Reform Alert - News from the Blues' Office of National Health Reform

Native Americans Provisions on the Exchange

Dec. 15, 2011

The Affordable Care Act includes provisions aimed to help improve health care for Native Americans across the country. The Affordable Care Act and Exchange proposed regulations provide some special arrangements for Native Americans, including the following:

Exemption from individual mandate penalty

Native Americans are exempt from the individual mandate penalty for failure to comply with the shared responsibility requirement to maintain minimum essential coverage. The Exchange must verify Native American status and must certify Native Americans as qualifying for the individual mandate exemption.

Special enrollment period

A Native American may enroll in a qualified health plan or change from one QHP to another one time per month.

Tribes and organizations

The Exchange may permit Indian tribes, tribal organizations and urban Indian organizations to pay QHP premiums on behalf of qualified individuals, subject to terms and conditions determined by the Exchange. Each Exchange must consult regularly, on an ongoing basis with federally recognized tribes located within the Exchange's geographic area. Indian tribes, tribal organizations, and urban Indian organizations may be eligible to serve as navigators.

Cost-sharing subsidies

The Affordable Care Act and Exchange proposed regulations specify that a QHP issuer may not impose any cost sharing on a Native American who has household income at or below 300 percent of the federal poverty level and is enrolled in a QHP on the individual market Exchange at any metal level of coverage. HHS will pay the QHP issuer the amount necessary to reflect the required increase in actuarial value.

Special cost-sharing rule regardless of income

If a Native American is enrolled in a QHP, a QHP may not impose any cost-sharing for services provided by the Indian Health Service directly, an Indian tribe, tribal organization, urban Indian organization or through referral for contract health services. This provision applies regardless of the individual's income or metal level of coverage. 

Blue Cross Blue Shield of Michigan will continue to monitor the provisions and will update as needed. 

For more information, please go to

The information on this website is based on BCBSM's review of the national health care reform legislation and is not intended to impart legal advice. Interpretations of the reform legislation vary, and efforts will be made to present and update accurate information. This overview is intended as an educational tool only and does not replace a more rigorous review of the law's applicability to individual circumstances and attendant legal counsel and should not be relied upon as legal or compliance advice. Analysis is ongoing and additional guidance is also anticipated from the Department of Health and Human Services. Additionally, some reform regulations may differ for particular members enrolled in certain programs such as the Federal Employee Program, and those members are encouraged to consult with their benefit administrators for specific details.