PPT tri-care
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Critical Application Assignment
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PPT tri-care
- 1. TRICARE Jennifer Reynolds HCA/230 February 7, 2013
- 2. SYNOPSIS • REQUIREMENTS OF ELIGIBILITY • COVERED vs. NON-COVERED SERVICES • COSTS OF PATICIPATING AND NON-PARTICIPATING PROVIDERS • IN vs. OUT-OF-NETWORK PROVIDERS AND FINANCIAL REIMBURSEMENT
- 3. WHO IS ELIGIBLE? • ACTIVE OR RETIRED MILITARY PERSONEL • MUST BE YOUNGER THAN 65 • DEPENDANT UNMARRIED CHILDREN • SPOUSES MARRIED TO AN ACTIVE OR RETIRED MILITARY SERVICE MEMBER
- 4. COVERED vs. NON-COVERED SERVICES COVERED • ALL EMERGENT CARE • HOSPITALIZATION • REGULAR EYE EXAMS • DURABLE MEDICAL EQUIPMENT • CARDIOVASULAR • PREVENTITIVE AND IMMUNIZATION NON-COVERED • BIRTH CONTROL • COUNSELING • COSMETIC PROCEDURES • WEIGHT LOSS • LONG TERM CARE FACILITIES • PODIATRY
- 5. PARTICIPATING vs. NON-PARTICIPATING PROVIDERS • A 1/4th to 20% co pay is required for outpatient services • Annual deductibles must be met out of pocket • Catastrophic Cap of 1,000-3,000 • Members are responsible for non participating services up to 115% of charges.
- 6. NETWORK vs. NON-NETWORK PROVIDERS AND FINANCIAL REIMBURSEMENT Network Providers • Fee schedule is a contractual agreement • Network Providers have a maximum allowable charge • Providers must Submit all service claims electronically for reimbursement Non Network Providers • Can not charge over 115% of allowable amount • Patient is responsible for co-insurance out of pocket • Non covered services will be billed directly to the patient
- 7. REFERENCE – AMRA TRICARE Supplement. (2012). Eligibility. Retrieved -------------from http://www.amratricaresupplement.com/Eligibility.html – HealthNet Federal Services. (2012). Becoming a TRICARE Non- Network Provider. Retrieved -------------from https://www.hnfs.net/provider/home/Becoming+A+Non- Network+Provider.htm – McGraw Hill Co. (2013). Medical Insurance: An Integrated Claims Process Approach, Third Edition. TRICARE AND CHAMPVA. Chapter 12. – TRICARE. (2012). What’s Not Covered. Retrieved-----------, from http://74.125.93.132/search? q=cache:4MnwaIWnvV8J:www.tricare.mil/tricareu/docs/19_Whats-Not- Covered.doc+services+not+covered+by+tricare&cd=1&hl=en&ct=clnk& gl=us&client=safari – TRIWEST Healthcare Alliance. (2012). TRICARE covered benefits and services. Retrieved --------------from http://www.triwest.com/document_library/pdf_docs/CvrBen_QRG.pdf
Editor's Notes
- Image obtained from: http://ra.defense.gov/_images/news/mainnews/tricare.jpg
- This presentation will discuss the important aspects of TRICARE benefit coverage. The presentation will include who is eligible, what is covered and what is not The presentation will discuss network providers and out of network providers, as well as participating providers vs. non participating providers, Lastly a review over reimbursement of charges.
- In order to qualify for TRICARE coverage the applicant must be married to or themselves be in the United States Armed Services and be younger than 65 years of age. The military service member can be in active duty or retired from service. The applicant can also add their dependent children to their policy. Members of the National Guard and Reserves are eligible for TRICARE coverage as well after 20 years of service and are at least 60 years old at the time they apply. AMRA TRICARE Supplement. (2012). Eligibility. Retrieved February 7, 2013, from http://www.amratricaresupplement.com/Eligibility.html
- Image obtained from: openingmindproductions.com TRICARE is consistent in the fact that all services covered must be medically necessary. Situations deemed emergency are always covered. Inpatient hospitalization is covered including required testing and procedures such as X-Ray, lab work, medication, and screening as appropriate. TRICARE covers preventative medicine such as cancer screening and immunizations. TRICARE covers long term illnesses such as diabetes. TRICARE also covers basic eye exams, dental exams, and hearing screening. For dependant children annual well child check up are also covered. Similar to other plans TRICARE excludes benefit coverage for certain services. Guidance counseling, birth control, weight loss, podiatry, are among these restrictions. While TRICARE covers a hospital stay they do not cover the cost of a private room unless deemed medically necessary to prevent spread of infection.Nursing home coverage and cosmetic procedures are also non covered services TRICARE. (2012). What’s Not Covered. Retrieved February 7, 2013, from http://74.125.93.132/search?q=cache:4MnwaIWnvV8J:www.tricare.mil/tricareu/docs/19_Whats-Not-Covered.doc+services+not+covered+by+tricare&cd=1&hl=en&ct=clnk&gl=us&client=safari TRIWEST Healthcare Alliance. (2013). TRICARE covered benefits and services. Retrieved February 7, 2013, from http://www.triwest.com/document_library/pdf_docs/CvrBen_QRG.pdf
- When seeing a participating TRICARE provider, similar to other insurance providers members must meet a deductible before full benefits take over. Members must meet a twenty percent co pay for any outpatient services. Spouses and children of deceased military and retired military have a 1/4th of total cost co payment. When seeing a provider who does not participate in the TRICARE program member are responsible up to 115% of the services rendered. Also, there is an annual catastrophic cap of 1,000.00 per active duty family per fiscal year and 3,000.00 per retired family per fiscal year. After this cap is met TRICARE covers 100%. McGraw Hill Co. (2008). Medical Insurance: An Integrated Claims Process Approach, Third Edition. TRICARE AND CHAMPVA. Chapter 12.
- Health care provider in TRICARE’s Network agree on a fee schedule for services rendered. Private practices sometimes determine weather or not to accept TRICARE on specific cases situation. The provider must submit all claims electronically to TRICARE for payment. Then the provider must collect the remaining patients portion from the patient. Non network providers may not charge past the fee schedule more than 115% or the patient can refuse to pay for services rendered. The patient is also responsible for any co insurance costs they incur out of pocket, When a out of network provider submits a claims to TRICARE and it is rejected, the patient is responsible for financial reimbursement to the provider. HealthNet Federal Services. (2012). Becoming a TRICARE Non-Network Provider. Retrieved February 7, 2013, from https://www.hnfs.net/provider/home/Becoming+A+Non-Network+Provider.htm