Purchased/Referred Care (PRC) + Disability Medicare in Big Horn County, MT: What Native Elders Are Owed — and Where the System Falls Short

What Is Purchased/Referred Care (PRC) — and Why Does It Matter More Than Most People Think?

Let's start with what most people don't know, including some people who work inside the system: IHS is not a government benefit. It is a treaty obligation. The Crow Nation and the Northern Cheyenne — both of whose members are served by the PHS Indian Hospital at Crow Agency in Big Horn County — entered into treaties with the United States government that guaranteed healthcare in exchange for land. We are talking about 500 million acres of land across this country. The federal government's end of that bargain runs through IHS — and through programs like Purchased/Referred Care.

Purchased/Referred Care (PRC) — you'll also see it called its older name, Contract Health Services or CHS — is the IHS program that pays for healthcare you cannot get at an IHS or tribal facility. Think of it this way: if the IHS hospital in Crow Agency doesn't have a cardiologist on staff, and your doctor there says you need one, PRC is what's supposed to pay for you to see one in Billings. That's the theory.

The reality is more complicated. PRC operates on an annual appropriated budget. That budget has been chronically, historically underfunded — by the IHS's own estimates, IHS receives roughly 70 cents for every dollar needed to meet the healthcare obligations created by those treaties. PRC funding typically runs out before the fiscal year ends. When it does, non-emergency referrals — the kind that manage your diabetes, your COPD, your heart failure, your failing kidneys — get deferred or denied. The IHS calls these "Priority I" through "Priority V" cases, with life-threatening emergencies first. Chronic disease management often falls in the middle of that list.

How Does Medicare on Disability Change the PRC Picture in Big Horn County?

If you are receiving Social Security Disability Insurance (SSDI), you become eligible for Medicare after a 24-month waiting period — not when your disability starts, but 24 months after your SSDI cash payments begin. For many Native elders in their 50s and early 60s with serious health conditions, that 24-month window is brutal. IHS and PRC are your primary coverage during that time.

Once your Medicare kicks in, the math changes significantly — and mostly in your favor, but with some important catches.

The good news: When you have Medicare and you receive care at the IHS hospital in Crow Agency (officially: PHS Indian Hospital Crow/Northern Cheyenne, 1010 South 7650 East, Crow Agency, MT 59022), the IHS facility bills Medicare directly and waives your cost-sharing. No deductible. No 20% coinsurance. This is authorized under a longstanding federal billing arrangement between IHS and CMS. The same applies to tribally operated facilities that have a Medicare billing agreement.

The catch: Once you have Medicare, IHS's PRC program treats Medicare as your primary payer for outside referrals. This means if PRC sends you to a cardiologist in Billings, Medicare pays first, and PRC is supposed to cover what Medicare doesn't — the deductible, the coinsurance, the Part B 20%. That's called "gap coverage," and it stretches PRC dollars further. But it also means that if that Billings specialist doesn't accept Medicare, the whole authorization can fall apart. And in a state like Montana, with significant provider shortages in rural areas, "doesn't accept Medicare" happens more than you'd think.

The second catch: Medicare Advantage plans — the private alternative to Original Medicare — can create serious problems with PRC. If you enroll in a Medicare Advantage HMO and your IHS hospital is not in that plan's network, you may lose the cost-sharing waiver and face significant out-of-pocket costs. Similarly, PRC authorizations are built around a fee-for-service (Original Medicare) framework. If you have Medicare Advantage, the PRC office has to navigate a completely different authorization pathway. Most IHS PRC offices strongly advise sticking with Original Medicare (Parts A and B) for this reason.

What Do the Hospitals in Big Horn County Actually Look Like?

Big Horn County has a population of approximately 12,751 people (CDC PLACES) and exactly two hospitals — both classified as Critical Access Hospitals (CAHs). Neither has a CMS overall quality star rating available as of 2026. Here's what we know:

The IHS hospital at Crow Agency is the primary care hub for enrolled tribal members of the Crow Nation and Northern Cheyenne. Services available on-site include primary care, emergency care, and some specialty clinics — but Big Horn County is a frontier county. Anything complex — cardiac catheterization, neurosurgery, advanced cancer treatment, transplant care — requires a PRC referral to Billings (roughly 60 miles away) or beyond.

Big Horn Hospital in Hardin is a Medicare-participating facility serving the non-tribal population of Hardin and surrounding areas, though Native patients may also seek care there. As a Critical Access Hospital, it receives enhanced Medicare reimbursement, which is why it remains open — Critical Access designation is a lifeline for rural hospitals, and proposed reimbursement cuts to CAH facilities nationally could threaten rural hospital stability in counties exactly like Big Horn.

The absence of CMS quality ratings for both facilities is worth noting. CMS's Hospital Compare methodology often has data gaps for small, rural, and IHS-operated facilities. The absence of a rating does not mean the quality is poor — it often means the reporting infrastructure wasn't built with frontier Indian Country in mind. Which tells you something about how the system was designed, and for whom.

How Bad Are the Health Disparities in Big Horn County? The Data Is Stark.

To understand why PRC demand is chronically high in Big Horn County, you need to understand the health burden that Native communities are carrying here. These are not random statistics. They are the direct, documented consequence of generations of poverty, inadequate healthcare access, environmental factors, and the cumulative stress of displacement. CDC PLACES 2022–2023 data for Big Horn County tells the story:

That 27.5% full tooth loss rate among seniors deserves a moment of pause. More than one in four Native elders in Big Horn County has lost every tooth. The national average is approximately 13% for adults 65+. Dental care under Medicare is notoriously limited — Original Medicare does not cover routine dental. Dental care under IHS is chronically underfunded. PRC dental authorizations are among the most contested and most often deferred. And yet: 22.1% of Big Horn County adults also experienced housing insecurity in the past 12 months. When you're not sure you'll have a roof over your head, you are not calling the PRC office to appeal a dental denial. The system counts on that.

How Does the PRC Authorization Process Actually Work — Step by Step?

Here's what the process is supposed to look like for an elder at the Crow Agency IHS hospital who needs, say, a pulmonologist in Billings for a COPD flare: