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About Spilyay tymoo. (Warm Springs, Or.) 1976-current | View Entire Issue (April 25, 1996)
SpilyayTymoo Warm Springs, Oregon April 25, 1996 7 Managed Care Program issues patient handbook- The Managed Care Program 1996 Patient Handbooks were mailed to all enrolled tribal member hcads-of-households during the week of April 15. Any Native American who feels they arc eligible for the services of the Managed Care Program and has not received a 1996 Patient Handbook may contact the Managed Care Program in the Health and Wellness Center or at (541)553-4948 for a copy. Following is the text of the 1996 Patient Hand book. 1) Overview of the Managed Care Program The Managed Care Program is managed by the Confederated Tribes of Warm Springs. Prior to October 1993, it was operated by the Indian Health Service and was referred to as Contract Health Services. The goal of the Managed Care Program is to make sure that when you sec a provider of medial services outside of the Health and Wellness Center, such as a doctor or a hospital, that you care is of good quality and at a reasonable cost. This program has a limited amount of funding, so it is important that it is used efficiently. In fact, there is no guarantee that these funds are always available. The funds are used mainly for medical services not available at the Health and Wellness Center or to supplement alternate resources (private or third party insurance) after they have been utilized. The use of alternate resources enables the Managed Care Program to provide more and better care for Native Americans. Payment to providers of health care outside the Health and Wellness Center can only be authorized by the Managed Care Program. Payments arc authorized based on medical priority guidelines and eligibility criteria. These guidelines and criteria are based on those found in the Indian Health Manual, Part 2, Chapter 3. Depending on funding available, payment for referrals may be restricted to only the highest priority. For example, during the US Government shutdown in late 1995 and early 1996, Medical Referrals were restricted to Priority I Level, defined as "EmergentAcutely Urgent Care Services". During these times, patients andor their alternate resources are responsible for paying the provider for Priority Level services not authorized by the Managed Care Program. 2) Who is eligible for Managed Care Program benefits? Native American are potentially eligible for two types of health care services through the Health and Wellness Center. These are "Direct Care" services and "Managed Care Program" services. These two types of services have their own set ot eligibility rules and guidelines. Some Native American are eligible only for Direct Care services and some are eligible for both Direct Care services and Managed Care Program services. The following explains the difference between the two. Direct Care Services Direct Care services refers to only those health services provided at the Health and Wellness Center. You are eligible for Direct Care services if: III You can provide proof of affiliation with a "federally recognized tribe" (through tribal membership or other recognition) OR You are an Indian of Canadian or Mexican origin recognized by any Indian Tribe or Group as a member of an Indian community served by the ndian Health program. Presently only the following groups are included: M. Regis Mohawk, Blackfeet and Tohono O'odham. OK You are a non-Indian woman pregnant by an eligible Indian male. You are eligible while you are pregnant (and usually six weeks after delivery). If you are not married to the father of your child, he must verify in writing that he is the father of your child. OR You are a non-Indian member of an eligible Indian's household and the medical officer-in-charge determines that you should receive helath care services to control a public health hazard or an acute infectious disease. Managed Care Program Managed Care Program services are services provided off the reservation by doctors and hospitals. These services are used in situations where: The Health and Wellness Center is unable to provide the required emergency care andor specialty care. A patient s alternate resource (insurance) is not enough to cover the total cost of required care. s Such services fall within medical priorities. Almost all Native Americans are eligible for Direct Care services. However, to be eligible for Managed Care Program services, you must be eligible for Direct Care serves and live on the Warm Springs Indian Reser vation. If you are a Native American living off the reservation, you must meet certain criteria to be eligible for Managed Care Program services, including: You must be a member of the Confederated Tribes of Warm Springs, including Wasco, Warm Springs, and Paiutc and live in a county which contains or is touched by the Warm Springs Indian Reservation. This area is called your Contract Health Services Delivery Area or CHSDA. The coun ties of the Warm Springs Indian Reservation CHSDA are: Jefferson, Linn, Wasco, Clackamas and Marion. In other words, if you arc a member of the Confederated Tribes of Warm Springs and you live off the reservation, you must reside within the CHSDA. OR If you are a member of another Indian Tribe, you must establish close social andor economic ties (by marriage or tribal resolution) to the Confed erated Tribes of Warm Springs and reside in the CHSDA OR You may be away from your CHSDA only because you arc a full-time student, foster child, or transient (migratoryseasonal worker) or, if none of the above apply, you must have left you CI ISDA less than 1 80 days before the datc(s) of medical service. Other persons eligible: A non-Indian woman pregnant by an eligible Indian male and residing within a CHSDA. a . .. t i ? t . r i t i t i p t . . . . " a non-moian mcmocr oi an ciigmie lniuan s nouscnoid who resides within a CHSDA, if the medical Officcr-In-Chargc determines that services are necessary to control a public health hazard. 3) Alternate Resources Alternate resources arc other sources of health care or helath care payment that may be available and accessible to you. Some examples of alternate resources: Medicare (part A andor part B); Medicaid or AS or Oregon Health Plan; Veterans Benefits (Champus); Private Insurance (such a Confederated Tribes Insurance, PH&L, BCBS, Mailhandlers); Children's Rehabilitative Service; Auto Insurance (liability); Workers Compensation; State Voca tional Rehabilitation; State Maternal and Child Health Programs. You are required by federal regulation (CI'R 42; Ch. 1 ; Subpt. 36.23, F) to apply for an alternate resource if there is reason to believe that you may be eligible for alternate resources. In many cases the alternate resource is Medicaid, often known as the Oregon Health Plan. Once on Medicaid, you are required to fill out Renewal Forms at intervals determined by Medicaid. If you are eligible for an alternate resource, please fill out any paperwork you may receive from the Patient Care Advocate in the Managed Care Program office and return it to the Patient Care Advocate in a timely manner. The Patient Care Advocate if very important in assisting you to apply for alternate resources. If you refuse to apply for, or renew, or refuse to use that alternate resource, this program will not be responsible for payment of you medical bills. You will be responsible for you medical bills! You do not have to use your own financial resources or sell valuable or property to qualify for alternate resources. Some people do not qualify for alternate resources like Medicaid simply because they make too much money. Using an alternate resource does not disqualify you from Direct Care service at the Health and Wellness Center. The Indian Health Service is required to bill you alternate resource. You will need to provide proof of you Indian descent in order to be exempted from paying the monthly premium for the Oregon Health Plan. It is to your advantage to sign up for alternate resources. The Managed Care Program has a limited amount of funds to pay for services by medical providers off the reservation. Using alternate resources can pay for health care serve that the Health and Wellness Center is unable to provide, which in turn will make the Managed Care Program funds go further to pay for other Native Americans who do not qualify for alternate resources. 4) Patient's Rights and Responsibilities As a patient, it is your responsibility to register with the Warm Springs Health and Wellness Center. Through registration, your eligibility for Direct Care services at the Center and Managed Care Program funds is determined. Potential and established alternate resources are also identified. You will need to provide proof of your Indian descent, and you may be asked to provide proof of residency. It is also your responsibility to keep information such as your address and phone number current at the Center. Please familiaric yourself with, and abide by, the regulations outlined in this Patient Handbook in order for your health care provided off the reservation to be paid for by the Managed Care Program. 5) Referral Process and Prior Approval You or someone acting for you must get prior approval for any n on- cmergency treatment you receive that will require Managed Care Program funds for payment. This is usually done when you are seen by a medical provider at the Health and Wellness Center, and the medical provider (ie physician, optometrist, dentist, etc.) refers you to a provider off the reserva tion, such as a specialist. I he medical provider that you saw at the Center will give you a referral form to be brought down to the Managed Care Program to be reviewed and authorized. If you do not get the referral form authorized, payment for your medical services may be denied, and you will be respon sible for your medical bills. If you are traveling away from the Warm Springs Indian Reservation and you receive emergency treatment from a non-Indian Health Service facility, you must notify this program within 72 hours. Our direct phone number is (800)880-2499 and lax machine number is (541553-2476. It is the patient's ultimate responsibility to get prior approval for non emergent service or to notify us w ithin 72 hours of emergency services (emergency room(). Otherwise payment for your medical services may be denied, and you will be responsible for your medical bills. Example of typical referral process: . Patient is referred by IHS Ml) to outside provider. 2. Patient take referral to Managed Care Program in Health and Wellness Center. 3. Health systems Specialist in MCP reviews referral for eligibility and alternate resources. 4. Case Manager in MCP approves referral. 5. Health Systems Specialist in MCP assigns PO and faxesmails PO to outside provider. 6. Patient keeps appointment with outside provider. Notify MCP if unable to keep appointment. 7. Outside provider bills alternate resources. 8. Outside provider sends "explanation of benefits" from alternate resources to managed care program as payor of last resort. 9. Managed Care Program pays bill. 6) Denial and Appeal Process If you are denied payment for medical bills from the Managed Care Program, a letter from the Program will explain the reason. There are several common reasons for which denials are issued: 1 . Ineligibility: You did not supply appropriate proof of Indian descent or you live oil the reservation or outside this CHSDA. 2. You did not obtain prior approval for non-emergency service. 3. You did not obtain approval within 72 hours for an emergency service. 4. You did not apply for or renew alternate resources andor did not use such resources it available. 5. You have a diagnosed medical problem that is not within established medical priorities. 6. You overuseabuse the emergency room with non-emergencies. When a denial of payment is issued, you have the right to appeal in writing within 30 days to the Administrator of the Managed Care Program located here in the Warm Springs Health and Wellness Center. Please include additional information which may not have been presented when your claim was filed. The Administrator will respond in writing, either upholding or overruling the decision. If the original denial is upheld by the Administrator, the final line of appeal is to an Appeals Board comprised of the following five individuals: 1. Director C&B MCP; 2. Human Services General Manager; 3. IHS Service Unite Director, 4. IHS Clinical Director and 5. Warm Springs Community Member-At-Large (Appointed by above four individuals). This final appeal should be submitted in writing within 30 days of the Administrator's decision to: Director C&B MCP, Confederated Tribes of Warm Springs, PO Box C, Warm Springs, OR 9776 1 . If you have any questions about the patient handbook, please stop by and see the Managed Care Program at the Warm Springs Health and Wellness Center. The office is open Monday through Friday form 8 a.m. to 5 p.m. The phone number is (541) 553-4948 pr 1-800-880-2499. Disclaimer: The Managed Care Program reserves the right to amend the contents of the 1996 Patient Handbook as the occasion arises. Please leave tribal sovereignty, spirituality and religious beliefs alone To the Editor, The Enola Hill controversy grinds on endlessly. Where is the truth among the legalistic half-truths and mixed agendas of this and other land use disputes? In the end, tribal spiri tuality, sovereignty and the ability to preserve traditional sites may be the only true and lasting victims. Tradi tional leaders, the Culture and Heritage Committee and Tribal Council met with the Forest Service staff to talk of their interests around Mt. Hood. A position paper on Enola Hill was adopted in 1993. Our spiritual songs of worship give timeless testimony to the belief that we are the people of the land. We were placed here with all the creations to care for one another. From the time of beginning, our lives were guided by respecting the bal ance of natural, spiritual and human laws. We worship and give thanks for the Creator's gifts through age less and sacred ceremonies that have been passed on from our elders un changed over the many centuries. Spirituality and sacredness was placed in our hearts and souls and therefore very personal and private from person to person. The traditions, beliefs and prac tices that have sustained our people for as long as 40,000 years are being threatened. Our spiritual beliefs and convictions were our strength to en dure the changes that would face our people. Our traditional ceremonies are celebrations of life and impor tant life events that hold us together as families and clans and gave us purpose for hundreds of generations. Over time and with the coming of new people, we were divided from one another as a people and given new names. The law of the new people said this was needed to sepa rate us from our lands to bring progress, success and prosperity for others. Treaties were to be the su preme law of the land to protect and respect our sovereignty and ways of life for all times. Promises were made to our people to secure more and more trade-offs for the sake of progress. The value of all those promises can be witnessed in the collapse of the salmon that is at the heart of our heritage. Our treaty is our contract with America representing two sovereigns acting in good faith. Tribal treaties were important to bring about the U.SVCanada Treaty as recognition of three distinct sets of sovereigns to decide salmon management issues that continue to benefit both Indian and non-Indian interests. Tribal treaties continue to serve broader interests across our landscape, as such, they are to be considered only within a government-to-government context. Our spirituality, our religious be liefs and traditional practices are precious gifts. Sovereignty, treaty rights and now, the sacred sanctity of spiritual and religious beliefs, have become the playground of environ mentalists, lawyers, government regulators, college classrooms and among business interests to under mine what our people invested their lifetimes to learn and pass on. Politics and economics were used to manipulate human laws that have brought us the natural disasters that we now have the inherited obliga tion to repair. Politics and econom- Message important to all To the Editor, Hello you all once more who take the time to read the Spilyay. I'm really sorry about Alvin "Bimbo" Charley. I can only write with my other hand, but to take the time to write letters, stories or poems or anything that has to do with writing, it sure can help to deal with and relieve grief, stress or anything that may be upset ting you. Alcohol does not solve problems, it only makes problems worse. We should all think of the many chances the Lord has given to us all. I'd love for you all to just "keep on keeping on" in for lives, okay? You know, like the "Little Engine that Could"? Remember, Christ Jesus is our savior and He lives today, tomorrow in our hearts. Amen. Thank you. Evette Patt Happy ?? Birthday Sheilah from your friend, Selena ics also won't allow us to agree on the natural laws and science that need to be parts of the remedy. Sadly, the spiritual teachings and practices that we preserved have been enlisted into the eco-gladiator's arsenal and is now the weapon of choice as their last resort. Our spirituality is sacred, but now it is the banner for civil disobedi ence. Tribal rights are topics being dissected in college classes to exam ine where and how they are appro priate, pitting urban perspectives against reservation perspectives. The Enola Hill forces most recent tactic is directed at promoting individual rights by undermining the role and authority of tribal governments. They are doing with friendly fire the same type of damage as Senator Stevens legislative proposal did to abrogate treaties. History can repeat itself with a little friendly persuasion by letting the Indians do each other in, one more time. As with the salmon, maybe we need a special program or agency to protect our spiritual beliefs from the emergence of these new saviors. The truth of what is sacred is not in the movies, novels, new-age prophets or the latest workshops inspiration. The trust is in the hearts, minds and souls of people that continue to live their lives rooted in an ageless world where customs, unwritten laws and time honored tradition are still understood and respected. We are reminded al most daily that natural resources management decision must preserve options for unborn generations and trie sacred trust that must be carried out on behalf of our people. On the Warm Springs Reserva- Thanks George! To the editor, Please print this letter for us. Thank you. Dear George (The Schwans Man); We would like to express our thanks and appreciation for the gen erous donation of the ice cream that you gave us for our fund raiser on April 11, 1996. The people enjoyed the delicious ice cream w ith their meal. Again, we would like to say thanks for your generosity. Sincerely, Bobbie Horn, Tonya Hall, Verleen & Annie Kalama tion the forest is our livelihood and ecosystem management is the law. We reduced our annual harvest in half as a result and shifted our em phasis to forest health in response to insect and disease problems because the forest represents more than a source of logs. Interestingly, diseased trees were helicopter-logged out of a legally designated ceremonial area under the guidance of our elders and religious leaders to save the natural and spiritual significance of the area. Our cultural resources and sacred sites can be abused or exploited by well-intentioned people and their application of the laws. Tribes would be forced to respond by telling the world what and where they are so the courts can decide the validity of our spirituality and heritage. Do the Mor mons have to defend the site Joseph Smith received his spiritual guidance? Our spiritual beliefs are subject to such scrutiny that efforts to protect important cultural values do repre sent remedies that are worse than the original threat by itself. In closing, the Enola Hill forces really ought to try settling their dif ferences on the merits of their own logic and arguments. Ourpeople, our beliefs and the resources that sustain our way of life are not bargaining chips. For the love and respect of all that is truly sacred, please leave or spirituality and religious beliefs alone. Respectfully submitted, Charles R. Calica Childrens' tooth decay totally preventable ? i y j. ii p ii uri t .v, .v . a w i minim, n? Nursing-Bottle Caries ' Nursing-Bottle Caries Nursing-Bottle Caries Nursing-Bottle Caries by Ken Wiedenfeld Pediatric Dental Specialist Nursing-Bottle Caries is a con dition which causes the upper front baby teeth to rot away due to cavi ties. This condition is caused by putting a child to bed with a bottle that contains any sugared liquid. It is also caused by letting a child fall asleep while drinking from a bottle or from prolonged frequent breast feeding where the child sleeps on the breast between feedings. Nursing-Bottle Caries is a significant problem in the Warm Springs com munity. It affects from 25-pcrccnt to 40-pcrccnt of all the children seen at the dental clinic. Most impor tantly, this condition is totally pre- ntable. Nursing-Bottle Caries usually altccts the upper tront hahy teeth, and decay begins soon after the teeth ciupt. The lower front teeth arc pro tected from decay by the position of (lie toneuc which covers the lower affects up to 40-percent of all Warm Springs children, is caused by putting a child to bed with a bottle, can lead to pain of loss of teeth in children, is preventable. teeth during nursing. The sugared liquid which includes milk, juice or any product with sweetener in it, pools around the upper front teeth as the child goes to sleep. This liquid then feeds the plaque which is on the teeth causing rapid and destructive decay. As the child sleeps, their sa liva production naturally decreases. Since saliva bathes and protects the teeth from cavities, this protection is lost. When left untreated, this decay often leads to pain, abscess, infec tion of the back teeth and possible even damage to the permanent teeth which are forming. This problem is preventable sim ply by not putting a child to bed w ith a bottle. Most pediatricians and pe diatric dentists recommend discon tinuing the bottle by twele months of age. Therefore, children should be transferred to a cup and com pletely off the bottle by one year of age. For children who are used to sleeping with a bottle. discontinuation can be very unnerv ing for the parents. A tapering off of the sugared liquid to plain water over a one-week period is some times helpful. This is accomplished by gradually decreasing the con centration of the drink until only water is in the bottle at the end of the week. The only safe liquid that can be allowed in a bottle is water. Cavities in children are totally preventable. Children are not old enough to correctly brush and floss their own teeth until around age ten. Brushing with an approved fluoride toothpaste after breakfast and be fore bedtime is essential. Remember to use only a small among of tooth paste (pea size) on a quality brush since children often swallow the paste. Also, cut down on the fre quency of snacks or juices. Com bining these habits with regular dental exams will assure that your child grows up with a healthy and beautiful smile. A