Fact Sheet: The Affordable Care Act and American Indian and Alaska Native People

The Affordable Care Act helps make health insurance coverage more affordable and accessible for millions of Americans. For American Indians and Alaska Natives, the law addresses inequities and increases access to quality, affordable health coverage, invests in prevention and wellness, and gives American Indian and Alaska Native individuals and families more control over their care.

At the Department of Health and Human Services (HHS), tribal consultation is a critical ingredient of a sound and productive Federal-tribal relationship, and crucial to the successful implementation of the Affordable Care Act. Consultation and outreach efforts provide education and information about the law and how it will impact Indian Country while ensuring policies and programs are responsive to feedback from tribal communities.

The Affordable Care Act provides over 500,000 uninsured American Indians and Alaska Natives an opportunity to get affordable health insurance coverage. The following gives an overview of the coverage and benefits available to American Indians and Alaska Natives.

Improving Health Care for American Indians and Alaska Natives

  • The Affordable Care Act permanently reauthorized the Indian Health Care Improvement Act (IHCIA) which authorizes new programs to ensure that the Indian Health Service (IHS) is more equipped to meet its mission to raise the health status of American Indians and Alaska Natives to the highest level.

Tribes or tribal organizations carrying out a program under the Indian Self-Determination and Education Assistance Act or urban Indian organizations carrying out a program under Title V of IHCIA may now purchase coverage for their employees from the Federal Employees Health Benefits Program (FEHB).

  • As of August 2015, 77 tribes participating in 20 states and about 16,500 tribal employees enrolled.
  • IHS and Tribal programs receive reimbursement payments from the Department of Veterans Affairs (VA) for direct care services provided to eligible veterans under the IHS VA reimbursement agreement signed as a result of a new authority in the Indian Health Care Improvement Act that was reauthorized in the Affordable Care Act. As of August 2015, there are 83 Federal agreements in place and 81 Tribal agreements. The total amount of collections since the beginning of the agreement is over $24 million.
  • Targeted interventions, such as the Partnerships to Improve Community Health (PICH) grants program to address the leading risk factors for the major causes of death and disability in the United States: tobacco use, poor nutrition, and physical inactivity. Major investments to improve quality of care are improving management of chronic diseases that are more prevalent among American Indians and Alaska Natives.
  • Over the last five years, the IHS has supported the National Indian Health Outreach and Education (NIHOE) project, an effort involving the National Congress of American Indians, the National Indian Health Board, and the National Council of Urban Indian Health and 11 regional entities, primarily Regional Tribal Health Boards, to conduct area specific outreach and education regarding the Affordable Care Act. As of August 2015, the NIHOE project has completed over 610 training sessions with tribes, tribal organizations, urban Indian health programs and national partners. The NIHOE project has also included training sessions for non-Indian assisters to provide a better understanding of the special protections for American Indians and Alaska Natives.

Better Access to Coverage for American Indians and Alaska Natives

  • Over 500,000 uninsured American Indians and Alaska Natives now have new opportunities for coverage through the Health Insurance Marketplace. As many as nine out of 10 of those may qualify for financial assistance either through tax credits to purchase coverage in the Marketplace, cost-sharing reductions that will reduce or eliminate out of pocket costs, or through Medicaid if their state expands eligibility.
  • American Indians and Alaska Natives are eligible to purchase coverage through the Health Insurance Marketplace. The Marketplace is a destination where consumers can compare health insurance options in simple, easy-to-understand language. At the Marketplace, consumers are able to compare insurance options based on price, benefits, quality and other factors with a clear picture of premiums and cost-sharing amounts to help them choose the insurance that best fits their needs.
  • American Indians and Alaska Natives earning between 100 percent of the federal poverty level (FPL) (or $24,250 for a family of four in 2015, $35,520 in Alaska) and 400 percent of FPL (or $97,000 for a family of four in 2015, $142,080 in Alaska) may be eligible for advance premium tax credits that immediately lower monthly premiums.
  • Certain American Indians and Alaska Natives who purchase health insurance through the Marketplace can enroll in a zero cost sharing plan, if eligible to receive advance premium tax credits, and do not have to pay co-pays or other cost-sharing if their income is between 100 and 300 percent of FPL, which is roughly between $24,250 and $72,750 for a family of four in 2015 (between $35,520 and $106,560 in Alaska).
  • Certain American Indians and Alaska Natives with income below 100 percent (below $24,250 for a family of four in 2015, $35,520 in Alaska) and above 300 percent of FPL (above $72,750 for a family of 4, above $106,560 in Alaska), can enroll in a limited cost sharing plan and pay no out-of-pocket costs to receive services from an Indian health care provider or from another provider if referred from an Indian health care provider.
  • In addition, certain American Indians and Alaska Natives may qualify for a special enrollment period so they may enroll in an insurance plan outside the yearly open enrollment period.
  • Many American Indians and Alaska Natives will be newly eligible for Medicaid under the Affordable Care Act. States have new opportunities to expand Medicaid coverage to include Americans with family incomes at or below 133 percent of the federal poverty level (generally $32,253 for a family of four in 2015 and $40,326 in Alaska). This expansion includes adults without dependent children living at home, who have not previously been eligible in most states.
  • All American Indians and Alaska Natives who are eligible to receive services from an Indian health care provider may receive an exemption from the shared responsibility payment if they do not maintain minimum essential coverage under the Affordable Care Act. Beginning with the 2014 tax filing year, all those eligible for the Indian exemption may now file for the exemption on their federal income tax return or through the Marketplace.
  • With greater numbers of American Indians and Alaska Natives receiving some form of coverage, including Medicaid, the Children’s Health Insurance Program (CHIP) and private insurance, IHS will be better able to provide needed health services. This coverage will improve reimbursements to IHS and will also benefit Indian health programs.

To learn more about the Health Insurance Marketplace, please visit: www.HealthCare.gov. For the most recent information on Affordable Care Act and IHCIA implementation, please visit: www.HealthCare.gov/tribal and www.ihs.gov.

Posted: March 21, 2011

Last Updated: August 26, 2015

Content last reviewed on August 26, 2015