TRICARE

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TRICARE Your Military Health Plan
Transitioning from Active Duty to Retirement -
2008
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Decision Process

• Where will you live?
• Will you be employed?
• How is your and your familys health?
• What health plans are available?
• What are the costs of the different plans?
• Are you and your family insurable?
• Will you need supplemental insurance?

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TRICARE Regions
Regional Contractors TRICARE North (Health
Net) 1-877-TRICARE (1-877-874-2273) TRICARE
South (Humana) 1-800-444-5445 TRICARE West
(TriWest) 1-888-TRIWEST (1-888-874-9378)
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TRICARE Eligibility

• Must show eligible in DEERS
• Active duty retired sponsors
• Medal of Honor recipients
• Family members (spouse and children)
• Unmarried children to age 21 23 if full-time
  student
• Incapacitated child (if determined physically or
  mentally disabled prior to age 21)
• Valid ID card required for all beneficiaries age
  10 and older
• Certain survivors
• Certain former spouses

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Defense Enrollment Eligibility Reporting System
(DEERS)

• Defense Enrollment Eligibility Reporting System
• Defense Manpower Data Center Support Office (DSO)
• Phone [phone]
• Fax [phone]
• Mail DSO (Attn COA or TFL), 400 Gigling Road,
  Seaside, CA 93955-6771
• Web www.tricare.mil/DEERS

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Making Changes in DEERS

• Demographic changes (address, phone)
• Can be done in person by phone, fax or mail or
  online
• To add or remove a family member
• Sponsor responsibility
• Personnel / ID Card Office
• Birth, death, adoption, marriage, divorce
• Documentation required
• Certificates
• Decrees

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DEERS Unremarried Former Spouses

• Unremarried Former Spouses
• Former spouses SSN used to verify eligibility
  (20/20/20 rule)
• Not eligible if covered by an employer-sponsored
  health plan
• Personnel / ID Card Office
• Stepchildren eligibility

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Accessing Care During Terminal Leave

• ADSM is still considered active duty during the
  terminal leave period and must access care under
  the Prime rules
• Access care through the nearest MTF
• Go to a civilian hospital-based emergency room
• Call back to PCM / Regional contractor to
  authorize urgent care through a civilian doctor
  or urgent care clinic
• Routine care from other than your PCM will not be
  authorized while on terminal leave

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How TRICARE Changes When You Retire
ADSMs are not eligible for TRICARE Extra or
TRICARE Standard for ADFMs only
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Military Treatment Facilities Access to Care

• Upon retirement, your access to services at an
  MTF will change to a lower priority
• You will have higher priority access to specialty
  care in an 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
• Access to most ancillary services will continue
  (pharmacy, lab, x-ray, immunizations, emergency
  room)

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Military Treatment Facility Priorities for Care

• Active duty service members
• Active duty family members enrolled in Prime
• Retirees, their family members, and others
  enrolled in Prime
• Active duty family members NOT enrolled in
  TRICARE Prime
• Retirees, their family members, and others NOT
  enrolled in Prime
• All other eligible beneficiaries
• If spouse is still active duty, use status as
  Active Duty Family Member when
• accessing medical care

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Catastrophic Cap

• Annual (fiscal year) out-of-pocket expense for
  TRICARE-covered benefits
• Deductibles
• Co-payments
• Active duty families
• 1000/year
• Retiree and retiree families
• 3000/year

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TRICARE Options

• Prime
• Managed Care Plan/HMO
• Extra
• PPO
• Standard
• Fee for Service

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TRICARE Standard

• Fee-for-service option (old CHAMPUS)
• No enrollment required
• Seek care from any TRICARE-authorized provider
• Responsible for annual deductibles and cost-
  shareshighest out-of-pocket expense
• May have to pay up-front, then file claim for
  reimbursement
• May seek care in an MTF on a space-available basis

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TRICARE Standard Costs

• Deductible
• 150 individual/300 family per fiscal year
• Cost-shares after deductible has been met
• Outpatient care 25 of TMAC (when using a
  non-participating provider, patient may be
  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

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TRICARE Extra

• 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

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TRICARE Extra Costs

• Deductible
• 150 individual/300 family annually
• 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

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TRICARE Standard Extra a Comparison

• Annual deductible
• Active duty E-4 and below 50 individual/100
  for family
• Active duty E-5 and above 150 individual/300
  for family
• Retirees and families 150 individual/300 for
  family
• Extra cost-shares (outpatient, after deductible)
• Active duty family members 15 of negotiated
  rate
• Retirees and their family members 20 of
  negotiated rate
• No balance-billing claims filed for you
• Standard cost-shares (outpatient, after
  deductible)
• Active duty family members 20 of TMAC
• Retirees and their family members 25 of TMAC
• Can balance bill up to 15 more than TMAC may
  have to file your own claims

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TRICARE Prime Enrollment

• Prime does not automatically carry over into
  retirement
• A new enrollment application must be completed
  for the Region where you will live to continue in
  TRICARE Prime
• Deadline for submission 20th of each month
• Annual 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
• If your spouse is active duty, enroll in Prime as
  an Active Duty Family Member (ADFM)
• Former spouse, if eligible, considered own
  sponsor
• Separate enrollment fees apply
• Must select or be assigned a PCM

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TRICARE Prime Enrollment Types

• New Enrollment
• First time enrollment as a retiree
• PCM Change
• Changing PCMs within the same Region
• Portability
• Changing PCMs from one Region to another
• Split Enrollment
• When family members live and enroll in different
  Regions enrollment fee paid in Region where the
  sponsor lives

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Primary Care Manager (PCM)

• MTF or network provider
• Provides most of your primary care and
  coordinates specialty care when needed
• Knows your family 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
  preventive vision check every two years at no
  cost

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TRICARE Prime Costs

• 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

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TRICARE Prime Point of Service (POS)

• Unauthorized, non-emergent care
• Retro-authorizations not granted
• Allows freedom of choice
• Outpatient fiscal year deductible
• 300/individual
• 600/family
• Patient responsibility 50 of TMAC
• Plus 15 more is possible for non-participating
  providers
• No upper limit to POS Catastrophic Cap

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TRICARE Prime Newborn Enrollment

• Conditional Enrollment
• Newborns are covered under TRICARE Prime for
  the first 60 days after birth - as long as one
  additional family member is enrolled in Prime

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Traveling with TRICARE Prime

• Use MTF if near a military base
• All routine medical care should be taken care of
  before traveling, or delayed until after
  returning
• Including immunizations, routine exams, and
  medication refills
• For out-of-area acute or urgent care, the PCM or
  the Regional contractor should be contacted for
  an authorization before obtaining care
• For out-of-area emergency care, call 911 or go to
  the nearest hospital-based emergency room
  (military or civilian Prudent Lay Person Rule)

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Access to Care when Living Overseas

• You and your eligible family members have access
  to MTF facilities overseas on a space-available
  basis
• You will not be eligible for enrollment in
  TRICARE Prime while living overseas, but will be
  covered for civilian health care under TRICARE
  Standard
• The same annual deductibles and cost-shares will
  apply as when using TRICARE Standard in the
  United States

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TRICARE and Other Health Insurance (OHI)

• TRICARE generally pays after all OHI plans
  except
• Medicaid
• TRICARE supplements (which are used to pickup
  remaining cost shares after TRICARE has processed
  the claim)
• Referrals and prior authorization are not
  required for TRICARE-covered services (except for
  adjunctive dental and behavioral health care)
• However, any OHI referral and authorization
  requirements must be followed
• Submit claims to TRICARE (with copy of OHIs EOB)
  for amounts not paid by OHI
• Use OHI with TRICARE Standard/Extra
• Not recommended with Prime

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Comparison of TRICARE Prime and OHI Premiums
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Claims Filing

• Who is responsible for filing claims?
• Network provider/participating provider
• Beneficiary
• Forms needed for filing claims
• TRICARE Claim Form (DD-2642)
• Full Itemized Statement (HCFA-1500)
• Statement of Personal Injury (DD-2527)
• OHI Explanation of Benefits (EOB)
• Prescriptions

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Claims Assistance

• Contact the TRICARE contractor for your Region
  (North, South or West)
• Go online to www.myTRICARE.com
• Contact the HBA/BCAC office at the nearest
  military hospital or clinic
• Claims normally process within 21 to 30 days of
  the date medical care was received and you will
  receive an Explanation of Benefits (EOB) in the
  mail

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TRICARE Pharmacy Program

• MTF Pharmacy
• TRICARE Mail Order Pharmacy (TMOP)
• Express Scripts 1-866-DoD-TMOP (363-8667)
• www.express-scripts.com/TRICARE
• TRICARE Retail Network Pharmacy
• Express Scripts 1-866-DoD-TRRx (363-8779)
• www.tricare.mil/pharmacy
• Non-network Retail Pharmacy

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TRICARE Pharmacy Generic Drug Use Policy

• Generic versions of prescription drugs will be
  dispensed when available
• Medical necessity must be justified when
  specifically requesting brand name drugs over
  generic versions
• When generic equivalents do not exist, the brand
  name version will be dispensed

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Pharmacy Costs
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Other Health Insurance (OHI) and Pharmacy

• The MTF pharmacy can still be used, even if you
  have OHI
• If prescription drugs are covered by OHI
• When using a retail pharmacy, OHI will be the
  primary payer, and TRICARE will be secondary
• Electronic coordination of benefits apply when
  using a network retail pharmacy (pharmacy files
  to both OHI and TRICARE)
• The Mail Order Pharmacy (TMOP) program cannot
  normally be used with OHI, unless you have
  reached the OHI benefit cap, or the prescribed
  drug is not covered by the OHI
• If using a non-network retail pharmacy, the
  pharmacy will generally file to OHI and you must
  submit a claim to TRICARE
• If prescription drugs are not covered by the OHI,
  or if you have reached the OHI benefit cap, you
  may use either the TMOP or retail pharmacy
  benefits

BR402101BET0504C
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TRICARE For Life

• Eligibility
• Medicare-eligible sponsors and family members,
  including retired guardsmen and reservists age 65
  and over, and widows and widowers
• Certain former spouses if eligible for TRICARE
  before age 65 (20/20/20 rule)
• Requires enrollment in Medicare Part B
• TFL coverage effective date
• First day of month eligible beneficiary turns 65
• DEERS and ID card must be updated

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TRICARE For Life

• Began October 1, 2001
• Claims filed automatically from Medicare to
  TRICARE (provider only needs to file to Medicare)
• Claims processor is Wisconsin Physician Services
  (WPS) - www.tricare4u.com
• If OHI exists, Medicare will pay first, OHI
  second, and TRICARE will pay last.
• No enrollment fees (except for Medicare Part B
  monthly premiums)
• Space-available access at MTFs
• Primary and specialty care appointments limited
• Most ancillary services accessible

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TRICARE Plus

• MTF primary care enrollment program
• Offered at certain MTFs
• Limited enrollment capacity
• No enrollment fees
• All TRICARE-eligible beneficiaries (except those
  enrolled in Prime or have a civilian HMO plan)
  may seek enrollment in TRICARE Plus
• Offers only primary care access to specialty
  care through the MTF is not guaranteed
• Enrollment in TRICARE Plus does not affect TFL
  benefits or other existing programs

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Dental

• TRICARE Dental Program (TDP)
• For active duty family members, National Guard
  Reserve members their families
• United Concordia is the contractor
• TRICARE Retiree Dental Program (TRDP)
• For retirees their families, Medal of Honor
  recipients their families, certain survivors
  former spouses
• Delta Dental Plan of California is the contractor

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Retiree Dental Program Premiums Locally (2008)
A prepayment of two months premiums is
required to enroll.
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TRICARE Assistance Information

• Beneficiary Counseling Assistance
  Coordinators/Health Benefit Advisors
• Located at NMCP and all clinics
• [phone]
• TRICARE Service Centers
• Health Net Federal Services
• 1 (877) TRICARE (874-2273)
• TSC Locations
• Naval Medical Center Portsmouth
• Kenner Army Health Clinic
• Langley 1st Medical Group
• McDonald Army Community Health Clinic
• www.TRICARE.mil

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TRICARE Assistance Information - BCACs

• Boone Branch Health Clinic, NAB Little Creek
• [phone]/8185
• Kenner Army Health Clinic, Fort Lee
• [phone]
• Langley 1st Medical Group, Langley AFB
• [phone]
• McDonald Army Community Health Clinic, Fort
  Eustis
• [phone]
• Naval Medical Center Portsmouth
• [phone]/2611
• Northwest Branch Health Clinic, NavComSta NW
• [phone]

• Oceana Branch Health Clinic, NAS Oceana
• [phone] (Option 7)
• Sewells Point Branch Health Clinic, Norfolk Naval
  Base
• [phone]
• TRICARE Prime Clinic Chesapeake
• [phone]
• TRICARE Prime Clinic Virginia Beach
• [phone]/6711
• Yorktown Branch Health Clinic, Naval Weapons
  Station
• [phone]
• Yorktown Coast Guard Health Clinic
• [phone]

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Thank You! Questions?