The Eastern Band of Cherokee Indians (EBCI) is a federally recognized Native American nation consisting of approximately 15,000 enrolled members. Most of these members reside in the Qualla Boundary, a Tribal land spanning five counties in western North Carolina. The Cherokee Indian Hospital Authority (CIHA) is the EBCI’s health system — the Tribe runs this system, having taken over governance from the federal government in 2002 under flexibilities created by the 1975 Indian Self-Determination and Education Assistance Act. CIHA delivers inpatient and outpatient care to EBCI members and others eligible for Indian Health Service (IHS) coverage within its service area.

In 2021, EBCI became the first Native nation in the country¹ to launch its own Medicaid managed care entity, through the state’s primary care case management program: EBCI Tribal Option. EBCI Tribal Option is housed in and operated by CIHA. As a primary care case management entity, EBCI Tribal Option is paid a risk-adjusted per member per month rate from the state to provide care management to its members; it does not take on financial risk or manage claims. Through partnership with the EBCI and the Cherokee Indian Hospital Foundation, EBCI Tribal Option is also able to offer value-added services to its members. To date, EBCI Tribal Option has enrolled 78 percent (5,100 of 6,500) of eligible people.

Background

American Indian and Alaska Native (AI/AN) people enrolled in Medicaid may interact differently with Medicaid managed care programs than Medicaid enrollees who are not members of a Tribe. Federal managed care protections limit the ability of states to require that AI/AN people enroll in the state’s managed care program, so many AI/AN people enrolled in Medicaid receive services through a fee-for-service delivery system. For AI/AN people who are enrolled in Medicaid managed care, these entities may not always be adept at meeting legally mandated managed care protections for AI/AN members, which can lead to limited access to care or lack of culturally relevant services. Additionally, Tribal leaders may feel that requirements to work closely with the many managed care entities in a state undermine Tribal sovereignty, straining Tribal governments’ ability to oversee health care for their own citizens.

An Indian Managed Care Entity (IMCE) — a managed care entity run by the Indian Health Service, a Tribe, a Tribal organization, or an Urban Indian Organization — can address these challenges. IMCEs can take many different forms, but all are designed to provide the benefits of care management (e.g., disease management and education, care planning and transition management, supporting medication adherence) to Tribal citizens, under a structure of Tribal self-governance, through an organization that is embedded in a specific Tribe’s culture and history. Becoming an IMCE is one way Tribal governments or health systems that want to take on new care management responsibilities can engage with Medicaid programs and receive financial support to do so. Currently, North Carolina and Oregon are the only states that have submitted a Medicaid state plan amendment that includes the creation of an IMCE.

The Value of an IMCE

AI/AN people often value being able to access health services through a Tribal health system. Mistrust of non-Tribal-affiliated organizations, a result of historical mistreatment of Native people and resulting intergenerational trauma, can inhibit Native people from engaging with service providers who come from outside their community. “We don’t want to know what you know, until we know who you are,” says James Burns, the Provider Network Manager at the EBCI Tribal Option. Within this context, EBCI Tribal Option prioritizes meaningful engagement with patients and the community they serve, even though the Tribal Option is Tribally affiliated. Staff are part of the community and regularly attend community club and council meetings to talk about EBCI Tribal Option’s services. EBCI Tribal Option and CIHA host events focused on health, well-being, and cultural and community connection — like their Story Walk, which pairs artwork and stories by EBCI children with prompts for physical activity in a local park. These community-focused efforts have led to high enrollment in EBCI Tribal Option and contribute to increased engagement in the program.

Designing the EBCI Tribal Option

Creating the EBCI Tribal Option was a logical next step in CIHA’s long-term vision, under CIHA’s Chief Executive Officer Casey Cooper, to provide more comprehensive and higher-quality care for its patients. CIHA had spent the prior decades working to strengthen primary care and relationship-based and team-based services. CIHA worked with another Tribal health care system, Southcentral Foundation in Alaska, to implement the Nuka system of care and became certified as an Advanced Medical Home in North Carolina’s Medicaid program. As North Carolina developed its Medicaid managed care program, which launched in July 2021, CIHA worked with the state’s Medicaid agency to design EBCI Tribal Option and engage its patients in Tribally run managed care.

CIHA partnered with North Carolina Medicaid and the Centers for Medicare & Medicaid Services to develop a state plan amendment for EBCI Tribal Option. This multi-year process relied on trusting relationships. “[Medicaid] listened to us, they understood Tribal sovereignty,” says Burns, and Medicaid staff regularly make the trip to Cherokee, NC, where CIHA and EBCI Tribal Option are based. Meeting in-person strengthens their relationship and improves Medicaid’s understanding of the Tribe’s vision for the health and well-being of its members.

Eligibility and Enrollment

Any Medicaid member in North Carolina who is eligible for care through IHS can enroll in EBCI Tribal Option, not just members of the EBCI. Eligibility for IHS includes people enrolled in federally recognized Tribes and can include some non-Native family members of Tribal citizens. In North Carolina, eligible people can choose to enroll in EBCI Tribal Option, or, if they do not select any managed care option when joining Medicaid, they are auto-assigned to EBCI Tribal Option with the option to opt out. EBCI Tribal Option staff continually work to get the word out about this opportunity for EBCI members. Accurate eligibility data is essential for managing enrollment, notes Gwynneth Wildcatt, Director of Accessibility, Resources, and Member Services at EBCI Tribal Option. To ensure accuracy, staff work closely with the state to maintain and share data effectively. The partnership with North Carolina Medicaid has been an integral part of this process.

Services

The care management services that EBCI Tribal Option is responsible for are outlined in the state plan amendment, including case management activities (e.g., telephonic and face-to-face case management, development of a member-driven care plan, coordination with specialists) and quality improvement activities (e.g., review of provider claims, support for practice improvement). Cultural concordance is embedded in the care management services and value-added services, for example, one value-added service members can access is enrollment in Cherokee language classes. Other value-added services include provision of breast pumps or gift card incentives for attending prenatal appointments, nutrition and cooking classes, transportation support, and shoes for youth to participate in sports.

Quality of Care

Primary care practices participating in EBCI Tribal Option must meet certain requirements, such as certification as an Advanced Medical Home and provision of 24/7 telephonic nurse triage. These practices must also meet performance targets. Performance measures currently incorporate three existing Healthcare Effectiveness Data and Information Set (HEDIS) metrics: Childhood Immunizations: Combination 10, Glycemic Status Assessment for Patients with Diabetes, and Controlling High Blood Pressure.

What’s Next?

Since its launch in 2021, EBCI Tribal Option has worked to improve quality of care, overall health, and well-being for its members. The program continues to focus both on increasing enrollment and expanding services. For instance, following North Carolina’s Medicaid expansion in December 2023, EBCI Tribal Option worked to enroll newly Medicaid-eligible members and increased its membership by almost 25 percent (over 1,200 people). In November 2024, CIHA announced upcoming participation in North Carolina Medicaid’s Healthy Opportunities Pilot, which will allow it to access Medicaid funding to address health-related social needs, such as food insecurity, for EBCI Tribal Option members. EBCI Tribal Option serves as a model for Tribal self-governance and effective collaboration with state Medicaid programs, offering valuable insights as Tribes and states nationwide seek to enhance health care for Medicaid enrollees who are members of Native communities.

1. Oregon’s Medicaid program also received approval for a state plan amendment to allow Indian Managed Care Entities in the state in 2021. Oregon’s State Plan Amendment would allow each of the nine federally recognized Tribes and one Urban Indian Organization in the state to create their own Indian Managed Care Entities. As of 2022, multiple IMCEs had been developed and approved by CMS, but were not yet operating.