American Indians and the Affordable Care Act

By Dr. Ron Shaw

The recent passage of public law 111-148, also known as the Affordable Care Act, holds the promise of more accessible and affordable healthcare for Osages. Special provisions for American Indians should provide an opportunity for some Osages to receive more preventive services and better access to specialists outside the Indian Health Service (IHS).

The Federal marketplace or health exchange will offer a choice of federally regulated health plans through which to offer the uninsured essential health services at an out-of-pocket rate calculated from one's modified adjusted gross income. If you already have employer provided insurance you need do nothing as in general it is probably best to stick with your current plan. If you have Medicaid or Medicare, these plans are generally adequate and satisfy the requirements for the individual mandate. The individual mandate refers to those regulations in the law that require all Americans (with few exceptions) to have health insurance or face a monetary fine or penalty that will increase over the next 3-4 years as the law is fully phased in.

For those who have incomes below 400 percent of the federal poverty level (see chart), federal subsidies are available to offset much of the premiums for self or family on health plans purchased through the federal exchange. The actual purchasing of these plans can be undertaken by computer/web site, U.S. mail, telephone or in person with the assistance of a certified application counselor.

Other special provisions specific to Osages and other tribes include an exemption from the individual mandate for health insurance if one provides documentation of eligibility to receive care from the Indian Health Service and is a member of a federally recognized tribe. This documentation includes both a CDIB and tribal membership card. A certificate number may be obtained from the health exchange web site or the previously mentioned documentation could be provided with your tax return at the end of the year. Members of non- federally recognized tribes may obtain a hardship waiver through the website.

Fortunately, if you are eligible to receive care at an IHS facility (whether you go there or not), then you are considered to have acceptable health insurance and are not subject to a penalty from this individual mandate. It is therefore important that a certificate number and/or an IHS eligibility documentation is available to file with your tax return. If you do not file a tax return you may not be eligible for any of the insurance plans offered through the federal exchange marketplace.

For those that currently have no health insurance and go to the IHS, the advantage for purchasing a plan include the ability to seek care from providers outside the IHS. If one continues to seek care at the IHS, no premiums or deductible will apply and the IHS clinic receives 100 percent of charges and all outside referrals would be paid for by your insurance plan instead of IHS Contract Health Services. Also, American Indians may disenroll from one plan and re-enroll in another plan once per month. All other Americans must wait for a yearly "open enrollment period.” In reality, if all uninsured eligible Indians purchased health plans or had them purchased on their behalf though the Federal Exchange, this would constitute a financial windfall for IHS facilities or compacted tribal clinics and lead to higher revenues with which to provide more care, see more patients, provide more contract services for those tribal members receiving care at those clinics. An enrolled Osage is not required to have a health insurance plan to escape the individual mandate but must have documentation/certificate number to prove they are eligible to receive care from the Indian Health Service.

The IHS Pawnee Service unit and Pawhuska Health clinic (per Pawnee Service Unit Director) will have a staff of certified application counselors to assist you with obtaining a certificate number and/or shop for a qualified health plan through the Federal Exchange Marketplace. They will be well trained to answer questions or advise you of all your options. There are to be one or more computers in the waiting area of these facilities for an individual to use in accessing the portal to the Federal Exchange Marketplace. Go to the desk and ask for personal assistance.

The Affordable Care Act is a sweeping piece of legislation that will affect all of us. Use the resources described above to get some help or access the web site itself as you may perform all tasks on your own.

The sign up period begins October 1, 2013 and plan coverage to begin January 1, 2014.

Get your family documents in order. You can do it!

Contact information for the Federal Exchange Marketplace is or call 1-800-318-2596. To contact the Pawhuska Indian Health Center, call (918) 287-4491.