AMERICAN INDIANS AND ALASKA NATIVES: Care Options, Financial Considerations, and Support

Overview

The Indian Health Service (IHS) is the health care system for federally recognized American Indian and Alaska Natives in the United States.

Comprehensive primary health care and disease prevention services are provided through a network of hospitals, clinics, and health stations on or near IHS Facilities.

For primary health and preventative care through the IHS you will typically go to the closest available facility, which will be one of these 3 types:

Federal Facility:

Federal facilities directly run by IHS.

Tribal Health Clinic /
93-638 Clinic:

Health care facilities managed by tribes / tribal organizations with funding from IHS.

Urban Indian Health Program Facility:

Private, non-profit, corporations that provide health and social services in their area.

Getting Started to Use IHS

If you are new to the area and have not lived on or near an IHS Facility

Visit the local IHS facility or Tribal Health Clinic facility and ask for the patient registration office. This needs to be done in person.

If you have your CDIB card

The registration staff will need to see your Certificate of Degree of Indian Blood (CDIB) to:

Enroll in the tribe.

Determine your eligibility as a federally recognized tribal member.

If you are not a member of the local tribe, you need to enroll in their “open door” services for federally recognized tribal members.

Example Certificate of Degree of Indian Blood (CDIB)

If you don’t have your CDIB card

Follow this link for more information on getting your CDIB card, or ask for help from a trusted source

Learn more about getting a CIBD Card

Next, schedule your appointments.

If you are living outside of your reservation, the services may look different than what’s provided to you on your reservation.

If there is no IHS or Tribal Health Clinic nearby OR if you are enrolled in a state-recognized (but not a federally recognized tribe), you need to use services other than IHS.

Contact your IHS Facility or Clinic office to learn if they can help with transportation to and from your home and the facility.

Care Options

1. Direct Care:

For Primary Health and Preventative Care

For primary health and preventative care through the IHS you will typically go to the closest available facility, which will be one of these 3 types:

Federal Facility

Tribal-owned & operated Health Clinic

Urban Indian Health Program Facility

For help finding a clinic

2. Purchased / Referred Care (PRC):

Private Healthcare for Specialist Care not available from Direct Care in your area

The PRC Program pays private healthcare providers for care that is not available from your local IHS or Tribal clinic.
These are a few common examples of when you are likely to need PRC: Hospitalization, medical emergencies or conditions that are a threat to life, diagnostic tests that use MRI, CT equipment / machines, specialists (e.g., cardiologist, orthopedists, urologist, gastroenterologist, internist, oncologist), visuals such as colonoscopies and endoscopies, pre-natal care, and dental root canals.
The PRC program only receives a limited amount of money from the federal government. For this reason, PRC may not have enough money to pay for all the medical care Tribal members need.

Steps to Take:

Get a referral from your Tribal Health facility provider. Without a referral, the cost may not be covered.
Ask your provider or contact the Direct Care Provider Office to learn your status on the waiting list.

“Category” [A (preventive and rehabilitative), B (medical, dental, vision and surgical services)  or C (reproductive and maternal/child health services) or D (behavioral health services)]
“Priority Level” [1. Core (e.g., necessary to protect life, limb or vision within next 30 days), 2 Intermediate or necessary services and 3 Elective, (justifiable services)].
NOTE: PRC does not include cosmetic, experimental, or controversial procedures.

Seek care outside the system if/when you are Category C and/or lower priority when PRC has already run out of money (typically after June).

3. Seek Care Outside the IHS System

Seek Care Outside the IHS System

When PRC is Not an Option (PRC is out of money or your case is not a top priority)

Consider:

Find a Federally Qualified Health Center with the Locator tool: https://findahealthcenter.hrsa.gov/
Find out if you have a medical benefits department or specialist in your Indian Health facility who can help you look for additional coverage options.
Federally Qualified Health Centers’ mission is to provide comprehensive primary care regardless of ability to pay.
Enrolling in health insurance such as Medicaid, Medicare, Children’s Health Insurance Program (CHIP), or a State Marketplace Plan.

Apply on:https://www.healthcare.gov/
OR find local help to assist with your application:https://www.healthcare.gov/find-local-help/
Seeking care outside IHS or tribal health clinics could leave you responsible for additional costs.

Refer to your Tribal Health facility for explanations of costs.

Consider:

Find a Federally Qualified Health Center with the Locator tool: https://findahealthcenter.hrsa.gov/
Find out if you have a medical benefits department or specialist in your Indian Health facility who can help you look for additional coverage options.
Federally Qualified Health Centers’ mission is to provide comprehensive primary care regardless of ability to pay.
Enrolling in health insurance such as Medicaid, Medicare, Children’s Health Insurance Program (CHIP), or a State Marketplace Plan.

Apply on:https://www.healthcare.gov/
OR find local help to assist with your application: https://www.healthcare.gov/find-local-help/
Seeking care outside IHS or tribal health clinics could leave you responsible for additional costs.
Refer to your Tribal Health facility for explanations of costs.

Common Situations and Questions

How do I handle appointments, medications and lab results?

Ask for help from an IHS receptionist or a Patient Navigator to coordinate appointments.
Know that each IHS facility and tribal health clinic has an on-site pharmacy to dispense medications:

Some medications need to be ordered by the pharmacy. Most tribes allow community health workers to deliver non-narcotic medications to your home, saving you from driving to the clinic when not feeling well.
Nurse Navigators can help you understand lab results and other medical information.
Ask for a paper prescription and bring this to your IHS doctor to see if it is available.

How can I advocate for myself?

Learn advocacy skills with the help of a Patient Navigator or Community Health Representative.
Educate yourself on your own health and health issues, come prepared with a list of your symptoms and written family health history.
Organize concerns into questions you can ask your healthcare team.
Ask if your facility has a patient portal. This is more common in cancer centers.

Who are “licensed healthcare providers” and what does that mean for me as a patient?

Licensed healthcare providers refer to professionals who have completed the necessary education, training, and state-mandated exams to legally practice medicine and provide health services.
This means the care that I need as a patient, meets strict quality and safety standards while providing the documentation needed for my tribal benefits.
Examples are board-certified physicians, nurse practitioners, physician assistants, dentists, and certified specialists (e.g., general surgeons, oncologists).
It also includes licensed support staff like registered nurses, pharmacists, and behavioral health consultants.

What can I do if I need help?

Seek Patient Navigation services, which are becoming more readily available for many types of health issues through community health workers and/or cancer centers.

Start by asking for a Patient Navigator when you are getting medical care (this can be a Native Patient Navigator, Social Work Navigator, Nurse Navigator, or Cultural Navigator).
The role of the Patient Navigator is to walk along side you throughout your journey when working with an illness or condition.
The Patient Navigator has multiple roles including coordinating appointments, explaining medical information in language easier-to-understand, answering your questions or helping you get answers from members of the healthcare team, and finding resources to help overcome issues you and your family may be experiencing.

Ask for interpretive services in your native language as they may be available to you. Ask the Doctor, Patient Navigator, or Community Health Worker for more information.

Don’t accept translation services from non-medical staff.
You should rely on health care professionals, including your medical team Physicians Assistant, Registered Nurse, and Medical Assistant to help you translate.

Alaska Native Patient Navigator Specifics:

Community Health Aids and Practitioners are available throughout Alaska Native Tribal Health Consortium clinical programs.

Community Health Aids and Practitioners receive training to educate patients on common conditions.
Because most rural / village clinics have intermittent access to a licensed healthcare provider, Community Health Aids and Practitioners are trained to help with emergency, acute, and preventive care as needed.
They provide the link to the licensed healthcare provider for guidance and referral assistance.

Alaska Native Tribal Health Consortium is supporting programs for more trained, certified Alaska Native Patient Navigators.

A Story About Sarah’s Family

Navigating Care Across Urban Settings and Reservations

About Sarah

Sarah is a mother of six, and her cousin Rose temporarily became caregiver to three of the children because Sarah was unable to feed all six of her children.
The focus is on Kaya, a 13-year-old who developed Type 2 diabetes while living with her aunt, Rose, in an urban setting.
This case highlights barriers to health care and medication access across Health Service systems that are on or near reservations and those in urban settings, the role of patient navigation, and the use of external support.

People in this story:

Sarah: Lives on a reservation, a mother of six children.

Rose (Sarah’s cousin): Living off the reservation; took custody of three of Sarah’s children during a summer ceremony.

Kaya (13): One of the 3 children who went to live with Rose and was later diagnosed with Type 2 diabetes.

Context and Challenges

The school district required Rose to obtain legal guardianship before enrolling the children.
Guardianship conflicted with Sarah’s desire to maintain parental authority.
Children required proof of tribal enrollment (CDIB cards). After delays, enrollment was permitted.
Full physicals and vaccinations were mandated for school enrollment.

Kaya’s Symptoms

Age at Onset: 13
Symptoms: Obesity, lethargy, irritability (out of character), abnormal amounts of urine, excessive thirst and hunger

Initial Barrier: The urban IHS clinic denied care because Kaya’s official residence was on the reservation.
Resolution: Rose used the “IHS Open Door Policy” and used the CDIB card to secure an exam.

Initial Barrier: The urban IHS clinic denied care because Kaya’s official residence was on the reservation.

Resolution: Rose used the “IHS Open Door Policy” and used the CDIB card to secure an exam.

Diagnosis and Treatment Path

Kaya was diagnosed with: Type 2 diabetes mellitus.
The doctors recommended: Family diabetes education, lifestyle modification (dietary changes, daily physical activity).
Kaya’s response following the Doctor’s recommendations: Her health was partially improved; Kaya remained obese after six months.
Medication: Metformin prescribed, dispensed monthly at no cost to Kaya’s family.

Kaya’s Transition Back to the Reservation

Two Years Later: Kaya returned to the reservation to live with her mother, Sarah.

Difficulties with treatment: Local IHS clinic had a three-month wait for new appointments.
Kaya required ongoing Metformin refills but could not access them in a timely fashion.

Help for Kaya

Patient Navigator Role: Tribal patient navigator facilitated coordination of care.
Social Work Support: Involved to identify medication resources.
Solution: Kaya was able to get her medication through NeedyMeds, a nonprofit program that provided a low-cost three-month supply of Metformin until IHS access resumed.

Learnings for Patients and Caregivers

Systemic Barriers:

Potential Challenge:Differences between urban IHS clinics, and those on or near reservations can limit access and disrupt care.
Opportunity:Understand the “Open Door Policy” and have your CDIB Card available.

Role of Patient Navigation:

Potential Challenge:Navigating multiple care locations, requirements, and regional differences can be difficult and confusing.
Opportunity:Patient navigators and tribal social workers can bridge gaps in medication access, education, and system navigation.

A Story About Mary

Navigating Transportation, Treatment, and Continued Care in Rural Alaska

About Mary

Mary is a 45-year-old female who is currently overweight and has a type 2 diabetes diagnosis.
She is a widow, with adult children living in a village nearby Nome, working as a 2^nd grade teacher.
This case highlights potential difficulties in the patient treatment journey for someone who prioritizes native traditions and values.

People in this story:

Mary: Lives in a village near Nome.

Her Family: Husband died whale hunting, two adult children, including her son Ken, live hundreds of miles away in other parts of Alaska without roads.

Her Alaska Native History: Siberian Yupik

Occupation: 2^nd grade teacher in the local school.

Context and Challenges

Mary is responsible for the class she teaches, and there is not much additional support in place at the school.
She likes to take part in traditional Alaska Native activities, such as whale hunting / processing, and there may be stigma around having an illness.
Travel may be difficult for Mary and her family due to the extremely rural nature of Alaska, where air may sometimes be the only way to travel.

Mary’s Symptoms

Age at Onset: 45
Symptoms: Pain and puckering in her right breast

Diagnosis and Treatment Path

After Mary felt the sharp burning sensation and the puckering in her right breast, she decided to go to her doctor as soon as her teaching duties allowed. This was the next weekend as there were no substitutes available to cover her class.
The local Community Health Aide Practitioner performed a clinical breast exam and told Mary she needed a mammogram, which she was able to schedule for the next week due to the circumstances.
Mary got a mammogram and then a diagnostic biopsy through Norton Sound Health Corporation, which confirmed a stage III breast cancer diagnosis.
Norton Sound Health provides extensive services to 15 villages but refers patients to Alaska Native Medical Center or Providence Hospital (in Anchorage) for surgeries, MRIs and other services that require specialized equipment.

Mary’s Journey to Surgery

The Community Health Aide Practitioner introduced Mary to Diane who works in the Corporation’s Patient Travel Department that provides air travel for Indigenous patients needing surgery (Between Nome and Anchorage, the cities are separated by over 400 miles of rugged wilderness and no roads).
Mary’s travel was covered by Indian Health Service and Alaska Medicaid, but she wanted at least one of her children to meet her in Anchorage before the surgery. Alaska Medicaid did not authorize either child’s travel because they were traveling independent of her.
However, the Norton Sound Health Corporation’s Community Health Aide Practitioner was able to submit a referral for at least one of the adult children to Angel Flight West (this is a volunteer program that operates throughout Alaska) and after a bit of “back and forth”, Angel Flight West agreed to bring up the daughter. Her son Ken booked a commercial flight also to be present before the surgery. The Alaska Native Medical Center provided lodging for all three to be together in Quyana House.

Surgery Outcome

Mary had a mastectomy on the right breast. Because she was young, she also had reconstruction surgery. Mary was anxious to get back to her students and insisted on returning home. Ken took off work to accompany his mother flying home and help her recover.

Healing from Surgery

The day after they returned, Mary insisted on helping butcher and distribute a whale for winter sustenance although Ken adamantly opposed Mary helping with the butchering.
Mary participated because she didn’t want everyone in the Village to know she had breast surgery. While butchering the whale meat, she ripped out her stitches. She developed an infection and the Norton Sound Health Corporation provided medical assistance and medications to eliminate the infection.

Continuing Care in Anchorage

Mary was supposed to go back to get post-surgery chemotherapy and radiation about 3 weeks after the surgery, however the infection delayed this 5 additional weeks.
By the time she was able to return for additional care, Ken had returned home and Mary had to get an approved absence to be gone for the rest of the school year to be in Anchorage for 3-6 months while getting her chemo and radiation.

Spiritual and Emotional Aspects

Mary experienced anxiety and depression from being alone for much of her time during treatment.
AN Medical Center provides traditional healing services and Mary increased her visits there. She found that these helped her recovery and optimistic balance in life and spirit.
Her community was very supportive of her, with students sending cards, and a big welcome home ceremony when she returned to her home near Nome.