Ch' 13 TRICARE and CHAMPVA

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Ch. 13 TRICARE and CHAMPVA

• TRICARE used to be CHAMPUS
• CHAMPUS Civilian Health and Medical Program of
  the Uniformed Services

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• Paid for care delivered by civilian health
  providers to the families of military personnel
  and retirees.
• Was formed to ease the burden on the military
  healthcare system

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• Gave dependents of active duty military personnel
  and military retirees the ability to use civilian
  medical services.
• To help stem the rising cost of health care, the
  CHAMPUS

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• Reform Initiative was established.
• After demonstration projects, TRICARE was
  developed as a managed care program in 1994

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• TRICARE the Defense Departments worldwide
  health care program for service families
• Provides benefits to active duty families,
  military retirees and their dependents.

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• 12 health services regions
• Each region has a lead agent at a Military
  Treatment Facility
• They coordinate the regional delivery of health
  care

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• TRICARE relies on a commercial contractor to
  develop and maintain a private sector network of
  health care providers.
• This network used by TRICARE beneficiaries when
  medical care

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• is not readily available at a Military Treatment
  Facility
• TRICARE is not considered insurance, but a
  service benefit program.

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Three TRICARE options

• TRICARE Standard
• TRICARE Prime
• TRICARE Extra

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TRICARE Standard

• Name change for the regular CHAMPUS program
• Standard fee-for-service program including
  deductibles and copayments
• Members have choice of providers but costs are
  higher than Prime and Extra

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TRICARE Prime

• TRICARE Prime a full-service HMO
• Covered services are like that of Standard plus
  additional preventive and primary care services

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• Beneficiaries receive most of care from military
  providers or civilian providers who belong to the
  TRICARE Prime network
• Voluntary enrollment

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• Primary care manager the TRICARE title for the
  managed care gatekeeper or primary care physician.

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• Point of service option can choose
  non-emergency services without referral from
  primary care manager, however must pay deductible
  and share 50 of the TRICARE allowable charge

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TRICARE Extra

• TRICARE Extra a preferred provider option that
  saves money
• Like Standard but care can be sought from a
  provider who is part of the TRICARE network

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• Beneficiaries can elect to use network providers
  on a case-by-case basis and receive a discount on
  services and reduced cost shares

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• DEERS- Defense Enrollment Eligibility Reporting
  System
• TRICARE Preauthorization
• TRICARE Extra and Standard require
  preauthorization for nonemergency inpatient
  services

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• in civilian hospitals and specific outpatient
  services if the sponsor lives within the
  catchment boundaries of a military treatment
  facility.

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• Nonavailability statement a certification from a
  military hospital stating that it cannot provide
  the care needed

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• TRICARE is secondary payer to all other
  insurances (including workers comp.,liability
  and Medicare)
• TRICARE is primary payer to Medicaid and TRICARE
  supplemental policies

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• Claims procedure, p. 416
• HCFA 1500
• Participating providers agree to accept TRICARE
  allowable charge as payment in full
• Can bill patient for copayment and noncovered
  services only

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• Nonparticipating providers cannot bill TRICARE
  patient more than 15 of the TRICARE allowable
  charge
• 100 TRICARE allowable
• Cant bill patient more than 115

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CHAMPVA

• Civilian Health and Medical Program of the
  Veterans Administration
• Service benefit program
• For the spouse and children of a veteran with a
  total, permanent service-connected disability or
  for the surviving spouse and children of a
  veteran who died as a result of a service
  connected disability

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