ATTENTION PRESENTER: To ensure that TRICARE beneficiaries receive the most up-to-date information about their health benefits, you must visit www.tricare.mil/briefings for the latest version of all briefings before each presentation. Briefings are continuously updated as benefit changes occur. Presenter Tips: Print out and review briefing with notes prior to presentation. Ensure “slide show” setting. Delete any slides that do not apply to your audience. You may add slides from other briefings as appropriate for your audience. Estimated Briefing Time: 30 minutes plus 30 minutes for questions Recommended Handouts: ( available at www.tricare.mil/smart ) Your TRICARE Resources fact sheet TRICARE Choices for the National Guard and Reserve fact sheet Briefing Objectives: Increase awareness of TRICARE eligibility and active duty benefits for National Guard and Reserve members and families Tell beneficiaries the necessary steps for accessing the TRICARE benefit Optional Presenter Comments: Welcome to the TRICARE Benefits/Programs for the National Guard and Reserve During Pre-Activation and Activation briefing. The goal of today’s presentation is to talk about how to use your TRICARE benefit during early activation and when activated for more than 30 days.
TRICARE is available worldwide and managed regionally. There are three TRICARE regions in the United States—TRICARE West, TRICARE North, and TRICARE South. Your benefits are the same regardless of where you live, but you will have different customer service contacts based on your region. Because you are in the [West, North, South] region, your contractor is [TriWest Healthcare Alliance; Health Net Federal Services; Humana Military Healthcare Services]. [TriWest; Health Net; Humana Military] partners with the Military Health System to provide you with health, medical, and administrative support including customer service, claims processing, and authorizations for certain health care services. Customer service information for each region will be provided at the end of this presentation. While TRICARE programs and services exist overseas and I’ll provide you with contact information to learn more about TRICARE overseas, we’ll focus on stateside regions for this particular presentation.
You and your family members must be registered in the Defense Enrollment Eligibility Reporting System, or DEERS before you can be made eligible for TRICARE benefits. DEERS is a worldwide database of service members and dependents who are entitled to military benefits, including TRICARE. Service members, or sponsors, should be automatically registered in DEERS. However, you must register your family members in DEERS for them to be eligible for TRICARE coverage when you are activated. To register your family members, visit a uniformed services identification, or ID, card-issuing facility or mail the information to the Defense Manpower Data Center Support Office.
TRICARE has many programs that enable National Guard and Reserve members and families to have continuous coverage throughout your military career. This diagram shows your TRICARE eligibility life cycle. When you receive active duty orders, you and your family members may become eligible for active duty TRICARE benefits. These benefits will continue when you begin serving on active duty. We will discuss the pre-activation and activation stages in greater detail later in this presentation. Other briefings discuss inactive status and deactivation.
Your family members may have different program options depending on their location. We’ll discuss each of these programs in greater detail over the next few slides. All active duty family members become eligible for TRICARE Standard and TRICARE Extra coverage by default as soon as they show eligible in DEERS. TRICARE Young Adult (TYA) is a premium-based health care plan available for purchase by qualified dependents. TYA extends TRICARE Standard coverage for eligible dependents who have not yet reached age 26. For more information, visit www.tricare.mil/tya. TRICARE Prime is available to beneficiaries living in Prime Service Areas, or PSAs. PSAs are areas near military hospitals or clinics and civilian provider offices, where regional contractors have established TRICARE Prime networks. Family members living in certain areas are also eligible for the US Family Health Plan, or USFHP, which is a TRICARE Prime option available in six designated areas across the United States. A map showing the designated areas will be provided later in this presentation.
TRICARE Prime Remote for Active Duty Family Members has been adapted for National Guard and Reserve families. Family members are eligible if they lived with their sponsor in a remote location when the sponsor received unaccompanied orders for active duty. In this case, the family members remain eligible as long as they stay in the location where they lived with their sponsor. To find out if you live in a remote service area, visit the ZIP code lookup on TRICARE.mil or contact your regional contractor. All TRICARE Prime programs require enrollment.
Once your Service personnel updates your status in DEERS, your family members should be covered by TRICARE Standard and TRICARE Extra. Although referrals are not required for most health care services, some services require prior authorization to determine medical necessity. Visit your regional contractor’s website for information about authorization requirements. In the event of an emergency, call 911 or go to the nearest emergency room. Referral or prior authorization is not required, but, if admitted, contact your regional contractor within 24 hours or the next business day to coordinate ongoing care. TRICARE Standard and TRICARE Extra beneficiaries may also receive care at military hospitals and clinics on a space-available basis, but space is very limited. TRICARE Standard and TRICARE Extra beneficiaries have the flexibility to visit any TRICARE-authorized provider, which is a doctor or other provider who is approved to provide care to TRICARE beneficiaries.
Now, let’s talk about costs associated with TRICARE Standard and Extra. Most TRICARE Standard and TRICARE Extra beneficiaries have an annual deductible, but the deductible is waived for National Guard and Reserve family members whose sponsor is activated for more than 30 consecutive days in support of a contingency operation. Your family is responsible for cost-shares and copayments. These are the amounts you pay for TRICARE-covered services, which vary depending on whether your family members see network or non-network providers. The cost-share for outpatient services, such as routine doctors’ visits, is 15 percent for TRICARE-network providers (Extra) and 20 percent for non-network providers (Standard). Costs apply through September 30, 2011 and may change each fiscal year, which is October 1 through September 30. For the most up-to-date cost information, visit www.tricare.mil/costs. Non-network TRICARE providers can choose to accept TRICARE rates, or “participate” in TRICARE, on a claim by claim basis. Nonparticipating providers can charge up to 115 percent of the TRICARE-allowable rate. Most TRICARE Standard and TRICARE Extra beneficiaries are responsible for paying the difference (the extra 15%), but the additional 15 percent is waived for National Guard and Reserve families whose sponsor was activated in support of a contingency operation. You are still responsible for the cost-share based on the 100% TRICARE-allowable rate. The catastrophic cap is the maximum amount you pay out-of-pocket for TRICARE-covered services per fiscal year. The $1,000 cap includes deductibles, cost-shares, and prescription copayments, but it does not include monthly TRICARE Reserve Select premiums you may have paid before you were called to active duty.
TRICARE Prime options provide affordable and comprehensive health care coverage while minimizing your out-of-pocket costs. TRICARE Prime enrollees will select or have assigned to them a primary care manager, or PCM, at military treatment facilities or within the TRICARE civilian provider network. Note: If you are enrolled in TRICARE Prime Remote and there are no network primary care managers in your area, you can visit any TRICARE-authorized provider for care. Primary care managers deliver routine care, such as preventive services and routine office visits, and they file claims on your behalf. TRICARE Prime enrollees who need urgent or specialty care are required to work with their primary care managers and/or regional contractors to coordinate referrals and authorizations. Urgent care is required for an illness or injury that won’t result in further disability or death if not treated immediately, but should be treated within 24 hours. Examples of urgent care situations include sprains, sore throats, and rising temperatures. Because these situations do not meet the standard for emergency services, you would need prior authorization to avoid out-of-pocket costs. Specialty care is generally defined as care that your primary care manager cannot provide. For emergencies, call 911 or go to the nearest emergency room. Referrals and authorizations are not required for emergency services, but, if admitted, contact your regional contractor within 24 hours or the next business day to coordinate ongoing care. Service members enrolled in TRICARE Prime, if admitted, should also contact their Command as soon as possible.
In general, those service members who are active duty status and enrolled in TRICARE Prime, have no out-of-pocket costs for health care services. However, family members are responsible for pharmacy copayments for prescriptions filled outside of military pharmacies. Details on pharmacy costs are provided later in this presentation. The point-of-service option, or POS, allows you to seek non-emergency care from any TRICARE-authorized provider without a referral. However, you will have significantly increased out-of-pocket costs. Specifically, the point-of-service option requires you to pay all allowable costs until your $300 deductible is met, and 50 percent of the TRICARE allowable amount afterwards—so it can be a very expensive option. The $1,000 catastrophic cap includes deductibles, cost-shares, and prescription copayments, but it does not include point-of-service charges.
You may use the TRICARE pharmacy benefit unless you are enrolled in the US Family Health Plan. To have a prescription filled, you will need the prescription, a valid uniformed services ID card, and up-to-date information in DEERS. Note: Pharmacies are legally permitted to copy military and dependent ID cards to verify TRICARE eligibility. You will normally receive a generic drug rather than a brand-name drug. Your doctor or other provider must prove medical necessity for you to receive a brand-name medication if a generic version is available. Non-formulary drugs are not available to active duty service members without medical-necessity approval. If the ADSM receives approval, the copayment is $0. Pharmacy costs depend on the pharmacy option you choose, whether the drug is generic or brand name, and whether it’s listed in the TRICARE formulary, which is the list of drugs covered by TRICARE. There is no copayment when you fill a prescription at an MTF pharmacy. If you have recurring prescriptions, such as allergy or blood pressure medicine, you can use TRICARE Pharmacy Home Delivery to order up to a 90-day supply by phone, online, or by mail. TRICARE Pharmacy Home Delivery copayments are $0 for generic formulary drugs, $9 for brand-name formulary drugs, and $25 for non-formulary drugs. If you need a prescription filled immediately, your best option is to find one of TRICARE’s 60,000-plus retail network pharmacies. To find a retail network pharmacy, visit the Express Scripts Web site provided at the bottom of the screen. The most expensive option is a non-network retail pharmacy.
TRICARE is the sole source of health care coverage for activated National Guard and Reserve members. If you have other health insurance, or OHI, you may choose to keep it for your family while you are activated. If you keep your other health insurance, TRICARE becomes the secondary payer for your family. That means when your family member goes to the doctor, the doctor will file a claim with your other health insurance first and TRICARE pays what is left, up to the TRICARE-allowable charge. Note: Does not apply to Medicaid and certain other state programs. If your other health insurance runs out, or for services covered by TRICARE that are not covered by your OHI, TRICARE becomes your primary payer. If you have other health insurance: Fill out a TRICARE Other Health Insurance Questionnaire and follow the guidelines for submission. You can download the questionnaire from TRICARE.mil/forms, or you can pick one up at your TRICARE Service Center. Because your other health insurance pays first, your family members should follow their rules for getting care. Make sure their providers know they have other health insurance and TRICARE. Keeping your regional contractor and health care providers informed about other health care coverage will allow them to better coordinate your benefits. Note: Unlike OHI, supplemental insurance pays after TRICARE pays its portion of the bill, reimbursing you for out-of-pocket medical expenses paid to civilian providers based on the plan’s policies. Remember that you have a $1,000 catastrophic cap when considering supplemental insurance.