Information for Health Care Workers of the Military Health System. Naval Medical Center Portsmouth

Transcription

1 Information for Health Care Workers of the Military Health System Naval Medical Center Portsmouth

2 Topics TRICARE is the uniformed services health care program for active duty service members, active duty family members, National Guard and Reserve members and their family members, retirees and their family members, survivors, and certain former spouses worldwide Affordable Care Act Tidewater MHS TRICARE Regions TRICARE Eligibility Military Treatment Facilities TRICARE Other Programs and Benefits TRICARE and the VA Information and Assistance

3 TRICARE and the Affordable Care Act (ACA) Beneficiaries covered by any TRICARE program except line-of-duty care or direct care only meet the minimum essential coverage (MEC) requirements of the ACA DEERS must be kept current for all TRICARE-eligible beneficiaries to ensure compliance under the ACA Veterans Affairs and the ACA Veterans enrolled in VA health care programs meet the MEC requirements of the ACA Veteran s family members enrolled in a VA health care program such as CHAMPVA or the Spina Bifida program meet the MEC requirements of the ACA ACA information

4 Hospital Corpsman Advancement Question Question Answer If someone is not covered under regular TRICARE, but is eligible to purchase one of the TRICARE premium-based plans, will that eligibility alone be enough to meet the minimum essential coverage (MEC) requirement of the ACA? No. Individuals who are only eligible under TRICARE for one of the premiumbased plans (such as TRICARE Reserve Select, TRICARE Retired Reserve, TRICARE Young Adult, or Continued Health Care Benefit Program), but who do not purchase a plan, must find another coverage option, such as an employersponsored health care plan, to comply with the ACA. They will comply if they do purchase one of the plans.

5 McDonald Army Health Center Joint Base Langley-Eustis 576 Jefferson Avenue Newport News, Virginia (757) Naval Medical Center Portsmouth Naval Support Activity 620 John Paul Jones Circle Portsmouth, Virginia (757) USAF Hospital Langley Joint Base Langley-Eustis 77 Nealy Avenue Hampton, Virginia (757)

6 Military Treatment Facilities in Tidewater Naval Medical Center Portsmouth (NMCP) Branch Health Clinic (BHC), Dam Neck (1) BHC, JEB Little Creek (Boone Clinic) (2) BHC, Naval Air Station Oceana (3) BHC, Naval Weapons Station Yorktown (4) BHC, Norfolk Naval Shipyard (5) BHC, Norfolk Naval Station (Sewell s Point) (6) BHC, Northwest Annex (7) TRICARE Prime Clinic (TPC) Chesapeake (8) TPC Virginia Beach (9) McDonald Army Health Center (MCAHC) Troop Medical Clinic 1 (10) Troop Medical Clinic 2 (10) JEB Fort Story Health Clinic (11) USAF Hospital Langley (USAF)/633 MDG USCG Clinic Portsmouth, Yorktown and Elizabeth City, NC

7 TRICARE Regions and Managed Care Support Contractors TRICARE Regional Office North Health Net Federal Services (877) TRICARE Regional Office South Humana Military (800) TRICARE Regional Office West United Healthcare Military and Veterans (877) TRICARE Overseas Program International SOS (888)

8 Hospital Corpsman Advancement Question Question Answer What is the role of the managed care support contractor (MCSC)? To provide health care services and support to augment the military health system for all TRICARE plan options except the U.S. Family Health Plan. In each region, they manage: Provider networks Toll-free customer service call centers Enrollment, referral, authorization and claims processing Beneficiary and provider education

9 TRICARE-eligible beneficiaries Sponsor/service member Active duty or retired (including active, inactive or retired National Guard or Reserves) Medal of Honor recipient Family members Spouse/former (divorced) spouse Unmarried children To age 21 (23 if a full-time college student) TRICARE Young Adult to age 26 Considerations for adult special needs children Survivors (spouse and children) Others (limited, space-available direct care only)

10 DEERS (Defense Enrollment Eligibility Reporting System) and ID cards Military personnel function Verify and update when there is a change in status, duty station, address, phone or ; or when adding or removing a family member Rapids site (Personnel/ID card office) (800) Rapids site locater Rapids site appointments

11 Hospital Corpsman Advancement Question Question True or False? A beneficiary s eligibility for TRICARE is determined by the Defense Health Agency. Answer False. Eligibility determination is a military personnel function of each military service component, and is coordinated through the Defense Enrollment Eligibility Reporting System (DEERS).

12 Newborns or newly adopted children Deemed TRICARE Prime for the first 60 days (if another family member is covered under Prime) Claims processed following Prime guidelines, except: Referral and authorization requirements waived Point-of-service (POS) charges do not apply To continue Prime after 60 days, must register in DEERS and enroll in Prime during the first 60 days If not, coverage reverts to TRICARE Extra/Standard on day 61 If not registered in DEERS within the first year, TRICARE eligibility will be lost

13 Special situation newborn of an unwed dependent daughter Not eligible for TRICARE unless the baby s father is a service member, or the dependent daughter s sponsor legally adopts the newborn, and registers the baby in DEERS For paternity issues, do testing as soon after birth as possible; this is not covered by TRICARE and is done at the patient s expense Limited space-available care in an MTF may be available Secretary of the Navy Designee Program at NMCP ( )

14 Special situation married service members If both parents of a child are service members, only one can be designated as the sponsor in DEERS If one spouse is retired and the other is on active duty, the family should register in DEERS under the active duty member to retain active duty preferences lower costs and better MTF access-to-care If both are retired, the family should register in DEERS under one or the other to help control costs one Prime family enrollment fee and one family catastrophic cap

15 Special situation terminal leave Service members continue as active duty service members (ADSMs) while on terminal leave, until the actual separation or retirement date Remain in TRICARE Prime at final duty station If leaving the area of the final duty station Seek care at any MTF, if available Contact PCM for authorization before seeking any non-emergency care, including urgent care May be pre-authorized by the PCM to seek nonemergency care at a Veterans Affairs (VA) facility Family members can keep their current coverage, switch programs or, if in Prime, change their PCM Note: TRICARE Prime is not available everywhere

16 Special situation retirement Regular retirement service members and family members retain TRICARE eligibility after transitioning from active duty to retirement Medical retirement service members with a service disability rating of at least 30% (not the same as a VA disability rating) Temporary Disability Retirement List (TDRL) service member (SM) and family members (FM) retain TRICARE eligibility SM evaluated every 18 months, for up to 5 years, when a decision is made to retain on the TDRL, separate from service, return to duty, or move to the Permanent Disability Retirement List (PDRL) PDRL SM and FMs retain TRICARE eligibility

17 Special situation Transitional Assistance Management Program (TAMP) Eligibility is determined by the separating ADSM s service branch, and is processed through DEERS The separating ADSM and family members may be eligible for 180 days of TAMP if the service member: Is involuntarily separated under honorable conditions Separates following an involuntary retention, or voluntary agreement to stay on active duty for less than one year, in support of a contingency operation Receives a sole-survivorship discharge, or Agrees to join the Selected Reserves Eligible beneficiaries will be issued a TA-180 ID card

18 TRICARE Choices for Eligible Beneficiaries During TAMP Prime/USFHP* Extra Standard Annual Deductible None (unless Pointof-Service is used) Sponsor E-1 to E-4: $50 individual/$100 family Sponsor E-5 and above: $150/$300 POS FY Outpatient Deductible $300/$600 N/A POS Co-pay 50% N/A Civilian Provider Office Visit Co-pay $0 15% 20% Hospitalization $0 $17.80/day $17.80/day Outpatient Behavioral Health Co-pay $0 15% 20% Providers MTF or Network Network Non-Network Balance Bill No Up to 15% Catastrophic Cap $1,000/family *TRICARE Prime or Uniformed Services Family Health Plan (USFHP). Prime is only available in Prime Service Areas (PSAs), and USFHP is only available in 6 geographic locations in the U.S.

19 Last day of active duty TAMP Timeline TAMP Eligible TAMP begins (day 1) TAMP ends (day 180) CHCBP begins (day 181) Active Duty* TAMP CHCBP Last day of active duty Active Duty* TAMP Ineligible CHCBP begins (day 1) CHCBP * Active duty time includes any period of terminal leave

20 Permanent eligibility criteria for special needs children Unmarried and incapable of self-support because of a qualifying disability that existed before age 21 (or between age 21 and 23 if a full-time student) Child relies on the sponsor for over 50% of support (or was at the time of a sponsor s death) Service points-of-contact and policy guidance USA Defense Financing and Accounting Office (DFAS) Indianapolis; Army Regulation USAF DFAS Denver; Air Force Instruction _IP USN Navy Personnel Command Millington; BUPERS Instruction C USMC Headquarters Marine Corps Quantico; Marine Corps Order D USCG Special Needs Program Manager Washington

21 Applying for permanent eligibility Apply through DEERS at least 90 days before current ID card expires, with the following required supporting documentation: Physician s written statement (dated within 90 days) If eligible, proof of Medicare A and B (not required for ADFMs) Birth certificate and parents marriage certificate Approved medical sufficiency statement/letter from an MTF Approved dependency determination (over 50%) from a uniformed service approval authority DD Form 1172, Application for Uniformed Services ID Card- DEERS Enrollment and DD Form 137-5, Dependency Statement- Incapacitated Child Over Age 21 Also required for an incapacitated student a physician s statement that the incapacitation occurred after age 21 and before age 23, and a letter from the school verifying the child was a full-time student when the incapacitation occurred

22 Losing TRICARE eligibility Situations where eligibility will be lost: Sponsor separate from active duty (not retiring); or end of TAMP Inactive or retired Guard or Reserve member (eligibility for other programs may apply) Spouse divorce (some exceptions) Former (divorced) spouse remarriage or employer coverage Former (widowed) spouse remarriage Children age or marriage

23 Losing TRICARE eligibility Health care options when eligibility for TRICARE is lost: Transitional Assistance Management Program (TAMP) 180 days of ADFM coverage for certain separating service members and families Continued Health Care Benefit Program (CHCBP) Temporary (18 36 months) coverage comparable to TRICARE Standard and Extra, but does not include use of MTFs Quarterly premiums - $1,275/individual; $2,868/family Managed by Humana

24 Priorities for military treatment facility (MTF) access-to-care for primary and specialty appointments, and inpatient care 1) Active duty service members (ADSMs) 2) Active duty family members (ADFMs) in Prime 3) Retirees, family members and survivors in Prime 4) TRICARE Plus 5) ADFMs not in Prime (includes TRS enrollees) 6) Retirees, family members and survivors not in Prime (includes TFL beneficiaries and TRR enrollees) 7) Others space-available direct care only Ancillary services usually available to all TRICARE-eligible beneficiaries on a walk-in basis ER, pharmacy, immunizations, laboratory and radiology

25 TRICARE Programs Triple Options Prime managed care; enrollment required Mandatory for ADSMs; optional for others Related Prime Remote, Overseas Prime and Prime Remote, and USFHP Extra civilian preferred provider network Standard civilian fee-for-service non-network TRICARE for Life (TFL) Medicare wrap-around coverage TRICARE Reserve Select (TRS) and TRICARE Retired Reserve (TRR) TRICARE Plus MTF-managed primary care program TRICARE Young Adult (TYA)

26 Program TRICARE Program Eligibility Based on Status ADSM ADFM Retirees and Retiree FMs Medicare- Ineligible Medicare-Eligible Prime (U.S.) Mandatory Option Option < age 65 Option USFHP No Option Option < age 65 Prime Remote, Overseas Prime/ Prime Remote Extra and Standard With orders Option if commandsponsored Option No Acts as Medicare supplement for TFL Option if Medicareeligible No to retain TRICARE Medicare required TFL No TRICARE Plus No Option if available TYA TRS TRR Adult children < age 26 not otherwise eligible for TRICARE Option for Inactive Selected Reserves and FMs No No Option for Gray Area Retired Reserves and FMs

27 Annual Retiree Enrollment Fee Annual Deductible (FY) POS Outpatient Deductible (FY) TRICARE Triple Options Prime/USFHP Extra Standard Single: $ Family: $ None except Point-of- Service (POS) None $300/$600 N/A POS Co-pay 50% N/A Civilian Provider Visit Co-pay Hospitalization Outpatient Behavioral Health Co-pay AD/ADFM: $0 Retiree/FM: $12 AD/ADFM: $0 Retiree/FM: $11/day AD/ADFM: $0 Retiree/FM: $25 (individual) $17 (group) E-4 and below ADFM: $50/$100 E-5 and above ADFM and Retiree/FM: $150/$300 ADFM: 15% Retiree/FM: 20% ADFM: $17.80/day Retiree/FM: $250/day or 25% ADFM: 15% Retiree/FM: 20% ADFM: 20% Retiree/FM: 25% ADFM: $17.80/day Retiree/FM: $764/day or 25% ADFM: 20% Retiree/FM: 25% Providers MTF or Network Network Non-Network Balance Bill No Up to 15% Catastrophic Cap Fiscal Year (FY) Active Duty Family: $1000; Retiree Family: $3000

28 Hospital Corpsman Advancement Question Question Answer Under which TRICARE option do non-active duty beneficiaries who are not enrolled in TRICARE Prime receive care from civilian TRICARE network providers? TRICARE Extra, which is similar to a civilian insurance preferred provider option (PPO). The network of civilian providers is maintained by the regional managed care support contractor (Health Net Federal Services for the TRICARE North Region).

29 Hospital Corpsman Advancement Question Question Which TRICARE option for non-active duty beneficiaries is similar to a civilian insurance fee-for-service program, and is available world-wide? Answer TRICARE Standard.

30 TRICARE Prime the managed care option that is available in Prime Service Areas (PSAs) (usually within 40 miles of an MTF or BRAC site) Mandatory coverage for ADSMs Optional coverage for ADFMs, retirees and retiree family members Not an option for retirees and retiree family members age 65 and older who have Medicare (also applies to the USFHP) TRICARE Prime Remote for ADSMs assigned duty in remote locations in the U.S. (usually more than 50 miles from an MTF). Optional for ADFMs, family members of activated Guard and Reserves, and certain surviving family members if certain criteria is met TRICARE Prime Overseas and TRICARE Prime Remote Overseas for ADSMs assigned to overseas locations Optional for command-sponsored ADFMs U.S. Family Health Plan (USFHP) option for ADFMs, retirees and retiree family members in six geographic locations in the U.S.

31 Hospital Corpsman Advancement Question Question An active duty service member assigned to recruiting duty in a rural location in the U.S. more than 50 miles from a military hospital or clinic is covered by which TRICARE program? Answer TRICARE Prime Remote.

32 TRICARE Prime Enrollment Coordinated by the regional contractor Health Net for the North Region (877) Update when there is a change in status, duty station or address Reenlistment or retirement new enrollment Moving between regions portability Moving or changing PCMs within the same region PCM change Split enrollment family members in different regions New enrollments 20 th of the month rule Medical Home provides patient and family-centered primary care Physician-led team of providers and support staff Improved quality, access and continuity; better communication and record-keeping; and wellness, healthy living and disease prevention PCM provides routine care and coordinates specialty and follow-up care, including urgent care, for chronic and acute illnesses

33 TRICARE Prime Primary Care Manager (PCM) Assignment ADSMs assigned to designated MTF for their command, or duty station medical department ADFMs priority assignment to MTF PCM, where available, or to civilian network PCM Retirees and family members priority assignment to MTF PCM, where available, or to civilian network PCM Only available in Prime Service Areas (PSAs) in the U.S. Not eligible for Prime Remote, Overseas Prime or Overseas Prime Remote

34 TRICARE Prime Appointments and Access-to-Care (ATC) Emergency immediately (911 or nearest ER) Urgent care 24 hours, or less Routine care 7 days, or less Specialty or wellness care 28 days, or less Follow-up care doctor s discretion Drive-time/distance ATC standards PCM 30 minutes (beneficiary can waive up to 100 miles) Specialty care 60 minutes Primary care and specialty care appointments in Tidewater MTF appointments Hampton Roads Appointment Center (HRAC) (866) , or call the clinic directly Civilian provider appointments call the provider s office directly

35 TRICARE Prime Referrals and Authorizations Required for most non-emergency care, including urgent and specialty care Exceptions first 8 outpatient behavioral visits each fiscal year (does not apply to ADSMs) and some preventive services Specialty care offered first at an MTF Referrals are for a specific time and number of visits Evaluate only/second opinion one or two visits Evaluate and treat for an episode of care Unauthorized non-emergency care point-of-service Beneficiaries with OHI (Medicare, employer plan) follow OHI rules

36 TRICARE Prime Referral Process MTF PCMs enter referral into MHS system Civilian PCMs fax referral to Health Net at (888) MTF specialty clinic reviews referrals patient will be seen in the MTF if an appointment is available; if not, patient will be deferred to a civilian network provider Patient calls HRAC to check on referral status and schedule MTF appointment If deferred, patient will receive a letter from Health Net Patient may call Health Net for information and assistance before receipt of letter (877)

37 TRICARE Prime Point-of-Service (POS) Beneficiary financial liability for a larger percentage of costs for unauthorized non-emergency care Includes urgent care and most specialty care without a referral and authorization Does not apply to ADSMs Outpatient deductible $300/individual; $600/family Inpatient and outpatient cost-share 50% of the TRICARE-allowable charge Possible additional 15% balance-billing for services received from non-network providers Beneficiary costs do not apply towards the catastrophic cap, and there is no upper limit

38 Traveling with TRICARE Prime If medical care is needed when traveling away from home, use an MTF, if available Emergencies call 911 or go to the nearest ER Notify PCM within 24 hours Coordinate all follow-up care with PCM Urgent care medically-necessary within 24 hours Coordinate with PCM Call the Nurse Advice Line (800) Unauthorized urgent care is point-of-service Coordinate all follow-up care with PCM Routine care not authorized

39 TRICARE Prime Travel Benefit for medically-necessary, nonemergency referrals to a specialist more than 100 miles from the patient s PCM Does not apply to ADSMs as patients or non-medical attendants (NMA) must have command travel orders MTF or TRICARE Regional Office (for patients with civilian PCMs) prior-authorization required in all cases Reimbursement for reasonable travel expenses for patient and one authorized NMA Meals, fuel, tolls, parking, lodging, transportation NMCP points-of-contact Health Benefits (757) Travel Office (757) /9376/9380/9787

40 TRICARE Claims charges for health care services received from civilian providers Network providers (Prime and Extra) file the paperwork Beneficiary claim form for reimbursement Patient s Request for Medical Payment (DD Form 2642) Claims processors North Health Net (PGBA) TFL and overseas Wisconsin Physician Services (WPS) Beneficiaries with other health insurance (OHI) (i.e., employer coverage or Medicare) should be familiar with coordinating benefits between the OHI and TRICARE With few exceptions (such as Medicaid), OHI is primary to TRICARE, which means the OHI pays first

41 TRICARE Explanation of Benefits (EOB) Monthly summary statement (not a bill) Individual EOBs sent for denied claims or payment due to the beneficiary Available online at For assistance: Provider s billing office PGBA Health Benefit Advisor

42 TRICARE Expense Item Terminology Balance billing Maximum 15% amount of the TRICARE Maximum Allowable Charge (TMAC) that beneficiaries may be charged for TRICAREcovered from non-network, non-participated civilian providers Catastrophic cap Maximum out-of-pocket expense in a fiscal year (FY) for which a family is financially liable for authorized TRICARE-covered services Co-payment (co-pay) Fixed dollar amount beneficiaries pay for TRICARE-covered services Cost-share Fixed percentage amount of TMAC or negotiated rates that beneficiaries pay for TRICARE-covered services Continued

43 TRICARE Expense Item Terminology (continued) Deductible Fixed dollar amount beneficiaries pay each FY for TRICAREcovered services before TRICARE starts to pay Enrollment fee Annual amount retirees and retiree family members pay to be enrolled in TRICARE Prime or the Uniformed Services Family Health Plan (USFHP) Point-of-service (POS) A TRICARE Prime/USFHP option that allows non-active duty service member (ADSM) beneficiaries to obtain certain TRICARE-covered services without referrals and/or prior authorization Premium Monthly or quarterly amount that beneficiaries pay for enrollment in certain TRICARE programs

44 TRICARE Changes when Transitioning from Active Duty to Retirement include: Lower priority for access-to-care in an MTF Higher out-of-pocket costs TRICARE Prime Annual enrollment fee and civilian provider office visit co-pay Only available in Prime Service Areas (PSAs) Routine vision exam once every two years TRICARE Standard/Extra Standard cost-share is 25% Extra cost-share is 20% Routine vision exam is not a covered benefit

45 Other considerations when transitioning to retirement Fiscal year (FY) family catastrophic cap increases from $1,000 to $3,000 Optional TRICARE dental coverage offered through Delta Dental (TRICARE Retiree Dental Program) Extended Care Health Option (ECHO) benefits are not available Beneficiaries with other health insurance (OHI), such as an employer health plan, must be familiar with the coordination of benefits Medicare-eligible beneficiaries entitled to premium-free Medicare Part A must purchase Medicare Part B to retain TRICARE coverage (TRICARE for Life)

46 Hospital Corpsman Advancement Question Question True or False? All retirees and their eligible family members may enroll in TRICARE Prime, regardless of their age or where they live. Answer False. TRICARE Prime is only available to retirees and their family members in a Prime Service Area. TRICARE Prime is not an option for retirees and their family members age 65 and older with Medicare.

47 Other TRICARE Programs and Benefits Applied Behavior Analysis (ABA) Cancer Clinical Trials Dental Programs Disengagement Extended Care Health Option (ECHO) Mental Health National Guard and Reserves Nurse Advice Line OB/Maternity Care Pharmacy Prevention/Wellness Prior Authorization TRICARE for Life (TFL) TRICARE Overseas Program (TOP) TRICARE Young Adult (TYA) Uniformed Services Family Health Plan (USFHP)

48 Applied Behavior Analysis (ABA) Comprehensive Autism Care Demonstration Beneficiaries with an autism spectrum disorder (ASD) diagnosis Consolidated three previous programs into one TRICARE Basic Program Autism Demonstration Autism Pilot Expanded benefit with fewer requirements Beneficiary cost depends on status and program All services require authorization from Health Net

49 Beneficiary Costs (Co-Pays and Cost-Shares) Direct ABA Services (expenses count towards the catastrophic cap) Reinforcement ABA Services (expenses do not count towards the catastrophic cap) ADFMs enrolled in TRICARE Prime $0 co-pay ADFMs with TRICARE Standard/Extra 15% cost-share in network (Extra); 20% out of network (Standard) Retired family members (FMs) enrolled in TRICARE Prime $12 co-pay per visit Retired FMs with TRICARE Standard/Extra - 20% cost-share in network (Extra); 25% out of network (Standard) FMs with TRICARE Reserve Select (TRS) 15% cost-share in network (Extra); 20% out of network (Standard) FMs with TRICARE Retired Reserve (TRR) 20% cost-share in network (Extra); 25% out of network (Standard) ADFMs monthly ECHO cost-share based on sponsor s pay grade All others 10% cost-share

50 Cancer Clinical Trials Department of Defense (DoD) partnership with the National Cancer Institute (NCI) Research studies for the prevention, diagnosis and treatment of cancers and other illnesses Open to all TRICARE beneficiaries; TRICARE shares the cost of evaluation and testing to determine participation eligibility, and medical care during the trial als.aspx (800)

51 Active Duty Dental Program (ADDP) for ADSMs Military dental treatment facility Authorized civilian care coordinated by United Concordia TRICARE Dental Program (TDP) for ADFMs Optional, premium-based coverage MetLife TRICARE Retiree Dental Program (TRDP) for retirees and retiree family members Optional, premium-based coverage Delta Dental Plan of California

52 Does not apply to ADSMs Disengagement of an MTF patient to civilian medical care may be necessary when required medical services are beyond the MTF s capability Alternative MTF sources should be considered first before disengaging a patient to civilian care Disengagement, or relinquishment of full responsibility for a patient by the MTF, is only for the episode of care for the medical reason for which the patient is being disengaged Patients to be disengaged should be counseled and advised of their rights and responsibilities, including eligibility for covered services and any potential financial liability Counseling must be documented Patients only entitled to MTF direct care (such as dependent parents, inlaws or siblings; or newborns of unwed dependent daughters) are not covered under TRICARE for any services received from civilian providers

53 Hospital Corpsman Advancement Question Question True or False? Answer Disengagement procedures must be followed when an active duty service member requires medical care that is beyond the capability of the MTF. False. Disengagement applies only to non-adsms who are sent to civilian providers for care that is beyond the MTF s capability. The MTF will always maintain some level of responsibility for an ADSM whose care is transferred to a civilian provider or facility; therefore, total relinquishment of responsibility for an ADSM cannot be accomplished.

54 Extended Care Health Option (ECHO) Supplements basic TRICARE benefits for ADFMs with qualifying physical or mental conditions Sponsor must be enrolled in the service-specific Exceptional Family Member Program (EFMP) before registering the family member in ECHO All services must be pre-authorized by Health Net Health Net ECHO case manager (877) Tidewater area ECHO case manager (800) Fiscal year limit on benefits $36,000/beneficiary Monthly cost-share per family based on sponsor s pay grade, and only applies in months benefits are used

55 ECHO Costs and Limits Monthly cost-share is per sponsor; not per ECHO beneficiary Cost-share is paid only if ECHO benefits are used during the month Fiscal year limit for what TRICARE will pay for covered benefits per ECHO beneficiary is $36,000 (not including the ECHO Home Health Care Benefit) Unused benefit amounts are not transferable between eligible family members Sponsor Pay Grade Monthly Cost Share Sponsor Pay Grade Monthly Cost Share E-1 to E-5 $25 W-5, O-5 $65 E-6 $30 O-6 $75 E-7, O-1 $35 O-7 $100 E-8, O-2 $40 O-8 $150 E-9, W-1, W-2, O-3 $45 O-9 $200 W-3, W-4, O-4 $50 O-10 $250

56 Hospital Corpsman Advancement Question Question What is required of a sponsor before family members become eligible for ECHO benefits? Answer The sponsor must be an active duty service member and enrolled in the servicespecific Exceptional Family Member Program (EFMP). Retiree family members are not entitled to ECHO benefits.

57 Inpatient and outpatient mental health services available from: Psychiatrists and other physicians Clinical psychologists Certified psychiatric nurse specialists Licensed clinical social workers Certified marriage and family therapists Counselors Non-ADSMs can self-refer for the first 8 outpatient visits each fiscal year Subsequent visits require authorization from Health Net

58 National Guard and Reserve Components Air Force Reserve Air National Guard Army National Guard Army Reserve Coast Guard Reserve Marine Corps Reserve Navy Reserve

59 National Guard and Reserve Categories Ready Reserve Inactive Army National Guard and Individual Ready Reserve Selected Reserve Active Guard and Reserve Individual Mobilization Augmentee (IMA) Selected Reserve Units and Military Technicians Retired Reserve and Standby Reserve

60 National Guard and Reserve access to TRICARE programs based on status Activated for less than 30 days line-of-duty care only Activated for more than 30 days ADSM/ADFM benefits TRICARE Reserve Select (TRS) inactive Selected Reserves and family members Voluntary, premium-based program ADFM TRICARE Standard/Extra benefits and costs TRICARE Retired Reserve (TRR) gray area retirees (under age 60) and family members Voluntary, premium-based program Retiree TRICARE Standard/Extra benefits and costs TRS and TRR Prime not an option; space-available care in an MTF

61 National Guard and Reserve Status Inactive Retired Status Preactivation (Mobilization) Deactivation (Demobilization) Active (Mobilized)

62 Inactive status Reserve member coverage Line-of-duty (LOD) care TRICARE Reserve Select (TRS) Optional; premium-based Selected Reserve members only TRICARE Dental Program (TDP) Optional; premium-based Family member coverage TRS sponsor must be enrolled TRICARE Young Adult (TYA) Standard sponsor must be enrolled in TRS TDP

63 Pre-activation status Early eligibility up to 180 days before activation with delayed-effective-date orders for more than 30 consecutive days in support of a contingency operation Eligibility ends if orders are cancelled Reserve member coverage TRICARE Prime Active Duty Dental Program (ADDP) Family member coverage TRICARE Prime TRICARE Extra/Standard TYA Prime or Standard TDP

64 Active status Activated for more than 30 consecutive days in support of a contingency operation Reserve member coverage* TRICARE Prime Active Duty Dental Program (ADDP) Family member coverage TRICARE Prime/USFHP TRICARE Extra/Standard TYA Prime or Standard TDP * All medical and dental care for ADSMs, including activated National Guard and Reserves, is coordinated through the Military Health System

65 De-activation status Following activation for more than 30 consecutive days in support of a contingency operation Reserve member coverage 180 days of Transitional Assistance Management Program (TAMP) TRICARE Prime/USFHP TRICARE Extra/Standard ADDP Family member coverage TRICARE Prime/USFHP TRICARE Extra/Standard TYA Prime or Standard TDP

66 Retired status Gray Area retiree under age 60 Reserve member coverage TRICARE Retired Reserve (TRR) TRICARE Retiree Dental Program (TRDP) Family member coverage TRR (sponsor must be enrolled) TYA Standard (sponsor must be enrolled in TRR) TRDP

67 Retired status regular retirement at age 60 Reserve member coverage TRICARE Prime/USFHP TRICARE Extra/Standard TRICARE for Life (TFL) when eligible for Medicare TRDP Family member coverage TRICARE Prime/USFHP TRICARE Extra/Standard TFL when eligible for Medicare TYA Prime or Standard TRDP

68 Line-of-duty (LOD) care For injuries or illnesses incurred or aggravated in the line of duty while on inactive duty training, or active duty orders for less than 30 days Includes injuries sustained while traveling under orders to and from a duty station LOD determination is made by the command or National Guard or Reserve unit Care provided at MTFs or coordinated by the Reserve and Service Member Support Office (R&SMSO) Formerly the Military Medical Support Office (MMSO)

69 TRICARE Reserve Select (TRS) Eligibility Inactive Selected Reservists and family members Not eligible for or enrolled in a Federal Employee Health Benefit Plan (FEHBP) (self or spouse) Benefits TRICARE Extra/Standard (Standard overseas) Monthly premiums $50.75/member; $205.62/member and family To qualify and purchase coverage complete the online DMDC Reserve Component Purchased TRICARE Application (RCPTA)

70 TRICARE Retired Reserve (TRR) Eligibility Gray area retirees and family members Not eligible for or enrolled in a Federal Employee Health Benefit Plan (FEHBP) (self or spouse) Benefits TRICARE Extra/Standard (Standard overseas) Monthly premiums $390.89/member; $961.35/member and family To qualify and purchase coverage complete the online DMDC Reserve Component Purchased TRICARE Application (RCPTA)

71 Hospital Corpsman Advancement Question Question At what age does a retired reservist become eligible for regular retiree TRICARE benefits? Answer At age 60. Eligible family members also become entitled to TRICARE at the same time as the sponsor.

72 TRICARE for Life (TFL) For Medicare-eligible beneficiaries Most people at age 65; under age 65 with a disability Entitled to premium-free Medicare Part A and enrolled in Part B Exceptions ADSMs and ADFMs not required to enroll in Part B until the sponsor retires Monthly Part B premium; no TFL enrollment fee TRICARE pays secondary to Medicare TRICARE Prime not an option for retiree and retiree family member TFL beneficiaries at age 65 Medicare-eligible beneficiaries under age 65 may enroll in Prime, where available, and the enrollment fee is waived Claims and information Wisconsin Physician Services Monthly TFL presentation at NMCP 2 nd Tuesday of each month (except June) at 9 a.m. in Internal Medicine

73 Primary care program at select MTFs Internal Medicine Clinic at NMCP The MTF manages the program and controls enrollment, which is usually by invitation only Most enrollees are TFL-eligible, and are not eligible for TRICARE Prime No enrollment fee or other costs for care received in the MTF Access to primary care appointments and benefits is the same as for TRICARE Prime Access to specialty care appointments is not guaranteed, but may be offered on a space-available basis or for continuity of care

74 TRICARE Nurse Advice Line (NAL) For all TRICARE beneficiaries in the U.S., including Alaska and Hawaii (does not include USFHP enrollees) Answer health care questions and concerns Advise on need for care self, routine, urgent or emergent Communicate with MTF PCMs and schedule appointments for TRICARE Prime MTF-enrolled patients

75 TRICARE OB and Maternity Care in Tidewater Most Prime patients in Tidewater will receive their OB and maternity care through Women s Health at NMCP ( ), or USAF Hospital Langley ( /6992) Includes ADSMs, ADFMs, retirees and retiree family members in Prime, with military or civilian PCMs Medically-necessary maternity care includes: Prenatal care, including OB visits and medicallynecessary ultrasounds Antepartum care for high risk pregnancies Hospitalization for labor and delivery Postpartum care for up to 6 weeks after delivery

76 TRICARE Prime Service ADSM/ADFM Retirees, Retiree Family Members and all Others Annual FY outpatient deductible $0 $0 Global maternity care fee* $0 $11/day ($25 minimum) Inpatient professional services for newborn care Newborn cost-share for hospital services Professional services fee (if mother delivers at home or as an outpatient) Authorized birthing center or hospitalbased outpatient birthing room $0 $11/day ($25 minimum) $0 Newborn date of admission matches date of birth: $11/day ($25 minimum) applies to 4th and subsequent inpatient days Newborn admitted after date of birth: $11/day ($25 minimum) applies to all inpatient days $0 $12/visit for mother $0 $25/day TRICARE Prime Point-of-Service (unauthorized non-emergency care; does not apply to catastrophic cap or to ADSMs) Annual FY outpatient deductible Inpatient and outpatient cost-share Annual FY outpatient deductible Global fee* cost share for ADFMs and TRS Global fee* cost share for all others ADSM N/A; All others $300/individual or $600/family ADSM N/A; All others 50% of TRICARE allowable charge TRICARE Extra (Network) and Standard (Non-network) (does not apply to ADSMs) ADFMs sponsor E-4 and below $50/individual or $100/family All others $150/individual or $300/family $17.80/day ($25 minimum); No separate cost share for separately billed professional services Extra: less of $250/day or 25% billed charges, plus 20% professional services Standard: less of $764/day or 25% billed charges, plus 25% professional services * After pregnancy is confirmed, most costs are grouped under one diagnosis code. The global fee covers prenatal, inpatient, delivery and postnatal care. Costs depend on beneficiary status, TRICARE program used, and provider (military or civilian).

77 TRICARE pharmacy choices MTF Home delivery (mail order) and retail network in the U.S. Express Scripts (877) Retail non-network in the U.S. Mail order overseas prescriptions must be written by a U.S.-licensed physician Claims processed by Wisconsin Physician Services (WPS) Note individuals enrolled in USFHP do not have access to an MTF for care or pharmacy, except in case of an emergency

78 Pharmacy Choices, Prescription Categories and Beneficiary Costs 1 Pharmacy Tier 1 2 Tier 2 Tier 3 3 MTF (up to 90 days supply) No Cost Not Available 4 Home Delivery/Mail Order 5 (up to 90 days) No Cost $16 $46 6 Retail Network (up to 30 days) $8 $20 $47 7 Retail Non-Network - TRICARE Prime (up to 30 days) 50% cost-share after POS deductible is met 8 Retail Non-Network - ADFMs TRICARE Standard/Extra or TRICARE Reserve Select (up to 30 days) Retail Non-Network - Non-ADFMs Standard/Extra, TFL, or TRICARE Retired Reserve (up to 30 days) Greater of $20 or 20% of the total cost 9 25% of the total cost 9 Greater of $47 or 20% 9 1. ADSMs do not pay for any authorized prescription medications at any pharmacy. The annual deductible for all other beneficiaries does not apply to prescriptions filled through home delivery or a retail network pharmacy. 2. When available, prescriptions will be filled with generic formulary (Tier 1) medications. Brand name formulary (Tier 2) drugs with a generic equivalent will only be dispensed if medical necessity is requested and approved by Express Scripts. If approved, the brand name co-pay will apply. If not approved, the beneficiary will be responsible for the entire cost of the medication. 3. Medications designated non-formulary (Tier 3) have been determined to be less clinically-effective or less cost-effective than other drugs in the same therapeutic class. 4. With limited exceptions, non-formulary medications are generally not available through anmtf pharmacy. 5. Beneficiaries with other health insurance (OHI) with a prescription benefit, including Medicare Part D, cannot use the home delivery program, unless a particular medicine is not covered by the OHI, or the OHI prescription benefit has been exhausted. 6. Non-formulary medications may be available through home delivery at the formulary co-pay if medical necessity is requested and approved by Express Scripts. 7. The availability of most non-formulary medications through a retail pharmacy is very limited. 8. The TRICARE Prime annual point-of-service (POS) deductible for non-adsms is $300/individual and $600/family. 9. The TRICARE Standard/Extra annual deductible for active duty family members (ADFMs) of a sponsor E-4 and below is $50/individual and $100/family, and for all other beneficiaries is $150/individual and $300/family.

79 An electronic prescription (erx) is a computer-generated prescription sent electronically from your health care provider directly to our pharmacy Tidewater MTF Pharmacy Site Published e-rx Site Name NCPDP/NPI Branch Health Clinic (BHC) Dam Neck DoD PORTS VA DAM NECK ephcy / BHC JEB Little Creek-Fort Story (Boone Clinic) DoD PORTS VA LITTLE CRK ephcy / BHC Naval Air Station Oceana DoD PORTS VA BHC OCEANA ephcy / BHC Norfolk Naval Station (Sewells Point Clinic) DoD PORTS VA BHC SEWELLS PT ephcy / BHC Naval Weapons Station Yorktown DoD PORTS VA BHC YORKTOWN ephcy / BHC Northwest DoD PORTS VA NORTHWEST NSG ephcy / Kenner Army Health Clinic, Fort Lee DoD FT LEE ephcy / McDonald Army Health Center (MCAHC) JEB Langley-Eustis DoD FT EUSTIS ephcy / Naval Medical Center Portsmouth (NMCP) DoD PORTS VA NMC ephcy / Scott Center Annex Norfolk Naval Shipyard Portsmouth DoD PORTS VA SCOTT CENTER ephcy / TRICARE Prime Clinic (TPC) Chesapeake DoD PORTS VA TPC CHESAPEAKE ephcy / TPC Virginia Beach DoD PORTS VA TPC VA BEACH ephcy / USAF Hospital Langley DoD LANGLEY ephcy / TRICARE Mail Order Pharmacy (Home Delivery) Express Scripts Home Delivery /

80 TFL Home Delivery Pharmacy Pilot Program For retirees and family members with TFL Mandatory maintenance medication refills through home delivery such as blood pressure, cholesterol or thyroid medications Exceptions and waivers Prescriptions filled at an MTF pharmacy Acute care meds (antibiotics, pain meds, etc.) Beneficiaries with OHI prescription coverage Program notifications by mail from Express Scripts (877)

81 Hospital Corpsman Advancement Question Question Beneficiaries enrolled in what program do not have access to MTFs and TRICARE facilities, including pharmacy benefits, except in an emergency? Answer U.S. Family Health Plan.

82 Preventive Health Care and Wellness Services Breast MRIs Clinical Preventive Exams Colon Cancer Screenings Immunizations and Vaccines Mammograms PAP Smears Well-Child Care Visits Cardiovascular Screenings Eye Exams 4 Genetic Testing Infectious Disease Screenings School Physicals 4 ADFMs and TRS Prime 1 Standard 2 TRS No copayment No copayment No cost-share Network: 15% Non-network: 20% 1 Prime, Prime Remote, Overseas Prime, USFHP, Young Adult Prime 2 Standard/Extra, Young Adult Standard/Extra 3 Prime, USFHP, Young Adult Prime 4 Benefit restrictions and limits may apply Retirees, FMs and TRR Prime 3 Standard 2 TRR No copayment No copayment No cost-share Network: 20% Non-network: 25%

83 Prior authorization is required for all TRICARE-eligible beneficiaries when TRICARE is the primary payer for: Certain medications Adjunctive (medically-necessary) dental Home health care and hospice Non-emergency substance abuse or behavioral health admissions Outpatient behavioral health (after the 8 th visit) Skilled nursing facility care (after day 100 for TFL) Most organ transplants ECHO (ADFM benefit only) Prior authorization from TRICARE is generally not required for services already authorized under Medicare or OHI

84 TRICARE Overseas Program (TOP) Prime and Overseas Prime Remote are only for ADSMs and command-sponsored family members All others TRICARE Standard Space-available MTF care Most care from host nation providers To find a provider or get assistance TOP Area Office or MTF U.S. Embassy or Consulate TOP regional contractor International SOS (888) (from the U.S. only)

85 TRICARE Young Adult (TYA) Program Eligibility requirements Unmarried child of a TRICARE-eligible sponsor At least 21 years of age (23 if a full-time student), but under age 26 Not eligible for an employer health plan National Guard and Reserve sponsors must be eligible for regular TRICARE or TAMP benefits, or must be eligible for and enrolled in either TRS or TRR Their children only eligible for TYA Standard/Extra Monthly premiums (January December 2015) Prime: $208; Standard/Extra: $181

86 Uniformed Services Family Health Plan (USFHP) Benefits and costs similar to TRICARE Prime 6 geographic locations Eligible beneficiaries same as TRICARE, except for ADSMs and TFL Except for emergencies, enrollees do not use TRICARE facilities (800) Martin s Point Health Care Brighton Marine Health Center Saint Vincent Catholic Medical Centers of New York Johns Hopkins Medicine CHRISTUS Health Pacific Medical Centers

87 Eligibility Veterans Affairs (VA) Eligibility CHAMPVA Dual Eligibility TRICARE and VA VA Health Care Programs VA Pharmacy VA Health Care Facilities The Veterans Health Administration (VHA) is the component of the Department of Veterans Affairs (VA) that oversees the delivery of health care benefits to veterans, their dependents and survivors

88 Eligible veterans Service member discharged or separated from military service under conditions other than dishonorable Minimum duty requirements may apply to veterans who enlisted after 07 September 1980, or who entered active duty after 16 October 1981 Reserve and National Guard member called to active duty (other than for training only) by federal order, and completed the full period of activation Dependents and survivors may be eligible for CHAMPVA For complete information about VA eligibility and health care benefits, go to:

89 Enrollment into the VA health care system Most veterans apply for enrollment (877) All applicants are assigned to one of eight priority groups based on a number of factors, including: VA disability rating, service history (dates and assignments) Employability, income and net worth Priority (or sub-priority) group designation determines: Priority for access to care and co-pay requirement

90 Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) eligibility Dependent spouse or child of a veteran having a serviceconnected total and permanent disability Non-TRICARE-eligible survivors of a veteran who died: From a VA-rated service-connected disability, or who was rated at the time of death by the VA as totally and permanently disabled, or In the line of duty, not due to misconduct A surviving spouse under age 55 who remarries loses eligibility, but may re-establish it if the remarriage ends If spouse remarries after age 55, eligibility is not lost Medicare-eligibility requires Parts A and B to keep CHAMPVA

91 Dual eligibility TRICARE and the VA Separating from active duty (not retirement) TRICARE certain service members and eligible family members may be entitled to 180 days of temporary coverage under TAMP, but otherwise lose eligibility upon separation from active duty VA veterans, with or without a VA disability rating for a service-connected condition, may apply for benefits after leaving active duty Continued

92 Dual eligibility TRICARE and the VA (continued) Retiring from active duty (including TDRL and PDRL) TRICARE service members and eligible family members retain eligibility after transitioning from active duty to retirement VA veterans, with or without a VA disability rating for a service-connected illness or injury, may apply for benefits after retirement CHAMPVA retiree family members or survivors eligible for TRICARE are not eligible for CHAMPVA benefits

93 Dual Eligibility Program Eligibility Based on Beneficiary Status Program ADSM ADFM Separating SM Separating FM Retired SM TRICARE Yes No Yes TFL TRS TRR No Option if Medicareeligible No Option for inactive Selected Reserve TYA No Option if eligible No TAMP No No No Option if sponsor is enrolled For certain separating SMs, deactivating Reservists, and FMs Retired FM Required if Medicare-eligible Option for retired Reserve < age 60 No Option if sponsor is enrolled Option if eligible If retirement is postponed by retention on AD for a contingency operation CHCBP No Option when TRICARE eligibility ends No VA CHAMPVA No No Yes must apply to meet requirements and access care No If sponsor rated totally and permanently disabled, died from a VA-rated serviceconnected disability, or was rated totally and permanently disabled at the time of death Yes must apply to meet requirements and access care No No

94 VA Health Care Programs for Veterans Outpatient and inpatient services Primary, specialty and surgical care Diagnostic testing Mental health and substance abuse treatment Prescription drugs (prescribed by a VA physician) Preventive services Immunizations and health education programs Physicals and health care assessments

95 VA Health Care Programs for Families CHAMPVA (800) Children of Women Vietnam Veterans For birth children Vietnam women veterans determined by the VA to have one or more covered birth defects (888) Spina Bifida Health Care Benefits For Vietnam and Korea veterans birth children in receipt of a VA award for spina bifida benefits ; (888)

96 VA pharmacies will only fill prescriptions written by VA physicians If a beneficiary, including someone who is dual-eligible, receives care at a VA facility for a VA-covered benefit, prescriptions should be filled at a VA pharmacy If a dual-eligible beneficiary receives care through TRICARE for a VA-rated service-connected condition, prescriptions should be filled through the TRICARE pharmacy program

97 Use of VA Health Care Facilities Based on Beneficiary Status Beneficiary Status Use for TRICARE-Covered Services* Use for VA-Covered Services ADSMs and Activated Guard and Reserves Emergency care; urgent and routine care with a referral and authorization ADSMs Terminal Leave All services, with prior authorization N/A ADFMs; or ADSMs and ADFMs during TAMP Separated (not retired) Service Member Separated (not retired) Family Member Retired Service Member (not Medicare-eligible) Retired Family Member (not Medicare-eligible) Retired Service Member (Medicare-eligible/TFL) Retired Family Member (Medicare-eligible/TFL) TRICARE Prime (if TRICARE PCM) or TRICARE Extra (if TRICARE network) N/A N/A TRICARE Prime (if TRICARE PCM) or TRICARE Extra (if TRICARE network) TRICARE Prime (if TRICARE PCM) or TRICARE Extra (if TRICARE network) Not Medicare-authorized; TRICARE pays 20%; beneficiary pays 80% Not Medicare-authorized; TRICARE pays 20%; beneficiary pays 80% N/A N/A For service-connected disability or if veteran s eligibility criteria is met CHAMPVA, if eligible For service-connected disability or if veteran s eligibility criteria is met N/A For service-connected disability * Most VA facilities participate as TRICARE network (Extra) providers, including all VA facilities in the TRICARE North Region. Some also participate in TRICARE Prime as primary care managers (PCMs). To find a participating facility or provider, go to the Health Net provider directory at N/A

98 Online TRICARE Medicare Social Security Reserve Affairs Veterans Affairs Veterans Health Administration NMCP

99 Health Benefit Advisors in Tidewater (area code 757) McDonald Community Army Health Center NMCP USAF Hospital Langley Branch Health Clinic (BHC) Dam Neck BHC Little Creek (Boone Clinic) BHC Norfolk (Sewell s Point) BHC Northwest BHC Oceana (option 7) BHC Yorktown TRICARE Prime Clinic (TPC) Chesapeake TPC Virginia Beach

100 Prepared by the Tidewater Military Health System (Tidewater Enhanced Multi-Service Market) TRICARE Marketing and Beneficiary Education Naval Medical Center Portsmouth 620 John Paul Jones Circle Portsmouth, Virginia Edward M. Coryell (757) Sonya Marsh, BCAC/DCAO (757) Rhita Walker-Smith Health Net Federal Services