Issues and Trends in HBI Ch 11

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  • Teaching Notes:
     
    Suggest to students that they review the key terms in this chapter prior to reading the chapter or hearing the lecture. This will enhance their understanding of the material.
     
  • Learning Outcome: 11.1 Discuss the eligibility requirements for TRICARE.
    Teaching Notes:
    Identify and discuss with students the eligibility requirements for TRICARE.
    Ask students how families of active military personnel are covered by TRICARE.
  • Learning Outcome: 11.1 Discuss the eligibility requirements for TRICARE.
    Teaching Notes:
    Note that coverage may no longer be valid if the sponsor is no longer active, the sponsor is divorced, or a child has reached 21 years of age.
    The TRICARE ID card must checked for expiration on every visit.
  • Learning Outcome: 11.2 Compare TRICARE participating and nonparticipating providers.
    Teaching Notes:
    Review with students the differences between participating and nonparticipating providers.
    Examine and discuss the advantages and disadvantages of participating and nonparticipating providers.
  • Learning Outcome: 11.2 Compare TRICARE participating and nonparticipating providers.
    Teaching Notes:
    Refer to the TRICARE cards in Figure 11.1 with students and describe each component.
    Examine and discuss the advantages and disadvantages of cost-sharing to the provider, the payer, and the patient.
  • Learning Outcome: 11.3 Explain how the TRICARE Standard, TRICARE Prime, and TRICARE Extra programs differ.
    Teaching Notes:
     
    Examine and describe with students the advantages provided by the TRICARE Standard plan.
    Discuss the differences and similarities between TRICARE and other healthcare plans.
  • Learning Outcome: 11.3 Explain how the TRICARE Standard, TRICARE Prime, and TRICARE Extra programs differ.
    Teaching Notes:
     
    Discuss what occurs when the catastrophic cap is met (once the catastrophic cap has been met, TRICARE pays 100 percent of additional charges for covered services for that coverage year).
    Note that nonavailability statement is an electronic document stating that the required service is not available at the nearby MTF.
  • Learning Outcome: 11.3 Explain how the TRICARE Standard, TRICARE Prime, and TRICARE Extra programs differ.
    Teaching Notes:
     
    Examine and discuss with students the provisions of the TRICARE Prime plan.
    Identify two advantages of having a Primary Care Manager (PCM).
  • Learning Outcome: 11.3 Explain how the TRICARE Standard, TRICARE Prime, and TRICARE Extra programs differ.
    Teaching Notes:
     
    Examine and discuss with students the advantages provided by TRICARE Prime Remote.
    Discuss the differences between TRICARE Extra and TRICARE Reserve Select.
  • Learning Outcome: 11.4 Discuss the TRICARE for Life program.
    Teaching Notes:
     
    Offered by the Department of Defense, TRICARE for Life is a secondary payer.
    The claim is submitted to the primary insurance, a decision on payment is made, and an RA is sent to the provider. The balance is then submitted to TRICARE.
  • Learning Outcome: 11.5 Discuss the eligibility requirements for CHAMPVA.
    Teaching Notes:
     
    Examine and discuss with students the positive impact that CHAMPVA makes for retired military personnel.
  • Learning Outcome: 11.5 Discuss the eligibility requirements for CHAMPVA.
    Teaching Notes:
     
    The VA is responsible for determining eligibility.
    All eligible beneficiaries possess a CHAMPVA authorization card.
  • Learning Outcome: 11.6 Prepare accurate TRICARE and CHAMPVA claims.
    Teaching Notes:
     
    CHAMPVA does not contract with providers.
    In most cases, CHAMPVA pays equivalent to Medicare/TRICARE rates.
    The maximum amount CHAMPVA will pay for a service or procedure is known as the CHAMPVA Maximum Allowable Charge (CMAC)
    Beneficiaries are responsible for the cost of services not covered by CHAMPVA.
  • Issues and Trends in HBI Ch 11

    1. 1. CHAPTER 11 TRICARE and CHAMPVA © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
    2. 2. Learning Outcomes 11-2 When you finish this chapter, you will be able to: 11.1 Discuss the eligibility requirements for TRICARE. 11.2 Compare TRICARE participating and nonparticipating providers. 11.3 Explain how the TRICARE Standard, TRICARE Prime, and TRICARE Extra programs differ. 11.4 Discuss the TRICARE for Life program. 11.5 Discuss the eligibility requirements for CHAMPVA. 11.6 Prepare accurate TRICARE and CHAMPVA claims.
    3. 3. 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 11-3 • Defense Enrollment Eligibility Reporting System (DEERS) • Military Treatment Facility (MTF) • nonavailability statement (NAS) • Primary Care Manager (PCM) • sponsor • TRICARE
    4. 4. Key Terms (continued) • • • • • TRICARE Extra TRICARE for Life TRICARE Prime TRICARE Prime Remote TRICARE Reserve Select (TRS) • TRICARE Standard 11-4
    5. 5. 11.1 The TRICARE Program 11-5 • 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
    6. 6. 11.1 The TRICARE Program (continued) 11-6 • 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
    7. 7. 11.2 Provider Participation and Nonparticipation 11-7 • 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
    8. 8. 11.2 Provider Participation and Nonparticipation (continued) 11-8 • 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
    9. 9. 11.3 TRICARE Plans 11-9 • 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
    10. 10. 11.3 TRICARE Plans (continued) 11-10 • 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
    11. 11. 11.3 TRICARE Plans (continued) • TRICARE Prime—basic managed care health plan – After enrollment, each individual is assigned a Primary Care Manager (PCM)—a provider who coordinates and manages the care of TRICARE beneficiaries – Offers additional preventive care, including routine physical examinations 11-11
    12. 12. 11.3 TRICARE Plans (continued) 11-12 • TRICARE Prime Remote—plan that provides no-cost healthcare 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 healthcare services from a network of healthcare professionals • TRICARE Reserve Select (TRS)—TRICARE coverage for military reservists – Premium-based health plan available for purchase
    13. 13. 11.4 TRICARE and Other Insurance Plans 11-13 • 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 healthcare at military treatment facilities
    14. 14. 11.5 CHAMPVA 11-14 • 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 – Healthcare expenses are shared between the Department of Veterans Affairs (VA) and the beneficiary
    15. 15. 11.5 CHAMPVA (continued) 11-15 • 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
    16. 16. 11.6 Filing Claims 11-16 • 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
    17. 17. Summary
    18. 18. Summary
    19. 19. Summary

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