Tribal Health Spotlight: Strategies to Cover Traditional Healing in Medicaid
Overview of Approaches and Key Questions for Tribal Nations
May 03, 2023
In recent years, health equity has become a critical lens for evaluating policy decisions across tribal, federal and state governments. A critical consideration for those influencing healthcare policy is to determine whether the delivery system is well positioned to provide culturally competent care. Authorizing Medicaid coverage of traditional healing has been a policy decision facing the Centers for Medicare & Medicaid Services (“CMS”) for several years with little traction; however, Medicaid’s recent health-equity focus may clarify federal policy. This brief highlights pending and approved initiatives for Medicaid coverage of traditional healing practices and poses key considerations for Tribal Nations.
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The menu of federal authorities for Medicaid coverage of traditional healing practices is informed by several factors that vary according to tribal community needs and state Medicaid programs and is beyond the scope of this brief. New Mexico, Arizona and California are highlighted as examples to support policy design discussions; note that, of the three Medicaid programs, only New Mexico has current authority to use Medicaid funding for traditional healing practices.
Since 2019, New Mexico’s Centennial Care 2.0 section 1115 demonstration has provided a self-directed community budget for specialized therapies to members with a nursing-facility level of care need (“NF LOC”) and who receive home and community-based services (“HCBS”). Native American Healers is among the specialized therapies under the member-managed annual $2000 budget.1 All tribal members with an NF LOC need are mandatorily enrolled in a health plan.2 Tribal members ineligible for HCBS and who have enrolled in a health plan may have access to an annual sum to use for traditional healing services; this arrangement is considered a “value-added service” subject to the health plan to provide or place parameters on the benefit. New Mexico’s section 1115 demonstration renewal is currently under CMS review; the application requests continuation of the current arrangement and seeks approval for an annual $500 self-directed budget for traditional healing services to tribal members enrolled in managed care and lacking an NF LOC need.4
In December 2020, Arizona requested federal authority for Medicaid coverage of traditional healing services provided in, at or as part of services offered by I/T/Us. As proposed, a qualifying entity — either the I/T/U’s governing body or the tribal governing body — would define (i) the qualifications of traditional healers who are contracted or employed by the facility and (ii) the scope of services reimbursable under Medicaid. Traditional healing services would need to be part of an individual’s care plan, and reimbursement would depend on the setting of care (e.g., outpatient all-inclusive rate or professional fee for qualifying inpatient stay).5 In October 2022, CMS indicated that the request for Medicaid coverage of traditional health services at IHS and tribal facilities remains under federal review.6
In 2021, California requested section 1115 demonstration authority to cover substance-use disorder services provided by traditional healers and natural helpers affiliated with Indian Health Care Providers (“IHCP”s) under the state’s county-based substance-use-disorder (“SUD”) managed-care delivery system (“DMC-ODS”). The request indicated that IHCPs would be required to use at least two evidence-based practices as set forth by the county delivery system or the state, in consultation with tribal and urban Indian partners.7 As of December 2021, CMS indicated that the request to cover substance-use-disorder services by traditional healers and natural helpers remains under federal review.8
Key Questions for Tribal Nations
Below is a non-exhaustive list of threshold questions when considering Medicaid coverage of traditional healing practices:
- Would Medicaid coverage of traditional healing practices enhance access for eligible tribal members?
- Would traditional healing practitioners be amenable to the Medicaid provider enrollment process?
- Is there a willingness among the tribal-healing-practitioner community to assign or negotiate a monetary value to their services and participate in the claim process?
- Is there a Medicaid delivery-system preference for tribal members and traditional healing practitioners (i.e., fee-for-service, managed care)?
- Which federal authorities are currently used by the respective state Medicaid agency?
- Are there alternatives to Medicaid coverage of traditional healing practices, such as specialized tribal-care management programs, that could support tribal members' access and use of traditional healing?
There are many developments in Medicaid to support a person-centered approach to health, wellness and well-being. For example, health-related social needs, such as housing and nutritional supports, may be covered under Medicaid.9 Furthermore, CMS authorized California’s coverage of a limited scope of benefits for justice-involved individuals prior to release, with several additional approvals expected.10 Traditional healing practices should be part of the policy discussion so long as the initiative can be designed in a manner that meets the needs of tribal communities.
1: Additional specialized therapies include acupuncture, biofeedback, chiropractic services, hippotherapy, massage therapy, and naprapathy. Angela D. Garner, Director, Division of System Reform Demonstrations, to Nicole Comeaux, Director, Medical Assistance Division, New Mexico Human Services Department. “New Mexico Centennial Care 2.0 1115 Demonstration Approval.” Centers for Medicare & Medicaid Services, Center for Medicaid and CHIP Services. July 21, 2020. Pages 86-88. https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/nm/nm-centennial-care-ca.pdf.
2: Ibid. at page 22; Standard Term and Condition at page 32.
3: Ibid. at page 88.
4: The current Centennial Care 2.0 Demonstration expires December 31, 2023. Michelle Lujan Grisham, Governor of New Mexico, to Secretary Xavier Becerra, U.S. Department of Health and Human Services. “Turquoise Care Section 1115 Medicaid Demonstration Waiver Renewal Request (formerly Centennial Care 2.0).” State of New Mexico: Human Services Department. December 9, 2022. Pages 46-47. https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/nm-centennial-care-pa5.pdf.
5: Douglas A. Ducey, Governor of Arizona, to Alex M. Azar II, CMS Administrator, U.S. Department of Health and Human Services. “Arizona’s Demonstration Project Renewal Application.” State of Arizona: Office of the Governor. December 21, 2020. Pages 28-30. https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/az-hccc-pa8.pdf.
6: Daniel Tsai, Deputy Administrator and Director, Center for Medicaid & CHIP Services, to Jami Snyder, Director, Arizona Health Care Cost Containment System. “AHCCCS Demonstration Extension and Housing & Health Opportunities Amendment Approval.” Center for Medicare & Medicaid Services, Center for Medicaid and CHIP Services. October 14, 2022. Page 11 of 132 (.pdf pagination). https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/az-hccc-ca-10142022.pdf.
7: Gavin Newsom, Governor of California, to Secretary Xavier Becerra, U.S. Department of Health and Human Services. “Request for Amendment and Five-Year Renewal of California’s Section 1115 Demonstration.” State of California: Office of the Governor. June 30, 2021. Pages 25, 183. https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ca-medi-cal-2020-pending-renewal-pa9.pdf.
8: Daniel Tsai, Deputy Administrator and Director, Center for Medicaid & CHIP Services, to Jacey Cooper, Chief Deputy Director, Health Care Programs for the California Department of Health Care Services. “California Advancing and Innovating Medi-Cal (CalAIM) Demonstration Approval.” Centers for Medicare & Medicaid Services, Center for Medicaid and CHIP Services. December 29, 2021. Page 4 of 205 (.pdf pagination). https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ca-calaim-ext-appvl-12292021.pdf.
9: Daniel Tsai, Deputy Administrator and Director, Center for Medicaid & CHIP Services. “SHO#: 21-001, RE: Opportunities in Medicaid and CHIP to Address Social Determinants of Health (SDOH).” Centers for Medicare & Medicaid Services, Center for Medicaid and CHIP Services. January 7, 2023. https://www.medicaid.gov/federal-policy-guidance/downloads/sho21001.pdf; “Health Related Social Needs.” Medicaid.gov.; Centers for Medicare & Medicaid Services. Last visited March 31, 2023. https://www.medicaid.gov/health-related-social-needs/index.html.
10: Daniel Tsai, Deputy Administrator and Director, Center for Medicaid & CHIP Services, to Jacey Cooper, Chief Deputy Director, Health Care Programs for the California Department of Health Care Services. “California Reentry Demonstration Initiative Amendment Approval.” Centers for Medicare & Medicaid Services, Center for Medicaid and CHIP Services. January 26, 2023. https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ca-calaim-ca1.pdf.