Chapter 8 TRICARE and Veterans Health Care Lesson

Chapter 8 TRICARE and Veterans’ Health Care

Lesson 8. 1 TRICARE and Veterans’ Health Care (Slide 1 of 4) 1. 2. 3. 4. 5. 6. Discuss the history of TRICARE. State who is eligible for TRICARE. List the circumstances when a nonavailability statement is necessary. Differentiate between authorized and nonauthorized providers. Explain the benefits of the TRICARE Select government program. State the TRICARE fiscal year.

Lesson 8. 1 TRICARE and Veterans’ Health Care (Slide 2 of 4) 7. 8. 9. 10. State the managed care features of TRICARE Prime and discuss enrollment, Primary Care Managers, preauthorization, and payments. Define individuals who enroll in the TRICARE Prime Remote program and discuss enrollment, preauthorization, and payments. Discuss TRICARE Reserve Select, TRICARE Retired Reserve, and TRICARE Young Adult programs. Explain TRICARE for Life benefits and those who are eligible individuals.

Lesson 8. 1 TRICARE and Veterans’ Health Care (Slide 3 of 4) 11. 12. 13. 14. Name individuals eligible for TRICARE Plus and discuss enrollment, preauthorization, and payments. Discuss the Supplemental Health Care Program, including enrollment and payments. Discuss the TRICARE Hospice Program. Identify individuals who are eligible for the Veterans Health Administration programs (CHAMPVA) and discuss enrollments and preauthorization.

Lesson 8. 1 TRICARE and Veterans’ Health Care (Slide 4 of 4) 15. 16. 17. Describe how to process a claim for an individual who is covered by various types of TRICARE programs. State the components of a TRICARE Summary Payment Voucher. List the components of a Veterans Health Administration (CHAMPVA) Explanation of Benefits document.

History of TRICARE 1966 CHAMPUS created (Civilian Health and Medical Program of the Uniformed Services) 1988 CHAMPUS Prime created as managed care plan option 1994 TRICARE became new title with three options Ø Ø Ø TRICARE Standard (fee-for-service) TRICARE Extra (PPO) TRICARE Prime (HMO) 2005 TRICARE consolidated into three regions TRICARE programs meet standards set by the 2010 health care reform federal legislation.

TRICARE Programs (Slide 1 of 5) Eligibility Ø Ø Ø Active duty service members Eligible family members of active duty service members Military retirees and eligible family members Surviving eligible family members of deceased active or retired service members Wards and preadoptive children Former spouses of active or retired service members (must meet requirements)

TRICARE Programs (Slide 2 of 5) Eligibility Ø Ø Ø Family members of active duty service members who were court-martialed or separated from their families for abuse Abused spouses/children of service members Spouses/children of NATO nation representatives Reservists and National Guard members activated for 30 or more consecutive days Disabled beneficiaries under 65 years with Medicare A and B Medicare-eligible beneficiaries in TRICARE for Life

TRICARE Programs (Slide 3 of 5) Defense Enrollment Eligibility Reporting System (DEERS) Ø A computerized database system in which all TRICARE-eligible persons must be enrolled Nonavailability Statement (NAS) Ø Ø Certification from a military hospital when it cannot provide care As of December 2003, not needed for individuals in the catchment area surrounding an MTF

TRICARE Programs (Slide 4 of 5) ID card required for all dependents over age 10 Not limited to using network providers for medically or psychologically necessary services Care usually sought at military hospital closest to home or identified through Health Care Finder (HCF) Authorized providers must be used. Preauthorization necessary for specialty care, hospitalization, and certain procedures Deductibles and copayments apply.

TRICARE Programs (Slide 5 of 5) TRICARE fiscal year Ø Begins October 1 and ends September 30 Authorized providers of health care Preauthorization Payments Ø Deductibles and copayments

TRICARE Select ID card required for all dependents over age 10 Preferred provider organization (PPO) option Network provider must be used Preauthorization necessary and coordinated by Health Care Finder for specialty care, hospitalization, and certain procedures Deductibles and copayments apply.

TRICARE Prime Voluntary health maintenance organization (HMO) option with annual fee required Minimum 12 months’ participation required Primary care manager (PCM) coordinates all care except emergencies. Referral from Health Care Finder required for use of non-network provider Preauthorization may be necessary for some specialty care, hospitalization, and certain procedures. Copayments and deductibles apply.

TRICARE Prime Remote Program For active duty service members only Must live at least 50 miles from military treatment facility Same benefits as TRICARE Prime No prior authorization for routine primary care PCM coordinates all care except emergencies No out-of-pocket expenses for in-network services

TRICARE Reserve Select Available to qualified members of the Selected Reserve and their families Similar to TRICARE Standard and Extra

TRICARE Retired Reserve and TRICARE Young Adult TRICARE Retired Reserve (TRR) Ø Premium-based health care plan available for purchase by qualified retired Reserve members and survivors TRICARE Young Adult (TYA) Ø Premium-based health care plan available for purchase by qualified dependents.

TRICARE for Life Supplementary payer to Medicare No separate ID card No referral or preauthorization requirements Payment is based on the services provided and coverage by both Medicare and TRICARE

TRICARE Plus ID card and DEERS enrollment required Enrollees use the military treatment facility as source of primary care Same benefits as TRICARE Prime when using military treatment facility Access to specialty providers at military treatment facility not guaranteed

Supplemental Health Care Program (SHCP) For active duty service members and other designated patients Enables beneficiaries to be referred to civilian providers when needed No deductibles or copayments if military treatment facility initiates referral

TRICARE Hospice Program Based on Medicare hospice program Life expectancy is 6 months or less Cannot also receive care under TRICARE basic programs

TRICARE and HMO Coverage Provider must meet TRICARE provider certification standards Type of care must be a TRICARE benefit and medically necessary TRICARE does not pay for emergency services received outside the normal HMO service area.

Veterans Health Administration Program (Slide 1 of 2) 1973 Civilian Health and Medical Program of the Veterans Administration (CHAMPVA) created Now called the Veterans Health Administration For spouses and dependent children of veterans with total, permanent disability Must not be eligible for TRICARE Standard or Medicare A Service benefit program

Veterans Health Administration Program (Slide 2 of 2) ID card required for all dependents over age 10 Benefits similar to TRICARE Standard for dependents of retired and deceased military personnel Freedom of choice in selecting civilian providers Preauthorization needed for some services

Claims Procedure (Slide 1 of 8) TRICARE Select administered by DOD (Department of Defense) Veterans Health Administration program administered by Veterans Administration (VA) Claims must be: Ø Ø Ø Billed on CMS-1500 (02 -12) form or electronically Submitted to the correct fiscal intermediary Filed within 1 year of service

Claims Procedure (Slide 2 of 8) TRICARE Select and TRICARE Prime Ø No claim forms filed by beneficiary if care provided is in network Providers must: Ø Ø Ø Use CMS-1500 (02 -12) form or electronic system to submit claims. Submit claims to correct subcontractor. File within 1 year of service.

Claims Procedure (Slide 3 of 8) TRICARE Prime Remote and Supplemental Health Care Program Ø Ø Ø Outpatient services are submitted with CMS-1500 (02 -12) form or electronically. Point-of-service (POS) option and Nonavailability Statement (NAS) requirement do not apply Claims must be filed within 1 year of service.

Claims Procedure (Slide 4 of 8) TRICARE for Life Ø Civilian provider submits claims to Medicare to pay first and then the claim is submitted to TRICARE for the remainder

Claims Procedure (Slide 5 of 8) TRICARE/Veterans Health Administration and Other Insurance Ø Ø TRICARE/Veterans Health Administration usually pay as secondary payer if beneficiary has other health insurance. An explanation of benefits (EOB) copy from primary carrier should be attached to the completed CMS-1500 (02 -12) claim form. Include copy of the physician’s complete itemized statement. Claim should then be sent to the local claims processor (fiscal intermediary).

Claims Procedure (Slide 6 of 8) Medicare Ø Ø Coordination of benefits Ø TRICARE is secondary, if under 65 with Part A and Part B Veterans Health Administration is secondary, if under 65 with Part A and Part B Needed for situations with dual coverage so there is no duplication of benefits paid TRICARE pays the lower of: Ø Ø Amount of TRICARE allowable charges after other plan has paid benefits Amount TRICARE would have paid as primary

Claims Procedure (Slide 7 of 8) Third-party liability Ø Ø Ø TRICARE form DD 2527 submitted with regular claim form CMS-1500 (02 -12) Provider can submit claims only to third-party liability carrier for reimbursement. Claims submitted with ICD-10 -CM diagnostic codes between S 00 – T 88 may trigger the fact that there may be third-party litigation, and the claims processor may request completion of form DD 2527.

Claims Procedure (Slide 8 of 8) Workers’ compensation Ø Ø TRICARE/CHAMPVA billed when workers’ compensation benefits are exhausted Beneficiary with work-related injury or illness must file the claim with the workers’ compensation carrier

After Claim Submission TRICARE Ø For each claim, a summary payment voucher is issued to the patient. • Details the payment of the claim, allowable charges, amount billed, amount TRICARE paid, how much deductible has been paid, and patient’s cost share amount Veterans Health Administration Ø For each claim, an explanation of benefits document is issued to the patient summarizing actions taken.

After Claim Submission Quality assurance Ø Continually assesses the effectiveness of inpatient and outpatient care Claims inquiries and appeals Ø Providers may request reconsideration of a denial of certification for coverage or of the amount paid for a submitted claim.