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Medical benefits of the Southern Ute tribal member health benefits plan

Photo Credit: SU Tribal Health Services

Greetings Southern Ute Tribal Membership,

At the beginning of this year, the Health Department wrote an article to provide clarity on the tribal member health benefits plan. The department would like to continue the effort to help individuals understand the sometimes-complex world of health. This article will cover some, but not all basic information in the medical portion of your plan.

All enrolled Southern Ute tribal members have a medical benefit plan that covers many typical medical expenses. These expenses include, but are not limited to, primary care visits, emergency room (ER) visits, and specialty clinic visits such as nephrology, cardiology or podiatry. Each member has 60 combined visits for chiropractic, massage and acupuncture care per calendar year starting in January. Inpatient substance abuse treatment is covered when coordinated through the Tribal Health Department or the Tribe’s third-party administrator (TPA) with a maximum allowance of $40,000 per calendar year. Hearing Aid services are covered at an unlimited amount when utilizing the Audiology clinic through the Southern Ute Heath Center. Otherwise outside services are set at a maximum of $5,000 per calendar year. Outpatient therapy such as occupational therapy allows for 20 visits per calendar year, physical therapy allows for 40 visits per calendar year and speech therapy allows for 20 visits per calendar year. Bariatric surgery is covered at $7,500 per occurrence and that is inclusive of all providers for that service. Post-bariatric cosmetic surgery procedures are covered at $15,000 per 120 months (10 years). It is important to know that some services or procedures do require a pre-authorization before being approved for payment. Pre-authorization of services are provided by Hines and Associates, a group contracted through Forrest County Potawatomi Insurance Department (FCPID), the tribe’s TPA. There is a pre-authorization phone number for providers to call on the back of your medical card to receive the pre-authorization of the service(s) being requested.

The following services require a pre-authorization: Inpatient hospital stay (required for non-emergency services before medical and/or surgical services are provided), emergency air ambulance, cardiac rehabilitation programs, chemical dependency, chemotherapy, cochlear implants, cosmetic services (treatment of congenital malformation or accidental injuries or illness), dialysis, growth hormone therapy, home health care, hospice care, mental disorders (partial day admissions), morbid obesity (bariatric surgery), positron emission tomography (PET) scan, and transplants (all services related to transplant management.

Members do not have to see an in-network provider, and they do not have to pay a co-pay, co-insurance or deductible. If the provider does charge an upfront cost, you may be reimbursed by submitting your receipts directly to FCPID or to the tribal health department and we will forward them to FCPID for you. Reimbursement will come in the form of a check from FCPID and can take up to 30 days for completion. The medical plan is administered by the Tribe’s current Third Part Administrator (TPA), Forest County Potawatomi Insurance Department (FCPID), as a TPA their roll is to process all medical claims. FCPID will receive the provider’s billed claim for services and ensure the rates for each service are correct and then they pay the lowest possible rate. FCPID forwards this information to the Tribe and payment is authorized. Tribal members were mailed the newest card in September 2019; if you did not receive a card please call the Tribal Health Department at 970-563-4742 or FCPID Customer Service at 1-800-960-5479. If you are unsure if a service or procedure is covered under your Tribal Member Health Benefit plan, please call the FCPID Customer Service number as mentioned above.

Thank you for your time and please look forward to the next article summarizing your vision benefits through Vision Service Plan (VSP). The THD Benefits Team continues to serve you during this uncertain time; we are available to assist the tribal membership between 8 a.m. through 5 p.m. Monday through Friday, please call our office phone at 970-563-4742. We hope that each and every one of you are continuing to stay safe and follow the public health orders issued to help slow or stop the spread of COVID-19.

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