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Circular 89-03


DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE
INDIAN HEALTH SERVICE

INDIAN HEALTH SERVICE CIRCULAR NO. 89-03


Effective Date:  April 21, 1989

Reimbursement Rates for Patient Care Provided at Indian Health Service Facilities

  1. PURPOSE.  The purpose of this circular is to establish Indian Health Service (IHS) policy on payment of hospital and clinic reimbursement rates for health care services provided by IHS personnel at IHS hospital, health center, and health clinic facilities.

  2. BACKGROUND.  The Snyder Act of November 2, 1921, (25 U.S.C. 13) provides authority for the IHS to expend monies for the conservation of the health of Indians.  The mission of the IHS provides a comprehensive health services delivery system for American Indians and Alaska Natives with opportunity for maximum tribal involvement in developing and managing programs to meet their health needs.  The goal of IHS is to raise the health level of the Indian and Alaska Native people to the highest possible level.  The IHS is further allowed to treat patients on an emergency and non-emergency basis who are within the scope of the IHS programs pursuant to regulation or statute [31 U.S.C. 1535]; [42 U.S.C. 249(b)]; [48 U.S.C. 49]; [42 CFR 32.111]; [42 CFR 36]; [80 Stat. 600]; [P.L. 100-713].

  3. POLICY.

    1. It is the policy of the Indian Health Service to charge patients who are not within the scope of the program for health services provided by IHS personnel at IHS facilities [42 CFR 32.111].

    2. It is the policy of the Indian Health Service to charge Medicare and Medicaid for services provided to beneficiaries of the IHS program who are enrolled in Medicare and Medicaid.  See Social Security Act Section 1911 [42 USC l396j], Section 1880 [42 USC 1395qq].

      Furthermore, it is the policy of the IHS to annually review all established revised or current rates and publish these in an IHS circular or the Federal Register (whichever mechanism is appropriate for the particular rate schedule) after the close of a fiscal year, if there are no statutory bars to increasing rates in any fiscal year.

  4. RATES

    1. The current Medicare and Medicaid reimbursement rates for inpatient, outpatient, and physician services provided at IHS facilities in Alaska and all other States appear in the Federal Register as follows:

      Alaska All Other States
      1.  Inpatient $421 $347
      2.  Outpatient 112 66
      3.  Physician 22 20

    2. The current rates for non-beneficiary inpatient and outpatient care provided at IHS facilities in Alaska and all other States are as follows:

      Hospitalization (Inpatient) Services

      Alaska All Other States
      1.  Inpatient Services $429 $397
      2.  Inpatient Physician/Consultation 22 20
      Outpatient Services

      Alaska All Other States
      1.  Outpatient (Ambulatory) Physician Services
      Brief
      Intermediate
      Comprehensive

      $35
      80
      140
      N/A
      NA
      NA
      2.  Laboratory Fees $1.15 per cap work unit N/A
      3.  Radiology Fees
      $50 per usable view
      (maximum of $250 per study)
      N/A
      Pharmacy Fees

      To be charged cost of drug plus $4.50 dispensing fee.
      N/A

    3. The current rates for emergency and non-emergency dental services provided to non-beneficiaries shall be the same as those established in the Veterans Administration fee schedule.

  5. DEFINITIONS.  The following definitions are taken from Physicians Current Procedural Terminology, Fourth Edition, published by the American Medical Association.

    Brief

    A level of service supervised by a physician but hot necessarily requiring his presence.  It includes evaluation and treatment of a condition requiring only an abbreviated history and examination, a review of the effectiveness of past medical management, the ordering and evaluation of appropriate diagnostic tests, the adjustment of therapeutic management, as indicated, and the discussion of findings and/or medical management.

    Intermediate

    A level of service pertaining to the evaluation of a new or existing condition complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis that necessitates the obtaining and evaluation of pertinent history and physical or mental status findings, diagnosis tests and procedures and the ordering of appropriate therapeutic management; or a formal patient, family, or hospital staff conference regarding patient medical management and progress.

    Comprehensive

    A level of service providing an indepth evaluation of a patient with a new or existing problem requiring the development of complete re-evaluation of medical data.  This procedure includes the recording of a chief complaint, and present illness, family history, past medical history, personal history, system review, a complete physical examination, and the ordering of appropriate diagnostic tests and procedures.

    Outpatient Ambulatory Physician Services

    These fees are to be charged the non-eligible patient when seen by an IHS physician in the ambulatory (outpatient) clinic of an IHS facility.  The fees do not include laboratory, radiology, and pharmacy charges.  The fee is to be based on the medical complexity of the case as determined by the physician.  See definitions of brief, intermediate, and comprehensive.

    Inpatient Physician Consultation

    This fee is to be charged non-eligible in-patients when they are seen in consultation by an IHS Physician upon request of the private physician who admitted the patient.

    CAP Unit

    The CAP units are those units that are defined in the latest edition of Laboratory Workload Recording Method published by the College of American Pathologists.

  6. RESPONSIBILITY.  The Associate Director, Office of Health Programs, Indian Health Service, will review and publish rates annually after the close of each fiscal year.

/Signature for/
Everett R. Rhoades, M.D.
Assistant Surgeon General
Director,
Indian Health Service


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