On April 25--just 48 hours before stricter federal requirements for community input took effect--the New Mexico Human Services Department submitted Centennial Care, its plan for redesigning the state's Medicaid program---, to the federal Centers for Medicare and Medicaid Services. Although HSD officials say they got plenty of public input, critics see the move as an attempt to sidestep the new requirements.

The same day the redesign was submitted, more than 100 members of Acoma, Laguna, Tamaya, Jemez, Isleta and Taos tribes attended a New Mexico Indian Council on Aging (NMICoA) health committee meeting at Laguna Pueblo to learn about the state's plan, many for the first time.

"Most of them were ill informed about the Centennial Care plan.  A lot of information does not get to the senior centers," Tamaya Pueblo Tribal Councilman and NMICoA member Manuel Cristobal says.

State Rep. Ray Begaye, D-San Juan, says the state's outreach to Native Americans was insufficient.

"In order to get really strong input, those public officials needed to go to the poor communities like Acoma, Zuni or Nageezi [a Navajo community] to talk to the people there," he says—in addition to arranging for tribal language translators.

Quela Robinson, a staff attorney for the Center on Law and Poverty, says the state failed to consider some critical issues.

"One change that many people may not have noticed, especially those in rural areas who don't have access to the internet, is the clause that takes away retroactive medical costs," Robinson says. (Studies have shown that the majority of Native Americans, especially those living in rural areas, lack access to the internet.)

For many Native Americans, the primary concern is the plan's requirement that they join a managed care organization—a private medical provider such as Presbyterian or Lovelace—rather than being able to choose their own doctors. About three-quarters of New Mexico's tribal leadership (which represents the state's 22 tribes) disagreed with this part of the plan during a March 20 tribal-state consultation, yet it remains in the plan that was submitted to CMS.

But HSD spokesman Matt Kennicott says he believes the plan will benefit Native Americans and that the agency received plenty of input.

"We have received tons of email," Kennicott says. "We have held meetings, tribal consults and workshops. We have been posting on the websites. We have kept phone lines open."

HSD plans to blanket the state with medical care coordination, which will mostly be delivered through virtual "health homes" with health specialists communicating with patients via phones, the internet and through a telemedicine system. But Begaye doubts the state's services will reach Native Americans living in rural areas because most of them don't have email—and National Congress of American Indians report states that telephone penetration on Indian reservations is just 68 percent.

If CMS accepts the redesign, New Mexico's federal funding (which pays for approximately 75 percent of the program's total cost) will remain around $3 billion a year. To simplify the administration of the program, MCOs would be reduced from the current 7 to "a smaller more manageable number", according to the submitted plan.

Begaye says that funneling state money to MCOs for Native American health care reminds him of the time in history when Navajo people were sent to a concentration camp in Ft. Sumner.

"Once there they were supposed to get cows, horses, mules, wagons, clothing and blankets, but the fat cats [military officers] kept the fat cows and beef and better blankets," Begaye says. "They would make themselves wealthy and throw bones to the Navajo prisoners."

CMS spokesman Alper Ozinal told SFR in March that CMS couldn't comment except to say that it will look closely at the impact of the state's proposal on the Native American population. The state is requesting CMS to expedite approval so that it can contract with MCOs by Jan. 1, 2013. Ozinal, however, said that there is no definitive time period for CMS review and approval.