[Federal Register Volume 64, Number 208 (Thursday, October 28, 1999)]
[Rules and Regulations]
[Pages 58318-58322]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 99-27417]
[[Page 58317]]
_______________________________________________________________________
Part VIII
Department of Health and Human Services
_______________________________________________________________________
42 CFR Parts 36 and 36a
Currently Effective Indian Health Service Eligibility Regulations; Rule
Federal Register / Vol. 64, No. 208 / Thursday, October 28, 1999 /
Rules and Regulations
[[Page 58318]]
DEPARTMENT OF HEALTH AND HUMAN SERVICES
42 CFR Parts 36 and 36a
RIN 0917-AAO3
Currently Effective Indian Health Service Eligibility Regulations
AGENCY: Indian Health Service, HHS.
ACTION: Republication of currently effective Indian Health Service
eligibility regulations.
-----------------------------------------------------------------------
SUMMARY: The HHS is publishing in the Federal Register, final
regulations governing eligibility for services from the Indian Health
Service. The eligibility regulations currently codified at 42 CFR part
36 are under a congressional moratorium. Republishing the regulations
that are currently in effect while the codified regulations are under
moratorium is being done for the convenience of the public and in
conformance with the requirement of the Administrative Procedure Act, 5
U.S.C. 552(a)(1), that the Code of Federal Regulations (CFR) must
contain currently effective regulations.
DATES: Effective October 28, 1999.
FOR FURTHER INFORMATION CONTACT:
Leslie M. Morris, Director, Division of Regulatory and Legal Affairs,
Suite 450, 12300 Twinbrook Parkway, Rockville, Maryland 20852,
telephone: (301) 443-1116. (This is not a toll-free number.)
SUPPLEMENTARY INFORMATION: On September 16, 1987, HHS published new
final regulations governing eligibility for IHS services at 52 FR
35044. These regulations were to supplant eligibility for IHS services
at 52 FR 35044. These regulations were to supplant eligibility
regulations effective prior to that date but were never implemented.
In the Fiscal Year 1988 Appropriations Act, Section 315, Public Law
100-202, Congress delayed implementation of the new regulations for one
year and has imposed a moratorium on the use of appropriated funds for
implementation of the new regulations in subsequent fiscal years. In
Section 719(a) of the Indian Health Care Amendments of 1988, Public Law
100-713, Congress directed the IHS ``* * * during the period of this
moratorium * * * to provide services pursuant to the criteria for
eligibility for such services that were in effect on September 15,
1987.''
In Section 719(b), Congress also directed the IHS to conduct a
study to determine, among other things, the financial impact of the
rules published September 16, 1987. The study has been completed
(Impact of the Final Rule ``Health Care Services of the Indian Health
Service'' 42 CFR Part 36--Final Report, contract No. 282-910065) and
sent to the tribes for comment, but it has not yet been submitted to
Congress. The IHS has not submitted a budget request reflecting
increased costs associated with the new regulations as directed by the
various appropriations acts.
The regulations in effect on September 15, 1987, which Congress has
made applicable during the moratorium, were last published in the CFR
in 1986. The new regulations have been published in each edition of the
CFR after 1986 but have not been implemented. This has caused
considerable confusion because a reader of the current CFR would assume
that the eligibility regulations published therein are currently
applicable, which is not the case.
Because the moratorium continues in effect, for the convenience of
the public, the HHS is republishing the eligibility regulations in
effect on September 1, 1987, so these regulations may appear in the CFR
printed in regular type, followed by the suspended regulations in small
type.
The suspended regulations are redesignated as part 36a for clarity
of citation purposes because two distinct regulations cannot use the
same regulation number.
The following eligibility rules that were in effect on September 1,
1987, along with 42 CFR subpart G, 36.61, payor of last resort,
(published February 9, 1990, at 55 FR 4609) are currently in effect for
the IHS. Subpart G has replaced Secs. 36.21(a) and 36.23(f) of the
rules in effect on September 15, 1987.
List of Subjects in 42 CFR Parts 36 and 36a
Alaska Natives, Contract health services, Employment, Government
contracts, Government procurement, Grant programs--education, Grant
programs--health, Grant programs--Indians, Health care, Health
facilities, Health service delivery areas, Indians, Penalties,
Reporting and recordkeeping requirements, Scholarships and fellowships,
Student aid.
Dated: September 2, 1999.
Michael E. Lincoln,
Acting Director, Indian Health Service.
Approved: September 29, 1999.
Donna E. Shalala,
Secretary of Health and Human Services.
For the reasons set forth in the preamble, 42 CFR chapter I is
amended as follows:
PART 36--[REDESIGNATED AS PART 36a]
1. Part 36 is redesignated as Part 36a.
2. In newly redesignated Sec. 36a.212, paragraphs (h)(i) through
(h)(iv) are redesignated as paragraphs (h)(i) through (h)(4).
3. In newly redesignated Part 36a, in the redesignated section and
paragraph listed in the first column below, references to the sections
listed in the second column are revised to read as shown in the third
column:
----------------------------------------------------------------------------------------------------------------
Redesignated section Old section reference New section reference
----------------------------------------------------------------------------------------------------------------
36a.12(a)(2), (a)(3), and (b)(1)....... 36.15..................... 36a.15
36a.15(b)(1)........................... 36.(a)(1) and (3)......... 36a.(a)(1) and (3)
36a.16(a).............................. 36.12(a).................. 36a.12(a)
36a.33(a).............................. 36.32(a).................. 36a.32(a)
36a.33(b).............................. 36.14..................... 36a.14
36a.34(b).............................. 36.14..................... 36a.14
36a.42(a).............................. 36.41..................... 36a.41
36a.43................................. 36.41..................... 36a.41
36a.53................................. 36.51..................... 36a.51
36a.53................................. 36.54..................... 36a.54
36a.56................................. 36.54..................... 36a.54
36a.106(a)(4).......................... 36.105.................... 36a.105
36a.116................................ 36.114.................... 36a.114
36a.120(a)............................. section 102(g) of this 36a.102(g)
subpart.
36a.205(b)(18)......................... 36.216.................... 36a.216
36a.208(b)(4).......................... 36.206.................... 36a.206
36a.212(h)(iv)......................... 36.214.................... 36a.214
[[Page 58319]]
36a.230(b)............................. 36.208.................... 36a.208
36a.230(b)............................. 36.214.................... 36a.214
36a.232................................ 36.233(a)................. 36a.233(a)
36a.302(v)(4).......................... 36.350(a)................. 36a.350(a)
36a.303 (a) and (d).................... 36.302.................... 36a.302
36a.321(d)............................. 36.320.................... 36a.320
36a.322(a)(2).......................... 36.332.................... 36a.332
36a.350(a) introductory text........... 36.351.................... 36a.351
36a.351(b)(5), (b)(6), (b)(7), (b)(9).. 36.350(a)................. 36a.350(a)
36a.353................................ 36.350(a) (7) and (8)..... 36a.350(a) (7) and (8)
36a.371(c), (d)........................ 36.370.................... 36a.370
36a.372(a)(2).......................... 36.332.................... 36a.332
----------------------------------------------------------------------------------------------------------------
4. Redesignated part 36a is suspended indefinitely.
5. A new part 36 is added to read as follows:
PART 36--INDIAN HEALTH
Subpart A--Purpose and Definitions
Sec.
36.1 Definitions.
36.2 Purpose of the regulations.
36.3 Administrative instructions.
Subpart B--What Services Are Available and Who Is Eligible To Receive
Care
36.11 Services available.
36.12 Persons to whom services will be provided.
36.13 [Reserved]
36.14 Care and treatment of ineligible individuals.
Subpart C--Contract Health Services
36.21 Definitions.
36.22 Establishment of contract health service delivery areas.
36.23 Persons to whom contract health services will be provided.
36.24 Authorization for contract health services.
36.25 Reconsideration and appeals.
Subpart D--[Reserved]
Subpart E--Preference in Employment
36.41 Definitions.
36.42 Appointment actions.
36.43 Application procedure for preference eligibility.
Subpart F--Abortions and Related Medical Services in Indian Health
Service Facilities and Indian Health Service Programs
36.51 Applicability.
36.52 Definitions.
36.53 General rule.
36.54 Life of the mother would be endangered.
36.55 Drugs and devices and termination of ectopic pregnancies.
36.56 Recordkeeping requirements.
36.57 Confidentiality.
Subpart G--Residual Status
36.61 Payor of last resort.
Authority: 25 U.S.C. 13; sec. 3, 68 Stat. 674 (42 U.S.C., 2001,
2003); Sec. 1, 42 Stat. 208 (25 U.S.C. 13); 42 U.S.C. 2001, unless
otherwise noted.
Subpart A--Purpose and Definitions
Sec. 36.1 Definitions.
When used in this part:
Bureau of Indian Affairs (BIA) means the Bureau of Indian Affairs,
Department of the Interior.
Indian includes Indians in the Continental United States, and
Indians, Aleuts and Eskimos in Alaska.
Indian health program means the health services program for Indians
administered by the Indian Health Service within the Department of
Health and Human Services.
Jurisdiction has the same geographical meaning as in Bureau of
Indian Affairs usage.
Service means the Indian Health Service.
Sec. 36.2 Purpose of the regulations.
The regulations in this part establish general principles and
program requirements for carrying out the Indian health programs.
Sec. 36.3 Administrative instructions.
The service periodically issues administrative instructions to its
officers and employees, which are primarily found in the Indian Health
Service Manual and the Area Office and program office supplements.
These instructions are operating procedures to assist officers and
employees in carrying out their responsibilities, and are not
regulations establishing program requirements which are binding upon
members of the general public.
Subpart B--What Services Are Available and Who Is Eligible To
Receive Care?
Sec. 36.11 Services available.
(a) Type of services that may be available. Services for the Indian
community served by the local facilities and program may include
hospital and medical care, dental care, public health nursing and
preventive care (including immunizations), and health examination of
special groups such as school children.
(b) Where services are available. Available services will be
provided at hospitals and clinics of the Service, and at contract
facilities (including tribal facilities under contract with the
Service).
(c) Determination of what services are available. The Service does
not provide the same health services in each area served. The services
provided to any particular Indian community will depend upon the
facilities and services available from sources other than the Service
and the financial and personnel resources made available to the
Service.
Sec. 36.12 Persons to whom services will be provided.
(a) In general. Services will be made available, as medically
indicated, to persons of Indian descent belonging to the Indian
community served by the local facilities and program. Services will
also be made available, as medically indicated, to a non-Indian woman
pregnant with an eligible Indian's child but only during the period of
her pregnancy through postpartum (generally about 6 weeks after
delivery). In cases where the woman is not married to the eligible
Indian under applicable state or tribal law, paternity must be
acknowledged in writing by the Indian or determined by order of a court
of competent jurisdiction. The Service will also provide medically
indicated services to non-Indian members of an eligible Indian's
household if the medical officer in charge determines that this is
necessary to control acute infectious disease or a public health
hazard.
(2) Generally, an individual may be regarded as within the scope of
the Indian health and medical service program if he/she is regarded as
an Indian by the community in which he/she lives as evidenced by such
factors as tribal membership, enrollment, residence on tax-exempt land,
ownership of restricted property, active participation in tribal
affairs, or other relevant factors in keeping with general
[[Page 58320]]
Bureau of Indian Affairs practices in the jurisdiction.
(b) Doubtful cases. (1) In case of doubt as to whether an
individual applying for care is within the scope of the program, the
medical officer in charge shall obtain from the appropriate BIA
officials in the jurisdiction information that is pertinent to his/her
determination of the individual's continuing relationship to the Indian
population group served by the local program.
(2) If the applicant's condition is such that immediate care and
treatment are necessary, services shall be provided pending
identification as an Indian beneficiary.
(c) Priorities when funds, facilities, or personnel are
insufficient to provide the indicated volume of services. Priorities
for care and treatment, as among individuals who are within the scope
of the program, will be determined on the basis of relative medical
need and access to other arrangements for obtaining the necessary care.
Sec. 36.13 [Reserved]
Sec. 36.14 Care and treatment of ineligible individuals.
(a) In case of an emergency, as an act of humanity, individuals not
eligible under Sec. 36.12 may be provided temporary care and treatment
in Service facilities.
(b) Charging ineligible individuals. Where the Service Unit
Director determines that an ineligible individual is able to defray the
cost of care and treatment, the individual shall be charged at rates
approved by the Assistant Secretary for Health and Surgeon General
published in the Federal Register. Reimbursement from third-party
payors may be arranged by the patient or by the Service on behalf of
the patient.
Subpart C--Contract Health Services
Sec. 36.21 Definitions.
(a) Alternate resources is defined in Sec. 36.61(c) of subpart G of
this part.
(b) Appropriate ordering official means, unless otherwise specified
by contract with the health care facility or provider, the ordering
official for the contract health service delivery area in which the
individual requesting contract health services or on whose behalf the
services are requested, resides.
(c) Area Director means the Director of an Indian Health Service
Area designated for purposes of administration of Indian Health Service
programs.
(d) Contract health service delivery area means the geographic area
within which contract health services will be made available by the IHS
to members of an identified Indian community who reside in the area,
subject to the provisions of this subpart.
(e) Contract health services means health services provided at the
expense of the Indian Health Service from public or private medical or
hospital facilities other than those of the Service.
(f) Emergency means any medical condition for which immediate
medical attention is necessary to prevent the death or serious
impairment of the health of an individual.
(g) Indian tribe means 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 to Indians because
of their status as Indians.
(h) Program Director means the Director of an Indian Health Service
``program area'' designated for the purposes of administration of
Indian Health Service programs.
(i) Reservation means any federally recognized Indian tribe's
reservation. Pueblo, or colony, including former reservations in
Oklahoma, Alaska Native regions established pursuant to the Alaska
Native Claims Settlement Act (43 U.S.C. 1601 et seq.), and Indian
allotments.
(j) Secretary means the Secretary of Health and Human Services to
whom the authority involved has been delegated.
(k) Service means the Indian Health Service.
(l) Service Unit Director means the Director of an Indian Health
Service ``Service unit area'' designated for purposes of administration
of Indian Health Service programs.
Sec. 36.22 Establishment of contract health service delivery areas.
(a) In accordance with the congressional intention that funds
appropriated for the general support of the health program of the
Indian Health Service be used to provide health services for Indians
who live on or near Indian reservations, contract health service
delivery areas are established as follows:
(1) The State of Alaska;
(2) The State of Nevada;
(3) the State of Oklahoma;
(4) Chippewa, Mackinac, Luce, Alger, Schoolcraft, Delta, and
Marquette Counties in the State of Michigan;
(5) Clark, Eau Claire, Jackson, La Crosse, Monroe, Vernon,
Crawford, Shawano, Marathon, Wood, Juneau, Adams, Columbia, and Sauk
Counties in the State of Wisconsin and Houston County in the State of
Minnesota;
(6) With respect to all other reservations within the funded scope
of the Indian health program, the contract health services delivery
area shall consist of a county which includes all or part of a
reservation, and any county or counties which have a common boundary
with the reservation.
(b) The Secretary may from time to time, redesignate areas or
communities within the United States as appropriate for inclusion or
exclusion from a contract health service delivery area after
consultation with the tribal governing body or bodies on those
reservations included within the contract health service delivery area.
The Secretary will take the following criteria into consideration:
(1) The number of Indians residing in the area proposed to be so
included or excluded;
(2) Whether the tribal governing body has determined that Indians
residing in the area near the reservation are socially and economically
affiliated with the tribe;
(3) The geographic proximity to the reservation of the area whose
inclusion or exclusion is being considered; and
(4) The level of funding which would be available for the provision
of contract health services.
(c) Any redesignation under paragraph (b) of this section shall be
made in accordance with the procedures of the Administrative Procedure
Act (5 U.S.C. 553).
Sec. 36.23 Persons to whom contract health services will be provided.
(a) In general. To the extent that resources permit, and subject to
the provisions of this subpart, contract health services will be made
available as medically indicated, when necessary health services by an
Indian Health Service facility are not reasonably accessible or
available, to persons described in and in accordance with Sec. 36.12 of
this part if those persons:
(1) Reside within the United States and on a reservation located
within a contract health service delivery area; or
(2) Do not reside on a reservation but reside within a contract
health service delivery area and:
(i) Are members of the tribe or tribes located on that reservation
or of the tribe or tribes for which the reservation was established; or
(ii) Maintain close economic and social ties with that tribe or
tribes.
(b) Students and transients. Subject to the provisions of this
subpart, contract health services will be made available to students
and transients who would be
[[Page 58321]]
eligible for contract health services at the place of their permanent
residence within a contract health service delivery area, but are
temporarily absent from their residence as follows:
(1) Student--during their full-time attendance at programs of
vocational, technical, or academic education, including normal school
breaks (such as vacations, semester or other scheduled breaks occurring
during their attendance) and for a period not to exceed 180 days after
the completion of the course of study.
(2) Transients (persons who are in travel or are temporarily
employed, such as seasonal or migratory workers) during their absence.
(c) Other persons outside the contract health service delivery
area. Persons who leave the contract health service delivery area in
which they are eligible for contract health service and are neither
students nor transients will be eligible for contract health service
for a period not to exceed 180 days from such departure.
(d) Foster children. Indian children who are placed in foster care
outside a contract health service delivery area by order of a court of
competent jurisdiction and who were eligible for contract health
services at the time of the court order shall continue to be eligible
for contract health services while in foster care.
(e) Priorities for contract health services. When funds are
insufficient to provide the volume of contract health services
indicated as needed by the population residing in a contract health
service delivery area, priorities for service shall be determined on
the basis of relative medical need.
(f) Alternate resources. The term ``alternate resources'' is
defined in Sec. 36.61(c) of Subpart G of this part.
Sec. 36.24 Authorization for contract health services.
(a) No payment will be made for medical care and services obtained
from non-Service providers or in non-Service facilities unless the
applicable requirements of paragraphs (b) and (c) of this section have
been met and a purchase order for the care and services has been issued
by the appropriate ordering official to the medical care provider.
(b) In nonemergency cases, a sick or disabled Indian, an individual
or agency acting on behalf of the Indian, or the medical care provider
shall, prior to the provision of medical care and services notify the
appropriate ordering official of the need for services and supply
information that the ordering official deems necessary to determine the
relative medical need for the services and the individual's
eligibility. The requirement for notice prior to providing medical care
and services under this paragraph may be waived by the ordering
official if:
(1) Such notice and information are provided within 72 hours after
the beginning of treatment or admission to a health care facility; and
(2) The ordering official determines that giving of notice prior to
obtaining the medical care and services was impracticable or that other
good cause exists for the failure to provide prior notice.
(c) In emergency cases, a sick or disabled Indian, or an individual
or agency acting on behalf of the Indian, or the medical care provider
shall within 72 hours after the beginning of treatment for the
condition or after admission to a health care facility notify the
appropriate ordering official of the fact of the admission or
treatment, together with information necessary to determine the
relative medical need for the services and the eligibility of the
Indian for the services. The 72-hour period may be extended if the
ordering official determines that notification within the prescribed
period was impracticable or that other good cause exists for the
failure to comply.
Sec. 36.25 Reconsideration and appeals.
(a) Any person to whom contract health services are denied shall be
notified of the denial in writing together with a statement of the
reason for the denial. The notice shall advise the applicant for
contract health services that within 30 days from the receipt of the
notice the applicant:
(1) May obtain a reconsideration by the appropriate Service Unit
Director of the original denial if the applicant submits additional
supporting information not previously submitted; or
(2) If no additional information is submitted, may appeal the
original denial by the Service Unit Director to the appropriate Area or
program director. A request for reconsideration or appeal shall be in
writing and shall set forth the grounds supporting the request or
appeal.
(b) If the original decision is affirmed on reconsideration, the
applicant shall be so notified in writing and advised that an appeal
may be taken to the Area or program director within 30 days of receipt
of the notice of the reconsidered decision. The appeal shall be in
writing and shall set forth the grounds supporting the appeal.
(c) If the original or reconsidered decision is affirmed on appeal
by the Area or program director, the applicant shall be so notified in
writing and advised that a further appeal may be taken to the Director,
Indian Health Service, within 30 days of receipt of the notice. The
appeal shall be in writing and shall set the grounds supporting the
appeal. The decision of the Director, Indian Health Service, shall
constitute final administrative action.
Subpart D--[Reserved]
Subpart E--Preference in Employment
Authority: 25 U.S.C. 44, 45, 46 and 472; Pub. L. 83-568, 68 Stat
674, 42 U.S.C. 2003.
Sec. 36.41 Definitions.
For purposes of making appointments to vacancies in all positions
in the Indian Health Service, a preference will be extended to persons
of Indian descent who are:
(a) Members of any recognized Indian tribe now under Federal
jurisdiction;
(b) Descendants of such members who were, on June 1, 1934, residing
within the present boundaries of any Indian reservation;
(c) All others of one-half or more Indian blood of tribes
indigenous to the United States;
(d) Eskimos and other aboriginal people of Alaska; or
(e) Until January 4, 1990, or until the Osage Tribe has formally
organized, whichever comes first, a person of at least one-quarter
degree Indian ancestry of the Osage Tribe of Indians, whose rolls were
closed by an act of Congress.
Sec. 36.42 Appointment actions.
(a) Preference will be afforded a person meeting any one of the
definitions of Sec. 36.41 whether the placement in the position
involves initial appointment, reappointment, reinstatement, transfer,
reassignment, promotion, or any other personnel action intended to fill
a vacancy.
(b) Preference eligibles may be given a schedule A excepted
appointment under 5 CFR 213.3116(b)(8). If the individuals are within
reach on a Civil Service Register, they may be given a competitive
appointment.
Sec. 36.43 Application procedure for preference eligibility.
To be considered a preference eligible, the person must submit with
the employment application a Bureau of Indian Affairs certification
that the person is an Indian as defined by Sec. 36.41 except that an
employee of the Indian Health Service who has a certificate of
preference eligibility on file in the Official Personnel Folder is not
required to resubmit such proof but
[[Page 58322]]
may instead include a statement on the application that proof of
eligibility is on file in the Official Personnel Folder.
Subpart F--Abortions and Related Medical Services in Indian Health
Service Facilities and Indian Health Service Programs
Authority: Sec. 1, 42 Stat. 208, (25 U.S.C. 13); sec. 1, Stat.
674, (42 U.S.C. 2001); sec. 3, 68 Stat. 674, (42 U.S.C. 2003).
Sec. 36.51 Applicability.
This subpart is applicable to the use of Federal funds in providing
health services to Indians in accordance with the provisions of
subparts A, B, and C of this part.
Sec. 36.52 Definitions.
As used in this subpart:
Physician means a doctor of medicine or osteopathy legally
authorized to practice medicine and surgery at an Indian Health Service
or tribally run facility, or by the state in which he or she practices.
Sec. 36.53 General rule.
Federal funds may not be used to pay for or otherwise provide for
abortions in the programs described in Sec. 36.51, except under the
circumstances described in Sec. 36.54.
Sec. 36.54 Life of the mother would be endangered.
Federal funds are available for an abortion when a physician has
found and so certified in writing to the appropriate tribal or other
contracting organization, or Service Unit or Area Director, that ``on
the basis of my professional judgment the life of the mother would be
endangered if the fetus were carried to term.'' The certification must
contain the name and address of the patient.
Sec. 36.55 Drugs and devices and termination of ectopic pregnancies.
Federal funds are available for drugs or devices to prevent
implantation of the fertilized ovum, and for medical procedures
necessary for the termination of an ectopic pregnancy.
Sec. 36.56 Recordkeeping requirements.
Documents required by Sec. 36.54 must be maintained for three years
pursuant to the retention and custodial requirements for records at 45
CFR part 74, subpart C.
Sec. 36.57 Confidentiality.
Information which is acquired in connection with the requirements
of this subpart may not be disclosed in a form which permits the
identification of an individual without the individual's consent,
except as may be necessary for the health of the individual or as may
be necessary for the Secretary to monitor Indian Health Service program
activities. In any event, any disclosure shall be subject to
appropriate safeguards which will minimize the likelihood of
disclosures of personal information in identifiable form.
Subpart G--Residual Status
Sec. 36.61 Payor of last resort.
(a) The Indian Health Service is the payor of last resort for
persons defined as eligible for contract health services under the
regulations in this part, notwithstanding any State or local law or
regulation to the contrary.
(b) Accordingly, the Indian Health Service will not be responsible
for or authorize payment for contract health services to the extent
that:
(1) The Indian is eligible for alternate resources, as defined in
paragraph (c) of this section, or
(2) The Indian would be eligible for alternate resources if he or
she were to apply for them, or
(3) The Indian would be eligible for alternate resources under
State or local law or regulation but for the Indian's eligibility for
contract health services, or other health services, from the Indian
Health Service or Indian Health Service funded programs.
(c) 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.
[FR Doc. 99-27417 Filed 10-28-99; 8:45 am]
BILLING CODE 4160-16-M
