Medicaid Work Requirements for American Indians and Alaska Natives
American Indians and Alaska Natives are exempt from the 80-hour rule wherever they live. Once your state confirms it, it does not check again.
Short answer: Yes, you are exempt. Federal law excludes Indians, Urban Indians, and California Indians as defined in the Indian Health Care Improvement Act, plus anyone determined eligible for Indian Health Service care. You do not have to live on a reservation. Once your state confirms your status, it may not recheck it.
The rule in the law
Federal law (sec. 1902(xx)(9)(A)(ii)(II)) excludes a person who:
- Is an Indian or an Urban Indian, as defined in the Indian Health Care Improvement Act (25 U.S.C. 1603(13) and (28))
- Is a California Indian described in 25 U.S.C. 1679(a), or
- Has otherwise been determined eligible as an Indian for the Indian Health Service
The CMS rule uses the existing Medicaid definition of "Indian" at 42 CFR 447.51, which covers all of these. It is the same definition Medicaid already uses to protect American Indians from cost sharing.
Who that includes
- Members of federally recognized tribes, including Alaska Native villages and Alaska Native corporations
- People living in cities who are tribal members (including some state-recognized or terminated tribes), children or grandchildren of members, Alaska Natives, or people the Interior or Health and Human Services departments treat as Indian
- Certain California Indians and their descendants
- Anyone the Indian Health Service has found eligible for its services
The exemption does not include Native Hawaiians, unless they also meet one of these definitions.
What proof is usually needed
Medicaid applications already ask about American Indian and Alaska Native status for cost-sharing protections, and CMS told states to use that information and their existing verification rules. Documents people often use include a tribal enrollment or membership card, a Certificate of Degree of Indian Blood (CDIB), or a letter showing you are eligible for IHS or tribal health services. Your state decides which documents it accepts. CMS says that once your status is verified, the state does not reverify it.
What to do next
- Answer the American Indian or Alaska Native question on your Medicaid application or renewal, even though the race question is optional.
- Keep a copy of your tribal ID, CDIB, or IHS eligibility letter.
- Use the free checker to see if the rule applies to you and which exemptions may fit.
- Find your state guide for start dates, how to report, and who to call.
- Got a notice? You have at least 30 days to answer, and you can ask for a fair hearing. See what to do about a notice.
Frequently asked questions
Are Native Americans exempt from Medicaid work requirements?
Yes. American Indians, Alaska Natives, Urban Indians, California Indians, and people eligible for Indian Health Service care are excluded from the requirement.
Do I have to live on a reservation?
No. The exemption applies wherever you live, including in cities.
I am a descendant but not enrolled. Am I exempt?
Possibly. The Urban Indian definition covers children and grandchildren of tribal members who live in urban areas, and the California Indian definition covers certain descendants. You are also covered if IHS has found you eligible. Ask your state what proof it accepts.
Will my state keep asking me to prove it?
No. CMS says that once your status is verified, the state does not need to verify it again.
Are Native Hawaiians exempt?
Not by that status alone. The law uses Indian Health Care Improvement Act definitions, which do not include Native Hawaiians. Another exemption may still apply.
Sources
- Public Law 119-21 (H.R. 1), sec. 71119: community engagement requirement (GovInfo)
- CMS interim final rule, Medicaid community engagement requirement, 91 FR 33348 (June 3, 2026)
- CMS-2454-IFC, official PDF (GovInfo)
- 42 CFR 447.51: definition of "Indian" used for the exclusion (eCFR)
- 25 U.S.C. 1603: Indian Health Care Improvement Act definitions (U.S. Code)