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12 TRICARE and CHAMPVA
Learning Outcomes <ul><li>When you finish this chapter, you will be able to: </li></ul><ul><li>12.1  Discuss the eligibili...
Key Terms <ul><li>catchment area </li></ul><ul><li>catastrophic cap </li></ul><ul><li>Civilian Health and Medical Program ...
Key Terms (Continued) <ul><li>TRICARE Extra </li></ul><ul><li>TRICARE for Life </li></ul><ul><li>TRICARE Prime </li></ul><...
12.1 The TRICARE Program <ul><li>TRICARE— government health program serving dependents of active-duty service members, mil...
12.1 The TRICARE Program (Continued) <ul><li>CHAMPUS— the Civilian Health and Medical Program of the Uniformed Services, w...
12.2 Provider Participation and Nonparticipation <ul><li>Participating providers: </li></ul><ul><ul><li>Accept the TRICARE...
12.2 Provider Participation and Nonparticipation (Continued) <ul><li>Patients: </li></ul><ul><ul><li>Pay the provider, and...
12.3 TRICARE Plans <ul><li>TRICARE Standard— fee-for-service health plan </li></ul><ul><ul><li>Medical expenses are shared...
12.3 TRICARE Plans (Continued) <ul><li>Catastrophic cap— maximum annual amount a   TRICARE beneficiary must pay for deduct...
12.3 TRICARE Plans (Continued) <ul><li>TRICARE Prime— basic managed care health plan </li></ul><ul><ul><li>After enrollmen...
12.3 TRICARE Plans (Continued) <ul><li>TRICARE Prime Remote— plan that provides no-cost health care through civilian provi...
12.4 TRICARE and Other Insurance Plans <ul><li>TRICARE for Life— program for beneficiaries who are eligible for both Medic...
12.5 CHAMPVA <ul><li>Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)— the government’s...
12.5 CHAMPVA (Continued) <ul><li>Individuals eligible for the CHAMPVA program include: </li></ul><ul><ul><li>Veterans who ...
12.6 Filing Claims <ul><li>Participating providers file TRICARE claims with the contractor for the region on behalf of pat...
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Survey of Medical Insurance pp ch12

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Survey of Medical Insurance pp ch12

  1. 1. 12 TRICARE and CHAMPVA
  2. 2. Learning Outcomes <ul><li>When you finish this chapter, you will be able to: </li></ul><ul><li>12.1 Discuss the eligibility requirements for TRICARE. </li></ul><ul><li>12.2 Compare TRICARE participating and nonparticipating providers. </li></ul><ul><li>12.3 Explain how the TRICARE Standard, TRICARE Prime, and TRICARE Extra programs differ. </li></ul><ul><li>12.4 Discuss the TRICARE for Life program. </li></ul><ul><li>12.5 Discuss the eligibility requirements for CHAMPVA. </li></ul><ul><li>12.6 Demonstrate the ability to prepare correct TRICARE and CHAMPVA claims. </li></ul>12-2
  3. 3. Key Terms <ul><li>catchment area </li></ul><ul><li>catastrophic cap </li></ul><ul><li>Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) </li></ul><ul><li>Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) </li></ul><ul><li>cost-share </li></ul>12-3 <ul><li>Defense Enrollment Eligibility Reporting System (DEERS) </li></ul><ul><li>Military Treatment Facility (MTF) </li></ul><ul><li>nonavailability statement (NAS) </li></ul><ul><li>Primary Care Manager (PCM) </li></ul><ul><li>sponsor </li></ul><ul><li>TRICARE </li></ul>
  4. 4. Key Terms (Continued) <ul><li>TRICARE Extra </li></ul><ul><li>TRICARE for Life </li></ul><ul><li>TRICARE Prime </li></ul><ul><li>TRICARE Prime Remote </li></ul><ul><li>TRICARE Reserve Select (TRS) </li></ul><ul><li>TRICARE Standard </li></ul>12-4
  5. 5. 12.1 The TRICARE Program <ul><li>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 </li></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>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 </li></ul></ul>12-5
  6. 6. 12.1 The TRICARE Program (Continued) <ul><li>CHAMPUS— the Civilian Health and Medical Program of the Uniformed Services, which was replaced by the TRICARE program </li></ul><ul><li>Sponsor— uniformed service member in a family qualified for TRICARE or CHAMPVA </li></ul><ul><li>Defense Enrollment Eligibility Reporting System (DEERS)— worldwide database of TRICARE and CHAMPVA beneficiaries </li></ul>12-6
  7. 7. 12.2 Provider Participation and Nonparticipation <ul><li>Participating providers: </li></ul><ul><ul><li>Accept the TRICARE allowable charge as payment in full for services </li></ul></ul><ul><ul><li>Are required to file claims on behalf of patients </li></ul></ul><ul><ul><li>May appeal a decision </li></ul></ul><ul><li>Nonparticipating providers: </li></ul><ul><ul><li>May not charge more than 115 percent of the allowable charge </li></ul></ul><ul><ul><li>May not appeal a decision </li></ul></ul>12-7
  8. 8. 12.2 Provider Participation and Nonparticipation (Continued) <ul><li>Patients: </li></ul><ul><ul><li>Pay the provider, and TRICARE pays its portion of the allowable charges directly to the patient </li></ul></ul><ul><li>Cost-share— coinsurance for a TRICARE or CHAMPVA beneficiary </li></ul>12-8
  9. 9. 12.3 TRICARE Plans <ul><li>TRICARE Standard— fee-for-service health plan </li></ul><ul><ul><li>Medical expenses are shared between TRICARE and the beneficiary </li></ul></ul><ul><ul><li>Most enrollees pay annual deductibles and cost-share percentages </li></ul></ul><ul><li>Military Treatment Facility (MTF)— provides medical services for members and dependents of the uniformed services </li></ul>12-9
  10. 10. 12.3 TRICARE Plans (Continued) <ul><li>Catastrophic cap— maximum annual amount a TRICARE beneficiary must pay for deductible and cost-share </li></ul><ul><li>Catchment area— geographic area served by a hospital, clinic, or dental clinic </li></ul><ul><li>Nonavailability statement (NAS)— form required when a TRICARE member seeks medical services outside an MTF </li></ul>12-10
  11. 11. 12.3 TRICARE Plans (Continued) <ul><li>TRICARE Prime— basic managed care health plan </li></ul><ul><ul><li>After enrollment, each individual is assigned a Primary Care Manager (PCM)— provider who coordinates and manages the care of TRICARE beneficiaries </li></ul></ul><ul><ul><li>Offers additional preventive care, including routine physical examinations </li></ul></ul>12-11
  12. 12. 12.3 TRICARE Plans (Continued) <ul><li>TRICARE Prime Remote— plan that provides no-cost health care through civilian providers for service members and their families who are on remote assignment </li></ul><ul><li>TRICARE Extra— managed care health plan that offers a network of civilian providers </li></ul><ul><ul><li>Individuals must receive health care services from a network of health care professionals </li></ul></ul><ul><li>TRICARE Reserve Select (TRS)— TRICARE coverage for military reservists </li></ul><ul><ul><li>Premium-based health plan available for purchase </li></ul></ul>12-12
  13. 13. 12.4 TRICARE and Other Insurance Plans <ul><li>TRICARE for Life— program for beneficiaries who are eligible for both Medicare and TRICARE </li></ul><ul><ul><li>Individuals age sixty-five and over who are eligible for both Medicare and TRICARE may continue to receive health care at military treatment facilities </li></ul></ul>12-13
  14. 14. 12.5 CHAMPVA <ul><li>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 </li></ul><ul><ul><li>Health care expenses are shared between the Department of Veterans Affairs (VA) and the beneficiary </li></ul></ul>12-14
  15. 15. 12.5 CHAMPVA (Continued) <ul><li>Individuals eligible for the CHAMPVA program include: </li></ul><ul><ul><li>Veterans who are totally and permanently disabled due to service-connected injuries </li></ul></ul><ul><ul><li>Veterans who were totally and permanently disabled due to service-connected conditions at the time of death </li></ul></ul><ul><ul><li>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 </li></ul></ul>12-15
  16. 16. 12.6 Filing Claims <ul><li>Participating providers file TRICARE claims with the contractor for the region on behalf of patients </li></ul><ul><li>Individuals file their own TRICARE claims when services are received from nonparticipating providers </li></ul><ul><li>Most CHAMPVA claims are filed by providers and submitted to the centralized CHAMPVA claims processing center </li></ul>12-16

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