The big picture
The Indian Health Service (IHS) and tribal and urban Indian health programs are not insurance. They deliver health care directly, as part of the federal government's responsibility to American Indians and Alaska Natives. Washington is part of the IHS Portland Area, which serves Oregon, Washington and Idaho.
Enrolling in Medicare doesn't affect your ability to use your Indian health care provider. You keep both. Indian health clinics and hospitals can bill Medicare for the services they give to people with Medicare, and that money helps them hire staff, buy equipment and stretch Purchased/Referred Care dollars for other patients.
Washington's 29 federally recognized tribes
The Governor's Office of Indian Affairs lists these federally recognized tribes based in Washington. Many run their own health programs or clinics.
- Confederated Tribes and Bands of the Yakama Nation
- Confederated Tribes of the Chehalis Reservation
- Confederated Tribes of the Colville Reservation
- Cowlitz Indian Tribe
- Hoh Indian Tribe
- Jamestown S'Klallam Tribe
- Kalispel Tribe of Indians
- Lower Elwha Klallam Tribe
- Lummi Nation
- Makah Tribe
- Muckleshoot Indian Tribe
- Nisqually Indian Tribe
- Nooksack Indian Tribe
- Port Gamble S'Klallam Tribe
- Puyallup Tribe
- Quileute Tribe
- Quinault Indian Nation
- Samish Indian Nation
- Sauk-Suiattle Indian Tribe
- Shoalwater Bay Indian Tribe
- Skokomish Indian Tribe
- Snoqualmie Indian Tribe
- Spokane Tribe of Indians
- Squaxin Island Tribe
- Stillaguamish Tribe of Indians
- Suquamish Tribe
- Swinomish Indian Tribal Community
- Tulalip Tribes
- Upper Skagit Indian Tribe
The directory also lists the Confederated Tribes of the Umatilla Indian Reservation, the Confederated Tribes of Warm Springs and the Nez Perce Tribe, which are based in Oregon and Idaho.
Why tribal members often enroll in Medicare
- Wider provider access. With Medicare you can see doctors and hospitals outside the IHS and tribal system that accept Medicare, without waiting for Purchased/Referred Care approval.
- Purchased/Referred Care is limited. It isn't an entitlement, and IHS pays only after other coverage. Federal rules make IHS the payer of last resort and name Medicare and Medicaid as resources you must use first.
- Hospital coverage outside tribal facilities. Medicare pays at participating hospitals nationwide.
- Travel coverage. Original Medicare works anywhere in the United States.
- Money back to tribal health. When you use an Indian health clinic, the clinic can bill Medicare, which helps fund care for everyone.
Specific provisions and rights
You keep your Indian health care
CMS says you can still use your Indian health care provider after you enroll in Medicare, or see a non-Indian provider, and either way your provider bills Medicare. Washington's Health Care Authority says the same for Apple Health: your enrollment doesn't change your access to tribal and urban Indian clinics.
No out-of-pocket costs at tribal and urban Indian clinics
According to HCA, American Indians and Alaska Natives can always go to tribal and urban Indian clinics, whether they have Apple Health or not, and won't have to pay out-of-pocket costs. Care you get outside those clinics can carry Medicare deductibles and coinsurance unless Purchased/Referred Care, Apple Health or other coverage pays them.
Purchased/Referred Care
Purchased/Referred Care (PRC) pays for care away from an IHS or tribal facility when you meet its residency, notification and medical-priority rules and have used other resources first, such as Medicare, Medicaid, VA or private insurance. In an emergency, federal rules generally require that the PRC office be told within 72 hours after treatment starts or you are admitted. Ask your tribal health program about its PRC rules before you get outside care when you can.
Drug coverage and Part D
Federal Part D rules list drug coverage from an IHS, tribal or urban Indian health program as a type of coverage that can count as creditable, meaning about as good as standard Part D. Ask your health program whether its coverage is creditable before you decide not to join a Part D plan. If you do join one, CMS suggests choosing a plan that works with your Indian health care provider, so the clinic pharmacy can be paid for drugs your plan covers.
Enrollment periods
Tribal membership doesn't by itself give you a special Medicare enrollment period; Medicare's enrollment periods are the same for everyone. If you have Apple Health or Extra Help, you can make certain changes to your drug coverage once a calendar month. See when you can change your Medicare plan.
Apple Health and tribal members
If you have limited income, Apple Health (Washington Medicaid) or a Medicare Savings Program can help pay Medicare premiums and costs. As an American Indian or Alaska Native on Apple Health, HCA says you can choose to enroll in an Apple Health managed care plan or get Apple Health without a managed care plan, and tribal and urban Indian clinic staff can help you decide. You can also choose the clinic as your primary care provider either way.
Your tribe's health benefits coordinator or patient registration office can help you apply. See Apple Health in Washington and Medicare and Apple Health together.
Medicare Advantage and D-SNPs
If you have both Medicare and Apple Health, you may qualify for a Dual-Eligible Special Needs Plan (D-SNP). CMS advises contacting your Indian health care provider before you join any Medicare Advantage plan, to make sure the plan works with them. Original Medicare works with any Indian health provider that bills Medicare.
A licensed insurance agent with Benefits Life can help you compare plans from the companies they work with: (206) SENIORS (206-736-4677), TTY 711. Or see plans in your ZIP code.
Working with your tribal benefits coordinator
Each Washington tribe handles benefits differently. Tribal health programs usually have benefits coordinators or patient registration staff who help members sign up for Medicare and Apple Health and use them alongside tribal health care. Contact your tribe's health program for guidance specific to your community, or find a clinic through HCA's list of Washington tribes and tribal clinics.
Sources
- Governor's Office of Indian Affairs — Federally Recognized Tribes in Washington State
- Indian Health Service — Portland Area
- Indian Health Service — Purchased/Referred Care
- eCFR — 42 CFR 136.61, IHS as payor of last resort
- eCFR — 42 CFR 136.24, authorization and 72-hour emergency notification
- eCFR — 42 CFR 423.56(b)(9), I/T/U coverage as a type of creditable drug coverage
- CMS — American Indian / Alaska Native: Important facts about Medicare
- Washington Health Care Authority — American Indians and Alaska Natives (AI/AN)
- Medicare.gov — Special Enrollment Periods
Frequently asked questions
Do tribal members lose IHS benefits if they enroll in Medicare?
No. You can keep using your Indian health care provider after you enroll in Medicare, and your provider bills Medicare for the care you get. You can also see non-Indian providers who accept Medicare.
Should tribal members enroll in Medicare?
It is your choice, but Medicare can add a lot. It covers care at hospitals and doctors outside the tribal system anywhere in the U.S., and Purchased/Referred Care expects you to use Medicare and other coverage first. When you use an Indian health clinic, the clinic can bill Medicare, which brings money back to the clinic.
Do tribal members get special Medicare enrollment periods?
Not because of tribal membership alone; Medicare's enrollment periods are the same for everyone. If you have Apple Health (Medicaid) or Extra Help, you can make certain changes to your drug coverage once a calendar month. Other Special Enrollment Periods, such as for moving or losing other coverage, apply as they do for anyone.
Do I pay out of pocket at a tribal or urban Indian clinic?
Washington's Health Care Authority says American Indians and Alaska Natives can always go to tribal and urban Indian clinics, whether or not they have Apple Health, without paying out-of-pocket costs. Care outside those clinics can have Medicare deductibles and coinsurance unless Purchased/Referred Care, Apple Health or other coverage pays them.
How many federally recognized tribes are in Washington?
The Governor's Office of Indian Affairs directory lists 29 federally recognized tribes based in Washington. The directory also lists three tribes based in Oregon and Idaho.
Medicare in your Washington county
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