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TRICARE… TRICARE… The Basics The Basics
TRICARE Liaison OfficeHeadquarters, Marine Corps
Manpower and Reserve Affairs1stLt M. M. Hoesing
TRICARE Prime
TRICARE Standard/Extra
TRICARE Prime Remote
TRICARE Prime Remote for Active Duty Family Members
What is TRICARE?
Unifomed Services “Medical Plan”Unifomed Services “Medical Plan”
3 Options:3 Options:
PRIME
EXTRA
STANDARD
BASIC ACRONYMS/DEFINITIONSBASIC ACRONYMS/DEFINITIONS
PCM
HCF
DCAO
MTF
BCAC
NURSELINE
USEFUL WEBSITESUSEFUL WEBSITES
www.manpower.usmc.milwww.manpower.usmc.mil
www.tricare.osd.milwww.tricare.osd.mil
TRICARE PrimeTRICARE Prime
TRICARE Prime
Prime TermsPrime Terms::
Primary Care Manager (PCM)
Point -of-Service (POS)
TRICARE Prime
EnrollmentEnrollment Need to identify/select a Primary Care
Manager (PCM) for each family member
• PCMs usually are assigned
– MTF or Civilian Network
– May be a Family Practitioner, Pediatrician, Internist, Flight Surgeon, sometimes an OB/Gyn
– May be a M.D., Physician Assistant, Nurse Practitioner, (Individual/Group/Team)
TRICARE Prime
Enrollment Enrollment Prime ID card/enrollee
• Always carry it with you!
“Split” enrollment…family members enrolled in other TRICARE regions
Prime follows you (portability)
TRICARE Prime
Portability…let’s talk!Portability…let’s talk! Prime Site-to-Prime Site
• “Transfer Enrollment” upon arrival– Follow authorization rules in transit
• Same anniversary dates• Enrollment fees transfer (All Others)
Prime Site-to-Non-Prime Site
• Disenroll upon arrival (covered enroute) Non-Prime Site-to-Prime Site
• It’s decision time!
TRICARE Prime
Getting care...Getting care... Always call your chosen (or assigned) Primary
Care Manager (PCM) first• Military or Civilian
• Manage your TOTAL care When referred for care, the authorization process
begins with the Primary Care Manager
• Via the Health Care Finder (HCF)
PCMHCF
TRICARE Prime
““Traveling-out-of-your-Area” CareTraveling-out-of-your-Area” Care Prime ID card Coverage
• Urgent care: Call PCM first!
• Emergency care: Notify MCSC
• No routine care when away from PCM!
TRICARE TRICARE Standard/ExtraStandard/Extra
TRICARE Standard/ExtraTRICARE Standard/Extra
TRICARE Standard TRICARE Standard (Same as CHAMPUS)(Same as CHAMPUS) Two Questions to always ask provider:
• First: Are you a TRICARE “authorized” provider?
• Second: Are you a “participating” provider?
TRICARE Standard/ExtraTRICARE Standard/Extra
TRICARE “Extra”TRICARE “Extra”
You are TRICARE Standard!!!
Use MCSC network visit-by-visit
– Shop the MCSC’s Provider Directory
Incentive: Get discount on cost share!
TRICARE Standard/ExtraTRICARE Standard/Extra
You pay for Standard/Extra care like this...
First, the Deductible (each Fiscal Year)
• Active Duty Family Member (ADFM)
– E-1 to E-4: $50 / individual & $100 / family
– E-5 & Up: $150/individual & $300 / family
• All Others
– $150 / individual & $300 / family
TRICARE Standard/ExtraTRICARE Standard/Extra
After Deductible is Met, THEN...
Pay Cost Share
• Active Duty Family Member (ADFM)
– Standard: 20%
– Extra: 15%
• All Others
– Standard: 25%
– Extra: 20%
TRICARE Standard/ExtraTRICARE Standard/Extra
Plus, with Standard (not Extra) you pay balance billing costs for care from non-participating providers
To avoid balance billing:
- Ask if provider will participate (may or may not)
- Or use network provider (Extra)
TRICARE Standard/ExtraTRICARE Standard/Extra
Maximum your family will pay for TRICARE covered services (Catastrophic Cap)
• ADFM (per SSN): $1000 / fiscal year
• All Others (per SSN): $3000 / fiscal year
TRICARE Standard/ExtraTRICARE Standard/Extra
Non-Availability Statements (NAS)
• Still need NAS for inpatient care
– When you live within 40 miles of MTF
• Except
– If you have other health insurance
– Emergency admission
TRICARE Standard/ExtraTRICARE Standard/Extra
Maternity Non-Availability Statements
• NAS required for all maternity care
– including birthing centers
– home delivery
• Issued once pregnancy is confirmed by MTF
TRICARE Standard/ExtraTRICARE Standard/Extra
What monies go towards catastrophic cap?What monies go towards catastrophic cap?
Deductibles
Cost-shares
* Note: For balance billing situations, monies paid over CMAC are not applied to catastrophic cap
When does MHS care change/When does MHS care change/end end for AD?for AD? Retirement
• May choose TRICARE Prime or TRICARE Standard/Extra as Retiree
Separate from Service
Active Duty & TRICARE Active Duty & TRICARE
TRICARE PrimeTRICARE PrimeRemoteRemote
“Bringing the Benefit to Where You Live…Wherever You Live”
TRICARE Prime RemoteTRICARE Prime RemotePurposePurpose
Provide easier access to civilian health care for remotely Provide easier access to civilian health care for remotely assigned Active Duty Service Members (ADSMs) & assigned Active Duty Service Members (ADSMs) & certain Active Duty Family Members (ADFM’s)certain Active Duty Family Members (ADFM’s)
Reduces hassles and separation from family
Assists Unit Commanders by keeping ADSMs on the job
Continues to ensure fitness for duty
ADFM’s MUST RESIDE with the ADSM to obtain eligibility for TPRFM
New program…new acronyms!!New program…new acronyms!!
MMSO - Military Medical Support MMSO - Military Medical Support
OfficeOffice
SPOC - Service Point of ContactSPOC - Service Point of Contact
EligibilityEligibility
Active Duty Service Members (ADSMs)Active Duty Service Members (ADSMs)
Includes Reservists or National Guard Members on orders to Active Duty for greater than 30 days
• TPR areas are designated by zip codes
• Must work and live in TPR designated areas
(*) Geographic barriers and other circumstances may justify “remote”designations that are less than 50 miles from an MTF
EligibilityEligibility
Active Duty Family Members:Active Duty Family Members:
ADFM’s MUST reside with the ADSMADFM’s MUST reside with the ADSM
Must enroll in Prime even if none available
ADFM’s get same benefit as those residing in “Prime Network” areas
“Waived Charges” benefit in place
EligibilityEligibilityAm I Eligible?Am I Eligible?
Two Ways to CheckTwo Ways to Check Check TRICARE Prime Remote Web
Site: “http://www.tricare.osd.mil/remote/”
• Provides Eligibility Information Based on Work and Home Zip Codes
Call Toll-Free Beneficiary Information Line for Local Region
EnrollmentEnrollment
ADSM and ADFM’s Complete ADSM and ADFM’s Complete Regional Enrollment Form. Regional Enrollment Form.
Available from Unit or Call Contractor’s Toll-Free Number
Sends to Regional Address Provided by Sends to Regional Address Provided by the Contractorthe Contractor
Getting CareGetting Care
Selecting A Provider...Two Options:Selecting A Provider...Two Options: 1. Choose a Primary Care Manager (PCM) from
the Network (if available)
2. If No Network Providers, Select Any TRICARE-Authorized Provider from the Community
• Must be A Primary Care Provider
• Examples Include: Family Practice, Internal Medicine, General Practice or OB/GYN
Finding a TRICARE Finding a TRICARE Authorized ProviderAuthorized Provider
Visit the TRICARE Web Site at Visit the TRICARE Web Site at http://www.tricare.osd.mil/ProviderDirectory/http://www.tricare.osd.mil/ProviderDirectory/
Call the Regional contractor for assistanceCall the Regional contractor for assistance
Ask the provider when you call to make an Ask the provider when you call to make an appointment - “Are you an authorized appointment - “Are you an authorized TRICARE provider?”TRICARE provider?”
Primary Care ServicesPrimary Care Services
See your PCM or Primary Care ProviderSee your PCM or Primary Care Provider
Prior-authorization is Not Required for Prior-authorization is Not Required for Primary Care ServicesPrimary Care Services
Primary Care ServicesPrimary Care ServicesExamplesExamples
Routine health services (sick call)Routine health services (sick call)
Laboratory testsLaboratory tests
X-raysX-rays
ImmunizationsImmunizations
Hearing tests/routine eye examsHearing tests/routine eye exams
Breast Exams and mammographyBreast Exams and mammography
Pap SmearsPap Smears
Prostate/early Cancer diagnosis examsProstate/early Cancer diagnosis exams
Specialty CareSpecialty Carefor the ADSMfor the ADSM
Pre-authorization is Required for All Specialty CarePre-authorization is Required for All Specialty Care
Your PCM (Your PCM (or Youor You) Must Call the Health Care Finder ) Must Call the Health Care Finder (HCF) for Pre-authorization(HCF) for Pre-authorization
The HCF Will Check with MMSO to Ensure Care Does Not Require A “Fitness for Duty” Evaluation by A Military Provider
You Will Receive Approval for Civilian Care or Referral to a Military Facility in 2 Working Days (sooner, if urgent)
Pre-AuthorizationPre-Authorization RequirementsRequirements
Specialty CareSpecialty Care
Routine maternity careRoutine maternity care
Physical therapyPhysical therapy
Mental Health servicesMental Health services
Family CounselingFamily Counseling
Smoking cessation programSmoking cessation programAll Require Pre-authorization!All Require Pre-authorization!
Filing Medical ClaimsFiling Medical Claims
Network and Participating Providers will file Network and Participating Providers will file claims claims
For Non-Participating Providers, ADSMs For Non-Participating Providers, ADSMs may have to file claimmay have to file claim
But...ADSMs will be FULLY reimbursed for authorized out-of-pocket costs
Filing Medical ClaimsFiling Medical Claims
When filing Medical Claims on your own, When filing Medical Claims on your own, you must have the following documents: you must have the following documents:
Completed DD Form 2642 (CHAMPUS Claim Form) available on TRICARE web site
Itemized medical bill
Proof of payment
Filing Medical ClaimsFiling Medical Claims
All claims (regardless of who files the claim) will All claims (regardless of who files the claim) will generate an “Explanation of Benefits (EOB)” to generate an “Explanation of Benefits (EOB)” to the ADSMthe ADSM
Information on the EOB Includes:Information on the EOB Includes: Amount of Billed Charges
CMAC (CHAMPUS Maximum Allowable Charge)
Amount Paid to the Provider or reimbursed to the ADSM
QUESTIONS???QUESTIONS???