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TRICARE Your 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)

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TRICARE Your Military Health Plan

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Tricare your military health plan

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

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

TRICARE Regions

Ft. Campbell moves to the South with T3

=TRICARE Regional Office (TRO)


Tricare regional contractors may change with t 3

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

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

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

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

Transitioning from Active Duty to Retirement

Health Care Options


Decision process

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

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

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 p riorities for care

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

How TRICARE Changes When You Retire

* ADSMs are not eligible for TRICARE Extra or TRICARE Standard


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

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

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

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


Tricare extra vs standard

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

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

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

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

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

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

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

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

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


Durable medical equipment

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

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

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 retirement1

Transitioning from Active Duty to Retirement

Pharmacy Options


Tricare pharmacy program

TRICARE Pharmacy Program

  • MTF Pharmacy

  • TRICARE Mail Order Pharmacy (TMOP) – now called home delivery

  • TRICARE Retail Network Pharmacy

  • Non-network Retail Pharmacy


Pharmacy co pay structure

Pharmacy Co-Pay Structure


G eneric drug use policy

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


T ricare and ohi

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

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

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

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 life1

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

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)


  • Medicare basics

    Medicare Basics


    2010 part b details

    2010 Part B details


    A bit of history

    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

    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

    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 life2

    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.


    How tfl works with medicare

    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 medicare1

    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 medicare2

    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 medicare3

    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 medicare4

    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%


    How tfl works with medicare5

    Medicare

    OHI

    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 other health insurance (OHI)

    Step 4: Beneficiary files a paper claim with the TRICARE For Life (TFL) claims processor

    Step 5: TFL pays TRICARE’s portion of the claim directly to the beneficiary


    Tricare for life overseas

    TRICARE For Life Overseas

    • TRICARE beneficiaries who live overseas must meet the same requirements as TRICARE beneficiaries who live in the United States...they need to be enrolled in Medicare Part B.

    • TRICARE For Life provides the same level of coverage overseas as provided to TFL beneficiaries living in the United States.


    Tricare for life overseas1

    TRICARE For Life Overseas

    • TRICARE For Life (TFL) is the primary payer for health care services received overseas since Medicaredoesn’t cover care received outside of the United States or its territories.

    • TFL overseas beneficiaries are responsible for meeting the TRICARE deductible of $150 individual/$300 family plus a 25% cost share.

    Example: Overseas doctor’s visit

    Medicare pays $0

    TRICARE pays 75%

    Beneficiary pays 25%


    Tricare for life overseas2

    TRICARE

    TRICARE For Life Overseas

    • Step 1: Beneficiary goes to a host nation provider

    • Step 2: Beneficiary pays provider upfront

    • Step 3: Beneficiary files a claim with the TRICARE overseas claims processor

    • Step 4: TRICARE For Life reimburses the beneficiary 75%

    • Expatriates must still carry Medicare Part “B” even though Medicare does not pay overseas.


    Skilled nursing facility care

    Skilled Nursing Facility Care

    • Skilled care is given in a skilled nursing facility (SNF).

    • A SNF can be part of a nursing facility or hospital.

    • Medicare certifies these facilities if they have the staff and equipment to give skilled nursing care and/or skilled rehabilitation services and other related health services.


    Skilled nursing facility care1

    Skilled Nursing Facility Care

    Medicare and TRICARE for Life will cover skilled care if the beneficiary:

    • Requires daily skilled services which can only be provided in a skilled nursing facility

    • Was admitted as an inpatient in a hospital at least 3 consecutive days or more, not counting the day the beneficiary leaves the hospital

    • Is admitted to a SNF within 30 days after leaving the hospital

    • Receives care for a condition that was treated in the hospital

    • The facility must be a Medicare participating SNF and must enter into a participation agreement with TRICARE


    Skilled nursing facility care payment

    Skilled Nursing Facility Care Payment


    Long term care

    Long-Term Care

    • Long-term care is a type of care beneficiaries may need if they can no longer perform everyday tasks ("activities of daily living") by themselves due to a chronic condition or cognitive impairment, like Alzheimer's disease.

    • Long-term care can be given in a variety of settings, including assisted-living facilities, adult day care centers, or nursing homes.

    • Long-term care isn’t covered by Medicare or TRICARE.


    Claims processing

    Claims Processing

    • Wisconsin Physician Services (WPS), the TRICARE For Life contractor, processes TRICARE For Life (TFL) claims.

      • Beneficiaries may call WPS TFL from 7a.m. to 10p.m. central time Monday through Friday at (866)773-0404.

      • Beneficiaries can visit the WPS TFL website at www.tricare4u.com.


    Tricare national resources

    TRICARE National Resources

    • TRICARE Web Site

      • www.tricare.mil

        • Five main portals

          • My Benefit (benefit information)

          • My Health (MTF online appointing, personal health information, medication/pharmacy tools)

          • MHS Staff (information about Military Health System)

          • Providers (information for TRICARE providers)

          • Pressroom (latest TRICARE news and information)

    • TRICARE FOR LIFE (1-866-773-0404 )


    Important contacts

    Important Contacts

    • DEERS

      1-800-538-9552

      www.tricare.mil/deers

    • TRICARE Mail Order Pharmacy

      (Express Scripts)

      1-866-DoD-TMOP (1-866-363-8667)

      www.express-scripts.com/TRICARE

    • TRICARE Retail Pharmacy

      (Express Scripts)

      1-866-DoD-TRRx (1-866-363-8779)

      www.tricare.mil/pharmacy


    Need further assistance

    Need Further Assistance?

    • Local TRICARE Support Office

    • www.TRICARE.mil

    • Health Safety & Work-Life Support Activity @ 1-800-9-HBA-HBA

      • HSWL SUPACT will contact the liaison officer of the applicable TRO

      • National problems will go to the liaison officer of the TRICARE Management Activity in Falls Church, VA


    Questions

    QUESTIONS ?


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