Title: Program for Persons With Disabilities
1Program for Persons With Disabilities
- TRICARE/CHAMPUS Programs
- a. Prime - most inexpensive way to go
- b. Extra (a PPO) next least expensive
because providers give discount - c. TRICARE Standard (most expensive way
to). However, the most all active duty providers
of services participates in their coverage).
However, the most all active duty families should
have to pay in any fiscal year is 1,000. (as
long as all providers of services participate in
their coverage)
2PFPWP
- PFPWD - Enhanced benefit program for A/D families
only. Can be used in addition to their regular
cover whether Prime or Standard - Who qualifies? Must have severe diagnosis -
sometimes can be a child who has never been
diagnosed, i.e., developmentally delayed.
3PFPWD
- What relation is there between the PFPWD and
EFMP? Non - two separate programs. However, if
a family is applying for services under the
PFPWD, then they should be enrolled in EFMP
because - What can you do to help these families
transition from one area to another? Everything
under the TRICARE/CHAMPUS Programs is physician
driven, there fore the families should be
referred to the closest TSC to enroll in Prime or
accomplish Portability from one region to another
and it is recommended they they go in person to
do this. Then the HCF can assist with an
appointment for the patient to be seen and the
physicians portion of the request for benefits
under PFPWD started. Even if a family indicates
their desire to remain under TRICARE/Standard
coverage and want to use the PFPWD, they need to
contact the 1-800-931-9501 and get the name of
some physicians in the Extra Network so that they
can get started with their medical care. - Also very good to refer them directly to the
nurses in charge at 399-7649, ext 3021 or 3030
4PFPWD
- Must e pre-authorized. Applications are good for
12 months w/authorization for for 6 months.
Applications completed by a physician in another
region is not acceptable however, if there is a
really serious case that needs immediate
assistance,please call one of the nurses to see
what can be done to expedite care and an
authorization.
5Program for Persons with Disabilities(PFPWD)
- Public funds must be utilized first and if not
available to cover the need, then there is a form
that must be completed that sates that is is not
available and this forms must be submitted with
the entire request package
6How much will it cost?
- Program pays up to 1,000 per month/with family
paying a flat rate based on pay grade, i.e.,
E-1-E-5 25 per month. Its like giving the
family 1,000 to budget because anything over the
1,000, the family will have to payDME is
prorated and can be done in two ways wheelchair
that costs 3,000, can be prorated x 3months.
With family paying 75 however, if there is a
possibility of the need for PT also then will go
to a table whereby 1,000 is divided into 3,000.
And, then multiplied by2 6 months prorate
thereby enabling the family to have left over
each month for PT.Most of the time, this is the
cheapest way to go for therapies. It is the only
way to obtain a hearing aid - not a covered
benefit under Prime or Standard coverage. Even
though you can use your regular coverage ad use
this program in addition, you cannot receive the
same service under both programs at the same
time, I.e., you cannot receive PT under this
program three times a week and under your Prime
once a week. All PT will have to go under one
program or the other.If there are more than one
family member who qualifies for this program,
family only pays for first person so the would
need to look at which family member has the most
serious diagnosis needs and let that member be
the one who goes for free - example, child 1
with moderate mental retardation and only needs
speech therapy two times a week child 2 with
cerebral palsy wheelchair confirmed and must have
PT, OT speech and needs a gait trainer. This
second child should be the one who gets to go for
free. Only catch is that claims must be
continuously going on child1 in order fore the
child 2 to have their claims paid at 100 of
allowable.Catastrophic cap does not apply to
this program - only applies retrospectively when
cap is met under the familys regular coverage
and the family must request that claims be
reconsidered for the FY.
7Points of Contact
- Tricare Service Center
1-800-931-9501 - PFPWD Case Manager
(757) 399-7649 Ext.. 3020/3021
8For More Information Visit
- www.AnthemAlliance.com
- www.tma.med.navy.mil
- www.tricare.osd.mil
- www.myTRICARE.com