This program serves enrolled Jamestown Tribal Citizens living outside of Clallam or East Jefferson Counties. The policies and procedures for this program are as follows:

I. Eligibility and Service Area

The Tribe will certify Tribal Citizens as eligible for Out-of-Area Health Benefits who:

  1. Have registered with the Tribal Health office; and
  2. Hold primary residence outside of Clallam and East Jefferson Counties in Washington State.

II. Payments and/or Reimbursements

A. The Tribe will establish a maximum amount of dollars per person, per year, payable for Health Benefits. The Tribe will make payment to the provider or reimburse the Tribal Citizens for services listed under Health Benefits up to the maximum amount established. Required Paperwork can be mailed to 808 N. 5th Ave., Sequim, WA 98382. Attention: OOA Health Benefits.
Note: Necessary documentation must be submitted to the Out of Area Health Benefits Program prior to January 31st of the following year in order to be considered for reimbursement.
B. The Tribe will make every effort to send payments or reimbursements within two weeks of the date appropriate documentation is received.
C. All payments and/or reimbursements are subject to the Availability of Funds.

III. Schedule of Health Benefits

Benefit Required Paperwork
Insurance Premium Invoice and copy of check for paymentReceipt from insurance company

Paycheck stub showing deductible for medical benefit

Automatic withdrawal or electronic Debit notice from bank

Co-payment, Deductible or Co-insurance Copy of invoice from provider and Explanation of Benefits from insurance company showing date of service and charges
Medical Services not covered by insurance Invoice from provider or receipt for payment that shows date of service, type of service and charges
Vision, Exam or Hardware Invoice from provider or receipt for payment that shows date of service, type of service and charges
Hearing, Exam or Aide Invoice from provider or receipt for payment that shows date of service, type of service and charges
Prescription Drug Cash register receipt and a pharmacy receipt showing date of service and charges
Dental Services Invoice from provider or receipt for payment that shows date of service, type of service and charges

IV. Use of Jamestown Family Health Clinic and Jamestown Family Dental Clinic

A. Jamestown Family Health Clinic

Tribal Citizens who choose to use the Jamestown Family Health Clinic will receive a 15% discount from normal billed charges.

B. Jamestown Family Dental Clinic

  1. Tribal Citizens who choose to use the Jamestown Family Dental Clinic will receive a 15% discount from normal billed charges.
  2. Tribal Citizens may choose to use up to three years of the maximum amount of dollars per person, per year as established by the Tribal Council to complete services that are detailed in a treatment plan that has been developed by the dentist and approved by the Health Administrator. Use of more than one year’s funding is done by borrowing from future years. The annual amount for the future years will be reduced by the amount borrowed to complete the treatment plan.

V. Exclusions

No payment will be made by the Tribe for:

A. Health services for people who are not eligible for Out-of-Area Health Benefits;

B. Health services that are cosmetic or elective;

C. Orthodontic services;

D. The cost for health services that could have been covered or paid for or are covered or paid for by Private Insurance, Medicare, Medicaid, an employer of any other party;

E. The costs for health benefits not listed in these Policies and Procedures;

F. Transportation costs, travel time, completion of a claim form, broken appointments or professional advice given on the phone.

VI. Appeals

The Tribal Council will appoint a minimum of three people to serve on a Tribal Appeal Committee. At minimum, one member will be selected from the Tribal Health Committee and one from the Health Department staff. The role of Committee members will be to review health benefits appeals made by Tribal Citizens.

Tribal Citizens who wish to appeal decisions made by the Out-of-Area Health Benefits Program must notify the Deputy Director, in writing, of the decision they wish to appeal. The following steps will be taken:

A. The Deputy Director will contact the individual to confirm receipt of the appeal and provide them with a timeline for the process of the appeal.

B. The Deputy Director will bring the appeal and supporting information to the Tribal Appeal Committee who will review the appeal and the Program Policies & Procedures.

C. The Tribal Appeal Committee will present the appeal, supporting information and their recommendation, either for payment or non-payment, to the Tribal Council.

D. The Council will inform the Tribal Citizen of the Council meeting date when the appeal will be discussed. The Tribal Citizen will be invited to attend the meeting.

E. The Tribal Council will make a final decision regarding payment or non-payment.

VII. Compliance

Tribal Citizens must provide the Tribe with the information and documentation necessary to enroll in the Out-of-Area Health Benefits Program. If the appropriate information in not provided, the Tribal Citizen will not be eligible for benefits.

In order for the Tribe to make payments and/or reimbursements under this program, the Tribal Citizen must provide the required paperwork shown in the Schedule of Health Benefits. If the required paperwork is not submitted, no payment will be made by the Tribe for Out-of-Area Health Benefits.

VIII. Definitions

A. Availability of Funds: Determined by the Tribal Council, based on an annual amount per person approved by the Tribal Council as a budget item for Out-of-Area Health Benefits.

B. Tribal Citizen: A person who has completed the Tribal enrollment process, been approved by the Tribal Council and received an enrollment number.

C. Tribe: the Jamestown S’Klallam Tribal Health Department, and the Jamestown S’Klallam Tribal Council and the Jamestown S’Klallam Tribal Enrollment Committee.

D. Tribal Appeal Committee: the Committee designated by the Tribe to hear appeals for health benefits.

E. Year: the Calendar year: January 1 – December 31

Please contact the Health Benefits Assistants; Billie Adams at (360) 582-4858 or Morgan Allen at (360) 582-4872. The fax number is (360) 582-4885.