Benefit Coordination

Eligibility

• CNHSA Eligibility Guidelines

CNHSA Eligibility Guidelines

ELIGIBILITY GUIDELINES
Revised April 2016 with updates on February 2020, July 2020, November 2020, April 2021, April 2022, September 2022, January 2023, March 2023, December 2023. The Choctaw Nation Health Services Authority (CNHSA) will provide health care services at the Choctaw Nation Health Care Center, Talihina, and all field Clinics according to the following guidelines:

1. NATIVE AMERICANS

   A Native American with a CDIB card, a Membership card, or letter of descendancy from a federally recognized tribe is eligible for services as described in the following guidelines. A Social Security card is required. If 18 or older, a Photo ID is also required.

   Please Note: In order to be eligible for Choctaw Referred Care, the patient must show proof of residency in Atoka, Choctaw, Haskell, Latimer, Leflore, McCurtain, Pittsburg, Pushmataha, or Bryan counties of Oklahoma. Residency must be for a time period of 180 days or more. Proof of residency consists of Oklahoma driver’s license or OK state issued identification with an address listed within the 9 covered counties and the following: tax returns, Oklahoma driver’s license, vehicle registrations, utility bills, bank statements, school enrollment, and physical address (no P.O. Box). The burden of proof is on the patient.

2. NATURAL CHILDREN

   Natural Children, under the age of 19 years, of an eligible parent are eligible for services. If a child has his/her own CDIB, State birth certificate and Social Security card are required. (Required by age one)

   If a child does not have his/her own CDIB, eligibility will be determined through the parents ONLY. A copy of the parent(s) CDIB, State birth certificate and Social Security card is required. (Required by age one) Grandparents, other relatives, or friends may verify the child’s eligibility by providing the aforementioned documents in addition to the letter from either parent authorizing medical care for the child. In certain instances, as determined by the Administrator, care may be rendered without producing a CDIB. Individuals will be required to provide documentation by their next visit. Failure to comply will result in billing for services rendered and ineligibility for further care.

3. ADOPTED, STEP, AND FOSTER CHILDREN

   An adopted child, stepchild, foster (i.e. placement) child, legal ward, or orphan under the age of 19 years of an eligible parent is eligible for services except for Diabetes Wellness Center services. A stepchild is required to live in the home of the Native and recertification is required once per year. The following documents must be provided to document eligibility.

   1. Marriage license of parent
   2. Birth Certificate of child
   3. CDIB, membership card or letter of descendancy of eligible parent
   4. Proof of dependency to establish permanent residency (i.e., divorce papers, tax forms, adoption papers, ICW/DHS papers, custody agreement, court orders, minor child affidavit) Note: school records can be used to show the address where the child lives.
   5. The eligible parent MUST come in and complete an affidavit of acknowledgement of
      dependency form once a year. (stepchild) (if signed outside the facility must be
      notarized)
   6. Choctaw Nation Health Services Authority does not recognize common-law marriages. Stepchildren from these circumstances are not eligible for care.

4. NON-ELIGIBLE SPOUSES

   Non-eligible spouses can be seen at the Choctaw Nation Health Care Center in Talihina ONLY.

   Non-eligible spouses are eligible for limited services on a fee basis. (With insurance, must have a third (3rd) party payer) non-eligible spouses can use Laboratory Services, Radiology, Surgery Clinic, Women’s Clinic, Family Practice, Emergency/Urgent Care, and In-Patient Services ONLY.

   Non-eligible spouses are responsible for deductibles and paying the remaining balance after the third (3rd) party payer has been billed.

   The following documents must be provided to determine eligibility:

   1. Marriage license
   2. CDIB, membership card, or letter of descendancy on eligible spouse
   3. Proof of Insurance: Medicare, Medicaid, or Private Insurance card
   4. Current Photo ID
   5. In the event of the eligible spouse’s death, services will continue until the non-eligible spouse remarries

5. NON-ELIGIBLE SPOUSES PREGNANT WITH AN ELIGIBLE CHILD

   Non-eligible spouse will be eligible for services at Talihina Hospital ONLY (with the exception of prescriptions related to pregnancy, as determined by physician, which will be available at any outlying clinic) until released by the provider.

   Non-eligible spouses that are pregnant with an eligible child: ALL services related to pregnancy are covered (to be determined by physician). The following documents must be provided to determine eligibility:

   1. Marriage license
   2. CDIB, membership card, or letter of descendancy
   3. Proof of pregnancy (positive test from the Health Department)
   4. Current Photo ID

   Please Note: If individuals are not married, paternity papers must be completed at the hospital during the first prenatal visit. The eligible party must be present for signature at that time. Individuals must submit a picture ID with a signature. This includes all types of paternity such as Denial of Paternity.

   The patient will be seen up to six weeks postpartum for routine medical care related to pregnancy and for eight weeks for sterilization procedures. If a condition continues after the pregnancy, care can be established with an outside provider.

   NOTE:
   If a stepchild and/or non-eligible dependent presents herself as being pregnant, the patient will be eligible for all services related to pregnancy until six weeks post-partum. After a stepchild and/or non-eligible dependent has delivered the baby then that individual becomes emancipated. (Emancipated means being considered as being an adult.) Additionally, the baby born at Choctaw Nation Health Care Center to the stepchild and/or non-eligible dependent (mother) will receive care for six weeks post-partum.

6. NON-ELIGIBLE EMERGENT CARE

   CNHCC will assess/treat any emergency with the potential of loss of life or loss or limb (CNHCC complies with all laws governing emergency services). Non-eligible patients presenting with a non-emergent complaint will be assessed to determine the necessity of treatment. (An attempt will be made to stabilize the patient before a transfer is made to another facility.) In questionable cases, the administrator on call will make a determination concerning admission or transfer. These individuals will be required to pay for the Episode of Care.

   A supply of medications will not be dispensed. If the provider determines it to be a medical necessity and an alternate source for obtaining medication is unavailable, the provider may give a one (1) time dose or a one-day dosage to start initial treatment.

7. NON-ELIGIBLE EMPLOYEES (SEE NON-ELIGIBLE EMPLOYEE POLICY IN HR SECTION)

8. ACTIVE-DUTY NON-INDIAN MEMBERS OF THE ARMED SERVICES INCLUDING SPOUSES AND DEPENDENTS- THIS INCLUDES COMMISSIONED CORP.

   Active-duty non-Indian members of the Armed Services are eligible for all services except Diabetes Wellness Center, Choctaw Referred Care, and Pharmacy on a fee basis.

   Non-eligible spouses and dependents (under age 18) of non-Indian Active-Duty members of the Armed Services are eligible for Laboratory, Radiology, Emergency, or Urgent Care ONLY on a fee basis. Talihina only

9. ACUTE INFECTIOUS DISEASE

   Non-Indian family members dwelling in the house of an eligible where an acute infectious disease has been diagnosed will be assessed/treated for the disease.

10. SPECIALITY SERVICES

    All patients seen by specialty services provided by CNHSA must meet the following guidelines:

    1. BIOLOGIC MEDICATIONS – Limited to CRC/Choctaw only (must be living in and have lived in 10 1⁄2 counties for at least the past three (3) years).
    2. CARDIOLOGY-18 y/o+; Echo 18 y/o+; Holter Monitor 18 y/o+- Limited to CRC only (any tribe living in 9 counties) Limited to CRC/Choctaw only (living in 10 1⁄2 counties).
    3. DENTAL PEDIATRIC (Children must be 8 y/o or less) – Limited to CRC/Choctaw only (must be living in 10 1⁄2 counties).
    4. DERMATOLOGY – CDIB holders (direct, any tribe living anywhere), any patient with consult, and non-eligible health care employee spouses and dependent children with a third-party payer.
    5. EEG – Limited to CRC/Choctaw only (living in 10 1⁄2 counties), ordered by Neurologist.
    6. Endocrinology- CDIB holders (direct, any tribe living anywhere), includes pediatric and FNA.
    7. Endodontic -14 y/o+ – Limited to CRC/Choctaw only (Living in 10 1⁄2 counties)
    8. ENT Talihina (incl Surgery) 2 y/o+- Limited to CRC only (any tribe living in 9 counties) Limited to CRC/Choctaw only (living in 10 1⁄2 counties)
    9. ENT- Durant- CDIB holders (direct, any tribe living anywhere)
    10. GASTROINTESTINAL – CDIB holders (direct, any tribe living anywhere).
    11. NEUROLOGY – Limited to CRC/Choctaw only (living in 10 1⁄2 counties), will see patients aged 2 y/o+. (For migraines, must have two (2) failed therapies. Will see for any other serious neurological issue).
    12. OPHTHALMOLOGY CATARACT SERVICES – Limited to CRC/Choctaw only w third party payer (living in 9 counties)
        Exception: IN HOUSE cataract surgery only, NOT CRC
        • Any Tribe in the 10.5 Counties
        • CDIB cardholders
        • May or may not have 3rd party
        • Choctaw tribal members in or outside the counties are eligible
        • Any patient who requires extraction to treat Diabetic Retinopathy, as determined by the Retina Clinic.
        • Same Criteria for Blepharoplasties and Pterygium removal.
    13. ORTHO MID-LEVEL – Limited to CRC only (any tribe living in 9 counties), Limited to CRC/Choctaw only (living in 10 1⁄2 counties).
    14. ORTHOPEDIC SURGEON – Limited to CRC/Choctaw only (living in 10 1⁄2 counties).
    15. PT-EMG/NCVS- Limited to CRC/Choctaw only (living in 10 1⁄2 counties)
    16. PULMONARY 18 y/o+- Limited to CRC only (any tribe living in 9 counties), Limited to CRC/Choctaw only (living in 10 1⁄2 counties)
    17. RHEUMATOLOGY – Limited to CRC/Choctaw only (living in 10 1⁄2 counties) Patients must be age 18 y/o+.
    18. SLEEP LAB – Limited to CRC/Choctaw only (living in 10 1⁄2 counties) Patients must be age 18 y/o+.

11. NON-SPECIALTY SERVICES

    1. 24 Hour Event Monitors- CDIB holders (direct, any tribe living anywhere)
    2. 30 Day Event Monitors- Limited to CRC only (any tribe living in 9 counties)
    3. ACC (anti-coagulation clinic)- CDIB holders (direct, any tribe living anywhere)
    4. Audiology-Hearing Test/Exam- CDIB holders (direct, any tribe living anywhere)
    5. Audiology-Hearing Aids/Batteries- Choctaw tribal members in or outside the counties are eligible every three years through EDH program.
    6. Behavioral Health- CDIB holders (direct, any tribe living anywhere), Non-Eligible Pregnant with an Eligible child up to 6 wks. post-partum (pregnancy related, crisis only, Talihina only), Non-Eligible Health Care Employee & Commission Corp. (Bariatric, with CNO Insurance).
    7. Chi Hullo Li- (Female)- CDIB holders (direct, any tribe living anywhere)
    8. Choctaw Referred Care (CRC)- Limited to CRC only (any tribe living in 9 counties)
    9. Community Health Nurse- CDIB holders (direct, any tribe living anywhere) (Immun). Limited to CRC only (any tribe living in 9 counties) (NB)
    10. Dental- – CDIB holders (direct, any tribe living anywhere)
    11. De-Sat Monitors- CDIB holders (direct, any tribe living anywhere)
    12. Diabetic Educator- CDIB holders (direct, any tribe living anywhere)
    13. Dietician- CDIB holders (direct, any tribe living anywhere)
    14. DWC (Diabetic Wellness Clinic)- CDIB holders (direct, any tribe living anywhere)
    15. Emergency Care- CDIB holders and any non-eligible
    16. Employee Health – All Employees, spouses and children, Non-eligible Health Care employee spouse and dependent children, ALL CNO Employees. Insurance not required.
    17. Eye clinic – CDIB holders (direct, any tribe living anywhere)
    18. Family Practice- CDIB holders (direct, any tribe living anywhere), Non-Eligible Pregnant with an Eligible child up to 6 wks. post-partum (pregnancy related, Talihina only), non-eligible spouse with insurance (Talihina only), Non-Eligible Health Care employee & Commission Corp. with Insurance, and Non-eligible Health care employee spouse and dependent children with insurance.
    19. Imaging (excluding MRI)- CDIB holders (direct, any tribe living anywhere), Non-Eligible Pregnant with an Eligible child up to 6 wks. post-partum (pregnancy related, Talihina only), non-eligible spouse with insurance (Talihina only), Non-Eligible Health Care employee & Commission Corp. with insurance, and Non-eligible Health care employee spouse and dependent children with insurance.
    20. In-Patient Services- CDIB holders (direct, any tribe living anywhere), Non-Eligible Pregnant with an Eligible child up to 6 wks. post-partum (pregnancy related, Talihina only), non-eligible spouse with insurance (Talihina only), Non-Eligible Health Care employee & Commission Corp. with insurance, and Non-eligible Health care employee spouse and dependent children with insurance.
    21. Laboratory- CDIB holders (direct, any tribe living anywhere), Non-Eligible Pregnant with an Eligible child up to 6 wks. post-partum (pregnancy related, Talihina only), non-eligible spouse with insurance (Talihina only), Non-Eligible Health Care employee & Commission Corp. with insurance, Non-eligible Health care employee spouses and dependent children with insurance.
    22. MRI- CDIB holders (direct, any tribe living anywhere), non-Eligible Health Care Employee & Commission Corp. with insurance, Non-eligible Health care employee spouse and dependent children with insurance.
    23. Nutrition Therapy Counseling- CDIB holders (direct, any tribe living anywhere), Non-Eligible Health Care employee & Commission Corp. (Bariatric, with CNO Insurance).
    24. Nutrition Therapy Supplement-Limited to CRC/Choctaw only (any tribe living in 10 ½ counties)
    25. OB (obstetrics)- CDIB holders (direct, any tribe living anywhere), Non-Eligible Pregnant with an Eligible child up to 6 wks. post-partum (pregnancy related, Talihina only), non-eligible spouse with insurance (Talihina only), Non-Eligible Health Care employee & Commission Corp. with insurance, Non-eligible Health care employee spouse and dependent children with insurance.
    26. OMT (osteopathic manipulation therapy)- Limited to CRC/Choctaw only (living in 10 ½ counties).
    27. Ophthalmology-Retinal- CDIB holders (direct, any tribe living anywhere)
    28. OR (operating room)- CDIB holders (direct, any tribe living anywhere), Non-Eligible Pregnant with an Eligible child up to 6 wks. post-partum (pregnancy related, Talihina only), non-eligible spouse with insurance (Talihina only), Non-Eligible Health Care employee & Commission Corp. with insurance, Non-eligible Health care employee spouse and dependent children with insurance.
    29. OT (occupational therapy)- CDIB holders (direct, any tribe living anywhere)
    30. Pediatric- CDIB holders (direct, any tribe living anywhere), Non-eligible Health care employee dependent children with insurance.
    31. Pharmacy- CDIB holders (direct, any tribe living anywhere), Non-Eligible Pregnant with an Eligible child up to 6 wks. post-partum (pregnancy related, Talihina only)
    32. Physical Therapy- CDIB holders (direct, any tribe living anywhere), Non-Eligible Pregnant with an Eligible child up to 6 wks. post-partum (pregnancy related, Talihina only), Breast program), non-eligible spouse with insurance (Talihina only), non-Eligible Health Care employee & Commission Corp. with insurance, Non-eligible Health care employee, spouses, and dependent children with insurance (Talihina only), only), Non- Eligible Health Care employee & Commission Corp. with insurance, Non-eligible Health care employee spouse and dependent children with insurance (Talihina only)..
    33. Podiatry- All ages- CDIB holders (direct, any tribe living anywhere)
    34. Recovery Center- (Male)- CDIB holders (direct, any tribe living anywhere)
    35. Respiratory Therapy- Direct (Any tribe living anywhere), Non-Eligible Pregnant with an Eligible child up to 6 wks. post-partum (pregnancy related, Talihina only), non-eligible spouse with insurance (Talihina only), Non-Eligible Health Care employee & Commission Corp. with insurance, Non-eligible Health care employee spouses and dependent children with insurance.
    36. Social Service- CDIB holders (direct, any tribe living anywhere), Non-Eligible Pregnant with an Eligible child up to 6 wks. post-partum (pregnancy related, Talihina only), non-eligible spouse with insurance (Talihina only), Non-Eligible Health Care employee & Commission Corp. with insurance, Non-eligible Health care employee, spouse, and dependent children with insurance.
    37. Specialty Transport- CDIB holders (direct, any tribe living anywhere)
    38. Speech Therapy- CDIB holders (direct, any tribe living anywhere)
    39. Surgery- CDIB holders (direct, any tribe living anywhere), Non-Eligible Pregnant with an Eligible child up to 6 wks. post-partum, 8 wks. For sterilization procedures. (pregnancy related, Talihina only), non-eligible spouse with insurance (Talihina only), Non-Eligible Health Care employee & Commission Corp. with insurance, Non-eligible Health care employee spouse and dependent children with insurance.
    40. Talihina Community Clinic- CDIB holders (direct, any tribe living anywhere), non-Eligible Pregnant with an Eligible child up to 6 wks. post-partum (pregnancy related, Talihina only), non-eligible spouse with insurance (Talihina only), Non- Eligible Health Care employee & Commission Corp. with insurance, Non-eligible Health care employee spouse and dependent children with insurance.
    41. Women’s Health- CDIB holders (direct, any tribe living anywhere), Non-Eligible Pregnant with an Eligible child up to 6 wks. post-partum, 8 wks. for sterilization procedure (pregnancy related, Talihina only), non-eligible spouse with insurance (Talihina only), Non-Eligible Health Care employee & Commission Corp. with insurance, Non-eligible Health care employee spouses and dependent children with insurance.

NOTE: Dependent Child refers to any child or legal ward of a CDIB holder and/or associate who is 18 years old or younger; or 19 to 26 years old and a beneficiary on their parent’s and/or legal guardian’s CNHSA sponsored UMR insurance plan.

Please note: The eligibility guidelines change frequently. As the guidelines are updated, Leadership, Executive Medical Staff and Governing Board will be presented with a cover sheet of amendments. Annually, the eligibility guidelines will be presented to these respective committees for approval.

• Social security card
• Photo identification card (driver's license)
• For children under 19 years of age, the following documents are required:
• Child's CDIB or a copy of either parent's CDIB
• State issued birth certificate or hospital birth record issued by an Indian Health Service or tribal facility