Indian Health Service Coverage
Indian Health Services (IHS) is the federal agency that provides health services to American Indians and Alaskan Natives. The IHS is the principal healthcare provider for many in the American Indian community serving millions of people in 567 tribes, across 35 states. More information about IHS can be found in the Indian Health Manual (ihs.gov).
However, IHS is not health insurance. It is a system of clinics and hospitals where American Indians and Alaska Natives can get health care services. Some of these clinics and hospitals are on tribal land but managed by IHS, some are managed by tribes, and some are in cities. If people need services not provided at an IHS location, IHS may pay for them to buy health care somewhere else. This is called “Purchased Referred Care.”
Purchase Referred Care (PRC) is health care purchased by the IHS from non-IHS providers and facilities when direct services are not available from IHS. It is limited to services that fall under IHS priorities (further defined below). There is also limited funding for PRC. Once funding runs out each year, no other services can be purchased. Learn more about Purchase Referred Care.
IHS is divided into 12 service regions which are outlined in the map below.
Congress requires that Indian Health Service funds such as PRC be used to provide health services for Indians who live on or near Indian reservations in areas known as Purchase Referred Care Delivery Areas (PRCDA). These areas typically include counties which include all of or part a reservation or any county that has a common boundary with the reservation. Additionally, PRCDA counties include:
- The entire states of Alaska, Nevada and Oklahoma.
- In Michigan, this includes: Chippewa, Mackinac, Luce, Alger, Schoolcraft, Delta, and Marquette counties.
- In Wisconsin, this includes: Clark, Eau Claire, Jackson, La Crosse, Monroe, Vernon, Crawford, Shawano, Marathon, Wood, Juneau, Adams, Columbia, and Sauk Counties
- In Minnesota, this includes: Houston County.
IHS is not the only health care resource available to American Indians and Alaskan Natives.
Indian Health Services uses a prioritization system to determine which services can be covered through Purchased Referred Care. The Indian Health Service Manual, Circular 95-3, provides an overview of major organ transplantation policy including covered services. Published in 1995, this manual outlines all organ transplantation management policies for IHS and includes cellular transplants as a covered service. In addition to medically necessary services before and during transplant, post-transplant services are considered part of the episode of care for purposes of reimbursement. This could include support services such as psychological, social services, and housing, etc.
Funds for ongoing immunosuppressant medications are considered a necessary expense and part of the episode of care. Admissions for late major complications, such as GVHD or second transplants, will be considered a new episode of care and thus subject to re-approval. PRC funds are used to supplement and compliment other health care resources available to eligible American Indian patients.
However, it is important to understand that IHS is not an insurance program. It is considered a “discretionary program” where federal funding must be approved on an annual basis by Congress, leaving it open to broad budget cuts. This means that coverage is not guaranteed under IHS if funding runs out or is cut. If services are not authorized for payment they will be denied or deferred.
Additionally, the Purchased Referred Care program cannot be used if a patient is eligible for coverage through an entitlement program such as Medicaid or Medicare but is not accessing that coverage. If a patient is determined to have been eligible for other coverage, PRC coverage will be denied.
Transplant Authorization Process
Transplants must be pre-authorized by the appropriate PRC program before the patient receives medical treatment in order for PRC to pay. To receive authorization for transplant, patients must present to an IHS/Tribal or American Indian Urban Facility and a referral must be written by an IHS/Tribal/Urban provider for medically indicated transplant which cannot be provided directly through IHS.
A referral does not authorize payment for medical care delivered. Although transplant is a covered service in the IHS manual, each PRC is allowed to have their own prioritization schedule and there may be variation so it is important to verify with the local PRC. Additionally, funds may run out and prevent covered services from being paid for. Once a referral is received, a review committee makes a determination by ranking the request. If a local tribe has assumed responsibility for their own PRC program, than the tribe makes the determination.
Priorities of care and treatment for health care services are determined on the basis of medical need. The Chief Medical Officer of each IHS region or tribe determines the ranking system used for evaluating requests. Services are limited to those medically indicated within the established medical priorities. IHS has 5 Medical Priorities Levels:
- Emergent or Acutely Urgent Care Services
- Preventive Care Services
- Primary and Secondary Care Services
- Chronic Tertiary Care Services
- Excluded Services
Generally, organ transplantation may or may not fall under the highest priority level when a regional PRC or tribe is reviewing a request. However, if services are approved, the patient will be contacted by PRC with appointment information to see a transplant provider/transplant center or they may contact their servicing PRC office to find out the status of their referral.
Reimbursement for Cellular Therapies
The Indian Health Manual contains important information providing an overview of the program including information on cellular therapy and hematopoietic cell transplantation. Accessing financial support for cellular therapies is a complex process. Outlined below are the three areas critical for understanding how patient eligibility, medical prioritization and billing requirements determine whether services will be reimbursed.
|Stage 1: Understanding Patient Eligibility||Stage 2: Medical Prioritization||Stage 3: Billing Requirements|
Patients are eligible if:
They are a member or descendant of a federally recognized tribe or have close ties acknowledged by a tribe; and
They live on a reservation or PRC Delivery Area county
They get prior approval for transplant.
Payment may be approved if:
The transplant is considered medically necessary as indicated by medical documentation provided; and
The transplant is not available at an accessible IHS or tribal facility (note: this is always true for transplants as there are no transplant centers in the IHS network); and
The local PRC committee determines that the case is within the current medical priorities as determined by each tribe or PRC office's medical director; and
PRC funds available are sufficient to pay for the transplant.
Services will be paid for if:
The payment applies for all alternative resources for which they may be eligible. (Medicare, Medicaid, etc); then
A PRC purchase order is issued to a provider authorizing payment for services; then
IHS or tribal staff and the authorized provider coordinate medical care; then
The authorized provider bills and collects from the patient's alternate resources, then
The authorized provider bills any unpaid balance to the PRC for payment (PRC is payer of last resort).
Required Registration for IHS Transplant Registry
All IHS eligible patients undergoing transplant must be registered for the transplant registry, regardless of the source of payment. A form must be submitted at the time of pre-transplant evaluation, within 2 weeks post-transplant, at 6 months and 1 year post-transplant, and when payment Information becomes available. Access the Transplant Registry Form (ihs.gov). View the IHS Transplant Management Policy.
Federal appeal: If services are denied, the patient may file an appeal. The IHS appeals process applies to IHS-administered PRC programs, and has 3 levels of appeal:
- A request for reconsideration of the appeal by the Service Unit CEO.
- A request for appeal to the Area Director.
- A final appeal to the Director, IHS (Rockville, Maryland).
Tribal appeal: Tribes that have assumed their PRC program are required to provide their own administrative appeal procedures and IHS is not involved.
• If a tribal appeal is submitted to an IHS PRC office, it is forwarded to the appropriate tribal PRC office for processing.
Contact Indian Health Service for more information.