1. Overview Activities and Funds Available to Tribes under ISDEAA Concepts and practices with emphasis on TRIBAL SHARES, especially for Headquarters.

2. Associated Key Concepts PSFA Tribal Share means programs, services, functions, and activities (or portions thereof) that IHS carries out that an Indian Tribe may elect to carryout through a contract or compact means the associated portion of funds used by IHS to carryout the PSFAs to be contracted Inherent Federal Function Residual mean those governmental functions which only IHS must perform which cannot legally be delegated to Tribes means associated portion of funds used by IHS to carry out remaining inherent Federal functions when all other PSFAs are contracted activities IHS carries out associated funds

3. Associated ISDEAA – P ERMITS T RANSFER FROM IHS TO T RIBES Programs, Services, Functions, Activities (PSFA) activitiesfunds Funds functionally associated with PSFA Tribe’s portion of associated funds Portions of PSFAs benefiting a Tribe are transferred to a Contract to carry out or redesign National $ shares National level By IHS Area level Local level National level $ Area level $ Local level $ By Tribes T R A N S F E R * Area $ shares Local program $ * A Tribal choice.

4. Transferrable Categories of PSFA Clinical & Preventative Health Services Facil- ities Additional laws also apply PFSA: Activities and associated funds are available to contract Inherent Federal Functions: are not legally contractible and associated funds are not available (a very small fraction of IHS funds) Other Categories: additional laws govern how Tribes participate Figures are suggestive of the proportions of the IHS budget. I.H. Scholarships, Loans Diabetes -- S.D.P.I. Urban I.H.P. Contract Support Costs No Yes

5. Extent of Self-Determination Contracts – Current and Hypothetically NOW Inherently Govern- mental Contracted PSFA Potentially Contractible PSFA ½ IHS Operated ½ Tribal Operated Contracted PSFA FUTURE “Residual” 100% Tribal Operated *Illustration only, bar scale is hypothetical ISDEAA anticipates that direct Federal spending will decrease commensurately as functions are transferred to Tribes

6. Share – portion of funds benefiting each Tribe A Tribe that contracts for its portion of an IHS PSFA which benefits multiple Tribes is entitled to that portion of funds (... the Secretary would have otherwise provided for the operation of the programs or portions thereof...) that benefit the Tribe or its members. PSFA Tribe ATribe BTribe C Benefits multiple tribes

7. Ways to determine portions of PSFA allocable to multiple Tribes. Direct Financial Measures: Shares are precisely determined when financial accounts record actual spending for PSFAs for a Tribe, e.g. IHS funds at a local site serving 1 Tribe. Program Measures : Shares may be calculated in proportion to workloads, services, or patient counts for each Tribe. Proxy Formula: A proxy formula calculates shares in proportion to indirect measures such as user counts, number of Tribes, or other general distributive factors. other- wise 1 2 3

8. Total of 3 Levels of Shares are Available IHS-wide (HQ) Shares Portion benefiting each Tribe Area Level Shares Portion benefiting each Tribe Local Level Shares Portion benefiting each Tribe PSFA and associated funds are available from all 3 levels of the IHS. Location and dispersion does not affect amounts available for contract. + +

9. “Transferred” for a Contract to Carry Out “Retained” for IHS to Carry Out A A C C B B............ X X Z Z Y Y PSFA Associated Shares Trans- ferred Retained Shares retained for other Tribes Tribe elects to contract A, B, C Leaves X, Y, Z for IHS to perform Associated funds are transferred to the contract Associated funds are retained by IHS to perform X, Y, Z XY Z ABCABC $ $ Terminology

10. Example of a Direct Financial Measure: 1 IHS Site Serving only 1 Tribe 100% of the Site Budget is Available to that Tribe Shares ($) for the Tribe Budget of the Local IHS Site to be contracted When financial accounts record IHS expenditures for a program serving only 1 Tribe, the process to identify that Tribe’s shares is straightforward. The entire amount may be labeled “shares” and 100% are available when the Tribe contracts the program. Only 1 Tribe is served there =

11. Example of a Program Measure Formula: CHS Fiscal Intermediary PSFA (IHS-wide) Average Cost Per Claim ($ / #) Average Cost Per Claim ($ / #) Shares ($) for the Tribe FI Fee Contract Amount $ The FI processes claims for IHS operated CHS programs. The FI is paid a fee per claim processed. A tribe can contract for this function. Shares associated with the CHS FI are proportional to the claims workload. Total # Claims Processed by the FI # Claims for the particular Tribe x =

12. Example of a proxy formula Tribal Size Adjustment (for most HQ PSFA) 92% of TSA $ is calculated per user for all tribes 8% if < 2,500 users TSA Formula + Aggregate funds for ~ 50 HQ PSFA Portions for all tribes Most HQ PSFA collectively benefit more than 560 tribes. The TSA calculates a $ benefit for all tribes in proportion to tribal user counts. 92% of the total funds associated with HQ PSFA are calculated on a per user basis (applies to every tribe) 8% of the total funds are identified for small tribes of less than 2,500 users and are calculated on a sliding scale that diminishes approaching 2,500 users

13. Timing and Protections Shares are determined at the point in time when the PSFA is initially contracted. The amount is recurring thereafter. Subsequent negotiations occur before annual appropriations are known. Shares are ESTIMATED then adjusted when the appropriation is enacted. Recurring shares for contracted PSFA are protected from reductions except for limited reasons stated in ISDEEA law. Congress anticipated that IHS would downsize, redesign, and reconfigure as PSFA and funds are transferred. When IHS reconfigures retained PSFA, shares may be reconfigured too. HQ has protected shares despite reconfigurations and will continue this practice if practical. Funds maybe added to a contract for special projects or limited time periods but are not recurring.

14. A few special circumstances Consortia – shares associated with individual tribes maybe consolidated for ISDEAA agreements Delegation to another Tribe – a tribe may direct it’s shares to another Tribe to carry out the PSFA for its members (some examples in Oklahoma) Grandfathered shares – a few unique agreements were implemented early in the 1990’s especially in pilot projects before self-governance became permanent. Some of the arrangements were grandfathered.

15. Shares Tables for 3 Levels 2) Area Level Tables NEW APPROPRIATION HQ Budget AREA Budgets HQ PFSA & $ HQ SHARES Breakout of HQ PSFA and funds. Table #1 Table #3 Shows any CHANGES to entire IHS appropriation Splits Appropriation into parts managed by HQ and Areas Exists for each individual tribe and shows the portion of $ available to it. Table #4 Area Budget Area PSFA & $ Table #2 3) National Level Tables Local Budgets Local PSFA & $ Local Shares 1) Local Level Tables Area Shares Format and content of Area and Local level tables will vary, but will generally cover the topics listed above. HQ Tracked $

16. Overview of Tables for HQ Table 1 - Entire IHS Appropriation Table 3 – HQ Budget Breakout by PSFA Table 2 - Split into HQ and Area Tracked Budgets Table 4 - Portion Available to a Tribe Entire Appropriation Tracked by HQ

17. Table 1 -IHS Appropriation Major IHS Accounts Changes made by Congress Final IHS Budget

18. Table 2 – HQ and Area Budget Split Total Amounts tracked on Area or Local Tables Amounts tracked on HQ Tables

19. Table 3 – HQ PSFA Breakout PSFA Available for Shares Unavailable for Shares

20. Table 4 – Shares Available to a Tribe Tribe’s Portion of each PSFA Portion available in contract year 1 or 2 if applicable

21. Final points about HQ Tables PSFA relate to functional categories – HQ PSFA tables do NOT correspond closely with the HQ organizational structure or staffing. HQ staff contribute to many different PSFA and staffing is managed in aggregate. Protected Shares – although the organizational structure has changed several times and staff and work evolves for changing circumstances and needs, shares for every tribe are protected – regardless of HQ internal realignments. Office of Finance and Accounting – responsible for HQ tables. Other HQ Offices – responsible for carrying out the PSFA and descriptions in the PSFA manual.

22. END Activities and Funds Available to Tribes