Your Tribe’s Name
TRIBAL PREMIUM SPONSORSHIP PROGRAM
POLICIES and PROCEDURES November, 2014
Acknowledgements; Port Gamble S’Klallam & Swinomish Tribes and input from in-person
visits with Confederated Tribes of the Colville Reservation, Tulalip Tribes, Makah Nation,
Quinault Nation, Lummi Nation, Nisqually and Muckleshoot Tribe and the Coeur d’Alene
Tribe of Idaho (with Washington and Idaho Patients).
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TRIBAL PREMIUM SPONSORSHIP PROGRAM ........................................................................................ 4
INTRODUCTION ................................................................................................................................ 4
Purpose .............................................................................................................................................................................. 4
Timeline and History ........................................................................................................................ 4
TERMS OF PARTICIPATION ................................................................................................................ 5
RESPONSIBILITIES, TPSP ..................................................................................................................... 5
Segregation of FUNDS FOR SPONSORSHIP OF PREMIUMS ................................................................... 6
Health Plan Finder ............................................................................................................................ 6
Health Plan Finder Payments ............................................................................................................. 7
Special Provisions- ACA .................................................................................................................... 7
TRIBAL CONSULTATION ................................................................................................................................................. 8
TRIBES PAYING PREMIUMS ........................................................................................................................................... 8
ESSENTIAL COMMUNITY PROVIDERS ......................................................................................................................... 8
THIRD PARTY PAYER ...................................................................................................................................................... 8
INDIAN ADDENDUM ......................................................................................................................................................... 9
NAVIGATORS ...................................................................................................................................................................... 9
DEFINITION OF INDIAN .................................................................................................................................................. 9
VERIFICATION OF INDIAN STATUS .............................................................................................................................. 9
Business Case for Sponsorship Program ......................................................................................... 10
Eligibility ........................................................................................................................................ 10
Plan Choice .................................................................................................................................... 10
Monthly enrollment option ............................................................................................................. 11
Alternate Resources ........................................................................................................................ 11
Alternate Resource (includes TPSP) Policy & Procedure .................................................................... 11
Medicaid......................................................................................................................................... 12
Medicare, Medicare A, Medicare B, Medicare C, Medicare D............................................................. 12
Private Insurance ............................................................................................................................ 12
Contract Health Service Program..................................................................................................... 12
CATASTROPHIC HEALTH EMERGENCY FUND .................................................................................... 13
YOUR TRIBE’S NAME TRIBE CONTRACT HEALTH SERVICE ................................................................. 13
CATASTROPHIC HEALTH EMERGENCY FUND (CHEF): ........................................................................ 13
FUNDING LIMITATIONS: .................................................................................................................. 13
CONTRACT HEALTH SERVICES DELIVERY AREA ................................................................................ 14
CONTRACT HEALTH SERVICES......................................................................................................... 14
Emergency ..................................................................................................................................... 14
E-Sign ............................................................................................................................................. 14
TRIBAL PREMIUM SPONSORSHIP DELIVERY AREA .............................................................................. 15
PERSONS TO WHOM CHS WILL BE PROVIDED ................................................................................... 15
Funds Available .............................................................................................................................. 15
Services .......................................................................................................................................... 15
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TRIBAL PREMIUM SPONSORSHIP/ CONTRACT HEALTH SERVICE ELIGIBILITY REQUIREMENTS .............. 15
Your Tribe’s Name Tribe Contract Health Services Establishment of Residence for Contract Health Services
Eligibility .......................................................................................................................................................................15
Documentation ............................................................................................................................... 16
Eligibility ........................................................................................................................................ 16
Close Economic and Social Ties ...................................................................................................... 16
Students ......................................................................................................................................... 16
Transients .......................................................................................................................................................................17
NOT TPSP Eligible -CHS Eligible ....................................................................................................... 17
Non-Indian Pregnant Woman – Same as CHS if Patient of Clinic ....................................................... 17
Authorities ..................................................................................................................................... 18
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TRIBAL PREMIUM SPONSORSHIP PROGRAM
The Your Tribe’s Name Tribe Will Purchase Health Insurance for Contract Health
Service Eligible Uninsured Community Members who are Eligible for Tax Subsidies in
the new Washington Health Benefits Exchange (Marketplace).
Official Launch November, 2014
Vision of the Program: To Connect Tribal Members and Their Families to the Health
Insurance Coverage that is Most Appropriate for Them, The Tribe, and the Health Services
Department Program
INTRODUCTION
Purpose
This Tribal Premium Sponsorship Program Tribal Premium Sponsorship Program manual
consolidates the policy, procedures, and guidance for the effective management of the
Indian Health Service (IHS) Contract Health Services (CHS) Program and alignment with the
Your Tribe’s Name Tribe, PGST, Tribal Premium Sponsorship, and TPSP program. The
authority to manage the operation of the TPSP Program is delegated to the greatest degree
possible to the Health Director, Business Office Manager and Contract Health Services
Manager.
Timeline and History

The Tribal Premium Sponsorship Program was developed between August 2014 and
November 2014.

Presented to Tribal Council, …..

Presented to Directors and Managers

Council Approval, by motion, …..

Launch Date of TPSP.

Training of in-person assisters and sponsorship representatives, ….

January 1, 2015 coverage begins for Marketplace plans.
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TERMS OF PARTICIPATION
There are additional participant requirements above those required for Indian Health
Service, IHS, Contract Health Service, (CHS), programs for sponsorship.

Information about income and verification of income (could be simply selfattestation) or verification of IRS provided income from 2014 tax filing.

All Uninsured who do not have employer sponsored health care insurance are
eligible which means:
o You can’t drop coverage and expect Tribal Premium Sponsorship without
prior verification of eligibility for subsidies.

Update Income Information.

Respond to requests for information from Tribal Staff, State or Federal agencies

Agree to work with sponsorship representative (a Healthplanfinder designation).

Agree to apply for financial assistance to pay health insurance.

Agree to apply full tax credit to premium

Agree to provide your current insurance card.

Follow CHS policies including using the Your Tribe’s Name Tribal Health Clinic for
primary care and referrals.
RESPONSIBILITIES, TPSP
Health Services Director, The Director, will: Establish general policies regarding the
administration of the TPSP program in the IHS for the first year in coordination with the
Health Committee.

Establish standards of performance

Assess the performance of the TPSP program.

Assess the long-term purpose and direction of the program and its contribution to
CHS program to ensure maximum effectiveness of the program in meeting the health
needs of Indian people.

Formulate long-term plans and objectives for the future development of the TPSP
program.
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
Provide staff assistance in matters of general policies and procedures.

Prepare budget justification for the total TPSP program.

Financial controls. Ensure funding and financial controls follow tribal requirements.

Promptly and appropriately respond to TPSP appeal denials by Health Advisory
Committee appeal.

Establish and implement a management control system for the TS.

Develop and establish policies and methods for the direction, control, review, and
evaluation of the TPSP programs.

Maintain records for planning and for controlling funds as required.

Promptly and appropriately respond to TPSP appeal denials
Segregation of FUNDS FOR SPONSORSHIP OF PREMIUMS
Funds for premiums shall be segregated in a fund or money market account by the Your
Tribe’s Name Tribe sufficient to fund six months of Insurance premiums. Estimate for 30 is
$20,000 (assumes adoption of 300% FPL limit and assumes 75% are enrolled Tribal
Members as bronze is much cheaper than silver for descendents).
Healthplanfinder
The Washington State Health Benefit Exchange website portal. The Exchange refers to the insurance
marketplace for the purchase of health plans and determination of and access to federal tax credits.
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Healthplanfinder
Payments
Delegation of Authority
Health Services Department will set up all financial arrangements for the payment of sponsored
community members.
Tax Subsidy
The sponsored eligible will work with tribal in-person assister or navigator to access 100% of the subsidy
(based on their income) to be applied toward the premium payment to health plan (carriers).
Tax Reconciliation
The IRS will determine any tax liability or refund necessary from changes in income over the course of
enrollment in a QHP. The TPSP Health fund will pay any IRS tax obligations (reconciliation). The Tribal
member or sponsored person will be reimbursed unless there is an admission of misreporting of income.
Tax Refund for use in subsequent year’s sponsorship
Community members participating in the TPSP are required to deposit any premium tax credit
reconciliation tax refund in the TPSP Trust Fund, money market account, or reserve if they wish to
participate in future sponsorship years.
Special Provisions- ACA
Affordable Care Act Provisions Relevant to American Indians/ Alaska Natives
The Affordable Care Act includes specific provisions relevant to American Indians and Alaska Natives (AI/ANs)
purchasing coverage in Exchanges, including the following:
– AI/ANs with household incomes below 300 percent of the federal poverty level who are
enrolled in a Qualified Health Plan (QHP) offered through the individual market Exchange will not have to pay
any cost-sharing; no deductible, no copays, no other cost sharing.
– If an AI/AN is enrolled in a QHP and receives services directly from IHS, Indian tribe, tribal
organization, urban Indian organization or through the Contract Health Service program, the individual will not
have to pay any cost sharing for those services;
– Exchanges are to provide special monthly enrollment periods for AI/ANs; and
– Members of Indian tribes are exempt from the individual responsibility payment for not
complying with the requirement to maintain essential insurance coverage.
Indian Provisions of the Exchange Final Rule
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
Tribal Consultation

Tribes Paying Premiums

Essential Community Providers

Third Party Payer

Navigators

Establishment of Network Adequacy for Certification of Qualified Health Plans

Definition of Indian

Verification of Indian Status
TRIBAL CONSULTATION
The Exchange final rule requires States to regularly consult with Federally recognized Tribes that are located
within the geographic region of the Exchange on policies that have tribal implications.
This requirement does not preclude States from seeking input from all tribal organizations and urban Indian
organizations.
HHS encourages States to develop a Tribal Consultation Policy that is approved by the State, the Exchange, and
Tribe(s).
HHS recognizes the potential that FFEs will have to improve access to health coverage for American Indians
and Alaska Natives in States that do not establish State-based Exchanges. HHS intends to consult with Tribes
to implement FFE policies that impact American Indians and Alaska Natives.
TRIBES PAYING PREMIUMS
Exchanges may permit Indian tribes, tribal organizations, and urban Indian organizations to pay the QHP
premiums for qualified individuals, subject to terms and conditions set by the Exchange.
We recognize that some Exchanges may wish to work with tribal governments to facilitate payment on behalf
of enrollees, including aggregated payment. We encourage Exchanges to include this option as part of its
consultation with tribal governments.
ESSENTIAL COMMUNITY PROVIDERS
In the final rule, the definition of an essential community provider is taken from section 1311 of the
Affordable Care Act.
The definition identifies essential community providers as providers that serve predominantly low-income,
medically underserved individuals and cites providers defined in section 340B of the Public Health Service
Act.1
• Includes urban Indian organizations and tribal organizations’ outpatient clinics.
• Exchanges may identify additional providers as essential community providers based upon local needs.
1.
42 U.S.C. § 1396r-8 (Section 1927 of the Social Security Act)
THIRD PARTY PAYER
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The Indian Health Care Improvement Act (IHCIA) provides that all Indian health providers have the right to
recover from any third party payers, including insurance companies:
– Up to the reasonable charges billed for providing health services; or
– If higher, the highest amount the insurer would pay to other providers to the extent that the
patient or another provider would be eligible for such recoveries.
In the final rule preamble, we note that section 206 of IHCIA applies to all third party payers, including QHPs.
INDIAN ADDENDUM
Your Tribe’s Name Tribe will work with other tribes to develop an acceptable Indian Addendum for use in
contracting..
In-person Assisters
The Your Tribe’s Name Tribe will continue to access the Medicaid Administrative Match program to pay for
50% of the cost of enrollment activities for the Medicaid program (and initial screening for both Medicaid and
Marketplace insurance). In addition, tribal staff will complete necessary training to become in-person assisters
and sponsorship representatives.
N AVIGATORS
Tribal Navigator funding is for enrollment in Marketplace Insurance plans. Subject to final rules the TPSP will
access all permissible funding to reimburse for enrollment in tribally purchased marketplace insurance
through the Healthplanfinder. See in-person assisters and tribal sponsorship representatives.
DEFINITION
OF INDIAN
Tribes support using the same definition of Indian used for Medicaid and HHS received comments regarding
the three definitions of Indian in the Affordable Care Act as they pertain to special enrollment periods, costsharing reductions, and individual responsibility exemptions.
VERIFICATION
OF INDIAN
STATUS
If an applicant attests that he or she is an Indian, the Exchange must verify Indian status.
The Exchange must rely on any electronic data sources that are available to the Exchange and have been
approved by HHS for this purpose. If approved data sources are unavailable, an individual is not represented in
the source, or the source is not reasonably compatible with an applicant’s attestation, the Exchange must
follow inconsistency procedures. Where permitted authorize staff will attest to tribal membership for Your
Tribe’s Name Tribe tribal members.
STATUTORY INDIAN EXEMPTION
AND
H ARDSHIP EXEMPTION
CHS business office will work with all patients to ensure they obtain exemption from the penalty assessed for
not having health insurance. This will be accomplished through tax return in 2015 by selected the appropriate
Indian status.
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Business Case for Sponsorship Program
Year one of the sponsorship program will cover all community members whose insurance
plan costs are equal to or less than the expected expenditures for the category of eligible.
Application Assisters The Health Services Department will employ experienced and
trained benefits counselors to assist community members in their selection of the best
coverage option. In-person assister is a term used mainly for those who screen for
eligibility for Medicaid and enroll, where eligible, in Medicaid.
Navigators are one type of assister established to determine eligibility for exchange health
plans.
1. Determine eligibility for subsidy
2. Verify Indian Status for cost sharing benefits
3. Help with QHP selection
Eligibility
Basic Eligibility
1. All members of household with income between 139 and 300% of poverty (some
states it will be 100 to 300% of poverty.
Expanded Eligibility (depending on availability of funds
1. Some otherwise not eligible may be covered with Tribal funds should funding become
available.
2. Expanded eligibility depends on funding and continued successful cooperation of the
terms of participation
3. Plan for making all tribal members in Washington State eligible in 2015.
Plan Choice
1. The Sponsorship Program only supports the purchase of the bronze option in the Healthplanfinder
Marketplace for enrolled tribal members.
2. The Sponsorship Program does not support the choice of a catastrophic program since subsidies are
not available under this plan choice.
3. The TPSP has the option of recommending a ‘preferred’ qualified health plan, but will consider the
special needs of applicant in choosing a plan.
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Monthly enrollment option
1. TPSP does not support changes in health plans, but on a case by case basis can
approve one change in a calendar year.
2. American Indians do have the option to change plans once a month, but TPSP will not
approve discretionary changes in plans without approval of the program.
3. Exercising a change is permitted, but tribal funds may not be approved for a second
plan based on this discretionary choice allowed under the law.
Alternate Resources
Your Tribe’s Name Tribe Contract Health Services Non-Compliance with Applying for
Alternate Resources Policy
Purpose:
To outline the process for Your Tribe’s Name Tribe Contract Health Services members who
do not follow through with applying for alternate resources. Alternate resources may
include, but are not limited to, Medicare, Medicaid, Vocational Rehabilitation, Veteran’s
Administration, private insurance, Crippled Children’s Programs, Victims of Crime, and any
other State or Federal programs.
Eligibility:
Any person covered by Your Tribe’s Name Tribe Contract Health Services.
Policy:
The Your Tribe’s Name Tribe requires all Contract Health Services eligible individuals to
apply for alternate resources to help offset the cost of health care for the program.
Alternate Resource (includes TPSP) Policy & Procedure
1. Eligible persons need to follow through with applying for alternate resources if asked to
do so by the Contract Health Services office including the TPSP.
2. Staff in the Contract Health Services office will be available to assist the eligible member
with the TPSP application process.
3. An outreach person will be available to come to the member’s house to assist with the
application process. This service will be limited to Contract Health Services members
residing or working on the Your Tribe’s Name Tribe Reservation.
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4. The TPSP eligible member is required to direct the Washington State Health Exchange to
provide duplicate communication to the CHS office address. The TTPSP member may use
the CHS office’s mailing address to have the staff assist with any information requests
from alternate resources to ensure continuation of coverage.
5. This is an option on the online application where premium payments due.
6. Members who do not follow through on applying for alternate resources will receive a
termination letter from the Contract Health Services office.
7. Members who do not update their income information will face potential termination.
8. The member will have an additional 30 days (as of the date of the termination letter) to
finalize the application process for the alternate resource they are eligible for. Failure to
complete the application process within the 30 days will result in termination of the
members Contract Health Services benefits.
9. The member will not be eligible for Contract Health Services coverage until a complete
application for alternate resources has been submitted to the Contract Health Services
office.
10. Any charges incurred for any health related care during the uncovered time period
would be the member’s responsibility.
Medicaid
Medicaid has no cost to the Health Services Department and is the required option for
uninsured under 139% of poverty. No tax credits are available if under 139% so
sponsorship does not apply.
Medicare, Medicare A, Medicare B, Medicare C, Medicare D
Medicare insurance is the required primary insurance for eligibles with wrap around
payments for costs not covered by Medicare.
Private Insurance
Some very complex medical cases may require the purchase of private insurance outside the
Healthplanfinder exchange.
Contract Health Service Program
See CHS manual. The TPSP is a part of the CHS program and all CHS rules apply.
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CATASTROPHIC HEALTH EMERGENCY FUND
The fund appropriated by Congress to partially cover the IHS portion of medical expenses
for catastrophic illnesses and events that are covered by IHS CHS medical priorities. The IHS
will pay, from the CHEF, for cases that are covered by IHS CHS medical priorities. The IHS is
not responsible to cover cases that are expensive but outside the CHS medical priorities.
YOUR TRIBE’S NAME TRIBE CONTRACT HEALTH SERVICE
CATASTROPHIC HEALTH EMERGENCY FUND (CHEF):
Catastrophic health emergency funding is made available to all Tribes throughout the nation
who are eligible for CHS and Indian Health Service (IHS) care. The CHEF program is
administered and funded by the IHS. Catastrophic cases are defined as a single case or
single incident where health care costs have reached a threshold of about $20,000
(changes).
NOTE:
An example of a single incident would be five program eligibles injured in a
single auto accident. When the collective health care costs for the five program
eligibles reach the current threshold, CHEF program becomes the primary source of
funding for payment of any medical bills exceeding the threshold amount.
For purposes of the PGSKT PLAN, PGSKT CHS funding shall not exceed the threshold costs
for a single case or incident as established by IHS guidelines.
NOTE:
In all cases, alternate resources shall be exhausted prior to any coverage
under the IHS CHEF or PGSKT CHS catastrophic health care coverage.
FUNDING LIMITATIONS:
Because of funding limitations, the IHS CHEF and PGSKT CHS catastrophic programs will no
longer consider a patient’s illness to be catastrophic for reimbursement purposes, 90 days
after discharge from an inpatient facility.
OBLIGATIONS IN EXCESS OF $50,000: Should a single case or incident exceed $50,000,
the PGSKT CHS office reserves the right to require medical and financial documentation.
The care provider may be required to explain why it is inappropriate to transfer a patient to
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a less costly facility or provider, such as an IHS inpatient facility or V.A. facility where the
same medical benefits may be available as from a care provider in the network.
THRESHOLD NOTIFICATION: It shall be the responsibility of the PGSKT CHS office to notify
the IHS CHEF office for filing of program recipients. Specific documentation and program
filing requirements may be found in the PGSKT CHS policies and procedures manual. It
shall also be the responsibility of the PGSKT CHS office to file for any funding available from
the stop-loss coverage available through the PGSKT CHS catastrophic program.
CONTRACT HEALTH SERVICES DELIVERY AREA
The geographic areas within which CHS will be made available. Kitsap county.
CONTRACT HEALTH SERVICES
Health services paid by the IHS that are provided to eligible AI/ANs by non-IHS public or
private providers (e.g., dentists, physicians, hospitals).
CONTRACT HEALTH SERVICES ELIGIBLE, TRIBAL PREMIUM SPONSORSHIP ELIGIBLE
A person as defined in as being eligible for CHS thus eligible for the Tribal Premium
Sponsorship Program
Emergency
Any medical condition for which immediate medical attention is necessary to prevent the
death or serious impairment of an individual’s health.
E-Sign
The electronic equivalent of a hand-written signature requiring user authentication and
verification, such as a digital certificate, smart card, or biometric methods. On June 30,
2000, Congress enacted the “Electronic Signatures in Global and National Commerce Act,”
(E-SIGN) to expand the use of electronic records and signatures in interstate and foreign
commerce and ensure the validity and legal effect of contracts entered into electronically.
E-SIGN ensures that contracts and purchase orders entered into electronically will be legally
effective and valid, and that consumers who enter into contracts electronically have the
same protections they have when contracting in the “brick and mortar” world.
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TRIBAL PREMIUM SPONSORSHIP DELIVERY AREA
Kitsap County is the county of residence for all sponsored beneficiaries in TPSP.
All approved Contract Health Service Delivery Areas (CHSDA) are specified in 42 CFR
§136.22 and may be changed only in accordance with the Administrative Procedures Act (5
U.S.C. 553).
PERSONS TO WHOM CHS WILL BE PROVIDED
Tribal Premium Sponsorship Eligible follows CHS Eligibility, with differences noted below:
Authority
The CFR, Title 42 Part 136 is the appropriate citation for all correspondence to providers
and AI/AN patients. This IHM chapter should not be cited as the authority for making
decisions on eligibility or payment denials.
Funds Available
There is no authority to authorize payment for the insurance premium under the TPSP
program unless funds are made available by the Tribe.
Services
Beyond Qualified Health Plan-provided service- Follow CHS Policy payment allowed.
TRIBAL PREMIUM SPONSORSHIP/ CONTRACT HEALTH SERVICE ELIGIBILITY
REQUIREMENTS
Your Tribe’s Name Tribe Contract Health Services Establishment of Residence for
Contract Health Services Eligibility
PURPOSE :
To verify permanent residence for persons wanting to establish eligibility for Contract
Health Services benefits.
POLICY :
The Your Tribe’s Name Tribe requires all persons who are trying to establish eligibility for
Contract Health Services benefits to provide proof of permanent residence on either the
Your Tribe’s Name Tribe Reservation, or in Kitsap County depending on their tribal
enrollment status.
PROCEDURE
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1. Eligible persons need to follow through with providing valid proof of permanent
residence in either Kitsap County or on the Your Tribe’s Name Tribe Reservation.
2. Proof of permanent residence includes: proof of being registered with the Port Gamble
S’Klallam Housing Authority, documents in the person’s name mailed to the address of
residence, and or a signed affidavit from the homeowner, within the service area, the
eligible person is living with.
Failure to provide valid proof of residence will result in denial of eligibility for the Contract
Health Services program and TPSP.
Documentation
An AI/AN claiming eligibility for CHS has the responsibility to furnish the CEO or the Tribal
program with documentation to substantiate the claim.
Eligibility
The definition of eligibility for CHS shall be consistent with Title 42 CFR § 136.23. If local
rules and Title 42 CFR §136.23 conflict, Federal regulations prevail. To be eligible for CHS
an individual must:
1.
2.
3.
4.
5.
Be eligible for direct care as defined in 42 CFR §136.12;
Reside within the U.S. on a Federally-Recognized Indian reservation; or
Reside 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.
Close Economic and Social Ties
The basis for determining a person’s close economic and social ties is established
by the Tribe(s) served and may include the following:
1. The person is married to or is the child of an eligible member of the Tribe; or
2. The Tribe determines and certifies that the person has close economic and social ties with
the Tribe whose reservation is located within the CHSDA.
Students
Students up to age 26 are eligible under the family insurance eligibility in many cases. Where they are not the
TPSP will examine eligibility according to the individual’s circumstances without regard to study status.
16
Transients
Persons who are traveling or who are temporarily employed, such as seasonal or migratory
workers, are not eligible for the TPSP.
NOT TPSP Eligible -CHS Eligible
Not Health Plan Eligible:

Dependents of an employee with employer sponsored insurance.

Children and spouses are typically not eligible for subsidies so they are not eligible
for the TPSP.
American Indian/Alaska Native Children Adopted by Non-Indian Parents. Indians adopted by
non-Indian parents must meet all CHS requirements to be eligible for care e.g., reside within
a CHSDA).
Foster Children. American Indian/Alaska Native children who are placed in foster care
outside a CHSDA by order of a court of competent jurisdiction and who were eligible for
CHS at the time of the court order shall continue to be eligible for CHS while in foster care.
Section 813(a)(1) of the IHCIA, states in part: “Any individual who-(A) has not attained 19
years of age, (B) is the natural or adopted child, step-child, foster-child, legal ward, or
orphan of an eligible Indian, and (C) is not otherwise eligible for the health services
provided by the Service, shall be eligible for all health services provided by the Service on
the same basis and subject to the same rules that apply to eligible Indians until such
individual attains 19 years of age.”
Non-Indian Pregnant Woman – Same as CHS if Patient of Clinic
Refer to CHS Office to review eligibility
17
Authorities
Your Tribe’s Name Tribe Tribal Council, Washington State Health Authorities, i.e.
Washington Health Benefit Exchange, PGST Health Services Director - See All CHS Rules ,
Authorities, Delivery Codes of Federal Regulations, ,(CFR’s)
“Geographic Composition of the Contract Health Service Delivery Areas (CHSDA) and Service
Delivery Areas (SDA) of the Indian Health Service,” Federal Register (FR): June 21, 2007
(Volume 72, Number 119) Pages 34262-34267
1.
“Persons to whom services will be provided.” 42 Code of Federal Regulations (CFR),
Title 42, §136.12 (3)
2.
“Definitions.” 42 CFR §136,21
3.
“Establishment of contract health service delivery areas.” 42 CFR §136.22
4.
“Redesignation of contract health service delivery areas.” 42 CFR §135.22(b)
5.
“Persons to whom contract health services will be provided.” 42 CFR §136.23
6.
“Priorities for contract health services.” 42 CFR §136.23(e)
7.
“Payor of last resort.” 42 CFR §136.61
8.
“Administrative Procedures Act,” 5 United States Code (U.S.C.) 500, et seq.
9.
“Alaska Native Claims Settlement Act,” 43 U.S.C. 1601 et seq.
10. “The Victims of Crime Act of 1984” 42 U.S.C. 112, §10601
11. “Indian Civil Rights Act of 1968,” 25 U.S.C. 1301, et seq.
12. “Eligibility of California Indians,” Rancheria Act of August 18, 1958, (72 Statutes at
Large (STAT.) 619)
13. “Social Security Amendments of 1972,” Public Law (P.L.) 92-603
14. “Indian Self-Determination and Education Assistance Act,” P.L. 93-638, as amended
15. “Indian Health Care Improvement Act,” P.L. 94-437, as amended
16. “Electronic Signatures in Global and National Commerce Act,” P.L. 106-229
17. “Federal Managers’ Financial Integrity Act of 1982,” P.L. 97-255
18. “The Fiscal Year (FY) 1987 Appropriations Act for the IHS,” P.L. 99-591
19. “Consolidated Omnibus Budget Reconciliation Act of 1985,” P.L. 99-272, Section
17003
Definitions
INDIAN TRIBE
18
Any Indian Tribe, band, nation, group, Pueblo or community, including any Alaska Native
village or Native group, which is Federally-recognized as eligible for the special programs
and services provided by the United States (U.S.) to AI/ANs, because of this status.
RESERVATION
Any Federally Recognized Indian Tribe’s reservation, Pueblo, colony, or Rancheria, including
former reservations in Oklahoma, and Alaska Native regions established pursuant to the
Alaska Native Claims Settlement Act (43 U.S.C. 1601, et seq.) and Indian allotments.
RESIDENCE
Where a person lives and makes his or her home as evidenced by acceptable proof of
residency or acceptable proof established by the Service Unit.
SERVICE
The Indian Health Service.
TRIBAL HEALTH DIRECTOR
The Director of a tribally operated program, or his/her designee, authorized to make
decisions on payment of CHS funds pursuant to a P.L. 93-638 contract.
TRIBAL MEMBER
A person who is an enrolled descendent of a Federally Recognized Tribe or is granted Tribal
membership by some other criteria in the Tribal constitution.
TRIBAL SELF INSURANCE
This Tribal Premium Sponsorship Program manual consolidates the policy, procedures, and
guidance for the effective management of the Indian Health Service (IHS) Contract Health
Services (CHS) Program and alignment with the Your Tribe’s Name Tribe, PGST, Tribal
Premium Sponsorship, and TPSP program. The authority to manage the operation of the
TPSP Program is delegated to the greatest degree possible to the Health Director, working
with the Health Services Manager, Business Office Manager and Contract Health Services
Officer
19
A health plan that is funded solely by a Tribe or Tribal organization and for which the Tribe
or Tribal organization assumes payment for health services covered under the plan either
directly or through an administrator. The plan may be re-insured, but the Tribe or Tribal
organization must bear some risk.
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ACA – Affordable Care Act
CFR - Code of Federal Regulations
CHEF - Catastrophic Health Emergency Fund
CHS - Contract Health Services
CHSDA - Contract Health Service Delivery Area
CHS/MIS - Contract Health Services/Management Information System
CHSO - Contract Health Service Officer
HIPAA - Health Insurance Portability and Accountability Act
IHCIA - Indian Health Care Improvement Act
QHP - Qualified Health Plan
RPMS - Resource and Patient Management System
TPSP –Tribal Premium Sponsorship Program
U.S.C. - United States Code
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