Initial Application

Template I6 – Initial Application Template – Tribal Input

INTRODUCTION

In Template I6, States provide information about tribal input and consultation pertaining to the package they are submitting. This template applies to Medicaid State plan amendments and amendments to a State’s CHIP program. This template must be completed for each separate package the State is submitting.

States should complete this template in accordance with the instructions in the Technical Guidance section below.

TECHNICAL GUIDANCE

Template I6 will display the following statement.

“One or more Indian health programs or Urban Indian Organizations furnish health care services in the State.”

The State should enter either “Y” (Yes) or “N” (No) in the box next to this statement.

The following statement will then be displayed.

“This State Plan Amendment is likely to have a direct effect on Indians, Indian health programs, or Urban Indian Organizations.”

The State should enter either “Y” (Yes) or “N” (No) in the box next to this statement.

If the State has entered “Y” in response to the statement above, the following statement will be displayed.

“The State has solicited advice from Tribal governments prior to submission of this SPA.”

The State must affirmatively assure that its submission package is in accordance with the above statement. The State provides this affirmative assurance by checking the box next to the above statement. Validation: If the State does not check this box, the system will not accept this template for review and approval.

If the State entered “N” in response to the statement above, the following two additional statements will be displayed. The State should select whichever of the two statements applies. Only one statement can be selected.

• “Even though not required, the State solicited advice from Tribal governments prior to submission of this SPA.”

• “The State has not solicited advice from Tribal governments prior to submission of this SPA.”

If the State:

• Selected “Y” in response to the statement “This State Plan Amendment is likely to have a direct effect on Indians, Indian health programs, or Urban Indian Organizations.” Or

• Selected the statement “Even though not required, the State solicited advice from Tribal governments prior to submission of this SPA.”

The following two statements will be displayed.

“Complete the following information regarding any tribal consultation conducted with respect to this submission.”

“Tribal consultation was conducted in the following manner:”

Three choices will then be displayed. The State should select as many of these choices apply to this package.

• Indian Tribes.

• Indian Health Programs.

• Indian Urban Organization.

For each of the choices selected, the State will be asked to enter the following information in the spaces provided.

• Name of the choice selected.

• Date of consultation. This should be entered as MM/DD/YYYY.

• Method/Location of consultation.

Review Criteria

The descriptions of the methods and locations of the consultations must be sufficiently clear, detailed and complete to permit the reviewer to understand how the consultations were conducted, and to determine that the State’s consultations meet applicable federal statutory, regulatory and policy requirements.

The State is then asked to upload copies of any notices sent to Indian tribes, Indian Health Programs, and Indian Urban Organizations.

The following statement will then be displayed.

“Indicate the key issues raised in the Indian consultative activities:”

Eight topic choices for comments will then be displayed. The State should check as many of these choices as apply. For each choice selected, the State must enter the following in the spaces provided.

• A summary of the comments.

• A summary of the response to the comments.

Review Criteria

Each summary entered by the State must be sufficiently clear, detailed and complete to permit the reviewer to understand the comments made and the State’s responses to them.

The eight topic choices are:

• Access.

• Quality.

• Cost.

• Payment methodology.

• Eligibility.

• Benefits.

• Service delivery.

• Other issue.

If “Other issue” is selected, the State must enter the name of the issue and a summary of both the comments and the State’s response to the comments in the spaces provided. If the State has more than one other issue the user can call up additional spaces where the required information can be entered.

Review Criteria

Each summary entered by the State must be sufficiently clear, detailed and complete to permit the reviewer to understand the comments made and the State’s responses to them.

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