CHS pays for specialty medical services that are not available within the Cherokee Nation (CN) health centers or W. W. Hastings hospital. Approximately 20 Managed Care Coordinators work in those facilities to process referrals. The referral must come from a CN or IHS, Tribal or Urban (I/T/U) medical provider. Referrals are reviewed daily and are for one visit (date of service) only, unless otherwise specified.
Cherokee Nation (CN) Contract Health Services (CHS) is funded by the Federal Government through Indian Health Services (IHS) at less than half its actual health care needs. Other costs are billed to third-party insurers for patients with private, employer or Marketplace insurance coverage; and through federal and state programs such as Medicare, Medicaid, etc. Remaining costs are being paid out-of-pocket by the tribe.
The federal government (IHS) has changed the name of its funding program from Contract Health Services (CHS), to Purchased & Referred Care or (PRC). Because the Cherokee Nation is a tribally managed health system, for now, we will continue to utilize the program name of Contract Health Services. But, you may see or hear PRC when you use your I/T/U government facilities. The name change does not change the function of the program.
CHS funds are available for IHS eligible patients living within the Cherokee Nation CHS Delivery Area (CHSDA): Hospital admission services are provided for Cherokee, Adair and Sequoyah Counties.
Outpatient (same day) services are provided for Cherokee, Adair, Sequoyah, Muskogee, Mayes, Delaware, Craig, Nowata and Washington Counties; and Cherokees in Rogers and North Tulsa Counties.
Supplemental Tribal CHS funding eligibility: These programs are available to Cherokee Citizens living within the Oklahoma 14 county Tribal Jurisdictional Service Area (TJSA) who meet the medical necessity of the CN CHS system:
o The TJSA includes all of the following counties: Cherokee, Adair, Sequoyah, Craig, Nowata and Washington Counties.
o This also includes portions of the following counties: Tulsa (North of Admiral), Muskogee, McIntosh, Wagoner, Mayes, Ottawa, Rogers and Mayes counties.
These Supplemental Tribal programs are available to citizens living within the TJSA, who meet medical necessity of the CN CHS System and other criteria listed below:
5% Program: These are funds set aside to supplement CHS services for patients living within the TJSA. o Patients who have been denied by another CHS office (Claremore or Creek Nation) will benefit from this program. o Patients should appeal with that office and use those documents to work with their local CHS office to access this program.
Medical Resource Program: Provides equipment for patients who are under the care of CN providers. o Have income less than 185% of Federal Poverty Level (FPL) o Have a statement of medical necessary (Rx) from a CN provider.
Denture Program: Provides patients with dentures or partials. o Have income less than 300% of FPL o Must be patient of record at one of the CN Dental Clinics, received an exam, and completed preparatory treatment. o Limited to once every five (5) years.
Eyeglass Program: Provides patients with single vision glasses or bifocals. o Must be examined by CN Provider. o Diabetic or under eighteen (18), full-time college student, or 55 years of age and over.
Hearing Aid Program: o Must be referred to CN Audiologist by CN Provider.
CHS is the payer of LAST RESORT: When other resources are available they must be utilized and are considered first. This includes Automobile Insurance, Liability Insurance, VA benefits and Employer Worker’s Compensation. Because CHS is underfunded, elective procedures may not be covered. Therefore, you are encouraged to sign up for employer benefits of which you are entitled or Health Insurance coverage through the Marketplace, under the Affordable Care Act (ACA).
When Emergency care has been necessary and treatment sought: You must contact your local CHS office within seventy-two (72) hours. Only those living within the TJSA are eligible for assistance with these services. You will be required to obtain medical records for review by CHS. CHS services may be denied: If the illness or injury is the result of the patient taking part in at-risk-activities or criminal behavior. Some examples are: o Injury sustained from use of All Terrain Vehicles (ATV), rodeo injuries, cage fighting, alcohol or drug intoxication. o Any activity resulting in a crime will be subject to review and illegal activity such as illicit drug use will be excluded.
Cherokee Nation CHS services are not available for Cherokee Citizens who live outside of the TJSA, both in Oklahoma & out of state/at-large
At-large Citizens who have need for CHS funding who want to travel to Oklahoma for services: Are eligible for services offered within our facilities. The patient must be evaluated by a provider within our facilities (the same process as citizens who live within the TJSA). If an at-large citizen needs services that we do not provide within our facilities; those services will not be available through CN CHS. Some examples of these services are: o Urology, oncology and cardiology, neurology, nephrology and others.
Denied Referral & Appeal process: You will be notified by letter for a denied referral. The denial letter will have an appeal form with instructions on how to appeal. You may appeal denied referrals three (3) times.
Discount Pharmacy mail-order benefits offered to all IHS eligible patients through the Pequot Pharmaceutical program: Call this number 1-800-342-5779 to talk to a representative about details and eligibility. For online information, Frequently Asked Questions (FAQ’s) http://www.prxn.com/ Link to online application: http://www.cherokee.org/Portals/0/Documents/2011/5 /30866PRxN_app.pdf The Pequot Pharmaceutical program will contact the Cherokee Nation to verify applicant’s IHS eligibility.
Because the funding provided to the Cherokee Nation by the IHS is approximately half of the need, it helps the Cherokee Nation immensely when patients have Medicare, Medicaid or private insurance. The implementation of the Affordable Care Act has been very good for the Cherokee Nation and Indians across the nation and we strongly encourage our patients without health insurance to explore what this program could provide to them and their families.
How the Affordable Care Act (ACA) can help both TJSA and at-large citizens with services not covered by CHS: Based on income and number in household you may qualify for Premium Tax Credits (assistance to pay for premiums) or Cost-Sharing Reductions (CSR) – (no co-pay, no deductible or co- insurance) for Essential Health Benefits (EHB). Having a Qualified Health Plan (QHP) through the Marketplace can help you & your family by giving you additional access to healthcare.
o The Zero and Limited CSR benefits are available for American Indian and Alaska Natives (AI/AN) and only on plans purchased through the Marketplace, for EHB’s with in-network providers.
o For those who have a QHP through the Marketplace with LIMITED Cost Sharing Reduction’s, to assure you receiving those benefits and avoiding out-of-pocket expense for EHB’s with in-network providers; the CHS Referral is necessary. Approval is not:
. Contact, or go by your local CN or I/T/U facility for your CHS referral/authorization.
. The referral/authorization can be faxed, emailed or handed to you for your upcoming appointment with an In-network provider for EHB’s.
. Know who your plan’s ‘in-network’ providers are.
o If you have a ZERO cost-sharing reduction QHP through the Marketplace, you do not need a referral or authorization from CHS.
A reminder that our Tribal Card is a benefits card and is not considered Health Insurance coverage.
Find out more by contacting the facilities listed at the end of this brochure and ask to speak to your Patient’s Benefit Coordinator (PBC) who is a Certified Application Counselor (CAC), they will help you, free of charge, with an application explaining your eligibility and what you qualify for.
GLOSSARY OF TERMS:
ACA: Affordable Care Act
AI/AN: American Indian / Alaskan Native
ATV: All terrain vehicles
CAC: Certified Application Counselor (assisting with ACA)
CHSDA: Contract Health Services Delivery Area
CHS: Contract Health Services
CN: Cherokee Nation
CSR: Cost Sharing Reductions (no co-pay, no deductible or co-insurance for essential health benefits); Zero & Limited plans for those who qualify.
EHB: Essential Health Benefits
FPL: Federal Poverty Level
IHS: Indian Health Services. Also, you can go to www.ihs.gov >find healthcare, enter your zip code to locate your nearest I/T/U facility.
I/T/U: Indian Health Service / Tribal / Urban (facilities)
Marketplace: Where you can shop, compare, enroll and purchase health insurance online, accessible by going to www.healthcare.gov .
PBC: Patient benefits coordinator
PRC: Purchased and Referred Care
QHP: Qualified Health Plan
RX: Prescription (order)
TJSA: Tribal Jurisdictional Service Area
CHS services are not available for Cherokee Citizens who live outside of the TJSA, both in Oklahoma & out of state/at-large:
If you are not sure you live within the Cherokee Nation TJSA or have any questions, you may call CN CHS at these locations:
Ochelata – Cooweescoowee Health Center. 918-535-6000 Jay – Sam Hider Health Center………………….……918-253-4271 Muskogee – Three Rivers Health Center………..918-781-6500 Nowata – Will Rogers Health Center………….…..918-273-0192 Salina - A-Mo Health Center………………………. 918-434-8500 Sallisaw – Redbird Smith Health Center………….918-775-9195 Stilwell – Wilma P. Mankiller Health Center….918-696-8800 Tahlequah – W.W. Hastings Hospital………………918-458-3500 Vinita – Vinita Health Center………………………….918-256-4800 Claremore - IHS Hospital…………………………………918-342-6560