Medicare first, then referred care
Under 42 CFR 136.61, IHS "is the payor of last resort." It won't pay for referred care to the extent you're eligible for "alternate resources," or would be if you applied, and the regulation names Medicare and Medicaid among them. IHS says any patient who is potentially eligible is required to apply for the alternate resource. So if you're 65 or older and eligible for Medicare, IHS expects Medicare to be in place before PRC pays.
CMS's guide for tribal Medicare beneficiaries says that with Original Medicare, PRC through your Indian health care provider coordinates referrals and often pays Medicare deductibles, copays and coinsurance. With a Medicare Advantage plan, you may have to use in-network providers and pay for out-of-network care.
The four PRC requirements
IHS says PRC "is not an entitlement program," and that each visit is reviewed separately. To be paid, care must meet all of these:
| Requirement | What IHS says |
|---|---|
| Residency | Live in the tribe's PRC delivery area: generally the reservation county and the counties bordering it |
| Notification | Get approval before non-emergency care; report emergency care within 72 hours (30 days for elders 65 and older and people too disabled to notify in time) |
| Medical priority | The care must fall within the medical priorities being funded at the time |
| Alternate resources | Apply for and use Medicare, Medicaid, private insurance and other coverage first |
IHS also says a referral is a recommendation, not a guarantee of payment, and that follow-up care may need a new authorization.
In Florida
Florida's federally recognized tribes, the Seminole Tribe of Florida and the Miccosukee Tribe of Indians of Florida, run their own health programs, which IHS lists as tribally administered. IHS says tribally administered programs "may have different eligibility requirements," so ask your tribe's health program how its referred care works, which counties it covers and whom to notify after an emergency. The Seminole Tribe has its own self-funded health plan; Medicare.gov says Medicare pays before a tribal health plan.
Going to an emergency room off the reservation? Contact your tribal health program within 72 hours, or within 30 days if you're 65 or older. Show your Medicare card too, so the hospital bills Medicare first.
What to do
- Enroll in Medicare Part A and Part B when you're first eligible. Apply at ssa.gov or 1-800-772-1213 (TTY 1-800-325-0778).
- Tell your tribal health program you have Medicare, and give providers both your Medicare card and your tribal health information.
- Check with the program before you choose a Medicare Advantage plan, because referrals may need to stay in the plan's network. You can also request a call from a licensed insurance agent.
More in our guide to the Seminole Tribe, the Miccosukee Tribe and Medicare.
Related questions
Do American Indians need Part B and Part D?
Penalties, creditable coverage and why enrolling helps.
Can Seminole Tribe members use tribal clinics?
The Seminole Tribe's clinics and Medicare.
How does Medicare work with the Miccosukee clinic?
The Miccosukee Tribe's health program.
Sources
- eCFR — 42 CFR 136.61, Payor of last resort
- Indian Health Service — Purchased/Referred Care
- Indian Health Service — PRC eligibility requirements
- Indian Health Service — PRC notification requirements
- Indian Health Service — PRC frequently asked questions
- Indian Health Service — Nashville Area health care facilities
- CMS Division of Tribal Affairs — Medicare and Tribal Medicare Beneficiaries
- Medicare.gov — Who pays first? (tribal health plans)
More questions in this guide
- Do American Indians in Florida need Medicare Part B and Part D if they use IHS or tribal clinics?
- How does Medicare work with the Miccosukee health clinic?
- Can Seminole Tribe of Florida members use tribal health clinics with Medicare?
Part of the guide: The Seminole Tribe, the Miccosukee Tribe and Medicare in Florida · All questions
Frequently asked questions
What is Purchased/Referred Care?
IHS says care at an IHS or tribal facility is direct care, and PRC is for medical or dental care provided away from those facilities. An IHS referral doesn't mean the care will be paid.
How fast must I notify the program after an emergency?
Within 72 hours under IHS's rules. IHS says elders 65 and older, and people too disabled to notify in time, have 30 days.
Does PRC pay my Medicare deductibles and coinsurance?
It can. CMS's tribal guide says that with Original Medicare, PRC coordinates referrals and often pays Medicare deductibles, copays and coinsurance. Each case must meet PRC's rules.
Medicare in your Florida county
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