Native American Health Insurance and the ACA: How Marketplace Coverage Works for Tribal Members

If you are Native American or Alaska Native, health insurance through the Affordable Care Act (ACA) may work very differently for you than it does for most Americans.

You may be able to enroll in health insurance any time during the year.

You may qualify for a Marketplace plan with no deductible, copays, or coinsurance.

You may also be able to continue receiving care through Indian Health Service (IHS) while using private health insurance for doctors, hospitals, prescriptions, specialists, and other services outside the Indian health system.

But there is an important catch:

Not everyone who identifies as Native American automatically qualifies for every special ACA benefit.

Your tribal status, household income, and how your Marketplace application is completed can make a major difference.

Here is what you need to know.

Do Native Americans Qualify for Special ACA Health Insurance Benefits?

Yes.

The Affordable Care Act includes special health insurance protections for certain American Indians and Alaska Natives (AI/AN).

Some of the most valuable benefits are available specifically to:

• Members of federally recognized tribes
• Alaska Native Claims Settlement Act (ANCSA) Corporation shareholders

Depending on your eligibility, these protections can include:

• Year-round Marketplace enrollment
• The ability to change Marketplace plans as often as once per month
• Special cost-sharing reductions
• Zero-cost-sharing Marketplace plans for certain income levels
• No cost sharing for certain care received through Indian health care providers
• Special Medicaid and CHIP protections

That can make ACA coverage extremely valuable even for someone who already receives services through Indian Health Service.

“I Have Indian Health Service. Why Would I Need Health Insurance?”

This is one of the biggest misunderstandings I see surrounding Native American health coverage.

Having access to Indian Health Service is not necessarily the same thing as having comprehensive health insurance.

IHS, tribal health programs, and urban Indian health programs provide important care, but they may not provide every service you or your family needs.

What happens if you need a specialist?

What if you need surgery at a hospital outside the Indian health system?

What if you are traveling?

What if a particular treatment or provider isn’t available through your local tribal health program?

That’s where having health insurance can become extremely important.

A Marketplace health insurance plan can give you access to the plan’s network of hospitals, physicians, specialists, pharmacies, and other medical services while still allowing you to receive care through Indian health care providers.

In other words, it doesn’t necessarily have to be IHS OR private insurance. You may be able to have both.

According to HealthCare.gov, enrolling in Marketplace coverage, Medicaid, or CHIP can provide access to services that IHS, tribal programs, or urban Indian programs may not provide.

Can Native Americans Get ACA Health Insurance Anytime?

For qualifying tribal members, yes.

Members of federally recognized tribes and ANCSA shareholders have a special enrollment opportunity that most Marketplace consumers do not have.

They can enroll in a Marketplace health insurance plan throughout the year rather than having to wait for the annual Open Enrollment Period.

Once enrolled, they may also change Marketplace plans as often as once per month.

That’s a major difference from the standard ACA rules.

Most consumers generally need to enroll during Open Enrollment or experience a qualifying life event to receive a Special Enrollment Period.

Qualifying tribal members have much more flexibility.

Can Family Members Qualify for the Tribal Special Enrollment Period Too?

This is another rule families should know about.

HealthCare.gov explains that when a qualifying tribal member or ANCSA shareholder applies with family members on the same Marketplace application, the other family members may also qualify to use the Special Enrollment Period.

That means it is important to look at how the entire household is applying for coverage instead of automatically submitting separate applications.

Marketplace rules can be surprisingly specific, and the way an application is completed matters.

What Is a Native American Zero Cost Sharing ACA Plan?

This is where the ACA’s special protections for qualifying Native Americans can become especially valuable.

Members of federally recognized tribes and ANCSA shareholders with household income between 100% and 300% of the Federal Poverty Level (FPL) who qualify for premium tax credits may be eligible for a zero cost sharing plan through the Health Insurance Marketplace.

What does “zero cost sharing” mean?

For covered essential health benefits, you may pay:

$0 deductible

$0 copays

$0 coinsurance

That’s very different from a typical ACA health insurance plan where someone might have a deductible of several thousand dollars before the insurance company begins paying for certain services.

And there is another important difference.

Unlike the standard ACA cost-sharing reductions that generally require consumers to choose a Silver plan, qualifying Native American zero-cost-sharing options can be available at any Marketplace metal level.

That means Bronze, Silver, Gold, and other available plan options should be carefully compared instead of assuming Silver is automatically the best choice.

Does Zero Cost Sharing Mean the Health Insurance Premium Is Free?

Not necessarily.

This is an important distinction.

Cost sharing and premiums are two different things.

Your premium is what you pay each month to keep the insurance.

Cost sharing includes things such as:

• Deductibles
• Copayments
• Coinsurance

You may qualify for a premium tax credit based on your household income that substantially reduces your monthly premium.

In some situations, the available tax credit may cover most or even all of the premium for certain plans.

But qualifying for zero cost sharing does not automatically mean your monthly premium is $0.

This is one reason it is important to compare the actual Marketplace options available to you.

What If My Income Is Above 300% of the Federal Poverty Level?

There are still special protections.

Members of federally recognized tribes and ANCSA shareholders can qualify for a limited cost sharing plan regardless of income or eligibility for premium tax credits.

With limited cost sharing, you generally don’t pay deductibles, copayments, or coinsurance when receiving covered care through an Indian health care provider.

There may also be situations where services received outside the Indian health system can receive special cost-sharing treatment when properly referred through an Indian health care provider.

The rules are different from the zero-cost-sharing plans, so understanding which version of a Marketplace plan you are selecting is important.

Can I Still Use Indian Health Service If I Enroll in an ACA Plan?

Yes.

Getting Marketplace health insurance does not mean you have to stop receiving care from IHS, tribal health programs, or urban Indian health programs.

You can continue receiving eligible services through those providers while also having access to providers covered by your Marketplace health plan.

There can actually be another benefit to the tribal health system.

When someone has health insurance, Medicaid, or CHIP, an eligible Indian health care provider may be able to bill that insurance for services.

Those payments can help support additional health services within tribal communities.

Do Native Americans Have Copays at Indian Health Service If They Have Marketplace Insurance?

Qualifying American Indians and Alaska Natives have special cost-sharing protections for care received through Indian health care providers.

HealthCare.gov states that, regardless of income, qualifying individuals won’t have out-of-pocket costs such as deductibles, copayments, or coinsurance for covered items and services provided through IHS, tribal programs, or urban Indian programs.

Exactly how coverage works outside those providers depends on which Marketplace cost-sharing option you qualify for.

Do Native Americans Qualify for Medicaid?

They can.

American Indians and Alaska Natives who meet their state’s Medicaid eligibility requirements may qualify for Medicaid, and additional protections apply to certain Native American Medicaid beneficiaries.

For individuals eligible to receive services through IHS, tribal health programs, urban Indian programs, or Purchased/Referred Care, special Medicaid protections can include no Medicaid premiums or enrollment fees and no out-of-pocket costs for Medicaid services.

Certain Indian income, resources, and payments may also receive special treatment when Medicaid or CHIP eligibility is determined.

Because Medicaid eligibility varies by state, it is important to evaluate Medicaid and Marketplace eligibility together.

Does Tribal Income Count When Applying for ACA Health Insurance?

This is another area where assumptions can cause problems.

The Marketplace generally asks applicants to report income that is reportable on their federal income tax return.

Certain Native American income that is exempt from federal taxation may therefore not be included as Marketplace income.

Medicaid and CHIP also have special rules regarding certain Indian income and resources.

Don’t automatically assume that every payment or distribution associated with your tribe should be treated exactly like ordinary wages when determining health insurance eligibility.

The source and tax treatment of the income matter.

What Documents Do I Need to Prove Native American or Tribal Status?

The Marketplace may require documentation before granting certain tribal benefits.

For Marketplace year-round enrollment and special cost-sharing protections, documentation can include a document issued by a federally recognized tribe showing tribal membership.

ANCSA shareholders may use qualifying documentation from an Alaska Native village, tribe, or ANCSA Corporation showing their status.

For Medicaid and CHIP, additional forms of documentation may be accepted, including certain tribal enrollment cards, Bureau of Indian Affairs documents, tribal census documents, or other documentation demonstrating tribal affiliation or eligibility for Indian health services.

If the Marketplace asks for documentation, don’t ignore the request.

Failing to submit the requested documents can affect the special benefits you receive.

Does Simply Having Native American Ancestry Qualify Me?

Not necessarily.

This distinction is extremely important.

Having Native American ancestry or identifying as Native American does not automatically make someone eligible for every ACA tribal protection.

Some Marketplace benefits specifically require membership in a federally recognized tribe or ANCSA shareholder status.

Other health program protections may use different eligibility standards, including eligibility to receive services through an Indian health care provider.

That’s why two people who both consider themselves Native American could potentially have different Marketplace eligibility.

Your specific tribal status matters.

Can Native Americans Receive ACA Premium Tax Credits?

Yes, if they otherwise meet the eligibility requirements.

Being a member of a federally recognized tribe does not prevent you from receiving an ACA premium tax credit.

The amount of financial assistance available depends on factors such as:

• Household income
• Household size
• Ages of household members
• Where you live
• The cost of Marketplace coverage available in your area
• Other health coverage available to you

The premium tax credit lowers the monthly cost of insurance.

The special Native American cost-sharing protections can then potentially reduce what you pay when you actually use your insurance.

Those are two separate benefits, and someone may qualify for both.

Why Choosing the Cheapest ACA Plan Isn’t Always the Best Strategy

Seeing a low monthly premium can be tempting.

But the premium is only one part of health insurance.

You should also consider:

• Which doctors participate in the network
• Which hospitals participate
• Prescription drug coverage
• Specialist access
• Your tribal or Indian health providers
• Whether you qualify for zero or limited cost sharing
• Your expected health care needs
• Whether other family members are enrolling
• How your income affects your Marketplace eligibility

The goal isn’t simply to find the cheapest insurance.

The goal is to understand the benefits available to you and choose coverage that actually works when you need it.

Frequently Asked Questions About Native Americans and ACA Health Insurance

Can Native Americans enroll in Obamacare anytime?

Members of federally recognized tribes and ANCSA shareholders can enroll in Marketplace coverage throughout the year. They may also have the ability to change Marketplace plans as often as once per month.

Do Native Americans get free health insurance?

Not automatically. Some people may qualify for enough premium tax credit to reduce their monthly Marketplace premium substantially or even to $0 for certain available plans, but eligibility depends on the household and the plans available. Special tribal cost-sharing rules can separately reduce or eliminate deductibles, copays, and coinsurance.

What is the ACA Native American zero cost sharing plan?

It is a special Marketplace plan available to qualifying members of federally recognized tribes and ANCSA shareholders with income between 100% and 300% of the Federal Poverty Level who qualify for premium tax credits. It can eliminate deductibles, copayments, and coinsurance for covered essential health benefits.

Do I have to choose a Silver plan to get Native American zero cost sharing?

No. Unlike ordinary ACA cost-sharing reductions, qualifying Native American zero-cost-sharing plans can be available at any Marketplace metal level.

Can I have ACA insurance and still use Indian Health Service?

Yes. Marketplace coverage does not prevent you from continuing to receive services through IHS, tribal programs, or urban Indian health programs.

Is Indian Health Service considered health insurance?

Receiving care through IHS is not the same thing as having a traditional comprehensive private health insurance plan. Marketplace coverage can provide access to additional providers and services outside the Indian health system.

Does every Native American qualify for special Marketplace benefits?

No. Some of the most significant ACA protections are specifically tied to membership in a federally recognized tribe or ANCSA shareholder status. Eligibility for IHS services alone can involve different rules.

Can my non-Native spouse or children enroll with me?

Potentially. HealthCare.gov explains that family members applying on the same Marketplace application as an eligible tribal member may also be able to use the tribal Special Enrollment Period. Their eligibility for other tribal protections may differ.

Do Native Americans qualify for Medicaid?

They may qualify based on their state’s Medicaid rules, and eligible American Indians and Alaska Natives receive additional Medicaid and CHIP protections.

Does tribal income count toward ACA eligibility?

It depends on the type of income. Marketplace applications generally use income reportable for federal income tax purposes, and certain Native American income is excluded from federal taxation. Medicaid and CHIP also have special rules for certain Indian income and resources.

The Bottom Line

If you are a member of a federally recognized Native American tribe or an Alaska Native shareholder, don’t assume health insurance works the same way for you as it does for everyone else.

You may have access to some of the strongest protections available through the Affordable Care Act, including:

• Year-round enrollment.
• The ability to change plans during the year.
• Special premium assistance based on income.
• Zero or limited cost sharing.
• Continued access to Indian health care providers.
• Additional Medicaid and CHIP protections.

But these benefits aren’t always automatically applied, and tribal status, household income, documentation, family composition, and plan selection can all affect the result.

This is exactly why I recommend looking at the entire situation instead of simply going online and choosing the first plan that appears inexpensive.

At Mere Benefits, we help individuals and families understand their health insurance options, what financial assistance they may qualify for, and how different plans actually work before they enroll.

If you’re Native American or Alaska Native and aren’t sure whether you’re receiving all of the ACA benefits available to you, reach out to us. We can help you review your options and understand what questions you should be asking before choosing coverage.

Simply For Your Benefit.