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Case number 19-5299, Swinomish Indian Tribal Community, Abelant, versus Alex M. Azar II, in his official capacity as Secretary, U.S.

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Department of Health and Human Services, et al.

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Mr. Fry for the Abelant, Mr. Coppell for the Appellees.

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Good morning, Mr. Fry, whenever you're ready.

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Good morning.

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May it please the court, I'm Paul Fry, representing the Swinomish Indian Tribal Community.

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The Supreme Court in the Rayma Navajo chapter case held that the Indian Self-Determination Act, quote, mandates that the secretary shall pay the full amount of contract support costs incurred by tribes in performing their contracts, end quote.

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This case will determine if the Indian Health Service is required to reimburse the tribe

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for its CSC on all of the federal program that it compacted to perform, including its generation of so-called program income, that is revenues from Medicare and Medicaid and third-party insurers.

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If the tribe's earning and collection of such program income is included in the compacted federal program, then the tribe should prevail under the plain language of Section 5325A3.

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I think there are three main points that I'd like to make this morning.

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First, the tribe's activities to generate program income are unquestionably part of the federal program that it compacted to perform, both in the compact and in the funding agreement.

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Second, subsections 5325A2 and 5325A3 entitled the tribe to the CSC on the entire federal program without regard to how well the tribe negotiated under subsection A1.

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And third, the tribe's construction of the act, we believe, is compelled by the plain language of A2 and A3 in 5325.

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But even if it's not, it's certainly a reasonable construction of the act.

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And under this court's decision in the Muskogee case, any reasonable construction of the act advanced by the tribe must be adopted.

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The funding agreement clearly requires us to both earn and collect program income.

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It states all Medicare, Medicaid, and other program income earned by the tribe.

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We have to earn it, then we collect it.

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earning that program income takes a lot of work and a lot of expense and a lot of overhead, the same expense and overhead that is incurred by the tribe in performing work for people who are not covered by Medicare, Medicaid or other third party insurance.

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Mr. Frey, let's assume that IHS is not running the medical services

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that the tribe is running the services, that they have a contract with IHS.

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And let's assume also that it's possible for Medicare and Medicaid program income to be generated.

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What is the tribe's option for letting IHS collect that income?

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And if IHS collects it,

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What does IHS do with it?

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If IHS collects that income, it will eventually funnel that money to the tribe.

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It will return that money to the tribe.

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It should return 100% of the program income to the tribe.

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So this is not a rhetorical question.

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I really don't know the answer to this.

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Run the health services yourself as a tribe, get the secretarial amount, get the CSC based on the secretarial amount, but let IHS collect the Medicare Medicaid program income and then let IHS spend that on the tribe.

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And you don't have any Medicare Medicaid compliance costs yourself.

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Well, the reason is, I think there are several reasons.

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One is, as a practical matter, there's no accountability.

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What we've found is that IHS will send us a check, but they won't necessarily send us the right amount of money.

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Secondly, there's a substantial delay in the IHS processing of these funds, and that actually harms the physical soundness of the tribes program.

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I think those are the two main ones.

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Let me ask you a question I'm gonna ask the government as well.

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Hopefully you're both in the same page because this is just a fact question.

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I'm trying, me trying to figure out how this works.

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Let's say that we go back to a time when IHS was running all the health services.

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And so IHS, and I'm just gonna use really simple numbers here.

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IHS was receiving $1,000 and then it was spending $1,000 on the tribe.

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And then it was also receiving $200 from Medicare, Medicaid, program income, et cetera.

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Was it spending all 200 of that on the tribe or

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Was it spending part of that on the tribe and spending part of that on compliance costs that come with dealing with Medicare and Medicaid?

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My understanding of the law is that under the Indian Health Care Improvement Act, section 1641C, IHS was required to spend program income on specific things.

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One, facilities, because the Indian health care facilities nationwide were dilapidated, and two, expanding and improving health care services.

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Now, what IHS

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was able to generate in order to cover its costs came from a separate fund called direct operations.

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And that's explained I think in great detail in the amici brief.

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So IHS has a separate bucket of funds to cover its costs in generating that, which if we don't get contract support costs, we are deprived of.

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And that would violate both the Section 5325A1 requirement that we get at least as much as the secretary would have provided or spent in performing the program, and also the Indian Health Care Improvement Act at Section 1602-7, which requires the same thing.

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I have one more question that's not related, but maybe I'll just ask it and I'll get out of your way and out of my colleague's way.

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Section 5326 informs section 5325, at least when we're dealing with sub-chapter one.

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The government, I think, wants us to say, well, when we're dealing with sub-chapter five, compact like we have here, we are directed to 5325.

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in order to figure all of this out.

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And then the government would say, as we read 5325, that is still informed by 5326.

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And I think you would say, no, that's wrong.

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5326 doesn't matter at all when we're dealing with subchapter five and compacts.

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Is that your position?

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And if so, what's your argument?

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Yes, the argument is that under section 5396, only enumerated parts of subchapter one apply to compacting tribes under subchapter five.

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But one of those enumerated parts is 5325.

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Correct.

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Which is informed by 5326.

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We would say that that kind of backdoor application of 5326 would violate 5396 because we did not opt to include 5326 as some of the sections of subchapter one in our funding agreement at joint appendix page 54.

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But can't any number of things inform 5325?

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The dictionary could inform it, history could inform it, and maybe 5326 can inform 5325.

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Well, our position is not that we are entitled to double dip, regardless of 5326.

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We're entitled to the same amount of money from the secretary as the secretary would have provided for the operation of this program.

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And it's absolutely clear that the secretary uses a lot of money

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to generate program income and that the secretary is reimbursed for IHS's overhead costs from a separate bucket.

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We simply want to substitute contract support costs to us, the tribe, for that separate bucket that allows the secretary to comply with 1641 in his or her use of those funds

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and also to cover costs of generating the program income.

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If we're looking at the San Carlos decision, which certainly is the 5326 decision that's been pointed out by IHS, I think we satisfy whatever requirements that court would have imposed on us assuming that 5326 does apply.

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the generation, the collection and earning of program income is certainly directly attributable to our contract.

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It's required by the Compact at Joint Appendix 40 and by the funding agreement, Joint Appendix 49.

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It's required by the payer of last resort provision

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in the Healthcare Improvement Act, Section 1623.

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But your funding agreement doesn't specifically discuss including these costs as part of CSC or in the program costs, right?

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I mean, you're relying on your

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your agreement to exclude 5326, and to say that this is contemplated, but there's a very detailed calculation of direct and indirect costs, and it doesn't include any of these costs.

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So even if, even putting aside your statutory arguments, why aren't you barred from making this argument because of the agreement that the tribe signed?

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Well and that seems to be the principal position of the government here and the reason is the funding agreement itself does not set those calculations in stone.

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What it says is we'll agree to follow the CSC manual and I'm quoting now from page 52 of the joint appendix to the extent it is consistent with the ISDEAA.

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That's the first

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caveat.

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The second one is because A3 says that we will be reimbursed for CSC incurred, that's backward looking.

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That's not something that you negotiate definitively at the outset.

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So the same page of the Joint Appendix says that our CSC may be adjusted

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based on Tribal CSC need.

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That's the words there.

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That's the second caveat in the funding agreement.

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The third is the very final sentence in that same paragraph on JA 52.

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Nothing in this provision shall be construed to waive any statutory claim that the compactor may assert it is entitled to under the Self-Determination Act.

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So we're relying on the operative provisions of the Self-Determination Act.

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We're not relying on stray words and alternative dictionary definitions.

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We're relying on the operative provisions of the Self-Determination Act that

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confirm our ability and our right to get contract support costs on the federal program that we've compacted to perform.

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I hope that wasn't too dogmatic, but the funding agreement itself, Your Honor, does set forth those three caveats with respect to what we negotiate at the outset of the year.

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Any questions from my colleagues?

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Okay.

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Thank you, Mr. Fry.

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Thank you.

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Mr. Capell, please proceed when you're ready.

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Thank you, Your Honor.

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And as I was trying to say at the beginning, it was nice to see you as well.

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May I please record John Capell from the Department of Justice.

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representing the Appellee's secretary.

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You're going to have to speak up.

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We can hear you, but it's faint.

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So please stay close to the phone and speak up.

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Okay.

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The plaintiff does not dispute that it's received all of the contact support costs

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that it was entitled to receive under the funding agreement and the compact.

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Instead, now, the plaintiff is seeking additional contract support costs, essentially, that are abstract costs.

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The plaintiff is not seeking any specific additional costs.

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Instead, it is

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It is making an abstract legal argument that is entitled to further contract support costs even though it has not shown any additional cost.

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And when one looks at the way contract support costs are computed, which is determined under the, not by the statute itself, but by the Indian Health Manual and the agreement of the parties,

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The plaintiff must, the calculation for contract support costs is based on the secretarial amount and the direct cost and then a percentage of that figure to compute indirect contract costs.

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Now, again, the plaintiff has not even attempted to show any additional

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Instead, the plaintiff is saying that it's entitled to 5.065 percent of the additional figure that comes from the program income.

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But that is not the way the contract support costs are computed under the Indian Health Manual.

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And the statute does not override that in any respect.

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The statute simply... Can I ask Mr. Capel, on the statute, one of the arguments is a very complicated scheme, but if I'm tracking it correctly, one of the arguments the tribe makes is that these costs

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fall within the secretarial amount.

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And one of the reasons they say that is that 5388C includes any funds that are specifically or functionally related to the provision of services and benefits to the Indian tribe.

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and that seems functionally related to the provision of benefits, seems like a broad formulation.

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Well, Your Honor, again, we have addressed 53-88-C in our brief, but that is not the way the statute should properly be read as a whole.

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The statute draws the clear distinction between program funding, or the secretarial amount, and program income.

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And that comes from the, first of all, from 5325A1-3, which defines the secretarial amount and then contract support costs.

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and 5325M and 53ADHA, which discuss program income.

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And the 5325A1 itself defines the funds the Secretary allows as the amount of funds provided

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under the terms of the self-determination contract, and it shall not be less than the appropriate secretary would have otherwise provided for the operation of the programs.

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So in other words, that is the secretarial amount.

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It is a substantive amount, and it has nothing to do with program income.

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Program income, I feel that

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That is defined in 53.5M, which shows that in child programming, some earned by the tribe in the court to carry out the contract, shall be used by the tribe to further the general purposes of the contract, and shall not be a basis for reducing the amount of funds otherwise obligated.

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In other words, we get the secretarial now.

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And what this does,

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And 6388J is comparable to that.

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It sort of does the same thing, but it uses a slightly different language.

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It says that the amount is, the program income is supplemental to the other, to program funding.

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But what those- I think you're right to the extent we're looking in the four corners

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of 53.25.

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I'm just wondering why 53.88C might not expand 53.25 because it says amount specified under 53.25A1, which is the secretarial amount, and amounts for support costs, which are the CSCs,

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And then it has this including language, which seems to broaden, seems to broaden the scope of what the secretary is obligated to fund.

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Well, again, that doesn't, in our view, that does not override

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override the definition of program funding or the secretarial amount and the distinction between that and program income.

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And again, it's also supported in 5326, which was previously discussed.

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which does indeed apply to contacts by its very terms.

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And it says that the contact support costs may be extended only for costs directly attributable to contracts and contacts, which again is not that the program income is not directly attributable to it.

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Again, we don't believe that the language in 5388c somehow overrides all of these other provisions of the ISDA.

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That.

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Okay, so Mr. Can I, can I ask you a question, Mr. Cabell.

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Um, Under the statute, would it be possible for the tribe to contract with IHS to receive CSC for the program funds.

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Or would that be barred by the statute's limits on duplication or other restrictions that are in 5325?

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I mean, is it possible for them to contract for that as part of CSC?

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No, Your Honor.

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We believe that they're getting all the CSC that they're entitled to under the statute and the contract by virtue of the existing arrangement.

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And of course, they do get their program billing

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That is something that they have undertaken to the extent that they are seeking third party costs and they have assumed that responsibility and they're getting reimbursed for that as part of the secretarial amounts.

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Would the statute bar contracting for reimbursement of those fees?

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Would it prohibit?

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I understand you're saying it's not required by the statute, but would they be prohibited from contracting for that reimbursement?

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Well, I believe that in that situation, the Indian Health Service would take the position that those are not proper costs and therefore it would decline the contract.

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Of course here,

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plaintiff has raised this kind of at the back end of the process.

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It's raised a contract, a claim, a contract is due to that claim for breach of contract for additional damages, which it is claiming are in the amount of this, as I said, abstract, unspecified,

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contract support costs.

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And that is just not, that's not the way the statute works.

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And that's really the essence of the government's position.

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Let me see if there's anything else that I wanted to cover.

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Let me jump in if I can, as long as I'm not interrupting, Judge Rao, I'm not interrupting your line.

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Mr. Cappell, let me ask two questions.

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And one of them, unfortunately for me at least, has a little bit of math.

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So I'm going to start with the other one.

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Doctors have compliance costs when they bill Medicaid.

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Back in the old days when IHS was running the services on tribal lands, IHS used to bill Medicaid.

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Did IHS have compliance costs back then when it billed Medicaid?

[00:27:10] Speaker 06:
I'm not sure.

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I don't believe so.

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I'm not entirely sure.

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When you're referring to compliance costs, what exactly does that entail?

[00:27:29] Speaker 03:
Well, as I understand it, the federal government

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sometimes requires audits, sometimes they require more complex accounting than a contractor might otherwise do.

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I mean, in the case of the tribal health services right now that are contracting with IHS, we're told that their compliance costs are something like 30% of the money they actually receive from the contract.

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And I'm not

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I'm not, I don't care whether it's 30% is right or 25 or 15.

[00:28:07] Speaker 03:
Um, but there seems to be a recognition that when, when you're getting money from the federal government, uh, the federal government imposes some, uh, requirements that cost you money, um, some compliance requirements.

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And I'm sure that every doctor in America who bills Medicaid

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has to satisfy some compliance requirements.

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And I'm sure that satisfying those compliance requirements cost them some time and money.

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And so I would imagine that IHS had compliance requirements back when it was running the services on the ground and when it was billing Medicaid and when it was receiving money from Medicaid.

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I don't really know how they couldn't have had some compliance costs that went with billing Medicaid.

[00:29:05] Speaker 03:
So my first question was, do you agree?

[00:29:09] Speaker 03:
And I'll ask you again, and if you don't know, you don't know.

[00:29:14] Speaker 06:
It's not the end of the world.

[00:29:17] Speaker 06:
Well, Your Honor, in our view, whatever compliance costs, whatever overhead and general costs they had would be factored in,

[00:29:26] Speaker 06:
under Medicare and Medicaid, and that's the program manual, but the Medicare provider reimbursement manual and the state Medicaid reimbursement manual.

[00:29:42] Speaker 06:
So I think- Let me interrupt.

[00:29:44] Speaker 06:
Part of that money is providing for overhead and whatever costs are incurred that way.

[00:29:55] Speaker 03:
Okay, Mr. Cappell, let me ask.

[00:29:58] Speaker 03:
I think that's right.

[00:30:00] Speaker 03:
That's what some of your briefing says about the fees that Medicaid and Medicare pay.

[00:30:08] Speaker 03:
They're based not just on the direct health services that are being provided, but they're also based on compliance costs.

[00:30:16] Speaker 03:
So here's my, again, at the risk of showing my lack of math skills, here's my math question.

[00:30:23] Speaker 03:
Back when IHS was running the services on tribal lands, let's say there was one year where, and I'm going to use really small, really simple numbers for my own sake here.

[00:30:38] Speaker 03:
Let's say there was one year where IHS build Medicaid for $2,000.

[00:30:45] Speaker 03:
Okay.

[00:30:49] Speaker 03:
and Medicaid then writes them a check for $2,000.

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And there's an obligation on IHS to spend that money on that tribe.

[00:31:03] Speaker 03:
Now, here's my question.

[00:31:05] Speaker 03:
Let's say that complying with Medicaid costs about 30% of what you get from Medicaid.

[00:31:17] Speaker 03:
My guess is that

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IHS would have then spent $1,400 of that $2,000 on providing direct health services.

[00:31:33] Speaker 03:
And it would have spent $600 of that $2,000 on the compliance costs that come with having to deal with Medicaid and Medicare, which to be frank is not something I would wish on my worst enemy.

[00:31:48] Speaker 03:
If that's the case, if that's how it worked, then I think that the tribe is wrong here.

[00:31:55] Speaker 03:
I think they're getting, assuming all else is the same and constant, they're getting $2,000 the next year from Medicaid.

[00:32:04] Speaker 03:
And they should spend 1,400 of that on direct health services, and they should spend 600 of that on compliance costs.

[00:32:12] Speaker 03:
And to the extent they chose to spend all 2,000 of the 2,000 on direct health services,

[00:32:18] Speaker 03:
and they don't have the money, the extra 600 left to spend on the compliance costs, well, they didn't do it the way they were supposed to do it.

[00:32:26] Speaker 03:
They spent too much.

[00:32:29] Speaker 03:
So I think you're right if that's how it all worked.

[00:32:31] Speaker 03:
But here's my question for you.

[00:32:33] Speaker 03:
Back in the old days when IHS was running those health services themselves, maybe it was the case that when IHS billed Medicaid for $2,000,

[00:32:43] Speaker 03:
IHS turned around and spent all 2000 of that on direct health services.

[00:32:49] Speaker 03:
And if that's the way it used to be, then this new system does seem like it's worse off for the tribe.

[00:32:56] Speaker 03:
There's 600 less dollars being spent on direct health services.

[00:33:00] Speaker 03:
And I suppose if this is the thing that had happened, if back in the old days Medicaid had spent all 2000 on direct health services,

[00:33:08] Speaker 03:
I mean, that's extra $600 compliance costs had to come from somewhere.

[00:33:12] Speaker 03:
It's possible IHS just found that money somewhere else out of its treasury, out of its, you know, some other account and spent it.

[00:33:21] Speaker 03:
And if that's what was going on, my concern is that the tribe is worse off when it has made a choice to provide health services itself rather than

[00:33:36] Speaker 03:
letting IHS run the show?

[00:33:40] Speaker 03:
So I guess that was a really long question, but there's really one small part of it that I wonder if you could help me with.

[00:33:45] Speaker 03:
Back in the old days when IHS was providing health services itself and it billed Medicaid for $2,000, did it spend all of that on direct health services or did it spend part of that on direct health services and the rest of it on compliance costs?

[00:34:06] Speaker 06:
Well, I'm really, I'm not sure I really, I mean, I can't answer that question sort of directly because I'm not exactly sure how, you know, how that works.

[00:34:22] Speaker 06:
But I do know that under the statute now,

[00:34:31] Speaker 06:
When the, when IHS is running the program, it's, it is obligated to pay all, to use all of the funds that it gets from Medicare and Medicaid for the program, for program costs.

[00:34:51] Speaker 06:
But perhaps the main point is that if the tribe believes that it has, that it actually has other costs,

[00:35:00] Speaker 06:
that it has incurred specific costs as a result of receiving program income.

[00:35:12] Speaker 06:
Certainly, it is able to make the claim like that and make a showing with the IHS.

[00:35:22] Speaker 06:
But it has not done anything like that here.

[00:35:24] Speaker 06:
What it has done, what it's done is arguing that basically it is a purely theoretical matter.

[00:35:29] Speaker 06:
based on its, in our view, incorrect understanding of the statute, that they were entitled to the two additional CSC computed in accordance with the formula of their own creation that's based on the amount of program income they've received.

[00:35:56] Speaker 06:
It's not really, it's not tied to any specific cost.

[00:36:00] Speaker 06:
And that's the crux of the problem with their position.

[00:36:07] Speaker 06:
And this is not the way the statute works.

[00:36:11] Speaker 06:
And it's clear that in our view, and in the view of three of the four district boards that have addressed this issue, it is clear on the face of the statute

[00:36:23] Speaker 06:
that that's not the way it works.

[00:36:25] Speaker 06:
And so can you just clear up Mr. Capell?

[00:36:31] Speaker 03:
Mr. Capell, can you just clear up?

[00:36:34] Speaker 03:
I heard you did to say in that answer that if the tribe wanted to, it could at least try to negotiate for a claim to get the compliance costs that come with billing Medicaid.

[00:36:52] Speaker 03:
They didn't do it here, you say, but they could at least try to do that negotiation if they could prove what they need to prove.

[00:37:01] Speaker 03:
But I thought you had told Judge Rao that they're not allowed to do that.

[00:37:06] Speaker 06:
Did I misunderstand one of those two answers?

[00:37:19] Speaker 06:
What I'm saying that they're not allowed to do is give them a percentage of the program income without any showing of actual costs, without any satisfaction of the criteria that the Indian Health Manual establishes for direct and indirect costs, contract support costs.

[00:37:47] Speaker 06:
We're not saying that they can't make a showing with respect to claims, additional contract support, cost expenses, but they have to be concrete, they have to be specific, and they can't be based on this abstract formulation or legal

[00:38:13] Speaker 06:
legal construct that the tribe has made here.

[00:38:21] Speaker 05:
Judge Rao?

[00:38:24] Speaker 05:
Judge Walker?

[00:38:26] Speaker 05:
Okay, thank you, Mr. Capel.

[00:38:28] Speaker 01:
Thank you, Your Honor.

[00:38:30] Speaker 02:
Mr. Frye, we'll give you a few minutes.

[00:38:33] Speaker 02:
Thank you very much.

[00:38:34] Speaker 02:
I can answer Judge Walker's question.

[00:38:38] Speaker 02:
Back in the old days, IHS spent 100%

[00:38:43] Speaker 02:
of its program income on facilities.

[00:38:47] Speaker 02:
It was required to under a previous incarnation of the law.

[00:38:52] Speaker 02:
Now, under 1641 C, IHS is required to spend 100%

[00:39:00] Speaker 02:
of its program income on either facilities or expanded health care, not overhead.

[00:39:06] Speaker 02:
So your hypothetical, Judge Walker, I think is correct.

[00:39:10] Speaker 02:
We are getting less for our compacting efforts than the government

[00:39:17] Speaker 02:
would have received under the old regime.

[00:39:21] Speaker 02:
And where it got that money is from a separate bucket, the direct operations bucket, which is under, I think it's A to B. That's a separate bucket from which the IHS gains revenues and which we're entitled to.

[00:39:42] Speaker 02:
Now, I agree with Judge Katz as well.

[00:39:45] Speaker 02:
53-88C, the including phrase.

[00:39:52] Speaker 05:
Sorry, before you get there, just walk me through that once more.

[00:39:57] Speaker 05:
You said that

[00:39:59] Speaker 05:
IHS would have to spend all of the program income on providing healthcare as opposed to overhead.

[00:40:12] Speaker 05:
Yes.

[00:40:13] Speaker 05:
So how would they

[00:40:17] Speaker 05:
from what source would they get funding for the overhead and the compliance costs and things like that?

[00:40:23] Speaker 02:
That would come from other funds in the department and specifically the direct operations budget item that funds these things.

[00:40:34] Speaker 02:
And that's, I think the contribution of the amici on pages 21 and 22 of their brief.

[00:40:52] Speaker 02:
So if that's sufficient, Judge.

[00:40:55] Speaker 05:
Yeah.

[00:40:58] Speaker 02:
Okay.

[00:41:00] Speaker 02:
So the including phrase in Section 5388C does indeed expand the tribe's entitlement.

[00:41:11] Speaker 02:
And the agency that agrees with us on that is HHS.

[00:41:17] Speaker 02:
42 CFR Section 137.79 construes that including language to be in addition.

[00:41:27] Speaker 02:
So, yes, we agree with the thought of Judge Katz in that respect.

[00:41:35] Speaker 03:
And to try the including phrase refers to services and benefits, which strike me as a little bit different than earnings.

[00:41:45] Speaker 03:
Can you help me with that concern?

[00:41:49] Speaker 02:
I will certainly try your honor.

[00:41:53] Speaker 02:
Well, see begins with the secretary shall provide funds

[00:41:58] Speaker 02:
including contract support costs, including any funds that are specifically or functionally related to the provision of services.

[00:42:08] Speaker 02:
So the funds are related to the provision of the services and the provision of the services are the provision of medical services to people covered by Medicare, Medicaid in my reading of that.

[00:42:22] Speaker 02:
Dr. Drow's question, the Indian Health Service will not even entertain negotiations on CSC being part of the A1 amount.

[00:42:33] Speaker 02:
It's off the table.

[00:42:35] Speaker 02:
And to the main point, I think, of my colleague, we agreed to an indirect cost rate of 31.91%.

[00:42:44] Speaker 02:
And Judge Rao, that's actually quite a bit less than even the percentage for HHS.

[00:42:53] Speaker 02:
There's a study that was done and reflected in a hearing

[00:42:56] Speaker 02:
in 1999, I believe, serial number 106-52.

[00:43:02] Speaker 02:
And the concern that was raised was all the tribes are getting out of control with their indirect cost rates.

[00:43:10] Speaker 02:
It turns out they're roughly half of what the indirect cost rates are for federal agencies, state agencies, universities, and others.

[00:43:20] Speaker 02:
And that's on page 26 of that particular study.

[00:43:23] Speaker 02:
The 31.91% isn't just a lawyer's abstraction.

[00:43:30] Speaker 02:
It's an agreed upon figure that the Office of Management and Budget recognizes is a necessary expedient.

[00:43:37] Speaker 02:
You can't go and nickel and dime different

[00:43:41] Speaker 02:
operations to find, you know, absolute specificity and precision to overhead costs.

[00:43:52] Speaker 02:
We don't and IHS doesn't have

[00:43:56] Speaker 02:
separate staff that provide services to people covered by Medicare and Medicaid.

[00:44:03] Speaker 02:
It's all within our organization.

[00:44:06] Speaker 02:
And we agreed that the 31.91% was the appropriate rate.

[00:44:11] Speaker 02:
And that extends throughout all of our program and all of our staff.

[00:44:16] Speaker 02:
And I note that this concern- You're over time, Mr. Fry.

[00:44:21] Speaker 05:
Judge Brown, any questions?

[00:44:24] Speaker 05:
Judge Walker?

[00:44:25] Speaker 05:
No.

[00:44:25] Speaker 05:
Okay.

[00:44:26] Speaker 05:
Thank you, Council.

[00:44:27] Speaker 05:
Thank you.