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Tricare & the VA - Financing Transplantation for Active Duty or Retired Military. OBJECTIVES. AWARENESS OF GOVERNMENT BENEFITS: Tricare Standard • Tricare for Life Tricare Extra • Champ V.A. Tricare Prime. TRICARE STANDARD
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Tricare & the VA - Financing Transplantation for Active Duty or Retired Military OBJECTIVES • AWARENESS OF GOVERNMENT BENEFITS: • Tricare Standard • Tricare for Life • Tricare Extra • Champ V.A. • Tricare Prime TRICARE STANDARD Government funding for family members of active duty, retired or deceased personnel may be available through Tricare. Tricare also covers living donor kidney, liver and lung transplants. Prior authorization by medical director required. Must meet Tricare Selection criteria.
TRICARE PRIME OVERVIEW Primary Care Manager The Point of Service Option Prime Pros and Cons Tricare Cost Comparison NOTE Active duty service personnel are automatically enrolled in Tricare Prime, THEY MUST COMPLETE AN ENROLLMENT FORM TO SELECT Prime as their coverage.
POINT OF SERVICE POSOption under Tricare Prime allows freedom to receive non-emergency health care from Civilian providers that may be in or out of the Tricare network.
ADVANTAGES OF TRICARE PRIME No enrollment fee for active duty and family members. Small fee to visit civilian providers - no fee for active duty member. No balance billing. Guaranteed appointments. Primary care manager supervises and coordinates care. Point of Service option. Reduced catastrophic cap for retirees ($7,500. Now decreased to $3,000.
TRICARE PRIME ADVANTAGES Enrollment fee for retirees and families. Provider choice limited. Specialty care by referral only. Not Universally available.
TRICARE FOR LIFE Plan for retirees generally 65 or older and their spouses that have Medicare A & B. YOU MUST HAVE MEDICARE PART B to get Tricare for Life, if eligible. October 2006 - Tricare will no longer reimburse Tricare for Life claims from providers who have opted out of Medicare. TRICARE FOR LIFE members MUST ASK if provider accepts Medicare.
MEDICARE A & B People eligible for Medicare A/B must take Medicare Part B in order to have Tricare Standard and/or Tricare for Life. EXCEPTION: Active Duty military personnel and family members ARE NOT REQUIRED TO TAKE MEDICARE PART B.
VETERANS ADMINISTRATION BENEFITS People who have served honorably in the military and have met the criteria for eligibility can obtain benefits through the V.A. V.A. has dedicated transplant centers, ie. McGuire. Patients should be referred to V.A. Center and/or go on-line and complete the 10-10EZ. Application can be obtained by visiting, calling and/or writing V.A. Health Care Facility
ELIGIBILITY ASSESSMENT 1) DD-214 REQUIRED. 2) App sent to V.A. Eligibility Center in Atlanta. 3) Confirmation of enrollment, status and priority group. 4) Financial Assessment, ie. Must be under $80,000. in our area.
COMMON PAYERS FOR TRANSPLANT Health Insurance COBRA Medicare Medicaid
FORGOTTEN PAYERS TRICARE V.A. Benefits for EligibleVeterans Charitable Organizations Fund Raising
CHAMPVA The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is a health benefits program in which the Department of Veterans Affairs (V.A.) shares the cost of certain health care services and supplies with eligible beneficiaries.
CHAMPVA ELIGIBILITY Cannot be eligible for Tricare. Spouse or child of a veteran permanently/totally disabled. Surviving spouse or child of a veteran who died from VA-rated service connected disability. Surviving spouse or child who at time of death rated permanently/totally disabled. Surviving spouse or child of military who died in line of duty (most eligible for Tricare).
CHAMPVA CAN END WHEN THERE IS ... Remarriage Divorce from Sponsor Eligibility for Medicare or Tricare All Changes Must Be Immediately Reported.
CHAMPVA AND MEDICARE CHAMPVA always pays last to MEDICARE or any other health insurance. ONLY EXCEPTION: Travel Overseas (When you return to U.S., does not pay Prime.)
SUMMARY • TRICARE: • Prime operates as an HMO; referral needed from PCM or specialist. • Standard operates as a PPO and no referrals are required. • Tricare for Life acts as a Medicare Supplement; no referral required. • All claims handled from Wisconsin and are approved if Medicare approves TDEFIC or Tricare Dual Eligibility applies when a beneficiary qualifies for Medicare before age 65. Patient may have Tricare Prime or Standard. Both will act as supplement to Medicare and Tricare will cover deductibles.
SUMMARY (continued) • Authorization is always required for: • Active duty for all levels of service and DME • Non-network providers • No authorization is currently required for: • Standard in-patient stays except transplants.
SUMMARY (continued) Medicare and Tricare • All Tricare beneficiaries must carry Medicare A & B to retain their Tricare coverage. • Exceptions: Active duty military member and their dependents have the option not to take Part B. Discussed: Tricare Standard Tricare Extra Tricare Prime Tricare for Life V.A. Benefits CHAMPVA
SUMMARY (continued) Most retired military understand their benefit, the ones you will try to identify are the folks that have served but were uninformed about their ability to access V.A. benefits. They can get 90 days worth of immunosuppressive drugs for a very small copayment. QUESTIONS ??