Background: More American Indians and Alaska Natives (AIAN) reside in California than any other single state in the United States; Los Angeles is home to the largest number of AIAN in the country. In 1997 the federal government initiated the State Children’s Health Insurance Program (SCHIP – called Healthy Families in CA). In 2000 federal regulations were amended to exempt AIAN children from any SCHIP cost sharing. Since the California waiver implementation date there has been no significant change in the rate of AIAN enrollment. Methods: This study examined the policy and implementation barriers for AIAN children to obtain Healthy Families coverage. The principal research methods focused on: (a) a review of administrative data; (b) the development of eligibility estimates of the AIAN population; and (c) key informant interviews with AIAN-health serving institutions, health care providers (including urban, rural, and non-Indian clinics), the Healthy Families administrative unit (MRMIB), Department of Health Services (DHS), and health insurance plans. Results: About 2,200 Healthy Family recipients are currently identified as AIAN, and we estimate that over 7,000 additional uninsured AIAN children in California are Healthy Families eligible. AIAN applicants using certified assistors are more likely to be approved for enrollment than those not using assistors, but one third of tho se using assistors are denied coverage. This research identified many barriers to AIAN enrollment including: diverse and inconsistent understandings of the waiver and eligibility requirements; insufficient training regarding the waiver; insufficient program awareness/outreach; and the additional application burden with requirement of tribal enrollment documentation. There will be a positive change in AIAN enrollment with parental eligibility and practical steps are presented that can be taken to improve the process/system. Conclusion: The California Legislature and MRMIB have made a series of program modifications that are designed to improve the coverage rate and total enrollment of Healthy Families. The AIAN population is a group with special implementation legislation that does not appear to have been reached adequately by those efforts; this research will assist policy makers in improving the coverage of AIAN children and families.