NORTHWEST December 30, 2013 PORTLAND Ms. Kitty Marx,

Submitted via email: kitty.marx@cms.hhs.gov; NDIANHEALTHBOARDBurns-Paiute TribeChehalis TribeCoeur d’Alene TribeColville TribeCoos, Siuslaw, &Lower Umpqua TribeCoquille TribeCow Creek TribeCowlitz TribeGrand Ronde TribeHoh TribeJamestown S’Klallam TribeKalispell TribeKlamath TribeKootenai TribeLower Elwha TribeLummi TribeMakah TribeMuckleshoot TribeNez Perce TribeNisqually TribeNooksack TribeNW Band of Shoshoni TribePort Gamble S’KlallamTribePuyallup TribeQuileute TribeQuinault TribeSamish Indian NationSauk-Suiattle TribeShoalwater Bay TribeShoshone-Bannock TribeSiletz TribeSkokomish TribeSnoqualmie TribeSpokane TribeSquaxin Island TribeStillaguamish TribeSuquamish TribeSwinomish TribeTulalip TribeUmatilla TribeUpper Skagit TribeWarm Springs TribeYakama Nation2121 S.W. BroadwaySuite 300Portland, OR 97201Phone: (503) 228-4185Fax: (503) 228-8182www.npaihb.orgDecember 30, 2013Ms. Kitty Marx,Ms. Nancy GoetschiusCenters for Medicare and Medicaid ServicesDepartment of Health and Human Services200 Independent Avenue S.W.Washington, DC 20201REF:Response to December 20, 2013 Email Titled “TTAG Updates and Advice andInput Needed”Dear Ms. Marx and Ms. Goetschius:In follow-up to the TTAG ACA Policy Subcommittee teleconference call held Thursday,December 19th, we are providing you with our recommendations on the draftdocuments that CMS intends to include with the guidance and instructions to theApplication for Exemption from the Shared Responsibility Payment for American Indiansand Alaska Natives (AI/ANs). You requested these comments be provided to CMS byDecember 30, 2013.We are providing you with our edits included on the two attached draft documents thatCMS/CCIIO will include along with guidance to the Application for Exemption from theShared Responsibility Payment for AI/ANs. The first document is a description ofindividuals eligible for services from Indian Health Care Providers. The second documentis a table that outlines Tribal and other documents to support verification of eligibilityfor the exemption available to persons eligible for services from Indian Health CareProviders.We believe you will find our recommendations self-explanatory. However if you shouldhave questions, please contact Jim Roberts, at jroberts@npaihb.org or (503) 228-4185.Thank you for the opportunity to provide these comments.Sincerely,Andy Joseph, Jr., NPAIHB ChairColville Tribal Council MemberAttachments:I/T/U Eligibility CriteriaDocuments Showing Tribal Membership/Tables

Formatted: Font: Headings (Cambria), 12 ptIndian Health Care Provider I/T/U Eligibility CriteriaWho is eligible for health services through the Indian Health Service, Ttribes and tribal organizations, orurban Indian organizations (referred to as “Indian Health Care Providers” or “I/T/Us”)?IndiansFormatted: Font: Headings (Cambria)Individuals of Indian descent belonging to the Indian community served by the local facilities and programof the Indian Health Service are eligible for services. An individual may be regarded as within the scope ofthe Indian Health Service program if he or she is regarded as an Indian by the community in which he orshe lives as evidenced by such factors as tribal membership, enrollment, residence on tax-exempt land,ownership of restricted property, active participation in tribal affairs, or other relevant factors in keepingwith general Bureau of Indian Affairs practices in the jurisdiction. Eligibility based on one’s status as aCalifornia Indian, Eskimo, Aleut, or other Alaska Native is included within this framework.Formatted: Font: Headings (Cambria)Non-IndiansAdditionally, the following non-Indians are eligible for services from the Indian Health Service:(A) Children under the age of 19 who are the natural child, adopted child, stepchild, foster child, legalward, or orphan of an eligible Indian;(B) Spouses of an eligible Indian, if the tTribe passed a tribal resolution that makes spouses eligible toreceive services from the Indian Health Service; or(C) Non-Indian women who are pregnant with the child of an eligible Indian.Urban IndiansFormatted: Font: Headings (Cambria)The Indian Health Service also contracts with urban Indian organizations to provides services to urbanpopulations for which special statutory eligibility criteria apply. To be eligible for services in an urbanarea, an individual must reside in the service area a city where an of an IHS urban Indian clinic or referralcenter is located n urban center and meet one or more of the following four criteria:(A) Be a member of a tribe, band, or other organized group of Indians, including those tribes, bands, orgroups terminated since 1940 and those recognized now or in the future by the State in which they reside,or who is a descendant, in the first or second degree, of any such member;(B) Be an Eskimo or Aleut or other Alaska Native;(C) Be considered by the Secretary of the Interior to be an Indian for any purpose; or(D) Be determined to be an Indian under regulations promulgated by the Secretary.Formatted: Indent: Left: 0.44"Formatted: Font: Headings (Cambria), 12 ptNEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-318-2596. Para obtener una copia de este formulario enEspañol, llame 1-800-318-2596. If you need help in a language other than English, call 1-800-318-2596 and tell the customer service representativethe language you need. We’ll get you help at no cost to you. TTY users should call 1-855-889-4325.

Documents Showing Tribal Membership or Eligibility for Services fromthe Indian Health Service, an Indian Tribe, Tribal Organization, or an UrbanIndian Organization (“Indian Health Care Provider”)Documents to support the Tribal Hardship Indian Exemption and theHardship Exemption for Personseople Eligible for Services fromHealth Carefrom an Indian Health Care Providerfrom the Shared Responsibility PaymentSubmit only copies of documents, not originals.Table 1. : Documents to demonstrate eligibility for the Indian Exemption and/or Exemptionfor Persons Eligible for Services from an Indian Health Care Provider Hardship Exemption(only one of these documents is needed)Status/Document TypeEnrollment or membershipdocumentDocument issued by AlaskaNative Village/Tribe, or anANSCA regional, or villagecorporation acknowledgingdescent, or affiliation, orshareholder status, orparticipation in village orAlaska Native communityaffairs.Document showing aperson who is listed on theplans for distribution of theassets of rancherias andreservations located withinthe State of California underthe Act of August 18, 1958or document showing trustinterests in public domain,national forest, or reservationallotments in California.Letter from IHS, Tribal orurban Indian health care1Alaska Native Claims Settlement ActSource ofdocumentFederallyRecognized TribeAlaska NativeVillage/Tribe orANSCA 1 corporationOther requirement?Tribal letterhead orenrollment/membership card thatcontains tribal seal or officialsignatureFor Alaska Natives onlyBureau of IndianAffairsFor California Indians onlyIHS, Tribal, or urbanIndian health careFacility letterhead, and withofficial signatureFormatted: CenteredFormatted: Strikethrough

providers verifying eligibilityfor servicesOther tribal documentacknowledging membership,descent , participation intribal community affairs,residence on tax exempt land,or that it regards the personas IndianBIA Form 4432facilityOther document issued byDepartment of Interior thatshows person is consideredto be an Indian.Department ofInteriorCertificate of Degree of IndianBlood (CDIB)FederallyRecognized TribeTribal letterhead, and thatcontains tribal seal or officialsignatureBureau of IndianAffairsBureau of IndianAffairs or TribeForm, signature of BIA/TribalOfficialForm, signature of BIA/TribalOfficialUrban Indian considered bySecretary of Interior to be anIndian for any purpose (such as ascholarship based on Indianstatus).Table 2.:Types of eligibility for Exemption for Persons Eligible for Services from an Indian HealthCare Provider Hardship Exemption that require more than one document to be submittedwith applicationDocument 1Documents related toSource of documentperson applying forexemptionPersons ofBirth certificate (s)State or localIndian descent,governmentincludingurban Indians,withoutpersonaldocumentationfrom Table IEligibility TypeDocument 2Second documentrequiredDocument fromTable 1 showingeligible ancestor forapplicant’s parentor grandparent. Ifgrandparent is usedto qualify, a birthcertificate linkingparent tograndparent is alsorequested.Eligibility based onstate recognizedtribe must be nogreater than 1st or2nd degree

Non-Indiannatural child,adopted child,stepchild,foster child,legal ward, ororphan of aneligible IndianNon-IndianSpousesNon-Indianwomanpregnant withan eligibleIndian’s childUrban Indianfrom staterecognizedTtribeBirth certificate oradoption papersState or TribalgovernmentDocuments fromTable 1 requiredfor eligible Indianparent or guardianMarriage certificate, ifnon-Indian spouses aremade eligible for IHSservices, as a class, by anappropriate resolutionof the governing body ofthe Indian tribe or tribalorganizationVerification ofpregnancyState or Tribe (issuerof marriagecertificate)Document fromTable 1 required foreligible IndianspouseAny medical provider.Unless married,paternity must beacknowledged inwriting by theeligible Indian ordetermined byorder of a court ofcompetentjurisdiction.Enrollment ormembership card/ID ordocument from staterecognized tribeacknowledgingmembershipState-r RecognizedTribeDocument fromTable 1 required foreligible Indianfather of child.Document showingresidency, such as arent statement,mortgage, utilitybill, voterregistration card,etc.

BIA Form 4432 Bureau of Indian Affairs Form, signature of BIA/Tribal Official Certificate of Degree of Indian Blood (CDIB) Bureau of Indian Affairs or Tribe Form, signature of BIA/Tribal Official Other document issued by Department of Interior that shows person is considered to be an