Frequently Asked Questions
Below are some questions that have been asked about the tribal member health plan. Many of the questions came from staff employees and then tribal members. If you have not signed up your family member then please do so and encourage other family members to submit there's. They will need to use this for eyeglass assistance, special meds, dental, dentures, etc. after the first of the year. There will be a transition period because not everyone will be signed up. Please make sure that you encourage your clients to come and fill out an application.
- Does the plan cover dentures?Yes
- Does the plan cover orthodontics?Yes
- Does the plan work at out of state hospitals, doctor's offices and pharmacies?Yes
- Does the plan cover glasses more than once a year for an elder that has serious eye problems that requires their prescription to change often?Eye exams are covered once a year,frames and lenses once every 2 years. (Elders should be able to use more than once but trying to verify.)
- Is there an appeals process for any disputes, chronic illness needs or major medical emergency needs?Yes, a letter with supporting documentation can be sent to the address on your card, and the appeal will be reviewed by the Executive Committee.
- How does the plan cover prescription drugs?If the plan is secondary to any other insurance, it will pick up the patient responsibility at 100% up to the calendar year max of $500.00. If you have no other coverage, the Tribal Member Plan will have a $0 co-pay for Generic drugs and a $25.00 co-pay for brand name up to the calendar year max of $500.00. If you are 55 years or older, there is no internal limit.
- How does someone with Medicare and Medicaid benefit from the program?Medicare and Medicaid have a great deal of non-covered items. These items are typically covered under the plan. A short sampling is listed. One example is coverage of your Medicare deductible.
- How does someone with Sooner Care benefit from the program?Soonercare is a form of Medicaid in Oklahoma. Many items are considered non-covered. A short sampling is listed.
- If someone has a primary insurance, does this affect their primary insurance?No. This is plan is used to supplement and help covered out of pocket costs for members that have insurance. If you do not have any coverage, this will give you access to basic coverage.
- If someone is on their spouse's insurance and has to list this coverage, will it affect their eligibility to be carried on their spouses insurance?Same for children.Tribal Member Plans are covered under the Indian Healthcare Reauthorization Act as well as the ACA are not required to be reported as minimum essential coverage in this situation.
- Does the plan work if the individual is having a baby and can the full $1,500 be applied to the delivery? For example: Tribal member can utilize a facility and pay $2,000 for the facility to deliver the baby. Yes if the member wants to use the full $1500.00 under Medical services. It is the member's choice on how to utilize the $1,500 first. If you are 55 or older, you do not have internal limits.
- Will there be a brochure developed for the Tribe showing the benefits of the health plan?Yes, this is in the process.
- Is chiropractic care covered?Yes
- Is counseling covered?Is there specific types? All counseling services are covered as long as they are medically necessary. This does include family and marital therapy which are many times not covered under standard plans.
- Can this insurance be used for tax purposes?This plan is not needed for tax purposes because all those covered are members of a Native American tribe and can use the Native American exemption if they do not already other coverage. The form can be found at irs.gov.
- Can diabetic shoes be purchased through the plan?Yes
All questions were responded to by RWI Benefits.