unit 2 health insurance basics chapter 10 military carriers: tricare/champva copyright © 2011,...

UNIT 2 UNIT 2 HEALTH INSURANCE BASICSHEALTH INSURANCE BASICS

CHAPTER 10 CHAPTER 10

MILITARY CARRIERS: MILITARY CARRIERS: TRICARE/CHAMPVATRICARE/CHAMPVA

Copyright © 2011, 2009, 2007 by Saunders, an imprint of Elsevier Inc.Copyright © 2011, 2009, 2007 by Saunders, an imprint of Elsevier Inc.

22Copyright © 2011, 2009, 2007 by Saunders, an imprint of Elsevier Inc.Copyright © 2011, 2009, 2007 by Saunders, an imprint of Elsevier Inc.

What is TRICARE?What is TRICARE?

TRICARE is a regionally based managed TRICARE is a regionally based managed healthcare program. healthcare program. active duty and retired members of the uniformed active duty and retired members of the uniformed

services services their dependent family members and survivors. their dependent family members and survivors.

TRICARE StandardTRICARE Standard has basically the same has basically the same benefits and cost-sharing structure as the benefits and cost-sharing structure as the original CHAMPUS program.original CHAMPUS program.


TRICARE’s main objectivesTRICARE’s main objectives

Accessibility & AffordabilityAccessibility & Affordability — serve as ways: — serve as ways: To improve access to health care for beneficiaries To improve access to health care for beneficiaries To provide faster, more convenient access to To provide faster, more convenient access to

civilian health care civilian health care To create a more efficient method for receiving To create a more efficient method for receiving

health care health care To offer enhanced healthcare services, including To offer enhanced healthcare services, including

preventive care; preventive care; To provide choices for health care To provide choices for health care To control escalating healthcare costsTo control escalating healthcare costs


TRICARE has been restructuredTRICARE has been restructured

The former 11 regions have merged to form The former 11 regions have merged to form just three: the West region, North Region, just three: the West region, North Region, and South Region.and South Region.

In addition, thee are 3 regions outside the In addition, thee are 3 regions outside the United States: TRICARE Europe; Canada/United States: TRICARE Europe; Canada/Latin America; and Puerto Rico/Virgin Latin America; and Puerto Rico/Virgin Islands.Islands.


TRICARE’S REGIONAL TRICARE’S REGIONAL DIRECTORSDIRECTORS

Each region is headed by a regional director Each region is headed by a regional director who is responsible for:who is responsible for: Overseeing all regional healthcare delivery Overseeing all regional healthcare delivery

activitiesactivities Providing oversight of operations and plans Providing oversight of operations and plans

administrationadministration Providing support to treatment facility Providing support to treatment facility

commanders in the regioncommanders in the region


TRICARE’S 3 BASIC PLANSTRICARE’S 3 BASIC PLANS

There are 3 basic plans under TRICARE:There are 3 basic plans under TRICARE: TRICARE TRICARE StandardStandard TRICARE TRICARE ExtraExtra TRICARE TRICARE PrimePrime


EligibilityEligibility

TRICARE-eligible individuals are referred to TRICARE-eligible individuals are referred to as as beneficiariesbeneficiaries. .

The service member (whether in active duty, The service member (whether in active duty, retired, or deceased) is called the retired, or deceased) is called the sponsorsponsor..


DEERSDEERS

Eligible individuals must be listed in the Eligible individuals must be listed in the Department of Defense’s (DoD) Defense Department of Defense’s (DoD) Defense Enrollment Eligibility Reporting System Enrollment Eligibility Reporting System (DEERS)(DEERS)..

DEERSDEERS is a computerized data bank that lists is a computerized data bank that lists all active and retired military service all active and retired military service members.members.


TRICARE-Eligible CategoriesTRICARE-Eligible Categories

Three TRICARE-eligible categories:Three TRICARE-eligible categories: Active military duty members and dependentsActive military duty members and dependents Military retires and eligible dependentsMilitary retires and eligible dependents Survivors of all uniformed service members not Survivors of all uniformed service members not

eligible for Medicareeligible for Medicare


Non-Eligible CategoriesNon-Eligible Categories

Most people who are 65 and eligible for Most people who are 65 and eligible for Medicare (except active-duty family Medicare (except active-duty family members) members)

Parents/parents-in-law of active-duty service Parents/parents-in-law of active-duty service members or uniformed services retirees, or of members or uniformed services retirees, or of deceased active-duty members or retirees deceased active-duty members or retirees

Persons who are eligible for benefits under Persons who are eligible for benefits under the Civilian Health and Medical Program of the Civilian Health and Medical Program of the Department of Veterans Affairs the Department of Veterans Affairs (CHAMPVA). (CHAMPVA).


What Does TRICARE Pay?What Does TRICARE Pay?

AllowedAllowed services, supplies, and procedures, services, supplies, and procedures, which are referred to as which are referred to as covered chargescovered charges..


CHAMPUS Maximum CHAMPUS Maximum Allowable Charge (CMAC) Allowable Charge (CMAC)

CMAC is the amount on which TRICARE figures a CMAC is the amount on which TRICARE figures a beneficiary’s cost-share (coinsurance) for covered beneficiary’s cost-share (coinsurance) for covered chargescharges


TRICARE StandardTRICARE Standard

A A fee-for-servicefee-for-service option option Basically the same benefits as the original Basically the same benefits as the original

CHAMPUS programCHAMPUS program


TRICARE Standard EligibilityTRICARE Standard Eligibility

CHAMPUS-eligible individuals CHAMPUS-eligible individuals Family members of military service personnel Family members of military service personnel

in the Army Reserves and National Guard in the Army Reserves and National Guard (reserve components or RCs)(reserve components or RCs) only if the RC is ordered to active duty for more only if the RC is ordered to active duty for more

than 30 consecutive days than 30 consecutive days if the orders are for an indefinite period of timeif the orders are for an indefinite period of time


Advantages of TRICARE Advantages of TRICARE StandardStandard

Broadest choice of providers Broadest choice of providers Widely available Widely available No enrollment feeNo enrollment fee Members may use TRICARE ExtraMembers may use TRICARE Extra


Disadvantages of TRICARE Disadvantages of TRICARE StandardStandard

Is no Primary Care Manager (PCM.Is no Primary Care Manager (PCM. Patient pays deductible and copayment. Patient pays deductible and copayment. Patient pays up to 15% above allowable Patient pays up to 15% above allowable

charge for non-PARs.charge for non-PARs. Beneficiaries may have to do their own Beneficiaries may have to do their own

paperwork and file their own claims if provider paperwork and file their own claims if provider is nonPAR.is nonPAR.


TRICARE Extra EligibilityTRICARE Extra Eligibility

Anyone who is CHAMPUS-eligible may use Anyone who is CHAMPUS-eligible may use TRICARE Extra.TRICARE Extra.


TRICARE Extra Advantages TRICARE Extra Advantages

Copayment is 5% less than TRICARE Copayment is 5% less than TRICARE Standard. Standard.

There is no balance billing.There is no balance billing. There is no enrollment fee. There is no enrollment fee. There is no deductible when using retail There is no deductible when using retail

pharmacy network.pharmacy network. Patient not responsible for filing forms.Patient not responsible for filing forms. Enrollees may also use TRICARE Standard.Enrollees may also use TRICARE Standard.


TRICARE Extra DisadvantagesTRICARE Extra Disadvantages

There is no Primary Care Manager (PCM).There is no Primary Care Manager (PCM). Provider choice is limited. Provider choice is limited. Patient must pay deductible & cost-share.Patient must pay deductible & cost-share. Nonavailability statement Nonavailability statement maymay be required for be required for

civilian inpatient care for areas surrounding civilian inpatient care for areas surrounding (MTFs).(MTFs).

Not available everywhere.Not available everywhere.


TRICARE Prime EligibilityTRICARE Prime Eligibility

Dependent family members and survivors of Dependent family members and survivors of active duty personnel active duty personnel

Retirees, their family members & survivors Retirees, their family members & survivors under age 65 under age 65

RCs and their family members called to active RCs and their family members called to active duty for 179 days or more (Also may be duty for 179 days or more (Also may be eligible for TRICARE Prime Remote) eligible for TRICARE Prime Remote)

Enrollment forms must be completed, and Enrollment forms must be completed, and MTFs and/or TRICARE Prime network MTFs and/or TRICARE Prime network providers must be used.providers must be used.


TRICARE Prime AdvantagesTRICARE Prime Advantages

No enrollment fee for active duty service No enrollment fee for active duty service members and their familiesmembers and their families

Pay only a small fee per visit to civilian providers Pay only a small fee per visit to civilian providers (no fee for active duty members)(no fee for active duty members)

No balance billing No balance billing Guaranteed appointments (access standards) Guaranteed appointments (access standards) Primary care manager (PCP) to supervise and Primary care manager (PCP) to supervise and

coordinate care coordinate care Away-from-home emergency coverage Away-from-home emergency coverage Point-of-Service (POS) optionPoint-of-Service (POS) option


TRICARE Prime DisadvantagesTRICARE Prime Disadvantages

Enrollment fee for retirees and their familiesEnrollment fee for retirees and their families Provider choice limited to those belonging to Provider choice limited to those belonging to

network network Specialty care by referral only Specialty care by referral only Not available outside the 50 United StatesNot available outside the 50 United States


Catastrophic Cap (cat cap)Catastrophic Cap (cat cap)

Both TRICARE Standard and TRICARE Extra Both TRICARE Standard and TRICARE Extra have an annual maximum out-of-pocket cost have an annual maximum out-of-pocket cost limit placed on covered medical bills. limit placed on covered medical bills. The annual limit for active duty family members The annual limit for active duty family members

(ADFM) is $1000.(ADFM) is $1000. The limit for all other TRICARE Standard and The limit for all other TRICARE Standard and

TRICARE Extra-eligible beneficiaries is $3000 TRICARE Extra-eligible beneficiaries is $3000 annually.annually.


What Applies to Cap?What Applies to Cap?

The cap applies to all covered services:The cap applies to all covered services: Annual deductibles Annual deductibles Pharmacy copays Pharmacy copays TRICARE prime enrollment fees TRICARE prime enrollment fees Other cost shares based on TRICARE-allowable Other cost shares based on TRICARE-allowable

chargescharges


TRICARE Prime Remote (TPR)TRICARE Prime Remote (TPR)

Provides coverage through civilian networks Provides coverage through civilian networks or authorized providers for members and their or authorized providers for members and their families who are on families who are on remote assignmentremote assignment..

TPR for Active Duty Family Members. TPR for Active Duty Family Members. (TPRADFM) is the plan for family members (TPRADFM) is the plan for family members with similar benefits and program with similar benefits and program requirements. requirements.

TPR & TPRADFM are offered in the 50 TPR & TPRADFM are offered in the 50 United States only.United States only.

Both require enrollment.Both require enrollment.


Nonavailability Statement (NAS)Nonavailability Statement (NAS)

If treatment is unavailable at MTF, Military If treatment is unavailable at MTF, Military personnel and their TRICARE-eligible personnel and their TRICARE-eligible dependents must obtain a dependents must obtain a NAS.NAS.

NAS is certification from the MTF saying it NAS is certification from the MTF saying it cannot provide the specific health care cannot provide the specific health care needed. needed.

NAS statements must be entered NAS statements must be entered electronically in the DEERS computer files by electronically in the DEERS computer files by the MTF.the MTF.


Change in NAS RequirementChange in NAS Requirement

As of December 2002, individuals covered by As of December 2002, individuals covered by TRICARE Standard no longer need approval TRICARE Standard no longer need approval from MTF for inpatient care at civilian from MTF for inpatient care at civilian hospitals.hospitals.


Other Health Insurance (OHI)Other Health Insurance (OHI)

If beneficiary has healthcare coverage If beneficiary has healthcare coverage besides TRICARE Standard, Extra, or Prime, besides TRICARE Standard, Extra, or Prime, it is considered it is considered other health insurance other health insurance (OHI)(OHI)..

OHI does not include TRICARE supplemental OHI does not include TRICARE supplemental insurance or Medicaid.insurance or Medicaid.


TRICARE Standard TRICARE Standard Supplemental InsuranceSupplemental Insurance

Secondary plans specifically designed to Secondary plans specifically designed to supplement TRICARE Standard benefits. supplement TRICARE Standard benefits.

Pay most or all of whatever is left after Pay most or all of whatever is left after TRICARE Standard pays.TRICARE Standard pays.

These policies are not specifically for retirees.These policies are not specifically for retirees. May be used by other TRICARE-eligible May be used by other TRICARE-eligible

families.families.


TRICARE for Life (TFL)TRICARE for Life (TFL)

Established by the National Defense Established by the National Defense Authorization Act. Authorization Act. Permanent benefit for all service branches as well Permanent benefit for all service branches as well

as individuals belonging to or employed by the as individuals belonging to or employed by the following:following:• Public Health ServicePublic Health Service

• National Oceanic & Atmospheric AdministrationNational Oceanic & Atmospheric Administration

• National Guard and ReservistsNational Guard and Reservists


TFL EligibilityTFL Eligibility

Based on three components:Based on three components: Retired from a uniformed service branch or one of Retired from a uniformed service branch or one of

the categories listed on previous slide. the categories listed on previous slide. Enrolled in Medicare Parts A and B.Enrolled in Medicare Parts A and B. Registered in the Defense Enrollment Eligibility Registered in the Defense Enrollment Eligibility

Reporting System (DEERS).Reporting System (DEERS).


TRICARE & MEDICARETRICARE & MEDICARE

Medicare-eligible uniformed services retirees, Medicare-eligible uniformed services retirees, their spouses, and survivors who are 65 and their spouses, and survivors who are 65 and older are entitled to expanded healthcare older are entitled to expanded healthcare benefits under the National Defense benefits under the National Defense Authorization Act of 2001.Authorization Act of 2001.

The new benefits include coverage under The new benefits include coverage under TRICARE and pharmacy coverage.TRICARE and pharmacy coverage.


Under the New LawUnder the New Law

TRICARE is secondary payer for eligible TRICARE is secondary payer for eligible beneficiaries who continue to receive medical beneficiaries who continue to receive medical care from Medicare providers. care from Medicare providers.

TRICARE pays out-of-pocket costs for services TRICARE pays out-of-pocket costs for services covered under Medicare and TRICARE. covered under Medicare and TRICARE.

Beneficiaries have access to TRICARE Beneficiaries have access to TRICARE benefits that may not be covered under benefits that may not be covered under Medicare. Medicare.

Medicare-eligible beneficiaries must be Medicare-eligible beneficiaries must be enrolled in Medicare Part B.enrolled in Medicare Part B.


Verifying TRICARE EligibilityVerifying TRICARE Eligibility

Patients claiming to be eligible for benefits Patients claiming to be eligible for benefits under one of the military’s healthcare under one of the military’s healthcare programs should have their eligibility verified programs should have their eligibility verified immediately.immediately.


TRICARE PARsTRICARE PARs

TRICARE PARs accept TRICARE allowable TRICARE PARs accept TRICARE allowable charge (including the cost-share and charge (including the cost-share and deductible, if any) as payment in full for the deductible, if any) as payment in full for the healthcare services provided.healthcare services provided.


Other ProvidersOther Providers

Can participate in TRICARE on case-by-case Can participate in TRICARE on case-by-case basis. basis.

PAR & nonPARs accepting assignment must PAR & nonPARs accepting assignment must file patient claims.file patient claims.

TRICARE sends payment directly to provider. TRICARE sends payment directly to provider. Hospitals participating in Medicare must Hospitals participating in Medicare must

participate in TRICARE Standard for inpatient participate in TRICARE Standard for inpatient care. care.

Hospitals may choose whether or not Hospitals may choose whether or not participate for outpatient care.participate for outpatient care.


CHAMPVA EligibilityCHAMPVA Eligibility

Dependents of veterans w/ total and Dependents of veterans w/ total and permanent service-connected disabilitypermanent service-connected disability

Survivors of veterans who died from Survivors of veterans who died from service-connected conditions; or who, at service-connected conditions; or who, at death, were permanently & totally disabled death, were permanently & totally disabled from a service-connected conditionfrom a service-connected condition

Survivors of persons who died in the line of Survivors of persons who died in the line of duty not due to misconduct and who are not duty not due to misconduct and who are not otherwise entitled to TRICARE benefitsotherwise entitled to TRICARE benefits


Who Manages CHAMPVA?Who Manages CHAMPVA?

VA's Health Administration Center (HAC) in VA's Health Administration Center (HAC) in Denver, ColoradoDenver, Colorado

There is no cost to CHAMPVA beneficiaries There is no cost to CHAMPVA beneficiaries when they receive healthcare treatment at a when they receive healthcare treatment at a VA facility.VA facility.


CHAMPVA EligibilityCHAMPVA Eligibility

Spouse/dependent childSpouse/dependent child of veteran with of veteran with permanent and total service-connected permanent and total service-connected condition/disability condition/disability Surviving spouse/Surviving spouse/dependent childdependent child of a veteran who died as a of a veteran who died as a result of service-connected condition; or who, result of service-connected condition; or who, at the time of death, was permanently and at the time of death, was permanently and totally disabled from a service-connected totally disabled from a service-connected condition condition

Surviving spouse or dependent childSurviving spouse or dependent child of a of a person who died in the line of duty and the person who died in the line of duty and the death was not due to misconductdeath was not due to misconduct


CHAMPVA BenefitsCHAMPVA Benefits

CHAMPVA covers most healthcare CHAMPVA covers most healthcare services/supplies that are medically and services/supplies that are medically and psychologically necessary. psychologically necessary.

Prescription drugs are free; over-the-counter Prescription drugs are free; over-the-counter medications are not covered. medications are not covered.

CHAMPVA benefits typically do not include CHAMPVA benefits typically do not include dental or most eye care.dental or most eye care.


The CHAMPVA-TRICARE The CHAMPVA-TRICARE ConnectionConnection

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


Medicare & CHAMPVAMedicare & CHAMPVA

Medicare is the primary payer to CHAMPVA. Medicare is the primary payer to CHAMPVA. CHAMPVA is the last payer after all other CHAMPVA is the last payer after all other

third party payers have met their obligations, third party payers have met their obligations, except for Medicaid and CHAMPVA except for Medicaid and CHAMPVA supplemental insurance.supplemental insurance.

For beneficiaries living or traveling overseas, For beneficiaries living or traveling overseas, CHAMPVA is primary, if all eligibility criteria is CHAMPVA is primary, if all eligibility criteria is met, until the individual returns to the States, met, until the individual returns to the States, unless there is OHI.unless there is OHI.


CHAMPVA & HMOsCHAMPVA & HMOs

If a CHAMPVA-eligible beneficiary has an If a CHAMPVA-eligible beneficiary has an HMO plan, CHAMPVA will pay any HMO plan, CHAMPVA will pay any copayments under the HMO.copayments under the HMO.

When medical services are available through When medical services are available through the HMO, and the patient chooses to seek the HMO, and the patient chooses to seek care outside the HMO, CHAMPVA will not care outside the HMO, CHAMPVA will not pay for that medical care.pay for that medical care.


CHAMPVA for Life (CFL)CHAMPVA for Life (CFL)

For spouses/dependents of veterans 65 or For spouses/dependents of veterans 65 or older. Must be family members of veterans older. Must be family members of veterans & meet one of the following conditions:& meet one of the following conditions: Veteran has a permanent and total Veteran has a permanent and total

service-connected disability. service-connected disability. Veteran died of a service-connected condition. Veteran died of a service-connected condition. Veteran was totally disabled from a Veteran was totally disabled from a

service-connected condition at the time of death. service-connected condition at the time of death. spouses and/or dependents must have Medicare spouses and/or dependents must have Medicare

coverage.coverage.


Filing CHAMPVA ClaimsFiling CHAMPVA Claims

CHAMPVA claims follow the same filing CHAMPVA claims follow the same filing deadline specifications as TRICARE.deadline specifications as TRICARE.

All CHAMPVA claims are sent to the VA All CHAMPVA claims are sent to the VA Health Administration Center in Denver, Health Administration Center in Denver, Colorado.Colorado.


Claims Deadline Claims Deadline

Submit within 30 days from date services Submit within 30 days from date services were rendered or as soon as possible after were rendered or as soon as possible after the care is rendered.the care is rendered.

No payment will be made for incomplete No payment will be made for incomplete claims or claims submitted claims or claims submitted more than one more than one yearyear after services are rendered for either after services are rendered for either PAR or NonPAR providers.PAR or NonPAR providers.

unit 2 health insurance basics chapter 10 military carriers: tricare/champva copyright © 2011,...

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