Chapter 1 - Eligibility for Services

Title	Section
Introduction	2-1.1
Purpose	2-1.1A
Authorities	2-1.1B
Persons Eligible for IHS Health Care Services	2-1.2
American Indian and/or Alaska Native	2-1.2A
Eligible Non-Indians	2-1.2B
Purchased/Referred Care	2-1.2C
Service Policy	2-1.3
Policy	2-1.3A
Alternate Resources	2-1.3B
Other IHS Service Areas	2-1.3C
Provision of Services	2-1.4
Health Promotion and Disease Prevention	2-1.4A
Medical Care	2-1.4B
Other Available Resources	2-1.4C
Scope	2-1.4D
Persons in Custody	2-1.4E
Priorities for Service	2-1.5
Priorities for Service	2-1.5A
Insufficient Funds	2-1.5B
Guidelines for Priorities	2-1.5C
Denial of Services	2-1.5D
Joint Planning for Care of Indians	2-1.6
Federally Recognized Tribes	2-1.7

2-1.1  INTRODUCTION

1. Pupose.

   This Chapter sets forth the policies, standards and procedures for determining those persons who fall within the scope of the Indian Health Service (IHS) health care program.  This policy applies to IHS direct care programs and facilities, as set forth in 42 Code of Federal Regulations (C.F.R.) § Part 136.

2. Authorities.
   1. The Snyder Act, 25 United States Code (U.S.C.) § 13.
   2. The Transfer Act, 42 U.S.C. § 2001 et seq.
   3. Indian Health Care Improvement Act (IHCIA), Public Law 94-437, 25 U.S.C. § 1601 et seq.
   4. 42 C.F.R. Part 136 (Eligibility Regulations Promulgated under the Snyder Act and Transfer Act).

2-1.2  PERSONS ELIGIBLE FOR IHS HEALTH CARE SERVICES.  A person may be regarded as eligible and within the scope of the IHS health care program if he or she is not-otherwise excluded by provision of law, and is:

1. American Indian and/or Alaska Native.  American Indian and/or Alaska Native (AI/AN) descent and belongs to the Indian community served by the IHS program, as evidenced by such factors as:
   1. Membership, enrolled or otherwise, in an AI/AN Federally-recognized Tribe or Group under Federal supervision.
   2. Resides on tax-exempt land or owns restricted property.
   3. Actively participates in tribal affairs.
   4. Any other reasonable factor indicative of Indian descent.
   5. In case of doubt that an individual applying for care is within the scope of the program, as established in 42 C.F.R. § 136.12(b), and the applicant's condition is such that immediate care and treatment are necessary, services shall be provided pending identification as an Indian beneficiary.
2. Eligible Non-Indians.  Care and treatment of non-Indians shall be provided, in accordance with 25 U.S.C. § 1680c, 42 C.F.R. §§136.12, and 136.14, as follows:
   1. Children.  Any individual who has not attained 19 years of age; is the natural or adopted child, stepchild, foster child, legal ward, or orphan of an eligible Indian; and is not otherwise eligible for health services provided by the IHS, shall be eligible for all health services provided by the IHS on the same basis and subject to the same rules that apply to eligible Indians until such individual attains 19 years of age.  The existing and potential health needs of all such individuals shall be taken into consideration by the IHS in determining the need for, or the allocation of, the health resources of the IHS.  If such an individual has been determined to be legally incompetent prior to attaining 19 years of age, such individual shall remain eligible for such services until 1 year after the date of a determination of competency [25 U.S.C. §1680c (a)].
   2. Spouses.  Any spouse, including a same-sex spouse, of an eligible Indian who is not an Indian, or who is of Indian descent but is not otherwise eligible for the health services provided by the IHS, shall be eligible for such health services if the governing body of the Indian Tribe or Tribal Organization providing such services deem them eligible by an appropriate resolution as a class.  The health needs of persons made eligible under this paragraph shall not be taken into consideration by the IHS in determining the need for, or allocation of, its health resources [25 U.S.C. §1680c (b)].
   3. A non-Indian woman pregnant with an eligible Indian's child for the duration of her pregnancy, and through post-partum (usually 6 weeks after delivery) (42 U.S.C. § 136.12).  In cases where the woman is not married to the eligible Indian under applicable law or tribal law, paternity must be acknowledged by either:
      1. The eligible Indian, in writing.
      2. Determined by order of a court of competent jurisdiction.
   4. A non-Indian member of an eligible Indian's household and the medical officer in charge determines that services are necessary to control a public health hazard or an acute infectious disease, as stated in 42 C.F.R. § 136.12(a).
   5. Other non-Indian beneficiaries are described in Part 2, Chapter 4 of the IHM, such as non-Indian employees and veterans, whom may also be authorized for limited services, as described in Part 2, Chapter 4 of the IHM.
3. Purchased/Referred Care (PRC).  There are additional eligibility requirements for authorized PRC services [See the Indian Health Manual (IHM), Part 2, Chapter 3, Contract Health Services (CHS) and 42 C.F.R. § 136.23] Note: CHS name was changed to PRC.

2-1.3  SERVICE POLICY

1. Policy.  The IHS will identify health services and resources available to each person who is recognized as within the scope of the IHS health care program.  The IHS will implement this policy by:
   1. Providing all services available at an IHS facility to any person within the scope of the IHS health care program who presents himself at the facility and for whom the IHS facility is more accessible than other programs and resources.
   2. Identifying alternate resources for which the persons within the scope of the IHS health care program may be eligible.
   3. Coordinating the provision of comprehensive health services from existing sources to all persons within the scope of the IHS health care program.
   4. Ascertaining whether other resource agencies will, in fact, provide necessary assistance.  Alternate resources may include: county, Tribal, State or Federal health programs [such as, Medicaid, Medicare, State Children's Health Insurance Programs (SCHIP), Veterans Affairs (VA) Hospital, and Department of Defense (DoD)]; and private or employee health insurance, or accident insurance, etc.
2. Alternate Resources.  If alternate resources cannot or will not provide the necessary assistance, the IHS may provide direct services based on the relative medical urgency of the case and the current availability of IHS resources subject to applicable eligibility requirements.
3. Other IHS Service Areas.  Persons within the scope of the IHS health care program in one Area will be provided available medical and/or other related services by any other Area in which they may require health services, except in the cases requiring PRC authorization (see the CHS policy in the IHM, 2-3.9 B).  The Area in which the services are rendered shall apply the same policies and have the same notification requirements for persons from other Areas as are applied to those persons within the Area.  Note:  CHS name was changed to PRC.

2-1.4  PROVISION OF SERVICES

1. Health Promotion and Disease Prevention.  Services at all IHS facilities shall be made available to all persons within the scope of the IHS programs.  As part of such service, those persons who are able and willing to utilize local IHS community health promotion and disease prevention services will be encouraged to do so.
2. Medical Care.  The medical care and treatment services, including hospitalization, based on the medical need of the persons within the scope of the program, are provided as available at IHS facilities or on a contractual basis when PRC funds are authorized.
3. Other Available Resources.  The IHS will encourage use of such services when at all possible.  The IHS will maintain relationships with agencies to facilitate the utilization of those resources.  Every effort should be made to effectively use other resources, particularly other Federal medical facilities wherever appropriate, to ensure adequate access to health care and the best utilization of resources available to patients.
4. Scope.  Persons determined to be within the scope of the program shall be eligible to participate in IHS Sanitation Facilities Construction Projects approved for the Indian community in which they reside.
5. Persons in Custody.  The cost of medical and related health services for eligible beneficiaries in custody of (non-Indian) law enforcement agencies is not the responsibility of the IHS, but is the responsibility of that particular agency.  Persons in the custody of Indian law enforcement agencies will be considered eligible on the same basis as other beneficiaries of the Service.  The IHS does not provide the same health services in each area served and services provided will depend upon the facilities and services available [42 C.F.R. § 136.11(c)].

2-1.5  PRIORITIES FOR SERVICE

1. Priorities for Service.  Limitations of funds, facilities, or staff may result in services not being available to all persons who come within the scope of the program.
2. Insufficient Funds.  When funds, facilities, or personnel are insufficient to provide the indicated volume of services, priorities for care and treatment among individuals who are within the scope of the program will be determined on the basis of relative medical need and access to other arrangements for obtaining the necessary care [42 C.F.R. § 136.12 (c)].
3. Guidelines for Priorities.  All services available at any IHS facility will be provided as needed to any person within the scope of the program who presents herself or himself at that facility and for whom the IHS facility is more accessible than other programs and resources at the time.  Services needed but not available at the IHS facility will be provided through the PRC program, depending upon the following criteria:
   1. The person's medical need, determined by a physician whenever possible.
   2. Availability of alternate resources.
   3. The financial resources available to the IHS facility at that time.
   4. The person's eligibility for PRC.
4. Denial of Services.
   1. The CEO, or appointed designee, may deny services to persons who, according to her or his determination, are not within the scope of the program.

      When services are denied, a written notice of such denial shall be given to the person.  Such written notice shall include:

      1. The basis for denial, listing the specific circumstances and facts upon which the priority decision was made.
      2. The name of the CEO or designated representative.
      3. The statement, "If you have any information which may affect this decision, you may submit it with a copy of this letter for review by the Area Director (Address)."
   2. A copy of each notice of denial for services shall be retained at the IHS facility and a copy shall be forwarded in the appeals process to the Area Office.

2-1.6  JOINT PLANNING FOR CARE OF AI/ANs

The Area Director is responsible for conducting joint planning with Tribal leaders and local, State and Federal agency representatives and other officials for the care of AI/ANs.

The Area Director will:

1. Recognize the principle that Indian people are entitled to State and local services when they meet the same requirements as other citizens of the State and locality.
2. Work with Indian groups affected and the State and local agencies for the utilization of available community services.
3. Follow the IHS Tribal Consultation Policy (IHS Circular No. 2006-01) when:
   1. An action is taken that will significantly affect Indian Tribes.
   2. New or revised policies or programs are proposed.
   3. The IHS budget request and annual performance plan are being developed.
4. Follow the IHS Policy on Conferring with Urban Indian Organizations (IHM Part 5, Chapter 26).
5. Identify gaps between comprehensive health needs of Indians and those services available through Federal, State and local community agencies, and jointly plan ways and means for bridging these gaps with those agencies.
6. Recognize the fact that in order to ensure the total services available to Indians are as comprehensive as possible, the IHS program and policy requirements may vary according to State and local situations.

2-1.7  FEDERALLY RECOGNIZED TRIBES

The Bureau of Indian Affairs (BIA), United States Department of Interior, issues a list of Federally-recognized American Indian Tribal entities, whom are eligible to receive services from the BIA, which is updated and posted in the Federal Register, annually.

The IHS also uses this list to identify Federally-recognized American Indian Tribal entities whom are eligible to receive services from IHS.  For a current listing of Tribal entities, please see the Indian Affairs Document Library websiteExit Disclaimer: You Are Leaving www.ihs.gov .