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Missouri Application for the State Children’s Health Insurance Program Effective Date: 05/01/2009 Approval Date:

Prior Approval Date: 09/28/2007 - 19 - The cost-effectiveness determination. 4.4.5 Child health assistance is provided to targeted low-income children in the state who are American Indian and Alaska Native. (Section 2102)(b)(3)(D)) (42 CFR 457.125(a))

Response: CMS officials have held that Missouri has no federally-recognized American Indian/Native American tribes within the state, and, therefore, Missouri has no specific obligations pursuant to 42 CFR § 457. The fact that Missouri has no federally-recognized American Indian/Native American tribes was affirmed by the CMS Region VII office as recently as May 2007. • The Eastern Shawnee Tribe of Oklahoma tribe is not associated with Missouri in the Federal Register’s “Indian Entities Recognized and Eligible To Receive Services From the United States Bureau of Indian Affairs” (Vol. 72, No. 55 / Thursday, March 22, 2007). • The Eastern Shawnee Tribe of Oklahoma (http://www.easternshawnee.org/index.html and http://www.eighttribes.org/eastern-shawnee/) listed above is actually centered on the Oklahoma/Missouri border. • Article II of the Constitution of the Eastern Shawnee Tribe (http://thorpe.ou.edu/constitution/eastshawcons.html) states that “...Eastern Shawnee lands, which are located in the north east section of the State of Oklahoma, and such other territory as may hereafter be added thereto.” This evidence is fully consistent with the CMS' position that Missouri has no federally-recognized American Indian/Native American tribes within the state. Recognizing that a member of a tribe may re-locate to the State, Missouri will exempt children who are members of federally-recognized tribes from cost- sharing requirements as stipulated in Section 2103(e)(1)(A). Children who identify themselves as American Indian or Native Alaskan on the SCHIP application will be notified that, upon receipt of documentation of tribal membership, they will no longer be required to submit monthly premiums. Any premiums paid will be reimbursed within 45 days of receipt of documentation of tribal membership. The materials sent to all new enrollees will include information on the cost-sharing exemption for members of federally-recognized American Indian or Native Alaskan tribes to ensure that