TRICARE Your Military Health Plan Retiree Benefits CCGNRC Annual Conference Mark Freese, DMD MPH MHA CAPT USPHS 27 April 2010

2 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

3 TRICARE Regions Ft. Campbell moves to the South with T3 =TRICARE Regional Office (TRO)

4 TRICARE Regional Contractors may change with T-3 TRICARE North Region –Health Net Federal Services, Inc. – –1-877-TRICARE ( ) TRICARE South Region –Humana Military Healthcare Services, Inc. – – TRICARE West Region –TriWest Healthcare Alliance – –1-888-TRIWEST ( )

5 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. DEERS (Defense Enrollment Eligibility Reporting System)

6 Visit an ID card issuing facility; locate one near you at Call: (address changes only) Fax changes to: Mail changes to: Defense Manpower Data Center Support Office Attn: COA 400 Gigling Road Seaside, CA Make address changes online at: Updating DEERS Information

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) 7

Transitioning from Active Duty to Retirement Health Care Options

9 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?

10 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.

11 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

12 1.Active duty service members 2.Active duty family members enrolled in TRICARE Prime * 3.Retirees, their family members, and others enrolled in TRICARE Prime 4.Active duty family members NOT enrolled in TRICARE Prime 5.Retirees, their family members, and others NOT enrolled in TRICARE Prime 6.All other eligible beneficiaries * If spouse is still active duty, use status as Active Duty Family Member when accessing medical care. MTF—Priorities for Care

13 How TRICARE Changes When You Retire When on Active DutyUpon Retirement TRICARE Options TRICARE Prime TRICARE Prime Remote TRICARE Extra * TRICARE Standard * TRICARE Prime TRICARE Extra TRICARE Standard TRICARE Prime No enrollment fees No copayments Enrollment fees apply Copayments apply in network TRICARE Extra15% cost-share20% cost-share TRICARE Standard20% cost-share25% cost-share Catastrophic Cap$1,000 annually$3,000 annually MTF Access ADSMs—1 st priority ADFMs—priority depends on enrollment in TRICARE Prime Priority depends on enrollment in TRICARE Prime Medicare-eligibility Family members not required to purchase Medicare Part B Must purchase Medicare Part B regardless of age * ADSMs are not eligible for TRICARE Extra or TRICARE Standard

14 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

15 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

16 Preferred provider option (PPO) No enrollment required Seek care from any TRICARE network provider 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

17 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

18 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 TRICARE network 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

19 TRICARE Prime Enrollment Prime does not automatically carry over into retirement A new enrollment application must be completed for the region you live in to continue in Prime Deadline for admission – 20 th 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

20 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. Enrollment Types

21 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 Primary Care Manager (PCM)

22 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

23 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

24 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

25 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

26 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

27 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.

28 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.

29 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: 1.Continuous home care 2.General hospice inpatient care 3.Inpatient respite care 4.Routine home care Note: Only available in the United States and Territories.

Transitioning from Active Duty to Retirement Pharmacy Options

31 MTF Pharmacy TRICARE Mail Order Pharmacy (TMOP) – now called home delivery TRICARE Retail Network Pharmacy Non-network Retail Pharmacy TRICARE Pharmacy Program

32 Pharmacy Co-Pay Structure Type of Pharmacy Formulary Non-Formulary (Tier 3) Generic (Tier 1) Brand Name (Tier 2) Military Treatment Facility (up to a 90-day supply) $0 Not applicable Home Delivery (up to a 90-day supply) $3$9 $22 unless medical necessity is established Retail Network (up to a 30-day supply) $3$9 $22 unless medical necessity is established Non-Network (up to a 30-day supply) $9 or 20 percent of the total cost, whichever is greater, after your annual outpatient deductible is met $22 or 20 percent, whichever is greater, after your annual outpatient deductible is met

33 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 Generic Drug Use Policy

34 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. TRICARE and OHI

35 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

36 Claims Assistance Call regional contractor for area you live in Go online to 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

37 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

38 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

39 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) What is Medicare?

40 Medicare Basics Part A Hospital Insurance Part B Medical Insurance Part C Medicare Advantage Plan Part D Prescription Drug Coverage Inpatient hospital care Skilled nursing care Home health care Hospice care Doctors’ services and outpatient care Preventive services Diagnostic tests Some therapies Durable medical equipment Combines Part A, Part B, and, sometimes, Part D Coverage managed by private insurance companies approved by Medicare. Outpatient prescription drugs

Part B details You Pay MonthlyIf Your Yearly Income is File Individual Tax Return File Joint Tax Return $ $85,000 or less$170,000 or less $ $85,001-$107,000$170,001-$214,000 $ $107,001-$160,000$214,001-$320,000 $ $160,001-$214,000$320,001-$428,000 $ Above $214,000Above $428,000

42 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 , Section 712

43 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

44 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.

45 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.

46 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 Medicare TRICARE

47 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

48 How TFL Works with Medicare Examples: Overseas care, shingles vaccine Services covered by TRICARE but not by 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

49 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%

50 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%

51 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 Medicare TRICARE OHI How TFL Works with Medicare

52 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.

53 TRICARE For Life (TFL) is the primary payer for health care services received overseas since Medicare doesn’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 Overseas

54 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. TRICARE TRICARE For Life Overseas

55 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.

56 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

57 Medicare Pays TRICARE Pays Beneficiary Pays Days %Remaining liability (if any)Nothing for services paid by Medicare and TRICARE Days All but $128/day 1 copay each benefit period $128/day copay Nothing for services paid by Medicare and TRICARE Days 101+ NothingNetwork Skilled Nursing Facility: Negotiated charges minus your copay/cost shares for institutional and professional charges Non-Network: Skilled Nursing Facility TRICARE allowed amount minus your cost shares for institutional and professional charges Network Hospital Skilled Nursing Facility $250/day copay or a 25% cost share of total negotiated institutional charges, whichever is less, plus a 20% cost share for separately billed negotiated professional charges Non-Network Skilled Nursing Facility 25% cost share of the TRICARE allowed amount for institutional charges, plus a 25% cost share of the TRICARE allowed amount for separately billed professional charges 1 These Medicare amounts are for 2009, and may change on January 1 st of each year. Skilled Nursing Facility Care Payment

58 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.

59 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) –Beneficiaries can visit the WPS TFL website at

60 TRICARE National Resources TRICARE Web Site – 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 ( )

61 DEERS TRICARE Mail Order Pharmacy (Express Scripts) DoD-TMOP ( ) TRICARE Retail Pharmacy (Express Scripts) DoD-TRRx ( ) Important Contacts

1.Local TRICARE Support Office Health Safety & Work-Life Support 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 62 Need Further Assistance?

63 QUESTIONS ?