Managed Care Services for Local Tribal Citizens

 

Medical Insurance is provided through the Tribal Health Benefits (THB).  Citizens who live in Clallam or East Jefferson Counties are eligible for THB Benefits.  There are four categories of coverage.

 
Medicare – Tribal citizens eligible for Medicare must sign up for both Parts A and B.  There is no premium for Part A and the THB will reimburse Tribal members for their Part B premium provided they sign up for this benefit.  The THB will purchase a Medicare Supplemental policy for each Member and provide prescription drug services.

 
Medicaid – Tribal citizens eligible for State Medicaid must sign up for and use Medicaid services.  THB staff can help with the application process.  Medical services not covered by Medicaid will be covered by the THB to the same level of benefits received under other categories of coverage.

 
Private Insurance – If you are eligible for free insurance coverage through your employer, spouse’s employer or another entity, you must sign up for the coverage and use it.  If you are eligible for coverage but there is a cost, the THB will either choose to pay for or reimburse you for your part of the premium or choose to purchase a similar, less expensive coverage for you.  The THB will pay for or reimburse you for out-of-pocket expenses for co-pays and deductibles.

 
Basic Health/Group Coverage – If you are not eligible for Medicare, Medicaid or Private Insurance, the THB will purchase Washington Basic Health coverage for you if you meet the income eligibility requirement for the coverage.  Tribal citizens who do not meet this requirement will be added to the THB group coverage.  The THB will pay for or reimburse you for out-of-pocket expenses for co-pays and deductibles.

The THB also covers the following:

 
Vision Services:  Vision exams and glasses or contacts are provided through pre-authorization from the THB.  Services that are not pre-authorized, will not be paid for by the Tribe.

 
Hearing Services:  Hearing aids can be provided through pre-authorization from the THB.  Services that are not pre-authorized, will not be paid for by the Tribe.

Other THB benefits, provided by pre-authorization, include chiropractic, over-the-counter medications for chronic conditions, preventive services, and other non-insurance covered medically necessary services.

*Please see the THB for a full copy of the Managed Care Program Policies and Procedures.