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U.S. Department of Health and Human Services
Indian Health Manual

Chapter 4 - New Or Restored Federally Recognized Tribes

Part 6 - Services To Tribal Governments And Tribal Organizations

Title Section
Introduction 6-4.1
    Purpose 6-4.1A
    Authority 6-4.1B
    Definitions 6-4.1C
Responsibilities 6-4.2
    Director, IHS 6-4.2A
    Directors, Headquarters Offices 6-4.2B
    Area Director 6-4.2C
Procedures 6-4.3
    Appropriation Request 6-4.3A
    Appropriation Request to Congress 6-4.3B
    Availability of Requested Appropriations 6-4.3C
    Funding Instrument 6-4.3D
Methodology to Compute Initial Funding 6-4.4
    Initial Funding Amount 6-4.4A
    Time-Frame 6-4.4B
    Data 6-4.4C
Personal Health Care Services 6-4.5
    Personal Health Care Services 6-4.5A
    Personal Health Care Services Amount 6-4.5B
    Personal Health Care Services Formula 6-4.5C
    Forecast Users 6-4.5D
    Cost Factor 6-4.5E
    Average Funding Percentage 6-4.5F
    Exclusions 6-4.5G
Wrap-Around Services 6-4.6
    Types of Wrap-Around Programs 6-4.6A
    Wrap-Around Services Amount 6-4.6B
    Wrap-Around Services Formula 6-4.6C
    Construction is Separate 6-4.6D
Program Administration and Support Amount 6-4.7
    Program Administration and Support Amount 6-4.7A
    Rationale for Separate Administration and Support Services Computation 6-4.7B
    Program Administration and Support Formula 6-4.7C
    Itemized Tribal Shares and Residual 6-4.7D
    Historical Average 6-4.7E
Accounting 6-4.8
    Financial Management System 6-4.8A
    Tracking 6-4.8B

Exhibit Description
Manual Exhibit 6-4-A Federal Disparity Index

6-4.1  INTRODUCTION

  1. Purpose.  This chapter revises the Indian Health Service (IHS) policy for integrating new Federally Recognized or Restored Tribes into the IHS system.
  2. Authority.
    1. Snyder Act, Title 25 United States Code (U.S.C.) Section 13, Chapter 1
    2. Procedures for establishing that an American Indian group exists as an Indian Tribe, Title 25 Code of Federal Regulations (CFR), Part 83
    3. Indian Health Service Regulations, Title 42 CFR Part 136
    4. Indian Self-Determination and Education Assistance Act, Public Law (P.L.) 93-638, as amended, Title 25 U.S.C., Section 14, Subchapter II
    5. Indian Health Care Improvement Act, as amended, Title 25 U.S.C., Chapter 18, "General Provisions," Section 1601, et seq.
    6. Transfer Act, Title 42 U.S.C., Chapter 22, Subchapter 1, Section 2001
  3. Definitions.
    1. Appropriations.  Funds appropriated and authorized by Congress and approved by the President in support of IHS operations.
    2. Appropriations Request.  A funding request.
    3. Area Director.  The Director of an IHS Area Office designated to administer IHS programs.  The Area Director reports to the Deputy Director, IHS.
    4. Area Office.  An IHS administrative entity that provides services and funds to the Service Units within a defined geographic area.
    5. Contract Health Service Delivery Area.  The geographic area within which contract health services (CHS) will be made available by the IHS or Tribes to members of an identified Indian community who reside in the area. (Reference: Title 42 CFR, Subpart C, Section 136.21(d))
    6. Contract Health Services.  Health services provided at the expense of the IHS that are obtained from public or private medical or hospital facilities other than those of the services. (Reference: Title 42 CFR, Subpart C, Section 136.21(e))
    7. New Federally Recognized Tribe.  A Tribal entity that has been formally recognized by the United States (U.S.) Government.  The Tribal Government is eligible to receive services from the IHS and other Federal Agencies by virtue of its status as an Indian Tribe or Alaska Native Corporation.  The Tribal Government is acknowledged to have the immunities and privileges available to other federally acknowledged Indian Tribes by virtue of its Government-to-Government relationship with the U.S., as well as the responsibilities, powers, limitations, and obligations of such Tribes.
    8. Indian Tribe.  Any Federally Recognized Indian Tribe, band, nation, group, Pueblo or community, including any Alaska Native village or Native group eligible for the special programs and services provided by the U.S. Government, to Indians because of their status as American Indians or Alaska Natives.  (Reference: Title 42 CFR, Subpart C, Section 136.21(g))
    9. Interim Funding.  Funding used by the IHS and Tribes for planning of Tribal health and program services.  Interim funding, if available, is non-recurring and may not be made available when doing so would have the effect of reducing services provided to, or funding received by, previously designated Federally Recognized Tribes.

6-4.2  RESPONSIBILITIES

  1. Director, IHS.  Upon receiving the verification from the Director, Office of Tribal Programs (OTP), that a Tribe has been newly recognized, the Director, IHS, shall notify, in writing, the appropriate Area Director to assign administrative responsibility.  The notification will establish the new Federally Recognized Tribe's status with respect to the designation of a contract health service delivery area (CHSDA) and any unique provisions included in the Tribe's recognition with such special instructions as may be necessary and not covered by existing policy.
  2. Directors, IHS Headquarters Offices.  The Director of the appropriate IHS Headquarters Office shall ensure that activities to identify the resource needs of new and restored Federally Recognized Tribes are supported.  The consideration of resource needs for this group shall be evaluated within the context of the programs, functions, services, and activities currently available to Tribes previously recognized by the Federal Government and served by the IHS.
    1. Director, Office of Tribal Programs.  The Director, OTP, is responsible for monitoring pending legislation and administrative actions regarding Federal Recognition of new Tribes and restored Tribes and informing the Director, IHS, of the status and disposition of applicants seeking Federal Recognition.
    2. Director, Division of Regulatory Affairs.  The Director, Division of Regulatory Affairs, in collaboration with the Director, OTP, will draft a memorandum for signature by the IHS Director that notifies the Area Director of a new or restored Federally Recognized Tribe.  The memorandum will include, to the extent available, the documentation and background information accompanying the new or restored Tribe's recognition application.
  3. Area Director.  The Area Director will identify an initial funding amount using the most current methodologies and data available.  The Area Director is responsible, in consultation and collaboration with the new or restored Federally Recognized Tribe, for:
    1. preparing a new or restored Federally Recognized Tribe's funding request and forwarding the request to the Director, Office of Finance and Accounting, for inclusion in either the IHS Director's budget request to the Secretary of Health and Human Services, or the President's annual budget to Congress, or the supplemental budget request, whichever is first;
    2. developing an appropriate Tribal health care delivery system plan, including short and long-term needs;
    3. preparing a budget request for funding through either the annual or the supplemental appropriations process;
    4. identifying any funds that are available for interim funding for planning; and
    5. ensuring that services and/or programs available at IHS-operated or funded facilities are provided to members of the new or restored Federally Recognized Tribe on the same basis as services are provided to other eligible Indians or Alaska Natives.

6-4.3  PROCEDURES

The following are procedures for evaluating new or restored Federally Recognized Tribes resource needs within the context of the programs, functions, services, and activities currently available to Tribes previously recognized by the Federal Government and served by the IHS.

  1. Appropriation Request.  The appropriation request shall be prepared as soon as possible.  The appropriation request shall include reasonable amounts or sufficient funds for:
    1. personal health care services (see Section 5) to members of the new or restored Federally Recognized Tribe,
    2. wrap-around services (see Section 6), and
    3. program administration and support services (see Section 7).
  2. Appropriation Request to Congress.
    1. The appropriation request to Congress will be included in the budget cycle immediately following the new or restored Tribe's recognition.
    2. The funding amount requested shall be determined by applying the formula specified in Section 6.
    3. The appropriation request will be forwarded for inclusion in either the annual or the supplemental budget formulation process, whichever is first.
    4. The funding amount will be itemized and requested in the appropriate IHS budget categories (e.g., Hospitals and Clinics, Contract Health Care, Preventive Care, etc.).
  3. Availability of the Requested Appropriations.
    1. Program funds for new or restored Federally Recognized Tribes will be provided to eligible members:
      1. when and to the extent funds are explicitly appropriated for this purpose, or
      2. to the extent and by such means as otherwise instructed by Congress.
    2. If the appropriated funds to serve eligible members of the new or restored Federally Recognized Tribe are less than the amount requested, the amounts made available for personal health care services, wrap-around services, and program administration and support services will be proportionately adjusted in the formula based on the appropriation.
    3. As new additional funding becomes available in subsequent years for a new or a restored Federally Recognized Tribe, the funding will be provided to eligible members:  following allocation of initial funding, the Area Director will determine and allocate funds that may become available on the same basis as for other Tribes.
  4. Funding Instrument.  The Area Director will consult with new or restored Federally Recognized Tribes to establish a funding instrument in consideration of the wishes, qualifications, and circumstances of the new or restored Federally Recognized Tribe.  Available instruments include the following:
    1. Self-Determination contract,
    2. Self-Governance compact after establishing status as mature Self-Determination contract,
    3. joining existing consortia of Tribal contract or compacts, if practical and mutually agreed to by the new or restored Federally Recognized Tribe,
    4. joining an existing IHS-operated program, if practical, or
    5. any combination of the above.

6-4.4  METHODOLOGY TO COMPUTE INITIAL FUNDING

  1. Initial Funding Amount.  The funding amount requested will consist of the sum of three parts:
    1. Personal health services amount as computed in Section 5.
    2. Wrap-around services amount as computed in Section 6.
    3. Program administration and support services amount as computed in Section 7.
  2. Time-Frame.  The Area Director will work with the new or restored Federally Recognized Tribe within 90 days following formal recognition to:
    1. orient the Tribe to the IHS,
    2. assess Tribal health plans for funding a new health care program for Tribal members, and
    3. collect and verify data necessary to compute the initial funding amount.
  3. Data.  The following data elements are required to compute the initial funding amount:
    1. Identification of the CHSDA applicable to the new or restored Federally Recognized Tribe.  (Reference: Title 42 CFR, Subpart C, Section 136.21(d))
    2. Estimates of the number of newly eligible beneficiaries who conform to current CHS eligibility regulations (as specified in Title 42, Subpart C, Section 136.21(d)) forecast to use health and medical services.
    3. Health care cost factors for the CHSDA using results from the Federal Employees Health Plan Disparity Index (FDI) methodology.  (See Manual Appendix 6-4-A.)

6-4.5  PERSONAL HEALTH CARE SERVICES

  1. Personal Health Care Services.  Personal health care services are medical and other health care services directly related to patient care provided to eligible American Indians and Alaska Natives.  Personal health care services for the Indian community served by the local facilities and program may include:
    1. hospital and medical care,
    2. dental care,
    3. public health nursing,
    4. preventive care (including immunizations), and
    5. health examination of special groups such as school children.
  2. Personal Health Care Services Amount.  The initial funding amount for personal health care services is computed as the product of three factors:
    1. the number of users forecast for the new or restored Federally Recognized Tribe, multiplied by,
    2. a personal health care cost factor for the CHSDA, multiplied by,
    3. the IHS average funding percentage.
  3. Personal Health Care Services Formula.  The formula for finding the Personal Health Care Services amount is:

    Personal Health Care Services Amount =Forecast Users multiplied by the Cost Factor multiplied by the Average Funding Percentage.

  4. Forecast Users.  Forecast users are newly eligible persons residing in the CHSDA who are likely to seek services and are not duplicated elsewhere in IHS or Tribal health program user counts.  The forecasted number of newly eligible persons will be determined following consultation by the IHS Headquarters staff, Area statistical and planning staff, and the new or restored Tribe, referencing current eligibility, as specified in Title 42 CFR, Part 136, Subpart B, Section 136.12.

    The forecasts will be based on the most credible data available and may include consideration of Tribal membership rolls, surveys and lists from Tribal plans, and other recognized health care planning factors.  Unemployment and insurance coverage data may be useful in estimating the percentage of eligible persons who would actually seek services (e.g., persons with health insurance through employers may not seek services).  Persons who are already counted in neighboring IHS or Tribal health care programs (e.g., some members of the new Federally Recognized Tribe may have descendancy or links to existing Federally Recognized Tribes) should be excluded to avoid duplication.

  5. Cost Factor.  The cost factor for a typical package of personal health care services will be provided from results of the FDI methodology.  The FDI methodology actuarially measures the health care costs for American Indian and Alaskan Native people using a mainstream health care benefit plan such as the Federal Employees Health Benefits Program.  The methodology considers age, sex, and demographic health risk factors for American Indian and Alaska Native people, geographic variations in health care costs, and an annual inflation rate for health plan premiums.  The personal health care services cost benchmark is supplied by IHS Headquarters staff for the relevant CHSDA. (See Manual Exhibit 6-4-A.)
  6. Average Funding Percentage.  Federal health care funding for almost all existing Tribes has been far less than projected by the FDI methodology.  To balance Federal allocations following the recognition of a new or restored Federally Recognized Tribe, Congress instructed the IHS to compute initial funding amounts for new or restored Federally Recognized Tribes consistent with the average funding percentage for all Tribes served by the IHS.  This ensures that any existing Tribe which had been under-funded is treated fairly.  The average funding percentage from the most recent application of the FDI methodology will be supplied by the Director, OTP.
  7. Exclusions.  Personal health care services exclude the following: public health programs, community health programs, certain mental health services, certain alcohol and substance abuse services, administration and support, and facilities.

6-4.6  WRAP-AROUND SERVICES

  1. Types of Wrap-Around Programs.  Indian Health Service programs for new or restored Tribes include important public health and community based programs that are not typically part of mainstream personal health care benefit packages in addition to personal health care services.  When local governmental infrastructure is insufficient or unavailable, the IHS often provides important public health programs in reservation areas.  The extent and type of public health and community based wrap-around type programs provided by the IHS vary with local circumstances and may include:
    1. Public health nursing
    2. Community health representatives
    3. Environmental health monitoring
    4. Emergency Medical Services
    5. Traditional healing and wellness programs
    6. Certain mental health services
    7. Certain alcohol and substance abuse services
  2. Wrap-Around Services Amount.  A wrap-around services amount is requested for public and community health care programs and certain other services that are not included in the personal health care services package, in addition to personal health care services that focus on patient care to individuals.
  3. Wrap-Around Services Formula.  The initial request for funds must be consistent with the extent that Congress has funded similar programs for existing Tribes.  The formula for computing the initial funding amount for wrap-around services follows:

    Personal Health Care Services Amount (as computed in Section 6-4.5C) multiplied by 15 percent = Initial Funding Amount

  4. Construction is Separate.  Construction of health care facilities, water supply facilities, and waste disposal facilities are provided in separate appropriations and are subject to conditions and priorities that cannot be represented in this computation for initial funding. Therefore, facility cost factors for medical buildings, water supply, and waste disposal sites are excluded from this computation. The new or restored Federally Recognized Tribe may request an assessment from the Office of Environmental Health and Engineering to be considered in the IHS sanitation construction priority system and the IHS facility construction priority system, if applicable.

6-4.7  PROGRAM ADMINISTRATION AND SUPPORT AMOUNT

  1. Program Administration and Support Amount.  An amount for the reasonable costs of program administration and support will be included in the appropriation request, in addition to amounts for personal health care services and wrap-around services.  Such functions are necessary for the prudent and efficient management of health care delivery programs.
  2. Rationale for Separate Program Administration and Support Computation.  The accounting methods used by mainstream hospitals, providers, and insurance plans to establish charges and premiums typically do not isolate support and administration costs from other costs of care.  Using comparable cost benchmarking methods, these costs ordinarily would be built into the personal health care services (Section 6-4.5C) and wrap-around amounts computed in Section 6-4.6C.  However, the unique Federal laws governing Indian health programs, particularly the Indian Self-Determination and Education Assistance Act (ISDEAA), P.L. 93-638, as amended, authorize Tribes to contract or compact for IHS health programs, including separate administrative and support functions typically performed in IHS Areas and Headquarters. Moreover, the ISDEAA recognizes certain functions as necessary for the IHS to fulfill legal responsibilities that must be carried out by Federal officials.  For these reasons, the appropriation request for initial funds for a new or restored Federally Recognized Tribe includes a separate amount for program administration and support that is itemized according to categories and practices developed to conform to ISDEAA requirements.
  3. Program Administration and Support Formula.  The IHS does not provide administrative or support functions to a Tribe prior to formal Federal recognition.  Area Office and Headquarters budgets contain no administrative or support funds for a new or restored Federally Recognized Tribe.  Consequently, an amount for program administration and support is computed in proportion to the funding attributed to existing Tribes based on historical experience.  This amount is computed by first summing the personal health care services amount and the wrap-around services amount and then multiplying the result by 18 percent.

    Program administration and support amount = (sum of personal health care services and wrap-around services amounts) multiplied by 18 percent.

  4. Itemized Tribal Shares and Residual.  The program administration and support amount is itemized to facilitate consistency with the nomenclature and financial accounting practices that have evolved in response to the unique requirements of the ISDEAA.  Tribal shares are composed of IHS administrative and support functions that the Tribe may assume in a Self-Determination contract or compact.  Inherently Federal functions that are retained by the IHS to fulfill its legal obligations are commonly referred to as residual functions.  These program administration and support amounts are further itemized by Area Offices and Headquarters, although this subdivision does not change the amounts that the new or restored Federally Recognized Tribe may elect to include in its contract or compact.  The program administration and support amount is itemized as follows:
    1. Tribal Shares Amount:  15 percent
    2. Area Office Tribal Shares Amount:  9 percent (60 percent of 15 percent)
    3. Headquarters Tribal Shares Amount:  6 percent (40 percent of 15 percent)
    4. Residual Amount:  3 percent
    5. Area Office Residual Amount:  1.8 percent (60 percent of 3 percent)
    6. Headquarters Residual Amount:  1.2 percent (40 percent of 3 percent)
  5. Historical Average.  The cost factor for program administration and support is a historical average based on IHS experience with existing Tribal contracts and compacts.  The actual cost rates experienced by individual Tribal contracts and compacts vary substantially depending on many circumstances.

6-4.8  ACCOUNTING

  1. Financial Management System.  Consistent with the funding instruments (see Section 6-4.3D) that a new or restored Federally Recognized Tribe may elect to use, the accounting of funds appropriated to serve members of the new Tribe will be tracked in the IHS financial management system.
  2. Tracking.  The tracking of appropriated funds accounting will occur as follows:
    1. Personal Health Care Services Funds.  Personal health care services funds will be tracked in Area Office accounts.
    2. Wrap-Around Services Funds.  Wrap-around services funds will be tracked in Area Office accounts.
    3. Area Office Tribal Share Funds.  Area Office Tribal share funds will be tracked in Area Office accounts.
    4. Area Office Residual Funds.  Area Office residual funds will be tracked in Area Office accounts.
    5. Headquarters Tribal Share Funds.  Headquarters Tribal share funds will be tracked in Headquarters accounts.
    6. Headquarters Residual Funds.  Headquarters residual funds will be tracked in Headquarters accounts.
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