TRICARE… The Basics TRICARE Liaison Office Headquarters, Marine Corps Manpower and Reserve Affairs 1stLt M. M. Hoesing

F F TRICARE Prime F F TRICARE Standard/Extra F F TRICARE Prime Remote F F TRICARE Prime Remote for Active Duty Family Members

What is TRICARE? F Unifomed Services “Medical Plan” * 3 Options: * PRIME * EXTRA * STANDARD

BASIC ACRONYMS/DEFINITIONS F F PCM F F HCF F F DCAO F F MTF F F BCAC F F NURSELINE

USEFUL WEBSITES F F

TRICARE Prime

F Prime Terms : * Primary Care Manager (PCM) * Point -of-Service (POS)

TRICARE Prime F Enrollment * Need to identify/select a Primary Care Manager (PCM) for each family member PCMs usually are assigned –MTF or Civilian Network –May be a Family Practitioner, Pediatrician, Internist, Flight Surgeon, sometimes an OB/Gyn –May be a M.D., Physician Assistant, Nurse Practitioner, (Individual/Group/Team)

TRICARE Prime F Enrollment * Prime ID card/enrollee Always carry it with you! * “Split” enrollment…family members enrolled in other TRICARE regions * Prime follows you (portability)

TRICARE Prime F Portability…let’s talk! * Prime Site-to-Prime Site “Transfer Enrollment” upon arrival –Follow authorization rules in transit Same anniversary dates Enrollment fees transfer (All Others) * Prime Site-to-Non-Prime Site Disenroll upon arrival (covered enroute) * Non-Prime Site-to-Prime Site It’s decision time!

TRICARE Prime F Getting care... * Always call your chosen (or assigned) Primary Care Manager (PCM) first Military or Civilian Manage your TOTAL care * When referred for care, the authorization process begins with the Primary Care Manager Via the Health Care Finder (HCF) PCM HCFHCF

TRICARE Prime F “Traveling-out-of-your-Area” Care * Prime ID card * Coverage Urgent care: Call PCM first! Emergency care: Notify MCSC No routine care when away from PCM!

TRICARE Standard/Extra

F TRICARE Standard (Same as CHAMPUS) * Two Questions to always ask provider: First: Are you a TRICARE “authorized” provider? Second: Are you a “participating” provider?

TRICARE Standard/Extra F TRICARE “Extra” * You are TRICARE Standard!!! * Use MCSC network visit-by-visit –Shop the MCSC’s Provider Directory * Incentive: Get discount on cost share!

TRICARE Standard/Extra TRICARE Standard/Extra * You pay for Standard/Extra care like this... * First, the Deductible (each Fiscal Year) Active Duty Family Member (ADFM) –E-1 to E-4: $50 / individual & $100 / family –E-5 & Up: $150/individual & $300 / family All Others –$150 / individual & $300 / family

TRICARE Standard/Extra * After Deductible is Met, THEN... * Pay Cost Share Active Duty Family Member (ADFM) –Standard: 20% –Extra: 15% All Others –Standard: 25% –Extra: 20%

TRICARE Standard/Extra * Plus, with Standard (not Extra) you pay balance billing costs for care from non- participating providers * To avoid balance billing: - Ask if provider will participate (may or may not) - Or use network provider (Extra)

TRICARE Standard/Extra * Maximum your family will pay for TRICARE covered services (Catastrophic Cap) ADFM (per SSN): $1000 / fiscal year All Others (per SSN): $3000 / fiscal year

TRICARE Standard/Extra * Non-Availability Statements (NAS) Still need NAS for inpatient care –When you live within 40 miles of MTF Except –If you have other health insurance –Emergency admission

TRICARE Standard/Extra * Maternity Non-Availability Statements NAS required for all maternity care – including birthing centers – home delivery Issued once pregnancy is confirmed by MTF

TRICARE Standard/Extra F What monies go towards catastrophic cap? * Deductibles * Cost-shares * Note: For balance billing situations, monies paid over CMAC are not applied to catastrophic cap

F When does MHS care change/end for AD? * Retirement May choose TRICARE Prime or TRICARE Standard/Extra as Retiree * Separate from Service Active Duty & TRICARE

TRICARE Prime Remote “Bringing the Benefit to Where You Live…Wherever You Live”

TRICARE Prime Remote Purpose F Provide easier access to civilian health care for remotely assigned Active Duty Service Members (ADSMs) & certain Active Duty Family Members (ADFM’s) * Reduces hassles and separation from family * Assists Unit Commanders by keeping ADSMs on the job * Continues to ensure fitness for duty * ADFM’s MUST RESIDE with the ADSM to obtain eligibility for TPRFM

New program…new acronyms!! F MMSO - Military Medical Support Office Office F SPOC - Service Point of Contact

Eligibility F Active Duty Service Members (ADSMs) * Includes Reservists or National Guard Members on orders to Active Duty for greater than 30 days TPR areas are designated by zip codes Must work and live in TPR designated areas (*) Geographic barriers and other circumstances may justify “remote”designations that are less than 50 miles from an MTF

Eligibility F Active Duty Family Members: F ADFM’s MUST reside with the ADSM * Must enroll in Prime even if none available * ADFM’s get same benefit as those residing in “Prime Network” areas * “Waived Charges” benefit in place

Eligibility Am I Eligible? F Two Ways to Check * Check TRICARE Prime Remote Web Site: “ Provides Eligibility Information Based on Work and Home Zip Codes * Call Toll-Free Beneficiary Information Line for Local Region

Enrollment F ADSM and ADFM’s Complete Regional Enrollment Form. * Available from Unit or Call Contractor’s Toll-Free Number F Sends to Regional Address Provided by the Contractor

Getting Care F Selecting A Provider...Two Options: * 1. Choose a Primary Care Manager (PCM) from the Network (if available) * 2. If No Network Providers, Select Any TRICARE-Authorized Provider from the Community Must be A Primary Care Provider Examples Include: Family Practice, Internal Medicine, General Practice or OB/GYN

Finding a TRICARE Authorized Provider F Visit the TRICARE Web Site at F Call the Regional contractor for assistance F Ask the provider when you call to make an appointment - “Are you an authorized TRICARE provider?”

Primary Care Services F See your PCM or Primary Care Provider F Prior-authorization is Not Required for Primary Care Services

Primary Care Services Examples F Routine health services (sick call) F Laboratory tests F X-rays F Immunizations F Hearing tests/routine eye exams F Breast Exams and mammography F Pap Smears F Prostate/early Cancer diagnosis exams

Specialty Care for the ADSM F Pre-authorization is Required for All Specialty Care F Your PCM (or You) Must Call the Health Care Finder (HCF) for Pre-authorization * The HCF Will Check with MMSO to Ensure Care Does Not Require A “Fitness for Duty” Evaluation by A Military Provider * You Will Receive Approval for Civilian Care or Referral to a Military Facility in 2 Working Days (sooner, if urgent)

Pre-Authorization Requirements F Specialty Care F Routine maternity care F Physical therapy F Mental Health services F Family Counseling F Smoking cessation program All Require Pre-authorization!

Filing Medical Claims F Network and Participating Providers will file claims F For Non-Participating Providers, ADSMs may have to file claim * But...ADSMs will be FULLY reimbursed for authorized out-of-pocket costs

Filing Medical Claims F When filing Medical Claims on your own, you must have the following documents: * Completed DD Form 2642 (CHAMPUS Claim Form) available on TRICARE web site * Itemized medical bill * Proof of payment

Filing Medical Claims F All claims (regardless of who files the claim) will generate an “Explanation of Benefits (EOB)” to the ADSM F Information on the EOB Includes: * Amount of Billed Charges * CMAC (CHAMPUS Maximum Allowable Charge) * Amount Paid to the Provider or reimbursed to the ADSM

QUESTIONS???