Health Insurance - covers medical expenses incurred during the insured's lifetime.

Navajo Nation Plan offers medical, prescription drug, dental, vision and short-term disability benefits. Currently, there are two (2) tiers of coverage: individual coverage(self only) and family coverage(self plus eligible dependents). Election of coverage for an employee includes medical, prescription drug, dental, vision and short-term disability. Election of coverage for dependent(s) includes medical, prescription drug, dental and vision only.

Medical Benefit Program

A standard Medical Calendar Year deductible applies and must be met before claims are paid.

Emergency Room Treatment
A $350 co-payment will apply per visit if treatment does not result in hospital confinement.

In-Patient Hospital Admission
A $250 co-payment will apply per in-patient admission.

Medical Calendar Year	Deductible
PER INDIVIDUAL	$400
PER FAMILY	$800
Maximum Out-Of-Pocket	PPO or Non-PPO Providers
PER INDIVIDUAL	$4000
PER FAMILY	$8000

Native Traditional Healing Benefit

The maximum benefit per covered family is $350.00 per calendar year Traditional ceremony must be directly related to health of an employee or his/her covered dependent. Must be conducted by a Native Healing Practitioner for the benefit of an employee or covered dependent. The Plan reserves the right to verify native practitioner information prior to the processing of a claim.

Claims Process

Native Traditional Healing Benefit form must be completed and original form submitted to our office. Fax or photocopy will not be accepted. Must be filed after ceremony has been performed and no later than 12 months from the date of service. Does not cover dwelling, livestock and others not considered health-related. Receipts are not required.

Forms

Native Traditional Healing Procedures
Native Traditional Healing Benefit Form

Vision Benefit Program

There is no deductible to be paid for Vision Benefits. One (1) eye examination per covered member per calendar year. One (1) Set of Lenses or Contact Lenses per covered member per calendar year. One (1) Set of vision ware (frames) per covered member per calendar year

Lasik Surgery

For more information about Lasik surgery, www.qualsight.com
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Health Claim Submission

Navajo Nation Employee Benefit Plan
Hawaii-Mainland Administrators, LLC
PO BOX 22009
Tempe, AZ 85285-2009

Toll Free: 800-448-3585
For Pre-Authorizations ONLY, fax to 866-293-9665

Dental Benefit Program

A standard Dental Calendar Year deductible applies and must be met before claims are paid:
The annual maximum benefits for Class I, II, and III services combined are $1,500.
There is a lifetime benefit amount for Class IV - orthodontic services of $2,000.

Dental Calendar Year	Deductible
PER INDIVIDUAL	$100
PER FAMILY	$300

The Dental Benefit is divided into four types of classes:

Dental Service	Plan Pays
Class I - Preventative Services	(no deductible) plan pays 100% of covered expenses.
Class II - Basic Services	$80% of covered expenses, after calendar year deductible
Class III - Major Services	80% of covered expenses, after calendar year deductible
Class IV - Orthodontic Services	50% of covered expenses, after calendar year deductible

Eligibility Requirements for Short Term Disability

The Navajo Nation Employee Benefit Program offers a Short Term Disability Benefit to eligible employees. To be eligible for Short-Term Disability the following criteria must be met:

Working at least 20 hours per week as a regular status employee
Become totally disabled as the result of a non-occupational injury or illness
Be under a physician’s regular care for the cause of the disability
Exhaust all sick leave hours

Claim Process

A claim must be submitted within 31 days from the date disability begins. If submitted past 31 day deadline, member must submit written justification of reason for delay to the Plan.

Once approved, Short-Term Disability Benefit

Begins the first (1) day of an injury or after a seven day waiting period for an illness or maternity leave.
Pay is 60% of employee's average weekly salary up to a maximum benefit of $600 per week.
Maximum benefit period of up to fifty-two (52) weeks.

Please note insurance premiums not collected during period of disability will be collected upon return to work to bring member current with employee and/or family coverage

Forms

Short-Term Disability Instructions
Short-Term Disability Sick leave Form
Short-Term Disability Preliminary Statement of Disability
Short-Term Disability Attending Physician Statement

*All Short-Term Disability participants will receive a W-2 for tax filing purposes. You will NEED to file your taxes with your W-2 form. Please be sure to keep your address updated as the W-2 will be mailed.

Simplify COBRA administration and streamline benefits with Infinisource.

The Consolidated Omnibus Budget Reconciliation Act of 1985.

If a qualified beneficiary loses coverage under the Navajo Nation Employee Benefit Plan due to a qualifying event, he/she may elect to continue coverage under the Plan in accordance with the COBRA requirements upon timely election and payment of monthly contribuations as specified. A qualified beneficiary must elect coverage within the sixty (60) day period beginning on the later of the date of the qualifying event, or the date he/she was notified of the right to continue coverage.

COBRA is the continuation of benefits that applies to medical, prescription drug, dental and vision coverage only. This section does not apply to life coverage or disability coverage.

COBRA montly rates are:

Single - $349.96
Family - $888.02

COBRA election notice and election form will be sent by US mail directly to the qualifying individual(s) upon notification of loss of eligibility under the Plan. The information will be mailed to the last known address on file with the benefit plan. Please keep address up to date.

For length of coverage and additional information, please refer to your Plan Document or you may call Infinisource Customer Service at (800)594-6957.

Infinisource.

Please send all COBRA payments to Infinisource at:
PO BOX 949
Coldwater, MI. 49036

Medical Benefit Program

Native Traditional Healing Benefit

Claims Process

Forms

Vision Benefit Program

Lasik Surgery

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Health Claim Submission

Dental Benefit Program

Eligibility Requirements for Short Term Disability

Claim Process

Forms

Simplify COBRA administration and streamline benefits with Infinisource.

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