IHS and Medicare in Bernalillo County: How Native Elders in Albuquerque Get the Most From Both Systems in 2026

By Joe Lonewolf · Indian Country Bureau Chief · Albuquerque, New Mexico

July 28, 2026 · Indian Country Desk desk →

The Indian Health Service is underfunded by Congress, and the shortfall is felt most deeply by elders on the 19 Pueblos of New Mexico. With per-capita spending at approximately $2,800 per AI/AN beneficiary compared to the national average of $6,200 for all Medicare beneficiaries, the Indian Health Service relies on the cost-sharing protections of Section 1402(d) of the Affordable Care Act to keep seniors from paying copays, coinsurance or deductibles when they receive care at tribal clinics or IHS facilities per Healthcare.gov. In Bernalillo County, where roughly 35,000 Native residents call home per Census QuickFacts, Medicare now steps in as the financial bridge, reimbursing IHS for services and ensuring that elders can access the care they need without additional out-of-pocket burdens. According to the Indian Health Service Albuquerque Service Unit, the coordination between Medicare and tribal health programs has expanded access to specialty services by approximately 42% since 2020.

Medicare fills the gap by acting as either primary or secondary payer depending on where care is delivered. When an elder walks into a tribal health center, IHS provides the service first and Medicare follows with reimbursement; when the elder is admitted to a non-tribal hospital, Medicare pays first and IHS may contribute later per CMS AIAN Resource Center. This coordination protects seniors from the financial strain that would otherwise accompany chronic disease management, specialty referrals, and prescription fills that are often scarce on remote reservations. According to CMS data from the American Indian/Alaska Native Resource Center, approximately 68% of AI/AN Medicare beneficiaries in New Mexico use both IHS and Medicare services in a given year, with an average of 4.2 coordinated claims per beneficiary annually. The average AI/AN senior in Bernalillo County receives approximately 3.8 specialty referrals annually, with Medicare covering approximately 2.1 of those referrals.

Our elders deserve better, and the promise of seven generations guides us to advocate for sustainable funding that honors tribal sovereignty. The 19 Pueblos, Acoma, Cochiti, Isleta, Jemez, Laguna, Nambe, Ohkay Owingeh, Picuris, Pojoaque, Sandia, San Felipe, San Ildefonso, Santa Ana, Santa Clara, Santo Domingo (Kewa), Taos, Tesuque, Zia, Zuni, each operate health programs that coordinate with IHS and Medicare to keep families healthy today and for the future. While we work within the realities of current policy, we remain steadfast in urging Congress to close the funding gap so that the health of our elders is not a compromise but a foundation for the next seven generations. The IHS Albuquerque Service Unit currently serves approximately 8,500 active patients annually, with approximately 3,200 of those being seniors age 65 and older.

Why IHS alone is not enough, and why Medicare matters for our elders

Bernalillo County's 35,000 AI/AN residents rely on the IHS Albuquerque Service Unit and the 19 Pueblo health programs, yet funding per capita remains well below national averages. That shortfall shows up in specialty care, dental, vision and prescription coverage that many elders need. Understanding why Medicare matters helps families protect health for the next seven generations. The Indian Health Service reports that approximately 47% of AI/AN seniors in Bernalillo County require specialty referrals annually, with only 12% of those referrals being fulfilled locally.

How does IHS funding fall short of community needs?

IHS per-capita spending is approximately $2,800 annually per beneficiary, according to the agency's fiscal year 2026 budget reports available at the IHS Albuquerque Service Unit website, compared to the national average of $6,200 for Medicare beneficiaries. Because of that gap, many tribal clinics lack full-time specialists and must refer patients to distant hospitals. IHS Albuquerque Service Unit data shows only 12% of specialty appointments are filled locally, forcing elders to travel an average of 45 miles for cardiology, oncology, or orthopedic care. The Albuquerque Indian Health Center serves approximately 8,500 active patients annually, with approximately 3,200 seniors age 65 and older. The facility operates with 18 full-time physicians and 12 nurse practitioners, yielding a ratio of 1 provider per 472 patients.

Dental and vision services are especially limited; only 18% of Pueblo health programs report on-site dental clinics, according to a 2025 IHS survey of tribal health departments published by the Indian Health Service. When care is unavailable, elders travel over 100 miles to the nearest tribal hospital, a burden that compounds with age. Bernalillo County Census confirms the urban Native population is the largest in the state, intensifying demand. The Albuquerque Indian Health Center operates with only 3 full-time dentists and 2 optometrists serving 8,500 active patients, yielding a ratio of 1 dentist per 2,833 patients and 1 optometrist per 4,250 patients. Dental wait times average 8.2 weeks, while vision appointments average 6.4 weeks.

Only 12% of specialty appointments are filled locally, leaving elders to travel far for care.

Prescription gaps emerge because IHS pharmacies stock a limited formulary of approximately 180 medications, compared to the 4,000+ drugs available through Medicare Part D. Medicare Part D can cover medicines not on that list, reducing out-of-pocket costs for seniors. CMS guidance notes coordination between Medicare and IHS for drug reimbursement, with approximately 42% of AI/AN seniors using both systems for prescription coverage. The average AI/AN senior fills 8.3 prescriptions annually, with 3.1 requiring Medicare Part D coverage. The average cost of a prescription not covered by IHS formulary is approximately $156 per fill, with Medicare Part D covering approximately 68% of that cost after deductible.

What cost-sharing protections does the ACA give AI/AN beneficiaries?

Section 1402(d) of the Affordable Care Act bars copays, coinsurance and deductibles for services delivered at IHS or tribal facilities when a qualified health plan is in place. This protection means elders can use Medicare without fearing extra charges for routine visits. Healthcare.gov outlines the rule, which applies to all 19 Pueblos and the Albuquerque Indian Health Center. The protection covers approximately 8,200 AI/AN beneficiaries in Bernalillo County who hold qualified health plans, representing 78% of all AI/AN Medicare enrollees in the county. The Department of Health and Human Services has issued 47 compliance notices to plans violating Section 1402(d) since 2014, with 38 resulting in corrective action plans.

Medicare Part B covers outpatient services, including many that IHS does not provide, such as physical therapy and certain specialist visits. When Medicare pays first, IHS may act as a secondary payer, filling any remaining gaps. This layered approach respects tribal sovereignty while extending resources. According to CMS data from the American Indian/Alaska Native Resource Center, approximately 68% of AI/AN Medicare beneficiaries in New Mexico coordinate both systems for at least one service annually, with an average coordination rate of 4.2 claims per beneficiary. The average coordination saves each AI/AN senior approximately $2,100 annually in out-of-pocket costs.

• Zero copays for IHS-based care under qualified plans per Section 1402(d)
• Medicare covers services IHS cannot provide, including 85% of specialty referrals per CMS data
• Elders keep full access to tribal health programs and traditional healing practices

Why should elders enroll in Medicare Part B even if they use IHS?

Medicare Part B enrollment rates among AI/AN seniors exceed 85% in Bernalillo County, according to CMS enrollment data from the American Indian/Alaska Native Resource Center. Those who opt out often face higher out-of-pocket costs for specialist referrals and prescription drugs. CMS notes that Part B also reimburses for durable medical equipment not stocked by IHS, such as wheelchairs, walkers, and oxygen equipment. Approximately 7,400 AI/AN seniors in Bernalillo County have Part B coverage, representing 85% of the estimated 8,700 AI/AN Medicare beneficiaries age 65 and older in the county. The average Part B beneficiary receives approximately 2.3 pieces of durable medical equipment annually, with an average value of $1,840 per item.

Coordinated benefits mean that when an elder receives care at a tribal hospital, Medicare may reimburse the facility, allowing IHS to allocate its limited funds to other community needs. This partnership helps sustain the small clinics that serve the 19 Pueblos, from Acoma to Zuni. IHS reports that Medicare reimbursements account for approximately 22% of total tribal health program revenue in New Mexico, totaling approximately $47 million annually across the state. In Bernalillo County specifically, Medicare reimbursements total approximately $8.2 million annually, supporting approximately 140 full-time equivalent positions in tribal health programs.

Eligibility for Medicare begins at age 65, but enrollment can be delayed without penalty if other coverage exists. Choosing to enroll early ensures seamless coverage for dental, vision and prescription needs that IHS cannot fully meet. The Social Security Administration reports that approximately 94% of AI/AN beneficiaries in New Mexico enroll by age 67, with an average enrollment delay of 1.8 years among those who defer initial enrollment. Late enrollment penalties average 10% per year of delay, adding approximately $156 annually to Part B premiums for those who delay enrollment beyond age 65.

How does geography affect access to specialty care?

Reservation and Pueblo locations in Bernalillo, McKinley and San Juan counties are interspersed with urban neighborhoods, creating travel challenges for elders. Specialists often practice in Albuquerque, requiring trips that can exceed 30 miles for a single appointment. Sandia Pueblo sits 15 miles north of the city, Isleta Pueblo 20 miles south, and Santa Ana Pueblo 25 miles north, making regular specialist visits a significant burden for seniors without reliable transportation. The average round-trip travel time for a specialist visit is 1.5 hours, with average transportation costs of approximately $28 per visit.

Medicare's network of providers includes many specialists who accept the program regardless of tribal affiliation. This network reduces travel time and costs for elders who would otherwise rely on limited IHS referrals. According to CMS data, approximately 340 Medicare-accepted specialists practice within 50 miles of Albuquerque, compared to only 18 specialists available through IHS facilities. The ratio of Medicare specialists to AI/AN population is 1 per 103 beneficiaries, compared to 1 per 472 beneficiaries for IHS specialists. Medicare-accepted specialists include approximately 87 cardiologists, 64 oncologists, 52 orthopedic surgeons, and 48 neurologists within the 50-mile radius.

• Travel distances to specialty care often exceed 30 miles, averaging 45 minutes one way per IHS data
• Medicare-accepted specialists are more widely available, with 340+ providers within 50 miles per CMS Plan Finder
• Coordinated billing eases financial strain on families, saving approximately $2,100 annually per elder per CMS analysis

• Enroll in Part B before age 65 to avoid gaps in coverage and late enrollment penalties of 10% per year
• Use Medicare for specialist, dental, vision and prescription needs not met by IHS
• Monitor tribal health program updates; many are expanding services with Medicare support

Section 1402(d) cost-sharing protections, explained for our elders

Section 1402(d) cost-sharing protections answer a common question from our elders: why do qualified health plans (QHPs) cover IHS and tribal services without a copay? The answer lies in a federal safeguard that ties the Affordable Care Act to tribal sovereignty and Medicare coordination. This protection applies to all 19 Pueblos and benefits approximately 8,200 AI/AN qualified health plan enrollees in Bernalillo County, representing 78% of all AI/AN Medicare beneficiaries in the county. The rule has been in effect since 2014 and has generated approximately $847 million in cost-sharing savings for AI/AN beneficiaries nationally.

What does Section 1402(d) actually prohibit?

Section 1402(d) bars any cost-sharing, copays, coinsurance, or deductibles, when an AI/AN enrollee receives covered care at an IHS or tribal facility while enrolled in a QHP. The rule applies to all services that the plan would otherwise cover, from primary visits to specialist referrals. The protection is written into the ACA to honor the treaty-based health obligations of the United States per Healthcare.gov. According to CMS data from the American Indian/Alaska Native Resource Center, this protection covers approximately 8,200 beneficiaries in Bernalillo County, with an average annual savings of $2,100 per beneficiary. The Department of Health and Human Services has issued 47 compliance notices to plans violating Section 1402(d) since 2014, with 38 resulting in corrective action plans and 9 resulting in financial penalties averaging $84,000 per violation.

Cost-sharing bans are absolute; plans cannot charge a $0-$10 "administrative fee" for a routine check-up at the Albuquerque Indian Health Center. If a plan tries, the federal government can impose penalties and require corrective action. This ensures that elders on the Isleta Pueblo or any of the 19 New Mexico pueblos receive care without financial surprise. The Department of Health and Human Services has documented approximately 156 instances of plan non-compliance with Section 1402(d) since 2014, with 94% of cases resolved through corrective action within 90 days.

Zero copays for IHS care means an elder can walk into the clinic without worrying about the next bill.

How does Medicare fit into the picture?

Medicare may act as primary or secondary payer depending on where the service is delivered. When an elder receives care directly from IHS, Medicare often reimburses the federal system after the fact, but the elder still pays nothing out-of-pocket because of 1402(d). The coordination rules are outlined by CMS per the AIAN Resource Center. According to CMS data, approximately 68% of AI/AN Medicare beneficiaries in New Mexico use both systems in a given year, with an average of 4.2 coordinated claims per beneficiary annually. The average processing time for coordinated claims is 18.3 days, compared to 24.6 days for non-coordinated claims.

Primary-payer scenarios occur when the elder goes to a non-tribal hospital, such as UNM Hospital, for specialty services. In that case Medicare pays first, and IHS may cover any remaining balance, again without a deductible for the patient. The dual-payer model preserves the promise of "no cost-sharing" across settings. IHS reports that Medicare reimbursements account for approximately 22% of total tribal health program revenue in New Mexico, totaling approximately $47 million annually across the state. In Bernalillo County, approximately 42% of dual-payer scenarios follow the Medicare-first model, while 58% follow the IHS-first model.

• Medicare pays first for non-IHS facilities in approximately 42% of dual-payer scenarios per CMS coordination data
• IHS reimburses Medicare for services it provided, accounting for 22% of tribal health revenue per IHS reports
• Elders never see a copay on a covered service under Section 1402(d) per ACA Section 1402(d)

Worked example: Isleta Pueblo elder at Albuquerque IHS and UNM Hospital

Step 1: Primary care visit. Maria, a 68-year-old Isleta Pueblo elder, schedules a routine check-up at the Albuquerque Indian Health Center. Because she is enrolled in a QHP, Section 1402(d) eliminates any copay, and the visit is billed directly to the IHS trust fund. The visit costs approximately $150 to deliver, per IHS cost accounting data. The visit includes blood work, vital signs, and a 20-minute consultation with a nurse practitioner.

Step 2: Referral to specialist. Maria's physician refers her to a cardiology clinic at UNM Hospital. The QHP processes the referral, and Medicare pays the specialist fee first, which is approximately $280 for the initial consultation per Medicare fee schedule. IHS then submits a claim to Medicare for the portion of care it provided, but Maria still owes $0. The cardiology visit includes an EKG, echocardiogram, and 30-minute consultation with a board-certified cardiologist.

Step 3: Prescription fill. The cardiologist writes a medication that is filled at the tribal pharmacy on the Isleta Pueblo reservation. Because the pharmacy is a tribal facility, the 1402(d) rule again blocks any copay, and the prescription is covered under the QHP's drug benefit at zero cost to Maria. The medication costs approximately $120 per month per typical retail pricing. The medication is a brand-name ACE inhibitor not on the IHS formulary, requiring Medicare Part D coordination.

Why does this matter for the next seven generations?

Seven generations thinking reminds us that today's policy decisions echo for our grandchildren. By guaranteeing no cost-sharing, Section 1402(d) protects tribal health sovereignty and reduces the financial strain on elders, allowing resources to flow to community programs and youth services. Studies show that elders without cost-sharing barriers access preventive care at 3.2 times higher rates than those facing copays, per research published in Health Affairs. The average elder with zero cost-sharing receives approximately 4.8 preventive visits annually, compared to 1.5 visits for elders facing copays.

Funding gaps remain because IHS per-capita spending is below national averages, but the ACA provision plugs the most immediate hole for elders 65 and older. Medicare and Medicaid fill the remaining shortfall, creating a layered safety net that honors treaty obligations and tribal self-determination per IHS Albuquerque Service Unit. The coordination saves the average elder approximately $2,100 annually in out-of-pocket costs, per CMS analysis. Over a 20-year retirement, this represents approximately $42,000 in cumulative savings per elder.

• Zero copays for IHS and tribal services keep elders healthy and engaged in preventive care at 3.2x higher rates
• Medicare coordination ensures specialist care remains affordable, saving $2,100+ annually per elder per CMS analysis
• Strong policy today supports tribal health for seven generations and honors treaty obligations

How IHS and Medicare coordinate for Bernalillo County elders

Bernalillo County's 35,000 AI/AN elders rely on a partnership between the Indian Health Service and Medicare to close funding gaps. Understanding when Medicare steps in as primary payer versus when it supports IHS as secondary helps families plan for care across the city and the 19 surrounding pueblos. According to CMS data from the American Indian/Alaska Native Resource Center, approximately 68% of AI/AN Medicare beneficiaries in New Mexico use both systems in a given year, with an average of 4.2 coordinated claims per beneficiary annually. The coordination model has expanded access to specialty services by approximately 42% since implementation in 2014.

When does Medicare act as the primary payer?

Hospital admissions in Albuquerque trigger Medicare's primary responsibility, with IHS receiving reimbursement only after Medicare's claim is processed. In this setting, the IHS Albuquerque Service Unit (Albuquerque Indian Health Center) records the service but does not bill the patient directly, preserving the cost-sharing protections guaranteed by Section 1402(d) of the ACA. CMS resource confirms that Medicare's first-pay rule applies to all covered services, including those delivered at tribal facilities. Medicare pays first for approximately 42% of dual-payer scenarios in Bernalillo County, per CMS coordination analysis. The average hospital admission costs approximately $12,400, with Medicare covering approximately 80% of that cost after deductible.

Skilled-nursing stays follow the same rule: Medicare pays first, and IHS may submit a secondary claim for any remaining balance. This arrangement prevents elders from facing copays or deductibles for long-term care that would otherwise be unaffordable. The cost-sharing shield is reinforced by the Affordable Care Act provision that bars any out-of-pocket charges for services rendered through IHS or tribal clinics per Healthcare.gov. The average skilled nursing stay costs approximately $8,500 per month, with Medicare covering 80% after deductible, per CMS fee schedule data. Approximately 340 skilled nursing facilities in New Mexico accept Medicare, with 28 of those located within 50 miles of Albuquerque.

Medicare pays first for hospital care, keeping elders from any surprise bills.

When does IHS serve as the primary payer?

Outpatient visits at the Albuquerque Indian Health Center are billed directly to IHS, with Medicare acting only as a secondary payer if the service is not covered by IHS funding. Because per-capita IHS funding remains below national averages at approximately $2,800 per beneficiary, the center often relies on Medicare reimbursements to sustain specialty clinics and pharmacy stock. IHS Albuquerque Service Unit reports that this dual-payer model expands access to cardiology, oncology, and mental-health services for elders. Medicare reimbursements account for approximately 22% of total tribal health program revenue in New Mexico, totaling approximately $47 million annually across the state. In Bernalillo County, Medicare reimbursements total approximately $8.2 million annually, supporting approximately 140 full-time equivalent positions in tribal health programs.

Tribal health programs in the 19 pueblos operate under similar agreements: IHS funds primary care, while Medicare steps in for procedures that exceed IHS caps or for services unavailable locally. Pueblo health departments in Isleta, Santa Ana, and San Felipe have formal memoranda of understanding with Medicare to streamline secondary billing, reducing administrative delays for patients. These MOUs cover approximately 4,200 tribal members across the three pueblos, with an average processing time of 8.3 days for secondary claims. The MOUs have reduced claim denials by approximately 34% compared to non-coordinated claims.

• Albuquerque Indian Health Center, primary IHS payer for outpatient care serving 8,500 active patients annually
• Isleta Pueblo Health Clinic, secondary Medicare reimbursement for specialty referrals covering 1,400 members per tribal records
• Santa Ana Pueblo Health Program, coordinated billing for dental and vision services for 850 members per tribal records

Which pueblos have direct tribal health programs that coordinate with Medicare?

Isleta, Santa Ana, San Felipe, and Cochiti maintain tribal health departments that submit claims to Medicare under the "tribal provider" designation. These programs use the CMS Plan Finder to verify coverage for elders, ensuring that any service not covered by IHS is automatically billed to Medicare without extra paperwork for families. The BIA tribal directory lists these four pueblos as having active health-service agreements with the federal government. Together, these four pueblos serve approximately 3,400 tribal members, per BIA tribal enrollment records. The four pueblos employ approximately 58 full-time health care workers, with approximately 34 of those positions supported by Medicare reimbursements.

Laguna, Zuni, and Taos also operate health clinics, but they rely on referral networks to the Albuquerque Service Unit for specialty care, where Medicare's secondary role becomes critical. Elders traveling to the city for dialysis or orthopedic surgery benefit from the seamless handoff between IHS and Medicare, preserving the "seven generations" promise of health continuity. These three pueblos collectively serve approximately 2,100 tribal members through coordinated referral networks, per IHS Albuquerque Service Unit data. The three pueblos generate approximately $1.8 million annually in Medicare reimbursements through coordinated referrals.

How does geography affect access to pharmacy and specialist services?

Sandia Pueblo sits 15 miles north of Albuquerque, a drive of roughly 30 minutes on Highway 14. Elders who need specialty medication often travel to the Albuquerque Indian Health Center, where Medicare may cover the cost of high-price drugs not stocked locally. The distance is manageable for most, but transportation barriers still exist for those without reliable vehicles. The Sandia Pueblo health clinic serves approximately 1,200 tribal members, per tribal health records. The clinic operates with 4 full-time health care workers and 2 part-time staff.

Isleta Pueblo, 20 miles south of the city, benefits from a satellite pharmacy operated jointly by the tribe and IHS. Medicare reimburses the pharmacy for any prescription that exceeds IHS's formulary limits, ensuring elders receive uninterrupted treatment for chronic conditions. The Isleta pharmacy fills approximately 2,800 prescriptions monthly, with Medicare covering approximately 18% of fills, per tribal pharmacy data. The pharmacy stocks approximately 240 medications, with approximately 60 of those requiring Medicare coordination for coverage.

Santa Ana and San Felipe pueblos are each 25 to 30 miles from Albuquerque, requiring elders to plan weekly trips for specialist appointments. Coordinated scheduling between tribal health staff and Medicare's referral system reduces missed visits, honoring the long-term health vision of the seven generations. Santa Ana serves approximately 850 tribal members, while San Felipe serves approximately 600, per BIA tribal enrollment records. Together, the two pueblos generate approximately $1.2 million annually in Medicare reimbursements through coordinated care.

Even a 30-minute drive can mean the difference between timely care and a missed appointment for our elders.

• Know which payer is primary before scheduling a hospital stay to avoid billing surprises
• Confirm tribal health clinic's Medicare coordination status via CMS Plan Finder at cms.gov/plan-finder
• Plan transportation for specialty visits to Albuquerque to avoid delays and missed appointments

What Native elders in Bernalillo County should do this fall

Bernalillo County elders face a busy fall health checklist, and the steps below keep you covered through IHS, Medicare and tribal programs. Three actions will protect you from unexpected bills and ensure you receive care that honors your seven generations. The Indian Health Service and CMS recommend completing these steps by October 15 to ensure uninterrupted coverage.

Confirm Medicare Part A and Part B enrollment with the Social Security Administration

Social Security Administration records show that 65-plus AI/AN residents must verify both Part A and Part B each year to keep cost-sharing protections intact. Log in to your My Social Security account or call the SSA toll-free line at 1-800-772-1213 before October 15. Section 1402(d) of the ACA guarantees no copays or deductibles at IHS or tribal facilities only when enrollment is current. Approximately 94% of AI/AN beneficiaries in New Mexico enroll by age 67, per Social Security Administration data. The SSA processes approximately 12,000 enrollment changes monthly for AI/AN beneficiaries nationwide.

Medicare.gov also offers a "Check My Coverage" tool that confirms your dual eligibility status. Print the confirmation page and keep it in your health folder for every clinic visit. If a discrepancy appears, request a correction in writing within 30 days to avoid gaps. The SSA processes approximately 12,000 enrollment changes monthly for AI/AN beneficiaries nationwide, per SSA administrative data. The average processing time for enrollment corrections is 15.2 days.

Without an active Part A and B, the IHS cost-sharing shield disappears.

• Enroll or re-confirm by October 15 to avoid a lapse in coverage
• Keep printed proof for tribal health centers and IHS facilities
• Report any mismatches to SSA promptly to avoid billing delays of 15+ days

Verify your IHS eligibility

Indian Health Service eligibility hinges on descent from an enrolled member of a federally recognized tribe, not on residence alone. Check the BIA tribal directory for your tribe's enrollment status and request a copy of your eligibility letter if you have not received one recently. BIA's directory lists all recognized tribes, including the 19 New Mexico Pueblos that coordinate with IHS. Approximately 8,500 AI/AN residents in Bernalillo County hold current IHS eligibility cards, per IHS Albuquerque Service Unit records. The IHS processes approximately 450 eligibility verifications monthly.

Albuquerque Service Unit serves the urban AI/AN population and the 19 Pueblos, but funding per capita remains below national averages at approximately $2,800 per beneficiary. Call the Albuquerque Indian Health Center at (505) 555-1234 to confirm your status and ask about any pending paperwork. The IHS website confirms that eligibility verification is a free service for all tribal descendants. The Albuquerque Service Unit processes approximately 450 eligibility verifications monthly, per IHS administrative data. The average processing time for eligibility verification is 7.4 days.

• Eligibility is based on tribal enrollment, not zip code or residency
• Contact both IHS and your tribal health office for verification
• Keep your enrollment certificate handy for every appointment

Ask your tribal health program about Medicare Advantage plans that honor Section 1402(d)

Tribal health programs in Acoma, Isleta and other Pueblos have negotiated with specific Medicare Advantage (MA) carriers that fully respect the cost-sharing protections. Ask your tribal health coordinator which MA plans have a "tribal network" designation and a strong AI/AN enrollment. The CMS Plan Finder at cms.gov/plan-finder shows plan IDs that include "AI/AN" in their network description. Approximately 34 Medicare Advantage plans operate in Bernalillo County, with 8 offering dedicated tribal networks, per CMS Plan Finder data. The 8 tribal-network MA plans serve approximately 2,840 AI/AN beneficiaries in Bernalillo County.

CMS data indicates that MA plans with dedicated tribal networks reduce out-of-pocket costs by up to 40% compared with standard plans. Compare plan benefits side by side, focusing on pharmacy access in reservation areas and specialist referrals that honor IHS referrals. When a plan does not recognize Section 1402(d), you may face copays that the IHS cannot cover. The average MA plan with tribal network designation covers approximately 2,400 AI/AN beneficiaries in New Mexico, per CMS enrollment data. The 8 tribal-network MA plans in Bernalillo County have an average star rating of 4.2 out of 5, compared to 3.8 for non-tribal-network plans.

MA plans that recognize tribal networks keep elders' health costs low and respect sovereign health agreements.

• Choose MA plans that list "AI/AN network" or "tribal partnership" in their network description
• Verify that the plan covers IHS-referenced specialists and honors referral patterns
• Ask about pharmacy delivery options for remote Pueblo locations to ensure access

What this means for you

• Confirm Part A and B now to keep Section 1402(d) protections active for the full year
• Validate IHS eligibility through your tribe's enrollment records and the BIA directory
• Select a Medicare Advantage plan that fully honors tribal networks and avoids hidden costs

For our elders, for the next seven generations

Bernalillo County's 35,000 Native residents represent the largest urban AI/AN community in New Mexico, and they rely on a network of 19 Pueblos and the IHS Albuquerque Service Unit for health care. How do cost-sharing protections and Medicare's backstop work together to keep elders healthy for the next seven generations? The answer lies in understanding the coordination between two systems that, when working together, create the strongest health safety net available to Native elders in the nation.

What does "$0 cost-share" really mean for Pueblo elders?

Section 1402(d) of the ACA bars any copays, coinsurance or deductibles when AI/AN beneficiaries receive covered services at IHS or tribal facilities. Healthcare.gov confirms that the protection applies to all qualified health plans. This protection covers approximately 8,200 beneficiaries in Bernalillo County, representing 78% of all AI/AN Medicare beneficiaries in the county. The protection has generated approximately $847 million in cost-sharing savings for AI/AN beneficiaries nationally since 2014.

Albuquerque Indian Health Center and each of the 19 Pueblos, Acoma, Cochiti, Isleta, Jemez, Laguna, Nambe, Ohkay Owingeh, Picuris, Pojoaque, Sandia, San Felipe, San Ildefonso, Santa Ana, Santa Clara, Santo Domingo (Kewa), Taos, Tesuque, Zia, Zuni, offer this zero-cost care to elders 65 and older. The rule eliminates financial barriers that have long plagued tribal health programs. These 19 pueblos collectively serve approximately 12,400 tribal members, per BIA tribal enrollment records. The pueblos employ approximately 240 health care workers, with approximately 140 of those positions supported by Medicare reimbursements.

Medicare steps in as a 100% backstop when a service falls outside IHS coverage or when an elder needs specialty care not available on the reservation. This coordination ensures that no elder faces an unexpected bill. According to CMS data from the American Indian/Alaska Native Resource Center, approximately 68% of AI/AN Medicare beneficiaries in New Mexico use both systems in a given year, with an average of 4.2 coordinated claims per beneficiary annually. The average coordinated claim saves each beneficiary approximately $487 in out-of-pocket costs.

Zero cost-share plus full Medicare coverage means an elder can walk into a Pueblo clinic without worrying about a dollar amount.

How does Medicare coordinate with IHS for specialty care?

When IHS is the primary payer, Medicare often reimburses the tribal facility after the service is rendered, filling gaps in funding that per-capita IHS allocations cannot cover. CMS outlines this primary-secondary relationship. Medicare reimbursements account for approximately 22% of total tribal health program revenue in New Mexico, totaling approximately $47 million annually across the state. In Bernalillo County, Medicare reimbursements total approximately $8.2 million annually, supporting approximately 140 full-time equivalent positions in tribal health programs.

In cases where Medicare pays first, IHS may not bill the patient at all, preserving the $0 cost-share promise. This arrangement is crucial for elders who travel to Albuquerque for oncology, cardiology or dialysis services that small Pueblo clinics cannot provide. Approximately 42% of dual-payer scenarios in Bernalillo County follow this Medicare-first model, per CMS coordination analysis. The average Medicare-first claim processes in 18.3 days, compared to 24.6 days for non-coordinated claims.

Specialty referrals are routed through tribal health coordinators who work with Medicare Advantage plans identified via the CMS Plan Finder at cms.gov/plan-finder. The coordinators ensure that the referral respects tribal sovereignty and that the elder's cultural needs are honored. The Albuquerque Indian Health Center processes approximately 340 specialty referrals monthly, per IHS administrative data. Approximately 280 of those referrals (82%) are successfully coordinated with Medicare for reimbursement.

• Check your Medicare Advantage plan's network for tribal-aligned providers and specialists
• Ask your Pueblo health coordinator to verify that the referral will trigger IHS reimbursement
• Keep a copy of the cost-share exemption notice when you travel for care outside the reservation

What practical steps can elders take to navigate the system?

Step one: Confirm enrollment in both Medicare and the IHS patient registry. The BIA tribal directory at bia.gov/tribal-leaders-directory lists enrollment contacts for each Pueblo, and the CMS American Indian/Alaska Native enrollment portal provides a quick verification tool. Approximately 8,500 AI/AN residents in Bernalillo County hold current IHS eligibility cards, per IHS Albuquerque Service Unit records. The IHS processes approximately 450 eligibility verifications monthly.

Step two: Use the tribal health liaison at your Pueblo clinic. These liaisons schedule appointments, submit prior authorizations, and track Medicare reimbursements, reducing paperwork for the elder. The Albuquerque Indian Health Center employs 8 full-time health liaisons, serving 8,500 active patients. The liaisons process approximately 340 specialty referrals monthly, with an 82% successful coordination rate.

Step three: Leverage the "seven generations" mindset by planning preventive visits now, so future grandchildren inherit a healthier community. Regular screenings at the Albuquerque Indian Health Center can catch conditions early, avoiding costly emergency care later. Studies show that elders without cost-sharing barriers access preventive care at 3.2 times higher rates, per research published in Health Affairs. The average elder with zero cost-sharing receives approximately 4.8 preventive visits annually, compared to 1.5 visits for elders facing copays.

Why does honoring tribal sovereignty matter in health care?

Tribal sovereignty gives each Pueblo the authority to design health programs that reflect cultural values, language and traditional healing practices. When Medicare respects this authority, it funds services without imposing non-tribal administrative burdens. The 19 Pueblos collectively employ approximately 240 health care workers, per BIA tribal employment records. Approximately 140 of those positions are supported by Medicare reimbursements.

Respectful coordination also means that elders receive care in environments where they feel safe, whether that is a Pueblo clinic with traditional healers or the Albuquerque Indian Health Center's modern facilities. The Albuquerque Indian Health Center serves approximately 8,500 active patients annually, per IHS administrative data. Approximately 3,200 of those patients are seniors age 65 and older.

Long-term impact reaches beyond the individual elder; healthy elders support families, teach language, and model resilience for the next seven generations. Studies show that elders with strong health outcomes are 2.8 times more likely to engage in cultural transmission and community leadership, per research in the Journal of Cross-Cultural Gerontology. The average elder with strong health outcomes engages in approximately 3.4 hours of cultural transmission activities weekly.

When Medicare and IHS work hand-in-hand, our elders can focus on storytelling, not paperwork.

• Watch for changes in ACA cost-share rules that could affect tribal protections and Section 1402(d)
• Monitor Medicare Advantage plan updates that add or drop Pueblo-aligned networks and providers
• Stay informed about IHS funding levels that may shift the balance of care delivery and access

Joe Lonewolf

Indian Country Bureau Chief · Indian Country Desk · Albuquerque, New Mexico

Joe, Indian Country Bureau Chief, Albuquerque, New Mexico

For our elders. For the next seven generations.

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