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Frequently Asked Questions (FAQ's)

Q. Are Indian descendents eligible for PRC if they reside on a reservation?

A: Yes. See 42 CFR 136.23 and 136.12.

Q. Are Indian descendents not eligible for PRC off the reservation?

A: Indian descendents residing off the reservation may be eligible if they meet certain conditions. Pursuant to 42 CFR 136.23(a)(2)(i) and (ii), if not residing on the reservation such individuals must live within the PRCDA and (1) be members of the tribe(s) located on the associated reservation or (2) "maintain close economic and social ties with that tribe or tribes."

Also see 42 CFR 136.23(b) related to students and transients, and 42 CFR 136.23(d) for foster children placed off the reservation.

Q. If 136.12 is mentioned in 136.23, does this mean Indians eligible for direct care are also automatically eligible for PRC?

A: No. In order to receive PRC, Indian beneficiaries must also meet the PRC eligibility requirements of 42 CFR 136.23, 136.24 and 136.61.

Q. Why do I have to apply for Alternate Resources?

A: This is required by 42 CFR 136.61, Payor of last resort. Approval of PRC payment for services is considered after all other Alternate Resources (AR) are applied. Any patient who is potentially eligible is required to apply for the alternate resource. IHS/Tribal facilities are considered resources.

Q. If I am eligible for PRC, why are some of my medical bills being paid and others not?

A: Each visit to a non-IHS health care provider and the associated medical bill is distinct and must be examined individually to determine PRC eligibility. All PRC requirements must be met for each episode (treatment) of care. A patient must meet residency, notification, medical priority of care and use of alternate resources requirements of 42 CFR 136.23, 136.24 and 136.61 in order to be eligible for PRC.

Example: If a PRC authorization is issued, IHS will pay the first medical treatment. Follow-up care or additional medical care are to be done nearest accessible IHS or tribal facility; or will require approval with a new PRC authorization. If this process is not followed, the patient may be responsible for the expense.

Q. An IHS doctor refers me to a specialist, why am I being held responsible for the bill?

A: Referrals are not a guarantee for payment. Referral is a recommendation for treatment/test only. The PRC program must review the referral to make the determination for IHS approval of payment. All PRC eligibility requirements must also be met. See 42 CFR 136.23, 136.24 and 136.61.

Q. If a hospital facility has a charity program, is this an alternate resource? Am I required to apply for this program?

A: This is examined on a case-by-case basis because charity programs vary in their coverage of care, funding for care, and requirements for eligibility. See 42 CFR 136.61.

Q. Can tribal self-insurance be billed as an Alternate Resource (AR)?

A: Sometimes. Tribal self-insurance can be billed as an AR, unless the insurance plan contains an exclusionary clause designating it as residual to IHS. Per IHS policy, to be consistent with direct service authority under section 206(f) of the Indian HealthCare Improvement Act (IHCIA) PL 94-427.

Q. Can a direct care patient be required to apply for an Alternate Resource?

A: No. Currently there is no requirement for patients to apply for an Alternate Resource when receiving direct care.

Q. Can the 180-day rule be extended?

A: No. 42 CFR 136.23(b)(1) and (c) clearly state the period is "not to exceed 180 days." The 180-day deadline is extended only to patients already receiving PRC authorized services.

Q. If a student/transient is covered under PRC, are the student/transient's dependents also covered?

A: Yes, dependents are eligible so long as the student/transient is eligible. The student/transient remains eligible for the duration of their education or transience and extends 180 days beyond that. See 42 CFR 136.23(c).

Q. Why do we have to provide direct care services to Indians that do not belong to the community?

A: 42 CFR 136.12 states that service will be extended "to persons of Indian descent belonging to the Indian community served by the local facilities and program" and "an individual may be regarded as within the scope of the Indian health and medical service program if he/she is regarded as an Indian by the community in which he/she lives as evidenced by such factors as tribal membership, enrollment, residence on tax-exempt land, ownership of restricted property, active participation in tribal affairs, or other relevant factors in keeping with general Bureau of Indian Affairs practices in the jurisdiction."

The IHS adheres to an "Open Door" policy in which all Indian descendants are provided direct health care. See Dear Tribal Leader Letter from Dr. Trujillo dated January 10, 2000.

Q. Where in the regulation does it state we have to follow medical priorities?

A: See 42 CFR 136.23(e), Priorities for contract health services.

Q. Children in foster care are eligible for PRC, but are they provided health care for all medical priorities, or only what the program is operating at?

A: Foster children are eligible on the same basis as other eligible Indians, including meeting the same standards for medical priority. See section 813(a)(1) of IHCIA.

Q. Can non-Indians be eligible for PRC?

A: Yes, but only for three classes of non-Indians. These include (1) non-Indian women pregnant with an eligible Indian's child during pregnancy through postpartum (42 CFR 136.12(a)); (2) non-Indians under 19 who are the natural, adopted, step-child, foster-child, legal ward, or orphan of an eligible Indian (section 813(a)(1) of IHCIA); and (3) non-Indian spouses of eligible Indians if all such spouses are made eligible through a tribal resolution (section 813(a)(2) of IHCIA).

Q. What does Social, Economic Ties mean in 42 CFR 136.23(a)(2)(ii)?

A: Close social and economic ties are determined by the governing body, or designee, of the local Tribe. The IHS considers employees of the Tribe and spouses and children of eligible members of the Tribe to have close social and economic ties. The determination of eligibility applies if all individuals with the same circumstances are made eligible through a tribal resolution.

Q. Can PRC/Direct Care eligibility be suspended due to abuse of regulations or other abuse (physical, fraud, etc.)?

A: No. Eligibility through IHS is a right and there is no provision for suspension of this right in the statutes or regulations. However, someone could be barred from a facility for dangerous behavior.

Q. If my PRC Program is operating on a strict budget, can PRC eligibility be suspended for non-Indians residing on and off the reservation?

A: Yes and no. No, for non-Indian children of eligible Indians made eligible under section 813(a)(1) of the IHCIA and non-Indian women pregnant with an eligible Indians child made eligible under 42 CFR 136.12(a). Yes, for non-Indian spouses made eligible under section 813(a)(2) of the IHCIA if the Tribe revokes the resolution which granted such individuals eligibility. No other non-Indians should be receiving PRC services.

Q. Can a PRC Program establish a cap on certain procedures, such as dental procedures, eyeglasses, etc.?

No. If a health service is within medical priorities, PRC must pay for the full amount of the service. See section 222 of IHCIA.

Q. Can a tribe decrease or increase their PRC delivery area?

A: Yes, but they must follow certain procedures (see 42 CFR 136.22(b)). Funding may not increase if the PRC delivery area expands, but it may decrease if the PRC delivery is reduced.

Q. Is the Crime Victims Act a viable AR?

A: No. The Crime Victims Act is not considered an AR under 42 CFR 136.61(c).

Q. If we are guaranteed health care from our treaties as long as the water flows and the grass grows, why are Indians required to apply for AR?

A: It is required under 42 CFR 136.61, Payor of last resort. While some treaties mention health care, the Indian Health Service is not an entitlement program, and therefore funding for PRC is not guaranteed by the Federal government. AR allow PRC funds to be conserved, thereby providing health care for more Indian beneficiaries.

Q. If I am residing in an area where there is a federally recognized tribe, but no reservation, can Social, Economic Ties be automatic to that tribe or do I have to apply/petition?

A: Social and economic ties are not automatic. The individual has to apply to the Tribe.

Q. If I move from one federally recognized reservation to another federally recognized reservation, does the 180-day rule apply?

A: See 42 CFR 136.23(a)(1) and (2). The 180-day rule applies until the client establishes residency and becomes eligible in another PRCDA.

Q. How does a PRC Program determine if a client has established residency? Does the program rely on program policy or tribal policy when it comes to determining residency on a reservation?

A: Residency it determined by both the physical presence of an individual in a location combined with the intent of the individual to remain there permanently. Intent is determined by IHS Proof of Residency and required documents verification.

Q. What is the citation that requires our PRC Program to provide PRC to non-Indian children?

A: See section 813(a)(1) of the IHCIA. PRC applies to non-Indian children if they are the natural, adopted, step-child, foster-child, legal ward, or orphan of an eligible Indian.

Q. Are we required to provide PRC to Commissioned Corps personnel and their families?

A: No. Commissioned Corps and their families are not eligible for PRC, unless they otherwise meet the eligibility requirements under 42 CFR 136.23.

Q. Can a CEO or Tribal Health Director determine Social, Economic Ties, or is this strictly a Tribal function?

A: This is a tribal function. However, this determination can be delegated by the relevant Tribe(s) to the CEO or Tribal Health Director.