TRICARE

Jennifer Reynolds

HCA/230

February 7, 2013

SYNOPSIS

•REQUIREMENTS OF ELIGIBILITY•COVERED vs. NON-COVERED

SERVICES•COSTS OF PATICIPATING AND NON-

PARTICIPATING PROVIDERS• IN vs. OUT-OF-NETWORK

PROVIDERS AND FINANCIAL REIMBURSEMENT

WHO IS ELIGIBLE?

•ACTIVE OR RETIRED MILITARY PERSONEL

•MUST BE YOUNGER THAN 65•DEPENDANT UNMARRIED CHILDREN

•SPOUSES MARRIED TO AN ACTIVE OR RETIRED MILITARY SERVICE MEMBER

COVERED vs. NON-COVERED SERVICES

COVERED• ALL EMERGENT CARE• HOSPITALIZATION• REGULAR EYE EXAMS• DURABLE MEDICAL

EQUIPMENT• CARDIOVASULAR• PREVENTITIVE AND

IMMUNIZATION

NON-COVERED• BIRTH CONTROL• COUNSELING• COSMETIC

PROCEDURES• WEIGHT LOSS• LONG TERM CARE

FACILITIES• PODIATRY

PARTICIPATING vs. NON-PARTICIPATING PROVIDERS

•A 1/4th to 20% co pay is required for outpatient services

•Annual deductibles must be met out of pocket

•Catastrophic Cap of 1,000-3,000•Members are responsible for non

participating services up to 115% of charges.

NETWORK vs. NON-NETWORK PROVIDERS AND FINANCIAL

REIMBURSEMENTNetwork Providers• Fee schedule is a

contractual agreement

• Network Providers have a maximum allowable charge

• Providers must Submit all service claims electronically for reimbursement

Non Network Providers• Can not charge over

115% of allowable amount

• Patient is responsible for co-insurance out of pocket

• Non covered services will be billed directly to the patient

REFERENCE– AMRA TRICARE Supplement. (2012). Eligibility. Retrieved -------------from

http://www.amratricaresupplement.com/Eligibility.html

– HealthNet Federal Services. (2012). Becoming a TRICARE Non-Network Provider. Retrieved -------------from https://www.hnfs.net/provider/home/Becoming+A+Non-Network+Provider.htm

– McGraw Hill Co. (2013). Medical Insurance: An Integrated Claims Process Approach, Third Edition. TRICARE AND CHAMPVA. Chapter 12.

– TRICARE. (2012). What’s Not Covered. Retrieved-----------, from http://74.125.93.132/search?q=cache:4MnwaIWnvV8J:www.tricare.mil/tricareu/docs/19_Whats-Not-Covered.doc+services+not+covered+by+tricare&cd=1&hl=en&ct=clnk&gl=us&client=safari

– TRIWEST Healthcare Alliance. (2012). TRICARE covered benefits and services. Retrieved --------------from http://www.triwest.com/document_library/pdf_docs/CvrBen_QRG.pdf