The coverage options at a glance
Many American Indian and Alaska Native elders in Oklahoma use more than one of these at the same time. The table shows what each one is and how you get it.
| Program | What it is | Where you can get care | How you get it |
|---|---|---|---|
| IHS, tribal and urban Indian clinics (I/T/U) | Health care services from IHS, a tribe's own health system or an urban Indian health program. Not insurance. | The program's own hospitals, clinics and pharmacies | Eligibility set by IHS and each tribe; ask your clinic |
| Purchased/Referred Care (PRC) | IHS or tribal funds that pay outside providers when your clinic refers you. Payer of last resort. | Outside providers, with an approved referral | Live in your tribe's PRC delivery area; care must be authorized (emergencies reported within 72 hours, 30 days for elders) |
| Original Medicare (Parts A and B) | Federal health insurance for people 65 and older or with certain disabilities | Any doctor or hospital in the U.S. that accepts Medicare, including Indian health facilities that bill Medicare | Sign up through Social Security during your Initial Enrollment Period |
| Medicare Part D | Prescription drug coverage from private plans approved by Medicare | The plan's network pharmacies; plans must offer contracts to every I/T/U pharmacy in their area | Join a plan when you first get Medicare or October 15 to December 7 |
| Medicare Advantage (Part C) | Private plans approved by Medicare that cover Part A and Part B and usually Part D | The plan's network; Indian health providers may not be in it | Must have Part A and Part B and live in the plan's service area |
| SoonerCare (Oklahoma Medicaid) | State and federal coverage for people with limited income and resources, run by the Oklahoma Health Care Authority | SoonerCare providers, including Indian health care providers | Apply through OHCA; can apply any time of year |
| Tribal employer or self-funded plans | Group health plans some tribes offer their employees, or programs that help members pay premiums | Depends on the plan | Through the tribe or your employer |
What you pay under each
| Program | Your costs |
|---|---|
| IHS, tribal and urban Indian clinics | CMS says no deductibles, coinsurance or copayments for covered services you get directly from these programs |
| Purchased/Referred Care | No deductibles, coinsurance or copayments for authorized referred care, per CMS; unauthorized care may not be paid |
| Original Medicare | Part B premium (standard $202.90 a month in 2026), plus deductibles and 20% coinsurance for care outside the Indian health system |
| Medicare Part D | The plan's premium and cost sharing at outside pharmacies; CMS says you pay nothing at an Indian health pharmacy. Out-of-pocket drug costs are capped at $2,100 for 2026 |
| Medicare Advantage | You keep paying the Part B premium; plan costs vary by plan and county |
| SoonerCare | OHCA says American Indian and Alaska Native members are exempt from copays; Medicare Savings Programs can pay Medicare premiums |
| Tribal employer plans | Set by each plan |
How they work together
| Your situation | Who pays first | What to watch |
|---|---|---|
| Medicare and you get care at your tribal clinic | The clinic bills Medicare for covered services | Medicare brings resources back to the clinic; your care there doesn't change |
| Medicare and your clinic refers you to an outside specialist | Medicare, then PRC if approved | PRC won't pay what Medicare would have paid; keep Part A and Part B active |
| No Medicare, but you're eligible | PRC may deny care that Medicare would have covered | Federal rules require you to apply for alternate resources such as Medicare |
| Medicare and SoonerCare | Medicare, then SoonerCare | SoonerCare can cover Medicare cost sharing and, through a Medicare Savings Program, premiums |
| Medicare and a tribal employer plan from current work | Depends on employer size; ask the plan | You may be able to delay Part B without a penalty while you have coverage from current work |
| Medicare Advantage and your tribal clinic | The plan, for covered care it pays | Check before you enroll whether the plan works with your clinic |
| Indian health pharmacy and a Part D plan | The Part D plan pays your Indian health pharmacy | IHS and tribal payments count toward your Part D out-of-pocket cap |
The penalties to avoid
- Part B: IHS and tribal clinic use don't give you a Medicare special enrollment period. CMS states that Medicare has no special enrollment provisions for American Indians or Alaska Natives. If you sign up late, you can pay a penalty of $10% of the standard premium for each full 12 months you went without Part B, for as long as you have it.
- Part D: there's no late penalty while you have drug coverage through an IHS, tribal or urban Indian program, because federal rules count it as creditable coverage.
Read the full guide: tribal health and Medicare in Oklahoma. See also Medicare Part B, SoonerCare and Medicare and working past 65.
Choosing what to add
- Keep your clinic. Medicare doesn't replace your Indian health program; it adds coverage that the program can bill.
- Get Part A and Part B on time. Sign up through Social Security during your Initial Enrollment Period unless you have coverage from current work.
- Ask about SoonerCare and Medicare Savings Programs. If money is tight, these can pay your Part B premium and cost sharing.
- Compare drug and health plans with your clinic in mind. Ask which plans your clinic and pharmacy work with. To compare plans from the companies they work with, you can request a call from a licensed insurance agent, or see plans for your ZIP code.
Sources
- CMS — 10 Important Facts about IHS and Health Insurance
- CMS — Important Dates for Health Insurance (American Indians and Alaska Natives)
- CMS — A Guide to Original Medicare and Medicare Advantage for Tribal Medicare Beneficiaries
- CMS — Medicare Prescription Drug Plans for American Indians and Alaska Natives
- IHS — Purchased/Referred Care: Eligibility
- IHS — Purchased/Referred Care: Alternate Resources
- eCFR — 42 CFR 136.61, Payor of last resort
- eCFR — 42 CFR 423.56, Creditable prescription drug coverage
- eCFR — 42 CFR 423.120, Access to I/T/U pharmacies
- eCFR — 42 CFR 423.100, Incurred costs
- Medicare.gov — Avoid late enrollment penalties
- Medicare.gov — Medicare and Other Health Benefits: Your Guide to Who Pays First
- Oklahoma Health Care Authority — American Indian/Alaska Native members
Frequently asked questions
Is IHS the same as health insurance?
No. CMS says IHS is not health insurance. It is the federal agency that delivers care to American Indians and Alaska Natives and funds tribal and urban Indian health programs. Medicare, SoonerCare and job-based plans are insurance that pays for care, including care at IHS and tribal facilities.
Who pays first if I have Medicare and use a tribal clinic?
When you get covered care at an IHS, tribal or urban Indian facility, the facility bills Medicare. For care outside the facility through a Purchased/Referred Care referral, Medicare and any other coverage pay first, because federal rules make IHS the payer of last resort.
If I still work for a tribe at 65, can I delay Part B?
Possibly. If you have group health coverage through your own or your spouse's current employment, you can usually delay Part B and sign up later during a special enrollment period without a penalty. Whether the tribal plan or Medicare pays first depends partly on the employer's size, so ask the plan before you decide.
Can I have both Medicare Advantage and use my tribal clinic?
Yes, but CMS warns that Indian health care providers may not be in a Medicare Advantage plan's network. CMS advises asking your Indian health care provider before you enroll to make sure the plan works with it.
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