by Jared Staheli
June 24th, 2015
The Indian Health Service (IHS) is the primary health care provider to the American Indian/Alaska Native (AI/AN) Medicare population. The Indian health care system, consisting of tribal, urban, and federally operated IHS health programs, delivers a spectrum of clinical and preventive health services to its beneficiaries, via a network of hospitals, clinics, and other entities. While §§1814(c) and 1835(d) of the Social Security Act (the Act), as amended, generally prohibit payment to any Federal agency, an exception is provided for IHS/Tribally owned and operated facilities under §1880. The enactment of Medicare, Medicaid, and State Children’s Health Insurance Program (SCHIP) Benefits Improvement and Protection Act of 2000 (BIPA), expanded payment for Medicare services provided in IHS/tribally owned and operated facilities beyond services provided in hospitals, skilled nursing facilities (SNFs) and swing-bed facilities.
Effective January 1, 2005, §630 of the Medicare Modernization ACT (MMA), extended to IHS facilities the ability to bill for all Medicare Part B covered services and items that were not covered under BIPA. This includes all screening and preventive services covered by Medicare. Section 2902 of the Patient Protection and Affordable Care Act (ACA) indefinitely extends §630 of the MMA, retroactive to January 1, 2010.
Tribally owned and operated facilities may choose to bill the Medicare program in one of two ways. First, these tribally owned and operated facilities are authorized to enroll or become certified to participate in the Medicare program as any other provider/supplier of Medicare services. Depending upon the type of supplier/provider, these entities file claims with the local Medicare Part B carrier or fiscal intermediary (FI) serving the specific geographic region where the facility is located and follow the same coverage and claims filing requirements as any other regular Medicare provider/supplier. On the other hand, since tribally owned and operated facilities are covered under the Indian Self Determination and Education Assistance Act (ISDEA), P.L.93-638 [25 U.S.C. 450 et seq.] (commonly referred to as “638”), this affords them the option of electing the same billing rights as facilities run by the IHS. Tribally owned and operated facilities choosing this option file claims with the designated Medicare Part B carrier and designated FI used for processing IHS claims instead of with the local Medicare Part B carrier or FI serving the specific geographic region where the facility is located. Because many tribally owned and operated facilities elect to file claims with the Medicare contractors designated for IHS, many tribal facilities not actually run by IHS are considered to be IHS for Medicare billing purposes. Unless otherwise specified, any references in this chapter to IHS providers, IHS suppliers or IHS physicians or practitioners includes: (1) tribally owned and operated facilities electing to bill as IHS; (2) tribally operated IHS facilities; (3) IHS owned and operated facilities; (4) tribally owned and IHS operated facilities. Tribally owned and operated facilities electing to bill the local Medicare Part B carrier or FI serving their specific geographic location should look to other pertinent chapters of this manual for instructions that apply to regular Medicare providers/suppliers, not to the provisions contained in this special chapter for IHS providers billing the designated IHS carrier and FI.
In this chapter the terms IHS provider, IHS supplier and IHS physician or practitioner pertain to the following:
• IHS provider refers to all hospital or hospital based-facilities, including outpatient clinics, unless otherwise noted.
• IHS supplier refers to a freestanding (non-hospital based) entity that furnishes durable medical equipment, prosthetics, orthotics, supplies (DMEPOS), and parenteral and enteral nutrition, unless otherwise noted.
• IHS physician or practitioners refers to physician and non-physician practitioners billing for services under Medicare Part B.
• NOTE: The ISDEA promotes maximum Indian participation in the government and education of the Indian people; provides for the full participation of Indian tribes in certain programs and services conducted by the Federal Government for Indians and encourages the development of the human resources of the Indian people; established and carries out a national Indian education program; to encourage the establishment of local Indian school control; to train professionals in Indian education; and establishes an Indian youth intern program.