Contact:
Suquamish Tribe Health Benefits
18490 Suquamish Way
Suquamish, WA 98392
360.394.8466 phone
360.598.3706 fax
Services provided to Tribal Members:
Health Benefits assists Tribal members in obtaining medical, dental, vision and hearing care, including needed medical equipment. The program also assists clients in accessing all available alternate resources including other state and federal programs such as DSHS, Veterans' Services, Social Security and Medicare. Health Benefits is also responsible for managing the annual enrollment of Tribal members and members of other tribes wo live on the reservation in the Suquamish Tribe's Health Benefits Plan.
The Health Benefits Department manages the Contract Health Services (CHS) program for the Suquamish Tribe. This is not insurance coverage even though the claims are processed through KPS Health Plans.
Funding is based on an Annual Funding Agreement with the Indian Health Service and the benefits are administered under a long-standing Demonstration Project. Through this innovative program the Tribe utilizes these specialty care funds to provide both primary and specialty services for tribal members. The Tribe also provides hard dollars to cover the I.H.S. shortfall.
We have negotiated unique contractual arrangements with various vendors to provide comprehensive medical, pharmacy, vision and hearing services. The department also coordinates dental services by combining direct care at the Port Gamble S’Klallam Tribe dental clinic with referred services to KPS Participating specialists.
In order to effectively manage the limited funding received from the Indian Health Service and to comply with the payer of last resort legislated requirements (42CFR32.61subpart G), the department aggressively pursues all available alternate resources. This includes State (Medicaid) and Federal programs, hospital and ambulance Charity Care programs, free services such as Shriner’s and St. Jude’s children’s hospitals, as well as employer-sponsored group health insurance coverage. Tribal members who have employer-sponsored health insurance coverage might still be eligible for DSHS Medicaid coverage – perhaps with a spenddown. The members may be required to apply for that coverage in the event they meet the program guidelines.
Members who have other primary health insurance coverage through an insurance company other than KPS must submit their carrier’s explanation of benefits forms to the Health Benefits department or to KPS directly. This explanation (EOB) is sent to members each time their carrier pays a claim. The Indian Health Plan cannot pay claims until we receive the other carrier’s EOB.
Indian Health benefits can be terminated:
Members will lose their eligibility for Indian Health Benefits if they decline health insurance when it is available at no cost to them through their employment. Members will also lose their eligibility for Indian Health Benefits if they do not comply with the DSHS application process. Members will also lose their eligibility if they do not complete the annual application for Health Benefits.
The notice to submit new applications is published in the Suquamish Tribe newsletter in the 4th quarter of every year and many are mailed directly to members. Health benefits are effective on the first of the month following receipt of completed applications. Applications signed in the last quarter (Oct/Nov/Dec) will be considered valid for a January 1 effective date. The application is only for the member listed at the top of the form. Each family member must submit a separate form. These applications are the foundation of the user population count that determines I.H.S. funding each year.
Primary and Specialty medical services are processed by KPS Health Plans. This is not an insured plan; Indian Health policies and Tribal policies determine payment.
Some services are excluded under KPS Health Plans coverage, but are provided directly through other Tribal programs. An example would be Nutritional Counseling for tribal members who are diagnosed with Diabetes. A doctor might refer the patient to Harrison Medical Center for Diabetes Education and Nutritional Counseling. However, this service isn’t payable at Harrison. The services are provided through direct programs in the Human Services department. Additionally, members must see KPS Participating Providers. The listings are available on the KPS website (www.mykps.net) or by asking the individual doctor if they are a KPS Participating Provider. Members may also call the KPS Customer Service phone number for assistance in finding a participating provider. Members may also see providers who are contracted with First Choice Health Networks.
Mental Health/Behavioral Health/Chemical Dependency services are only available when they are coordinated by or provided by the Wellness Center.
Pharmacy benefits are provided through NW Pharmacy Services – not KPS. Additionally, maintenance medications must be ordered through the mail-order program through Bellegrove Pharmacy. This mail-order program stretches the available funding by dispensing generic medications and because we are able to access special pricing for medication. On average we save 17% of the available prescription funds by using Bellegrove Pharmacy.
All Vision services must be authorized in advance and must be received at Pacific Eye Care in Poulsbo, Bainbridge Island or Silverdale. We have negotiated package prices that include only certain frames and lens types.
All Dental services must be approved in advance and a Purchase Order issued in order for dental services to be paid. Dental payments are made at 100% of the KPS Allowance.
Port Gamble S’Klallam Dental Clinic: If members decide to use the services at the Port Gamble Dental Clinic advance authorization is not required. However, if the clinic refers the member to another dentist those referred services must be approved in advance. The member must receive a Purchase Order number from Health Benefits in order for services to be paid. Services will only be authorized when the member sees a KPS Participating Dental Provider.
Members who have primary dental insurance: Members must receive advance authorization and a Purchase Order for all services. Members need to follow the requirements of the primary dental plan. Payment of deductibles, copays, or other charges can’t be made if services were not pre-authorized.
All Hearing services must be authorized in advance of receiving any treatment.
The Health Benefits staff is not authorized to allow exceptions to benefits. The KPS benefit booklet details the appeal process for denied claims and services.