Frequently Asked Questions (FAQ's)QUESTION: Are Indian descendents eligible for CHS if they reside on a reservation?
Answer: Yes. See 42 C.F.R. 136.23 and 136.12
QUESTION: Why are Indian descendents not eligible for CHS off the reservation?
Answer: Indian descendents residing off the reservation may be eligible if they meet certain conditions. Pursuant to 42 C.F.R. 136.23 (a)(2)(i) and (ii), if not residing on the reservation such individuals must live within the CHSDA and (1) be members of the tribe(s) located on the associated reservation or (2) "maintain close economic and social ties with that tribe or tribes."
Also see 42 C.F.R.136.23(b) related to students and transients, and 42 C.F.R.136.23(d) for foster children placed off the reservation.
QUESTION: If 136.12 is mentioned in 136.23, does this mean Indians eligible for direct care are also automatically eligible for CHS?
Answer: No. In order to receive CHS, Indian beneficiaries must also meet the CHS eligibility requirements of 42 C.F.R. 136.23, 136.24 and 136.61.
QUESTION: Why do I have to apply for Alternate Resources?
Answer: This is required by 42 C.F.R. 136.61, Payor of last resort. Approval of CHS payment for services is considered after all other Alternate Resources (AR) are applied. Any patient who is potentially eligible is required to apply for the alternate resource.
QUESTION: If I am eligible for CHS, why are some of my medical bills being paid and others not?
Answer: Each visit to a non-IHS health care provider and the associated medical bill is distinct and must be examined individually to determine CHS eligibility. All CHS requirements must be met for each episode (treatment) of care. A patient must meet residency, notification, medical priority of care and use of alternate resources requirements of 42 CFR 136.23, 136.24 and 136.61 in order to be eligible for CHS. Example: If a CHS authorization is issued, IHS will pay the first medical treatment. Follow up care or additional medical care are to be done nearest accessible IHS or tribal facility; or will require approval with a new CHS authorization. If this process is not followed, the patient may be responsible for the expense.
QUESTION: An IHS doctor refers me to a specialist, why am I being held responsible for the bill?
Answer: Referrals are not a guarantee for payment. Referral is a recommendation for treatment/test only. The CHS program must review the referral to make the determination for IHS approval of payment. All CHS eligibility requirements must also be met. See 42 C.F.R. 136.23, 136.24 and 42 CFR 136.61.
QUESTION: If a hospital facility has a charity program, is this an alternate resource, and am I required to apply for this program?
Answer: This is examined on a case-by-case basis because charity programs vary in their coverage of care, funding for care, and requirements for eligibility. See 42 C.F.R. 136.61
QUESTION: Can tribal self-insurance be billed as an Alternate Resource (AR)?
Answer: Sometimes. Tribal self-insurance can be billed as an AR, unless the insurance plan contains an exclusionary clause designating it as residual to IHS. Per IHS policy, to be consistent with direct service authority under section 206(f) of the Indian HealthCare Improvement Act (IHCIA) P.L. 94-427.
QUESTION: Can a direct care patient be required to apply for an Alternate Resource?
Answer: No. Currently there is no requirement for patients to apply for an Alternate Resource when receiving direct care.
QUESTION: Can the 180-day rule be extended?
Answer: No. 42 C.F.R. 136.23(b)(1) and (c) clearly state the period is "not to exceed 180 days." A patient receiving CHS authorized services prior to the 180 day deadline is extended.
QUESTION: If a student/transient is covered under CHS, are the student/transient's dependents also covered?
Answer: Yes, dependents may be covered for CHS up to 180 days if they were eligible for CHS at their orginal (home) CHSDA. See 42 C.F.R. 136.23(c). Continued CHS eligibility is not a requirement after 180 days.
QUESTION: 42 C.F.R. 136.12 states "to persons of Indian descent belonging to the Indian community served by the local facilities and program.", and "an individual may be regarded as within the scope of the Indian health and medical service program if he/she is regarded as an Indian by the community in which he/she lives as evidenced by such factors as tribal membership, enrollment, residence on tax-exempt land, ownership of restricted property, active participation in tribal affairs, or other relevant factors in keeping with general Bureau of Indian Affairs practices in the jurisdiction.", why do we have to provide direct care services to Indians that do not belong to the community?
Answer: The IHS adheres to an "Open Door" policy in which all Indian descendants are provided direct health care. See Dear Tribal Leader Letter from Dr. Trujillo dated January 10, 2000.
QUESTION: Where in the regulation does it state we have to follow medical priorities?
Answer: See 42 C.F.R. 136.23(e), Priorities for contract health services.
QUESTION: Children in foster care are eligible for CHS, but are they provided health care for all medical priorities, or only what the program is operating at?
Answer: Foster children are eligible on the same basis as other eligible Indians, including meeting the same standards for medical priority. See section 813(a)(1) of IHCIA.
QUESTION: Can non-Indians be eligible for CHS?
Answer: Yes, but only for three classes of non-Indians. These include (1) non-Indian women pregnant with an eligible Indian's child during pregnancy through postpartum (42 C.F.R. 136.12(a)); (2) non-Indians under 19 who are the natural, adopted, step-child, foster-child, legal ward, or orphan of an eligible Indian, section 813(a)(1) of IHCIA); and (3) non-Indian spouses of eligible Indians if all such spouses are made eligible through a tribal resolution, section 813(a)(2) of IHCIA).
QUESTION: What does Social, Economic Ties mean, 42 C.F.R. 136.23(a)(2)(ii)?
Answer: Close social and economic ties are determined by the governing body, or designee, of the local Tribe. The IHS considers employees of the Tribe and spouses and children of eligible members of the Tribe to have close social and economic ties. The determination of eligibility applies if all individuals with the same circumstances are made eligible through a tribal resolution.
QUESTION: Can CHS/Direct Care eligibility be suspended due to abuse of regulations or other abuse (physical, fraud, etc)?
Answer: No. Eligibility through IHS is a right and there is no provision for suspension of this right in the statutes or regulations. However, someone could be barred from a facility for dangerous behavior.
QUESTION: If my CHS Program is operating on a strict budget, can CHS eligibility be suspended for non-Indians residing on and off the reservation?
Answer: Yes and no. No, for non-Indian children of eligible Indians made eligible under section 813(a)(1) of the IHCIA and non-Indian women pregnant with an eligible Indians child made eligible under 42 C.F.R. 136.12(a). Yes, for non-Indian spouses made eligible under section 813(a)(2) of the IHCIA if the Tribe revokes the resolution which granted such individuals eligibility. No other non-Indians should be receiving CHS services.
QUESTION: Can a CHS Program establish a cap on certain procedures, such as dental procedures, eyeglasses, etc.?
Answer: No. If a health service is within medical priorities CHS must pay for the full amount of the service. See section 222 of IHCIA.
QUESTION: Can a tribe decrease or increase their CHSDA?
Answer: Yes, but they must follow certain procedures (see 42 CFR 136.22(b)). Funding may not increase if the CHSDA expands, however it may decrease if the CHSDA is reduced.
QUESTION: Is the Crime Victims Act a viable AR?
Answer: No. The Crime Victims Act is not considered an AR under 42 C.F.R. 136.61(c).
QUESTION: If we are guaranteed health care from our treaties for as long the water flows and the grass grows, why are Indians required to apply for AR?
Answer: It is required under 42 C.F.R. 136.61, Payor of last resort. While some treaties mention health care, the Indian Health Service is not an entitlement program, and therefore funding for CHS is not guaranteed by the Federal government. AR allow CHS funds to be conserved, thereby providing health care for more Indian beneficiaries.
QUESTION: If I am residing in an area where there is a federally recognized tribe, but no reservation, can Social, Economic Ties be automatic to that tribe or do I have to apply/petition?
Answer: No. Social and economic ties are not automatic. The individual has to apply to the Tribe.
QUESTION: If I move from one federally recognized reservation to another federally recognized reservation, does the 180-day rule apply?
Answer: See 42 C.F.R. 136.23(a)(1) and (2). The 180-day rule applies until the client establishes residency and becomes eligible in another CHSDA.
QUESTION: How does a CHS Program determine if a client has established residency? Does the program rely on program policy or tribal policy when it comes to determining residency on a reservation?
Answer: Residency it determined by both the physical presence of an individual in a location combined with the intent of the individual to remain there permanently.
QUESTION: What is the citation that requires our CHS Program to provide CHS to non-Indian children?
Answer: See section 813(a)(1) of the IHCIA. CHS applies to non-Indian children if they are the natural, adopted, step-child, foster-child, legal ward, or orphan of an eligible Indian.
QUESTION: Are we required to provide CHS to Commissioned Corps personnel and their families?
Answer: No. Commissioned Corps and their families are not eligible for CHS, unless they otherwise meet the eligibility requirements under 42 C.F.R. 136.23.
QUESTION: Can a CEO or Tribal Health Director determine Social, Economic Ties, or is this strictly a Tribal function?
Answer: This is a tribal function. However, this determination can be delegated by the relevant Tribe(s) to the CEO or Tribal Health Director.