How Tribal Self-Funded Plans Use MLR and Payer-of-Last-Resort Rules to Stretch Every Tribal Dollar

Self-Funded Tribal Benefits: Control with Protection

Self-funding moves your plan away from one-size-fits-all insurance. Instead of paying a carrier for a fixed premium, the Tribe funds claims directly, guided by its own plan document and supported by a Tribal-focused Third-Party Administrator (TPA).

The benefits of this approach include:

• More control over plan design and covered services;
• Freedom to choose the networks, care management, and vendors that fit your community; and
• The ability to keep savings in Tribal programs instead of carrier surplus.

The key is to design the plan around the tools that are already available to Tribal Nations, including IHS, PRC, Medicare-like rates, and payer-of-last-resort protections.

Payer-of-Last-Resort Rules: Making Other Coverage Pay First

Payer-of-last-resort rules are meant to ensure that federal and state programs, as well as other group health plans, meet their responsibilities before Tribal dollars are spent. For many members, this means that Medicare, Medicaid, or another employer plan should be primary.

A Tribal self-insurance plan can support this by:

• Requiring members to enroll in other available coverage when eligible;
• Coordinating benefits so the Tribal plan pays after primary coverage; and
• Working with IHS and PRC so authorizations and referrals follow payer-of-last-resort rules.

When this system works, your Tribal self-funded health plan becomes a smart backstop rather than the first payer for every claim.

Medicare-Like Rates: Built-In Discounts Many Plans Miss

Medicare-like rates allow IHS and Tribal health programs to cap what certain hospitals and providers can charge for authorized services. Without this protection, large claims can quickly drain PRC budgets and self-insurance funds.

With the right plan language and workflows, your Tribal plan can:

• Route eligible care through PRC for authorization;
• Apply Medicare-like rates to qualifying services; and
• Use the self-funded plan to fill in remaining gaps for members.

The result is a more affordable Tribal self-funded insurance program that still delivers timely, appropriate care.

Plan Language, Liability, and Sovereignty

To unlock these savings, the details in your plan document matter. Language that works for a non-Tribal employer may not reflect payer-of-last-resort rules, IHS and PRC processes, or how Medicare-like rates apply in Indian Country.

Tribal self-funded plan language should:

• Describe how the plan coordinates with IHS and PRC;
• Clarify when the plan is primary and when it is secondary;
• Protect the Tribe from taking on unnecessary liability; and
• Respect Tribal sovereignty and decision-making authority.

Summit as a Tribal-Focused Third-Party Administrator

Summit Administration Services has decades of experience supporting Tribal Nations and Tribal enterprises with self-funded health, dental, and vision plans. Our team understands Tribal governance, payer-of-last-resort rules, and Medicare-like rates, and we act as an extension of your internal staff rather than just a claims shop.

As your TPA, Summit can help you:

• Evaluate your current plan language and identify gaps that may cost the Tribe money;
• Implement MLR and PRC coordination in a way that works in real life, not just on paper;
• Produce clear reporting for Tribal leadership on how much is being saved through these tools; and
• Tell this story to stop-loss carriers so premiums account for your lower net risk.