1. Chapter 11 Military Carriers

2. What is Tricare?  Military healthcare services that utilize medical teams from uniformed services (Navy, Army, Air Force, etc.) AND civilian professionals  Available to active duty, retirees and beneficiaries

3. Who is Tricare for?  Active duty and retired members of uniformed services, their families, and survivors  Unmarried spouse and dependents under 19 of deceased active military

4. Terminology  Beneficiary—an individual who qualifies for TRICARE  Sponsor—active duty service member  It is the sponsor’s responsibility to report changes in beneficiary status

5. Who is Not Qualified?  Anyone on CHAMPVA (veterans)  Parents of active military  Secretarial and civilian positions

6. DEERS  Defense Enrollment Eligibility Reporting System  Computerized Database containing names and numbers of sponsors and beneficiaries  Used to verify eligibility

7. Authorized Providers  Credentialed through TRICARE by meeting their standards  Receive a portion of allowable services  Submit claims within 30 days from DOS  Deductibles are in effect October 1- Sept. 30  Accept assignment

8. Participating Providers  Must be authorized providers  May appeal claims decisions  Agree to accept TRICARE allowable  Collect patient coinsurance and bill TRICARE  TRICARE pays the provider

9. NonParticipating Providers  Cannot charge more than 115% of Tricare’s allowable.  Cannot appeal claim decisions  Patient is responsible for payment to provider  TRICARE sends their portion to the patient

10. Payments  TRICARE fee schedule is based on Medicare fee schedule  Network Providers—bill TRICARE and collect copays and coinsurance from pt  Non-Network Providers—collect TRICARE maximum allowed (115%)

11. Plan Types  Standard  Prime  Remote  Extra  Life

12. Tricare Standard  fee-for-service  cost share  MTF or civilian approved doctors  Tricare pays 50% out of network  priority given to active service members  catastrophic cap

13. Tricare Prime  managed care—fewest out-of- pocket expenses  Active duty automatically enrolled (no other options)  PCP  Majority of services provided at MTF  Nonactive duty members pay annual enrollment fee  No deductibles or payment at outpatient MTF

14. Prime Remote  active duty service members on remote assignment  More than 50 miles from nearest MTF  no out-of-pocket  Required enrollment

15. Tricare Extra  Managed Care  For civilian services (must be network)  If seek care at MTF, not priority  Annual deductible  15% coinsurance

16. TRICARE for Life  Medicare-eligible retirees over 65  Required to enroll in Medicare A and B  MTF  Medicare billed first, automatically sent to Tricare (crossover claim)

17. CHAMPVA Who qualifies?  The spouse or child of a Veteran who has been rated permanently and totally disabled for a service-connected disability by a VA regional office.  The surviving spouse or child of a Veteran who died from a VA-rated service-connected disability.  The surviving spouse or child of a Veteran who was at the time death rated permanently and totally disabled from a service-connected disability.  The surviving spouse or child of a military member who died in the line of duty, not due to misconduct (in most of these cases, these family members are eligible for TRICARE, not CHAMPVA). http://www.va.gov

18. CHAMPVA  Use VA facility  Cost share, annual deductible, catastrophic cap  All treatments must be approved  CHAMPVA pays after any other payer (except Medicaid)

19. Submitting Claims  Submit as soon as services are provided or within 30 days  Submit no later than one year after service  Do not batch bill—an error on one will hold up all

20. Completing the Claim  Block 1a: sponsor’s SSN or DoD number  Block 2: patient name as it appears on military ID card  Block 4: sponsor’s name (self can write SAME)  Block 7: will be different if sponsor is living away from family

21. Filing Claims  PAR files for patient  NonPAR has patient pay all; patient sends bill to TRICARE

22. Similarities to Medicare  Non PAR receives 115 % of Medicare PAR fee  NonPAR collects payment from patient  Tricare will not pay any portion if doctor is out of network  Fee schedule is same as Medicare