A Seattle Indian Health Board booth at the Seafair Indian Days Pow Wow at Daybreak Star Cultural Center in Seattle (2009). Photo: Joe Mabel / Wikimedia Commons, CC BY-SA 3.0.
The National Council of Urban Indian Health is urging federal regulators to make sure that Native people living in cities are not wrongly cut off from Medicaid under new work and community engagement requirements, according to comments the organization submitted to the Centers for Medicare and Medicaid Services.
The exemption
H.R. 1, the budget and tax law President Donald Trump signed July 4, 2025, created new requirements for many adults to keep Medicaid and Supplemental Nutrition Assistance Program benefits. Indians, Urban Indians, California Indians and people determined eligible for Indian Health Service care are excluded from the Medicaid requirements and included in exclusions from SNAP work requirements, according to NCUIH.
On June 3, 2026, CMS published an interim final rule, “Medicaid Program; Community Engagement Requirement for Certain Individuals,” to implement the requirements. NCUIH submitted comments to CMS Administrator Dr. Mehmet Oz on July 31.
What NCUIH wants
An exemption only works if states apply it. NCUIH recommended that CMS:
- Advise states to accept self-attestation as sufficient to establish eligibility for the American Indian and Alaska Native exclusion.
- Advise states to partner with urban Indian organizations, tribes and tribal organizations to prevent procedural disenrollments of Native beneficiaries.
- Require states to collect data on how the exclusion is implemented.
- Use strong, consistent language in the final rule about states not reverifying Native status.
- Advise states to engage with urban Indian organizations through Urban Confer, the formal consultation process for urban Indian organizations, when developing policies related to the exclusion.
A large population, often overlooked
Most American Indians and Alaska Natives now live in urban areas, a pattern shaped in part by the federal Indian Relocation program of the 1950s and 1960s, which moved Native families from reservations to cities with promises of jobs and housing that often went unfulfilled. Urban Indian organizations grew up in that era to fill gaps in services.
Why it matters in cities
Urban Indian organizations are nonprofit providers, funded in part by the Indian Health Service, that serve Native people living away from reservations. Their patients come from many different nations and may not carry the tribal documentation a state caseworker expects to see. Requiring additional proof of status, or reverifying it at each renewal, risks losing eligible people to paperwork, the kind of “procedural disenrollment” NCUIH warns against.
The federal exemption reflects the government’s trust responsibility to Native people, which does not end at reservation boundaries. Whether that principle holds in practice will depend on how 50 state Medicaid agencies write their procedures.
NCUIH said it will continue to follow the development of the final rule.
