Tribal Member Health Benefit Program FAQ

What is the Tribal Member Health Benefit Program?

The Tribal Member Health Benefit Program pays medical bills for the members. It covers most services that members obtain outside of the Southern Ute Health Center.

What does the program mean to me?

It provides the ability to access most medical services outside the Southern Ute Health Center without the need for an up-front payment like most doctors, hospitals, and clinics require today.

The Tribal Member Health Benefit Program is similar to the health insurance provided to tribal employees.

How does the program work?

Members will continue to have access to the Southern Ute Health Center as their primary care coverage. Members who do not access providers in the local vicinity (Ignacio) will still have coordination of care through the Southern Ute Tribal Health Department. The department will make and approve referral to services outside of the Southern Ute Health Center.

Members will have an identification card that will indicate the Southern Ute Tribal Health Department provides their coverage. This card must be presented to any doctor, hospital or clinic that the member sees for medical care.

Do I have benefits from the tribe now?

Yes. The tribe has covered expenses for tribal members since 2003 through the Tribal Member Resource Pool. These expenses will now be covered through the Tribal Member Health Benefit Program.

Will I have an insurance card?

Yes. The Health Benefit Identification Card will give the doctor, hospital or clinic information about the contracted provider network and the Tribal Member Health Benefit Program.

How is the program different than what I have now?

The Health Benefit Identification Card tells the doctor, clinic or hospital that you are covered by a Preferred Provider Organization (PPO) network, just like an insurance identification card. This PPO network is a national network that offers access to providers in most areas of the United States.

Through the Tribal Health Benefit Program, the tribe is also able to provide coordination of services outside the Southern Ute Health Center to improve the overall health of the membership. Through the Tribal Health Benefit Program, the tribe has the ability to provide some cost controls for medical expenses incurred by the membership.

What does a PPO network mean to the tribe?

The PPO network gives members access to providers outside the Southern Ute Health Center and across the United States. The PPO network also provides significant discounts to medical services for the tribal membership. When members present their Health Benefit Identification Card to a PPO network doctor, hospital or clinic, there is no up-front payment for services.

Why not just buy a health insurance policy for the members?

The cost of providing services has risen from $4 million in 2007 to $8 million in 2013. Last year, the tribe spent more than $6 million dollars in health care claims for tribal members. Changes are required to help control costs in order to sustain the program and ensure that the tribe can continue to cover the health needs of the membership.

How does the program save the tribe money?

The Tribal Health Department will reimburse medical expenses with a combination of existing funding, both federal and tribal. The program uses a national PPO network for discounted services. By continuing to use IHS funds and capturing discounts through the PPO network, the program will allow tribal funds to go farther for the membership.

How much will the program cost me?

There is no premium or cost to you to be covered under the Tribal Member Health Benefit Program. If you utilize PPO network doctors, hospitals and clinics, there should be no cost to you. If you use a non-PPO network (or “out of network”) doctor, hospital or clinic, there will be a cost to you that is not reimbursed by the program.

Why would it cost me anything to see a doctor?

The Southern Ute Tribal Health Department has identified a PPO network to provide services to tribal members. This network consists of doctors, hospitals and clinics who have agreed to provide discounted services to the membership. These PPO network doctors, hospitals and clinics have agreed beforehand to a set rate, or discount, for services provided to members.

For Non-PPO network doctors, hospitals, and clinics who have not agreed to a pre-negotiated rate, or discount, there will be a cost (normally non-reimbursed deductible and coinsurance) to you for their services. You may be required to pay for services at the time you receive services.

What is a deductible?

A deductible is a fixed dollar amount during the benefit period – usually a calendar year – that members pay before the Tribal Member Health Benefit Program pays for medical services.

What is coinsurance?

Coinsurance is a form of medical cost sharing that requires members to pay a percentage of the bill once they have met their up-front deductible. The Tribal Member Health Benefit Program is responsible for paying the rest of the reimbursement to the doctor, hospital, or clinic; i.e. the member pays 30 percent after deductible; the program reimburses the remaining 70 percent.

How do I find a PPO network provider?

The Tribal Member Health Benefit Program uses the First Health PPO Network. To see if a doctor, hospital or clinic is in the PPO network, you may call the Southern Ute Tribal Health Department or visit www.firsthealth.com and use the “Locate a Provider” link.

My doctor in Durango is not in the PPO Network; now what?

The Tribal Health Department’s goal is to enroll as many of the local providers in the PPO network as possible. If you have a doctor, hospital or clinic that is not in the PPO network, please let the department know and it will attempt to enroll the provider so you can have access to the highest level of benefits.

Why is my doctor not in the PPO network?

The doctor either has not been asked to participate, is not enrolled as of yet, or may have chosen to not participate in the PPO network. When a doctor is asked to join a PPO network, they agree to accept a negotiated rate or discount for services provided to the patients of that PPO network.

If my doctor is not in the PPO network, will it cost me?

Yes, those doctors are considered Non-PPO network providers. A deductible and coinsurance will apply to those visits and services. A Non-PPO provider may ask you to pay out-of-pocket at the time of your service. If you are required to pay out-of-pocket for services, or if you receive bills from non-PPO providers, please call the Southern Ute Tribal Health Department.

For tribal members employed by the tribe, are the employee contributions to the Southern Ute Indian Tribe Employer Health Plan paid by the Southern Ute Tribal Health Department (Resource Fund)?

Currently, those premium costs are not reimbursed for tribal members. Under the revised Tribal Member Health Benefit Program, employee contributions to the Southern Ute Indian Tribe Employer Health Plan will be reimbursed by the Tribal Health Department.

Will tribal members be required to pay anything, such as co-pays or deductibles, for health care if they purchase employer health insurance?

As long as the member uses PPO network services under their employer health insurance, any co-pays, deductibles and coinsurance will be reimbursed by the Tribal Health Department. If the member uses non-PPO network services, then the member will be required to pay for the co-pays, coinsurance and deductibles and will not be reimbursed.

Can other non-tribal-member family members buy into the Tribal Member Health Benefit Program?

No, not at this time.

If members employed by the tribe cover dependents under the Southern Ute Indian Tribe Employer Health Plan, what happens to those family members who are not tribal members?

If the member enrolls in family or dependent coverage through the Southern Ute Indian Tribe Employer Health Plan, the member will be required to pay for that level of coverage. The Southern Ute Tribal Health Department will reimburse the member for any costs (co-pays, etc.) of the individual employee coverage, but the remainder will be the member employee’s responsibility. The premium cost for dependents who are not tribal members will not be covered by the Southern Ute Tribal Health Department.

Will the Tribal Member Health Benefit Program include dental or vision services?

Due to the greater demand for members to receive medical services locally (and nationally, for those living away from Ignacio), coverage for medical services is being implemented first. Once medical coverage under the program is implemented, dental and vision coverage will be addressed in a similar manner.

Will the tribe continue to operate the Health Center?

Yes, it is important to continue to provide access to health care for members and other eligible beneficiaries at the Southern Ute Indian Health Center.

What are member “navigator” service representatives?

The Tribal Health Department staff has been trained in assisting members to use and understand the Tribal Member Health Benefit Program. In many ways, the plan simply improves upon and clarifies the processes that you have been using for years; however, please take some time to discuss the Tribal Member Health Benefit Program with a navigator to better understand how the program will benefit you.

Contact numbers

Please direct any questions about the Tribal Member Health Benefit Program to the Southern Ute Tribal Health Department at 970-563-4742.

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