• 2016 MHA Nation Health Insurance Application

    Please fill out the form below to apply
  • If you have trouble filling out this online application, you may also call our Enrollment Department at 1-888-215-4628 to apply over the phone Monday thru Friday 8am-5pm CST.

    PLEASE NOTE: Filling out this health insurance application form does NOT guarantee health insurance coverage. All information must be processed, verified and approved by MHA Nation. Information entered on this form will be sent directly to Tribal-Care Insurance enrollment department who will work in partnership with the appropriated MHA Nation office to finalize and approve all eligible enrollments.

  • Verification of Your Current Health Insurance:

  • PLEASE SELECT NEXT TO CONTINUE

  • We apologize, at this time the health insurance plan chosen by the Tribe is only offered to members who DO NOT have access to full health insurance coverage. If you believe you have a unique situation or have further questions please do not hestitate to call us at 888-215-4628. Thank you.

  • 2016 MHA Nation Health Insurance Application Continued....

  • NOTE: All questions without an asterick * next to it are optional and are not required to be answered in order to submit your application for the health plan being offered to MHA Nation members by the Three Affiliated Tribes.

  •  -  - Pick a Date
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  • What is your height? (Please select Feet and Inches in the dropboxes below)

  • Other Available Healthcare Assistance Information:

  • STATE MEDICAID PROGRAM

  • NOTE: Medicaid and the Children’s Health Insurance Program (CHIP) provide free or low-cost health coverage to millions of Americans, including some low-income people, families and children, pregnant women, the elderly, and people with disabilities.

    You may also click on this link to find out more information on your states Medicaid program eligibility and guidelines: https://www.healthcare.gov/lower-costs/

  • IHS

  • PLEASE SELECT NEXT TO CONTINUE

  • You have indicated there are more people in your household that will be on the plan with you. Please fill out the information below to continue:

  • Person #2 added onto your application:

  •  -  - Pick a Date
  • PLEASE SELECT NEXT TO CONTINUE

  • You have indicated there are more people in your household that will be on the plan with you. Please fill out the information below to continue:

  • Person #3 added onto your application:

  •  -  - Pick a Date
  • PLEASE SELECT NEXT TO CONTINUE

  • You have indicated there are more people in your household that will be on the plan with you. Please fill out the information below to continue:

  • Person #4 added onto your application:

  •  -  - Pick a Date
  • PLEASE SELECT NEXT TO CONTINUE

  • You have indicated there are more people in your household that will be on the plan with you. Please fill out the information below to continue:

  • Person #5 added onto your application:

  •  -  - Pick a Date
  • PLEASE SELECT NEXT TO CONTINUE

  • You have indicated there are more people in your household that will be on the plan with you. Please fill out the information below to continue:

  • Person #6 added onto your application:

  •  -  - Pick a Date
  • PLEASE SELECT NEXT TO CONTINUE

  • You have indicated there are more people in your household that will be on the plan with you. Please fill out the information below to continue:

  • Person #7 added onto your application:

  •  -  - Pick a Date
  • PLEASE SELECT NEXT TO CONTINUE

  • You have indicated there are more people in your household that will be on the plan with you. Please fill out the information below to continue:

  • Person #8 added onto your application:

  •  -  - Pick a Date
  • PLEASE SELECT NEXT TO CONTINUE

  • You have indicated there are more people in your household that will be on the plan with you. Please fill out the information below to continue:

  • Person #9 added onto your application:

  •  -  - Pick a Date
  • PLEASE SELECT NEXT TO CONTINUE

  • You have indicated there are more people in your household that will be on the plan with you. Please fill out the information below to continue:

  • Person #10 added onto your application:

  •  -  - Pick a Date
  • PLEASE SELECT NEXT TO CONTINUE

  • We apologize, but you must be an enrolled MHA Nation member in order to apply for this health insurance plan. Please contact your local councilman office to find out more details on how you can become an enrolled MHA Nation member and how to register to vote. Thank you.

  • 2016 MHA Nation Health Insurance Application -Submission Page-

  • You are almost done.......please sign below and click submit.

  • By signing below, I attest under penalty of perjury, that all information on this application is correct and true to the best of my knowledge.

  • Please click the submit button below to send your application to be processed. Thank you.

  • If you have more members to add to your health insurance application please contact us at 888-215-4628. Thank you

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