Requirements: EligibilityEligibility requirements for Purchased/Referred Care (PRC) are in addition to meeting the requirements for direct care services at an IHS or tribal facility. The PRC is not an entitlement program. An individual must meet the eligibility requirements as defined by Federal regulations published in Code of Federal Regulations (CFR), at Title 42, Section 136.21 through 136.25, and Indian Health Services, Part 2, Chapter 3, "Contract Health Services" dated January 5, 1998. These federal regulations are available at local Area IHS health centers and hospitals including the PRC webpage Resources Section. A person may be regarded as within the scope of the Indian Health program if he/she is not otherwise excluded there from by provision of law. There are five eligibility requirements, which must be met by each person needing and applying for PRC assistance.
The eligibility requirements are:
- Is of Indian and/or Alaska Native descent as evidenced by one or more of the factors:
Meaning an individual must be of Indian descent and belong to the Indian community which may be verified by tribal descendency or census number. An individual must be a member, enrolled or otherwise, or an Indian or Alaska Native Tribe or Group under Federal supervision;
Any other reasonable factor indicative of Indian descent; or
- Is an Indian of Canadian or Mexican origin recognized by any Indian tribe or group as a member of an Indian community served by the Indian Health program; or
- Is a non-Indian woman pregnant with an eligible Indian's child for the duration of her pregnancy through post partum (usually 6 weeks); or
- Is a non-Indian member of an eligible Indian's household and the medical officer in charge services are necessary to control a public health hazard or an acute infectious disease which constitutes a public health hazard.
- An individual resides within his/her Tribal Contract Health Service Delivery Area (CHSDA)
The Tribal CHSDA encompasses the Reservation, trust land, and the counties that border the reservation. Resides on tax-exempt land or owns restricted property;
The following individuals also must meet the residency requirements:
- Students who are temporarily absent from his/her CHSDA during full-time attendance of boarding school, college, vocational, technical, and other academic education. The coverage ceases 180 days after completing the study.
- A person who is temporarily absent from his/her CHSDA due to travel, employment, etc. eligibility ceases after 180 days.
- Children placed in foster care outside of the CHSDA by court order.
- Other Indian persons who maintain "close social and economic ties" with the Tribe.
- Notification and authorization of approval for payment. An individual must be authorized by PRC authorizing official for the payment of services.
- Authorization is based on a IHS provider issuing a referral for medical care being submitted to PRC program. The referral is reviewed by the Managed Care Committee who will determine the medical priority.
- In cases of emergency based on IHS medical priorities; a 72-hour notification to the PRC program must be made by the individual, provider, hospital, or someone on behalf of the individual.
- Notification is extended to 30-days for the elderly and disabled. Disabled meaning the individual cannot physically/mentally notify the PRC program.
- PRC funds are limited to the medical or dental services considered medically necessary and listed within the established Area IHS medical/dental priorities. A copy of the Area IHS medical/dental priorities is available at the local IHS health centers and hospitals including Priorities or Care section of this webpage. An individual medical need at the time of services must be within the medical priorities being funded at that time.
- 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. 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.
- 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. Citation CFR at Title 42 ï¿½136.61.