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Requirements: Alternate Resources

The IHS is considered the payor of last resort, and as such, the use of alternate resources is required when such resources are available and accessible to the individual. The Indian Health Care Improvement Act Amendments (P.L. 100-713) include the following explicit requirement:

Establish a procedure that will ensure no payment shall be made from the Fund to any provider of treatment to the extent that such provider is eligible to receive payment for the treatment from any other Federal, State, local, or private source of reimbursement for which the patient is eligible.

To ensure compliance with the requirement for the use of alternate resources, Service Unit Directors, and their tribal counterparts, will be required to follow PRC rules and regulations governing such procedures. Funds expended for medical cases later reimbursed by alternate resources must be returned to the facility program account.

An individual must apply for and use all alternate resources that are available and accessible, such as:

  • Medicare A and B,
  • State Medicaid,
  • State or other federal health program,
  • Private insurance, etc.
  • IHS or Tribal health facilities

The IHS is the "payor of last resort" of persons defined as eligible for PRC, notwithstanding any state or local law or regulation to the contrary.

The IHS facility is also considered a resource, and therefore, the PRC funds may not be expended for services reasonably accessible and available at IHS facilities. When a IHS facility capable of providing these services is within ninety minutes (90) minutes one-way surface transportation time from the person's place of residence to the nearest IHS facility.

42CFR136.61 Subpart G (c) Alternate resources means health care resources other than those of the Indian Health Service. Such resources include health care providers and institutions, and health care programs for the payment of health services including but not limited to programs under titles XVIII or XIX of the Social Security Act (i.e., Medicare, Medicaid), State or local health care programs, and private insurance. [64 FR 58322, Oct. 28, 1999]