TRICAREYour Military Health Plan Retiree Benefits CCGNRC Annual Conference Mark Freese, DMD MPH MHA CAPT USPHS 27 April 2010
TRICARE Management Activity Headed by the ASD(HA) • 21 April - President Obama nominated Dr. Jonathan Woodson for ASD(HA) • BG Army Reserves assigned as Assistant Surgeon General Force Management, Mobilization, Readiness & Reserve Affairs • Associate professor of surgery and associate dean at Boston University School
TRICARE Regions Ft. Campbell moves to the South with T3 =TRICARE Regional Office (TRO)
TRICARE Regional Contractorsmay change with T-3 • TRICARE North Region • Health Net Federal Services, Inc. • www.healthnetfederalservices.com • 1-877-TRICARE (1-877-874-2273) • TRICARE South Region • Humana Military Healthcare Services, Inc. • www.humana-military.com • 1-800-444-5445 • TRICARE West Region • TriWest Healthcare Alliance • www.triwest.com • 1-888-TRIWEST (1-888-874-9378)
DEERS (Defense Enrollment Eligibility Reporting System) • Who is eligible? • Sponsor • Spouse/certain former spouses • Children to age 21 (age 23 if fulltime student) • Incapacitated child (determined physically or mentally disabled prior to age 21). Visit PSD for application package. • Valid ID Card needed for all age 10 and older • Keep your DEERS information current to ensure continued eligibility • Proper documentation needed to make any changes to DEERS other than an address change.
Updating DEERS Information • Visit an ID card issuing facility; locate one near you at www.dmdc.osd.mil/rsl • Call: 1-800-538-9552 (address changes only) • Fax changes to: 1-831-655-8317 • Mail changes to: Defense Manpower Data Center Support Office Attn: COA 400 Gigling Road Seaside, CA 93955-6771 • Make address changes online at: www.tricare.mil/DEERSAddress
Patient Protection and Affordable Care Act • The Patient Protection and Affordable Care Act leaves TRICARE under sole authority of the Defense Department and the Secretary of Defense. TRICARE is a benefit, not insurance. • TRICARE and TRICARE for Life are qualifying coverage. • Coverage to age 26 for children. TRICARE may mirror this change if Congress institutes a change in the CFRs. (Health card only)
Transitioning from Active Duty to Retirement Health Care Options
Decision Process • Where will you live? • Will you accept employment? • How is your health (and family)? • What health plans are available? • Cost of competing health plans? • Insurability? • Do I need supplemental insurance?
Accessing Care During Terminal Leave • ADSM is still considered active duty during the terminal leave period and must access care under the current Prime rules. • Access care through nearest MTF • Go to a civilian hospital based emergency room • Call back to PCM/regional contractor to authorize care through a civilian doctor or urgent care clinic • Routine care will not be authorized outside your PCM while on terminal leave.
Military Treatment Facilities (MTFs) • Upon retirement, your access to services at the MTF will change • You will retain priority access to specialty care in the MTF if you enroll in TRICARE Prime • If you choose to use TRICARE Extra or TRICARE Standard, you will continue to have access to care in an MTF on a space-available basis only
MTF—Priorities for Care • Active duty service members • Active duty family members enrolled in TRICARE Prime * • Retirees, their family members, and others enrolled in TRICARE Prime • Active duty family members NOT enrolled in TRICARE Prime • Retirees, their family members, and others NOT enrolled in TRICARE Prime • All other eligible beneficiaries * If spouse is still active duty, use status as Active Duty Family Member when accessing medical care.
How TRICARE Changes When You Retire * ADSMs are not eligible for TRICARE Extra or TRICARE Standard
TRICARE Standard • Fee-for-service option (Old CHAMPUS) • No enrollment required • Seek care from any TRICARE authorized provider • Responsible for annual deductibles and cost- shares—highest out-of-pocket expense • May have to pay provider, then file claim for reimbursement • May seek care in an MTF on a space-available basis
TRICARE Standard—Costs • Deductible • $150 individual/$300 family annually • Cost-shares after deductible has been met • Outpatient care 25% of TMAC (when using a non-participating provider, patient responsible for 15% above the TMAC) • Inpatient Care Lesser of$535 per day or 25% of billed charges for facility bill, plus 25% of allowable professional fees • Catastrophic Cap • $3000 per fiscal year
TRICARE Extra • Preferred provider option (PPO) • No enrollment required • Seek care from any TRICARE networkprovider • Responsible for annual deductibles and discounted cost-shares • Providers required to file claims for you • May seek care in an MTF on a space-available basis
TRICARE Extra—Costs • Deductible • $150 individual/$300 family annually (fiscal year) • Cost-shares after deductible has been met • Outpatient care 20% of negotiated rate • Inpatient care Lesser of $250 per day or 25% of negotiated charges for facility bill, plus 20% of negotiated professional fees • Catastrophic Cap • $3000 per fiscal year
Standard Any TRICARE authorized provider Cost-share: 25% of allowable charge May have to file claims Nonparticipating providers may charge up to 15% above allowable charge for services Extra Any TRICAREnetwork provider Cost-share: 20% of negotiated rate Providers required to file claims for you Not responsible for additional charges for covered benefits TRICARE Extra vs. Standard
TRICARE Prime Enrollment • Prime does not automatically carry over into retirement • A new enrollment application mustbe completed for the region you live in to continue in Prime • Deadline for admission – 20th of each month • Enrollment fees will apply • $230 Individual/$460 Family • Paid monthly, quarterly, or annually • Include the Enrollment Fee Allotment Authorization Letter with application if paying by allotment • Spouse still Active Duty??? • Enroll in Prime as Active Duty Family Member • Former Spouse considered own sponsor • Separate enrollment fees apply • Must select or be assigned PCM
Enrollment Types • New Enrollment – First time enrollment as retiree • PCM Change – Changing providers within the same region • Portability – Transferring enrollment between regions as you move • Split Enrollment – When family members live and enroll in different regions. Enrollment fee paid in region sponsor lives.
Primary Care Manager (PCM) • MTF or network provider- Your Medical Home • Provides most of your care and coordinates specialty care when needed • Knows your family and medical history, lifestyle, and habits • Helps you develop and carry out a personal health maintenance and improvement program • Prevents and detects health problems through regular screenings and wellness education • Retirees enrolled in Prime are entitled to one preventative vision check every two years at no cost
Cost of Care • MTF Care • Outpatient care at no cost • Inpatient care at subsistence rate • Civilian Care • PCM/Specialty Outpatient visit: $12 copayment • Inpatient visit: $11 per day ($25 minimum) • Emergency services: $30 copayment • Behavioral health outpatient visit: • $25/individual • $17/group • Behavioral health inpatient visit: $40 per day
TRICARE Point of Service (POS) • Non-authorized, non-emergent care • Retro-authorizations not granted • Freedom of choice • $300 Deductible/50% of TMAC • No upper limit to POS Catastrophic Cap
TRICARE Plus • MTF primary care enrollment program • Offered at limited number of MTFs • Limited capacity • All beneficiaries eligible for care in the MTF (except those enrolled in Prime or other civilian HMO plan) may seek enrollment in TRICARE Plus • Offers only primary care – specialty care through MTF is not guaranteed • Enrollment in TRICARE Plus does not affect TFL benefits or other existing programs
Accessing Out of Area Care • Use MTF care if near a Military site • Emergency care – go to nearest hospital-based emergency room (Prudent Lay Person Rule) • Acute care (includes urgent care clinics) • Covered only when you receive prior authorization from your PCM • First call PCM to notify need for care • Second call regional contractor for authorization • Routine care not authorized while out of area
Access to Care when Living Overseas • You and your family members have access to MTFs overseas on a space-available basis • You will not be eligible for enrollment in TRICARE Prime while living overseas, but will be covered for all civilian health care under TRICARE Standard • The same annual deductibles and cost-shares will apply as in the stateside TRICARE Standard option
TRICARE covers durable medical equipment (DME) when prescribed by a physician and if the DME: Improves, restores, or maintains the function of a malformed, diseased, or injured body part, or can otherwise minimize or prevent the deterioration of the patient's function or condition Maximizes the patient's function consistent with the patient's physiological or medical needs Provides the medically appropriate level of performance and quality for the medical condition present Is not otherwise excluded by the regulation and policy TRICARE does not cover: DME for a beneficiary who is a patient in a type of facility that ordinarily provides the same type of DME item to its patients at no additional charge in the usual course of providing its services is excluded. DME when it's available from a military treatment facility DME with deluxe, luxury, or immaterial features which increase the cost of the item to the government relative to similar item without those features. Maintenance agreement. Durable Medical Equipment
Home Health Care • TRICARE covers a maximum of 28 hours per week part time, or 35 hours per week intermittent, skilled nursing care, home health aide services, any physical, speech and occupational therapy. All care must be provided by a participating home health agency. • The services covered under TRICARE are the same as those covered by Medicare.
Hospice Care TRICARE covers hospice care under the following guidelines: • Care will only start with a doctor's order. • The patient/caretaker must complete an "election statement" and file it with the regional contractor. • With prior certification of the terminal illness for each period • Two 90 day periods • Unlimited 60 day periods • If a beneficiary revokes a hospice election, any remaining days in that period are forfeited. • There are four levels of care within the hospice benefit: • Continuous home care • General hospice inpatient care • Inpatient respite care • Routine home care • Note:Only available in the United States and Territories.
Transitioning from Active Duty to Retirement Pharmacy Options
TRICARE Pharmacy Program • MTF Pharmacy • TRICARE Mail Order Pharmacy (TMOP) – now called home delivery • TRICARE Retail Network Pharmacy • Non-network Retail Pharmacy
Generic Drug Use Policy • Generic drugs will be substituted for brand names when available • Must justify medical necessity for brand name to be dispensed • If generic equivalent drug does not exist the brand name drug will be dispensed
TRICARE and OHI • TRICARE pays after all other health insurance (OHI) plans except: • Medicaid • TRICARE supplements • Used to pickup remaining cost shares after TRICARE has processed the claim • You must notify TRICARE of OHI Failure to do so could result in TRICARE coverage being restricted or denied.
Claims Filing • Who is responsible for filing claims? • Network provider/participating provider • Beneficiary • Forms needed for filing claim • TRICARE Claim Form (DD2642) • Full Itemized Statement (HCFA-1500) • Statement of Personal Injury (DD2527) • OHI Explanation of Benefits (EOB) • Prescriptions
Claims Assistance • Call regional contractor for area you live in • Go online to www.myTRICARE.com • Contact HBA/BCAC at your nearest MTF • Normally claim should process and EOB be received within 21 to 30 days of date medical care was rendered
TRICARE For Life • Began October 1, 2001 • Claims filed automatically from Medicare to TRICARE (provider only needs to file to Medicare) • If OHI exists, Medicare will pay first, OHI second, and TRICARE will pay last. • No monthly enrollment fees (except for Medicare Part B) • Space available access at MTF continues
TRICARE For Life • Eligibility • Medicare eligible sponsors including retired guardsmen and reservists age 65 and over • Medicare eligible family members and widow/widowers • Certain former spouses if eligible for TRICARE before age 65 • Mandatory enrollment in Medicare Part B • TFL coverage effective date • First day of month eligible beneficiary turns 65
What is Medicare? A health insurance program for: • People 65 years of age and older • People under age 65 with certain disabilities • People with End-Stage Renal Disease (ESRD) Medicare is managed by Centers for Medicare & Medicaid Services (CMS) • Enrollment is managed by the Social Security Administration (SSA) or Railroad Retirement Board (RRB)
A Bit of History Before October 2001 TRICARE beneficiaries who became entitled to premium-free Medicare Part A based on age, would: • Lose their TRICARE-eligibility • Only have access to health care in military treatment facilities on a space-available basis National Defense Authorization Act for Fiscal Year 2001* • Restored TRICARE medical and pharmacy benefits to all Medicare-TRICARE eligible uniformed services retirees, their family members and survivors, effective October 1, 2001 • The benefit is know as TRICARE For Life *Public Law 106-398, Section 712
What Is TRICARE For Life? • TRICARE For Life (TFL) is a TRICARE option that offers Medicare-wraparound coverage by acting as a second payer to Medicare. • TFL minimizes the Medicare-TRICARE beneficiary’s out-of-pocket expenses (similar to a Medicare supplement) TRICARE Medicare
Who Is TRICARE For Life For? • TRICARE For Life (TFL) is for Medicare-TRICARE beneficiaries who are: • Entitled to premium-free Medicare Part A; • Enrolled in Medicare Part B (if other than an active duty family member) • Note this is not age dependent.
TRICARE For Life • Medicare Part B Rule • Federal law requires TRICARE beneficiaries eligible for premium-free Medicare Part A to have Medicare Part B to remain TRICARE-eligible. • But for every rule, there’s an exception… • Active duty family members entitled to premium-free Medicare Part A, don’t have to have Medicare Part B until their sponsor retires.
Medicare TRICARE How TFL Works With Medicare Step 1: Beneficiary goes to a Medicare provider Step 2: Provider files claim with Medicare Step 3: Medicare pays its portion and electronically forwards the claim to the TRICARE For Life (TFL) claims processor Step 4: TFL pays the provider directly for TRICARE-covered services
How TFL Works with Medicare • Services covered by both Medicare and TRICARE • Medicare pays first and TRICARE For Life (TFL) pays the beneficiary’s remaining Medicare coinsurance Example: Doctor Visit Medicare pays 80% TRICARE pays 20% Beneficiary pays $0
How TFL Works with Medicare Services covered by TRICARE but notby Medicare • TRICARE For Life (TFL) pays first and Medicare pays nothing • Beneficiary is responsible for paying the TRICARE fiscal year deductible and cost share • Deductible $150/person or $300/family • The provider’s network status determines the beneficiary’s cost share • Network provider 20% cost share • Non-network provider 25% cost share Examples: Overseas care, shingles vaccine
How TFL Works with Medicare • Services covered by Medicare but not by TRICARE • Medicare pays first and TRICARE For Life (TFL) pays nothing • Beneficiary is responsible for paying the Medicare deductible and coinsurance Example: Chiropractic Services Medicare pays 80% TRICARE pays $0 Beneficiary pays 20%
How TFL Works with Medicare • Services not covered by either Medicare nor TRICARE • Medicare and TRICARE For Life (TFL) pay nothing • Beneficiary is responsible for the entire bill Example: Cosmetic surgery Medicare pays $0 TRICARE pays $0 Beneficiary pays 100%