TRICARE and CHAMPVA

1. TRICARE and CHAMPVA Chapter 11

2. TRICARE and CHAMPVA • Learning Outcomes • Explain who is eligible for TRICARE and CHAMPVA and how to verify eligibility. • Discuss the programs offered to TRICARE beneficiaries. • Describe the use of the nonavailability statement in the TRICARE program. • Explain where to file claims first when TRICARE and CHAMPVA beneficiaries are also covered by other insurance programs. • Identify filing deadlines and time limits for responses to requests for additional information. Chapter 11

3. Catastrophic cap CHAMPVA CHAMPVA for Life Cost-share Defense Enrollment Eligibility Reporting System (DEERS) Military treatment facility (MTF) Nonavailability statement Primary Care Manager (PCM) Sponsor TRICARE TRICARE Extra TRICARE for Life TRICARE Prime TRICARE Reserve Select (TRS) TRICARE Standard Key Terms Chapter 11

4. Army Air Force Coast Guard NOAA Navy Marine Public Health Service TRICARE • Department of Defense’s (DOD) health plan for families of active-duty members of: • Previously known as CHAMPUS Chapter 11

5. Active-duty military personnel or members of NOAA or Public Health Service Active-duty service member’s medical coverage provided by branch of service Care provided at Military Treatment Facilities (MTFs) Sponsor Chapter 11

6. Beneficiaries • TRICARE covers: • Dependents of active-duty service members • Retirees and families • Some former spouses • Survivors of deceased military members • Verify beneficiaries in DEERS database Chapter 11

7. TRICARE Standard • Fee-for-service plan • Must first seek treatment at an MTF • Able to utilize civilian physicians when treatment not available from an MTF • First priority at MTF is to active duty • Treatment must be medically necessary Chapter 11

8. TRICARE Standard (cont’d) • Nonavailability Statement (NAS) • Treatment at an MTF is not available within a certain proximity • Electronic document transmitted in DEERS • Required for inpatient services • Not required for emergency care • Not required if TRICARE Standard is the secondary payer Chapter 11

9. TRICARE Standard (cont’d) • Medical expenses shared between TRICARE and beneficiary • Cost-share = coinsurance • Annual catastrophic cap • Upper limit on total expenditures incurred in one year by beneficiary • TRICARE pays 100% after catastrophic cap is met Chapter 11

10. TRICARE Prime • Managed care plan • Primary Care Manager (PCM) • Coordinates and manages patient’s medical care • May be military or civilian provider • Encompasses TRICARE Standard, plus provides preventive care Chapter 11

11. TRICARE Prime (cont’d) • Active-duty personnel automatically enrolled • Annual enrollment fee • No deductible • No payment for outpatient treatment at MTFs • Different copays apply for some beneficiaries if using civilian network providers Chapter 11

12. TRICARE Extra • An alternative to TRICARE Standard • For individuals who wish to use mostly civilian facilities and physicians • No enrollment fee • Annual deductible • Network of providers • TRICARE Prime members receive first priority at MTFs Chapter 11

13. Covers: Families of veterans who are totally and permanently disabled due to service-related injuries Surviving spouse and children of vets who died of service-related injuries Some surviving spouses of people who died while on active duty CHAMPVA • Civilian Health and Medical Program of the Veteran’s Administration Chapter 11

14. CHAMPVA (cont’d) • Veterans Health Care Eligibility Reform Act of 1996 • Veterans with 100% disability must be enrolled to receive benefits • Department of Veterans Affairs determines eligibility • Not eligible for treatment at MTFs; don’t need NAS Chapter 11

15. Beneficiary Identification Cards • Photocopy card for files • Effective date and expiration date • Check parent’s card for children under 10 • Ask if enrolled in DEERS • Sponsor may be a recent recruit or data may not be current • Sponsors may contact DEERS directly; providers may not • HIPAA Privacy Act (protects PHI) Chapter 11

16. Billing TRICARE • Only pays authorized providers • Each authorized provider is assigned a PIN • PAR • Accepts assignment, files claims, payment made to provider • NonPAR • Beneficiary is billed for total actual charge • Beneficiary files claim • Provider may balance bill Chapter 11

17. Billing CHAMPVA • Doesn’t contract with providers • Beneficiary gets care from licensed provider of their choosing • Providers cannot charge more than CHAMPVA allowable amount • Providers agree to accept payment and patient’s cost-share as payment in full Chapter 11

18. TRICARE,CHAMPVA, and HIPAA • Both the TRICARE and the CHAMPVA program are covered by HIPAA regulations • HIPAA Electronic Health Care Transaction and Code Sets requirements • HIPAA Security Rule • HIPAA Privacy Act Chapter 11

19. Filing TRICARE Claims • PAR providers file claims with contractor for region based on patient’s home address • Use HIPAA 837 claim • In some cases, paper claim CMS-1500 may be used • TRICARE Web site • Information on regional contractors • Perimeters of each region subject to change Chapter 11

20. Filing TRICARE Claims (cont’d) • NonPAR providers • Individuals file claims • Use DOD Form 2642, Patient’s Request for Medical Payment • Copy of itemized bill from provider must be attached Chapter 11

21. Filing CHAMPVA Claims • Filed by provider • Submitted to centralized processing center in Denver • Use HIPAA 837 claim • In some cases, paper claim CMS-1500 may be used • Beneficiaries may file own claims • Use VA Form 10-7959A • Attach copy of itemized bill from provider Chapter 11

22. Primary or Secondary Payer? • TRICARE and CHAMPVA do not duplicate benefits of other insurance • Medicaid or supplemental policy • TRICARE/CHAMPVA is primary • Other health plan • TRICARE/CHAMPVA is secondary • Workers’ compensation • TRICARE/CHAMPVA pays only when all other benefits are exhausted Chapter 11

23. TRICARE and Medicare • At age 65, most beneficiaries become eligible for TRICARE for Life • Must enroll in Medicare Parts A and B • Can continue to get treatment at MTFs Chapter 11

24. TRICARE for Life • Similar to a Medicare HMO • Includes prescription coverage • Must also be enrolled in Medicare Parts A and B and have premiums deducted from Social Security benefit • TRICARE for Life is secondary payer to Medicare • If already in a Medicare HMO, may not participate • No enrollment fees or cost-share fees Chapter 11

25. CHAMPVA and Medicare • At age 65, eligible for CHAMPVA for Life • Similar to TRICARE for Life • Acts as secondary payer to Medicare • Must be enrolled in Medicare Parts A and B Chapter 11

26. Timely Filing Guideline • Claims must be filed no later than one year from the date service is provided • In unusual circumstances, contact fiscal intermediary for the area Chapter 11

27. Critical Thinking • Explain when TRICARE and CHAMPVA are the primary or secondary payer. If the beneficiary is covered by Medicaid or a supplemental policy, TRICARE or CHAMPVA is the primary payer. If the beneficiary is covered by another health plan, TRICARE or CHAMPVA is the secondary payer. In workers’ compensation cases, TRICARE or CHAMPVA pays only when all workers’ compensation benefits have been exhausted. Chapter 11