tricare… the basics tricare liaison office headquarters, marine corps manpower and reserve affairs...

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 “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!


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


After Deductible is Met, THEN...

Pay Cost Share

• Active Duty Family Member (ADFM)

– Standard: 20%

– Extra: 15%

• All Others

– Standard: 25%

– Extra: 20%


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)


Maximum your family will pay for TRICARE covered services (Catastrophic Cap)

• ADFM (per SSN): $1000 / fiscal year

• All Others (per SSN): $3000 / fiscal year


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


Maternity Non-Availability Statements

• NAS required for all maternity care

– including birthing centers

– home delivery

• Issued once pregnancy is confirmed by MTF


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


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


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???

tricare… the basics tricare liaison office headquarters, marine corps manpower and reserve affairs...

Documents

tricare prime slide

tricare prime f enrollment

tricare prime f traveling

tricare standardextra

f prime terms

family slide

tricare regions

standard slide