CA

RE: CMS-2244-FCl; Comment re Section 5006(a) of ARRA CMS Administrator Berwick: CA Rural Indian Health Board agrees with CMS that further delay in enacting rules regarding implementation of protections against premiums and cost sharing for Indians and Alaska Natives would have been harmful and that CMS had provided opportunities for Tribal leaders, directly and through the Tribal Technical Advisory Group to CMS, to be involved in the development of the rules. We do appreciate this additional comment period, however. We support the definition of “Indian” adopted in the new paragraph (b) added to Section 447.50. The inclusiveness of the rule assures that all individuals who are considered “Indian” or “Alaska Native” will enjoy the protection of the rule and that determining who an Indian is will be administratively simple. We recommend this definition be applied when other protections against costs and access to benefits intended for Indians are being implemented. The relationship of Indians and Tribes with their States varies widely, but even in the best of circumstances is fraught with potential difficulties. By making the definition broad and describing in the explanation of the rule the range of documentation that States should consider adequate, CMS has provided important direction to States about implementation and improved the likelihood that Indians will be able to enroll in Medicaid and enjoy its benefits without incurring costs that are inconsistent with the statute and with the Federal trust relationship with Indian tribes. We also appreciate the clear exemption from co-payments for services provided under a referral from the Contract Health Services (CHS) program of the Indian Health Service, a tribal health program, and an urban Indian organization, whether payment was authorized or not. This rule reflects a correct understanding of the CHS program and assures that the rules adopted by CMS fulfill the intent of Congress and of the Tribal leaders who advocated for these changes to the law. We expect these new rules to assist States in their continuing implementation of the protections for Indians against premiums and cost sharing. We know, however, that continued guidance from CMS to States may continue to be needed and look forward to that assistance being provided when needed. James Crouch, CA Rural Indian Health Board Executive Director