2018- TSGAC Letter: Inclusion of Purchased and Referred Care (PRC) in Veterans Affairs and Indian Health Service Reimbursement Agreements


“The VA-IHS Memorandum of Agreement (MOU) does not currently provide for reimbursement of PRC at IHS or Tribal healthcare facilities. Consequently, veterans are forced to maneuver through a complex healthcare system and an elaborate administrative process
usually requiring multiple referrals in order to address their healthcare needs. This overly burdensome duplicative referral process is counterproductive and impedes timely and efficient access to care for Native veterans. Although the MOUs have demonstrated success in facilitating patient care for veterans, neither the current national agreement nor the Tribal agreements include reimbursement for
PRC. The legal authority that authorizes this provision of care already exists. Section 405(c) of the IHCIA, as amended and enacted by the Affordable Care Act (ACA), requires the VA to reimburse the IHS or Tribal healthcare facilities for services provided to beneficiaries.
Veterans often require additional services that are not available at IHS or Tribal healthcare facilities. In many instances, eligible veterans are also eligible for PRC services. The PRC program authorizes Indian Healthcare facilities to purchase services from a network of private providers. IHS and Tribal health programs are the payors of last resort, which require that all other sources of obtaining health services must be exhausted prior to receiving care through the PRC program. These services may include primary or specialty care that is not available at an IHS and/or Tribal healthcare facility. Many Tribes utilize provider networks to ensure veteran’s healthcare needs are being met.”