TriCare

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TriCare CHAMPVA
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What is it?

• TriCare is simply the Department of Defenses
  health insurance plan for the military.
• TriCare, a managed care program, REPLACED CHAMPUS.

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Why did it change?

• More people were joining the military than were
  leaving. This caused a dilemma for the military.
• In order to provide cost effective health care,
  they opted to go with TriCare for their members.

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Who is Eligible?

• Army
• Navy
• Air Force
• Marines
• Coast Guard
• Public Health Service
• National Oceanic Atmospheric Admin.

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Special Term

• The uniformed service member is called a sponsor.
• Why? Because it is his/her involvement with the
  armed services that makes it possible for his/her
  family to be covered therefore, they are called
  sponsors.

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When the patient arrives

• Photocopy of military ID
• Check expiration dates
• DEERS (Defense Enrollment Eligibility Reporting
  Service) keeps list of all eligible sponsors
  but..

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Guess What?

• The sponsor can call to verify their eligibility
  but you or the MD cannot.
• The information is protected by the Privacy Act.
• You cannot call TriCare either.the branches of
  the military are the ones that make eligibility
  decisions!

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Participating vs NonParticipating

• TriCare will only pay if the service was provided
  by an authorized provider. Authorized providers
  are issued a PIN
• They have met certain educational/certification
  requirements.

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More.

• Once again, if you participate, PAR, you agree to
  accept the TriCare allowable charge as payment in
  full.
• Different from the othersyou can decide on a
  case by case basis whether to accept a TriCare
  patient.

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Even More.

• If you are a PAR, you have to file the claims for
  the sponsor.
• Payment is sent directly to the MD
• PARs are paid within 21 days of submitting a
  claim..pretty fast

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NonPARs

• A familiar figure of 115
• You cannot charge over 115 of TriCares
  allowable charge.
• If you do, the sponsor can say NoI am not going
  to pay it.

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115 Example

• TriCare allows 50.00 for a procedure.
• A NonPAR can charge 57.50 (115 of 50.00)
• If the NonPAR decides to charge in excess of 115
  then the patient can refuse to pay the difference
  and the MD would have to write it off

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Copy Cat, Copy Cat

• Guess where the fee schedule for basic TriCare
  comes from?
• Medicare Fee Schedule

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TriCare

• The Prefix Tri Three (3)
• There are three types of TriCare
• TriCare Standard
• TriCare Prime
• TriCare Extra

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TriCare Standard

• The fee-for-service program that replaced CHAMPUS
  (which was also fee for service)

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TriCare Prime

• What active duty service members are enrolled in.
• Like an HMOassigned a PCM or Primary Care
  Manager
• Majority of treatment is received on base
• Enrollment fee 230/individual and 460/family.
  No deductible. Standard had a deductible

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TriCare Extra

• If you dont want to receive care on base or in a
  military facilitythis is for you.
• More expensive. You get to see civilian MDs but
  you can see a military MD however, TriCare Prime
  people get in first.
• No enrollment fee.
• 150.00 deductible/individual, 300.00/family

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Filing Claims

• PARs have to do it for free.
• Use HCFA 1500 form.

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CHAMPVA

• Civilian Health and Medical Program of the
  Veterans Administration.
• Government program for veterans with 100
  service-related disability and their families.

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Eligibility

• Dependents of a vet who is totally and
  permanently disabled due to service (you went to
  war, stepped on a land mine and had your arms and
  legs removed)
• Survivors of a vet who died due to a service
  related disability (you went to war, stepped on a
  land mine get sent back home, get sepsis and
  dieyour wife and kids are cared for)

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And...

• Survivors of a veteran who died in the line of
  duty (you go to war and you step on a land mine
  and are killedyour wife and children are cared
  for)

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CHAMPVA

• Does not contract with providers.as long as the
  MD is licensed, they can see them.
• Still have to abide by the fee schedule.
• People have to pay a deductible and cost share
  (copayment)

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Special Term

• Catastrophic Cap The amount the sponsor has to
  pay Out of Pocket each calendar year before
  CHAMPVA pays at 100.
• 7500.00/year
• In 2000, the annual deductible was 50.00/person

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Secondary Payor

• If the patient has CHAMPVA and another insurance,
  CHAMPVA is almost ALWAYS secondary payor

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You knew there would be an exception...

• At least 1 Exception
• Medicaid (Payor of Last Resort)

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Filing Deadline

• One year from the date of service or discharge.