The Indian Health Service covers primary and preventive medical care, dental, behavioral health, pharmacy, and vision services at no direct cost to eligible American Indians and Alaska Natives, delivered through more than 600 federal, tribal, and urban facilities across 37 states.1Performance.gov. Indian Health Service What that looks like in practice depends on your local facility, because IHS runs on a fixed annual congressional appropriation rather than as an entitlement. When the local facility cannot provide the care you need, a separate program called Purchased/Referred Care may pay an outside provider — but only if funds are available and the referral clears a priority review.
What You Get at IHS and Tribal Facilities
There is no defined benefits package the way private insurance works. Each facility provides whatever care its staff and equipment can deliver, and eligible patients pay no premiums, deductibles, or copayments for services received on site.
Most facilities focus on primary and preventive care: routine checkups, chronic disease management, immunizations, prenatal care, and treatment of common illnesses and injuries. A large IHS hospital may add lab work, imaging, pharmacy, dental, optometry, and behavioral health under one roof. A small health station might handle only basic primary care visits and refer everything else out.2Indian Health Service. About IHS
Roughly 70 percent of AI/AN people live in urban areas away from reservation facilities. IHS funds 41 nonprofit urban Indian organizations that provide services at 59 locations across the country, and the scope of what they offer varies widely — some run comprehensive outpatient clinics, others focus mainly on referrals and outreach.3Indian Health Service. Urban Indian Health Program Fact Sheet
Care From Outside Providers: Purchased/Referred Care
When IHS or tribal facilities cannot perform the care you need, the Purchased/Referred Care (PRC) program pays private-sector providers on your behalf. PRC applies when no IHS or tribal facility exists nearby, the local facility lacks the specialty capability, or its capacity is exceeded.4Indian Health Service. Purchased/Referred Care Program Fact Sheet
PRC is where the funding limits hit hardest. It is explicitly not an entitlement, and a referral from an IHS provider does not guarantee that the outside care will be paid for.5Indian Health Service (IHS). Purchased/Referred Care Whether your referral gets funded depends on three things: whether PRC funds remain in the budget, your medical priority level, and whether you have used all other available insurance first. You also generally must live within a designated Contract Health Service Delivery Area, typically the counties that include or border a reservation.6Federal Register. Geographic Composition of the Contract Health Service Delivery Areas
Notification Deadlines That Can Void Coverage
For non-emergency care, you must get prior authorization from the PRC office before seeing an outside provider. Skipping this step is one of the most common reasons PRC claims get denied, and it is rarely fixable after the fact.
For emergency care, you or someone acting on your behalf must notify the PRC program within 72 hours of treatment. Patients who are 65 or older or disabled get 30 days instead of 72 hours. The window can be extended if the PRC office determines that timely notification was impractical or that other good cause existed.7Indian Health Service. Requirements – Notification
How Referrals Are Ranked
When PRC funds run low, referrals are ranked by medical urgency:
- Priority 1 (Essential): services necessary to protect life, limb, or vision, and that represent a basic component of current standards of care.
- Priority 2 (Necessary): standard-of-care services for diagnosing and managing chronic or non-emergency acute conditions.
- Priority 3 (Elective): clinical services intended to enhance health and well-being.
Later in the fiscal year, when budgets are thinning out, some facilities fund only Priority 1 cases. A legitimately needed but non-urgent referral submitted in August may not be approved until new funding arrives in October.4Indian Health Service. Purchased/Referred Care Program Fact Sheet
Dental, Behavioral Health, Pharmacy, and Vision
Dental
IHS dental programs use a five-level priority system: emergency care (Level I), preventive services like cleanings and sealants (Level II), basic restorative work such as fillings (Level III), complex restorative procedures like crowns and onlays (Level IV), and complex rehabilitation (Level V).8Indian Health Service. IHS Levels of Dental Care Facilities with limited dental staff may only get through Levels I and II consistently, which is why many patients experience IHS dental care as mostly extractions, pain relief, and preventive visits. Complex restoration happens when resources allow, not as a routine benefit.
Behavioral Health
Behavioral health services address mental health counseling, substance use treatment, and suicide prevention. Many facilities integrate these services into primary care.9Indian Health Service (IHS). IHS Fact Sheet – Behavioral Health Care that exceeds local capacity, such as inpatient psychiatric admission or long-term residential substance use treatment, is handled through PRC referrals when funding allows.
Pharmacy
IHS facilities dispense prescription medications through on-site pharmacies at no cost. The IHS National Core Formulary establishes the baseline list of drugs all federal IHS facilities must carry, and individual facilities can add medications based on local needs.10Indian Health Service. Formulary – National Pharmacy and Therapeutics Committee If you need a drug your facility does not stock and cannot add, you may have to use outside insurance to fill that prescription at a retail pharmacy.
Vision
IHS provides general and specialty eye exams, prescription eyeglasses, and ophthalmic surgery to the extent local resources allow.11Indian Health Service (IHS). Optometry Not every facility has an optometrist on staff. Complex eye surgeries are typically referred out through PRC.
What IHS Does Not Cover
Certain categories of care are generally excluded from both direct services and PRC:
- Cosmetic procedures with no medical justification.
- Experimental or unproven treatments not recognized as standard of care.
- Non-emergency long-term institutional care, such as nursing home placement.
Beyond these categorical exclusions, every coverage decision comes down to two things: whether an IHS provider determines the care is medically necessary, and whether the local service unit has the resources to provide or pay for it. When resources fall short, the facility prioritizes based on relative medical need and the patient’s access to other sources of care.12eCFR. 42 CFR 136.12 – Persons to Whom Services Will Be Provided
The funding constraint is the story behind most of what looks like limited coverage. IHS is funded through annual congressional appropriations, and the budget has historically been well below the level needed to serve the entire eligible population. When funding falls short, facilities cut services, PRC tightens, and wait times grow.
How IHS Works With Other Insurance
IHS is legally designated the payer of last resort. Federal regulations require that all other available health coverage be billed before IHS or PRC funds pay for care. This includes Medicare, Medicaid, Veterans Affairs benefits, private employer insurance, and marketplace plans. If you are eligible for alternate coverage but have not applied for it, IHS treats you as though you have it and will not authorize PRC payment for the portion that coverage would have paid.13eCFR. 42 CFR 136.61 – Payor of Last Resort
Enrolling in Medicaid, Medicare, or a marketplace plan directly helps you: it expands the range of providers and services available beyond what IHS facilities offer, and it stretches limited PRC budgets for everyone.14Indian Health Services. Chapter 3 – Purchased/Referred Care
Members of federally recognized tribes and ANCSA shareholders have particular advantages in the ACA marketplace. You can enroll or change plans any month of the year, not just during open enrollment. If your household income falls between 100 and 300 percent of the federal poverty level, you qualify for a zero cost-sharing plan with no deductibles, copayments, or coinsurance for covered care. And regardless of income, services received from an Indian health care provider carry no out-of-pocket costs under any marketplace plan.15HealthCare.gov. Health Care Coverage for American Indians and Alaska Natives Marketplace coverage does not replace your IHS eligibility. You keep full access to IHS, tribal, and urban Indian facilities.
If Care Is Denied
If your PRC referral is denied, you have the right to challenge the decision through a multi-step administrative appeal process spelled out in federal regulations.16eCFR. 42 CFR 136.25 – Reconsideration and Appeals The denial must come to you in writing with a stated reason. From there, you have 30 days to respond in one of two ways:
- Request reconsideration from the Service Unit Director by submitting new supporting information that was not part of the original decision.
- Appeal directly to the Area or program director if you have no new information to add but believe the decision was wrong.
If reconsideration upholds the denial, you get another 30 days to appeal to the Area or program director. If that appeal also fails, a final appeal goes to the Director of the Indian Health Service, whose decision is the last word administratively. Every appeal must be in writing and explain why the denial should be reversed.
For complaints about direct care at an IHS facility rather than PRC denials, each service unit has a grievance committee. Unresolved complaints move up to the Service Unit Director, who must investigate and provide a written response, and from there to the Area Director for a final decision.17Indian Health Services. Patient Rights and Grievances Written explanations of the grievance process are required to be posted in the waiting areas of all IHS facilities.