CMS Pub. 100-04, ch. 19, § 10

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 MAC for the type of service and which serves the specific geographic

region where the facility is located. They 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 MAC used for processing IHS claims instead of with the

MAC 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 MAC

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

MAC.

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.