TRICARE For Life

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TRICARE For Life
2010
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• Your Presenters
• Edward Coryell
• Benita Davis
• Rhita Walker-Smith
• Nidia Alicea

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TRICARE Regions

• TRICARE North
• Health Net Federal Services, LLC
• 1-877-TRICARE (1-877-874-2273)
• www.healthnetfederalservices.com
• TRICARE South
• Humana Military Healthcare Services, Inc.
• 1-800-444-5445
• www.humana-military.com
• TRICARE West
• TriWest Healthcare Alliance Corp.
• 1-888-TRIWEST (1-888-874-9378)
• www.triwest.com

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TRICARE Programs

• Active Duty
• Prime or Prime Remote
• Active Duty Family Members
• Prime or Prime Remote
• Extra
• Standard
• Retirees Family Members
• Prime
• Extra
• Standard
• Medicare-Eligible Retirees
• TRICARE For Life
• TRICARE Plus
• TRICARE Prime (under age 65)

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TRICARE Eligibility

• Service Member (Sponsor)
• Medal of Honor Recipients
• Family Members
• Spouse
• Certain former spouses
• Children step-children
• Unmarried, to age 21
• Unmarried, full-time student, to age 23
• Certain others

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DEERS ID Cards

• Update DEERS when
• Changing status
• Reenlisting or retiring
• Moving changing address or phone number
• Adding or removing a family member
• Becoming eligible for Medicare
• New ID card required at age 65

To schedule an appointment with an ID Card Office
to update DEERS or get a new ID card, visit
HTTPS//ES.CAC.NAVY.MIL/SIGNUP.PL
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Former Spouses

• Divorced, unremarried former spouses
• Former spouse uses own SSN
• 20/20/20 rule
• 20/20/15 rule
• Eligible for only one year from the date of the
  divorce decree
• Not eligible if covered by an employer-sponsored
  health plan
• Stepchildren eligibility

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Military Treatment Facilities

• Access to care priorities
• Active duty
• Active duty family members enrolled in Prime
• Retirees family members enrolled in Prime
• TRICARE Plus
• Active duty family members not in Prime
• Retirees family members not in Prime (includes
  TFL)

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TRICARE For LifeBecame Law01 October 2001
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TRICARE For Life MedicareTRICARE
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TRICARE For Life Requires Medicare Parts A
B (with limited exceptions) Medicare
Primary TRICARE - Secondary
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Before Since TFL (a comparison)
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Medicare Parts

• A Hospitalization
• B Outpatient
• C Medicare Advantage Plans
• D Prescription Drug Plans

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Medicare Eligibility

• Most at age 65
• Under age 65 disability
• Most disabilities 2 year wait
• No wait
• End-Stage Renal Disease (ESRD)
• Amyotrophic Lateral Sclerosis (ALS/Lou Gehrigs
  Disease)
• Some may qualify under sponsors Social Security
  Number
• Social Security eligibility age may be different

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Medicare Eligibility (continued)

• Premium-free Medicare Part A
• Under own SSN with 40 or more quarters of
  Medicare-covered employment
• Under spouses (or divorced/deceased spouses)
  SSN, if spouse is age 62, or older has 40 or
  more quarters
• If spouse is not yet 62, re-file for Part A when
  he or she reaches that age
• Enroll in Medicare Part B when first eligible to
  avoid premium penalty and loss of TRICARE coverage

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Medicare Eligibility (continued)

• If not eligible for premium-free Medicare Part A
  under own SSN or spouses SSN
• Obtain Notice of Award or Notice of
  Disapproved Claim from the Social Security
  Administration
• Take the Social Security Notice to an ID Card
  Issuing Facility to update DEERS obtain a new
  ID card
• You will remain eligible for regular TRICARE
  benefits (Prime, Extra or Standard)

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Medicare Eligibility (continued)

• Exceptions to requirement for Medicare Part B
• Active duty service members
• Active duty family members
• Must enroll in Part B when service member
  retires
• Do this before retirement date to avoid a break
  in TRICARE coverage
• Special Enrollment Period

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Enrolling in Medicare B

• Usually automatic at age 65
• Initial 7-month enrollment period
• Annual general enrollment period
• January 1st March 31st
• Premium surcharge/penalty
• Special enrollment situations
• Disability
• Active duty service member or family member
• Still employed at age 65

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Medicare Part B Costs

• Medicare Part B monthly premium
• 96.40 or 110.50 per month for most
• More for higher incomes
• Individual gt 85K/year
• Joint gt 170K/year
• Usually goes up annually
• Inpatient (Part A) outpatient (Part B)
  deductibles, co-pays limits
• TRICARE will cover most of these costs, for
  covered benefits

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Medicare B Premiums
For beneficiaries whoce Medicare Part B
premiums were withheld from their Social Security
check in 2009 For all others
Note Medicare premiums do not apply towards the
catastrophic cap however, they may be tax
deductible. Premiums are usually not paid with
pre-tax dollars. Check with your accountant or
tax specialist for details.
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Medicare Card

• No TRICARE For Life card
• Just show this Medicare card along with your
  uniformed services ID card

Call 1-800-MEDICARE or visit www.medicare.gov if
you need a new card.
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Medicare TRICARE Who Pays For What
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TFL Prior Authorization Requirements

• Prior authorization is required for some
  services when TFL is the primary payer instead of
  Medicare
• Adjunctive dental care dental anesthesia
• Institutional care inpatient mental health
• Psychoanalysis all outpatient psychotherapy
  after the first 8 sessions per FY
• Organ stem cell transplants
• Hospice care
• Extended Care Health Option (available to active
  duty family members only)

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TRICARE For Life Costs

• No enrollment fee or premium
• Same TRICARE Standard Extra deductibles
  co-pays apply for services only covered by
  TRICARE
• Beneficiaries under age 65 with Medicare can
  still enroll in TRICARE Prime, the annual
  enrollment fee is waived

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TRICARE For Life Catastrophic Cap

• 3000 per family per fiscal year
• Out-of-pocket expenses for covered services
• Does not include
• Medicare Part B premiums
• Other health insurance premiums
• Non-covered services

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TRICARE For Life MTF Access-to-Care

• Primary care space available
• Except TRICARE Plus
• Specialty care space available
• Ancillary care walk-in
• Laboratory
• Radiology (limitations)
• Pharmacy
• Immunizations
• Emergency room

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TRICARE Plus

• Primary care program at some MTFs (Internal
  Medicine _at_ NMCP)
• Same primary care access as TRICARE Prime
• No enrollment fees, deductibles or co-pays
• Specialty care not guaranteed
• Continued availability not guaranteed
• Limited enrollment space often by invitation
  only

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TRICARE Pharmacy

• Military hospital or clinic
• www.tricare.mil/pharmacy
• Mail order retail pharmacy
• 1-877-363-1303
• www.express-scripts.com/TRICARE
• Mail order pharmacy (overseas)
• 1-866-275-4732
• Retail non-network
• Note prescriptions filled overseas must be
  written by a U.S.-licensed physician

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Pharmacy Costs
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Pharmacy Claims

• Prescriptions purchased in the United States,
  Puerto Rico, U.S. Virgin Islands Guam are
  processed by Express Scripts
• 1-877-363-1303
• Prescriptions purchased overseas are processed
  by Wisconsin Physician Services
• 1-608-301-2310 (Europe Pacific)
• 1-608-301-2311 (Latin America Canada)
• www.TRICARE4u.com

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Medicare Part C

• Includes both Parts A B
• Some may also include Part D
• Medicare Advantage Plans
• Preferred Provider Organization (PPO)
• Health Maintenance Organization (HMO)
• Private Fee-for-Service (PFFS)
• Medical Savings Account (MSA)
• Special Needs Plan (SNP)
• Provider Sponsored Organization (PSO)
• Religious Fraternal Benefit (RFB)
• Commercially available plans
• Benefits, costs savings vary between plans

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Medicare Part D

• Most TFL beneficiaries do not need Part D
• Exception may be people also eligible for
  Medicaid
• Things to consider
• Monthly premiums, deductibles, co-pays, claims
• Donut hole
• Drug coverage
• Annual open enrollment
• November 15th December 31st

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Preventive Services

• Clinical Preventive Services
• Cancer screening
• Disease prevention
• Immunizations vaccinations
• Smoking cessation healthy living education
• One-time Welcome to Medicare physical exam
• Within the first 6 months of having Medicare

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Long Term Care

• Long term (custodial) care
• Not covered by Medicare or TRICARE
• Assistance with activities of daily living
  (comfort, personal hygiene, cooking feeding,
  wellness)
• Commercial plans available
• Federal Long Term Care Insurance Program
• 1-800-582-3337
• www.opm.gov/insure/ltc

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Skilled Nursing Care

• Generally covered, if medically necessary
• Doctors plan of care needed to justify skilled
  nursing services
• Nursing rehabilitation physical,
  occupational speech therapy
• Usually delivered in a skilled nursing facility
• Medicare has a 100-day limit

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Claims Processing

• Wisconsin Physician Services (WPS) is the claims
  processor
• Provider files a claim with Medicare
• Medicare processes the claim forwards it to
  WPS
• Patient receives explanations of benefit (EOB)
  from both Medicare TRICARE
• 1-866-773-0404 (WPS Customer Service) TDD
  1-866-773-0405
• www.TRICARE4u.com

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TFL Claims EOBs

• Wisconsin Physician Services mails monthly EOB
  summaries
• Individual EOBs are mailed for
• A claim that includes rejected services that
  have appeal rights
• A claim which includes a payment to the
  beneficiary
• Beneficiaries can choose to get their EOBs
  online (www.TRICARE4u.com) rather than by mail,
  will get an electronic notification (email) each
  time a claim processes

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TFL Other Health Insurance (OHI)

• Employer-sponsored plan or Medicare supplement
• Employer OHI is usually primary
• With 20 or more employees in the plan
• Medicare is secondary
• Medicare supplement is next
• TRICARE is last
• Except for Medicaid or TRICARE supplement
• May have to file a paper claim for TRICARE
  reimbursement

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TFL OHI (continued)
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TFL Overseas

• Medicare does not provide coverage in most
  overseas locations
• Medicare does provide coverage in U.S.
  territories aboard ships in U.S. territorial
  waters
• Guam, Puerto Rico, U.S. Virgin Islands, American
  Samoa Northern Mariana Islands
• Medicare Parts A B are still required to have
  TRICARE coverage overseas
• www.tricare.mil/overseas
• 1-888-777-8343

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TRICARE Retiree Dental Program

• Delta Dental Plan of California
• 1-888-838-8737 www.trdp.org
• For retirees their families, Medal of Honor
  recipients their families, certain survivors
  former spouses

Note Medicare-eligible active duty family
members can enroll in the TRICARE Dental Program
through United Concordia
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TRICARE Veterans Affairs (VA)

• Some TRICARE beneficiaries are also eligible for
  health care benefits from the VA
• Veterans seeking care for a service-connected
  condition in a VA medical facility must use their
  veterans' medical benefit. The VA does not bill
  TRICARE for treatment of service-connected
  conditions
• For treatment of non service-connected
  conditions, dual-eligible veterans must choose to
  use either their veterans' or TRICARE benefits at
  the onset of each episode of care.

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U.S. Family Health Plan

• Program similar to TRICARE Prime
• Available in six areas of the U.S.
• Eligibility
• Active duty family members
• Retirees eligible family members (including
  those age 65 older)
• Except for emergency care, enrolled
  beneficiaries cannot use other TRICARE options,
  including MTF pharmacy benefits
• www.usfamilyhealthplan.org

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U.S. Family Health Plan Locations

• Johns Hopkins Medicine Maryland, Washington
  D.C., parts of Pennsylvania, Virginia, West
  Virginia Delaware
• Martins Point Health Care Maine, New
  Hampshire, Vermont northeastern New York
• Brighton Marine Health Center Rhode Island
  Massachusetts
• Saint Vincent Catholic Medical Centers New
  Jersey, parts of New York (including NYC),
  southeastern Pennsylvania western Connecticut
• Christus Health Southeast Texas southwest
  Louisiana
• Pacific Medical Center Puget Sound area of
  Washington State

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Help Information

• Health Benefit Advisors (HBA)
• Beneficiary Counseling Assistance Coordinators
  (BCAC)
• Located at NMCP most area military clinics
• NMCP Building 3, 3rd Floor
• [phone]
• www.tricare.mil/bcacdcao

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Help Information (continued)

• TRICARE Service Centers
• Health Net Federal Services
• 1-877-874-2273 (1-877-TRICARE)
• Four locations in Hampton Roads
• NMCP, Building 249
• Kenner Army Health Clinic, Fort Lee
• Langley AFB 1st Medical Group
• McDonald Army Community Health Clinic, Fort
  Eustis
• www.healthnetfederalservices.com

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Help Information (cont)

• TRICARE
• www.tricare.mil
• DEERS
• www.tricare.mil/DEERS
• www.dmdc.osd.mil/rsl
• 1-800-538-9552
• Medicare
• www.medicare.gov
• 1-800-633-4227
• Social Security
• www.ssa.gov
• 1-800-772-1213

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Thank You!