This is the accessible text file for GAO report number GAO-08-724 
entitled 'Medicare and Medicaid: CMS and State Efforts to Interact with 
the Indian Health Service and Indian Tribes' which was released on 
August 7, 2008. 

This text file was formatted by the U.S. Government Accountability 
Office (GAO) to be accessible to users with visual impairments, as part 
of a longer term project to improve GAO products' accessibility. Every 
attempt has been made to maintain the structural and data integrity of 
the original printed product. Accessibility features, such as text 
descriptions of tables, consecutively numbered footnotes placed at the 
end of the file, and the text of agency comment letters, are provided 
but may not exactly duplicate the presentation or format of the printed 
version. The portable document format (PDF) file is an exact electronic 
replica of the printed version. We welcome your feedback. Please E-mail 
your comments regarding the contents or accessibility features of this 
document to Webmaster@gao.gov. 

This is a work of the U.S. government and is not subject to copyright 
protection in the United States. It may be reproduced and distributed 
in its entirety without further permission from GAO. Because this work 
may contain copyrighted images or other material, permission from the 
copyright holder may be necessary if you wish to reproduce this 
material separately. 

Report to the Committee on Finance, U.S. Senate: 

United States Government Accountability Office: 

GAO: 

July 2008: 

Medicare and Medicaid: 

CMS and State Efforts to Interact with the Indian Health Service and 
Indian Tribes: 

CMS and State Interactions with IHS and Tribes: 

GAO-08-724: 

GAO Highlights: 

Highlights of GAO-08-724, a report to the Committee on Finance, U.S. 
Senate. 

Why GAO Did This Study: 

By law, facilities funded by the Indian Health Service (IHS) may retain 
reimbursement from Medicare and Medicaid without an offsetting 
reduction in funding. Ensuring that IHS-funded facilities enroll 
individuals in—and obtain reimbursement from—Medicare and Medicaid can 
provide an important means of expanding the funding for health care 
services for the population served by IHS. The Centers for Medicare & 
Medicaid Services (CMS), the agency within the Department of Health and 
Human Services (HHS) that administers Medicare and oversees states’ 
Medicaid programs, is required by Executive Order and HHS policy to 
consult with Indian tribes on policies that have tribal implications. 
This requirement is in recognition of the unique government-to-
government relationship between the 562 federally recognized Indian 
tribes and the federal government. 

GAO was asked to (1) describe interactions between CMS and IHS, (2) 
examine mechanisms CMS uses to interact and consult with Indian tribes, 
(3) examine mechanisms that selected states’ Medicaid programs use to 
interact and consult with Indian tribes, and (4) identify barriers to 
Medicare and Medicaid enrollment and efforts to help eligible American 
Indians and Alaska Natives apply for and enroll in these programs. GAO 
reviewed documents, interviewed federal and state officials, and 
visited a judgmental sample of Indian tribes and IHS-funded facilities 
in six states. 

What GAO Found: 

CMS and IHS have interacted to (1) provide support to IHS-funded 
facilities and tribes in their access to Medicare and Medicaid and (2) 
address broader policy and regulatory concerns regarding these 
programs. Their interactions to provide support have included education 
and technical assistance; the agencies also have interacted to obtain 
input from tribal representatives on program operations. On broader 
policy and regulatory concerns, CMS and IHS have worked on policy 
initiatives aimed at ensuring that existing health care policies meet 
the needs of IHS-funded facilities and the populations they serve. CMS 
and IHS have had mixed success identifying whether proposed CMS 
regulatory changes would affect IHS-funded facilities or their 
populations and thus warrant IHS review. CMS has been working to 
improve its identification of such regulations. 

CMS has used two key mechanisms—tribal liaisons and an advisory 
board—to interact with representatives from Indian tribes, and it has 
relied primarily on annual regional sessions sponsored by HHS as its 
mechanism to consult with Indian tribes. Tribal liaisons in CMS’s 
central and regional offices generally served as the point of contact 
for tribal representatives. CMS’s tribal advisory board, which is meant 
to complement but not replace consultation, has provided the agency 
with advice on policies affecting the delivery of health care for 
American Indians and Alaska Natives. CMS has used annual HHS regional 
consultation sessions as the primary basis for consulting with Indian 
tribes. However, consulting with tribes is an inherently difficult 
task, in part because of the variation in tribes’ size, location, and 
economic status. Further, these HHS regional sessions—which generally 
lasted 1 to 2 days and covered all HHS programs—have offered limited 
time for consultation and discussion. 

The six state Medicaid programs we reviewed have used at least one of 
three mechanisms—tribal liaisons, advisory boards, and regular 
meetings—to interact and consult with Indian tribes. Five of the six 
states reported having policies in place that governed the interactions 
between the state’s Medicaid program and Indian tribes, with most of 
these policies establishing guidelines for how consultation should be 
conducted. Five states reported consulting with tribes about changes to 
their Medicaid programs. 

American Indians and Alaska Natives have faced several barriers to 
Medicare and Medicaid enrollment despite efforts to assist them with 
the application process. Many of these barriers are similar to those 
experienced by other populations, such as transportation and financial 
barriers. To help eligible American Indians and Alaska Natives enroll 
in Medicare and Medicaid, almost all of the IHS-funded facilities we 
visited had staff who assisted patients with the application process, 
including helping them complete and submit applications, and collecting 
required documentation. 

In commenting on a draft of this report, CMS noted that it was 
appreciative of GAO’s review of CMS activities related to interactions 
with IHS and tribes. 

To view the full product, including the scope and methodology, click on 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-724]. For more 
information, contact Kathleen M. King at (202) 512-7114 or 
kingk@gao.gov. 

[End of section] 

Contents: 

Letter: 

Results in Brief: 

Background: 

CMS and IHS Have Interacted to Provide Support as Well as Address 
Broader Policy and Regulatory Concerns: 

CMS Has Used Two Key Mechanisms to Interact, and the Annual HHS 
Regional Sessions to Consult, with Indian Tribes: 

Selected States' Medicaid Programs Have Used Multiple Mechanisms to 
Interact and Consult with Tribes: 

American Indians and Alaska Natives Have Faced Several Barriers to 
Medicare and Medicaid Enrollment Despite Efforts to Assist with the 
Application Process: 

Agency and State Comments and Our Evaluation: 

Appendix I: Locations of Indian Health Service (IHS) Areas and Centers 
for Medicare & Medicaid Services (CMS) Regions: 

Appendix II: Methodology for Selecting IHS Areas, Facilities, and 
Tribes Visited: 

Appendix III: Comments from the Department of Health and Human 
Services: 

Appendix IV: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Types of Interactions between CMS Tribal Liaisons and Indian 
Tribes: 

Table 2: Description of the CMS TTAG: 

Table 3: Examples of Duties Performed by Tribal Liaisons: 

Table 4: Highlights of Guidelines Established by State Tribal 
Consultation Policies: 

Table 5: Description of Barriers American Indians and Alaska Natives 
Have Experienced Enrolling in Medicare and Medicaid: 

Table 6: Selected Characteristics of IHS Areas Visited: 

Table 7: Characteristics of IHS-Funded Facilities Visited: 

Figures: 

Figure 1: IHS Medicare and Medicaid Reimbursement, Fiscal Years 1998 
through 2007: 

Figure 2: Points in CMS Regulation Development Process When IHS Can Be 
Informed about a Proposed Regulation: 

Figure 3: Example of How Facilities Use the Patient Registration 
Process to Identify Patients Needing Medicare or Medicaid Application 
Assistance: 

Abbreviations: 

CMS: Centers for Medicare & Medicaid Services: 

HHS: Department of Health and Human Services: 

IHS: Indian Health Service: 

NAC: Native American Contacts: 

SSA: Social Security Administration: 

TTAG: Tribal Technical Advisory Group: 

United States Government Accountability Office: 

Washington, DC 20548: 

July 11, 2008: 

The Honorable Max Baucus: 
Chairman: 
The Honorable Charles E. Grassley: 
Ranking Member: 
Committee on Finance: 
United States Senate: 

The United States recognizes each of the more than 560 federally 
recognized Indian tribes as sovereign nations within its 
borders.[Footnote 1] These tribes, which are located in over 30 states, 
vary greatly in population, economic status, and land ownership, and 
have a unique government-to-government relationship with the federal 
government. According to federal law, this unique relationship includes 
a responsibility for the provision of health care to American Indians 
and Alaska Natives. The Indian Health Service (IHS), an agency within 
the Department of Health and Human Services (HHS), provides or arranges 
for the provision of health care services for American Indians and 
Alaska Natives.[Footnote 2] In fiscal year 2007, IHS provided or 
arranged health care services for approximately 1.5 million American 
Indians and Alaska Natives. Services are provided through IHS-funded 
facilities, including those operated by IHS and those operated by 
tribes, or purchased from other public and private providers--referred 
to as contract health services. 

IHS is funded through appropriations, which in fiscal years 2006 and 
2007 were approximately $3.0 billion and $3.2 billion, respectively. In 
addition to federal appropriations, IHS-funded facilities can seek 
reimbursement for services they provide to individuals enrolled in 
Medicare, the federal health insurance program for elderly and disabled 
individuals, and for those enrolled in Medicaid, a joint federal and 
state health financing program for certain low-income families and low- 
income individuals who are aged or disabled.[Footnote 3] Reimbursement 
from Medicare and Medicaid can increase the amount of funds available 
to IHS-funded facilities because by law they can retain reimbursement 
from these programs without an offsetting reduction in their 
appropriated funding.[Footnote 4] In fiscal year 2007, IHS reported 
approximately $677 million in reimbursement from Medicare and 
Medicaid;[Footnote 5] however, facilities vary greatly in the total 
reimbursement obtained from these programs. For example, our prior work 
found that Medicaid reimbursement across 12 IHS-funded facilities 
ranged from 2 percent to 49 percent of the total direct medical care 
budgets of these facilities, and that facilities with higher 
reimbursement had additional funds to hire staff and purchase equipment 
and supplies.[Footnote 6] As a result, ensuring that eligible American 
Indians and Alaska Natives are enrolled in Medicare and Medicaid, and 
that IHS-funded facilities obtain reimbursement for services provided 
to these enrolled individuals, can provide an important means of 
expanding the funding for health care services available to this 
population. 

Changes to Medicare and Medicaid can affect the enrollment of American 
Indians and Alaska Natives in these programs and the ability of IHS- 
funded facilities to claim reimbursement for enrolled individuals. 
Interactions between Indian tribes, IHS, and the Centers for Medicare & 
Medicaid Services (CMS), the agency within HHS that administers 
Medicare and oversees states' Medicaid programs, can help prevent 
policy changes from having unforeseen effects on tribes and IHS-funded 
facilities. For example, if changes in a Medicaid program's delivery 
system--such as moving to a system of managed care--are discussed with 
tribes and IHS officials, then consequences--such as IHS-funded 
facilities not being part of managed care systems--may be avoided. 
Recognizing the unique status of Indian tribes, a 1998 Executive Order 
required a specific type of interaction between federal agencies and 
Indian tribes, called consultation, which required federal agencies to 
have an effective process to ensure meaningful and timely input by 
tribal officials in the development of regulatory policies that have 
tribal implications.[Footnote 7] In 2005, HHS adopted a tribal 
consultation policy, under which every agency within HHS shares the 
responsibility to coordinate, communicate, and consult with Indian 
tribes. Thus, CMS is required to consult with Indian tribes on program 
issues that have tribal implications. In contrast, states are not 
subject to the Executive Order or HHS's tribal consultation policy. 
However, CMS has encouraged state Medicaid programs to consult with 
tribes when making changes to their Medicaid programs. Moreover, some 
states have policies requiring consultation between the state Medicaid 
program and Indian tribes. 

Given the importance of CMS programs to American Indians and Alaska 
Natives, you asked us to examine the interactions between the Medicare 
and Medicaid programs with IHS-funded facilities. This report (1) 
describes interactions between CMS and IHS, (2) examines mechanisms CMS 
uses to interact and consult with Indian tribes, (3) examines 
mechanisms that selected states' Medicaid programs use to interact and 
consult with Indian tribes, and (4) identifies barriers to enrollment 
in Medicare and Medicaid and efforts to help eligible American Indians 
and Alaska Natives apply for and enroll in these programs. 

To describe interactions between CMS and IHS, we interviewed officials 
from both agencies. Specifically, within CMS, we interviewed officials 
from its central office and 9 of its 10 regional offices who have 
responsibility for coordinating issues related to Indian tribes and 
IHS, as well as other CMS officials, including officials knowledgeable 
about interactions between CMS and IHS.[Footnote 8] Within IHS, we 
interviewed headquarters officials involved in interacting with CMS, 
including those in the Office of Resource Access & 
Partnerships.[Footnote 9] We also interviewed officials in each of 
IHS's 12 area offices identified by IHS executives as being the most 
knowledgeable about Medicare-and Medicaid-related issues. (See app. I 
for a map of the locations covered by the IHS area offices and the CMS 
regional offices.) In our interviews, we asked CMS and IHS officials 
about their interactions with the other agency. During the interviews 
we obtained information about the development and review process for 
regulations and how CMS and IHS interact to identify proposed CMS 
regulations that may affect IHS-funded facilities. To supplement this 
information, we interviewed officials from the HHS Office of the 
Executive Secretariat, which is responsible for determining which 
agencies within HHS should have the opportunity to review a regulation. 
We also interviewed officials from the HHS Office of Tribal Affairs 
about HHS activities related to American Indians and Alaska Natives 
that involve IHS and CMS. Additionally, we reviewed relevant CMS and 
IHS documentation to supplement information obtained during our 
interviews. 

To examine mechanisms that CMS uses to interact and consult with Indian 
tribes, we reviewed information obtained during our interviews with the 
CMS and HHS officials noted above. We also interviewed tribal 
representatives to obtain their opinions about interactions with CMS. 
During the course of our interviews with CMS and HHS officials, we 
asked them about past and present interactions, including 
consultations, with tribes. We conducted site visits in 3 of the 12 IHS 
areas from September through November 2007.[Footnote 10] We selected 
these 3 areas to represent a mix in terms of geographic location, level 
of reliance on contract health services, and the entities operating the 
facilities (IHS or tribes).[Footnote 11] (See app. II for more detailed 
information about the methodology for our site visits.) During our site 
visits we met with tribal leaders or designated officials from 14 
tribes, and interviewed them regarding their interactions with CMS and 
elicited their opinions about CMS's consultation with Indian tribes. To 
better understand CMS's consultation activities, we reviewed CMS's 
involvement in HHS regional consultation sessions. To do this, we 
interviewed HHS officials from the four HHS regional offices that 
corresponded to the location of the tribes we visited and reviewed 
agendas and reports from these regions' consultation sessions.[Footnote 
12] We interviewed over 15 additional tribal representatives, including 
officials from area health boards--who serve as the voice for tribes in 
their area on health-related issues--and tribal representatives who are 
members of CMS's Tribal Technical Advisory Group (TTAG), an advisory 
board created to inform CMS about issues affecting the delivery of 
health care to American Indians and Alaska Natives served by CMS 
programs. Finally, we observed several TTAG meetings and reviewed 
relevant documentation, such as minutes, from prior TTAG meetings. 

To examine mechanisms that selected states' Medicaid programs use to 
interact and consult with Indian tribes, we interviewed Medicaid 
officials in the six states that corresponded to the location of the 14 
tribes we visited.[Footnote 13] We asked these officials about 
interactions and consultations between the state Medicaid program and 
Indian tribes in the state. We also reviewed relevant documentation, 
such as state policies that govern interactions with tribes. 
Additionally, we used information gathered from our interviews with 
tribal leaders and other tribal representatives. 

To identify barriers to enrollment in Medicare and Medicaid and efforts 
to help eligible American Indians and Alaska Natives apply for and 
enroll in these programs, we used information obtained from our 
interviews with CMS, IHS, and state officials as well as tribal 
representatives. Additionally, during our site visits, we interviewed 
officials at 25 IHS-funded facilities, 13 of which were operated by IHS 
and 12 of which were operated by tribes. During these interviews, we 
asked officials about barriers to Medicare and Medicaid enrollment, 
enrollment assistance provided, and outreach activities. We also 
interviewed officials from the Social Security Administration (SSA), 
the federal agency responsible for Medicare enrollment, about barriers 
to Medicare enrollment and the agency's outreach activities. In 
addition, we conducted a literature review about barriers related to 
enrolling in Medicare and Medicaid. Where available, we reviewed 
relevant documentation to supplement the information found during our 
interviews. 

The information from the six state Medicaid programs provides insight 
about the interactions and consultations between state Medicaid 
programs and Indian tribes, but it cannot be generalized to other 
states. Additionally, the information we obtained from tribal 
representatives cannot be generalized to all 562 federally recognized 
tribes. We conducted our work from December 2006 through July 2008 in 
accordance with generally accepted government auditing standards. 

Results in Brief: 

CMS and IHS have interacted to (1) provide support to IHS-funded 
facilities and Indian tribes in accessing Medicare and Medicaid and (2) 
address efforts associated with broader policy and regulatory concerns 
regarding the two programs. 

* With regard to support, CMS and IHS have interacted to educate staff 
from IHS-funded facilities and tribal members about Medicare and 
Medicaid, and CMS has assisted these facilities with Medicare and 
Medicaid billing procedures and other concerns. CMS and IHS have 
interacted to ensure that they obtain input from tribal representatives 
at meetings and other sessions designed to inform CMS about issues 
affecting the delivery of health care for American Indians and Alaska 
Natives. 

* With regard to broader policy and regulatory concerns, CMS and IHS 
have interacted on policy initiatives aimed at ensuring that existing 
health care policies meet the needs of IHS-funded facilities and the 
populations they serve. CMS and IHS have had mixed success identifying 
CMS regulatory changes that have the potential to affect IHS-funded 
facilities and their populations and thus warrant IHS review. However, 
identifying such regulatory changes can be challenging because of 
factors such as the high volume of CMS regulations. For this reason, 
CMS has been working to develop and implement additional procedures to 
identify whether a regulation could affect IHS and the tribes. 

CMS has used two key mechanisms--tribal liaisons and an advisory board-
-to interact with representatives from Indian tribes, and it has relied 
primarily on annual regional sessions sponsored by HHS as its mechanism 
for consulting with Indian tribes. 

* CMS has tribal liaisons in its central and regional offices who 
generally served as the points of contact for tribal representatives. 
These liaisons have provided assistance and obtained input from tribes 
through activities such as visiting Indian reservations and providing 
technical assistance and written guidance to Indian tribes. 

* CMS has a tribal advisory board, which includes tribal 
representatives from each IHS area and three Washington, D.C.-based 
tribal associations. While the advisory board is meant to complement 
but not replace consultation, its composition, meeting schedule, and 
organizational structure have provided an opportunity for CMS to obtain 
input from tribal representatives. 

* CMS's efforts to consult with Indian tribes have relied primarily on 
participating in the annual HHS regional consultation sessions. 
However, consulting with so many tribes is an inherently difficult 
task, in part because of the variation in the size, location, and 
economic status of the Indian tribes. Additionally, these HHS regional 
sessions--which generally lasted 1 to 2 days and covered all HHS 
programs--have offered limited time for consultation and discussion. 

The six state Medicaid programs we reviewed have used at least one of 
three mechanisms to interact and consult with Indian tribes: tribal 
liaisons, advisory boards, and regularly scheduled meetings. All six 
state Medicaid programs reported using at least one designated tribal 
liaison who served as a communication and coordination link between 
tribes and the program and provided training and technical assistance 
to Indian tribes. Three of the six state Medicaid programs reported 
using advisory boards to interact, and in some cases consult, with 
Indian tribes. For example, Utah used an advisory board to determine if 
proposed changes to the state Medicaid program had tribal implications 
and thus required additional consultation with tribal representatives. 
Four of the six state Medicaid programs also reported having regularly 
scheduled meetings with tribal representatives to discuss Medicaid 
issues; the meetings ranged in frequency from bimonthly to annually. In 
addition to these mechanisms, five of the six states we reviewed also 
reported having policies in place that provided a mechanism to govern 
their interactions--including consultations--with Indian tribes. Most 
states reported consulting with tribes when making changes to their 
Medicaid programs. For example, New Mexico officials reported that 
consultations with tribes resulted in revisions to a long-term care 
program, such as requiring the use of tribal liaisons. 

American Indians and Alaska Natives have faced several barriers to 
Medicare and Medicaid enrollment despite efforts to assist them with 
the application process. Some of these barriers to enrollment were 
associated with the unique status of the tribal community. For example, 
one barrier was the belief among some American Indians and Alaska 
Natives that they should not have to apply for Medicare or Medicaid 
because the federal government has a duty to provide them with health 
care. Other enrollment barriers were similar to those experienced by 
other populations, such as lack of transportation, financial barriers, 
and limited access to telephones and other communication devices. 
Efforts to help eligible American Indians and Alaska Natives enroll in 
Medicare and Medicaid generally have focused on providing assistance 
with the application process. Almost all of the IHS-funded facilities 
we visited had staff who assisted patients with applying for Medicare 
and Medicaid, including helping them complete and submit applications, 
and collecting required documentation. In some cases, this application 
assistance was available directly from Medicaid or Medicare eligibility 
staff who worked at, or traveled to, IHS-funded facilities. Many 
organizations--including CMS and IHS--have conducted outreach efforts 
to educate the tribal community about Medicare and Medicaid and 
encourage individuals to apply. For example, in 2007, CMS released a 
video, to be used at IHS-funded facilities, which emphasized the 
community benefit to enrollment in Medicare and Medicaid. 

In commenting on a draft of this report, CMS noted that it was 
appreciative of our review of its activities related to interactions 
with IHS and tribes. Technical comments from CMS, Arizona, New Mexico, 
and Montana were incorporated as appropriate. 

Background: 

The federal government recognizes 562 Indian tribes, which are located 
in 33 states, and vary greatly in size, economic status, and land 
ownership.[Footnote 14] According to the Bureau of Indian Affairs, the 
tribes range in size from villages in Alaska that have fewer than 50 
members to tribes with over 240,000 members.[Footnote 15] The economic 
status of tribes also varies, ranging from those with unemployment 
rates that are more than 90 percent to those with unemployment rates 
that are below 10 percent. Some tribes also have significant economic 
opportunities for tribal members, including employment or payments 
provided to tribal members. With regard to land ownership, reservation 
lands ranged from 16 million acres to less than 100 acres. 

Overall, American Indians and Alaska Natives living in IHS areas have 
lower life expectancies than the U.S. population as a whole and face 
considerably higher mortality rates for some conditions. For American 
Indians and Alaska Natives ages 15 to 44 living in those areas, 
mortality rates are more than twice those of the general population. 
American Indians and Alaska Natives living in IHS areas have 
substantially higher rates for diseases such as diabetes, as well as a 
higher incidence of fatal accidents, suicide, and homicide. 

IHS Provision of Health Care: 

IHS arranges for the provision of health care to American Indians and 
Alaska Natives who are members of federally recognized tribes. 
Specifically, in 2007, IHS funded health care delivered to 
approximately 1.5 million American Indians and Alaska Natives. IHS 
consists of a system of more than 650 IHS-funded facilities organized 
into 12 geographic areas of various sizes. Within the 12 areas, direct 
care services are generally delivered by IHS-funded hospitals, health 
centers, and health stations.[Footnote 16] Tribes have the option of 
operating their own direct care facilities. Thus, direct care is 
provided by IHS-funded facilities that are either IHS operated or 
tribally operated. Services not available through direct care at IHS- 
funded facilities may be purchased by the facilities through 
arrangements with outside providers; these services are referred to as 
contract health services. 

Eligibility requirements for direct care and contract health services 
differ. In general, all American Indian and Alaska Native tribal 
members are eligible to receive direct care at IHS-funded facilities 
free of charge.[Footnote 17] To be eligible for contract health 
services, however, American Indians and Alaska Natives must reside 
within a contract health services delivery area that is federally 
established and either (1) reside on a reservation within the area or 
(2) belong to or maintain close economic and social ties to a tribe 
based on such a reservation.[Footnote 18] IHS-funded facilities will 
not authorize or pay for contract health services for individuals who 
are eligible to obtain such services through other sources, such as 
Medicare or Medicaid. 

Medicare and Medicaid: 

Medicare finances health services for approximately 44 million elderly 
and disabled individuals and consists of several different components, 
namely: 

* Medicare Part A, Hospital Insurance--which helps cover inpatient care 
in hospitals. There is typically no premium for Part A. 

* Medicare Part B, Medical Insurance--which covers doctors' services, 
outpatient care, and certain other services, such as physical and 
occupational therapy and medical supplies. In 2008, the monthly premium 
for Part B is $96.40 for most individuals.[Footnote 19] 

* Medicare Part C, or Medicare Advantage--which provides coverage for 
Medicare Parts A and B services through private health plans. 

* Medicare Part D, or Prescription Drug Coverage--a voluntary insurance 
program for outpatient prescription drug benefits. Most Medicare drug 
plans charge a monthly premium. However, beneficiaries eligible for 
both Medicare and Medicaid (dual-eligibles) are generally not required 
to pay a premium, and certain low-income beneficiaries are eligible for 
premium subsidies. 

IHS has the authority to pay Medicare Part B premiums on behalf of 
individuals eligible to receive direct care, although the agency has 
not yet utilized that authority.[Footnote 20] Some Indian tribes pay 
the Medicare Part B or Part D premiums of their members. 

American Indians and Alaska Natives may also be eligible for health 
care benefits under Medicaid, a joint federal-state program that 
finances health care for certain low-income children, families, and 
individuals who are aged or disabled. Generally, the federal government 
and the states share in the cost of the Medicaid program. However, the 
federal government pays 100 percent of the Medicaid program's cost to 
provide services to American Indians and Alaska Natives at IHS-or 
tribally operated facilities. 

IHS Funding: 

In fiscal year 2007, Congress appropriated approximately $3.2 billion 
for IHS, which included funding for the provision of direct care at IHS-
funded facilities, contract health services, and other functions. In 
addition to IHS's federal appropriation, IHS-funded facilities can be 
reimbursed by other payers, including Medicare and Medicaid, for the 
services the facilities provide.[Footnote 21] IHS-funded facilities are 
allowed to retain reimbursements without an offsetting reduction in 
their IHS funding. Thus, revenues from Medicare and Medicaid can 
increase the financial capacity of IHS-funded facilities to provide 
needed medical services. 

According to IHS data, the amount of Medicaid and Medicare 
reimbursement that IHS has collected has increased over time (see fig. 
1). In fiscal year 2007, IHS reported approximately $516 million in 
Medicaid reimbursement and $161 million in Medicare reimbursement, for 
a total of $677 million. These data do not account for all collections 
by IHS-funded facilities because tribally operated facilities are not 
required to report such information. 

Figure 1: IHS Medicare and Medicaid Reimbursement, Fiscal Years 1998 
through 2007: 

This figure is a multiple line graph showing IHS medicare and medicaid 
reimbursement, fiscal years 1998 through 2007. The X axis represents 
the fiscal year, and the Y axis represents the dollars (in millions). 
The lines represent medicare, medicaid, and total. 

Fiscal year: 1998; 
Medicare: $82; 
Medicaid: $207; 
Total: $289. 

Fiscal year: 1999; 
Medicare: $87; 
Medicaid: $270; 
Total: $357. 

Fiscal year: 2000; 
Medicare: $109; 
Medicaid: $283; 
Total: $392. 

Fiscal year: 2001; 
Medicare: $115; 
Medicaid: $316; 
Total: $431. 

Fiscal year: 2002; 
Medicare: $109; 
Medicaid: $375; 
Total: $485. 

Fiscal year: $2003; 
Medicare: $119; 
Medicaid: $418; 
Total: $537. 

Fiscal year: 2004; 
Medicare: $129; 
Medicaid: $446; 
Total: $575. 

Fiscal year: 2005; 
Medicare: $136; 
Medicaid: $472; 
Total: 609. 

Fiscal year: 2006; 
Medicare: $142; 
Medicaid: $464; 
Total: $606. 

Fiscal year: 2007; 
Medicare: $161; 
Medicaid: $516; 
Total: $677. 

[See PDF for image] 

Source: IHS. 

Note: Data do not account for all collections by IHS-funded facilities 
because tribally operated facilities are not required to report such 
information. 

[End of figure] 

Federal Consultation Requirements: 

In recognition of the unique government-to-government relationship 
between the federal government and Indian tribes, federal agencies are 
required by Executive Order to consult with Indian tribes on "policies 
that have tribal implications."[Footnote 22] The order states that 
"[e]ach agency shall have an accountable process to ensure meaningful 
and timely input by tribal officials in the development of regulatory 
policies that have tribal implications." The order defines policies 
that have tribal implications as regulations, legislative comments or 
proposed legislation, and other policy statements or actions that have 
substantial direct effects on one or more Indian tribes, on the 
relationship between the federal government and Indian tribes, or on 
the distribution of power and responsibilities between the federal 
government and Indian tribes. 

On January 14, 2005, HHS adopted a tribal consultation policy that 
formalized HHS's requirement to consult with Indian tribes in policy 
development. HHS's policy defines consultation as: "An enhanced form of 
communication, which emphasizes trust, respect and shared 
responsibility." In addition, the HHS policy explains that consultation 
is "integral to a deliberative process, which results in effective 
collaboration and informed decision making with the ultimate goal of 
reaching consensus on issues." Under the HHS tribal consultation 
policy, every agency within HHS, including CMS, shares in the 
departmentwide responsibility to coordinate, communicate, and consult 
with Indian tribes. Among other things, the HHS tribal consultation 
policy specifies that each of the 10 HHS regions should have an annual 
consultation session to solicit information on Indian tribes' 
priorities and needs related to health and human services. Within CMS, 
issues related to American Indians and Alaska Natives are coordinated 
by the agency's Tribal Affairs Group and by designated Native American 
Contacts (NAC) in each of its 10 regional offices.[Footnote 23] 

State Consultation Requirements: 

While the Executive Order establishes clear requirements for federal 
agencies to consult with Indian tribes, in general, states determine 
how to interact, and whether to consult, with the tribes in their 
states. However, CMS has provided guidance to state Medicaid programs 
that encourages the programs to consult with tribes and be as 
responsive as possible to their issues and concerns when making changes 
to state Medicaid programs.[Footnote 24] While states have flexibility 
in making many changes to their Medicaid programs, some changes require 
states to obtain a waiver of certain Medicaid requirements. 
Specifically, the Social Security Act authorizes the Secretary of HHS 
to waive certain federal Medicaid program requirements under certain 
conditions.[Footnote 25] CMS guidance indicates that evidence of 
consultation with the tribes is one criterion that CMS will use during 
its review of proposed state Medicaid program changes that require a 
waiver of Medicaid requirements.[Footnote 26] 

CMS and IHS Have Interacted to Provide Support as Well as Address 
Broader Policy and Regulatory Concerns: 

CMS and IHS have interacted to provide support to IHS-funded facilities 
and Indian tribes in accessing Medicare and Medicaid as well as to 
address efforts associated with broader policy and regulatory concerns 
regarding the two programs. With regard to support, CMS and IHS have 
interacted to educate staff from IHS-funded facilities and American 
Indians and Alaska Natives about Medicare and Medicaid. Additionally, 
CMS has assisted IHS-funded facilities with Medicare and Medicaid 
billing procedures and other concerns. CMS and IHS also have worked to 
obtain input from tribal representatives through an advisory board and 
consultation sessions. At a broader policy level, CMS and IHS have 
worked together on policy initiatives aimed at ensuring that existing 
health care policies meet the needs of IHS-funded facilities and the 
populations they serve. CMS's regulatory process--the process through 
which CMS issues regulations--can necessitate the review of 
approximately 140 major rule-making documents on a yearly basis. Thus, 
it has provided an important, but challenging, opportunity for CMS and 
IHS to identify regulatory changes that may affect American Indians' 
and Alaska Natives' eligibility for Medicare and Medicaid or these 
programs' reimbursements to IHS-funded facilities. 

CMS and IHS Have Interacted to Provide Education and Assistance as Well 
as to Obtain Input from Tribal Representatives: 

CMS and IHS have interacted to educate IHS-funded facility staff and 
American Indians and Alaska Natives about the Medicare and Medicaid 
programs. The following are examples of such activities: 

* CMS and IHS have interacted to train staff from IHS-funded facilities 
on Medicare and Medicaid program topics. For example, in August 2007, 
the two agencies held a training session in the Aberdeen IHS area 
titled "Working Together - CMS, Tribes and the Aberdeen Area." The 
session included presentations by both CMS and IHS officials on 
strategies to increase Medicare and Medicaid enrollment, changes to 
contract health service payments, and other topics. 

* In 2007, CMS, IHS, and tribal officials coordinated tribal stops on 
the Medicare prevention tour, a nationwide CMS outreach effort that 
involved a bus traveling to different venues to encourage Medicare 
beneficiaries to utilize the preventive services covered by Medicare, 
such as cancer and diabetes screenings. Through CMS's coordination with 
IHS and tribes, the CMS Medicare prevention bus visited approximately 
15 tribal locations across five different CMS regions. 

* CMS has also educated IHS staff about Medicare Part D. For example, 
CMS has held multiple training sessions in each of the 12 IHS areas to 
educate IHS-funded facility staff about the Medicare Part D program and 
encourage American Indians and Alaska Natives to enroll in the program. 

Additionally CMS and IHS interactions have included assistance intended 
to maximize IHS-funded facilities' collection of Medicare and Medicaid 
reimbursement. Many of these activities have included helping 
facilities become providers for Medicare and Medicaid, as well as 
assisting with billing and other concerns. Examples include the 
following: 

* CMS has assisted IHS-funded facilities in becoming Medicare and 
Medicaid providers, which is necessary to bill these programs. IHS 
officials from the Bemidji area told us that CMS officials provided 
instructions to IHS-funded facilities on how to sign up to participate 
in Medicare and Medicaid. Additionally, in 2007, CMS helped an IHS- 
operated health center and its satellite clinics to qualify as provider-
based facilities, which would allow the facilities to bill Medicare 
Part A and potentially increase their Medicare reimbursement.[Footnote 
27] 

* CMS has provided technical assistance to IHS to resolve billing 
concerns. For example, CMS and IHS officials corrected a problem with 
the IHS electronic billing system that according to CMS officials, had 
resulted in some IHS-funded facilities being underpaid for certain 
Medicare services. 

* A CMS official helped IHS-funded facilities navigate the CMS survey 
process, a process through which facilities are inspected for 
compliance with federal quality standards. 

Finally, CMS and IHS have interacted to ensure that they obtain input 
from tribal representatives. For example, CMS and IHS have interacted 
through CMS's TTAG, an advisory board created to inform CMS about 
issues affecting the delivery of health care to American Indians and 
Alaska Natives served by CMS programs. Specifically, the IHS area 
offices helped identify and appoint tribal representatives to serve on 
the TTAG. Additionally, both CMS and IHS officials have attended TTAG 
meetings and participated in TTAG subcommittees, which focus on 
specific Medicare-or Medicaid-related issues. CMS and IHS officials 
also have interacted through annual HHS regional tribal consultation 
sessions, held in each region as part of HHS's implementation of its 
tribal consultation policy. In addition to participating in the 
consultation sessions, CMS and IHS officials may work together to plan 
the sessions. For example, in the Chicago region, CMS regional and IHS 
Bemidji area officials served on the planning committee that organized 
the consultation session. 

CMS and IHS Have Interacted about Specific Policies, but Have Had Mixed 
Success Identifying CMS Regulations Warranting IHS Review: 

With regard to specific policy issues, CMS and IHS have interacted on 
issues related to Medicare Parts B and D; they also jointly issued 
regulations to limit the amount that IHS-funded facilities must pay 
hospitals for contract health services, as shown in the following 
examples. 

* Medicare Part B: CMS and IHS have been determining which American 
Indians and Alaska Natives are eligible for an exemption from financial 
penalties incurred for late enrollment into Medicare Part B.[Footnote 
28] This exemption, referred to as equitable relief, is granted to 
individuals who did not initially enroll because of erroneous 
information provided by a government agency. In this case, IHS, while 
operating under specific interagency agreements with CMS, told some 
individuals not to enroll in Medicare Part B because, at the time, IHS 
was unable to bill Medicare Part B.[Footnote 29] 

* Medicare Part D: During the implementation of Medicare Part D, CMS 
and IHS worked to ensure that IHS-funded facilities would be able to 
bill and receive reimbursement from prescription drug plans. This 
required special provisions to enable tribally operated facilities to 
enter into contracts with prescription drug plans, while retaining 
tribal sovereignty. 

* Contract health services: In 2007, CMS and IHS jointly issued a 
regulation requiring hospitals that receive Medicare funds to accept 
rates based on Medicare as full payment for contract health services 
provided to eligible American Indians and Alaska Natives.[Footnote 30] 
Termed Medicare-like rates, this regulation prevents hospitals from 
accepting fees from IHS-funded facilities in excess of what Medicare 
would pay.[Footnote 31] 

With regard to regulations, CMS and IHS have had mixed success 
identifying CMS regulatory changes that have the potential to affect 
IHS-funded facilities and their populations and thus warrant IHS 
review. IHS officials reported reviewing and commenting on CMS 
regulations addressing Medicare payment issues, Medicaid managed care, 
and Medicare Part D, noting that CMS made changes to these regulations 
in response to their comments. For example, IHS informed CMS that 
regulations implementing a new payment methodology for reimbursing 
outpatient facilities under Medicare would adversely affect IHS-funded 
facilities because a number of facilities would have to hire new staff 
to implement the payment system.[Footnote 32] As a result of this 
interaction, CMS exempted IHS-funded facilities from the new payment 
methodology. In contrast, IHS officials also reported three examples 
where they did not have an opportunity to review CMS regulations prior 
to the public comment period. One regulation had the potential to 
affect Medicaid prescription drug reimbursement for IHS-funded 
facilities, while the other two regulations had the potential to affect 
Medicaid enrollment for American Indians and Alaska Natives by 
requiring documentation of U.S. citizenship and affected tribes' access 
to federal funds that could be used for Medicaid outreach.[Footnote 33] 

Multiple opportunities exist for CMS and HHS to identify regulations 
that are important for IHS to review (see fig. 2). However, identifying 
such regulations can be challenging, as shown below. 

* CMS: The Tribal Affairs Group has an opportunity to review all draft 
proposed regulations and notify IHS about regulations it determines are 
relevant to the agency. However, Tribal Affairs Group officials 
explained that the large number of regulations (approximately 140 
regulatory documents a year), coupled with the size of their staff, 
means that they have difficulty doing more than a cursory review of the 
regulations.[Footnote 34] 

* HHS: Responsible for sending proposed regulations to affected 
agencies, HHS staff use their judgment to determine which HHS agencies 
should be provided regulations for review. However, the HHS staff 
making the determination may not have expertise on IHS and thus might 
not foresee the potential effect a regulation could have on American 
Indians' and Alaska Natives' eligibility for Medicare and Medicaid or 
these programs' reimbursements to IHS-funded facilities. HHS officials 
told us that they make these determinations by reviewing regulations 
and looking for key legislative terms, such as "Indian," to determine 
which agencies should be involved in the review. However, it is not 
clear that the HHS staff consistently used certain key terms, as the 
three proposed regulations that IHS reported not having the opportunity 
to review each contained the word "Indian." 

If regulations are not identified by CMS or HHS, then IHS may identify 
proposed CMS regulations that could affect its facilities or service 
population by reviewing quarterly CMS updates listing regulations and 
major policy changes under development. IHS may also review the Unified 
Agenda of Federal Regulatory and Deregulatory Actions, a semiannual 
listing of the regulatory actions that federal agencies--including CMS-
-are developing or have recently completed. 

Figure 2: Points in CMS Regulation Development Process When IHS Can Be 
Informed about a Proposed Regulation: 

This is a flowchart discussing points in CMS regulation development 
process when IHS can be informed about a proposed regulation. 

[See PDF for image] 

Source: GAO analysis of CMS regulation process, January 2008. 

Note: This figure highlights the steps in the regulations development 
process that are related to opportunities for IHS to be informed about 
a proposed regulation. However, it does not depict all steps in the CMS 
regulation development process. For example, it does not include steps 
related to the Office of Management and Budget's review of regulations. 

[End of figure] 

Recognizing the difficulties associated with identifying a regulation 
that could affect IHS and the tribes, CMS has been working to develop 
and implement additional procedures aimed at improving these efforts. 
In particular, the CMS Tribal Affairs Group has been working to obtain 
information from IHS to compile a profile of the types of providers 
available in tribal locations, which would assist CMS in determining 
the regulations that could have tribal implications. Additionally, CMS 
staff with responsibility for overseeing the regulations process have 
begun asking the staff who draft a regulation whether it affects 
tribes. If a potential tribal effect is identified, then CMS will 
indicate, on a cover sheet transmitting the regulation to HHS, that IHS 
should be provided the regulation for review. 

CMS Has Used Two Key Mechanisms to Interact, and the Annual HHS 
Regional Sessions to Consult, with Indian Tribes: 

CMS has used two key mechanisms--tribal liaisons and an advisory board-
-to interact with Indian tribes and has relied primarily on the annual 
HHS regional consultation sessions as its mechanism for consultation. 
CMS tribal liaisons have provided assistance and obtained input from 
tribes through activities such as participating in conferences and 
training sessions, visiting Indian reservations, and providing 
technical assistance and written guidance. The composition, meeting 
schedule, and organizational structure of CMS's tribal advisory board-
-the TTAG--also has provided an opportunity for CMS to obtain input 
from tribal representatives. With regard to consultation activities, 
CMS has relied on annual HHS regional consultation sessions as the 
primary mechanism to ensure input from tribal officials in the 
development of regulatory policies, although CMS officials noted that 
they have also held consultation meetings with individual tribes. 
However, consulting with over 560 tribes is an inherently difficult 
process, primarily because of complexities such as considering the 
needs and priorities of individual tribes. Tribal representatives' 
opinions on the effectiveness of CMS's consultation with Indian tribes 
and the agency officials involved varied considerably. 

CMS Has Used Tribal Liaisons and an Advisory Board as Its Mechanisms to 
Interact with Indian Tribes: 

CMS has used two key mechanisms to interact with representatives from 
Indian tribes, namely (1) tribal liaisons, who generally serve as 
tribal representatives' points of contact within CMS and provide 
assistance with Medicare and Medicaid, and (2) an advisory board, which 
provides input to CMS about issues affecting the delivery of health 
care to American Indians and Alaska Natives. 

Tribal Liaisons: 

CMS tribal liaisons are located in both CMS central and regional 
offices. In its central office, the CMS Tribal Affairs Group had four 
staff who served as the points of contact for tribal-related issues; 
these staff provided assistance to tribes and tribal representatives 
and coordinated issues within CMS.[Footnote 35] Formed in November 
2006, the Tribal Affairs Group has served many functions, including (1) 
serving as an internal resource for CMS staff, educating staff about 
the needs and priorities of American Indians and Alaska Natives; (2) 
coordinating the creation of informational materials on CMS programs, 
such as Medicare and Medicaid, for tribal communities; and (3) 
representing CMS in communications with Indian tribes and tribal 
representatives. In addition, the Tribal Affairs Group has served as an 
advisor to the CMS Administrator, reporting directly to his office and 
briefing him or his deputy approximately eight times per year about 
issues raised by tribal representatives. 

In addition to the CMS Tribal Affairs Group, each CMS regional office 
has had a designated official, the NAC, who serves as a liaison between 
the agency and Indian tribes in the region.[Footnote 36] Key roles of 
the NAC have included providing training about CMS programs to Indian 
tribes in the region; helping address tribal concerns, including 
assisting tribes and IHS-funded facilities in solving problems and 
obtaining answers to questions that arose; and serving as a CMS 
information source on American Indians and Alaska Natives. Except for 
two regions, the NAC role was a part-time responsibility, with the 
percentage of time spent on NAC-related duties ranging from 20 to 50 
percent.[Footnote 37] In the remaining regions--Denver and Seattle--the 
NAC positions are full-time because these staff have additional 
responsibilities as the lead NACs who coordinate activities across all 
CMS regions and because there are a significant number of tribes within 
these two regions. The NAC officials have coordinated their efforts 
with the CMS central office through monthly conference calls with the 
Tribal Affairs Group. 

The CMS Tribal Affairs Group and NACs have interacted, or coordinated 
other CMS staff's interactions, with tribal representatives using 
several methods, including participating in conferences and training 
sessions, visiting Indian reservations, and providing technical 
assistance and written guidance to Indian tribes (see table 1). 

Table 1: Types of Interactions between CMS Tribal Liaisons and Indian 
Tribes: 

Type of Interaction: Conferences and training sessions; 
Examples: * CMS has sponsored a day at the National Indian Health 
Board's Annual Consumer Conference, during which staff from the Tribal 
Affairs Group and NACs participate in sessions about CMS programs. For 
example, the 2007 conference featured sessions on understanding 
Medicaid, Medicare and Medicaid outreach, and advising IHS and tribal 
providers on how to navigate Medicare and Medicaid; 
* In 2007, the Tribal Affairs Group began producing monthly educational 
sessions on Medicare and Medicaid topics pertinent to IHS-funded 
facilities. The sessions are broadcast over satellite dishes provided 
to some IHS-funded facilities and on the internet. Topics of past 
sessions include introductions to Medicare and Medicaid and Medicare 
Part D reimbursement; 
* In August 2007, CMS staff, including CMS tribal liaisons, provided 
training in the Aberdeen IHS area to increase overall understanding of 
the Medicare and Medicaid programs. The training was attended by over 
200 people, including representatives from 13 Indian tribes. 

Type of Interaction: Site visits; 
Examples: * During a 2007 visit to a North Carolina tribe, the CMS 
Atlanta Region NAC discussed an issue related to youth treatment 
facilities that the tribe was having with the state Medicaid program; 
* During the CMS Kansas City Region NAC's visits to tribes in the 
region, she meets with the tribal councils, health officials, or both 
to update them on CMS program changes and discuss her role as the NAC; 
* During a 2004 visit to a Nebraska tribe, a CMS NAC and other CMS 
program staff provided guidance to the tribe on how its medical 
provider could become a Medicare-certified provider. 

Type of Interaction: Technical assistance; 
Examples: * CMS tribal liaisons have provided or coordinated the 
provision of technical assistance to Indian tribes and tribally 
operated facilities on topics including Medicaid eligibility, becoming 
a Medicare-participating provider, and Medicare and Medicaid billing; 
* The CMS Tribal Affairs Group worked with another CMS official to 
assist a tribally operated facility in recovering Medicare funds for 
over 4 years worth of claims that were underpaid because of an error in 
IHS's electronic billing system. Additionally, CMS worked with IHS 
staff to correct the program and ensured that other IHS-funded 
facilities were notified about the possibility of past underpayment; 
* In 2007, the Kansas City NAC coordinated technical assistance 
regarding Medicaid reimbursements for pharmaceuticals and related 
licensure requirements for IHS-funded facilities. As a result of this 
assistance, pharmacies at IHS-funded facilities in Kansas will be able 
to enroll as Medicaid providers and get reimbursed on a fee-for-service 
basis for pharmaceuticals, including refills. 

Type of Interaction: Written guidance; 
Examples: * In 2006, the Dallas Region NAC distributed a letter to 
tribal leaders on how tribes can be reimbursed for payments made to 
Medicare Part D prescription drug plans on behalf of tribal members; 
* With the help of the NAC, the Administrator of the CMS Kansas City 
regional office sent a letter to tribal leaders in the region 
describing an option that groups, such as tribes, have for paying the 
Medicare Part B premiums for their members. 

Source: GAO analysis of CMS and tribal information. 

[End of table] 

Tribal representatives with whom we spoke had varying opinions on the 
effectiveness of the CMS tribal liaisons. For example, a few tribal 
representatives we spoke with praised the efforts of the CMS Tribal 
Affairs Group staff; one representative noted that the Tribal Affairs 
Group is a critical link between Indian tribes and CMS, while other 
representatives noted the group's responsiveness to tribal concerns. 
Additionally, some tribal representatives mentioned specific 
interactions with the NAC, such as the NAC's working with the tribe to 
resolve issues with the state Medicaid program. However, some tribal 
representatives raised concerns about the liaisons' lack of decision- 
making authority. 

Advisory Board: 

In addition to liaisons, CMS has received input from tribal 
representatives through an advisory board. Specifically, in 2003, CMS 
created an advisory board, the TTAG, to provide it with expertise on 
policies, guidelines, and programmatic issues affecting the delivery of 
health care for American Indians and Alaska Natives served by Medicare, 
Medicaid, or other health care programs funded by CMS. Interactions 
between CMS officials and the TTAG are meant to complement, but not 
replace, consultation between CMS and Indian tribes. The TTAG was 
created to increase understanding between CMS and Indian tribes. 

The TTAG has been an important vehicle for CMS to obtain input from 
tribal representatives. (See table 2 for a description of the TTAG.) 
The agenda for TTAG meetings has been formulated jointly by tribal 
representatives and CMS officials, allowing for both CMS and tribal 
priorities to be discussed. The TTAG's composition, schedule, and 
structure have provided an opportunity for CMS to obtain input from 
tribal members. For example: 

* The TTAG has members from each IHS area and TTAG members gather 
information and views about CMS policies from tribes nationwide. 
Specifically, seven of the eight TTAG area representatives we spoke 
with indicated that they solicited information and obtained input from 
regular meetings with tribes in their area, often through the area 
health board or its equivalent.[Footnote 38] Similarly, the TTAG 
representatives from two of the three Washington, D.C.-based tribal 
associations indicated that they received input from regular meetings 
with the membership or from the board of their associations. 

* The TTAG generally has met monthly, which provides an opportunity for 
tribal representatives and CMS to discuss issues as they arise. For 
example, in February 2007, TTAG members were able to have a timely 
discussion with CMS about tribal representatives' concerns that a 
proposed regulation would prevent tribes and tribal organizations from 
collecting federal matching funds for Medicaid-related administrative 
activities, such as outreach. As a result of tribal representatives' 
concerns, the regulation was revised prior to issuance.[Footnote 39] 

* The TTAG's subcommittee structure has allowed tribal representatives 
and CMS officials to conduct in-depth analysis, work, and dialogue on 
Medicare and Medicaid topics that are a priority for CMS, American 
Indians and Alaska Natives, or both. Subcommittees have focused on 
topics such as the availability of CMS data on Medicare and Medicaid 
enrollment and service use among American Indians and Alaska Natives, 
outreach and education, and long-term care. 

Table 2: Description of the CMS TTAG: 

TTAG: Composition; 
Description: * TTAG members: An elected tribal leader (or designated 
employee with authority to act on his or her behalf) from each of the 
12 IHS areas and a representative from three Washington, D.C.-based 
tribal associations.[A]; 
* Technical advisors: Individuals selected by the TTAG members who have 
expertise in Medicare, Medicaid, and tribal issues. 

TTAG: Meeting schedule; 
Description: * Generally monthly; 
* Meetings occur in-person approximately three times a year and through 
conference calls during the other months. 

TTAG: Organizational structure; 
Description: * A chair and co-chair are elected annually by the 12 IHS 
area representatives; 
* Subcommittees are created to focus on particular Medicare and 
Medicaid topics affecting American Indians and Alaska Natives; 
the subcommittees include TTAG representatives, their technical 
advisors, and employees from CMS and IHS. 

Source: GAO analysis of the CMS TTAG, April 2008. 

[A] The three Washington, D.C.-based tribal associations are the 
National Congress of American Indians, the National Indian Health 
Board, and the Tribal Self-Governance Advisory Committee. 

[End of table] 

The TTAG and CMS have worked together on a number of issues. For 
example, the TTAG worked with CMS and IHS officials to develop a 
strategy to (1) educate Indian tribes and their members about the 
Medicare Part D benefit and (2) assist IHS-funded facilities in 
contracting with the program's prescription drug plans. Additionally, 
the TTAG created a strategic plan to outline a path for CMS to take 
over a 5-year period to resolve high-priority issues related to health 
care for American Indians and Alaska Natives. 

CMS Efforts to Consult with Indian Tribes Have Relied Primarily on HHS 
Annual Regional Consultation Sessions: 

CMS has used the annual HHS regional consultation sessions as its main 
mechanism to consult with the 562 federally recognized Indian tribes; 
CMS is required by Executive Order and HHS policy to consult with 
Indian tribes about policies that have tribal implications.[Footnote 
40] HHS designed the regional consultation sessions to (1) solicit 
Indian tribes' priorities and needs on health and human services 
programs and (2) provide an opportunity for tribes to articulate their 
comments and concerns on health and human services policy matters 
related to CMS and HHS. However, consulting with so many tribes is an 
inherently difficult task, in part because of the variation in the 
size, location, and economic status of the Indian tribes. Differences 
in the priorities of tribal participants may also make it difficult to 
have discussions that are meaningful for all participants. 

The HHS regional consultation sessions have offered limited time for 
consultation and discussion, as the sessions have generally occurred in 
the spring and lasted 1 to 2 days.[Footnote 41] Specifically, a review 
of a sample of eight consultation session agendas found that the time 
devoted to discussion of CMS-related issues ranged from less than 30 to 
90 minutes.[Footnote 42] Additionally, since the consultation sessions 
only occurred once a year, they may not allow for meaningful 
discussions in a timely manner, as CMS makes policy changes throughout 
the year. 

While the consultation sessions have been open to all tribes, the 
number of tribes that have participated is relatively small. According 
to HHS, representatives from 100 tribes attended a 2006 HHS regional 
consultation session and representatives from 152 tribes attended a 
2007 session; this equates to approximately 18 percent and 27 percent 
of federally recognized tribes, respectively. Several HHS officials 
noted that tribal attendance at the consultation sessions has varied, 
depending on the location of the session, which generally differed each 
year. Additionally, tribal participation in the sessions may be 
hindered by the amount of notice provided regarding the date of the 
sessions. The amount of notice tribes were given about the date of the 
regional consultation session ranged from 3 to 8 weeks across the four 
HHS regions we reviewed. 

In addition to the CMS-related discussions at the HHS consultation 
sessions, CMS officials have held consultation meetings with individual 
tribes or smaller groups of tribes.[Footnote 43] For example, CMS has 
consulted with the Navajo Nation about Medicaid issues the tribe has 
faced since its reservation is located across three states. 
Additionally, in January 2008, CMS officials traveled to Washington 
State to consult with the state's Medicaid program and Indian tribes 
about a proposed amendment to Washington State's Medicaid program that 
would stipulate how tribes in Washington state can receive federal 
reimbursement for Medicaid administrative activities. 

Tribal representatives had varying opinions on the effectiveness of the 
CMS and HHS consultations, including varying perspectives on the agency 
officials involved and the format of the consultation sessions. One 
tribal representative commented that leaders in CMS attend the meetings 
and are willing to share information, while another tribal 
representative commented that the officials who attend the sessions are 
not able to make decisions. Additionally, a third tribal representative 
explained that high-level officials who can make decisions attend the 
consultation sessions, but that these officials do not have the 
necessary information to answer questions. This variation may be due, 
at least in part, to regional differences in participation. Regarding 
the format of the consultation sessions, one tribal representative 
commented that the regional consultation sessions were fairly effective 
at identifying the issues that should be raised at the national level. 
However, a few tribal representatives commented that the HHS regional 
consultation sessions were too short and thus did not allow for 
meaningful tribal input or dialogue. 

Selected States' Medicaid Programs Have Used Multiple Mechanisms to 
Interact and Consult with Tribes: 

The six state Medicaid programs we reviewed have used at least one of 
the following three mechanisms to interact and consult with Indian 
tribes: tribal liaisons, advisory boards, and regularly scheduled 
meetings. Most of the states also reported having policies in place 
that provided a mechanism to govern their interactions, including 
consultations, with the Indian tribes. Most of the state Medicaid 
programs reviewed reported consulting with Indian tribes about changes 
to their Medicaid program. Tribal representatives' opinions on state 
Medicaid program's consultation practices varied. 

Medicaid Programs Have Used Mechanisms, Such as Tribal Liaisons, and 
State Policies to Interact and Consult with Indian Tribes: 

The six state Medicaid programs we reviewed have used at least one of 
three mechanisms to interact and consult with Indian tribes: (1) tribal 
liaisons--who serve as the tribes' primary contact with the states on 
issues related to Medicaid; (2) advisory boards--which, among other 
things, inform the state about Medicaid issues affecting American 
Indians and Alaska Natives; and (3) other regularly scheduled meetings-
-which states and tribes used to discuss Medicaid issues and identify 
opportunities for collaboration, technical assistance, and 
consultation.[Footnote 44] Additionally, five of the six states we 
reviewed had policies in place that provided a mechanism to govern 
interactions, including consultations, between the state Medicaid 
program and Indian tribes. 

Tribal Liaisons: 

All six state Medicaid programs have used at least one designated 
tribal liaison in their interactions, including consultations, with 
tribes about issues related to Medicaid. In addition to serving as a 
communication and coordination link between tribes and state Medicaid 
programs, some state tribal liaisons also have provided input on state 
Medicaid policies affecting American Indians and Alaska Natives and 
training and technical assistance to tribes on Medicaid (see table 3). 
Additionally, tribal liaisons have been involved in consultations with 
Indian tribes. For example, one of New Mexico tribal liaisons oversees 
the Medicaid program's consultations with Indian tribes, while a 
Wisconsin tribal liaison helps to coordinate an annual tribal 
consultation session. 

Table 3: Examples of Duties Performed by Tribal Liaisons: 

Roles and duties performed: Providing input on state policies; 
Examples: * The liaison in Montana presented a report in January 2007 
to the Medicaid agency identifying barriers tribes faced in obtaining 
Medicaid coverage. The liaison also researched ways that tribes could 
obtain additional Medicaid funding, which were communicated to tribes 
in a November 2006 letter; 
* The Utah tribal liaison reported advising the governor's office, Utah 
legislature, and Utah congressional members about public health policy, 
including Medicaid, and its implications for American Indians in Utah. 

Roles and duties performed: Technical assistance and training; 
Examples: * The New Mexico tribal liaison reported working with the 
tribes on issues such as Medicaid billing issues, provider enrollment, 
payment policies, and eligibility; 
* The Minnesota tribal liaison also reported providing training and 
technical assistance to the tribes on issues such as Medicaid billing; 
* The Wisconsin tribal liaison reported having a lead role in ensuring 
that Medicaid program staff are trained on tribal perspectives and 
cultural issues. 

Source: GAO analysis of six states' information. 

[End of table] 

Tribal representatives we spoke with had varying opinions on the effect 
tribal liaisons have had on interactions between the tribes and state 
Medicaid programs. For example, representatives from a Montana tribe 
reported that interactions with the state Medicaid program's tribal 
liaison resulted in changes to the state's Medicaid application. 
Specifically, after the tribe explained to the tribal liaison that the 
length of the application was a barrier to American Indians and Alaska 
Natives enrolling in Medicaid, the state simplified its Medicaid 
application. Additionally, individuals representing selected tribes in 
Arizona told us that the establishment of a tribal liaison position in 
that state's Medicaid program has improved tribes' ability to provide 
input on health policy issues and resulted in progress regarding those 
issues. In contrast, representatives from a Minnesota tribe noted that 
working with the state is difficult even though there is a tribal 
liaison. Similarly, while officials from a Southwest tribe noted the 
importance of tribal liaisons, they also expressed concern that tribal 
liaisons are sometimes kept out of decision making. 

Advisory Boards: 

Three of the six state Medicaid programs--Arizona, New Mexico, and 
Utah--reported using advisory boards to interact, and in some cases 
consult, with Indian tribes. For example, Utah has utilized an advisory 
board to determine if proposed state Medicaid policy or program changes 
have tribal implications and thus require additional consultation with 
the advisory board or other tribal representatives. 

The Medicaid programs described using two types of advisory boards to 
interact with the Indian tribes: (1) Indian advisory boards, which 
address a broad array of issues affecting the provision of health care 
to American Indians and Alaska Natives, and (2) Medicaid advisory 
boards, which address issues affecting all Medicaid beneficiaries, 
including American Indians and Alaska Natives. Specifically, one state 
Medicaid program (Arizona) reported using Indian advisory boards; one 
program (New Mexico) reported using its Medicaid advisory board, which 
includes tribal representation; and one program (Utah) reported using 
both. 

While both types of advisory boards are mechanisms for interactions 
between the state and tribal representatives, the composition of the 
advisory boards varied. Specifically, the Indian advisory boards 
included numerous tribal representatives, while there were fewer tribal 
representatives on the Medicaid advisory boards. For example, the Utah 
Indian advisory board, which meets monthly, includes appointed 
representatives from all of the Utah tribes as well as the state's 
tribal liaison, other state and tribal officials, and IHS staff. In 
comparison, Utah's Medicaid advisory board has one individual to 
represent the seven tribes in the state. New Mexico's Medicaid advisory 
board has two tribal representatives who may also serve on a 
subcommittee on tribal issues.[Footnote 45] 

Meetings: 

Four of the six state Medicaid programs (Arizona, Minnesota, New 
Mexico, and Wisconsin) reported holding regularly scheduled meetings to 
interact, and in some cases consult, with Indian tribes.[Footnote 46] 
The frequency of these meetings ranged from bimonthly to annually, and 
states reported discussing issues such as the Medicaid budget and 
reimbursement. For example, New Mexico officials reported holding an 
annual meeting to consult with tribal representatives about pertinent 
Medicaid policy and program changes and the Medicaid program's budget 
prior to the state legislative session. A Wisconsin official reported 
that the state's bimonthly meetings with tribal health directors focus 
on specific issues, such as increasing Medicaid reimbursements for 
tribally operated facilities and accessing federal matching funds for 
tribal Medicaid expenditures. 

Tribal representatives' assessments of the value of the regularly 
scheduled meetings with the states varied. For example, representatives 
from one tribe, which participates in quarterly meetings with officials 
who oversee Minnesota's Medicaid program, said that the meetings were 
successful in helping address tribal needs. However, representatives 
from two Wisconsin tribes noted that the number of tribes involved and 
the brevity of the annual meetings with the state made discussing 
specific issues difficult. Tribes also reported that location was a 
factor that contributed to the success of these meetings. Specifically, 
representatives from Wisconsin and Minnesota tribes indicated that 
holding meetings in convenient locations affects tribal participation 
and increased the meetings' effectiveness, respectively. 

Policies: 

Five of the six states we reviewed--Arizona, Minnesota, New Mexico, 
Wisconsin, and Utah--reported having policies in place that govern the 
interactions, and in most cases consultations, between their states' 
Medicaid programs and Indian tribes.[Footnote 47] The states had two 
types of policies governing interactions with Indian tribes: (1) 
governor's orders, which specify that all state agencies should 
interact with Indian tribes on a government-to-government basis and 
provide for consultation between the state and Indian tribes, and (2) 
tribal consultation policies, which establish guidelines that state 
agencies, including Medicaid agencies, should use to consult with 
Indian tribes. Specifically, one state (Minnesota) reported having a 
governor's order, two states (Utah and Wisconsin) reported having 
tribal consultation policies, and two states (Arizona and New Mexico) 
reported having both.[Footnote 48] The four states' tribal consultation 
policies established guidelines with varying degrees of specificity for 
how consultation between the Medicaid agency and Indian tribes should 
be conducted. Table 4 provides an overview of the guidelines in the 
four states' consultation policies. 

Table 4: Highlights of Guidelines Established by State Tribal 
Consultation Policies: 

State: Arizona; 
Guidelines: * Consultation meetings can be scheduled upon request; 
* If the Medicaid program identifies a policy likely to have a 
significant impact on Indian tribes, then it should provide timely 
written notice to tribal leaders soliciting feedback and 
recommendations; 
* At the request of tribal officials, the Medicaid program should 
provide additional information either verbally or in written 
correspondence. 

State: New Mexico; 
Guidelines: * Consultation can be initiated by the state or by tribal 
leaders; 
* The state and tribes may engage in direct consultation, establish a 
work group, or both; 
* The state and tribes shall meet annually to consult on health and 
human services issues. 

State: Utah; 
Guidelines: * The state will initiate consultation following a request 
from a tribe(s); 
* The consultation process will include, but is not limited to; 
- an initial meeting to present the intent and broad scope of the 
policy to the state's Indian advisory board; 
- discussions with the advisory board to understand the specifics and 
impact of a proposed policy; 
- open meetings for all interested parties to receive information and 
provide comment; 
- a presentation by tribal representatives of their concerns about the 
proposed policy; 
- continued meeting until concerns have been fully discussed, and; 
- a written response from the state as to the action on tribal 
concerns; 
* When possible, the state will provide 90 days' notice of a proposed 
policy by making a presentation to the Indian Advisory Board and 
sending a formal letter to tribal leaders. 

State: Wisconsin; 
Guidelines: * Annual consultation meeting shall be scheduled with the 
agenda, date, and location being jointly determined by the state and 
tribal leaders; 
* Additional consultation meetings shall be scheduled as deemed 
necessary by either the state or a majority of tribal leaders; 
* The state is responsible for drafting an annual implementation plan 
that shall include (1) a list of programs and services available to 
tribes; (2) a description of new initiatives, programs, and policies 
affecting tribes; (3) priority issues for resolution with the tribes; 
(4) the procedures to be used to consult with tribes; and (5) an 
evaluation process. 

Source: GAO analysis of state consultation policies, January 2008. 

[End of table] 

Most States Reviewed Reported Consulting with Indian Tribes about 
Medicaid Changes: 

Most of the state Medicaid programs we reviewed reported consulting 
with Indian tribes in their state when making changes to their Medicaid 
programs.[Footnote 49] Specifically, four states (Minnesota, New 
Mexico, Utah, and Wisconsin) reported consulting with Indian tribes on 
any Medicaid program changes that they believed affected Indian tribes, 
and one state (Montana) reported consulting only on Medicaid program 
changes that required a waiver.[Footnote 50] The remaining state-- 
Arizona--reported that it has not consulted with Indian tribes about 
Medicaid program changes.[Footnote 51] States used a variety of 
mechanisms to consult with Indian tribes, such as regularly scheduled 
quarterly meetings with tribal health directors and advisory boards. 

The states reported consulting with Indian tribes about a variety of 
topics. For example, New Mexico officials reported an extensive 
consultation process with tribes about a new Medicaid program for 
coordinated long-term services. These consultations resulted in changes 
to the program, including requiring the program's managed care plans to 
have tribal liaisons. Additionally, Minnesota noted that it consulted 
with Indian tribes about changing the process by which Medicaid 
eligibility determinations are made for children in foster care and 
adoption assistance programs. 

Tribal representatives' opinions on state Medicaid program's 
consultation practices varied. For example, representatives from one 
Wisconsin tribe noted that consultation was not hurtful but was also 
not helpful. They explained that consultation provides opportunities to 
interact directly with agency officials and voice concerns but does not 
necessarily lead to changes in agency processes. In contrast, 
representatives from a Minnesota tribe provided examples of specific 
actions the Medicaid program took as a result of consultation. A 
representative from a Minnesota tribe noted that consultation was 
effective when there was a personal relationship with state officials. 
However, representatives from several tribes in Montana reported that 
consultation did not occur. For example, representatives from one 
Montana tribe noted that rather than consulting with tribes about 
changes to the Medicaid program, the state informed tribes after 
changes had already been made. 

American Indians and Alaska Natives Have Faced Several Barriers to 
Medicare and Medicaid Enrollment Despite Efforts to Assist with the 
Application Process: 

American Indians and Alaska Natives have faced several barriers to 
Medicare and Medicaid enrollment despite efforts to provide assistance 
with the application process. While two of the barriers to Medicare and 
Medicaid enrollment are associated with the unique status of the tribal 
community, most of the enrollment barriers faced by American Indians 
and Alaska Natives are similar to those experienced by other 
populations--such as individuals with low incomes. Efforts to enroll 
American Indians and Alaska Natives have focused on providing 
assistance with the Medicaid and Medicare application processes. For 
example, almost all of the IHS-funded facilities we visited had staff 
who help patients complete and submit Medicare and Medicaid 
applications. Many organizations, including CMS and IHS, have conducted 
outreach to educate American Indians and Alaska Natives about the 
programs. 

American Indians and Alaska Natives Have Faced Barriers Enrolling in 
Medicare and Medicaid: 

American Indians and Alaska Natives have faced barriers to Medicare and 
Medicaid enrollment (see table 5). Two of the barriers are unique to 
the tribal community. First, some officials we spoke with reported that 
some American Indians and Alaska Natives believe they should not have 
to apply for Medicare or Medicaid because the federal government has a 
duty to provide them with health care as a result of treaties with 
Indian tribes. Second, American Indians and Alaska Natives may not see 
a personal benefit to enrolling in Medicare or Medicaid because they 
have access to free health care at IHS-funded facilities regardless of 
whether they enroll. 

Other barriers were similar to those faced by other populations. For 
example, similar to low-income populations, American Indians and Alaska 
Natives have experienced transportation and financial barriers, as well 
as barriers related to limits on access to communication devices, such 
as telephones and regular mail delivery. While similar to the barriers 
faced by other populations, some officials believed that there are some 
distinct aspects to the barriers faced by American Indians and Alaska 
Natives. For example, application processes, such as the Medicaid 
requirement to provide documentation of U.S. citizenship, may be 
especially difficult for American Indians and Alaska Natives as this 
population was traditionally not born in a hospital. As a result, some 
officials reported that some American Indians and Alaska Natives, 
particularly those who are elderly, do not have an official record of 
their birth. 

Table 5: Description of Barriers American Indians and Alaska Natives 
Have Experienced Enrolling in Medicare and Medicaid: 

Barrier: Barriers unique to American Indians and Alaska Natives: Belief 
in a federal responsibility to provide health care; 
Description: Barriers unique to American Indians and Alaska Natives: A 
belief that the federal government has a responsibility based on 
treaties with Indian tribes to provide health care for American Indians 
and Alaska Natives and therefore they should not have to apply for 
Medicare or Medicaid. 

Barrier: Barriers unique to American Indians and Alaska Natives: Belief 
that enrollment provides limited personal benefit; 
Description: Barriers unique to American Indians and Alaska Natives: A 
lack of understanding of the benefit of enrolling in Medicare and 
Medicaid because of the availability of free healthcare at IHS-funded 
facilities. 

Barrier: Barriers faced by American Indians and Alaska Natives as well 
as other populations: Complex application process; 
Description: Barriers unique to American Indians and Alaska Natives: 
Includes the length of the application; the need to go to eligibility 
offices; and documentation requirements, such as proof of income and 
citizenship. 

Barrier: Barriers faced by American Indians and Alaska Natives as well 
as other populations: Cultural; 
Description: Barriers unique to American Indians and Alaska Natives: 
Includes American Indians and Alaska Natives' reluctance to pursue 
enrollment if initially denied, aversion to revealing personal 
information required for application, and reluctance to apply for 
Medicaid because of requirements for seeking child support. 

Barrier: Barriers faced by American Indians and Alaska Natives as well 
as other populations: Financial; 
Description: Barriers unique to American Indians and Alaska Natives: 
Includes premiums requirements that are associated primarily with 
Medicare Part B and D enrollment and concerns about losing assets 
because of Medicaid estate recovery requirements.[A]. 

Barrier: Barriers faced by American Indians and Alaska Natives as well 
as other populations: Lack of knowledge about the programs; 
Description: Barriers unique to American Indians and Alaska Natives: 
Includes a lack of awareness about the programs' existence, the 
differences between the programs, and their requirements for 
eligibility. 

Barrier: Barriers faced by American Indians and Alaska Natives as well 
as other populations: Language; 
Description: Barriers unique to American Indians and Alaska Natives: 
Includes limits to understanding, speaking, or reading English. 

Barrier: Barriers faced by American Indians and Alaska Natives as well 
as other populations: Limited access to communication devices; 
Description: Barriers unique to American Indians and Alaska Natives: 
Includes a lack of access to reliable and regular mail delivery and 
phone service. 

Barrier: Barriers faced by American Indians and Alaska Natives as well 
as other populations: Mistrust of government; 
Description: Barriers unique to American Indians and Alaska Natives: In 
addition to just a general mistrust of the government, also includes 
concerns about prejudice, racism, and mistreatment by government 
officials. 

Barrier: Barriers faced by American Indians and Alaska Natives as well 
as other populations: Transportation; 
Description: Barriers unique to American Indians and Alaska Natives: 
Includes a lack of reliable transportation options, including public 
transportation services, and the need to travel long distances to 
eligibility offices. 

Source: GAO analysis, April 2008. 

[A] Estate recovery is the requirement that state Medicaid programs 
seek to collect from the estate of a deceased Medicaid beneficiary the 
amounts paid on the individual's behalf for certain Medicaid-covered 
services, such as nursing facility services. While not totally exempt 
from Medicaid estate recovery, CMS has instituted certain protections 
on the estates of American Indians and Alaska Natives. 

[End of table] 

Enrollment Efforts Have Focused on Assisting American Indians and 
Alaska Natives with Applying for Medicare and Medicaid: 

Efforts to enroll eligible American Indians and Alaska Natives in 
Medicare and Medicaid generally have focused on providing assistance 
with the application process. Specifically, almost all of the IHS- 
funded facilities we visited offered patients assistance with applying 
for Medicare and Medicaid.[Footnote 52] The assistance included helping 
complete and submit applications, collecting and possibly certifying 
required documentation, translating application information into tribal 
languages, and offering these services through home visits. Facility 
staff generally identified patients needing application assistance 
through their patient registration process, which is the process 
through which patients sign in for their medical appointments. For 
example, facility registration staff used information about a patient's 
age, employment status, and existence of health insurance to determine 
whether the patient might qualify for Medicare or Medicaid and thus 
should be referred to a patient benefit coordinator for assistance (see 
fig. 3). In addition to the patient registration process, some 
facilities also generated reports listing individuals who were 
potentially eligible for, but not enrolled in, Medicare or Medicaid. 
For example, one facility indicated that it generated monthly reports 
of (1) individuals aged 65 and older who did not have Medicare and (2) 
individuals aged 19 or younger without health insurance and thus 
potentially eligible for Medicaid. This same facility also generated 
reports of individuals who were age 64 to alert patient benefit 
coordinators that these individuals may soon be eligible for Medicare. 

Figure 3: Example of How Facilities Use the Patient Registration 
Process to Identify Patients Needing Medicare or Medicaid Application 
Assistance: 

This figure is a flowchart showing an example of how facilities use the 
patient registration process to identify patients needing medicare or 
medicaid application assistance. 

[See PDF for image] 

Source: GAO analysis of IHS-funded facility information, January 2008/ 

[End of figure] 

Facilities we visited used staff--referred to as patient benefit 
coordinators--to provide Medicare and Medicaid application assistance. 
Among the facilities offering assistance, the number of patient benefit 
coordinator positions ranged from one to eight; hospitals generally had 
a higher number of patient benefit coordinator positions. 

American Indians and Alaska Natives may also receive application 
assistance directly from Medicaid or Medicare eligibility staff. State 
or county Medicaid eligibility staff worked at or traveled to four of 
the IHS-funded facilities we visited to provide application assistance 
and conduct on-site eligibility determinations; these eligibility staff 
were located at two of the facilities full-time, that is, 5 days a 
week.[Footnote 53] State or county Medicaid eligibility staff were also 
located at, or traveled to, tribal offices on three of the reservations 
we visited.[Footnote 54] Specifically, one of the reservations had a 
satellite Medicaid eligibility office, which was open 5 days a week and 
housed several county Medicaid eligibility staff. The second 
reservation had a staff member on-site 5 days a week, while a staff 
member was available on the third reservation 2 days a week. 
Additionally, a few of the tribes we visited had the authority to 
determine Medicaid eligibility for at least some tribal members and 
therefore had additional Medicaid application assistance available at 
the tribal office where eligibility determinations occurred.[Footnote 
55] Finally, staff from SSA, the federal agency responsible for 
Medicare enrollment, provided Medicare application assistance at some 
IHS-funded facilities. Specifically, staff from two of the IHS-funded 
facilities we visited indicated that SSA office staff visited their 
facilities at least monthly, while staff from a third IHS-funded 
facility indicated that SSA staff came to a building nearby at least 
monthly. 

Many organizations, including CMS and IHS, have conducted outreach to 
educate the tribal community about Medicare and Medicaid and encourage 
those in the community to apply. For example, beginning in May 2005, 
there was a concerted effort by CMS, IHS, and SSA to educate and enroll 
American Indians and Alaska Natives in the Medicare Part D prescription 
drug benefit, including training for patient benefit coordinators in 
each IHS area and informational materials, such as posters and fact 
sheets, targeted to the tribal community. In 2007, CMS and the TTAG 
released an outreach video, to be used at IHS-funded facilities, which 
emphasizes the community benefit to enrollment in Medicare and 
Medicaid.[Footnote 56] Additionally, in 2007, IHS published a poster 
and brochure to educate American Indians and Alaska Natives about 
existing federal and state health benefit programs, such as Medicare 
and Medicaid.[Footnote 57] Other outreach efforts targeted to the 
tribal community included radio advertisements, which a few of the 
state Medicaid programs we reviewed reported using, and newspaper or 
newsletter articles, which some IHS-funded facilities reported using. 
Finally, several of the IHS-funded facilities we visited provide 
information about Medicare and Medicaid at facility-based or community 
health fairs and events at schools, senior centers, or other community 
venues. 

Agency and State Comments and Our Evaluation: 

We provided copies of a draft of this report to HHS and provided the 
six states we reviewed (Arizona, Minnesota, Montana, New Mexico, Utah, 
and Wisconsin) with copies of the portion of the report related to 
state Medicaid programs' mechanisms for interacting and consulting with 
Indian tribes. HHS provided us with written comments from CMS (see app. 
III). We also received technical comments from CMS and three of the six 
states (Arizona, Montana, and New Mexico), which we incorporated as 
appropriate. 

In written comments, CMS noted that it was pleased that our findings 
highlight a number of activities that CMS engages in with IHS and 
commented that the report reinforces the benefit of the multiple 
processes CMS has put in place in working with IHS and the tribes. CMS 
acknowledged that it is working to improve its process for identifying 
whether proposed regulatory changes would affect IHS-funded facilities 
and the populations they serve. CMS noted that its regulations also 
affect programs directly operated by tribes, which have broader 
authority than IHS in operating programs and facilities such as nursing 
homes. We agree with CMS about the potential impact of its regulations 
on tribally operated programs and facilities, and we encourage the 
agency to consult with tribes when developing its regulations as 
required by Executive Order and HHS's tribal consultation policy. 

As agreed with your offices, unless you publicly announce the contents 
earlier, we plan no further distribution of this report until 30 days 
after its issue date. At that time, we will send copies of this report 
to the Administrator of the Centers for Medicare & Medicaid Services 
and the Director of the Indian Health Service. We will also provide 
copies to others upon request. In addition, the report will be 
available at no charge on the GAO Web site at [hyperlink, 
http://www.gao.gov]. 

If you or your staffs have any questions about this report, please 
contact me at (202) 512-7114 or kingk@gao.gov. Contact points for our 
Offices of Congressional Relations and Public Affairs may be found on 
the last page of this report. GAO staff who made major contributions to 
this report are listed in appendix IV. 

Signed by: 

Kathleen M. King: 

Director, Health Care: 

[End of section] 

Appendix I: Locations of Indian Health Service (IHS) Areas and Centers 
for Medicare & Medicaid Services (CMS) Regions: 

Figure: 

This figure is a map showing locations of Indian Health Service (IHS) 
areas and Centers for Medicare Services (CMS) regions. 

[See PDF for image] 

Source: GAO-08-90 and information from CMS. 

Note: Data on counties in the IHS areas are as of June 2007. 

[End of section] 

Appendix II: Methodology for Selecting IHS Areas, Facilities, and 
Tribes Visited: 

We used a two-tiered approach to selecting facilities and tribes for 
site visits, which included selecting 3 of the 12 IHS areas and then 
selecting facilities and tribes within those 3 areas. Based on this 
approach, we interviewed officials from 25 IHS-funded facilities and 
leaders (or designated officials) from 14 tribes. 

In the first tier, we selected three IHS areas to represent a mix in 
geographic location, the entities operating the facilities (IHS or 
tribes), and the level of reliance on contract health 
services.[Footnote 58] Table 6 shows the characteristics of the areas 
selected. 

Table 6: Selected Characteristics of IHS Areas Visited: 

Factors considered: Geographic location; 
Bemidji: Michigan, Wisconsin, and most of Minnesota; 
Billings: Montana and Wyoming; 
Navajo: Parts of Arizona, New Mexico, and Utah. 

Factors considered: Percentage of facilities operated by tribes[A]; 
Bemidji: 89; 
Billings: 14; 
Navajo: 28. 

Factors considered: Reliance on contract health services[B]; 
Bemidji: Moderate; 
Billings: High; 
Navajo: Low. 

Source: GAO analysis of IHS data. 

[A] Includes hospitals, health centers, and health stations. 

[B] Determined based on contract health services dollars as a 
percentage of total clinical care dollars for fiscal year 2003. 

[End of table] 

In the second tier, we selected facilities within the three IHS areas. 
When selecting facilities, we considered recommendations from CMS and 
IHS officials and tribal representatives, the type of facility (for 
example, hospital or health center), and whether it was IHS or tribally 
operated. We also used pragmatic considerations, such as distance 
between facilities, to guide our selections. See table 7 for the 
characteristics of the 25 facilities in which we interviewed officials. 
For each facility visited, we requested interviews with the leaders of 
the tribe primarily served by the facility.[Footnote 59] We were able 
to interview leaders or designated officials from 14 tribes--7 from the 
Bemidji area, 5 from the Billings area, and 2 from the Navajo area. 
Because of the judgmental nature of our sample, information obtained 
from the facilities and tribal leaders cannot be generalized. 

Table 7: Characteristics of IHS-Funded Facilities Visited: 

IHS area: Bemidji; 
Facility type: Hospital; 
Operating body: IHS: 1; 
Operating body: Tribe: 0. 

IHS area: Bemidji; 
Facility type: Health center; 
Operating body: IHS: 1; 
Operating body: Tribe: 7. 

IHS area: Billings; 
Facility type: Hospital; 
Operating body: IHS: 3; 
Operating body: Tribe: 0. 

IHS area: Billings; 
Facility type: Health center[A]; 
Operating body: IHS: 2; 
Operating body: Tribe: 2. 

IHS area: Billings; 
Facility type: Health station; 
Operating body: IHS: 1; 
Operating body: Tribe: 0. 

IHS area: Navajo; 
Facility type: Hospital; 
Operating body: IHS: 3; 
Operating body: Tribe: 1. 

IHS area: Navajo; 
Facility type: Health center; 
Operating body: IHS: 2; 
Operating body: Tribe: 2. 

Source: GAO summary of information on 25 facilities. 

[A] On one reservation, we spoke with officials from the Tribal Health 
and Human Services Department, which oversees the tribe's health 
centers, instead of staff from the actual facilities. Although the 
tribe operates more than one health center, the facilities' operations 
are centralized. Therefore, for purposes of this report, we counted 
this tribe's facilities as a single health center. 

[End of table] 

[End of section] 

Appendix III: Comments from the Department of Health and Human 
Services: 

The Secretary Of Health And Human Services: 
Washington, DC 20201:  

June 24, 2008: 

Kathleen King: 
Director, Health Care: 
U.S. Government Accountability Office: 
Washington, DC 20548: 

Dear Ms. King,

Enclosed are the Department's comments on the U.S. Government 
Accountability Office's (GAO) draft report entitled, "Medicare and 
Medicaid: CMS and State Efforts to Interact with the Indian Health 
Service and Indian Tribes" (GAO-08-724). 

The Department appreciates the opportunity to review and comment on 
this draft before its publication.

Sincerely, 

Signed by: 

Jennifer R. Luong: 

for: 

Vincent J. Ventimiglia, Jr.: 

Assistant Secretary for Legislation: 

Attachment: 

Department Of Health & Human Services: 
Centers for Medicare & Medicaid Services: 

Administrator: 
Washington, DC 20201: 

Date: June 24, 2008:  

To: Kathleen King: 
Director, Health Care: 
Government Accountability Office: 

From: Kerry Weems: 
Acting Administrator: 

Signed by: 

Kerry Weems: 

Subject: Government Accountability Office (GAO) Draft Report: "Medicare 
And Medicaid I and State Efforts to Interact with the Indian Health 
Service and Indian Tribes" (GAO-08-724) 

The Centers for Medicare & Medicaid Services (CMS) appreciates the 
opportunity to respond to GAO's draft report entitled, "Medicare And 
Medicaid: CMS and State Efforts to Interact with the Indian Health 
Service and Indian Tribes." CMS has focused on developing a process 
where the Indian Health Service (IHS) and Tribal programs can learn 
more about Medicare, Medicaid, and the State Children's Health 
Insurance Program (SCHIP) and on reinforcing ways in which Tribes can 
provide input into the policy development; specifically through the 
regulations process. 

We were pleased to see GAO highlight a number of activities that CMS 
engages in with IHS in support of the Department of Health and Human 
Services' (HHS) strategic goals related to increasing the availability 
and accessibility of health care service, as well as addressing the 
needs, strengths, and abilities of vulnerable populations. Some of the 
CMS activities recognized by the GAO include: annual IHS area training 
sessions, tribal stops in the Medicare prevention tour, and training in 
the implementation of Medicare Part D. Additionally, as referenced in 
the report, CMS sponsors an annual CMS Day during the National Indian 
Health Board Consumer Conference; conducts a monthly TV and Web-based 
broadcast called Medicine Dish; provides technical assistance to 
individual Tribes and facilities through the CMS regional office 
network of Native American Contacts; develops outreach materials 
specific to the needs of the American Indian and Alaska Native 
beneficiary populations; and works closely with the CMS Tribal 
Technical Advisory Group through a series of monthly conference calls 
and face- to-face meetings with CMS' program staff. The CMS Tribal 
Affairs Group (TAG), put into place in 2007, is the central point of 
contact for CMS' activities related to IHS and Tribes. One of the key 
initiatives undertaken by the TAG is providing annual training to CMS' 
staff to enhance CMS' ability overall to work more effectively with IHS 
and Tribal Governments.

The GAO report contains no recommendations as to areas CMS can improve 
upon in our work with IHS and Tribes, but expresses that CMS has mixed 
success in identifying whether proposed regulatory changes would affect 
IHS-funded facilities and the populations they serve. As the report 
notes, we are working to improve this process. However, regulations 
issued by CMS not only impact the IHS-funded facilities, they also 
impact programs directly operated by Tribes outside of IHS Medicare and 
Medicaid authorities. We are becoming more familiar with these programs 
as we work more directly with Tribes. Tribes have broader authorities 
than IHS in operating programs such as Federally Qualified Health 
Centers, Assisted Living Facilities, Nursing Homes, and Home and 
Community Based Services. CMS is committed to continually seeking ways 
in which we can work more effectively with both the IHS and Tribes in 
meeting all provider needs; and in this way increasing access to 
Medicare, Medicaid, and SCHIP services for the populations they serve. 

The CMS is appreciative of GAO for its review of CMS' activities 
related to our interactions with IHS and Tribes. This report reinforces 
the benefit of the multiple processes CMS has put into place in working 
with the IHS and Tribes; assisting them to become more knowledgeable of 
Medicare, Medicaid, and SCHIP, with the goal of increasing access to 
CMS' program services for the American Indian and Alaska Native 
beneficiary populations. Understanding that CMS programs are important 
to the sustainabIlity of health care services for these vulnerable 
populations, we are committed to continually improving our interactions 
with IHS and with Tribes. 

[End of section] 

Appendix IV: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Kathleen M. King, (202) 512-7114 or kingk@gao.gov: 

Acknowledgments: 

In addition to the contact named above, Carolyn Yocom, Assistant 
Director; Krister Friday; Elayne Heisler; Kevin Milne; Michelle 
Rosenberg; and Elijah Wood made key contributions to this report. 

[End of section] 

Footnotes: 

[1] A federally recognized Indian tribe is an Indian or Alaska Native 
tribe, band, nation, pueblo, village, or community that the Secretary 
of the Interior acknowledges to exist as an Indian tribe pursuant to 
the Federally Recognized Indian Tribe List Act of 1994, 25 U.S.C. § 
479a. 

[2] To be eligible for IHS services, an individual must be a person of 
American Indian or Alaska Native descent as evidenced by such factors 
as tribal membership, living on tax-exempt land, owning restricted 
property, participating actively in tribal affairs, or other relevant 
factors. The most common standard applied for eligibility for IHS 
services is that the individual is an enrolled member of a federally 
recognized tribe. 

[3] IHS-funded facilities can also seek reimbursement from other 
sources, such as private health insurance. 

[4] See 25 U.S.C. §§ 1621f, 1645 (2000). 

[5] These data do not account for all collections by IHS-funded 
facilities because tribally operated facilities are not required to 
report such information. 

[6] GAO, Indian Health Service: Health Care Services Are Not Always 
Available to Native Americans, GAO-05-789 (Washington, D.C.: Aug. 31, 
2005). 

[7] See Executive Order 13084, 63 Fed. Reg. 27,655 (May 19, 1998). The 
1998 Executive Order was replaced by Executive Order 13175, issued on 
November 6, 2000. According to this order, policies that have tribal 
implications include regulations, legislative comments or proposed 
legislation, and other policy statements that have substantial direct 
effects on one or more Indian tribes, on the relationship between the 
federal government and Indian tribes, or on the distribution of power 
and responsibility between the federal government and Indian tribes. 
See 65 Fed. Reg. 67,249 (Nov. 9, 2000). 

[8] We did not speak with officials from one region (Philadelphia) 
because there are no federally recognized Indian tribes in that region. 

[9] IHS's Office of Resource Access & Partnerships works with external 
organizations and other federal agencies to increase access and 
resources and to develop partnerships aimed at improving the health 
status of American Indians and Alaska Natives. 

[10] The three IHS areas we visited were (1) Bemidji, which includes 
Michigan, Wisconsin, and most of Minnesota; (2) Billings, which 
includes Montana and Wyoming; and (3) Navajo, which includes portions 
of Arizona, New Mexico, and Utah. 

[11] In selecting these areas, we also considered other factors, such 
as whether we had visited the area previously and experts' views on the 
relationship between tribes and states in the area. 

[12] The four HHS regional offices were Chicago, Dallas, Denver, and 
San Francisco. HHS has the same regional office structure as CMS. 

[13] The six states are Arizona, Minnesota, Montana, New Mexico, Utah, 
and Wisconsin. 

[14] To identify the number of states with tribal locations, we 
analyzed the 2008 list of Indian Entities Recognized and Eligible To 
Receive Services (see 73 Fed. Reg. 18,553 (Apr. 4, 2008)). We excluded 
one state on this list (Indiana) because it did not have reservations 
or trust lands. 

[15] See Department of the Interior, Bureau of Indian Affairs, American 
Indian Population and Labor Force Report 2003 (Washington, D.C.: 2003). 

[16] A health station is a facility, physically separated from a 
hospital or health center, where primary care physician services are 
available on a regularly scheduled basis but for less than 40 hours a 
week. 

[17] Under IHS regulations, an individual is eligible for direct care 
if the individual is regarded as an American Indian or Alaska Native by 
the community in which he or she lives, as evidenced by factors such as 
tribal membership, enrollment, residence on tax-exempt land, ownership 
of restricted property, active participation in tribal affairs, or 
other relevant factors. In certain very limited circumstances, 
individuals who are not American Indians or Alaska Natives may be 
eligible for direct care services. 42 C.F.R. § 136.12 (2007). 

[18] In most cases, a contract health service delivery area consists of 
the county or counties in which a reservation is located, as well as 
any counties it borders. 

[19] Medicare Part B premiums are higher for individuals with incomes 
above a certain level and a late payment penalty is assessed for 
individuals who do not apply before the enrollment deadline. 
Additionally, state Medicaid programs pay some or all of the premium 
for certain low-income individuals. 

[20] IHS does not currently have the authority to pay individuals' 
Medicare Part D premiums. 

[21] IHS has had the authority to bill Medicare and Medicaid since 
1976. 

[22] See Executive Order 13175, 65 Fed. Reg. 67,249 (Nov. 9, 2000). 

[23] Although there is a designated NAC in each of the 10 CMS regions, 
the NAC in the Philadelphia region is not involved as there are no 
federally recognized Indian tribes in that region. CMS has the same 
regions as HHS. 

[24] CMS provided this guidance through a state Medicaid directors 
letter issued November 9, 2006. 

[25] For example, the Secretary may waive certain federal Medicaid 
requirements and authorize Medicaid expenditures for experimental, 
pilot, or demonstration projects that are likely to assist in promoting 
Medicaid objectives. See Social Security Act § 1115. The Secretary can 
also waive Medicaid requirements in order to allow long-term care 
services to be delivered in community settings. See Social Security Act 
§ 1915(c). 

[26] CMS provided this guidance through a state Medicaid directors 
letter issued July 17, 2001. 

[27] A provider-based facility is a facility that is owned and operated 
by a separate inpatient facility, such as a hospital. 

[28] Specifically, an individual may face a late enrollment penalty for 
Medicare Part B in the form of an increased premium of 10 percent for 
each 12-month period that the individual was eligible for, but did not 
enroll in, the program. 

[29] IHS received the authority to bill Medicare Part B in 2001. 

[30] See 72 Fed. Reg. 30,706 (June 4, 2007). 

[31] This regulation will likely make it less expensive for IHS to 
purchase contract health services from hospitals. 

[32] IHS-funded facilities are generally paid per encounter, regardless 
of the specific medical services provided; this is referred to as the 
all-inclusive rate. Given this, IHS-funded facilities may not have 
sufficient and qualified staff to submit claims under a methodology 
that pays on the basis of specific medical services. 

[33] See (1) Medicaid Program; Prescription Drugs, 71 Fed. Reg. 77,174 
(Dec. 22, 2006); (2) Medicaid Program; Citizenship Documentation 
Requirements, 71 Fed. Reg. 39,214 (July 12, 2006); and (3) Medicaid 
Program; Cost Limit for Providers Operated by Units of Government and 
Provisions To Ensure the Integrity of Federal-State Financial 
Partnership, 72 Fed. Reg. 2,236 (Jan. 18, 2007). 

[34] As of March 2008, the Tribal Affairs Group had four staff members. 

[35] In 2007, the Tribal Affairs Group had as many as five staff. 
However, because of an agency hiring freeze, an employee who left the 
group in November 2007 has not been replaced as of March 2008. 

[36] Although there was a designated NAC in each of the 10 CMS regions, 
the NAC in the Philadelphia region was not involved, as there are no 
federally recognized Indian tribes in that region. 

[37] For the remaining percentage of their time the NACs perform 
varying functions, including serving as Medicare or Medicaid program 
staff and organizing CMS outreach and education efforts. 

[38] Area health boards are generally associations created to advocate 
for health-related issues on behalf of the tribes they represent. 

[39] See Medicaid Program; Cost Limit for Providers Operated by Units 
of Government and Provisions To Ensure the Integrity of Federal-State 
Financial Partnership, 72 Fed. Reg. 29,748 (May 29, 2007). Congress 
imposed a moratorium on this rule delaying its implementation until May 
25, 2008. See Pub. L. No. 110-252, § 7001, 122 Stat. 2323. 

[40] While subject to the HHS consultation policy, CMS has been working 
with the TTAG to adopt its own consultation policy. In April 2007, the 
TTAG submitted a draft policy to CMS for its review. As of June 2008, 
the draft policy was under HHS review. 

[41] Although there are 10 HHS regions, there are only 7 consultation 
sessions each year because, at the request of tribes, 3 HHS regions 
(Atlanta, Boston, and New York) do a combined consultation session. 
These three HHS regions are included in the Nashville IHS area. 
Additionally, another HHS region (Philadelphia), which is also in the 
Nashville IHS area, does not have any federally recognized tribes. 

[42] We reviewed consultation session agendas for the Chicago, Dallas, 
Denver, and San Francisco regions, as well as the combined consultation 
session for the HHS regions that compose the Nashville IHS Area. For 
some regions we reviewed agendas from multiple years. 

[43] CMS officials will also participate in the annual HHS Budget 
Consultation, which is intended to give Indian tribes the opportunity 
to present their budget priorities and recommendations to HHS. 

[44] While states are not subject to the Executive Order on consulting 
with Indian tribes, states may have their own policies governing 
consultation with Indian tribes. 

[45] Additional tribal representatives may participate in meetings of 
this subcommittee, which are open to the public. 

[46] In addition to its regularly scheduled meetings, Arizona and New 
Mexico officials reported holding ad hoc meetings with tribal 
representatives. One other state, Montana, also reported holding 
meetings with tribal representatives on an ad hoc basis. 

[47] The remaining state, Montana, reported that its state legislature 
passed a bill in 2003 that instructed the state to develop a government-
to-government relationship with the tribes. 

[48] Among the four states with tribal consultation policies, one state 
(Arizona) had a policy specific to its Medicaid program, while the 
consultation policies in the remaining three states were for the larger 
department under which the Medicaid program operates. 

[49] Such changes are either made through an amendment to the state's 
approved Medicaid plan or through a waiver of certain Medicaid program 
requirements. 

[50] CMS guidance indicates that evidence of consultation with tribes 
is a criterion that CMS will use during its review of states' waiver 
requests. 

[51] The state indicated, however, that tribes have been invited to 
attend general community forums at which proposed waiver requests have 
been discussed. 

[52] The two facilities we visited that did not offer such assistance 
were both satellite clinics of larger facilities, where such assistance 
was available. 

[53] All four facilities were located in the Navajo IHS area; 
specifically, two were in New Mexico, one was in Arizona, and one was 
in Utah. 

[54] Two reservations were located in Montana, which is part of the 
Billings IHS area, while the third was located in Minnesota, which is 
part of the Bemidji IHS area. 

[55] Only tribes that operate their own Temporary Assistance for Needy 
Families program, a cash assistance program for needy families with 
children, are able to obtain the authority to make Medicaid eligibility 
determination decisions and generally only for the population covered 
by their Temporary Assistance for Needy Families program. 

[56] The video is entitled Our Health, Our Community: Medicare, 
Medicaid and SCHIP Outreach to American Indians/Alaskan Natives. 

[57] The brochure is entitled Make the Most of Your Benefits: Be 
ResourceSmart. IHS also published a reference guide for IHS-funded 
facility staff entitled How to Assess & Enroll Patients in Alternate 
Resources, which provides an overview of existing federal and state 
health benefit programs and steps to determine a patient's potential 
eligibility for a program. 

[58] In selecting areas, we also considered other factors, such as 
whether we had visited the area previously and experts' views on the 
relationship between tribes and states in the area. 

[59] While IHS-funded facilities may see patients from multiple tribes, 
we were interested in the tribe that primarily receives services at a 
given facility. 

GAO's Mission: 

The Government Accountability Office, the audit, evaluation and 
investigative arm of Congress, exists to support Congress in meeting 
its constitutional responsibilities and to help improve the performance 
and accountability of the federal government for the American people. 
GAO examines the use of public funds; evaluates federal programs and 
policies; and provides analyses, recommendations, and other assistance 
to help Congress make informed oversight, policy, and funding 
decisions. GAO's commitment to good government is reflected in its core 
values of accountability, integrity, and reliability.  

Obtaining Copies of GAO Reports and Testimony: 

The fastest and easiest way to obtain copies of GAO documents at no 
cost is through GAO's Web site [hyperlink, http://www.gao.gov]. Each 
weekday, GAO posts newly released reports, testimony, and 
correspondence on its Web site. To have GAO e-mail you a list of newly 
posted products every afternoon, go to [hyperlink, http://www.gao.gov] 
and select "E-mail Updates."  

Order by Mail or Phone: 

The first copy of each printed report is free. Additional copies are $2 
each. A check or money order should be made out to the Superintendent 
of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or 
more copies mailed to a single address are discounted 25 percent. 
Orders should be sent to:  

U.S. Government Accountability Office: 
441 G Street NW, Room LM: 
Washington, D.C. 20548:  

To order by Phone: 
Voice: (202) 512-6000: 
TDD: (202) 512-2537: 
Fax: (202) 512-6061:  

To Report Fraud, Waste, and Abuse in Federal Programs:  

Contact:  

Web site: [hyperlink, http://www.gao.gov/fraudnet/fraudnet.htm]: 
E-mail: fraudnet@gao.gov: 
Automated answering system: (800) 424-5454 or (202) 512-7470:  

Congressional Relations:  

Ralph Dawn, Managing Director, dawnr@gao.gov: 
(202) 512-4400: 
U.S. Government Accountability Office: 
441 G Street NW, Room 7125: 
Washington, D.C. 20548:  

Public Affairs: 

Chuck Young, Managing Director, youngc1@gao.gov: 
(202) 512-4800: 
U.S. Government Accountability Office: 
441 G Street NW, Room 7149: 
Washington, D.C. 20548: