Offering the below described benefits to tribal members provides them with a wider range of providers and can reduce their overall healthcare costs. These advantages are not only enjoyed by the employee/member, but also by the employer/tribe.
Specialty TPA Services For Self Funded Tribal Groups
Through the agency of Indian Health Service (IHS), members of American Indian and Alaska Native tribes are covered for certain health services. Although these benefits are available to eligible tribal members, tribal health plans must provide the necessary administrative services tribal members need to leverage Medicare Like Rates (MLR) and Catastrophic Health and Emergency Funds (CHEF) to better manage their health costs. Healthcare Management Administrators (HMA) has been offering these cost-saving services since 2009 and is one of the few Third Party Administrators in the Pacific Northwest that does so.
Offering these additional benefits to tribal members allows them to receive care that is not available from their local tribal clinic at a substantial cost savings. These advantages are not only enjoyed by the employee but by the employer. When eligible tribal members are afforded Medicare Like Rates (MLR), claims costs are reduced, saving money for both the employer/tribe and the employee/member.
Medicare Like Rates (MLR)
Many tribal members receive medical care directly from tribal clinics and health facilities near their place of residence. However, some medical services are not available through tribal clinics and must be referred to other providers in the community. A program called Contract Health Services (CHS) was instituted to supplement and complement other health care resources available to eligible tribal members; however funds for the CHS are limited and can be exhausted before a year's end.
HMA's Tribal Member Services allows members to receive a wide range of MLR medical services.
In order to stretch these funds further, The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 allows tribal members to take advantage of MLR with CHS funded claims incurred at Medicare eligible facilities. These services include inpatient and outpatient hospital services and must be authorized by Indian Health Services (IHS), Tribal or urban Indian organization entities. An educational letter was sent to all hospitals in 2009 when HMA began implementing MLR. The notification informed hospitals* that members would be presenting themselves for services through the network with MLR coverage.
MLR can be cumbersome for an employer to handle alone; HMA can help. We handle all administration required for MLR as outlined below:
- Medicare Like Rates are applied to the facility charges
- Claims are priced by the network
- Claims are adjudicated and paid through HMA
- The lower of the MLR or network price is paid to the provider
- A small per claim fee is charged by HMA for MLR pricing and handling
*A Medicare participating hospital (available through the HMA Preferred Network) cannot discriminate in any way just because a patient is eligible for MLR. It is illegal to do so.
Catastrophic Health and Emergency Fund (CHEF)
HMA also provides assistance with applications for CHEF. CHEF was created by Indian Health Services (IHS) to meet the extraordinary medical costs associated with treating victims of disasters or catastrophic illnesses who are tribal members. It also provides access to IHS funds for single catastrophic events where paid claims exceed $25,000.
- HMA generates monthly claims reports for all eligible Tribal members
- HMA sorts claims information to identify members who have had a catastrophic event
- HMA gathers required claims documentation and submits it to Tribal representative
- The Tribal representative completes the documentation and submits to IHS for CHEF reimbursement
- HMA provides these services at no additional charge if the tribal member is currently receiving MLR pricing services.
To learn more about the services we offer, please contact Sales.