In recognition of the unique legal and political status of federally recognized Tribes, the Centers for Medicare & Medicaid Services (CMS) has established a Tribal Exemption from participation in the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP). This fact sheet provides background on that exemption, its legal basis, and its significance for American Indian and Alaska Native (AI/AN) beneficiaries.
BACKGROUND
The United States (U.S.) maintains a special government-to-government relationship with federally recognized Tribes. This relationship is grounded in:
- U.S. treaties and federal laws
- Supreme Court decisions
- Executive Orders
- The U.S. Constitution
This foundational relationship forms the basis for the federal government's obligation to provide health services to AIs/ANs. It distinguishes Tribal health care providers from other suppliers in the Medicare and Medicaid context.
LEGAL AUTHORITY
In 1976, Congress enacted the Indian Health Care Improvement Act (IHCIA) (Public Law 94–437, September 30, 1976), which amended the Social Security Act to permit Medicare and Medicaid payment for services provided to AIs/ANs in:
- Indian Health Service (IHS)-operated facilities and programs
- Tribally operated facilities and programs operating under Title I or Title V of the Indian Self-Determination and Education Assistance Act (ISDEAA) (Public Law 93–638, as amended)
This authority allows Medicare services to be furnished to AI/AN Medicare beneficiaries through IHS and Tribally operated facilities and programs, recognizing the distinct nature of Tribal health care delivery.
TRIBAL EXEMPTION
The Tribal exemption from the DMEPOS CBP reflects the federal government's unique government-to-government relationship with federally recognized Tribes and acknowledges that IHS and Tribally operated facilities and programs operate under a distinct legal framework. Requiring these entities to participate in a competitive bidding process designed for commercial suppliers would be inconsistent with the government-to-government relationship and the statutory authorities under which Tribal health programs operate.
The exemption applies to:
- IHS-operated facilities and programs
- Tribally operated facilities and programs functioning under Title I or Title V of the ISDEAA
These entities serve AI/AN Medicare beneficiaries and are not subject to the same competitive bidding requirements as other DMEPOS CBP suppliers operating in competitive bidding areas.
The exemption ensures that eligible beneficiaries receiving DMEPOS items through IHS or Tribal health programs are not disrupted by competitive bidding contract requirements. It therefore preserves access to care through established Tribal and IHS health care infrastructure.
The Tribal exemption provisions are consistent with CMS's longstanding policy of honoring the unique status of Tribal health programs within the Medicare framework.