Serving tribal communities in NEMT: Indian Health Service travel, tribal Medicaid rides, and partnerships

Three ways a ride for a tribal member gets paid

Rides for American Indian and Alaska Native patients can be paid by Medicaid, by the Indian Health Service (IHS), or by the tribe itself. The payer decides who books the trip, what paperwork you need, and what rate applies, so sort out which one you are dealing with before the first ride.

IHS serves about 2.8 million American Indians and Alaska Natives. The federal system runs 21 hospitals, 53 health centers, and 25 health stations, while tribes and Alaska Native corporations, under self-determination contracts, run 22 hospitals, 330 health centers, 76 health stations, and 146 Alaska village clinics. Most IHS-funded facilities are run by tribes, not by the federal government, so the tribe is usually the one to talk to.

For the wider map of payers, see who pays for NEMT.

The 100 percent federal match

Medicaid is normally split between the state and the federal government. For services “received through an Indian Health Service facility whether operated by the Indian Health Service or by an Indian tribe or tribal organization,” Social Security Act section 1905(b) sets the federal share at 100 percent. For those services, the state pays nothing.

CMS widened what counts in SHO #16-002, a letter to state Medicaid directors dated February 26, 2016. Two changes matter to transportation companies:

1. Transportation is included. The letter applies the policy to transportation covered under the state plan, including both non-emergency and emergency medical transportation, and to related travel costs such as meals, lodging, and an attendant when needed.
2. Outside providers can qualify. A service furnished by a non-IHS provider counts as received through the facility when a facility practitioner requests it for a patient, under a written care coordination agreement.

The agreement has conditions. Both the facility and the outside provider must be enrolled in the state’s Medicaid program. The patient must have an established relationship with a practitioner at the facility, who stays responsible for the patient’s care while the facility keeps control of the medical record. At a minimum, the practitioner sends a request for specific services, the outside provider sends back information about the care it gave, and the facility adds that information to the patient’s record.

What it means for you:

• The request has to come from the facility. A rider who calls you directly, or a referral from another outside provider, does not qualify for the full federal match. You can still serve the rider and bill Medicaid as usual, and the state claims its regular federal share.
• Your rate does not change. When you bill Medicaid directly under an agreement, the state must pay you the same rate it pays you for any other member.
• The agreement can be simple. CMS lists a formal contract, a provider agreement, or a memorandum of understanding as acceptable forms, and says they are not governed by federal procurement rules to the extent that fits IHS authority. The facility picks the form.
• Nobody is forced to use you. Neither states nor facilities may require a tribal member to use the outside provider the facility referred them to. Members keep their free choice of Medicaid providers.

IHS Purchased/Referred Care

When an IHS or tribal facility cannot provide a service itself, its Purchased/Referred Care program can buy it from outside providers. The Indian Health Manual groups PRC claims into inpatient care, outpatient care, and patient transportation, so rides are part of what it buys. PRC is not an entitlement, and its money is limited, so understand the rules before you count on it.

Who is eligible. Under 42 CFR 136.23, PRC serves people eligible for IHS care who live on a reservation within a PRC delivery area, or who live in the delivery area and belong to the tribe or keep close economic and social ties with it. Full-time students and transients stay eligible while away, and others who move out remain eligible for 180 days. When money runs short, the program ranks requests by medical need.

How a trip gets authorized. No payment is made without a purchase order from the ordering official (42 CFR 136.24). For non-emergency care, the patient, someone acting for them, or the provider must notify the PRC office before the service. In emergencies, notice is due within 72 hours, and IHS extends that window to 30 days for elderly and disabled patients.

Who pays first. IHS is the payer of last resort (42 CFR 136.61). It will not pay to the extent the patient has Medicaid, Medicare, state programs, or private insurance, or would qualify for them by applying. If your rider has Medicaid, bill Medicaid first. See third-party liability for how payer order works on claims.

What PRC pays. 42 CFR 136.203 sets the rate for non-hospital services:

Medicare has no rate for wheelchair or stretcher van trips. Without a signed rate agreement, a van ride PRC authorizes is paid at a repricing network rate or your most-favored-customer rate if one is available, and otherwise at 65 percent of your authorized charge. Negotiate the rate in writing before you run PRC trips. These payment limits bind IHS programs and urban Indian organizations, and they bind a tribal program only when its contract or compact with IHS agrees to them (42 CFR 136.201), so ask each tribal PRC office which terms it uses.

No billing the patient. Under 25 U.S.C. 1621u, a patient who receives IHS-authorized care owes none of its charges. Accepting a PRC referral or payment also means accepting the PRC amount as payment in full.

How states handle tribal Medicaid rides

States organize tribal rides very differently. Some route them through tribal programs, some carve out a separate payer, and one requires tribal licenses. Read your state guide alongside these examples.

In Utah, members in the tribal counties must use the tribal program, so an outside company gets that work by subcontracting with the program. In Alaska, the tribal travel offices book their patients’ trips, so the office is the customer to win. Arizona is open to any registered provider, but only with each tribe’s license in hand.

Working with a tribe as an outside provider

A tribe is a government, and its health program is often both your customer and your referral source. These steps come from the federal rules above.

1. Learn who books the rides. Ask the tribal health department whether rides run through a travel office, the PRC office, a tribal transit program, or the state’s broker. Each has its own contact and paperwork.
2. Get licensed on tribal land. Ask each tribe what business license or permit it requires. In Arizona, Medicaid will not pay without it.
3. Expect preference rules. Under 25 U.S.C. 5307(b), subcontracts under federal contracts and grants for the benefit of Indians must, to the greatest extent feasible, give preference to Indian organizations and Indian-owned businesses. For a self-determination contract that benefits one tribe, that tribe’s own employment and contracting preference laws govern instead.
4. Offer a care coordination agreement for Medicaid rides. Show the facility how you will receive ride requests from its practitioners and send trip details back, since that exchange is what the agreement requires.
5. Put PRC rates in writing. A signed rate beats the 65 percent default.
6. Ask about tribal transit funds. Under 49 U.S.C. 5311(j)(2), a tribe may use its public transportation formula funds to pay a non-tribal provider whose service connects tribal lands with nearby communities or improves access to health care. That work follows transit rules. For how transit-funded work is bid and run, see our guides to Section 5310 grants and government contracts.
7. Plan for background checks on children’s rides. Federal Indian child protection rules require IHS and tribes to run background investigations for positions with regular contact with Indian children, and tribes decide which positions in their programs qualify (42 CFR 136.409). Ask whether your drivers will be covered.
8. Stay in the loop on state changes. States must seek advice from Indian health programs, on a regular basis, about Medicaid matters likely to affect them directly (42 U.S.C. 1396a(a)(73)). Ask your tribal contacts about Medicaid changes that are under discussion.

Distance shapes this work too. Reservation trips can be long and far from other pickups, so price them with care. Our guides to rural NEMT and long-distance trip pricing cover the math.

Keeping each payer’s trips straight

Tribal work often means Medicaid, PRC, and a tribal contract on the same day, each with its own rate. In HealthRide, finished trips turn into invoices, each priced at that payer’s own rates. Payments by check, card, broker, or insurance are recorded against the matching trips and invoices, so you can see what each payer still owes. See invoicing for how it works.