TRIBAL AND INDIAN HEALTH SERVICES
Regarding ______________________
Dear _____________________________:
T
he 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.
To be eligible for these exemptions, verification must be provided to show that they are:
1. A member 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 they 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 additional questions or concerns, contact your caseworker
at __________________________for
information, or call the NC Medicaid Contact Call Center toll free at 1-888-245-0179.
Date:______________
