# IHS Reimbursement Methods

IHS Reimbursement Methods provide an overview of how IHS and Tribes are
paid for services rendered to patients in IHS facilities. These methods
generally apply to Tribal programs, but should be adjusted as needed.

The Fiscal Intermediaries (FI) and/or carrier process and pay claims.
Trailblazer is the sole Medicare FI for IHS. Tribes can use other FIs or
carriers. In addition, other payers can pay direct or use other FIs to
process and pay claims.

Indian Health Service Reimbursement Methods

<table>
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<thead>
<tr class="header">
<th rowspan="2">Payer</th>
<th rowspan="2">FI</th>
<th colspan="2">Provider</th>
<th rowspan="2">Hospital</th>
<th rowspan="2"><p>CAH</p>
<p>Hospital</p></th>
<th rowspan="2"><p>Hospital</p>
<p>Outpatient</p></th>
<th rowspan="2"><p>Ambulatory</p>
<p>Surgery</p></th>
<th rowspan="2">Pharmacy</th>
<th rowspan="2">Dental</th>
</tr>
<tr class="odd">
<th>Inpatient</th>
<th>Outpatient</th>
</tr>
</thead>
<tbody>
<tr class="odd">
<td>Medicare</td>
<td>Trailblazers</td>
<td>FFS Part B</td>
<td>FFS Part B</td>
<td>DRG (PPS)</td>
<td>AIR</td>
<td>AIR</td>
<td>ASC rate</td>
<td>FFS 2006</td>
<td>N/A<strong><sup>*</sup></strong></td>
</tr>
<tr class="even">
<td>Medicaid</td>
<td>State FI</td>
<td>FFS</td>
<td>AIR</td>
<td>AIR</td>
<td>AIR</td>
<td>AIR</td>
<td>ASC rate</td>
<td>AIR/FFS</td>
<td>AIR/FFS</td>
</tr>
<tr class="odd">
<td>Private Insurance</td>
<td>PI FI</td>
<td>FFS</td>
<td>FFS</td>
<td>FFS</td>
<td>FFS</td>
<td>FFS</td>
<td>FFS</td>
<td>FFS</td>
<td>FFS</td>
</tr>
<tr class="even">
<td><p>SCHIP PI<strong><sup>1</sup></strong></p>
<p>Model</p></td>
<td></td>
<td>FFS</td>
<td>FFS</td>
<td>FFS</td>
<td>FFS</td>
<td>FFS</td>
<td>FFS</td>
<td>FFS</td>
<td>FFS</td>
</tr>
<tr class="odd">
<td><p>SCHIP<strong><sup>2</sup></strong> Medicaid</p>
<p>Model</p></td>
<td></td>
<td>FFS</td>
<td>AIR</td>
<td>AIR</td>
<td>AIR</td>
<td>AIR</td>
<td>ASC rate &amp; FFS</td>
<td>AIR &amp; FFS</td>
<td>AIR &amp; FFS</td>
</tr>
<tr class="even">
<td><p>FQHC<strong><sup>3</sup></strong></p>
<p>Tribes only</p></td>
<td></td>
<td>AIR capped</td>
<td>AIR</td>
<td>N/A</td>
<td>N/A</td>
<td>N/A</td>
<td>N/A</td>
<td>FFS/340B</td>
<td>AIR</td>
</tr>
<tr class="odd">
<td>FMCRA</td>
<td></td>
<td>FFS</td>
<td>FFS</td>
<td>FFS</td>
<td>FFS</td>
<td>FFS</td>
<td>FFS</td>
<td>FFS</td>
<td>FFS</td>
</tr>
<tr class="even">
<td>Military (Army, Navy etc)</td>
<td></td>
<td><p>AIR or</p>
<p>TRICARE</p></td>
<td><p>AIR or</p>
<p>TRICARE</p></td>
<td><p>AIR or</p>
<p>TRICARE</p></td>
<td><p>AIR or</p>
<p>TRICARE</p></td>
<td><p>AIR or</p>
<p>TRICARE</p></td>
<td><p>AIR or</p>
<p>TRICARE</p></td>
<td><p>AIR or</p>
<p>TRICARE</p></td>
<td><p>AIR or</p>
<p>TRICARE</p></td>
</tr>
<tr class="odd">
<td><p>Commission</p>
<p>Corp<strong><sup>4</sup></strong></p></td>
<td><p>TRICARE</p>
<p>AIR</p></td>
<td><p>TRICARE</p>
<p>AIR</p></td>
<td><p>TRICARE</p>
<p>AIR</p></td>
<td><p>TRICARE</p>
<p>AIR</p></td>
<td><p>TRICARE</p>
<p>AIR</p></td>
<td><p>TRICARE</p>
<p>AIR</p></td>
<td><p>TRICARE</p>
<p>AIR</p></td>
<td><p>TRICARE</p>
<p>AIR</p></td>
<td><p>TRICARE</p>
<p>AIR</p></td>
</tr>
</tbody>
</table>

  -------- --------------------------------------------------------------
           

  Notes:   1\. PI rules apply

           2\. Medicaid rules apply

           3\. FQHC only pertains to Tribal outpatient clinics. HIS is
           not eligible for this provider status. Their rates are capped
           by Medicare regardless of costs and for Medicaid some states
           pay based on average PPS. The reimbursement is paid to tribes,
           not IHS

           4\. Commissioned Officer and Dependents are eligible for
           services at remote facilities. TRICARE is the Plan which
           governs payments and provision of health services.

           \*Certain exceptions under Medicare
  -------- --------------------------------------------------------------

+-------+--------+----------------------------------------------------+
|       | AIR =  | All inclusive rate (per diem)                      |
|       |        |                                                    |
|       |        | The Medicare and Medicaid AIR is negotiated with   |
|       |        | CMS and published annually in the Federal          |
|       |        | Register. CAHs IP and OP Medicare rates are set    |
|       |        | based on cost reports sent directly to the FI for  |
|       |        | review. The basis of the AIR is derived from 47    |
|       |        | hospital cost reports. IP and OP RPMS Workload is  |
|       |        | used to calculate the average AIR.                 |
+-------+--------+----------------------------------------------------+
|       | ASC =  | ASC = Ambulatory Surgery Center rate               |
+-------+--------+----------------------------------------------------+
|       | FFS =  | Fee-for-service                                    |
+-------+--------+----------------------------------------------------+
|       | FMCRA  | Federal Medical Care Recovery Act                  |
|       | =      |                                                    |
+-------+--------+----------------------------------------------------+
|       | FQHC = | Federally Qualified Health Center                  |
+-------+--------+----------------------------------------------------+
|       | SCHIP  | State Children Health Insurance Program            |
|       | =      |                                                    |
+-------+--------+----------------------------------------------------+