IHS-funded facilities are allowed to retain reimbursements  without an offsetting reduction in their IHS funding. Federal Consultation Requirements

In recognition of the unique government-to-government relationship  between the federal government and Indian tribes, federal agencies are  required by Executive Order to consult with Indian tribes on “policies that  have tribal implications.” The order states that “ach agency shall have  an accountable process to ensure meaningful and timely input by tribal  officials in the development of regulatory policies that have tribal  implications.” The order defines policies that have tribal implications as  regulations, legislative comments or proposed legislation, and other policy  statements or actions that have substantial direct effects on one or more  Indian tribes, on the relationship between the federal government and  Indian tribes, or on the distribution of power and responsibilities between  the federal government and Indian tribes. CMS and IHS Have Interacted to Provide Support as Well as Address Broader Policy and Regulatory Concerns

CMS and IHS have interacted to provide support to IHS-funded facilities  and Indian tribes in accessing Medicare and Medicaid as well as to address  efforts associated with broader policy and regulatory concerns regarding  the two programs. At a  broader policy level, CMS and IHS have worked together on policy  initiatives aimed at ensuring that existing health care policies meet the  needs of IHS-funded facilities and the populations they serve. Additionally CMS and IHS interactions have included assistance intended  to maximize IHS-funded facilities’ collection of Medicare and Medicaid  reimbursement. With regard to regulations, CMS and IHS have had mixed success  identifying CMS regulatory changes that have the potential to affect IHS- funded facilities and their populations and thus warrant IHS review. CMS Has Used Tribal Liaisons and an Advisory Board as Its Mechanisms to Interact with Indian Tribes

CMS has used two key mechanisms to interact with representatives from  Indian tribes, namely (1) tribal liaisons, who generally serve as tribal  representatives’ points of contact within CMS and provide assistance with  Medicare and Medicaid, and (2) an advisory board, which provides input  to CMS about issues affecting the delivery of health care to American  Indians and Alaska Natives. Interactions between CMS officials and the  TTAG are meant to complement, but not replace, consultation between  CMS and Indian tribes. The TTAG has been an important vehicle for CMS to obtain input from  tribal representatives. CMS Efforts to Consult with Indian Tribes Have Relied Primarily on HHS Annual Regional Consultation Sessions

CMS has used the annual HHS regional consultation sessions as its main  mechanism to consult with the 562 federally recognized Indian tribes; CMS  is required by Executive Order and HHS policy to consult with Indian  tribes about policies that have tribal implications. However,  consulting with so many tribes is an inherently difficult task, in part  because of the variation in the size, location, and economic status of the  Indian tribes. The HHS regional consultation sessions have offered limited time for  consultation and discussion, as the sessions have generally occurred in the  spring and lasted 1 to 2 days. Most of the state Medicaid programs reviewed reported  consulting with Indian tribes about changes to their Medicaid program. Medicaid Programs Have Used Mechanisms, Such as Tribal Liaisons, and State Policies to Interact and Consult with Indian Tribes

The six state Medicaid programs we reviewed have used at least one of  three mechanisms to interact and consult with Indian tribes: (1) tribal  liaisons—who serve as the tribes’ primary contact with the states on  issues related to Medicaid; (2) advisory boards—which, among other  things, inform the state about Medicaid issues affecting American Indians  and Alaska Natives; and (3) other regularly scheduled meetings—which  states and tribes used to discuss Medicaid issues and identify  opportunities for collaboration, technical assistance, and consultation. Policies

Five of the six states we reviewed—Arizona, Minnesota, New Mexico,  Wisconsin, and Utah—reported having policies in place that govern the  interactions, and in most cases consultations, between their states’  Medicaid programs and Indian tribes. American Indians and Alaska Natives Have Faced Several Barriers to Medicare and Medicaid Enrollment Despite Efforts to Assist with the Application Process

American Indians and Alaska Natives have faced several barriers to  Medicare and Medicaid enrollment despite efforts to provide assistance  with the application process. For  example, almost all of the IHS-funded facilities we visited had staff who  help patients complete and submit Medicare and Medicaid applications. Other barriers were similar to those faced by other populations. CMS  acknowledged that it is working to improve its process for identifying  whether proposed regulatory changes would affect IHS-funded facilities  and the populations they serve. At that time, we will send copies of this report to the  Administrator of the Centers for Medicare & Medicaid Services and the  Director of the Indian Health Service.
Why GAO Did This Study

By law, facilities funded by the Indian Health Service (IHS) may retain reimbursement from Medicare and Medicaid without an offsetting reduction in funding. Ensuring that IHS-funded facilities enroll individuals in--and obtain reimbursement from--Medicare and Medicaid can provide an important means of expanding the funding for health care services for the population served by IHS. The Centers for Medicare & Medicaid Services (CMS), the agency within the Department of Health and Human Services (HHS) that administers Medicare and oversees states' Medicaid programs, is required by Executive Order and HHS policy to consult with Indian tribes on policies that have tribal implications. This requirement is in recognition of the unique government-to-government relationship between the 562 federally recognized Indian tribes and the federal government. GAO was asked to (1) describe interactions between CMS and IHS, (2) examine mechanisms CMS uses to interact and consult with Indian tribes, (3) examine mechanisms that selected states' Medicaid programs use to interact and consult with Indian tribes, and (4) identify barriers to Medicare and Medicaid enrollment and efforts to help eligible American Indians and Alaska Natives apply for and enroll in these programs. GAO reviewed documents, interviewed federal and state officials, and visited a judgmental sample of Indian tribes and IHS-funded facilities in six states.

What GAO Found

CMS and IHS have interacted to (1) provide support to IHS-funded facilities and tribes in their access to Medicare and Medicaid and (2) address broader policy and regulatory concerns regarding these programs. Their interactions to provide support have included education and technical assistance; the agencies also have interacted to obtain input from tribal representatives on program operations. On broader policy and regulatory concerns, CMS and IHS have worked on policy initiatives aimed at ensuring that existing health care policies meet the needs of IHS-funded facilities and the populations they serve. CMS and IHS have had mixed success identifying whether proposed CMS regulatory changes would affect IHS-funded facilities or their populations and thus warrant IHS review. CMS has been working to improve its identification of such regulations. CMS has used two key mechanisms--tribal liaisons and an advisory board--to interact with representatives from Indian tribes, and it has relied primarily on annual regional sessions sponsored by HHS as its mechanism to consult with Indian tribes. Tribal liaisons in CMS's central and regional offices generally served as the point of contact for tribal representatives. CMS's tribal advisory board, which is meant to complement but not replace consultation, has provided the agency with advice on policies affecting the delivery of health care for American Indians and Alaska Natives. CMS has used annual HHS regional consultation sessions as the primary basis for consulting with Indian tribes. However, consulting with tribes is an inherently difficult task, in part because of the variation in tribes' size, location, and economic status. Further, these HHS regional sessions--which generally lasted 1 to 2 days and covered all HHS programs--have offered limited time for consultation and discussion. The six state Medicaid programs we reviewed have used at least one of three mechanisms--tribal liaisons, advisory boards, and regular meetings--to interact and consult with Indian tribes. Five of the six states reported having policies in place that governed the interactions between the state's Medicaid program and Indian tribes, with most of these policies establishing guidelines for how consultation should be conducted. Five states reported consulting with tribes about changes to their Medicaid programs. American Indians and Alaska Natives have faced several barriers to Medicare and Medicaid enrollment despite efforts to assist them with the application process. Many of these barriers are similar to those experienced by other populations, such as transportation and financial barriers. To help eligible American Indians and Alaska Natives enroll in Medicare and Medicaid, almost all of the IHS-funded facilities we visited had staff who assisted patients with the application process, including helping them complete and submit applications, and collecting required documentation. In commenting on a draft of this report, CMS noted that it was appreciative of GAO's review of CMS activities related to interactions with IHS and tribes.