[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]]

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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