Chapter 11 Military Carriers

What is Tricare?  Military healthcare services that utilize medical teams from uniformed services (Navy, Army, Air Force, etc.) AND civilian professionals  Available to active duty, retirees and beneficiaries

Who is Tricare for?  Active duty and retired members of uniformed services, their families, and survivors  Unmarried spouse and dependents under 19 of deceased active military

Terminology  Beneficiary—an individual who qualifies for TRICARE  Sponsor—active duty service member  It is the sponsor’s responsibility to report changes in beneficiary status

Who is Not Qualified?  Anyone on CHAMPVA (veterans)  Parents of active military  Secretarial and civilian positions

DEERS  Defense Enrollment Eligibility Reporting System  Computerized Database containing names and numbers of sponsors and beneficiaries  Used to verify eligibility

Authorized Providers  Credentialed through TRICARE by meeting their standards  Receive a portion of allowable services  Submit claims within 30 days from DOS  Deductibles are in effect October 1- Sept. 30  Accept assignment

Participating Providers  Must be authorized providers  May appeal claims decisions  Agree to accept TRICARE allowable  Collect patient coinsurance and bill TRICARE

NonParticipating Providers  Cannot charge more than 115% of Tricare’s allowable.  Cannot appeal claim decisions  Patient is responsible for payment to provider  TRICARE sends their portion to the patient

Payments  TRICARE fee schedule is based on Medicare fee schedule  Network Providers—bill TRICARE and collect copays and coinsurance from pt  Non-Network Providers—collect 100% of TRICARE maximum allowed (115%)  TRICARE does not pay anything for out of network

Plan Types  Standard  fee-for-service  cost share  MTF or civilian doctors  priority given to active service members  catastrophic cap

 Prime  managed care—fewest out-of- pocket expenses  Active duty automatically enrolled (no other options)  PCP  Majority of services provided at MTF  Nonactive duty members pay annual enrollment fee  No deductibles or payment at outpatient MTF

 Prime Remote  active duty service members on remote assignment  More than 50 miles from nearest MTF  no out-of-pocket  Required enrollment

 Extra  Managed Care  For civilian services (must be network)  If seek care at MTF, not priority  Annual deductible  15% coinsurance

 TRICARE for Life  Medicare-eligible retirees over 65  Required to enroll in Medicare A and B  MTF  Medicare billed first, automatically sent to Tricare (crossover claim)

 CHAMPVA  veterans and families of veterans with 100% service-related disabilities or death  Use VA facility  Cost share, annual deductible, catastrophic cap  All treatments must be approved  CHAMPVA pays after any other payer (except Medicaid)

Submitting Claims  Submit as soon as services are provided or within 30 days  Submit no later than one year after service  Do not batch bill—an error on one will hold up all

Completing the Claim  Block 1a: sponsor’s SSN or DoD number  Block 2: patient name as it appears on military ID card  Block 4: sponsor’s name (self can write SAME)

Filing Claims  PAR files for patient  NonPAR has patient pay all; patient sends bill to TRICARE