1. 1 Uniformed Services Programs

2. 2 Who are Active Duty Service Members? An active Duty Service Member (ADSM) from any of the seven branches of Armed forces is considered active. Reserve component members on active duty for more than 30 days under federal orders are also considered active. Who is Eligible for coverage? Active Duty personnel are eligible for healthcare services provided by a MTF (Military Treatment Facility) where they are given the highest priority for services. Active Duty personnel are only eligible to receive services at UCSD when they are authorized by the MTF. How do you identify the patient? These patients must present a military identification card with a valid expiration date. Active Duty Service Members

3. 3 Who are veterans? Veterans who have been rated as service connected by the US Department of Veterans Affairs (DVA). It does not matter how long they were in the service. Who is eligible? Any Veteran that has been determined to have a service connected injury, illness or death and is not dishonorably discharged are eligible for state veteran’s benefits regardless of when they served on active duty. How do you identify the patient? These patients must present a military identification card with a valid expiration date. Veterans

4. 4 Who are Retiree Service Members? Retirees are service members that have 20 years of service. This is different than a disabled veteran. Sometimes a person may be eligible for both categories. The individual may choose to receive non service connected treatments at the VA but can not receive service connected treatment outside of the VA. Who is eligible for coverage? Any member that has 20 years or more of service and is not dishonorably discharged from service. How do I identify the patient? These patients must present a military identification card with a valid expiration date. Retirees

5. 5 Who are Dependent Members? The dependents are family members of Active Duty Service Members, Veterans or Retired Service Members. This includes spouses, widow and widower, children and step children. Who is eligible for coverage? All dependents have stipulations on their eligibility. Spouses must be currently married to the sponsor Former spouses must have not remarried or covered by an Employer Group Health Plan. Children have coverage until age 21. An extension will be granted to age 23 for full time enrollment in school. Parents and Parent-in-laws are not considered dependents How do you identify the patient? These patients must present a military identification card with a valid expiration date. Children under the age of 10 may not have an ID. Check with the parent, if no ID then parent’s card can serve as eligibility. Dependents

6. 6 The Department of Defense introduced the C ivilian H ealth and M edical P rogram of the U niformed S ervices ( CHAMPUS ) to provide care for military families in civilian hospitals and to ease the stress on the Military Treatment Facilities (MTF’s). Tricare is the name of the insurance program that was developed to cover these service members. What is Tricare?

7. 7 Tricare provides 3 levels of coverage for military families and retirees: Tricare Prime (similar to HMO coverage) Tricare Extra (similar to PPO coverage) Tricare Standard (similar to indemnity coverage) In essence, this coverage is a tiered Point of Service Plan (POS Plan) Tricare’s levels of coverage….

8. 8 TRICARE Prime- is an HMO plan for eligible sponsors/service members. Enrollees are assigned to a Primary Care Manager (PCM), which could be a military medical facility or an off base civilian doctor or medical facility. Note: The acronym PCM is very similar in definition to a PCP. UC San Diego Health System is one of the civilian physician and facility options for civilian care. As with any HMO type coverage, the PCM is to provide and coordinate care, maintain the health records and make referrals as needed to specialists. Patients will not be covered if they go anywhere else without a PCM referral. In addition, since UCSD is a contracted provider for TRICARE, the TRICARE Standard coverage is not an option. If the patient has an UCSD Primary Care Manager (PCM) or a referral from their own PCM, they would be using the TRICARE Prime coverage. Tricare Prime (HMO) 8

9. 9 TRICARE Extra – A PPO option that does not require beneficiary enrollment or a PCM. Members select providers from a TRICARE directory of designated providers. They will have higher out of pocket expenses than with TRICARE Prime. Note: TRICARE Extra is not available to active duty service members. If the patient is directing their own care without the referral of their PCM, they would be using the TRICARE Extra (PPO) coverage. Tricare Extra

10. 10 TRICARE Standard –The same as the original CHAMPUS program. When beneficiaries choose to go to a provider that does not have a contract with TRICARE, they would need to use their TRICARE Standard benefits. Since UCSD is a contracted facility, patients coming here would be either TRICARE Prime or TRICARE Extra. While this plan offers the patient the greatest flexibility, it also results in the highest level of out of pocket expenses. Tricare Standard 10

11. 11 TRICAR PRIME HMO TRICAR EXTRA PPO When is TRICARE primary/ secondary? TRICARE is secondary to all health benefit and insurance plans except for Medi-Cal, Medicaid, TRICARE Supplements or the Indian Health Service. Beneficiaries who have other health insurance are not required to obtain referrals or pre-authorizations for covered services except for adjunctive dental care, organ transplants and behavioral health care services. What coverage should be used?

12. 12 Currently there are two available resources to verify eligibility for Tricare members: RTE (Real Time Eligibility) Tricare 1-877-988-WEST (1-877-988-9378) Verifying eligibility

13. 13 Sponsor social security number or DOD (Department of Defense) number Information required to run RTE

14. 14 RTE response

15. 15 The TRICARE system uses the Health Care Finder (HCF) to act in a utilization review role for providers and TRICARE members. HCF is a team of registered nurses who coordinate care in both the military and civilian health systems. When a TRICARE member needs specialty care or hospitalization, the PCM/PCP or other civilian provider works with the HCF to arrange for pre-authorization of these services. There are two types of authorizations: The first is called NAS – Non Availabilities Statement- A NAS states that the service is not available at an MTF in a reasonable amount of time The second is called a referral- A referral states there is a medical necessity for the service. Sometimes one or both may be required How is authorization obtained?

16. 16 What do I need to collect at the point of service? No payments are collected from Active Duty Service Members. Any retirees or ADSM Dependents that seek service under TRICARE Prime should pay the appropriate co-payment. Services for TRICARE Extra will be billed like all other PPO plans. What are the patient’s out of pocket responsibilities?

17. 17 What is Tricare for Life? This is a benefit for TRICARE members who are 65 and over. This program is called TRICARE for Life. Its purpose is to serve as a supplemental insurance to Medicare. Who is eligible for coverage? TFL is available to uniformed service retirees, their spouses and survivors age 65 and over who are entitled to Medicare part A and enrolled in Medicare Part B. TRICARE benefits automatically convert to TFL at age 65. Tricare for Life (TFL)

18. 18 Eligible beneficiaries must possess a current Military ID and a Medicare card indicating Part B enrollment. A separate TRICARE for Life beneficiary card is not required to receive benefits under this program. The Uniformed Services Identification (I.D.) card and the Medicare card are all that is needed for Medicare and TRICARE for Life to pay on the claim. How do you identify the patient?

19. 19 The patient would have the same coverage under TRICARE for Life. Coverage will serve as a supplement to Medicare coverage. What other coverage might a patient have? In most cases, TFL eligible beneficiaries should have little need for other health insurance besides Medicare and TFL. but…… If a beneficiary retains a supplemental policy or has other health insurance through an employer, TFL then will become the third payer. What coverage is provided at UCSD?

20. 20 Outpatient TRICARE FOR LIFE When is it primary/secondary? It will never be primary, TFL serves only as a supplement to Medicare coverage. What coverage should be used?

21. 21 The military ID card and the Medicare card are all that is needed for Medicare to pay first and TRICARE for Life to pay second on the claim. What information do you need? Identification numbers, effective dates and other related data elements. How do you determine if a patient is eligible for coverage?

22. 22 What is the Veteran Health Administration? The DVA was created to assist veterans with medical care after their service in the military. Throughout the United States there are: 173 medical centers More than 350 Outpatient, Community and Outreach clinics 126 nursing home care units 35 domiciliaries All administered by the Department of Veteran Administration (DVA). DVA healthcare facilities provide a broad spectrum of medical, surgical, and rehabilitative care. Veterans Health Administration (VHA)

23. 23 This Federal Government program provides healthcare services to Veterans with a service-connected disability, disease or injury. Military retirees not meeting these criteria are not eligible for VA coverage. Who is eligible for coverage?

24. 24 You can use the patient’s Military ID to identify their status. Patients will likely present for services with an authorization form. How do you identify the patient?

25. 25 The Veteran Health Administration offers qualifying military personnel a full range of services for illnesses, injuries or disabilities that are service-connected. In most cases those services are provided at the Veteran’s Administration Hospital in La Jolla, CA. When the service can not be provided by the VA facility, the patient may possibly be referred to UCSD for authorized care. What coverage is provided at UCSD?

26. 26 Patients may have other healthcare coverage. However it is not required if the patient is going through the VA for a service connected to an illness, injury or services connected disability. What other coverage might a patient have?

27. 27 Outpatient VETERANS ADMIN When is VA primary? When the patient is referred to UCSD for treatment of a service-connected illness, injury or disability. When is VA secondary? It is rare that VA benefits would have a coordination of benefits with any other payor. In the event additional benefits are available and required to be used, it would be stated as such on the authorization for services given by the VA facility. What coverage should be used?

28. 28 The Station of Jurisdiction – Veterans Administration Hospital in La Jolla should be contacted in order to verify eligibility. Department of Veteran Affairs office: 1-800-733-8387 How do you determine if a patient is eligible for coverage?

29. 29 Outpatient: Patient should present with an authorization form (VA form 10-7079). If the VA Hospital gives a verbal authorization, it should be followed with a written/faxed document. There are no out of pocket expenses. What are the authorization requirements?

30. 30 What is CHAMPVA and who is eligible? CHAMPVA is a healthcare benefits program, administered by the Veterans Administration (VA) for: Dependents of veterans who have been rated by VA as having a total and permanent disability. Survivors of veterans who died from VA rated service connected conditions, or who at the time of death were rated permanently and totally disabled from a VA rated service-connected condition. Survivors of a person who died in the line of duty and not due to misconduct. Note: CHAMPVA bases its benefit structure on the TRICARE Standard option, however there are no other ties between the programs. CHAMPVA is for qualifying family members of an eligible deceased veteran, as well as the 100% permanently and totally disabled veterans. Military dependents eligible for Tricare are NOT eligible for CHAMPVA CHAMPVA

31. 31 Every CHAMPVA beneficiary has a CHAMPVA Authorization Card. The CHAMPVA Authorization (A-card) Number will be the same as the patient’s social security number. Not all cards will have a Plan or Group number. Children will have their own ID card. How do you identify the patient?

32. 32 Full scope care is available to CHAMPVA beneficiaries as long as proper eligibility and authorization requirements have been met. What other coverage might a patient have? Group coverage, Private insurance or Medicare What coverage should be used? CHAMPVA When is CHAMPVA primary? CHAMPVA is the primary payer only when there is no other insurance and when the patient is eligible to be covered by state public programs such as Medi-Cal, CMS, and Victims of Crime. When is CHAMPVA secondary? CHAMPVA is always secondary unless the above conditions exist What coverage is provided at UCSD?

33. 33 Eligibility can be verified by using RTE or phone calling the Department of Veteran Affairs office at: 1-800-733-8387 How do you determine if the patient is eligible for coverage?