TRICAREYour Military Health Plan

Retiree BenefitsCCGNRC Annual Conference

Mark Freese, DMD MPH MHACAPT USPHS27 April 2010

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TRICARE Management Activity Headed by the ASD(HA)

21 April - President Obama nominated Dr. Jonathan Woodson for ASD(HA)• BG Army Reserves assigned as Assistant Surgeon General Force

Management, Mobilization, Readiness & Reserve Affairs • Associate professor of surgery and associate dean at Boston

University School

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TRICARE Regions

Ft. Campbell moves to the South with T3

=TRICARE Regional Office (TRO)

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TRICARE Regional Contractorsmay change with T-3

• TRICARE North Region– Health Net Federal Services, Inc.– www.healthnetfederalservices.com– 1-877-TRICARE (1-877-874-2273)

• TRICARE South Region– Humana Military Healthcare Services, Inc. – www.humana-military.com– 1-800-444-5445

• TRICARE West Region– TriWest Healthcare Alliance– www.triwest.com – 1-888-TRIWEST (1-888-874-9378)

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• Who is eligible?– Sponsor– Spouse/certain former spouses– Children to age 21 (age 23 if fulltime

student)– Incapacitated child (determined

physically or mentally disabled prior to age 21). Visit PSD for application package.

• Valid ID Card needed for all age 10 and older

• Keep your DEERS information current to ensure continued eligibility

• Proper documentation needed to make any changes to DEERS other than an address change.

DEERS (Defense Enrollment Eligibility Reporting System)

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• Visit an ID card issuing facility; locate one near you at www.dmdc.osd.mil/rsl

• Call: 1-800-538-9552 (address changes only)• Fax changes to: 1-831-655-8317• Mail changes to:

Defense Manpower Data Center Support Office

Attn: COA400 Gigling RoadSeaside, CA 93955-6771

• Make address changes online at: www.tricare.mil/DEERSAddress

Updating DEERS Information

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Patient Protection and Affordable Care Act

• The Patient Protection and Affordable Care Act leaves TRICARE under sole authority of the Defense Department and the Secretary of Defense. TRICARE is a benefit, not insurance.

• TRICARE and TRICARE for Life are qualifying coverage.

• Coverage to age 26 for children. TRICARE may mirror this change if Congress institutes a change in the CFRs. (Health card only)

Transitioning from Active Duty to Retirement

Health Care Options

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Decision Process

Where will you live?Will you accept employment?How is your health (and family)?What health plans are available?Cost of competing health plans? Insurability?Do I need supplemental

insurance?

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Accessing Care During Terminal Leave

• ADSM is still considered active duty during the terminal leave period and must access care under the current Prime rules.– Access care through nearest MTF– Go to a civilian hospital based emergency

room– Call back to PCM/regional contractor to

authorize care through a civilian doctor or urgent care clinic

– Routine care will not be authorized outside your PCM while on terminal leave.

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Military Treatment Facilities (MTFs)

• Upon retirement, your access to services at the MTF will change

• You will retain priority access to specialty care in the MTF if you enroll in TRICARE Prime

• If you choose to use TRICARE Extra or TRICARE Standard, you will continue to have access to care in an MTF on a space-available basis only

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1. Active duty service members2. Active duty family members enrolled in

TRICARE Prime *3. Retirees, their family members, and

others enrolled in TRICARE Prime4. Active duty family members NOT enrolled

in TRICARE Prime 5. Retirees, their family members, and

others NOT enrolled in TRICARE Prime 6. All other eligible beneficiaries

* If spouse is still active duty, use status as Active Duty Family Member when accessing medical care.

MTF—Priorities for Care

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How TRICARE Changes When You Retire

When on Active Duty Upon Retirement

TRICARE Options

• TRICARE Prime • TRICARE Prime Remote• TRICARE Extra*• TRICARE Standard*

• TRICARE Prime• TRICARE Extra• TRICARE Standard

TRICARE Prime• No enrollment fees• No copayments

• Enrollment fees apply• Copayments apply in

network

TRICARE Extra 15% cost-share 20% cost-share

TRICARE Standard

20% cost-share 25% cost-share

Catastrophic Cap

$1,000 annually $3,000 annually

MTF Access

ADSMs—1st priorityADFMs—priority depends on enrollment in TRICARE Prime

Priority depends on enrollment in TRICARE Prime

Medicare-eligibility

Family members not required to purchase Medicare Part B

Must purchase Medicare Part B regardless of age

* ADSMs are not eligible for TRICARE Extra or TRICARE Standard

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• Fee-for-service option (Old CHAMPUS)• No enrollment required • Seek care from any TRICARE

authorized provider• Responsible for annual deductibles and

cost- shares—highest out-of-pocket expense

• May have to pay provider, then file claim for reimbursement

• May seek care in an MTF on a space-available basis

TRICARE Standard

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TRICARE Standard—Costs

• Deductible – $150 individual/$300 family annually

• Cost-shares after deductible has been met– Outpatient care

25% of TMAC (when using a non-participating provider, patient responsible for 15% above the TMAC)

– Inpatient Care

Lesser of $535 per day or 25% of billed charges for facility bill, plus 25% of allowable professional fees

• Catastrophic Cap– $3000 per fiscal year

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• Preferred provider option (PPO)• No enrollment required• Seek care from any TRICARE network

provider• Responsible for annual deductibles

and discounted cost-shares• Providers required to file claims for

you• May seek care in an MTF on a space-

available basis

TRICARE Extra

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TRICARE Extra—Costs

• Deductible – $150 individual/$300 family annually (fiscal year)

• Cost-shares after deductible has been met– Outpatient care

20% of negotiated rate– Inpatient care

Lesser of $250 per day or 25% of negotiated charges for facility bill, plus 20% of negotiated professional fees

• Catastrophic Cap– $3000 per fiscal year

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Standard• Any TRICARE

authorized provider• Cost-share: 25% of

allowable charge• May have to file

claims• Nonparticipating

providers may charge up to 15% above allowable charge for services

Extra• Any TRICARE

network provider• Cost-share: 20% of

negotiated rate• Providers required to

file claims for you• Not responsible for

additional charges for covered benefits

TRICARE Extra vs. Standard

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TRICARE Prime Enrollment

• Prime does not automatically carry over into retirement• A new enrollment application must be completed for

the region you live in to continue in Prime • Deadline for admission – 20th of each month• Enrollment fees will apply

– $230 Individual/$460 Family– Paid monthly, quarterly, or annually

• Include the Enrollment Fee Allotment Authorization Letter with application if paying by allotment

• Spouse still Active Duty???– Enroll in Prime as Active Duty Family Member

• Former Spouse considered own sponsor– Separate enrollment fees apply

• Must select or be assigned PCM

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• New Enrollment – First time enrollment as retiree

• PCM Change – Changing providers within the same region

• Portability – Transferring enrollment between regions as you move

• Split Enrollment – When family members live and enroll in different regions. Enrollment fee paid in region sponsor lives.

Enrollment Types

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• MTF or network provider- Your Medical Home

• Provides most of your care and coordinates specialty care when needed

• Knows your family and medical history, lifestyle, and habits

• Helps you develop and carry out a personal health maintenance and improvement program

• Prevents and detects health problems through regular screenings and wellness education– Retirees enrolled in Prime are entitled to one

preventative vision check every two years at no cost

Primary Care Manager (PCM)

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Cost of Care

• MTF Care– Outpatient care at no cost– Inpatient care at subsistence rate

• Civilian Care– PCM/Specialty Outpatient visit: $12

copayment– Inpatient visit: $11 per day ($25 minimum)– Emergency services: $30 copayment– Behavioral health outpatient visit:

• $25/individual• $17/group

– Behavioral health inpatient visit: $40 per day

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TRICARE Point of Service (POS)

• Non-authorized, non-emergent care– Retro-authorizations not granted

• Freedom of choice• $300 Deductible/50% of TMAC• No upper limit to POS Catastrophic Cap

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TRICARE Plus

• MTF primary care enrollment program• Offered at limited number of MTFs• Limited capacity• All beneficiaries eligible for care in the MTF

(except those enrolled in Prime or other civilian HMO plan) may seek enrollment in TRICARE Plus

• Offers only primary care – specialty care through MTF is not guaranteed

• Enrollment in TRICARE Plus does not affect TFL benefits or other existing programs

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Accessing Out of Area Care

• Use MTF care if near a Military site• Emergency care – go to nearest hospital-based

emergency room (Prudent Lay Person Rule)

• Acute care (includes urgent care clinics)– Covered only when you receive prior

authorization from your PCM• First call PCM to notify need for care• Second call regional contractor for authorization

• Routine care not authorized while out of area

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Access to Care when Living Overseas

• You and your family members have access to MTFs overseas on a space-available basis

• You will not be eligible for enrollment in TRICARE Prime while living overseas, but will be covered for all civilian health care under TRICARE Standard

• The same annual deductibles and cost-shares will apply as in the stateside TRICARE Standard option

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Durable Medical Equipment

TRICARE covers durable medical equipment (DME) when prescribed by a physician and if the DME:

• Improves, restores, or maintains the function of a malformed, diseased, or injured body part, or can otherwise minimize or prevent the deterioration of the patient's function or condition

• Maximizes the patient's function consistent with the patient's physiological or medical needs

• Provides the medically appropriate level of performance and quality for the medical condition present

• Is not otherwise excluded by the regulation and policy  TRICARE does not cover:• DME for a beneficiary who is a patient in a type of facility that ordinarily

provides the same type of DME item to its patients at no additional charge in the usual course of providing its services is excluded.

• DME when it's available from a military treatment facility • DME with deluxe, luxury, or immaterial features which increase the cost

of the item to the government relative to similar item without those features.

• Maintenance agreement.

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Home Health Care

• TRICARE covers a maximum of 28 hours per week part time, or 35 hours per week intermittent, skilled nursing care, home health aide services, any physical, speech and occupational therapy. All care must be provided by a participating home health agency.

• The services covered under TRICARE are the same as those covered by Medicare.

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Hospice Care

TRICARE covers hospice care under the following guidelines:

• Care will only start with a doctor's order. • The patient/caretaker must complete an "election

statement" and file it with the regional contractor. • With prior certification of the terminal illness for each period

– Two 90 day periods– Unlimited 60 day periods

• If a beneficiary revokes a hospice election, any remaining days in that period are forfeited.

• There are four levels of care within the hospice benefit: 1. Continuous home care 2. General hospice inpatient care 3. Inpatient respite care 4. Routine home care

• Note: Only available in the United States and Territories.

Transitioning from Active Duty to Retirement

Pharmacy Options

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• MTF Pharmacy• TRICARE Mail Order Pharmacy (TMOP) –

now called home delivery• TRICARE Retail Network Pharmacy• Non-network Retail Pharmacy

TRICARE Pharmacy Program

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Pharmacy Co-Pay Structure

Type of Pharmacy

FormularyNon-Formulary

(Tier 3)Generic (Tier 1)

Brand Name (Tier 2)

Military Treatment Facility(up to a 90-day supply)

$0 $0 Not applicable

Home Delivery(up to a 90-day supply)

$3 $9 $22 unless medical necessity is established

Retail Network(up to a 30-day supply)

$3 $9 $22 unless medical necessity is established

Non-Network(up to a 30-day supply)

$9 or 20 percent of the total cost, whichever is greater, after your annual outpatient deductible is met

$22 or 20 percent, whichever is greater, after your annual outpatient deductible is met

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• Generic drugs will be substituted for brand names when available

• Must justify medical necessity for brand name to be dispensed

• If generic equivalent drug does not exist the brand name drug will be dispensed

Generic Drug Use Policy

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• TRICARE pays after all other health insurance (OHI) plans except:– Medicaid– TRICARE supplements

• Used to pickup remaining cost shares after TRICARE has processed the claim

• You must notify TRICARE of OHI Failure to do so could result in TRICARE coverage being restricted or denied.

TRICARE and OHI

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Claims Filing

• Who is responsible for filing claims?– Network provider/participating provider– Beneficiary

• Forms needed for filing claim– TRICARE Claim Form (DD2642)– Full Itemized Statement (HCFA-1500)– Statement of Personal Injury (DD2527)– OHI Explanation of Benefits (EOB)– Prescriptions

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Claims Assistance

• Call regional contractor for area you live in

• Go online to www.myTRICARE.com• Contact HBA/BCAC at your nearest MTF• Normally claim should process and EOB

be received within 21 to 30 days of date medical care was rendered

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TRICARE For Life

• Began October 1, 2001• Claims filed automatically from Medicare to

TRICARE (provider only needs to file to Medicare)

• If OHI exists, Medicare will pay first, OHI second, and TRICARE will pay last.

• No monthly enrollment fees (except for Medicare Part B)

• Space available access at MTF continues

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TRICARE For Life

• Eligibility– Medicare eligible sponsors including retired

guardsmen and reservists age 65 and over– Medicare eligible family members and

widow/widowers– Certain former spouses if eligible for

TRICARE before age 65• Mandatory enrollment in Medicare Part B• TFL coverage effective date

– First day of month eligible beneficiary turns 65

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A health insurance program for:– People 65 years of age and older

– People under age 65 with certain disabilities

– People with End-Stage Renal Disease (ESRD)

Medicare is managed by Centers for Medicare & Medicaid Services (CMS)

•Enrollment is managed by the Social Security Administration (SSA) or Railroad Retirement Board (RRB)

What is Medicare?

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Medicare Basics

Part A HospitalInsurance

Part BMedicalInsurance

Part CMedicare Advantage Plan

Part DPrescription Drug Coverage

•Inpatient hospital care •Skilled nursing care•Home health care•Hospice care

•Doctors’ services and outpatient care•Preventive services •Diagnostic tests•Some therapies•Durable medical equipment

•Combines Part A, Part B, and, sometimes, Part D •Coverage managed by private insurance companies approved by Medicare.

•Outpatient prescription drugs

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2010 Part B details

 You Pay Monthly If Your Yearly Income is

   File Individual Tax Return

 File Joint Tax Return

 $110.50  $85,000 or less $170,000 or less

 $154.70  $85,001-$107,000 $170,001-$214,000

 $221.00  $107,001-$160,000 $214,001-$320,000

 $287.30  $160,001-$214,000 $320,001-$428,000

 $353.60  Above $214,000 Above $428,000

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A Bit of History

Before October 2001TRICARE beneficiaries who became entitled to

premium-free Medicare Part A based on age, would:

• Lose their TRICARE-eligibility• Only have access to health care in military treatment

facilities on a space-available basis

National Defense Authorization Act for Fiscal Year 2001*

• Restored TRICARE medical and pharmacy benefits to all Medicare-TRICARE eligible uniformed services retirees, their family members and survivors, effective October 1, 2001

• The benefit is know as TRICARE For Life

*Public Law 106-398, Section 712

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What Is TRICARE For Life?

• TRICARE For Life (TFL) is a TRICARE option that offers Medicare-wraparound coverage by acting as a second payer to Medicare.

• TFL minimizes the Medicare-TRICARE beneficiary’s out-of-pocket expenses (similar to a Medicare supplement)

TRICARE

Med

icar

e

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Who Is TRICARE For Life For?

• TRICARE For Life (TFL) is for Medicare-TRICARE beneficiaries who are:– Entitled to premium-

free Medicare Part A;

– Enrolled in Medicare Part B (if other than an active duty family member)

• Note this is not age dependent.

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TRICARE For Life

• Medicare Part B Rule– Federal law requires TRICARE

beneficiaries eligible for premium-free Medicare Part A to have Medicare Part B to remain TRICARE-eligible.

– But for every rule, there’s an exception…• Active duty family members entitled to

premium-free Medicare Part A, don’t have to have Medicare Part B until their sponsor retires.

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How TFL Works With Medicare

Step 1: Beneficiary goes to a Medicare provider

Step 2: Provider files claim with Medicare

Step 3: Medicare pays its portion and electronically forwards the claim to the TRICARE For Life (TFL) claims processor

Step 4: TFL pays the provider directly for TRICARE-covered services

Medicare

TRICARE

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How TFL Works with Medicare

Services covered by both Medicare and TRICARE• Medicare pays first and TRICARE For Life (TFL) pays the

beneficiary’s remaining Medicare coinsuranceExample: Doctor Visit

Medicare pays 80%

TRICARE pays 20%

Beneficiary pays $0

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How TFL Works with Medicare

Examples: Overseas care, shingles vaccine

Services covered by TRICARE but not by Medicare

• TRICARE For Life (TFL) pays first and Medicare pays nothing

• Beneficiary is responsible for paying the TRICARE fiscal year deductible and cost share

• Deductible $150/person or $300/family• The provider’s network status determines the

beneficiary’s cost share– Network provider 20% cost share– Non-network provider 25% cost share

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How TFL Works with Medicare

Services covered by Medicare but not by TRICARE

• Medicare pays first and TRICARE For Life (TFL) pays nothing

• Beneficiary is responsible for paying the Medicare deductible and coinsurance

Example: Chiropractic Services

Medicare pays 80%

TRICARE pays $0

Beneficiary pays 20%

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How TFL Works with Medicare

Services not covered by either Medicare nor TRICARE

• Medicare and TRICARE For Life (TFL) pay nothing

• Beneficiary is responsible for the entire bill

Example: Cosmetic surgery

Medicare pays $0

TRICARE pays $0

Beneficiary pays 100%

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Step 1: Beneficiary goes to a Medicare provider

Step 2: Provider files claim with Medicare

Step 3: Medicare pays its portion and electronically forwards the claim to the other health insurance (OHI)

Step 4: Beneficiary files a paper claim with the TRICARE For Life (TFL) claims processor

Step 5: TFL pays TRICARE’s portion of the claim directly to the beneficiary

Medicare

TRICARE

OHI

How TFL Works with Medicare

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TRICARE For Life Overseas

• TRICARE beneficiaries who live overseas must meet the same requirements as TRICARE beneficiaries who live in the United States...they need to be enrolled in Medicare Part B.

• TRICARE For Life provides the same level of coverage overseas as provided to TFL beneficiaries living in the United States.

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•TRICARE For Life (TFL) is the primary payer for health care services received overseas since Medicare doesn’t cover care received outside of the United States or its territories.

•TFL overseas beneficiaries are responsible for meeting the TRICARE deductible of $150 individual/$300 family plus a 25% cost share.

Example: Overseas doctor’s visit

Medicare pays $0

TRICARE pays 75%

Beneficiary pays 25%

TRICARE For Life Overseas

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Step 1: Beneficiary goes to a host nation provider

Step 2: Beneficiary pays provider upfront

Step 3: Beneficiary files a claim with the TRICARE overseas claims processor

Step 4: TRICARE For Life reimburses the beneficiary 75%

• Expatriates must still carry Medicare Part “B” even though Medicare does not pay overseas.

TRICARE

TRICARE For Life Overseas

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Skilled Nursing Facility Care

• Skilled care is given in a skilled nursing facility (SNF).

• A SNF can be part of a nursing facility or hospital.

• Medicare certifies these facilities if they have the staff and equipment to give skilled nursing care and/or skilled rehabilitation services and other related health services.

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Skilled Nursing Facility Care

Medicare and TRICARE for Life will cover skilled care if the beneficiary:

• Requires daily skilled services which can only be provided in a skilled nursing facility

• Was admitted as an inpatient in a hospital at least 3 consecutive days or more, not counting the day the beneficiary leaves the hospital

• Is admitted to a SNF within 30 days after leaving the hospital

• Receives care for a condition that was treated in the hospital

• The facility must be a Medicare participating SNF and must enter into a participation agreement with TRICARE

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Medicare Pays TRICARE Pays

Beneficiary Pays

Days 1-20

100% Remaining liability (if any)

Nothing for services paid by Medicare and TRICARE

Days 21-100

All but $128/day1

copay each benefit period

$128/day copay

Nothing for services paid by Medicare and TRICARE

Days 101+

Nothing Network Skilled Nursing Facility:Negotiated charges minus your copay/cost shares for institutional and professional chargesNon-Network:Skilled Nursing Facility TRICARE allowed amount minus your cost shares for institutional and professional charges

Network Hospital Skilled Nursing Facility$250/day copay or a 25% cost share of total negotiated institutional charges, whichever is less, plus a 20% cost share for separately billed negotiated professional chargesNon-Network Skilled Nursing Facility25% cost share of the TRICARE allowed amount for institutional charges, plus a 25% cost share of the TRICARE allowed amount for separately billed professional charges

1 These Medicare amounts are for 2009, and may change on January 1st of each year.

Skilled Nursing Facility Care Payment

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Long-Term Care

• Long-term care is a type of care beneficiaries may need if they can no longer perform everyday tasks ("activities of daily living") by themselves due to a chronic condition or cognitive impairment, like Alzheimer's disease.

• Long-term care can be given in a variety of settings, including assisted-living facilities, adult day care centers, or nursing homes.

• Long-term care isn’t covered by Medicare or TRICARE.

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Claims Processing

• Wisconsin Physician Services (WPS), the TRICARE For Life contractor, processes TRICARE For Life (TFL) claims.– Beneficiaries may call WPS

TFL from 7a.m. to 10p.m. central time Monday through Friday at (866)773-0404.

– Beneficiaries can visit the WPS TFL website at www.tricare4u.com.

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TRICARE National Resources

• TRICARE Web Site – www.tricare.mil

• Five main portals– My Benefit (benefit information)– My Health (MTF online appointing,

personal health information, medication/pharmacy tools)

– MHS Staff (information about Military Health System)

– Providers (information for TRICARE providers)

– Pressroom (latest TRICARE news and information)

• TRICARE FOR LIFE (1-866-773-0404 )

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• DEERS1-800-538-9552www.tricare.mil/deers

• TRICARE Mail Order Pharmacy (Express Scripts)1-866-DoD-TMOP (1-866-363-8667)www.express-scripts.com/TRICARE

• TRICARE Retail Pharmacy (Express Scripts) 1-866-DoD-TRRx (1-866-363-8779)www.tricare.mil/pharmacy

Important Contacts

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1. Local TRICARE Support Office2. www.TRICARE.mil3. Health Safety & Work-Life Support

Activity @ 1-800-9-HBA-HBA– HSWL SUPACT will contact the

liaison officer of the applicable TRO – National problems will go to the

liaison officer of the TRICARE Management Activity in Falls Church, VA

Need Further Assistance?

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QUESTIONS ?