Chapter 10: Military Carriers: Tricare and CHAMPVA



Chapter 10: Military Carriers: Tricare and CHAMPVA

I. Military Health Programs

a. Tricare: developed from the CHAMPUS Reform Initiatice in 1988; regionally based; for active duty and retired members of the uniformed services, their families and survivors

i. Main objectives: accessibility and affordability

ii. Regionally based: 11 regions (map p. 195)

1. lead agent: manages each region

2. military treatment facility (MTF): responsible for development and execution of an integrated plan for the delivery of healthcare within that region

3. military health system: name for the total healthcare system of the US uniformed services

iii. Military health system: name for the total healthcare system of the US uniformed services

iv. Tricare management activity: began operation 1998 to oversee the Tricare managed healthcare program

v. 3 lans under Tricare

1. tricare standard

2. tricare extra

3. tricare prime

b. Who is eligiblie for Tricare?: referred to no beneficiaries the service member is called the sponsor

i. Categories of eligible include

1. active duty military members and their dependent family members

2. military retirees and their eligible family members

3. survivors of all uniformed service members who are not eligible for Medicare

c. Who is not eligible for Tricare?

i. Most individuals who are 65 and eligible for Medicare

ii. Parents and parents-in-law of sponsors

iii. Individuals eligible for CHAMPVA

d. What Tricare pays: only for their allowed services, supplies and procedures

II. Tricare’s Three Choices for Healthcare

a. Tricare Standard: FFS; original Champus; may be only option in some locations

i. Advantages: broadest choice of providers, widely available, no enrollment fee, may also use Tricare Extra

ii. Disadvantages: no primary care manager(PCM): patients pay deductible and copayment; patient pays up to 15% over and above all charges for nonPAR providers, beneficiaries may have to do their own paperwork and file their own claims if provider is nonPAR

b. Tricare Extra: PPO option; chooses a physician, hospital or other medical provider directory

i. Advantages: copayment 5% less than Tricare Standard, no balance billing, no enrollment fee, no deductible when using retail pharmacy network, patient not responsible for filing forms, enrollees may also use Tricare Standard

ii. Disadvantages: No PCM, limited providers, must pay deductible and cost share, not available everywhere

c. Tricare Prime: HMO type—MFTs are principle source of healthcare

i. Advantages: no enrollment fee, pay only a small fee per visit, no balance billing, guaranteed appointments, PCM supervises and coordinates care, away from home emergency care, POS option

ii. Disadvantages: enrollment fee for retirees and their families, provider choice limited to providers in network, specialty care by referral only, not available outside the 50 states

III. Tricare Claims Processing

a. Who submits claims?: if patient is enrolled in Tricare Prime and goes to a Prime provider, the provider submits claims; Tricare Standard benficiaries are usually responsible for submitting their own claims; can be downloaded from the internet

b. Deadline for submitting claims: within 30 days from the date services were rendered or ASAP

IV. CHAMPVA: VA shares the costs with eligible beneficiaries; managed by the VA

a. Eligibility: spouse or dependent child of eligible vet, surviving spouse or dependent child of vet who died as a result of service connected condition, surviving spouse or dependent child of a person who died in the line of duty

b. Benefits: covers most helahtcare services and supplies that are medically and psychologically necessary; prescription meds are free; doesn’t include dental or eye care

c. Filing claims: providers accepting assignment must submit claims; if provider is nonPAR, patient must submit own claims; must be filed within30 days

V. Instructions for Completing Tricare/CHAMPVA claims

a. Appeals and reconsiderations: must be filed within 90 days

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