DHB-2040B 9/2021 Page 1 of 1
TRIBAL AND INDIAN HEALTH SERVICES
Ben
eficiary ______________________ Date: __________________
Dear _____________________________:
The individual shown above has indicated they are a member of a federally recognized Indian tribe
or eligible for Indian Health Services (IHS), which means they may be exempt from paying
Medicaid/NC Health Choice for Children enrollment fees, copayments, and premiums in the future.
Verification was previously provided to prove tribal membership or IHS eligibility, however,
the documentation that was provided is not valid. To continue to be exempt from paying
Medicaid/NC Health Choice for Children enrollment fees, copayments, and premiums in the
future, please provide valid documentation that verifies tribal membership or IHS eligibility
for the individual named above. Failure to provide valid documentation will result in an end to
the exemptions.
To
be eligible for these exemptions, verification must be provided to show that they are:
1.A m
ember of a Federally Recognized Indian Tribe,
2.A descendant of a member of a tribe or
3.A pregnant woman carrying the child of a tribal member.
If t
hey are a pregnant woman carrying a child of a tribal member, they will no longer be eligible for
exemptions once their pregnancy benefits end.
Below is a list of items that can be provided to the Medicaid caseworker to verify tribal/IHS status:
•A
document issued by a federally recognized tribe indicating tribal membership
•An enrollment card
•A certificate of degree of Indian blood issued by the Bureau of Indian Affairs
•A tribal census document
•Any document indicating affiliation with a tribe.
•A letter from a tribe verifying eligibility for IHS
If you have a
dditional questions or concerns, contact your caseworker
_________________________________________ at __________________________for
information, or call the NC Medicaid Contact Call Center toll free at 1-888-245-0179.
