health Plans (Ohio)
Pennsylvania’s Medicaid Managed Care Organizations (PAMCO) (Pennsylvania)