Eligibility for Services

ELIGIBILITY GUIDELINES


Revised April 2016 with updates September 2019. 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. 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 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 is required and social security card 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 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 child, legal ward or orphan under the age of 19 years of an eligible parent is eligible for services except Diabetes Wellness Center. 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 (i.e. divorce papers, tax forms, adoption papers, custody agreement, court orders, minor child affidavit) Note: school records can show address where child lives
    5. 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 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 can be seen at Talihina Hospital 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
    6. Non-eligible spouses can be seen at the Choctaw Nation Health Care Center in Talihina ONLY.

     

  5. NON-ELIGIBLE SPOUSES PREGNANT WITH AN ELIGIBLE CHILD
    Non-eligible spouses pregnant with an eligible child: ALL services related to pregnancy. (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 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. Individuals must submit picture ID with signature. This includes all types of paternity such as Denial of Paternity.
    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 provider. Patient will be seen up to six weeks post-partum for medical care related to pregnancy. If the condition continues after the pregnancy, care can be established with an outside provider.
    NOTE:
    If a step-child 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 step-child and/or non-eligible dependent has delivered then that individual becomes emancipated. (Emancipated is considered as being an adult.)
    The child born at Choctaw Nation Health Care Center to the step-child 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 potential loss of life 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 to treat. (An attempt will be made to stabilize the patient prior to transfer to another facility.) In questionable cases, the administrator on call will make the determination concerning admission. These individuals will be required to pay for the Episode of Care.
    A supply of medications will not be dispensed. If the provider determines 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 member for 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 member 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 in house must meet the following guidelines:
    1. ORTHOPEDIC SURGEON – Choctaw CDIB, must live in 10 ½ counties, can be Mississippi Choctaw if issued out of Talihina BIA.
    2. ORTHO MID-LEVEL – Any CDIB card holder within 10 ½ counties, EXCEPT acute fracture seen in ER which is open to any CDIB card holder.
    3. PEDIATRIC DENTAL – Choctaw CDIB, must live in 10 ½ counties, children must be 8 years old and under.
    4. CARDIOLOGY – CHS/Direct any tribe, 18 years old and up. Lives in 10 ½ counties.
    5. SLEEP LAB – Choctaw CDIB, must live in 10 ½ counties, age 15 and up is for non-diabetic and age 10-15 must be diabetic.
    6. 6. CATARACT SERVICES – Choctaw CDIB, must live in 10 ½ counties.
      Exception: IN HOUSE cataract surgery only, NOT CRC
      • Must be Choctaw
      • CDIB must have been issued in Oklahoma. This includes Mississippi Band, as long as issued in OK.
      • They Do Not have to live in the counties.
      • May or May not have 3rd party.
      • May also qualify for cataract surgery regardless of Tribe, if being treated by Dr. Fransen (retina Clinic), and he requires extraction to continue his treatment/care.
    7. RETINA SERVICES – Any CDIB card holder. (Direct)
    8. EMG’S – Performed by Physical Therapy, Choctaw CDIB, must live in 10 ½ counties.
    9. BIOLOGIC MEDICATIONS – Humira and Remicade, to be eligible for Biologic Medications, patients must have Choctaw CDIB and prove residency in the 10 ½ county service area for at least three (3) years.
    10. NEUROLOGY – Choctaw CDIB, must live in 10 ½ counties, will see patients age 2 and over. (For migraines, must have had two (2) failed therapies. Will see for any other serious neurological issue.)
    11. OMT (OSTEOPATHIC MANIPULATION THERAPY) – Any CDIB card holder. (Direct)
    12. ENT – CHS (Any CDIB , must live in 10 ½ counties)
    13. PULMONARY – CHS/Direct any tribe, ages 15 and up. Lives in 10 ½ counties.
    14. EEG – Ordered by Neurologist, Choctaw CDIB, must live in 10 ½ counties, age 2 and up.
    15. DERMATOLOGY – Any patient with consult and non-eligible spouses with third party payer.
    16. MRI – Any CDIB card holder. (Direct)
    17. RHEUMATOLOGY – Choctaw CDIB, must live in 10 ½ counties, no patients under age 18.
    18. GASTROINTESTINAL – CHS/Direct any tribe. Lives in 10 ½ Counties.
    19. DWC- Any CDIB card holder. (Direct)
    20. Audiology- Any CDIB for hearing test/exam. Choctaw only for hearing aids and batteries. ( EDH only pays for Choctaw)
    21. Podiatry- Any CDIB card holder. (Direct)
    22. Endocrinology- Any CDIB card holder. (Direct) Includes Pediatric and FNA
    23. Diabetic Educator- Any CDIB card holder. (Direct)
    24. Dietician- Any CDIB card holder. (Direct)

 

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.