Home- and Community-Based Services for American Indians and Alaska Natives: Recommendations for Increasing Access and Recognizing Resiliency – Justice in Aging

Acknowledgements and Process

Justice in Aging and the Autistic Self-Advocacy Network conducted policy research to increase knowledge about home- and community-based services (HCBS) in Indian Country. Our methods sought to highlight culturally responsive, Tribally-driven services and recommendations for overcoming structural barriers. We met individually with HCBS program leaders in Indian Country and aging and disability experts and advocates working with Tribal communities across the U.S. We also formed a workgroup with those working directly in Indian Country and individuals identifying as American Indian and Alaska Native (AI/AN) serving within larger state Medicaid systems.

We would like to express our sincere gratitude to the Tribal Nation policy leaders, advocates, and partners whose experience and recommendations have guided this work. We also want to acknowledge those who served on the workgroup and have been long-term contributors to ensuring equitable access to health care and HCBS for AI/ANs across the United States, including Larry Curley (Navajo), Dr. Donald Warne (Oglala Lakota), and Dr. Kimberly Yellow Robe (Rosebud Sioux).

We also thank Ruby Siegel, Kim The, and Teresa Nguyen for their support.

Download the plain language version of this issue brief.

Introduction

Medicaid home- and community-based services (HCBS) enable people with disabilities and older adults to live independently in their communities by providing a wide range of personalized assistance with daily activities.

However, many American Indian and Alaska Native (AI/AN) elders and relatives with disabilities face barriers to receiving care in their own homes and communities. Limited access to these HCBS force AI/AN elders and relatives with disabilities to relocate far from family, culture, and traditions, which leads to poorer health outcomes and loss of cultural connection.

Many American Indian and Alaska Native elders and relatives with disabilities face barriers to receiving care in their own homes and communities.

This brief examines barriers for AI/AN elders and relatives with disabilities in accessing Medicaid HCBS and identifies policy recommendations to improve access to support better health and independence and reduce the need for more costly care.

Recommendations include increasing federal funding for HCBS and other programs, strengthening partnerships between states and Tribal Nations, and supporting culturally-grounded care. These recommendations are centered on recognizing Tribal Nations’ capacity to develop and implement solutions that best meet the needs of their own AI/AN elders and relatives with disabilities.

Background and Context

Tribal Nations and Impact of Colonization on Health of AI/AN Elders and Relatives with Disabilities

Prior to colonization, there were thousands of distinct nations within the borders of what is now considered the United States. From these, 575 federally recognized Tribal Nations remain in the U.S.,[1] and an estimated 8.85 million people identify as having AI/AN ancestry.^[2]

The system of settler-colonialism did not only involve land removal, but also the intentional erasure of Indigenous knowledge, culture, tradition, and ways of being. This severance of identity has contributed to gaps in health care and long-term services and supports (LTSS) for AI/AN people today.

As a result, AI/AN people experience significant health inequities when compared to non-AI/AN people. For example, AI/AN populations have the lowest life expectancy rates among people living in the U.S.^[3] Tribal elders experience chronic health conditions, like hypertension and diabetes, and Alzheimer’s Disease at higher rates than their non-AI/AN counterparts.^[4]

Disabilities are also more prevalent among AI/AN individuals at all ages, with 47% of Tribal elders reporting having a disability.^[5] Furthermore, research demonstrates that when adjusting for age, people who are AI/AN or Native Hawaiian/Pacific Islander have higher LTSS needs.^[6]

Despite the greater need for LTSS, geographic isolation and underfunded health systems limit access to in-home care and culturally appropriate support for AI/AN elders and relatives with disabilities.

The Role of Home- and Community- Based Services (HCBS) in AI/AN Communities

Tribal communities embody a holistic and community-centered approach to care for elders and relatives with disabilities. Care is not focused solely on meeting the person’s health needs, but also maintaining a strong connection to family, community, and culture. HCBS therefore can play an important role in meeting the needs of AI/AN elders and relatives with disabilities.

HCBS are LTSS provided in non-institutional settings to older adults and people with disabilities that enable them to remain in their homes and communities. HCBS help with activities of daily living, such as walking, eating, bathing, dressing, or toileting, as well as instrumental activities of daily living such as managing medications, shopping and meal preparation, house cleaning and maintenance, and managing finances. Examples of HCBS include personal care aide services, transportation, adult day care, meal delivery and congregate meal sites, job supports, and case management, all tailored to the needs of the individual.

Medicaid, jointly funded by federal and state governments, is the largest payer of HCBS in the U.S., paying for an estimated 70% of all HCBS.[11] Across the country, over 8 million people receive a variety of HCBS, the majority of which are people younger than 65.^[12] As of 2023, there were approximately 90,000 AI/AN people receiving Medicaid HCBS, making up 1.1% of the total HCBS population.^[13]

Most older adults and people with disabilities who need LTSS prefer at-home care, as opposed to an institutional setting such as a nursing facility.^[14] AI/AN people face discrimination in all areas of life, including health care, and hostilities are reportedly higher for those living in “majority Native areas.”^[15] Therefore, for AI/AN elders and relatives with disabilities, institutionalization can also carry the risk of discomfort and discrimination when service providers are not culturally grounded or from Tribal communities. Institutionalization away from the community can also disrupt important cultural preservation, for example hindering Tribal elders’ ability to pass down cultural history and traditions to younger generations.

In addition to being preferred and more culturally responsive, HCBS are also more cost-effective than institutional LTSS.^[16] Recognizing this, federal and state policy makers have implemented Medicaid policies and programs to shift care and spending from institutional settings toward HCBS.^[17]

One such program is the Medicaid Money Follows the Person Program (MFP). States across the country use MFP funding to develop and implement infrastructure to enable people to successfully transition from institutional settings back into their community.^[18] The Money the Follows the Person Tribal Initiative (MFP-TI) is a targeted MFP program focused on increasing the availability of and access to HCBS in Tribal communities by establishing and strengthening partnerships between Tribal Nations, states, and the federal government.^[19] MFP-TI is currently operating in five states: Minnesota, Oklahoma, North Dakota, Washington, and Wisconsin.

Policy Goals and Recommendations

To expand HCBS for AI/AN elders and relatives with disabilities, federal and state policymakers should increase federal funding and partner with Tribal Nations to design and implement health and LTSS systems that support culturally-grounded care.

Increase Federal Funding

The chronic underfunding of Medicaid HCBS broadly as well as within Tribal communities specifically is a fundamental barrier to expanding access to home-based care and meeting the needs of AI/AN elders and relatives with disabilities. For AI/AN elders and relatives with disabilities, the limited funding for HCBS is compounded by geographic isolation and limited LTSS infrastructure in Indian Country.

Staffing shortages, limited service offerings, and access barriers caused by funding gaps hamper I.H.S.’s ability, and therefore the federal government’s ability, to fulfill its mission of providing health care to the millions of AI/AN people.

As of 2025, there were only 24 nursing facilities and 14 assisted living facilities operated by Tribal Nations.[20] As a result, a Tribal elder or relative who is placed in a facility after a stroke or fall, for example, is often geographically isolated from their community, and also less likely to receive culturally competent care. The distance and isolation makes transitioning back to the community even more difficult, especially with an under-resourced HCBS system.

Medicaid’s institutional bias underlies the historic and persistent underfunding of HCBS. Under federal Medicaid law, HCBS is considered an “optional” service that each state can choose to provide, whereas institutional LTSS are a mandatory service.^[21] While every state does provide HCBS, most commonly through Medicaid “waivers” or “demonstration projects,” the fact that services are optional means states can choose to limit and scale back their programs.

Most states cap the number of people who can access HCBS programs at any one time, restrict eligibility to specific populations, and limit the scope of services provided. The optional nature of HCBS also puts these programs at risk of being scaled back or eliminated when state budgets are tight, as they are now due to federal Medicaid funding cuts enacted under the 2025 Budget Reconciliation Act (H.R. 1).^[22] When states limit or end Medicaid HCBS programs, Tribal Nations likely do not have the resources to continue the same level of support for their AI/AN elders and relatives with disabilities.

Moreover, while the federal government can cover 100% of the costs for Medicaid-covered services provided to AI/AN Medicaid enrollees in I.H.S. or Tribal facilities,^[23] that enhanced reimbursement is difficult to access. In addition to Tribal health programs having to meet several specific requirements to be eligible for 100% federal reimbursement, HCBS are not typically delivered by I.H.S. or in Tribal facilities.

Along with Medicaid funding challenges, persistent underfunding of I.H.S. continues to disadvantage Tribal communities and AI/AN elders’ and relatives with disabilities’ ability to remain healthy and independent. I.H.S. has been chronically underfunded since its inception, with some estimates showing that I.H.S.’s budget meets only 50% of the health care needs of AI/AN people.^[24]

Staffing shortages, limited service offerings, and access barriers caused by funding gaps hamper I.H.S.’s ability, and therefore the federal government’s ability, to fulfill its mission of providing health care to the millions of AI/AN people. In addition, under the Affordable Care Act, Congress authorized but has yet to allocate funding to I.H.S. to provide HCBS.^[25]

Similarly, Title VI of the Older Americans Act (OAA), which provides federal funding directly to Tribal Nations for nutrition, supportive services for elders, and caregiver services, is inadequately funded to meet the full needs of AI/AN elders.^[26] When it was first funded in 1980, OAA Title VI served 20,000 Tribal elders with $6 million. By 2008, Title VI expanded to serve over 150,000 elders and caregivers, but the funding increased to only $34 million.^[27] In 2021, during the COVID-19 pandemic, Title VI programs served over 237,000 elders and caregivers. In response, Congress increased funding to over $80 million, but those supplemental funds have not been renewed.^[28]

Federal policy changes that would increase necessary funding for HCBS in Tribal communities include:

• Making HCBS a mandatory service under federal Medicaid law, putting coverage on par with coverage of institutional LTSS.
• Expanding and streamlining access to 100% federal reimbursement for all Medicaid services, including HCBS, provided to AI/AN people;
• Making the Medicaid Money Follows the Person Program permanent with dedicated funding for MFP Tribal Initiatives.
• Rectifying the persistent underfunding of I.H.S. and Title VI of the OAA programs, and
• Repealing Medicaid funding cuts passed under H.R. 1.

Expand Partnerships between State Medicaid Agencies and Tribal Nations

To expand access to HCBS for AI/AN elders and relatives with disabilities, states should consider Tribal Nations as partners in designing the health and LTSS systems and in delivering care.

Expand Partnership Models that are Working

The MFP-TI programs have demonstrated both the importance of meaningful government-to-government relationships and strategies that states should employ.^[29] Through these partnerships, states have been able to support Tribal Nations in designing and building HCBS capacity in their communities. For example, MFP-TI can support Tribal Nations in conducting needs assessments and identifying opportunities to implement and optimize Medicaid HCBS programs.^[30]

MFP-TI programs have also helped facilitate policy changes and new services that are centered in AI/AN traditions and practices. For example, Tribal Nations in Minnesota are working with the MFP-TI to establish healing centers, assisted living programs, and tiny home villages for their elders.^[31]

MFP-TI currently operates in five states. More states should consider partnering with Tribal Nations to create MFP-TI programs and similar partnerships to expand HCBS for AI/AN elders and relatives with disabilities.

Engage in Meaningful Tribal Consultation

Tribal consultation is another mechanism for federal and state agencies to honor Tribal sovereignty and the government-to-government relationship between the U.S. government and Tribal Nations.^[32] States have their own policies governing Tribal consultation, which vary in terms of frequency and the actions that trigger consultation.^[33]

In the context of HCBS, successful Tribal consultation requires building trust and federal and state Medicaid agencies demonstrating ongoing commitment to Tribal Nations as equal partners.

While structure and funding for Tribal consultation are important, accountability mechanisms for both agency staff and elected officials are necessary to cement a true government-to-government relationship between states and Tribal Nations. Washington state, for example, requires its agencies to make reasonable efforts to collaborate with Tribal Nations, designate Tribal liaisons who undergo training, and submit an annual report to the governor on the agencies’ involvement with Indian Tribes and on implementation of the state’s law on government-to-government relationship with Tribal Nations.^[35]

A critical element of accountability is for non-AI/AN people and entities in state government to also engage in Tribal competency training. New Mexico, for example, requires state managers and employees who have ongoing communications with Tribal Nations to participate in trainings about legal concepts, such as Tribal sovereignty, governance, and consultations; history of Tribal Nations; and communication and collaboration strategies.^[36]

Invest in Tribally-Led HCBS Navigation Programs

AI/AN elders and relatives with disabilities and their families may also encounter barriers in accessing HCBS for themselves. Navigating eligibility and enrollment for Medicaid, and more specifically for HCBS, is complex and challenging. Given the patchwork nature of HCBS nationwide, even knowing the name of the local HCBS programs and where to find information about them can be a barrier. Moreover, AI/AN elders and relatives with disabilities may experience confusion about whether Medicaid is available to them, how it interacts with I.H.S., and what HCBS entails.

Transportation and digital access barriers are also significant for Tribal communities. The rural nature of many reservations, combined with other barriers like poor road conditions or disabilities that prevent driving, make it difficult for some AI/AN elders and relatives with disabilities to access in-person support. Moreover, Tribal communities have the lowest rates of broadband access in the country and the increasing reliance on digital formats–such as online portals for applications and certifications or virtual chatbots–pose significant accessibility challenges.

Roles For Tribal Navigators & Benefit Coordinators

Tribal navigators and benefit coordinators who act as liaisons and support AI/AN elders and relatives with disabilities with accessing HCBS are a practical model to address these barriers. Specific navigation supports include informing elders and people with disabilities of the availability of HCBS services; providing logistical support in applying and recertifying eligibility; troubleshooting problems; arranging for providers and providing warm introductions to establish trust; making referrals for other social services; and advocating for the individual in ways that are consistent with their cultural values. Alaska’s Community Health Aide Program^[37] and Oregon’s Aging and Persons with Disabilities Tribal Navigator Program are two examples.^[38]

To support HCBS navigation assistance for AI/AN elders and relatives with disabilities, states should:

• Partner with and provide funding to Tribal Nations to create navigator and benefit coordinator programs.
• Recognize and compensate the time and resources necessary for navigators to develop relationships, both with elders, relatives with disabilities, and their families, as well as with the Medicaid agency staff and HCBS providers.

Support Culturally-Grounded Care

Recognizing Tribal Nations’ capacity and expertise to design and deliver care to their communities is essential to the success of HCBS programs serving AI/AN elders and relatives with disabilities. The recognition depends on states honoring the sovereignty of Tribal Nations and the federal government honoring its treaty trust responsibilities.

Strengthen the Direct Care Workforce and Support for Family Caregivers

Workforce shortages greatly impact the availability of HCBS in Tribal communities.[39] When it comes to addressing this issue, Tribal communities have consistently recommended investing in providers and supporting caregivers who are AI/AN to best ensure the care provided is grounded in the culture of the elder or relative with disabilities.

Moreover, HCBS involve very intimate matters of daily living, provided in the home, underscoring the need for elders and relatives with disabilities to trust the person providing care. Direct care workers who are AI/AN and from the same community can help elders and relatives with disabilities, and their families, feel comfortable accessing HCBS.^[40]

Some states have addressed the barriers that hinder AI/AN people from joining the direct care workforce. For example, Washington developed the Home Care Aide Training program, which enables high school students to participate in a certificate program and begin direct care work as early as age 18.^[41]

Tribal Nations in Minnesota advocated to be recognized as providers in the state’s Tribal Vulnerable Adult and Developmental Disability Targeted Case Management Medical Assistance Benefit statute. Not only does this enable Tribal Nations to care for their elders and relatives with disabilities in the way they know how and be reimbursed for the culturally-accessible services they provide, but also supports economic security for a community that is inequitably impoverished.^[42]

Relatedly, expanding Medicaid coverage of both respite services and payment to family caregivers providing HCBS would also help alleviate the direct care workforce shortage and support AI/AN elders and relatives with disabilities to receive culturally competent care. Family caregivers can ensure that elders and people with disabilities can participate in spiritual and cultural events, access traditional medicine, and receive care and information about their care in their Native language.

Revise Medicaid Policies to Support Tribal Nations in Utilizing HCBS Programs

Medicaid HCBS is underutilized in Tribal communities due to administrative barriers and limitations on uses of Medicaid funding that do not support culturally-grounded care. For example, requirements that HCBS programing and training of caregivers and other providers must be “evidence based” to be reimbursed fails to recognize Indigenous knowledge and ways of being as adequate evidence. Traditional medicine and Indigenous ways of being are both known to be effective in the community and date back centuries.

These requirements hinder and even preclude Tribal Nations from pursuing activities that best serve their community. For example, a Tribal Nation may not be able to afford to provide culturally responsive trainings and HCBS if they do not have the resources to certify them as “evidence based” under Medicaid standards in order to get reimbursed.

Requirements that HCBS programming and training of caregivers and other providers must be “evidence based” to be reimbursed fails to recognize Indigenous knowledge and ways of being as adequate evidence.

Medicaid rules also create barriers to integrating traditional medicine into HCBS. Traditional medicine is key to many Tribal cultures, emphasizing the connection between community, land, and spirituality. Examples include access to medicine people with specialized skills; Native foods and natural remedies; cultural practices, such as dancing, music, and sweat lodges; and sacred ceremonies.[43]

Traditional medicine is typically not reimbursed by Medicaid, nor is it recognized as an HCBS service. Recently, by using a Section 1115 Medicaid demonstration waiver, Arizona, California, New Mexico, and Oregon received approval to bill Medicaid for Indigenous health care practices provided by I.H.S. facilities, Tribally operated health centers, and Urban Indian Organizations.^[44] However, because the demonstration waiver does not extend to HCBS and is limited to four states, Medicaid coverage remains unavailable for traditional medicine provided to many AI/AN elders and relatives with disabilities.

Limits on how Medicaid funding may be used can also prevent Tribal Nations from implementing practical solutions. For example, a Tribal Nation may decide that it wants to provide transportation to elders and relatives with disabilities living in remote areas. While transportation is an HCBS service, a Tribal Nation may not be able to use Medicaid funding to purchase and maintain a vehicle to provide this service to their own people due to limitations in Medicaid regulations and guidance.

Instead, the Tribal Nation would need to contract with a Medicaid certified transportation provider that likely is not from the community and does not know how to navigate the area. Other examples include requiring HCBS recipients to meet stringent diagnosis criteria, a factor that particularly impacts AI/AN elders and relatives with disabilities who face geographic or financial barriers in accessing health specialists.

Finally, the state-based nature of Medicaid HCBS does not account for the fact that Tribal Nations—both the people and reservation land–often span multiple states. An individual, however, can only be enrolled in one state’s Medicaid program. For example, the Navajo Nation, spans across Arizona, New Mexico, and Utah.

While members of the Navajo Nation have a shared identity that predates the U.S., Navajo elders and relatives with disabilities have to navigate different Medicaid HCBS eligibility, enrollment, and coverage rules depending on which state borders they reside in.^[45] This limitation can lead to confusion, misinformation, or mistrust among AI/AN elders and relatives with disabilities and complicates Tribal Nations’ ability to oversee their members’ access to Medicaid HCBS.

Conclusion

Expanding culturally grounded Medicaid HCBS can improve AI/AN elders’ and relatives with disabilities’ independence and well-being. States and federal policymakers should partner with Tribal Nations to increase funding, engage in meaningful consultation, expand collaboration, reduce administrative barriers, and strengthen the direct care workforce. Recognizing the resiliency of AI/AN people, these recommendations are centered in honoring Tribal Nations’ values and ways of being in delivering care to their communities.

Funding Statement

The content of this brief was developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90RTCP0006). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). The content is solely the responsibility of the authors and does not necessarily represent the official views of NIDILRR, ACL, or HHS.

How to Cite This Brief

Takshi, S., Kean, N., & Robinson, G., (2026, July). Home- and Community-Based Services for American Indians and Alaska Natives: Recommendations for Increasing Access and Recognizing Resiliency

[Research brief]. Community Living Equity Center, Brandeis University; Justice in Aging; Autistic Self Advocacy Network.

Endnotes

1. Tribal Leaders Directory. (2026, Jan. 30). U.S. Department of the Interior | Indian Affairs. Retrieved May 20, 2026, from https://www.bia.gov/service/tribal-leaders-directory. ↑

2. S0201 | Selected Population Profile in the United States (American Community Survey 1-Year Estimates Selected Population Profiles No. S0201). (2023). United States Census Bureau. https://data.census.gov/table?q=United%20States&t=001:006:009:01A:588:Language%20Spoken%20at%20Home&g=010XX00US&y=2023. (3.34 million people reported their race as only AI/AN, and 5.5 million reported their race as AI/AN in combination with another race). ↑

3. Ndugga, N., Hill, L., & Artiga, S. (2026, March 6). Racial disparities in life expectancy. KFF. https://www.kff.org/racial-equity-and-health-policy/racial-disparities-in-life-expectancy/ ↑

4. Manson, S. M., & Buchwald, D. S. (2021). Aging and health of American Indians and Alaska Natives: Contributions from the Native Investigator Development Program. Journal of Aging and Health, 33(7-8 Suppl), 3S-9S. https://doi.org/10.1177/08982643211014399. ↑

5. Thayil, J., & Kaye, N. (2024, December 6). How states and tribes can work together to improve Long-Term Services and Supports for American Indian/Alaska Native elders and their caregivers. National Academy for State Health Policy | NASHP. https://nashp.org/how-states-and-tribes-can-work-together-to-improve-long-term-services-and-supports-for-american-indian-alaska-native-elders-and-their-caregivers/; Understanding disabilities in American Indian & Alaska Native communities toolkit guide. (2023). National Council on Disability; National Indian Council on Aging. https://www.ncd.gov/assets/uploads/reports/2022/ncd_understanding_disabilities_in_american_indian_508.pdf ↑

6. Bixby, L., Nguyen, T., & Caldwell, J. (2026). Racial and ethnic variation in the prevalence of long-term services and supports needs [Research Brief]. Community Living Equity Center, Lurie Institute for Disability Policy, Brandeis University. https://heller.brandeis.edu/community-living-policy/clec/research/publications/pdfs/racial-and-ethnic-variation-in-the-prevalence-of-ltss-needs.pdf. ↑

7. U.S. Const. Art. 1, § VIII. Three cases comprise the Marshall Trilogy: Johnson v. M’Intosh 21 U.S. 543 (1823); Cherokee Nation v. Georgia 30 U.S. 1 (1831); Worcester v. Georgia 31 U.S. 515 (1832). ↑

8. Somes, W. (2026, January 28). Money follows the person and LTSS rebalancing: Opportunities for states. Community Living Policy Center, Lurie Institute for Disability Policy, Brandeis University. https://heller.brandeis.edu/community-living-policy/resources/webinars/mfp-ltss-rebalancing/mfp-ltss-rebalancing-compressed.pdf. ↑

9. Rey-Bear, D. I., & Fletcher, M. L. M. (2017). We need protection from our protectors: The nature, issues, and future of the federal trust responsibility to Indians. Michigan Journal of Environmental & Administrative Law, 6(2), 397–461. https://doi.org/10.36640/mjeal.6.2.we (page 402-403). ↑

10. Permanent reauthorization of the Indian Health Care Improvement was enacted as part of the Patient Protection and Affordable Care Act, Pub. L. Nos. 111–148 (2010); Snyder Act, Pub. L. Nos. 67–85 (1921). ↑

11. Mohamed, M., Burns, A., & O’Malley Watts, M. (2025, November 20). States’ management of Medicaid home care spending ahead of H.R. 1 effects. KFF. https://www.kff.org/medicaid/states-management-of-medicaid-home-care-spending-ahead-of-h-r-1-effects/. ↑

12. Carpenter, A., Stepanczuk, C., & Wysocki, A. (2025). Characteristics of people using Medicaid long-term services and supports, 2023. Mathematica for Centers for Medicare and Medicaid (CMS). https://www.medicaid.gov/medicaid/long-term-services-supports/downloads/ltss-user-character-brief-2023.pdf. ↑

13. Id. ↑

14. Gardiner, F. (2021). Care can’t wait: How do inadequate home- and community-based services affect community living and health outcomes? [Research Brief]. Community Living Policy Center, Lurie Institute for Disability Policy, Brandeis University. https://heller.brandeis.edu/community-living-policy/images/pdfpublications/care-cant-wait.pdf. ↑

15. Neel, J. (2017, November 14). Poll: Native Americans see far more discrimination in areas where they are a majority. NPR. https://www.npr.org/2017/11/14/563306555/poll-native-americans-see-far-more-discrimination-in-areas-where-they-are-a-majo. ↑

16. McGarry, B. E., & Grabowski, D. C. (2023). Medicaid home and community-based services spending for older adults: Is there a “woodwork” effect? Journal of the American Geriatrics Society, 71(10), 3143–3151. https://doi.org/10.1111/jgs.18478. (Finding that a 41 increase in HCBS spending was associated with $0.74 increase in total LTSS spending, suggesting each dollar directed to HCBS was offset by $0.26 savings from decreased nursing home use and that increased HCBS waiver spending was associated with more older adults receiving LTSS at a lower cost per beneficiary served relative to the nursing home setting.) ↑

17. Caldwell, J., Bixby, L., Siegel, R., Pickern, S., Stober, K., & Cahn, D. (2026). Home and community-based services improve outcomes while reducing costs [Research Brief]. Community Living Policy Center, Lurie Institute for Disability Policy, Brandeis University. ↑

18. Centers for Medicare & Medicaid Services. (n.d.). Money follows the person. Medicaid. Retrieved May 20, 2026, from https://www.medicaid.gov/medicaid/long-term-services-supports/money-follows-person. ↑

19. Report to congress: Best practices in the money follows the person (MFP) demonstration. (2024). United States Department of Health and Human Services, Centers for Medicare & Medicaid Services. https://www.medicaid.gov/medicaid/long-term-services-supports/downloads/mfp-best-practices-rtc-feb2024.pdf. ↑

20. Tribal nursing home & assisted living facility directory. (2025). U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. https://www.cms.gov/files/document/tribal-nursing-home-assisted-living-facility-directory-2025.pdf. ↑

21. Chidambaram, P., & Burns, A. (2024, July 8). 10 things about long-term services and supports (LTSS). KFF. https://www.kff.org/medicaid/issue-brief/10-things-about-long-term-services-and-supports-ltss/. ↑

22. What’s in the Budget Reconciliation Act of 2025 and what does it mean for low-income older adults’ access to health and long-term care? (2025). Justice in Aging. https://justiceinaging.org/wp-content/uploads/2025/08/HR-1-Fact-Sheet-August-2025.pdf; Saunders, H., Burns, A., & Levinson, Z. (2025, July 14). How might federal Medicaid cuts in the enacted reconciliation package affect rural areas? KFF. https://www.kff.org/medicaid/how-might-federal-medicaid-cuts-in-the-enacted-reconciliation-package-affect-rural-areas/. ↑

23. Centers for Medicare & Medicaid Services. (2026, March 10). 100% FMAP for LTSS — Educate your state. https://www.cms.gov/training-education/partner-outreach-resources/american-indian-alaska-native/ltss-ta-center/information/ltss-financing/100-fmap-ltss-educate-your-state. ↑

24. Per capita IHS expenditures are less than one-third of the federal health expenditures for all other populations. Broken promises: Continuing federal funding shortfall for Native Americans. (2018). [Briefing Report]. U.S. Commission on Civil Rights. https://www.usccr.gov/files/pubs/2018/12-20-Broken-Promises.pdf (page 4). ↑

25. Long-term services and supports fact sheet. (2016). National Indian Council on Aging. https://nicoa.org/wp-content/uploads/2016/02/14-LTSS-fact-Sheet-IIi.pdf. ↑

26. 2024 chartbook supporting Native elders in their communities: Title VI Native American aging programs and services. (2024). USAging and the Scripps Gerontology Center at Miami University. https://www.usaging.org/Files/24-TitleVI-Chartbook-508-fnl.pdf. ↑

27. LaCounte, C. (2022, February 23). American Society on Aging. Generations Journal. Title VI of the Older Americans Act: Past, Present, and Future. https://generations.asaging.org/title-vi-older-americans-act/. ↑

28. Id. ↑

29. Report to congress: Best practices in the money follows the person (MFP) demonstration. (2024). United States Department of Health and Human Services, Centers for Medicare & Medicaid Services. https://www.medicaid.gov/medicaid/long-term-services-supports/downloads/mfp-best-practices-rtc-feb2024.pdf. ↑

30. Id. ↑

31. Somes, W. (2026, January 28). Money follows the person and LTSS rebalancing: Opportunities for states. Community Living Policy Center, Lurie Institute for Disability Policy, Brandeis University. https://heller.brandeis.edu/community-living-policy/resources/webinars/mfp-ltss-rebalancing/mfp-ltss-rebalancing-compressed.pdf. ↑

32. What is Tribal consultation? (n.d.). U.S. Dept. of the Interior | Indian Affairs. Retrieved May 20, 2026, from https://www.bia.gov/service/tribal-consultations/what-tribal-consultation; U.S. Dept. of Health & Hum. Sevs., Centers for Medicare and Medicaid Tribal Consultation Policy (2015), https://www.cms.gov/outreach-and-education/american-indian-alaska-native/aian/downloads/cmstribalconsultationpolicy2015.pdf. ↑

33. See, e.g., Washington state’s Tribal consulation policy: Section II – Consultation process. (n.d.). Governor’s Office of Indian Affairs. Retrieved May 20, 2026, from https://goia.wa.gov/state-tribal-relations-centennial-accord/millennium-agreement/executive-summary-government-government-implementation-guidelines/section-ii-consultation-process. ↑

34. The Medicaid Access Rule finalized in 2024 required all states to establish Beneficiary Advisory Councils (BACs) by July 2025. 42 C.F.R. § 431.12. While the federal rules do not require states to include AI/AN Medicaid enrollees or caregivers in their BACs, states should prioritize their participation. For information about other best practices regarding Beneficiary Advisory Councils, see Schultz, E., & Patel, S. (2025). Medicaid Beneficiary Advisory Councils: A guide to evaluating process and impact [Tool]. Center for Health Care Strategies. https://www.chcs.org/resource/medicaid-beneficiary-advisory-councils-a-guide-to-evaluating-process-and-impact/; Young, D., & Turner, W. (2024). Medicaid Advisory Committees: Best practices for effective stakeholder engagement. National Health Law Program. https://healthlaw.org/wp-content/uploads/2024/08/Best-Practices-for-Effective-Medicaid-Advisory-Committees-8.28.2024_final.pdf. ↑

35. Revised Code of Washington, Chapter 43.376 RCW GOVERNMENT-TO-GOVERNMENT RELATIONSHIP WITH INDIAN TRIBES. https://app.leg.wa.gov/rcw/default.aspx?cite=43.376. ↑

36. Cultural competency training. (n.d.). New Mexico Indian Affairs Department. Retrieved May 20, 2026, from https://www.iad.nm.gov/programs/tribal-consultation-and-collaboration/cultural-competency-training/; see also Revised Code of Washington, Chapter 43.376.040 RCW GOVERNMENT-TO-GOVERNMENT RELATIONSHIP WITH INDIAN TRIBES. https://app.leg.wa.gov/RCW/default.aspx?cite=43.376.040. ↑

37. Community Health Aide Program. (2026). CHAP Alaska. https://www.akchap.org/community-health-aide/ ↑

38. Black, B., Broncheau, D., Hunker, L., McCuin, D., & Weidanz, J. (2026, January 28). Oregon’s aging and people with disabilities Tribal Navigator Program. Oregon Department of Human Services. https://www.cms.gov/files/document/ltss-webinar-january-2026-oregons-aging-people-disabilities-tribal-navigator-program.pdf. ↑

39. Report to congress: Best practices in the money follows the person (MFP) demonstration. (2024). United States Department of Health and Human Services, Centers for Medicare & Medicaid Services. https://www.medicaid.gov/medicaid/long-term-services-supports/downloads/mfp-best-practices-rtc-feb2024.pdf (page 52). ↑

40. Id. page 71. ↑

41. Id. page 53. ↑

42. Tribal vulnerable adult and developmental disability targeted case management medical assistance benefit: Recommendations from engagement sessions. (2025). [Legislative Report]. Minnesota Department of Human Services Transitions Tribal & Transformation Division. https://www.lrl.mn.gov/docs/2025/mandated/251286.pdf ↑

43. Traditional health care for Tribal elders through special Medicaid waivers. (2025, January 9). Justice in Aging. https://justiceinaging.org/traditional-health-care-for-tribal-elders/. ↑

44. Biden-Harris administration takes groundbreaking action to expand health care access by covering traditional health care practices. (2024, October 16). Centers for Medicare & Medicaid Services. https://www.cms.gov/newsroom/press-releases/biden-harris-administration-takes-groundbreaking-action-expand-health-care-access-covering. ↑

45. See generally, Report to congress on the feasibility of a Navajo Nation Medicaid agency. (2014). Department of Health & Human Services, Centers for Medicare & Medicaid Services. https://www.medicaid.gov/medicaid/indian-health-medicaid/downloads/navajo-nation-medicaid-agency-feasibility-report-to-congress.pdf. ↑