Chapter 14 TRICARE and Veterans’ Health Care

1. Insurance Handbook for the Medical Office 13th edition Chapter 14 TRICARE and Veterans’ Health Care

2. TRICARE and Veterans Health Administration (CHAMPVA) Overview Define pertinent TRICARE and Veterans Health Administration (CHAMPVA) terminology and abbreviations. State who is eligible for TRICARE. List the circumstances when a nonavailability statement is necessary. Explain the benefits of the TRICARE Standard government program. State the TRICARE fiscal year. Lesson 14.1

3. TRICARE and Veterans Health Administration (CHAMPVA) Overview (cont’d) Name authorized providers who may treat a TRICARE Standard patient. List the managed care features of TRICARE Extra. State the managed care features of TRICARE Prime. Explain TRICARE for Life benefits and those who are eligible individuals. Name individuals eligible for TRICARE Plus. Lesson 14.1

4. TRICARE and Veterans Health Administration (CHAMPVA) Overview (cont’d) Define individuals who may enroll in the TRICARE Prime Remote program. Identify individuals who are eligible for the Veterans Health Administration program (CHAMPVA). Lesson 14.1

5. History of TRICARE • 1966 CHAMPUS created (Civilian Health and Medical Program of the Uniformed Services) • 1988 CHAMPUS Prime created as managed care plan option • 1994 TRICARE became new title with 3 options: • TRICARE Standard (fee-for-service) • TRICARE Extra (PPO) • TRICARE Prime (HMO) • 2005 TRICARE consolidated into 3 regions

6. TRICARE Programs • Eligibility • Active duty service members (Prime Remote) • Eligible family members of active duty service members • Military retirees and eligible family members • Surviving eligible family members of deceased active or retired service members • Wards and preadoptive children • Former spouses of active or retired service members (must meet requirements)

7. TRICARE Programs • Eligibility • Family members of active duty service members who were court-martialed or separated from their families for abuse • Abused spouses/children of service members • Spouses/children of NATO nation representatives • Reservists and National Guard members activated for 30 or more consecutive days • Disabled beneficiaries under 65 years with Medicare A & B • Medicare-eligible beneficiaries in TRICARE for Life

8. TRICARE Programs • Defense Enrollment Eligibility Reporting System (DEERS) • A computerized database system that all TRICARE-eligible persons must be enrolled in • Nonavailability Statement (NAS) • Certification from a military hospital when it cannot provide care • 2003 not needed for individuals in the catchment area about an MTF

9. TRICARE Standard • ID card required for all dependents over age 10 • Not limited to using network providers for medically or psychologically necessary services • Care usually sought at military hospital closest to home or identified through Health Care Finder (HCF) • Authorized providers must be used • Preauthorization necessary for specialty care, hospitalization, and certain procedures • Deductibles and copayments apply

10. TRICARE Extra • ID card required for all dependents over age 10 • PPO option • Network provider must be used • Preauthorization necessary and coordinated by Health Care Finder for specialty care, hospitalization, and certain procedures • Deductibles and copayments apply

11. TRICARE Prime • Voluntary HMO option with annual fee required • Minimum 12 months participation required • PCM coordinates all care except emergencies • Referral from Health Care Finder required for use of non-network provider • Preauthorization may be necessary for some specialty care, hospitalization, and certain procedures • Copayments and deductibles apply

12. TRICARE Reserve Select • Available to qualified members of the Selected Reserve and their families • Similar to TRICARE Standard and Extra

13. TRICARE for Life • Supplementary payer to Medicare • No separate ID card • No referral or preauthorization requirements • Payment is based on the services provided and coverage by both Medicare and TRICARE

14. TRICARE Plus • ID card and DEERS enrollment required • Enrollees use the military treatment facility as source of primary care • Same benefits as TRICARE Prime when using military treatment facility • Access to specialty providers at military treatment facility not guaranteed

15. TRICARE Prime Remote Program • For active duty service members only • Must live at least 50 miles from military treatment facility • Same benefits as TRICARE Prime • No prior authorization for routine primary care • PCM coordinates all care except emergencies • No out-of-pocket expenses for in-network services

16. Supplemental Health Care Program • For active duty service members and other designated patients • Enables beneficiaries to be referred to civilian providers when needed • No deductibles or copayments if military treatment facility initiates referral

17. TRICARE Hospice Program • Based on Medicare hospice program • Life expectancy is 6 months or less • Cannot also receive care under TRICARE basic programs

18. TRICARE and HMO Coverage • Provider must meet TRICARE provider certification standards • Type of care must be a TRICARE benefit and medically necessary • TRICARE does not pay for emergency services received outside the normal HMO service area

19. Veterans Health Administration Program • 1973 CHAMPVA created (Civilian Health and Medical Program of the Veterans Administration) • Now called the Veterans Health Administration • For spouses and dependent children of veterans with total, permanent disability • Must not be eligible for TRICARE Standard or Medicare A • Service benefit program

20. Veterans Health Administration Program • ID card required for all dependents over age 10 • Benefits similar to TRICARE Standard for dependents of retired and deceased military personnel • Freedom of choice in selecting civilian providers • Preauthorization needed for some services

21. Claims Procedure • TRICARE Standard administered by DOD (Department of Defense) • Veterans Health Administration program administered by VA (Veterans Administration) • Claims must be: • Billed on CMS-1500 (02-12) form or electronically • Submitted to the correct fiscal intermediary • Filed within 1 year of service

22. Claims Procedure • TRICARE Extra and TRICARE Prime • No claim forms filed by beneficiary if care provided is in-network • Providers must: • Use CMS-1500 (02-12) form or electronic system to submit claims • Submit claims to correct subcontractor • File within 1 year of service

23. Claims Procedure • TRICARE Prime Remote and Supplemental Health Care Program • Outpatient services are submitted with CMS-1500 (02-12) form or electronically • POS option and NAS requirement do not apply • Claims must be filed within 1 year of service

24. Claims Procedure • TRICARE for Life • Civilian provider submits claims to Medicare to pay first and then the claim is submitted to TRICARE for the remainder

25. Claims Procedure • TRICARE/Veterans Health Administration and Other Insurance • TRICARE/Veterans Health Administration usually pay as secondary payer if beneficiary has other health insurance • EOB copy from primary carrier should be attached to the completed CMS-1500 (02-12) claim form • Include copy of the physician’s complete itemized statement • Claim should then be sent to the local claims processor (fiscal intermediary)

26. Claims Procedure • For Medicaid: • TRICARE/Veterans Health Administration is primary • For Medicare: • TRICARE is secondary, if under 65 with Part A & Part B • Veterans Health Administration is secondary, if under 65 with Part A & Part B

27. Claims Procedure • Coordination of benefits • Needed for situations with dual coverage so there is no duplication of benefits paid • TRICARE pays the lower of: • Amount of TRICARE allowable charges after other plan has paid benefits • Amount TRICARE would have paid as primary

28. Claims Procedure • For third-party liability: • TRICARE form DD 2527 is submitted with regular claim form CMS-1500 (08-05) • Provider can submit claims only to third-party liability carrier for reimbursement • If ICD-9-CM code between 800–999, claims processor may request completion of form DD 2527

29. Claims Procedure • For Workers’ Compensation: • TRICARE/CHAMPVA billed when workers’ compensation benefits are exhausted • Beneficiary with work-related injury or illness must file the claim with the workers’ compensation carrier

30. After Claim Submission • TRICARE • For each claim a summary payment voucher is issued to the patient

31. After Claim Submission • Veterans Health Administration • For each claim an explanation of benefits document is issued to the patient summarizing actions taken

32. Questions?