Medical Travel Assistance Policies

 

1. Must be an enrolled member of the Fort Peck Assiniboine and Sioux Tribes.

2. Applicant and/or patient must have a written medical deemed appointment or hospitalization to qualify.

3. Enrolled members applying for assistance for a non-enrolled person must be common law married, legally married or have legal custody of minor/s.

4. Applicants and/or patient must reside within the reservation boundaries (90 days minimum for eligibility).

5. Complete Authorization for Use or Disclosure of Protected Health Information.

6. Applicant and/or patient must be first seen by an I.H.S. Physician, unless patients are flown out on weekends or holidays.

7. Applicant of patients with Psychiatric appointments, or any related hospitalizations must have a written approval to qualify, and be deemed medically necessary.

8. Hotal Accommodations are provided only when patients are flown out on weekends and holidays. Applicants/Patients are eligible to receive up to $160.00 per week, or receive accommodations equal to $160.00 per week instead of the dollar amount (only one family member is eligible for assistance). Condition must be deemed medically necessary.

9. Applicant must NOT owe money to the Medical Assistance Program.

10. Self-Referrals (if the patient makes an appointment for themselves, or the patient), and qualifies for Medicaid, the following guidelines apply:

Pain management medical appointments will be eligible on a (1) time basis, and provides CHR transportation with 72 hours notification. Chronic or Co-Morbidity conditions will be considered for a maximum of (3) times per year with appropriate refferal and provide CHR transportation with 72 hours notification.

11. Self-Referral Medical Appointments to any I.H.S. or 638 Medical Facility will not be el;igible for transportation or medical assistance.

12. In order to qualify for a patient escort, a written medical decision will ne made bya medical doctor and provided to the Tribal Health Program (maximum of 1 escort for eligibility).

13. Current Allocation for eligible applicants:

$200.00 for persons traveling out of state
$160.00 for one applicant/patient flown out
$160.00 for one applicant/patient receiving inpatient services
Psychiatric Inpatient one time eligibilty only
$160.00 for a patient with 2 day appointments
$120.00 for 1 day appointment
$80.00 for patient or $90.00 for a person with an approved escort for patients traveling with an I.H.S. or C.H.R. driver
$80.00 surgery and $25.00 check up for baby bottle tooth decay in Glasgow
$25.00 per appointment or $100.00 per week for active cancer patients in Glasgow, Sidney MT, or Williston ND

Note: Sidney and Glasgow MT , Williston ND, are considered local travel and no assistance is provided except for cancer patients

14. Veterans receive a flat rate of $30.00 for any appointment and a CHR transport, as they are provided lodging and mileage from the Veterans Association, when seeing any Veterans Association Provider

Medical Travel Assistance Forms are available for download below:

Medical Travel Assistance Policies

Medical Assistance Application

Informed Consent and Authorization for Use or Disclosure of Protected Health Information

Proof of Appointment

 


 

 

"Fort Peck's Total Health Care Program"