Proposed Rule2023-14849
Catastrophic Health Emergency Fund
Primary source
Metadata and text below are from the Federal Register, a public-domain U.S. government work. Always verify the official published version before relying on it for any legal matter.
Published
July 18, 2023
Issuing agencies
Health and Human Services DepartmentIndian Health Service
Abstract
The Indian Health Service (IHS or Service) administers the Catastrophic Health Emergency Fund (CHEF) pursuant to section 202 of the Indian Health Care Improvement Act (IHCIA). The purpose of the CHEF is to meet the extraordinary medical costs associated with the treatment of victims of disasters or catastrophic illnesses who are within the responsibility of the Service. This notice proposes regulations governing the administration of the CHEF.
Full Text
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<title>Federal Register, Volume 88 Issue 136 (Tuesday, July 18, 2023)</title>
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[Federal Register Volume 88, Number 136 (Tuesday, July 18, 2023)]
[Proposed Rules]
[Pages 45867-45872]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2023-14849]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Indian Health Service
42 CFR Part 136
RIN 0917-AA10
Catastrophic Health Emergency Fund
AGENCY: Indian Health Service, HHS.
ACTION: Proposed rule.
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SUMMARY: The Indian Health Service (IHS or Service) administers the
Catastrophic Health Emergency Fund (CHEF) pursuant to section 202 of
the Indian Health Care Improvement Act (IHCIA). The purpose of the CHEF
is to meet the extraordinary medical costs associated with the
treatment of victims of disasters or catastrophic illnesses who are
within the responsibility of the Service. This notice proposes
regulations governing the administration of the CHEF.
DATES: Send comments on or before September 18, 2023.
ADDRESSES: You may submit comments by the following method:
Electronically: Go to the Federal eRulemaking Portal: <a href="https://www.regulations.gov">https://www.regulations.gov</a>. In the Search box, enter the Regulation Identifier
Number (RIN) (presented above in the document headings). For best
results, do not copy and paste the number; instead, type the RIN into
the Search box using hyphens. Then, click on the Search button. On the
resulting page, in the panel on the left side of the screen, under the
Document Type heading, check the Proposed Rule box to locate this
document. You may submit a comment by clicking on ``Comment.''
Instructions: Comments sent by any other method, to any other
address or individual, or received after the end of the comment period,
may not be considered by the IHS. All comments received are a part of
the public record and will generally be posted for public viewing on
<a href="http://www.regulations.gov">www.regulations.gov</a> without change. All submissions are voluntary, and
such voluntary submission of personal identifying information (e.g.,
name, address, etc.), confidential business information, or otherwise
sensitive information constitutes permission for IHS to make the
information publicly accessible. The IHS will accept anonymous comments
(enter ``N/A'' in the required fields if you wish to remain anonymous).
FOR FURTHER INFORMATION CONTACT: For technical questions concerning
this rule contact: Carl Mitchell, Director, Division of Regulatory and
Policy Coordination (DRPC), Office of Management Services (OMS), Indian
Health Service, 301-443-6384, <a href="/cdn-cgi/l/email-protection#0c6f6d7e60226165786f646960604c65647f226b637a"><span class="__cf_email__" data-cfemail="c4a7a5b6a8eaa9adb0a7aca1a8a884adacb7eaa3abb2">[email protected]</span></a>; or CAPT John Rael,
Director, Office of Resource Access and Partnerships (ORAP), Indian
Health Service, 301-443-0969, <a href="/cdn-cgi/l/email-protection#573d383f39792536323b173e3f2479303821"><span class="__cf_email__" data-cfemail="fd97929593d38f9c9891bd94958ed39a928b">[email protected]</span></a>.
SUPPLEMENTARY INFORMATION: The CHEF was established by section 202 of
the IHCIA, Public Law 94-437 (25 U.S.C. 1621a). The Patient Protection
and Affordable Care Act, Public Law 111-148 as amended by the Health
Care and Education Reconciliation Act of 2010, Public Law 111-152
(collectively, the Affordable Care Act or ``the ACA''), reauthorized
the IHCIA and amended the CHEF, directing the Secretary to promulgate
regulations governing the administration of the CHEF.
I. Background
The purpose of the CHEF is to meet the extraordinary medical costs
associated with the treatment of victims of disasters or catastrophic
illnesses who are within the responsibility of the Service. The IHS
administers the CHEF to reimburse certain IHS and Tribal purchased/
referred care (PRC) costs that exceed the cost threshold. Although the
CHEF was first established in 1988, a similar fund was authorized by
Public Law 99-591, a Joint Resolution continuing appropriations for
fiscal year (FY) 1987. The IHS developed operating guidelines for the
management of the CHEF in August of 1987, which were approved by the
Office of Management and Budget (OMB). Those guidelines were developed
with input from Tribal Organizations and the IHS personnel who work
with the daily processing and management of Contract Health Services
(CHS), now known as the Purchased/Referred Care (PRC) Program. Congress
passed the Indian Health Care Improvement Reauthorization and Extension
Act of 2009, S. 1790, 111th Cong. (2010) (IHCIREA), as section 10221(a)
of the Patient Protection and Affordable Care Act, Public Law 111-148.
Through IHCIREA, Congress permanently reauthorized and amended the
IHCIA, Public Law 94-437. Section 202 of the IHCIA (25 U.S.C. 1621a)
establishes the CHEF and directs the IHS to promulgate regulations for
its administration. The operating guidelines and twenty-eight (28)
years of experience (FYs 1987-2015) contributed to the design of the
proposed rule published January 26, 2016, (81 FR 4239). Following
additional consultation and additional years of experience, the IHS is
issuing this new notice of proposed rulemaking (NPRM). This NPRM
supersedes and replaces the proposed rule published January 26, 2016,
(81 FR 4239); as such, the 2016 NPRM is hereby rescinded.
II. Provisions of This Proposed Regulation
This regulation proposes to (1) establish definitions governing the
CHEF, including definitions of disasters and catastrophic illnesses;
(2) establish that a Service Unit shall not be eligible for
reimbursement for the cost of treatment from the CHEF until its cost of
treating any victim of such catastrophic illness or disaster has
reached a certain threshold cost; (3) establish a procedure for
reimbursement
[[Page 45868]]
of the portion of the costs for authorized services that exceed such
threshold costs; (4) establish a procedure for payment from the CHEF
for cases in which the exigencies of the medical circumstances warrant
treatment prior to the authorization of such treatment; and, (5)
establish a procedure that will ensure no payment will be made from the
CHEF to a Service Unit to the extent the provider of services is
eligible to receive payment for the treatment from any other Federal,
state, local, or private source of reimbursement for which the patient
is eligible.
No part of the CHEF, or its administration, shall be subject to
contract or grant under any law, including the Indian Self-
Determination and Education Assistance Act (ISDEAA), Public Law 93-638
(25 U.S.C. 5301 et seq.) and may not be allocated, apportioned, or
delegated to a Service Unit, Area Office, or any other IHS
organizational unit. Accordingly, the IHS Division of Contract Care
within ORAP, IHS, shall remain responsible for administration of the
CHEF.
The proposed regulation also incorporates provisions on
severability. Congress has specifically directed the promulgation of
these rules for the administration of the CHEF, which is administered
by the Secretary, Department of Health and Human Services (HHS) (``the
Secretary'') acting through the Headquarters of the Indian Health
Service (IHS) (``the Service''). The sole purpose of the CHEF is
meeting extraordinary medical costs associated with treatment of
victims of disasters or catastrophic illnesses who are within the
responsibility of the Service. In the event that any portion of the
proposed regulation is declared invalid, the Secretary, acting through
the IHS, will continue to be responsible for the administration of the
CHEF. The IHS anticipates that the remainder of the regulation could
function sensibly and continue to govern the administration of the
CHEF. For these reasons, if any portion of the proposed regulation is
declared invalid, the IHS intends that the remaining provisions be
severable.
A. Definitions
The IHS proposes establishing the following definitions for
governing the CHEF, including definitions of disasters and catastrophic
illnesses:
1. Alternate Resources--health care resources other than those of
the IHS. Such resources include health care providers and institutions
and health care programs for the payment of health services including
but not limited to programs under titles XVIII or XIX of the Social
Security Act (i.e., Medicare, Medicaid), state or local health care
programs, and private insurance.
2. Catastrophic Health Emergency Fund (CHEF)--the fund established
by Congress to reimburse extraordinary medical expenses incurred for
catastrophic illnesses and disasters paid by a PRC program of the IHS,
whether such program is carried out by the IHS or an Indian Tribe or
Tribal Organization under the ISDEAA.
3. Catastrophic Illness--a medical condition that is costly by
virtue of the intensity and/or duration of its treatment. Examples of
conditions that frequently require multiple hospital stays and
extensive treatment are cancer, burns, premature births, cardiac
disease, end-stage renal disease, strokes, trauma-related cases such as
automobile accidents and gunshot wounds, and certain mental disorders.
The CHEF is intended to insulate the IHS and Tribal PRC operations from
financial disruption caused by the intensity of expenses incurred as a
result of high cost illnesses and/or disasters.
4. Disasters--situations that pose a significant level of threat to
life or health or cause loss of life or health stemming from events
such as tornadoes, earthquakes, floods, catastrophic accidents,
epidemics, fires, and explosions. The CHEF is intended to insulate the
IHS and Tribal PRC operations from financial disruption caused by the
intensity of expenses incurred as a result of high cost illnesses and/
or disasters.
5. Episode of Care--the period of consecutive days for a discrete
health condition during which reasonable and necessary medical services
related to the condition occur.
6. Purchased/Referred Care (PRC)--any health service that is--
(a) delivered based on a referral by, or at the expense of, an
Indian health program; and
(b) provided by a public or private medical provider or hospital
that is not a provider or hospital of the IHS health program.
7. Service Unit--an administrative entity of the Service or a
Tribal health program through which services are provided, directly or
by contract, to eligible Indians within a defined geographic area.
8. Threshold Cost--the annual designated amount above which
incurred medical costs will be considered for the CHEF reimbursement
after a review of the authorized expenses and diagnosis.
B. Threshold Cost
The IHCIA section 202 provides that a Service Unit shall not be
eligible for reimbursement from the CHEF until its cost of treating any
victim of a catastrophic illness or event has reached a certain
threshold cost. The Secretary is directed to establish the initial CHEF
threshold at--
(1) the FY 2000 level of $19,000; and
(2) for any subsequent year, the threshold will not be less than
the threshold cost of the previous year increased by the percentage
increase in the medical care expenditure category of the Consumer Price
Index (CPI) for all urban consumers (United States city average) for
the 12-month period ending with December of the previous year.
The IHS intends to set the initial threshold governed by this rule
at $19,000 for FY 2023. In reaching this determination, the IHS adopted
the recommendation of the IHS Director's Workgroup on Improving PRC
(Workgroup). The Workgroup, composed of Tribal leaders and Tribal and
Federal representatives, voted 18-2 to recommend $19,000 as the initial
threshold. For this recommendation, the Workgroup considered several
factors, including (1) Tribal concerns regarding the lower threshold
and the potential to exhaust the CHEF earlier in the fiscal year
leaving PRC programs without the ability to recover costs for treating
victims of catastrophic illnesses or disasters; and, (2) Tribal
concerns about setting the threshold at the FY 2000 level and then
applying the CPI-U Medical for each year since FY 2000, which would
have resulted in a $30,000 plus threshold requirement by FY 2013. At
this higher level, PRC programs with limited budgets would be unable to
access the CHEF to seek recovery for extraordinary medical costs.
Accordingly, the IHS intends to set the initial threshold at $19,000
for FY 2023, with increases in subsequent years based on the annual
CPI-U Medical factor. The IHS will publish the revised threshold costs
yearly in the Federal Register.
C. Compliance With PRC Regulations
The IHS proposes to follow PRC regulations 42 Code of Federal
Regulations (CFR) part 136 for payment from the CHEF. For example,
payment or reimbursement from the CHEF may be made for the costs of
treating persons eligible for PRC in accordance with 42 CFR 136.23 and
authorized for PRC in accordance with 42 CFR 136.24. In cases where the
exigencies of the medical circumstances warrant treatment prior to the
authorization of such treatment by the Service Unit, authorization must
be obtained in accordance with 42 CFR 136.24(c). For example, claims
for reimbursement of services provided that
[[Page 45869]]
do not meet the 72 hour emergency notification requirements found at 42
CFR 136.24(c) will be denied. The applicable Area PRC program shall
review the CHEF requests for CHEF reimbursement to ensure consistency
with PRC regulations. The IHS seeks comment on whether payments by PRC
programs to patients, or other individuals/entities that are not PRC
providers, should be included as eligible for CHEF reimbursement under
these regulations and if so, under what circumstances.
D. Alternate Resources
In accordance with section 202(d)(5) of the IHCIA [25 U.S.C. 1621a
(d)(5)], alternate resources must be exhausted before reimbursement is
made from the CHEF. No reimbursement shall be made from the CHEF to any
Service Unit to the extent that the provider of treatment is eligible
to receive payment for the treatment from any other Federal, state,
local, or private source of reimbursement for which the patient is
eligible. Medical expenses incurred for catastrophic illnesses and
events will not be considered eligible for reimbursement if they are
payable by alternate resources, as determined by the IHS. The IHS is
the payor of last resort and, if the provider of services is eligible
to receive payment from other resources, the medical expenses are only
payable by PRC and reimbursable by the CHEF to the extent the IHS would
not consider the other resources to be ``alternate resources'' under
the applicable regulations and the IHS policy. Expenses paid by
alternate resources are not eligible for payment by PRC or
reimbursement by the CHEF. However, if the patient is found to have
been eligible for alternate resources at the time of service, the
Service Unit shall promptly return all funds reimbursed from the CHEF
to the Headquarters CHEF account.
E. Reimbursement Procedure
A patient must be eligible for PRC services and the Service Unit
must adhere to regulations (42 CFR 136.23(a) through (f)) governing the
PRC program to be reimbursed for catastrophic cases from the CHEF. Once
the catastrophic case meets the threshold requirement and the Service
Unit has authorized PRC resources exceeding the threshold requirement,
the Service Unit may qualify for reimbursement from the CHEF.
Reimbursable costs are those costs that exceed the threshold
requirement after payment has been made by all alternate resources such
as Federal, state, local, private insurance, and other resources.
Reimbursement of PRC expenditures incurred by the Service Unit and
approved by the PRC program at Headquarters will be processed through
the respective IHS Area Office. Reimbursement from the CHEF shall be
subject to availability of funds.
F. Recovery of the CHEF Reimbursement Funds
In the event a PRC program has been reimbursed from the CHEF for an
episode of care and that same episode of care becomes eligible for and
is paid by any Federal, state, local, or private source (including
third party insurance), the PRC program shall return all the CHEF funds
received for that episode of care to the CHEF at the IHS Headquarters.
These recovered CHEF funds will be used to reimburse other approved
CHEF requests.
III. Collection of Information Requirements
Prior to implementing the rule, the IHS may be required to develop
new information collection forms that would require approval from the
Office of Management and Budget in accordance with the Paperwork
Reduction Act of 1995, 44 United States Code 3507(d).
IV. Response to Comments
Because of the large number of public comments normally received on
Federal Register documents, we are not able to acknowledge or respond
to them individually. We will consider all comments received by the
date and time specified in the DATES section of the preamble of this
proposed rule, and, when we proceed with a final rule, we will respond
to the comments in the preamble to that rule.
V. Regulatory Impact Analysis
We have examined the impacts of this rule as required by Executive
Order (E.O.) 12866 on Regulatory Planning and Review (September 30,
1993); section 603 of the Regulatory Flexibility Act (RFA), Public Law
96-354 [5 U.S.C. 601-612], as amended by subtitle D of the Small
Business Regulatory Fairness Act of 1996, Public Law 104-121; the
Unfunded Mandates Reform Act (UMRA) of 1995, Public Law 104-4; E.O.
13132 on Federalism (August 4, 1999); and E.O. 13175 Consultation and
Coordination with Indian Tribal Governments.
A. Executive Order 12866
Executive Order 12866, as amended by Executive Order 14094, directs
agencies to assess all costs and benefits of available regulatory
alternatives and, if regulation is necessary, to select regulatory
approaches that maximize net benefits (including potential economic,
environmental, public health and safety effects, distributive impacts,
and equity). Section 3(f) of Executive Order 12866, as amended, defines
a ``significant regulatory action'' as one that is likely to result in
a rule that may: (1) have an annual effect on the economy of $200
million or more in any one year (adjusted every three years by the
Administrator of OIRA for changes in gross domestic product), or
adversely affect in a material way a sector of the economy,
productivity, competition, jobs, the environment, public health or
safety, or State, local, territorial, or tribal governments or
communities (2) create a serious inconsistency or otherwise interfering
with an action taken or planned by another agency; (3) materially alter
the budgetary impact of entitlements, grants, user fees, or loan
programs or the rights and obligations of recipients thereof; or (4)
raise legal or policy issues for which centralized review would
meaningfully further the President's priorities or the principles set
forth in Executive Order 12866. While the Office of Information and
Regulatory Affairs has determined that this is a significant regulatory
action as defined by Executive Order 12866, they have also determined
that it does not confer significant costs and does not warrant a
regulatory impact analysis.
B. Regulatory Flexibility Act (RFA)
RFA requires analysis of regulatory options that minimize any
significant economic impact of a rule on small entities, unless it is
certified that the proposed rule is not expected to have a significant
economic impact on small entities. This rule is not expected to have a
significant economic impact on small entities, because the rule only
governs reimbursements of certain expenditures made by Service Units
under Purchased/Referred Care (PRC) authorities. Many PRC programs are
operated by the Federal Government, through the Indian Health Service
(IHS). The remaining PRC programs are operated by Tribes and tribal
organizations under Indian Self-Determination and Education Assistance
Act (ISDEAA) agreements with the IHS. Presently, there are 62 federally
operated PRC programs and 188 tribally operated PRC programs. Some of
the entities operating PRC programs may be small entities, but the rule
does not directly impact a substantial number of small entities and the
rule is not expected to reduce their revenues or raise their costs.
[[Page 45870]]
C. Unfunded Mandates Reform Act (UMRA)
Section 202 of UMRA (Pub. L. 104-4) requires an assessment of
anticipated costs and benefits before proposing any rule that may
result in expenditure by state, local, and Tribal Governments, in
aggregate, or by the private sector of $100 million or more (adjusted
annually for inflation) in any one year. The current threshold after
adjustment for inflation is $165 million, using the most current (2021)
Implicit Price Deflator for the Gross Domestic Product. We have
determined that this rule is consistent with the principles set forth
in the executive orders and in these statutes and find that this rule
will not have an effect on the economy that exceeds the UMRA threshold
in any one year. The IHS FY 2022 annual appropriation for the CHEF was
$53 million. This final rule is not anticipated to have an effect on
state, local, or Tribal Governments in the aggregate, or by the private
sector of $165 million or more. This rule does not impose any new costs
on small entities, and it will not result in a significant economic
impact on a substantial number of small entities. Thus, no further
analysis is required.
D. Federalism
E.O. 13132 establishes certain requirements that an agency must
meet when it promulgates a proposed rule (and subsequent final rule)
that imposes substantial direct requirement costs on State and local
Governments, preempts state law, or otherwise has federalism
implications. We have reviewed this proposed rule under the threshold
criteria of E.O. 13132 and have determined that this proposed rule
would not have substantial direct effect on the states, on the
relationship between the Federal Government and the states, or on the
distribution of power and governmental responsibilities among the
various levels of the Government(s). As this rule has no Federal
implications, a federalism summary impact statement is not required.
E. E.O. 13175 Consultation and Coordination With Indian Tribal
Governments
This rule has Tribal implications under E.O. 13175, Consultation
and Coordination with Indian Tribal Governments, because it would have
a substantial direct and positive effect on one or more Indian Tribes.
The first proposed CHEF rule, published in January 2016 (81 FR
4239), was developed with input from Tribes and the IHS personnel who
work with the daily processing and management of PRC resources.
Specifically, the IHS Director's Workgroup on Improving PRC met and
discussed the CHEF guidelines on October 12-13, 2010, and June 1-2,
2011, in Denver, Colorado, and on January 11-12, 2012, in Albuquerque,
New Mexico. In addition, the IHS issued ``Dear Tribal Leader'' letters
related to the development of these regulations on February 9, 2011,
and May 6, 2013.
The IHS has sought additional Tribal input throughout the
development of this new proposed rule. Specifically, Tribal
consultation sessions were held in the fall of 2016. At meetings of the
Workgroup in 2015 and 2018, the Workgroup recommended establishing a
$19,000 CHEF threshold. Moreover, in November 2020, the Workgroup
recommended that the IHS promulgate new regulations based on Workgroup
input. Based on the recommendation of the Workgroup, the threshold
amount of $19,000 is proposed to be established for the current fiscal
year. This proposed rule serves as additional Tribal consultation with
affected Tribes by giving interested Tribes the opportunity to comment
on the regulation before it is finalized. The IHS intends to consult as
fully as possible with Tribes prior to the publication of a final rule.
List of Subjects in 42 CFR Part 136
Alaska Natives, Purchased/Referred Care (formerly Contract Health
Services), Health, Health facilities, Indians.
For the reasons set out in the preamble, the IHS proposes to amend
42 CFR chapter I as set forth below:
PART 136--INDIAN HEALTH
0
1. The authority citation for part 136 is revised to read as follows:
Authority: 42 U.S.C. 2001 and 2003; 25 U.S.C. 13; and 25 U.S.C.
1621a.
0
2. Add new subpart L consisting of Sec. Sec. 136.501-136.510 to read
as follows:
Subpart L--Indian Catastrophic Health Emergency Fund
Sec.
136.501 Definitions.
136.502 Purpose of the regulations.
136.503 Threshold cost.
136.504 Reimbursement procedure.
136.505 Reimbursable services.
136.506 Alternate resources.
136.507 Program integrity.
136.508 Recovery of reimbursement funds.
136.509 Reconsideration and appeals.
136.510 Severability.
Sec. 136.501 Definitions.
Alternate Resources means health care resources other than those of
the Indian Health Service. Such resources include health care providers
and institutions and health care programs for the payment of health
services including but not limited to programs under titles XVIII or
XIX of the Social Security Act (i.e., Medicare, Medicaid), state or
local health care programs, and private insurance.
Catastrophic Health Emergency Fund (CHEF) means the fund
established by Congress to reimburse extraordinary medical expenses
incurred for catastrophic illnesses and disasters paid by a PRC program
of the IHS, whether such program is carried out by the IHS or an Indian
Tribe or Tribal Organization under the ISDEAA.
Catastrophic Illness refers to a medical condition that is costly
by virtue of the intensity and/or duration of its treatment. Examples
of conditions that frequently require multiple hospital stays and
extensive treatment are cancer, burns, premature births, cardiac
disease, end-stage renal disease, strokes, trauma-related cases such as
automobile accidents, and gunshot wounds, and some mental disorders.
The CHEF is intended to insulate the IHS and Tribal PRC operations from
financial disruption caused by the intensity of expenses incurred as a
result of high cost illnesses and/or disasters.
Disaster means a situation that poses a significant level of threat
to life or health or causes loss of life or health stemming from events
such as tornadoes, earthquakes, floods, catastrophic accidents,
epidemics, fires, and explosions. The CHEF is intended to insulate the
IHS and Tribal PRC operations from financial disruption caused by the
intensity of expenses incurred as a result of high cost illnesses and/
or disasters.
Episode of Care means the period of consecutive days for a discrete
health condition during which reasonable and necessary medical services
related to the condition occur.
Purchased/Referred Care means any health service that is--
(1) delivered based on a referral by, or at the expense of, an
Indian health program; and
(2) provided by a public or private medical provider or hospital
which is not a provider or hospital of the Indian health program.
Service Unit means an administrative entity of the Service or a
Tribal Health Program through which services are provided, directly or
by contract, to eligible Indians within a defined geographic area.
[[Page 45871]]
Threshold Cost means the annual designated amount above which
incurred medical costs will be considered for the CHEF reimbursement
after a review of the authorized expenses and diagnosis.
Sec. 136.502 Purpose of the regulations.
The Indian Catastrophic Health Emergency Fund (hereafter referred
to as ``CHEF'') is authorized by section 202 of the Indian Health Care
Improvement Act (IHCIA) [25 U.S.C. 1621a]. The CHEF is administered by
the Secretary, Department of Health and Human Services (HHS) (``the
Secretary'') acting through the Headquarters of the Indian Health
Service (IHS) (``the Service''), solely for the purpose of meeting
extraordinary medical costs associated with treatment of victims of
disasters or catastrophic illnesses who are within the responsibility
of the Service.
These regulations:
(a) establish definitions of terms governing the CHEF, including
definitions of disasters and catastrophic illnesses for which the cost
of treatment provided under contract would qualify for payment from the
CHEF;
(b) establish a threshold level for reimbursement for the cost of
treatment;
(c) establish procedures for reimbursement of the portion of the
costs incurred by Service Units that exceeds such threshold costs,
including procedures for when the exigencies of the medical
circumstances warrant treatment prior to the authorization of such
treatment by the Service; and
(d) establish procedures for reimbursements pending the outcome or
payment by alternate resources.
Sec. 136.503 Threshold cost.
A Service Unit shall not be eligible for reimbursement from the
CHEF until its cost of treating any victim of a catastrophic illness or
disaster for an episode of care has reached a certain threshold cost.
(a) The threshold cost shall be established at the level of
$19,000.
(b) The threshold cost in subsequent years shall be calculated from
the threshold cost of the previous year, increased by the percentage
increase in the medical care expenditure category of the Consumer Price
Index for all urban consumers (United States city average) for the 12-
month period ending with December of the previous year. The revised
threshold costs shall be published yearly in the Federal Register.
Sec. 136.504 Reimbursement procedure.
Service Units whose scope of work and funding include the purchase
of medical services from private or public vendors under PRC are
eligible to participate. The CHEF payments shall be based only on valid
PRC expenditures, including expenditures for exigent medical
circumstances without prior PRC authorization. Reimbursement from the
CHEF will not be made if applicable PRC requirements are not followed.
(a) Claim Submission: Requests for reimbursement from the CHEF must
be submitted to the appropriate IHS Area Office. Area PRC programs will
review requests for reimbursement to ensure compliance with PRC
requirements, including but not limited to: patient eligibility,
medical necessity, notification requirements for emergent and non-
emergent care, medical priorities, allowable expenditures, and
eligibility for alternate resources. Following this review, Area PRC
programs may provide Service Units an opportunity to submit missing
information or to resubmit documents that are indecipherable. Area PRC
programs will then forward all requests to the Division of Contract
Care, along with any recommendations or observations from the Area PRC
program regarding compliance with PRC or other CHEF requirements. The
Division of Contract Care will adjudicate the claim based upon an
independent review of the claim documentation, but it may consider any
recommendations or observations from the Area PRC program.
(b) Content of Claims: All claims submitted for reimbursement may
be submitted electronically utilizing the secure IHS system(s)
established for this purpose or may be submitted in paper form but must
include:
(1) A fully completed Catastrophic Health Emergency Fund
Reimbursement Request Form.
(2) A statement of the provider's charges on a form that complies
with the format required for the submission of claims under title XVIII
of the Social Security Act. For example, charges may be printed on
forms such as the Centers for Medicare & Medicaid Services (CMS) 1500,
UB-04 (formerly CMS-1450), American Dental Association (ADA) dental
claim form, or National Council for Prescription Drug Program (NCPDP)
universal claim forms. The forms submitted for review must include
specific appropriate diagnostic and procedure codes.
(3) An explanation of benefits or statement of payment identifying
how much was paid to the provider by the Service Unit for the
Catastrophic Illness or Disaster. Payments to the patient or any other
entity are ineligible for the CHEF reimbursement.
(4) The Division of Contract Care may request additional medical
documentation describing the medical treatment or service provided,
including but not limited to discharge summaries and/or medical
progress notes. Cases may be submitted for 50% reimbursement of
eligible expenses pending discharge summaries. Medical documentation
must be received to close the CHEF case.
(c) Limitation of Funds and Reimbursement Procedure: Because of the
limitations of funds, full reimbursement cannot be guaranteed on all
requests and will be based on the availability of funds at the time the
IHS processes the claim. To the extent funds are available, the CHEF
funds may not be used to cover the cost of services or treatment for
which the funds were not approved. Unused funds, including but not
limited to, funds unused due to overestimates, alternate resources, and
cancellations must be returned to the CHEF.
Sec. 136.505 Reimbursable services.
The costs of catastrophic illnesses and disasters for distinct
episodes of care are eligible for reimbursement from the CHEF in
accordance with the medical priorities of the Service. Only services
that are related to a distinct episode of care will be eligible for
reimbursement.
(a) Some of the services that may qualify for reimbursement from
the fund are:
(1) Emergency treatment.
(2) Emergent and acute inpatient hospitalization.
(3) Ambulance services; air and ground (including patient escort
travel costs).
(4) Attending and consultant physician.
(5) Functionally required reconstructive surgery.
(6) Prostheses and other related items.
(7) Reasonable rehabilitative therapy exclusive of custodial care
not to exceed 30 days after discharge.
(8) Skilled nursing care when the patient is discharged from the
acute process to a skilled nursing facility.
(b) [Reserved]
Sec. 136.506 Alternate resources.
(a) Expenses paid by alternate resources are not eligible for
payment by PRC or reimbursement by the CHEF. No payment shall be made
from the CHEF to any Service Unit to the extent that the provider of
services is eligible to receive payment for the treatment from any
other Federal, state, local, or private source of reimbursement for
which the
[[Page 45872]]
patient is eligible. A patient shall be considered eligible for such
resources and no payment shall be made from the CHEF if:
(1) The patient is eligible for alternate resources, or
(2) The patient would be eligible for alternate resources if he or
she were to apply for them, or
(3) The patient would be eligible for alternate resources under
Federal, state, or local law or regulation but for the patient's
eligibility for PRC, or other health services, from the Indian Health
Service or Indian Health Service funded programs.
(b) The determination of whether a resource constitutes an
alternate resource for the purpose of the CHEF reimbursement shall be
made by the Headquarters of the Indian Health Service, irrespective of
whether the resource was determined to be an alternate resource at the
time of PRC payment.
Sec. 136.507 Program integrity.
All the CHEF records and documents will be subject to review by the
respective Area and by Headquarters. Internal audits and administrative
reviews may be conducted as necessary to ensure compliance with PRC
regulations and the CHEF policies.
Sec. 136.508 Recovery of reimbursement funds.
In the event a Service Unit has been reimbursed from the CHEF for
an episode of care and that same episode of care becomes eligible for
and is paid by any Federal, state, local, or private source (including
third party insurance) the Service Unit shall return all the CHEF funds
received for that episode of care to the CHEF at the IHS Headquarters.
These recovered CHEF funds will be used to reimburse other valid CHEF
requests.
Sec. 136.509 Reconsideration and appeals.
(a) Any Service Unit to whom payment from the CHEF is denied will
be notified of the denial in writing together with a statement of the
reason for the denial within 130 business days from receipt.
(b) If a decision on the CHEF case is not made by the CHEF Program
Manager within 180 calendar days from receipt, the Service Unit that
submitted the claim may choose to appeal it as a deemed denial.
(c) In order to seek review of a denial decision or deemed denial,
the Service Unit must follow the procedures set forth in paragraphs
(c)(1) and (c)(2) of this section.
(1) Within 40 business days from the receipt of the denial provided
in paragraph (a) of this section, the Service Unit may submit a request
in writing for reconsideration of the original denial to the Division
of Contract Care. The request for reconsideration must include, as
applicable, corrections to the original claim submission necessary to
overcome the denial; or a statement and supporting documentation
establishing that the original denial was in error. If no additional
information is submitted the original denial will stand. The Service
Unit may also request a telephone conference with the Division of
Contract Care, to further explain the materials submitted, which shall
be scheduled within 40 business days from receipt of the request for
review. A decision by the Division of Contract Care shall be made
within 130 business days of the request for review. The Division of
Contract Care Director, or designee, shall review the application de
novo with no deference to the original decision maker or to the
applicant.
(2) If the original decision is affirmed on reconsideration, the
Service Unit will be notified in writing and advised that an appeal may
be taken to the Director, Indian Health Service, within 40 business
days of receipt of the denial. The appeal shall be in writing and shall
set forth the grounds supporting the appeal. The Service Unit may also
request a telephone conference through the Division of Contract Care,
which shall be scheduled with the Director or a representative
designated by the Director, to further explain the grounds supporting
the appeal. A decision by the Director shall be made within 180
calendar days of the request for reconsideration. The decision of the
Director, Indian Health Service or designee, shall constitute the final
administrative action.
Sec. 136.510 Severability.
If any provision of this subpart is held to be invalid or
unenforceable by its terms, as applied to any person or circumstance,
or stayed pending further agency action, the provision shall be
construed to continue to give the maximum effect to the provision
permitted by law, including as applied to those not similarly situated
or to dissimilar circumstances. However, if such holding is that the
provision of this subpart is invalid and unenforceable in all
circumstances, the provision shall be severable from the remainder of
this subpart and shall not affect the remainder thereof.
Dated: July 10, 2023.
Xavier Becerra,
Secretary, Department of Health and Human Services.
[FR Doc. 2023-14849 Filed 7-17-23; 8:45 am]
BILLING CODE 4165-16-P
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</html>Indexed from Federal Register on July 18, 2023.
This is legal information, not legal advice. Laws vary by jurisdiction and change frequently. Always verify current law with official sources and consult a licensed attorney in your jurisdiction for advice on your specific situation.