The Centers for Medicare and Medicaid Services (CMS) has indicated that it has approved Medicaid State Plan amendments for Minnesota, New Mexico, Oregon, South Dakota, Washington, and Wyoming that confirm Medicaid coverage for clinic services provided by tribally-operated health care programs beyond the physical clinic site, including in homes, schools, and other appropriate community locations. By way of background, last year, CMS revised the Medicaid clinic services regulation (at 42 CFR 440.90) to authorize Medicaid coverage for clinic services furnished by IHS and Tribal clinics outside the “four walls” of their facilities. As a result of that change, tribal clinics were able to claim Medicaid reimbursement at the facility or encounter rate for healthcare services provided away from the clinic, including services furnished by contract healthcare providers. The approvals for Minnesota, New Mexico, Oregon, South Dakota, Washington, and Wyoming now provide assurances that the Medicaid programs in those states will conform to the change made in the federal regulations.
The change in regulations provides tribal programs with a meaningful way to expand the reach of their health care programs. Before CMS amended the federal regulations to allow tribally-operated programs to provide clinic services away from the clinic site, tribally-operated programs that wanted to provide services in places like schools would most likely have considered establishing a tribal program site at those remote locations in order to bill for those services at the Medicaid facility or encounter rate. The change in regulations provides more flexibility for tribally-operated programs to provide clinic services at remote locations, especially through the ability to now arrange for services to be provided by contracts with community providers and to be paid for them at the facility or encounter rate.