The intent of this article is to provide information and clarification of the eligibility requirements for the Indian
Health Service (IHS) Contract Health Service (CHS) program. Even though the requirements have been published
in the Code of Federal Regulations since August 4, 1978, most medical providers believe all Indians are eligible for all
medical services. Many Indians,
including those employed by the IHS or tribes, and live on reservations
and in urban areas, do not know (1) if they are eligible for CHS; (2) that
direct care and CHS care have separate eligibility requirements; and (3)
patient responsibilities - if they expect their medical bills to be paid
by IHS. Many Indians erroneously assume that since they are eligible for
direct care in an IHS/tribal hospital/clinic, they are also eligible for
CHS when referred to private sector medical providers by IHS/tribal physicians.
Who Determines Eligibility for Direct and CHS Care?
The Phoenix Area IHS/tribal facilities are unique because the Business
Office Patient Registration staffs determine eligibility for direct and
CHS care in addition to registering patients in the computer system.
In other Areas throughout the country, only CHS staffs determine eligibility.
In addition, Patient Registration staffs inform patients about the CHS
federal regulations, policies and procedures, and establish their potential
eligibility for alternate resource programs. Alternate resource programs
pay for health care other than those of the IHS. Some examples of alternate
resources are Medicare,
State Medicaid,
AHCCCS (Arizona Medicaid),
Kids Care, Medi-Cal (California Medicaid),
Healthy Families,
Nevada Check Up,
Utah Children's Health Insurance Program,
Private Health Insurance, Workers Compensation,
Veterans Administration Benefits and others. If
a patient is determined to be potentially eligible for an alternate resource,
he/she is referred to a Benefits Coordinator or Contact Representative,
whose responsibility is to provide the patient with assistance and guidance
in the application process.
What Is Direct Care?
Direct care is primary health care provided in IHS/tribal facilities
at no cost to federally recognized Indians. Unfortunately, many specialty
services are not available in these facilities; consequently, the CHS
program was established to supplement direct care services.
What Is CHS Care?
Health care, usually specialty services, which are provided at the
expense of the CHS program and are purchased from other federal, public
and private hospitals and health providers because IHS/tribal facilities
do not provide that service. Also, IHS/tribes use CHS funds to pay for
health care where no direct care hospital or clinic exists. Although
IHS/tribal physicians, physician assistants, nurse/pharmacy practitioners
or other health care professionals refer patients to non-IHS facilities,
only specific authorizing officials can authorize CHS payment.
The CHS program is not a federal entitlement program such as Medicare/Medicaid
and it is not a Health Insurance Company; rather, it is a residual source
of payment for eligible Indians’ medical care and is funded annually
by the U.S. Congress. Funding is limited, therefore, the program cannot
pay for all needed medical care services.
Eligibility for Direct Care
Individuals must provide the IHS with documentation that they are
a descendant of a member of a federally recognized American Indian Tribe,
or he/she is an enrolled member of a federally recognized tribe. The
most common forms of documentation are provided by the Bureau of Indian
Affairs (BIA), tribal enrollment cards, tribal census numbers, and Certificate
of Degree of Indian Blood (CDIB) Cards. Indian tribes from Canada, Mexico,
Central America, and South America are not federally recognized and their
members are not eligible for direct or CHS care.
Eligibility for CHS Care
To be eligible for CHS, an individual must meet the eligibility requirements
as defined in the Code of Federal Regulations (CFR), Title 42, Subpart
C, Section 136.21 and Subpart G, Section 136.61, which states:
1. Individuals must first meet the eligibility requirements for direct
care; and
2. live in the United States and on a reservation located within a CHS
delivery area, or CHSDA;
(A CHSDA is a geographic area where CHS is made available by the IHS/tribe(s).
In Arizona and Utah, a CHSDA consists of a county which includes all or
part of an Indian reservation, and any county or counties which have a
common boundary with the reservation. In Nevada, the entire state is designated
a CHSDA for native Nevada Indian Tribes. CHSDAS were established for each
Indian reservation and are listed in the Federal Register. They identify
the county/counties and states where Indians must live to be considered
eligible for CHS.)
3. Reside within the United States, and within a CHSDA, and be a member
of the tribe or tribes located on that reservation; or maintain close economic
and social ties with that tribe or tribes. The basis for determining close
economic and social ties are established by (1) the Indian must be employed
with a tribe whose reservation is located within a CHSDA in which the applicant
lives; (2) the Indian must be married to or be a minor child under 19 years
of age of an eligible member of the tribe; or (3) the Indian must provide
the IHS CHS program with certification from the tribe or tribes whose reservation
is located within the CHSDA in which the applicant lives that asserts the
applicant maintains close economic and social ties with the tribe or tribes.
4. Be a full-time student in a BIA boarding school. Boarding school students
are eligible for CHS whether or not they resided in a CHSDA before attending
the school.
5. Full-time students, including their spouse and minor children,
are eligible for CHS through their Area of Record or Home Service Unit,
while they attend a university, college, vocational, or technical school.
The student must have been eligible for CHS at the place of his/her permanent
residence within a CHSDA prior to enrollment. The individual must provide
the IHS with proof of his/her full-time student status from the school
registrar’s office. However, full-time students and their family
members must comply with all CHS federal regulations requirements before
their medical care can be authorized. Full-time students remain eligible
during school breaks, vacations and 180 days or six months after they leave
school.
6. Transients are eligible for CHS through their Area of Record or Home
Service Unit during their absence from their permanent place of residence.
Transients are persons who are in travel status or are temporarily employed
away from their homes, such as seasonal or migratory workers. However,
transients must comply with all CHS federal regulation requirements before
their medical care can be authorized.
7. Individuals who leave the CHSDA where they are eligible for CHS, and
are neither students nor transients, will lose their CHS eligibility after
180 days, or six months.
8. Indians adopted by non-Indian parents are CHS eligible if they meet
all CHS eligibility requirements.
9. Foster/custodial children remain CHS eligible when they are placed
in foster care outside their CHSDA by order of a court of competent jurisdiction,
and who were CHS eligible at the time of the court order.
Other CHS Eligibility Considerations Are Extended To
10. A non-Indian woman who is pregnant with an eligible Indian’s
child during pregnancy through postpartum. The States of Arizona, Nevada,
and Utah do not recognize “common law marriage”; therefore,
if the non-Indian pregnant woman is not married to the eligible Indian,
she must present proof of legal paternity.
11. A non-Indian member of an eligible Indian’s household, if the
Service Unit Medical Officer determines that CHS are necessary to control
a public health hazard or an acute infectious disease that would endanger
the members of the Indian household.
12. A non-Indian child, under 19 years of age, who is the natural, adopted,
step, foster, legal ward, or orphan of a CHS eligible Indian, and is not
otherwise eligible.
13. In non-emergency cases, individuals must obtain prior authorization
from the CHS authorizing official for all non-emergency medical care, e.g.,
office visits, diagnostic testing, chronic conditions, etc.
14. In emergency cases, individuals or medical providers must notify the
CHS authorizing official within 72 hours after receiving emergency treatment
or emergency hospitalization. An exception is made for the elderly, 65
years and older, or those who are physically/mentally disabled. They are
allowed 30 days to notify the CHS authorizing official of emergency treatment
or emergency hospitalization.
15. Medical services requested or received from private sector providers
must fall within IHS medical priorities for CHS payment.
16. Individuals who are potentially eligible for alternate resources must
apply and complete the application process and provide the CHS program
with a copy the program determination. IHS/tribal hospitals/clinics are
considered as an alternate resource for health care, therefore, the CHS
program will not pay for medical services that are reasonably accessible
and available at IHS/tribal facilities.
CHS Denial and Appeal Process:
Payment will be denied when the above requirements are not met or
when there is insufficient patient information. There are three levels
in the CHS denial process, as follows:
1. If the patient or provider(s) disagrees with the denial, he/she may
appeal to the Chief Executive Officer at his/her Service Unit within 30
days from the date the denial is received.
2. If the Chief Executive Officer upholds the original decision to deny
payment, the patient or provider may appeal to the Area Director.
3. If the Area Director sustains the original decision to deny payment,
the patient or provider may appeal to the Director of IHS, whose decision
constitutes the final administrative action.
Eligibility for CHS can change when an individual leaves his/her reservation/CHSDA;
establishes residency on another tribe’s reservation; establishes
residency in another country; marries an eligible Indian; divorces an eligible
Indian; gets pregnant; changes employment; and other reasons. Therefore,
it is important to report any of these changes to the local IHS/tribal
facility.
For more information about the CHS program, please contact Rita Moreno, Acting CHS Officer, at (602) 364-5146.
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