TRICARE AND CHAMPVA

Government health program serving dependents of active-duty service members, military retirees and their families, some former spouses, and survivors of deceased military members. TRICARE is the Department of Defense's health insurance plan for military personnel and their families. TRICARE, which includes managed care options, replaced the program known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS). TRICARE is a regionally managed health care program that brings the resources of military hospitals together with a network of civilian facilities and providers to offer increased access to health care services. All military treatment facilities, including hospitals and clinics, are part of the TRICARE system. TRICARE also contracts with civilian facilities and physicians to provide more extensive services to beneficiaries. Members of the following uniformed services and their families are eligible for TRICARE: The Army, Navy, Air Force, Marine Corps, Coast Guard, Public Health Service (PHS), and National Oceanic and Atmospheric Administration (NOAA). Reserve and National Guard personnel become eligible when on active duty for more than thirty consecutive days or when they retire from reserve status at age sixty. The uniformed services member is referred to as a sponsor, since the member's status makes other family members eligible for TRICARE coverage.

When a TRICARE patient arrives for treatment, the medical information specialist photocopies both sides of the individual's military ID card and checks the expiration date to confirm that coverage is still valid. Decisions about eligibility are not made by TRICARE; the various branches of military service make them. Information about patient eligibility is stored in the Defense Enrollment Eligibility Reporting System (DEERS). Sponsors may contact DEERS to verify eligibility; providers may NOT contact DEERS directly because the information is protected by the Privacy Act. TRICARE pays only for services rendered by authorized providers. Authorized providers are certified by TRICARE regional contractors to have met specific educational, licensing, and other requirements. Once authorized, a provider is assigned a PIN and must decide whether to participate. TRICARE participating providers file claims on behalf of patients, following HIPAA regulations. Claims are filed with the regional contractor for that region, based on the patient's home address, not the location of the facility. Contact information for regional contractors is available on the TRICARE website. The three administration regions for TRICARE are: TRICARE North, TRICARE South, and TRICARE West. A fourth region covers international claims. Individuals file their own claims when services are received from nonparticipating providers, using DD Form 2642, Patient's Request for Medical Payment. A copy of the itemized bill from the provider must be attached to the form.

Now called the TRICARE program.

Uniformed service member in a family qualified for TRICARE or CHAMPVA.

Worldwide database of TRICARE and CHAMPVA beneficiaries.

Providers who participate agree to accept the TRICARE allowable charge as payment in full for services. Individual providers may decide whether to participate on a case-by-case basis. Participating providers are required to file claims on behalf of patients. The regional TRICARE contractor sends payment directly to the provider, and the provider collects the patient's share of the charges. Only participating providers may appeal claim decisions.

A provider who chooses not to participate may not charge more than 115 percent of the allowable charge. If a provider bills more than 115 percent, the patient may refuse to pay the excess amount. If a nonparticipating provider charges more than 115 percent of the allowed charge, the patient is NOT responsible for the amount that exceeded 115 percent of the allowed amount. The difference would have to be written off by the provider. The patient would pay the cost-share (either 20 or 25 percent) -- a TRICARE term for the coinsurance, the amount that is the responsibility of the patient. Once the nonPAR provider submits the claim, TRICARE pays its portion of the allowable charges, but instead of going directly to the provider, the payment is mailed to the patient. The patient is responsible for paying the provider. Payment should be collected at the time of the visit.

Coinsurance for a TRICARE or CHAMPVA beneficiary.

Providers who participate in the basic TRICARE plan are paid the amount specified in the Medicare Physician Fee Schedule for most procedures. Medical supplies, durable medical equipment, and ambulance services are not subject to Medicare limits. The maximum amount TRICARE will pay for a procedure is known as the TRICARE Maximum Allowable Charge (TMAC). Providers are responsible for collecting the patients' deductibles and their cost-share portions of the charges. The TRICARE Maximum Allowable Charge Table is located at: www.tricare.mil/allowablecharges/

Providers who are authorized to treat TRICARE patients may also contract to become part of the TRICARE network. These providers serve patients in one of TRICARE's managed care plans. They agree to provide care to beneficiaries at contracted rates and to act as participating providers on all claims in TRICARE's managed care programs.

Providers who choose not to join the network may still provide care to managed care patients, but TRICARE will NOT pay for the services. The patient is 100 percent responsible for the charges.

For a service to be eligible for payment, it must be medically necessary, delivered at the appropriate level for the condition, and be at a quality that meets professional medical standards.

Check the date when collecting TRICARE deductibles; TRICARE's fiscal year is from October 1 through September 30, so annual deductibles renew based on this cycle.

Tricare offers beneficiaries access to a variety of health care plans including: (1) TRICARE Standard, (2) TRICARE Prime, (3) TRICARE Prime Remote, (4) TRICARE Extra, and (5) TRICARE Reserve Select.

Fee-for-service health plan that replaces the CHAMPUS program, which was also fee-for-service. The program covers medical services provided by a civilian physician or by a Military Treatment Facility (MTF). Military families may receive services at a MTF, but available services vary by facility, and first priority is given to service members on active duty. When service is not available, the individual seeks treatment from a civilian provider, and TRICARE Standard benefits go into effect. Under TRICARE Standard, medical expenses are shared between TRICARE and the beneficiary. Most enrollees pay annual deductibles. In addition, families of active duty members pay 20 percent of outpatient charges. Retirees and their families, former spouses, and families of deceased personnel pay a 25 percent cost-share for outpatient services. Patient cost-share payments are subject to an annual catastrophic cap, a limit on the total medical expenses that beneficiaries are required to pay in one year. For active-duty families, the annual cap is $1,000, while for all other beneficiaries the limit is $3,000. Once these caps have been met, TRICARE pays 100 percent of additional charges for covered services for that coverage year. A beneficiary who is treated by a provider who does not accept assignment, is also responsible for the provider's additional charges, up to 115 percent of the allowable charge, at the time of service unless other arrangements are in place.

Provides medical services for members and dependents of the uniformed services.

Maximum annual amount a TRICARE beneficiary must pay for deductible and cost-share.

TRICARE Standard covers care such as inpatient and outpatient services, diagnostic testing, and many preventive benefits. It does NOT cover cosmetic, custodial, or experimental procedures. A beneficiary who needs hospital care is encouraged by TRICARE to first seek care at a military treatment facility (MTF) if living in a catchment area.

Geographic area served by a hospital, clinic, or dental clinic and usually based on Zip codes to set an approximate 40-mile radius of military inpatient treatment facilities.

Form required when a TRICARE member seeks medical services outside an MTF. A nonavailability statement is an electronic document stating that the required service is not available at the nearby military treatment facility. The form is electronically transmitted to the DEERS database.

Most high-cost procedures need preauthorization. Medical administrative assistants should contact the TRICARE contractor for specific information.

Basic managed care health plan. TRICARE Prime is a managed care plan similar to an HMO. Note that all active-duty service members are limited in their choices and must enroll in one of the TRICARE Prime programs, rather than the additional TRICARE options. After enrolling in the plan, individuals are assigned a Primary Care Manager (PMC) who coordinates and manages their medical care. The PCM may be a single military or civilian provider or a group of providers. In addition to most of the benefits offered by TRICARE Standard, TRICARE Prime offers preventive care, including routine physical examination. Active-duty service members are automatically enrolled in TRICARE Prime. TRICARE Prime enrollees receive the majority of their health care services from military treatment facilities and receive priority at these facilities. To join the TRICARE Prime program, individuals who are NOT active- duty family members must pay annual enrollment fees of $260 for an individual or $520 for a family. TRICARE Prime has no deductible, and no payment is required for outpatient treatment at a military facility. For active-duty family members, no payment is required for visits to civilian network providers, but different copayments apply for other beneficiaries. For example, for retirees and their family members, outpatient visits with civilian providers require $12 copayments. TRICARE Prime also has a point-of-service (POS) option that patients may select. The POS option has a deductible and coinsurance requirements.

Provider who coordinates and manages the care of TRICARE beneficiaries.

No-cost health care through civilian providers for service members and their families on remote assignment. TRICARE Prime Remote provides no-cost health care through civilian providers for service members and their families who are on remote assignment. Participants must live and work more than 50 miles (approximately one hour's drive time) from the nearest Military Treatment Facility. Their residence address must be registered with DEERS for eligibility, which is based on their Zip code.

Managed care health plan that offers a network of civilian providers. TRICARE Extra is an alternative managed care plan for individuals who want to receive services primarily from civilian facilities and physicians rather than from military facilities. Since it is a managed care plan, individuals must receive health care services from a network of health care professionals. They may also seek treatment at military facilities, but active-duty personnel and other TRICARE Prime enrollees receive priority at those facilities, so care may not always be available. TRICARE Extra is more expensive than TRICARE Prime, but less costly than TRICARE Standard. There is no enrollment fee, but there is an annual deductible of $150 for an individual and $300 for a family. TRICARE Extra beneficiaries pay 15 percent (5 percent less than TRICARE Standard enrollees) for civilian outpatient charges. Beneficiaries are not subject to additional charges of up to 115 percent of the allowable charge, since participating physicians agree to accept TRICARE's fee schedule.

Coverage for reservists. Due to the large number of military reservists who have been called up for active duty, the Department of Defense implemented TRICARE Reserve Select (TRS). This program is a premium based health plan available for purchase by certain members of the National Guard and Reserve activated on or after September 11, 2001. TRS provides comprehensive health care coverage similar to TRICARE Standard/Extra for TRS members and covered family members.

If the individual has other health insurance coverage that is primary to TRICARE, that insurance carrier MUST be billed first. TRICARE is the secondary payer in almost all circumstances; among the few exceptions is Medicaid.

Many TRICARE beneficiaries purchase supplemental insurance policies to help pay deductible and cost-share or copayment fees. Most military associations offer supplementary plans, and so do private insurers. Supplemental plans are not regulated by TRICARE, so coverage varies. TRICARE is the primary payer; the purpose of a supplemental policy is simply to pick up the costs not paid by TRICARE.

Program for beneficiaries who are both Medicare and TRICARE eligible. The Department of Defense offers a program for Medicare-eligible military retirees and Medicare-eligible family members called TRICARE for Life (TFL). TFL offers the opportunity to receive health care at a military treatment facility to individuals age sixty-five and over who are eligible for both Medicare and TRICARE. TRICARE beneficiaries entitled to Medicare Part A based on age, disability, or end stage renal disease are required by law to enroll in Medicare Part B to retain their TRICARE benefits. TRICARE for Life acts as a secondary payer to Medicare; Medicare pays first, and TRICARE pays the remaining out-of-pocket expenses. These claims are filed automatically. Enrollees do not need to submit a paper claim. Medicare pays its portion for Medicare covered services and automatically forwards the claim to Wisconsin Physicians Service (WPS), the TFL contractor WPS/TFL for processing. If the patient has other health insurance (OHI), the claim does not automatically cross over to TRICARE. Instead, the patient must submit a claim to WPS/TFL. The patient's Medicare Summary Notice along with a TRICARE paper claim (DD Form 2642) and the OHI's Explanation of Benefits (EOB) statement should be mailed by the patient. Benefits are similar to those of a Medicare HMO, with an emphasis on preventive and wellness services. Prescription drug benefits are also included. Other than Medicare costs, TRICARE for Life beneficiaries pay no enrollment fees and no cost-share fees for inpatient or outpatient care at a military facility. Treatment at a civilian network facility requires a copay.

TRICARE and TRICARE for Life are payers of the last resort, except when the patient also has Medicaid. In that case, TRICARE pays before Medicaid.

Shares health care costs for families of veterans with 100 percent service-connected disabilities and the surviving spouses and children of veterans who die from service-connected disabilities. CHAMPVA is the government's health insurance program for the families of veterans with 100 percent service-related disabilities. Under the program, health care expenses are shared between the Department of Veterans Affairs (VA) and the beneficiary. The Veterans Health Care Eligibility Reform Act of 1996 requires a veteran with a 100 percent disability to be enrolled in the program in order to receive benefits.

The VA is responsible for determining eligibility for the CHAMPVA program. Eligible beneficiaries include: (1) dependents of a veteran who is totally and permanently disabled due to a service-connected injury; (2) dependents of a veteran who was totally and permanently disabled due to a service-connected condition at the time of death; (3) survivors of a veteran who died as a result of a service-related disability; and (4) survivors of a veteran who died in the line of duty.

Each eligible beneficiary possesses a CHAMPVA Authorization Card, known as an A-Card. The provider's office checks this card to determine eligibility and photocopies or scans the front and back for inclusion in the patient record.

Most persons enrolled in CHAMPVA pay an annual deductible and a portion of their health care charges. Some services are exempt form the deductible and cost-share requirement. A patient's out-of-pocket costs are subject to a catastrophic cap of $3,000 per calendar year. Once the beneficiary has paid $3,000 in medical bills for the year, CHAMPVA pays claims for covered services at 100 percent for the rest of that year. CHAMPVA provides coverage for most medically necessary inpatient and outpatient services. Some procedures must be approved in advance; if they are not, CHAMPVA will not pay for them. It is the patient's responsibility, not the provider's, to obtain preauthorization.

For most services, CHAMPVA does not contract with providers. Beneficiaries may receive care from providers of their choice, as long as those providers are properly licensed to perform the services being delivered and are not on the Medicare exclusion list. Providers who treat CHAMPVA patients are prohibited from charging more than the CHAMPVA allowable amounts. Providers agree to accept CHAMPVA payment and the patient's cost-share payment as payment in full for services. For mental health treatment, CHAMPVA maintains a list of approved providers. In most cases, CHAMPVA pays equivalent to Medicare/TRICARE rates. The maximum amount CHAMPVA will pay for a procedure is known as the CHAMPVA Maximum allowable Charge (CMAC). CHAMPVA has an outpatient deductible ($50 per person up to $100 per family per calendar year) and a cost-share of 25 percent. The cost-share percentages are 75 percent for CHAMPVA and 25 percent for the beneficiary to pay. Beneficiaries are also responsible for the costs of health care services not covered by CHAMPVA.

When the individual has other health insurance benefits in addition to CHAMPVA, CHAMPVA is almost always the secondary payer. Two exceptions are Medicaid and supplemental policies purchased to cover deductibles, cost-shares, and other services. Insurance claims are first filed with the primary payer. When the remittance advice from the primary plan arrives, a copy is attached to the claim that is then filed with CHAMPVA. Persons under age sixty-five who are eligible for Medicare benefits and who are enrolled in Parts A and B may also enroll in CHAMPVA.

CHAMPVA for Life extends CHAMPVA benefits to spouses or dependents who are age sixty-five and over. Similar to TRICARE for Life, CHAMPVA for Life benefits are payable after payment by Medicare or other third-party payers. Eligible beneficiaries must be sixty-five or older and must be enrolled in Medicare Parts A and B. For services not covered by Medicare, CHAMPVA acts as the primary payer.

The CHAMPVA program is covered by HIPAA regulations. Most CHAMPVA claims are filed by providers and are submitted to the centralized CHAMPVA claims processing center in Denver, Colorado. The information required on a claim is the same as the information required for TRICARE. In instances in which beneficiaries are filing their own claims, CHAMPVA Claim Form (VA Form 10-7959A) must be used. The claim must always be accompanied by an itemized bill from the provider. Claims must be filed within one year of the date of service or discharge.