1. UNIT 2 HEALTH INSURANCE BASICS
CHAPTER 10
MILITARY CARRIERS: TRICARE/CHAMPVA
Copyright © 2011, 2009, 2007 by Saunders, an imprint of Elsevier Inc.

2. What is TRICARE?
TRICARE is a regionally based managed healthcare program.
active duty and retired members of the uniformed services
their dependent family members and survivors.
TRICARE Standard has basically the same benefits and cost-sharing structure as the original CHAMPUS program.
How does TRICARE relate to the original CHAMPUS program?
TRICARE is a regionally based managed healthcare program for active duty and retired members of the uniformed services, their dependent family members and survivors.
TRICARE Standard has basically the same benefits and cost-sharing structure as the original CHAMPUS program.

3. TRICARE’s main objectives
Accessibility & Affordability — serve as ways:
To improve access to health care for beneficiaries
To provide faster, more convenient access to civilian health care
To create a more efficient method for receiving health care
To offer enhanced healthcare services, including preventive care;
To provide choices for health care
To control escalating healthcare costs
Accessibility and Affordability, which serve as ways:
To improve overall access to health care for beneficiaries
To provide faster, more convenient access to civilian health care
To create a more efficient method for receiving health care
To offer enhanced health care services, including preventive care
To provide choices for health care
To control escalating health care costs

4. TRICARE has been restructured
The former 11 regions have merged to form just three: the West region, North Region, and South Region.
In addition, thee are 3 regions outside the United States: TRICARE Europe; Canada/ Latin America; and Puerto Rico/Virgin Islands.
TRICARE is administered on a regional basis. Up until 2005, TRICARE had 11 regions.
These 11 regions have since merged to form just three: West, North, and South regions.
There are also 3 regions outside the United States—TRICARE Europe, Canada/Latin America, and Puerto Rico/Virgin Islands.

5. TRICARE’S REGIONAL DIRECTORS
Each region is headed by a regional director who is responsible for:
Overseeing all regional healthcare delivery activities
Providing oversight of operations and plans administration
Providing support to treatment facility commanders in the region
Each region is headed by a regional director who is responsible for all healthcare delivery activities within his/her region.
Regional directors provide oversight of regional operations and health plan administration along with management of the healthcare support contracts.
Regional directors also are responsible for providing support to the military treatment facility commanders in the region; sustaining quality care and improving customer satisfaction across the healt care delivery system.

6. TRICARE’S 3 BASIC PLANS There are 3 basic plans under TRICARE:
TRICARE Standard
TRICARE Extra
TRICARE Prime
Which of TRICARE’s 3 plans cover active duty personnel ?
There are three basic plans under TRICARE:
TRICARE Standard
TRICARE Extra
TRICARE Prime
TRICARE Extra & TRICARE Prime are available only in areas where TRICARE is in operation and a civilian provider network has been established to support the program.

7. Eligibility
TRICARE-eligible individuals are referred to as beneficiaries.
The service member (whether in active duty, retired, or deceased) is called the sponsor.
What individual creates TRICARE eligibility?
Like Medicaid and Medicare, TRICARE-eligible individuals are referred to as beneficiaries.
The service member (whether in active duty, retired, or deceased) is called the sponsor.
It is the sponsor’s relationship to the beneficiary (spouse, child, parent, etc.) that creates eligibility under TRICARE.

8. DEERS
Eligible individuals must be listed in the Department of Defense’s (DoD) Defense Enrollment Eligibility Reporting System (DEERS).
DEERS is a computerized data bank that lists all active and retired military service members.

9. TRICARE-Eligible Categories
Three TRICARE-eligible categories:
Active military duty members and dependents
Military retires and eligible dependents
Survivors of all uniformed service members not eligible for Medicare
What are the 3 TRICARE-eligible categories?
Active military duty members and their dependent family members
Military retirees and their eligible family members
Survivors of all uniformed service members who are not eligible for Medicare

10. Non-Eligible Categories
Most people who are 65 and eligible for Medicare (except active-duty family members)
Parents/parents-in-law of active-duty service members or uniformed services retirees, or of deceased active-duty members or retirees
Persons who are eligible for benefits under the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA).
Why would a 65-year-old individual fall into a non-eligible category?

11. What Does TRICARE Pay?
Allowed services, supplies, and procedures, which are referred to as covered charges.
What do TRICARE’s covered charges typically include?
Covered charges include medical and psychological services and supplies that are considered appropriate care and are generally accepted by qualified professionals to be reasonable and adequate for the diagnosis and treatment of illness, injury, pregnancy, mental disorders, or well-child care.

12. CHAMPUS Maximum Allowable Charge (CMAC)
CMAC is the amount on which TRICARE figures a beneficiary’s cost-share (coinsurance) for covered charges
How does TRICARE establish their covered charges?”
TRICARE calculates this allowable charge by looking at all professional (non-institutional) providers’ fees for the same or similar services nationwide over the past year, with adjustments for specific localities.

13. TRICARE Standard A fee-for-service option
Basically the same benefits as the original CHAMPUS program
What is meant by fee-for-service?
TRICARE Standard is a fee-for-service option which has basically the same benefits as the original CHAMPUS program.
Under this plan, eligible enrollees can see the authorized provider of their choice.
In some locations, TRICARE Standard may be the only option available.

14. TRICARE Standard Eligibility
CHAMPUS-eligible individuals
Family members of military service personnel in the Army Reserves and National Guard (reserve components or RCs)
only if the RC is ordered to active duty for more than 30 consecutive days
if the orders are for an indefinite period of time
Into which of TRICARE’s three plans are active duty personnel automatically enrolled?
Anyone who is CHAMPUS-eligible may use TRICARE Standard. (It is important to note here that active duty personnel are not CHAMPUS-eligible and are automatically enrolled in TRICARE Prime.) Family members of military service personnel in the Army Reserves and National Guard, called reserve components (RCs), are eligible for TRICARE Standard only if the RC is ordered to active duty for more than 30 consecutive days, or if the orders are for an indefinite period of time. The RC is entitled to TRICARE Prime benefits as soon as he or she goes into active duty.

15. Advantages of TRICARE Standard
Broadest choice of providers
Widely available
No enrollment fee
Members may use TRICARE Extra

16. Disadvantages of TRICARE Standard
Is no Primary Care Manager (PCM.
Patient pays deductible and copayment.
Patient pays up to 15% above allowable charge for non-PARs.
Beneficiaries may have to do their own paperwork and file their own claims if provider is nonPAR.

17. TRICARE Extra Eligibility
Anyone who is CHAMPUS-eligible may use TRICARE Extra.
How does TRICARE Extra differ from TRICARE Standard?
(Remember: Active duty personnel are not CHAMPUS-eligible and are automatically enrolled in TRICARE Prime.)

18. TRICARE Extra Advantages
Copayment is 5% less than TRICARE Standard.
There is no balance billing.
There is no enrollment fee.
There is no deductible when using retail pharmacy network.
Patient not responsible for filing forms.
Enrollees may also use TRICARE Standard.

19. TRICARE Extra Disadvantages
There is no Primary Care Manager (PCM).
Provider choice is limited.
Patient must pay deductible & cost-share.
Nonavailability statement may be required for civilian inpatient care for areas surrounding (MTFs).
Not available everywhere.

20. TRICARE Prime Eligibility
Dependent family members and survivors of active duty personnel
Retirees, their family members & survivors under age 65
RCs and their family members called to active duty for 179 days or more (Also may be eligible for TRICARE Prime Remote)
Enrollment forms must be completed, and MTFs and/or TRICARE Prime network providers must be used.
How does a TRICARE-eligible individual become eligible for TRICARE prime?
There is no enrollment fee for TRICARE Prime, but there is a registration process. Besides active service members’ automatic enrollment, the following categories of people may also enroll in TRICARE prime:
Dependent family members and survivors of active duty personnel
Retirees and their family members and survivors under age 65
RCs and their family members called to active duty for 179 days or more, may enroll in TRICARE Prime or may be eligible for TRICARE Prime Remote.
Enrollment forms must be completed, and MTFs and/or TRICARE Prime network providers must be used.

21. TRICARE Prime Advantages
No enrollment fee for active duty service members and their families
Pay only a small fee per visit to civilian providers (no fee for active duty members)
No balance billing
Guaranteed appointments (access standards)
Primary care manager (PCP) to supervise and coordinate care
Away-from-home emergency coverage
Point-of-Service (POS) option

22. TRICARE Prime Disadvantages
Enrollment fee for retirees and their families
Provider choice limited to those belonging to network
Specialty care by referral only
Not available outside the 50 United States

23. Catastrophic Cap (cat cap)
Both TRICARE Standard and TRICARE Extra have an annual maximum out-of-pocket cost limit placed on covered medical bills.
The annual limit for active duty family members (ADFM) is $1000.
The limit for all other TRICARE Standard and TRICARE Extra-eligible beneficiaries is $3000 annually.
Why do you think TRICARE places an out-of-pocket cost limit on covered medical bills?
Note: Cat cap amounts are subject to change each fiscal year.

24. What Applies to Cap? The cap applies to all covered services:
Annual deductibles
Pharmacy copays
TRICARE prime enrollment fees
Other cost shares based on TRICARE-allowable charges

25. TRICARE Prime Remote (TPR)
Provides coverage through civilian networks or authorized providers for members and their families who are on remote assignment.
TPR for Active Duty Family Members. (TPRADFM) is the plan for family members with similar benefits and program requirements.
TPR & TPRADFM are offered in the 50 United States only.
Both require enrollment.
What is meant by remote assignment?
Provides coverage through civilian networks or TRICARE-authorized providers for Uniformed Service members and their families who are on remote assignment (50 miles + from a MTF).
TPR for Active Duty Family Members (TPRADFM) is the plan for family members with similar benefits and program requirements.
TPR & TPRADFM are offered in the 50 United States only; both require enrollment.

26. Nonavailability Statement (NAS)
If treatment is unavailable at MTF, Military personnel and their TRICARE-eligible dependents must obtain a NAS.
NAS is certification from the MTF saying it cannot provide the specific health care needed.
NAS statements must be entered electronically in the DEERS computer files by the MTF.
Does a TRICARE-eligible enrollee have to obtain a NAS for all medical care received in facilities other than MTFs?
If treatment is not available at an MTF, Military personnel and their TRICARE-eligible dependents must (under certain circumstances) obtain a NAS indicating that care is not available from the MTF.
A NAS is certification from the MTF that says it cannot provide the specific health care the beneficiary needs.
NAS statements must be entered electronically in the Defense Department's DEERS computer files by the MTF.

27. Change in NAS Requirement
As of December 2002, individuals covered by TRICARE Standard no longer need approval from MTF for inpatient care at civilian hospitals.
Under what circumstances must an enroll always obtain a NAS?
NAS must be procured before seeking non-emergency inpatient mental healthcare services.

28. Other Health Insurance (OHI)
If beneficiary has healthcare coverage besides TRICARE Standard, Extra, or Prime, it is considered other health insurance (OHI).
OHI does not include TRICARE supplemental insurance or Medicaid.
What are some examples of third party coverage that would be considered primary to TRICARE?
If a TRICARE-eligible beneficiary has health care coverage besides TRICARE Standard, Extra, or Prime, TRICARE considers this other health insurance (OHI).
It may also be called double coverage or coordination of benefits. OHI does not include TRICARE supplemental insurance or Medicaid.

29. TRICARE Standard Supplemental Insurance
Secondary plans specifically designed to supplement TRICARE Standard benefits.
Pay most or all of whatever is left after TRICARE Standard pays.
These policies are not specifically for retirees.
May be used by other TRICARE-eligible families.
How is TRICARE supplemental insurance similar/different from a Medicare supplement policy?
Secondary health benefit plans specifically designed to supplement TRICARE Standard benefits.
Generally pay most or all of whatever is left after TRICARE Standard has paid its share of the cost of covered healthcare services and supplies.
Such policies are not specifically for retirees and may be useful for other TRICARE-eligible families as well.

30. TRICARE for Life (TFL)
Established by the National Defense Authorization Act.
Permanent benefit for all service branches as well as individuals belonging to or employed by the following:
Public Health Service
National Oceanic & Atmospheric Administration
National Guard and Reservists
What categories of individuals are eligible for TFL?
Does TRICARE for Life (TFL) cover long-term care?
A comprehensive program established by the National Defense Authorization Act.
Available to uniformed services retirees, their spouses, and survivors who are age 65 or older, are Medicare-eligible, and have purchased Medicare Part B coverage. There is no monthly premium.
A permanent health care benefit for all uniformed service branches as well as those individuals belonging to or employed by the following:
Public Health Service
National Oceanic & Atmospheric Administration
National Guard and Reservists

31. TFL Eligibility Based on three components:
Retired from a uniformed service branch or one of the categories listed on previous slide.
Enrolled in Medicare Parts A and B.
Registered in the Defense Enrollment Eligibility Reporting System (DEERS).

32. TRICARE & MEDICARE
Medicare-eligible uniformed services retirees, their spouses, and survivors who are 65 and older are entitled to expanded healthcare benefits under the National Defense Authorization Act of 2001.
The new benefits include coverage under TRICARE and pharmacy coverage.

33. Under the New Law
TRICARE is secondary payer for eligible beneficiaries who continue to receive medical care from Medicare providers.
TRICARE pays out-of-pocket costs for services covered under Medicare and TRICARE.
Beneficiaries have access to TRICARE benefits that may not be covered under Medicare.
Medicare-eligible beneficiaries must be enrolled in Medicare Part B.
What type of coverage is ALWAYS secondary to both Medicare and TRICARE?
TRICARE is the secondary payer for eligible beneficiaries who continue to receive medical care from their current Medicare providers.
TRICARE pays out-of-pocket costs for services covered under Medicare and TRICARE.
Beneficiaries will have access to TRICARE benefits that may not be covered under Medicare.
Medicare-eligible beneficiaries must be enrolled in Medicare Part B.

34. Verifying TRICARE Eligibility
Patients claiming to be eligible for benefits under one of the military’s healthcare programs should have their eligibility verified immediately.
How does a health insurance professional verify TRICARE eligibility?
When a patient comes to the office for an appointment and informs the health insurance professional that he or she is eligible for benefits under one of the military’s healthcare programs, eligibility should be verified immediately.

35. TRICARE PARs
TRICARE PARs accept TRICARE allowable charge (including the cost-share and deductible, if any) as payment in full for the healthcare services provided.
Can TRICARE PARs balance bill?
If not, what happens to any left over amounts that are excluded from TRICARE payments?
Must agree to accept the TRICARE allowable charge (including the cost-share and deductible, if any) as payment in full for the health care services provided.

36. Other Providers Can participate in TRICARE on case-by-case basis.
PAR & nonPARs accepting assignment must file patient claims.
TRICARE sends payment directly to provider.
Hospitals participating in Medicare must participate in TRICARE Standard for inpatient care.
Hospitals may choose whether or not participate for outpatient care.
Providers who do not accept assignment on all claims (nonPARs) can participate in TRICARE on a case-by-case basis.
PAR providers and nonPARs who accept assignment must file the claim for the patient, and TRICARE then sends the payment (if any) directly to the provider.
Hospitals that participate in Medicare must, by law, also participate in TRICARE Standard for inpatient care. For outpatient care, hospitals may choose whether or not participate.

37. CHAMPVA Eligibility
Dependents of veterans w/ total and permanent service-connected disability
Survivors of veterans who died from service-connected conditions; or who, at death, were permanently & totally disabled from a service-connected condition
Survivors of persons who died in the line of duty not due to misconduct and who are not otherwise entitled to TRICARE benefits
To be eligible for CHAMPVA, an individual must also be eligible for TRICARE. (T/F)
A healthcare benefits program for dependents of veterans who:
have been rated by the VA as having a total and permanent service-connected disability
are survivors of veterans who died from VA-rated service-connected conditions or who, at the time of death, were rated permanently and totally disabled from a VA-rated service-connected condition
survivors of persons who died in the line of duty that was not due to misconduct and who are not otherwise entitled to TRICARE benefits.

38. Who Manages CHAMPVA?
VA's Health Administration Center (HAC) in Denver, Colorado
There is no cost to CHAMPVA beneficiaries when they receive healthcare treatment at a VA facility.

39. CHAMPVA Eligibility
Spouse/dependent child of veteran with permanent and total service-connected condition/disability Surviving spouse/ dependent child of a veteran who died as a result of service-connected condition; or who, at the time of death, was permanently and totally disabled from a service-connected condition
Surviving spouse or dependent child of a person who died in the line of duty and the death was not due to misconduct
CHAMPVA provides coverage to the spouse or widow(er) and to the children of a veteran who:
• is rated permanently and totally disabled due to a service-connected disability
• was rated permanently and totally disabled due to a service connected condition at the time of death
• died of a service-connected disability
• died on active duty and the dependents are not eligible for DoD TRICARE benefits
What is the impact of divorce or remarriage of a surviving spouse or dependent child on CHAMPVA eligibility?

40. CHAMPVA Benefits
CHAMPVA covers most healthcare services/supplies that are medically and psychologically necessary.
Prescription drugs are free; over-the-counter medications are not covered.
CHAMPVA benefits typically do not include dental or most eye care.
CHAMPVA covers the same procedures/services/supplies as Medicare. (T/F)

41. The CHAMPVA-TRICARE Connection
Both CHAMPVA and TRICARE are federal programs; however, an individual who is eligible for TRICARE is not eligible for CHAMPVA.

42. Medicare & CHAMPVA Medicare is the primary payer to CHAMPVA.
CHAMPVA is the last payer after all other third party payers have met their obligations, except for Medicaid and CHAMPVA supplemental insurance.
For beneficiaries living or traveling overseas, CHAMPVA is primary, if all eligibility criteria is met, until the individual returns to the States, unless there is OHI.
When a patient has both Medicare and CHAMPVA, which plan is the primary payer?
CHAMPVA is the last payer after all other third party payers have met their obligations, except for Medicaid and CHAMPVA supplemental insurance.
When a CHAMPVA-eligible beneficiary resides or travels overseas, if all eligibility criteria is met, CHAMPVA will be the primary payer (unless there is OHI) until the individual returns to the States.

43. CHAMPVA & HMOs
If a CHAMPVA-eligible beneficiary has an HMO plan, CHAMPVA will pay any copayments under the HMO.
When medical services are available through the HMO, and the patient chooses to seek care outside the HMO, CHAMPVA will not pay for that medical care.

44. CHAMPVA for Life (CFL)
For spouses/dependents of veterans 65 or older. Must be family members of veterans & meet one of the following conditions:
Veteran has a permanent and total service-connected disability.
Veteran died of a service-connected condition.
Veteran was totally disabled from a service-connected condition at the time of death.
spouses and/or dependents must have Medicare coverage.
What is CHAMPVA for Life (CFL)?
Who is eligible for CFL?
CFL is designed for spouses or dependents of veterans who are 65 or older. They must be family members of veterans and meet one of the following conditions:
The veteran has a permanent and total service-connected disability.
The veteran died of a service-connected condition.
The veteran was totally disabled from a service-connected condition at the time of death.
The spouses and/or dependents must have Medicare coverage.

45. Filing CHAMPVA Claims
CHAMPVA claims follow the same filing deadline specifications as TRICARE.
All CHAMPVA claims are sent to the VA Health Administration Center in Denver, Colorado.
What is the deadline for filing CHAMPVA claims?
Where can a health information professional get more information on CHAMPVA?
• Web site: select CHAMPVA
• Write: CHAMPVA PO Box Denver, CO •
• Call , Monday through Friday from 8:05 a.m.–7:30 p.m. Eastern Time

46. Claims Deadline
Submit within 30 days from date services were rendered or as soon as possible after the care is rendered.
No payment will be made for incomplete claims or claims submitted more than one year after services are rendered for either PAR or NonPAR providers.
TRICARE claims should be submitted within 30 days from the date services were rendered or as soon as possible after the care is rendered.
No payment will be made for incomplete claims or claims submitted more than one year after services are rendered for either participating and non-participating providers.