This page contains information regarding program functions and funding; it is intended for use primarily by CHS program staff.The CHS program responsibility is to administer and manage the contracting of health care services with non-IHS providers for services of Indian people residing on or near reservations. The CHS funds are used to supplement and complement other health care resources available to eligible Indian people. This responsibility is accomplished through the staff located at the IHS Headquarters in Rockville, Maryland; at each of the twelve Area Offices located across the nation; at IHS and Tribal facilities are CHS program staff. The program directory on this website provides the twelve Areas and the contact numbers for each of these CHS program locations.
The CHS funds are utilized in situations where: (1) no IHS direct care facility exists, (2) the direct care element is incapable of providing required emergency and/or specialty care, (3) the direct care element has an overflow of medical care workload, and (4) supplementation of alternate resources (i.e., Medicare, private insurance) is required to provide comprehensive care to eligible Indian people.
The program accomplishes the responsibilities or functions with dedicated CHS program staff. The staff or Full time Equivalent (FTE) provide comprehensive administrative management functions using a Headquarters criteria and the staffing module to estimate the requirements to perform the functions. The standards from the IHS Resource.
Requirements Methodology (RRM) identifies the workload and related functions:
- Patient eligibility for contract health care.
- Processing procurement orders for requested contract health services.
- Assistance to patients with alternate resources compliance.
- Correspondence related to CHS authorizations for payment or non-payment.
- Tracking allocation of CHS funds to assure the program stays within budget
- Coordination of activities associated with contract health care.
The key variable is number of CHS authorizations for health care for eligible individuals. Program functions for Area and Service Units are located in the IHS Manual, Part 2, Chapter 3. "Contract Health Services"
The minimum fixed staffing criteria:Area:
- CHS Director at fixed minimum
- Secretary at fixed minimum
- 1.0 FTE for each $5 Million budgeted for CHS care (Non-tribal funds)
- .25 FTE for each $15 Million in Tribal contract/agreements.
- CHS Manager; 1.0 FTE for each facility that processes 100 or more CHS authorizations for health care services.
- Utilization Review staff; 1.0 FTE for every 10,000 CHS authorizations for health care services.
- CHS staff: 1.0 FTE for every 2,000 CHS authorizations for health care services. At facilities that have over 100 CHS authorizations a year.
The CHS program developed and established prototype position descriptions for CHS staff. The prototypes descriptions received Headquarters personnel office approval in 1996. As prototypes for the area and service unit positions, the areas will be responsible for completing the classification of the position descriptions for their individual area. The CHS prototypes have been developed for the following positions:
OPERATING UNIT (SERVICE UNIT)MEDICAL CLERK (O/A), GS-679 POSITIONS
Medical Clerk (O/A) GS-679-04 [DOC-64KB]
Medical Clerk (O/A) GS-679-05 [DOC-82KB]
Medical Clerk (O/A)/Medical Assistant GS-679-06 [DOC-58KB]
HEALTH SYSTEM SPECIALIST POSITIONS
Health System Specialist GS-671-05-SU [DOC-72KB]
Health System Specialist GS-671-07-SU [DOC-68KB]
Health System Specialist GS-671-09-SU [DOC-68KB]
Health System Specialist GS-671-11-SU [DOC-72KB]
AREA OFFICEHealth System Specialist GS-671-11-Area [DOC-67KB]
Health System Specialist GS-671-12-Area [DOC-58KB]
Supv. Health System Specialist GS-671-13-Area [DOC-56KB]
Managed Care Consultant GS-671-13-Area [DOC-101KB]
The program's role is to provide effective management of the CHS program. Tools for accomplishing the administration and management of purchasing of health care services are: the guidance material's, the CHS manual, procedures, policies, regulations that have developed from the legislation for the health care of Indian people. The CHS funds for purchasing health care services come from Congressional appropriations determined from the Presidents yearly budget. The appropriation funding may vary year to year; with each year the program providing the data on CHS services provided and the expenditure of the CHS funds for that care. Related program changes are shared through print, meetings, & trainings with staff.
The program operates the CHS program within the limits of available funds, with the authority for the operation of the CHS Program to Area Directors and the Service Unit Directors, (SUD). To clarify and explain CHS policies and procedures for Public Law (P.L.) 93-638, the Indian Self-Determination and Education Assistance Act, contractors, when applicable. To further explain the Code of Federal Regulations (CFR) at Title 42, Sections 136.21 through 136.25. However, the manual should not be cited as authority for making decisions on eligibility or payment denials. The CFR is the proper citation for correspondence to providers and American Indian and Alaska Native patients.
Additional program tools used in administering and managing the program are the Catastrophic Health Emergency Funds (CHEF), fiscal intermediary (FI), management information system (MIS), quality assurance, and the new Medicare like rate payment. The CHEF is funded from a separate Congressional funding that is administered at programs headquarters based on legislation on to provide a funding for patients high cost cases. The CHS program's CHEF funding normally depletes before the end of the fiscal year. The Fiscal Intermediary (FI) is a contracted function for the payment of the authorized CHS services purchased. The FI processes the CHS authorized purchase orders from the claims submitted by the non-IHS providers; pays the reviewed approved claims; and provides data reports. The CHS MIS is data system module of the IHS information system for enter patient CHS services. The quality assurance is non-recurring funding to support initiatives and projects for quality patient care related to services and funding accountability from contract providers. The new Medicare like rate legislation provides for IHS & Tribal programs to pay for in-patient services at the Medicare like rate to non-IHS providers.
The Program Staff section will continue to be developed for program related information.