Transcript TRICARE Extra

CHAPTER
12
TRICARE and
CHAMPVA
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
12-2
Learning Outcomes
When you finish this chapter, you will be able to:
12.1
12.2
12.3
12.4
12.5
12.6
Discuss the eligibility requirements for TRICARE.
Compare TRICARE participating and
nonparticipating providers.
Explain how the TRICARE Standard, TRICARE
Prime, and TRICARE Extra programs differ.
Discuss the TRICARE for Life program.
Discuss the eligibility requirements for CHAMPVA.
Demonstrate the ability to prepare correct TRICARE
and CHAMPVA claims.
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
Key Terms
• catchment area
• catastrophic cap
• Civilian Health and
Medical Program of the
Department of Veterans
Affairs (CHAMPVA)
• Civilian Health and
Medical Program of the
Uniformed Services
(CHAMPUS)
• cost-share
12-3
• Defense Enrollment
Eligibility Reporting
System (DEERS)
• Military Treatment
Facility (MTF)
• nonavailability statement
(NAS)
• Primary Care Manager
(PCM)
• sponsor
• TRICARE
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
Key Terms (Continued)
12-4
•
•
•
•
•
TRICARE Extra
TRICARE for Life
TRICARE Prime
TRICARE Prime Remote
TRICARE Reserve
Select (TRS)
• TRICARE Standard
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
12.1 The TRICARE Program
12-5
• TRICARE—government health program serving
dependents of active-duty service members,
military retirees and their families, some former
spouses, and survivors of deceased military
members
– Members of the Army, Navy, Air Force, Marine Corps,
Coast Guard, Public Health Service, and National
Oceanic and Atmospheric Administration and their
families are eligible for TRICARE
– Reserve and National Guard personnel become
eligible when on active duty for more than thirty
consecutive days or on retirement from reserve status
at age sixty
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
12.1 The TRICARE Program (Continued)
12-6
• CHAMPUS—the Civilian Health and Medical
Program of the Uniformed Services, which was
replaced by the TRICARE program
• Sponsor—uniformed service member in a
family qualified for TRICARE or CHAMPVA
• Defense Enrollment Eligibility Reporting
System (DEERS)—worldwide database of
TRICARE and CHAMPVA beneficiaries
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
12.2 Provider Participation and
Nonparticipation
12-7
• Participating providers:
– Accept the TRICARE allowable charge as payment in
full for services
– Are required to file claims on behalf of patients
– May appeal a decision
• Nonparticipating providers:
– May not charge more than 115 percent of the
allowable charge
– May not appeal a decision
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
12.2 Provider Participation and
Nonparticipation (Continued)
12-8
• Patients:
– Pay the provider, and TRICARE pays its portion of the
allowable charges directly to the patient
• Cost-share—coinsurance for a TRICARE or
CHAMPVA beneficiary
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
12.3 TRICARE Plans
12-9
• TRICARE Standard—fee-for-service health plan
– Medical expenses are shared between TRICARE and
the beneficiary
– Most enrollees pay annual deductibles and cost-share
percentages
• Military Treatment Facility (MTF)—provides
medical services for members and dependents
of the uniformed services
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
12.3 TRICARE Plans (Continued)
12-10
• Catastrophic cap—maximum annual amount a
TRICARE beneficiary must pay for deductible
and cost-share
• Catchment area—geographic area served by a
hospital, clinic, or dental clinic
• Nonavailability statement (NAS)—form
required when a TRICARE member seeks
medical services outside an MTF
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
12.3 TRICARE Plans (Continued)
12-11
• TRICARE Prime—basic managed care health
plan
– After enrollment, each individual is assigned a
Primary Care Manager (PCM)—provider who
coordinates and manages the care of TRICARE
beneficiaries
– Offers additional preventive care, including routine
physical examinations
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
12.3 TRICARE Plans (Continued)
12-12
• TRICARE Prime Remote—plan that provides
no-cost health care through civilian providers for
service members and their families who are on
remote assignment
• TRICARE Extra—managed care health plan
that offers a network of civilian providers
– Individuals must receive health care services from a
network of health care professionals
• TRICARE Reserve Select (TRS)—TRICARE
coverage for military reservists
– Premium-based health plan available for purchase
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
12.4 TRICARE and Other Insurance Plans 12-13
• TRICARE for Life—program for beneficiaries
who are eligible for both Medicare and TRICARE
– Individuals age sixty-five and over who are eligible for
both Medicare and TRICARE may continue to receive
health care at military treatment facilities
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
12-14
12.5 CHAMPVA
• Civilian Health and Medical Program of the
Department of Veterans Affairs (CHAMPVA)—
the government’s health insurance program for
veterans with 100 percent service-related
disabilities and their families
– Health care expenses are shared between the
Department of Veterans Affairs (VA) and the
beneficiary
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
12-15
12.5 CHAMPVA (Continued)
• Individuals eligible for the CHAMPVA program
include:
– Veterans who are totally and permanently disabled
due to service-connected injuries
– Veterans who were totally and permanently disabled
due to service-connected conditions at the time of
death
– Spouses or unmarried children of a veteran who is
100 percent disabled or who died as a result of a
service-related disability in the line of duty
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.
12.6 Filing Claims
12-16
• Participating providers file TRICARE claims with
the contractor for the region on behalf of patients
• Individuals file their own TRICARE claims when
services are received from nonparticipating
providers
• Most CHAMPVA claims are filed by providers
and submitted to the centralized CHAMPVA
claims processing center
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.