Passamaquoddy at Sipayik

Pleasant Point Tribal Government

Pleasant Point Health Center

P.O. Box 351 Perry, ME 04667

Phone Number (207) 853-2347


Patient Handbook

This Patient Handbook is dedicated to the memory of Mrs. Hazel R. Dana, RN. Hazel was instrumental in bringing health care services to our community. Kci Woliwon Hazel

Table of Contents

Part 1 - Our Mission of Quality of Care

Part 2 - Patients Bill of Rights

Part 3 - Hours of Operation

Part 4 - Tribal Eligibility Requirements

Part 5 - Support Services

Patient Registration

Contract Health Care

Third Party Billing

Medical Records

Part 6 - Programs & Services Offered

Dental Services

Pharmacy

Emergency Medical Services

Wolipomawsu Program

Part 7 - Medical Services

Part 8 - Specialty Clinics

Chiropractic Care

Optometry

Podiatric Medicine

Pulmonology

Pediatrics Clinic

Men’s Clinic Office of Environmental Health

WIC & Nutrition Services

Fitness Center

Part 9 - Policies & Procedures

Eyeglasses Policy

72-Hour Notification

Health Services for Ineligible Persons

Description of Medical Priority Levels

Appendices

Organizational Chart

Service Area Map

Registration Forms

PART 1 - OUR MISSION OF QUALITY OF CARE The mission of the Pleasant Point Health Center is to provide the highest quality of health care available to the community we serve. We are funded through a contract with the Federal Indian Health Services. The Pleasant Point Health Center operates as a local comprehensive Health Care Delivery System under the “P.L. 638, Indian Self Determination Act.” Our primary contracting office is located in Nashville, Tennessee. Alternate Resources, such as payment from Medicaid, Medicare, Veterans’ Benefits, and Private insurance, provide additional funding to provide essential services to our community. We rely heavily on income from third party payers, as the level of funding that we receive from Indian Health Services is limited.

The Contract Health Service Delivery Area (CHSDA) is defined as all of the area in Washington County, Maine described as: South of Route Nine (9) from Milbridge in the Southwest section to Calais in the Northeast section. Eligibility Criteria for Passamaquoddy Tribal Members is determined by the Congress of the United States and published in the Federal Register.

It is our hope that the information contained in the following pages is helpful to you. It has been assembled to assist you in accessing services available at the Pleasant Point Health Center. We may not be able to answer all of your questions, but we hope that this information has been helpful to you in learning about your health clinic and the types of services that we can offer to you, the patient. We look forward to continuing to provide a wide range of services designed to help Passamaquoddy People live longer and stronger.

If you have any questions, or would like to discuss any aspect of health care delivery, feel free to call us at (207) 853-0644.

 PART 2 - PATIENT BILL OF RIGHTS

All Patients at the Pleasant Point Health Center are entitled to Respect and dignity - The right to health care that is considerate, respectful, and sensitive to his or her culture and beliefs.

 *Privacy and Confidentiality - The right to privacy and confidentiality concerning case discussion, examination, treatment, medical records, and other information. The patient has the right to refuse the presence of health care students.

*Personal Safety - The right to expect reasonable safety insofar as the health center practices and environment are concerned.

 *Identity - The right to know the name and qualifications of the person(s) who will be responsible for his or her treatment.

*Information - The right to receive (patient or appropriate family member) all information from the physician concerning health care. The right to formally request medical records information and receive copies of such information. The right to disagree with comments and document these comments in the record. However professional statements may not be removed from the record.

*Consent - The rights concerning Informed Consent (approval to have procedures and treatments performed). The physician must provide all information necessary for the patient to make a decision as to whether the procedure or treatment is acceptable, including an explanation of the risks that involved, whether or not any incapacity for normal living will result and if there are any alternative types of treatment. In bona fide emergency situations (life threatening or possibility of permanent loss of limb, eyesight, or other critical functions), the physician may need to provide information to the family of the patient. In such instances the physician would not be responsible for providing extensive information if it would further jeopardize the well being of the patient.

*Consultation - The patient, at their own expense, has the right to consult with private specialists

*Refusal of Treatment - The right to refuse treatment to the extent provided by the law. If care is refused, he or she must be informed of the risks incurred by doing so. If the patient is a minor and has a recognized guardian, the guardian and or family must be told of the risks incurred if treatment for the minor is refused. The patient is responsible for the deterioration of his or her condition when treatment is refused or the practitioner’s instructions are not followed.

*Transfer and Continuity of Care - The right when care is requested, to receive services provided by the health department. When services are not available at the health department, the patient and his or her family will be informed about the availability of specialized services at another center/clinic/hospital. The patient has the right to expect reasonable continuity of care for his or her illness or condition.

*Compliance with Instructions - The patient is responsible for following the treatment plan recommended by the physician, including the instructions of nurses and allied health personnel. The patient is responsible for keeping appointments, and when unable to do so, notifying the health center/clinic or hospital.

*Provision of Information - The patient has the responsibility to provide accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other health related matters. The patient has the responsibility for reporting unexpected changes in his or her condition to the responsible physician.

*Right of Appeal - Any person who has been denied payment for Contract Health Services shall be notified in writing together with a statement of the reason for denial. The Quality Assurance Team may make a reconsideration of the denial if additional documentation is presented. If you have no additional information, or if your reconsideration is denied, you may appeal, in writing, to the Director of Indian Health Services-Nashville Area Office within 30-days of the denial letter.

PART 3 - HOURS OF OPERATION

The Pleasant Point Health Center offers a wide range of services ranging from Dental to Mental Health. The hours these services are provided are listed below:

1.Regular hours of operation: Monday – Friday from 8:00 AM – 4:30 PM

2.Walk-in Clinic: Monday – Friday (Please come in between 10:45 AM - 11:15 AM to register.)

3.Routine and Follow-up appointments are scheduled for patients by the receptionist (Please provide 24-hour notice for cancellations.)

4. Pharmacy: Monday – Friday from 8:00 AM – 4:30 PM 5. Dental services: Tuesday – Friday from 8:00 AM – 4:30 PM

The Pleasant Point Health Center is pleased to have 24-hour Emergency Medical Services as part of their team. For all of your emergency services, please call the Sipayik Ambulance at (207) 853-2551 or 4811. In addition to regular services, the Sipayik Ambulance also has paramedic coverage on weekends.

Please note that the Pleasant Point Health Center is not able to pay for transportation by any service other than the Sipayik Ambulance. If the Sipayik Ambulance is unavailable, they will dispatch another service for you, which will be paid by the Pleasant Point Health Center.

If you have an emergency during non-working hours, be sure to call the Receptionist at the Pleasant Point Health Center within 72-hours to notify. Failure to make notification within 72-hours will result in non-payment of any bill associated with the emergency.

PART 4 - ELIGIBILITY REQUIREMENTS - Contract Health Services

Enrolled Members of the Passamaquoddy Tribe at Pleasant Point are eligible for Direct (on-site) Medical Services. This includes members who reside within and outside of the Contract Health Service Delivery Area. (CHSDA)

Enrolled Members of the Passamaquoddy Tribe at Pleasant Point shall be given resident status and deemed eligible for Contract Health Care (off-site services) once all requirements for eligibility have been met. Health care coverage will continue for a period of six (6) months after the eligible member has left the Service Area. However, if a person leaves the Service Area prior to establishing residency, they will be considered a non-resident and therefore ineligible for Contract Health Care. If moving from one reservation to another, no residency period is required.

To be eligible for Contract Health Services(CHS), members must:

1.Provide proof of residency

2.Apply for alternate resource (if none exists)

Enrolled members of the Passamaquoddy Tribe at Pleasant Point who are students or serving in the U.S Military shall not lose their resident status or eligibility for Contract Health Services while attending school or serving in the military full-time. However, if they elect to remain outside the Service Area, an eligibility period of six (6) months coverage will start on the date of:

1.Discharge from the U.S Military

2.Graduation Date from an Academic Institution

3.Drop-out or Dismissal from an Academic Institution

Indian children residing in the Service Area, who have been adopted by or are in the foster care of:

Non-Tribal Members, shall be eligible for services through the Pleasant Point Health Center if they are a Non-Indian Child who has been adopted or a Non-Indian women seeking prenatal care when pregnant with an Indian child.

A Non-Indian Child who is adopted by an Enrolled Member of the Passamaquoddy Tribe at Pleasant Point is eligible for Direct (on-site) Health Services until they have reached the age of nineteen (19). First generation descendants of Enrolled Tribal Members shall be eligible for Direct Services until the age of nineteen (19).

Pre-Natal Care is available to a Non-Indian Mother pregnant with the child of an Enrolled Member of the Passamaquoddy Tribe at Pleasant Point. Health Care Services are for the duration of the pregnancy and for a period of six (6) weeks Post-Partum. Notarized acknowledgement of paternity is required if not married. Also, she must comply with CHS Guidelines and apply for any alternative resources available.

PART 5 - SUPPORT SERVICES 

Patient Registration

Once a patient has checked in with the Receptionist, they report to the Patient Registration Office. Our Patient Registration Office is in the lobby area for your convenience. All new patients must report to the Patient Registration Office to be signed up for services.

The process of registering at the Pleasant Point Health Center takes just a few minutes. Please come early for your appointment so that we may have the opportunity to complete your file. Stop by the Patient Registration office to report any changes to your file. We request that the Patient Registration form to be updated quarterly.

Our Patient Registration staff is willing and able to assist you with your application for Medicaid. We have application forms at the clinic so there is no need to request these forms from DHS.

In addition, Patient Registration staff can assist with your application for SSI and Disability Benefits, Food Stamps, and Social Security Cards for you and your family. Also, we offer Medicaid mileage through WHCA. (You must give provide one week in advance to process the paperwork.)

Contract Health Care

Contract Health Services are those services that are provided by outside agencies for eligible members of the Passamaquoddy Tribe at Pleasant Point. The referral for these types of services arises when the patient’s provider sees the need for more specialized services in order to maintain the health of the patient. Funds for these services are provided as part of our contract from Indian Health Services.

In order to receive a referral for services outside of the clinic, a patient must:

1.Visit their provider at the Pleasant Point Health Center to determine if a referral for outside services is necessary.

2.The Patient will then take the referral to the Contract Health Care Office to confirm the patient’s eligibility for Contract Care. (Based on confirmation of alternate resource availability)

3.Upon confirmation of eligibility for Contract Health Care, the Patient takes the referral to the Receptionist so that an appointment can be made.

We require 72-hour notification for any Emergency Room visits. Failure to provide proper notice will result in non-payment of any bills associated with the Emergency Room Visit.

If you have been denied payment for services, you may appeal the decision by submitting, in writing, a letter explaining why you feel it should be paid and any supporting documentation. Any appeal must be done within 30-days of the receipt of a denial letter. All requests for appeal are reviewed by the Quality Assurance Team to ensure that a correct decision has been made.

ALL PATIENTS MUST BE REFERRED BY THE HEALTH CENTER TO ENSURE PAYMENT. THIS INCLUDES FOLLOW-UP APPOINTMENTS.

Thrid party Billing

The Pleasant Point Health Center, through payment for services from third party payers, has established a budget that is commonly known as the “ Third Party Budget.” The Authorization to create this funding is authorized by the Indian Health Services through their Nashville Area Office.

The Third Party money pays for wages of some employees at the Pleasant Point Health Center, but a majority of the funds collected go back into direct services to our community. Many of the services offered are paid for by Third Party, They include, but are not limited to:
1.On-site Specialty Clinics
2.Eyeglasses and Hearing Aids for our Elders and our Disabled people
3.Transportation assistance for the Elders and Disabled

4.Other types of specialty assistance when funds are available

These are just some of the reasons why it is so important for us to have your health insurance information. When we bill for services provided at the clinic, all of the money collected comes back to our community in the form of additional programs and services.

Medical Records

The Medical Records Department houses the files of all medical patients at the Pleasant Point Health Center (PPHC). We are open Monday through Friday from 8:00 AM – 4:30 PM.

We adhere to the Policies and Procedures set forth by Indian Health Services and work diligently to protect the CONFIDENTIALITY of all patients. If a patient requires information, please note the following:

1.Obtain a signed release for medical records to and from the PPHC

2.Provide 24-hour notice for photocopying of chart information

The Medical Records Department is unable to accept “ verbal” results from outside providers. Also, we cannot give patients results over the telephone.

PART 6 - PROGRAMS AND SERVICES OFFERED

The Pleasant Point Health Center is proud to offer a wide variety of services that is continuing to grow with our community.
1.Dental Services
2.Emergency Medical Services
3.Wolipomawsu
4.Behavioral Health
5.Counseling and Treatment
6.Medical Services
7.Laboratory Services
8.Nursing services
9.Home Health Care
10.LifeLine Installation, Maintenance, and Management
11.Limited Environmental Health Services
12.WIC Program and Associated Services
13.Nutrition Education
14.Telemedicine (Consults/Education)
15.Exercise Program/Fitness Training
16.Full Service Pharmacy
Prescriptions & Limited Over-the-Counter Drugs
17.Specialty Clinics
Chiropractic Care
Optometry Clinic
Podiatry Clinic
Pediatrics
Pulmonology
Men’s Clinic

Our Programs and Services
Dental Services
The Dental Program at the Pleasant Point Health Center offers a wide range of patient services to the Pleasant Point Community. On-site we are able to provide the following

*Dental Exams

*Sealants

*Dental Cleanings

*X-Rays

*Fillings

*Extractions

*Consultations

Referrals to outside specialists are done only as necessary and in accordance with the Dental Priority System set forth by Indian Health Services.

Pharmacy

A registered Pharmacist is available to fill prescriptions form Monday through Friday, 8:00 AM to 4:30 PM. Emergency prescriptions may be filled after hours, on weekends, or holidays, at Havey & Wilson (Eastport), and Rite-Aid (Calais), and Treworgy Rexall (Calais), provided that you notify the Pleasant Point Health Center within 72 hours (3 days). Failure to notify us will result in your prescription cost not being covered by the Pleasant Point Health Center

Emergency Medical Services

The Pleasant Point Ambulance Corps is a group of top-rated, professional persons that offers emergency medical services to the injured and sick of the Pleasant Point as well as surrounding communities. We have two new ambulances stocked with the latest “high-tech” medical equipment on board. With our new ambulances, we are able to respond quickly to your emergency and make prompt transport to the nearest emergency medical facility.

A core of dedicated medical technicians and experienced paramedics now offers basic and advanced life support services 24 hours a day. The staff is state certified to respond to medical emergencies including, but not limited to, trauma, cardiovascular and psychiatric needs. Paramedic services are offered on weekends and holidays.

We have been classified by the National Indian Health Services as “ Superior” in meeting the needs of our patients. The Pleasant Point Ambulance Corps is proud of this ranking, and will continue to work hard to meet the needs of our community.

We are pleased to offer complete paramedic coverage on the weekends.

Wolipomawsu Program

The Wolipomawsu Program offers general psychiatric, psychological and substance abuse services. These services cover the full range of child and adolescent treatment through to adult and geriatric age groups.

We are open Monday through Friday from 8:00 AM until 4:30 PM. The hour of 1:00 PM – 2:00 PM is reserved for emergency walk-in visits every day. Our specialties include:
Fitness for Duty Evaluations
Psycho-educational Services
Crisis Intervention Services
Referral Services
Critical Incident Stress De-briefing Services
Suicide Assessment and Prevention
Couples Counseling
Family Therapy
Psychological Testing
Psychiatric Medications Management
Substance Abuse assessment/evaluations and Counseling

PART 7 - MEDICAL SERVICES

The Pleasant Point Health Center is pleased to have a professional staff, able and willing to provide a wide range of services to all patients in our community. All providers are accessible via the walk-in clinic, which runs from 10:45 AM through 12:00 PM Monday through Friday.

In addition to specialty clinics, patients can access the following:
1.General family medicine
2.Well-Child and limited pediatrics
3.Internal Medicine
4.Women’s Health

Laboratory Services:
1.Screening for: drugs (Court Ordered), lead, and medical drug levels
2.Testing services: AIDS/HIV, paternity, pregnancy
3.Lipid profiles, glucose tolerance, glycoprotein          4.And home visits as recommended by Medical Dept

Nursing Services:

1.Prenatal education
2.Diabetes Mellitus screening and education
3.Hypertension screening
4.Well child services
5.Immunization clinics                                                       6.Facilitate off-site patient care services

Home Health Care Services:

1.Hospital discharge follow-up
2.Phlebotomy services for homebound patients
3.Medication review
4.Patient education                                                   5.LifeLine installation, maintenance, and management

PART 8 - SPECIALTY CLINICS 

Through funds provided by Third Party Revenue, the Pleasant Point Health Center is able to offer certain specialty services on-site.

Chiropractic Care This clinic provides spinal manipulation to restore normal joint movement and reduce pressure on the nerve, joint and muscles in the affected area; Deep-muscle Accupressure therapy to improve muscle movement and reduce pain; and care for chronic pain (low back, upper back, neck and headaches) Appointments are available from 8:00 AM through 4:00 PM on the second and fourth Wednesday of each month.

Optometry This clinic provides eye examinations as well as screening for glaucoma. Special emphasis is placed on the elderly and diabetic population of our community; however, appointments for eye exams for the general population can be made with the Receptionist. The Pleasant Point Health Center utilizes some of the most modern up to date equipment to provide a full and professional service. The optometrist is available twice a month from 8:00 AM through 4:00 PM. As the days vary, please call the set an appointment.

Podiatric Medicine This clinic provides services related to the foot, ankle, and lower leg. This includes but is not limited to the following conditions Achilles tendonitis, ankle and foot injuries, bunions, corns and calluses, plantar warts, rheumatoid arthritis and skin cancer. Special emphasis is placed on the elderly and diabetic population of our community; however, appointments for the general population can be made with the Receptionist. Appointments are available from 8:00 AM through 4:00 PM on the second and fourth Monday of each month.

 Pulmonology This clinic provides services related to lung health. This includes but is not limited to colds, asthma, bronchitis, lung cancer, chronic cough, and tuberculosis. Appointments are limited to those patients with pulmonary function problems. This clinic is on the second and fourth Monday of each month available from 8:00 AM through 4:00 PM. Call the Receptionist to schedule an appointment.

 Pediatrics Clinic Pleasant Point Health Center is now pleased to be able to offer a Pediatrics Clinic and now many babies and families within the community will be afforded professional healthcare without having to drive long distances. Dr. Lichauco, who began practicing in Machias in July 2001, provides this service and brings with him several years of experience.

 Men’s Clinic A range of professional services are offered in the men’s clinic dealing with prevention and early detection of a range of health issues that are of particular concern to men. The men’s clinic is offered once a month and the date and times can be obtained by calling the Health Center receptionist. Office of Environmental Health

 The OEH Program is funded by the Pleasant Point Health Center through Third Party Funds. Our OEH Technician is trained to provide the following services from 8:00 AM - 4:30 PM Monday –Friday:

Water testing

Radon Testing

Carbon Monoxide Testing

Community education on health and safety issues

WIC & Nutrition Services The Pleasant Point Health Center’s WIC Program offers assistance with food and nutrition services for Pregnant Women, Infants and Children up to age five. We are open from 8:00 AM - 4: 30 PM Monday - Friday.

In addition to the WIC Program, we offer the Car Seat Loan Program. This program provides car seats for infants and children up to 60 pounds.

This program operates during the same hours as the WIC Program. Also, Pleasant Point also offers the Farmers Market Nutrition Program.

  A licensed provider, through the State of Maine, offers nutrition services and is available Thursday and Friday from 8:00 AM - 4:30 PM.

The Pleasant Point Health Center’s Nutrition Program offers the following services to our community:

Assessment and counseling for obesity

Education for Diabetics

Consultation services for meal programs offered by the tribe

Consultation and nutrition education for Head Start Program

Nutrition services for the WIC Program

Program planning with various State of Maine Nutrition Programs

 Fitness Center Our wellness facility has recently undergone a considerable re-development with a new building and significant investment in new high quality equipment. The fitness room is open from Monday through Friday and offers free weights, universals, as well as treadmills, a stair master, recumbent bike and other equipment for total fitness activities. There are no dues or fees to use our fitness center. Special sessions are offered for elderly, diabetics, youth, men, and women.

All users are asked to get clearance from their doctor before beginning a program of physical fitness. You must also have a physical and have all your forms signed before you can utilize the fitness center. A parent or legal guardian must accompany all persons under the age of sixteen (16) at all times.

Open for special groups or persons. Nighttime hours are open for all unless specified on the schedule, if there is a volunteer. Please call for available times or scheduled times. Schedule is subject to change without notice.

If you would like to volunteer to open the center, please call the Fitness Coordinator at the Pleasant Point Health Center at 853-0644 ext 335.

 PART 9 - POLICIES AND PROCEDURES

 Eyeglasses Policy When you are a patient at our clinic, we bill your insurance company to reimburse us for costs associated with your visit. We call the money that comes in, Third Party Income. Third Party income is used primarily to provide money for:

1.Specialty Clinics

Optometry

Podiatry

Chiropractic care

2.Contract Health Care (Outside Referrals)

3.Additional staffing

4.Eyeglasses

Each eligible Tribal member receives $100.00 toward the purchase of new eyeglasses. Due to the high demand for new prescriptions, we are unable to assist with replacements or repairs of eyeglasses. The eligibility for this service is two tiered. The first tier is eligible for assistance on an annual basis.

Top priority is given to:

1.Tribal members age 55 and older

2.Diabetics (any age)

Once the top tier group has been taken care of, providing funding remains, the second tier eligible is:

1.Children in grades K-8

2.High school students

3.Full-time College Students

4.All other eligible tribal members

Eye examinations are done at the clinic at no charge to the patient. Please see the Receptionist to schedule an appointment.

Due to increased costs of health care, we can no longer afford to provide assistance to everyone who requests it. This policy will be in effect as of January 1, 2001.

72-Hour Notification

All patients (or someone operating on their behalf) are required to notify the Pleasant Point Health Center within 72-hours of emergency room visit, unless a Medical Provider of the Pleasant Point Health Center has issued a referral. Failure to notify will result in the denial of payment for the service. (42 CFR 36.2).

Health Services for Ineligible Persons 

[3(c)] The service may provide health services under this subsection to individuals who are not eligible for health services provided by the service under any other subsection of this section or under any other provision of law in order to:

1.Achieve stability in a medical emergency

2.Prevent the spread of a communicable disease or otherwise deal with a public health hazard

3.Provide care to non-Indian women pregnant with an eligible Indians child for the duration of the pregnancy through postpartum, or

4.Provide care to immediate family members of an eligible person if such care is directly related to the treatment of the eligible person

Indian Health Services

Medical Priorities Contract Health Services Medical Care

Description of Medical Priority Levels

I. Emergency / Acutely Urgent Care Services DEFINITION: Diagnostic or therapeutic services which are necessary to prevent the immediate death or serious impairment of the health of the individual, and which, because of the threat to the life or health of the individual, necessitate the use of the most accessible health care available and capable of furnishing such services. Diagnosis and treatment of injuries or medical conditions that, if left untreated, would result in uncertain but potentially grave outcomes.

Categories of Covered Services: (random order)

1.Emergency room care for emergent/urgent medical conditions, surgical conditions or acute trauma

2.Emergency impatient care for emergent/urgent medical conditions, surgical conditions or acute injury

3.Renal dialysis, acute and chronic

4.Emergency psychiatric care involving suicidal persons or those who are a serious threat to themselves or others

5.Services and procedures necessary for the evaluation of potentially life threatening illnesses or conditions

6.Obstetrical deliveries and acute prenatal care

7.Neonatal care

II. Preventative Care Services DEFINITION: Primary health care that is aimed at the prevention of disease or disability. This includes services proven effective in avoiding the occurrence of a disease (primary prevention) and services proven effective in mitigating the consequences of an illness or condition (secondary prevention). Level II services are available at most I.H.S facilities.

Categories of Services included (random order) 

1. Routine prenatal care

2. Non-urgent preventive ambulatory care (primary prevention)

3. Screening for known disease entities (secondary prevention

4. Screening Mammograms

5. Public Health Intervention

III. Primary and Secondary Care Services DEFINITION: Inpatient and outpatient care services that involve the treatment of prevalent illnesses or conditions that have a significant impact on morbidity and mortality. This involves treatment for conditions that may be delayed without progressive loss of function or risk of life, limb, or senses. It includes services that may not be available at many I.H.S facilities and/or may require specialty consultation.

Categories of Services Included (random order)

1. Scheduled ambulatory services for non-emergent conditions

2.Specialty consultations in surgery, medicine, obstetrics, gynecology, pediatrics, ophthalmology, ENT, orthopedics, dermatology

3. Elective, routine surgeries that have a significant impact on morbidity and mortality

4. Diagnostic evaluations for non-acute conditions

5.Specialized medications no available at I.H.S facility when no suitable alternative exists

IV. Chronic Tertiary and Extended Care Services DEFINITION: Inpatient and outpatient care services that (1) are not essential for initial/emergent diagnosis or therapy, (2) have less impact on mortality than morbidity, or (3) are high cost, are elective, and often require tertiary care facilities. These services are not readily available from direct care I.H.S facilities. Careful case management by the service unit CHS committee is a requirement, as is monitoring by the Area Chief Medical Officer, or his/her designee. Depending on cost, the referral may require concurrence by the Chief Medical Officer.

 Categories of Services Included (random order)

1. Rehabilitation care

2. Skilled nursing home care

3. Highly specialized medical services/procedures

4. Restorative orthopedic and plastic surgery

5. Other specialized elective surgery such as obesity surgery

6. Elective open cardiac surgery

7. Organ Transplantation (HCFA approved organs only)

8.Care provided under the direction of an advance directive

 V. Excluded Services DEFINITION: Services and procedures that are considered purely cosmetic in nature, experimental or investigation, or have no proven medical benefit.

1.Cosmetic Procedures – Payment for certain cosmetic procedures may be authorized if these services are necessary for proper mechanical function or psychological reasons. Approval from the Chief Medical Officer is required.

2.Experimental and other Excluded Services – Payment is not authorized, unless the Office of Health Programs, at the Indian Health Services/Nashville Area Office, has granted a formal exception.

The list of therapies and procedures classified as potentially cosmetic in nature, experimental, or excluded will be reviewed and updated on an annual basis.

 Categories of Excluded Services:

1. All purely cosmetic (not re-constructive) plastic surgery

2. Procedures listed as experimental by HCFA

3. Procedures for which there is no proven medical benefit – procedures listed as “ Not Covered” in the Medicare Coverage Issuance Manual, Section 27,200

4. Extended care nursing homes (intermediate or custodial care)

5.Alternate medical care (homeopathy, acupuncture, chemical endarterectomy, naturopathy)