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     Indian Health Manual

Part 2, Chapter 3:  Manual Exhibit 2-3-M

Sample Template
Re-Designation of Contract Health Service Delivery Area
Indian Health Service
Re-designation of Contract Health Service Delivery Area


Indian Health Service



SUMMARY:  This notice advises the public that the Indian Health Service (IHS) is re-designating the geographic boundaries of the Contract Health Service Delivery Area (CHSDA) for the [NAME OF TRIBE] (“The Tribe”).  The Tribe’s CHSDA is comprised of [name existing counties in Tribe’s CHSDA].  These counties were designated as the Tribe’s CHSDA when the IHS published its updated list of CHSDA in the Federal Register (FR) of January 10, 1984 (49 FR 1291).  It is proposed that the re-designated CHSDA be comprised of [name existing counties plus names of new counties to be added].  This notice is issued under authority of 43 FR 34654, October 1, 2002.

DATES:  Comments must be received on or before [Federal Register insert 30 days after publication].

ADDRESSES:  Comments may be mailed to: Regulations Officer, Division of Regulatory Affairs, Indian Health Service, 801 Thompson Avenue - TMP Suite 450, Rockville, MD 20852, Telephone 301-443-7899.  (This is not a toll-free number.)  Comments received will be available for inspection at the address above from 9L00 a.m. to 3:00 p.m., Monday through Friday, beginning approximately two weeks after publication.

FOR FURTHER INFORMATION CONTACT:  Director, Division of Regulatory Affairs, Office of Management Services, Indian Health Service -801Thompson Avenue, TMP Suite 450, Rockville, MD 20852, Telephone 301-443-1116.  (This is not a toll-free number.)

SUPPLEMENTARY INFORMATION:  On October 1, 2002,the IHS published regulations establishing eligibility criteria for receipt of contract health services and for the designation of a CHSDA (43 FR 43654, codified at 42 Code of Federal Regulations (CFR) 136.22, last published in the 2002 version of the CFR).  On September 16, 1987, the IHS published new regulations governing eligibility for IHS services.  Congress has repeatedly delayed implementation of the new regulations by imposing annual moratoriums.  Section 719(a) of the Indian Health Care Amendments of 1988, Public Law 100-713, explicitly provides that during the period of the moratorium placed on implementation of the new eligibility regulations, the IHS will provide services pursuant to the criteria in effect on September 15, 1987.

Thus, the IHS CHS program continues to be governed by the regulations in effect on September 15, 1987.  See 42 CFR 136.21, et seq. (2002).

As applicable to the Tribe, these regulations provide that, unless otherwise designated, a CHSDA shall consist of a county which includes all or part of a reservation and any county or counties which have a common boundary with the reservation (42 CFR 136.22).  The regulations also provide that after consultation with the Tribal governing body or bodies of these reservations included in the CHSDA, the Secretary may, from time to time, re-designate areas within the United States for inclusion in or exclusion from a CHSDA.  The regulations require that certain criteria must be considered before any re-designation is made.  The criteria are as follows:

  1. The number of Indians residing in the area proposed to be so included or excluded;
  2. Whether the Tribal governing body has determined that Indians residing in the area near the reservation are socially and economically affiliated with the Tribe;
  3. The geographic proximity to the reservation of the area whose inclusion or exclusion is being considered; and
  4. The level of funding which would be available for the provision of contract health services.

Additionally, the regulations require that any re-designation of a CHSDA must be made in accordance with the procedures of the Administrative Procedure Act (5 U.S.C. 553).  In compliance with this requirement, we are publishing this proposal and requesting public comment.

Pursuant to Tribal Resolution _________________, dated _______________, the Tribe requested the IHS to re-designate their current CHSDA, which incorporates [name of counties in existing CHSDA], to include [names of new counties to be added to CHSDA.]

In applying the aforementioned CHSDA re-designation criteria required by operative regulations criteria required by operative regulations 42 CFR 136.22, the following findings are made:

[CHSDA committee applies the Tribal specific facts to criteria (1) through (4)above.  The following language in italics was published in the Rosebud CHSDA FR notice and is provided here as an example of how to apply the specific Tribal facts to the regulations criteria.]

  1. The Tribe enrollment and census records identify 519 Tribal members residing in Gregory County and 0 Tribal members residing in Lyman County.
  2. The Tribe has determined that CHS would be available to all its members and members of other federally recognized Tribes who reside in Gregory County and Lyman County having close social and economic ties with the Tribe.
  3. Gregory County is presently a CHSDA county for the Yakton Sioux Tribe.  There are 158 Tribal members, of 519 total, who are eligible for the Yankton Sioux CHS program because if close economic-social ties.  The Yankton Sioux and Rosebud Sioux CHS programs will work together on the eligibility and CHS coverage on a case-by-case basis.
  4. Lyman County us presently a CHSDA county for the Lower Brule Sioux Tribe.  There are 0 Tribal members who are eligible for the Lower Brule Sioux CHS program.  The Lower Brule and Rosebud CHS program will work together on the eligibility and CHS coverage on a case-by-case basis if/when there are Rosebud Sioux residing within Lyman County.
  5. At this time, although Gregory County does not border the Rosebud Sioux's reservation, Gregory County was within the original boundaries of the reservation and continues to have a significant population of Rosebud Sioux.  The Tribe chose to include Lyman County in the expansion even though, at the time of the analysis, there were no Rosebud Sioux Tribal members residing in Lyman County.  The close proximity to the original boundaries of the reservation was considered because there could be members residing in Lyman County in the future.
  6. The 529 Tribal members residing in Gregory County presently utilize the Rosebud IHS facility's direct care services.  Therefore, the clinical work load units will not be impacted.  It is estimated that the current eligible contract health service population will be increased by 519 in Gregory County.  The Rosebud CHS program has a recurring CHS funding base of $4,233,730.  The formula used to determine what impact the additional 519 members, residing in Gregory County, would have on the Rosebud CHS fund is determined by using the Aberdeen Area's type of facility per capita of $327 X 519 = $169,713.  The 0 number residing in Lyman County would have no impact at this time.  The Rosebud IHS facility recognizes that there will be no additional CHS funding for this CHSDA expansion but they do not expect a significant impact on their present funding and support the Tribe's CHSDA expansion and re-designation.  The expansion and re-designation of the CHSDA to include both Gregory County and Lyman County is within the present available resources.

Accordingly, after considering the Tribe's request in light of the criteria specified in the regulations I am proposing to re-designate the CHSDA of the Tribe to consist of [names of all counties in CHSDA].

This notice does not contain reporting or recordkeeping requirements subject to prior approval by the Office of Management and Budget under the Paperwork reduction Act of 1980.

Robert G. McSwain
Director, Indian Health Service


  1. Two Options to Request a Change in CHSDA
    1. Administrative
    2. Congressional

    The Indian Health Service (IHS) and the Department of Health and Human Services (HHS) are not involved with this option

  2. Administrative Option

    The process to expand the CHSDA for a Tribe is described in the regulations and the Indian Health Manual.  Since requests for expansion of a CHSDA are thoroughly reviewed, the material should be clear.

    1. The Tribe should provide the following types of information in writing to the Area Director:
      1. A resolution in support of the CHSDA expansion.
      2. State the county(s) proposed to be added or deleted from the existing CHSDA.
      3. The number of Indians residing in the counties proposed to be included or excluded.
        1. identify the number of members of the Tribe residing in each county.
        2. identify the number of members of other Federally-recognized Tribes residing in each county.
      4. Whether the Tribal governing body has determined that Indians residing in the proposed added county(s) are socially and economically affiliated with the Tribe; if the Tribe is granting close ties to members of other federally recognized Tribes, how many additional individuals will be eligible for CHS in each county to be added to the existing CHSDA?
      5. The geographic proximity to the reservation of the county(s) whose inclusion or exclusion is being considered.
      6. The level of funding which would be available for the provision of CHS if the requested expansion is approved.
      7. The total number if new users.
      8. The additional number of clinical work units.
      9. The potential added costs.
      10. The total resources already available.
      11. The current level of need funded.
      12. The anticipated decrease in level of need funded.
      13. List the metropolitan areas that are included in the proposed expansion.
      14. List other Tribes whose CHSDA are included in the proposed expansion; identify by county the other Tribes whose CHSDA already include the counties which are in the proposed expansion.
      15. Other information which would support the request such as maps, narratives describing the Tribes' concerns, etc.
    2. The Area will analyze the proposal outlining positive and negative features, and will recommend acceptance or rejection over the signature of the Area Director to the Director, IHS.  The Area should submit for Tribes that have a reservation a draft CHSDA re-designation Federal Register notice using the template developed by the Division of Regulatory Affairs.
    3. The Director, IHS will either approve or disapprove the requested change in a Tribe's CHSDA.  However, for Tribes that have a reservation a decision of the Director, IHS to approve expansion of a Tribe's CHSDA will not be effective until the date a final rule is published in the Federal Register.

      Note:  Expanding a CHSDA does not automatically increase the funding to a Tribe.

  1. Indentify a Count of Eligible CHS Beneficiaries.  Determine the count of Indian people who will be eligible for Contract Health Service (CHS) coverage in a new or expanded Contract Health Service Delivery Area (CHSDA) (reside in the added Counties or portions of counties).  Data considerations are:
    1. All CHSDA correspondence with county and county subdivisions.
    2. Census counts of American Indian/Alaska Native (AI/AN) for counties and subdivisions.  Census counts are "self-identification" and may include members of Tribes that are not Federally-recognized.  Adjustments may be necessary.
    3. Are Tribal roles with place of residence available to help estimate potential CHS beneficiaries?
    4. Enrollment lists if available.
    5. Work closely with the Area Office Statistical/Planning office on the Areas and with Office of Program Statistics in Headquarters to estimate potential eligible beneficiaries.
  2. Identify Subsets for CHS and Direct and CHS Only.  Identify newly eligible CHS beneficiaries who get some health care services from existing IHS, Tribal, or Urban (I/T/U) hospitals/clinics.  This combination is known as (CHS and Direct).  The balance of beneficiaries [CHS Only] do not obtain services from I/T/U sites and rely on CHS to the extent their health care costs are not covered by alternate sources such as health care insurance; Medicare or Medicaid.  Anticipated CHS costs for beneficiaries dependent on CHS exclusively can be higher than for those who obtain direct care services.
  3. CHS and Direct Count.  The CHS and Direct Count is that portion of newly CHS eligible count (#1) that obtains some services at I/T/U sites.  Considerations:
    1. Consult with the statistical office to obtain counts (if any) for AI/AN residing in the CHSDA who use IHS/Tribal/Urban direct care facilities.
    2. Will these users continue to obtain direct care services after obtaining eligibility?

    [CHS Only Counts].  The CHS Only Count is derived from the total eligible count in #1, subtract the [CHS and Direct Count].

  4. Net Counts Considering Other Coverage.  Experience shows that some eligible AI/AN do not seek Federal IHS health care services - especially if health benefits are provided through their employers.  There would be little financial impact by eligible AI/AN who do not use program.  To reduce the eligible beneficiary counts by a percentage for expected non-use:
    1. [NET CHS and Direct Count] = 2.a] X [100%].  Existing users have demonstrated they will seek IHS services and would likely continue seeking IHS services after CHSDA expansion.  Unless exceptional circumstances warrant, the expected utilization factor is 100% for those already seeking services.
    2. [NET CHS Only Count] = [2.b] X [Utilization 5].  Use judgment to estimate a reasonable utilization percentage based insurance coverage, employment, or other related data.  The judgment should consider actual experience if available, distance to source of care, employment rates, and other knowledge about the circumstances in the CHSDA that are reasonable factors in predicting utilization by newly eligible beneficiaries that have no direct services.
  5. CHS Cost Benchmarks.  There is no standard for CHS costs per person because there is no fixed set of benefits assured under all IHS CHS programs.  The extent and scope of CHS costs varies at the local level.  All CHS services (or payments) are rationed uniquely in each service unit and over time depending on funds availability.  In lieu of a fixed standard, the cost benchmarks below are suggested as guidelines for estimating cost impacts.

    The Federal Disparity Index (FDI) methodology computes a cost per person for a comprehensive personal health care services plan similar to that available to federal employees.  It accounts for local regional cost variations, other factors such as health, and discounts for expected levels of reimbursement from other sources.  The 2002 FDI estimate is $2,625 per person annually net of expected reimbursements and cost avoidance for Medicare, Medicaid, and PI.

    In an existing CHSDA in which direct care services are also available, approximately 30% of medical services are purchased from outside sources.  Such purchases are often paid from the CHS account.  Therefore, the average portion of the FDI cost benchmark would be .3 X $2,625 =$788 per user per year.  But this national average masks wide variation at the local level.  Purchase percentages range from 15% to 90% depending on the extent of services available at the I/T/U site.  A more refined estimate will account for whether direct services are limited to ambulatory care or include some hospital care.

    We further assume that most secondary and all tertiary care services would be obtained from private sources and paid under CHS.  Choose an appropriate benchmark depending on the extent of direct care services available to the CHSDA:

    If Only Ambulatory Care is available at I/T/U sites:
    [CHS and Direct Cost] =40% X $2,625 = $1,050
    Direct Ambulatory care is accessible. Contract Health Service will pay for hospital and most secondary and tertiary ambulatory care.  Beneficiaries with access to I/T/U ambulatory care only will have higher CHS cost impact.

    If Both Ambulatory and Hospital Care are available at I/T/U sites:
    [CHS and Direct Cost] =20% X $2,625 = $525
    Direct Hospital and Ambulatory care is accessible.  Contract Health Service will pay for most secondary and tertiary care whether ambulatory or inpatient.  Beneficiaries with access to I/T/U ambulatory care and hospital care will have lower than average cost.

    B.  If neither Ambulatory nor Hospital Care are available at I/T/U sites: [CHS Only Cost] = 100%X $2,625 = $2,625

  6. Estimate Financial Impact.  The financial impact is based on separate factors;
    1. Financial Impact [CHS and Direct]:

      If Only Ambulatory Direct Care is Available

      [3a:  NET CHS and CHS Count] X [4a1: $1,050] or

      If ambulatory and Hospital Direct Care are Available

      [3a:  NET CHS and Direct Count] X [4a2: $525]

    2. Financial Impact [CHS Only]

      [3b:  NET CHS Only Count] X [4b: $2,625]
    3. Total Financial Impact = A + B.
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