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Indian Health Service The Federal Health Program for American Indians and Alaska Natives


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Part 2 - Services To Indians And Others

Chapter 4 - Other Beneficiaries

Title Section
General 2-4.1
Basis for Services 2-4.2
    Commissioned Officers of the PHS 2-4.2A
    Dependents of Commissioned Officers of the PHS 2-4.2B
    Office of Federal Employees' Compensation Beneficiaries 2-4.2C
    Applicants for Federal Employment with the U.S. PHS 2-4.2D
    Non-Natives in Alaska 2-4.2E
    Beneficiaries of the Federal Veterans Administration 2-4.2F
    Members of the Uniformed Services 2-4.2G
    Beneficiaries of the Health Program Service 2-4.2H
    Jobs Corps Enrollees and VISTA Volunteers 2-4.2I
    Emergency Cases 2-4.2J
Types of Services 2-4.3
    Commissioned Officers of the PHS 2-4.3A
    Dependents of Commissioned Officers of the PHS on Duty at Indian Health
    Facilities
2-4.3B
    Office of Federal Employees' Compensation Beneficiaries 2-4.3C
    Applicants for Federal Employment in the U.S. PHS 2-4.3D
    Beneficiaries of the Veterans Administration 2-4.3E
    Members of the Uniformed Services 2-4.3F
    Beneficiaries of the Federal Health Programs Services 2-4.3G
    Job Corps Enrollees and Vista Volunteers 2-4.3H
    Emergency Cases 2-4.3I
    Non-Emergency - Non-Beneficiary in Alaska 2-4.3J
    Dental Laboratory Bills for PHS Commissioned Officers Serving with the IHS 2-4.3K
Schedule of Fees 2-4.4
    Commissioned Officers of the PHS 2-4.4A
    Office of Federal Employees' Compensation Beneficiaries 2-4.4B
    Applicants for Federal Employment with the U.S. PHS 2-4.4C
    Beneficiaries of the Veterans Administration, Federal Health Programs
    Service, and Members of the Uniformed Services
2-4.4D
      Other than Alaska 2-4.4D(1)
      Alaska 2-4.4D(2)
    Non-Beneficiary - Emergency Cases 2-4.4E
    Non-Beneficiary - Non Emergency Cases In Alaska 2-4.4F
Payment, Collection, and Disposition of Fees for Services 2-4.5
    Commissioned Officers of the PHS 2-4.5A
    Dependents of Commissioned Officers of the PHS 2-4.5B
    Beneficiaries of the Veterans Administration, Federal Health Programs Service,
    and Members of the Uniformed Services
2-4.5C
    Non-Beneficiary - Emergency Cases 2-4.5D
    Non-Beneficiary - Non Emergency Cases (Alaska only) 2-4.5E
    Job Corps Enrollees and VISTA Volunteers 2-4.5F
Special Study Patients 2-4.6
    Citation from PHS Act 2-4.6A
    Authority 2-4.6B
    Definitions 2-4.6C
      Teaching/Training 2-4.6C(1)
      Research 2-4.6C(2)
    Special Instructions 2-4.6D
    Research 2-4.6E
      National Institutes of Health Support 2-4.6E(1)
      Other Support 2-4.6E(2)
    Reports 2-4.6F
Care at Remote Facilities 2-4.7
    Designation 2-4.7A
    Availability of Services 2-4.7B
      Application for Treatment or Care 2-4.7B(1)
      Limitations and Priorities 2-4.7B(2)
      Denial of Treatment or Care 2-4.7B(3)
    Federal Employee Defined 2-4.7C
    Penalties 2-4.7D
    Charges for Treatment 2-4.7E
Provision of Direct Care Health Services to Ineligible Individuals Under Section (813(b)(1)(A) of the Indian Health Care Improvement Act 2-4.8
    Purpose 2-4.8A
    Background 2-4.8B
    Authority 2-4.8C
    Policy 2-4.8D
    Procedures 2-4.8E
      Request by Tribe(s) to Serve Ineligible Individuals 2-4.8E(1)
      Joint Determination 2-4.8E(2)
      Case-by-Case Determination 2-4.8E(3)
      Necessary Determination Under Section 813 2-4.8E(4)
    Factors for Making Determination 2-4.8F
      Reasonable Alternative Health Facility or Services 2-4.8F(1)
      Existing Alternative Health Facilities or Services 2-4.8F(2)
      Other Factors 2-4.8F(3)
      Health Care Facilities (e.g., Hospitals, Clinics, etc.) and Providers (e.g.,
      Physicians, Surgeons, Dentists, Optometrists, Pharmacists, etc.) Located Within 30
      Miles of the IHS Operated Health Facility
2-4.8F(4)
    Range of Services Available from These Health Care Facilities and Providers 2-4.8F(5)
  Services to Eligible Indian Beneficiaries are Neither Denied nor Diminished 2-4.8G
  Tribally-initiated Termination 2-4.8H
    Single Tribe Service Area 2-4.8H(1)
    Multi-Tribe Service Area 2-4.8H(2)
  Termination Procedures 2-4.8I
  Liability for Payment 2-4.8J

Manual Appendix Description
Appendix A Application for Treatment at Remote PHS Facility
Appendix B Definition of Employee (5 U.S.C. § 2105)
Appendix C Table of Available Services
Appendix D OFEC District Offices
Appendix E Statutes That Allow Health Services to be Provided to Ineligible Individuals at IHS Facilities
Appendix F Indian Health Care Improvement Act, Public Law 94-437, as Amended, Section 813
Appendix G IHS/Tribal Section 813(b)(1)(A) Joint Determination Worksheet

2-4.1  GENERAL

  1. This Chapter sets forth the policy and procedures for medical and dental services and payments for such services provided to non-Indian beneficiaries of the Federal Government and non-beneficiaries of facilities operated by the Indian Health Service.
  2. For purposes of this Chapter, the following definitions apply:

    1. "Indian Health Facilities" means Indian and Alaska Native hospitals, health centers and stations, and Indian school health centers.
    2. "Voucherable expenditures” means those items or appliances not normally stocked or made at the facility which are purchased from the outside, and specialist services obtained from outside.
  3. Non-Indian patients may be extended health care at the Talihina Hospital in Talihina, Oklahoma, and the Zuni-Ramah Indian Health Service Unit in Zuni, New Mexico, if such care can be extended without impairing the ability of the Indian Health Service to fulfill its responsibility to provide health care to Indians served by such facilities and subject to such reasonable charges as the Secretary of Health and Human Services shall prescribe, the proceeds of which shall be deposited in the fund established by sections 401 and 402 of the Indian Health Care Improvement Act.

2-4.2  BASIS FOR SERVICES.  In general, and within the provisions specified below, services to the following non-Indian beneficiaries may be provided in Indian Health facilities when the Service Unit Director determines that suitable facilities are available and that services will not interfere with services to Indians.
  1. Commissioned Officers of the Public Health Service, regular or reserve, who are on duty at Indian Health facilities.

    1. When a Public Health Service (PHS) Commissioned Officer is an inpatient in an Indian Health facility, care may be provided as is deemed necessary in the judgment of the attending physician and approved by the Service Unit Director.  However, any and all voucherable expenditures must have prior authorization by the Director of the Division of Beneficiary Medical Programs (DBMP) as covered in 2-4.2A(3).  The DBMP is in the Bureau of Health Care Delivery and Assistance, HRSA, PHS, and is located at 5600 Fishers Lane, Rockville, Maryland 20857.  Bills for authorized expenditures may be sent to DBMP with an explanatory memorandum for reimbursement.
    2. The closure of PHS hospitals and clinics has necessitated the establishment of a centralized patient care coordinating program to provide medical services to active duty officers having continued entitlement to medical care from PHS.  This program will provide the following services:

      1. Primary medical and dental services and required pharmaceuticals will be provided through contracts with physicians, dentists, and community pharmacies.
      2. Secondary and specialized tertiary care services through contracts with a network of hospitals.  These hospitals will serve as regional referral centers and will accept patients authorized by PHS requiring such services.
      3. Authorizations for necessary medical care services for eligible PHS beneficiaries in areas where PHS contract resources or Department of Defense medical facilities are not available.
      4. Retirees and dependents are not covered by this program.
    3. A toll-free telephone service is available for use by commissioned officers.  Officers may use this service to obtain:  (a) advice concerning referrals to the contract patient care providers, (b) general information concerning the contract program, and (c) medical/dental services authorizations.  This service may be accessed from most sites by dialing:
      l-800-368-2777

      In Maryland call collect:  (301)443-1943

      The toll-free service is presently available in the continental United States only.  Officers stationed in Alaska, Hawaii, and Puerto Rico may call on (301) 443-1943 collect or FTS, if available.

      The toll-free telephone number will be staffed from 8:30 a.m. to 5:00 p.m., Monday through Friday, eastern time.  During other hours, the officer will be asked to leave his/her name and telephone number.  These calls will be returned during the following working day.
    4. Selection of Contract Providers.  Provider contracts have been negotiated in accordance with the Department of Health and Human Services’ regulations.  Officers will be advised on a timely basis of the names and locations of providers as these contracts are finalized or updated.
    5. Use of Contract Providers.  Officers are expected to use contract providers within the areas in which they are stationed.  Care may be obtained from contract physicians and dentists upon presentation by the officer of his/her green (active-duty) identification card.

      In the event that non-emergency hospitalization may be required on a local level in the course of being treated by a contract physician, prior approval of the hospitalization (using the toll-free telephone service) must be obtained by the physician as part of his/her contractual obligations.  Depending on the nature of the medical problem and the location of the officer, PHS may require that the officer be hospitalized at a military facility or at a PHS regional referral hospital.  Officers should ensure that approval is obtained prior to any hospital admission by a contract physician.  Without such approval, the officer may be required to assume the financial burden for the hospitalization.  Additionally, inpatient care will be monitored by PHS to ensure that transfers to military or PHS contract hospitals, when indicated, are carried out on a timely basis.

      Dental care to be provided by contract dentists involving expenses in excess of $500 requires the prior approval of a dental treatment plan.  As in the case of hospitalizations, this type of prior approval is a contractual obligation of the dentist.  However, the officer should ensure that such approval is secured prior to the treatment.

      Outpatient care obtained from contract dentists involving charges of less than $500 and care from contract physicians do not require approval.  PHS will reimburse these contract providers directly for services rendered.  Similarly, drugs may be obtained from contract pharmacies in connection with these services.  Provider bills will be paid directly by PHS.

      NOTE:  Any non-emergency care provided by non-contract physicians or dentists requires prior approval by DBMP.

      Use of PHS contract hospitals is generally limited to the provision of tertiary care services rendered on a referral basis by PHS.  Additionally, PHS will utilize these facilities if specialized diagnostic services are required for determining an officer’s fitness for duty.
    6. Use of Non-Contract Providers.  Non-contract providers may be used in areas where PHS contract providers may not be available, and where military facilities are not available.  In unusual instances, non-contract providers may be used in areas served by contract providers or military facilities, subject to the prior authorization process described below.  Normally, this type of care would not be authorized, except in extenuating circumstances.
    7. Use of non-contract care physicians and dentists requires prior authorization from DBMP in all instances involving non-emergency care.  The officer must obtain prior approval or arrange for the provider to obtain prior approval through the use of the toll-free telephone service.  When requesting prior approval, the officer must provide the name and address of the provider, his/her tax I.D. No., and the anticipated charge for services.  This information will be used to prepare a purchase order for the payment of the provider or pharmacy.

    8. Emergencies.  In the case of true emergencies, the officer should seek care at the nearest available health care facility or provider.  The officer or his/her designee must contact PHS through the use of the toll-free telephone service or have the facility do so as soon as possible after emergency treatment is rendered.  All inpatient emergency admissions should be reported not later than 72 hours after admission.  The telephone service may also be used by the facility or provider to confirm the officer’s eligibility.
    9. Use of Government Facilities.  Officers are expected to use Government facilities if situated within a 40-mile radius of their duty station and if a PHS contract provider is not located within a duty station city.  Exceptions may be granted if adequate justification is presented to the Medical Advisor, DBMP.
    10. Physical Examinations.  Commissioned Officers who require physical examinations will be examined in accordance with procedures in Commissioned Corps Personnel Manual Chapter 29, Subchapter 29.3, Instruction 5.  A list of Indian Health Area Offices and other locations where arrangements can be made for the required physical examinations is attached.
    11. Again, it is stressed that active duty personnel are not eligible for CHAMPUS.  All CHAMPUS bills received will be returned to the officer for payment.
  2. Dependants of Active Duty Commissioned Officers of the Public Health Service who are stationed at an Indian Health facility are eligible for care on a space available basis at that facility provided conditions prescribed in Section 2-4.2 are met.  Dependents' Charges will be $6.30 per day.  No charge will be made for new born infants or for outpatient care.

    Services for dependents at other facilities, government or private, are covered by the various CHAMPUS regulations and policies
    NOTE:  In Alaska 48 U.S.C. 49 authorized the admission of patients other then Eskimos, Indians, Aleuts and Natives to Indian Health Service facilities.  This would authorize the admission and treatment of dependents not stationed at Indian Health facilities under the Dependents' Medical Care Act.  For charges see Section 2-4.3B.

    1. Family planning services and supplies, including counseling and guidance, shall be provided in accordance with sound medical practice, and subject to availability of space and facilities and the capabilities of the medical staff, to any eligible dependent upon his/her request.
    2. Except in emergencies or during a period of absence from the area of the sponsor's household on a trip, dependents of active duty personnel who reside with their sponsors require a Nonavailability Statement, DD Form 1251, from a Uniformed Services facility prior to applying for hospitalization in a civilian facility in the United States and Puerto Rico.  Regulations require these dependents to use Uniformed Services hospitals when available and when the care required can be provided in these facilities.
    3. Dependents of active duty personnel who are residing with their sponsor but are located more than 30 miles from a Uniformed Services hospital or living in Iowa, Minnesota, Oregon, Vermont, West Virginia or Wisconsin, do not need to obtain a Nonavailability Statement before receiving inpatient civilian care.
  3. Office of Federal Employees' Compensation Beneficiaries includes:
    1. Any Federal employee injured while on duty or any Federal employee with an illness resulting from his Federal employment.
    2. Any Federal employee claiming disability or illness as a result of his employment.  The latter will be examined to determine the validity of the claim.  Employees who are determined to be eligible for Federal Employees' Compensation (formerly B.E.C.) will continue to be treated in accordance with the Federal Employees' Compensation Regulations.  Employees whose claims are not approved by FEC will be referred to private facilities as soon as their condition permits, unless the employee is also eligible as an Indian.  In that case his classification will be changed to show him as an Indian beneficiary, retroactive to the date of admission.

  4. Applicants for Federal Employment with the U.S. Public Health Service.
  5. Non-Natives in Alaska.  In Alaska there is statutory authority (48 U.S.C. 49) for the admission of persons other than Eskimos, Aleuts, and Indians to Indian Health Service facilities provided conditions prescribed in Section 2-4.2 are met.  Limited outpatient or short-term hospitalization may be provided.  This excludes major elective surgery and extensive diagnostic studies.
  6. Beneficiaries of the Veterans Administration when a Veterans Administration facility is not in the area and only with the prearranged approval of both the Indian Health Service and the Veterans Administration.
  7. Members of the Uniformed Services (Army, Navy, Air Force, Marine Corps) will be treated on an emergency basis only.
  8. Beneficiaries of the Federal Health Programs Service.  When a facility of that service is not in the area and only with the prearranged approval of both the Indian Health Service and the Federal Health Programs Service.
  9. Job Corps Enrollees and VISTA Volunteers (Office of Economic Opportunities}.  Medical services may be provided in accordance with agreement reached with Job Corps and VISTA (Volunteers in Service to America) officials of the Office of Economic Opportunity.
  10. Emergency Cases.  As an act of humanity in an emergency, and in accordance with PHS Regulations 32.111, non-beneficiaries may be provided services.  The Service Unit Director is responsible for determining whether an emergency exists.  Emergency treatment or care shall be documented on Form HSM-36 (formerly PHS-2093) Referral for Determination of Medical Emergency and Authorization for Admission of Non-beneficiaries in Emergencies.

    Patients admitted for emergency treatment shall be investigated immediately to ascertain the possibility of their eligibility as a beneficiary.

    Every effort shall be made, as soon as the medical condition of a patient admitted as a non-beneficiary emergency case permits, to discharge, transfer, or otherwise remove him to private or other appropriate facilities.

    If the patient's condition is considered non-emergent and no treatment is given, the physician must record sufficient data to support his decision on Form HSM-36.

2-4.3  TYPES OF SERVICES.  Within the limitations prescribed in Section 2-4.2 above, the following may be provided services as indicated:

  1. Commissioned Officers of the Public Health Service on Duty at Indian Health Facilities may be provided hospital care, outpatient medical and dental care, including annual and termination physical examinations.  The Service Unit Director may authorize voucherable expenditures which, in his judgment, are both necessary and reasonable for adequate care and treatment while the Commissioned Officer is under his general care.  Consultants or special services, or dental treatment which are not available through the local Indian Health facilities must be authorized in advance by the Director of the nearest Federal Health Programs Service installation.
    1. Whenever a PHS Commissioned Officer is hospitalized for any purpose, emergency or otherwise, the individual in charge of the facility will send telegrams to the Office of Personnel and the Director, Indian Health Service containing the following information:

      1. Name and address of the Indian Health Service facility.
      2. Name, Rank, and Serial Number of the Officer hospitalized.
      3. Permanent Duty Station of the Officer.
      4. Reason for hospitalizing the Officer.
      5. That Form HSM-33 (formerly PHS-1731) "Medical Report of Duty Status" follows.

  2. Dependents of Commissioned Officers of the Public Health Service on Duty at Indian Health Service Facilities and who, in fact are living with such officers may be provided inpatient and outpatient care at Indian Health Service facilities as authorized in the Uniformed Services Health Benefits Program provided conditions prescribed in 2-4.2 are met.  The Service Unit Director may authorize voucherable expenditures which in his judgment are both necessary and reasonable for adequate care and treatment while the dependent is under his general care.

    Dental Treatment is limited to that which is necessary for allaying pain and for treatment of acute oral pathological conditions.

    1. Health Services Authorized Dependents.  Subject to the availability of space, facilities and capabilities of the professional staff, health benefits authorized includes the following:

      1. Inpatient care, including services and supplies normally furnished by the hospital.
      2. Outpatient care and services.
      3. Drugs.
      4. Medical and surgical conditions.
      5. Nervous, mental and emotional disorders.
      6. Chronic conditions and diseases.
      7. Contagious diseases.
      8. Physical examinations, including eye examinations and hearing evaluation, and all other tests and procedures necessary for a complete physical examination.
      9. Immunizations.
      10. Maternity (obstetrical) and infant care, routine care and examination of the new born infant and well-baby care.
      11. Diagnostic tests and services, including laboratory and X-ray examinations.
      12. Family planning services and supplies including counseling and guidance upon request.
        NOTE:  For additional information consult the Officer's Handbook for Commissioned Officers, CCPM Pamphlet 10-J and PHS General Circular No. 6, on Medical Services Uniformed Services Health Benefits, September 15, 1970.
  3. Federal Employees' Compensation Beneficiaries (formerly B.E.C.) will be given necessary immediate care provided conditions prescribed in 2-4.2 are met.

    Elective surgery, extensive diagnostic studies, and long-term care must be authorized by the Office of Federal Employees' Compensation.  Except for minor orthopedic or prostetic appliances costing less than $50, prior authorization to procure services or supplies not available at Indian Health facilities must be obtained from the appropriate district office of the Office of Federal Employees' Compensation (OFEC).  (See Appendix D for list of district offices).  Items requiring prior authorization are consultants' fees, major prosthetic and orthopedic appliances, ambulance hire, X-ray services, etc.  Prior authorization is not required for the repair, adjustment or minor alterations to major appliances which have previously been authorized or purchased.  Replacement of such items, however, must have prior approval from the Office of Federal Employees' Compensation.
  4. Applicants for Federal Employment in the U.S. Public Health Service will be provided such examinations, tests, X-rays, etc., as are necessary to determine fitness for the position.
  5. Beneficiaries of the Veterans Administration may be provided such care as is authorized and approved by both the Indian Health Service and the Veterans Administration.
  6. Members of the Uniformed Services may be provided indicated medical care, on an EMERGENCY basis, within the limitations of available local staff or facility.
  7. Beneficiaries of the Federal Health Programs Service may be provided such care as is authorized and approved by both the Indian Health Service and the Federal Health Programs Service.
  8. Job Corps Enrollees and VISTA Volunteers (Office of Economic Opportunity).

    1. Physical Examinations:  The Indian Health Service will provide physical examinations for all Indian applicants who have a beneficiary status.  To the extent possible, examinations will be performed in our facilities and will be on a non-reimbursable basis.  Once the Indian applicant has been accepted by the Job Corps or VISTA, he will be placed in a low priority similar to an Indian in the Armed Forces, and will not be entitled to Indian Health services simply by virtue of being an Indian or Alaska Native.

      Non Indian applicants to the Job Corps or VISTA shall be provided examination as provided for under agreement with the Office of Economic Opportunity and shall be charged at the established interagency reimbursable rate.
    2. Inpatient and outpatient treatment of Job Corpsmen and VISTA personnel:  To the extent compatible with maintaining the primary mission of the Indian Health Service the Service will provide, on a reimbursable basis, routine inpatient and outpatient health services to Job Corpsmen and VISTA personnel where Indian Health facilities and personnel are within reasonable proximity to the Job Corps Conservation Centers.

      In these instances, services will be limited to the extent of existing capability, as determined by the local Officer in Charge of the Indian Health Service facility.

      Emergency health services will be provided at Indian Health facilities without regard to the availability of other resources when necessary.

      Dental care will be available only on an emergency basis.
  9. Emergency Cases will be provided such medical and dental care as is necessary and available to alleviate the immediate condition and prepare the patient for transportation to another facility.
  10. Non-Emergency - Non-Beneficiary in Alaska.  In Alaska, there is authority to admit non-beneficiaries to treatment under the provisions of 48 U.S.C. 49 which provides that patients who are not indigent may be admitted to the hospitals erected for medical and sanitary relief of the Eskimos, Aleuts, Indians and other Natives of Alaska for care and treatment on a fee basis.
  11. Dental Laboratory Bills for PHS Commissioned Officers Serving with the Indian Health Service.

    1. Public Health Service active duty Commissioned Officers serving with the Indian Health Service are eligible to receive dental treatment at facilities of the Indian Health Service at nominal reimbursement ($1.00 per outpatient visit) by the Federal Health Programs Service.
    2. Dental laboratory bills for these officers, when treated at an Indian Health facility, will be funded by Headquarters (Federal Health Programs Service}, subject to prior approval and provided that funds are available.
    3. Headquarters Federal Health Programs Service will consider each request on an individual case basis.
    4. Such requests should be forwarded from the Service Unit Director of the involved Indian Health facility to the Director, Federal Health Programs Service, through appropriate channels, for Headquarters' approval.  The memorandum should include the name, grade, and PHS serial number of the patient, a brief outline of the treatment plan, and an itemized statement of the laboratory cost.  Following approval of the expenditure by Headquarters (FHPS) and completion of the case, the bill should be forwarded for payment to the Director, Federal Health Programs Service, Attention:  Chief, Financial Management Branch.

      For emphasis, it is restated that services may not be contracted at private dental laboratories without prior authorization by the responsible official of the Federal Health Programs Service.

2-4.4  SCHEDULE OF FEES.  Individuals receiving treatment in Indian Health Service facilities within the limitations prescribed in Section 2-4.3 above will be charged in accordance with the following schedule of fees.
  1. Commissioned Officers of the Public Health Service will be required to pay $1 per day for each day of hospitalization, which is a return of their subsistence allowance.  Also, the Federal Health Programs Service will be requested to reimburse the Indian Health Service for hospitalization or outpatient medical or dental care of Commissioned Officers as follows:
    $1.75 per day for hospitalization

    $1.00 per visit for outpatient treatment
  2. Federal Employees' Compensation (OFEC) Beneficiaries.

    1. No charge will be made to the F.E.C. patient for medical care or supplies provided him at the local Indian Health facilities, however, a SF-1081 should be sent to the Office of Employees' Compensation for reimbursement for the care provided him.  An SF-1081 will be prepared for Indian beneficiaries who are eligible as beneficiaries of Federal Employees' Compensation.  The charge for medical, hospital, and related services not available at Indian Health Service facilities must be obtained from the appropriate district office of the Office of Federal Employees' Compensation (OFEC).  (See Appendix D for list of district offices.)

      The charge for medical, hospital and related services not available at the local facility and furnished to F.E.C. patients shall be submitted by the establishment; consultants or vendors on their own letter head stationary directly to the appropriate district office of the Federal Employees' Compensation.

      In submitting bills for services rendered, the following apply:

      1. Bills must be submitted in duplicate, a separate one being predated for each patient identifying him or her by name.
      2. A statement must be made on each bill to the effect that the services or supplies were furnished under the supervision of, and on the order of the U.S. Public Health Service.
      3. Dates of treatment, description of services or supplies, and amount charged for each must be itemized on the bill.  If a contract is involved the contract number should be stated on the bill.
      4. Charges for X-ray must indicate the number of views taken and the parts of the body X-rayed.
      5. Hospitalization charges for care in contract or other non-Service hospitals must state the rate charged a day or week and the number of days hospitalized.  Bills should be submitted upon discharge of the patient from the hospital unless hospitalization extends beyond 30 days in which case bills may be submitted at the end of each 30 days.  If private room accommodations are furnished, the attending physicians must certify to the necessity therefor.
      6. Bills covering services of private-duty nurses, consultants, medications, prosthetic, orthopedic, and other appliances, physiotherapy, etc., must be approved by the physician in charge of the case.  Major appliances costing more than $50 such as artificial limbs, etc., must be specifically authorized by the Office of Federal Employees' Compensation.
      7. If a contract or other non-Service physician or hospital has paid a corporation or firm for individual services or supplies furnished a Federal Employees' Compensation patient, the amount paid may be included in the bill of the physician or hospital but must be supported by a receipted itemized statement in duplicate.
    2. Those Indians enrolled in vocational training programs (25 U.S.C. 309 and 309a) administered by the Bureau of Indian Affairs and assigned to a Federal Agency where their services will:

      1. Further the program of the Federal Agency; and
      2. Be of a type appropriate for a Federal employee of the agency; and
      3. Be performed under the technical direction and supervision of an employee of the Federal Agency;

      Are employees of the United States within the meaning of 5 U.S.C. 8101(1).  As such they are eligible for F.E.C. care when injured while on duty or with an illness resulting from their Federal employment.

      Such employees should be carried in the records as F.E.C. cases and the Office of Federal Employees' Compensation has agreed to reimburse the Indian Health Service for such care at the Federal Reimbursement Rate in effect at the time the services are rendered, although they may be otherwise eligible as Indians.  SF-1081 should be sent to the appropriate district office of the Office of Federal Employees' Compensation for reimbursement.

      Services outside the Indian Health facility should be billed as other F.E.C. bills are rendered.  See 2-4.3C and 2-4.4B(1) of this manual.

    3. Report of Services Provided.  For each patient, a copy of Form SF-502, Narrative Summary, must be completed and submitted to the Office of Federal Employees' Compensation, U.S. Department of Labor, Washington, D.C. 20211.  Detailed information on preparation of this form is contained in REGULATIONS Governing Administration of the Federal Employees' Compensation Act of September 7, 1916, as amended, available from the Office of Federal Employees' Compensation, U.S. Department of Labor, Washington, D.C. 20211.
  3. Applicants for Federal Employment with the U.S. Public Health Service.  No fees are charged for pre-employment examinations, tests, X-rays, etc., which are necessary to determine fitness for the position.
  4. Beneficiaries of the Veterans Administration, and Federal Health Programs Service, and Members of the Uniformed Services.

    1. Other than Alaska.  Reimbursements will be requested from the Government Agency involved for services provided beneficiaries of the Veterans Administration and Federal Health Programs Service and members of the uniformed services facilities except in Alaska:

      Hospitalization    1/

      $42.00 pre diem

      Obstetrical and Maternity Services

        

      Day of delivery and 4 days thereafter

       82.00 1/
      All other hospital days

       61.00 1/

      Newborn care (beginning on 6th day or first day mother is not in hospital, if earlier.

       14.00 1/

      Other than obstetrical and maternity services  61.00 1/

      Medical    2/

      A visit for outpatient medical treatment may include more than one dental treatment in one or more medical clinics.

       $3.75 per visit

      Immunization Visit

         $2.00

      Dental.  A visit to the dental clinic may include more than one dental treatment.
      The charge will be

       $3.75 per visit

      Examination.  Except for those officers eligible for medical examinations/immunizations as specified by CC Personnel Manual Chapter CC26.1d, Personnel Instruction 3, the charge for medical examinations shall be

       10.00
    2. 1/  These rates subject to change by the Office of Management and Budget.

      2/  FHPS and VA pay in acordance with agreement.

    3. Alaska.

      The following reimbursements will be requested from the Government Agency involved for services provided to beneficiaries of the Veterans Administration and Federal Health Programs Service and members of the uniformed services at Indian Health facilities in Alaska:

      Hospitalization    1/

      $42.00 pre diem

      Obstetrical and Maternity Services

        

      Day of delivery and 4 days thereafter  82.00 1/
      All other hospital days

       61.00 1/

      Newborn care (beginning on 6th day or first day mother is not in hospital, if earlier.

       14.00 1/

      Outpatient Medical Treatment    3.75 1/

      Medical Examination

      $10.00

      Dental Services

         3.00

      Radiograph--first film    3.00
      Series (8 films to and including full mouth)

       18.00
      Prophylaxis  10.00
      Impactions, according to severity  10.00 to 30.00
      Extirpation, of pulp, treatment and filling of canals

       12.00

      Amalgam Fillings   
      1 surface    6.00
      2 surfaces    8.00
      3 surfaces  12.00
      Silicate cement fillings    8.00
      Acrylic  10.00
      Recementing inlay    5.00
      Recementing crown    5.00
      Recementing bridge    6.00
      Denture repairs  10.00
      No additional charges over and above the established reciprocal per diem rate will be made for adjunct supplies and services furnished hospitalized pay patients.  This is in accordance with the Bureau of Budget's ruling of March 27, 1952.
  5. Non-Beneficiary Emergency Cases.

    PHS Regulation 32.111b provides for charging non-beneficiary emergency cases for care and treatment.  These charges are deemed to constitute the entire charge in each instance.

    For hospitalization the rate, as prescribed by the Office of Management and Budget, shall be the per diem reimbursement rate for Federal general and tuberculosis hospitals for patients authorized to receive care at no expense to the Government.  The approved rate for fiscal years 1972 and 1973 is $61.00.

    In the case of outpatient treatment, the charge shall be at the rate established by the Surgeon General and approved by the Secretary.  The present approved rate is $55.00 for each visit.  These paragraphs do not apply to non-emergency services for non-beneficiaries in Alaska.  (See 2-4.4F)
  6. Non-Beneficiary Non-Emergency Cases in Alaska:

    For those hospitals and clinics listed below 1/ and located within the designated isolated areas in Alaska, charges for services shall be at the following rates:

    Inpatient hospital services

    $336.00 per day

    Inpatient physician consultation $  22.00 per day

    Fees for outpatient ambulatory physician services

                Brief $ 20.00 per visit
                Intermediate $ 50.00 per visit
                Comprehensive $ 90.00 per visit

    Fees for outpatient ambulatory facility use charge (does not include laboratory, radiology, pharmacy, or physician)

                Brief $ 15.00 per visit
                Intermediate $ 30.00 per visit
                Comprehensive $ 50.00 per visit

    Fees for Emergency Room facility use charge (does not include laboratory, radiology, pharmacy, or physician)

                Brief $ 30.00 per visit
                Intermediate $ 50.00 per visit
                Comprehensive $ 70.00 per visit

    Outpatient laboratory fees

    $   1.00 per CAP unit

    Outpatient Radiology fees

    $  25.00 per usable view includes radiologist interpretation.
    (Maximum charge $200.00 per study)

    Outpatient Pharmacy fees $  15.00 per Prescription

    1/
    Hospitals Clinics   
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    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 not necessarily requiring his presence.  Also includes a level of service pertaining to the evaluation and treatment of a condition requiring only an abbreviated history and examination, review of 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, diagnostic 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.

    Outpatient Ambulatory Facility Use Charge

    This fee is to be charged non-eligible patients who are seen in IHS ambulatory (outpatient) clinic facilities by private physicians. This fee does not include laboratory, radiology, pharmacy or physician 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.

    Emergency Room Facility Use Charge

    This fee is to be charged emergency non-eligible patients who are seen in IHS Emergency Rooms by private physicians or IHS physicians.  This fee does not include laboratory, radiology, pharmacy or physician 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.

    A copy of this schedule shall be posted in each designated IHS facility in Alaska and copies made available for each non-beneficiary non-emergency case that is treated.

    Dental services for emergency and non-emergency care of non-beneficiaries shall be the fees established in the Veterans Administration Fee Schedule for Alaska.

2-4.5  PAYMENT COLLECTION, AND DISPOSITION OF FEES FOR SERVICES.

  1. Commissioned Officers of the Public Health Service.

    1. Reimbursement by the Federal Health Programs Service for hospitalization and outpatient treatment for Public Health Service Commissioned Officers at Indian Health facilities will be accomplished by means of Form SF-1081, Voucher and Schedule of Withdrawals and Credits, in accordance with procedures in the Public Health Service Budget and Finance Manual, Receipts and Disbursements, Chapter 2, Section 3.
    2. Moneys collected as a return of the Officer's subsistence will be credited to the appropriation from which the services were furnished.
  2. Dependents of Commissioned Officers of the Public Health Service.

    1. If the dependent is admitted for hospitalization and is discharged within the same calendar month, the bill should be rendered to the Officer when the patient is discharged or upon conclusion of treatment.  Where the dependent is admitted during the month and is discharged during the subsequent calendar month, billing will be effective on the last day of each month, with final bill rendered when the patient is discharged or upon conclusion of treatment.  Dependents' charges will be $1.75 a day.
    2. Officers shall be billed for hospitalization of their dependents on SF-1114, Bill for Collection which will be sent to the Financial Management Branch, Federal Health Programs Service, 5600 Fishers Lane, Rockville, Maryland 20852.
    3. Moneys collected for hospitalization of dependents should be credited to the appropriation from which the services where rendered.
  3. Beneficiaries of the Veterans Administration, Federal Health Programs Service, and Members of the Uniformed Services.

    1. Reimbursements from the Federal Agency concerned will be accomplished by means of Form SF-1081.
    2. Moneys collected will be credited to the appropriation from the services were furnished.
  4. Non-Beneficiary Emergency Cases.

    1. The patient shall be advised of the daily inpatient charge upon admittance or as soon thereafter as feasible.  He shall be advised of and requested to pay the total charge for services at the time of discharge or upon completion of his outpatient treatment if the medical officer in charge determines that the patient is able to defray the cost of care and treatment.
    2. Form HSM-307 (formerly PHS-2476) Field Receipt, will be prepared if the patient pays for services at the conclusion of his treatment, otherwise Form SF-1114, Bill for Collection, will be prepared.
  5. Non-Beneficiary Non-Emergency Cases.  (Alaska Only).

    1. Such patients or their sponsors shall be advised of the established charges as soon as possible.  Request for payment shall be made at the time of discharge or upon completion of outpatient treatment.
    2. Form HSM-307 (formerly PHS-2476) Field Receipt, Indian Health Activities, will be prepared if payment is made, otherwise SF-1114, Bill for Collection, will be issued and the prescribed collection procedures will be followed.
    3. Moneys collected will be specifically identified and credited to the appropriation current at the time of receipt.
  6. Job Corps Enrollees and VISTA Volunteers (Office of Economic Opportunity).

    Reimbursement billings on SF-1080, accompanied by the original authorization, or reference to Blue Cross card number, for service rendered shall be sent to the referring agency (Job Corps or VISTA) as appropriate.

2-4.6  SPECIAL STUDY PATIENTS - BASIC AUTHORITY AND POLICY

  1. Citation from the PHS Act (Sec. 301f)

    "The Surgeon General shall conduct the Service, and encourage, cooperate with, and render assistance to other appropriate public authorities, scientific instructions....  In carrying out the foregoing, the Surgeon General is authorized to-­
    (f) For purposes of study, admit and treat at institutions, hospitals and stations of the Service, persons not otherwise eligible for such treatment..."
  2. Authority.  PHS Regulation 32.6(c)(1) provides for the admission and treatment of persons not otherwise eligible for treatment for purposes of study based on instructions issued by operating Services.  These instructions have that purpose.
  3. Definitions.  A case may be considered as a special study case if it meets one or more of the following criteria:

    1. Teaching/Training.  For lack of clinical material in routine beneficiaries, it is necessary to keep the diagnostic acumen and professional skills of medical and dental officers in line with current medical progress and the Service Unit Director or the Medical Officer in Charge feels that such cases are necessary for teaching purposes and/or the professional development of his staff.  These cases may include unusual features of commonly encountered diseases, infrequently seen disease entities, medical or surgical conditions which, though not in themselves rare are not met with sufficient frequency among Indians.
    2. Research.  When the case affords opportunity for the use, under carefully controlled conditions, of new and experimental treatment or methods or for inclusion in a clinical research project.
  4. Special Instructions.  The admission of special study cases for teaching/training is anticipated to be a very rare action in the Indian Health Service.
  5. Research.  Admission of special study cases for research support shall specify the type of research project in the memorandum report that is prescribed in paragraph F.
    1. NIH Support Director Grant:  This is an award to an IHS hospital from the National Institutes of Health for the type of project which requires NIH Study Section and National Advisory Council review and approval.

      University Grant:  An award to a University from NIH with the principal investigator or co­investigator in an IHS Hospital.
    2. Other Support.  A research project which is local for an IHS hospital for which the protocol has been approved by the IHS Director.

  6. Reports.  Whenever a special study case who is not a beneficiary is admitted to an IHS hospital, a memorandum report stating all pertinent facts shall be sent through channels, within three days of admission to the Indian Health Service, Attention:  Director, Division of Program Operations.

2-4.7  CARE AT REMOTE FACILITIES

This is to designate remote PHS medical facilities, and to set forth the basis for providing and charging for medical services rendered to Federal employees and their dependents at such facilities.
Public Law 90-174 amended Section 324 of the PHS Act (42 U.S.C. 251) by adding the following new subsection:
"(b) The Secretary is authorized to provide medical, surgical, and dental treatment and hospitalization and optometric care for Federal employees (as defined in section 8901 (1) of Title 5 of the United States Code) and their dependents at remote medical facilities of the Public Health Service where such care and treatment are not otherwise available.  Such employees and their dependents who are not entitled to this care and treatment under any other provision of law shall be charged for it at rates established by the Secretary to reflect the reasonable cost of providing the care and treatment.  Any payments pursuant to the preceding sentence shall be credited to the applicable appropriation to the Public Health Service for the year in which such payments are received."

  1. Designation.  Pursuant to Section 324 (b) of the Public Health Service Act, 42 U.S.C. 251, as amended, the following medical facilities of the Service are designated as remote facilities:
    PHS Alaska Native Hospitals

    Barrow, Alaska       Bethel, Alaska
    Kanakanak, Alaska       Kotzebue, Alaska

    PHS Indian Hospitals
    Arizona Minnesota
    Fort Defiance
    Keams Canyon
    Parker
    Sells
    Tuba City
    Whiteriver

    New Mexico
    Crownpoint
    Shiprock
    Zuni

    Oklahoma
    Talihina
    Redlake

    Montana
    Browning
    Harlem

    Nevada
    Owhee

    North Dakota
    Eagle Butte
    Rosebud
    PHS Alaska Native Health Centers

    Fort Yukon
    nome

    Arizona Montana
    Kayenta
    Peach Springs

    New Mexico
    Dulce
    Lame Deer
    Rocky Boy's

    Washington
    Owhee

    North Bay
    Taholah
    Wyoming

    Fort Washakie

    The above designations are subject to change by the addition or deletion of facilities.
  2. Availability of Services.  At a remote medical facility the Service is authorized to provide medical, surgical, and dental treatment and hospitalization and optometric care for Federal employees and their dependents who reside or work within a thirty mile radius of the remote facility.  The remote facility may also provide such services to Federal employees and their dependents who reside or work outside of the thirty mile radius of the remote facility, who would otherwise be required to travel a greater distance from their residence or place of employment for private care, than the distance from their residence or place of employment to the remote facility, or for whom transportation for private care, from their place of residence or employment is unavailable, hazardous, protracted or unreasonably expensive because of such unfavorable factors as unsurfaced or mountainous winding roads, or toll bridges and roads, or adverse weather conditions.

    1. Application for treatment or care.  Application for services authorized by Section 324 shall be made by the Federal employee for himself or on behalf of his dependents in writing, at a remote facility on a form provided by the facility.  (See Appendix A).  The applicant shall establish his status as a Federal employee, to the satisfaction of the Service Unit Director.
    2. Limitations and priorities.  The Service Unit Director of each remote facility, with the approval of the Indian Health Area Director, is authorized to establish limitations and priorities for the furnishing of medical care to Federal employees and their dependents, as dictated by the primary mission of the facility, the availability of physical plant and staff, and other circumstances related to the provision of medical services.
    3. Denial of treatment or care.  The Service Unit Director of a remote station or his designee may deny treatment or care to Federal employees and their dependents who cannot establish their status as such to the satisfaction of the Service Unit Director, or who cannot establish that they must otherwise travel at least thirty miles for private health services or that transportation to obtain private health services is unavailable, hazardous, protracted, or unreasonably expensive because of such unfavorable factors as unusual climatic conditions, unsurfaced or mountainous winding roads, or toll bridges and roads.  A written notice of such denial shall be given, setting forth the following:

      1. The name and address of the applicant.
      2. The date of the denial.
      3. The basis for the denial, listing the specific circumstances upon which it is based.
      4. The name of the Service Unit Director or his designated representative.
      5. The statement, "If you have any information which may affect this decision, you may submit it with a copy of this denial, for review by the Indian Health Area Director. __________________________________________________ __________________________________________________
                                            (Address)
  3. A copy of each notice of denial shall be retained at the remote facility, preferably in the persons' case folder, and a copy shall be forwarded to the Area Office.

  4. Federal Employee Defined.  Generally the term "Federal employee" means:

    1. A person duly appointed in the civil service;
    2. A wage board employee;
    3. A person engaged in the performance of a Federal function under authority of law or an Executive act; and
    4. Any other person defined in 5 U.S.C. § 2105. (See Appendix B)
  5. Penalties.  False or fraudulent statements made in connection with an application for services are punishable under 18 United States Code § 1001 which provides:  "Whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device a material fact, or makes any false, fictitious or fraudulent statements or representations, or makes or uses any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than five years, or both."
  6. Charges for Treatment and Care.  Federal employees and their dependents who are not otherwise entitled by law to the care and treatment authorized by Section 324 of the amended PHS Act, shall be charged for care rendered under Section 324 at the current Office of Management and Budget rates.  The present rates are $13.00 per facility outpatient visit and $61.00 per facility inpatient day.  The rates represent the reasonable value of services provided, and are subject to change.  Payments made pursuant to this provision shall be credited to the applicable appropriation to the PHS for the year in which received.  Contract medical care funds will not be available for care of employees and dependents (who are not otherwise entitled thereto as beneficiaries of the PHS).

2-4.8  PROVISION OF DIRECT CARE HEALTH SERVICES TO INELIGIBLE INDIVIDUALS UNDER
          SECTION 813(b)(1)(A) OF THE INDIAN HEALTH CARE IMPROVEMENT ACT

  1. Purpose.  The purpose of this section is to establish policy and guidance for the Indian Health Service (IHS) to use in making a determination with a Tribe or Tribes when direct care health services may be provided to ineligible individuals at IHS facilities under section 813(b)(1)(A) of the Indian Health Care Improvement Act (IHCIA).
  2. Background.  Section 813(b)(1)(A) is only one of several statutes that grant the IHS the authority to provide direct care health services to certain classes of ineligibles in certain situations at IHS facilities.  Examples of other statutes (a table of these statutes is included as Appendix E) that allow the IHS to provide health services to certain classes of ineligibles are:

    1. United States Public Health Service Commissioned Corps active and retired members and their dependents (42 United States Code (U.S.C.) § 253.42 Code of Federal Regulations (CFR) 31.2(c) and 42 CFR 31.9);
    2. Federal employees and their dependents at remote stations (42 U.S.C. § 251(b));
    3. Children and spouses of eligible Indians (25 U.S.C. § 1680c(a)); and
    4. Individual receiving emergency treatment (25 U.S.C. § 1680c(c)).
  3. Authority.  Section 813(b)(1)(A) of the IHCIA, Public Law 94-437,25, U.S.C. §1680c(b)(1)(A).  (The full text of section 813 is included as Appendix F.)
  4. Policy.  It is the policy of the IHS that at IHS-operated health facilities, direct care health services may be provided to individuals who reside within the service area of the service unit and who are not eligible for direct care health services under any other provision of law only upon the request of the Tribe or all Tribes served by such service unit and upon a joint determination by the IHS and the Tribe or Tribes that the criteria in section 813(b)(1)(A)(ii)(I) and (II) have been met.
  5. Procedures.  The Area Director or the IHS service unit Chief Executive Officer (CEO) may initiate discussion with a Tribe or Tribes concerning the provision of direct care health services to ineligible individuals; however, services may only be provided at the request of a Tribe or Tribes and after a joint determination has been made in accordance with this policy.

    1. Request by Tribe(s) to Serve Ineligible Individuals.  Upon the written request of all Tribes served by an IHS-operated service unit that direct care health services be provided to ineligible individuals under section 813(b)(1)(A), IHS staff shall use a worksheet (See Appendix G) to ensure that the following information is considered:

      1. The type(s) of direct care health service(s) the Tribe or Tribes request that the IHS provide.
      2. A list of alternative health facilities or services located within 30 miles of the IHS-operated health facility where services are proposed to be provided.
      3. The estimated population of ineligible individuals residing within the service area of the service unit and the estimated population of ineligible individuals expected to utilize the IHS-operated health facility.  This data will be used to estimate the increased workload on the IHS-operated health facility should direct care health services be provided to these individuals.
    2. Joint Determination.  After the IHS has obtained the above information from the Tribe or Tribes, IHS staff will consult with the Tribe or Tribes served by the service unit and make a joint determination regarding whether the criteria of section 813(b)(1)(A)(ii)(I) and (II) have been met.
    3. Case-by-Case Determination.  The determination under section 813(b) of whether there are reasonable alternative health facilities or services available and whether there will be a denial or diminution of services to eligible Indians is a case-by-case determination.  This determination shall be made by taking into account and weighing the information the Tribe or Tribes provide, the factors that are included in this chapter, and other relevant factors, if they are consistent with the intent of this chapter.
    4. Necessary Determinations Under Section 813.

      1. No Reasonable Alternative Health Facility or Services.  The first determination that must be made is whether there is any reasonable alternative health facility or services available for the services proposed to be provided to ineligible individuals.  If there is a reasonable alternative health facility or services available, direct care health services shall not be provided to individuals under the authority of 813(b)(1)(A).  In such an instance, further analysis into the second necessary determination (whether service to such ineligible individuals will result in a denial or diminution of services to eligible individuals) will not be necessary.
      2. No Denial or Diminution of Services.  If there is no reasonable alternative health facility or services available, then a determination of whether the provision of direct care health services to ineligible individuals will result in a denial or diminution of health services to eligible Indians must be made.

        Should a Tribe or Tribes prefer that only certain direct care health services be provided to ineligible individuals, or if the provision of a complete range of direct care health services to ineligible individuals would result in diminished services to eligible Indian beneficiaries, a Tribe or Tribes may request that only certain defined direct care health services be provided to ineligible individuals.
      3. Final Determination To Be in Writing.  After following the procedures and weighing the factors in this chapter, the CEO of the service unit shall present a recommended decision to the Area Director for formal approval.  The determination of the Area Director shall be in writing so that it is clear that if direct care health services are provided to ineligible individuals under the authority of section 813(b)(1)(A), the provision of such services is within the scope of employment of the Federal employees providing the services.  Any written determination shall also be sent to the Tribe or Tribes.  In the event of an adverse determination, the Tribe or Tribes should be notified of their right to appeal the Area Director’s decision to the Director, IHS.
      4. Affirmative Determinations.  Affirmative determinations shall be reviewed annually, and as circumstances dictate, to ensure that the provision of direct care health care services to ineligible individuals is still allowable under the criteria set forth in this chapter and section 813(b)(1)(A).

        1. If circumstances are unchanged, then a decision to renew the joint determination shall be documented by the Area Director with a copy being provided to the Tribe or Tribes.
        2. If circumstances have changed, the Area Director shall initiate discussion with the Tribe or Tribes to jointly determine if a change in the initial determination is warranted.
  6.                                 (a)  If it is determined that the provision of services to ineligible individuals is no longer allowable under this policy, the provision of services to ineligible individuals shall terminate at the end of the fiscal year succeeding the fiscal year in which the change to the initial determination is made.

                                    (b)  The Area Director shall document this decision and the facts that contributed to the termination and shall provide a copy of this documented decision to the Tribe or Tribes (see Section I, “Termination Procedures”).

  7. Factors for Making Determination.  The following criteria are to be considered in making a determination of whether there is a reasonable alternative health facility or alternative services available:

    1. Reasonable Alternative Health Facility or Services.  Generally, a reasonable alternative health facility or alternative services will be determined to exist if there is, within 30 miles of the IHS-operated health facility, a licensed or accredited health care facility or licensed private health care providers (e.g., physicians, surgeons, dentists, optometrists, etc.) available to provide the necessary direct care health services.
    2. Existing Alternative Health Facilities or Services.  Existing alternative health facilities or services are presumed to be reasonable unless extenuating factors exist that can be clearly demonstrated.  These extenuating factors will be considered on a case-by-case basis.
    3. Other Factors.  The Agency may consider other factors the Tribe or Tribes consider important.  These factors will be considered on a case-by-case basis.
    4. Health Care Facilities (e.g., Hospitals, Clinics, etc.) and Providers (e.g., Physicians Surgeons, Dentists, Optometrists, Pharmacists, etc.) Located Within 30 Miles of the IHS Operated Health Facility.  In Areas where transportation is hazardous or protracted because of unfavorable climatic conditions or unsurfaced or mountainous roads, health care facilities and services located within 30 miles of the IHS operated health facility will be given additional scrutiny as to whether they are reasonable alternative health facilities or services.
    5. Range of Services Available from These Health Care Facilities and Providers.  If the health facilities and providers located within 30 miles of an IHS operated health facility do not offer particular services (e.g., dentistry, eye care, OB-GYN, etc.), then it could be determined that such services are not reasonably available, and the IHS-operated health facility could provide the services subject to paragraph G below.
  8. Services to Eligible Indian Beneficiaries are Neither Denied nor Diminished.  In the event a determination is made that no reasonable alternative health care facility or services exist, direct care health services may be provided to ineligible individuals to the extent that services to eligible Indian beneficiaries are neither denied nor diminished.

    Whether services to eligible Indian beneficiaries will be denied or diminished is to be determined by considering the estimated population of ineligible individuals expected to utilize the services and the impact that providing services to these ineligible individuals under section 813(b)(1)(A) will have on such factors as:  waiting times for health care appointments, provider-to-patient ratio, quality of services, availability of services, and any other relevant factors that impact the reduction of services to eligible Indians.
  9. Tribally-initiated Termination.  The governing body of a Tribe or Tribes may request, at any time, that services being provided to ineligible individuals under section 813(b)(1)(A) be discontinued.

    1. Single Tribe Service Area.  Pursuant to Section 813(b)(3)(A):  In the case of a service area which serves only one Tribe, the authority of the Secretary to provide direct care health services under section 813(b)(1)(A) shall terminate at the end of the fiscal year succeeding the fiscal year in which the governing body of the Tribe revokes its concurrence to the provision of such direct care health services.
    2. Multi-Tribe Service Area.  Pursuant to section 813(b)(3)(B):  In the case of a multi-Tribal service area, the authority of the Secretary to provide direct care health services under section 813(b)(1)(A) shall terminate at the end of the fiscal year succeeding the fiscal year in which at least 51 percent of the number of Tribes in the service area revoke their concurrence to the provision of such direct care health services.
  10. Termination Procedures.  Before discontinuing services to ineligible individuals, the IHS Area Director will determine the best method of discontinuing services and how such notice should be provided to the ineligible individuals.  Consultation with the IHS Office of Clinical and Preventive Services, Division of Regulatory and Legal Affairs, and/or the Regional Counsel may be appropriate.
  11. Liability for Payment.  Persons receiving direct care health services provided by reason of Section 813(b)(1)(A) shall be liable for payment of such direct care health services and shall be billed under existing IHS reimbursement authorities and billing practices.

1/  These rates are subject to change by the Office of Management and Budget.

2/  FHPS and VA pay in accordance with agreement

3/  Hospitals     Clinics

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