Exempt from Medicaid work rules, Native enrollees still risk losing coverage

Federal law exempts American Indians and Alaska Natives from work requirements, but no standard way to prove status leaves coverage exposed to paperwork.

The One Big Beautiful Bill Act exempts Native Americans from Medicaid work requirements. But CMS rules did not create a standard system for states to identify who is exempt. Guidance issued in June tells states to use existing data before asking Native enrollees for more records, yet it sets no standard process for proving Native status. States can therefore demand proof beyond federal requirements, and they are not required to share data with tribes or coordinate with Native health providers or managed-care plans. The exemption also covers American Indians and Alaska Natives but leaves out some Indigenous groups, such as Native Hawaiians.

States are improvising. KFF Health News asked 14 states about their approach. Arizona, Colorado, Montana, Nevada, New Mexico and Washington let enrollees identify tribal status on application forms. South Dakota linked its claims system to identify people served by Indian Health Service. Oklahoma relies on a 2022 data-sharing agreement with tribes. North Carolina requires a tribal enrollment card, a tribal census record, or confirmation from the Eastern Band of Cherokee Indians' Tribal Option program. It has 3,400 verified Native enrollees who will be exempted automatically, but does not know how many more qualify through tribal citizenship.

The risk is that coverage is lost to paperwork rather than ineligibility. An estimated 850,000 Native Americans lost Medicaid by May 2024 during the post-covid unwinding, often over paperwork. About 87% of Native people live outside Census-defined tribal statistical areas, per 2020 data, which can complicate verification for people living away from their tribes' home states. For communities that depend on Medicaid for health care, an exemption that is hard to prove narrows access in practice.

In July, a CMS tribal advisory group recommended that states accept self-attestation as standard proof and share eligibility data with tribal health programs. Checks began in Montana in July, with Iowa starting Dec. 1 and a Jan. 1 federal deadline. CMS did not say whether it will issue more guidance. A.C. Locklear said that if it waits until December, states will already have set their own processes. Coverage-loss concerns are projections from tribal leaders, not documented outcomes, and most states did not say how many Native enrollees they have verified.

Source: KFF Health News