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​​Phone - (888) 316-1933

Fax - (888) 316-8572

Medicare Like Rates

Under the  Medicare  Modernization Act,  Indian Tribal Entities  are eligible to take advantage of Medicare

Like  Rate Pricing  or the  Contracted rate  for all  hospital and hospital owned entities.  Health West prices

claims for all tribal members and provides the best contracted rates for Tribal entities in order for them to

take  advantage  of  the   best   pricing  available.   We  separate  the  tribal  member  claims  from  the  other

members  and  provide  the  appropriate  pricing  levels.


 Tribal Solutions


  We have been providing Indian Tribal Enterprises and Tribes

  with custom provider networks and MLR pricing since 2009.


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Advantages of using Health West

Every year there  are  changes  in the  Medicare  Pricing  Methodology  and we  find  that  most  Tribal  Entities  are  over  paying  on  their  MLR   claims because  other companies  do not stay  abreast of the  changes and update their  systems  in a timely  manner. Based  on  actual  audits  we have found that 1 out of every 2 claims  were  paid incorrectly. The average savings for  Tribes using  Health West  was an additional 32.9%. Health West  will  also   perform  the  collection  and  recovery  for  the  plan  for  an  additional  fee.

We  develop   custom  networks   and   establish  discounts   for  non - MLR services  such  as  physicians,  labs  and  ancillary  care  in  order  to  provide best pricing for non-hospital providers. We customize and supplement the Medicare  Like  Rate  pricing with  your chosen providers  in order to assist with  directing  care  into  your   higher  quality   and  lower  cost  providers.

We  provide  MLR  pricing  services  based  on  a  % of savings,  a  per  claim cost and /  or a per employee per month cost and allow the tribal entity the ability  choose  based  on  their  needs.

The final ruling for Tribal entities Medicare Like Rates is found in “Section 506 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003—Limitation on Charges for services furnished by Medicare Participating Inpatient Hospitals to Individuals Eligible for Care Purchased by Indian Health Programs”

(72 FR 30706), includes all “IHS-Funded” health care programs whether operated by the IHS, Tribes, Tribal Organizations, or Urban Indian Organizations.”

The payment methodology applies to all levels of care furnished by a Medicare-participating hospital whether provided as inpatient, outpatient, skilled nursing facility care as other services of a department, subunit, distinct part or other component of a hospital. All hospitals that participate in Medicare, including any hospital clinics located off-site and Critical Access Hospitals. "Hospitals" may include:

  • Acute Care Hospitals
  • Distinct parts of inpatient hospitals (rehabilitation, psychiatric, etc.)
  • Hospital based clinics
  • Psychiatric Hospitals
  • Rehabilitation Hospitals,
  • Long Term Care Hospitals
  • Critical Access Hospitals (including rehab and psych units)
  • Children's Hospitals
  • Cancer Hospitals
  • SNFs & Swing Beds


The Medicare Like Rates regulations enable Indian health programs to use the resulting savings to increase services to their beneficiaries.

  1. The Tribe must be qualified and Individuals must be eligible for CHS coverage as defined by 42 CFR Part 136.
  2. Third Party funds can be added to CHS funds and Medicare Like Rates still apply.
  3. Tribes who have an IHCS 638 contract and a CHS program are also eligible.
  • Low fees
  • Keep your Third Party Administrator
  • Keep your Stop Loss Carrier
  • Keep your current Broker
  • No costly hardware or software to purchase
  • No additional employees to hire.
  • Average savings over current PPO network is 5-10%
  • Average savings with MLR rates is 35-40%  

Section 506  

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