CHAPTER

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11TRICARE and

CHAMPVA

Learning Outcomes

When you finish this chapter, you will be able to:11.1 Discuss the eligibility requirements for TRICARE.

11.2 Compare TRICARE participating and nonparticipating providers.

11.3 Explain how the TRICARE Standard, TRICARE Prime, and TRICARE Extra programs differ.

11.4 Discuss the TRICARE for Life program.

11.5 Discuss the eligibility requirements for CHAMPVA.

11.6 Prepare accurate TRICARE and CHAMPVA claims.

11-2

Key Terms

• catchment area• catastrophic cap• Civilian Health and

Medical Program of the Department of Veterans Affairs (CHAMPVA)

• Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)

• cost-share

11-3

• Defense Enrollment Eligibility Reporting System (DEERS)

• Military Treatment Facility (MTF)

• nonavailability statement (NAS)

• Primary Care Manager (PCM)

• sponsor

• TRICARE

Key Terms (continued)

• TRICARE Extra

• TRICARE for Life

• TRICARE Prime• TRICARE Prime Remote• TRICARE Reserve

Select (TRS)• TRICARE Standard

11-4

11.1 The TRICARE Program 11-5

• TRICARE—government health program serving dependents of active-duty service members, military retirees and their families, some former spouses, and survivors of deceased military members– Members of the Army, Navy, Air Force, Marine Corps,

Coast Guard, Public Health Service, and National Oceanic and Atmospheric Administration and their families are eligible for TRICARE

– Reserve and National Guard personnel become eligible when on active duty for more than thirty consecutive days or on retirement from reserve status at age sixty

11.1 The TRICARE Program (continued) 11-6

• CHAMPUS—the Civilian Health and Medical Program of the Uniformed Services, which was replaced by the TRICARE program

• Sponsor—uniformed service member in a family qualified for TRICARE or CHAMPVA

• Defense Enrollment Eligibility Reporting System (DEERS)—worldwide database of TRICARE and CHAMPVA beneficiaries

11.2 Provider Participation and Nonparticipation

11-7

• Participating providers:– Accept the TRICARE allowable charge as payment in

full for services– Are required to file claims on behalf of patients– May appeal a decision

• Nonparticipating providers:– May not charge more than 115 percent of the

allowable charge– May not appeal a decision

11.2 Provider Participation and Nonparticipation (continued)

11-8

• Patients:– Pay the provider, and TRICARE pays its portion of the

allowable charges directly to the patient

• Cost-share—coinsurance for a TRICARE or CHAMPVA beneficiary

11.3 TRICARE Plans 11-9

• TRICARE Standard—fee-for-service health plan– Medical expenses are shared between TRICARE and

the beneficiary– Most enrollees pay annual deductibles and cost-share

percentages

• Military Treatment Facility (MTF)—provides medical services for members and dependents of the uniformed services

11.3 TRICARE Plans (continued) 11-10

• Catastrophic cap—maximum annual amount a TRICARE beneficiary must pay for deductible and cost-share

• Catchment area—geographic area served by a hospital, clinic, or dental clinic

• Nonavailability statement (NAS)—form required when a TRICARE member seeks medical services outside an MTF

11.3 TRICARE Plans (continued) 11-11

• TRICARE Prime—basic managed care health plan– After enrollment, each individual is assigned a

Primary Care Manager (PCM)—a provider who coordinates and manages the care of TRICARE beneficiaries

– Offers additional preventive care, including routine physical examinations

11.3 TRICARE Plans (continued) 11-12

• TRICARE Prime Remote—plan that provides no-cost healthcare through civilian providers for service members and their families who are on remote assignment

• TRICARE Extra—managed care health plan that offers a network of civilian providers– Individuals must receive healthcare services from a

network of healthcare professionals

• TRICARE Reserve Select (TRS)—TRICARE coverage for military reservists– Premium-based health plan available for purchase

11.4 TRICARE and Other Insurance Plans11-13

• TRICARE for Life—program for beneficiaries who are eligible for both Medicare and TRICARE – Individuals age sixty-five and over who are eligible for

both Medicare and TRICARE may continue to receive healthcare at military treatment facilities

11.5 CHAMPVA 11-14

• Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)—the government’s health insurance program for veterans with 100 percent service-related disabilities and their families– Healthcare expenses are shared between the

Department of Veterans Affairs (VA) and the beneficiary

11.5 CHAMPVA (continued) 11-15

• Individuals eligible for the CHAMPVA program include:– Veterans who are totally and permanently disabled

due to service-connected injuries– Veterans who were totally and permanently disabled

due to service-connected conditions at the time of death

– Spouses or unmarried children of a veteran who is 100 percent disabled or who died as a result of a service-related disability in the line of duty

11.6 Filing Claims 11-16

• Participating providers file TRICARE claims with the contractor for the region on behalf of patients

• Individuals file their own TRICARE claims when services are received from nonparticipating providers

• Most CHAMPVA claims are filed by providers and submitted to the centralized CHAMPVA claims processing center

Summary

Summary

Summary