Kim Weidenaar
Medicaid Reimbursement for Services for American Indians and Alaska Natives.
The Indian Health Service (IHS), part of the federal Department of Health and Human Services, is the federal agency with primary responsibility for fulfilling the United States' trust obligation to provide health care for American Indians and Alaska Natives (AI/AN). Of Washington's 29 federally recognized Tribes, 27 Tribes operate their own health care clinics or have a health clinic operated by the IHS on their lands. In addition, there are two urban Indian health programs in Seattle and Spokane that provide care to urban AI/ANs. Under Medicaid, the federal government pays 100 percent of the Federal Medical Assistance Percentage for AI/ANs for: covered services received through IHS facilities and tribal health care facilities; and Medicaid services provided by non-IHS or non-Indian health providers through a care coordination agreement.
Section 1115 Waivers for Traditional Health Care Practices.
On October 16, 2024, the Centers for Medicare and Medicaid Services (CMS) approved Section 1115 waivers in four states—Arizona, California, New Mexico, and Oregon—that allow state Medicaid agencies to cover AI/AN traditional health care practices. Traditional health care practices have previously been offered at some IHS, Tribal, and Urban Indian Organization health care facilities, but have typically been paid for through a combination of IHS appropriations, Tribal revenues, and grant funding. The waivers in Arizona, New Mexico, and Oregon allow anyone covered by Medicaid and eligible for care through the IHS to receive traditional health care services.
By September 1, 2025, the HCA must apply for a Section 1115 waiver from the CMS to provide expenditure authority for coverage of traditional health care practices. Upon approval from the CMS, the HCA must provide coverage for traditional health care practices received through Indian Health Service facilities or facilities operated by Tribes or Urban Indian Organizations. Coverage of these traditional health care practices must be available to Medicaid beneficiaries who are able to receive services delivered by or through these facilities.
"Traditional health care practices" are the sum total of the knowledge, skill, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement, or treatment of physical and mental illness.
The substitute bill:
(In support) Traditional health care practices include a range of holistic treatments used by indigenous healers to treat acute or chronic conditions or to promote health and well-being. This bill would recognize and strengthen the Indian health care system by finally recognizing traditional medicine like Western medicine. A bill is required because the HCA requires authorization from the Legislature in order to apply for the 1115 Waiver. With the waiver, traditional Indian medicine practitioners would be recognized as Indian health care providers and their services would be reimbursed by the federal government. The CMS has already approved waivers in Arizona, California, Oregon, and New Mexico and is reviewing an application from Utah. Washington Tribes have been asking for this reimbursement for years.
Traditional health care practices were outlawed across the country and so generations have lost this knowledge. Traditional health care is so important. A number of tribes have started behavioral health programs which have been very successful. Native individuals who entered treatment following drug court and have the most disparities were doing better in the tribal behavioral health programs than those that went to other treatment programs, and it is because of the traditional healing practices included in the treatment. Individuals come a long way to be able to participate in these practices and care.
A lot of ground work is already being done in preparation for this waiver, including developing billing codes and a credentialing system. Washington is always a leader in the nation and so we should be right there with the other states that have done this and recognize traditional practices for tribes.
This bill adopts the World Health Organization's traditional health care practices definition. This bill has the potential to significantly improve health care outcomes by introducing holistic perspectives that considers the whole person. Herbal medicines have fewer side effects than many drugs. Traditional health practices are more accessible and are rooted in culture and lifestyle and focus on the mind, body, and spirit.
Suicide cost the United States $484 billion dollars in 2024. Certain Urban Indian Tribal Organizations have embedded traditional medicine services into their systems and have seen very positive results with greatly reducing suicidal ideation as well as binge drinking, depression, and anxiety. This bill makes economic sense and saves money.
(Opposed) None.
(Other) This is something that tribes and Indian health care providers have been requesting for many decades. The 1115 waiver allows for tribes to attest to what services they provide and what providers and practitioners are eligible. These services will pay at the Indian Health Service all-inclusive rate, not at the state rates. The current rate is $801. This benefit would be open to all Medicaid beneficiaries seen by an IHS or Tribal health facility, which opens up the possibility for general fund impact. States are required to provide a state match for encounters that are not eligible for 100 percent federal Medicaid assistance percentage.
(In support) Representative Debra Lekanoff, prime sponsor; Esther Lucero, Seattle Indian Health Board; Steve Kutz, American Indian Health Commission for Washington State; Loni Greninger, Jamestown S'Klallam Tribe; and Alison Boyd-Ball, Confederated Tribes of the Colville Reservation.