TRICARE and CHAMPVA Content for Caregiver Guide

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1 Health Care and Medical Insurance TRICARE TRICARE and CHAMPVA Content for Caregiver Guide TRICARE is the health insurance program for military beneficiaries. While active duty members and families are mostly exempt from TRICARE fees, that fact is no longer true once you enter retired status. Coverage and fees can vary, depending on what kind of TRICARE coverage you choose in retirement. Coverage and fees can vary, depending on: (a) whether the military sponsor is on active duty or retired, (b) whether the beneficiary is eligible for Medicare, or (c) whether the beneficiary uses military or civilian facilities for health care and medications See the following charts for programs and fees applicable to: Active duty members and family members Retired service members and family members (not Medicare-eligible) Medicare-eligible retired service members and family members Special considerations for military disability retirees under TRICARE: Protection against annual fee increases: Under current law, military disability retirees are exempt from annual increases in TRICARE Prime enrollment fees and pharmacy copays that apply to non-disability retirees. Military disability retirees do not include all retirees who have a disability rating from the VA. They only include those who received a medical (Chapter 61) retirement from their parent service. To ensure exemption from future annual fee increases, retirees in this category should contact DEERS to ensure their records reflect the medical/disability retirement as a Chapter 61 retiree. Medicare and TRICARE: How will the TRICARE benefit be affected if I become eligible for Medicare Part B? Answer: Once you become eligible for Medicare Part B --which happens when you reach age 65 or you reach the twenty-fourth month of being rated as 100% disabled by Social Security (not DoD or VA) -- you MUST enroll in Medicare Part B in order to keep your TRICARE eligibility. The TRICARE benefit for people who are Medicare-eligible is called TRICARE For Life (TFL). It is completely different from TRICARE Standard and TRICARE Prime, and has a separate page on the Web that provides details on how TFL works. Active Duty and Activated National Guard or Reserve Members(referred to here as active duty): In some cases, severely injured, ill, or wounded service members may qualify for Medicare while still on active

2 duty and awaiting medical retirement. Normally, if you are eligible to enroll in Medicare Part B (which has monthly premiums of about $100 per month per person), you must enroll in Part B to maintain coverage under TRICARE. Active-duty Medicare eligible service members and their Medicare eligible SSDI family members enrolled in a TRICARE Prime option are allowed a special enrollment period for the service member s remaining time on active duty. They can delay their enrollment in Medicare Part B until their service retirement or medical retirement. People in this situation must request an active duty certificate of creditable coverage from the Defense Manpower Data Center Support Office to use the special enrollment period. But they MUST enroll in Medicare Part B BEFORE THEY RETIRE OR ARE MEDICALLY RETIRED from active duty or activation orders in order to avoid a break in medical coverage and a Medicare penalty. It is highly advisable to accept Medicare when it is offered and pay the monthly enrollment fee if you are worried that you may forget to make the phonecall to start paying Medicare premiums when service member retires. Retired Members: If Medicare eligibility due to disability is established after retirement, you MUST enroll in Part B in order to retain health coverage under TRICARE. (For details on how the coverage works, see the Section on TRICARE For Life, under which TRICARE acts as second payer to Medicare.) How does SSDI affect Medicare and TRICARE under age 65? Upon receipt of SSDI for 24-months, you will be automatically enrolled in Medicare Part B unless you decline coverage. Should you decline; the retiree or their SSDI eligible family member will be subject to a lifetime penalty of 10% for every 12-month they failed to enroll. However, the active duty /activated service member or their SSDI eligible family member enrolled in a TRICARE Prime option can decline Medicare Part B without penalty but must enroll before the service members retirement or medical retirement in order to keep TRICARE without a break in coverage and without incurring a penalty. How do Medicare and TRICARE benefits work under age 65? Medicare and TRICARE benefits for SSDI eligible members under age 65 are identical to that of over age 65 TRICARE for Life (TFL) eligible members. This category of care is also known as Dual-Eligible meaning eligible for both TRICARE and Medicare under age 65. Does receipt of SSDI by the service member affect the health benefits of their family members? No, the family member coverage and fees depend upon the following: (a) the military sponsor status active duty or retired, (b) the family member s eligibility for Medicare, or (c) their geographic location. If within a 40-mile radius of a Military Treatment Facility (MTF) they can enroll in TRICARE Prime. If not, by default their option is TRICARE Standard. See the Defense Department s TRICARE and Medicare Under-65 Fact Sheet for additional details on the effects of failing to enroll on time.

3 TRICARE For Life TRICARE For Life (TFL) is the TRICARE program for people who are eligible for Medicare. That includes: (a) all military beneficiaries who are age 65 or older, and (b) military retirees or dependents rated as 100% disabled by Social Security (not DoD or VA) at an earlier age for at least 24 consecutive months Once you become eligible for Medicare, you MUST enroll in Medicare Part B to keep TRICARE coverage. In 2013 Medicare Part B premiums are about $100 per month per person for most people, but can be higher for people in higher income brackets ($85,000 a year for singles and $170,000 a year for married couples). Part B premiums are adjusted every January based on how much Medicare costs have risen. In recent years, that s been 3% to 4% a year. Once you enroll in Part B, Medicare is first payer, and normally pays 80% of the cost for covered benefits. TFL pays the remaining 20% --whatever Medicare does not pay (including the Medicare deductible, as long as you use a doctor who takes Medicare and the services are both Medicare and TRICARE covered services or facilities. The doctor simply files a claim with Medicare, and the Medicare claim is sent to TRICARE automatically to pay the TRICARE cost-share. There is no need for the doctor (or you) to file a separate claim with TRICARE. It is important to note that not every doctor or facility is covered by Medicare and TRICARE. MOST are, but it is important to ask your doctor s office if they accept Medicare and Tricare. You should also ask about tests and procedures. And finally you should ask about facilities. Nursing homes are not covered by Medicare or TRICARE. When you go to the doctor, present your Medicare card and your military ID card. (If you are under sixty-five and on Medicare Part B, it is important to make sure that the doctor s office files the claim as Medicare first.) As long as you use doctors and other TRICARE authorized facilities that accept Medicare, you limit your out-of-pocket costs for doctor or hospital visits, except copays for any medications you get from nonmilitary pharmacies. TFL falls under the same catastrophic cap as TRICARE plans under age 65. The maximum out-of pocket cost you will pay per family for TRICARE covered benefits in any fiscal year (Oct-Sep) is $3000. US Family Health Plan (USFHP) The USFHP is a TRICARE Prime option available to active duty and retired members and families who live in certain areas of the country, mainly the northeast (including all or parts of states from northern Virginia to New York and Maine), the Puget Sound area of Washington State, and Southeast Texas/Southwest Louisiana.

4 The USFHP is administered through six major facilities that have a separate, unique TRICARE Prime contract, maintain their own networks of doctors (separate from the regular TRICARE networks) and provide certain enhanced services. Enrollees with access to USFHP coverage generally express very high satisfaction with the program. One unique aspect of the program is that some enrollees can continue TRICARE Prime coverage under USFHP even after they have attained Medicare eligibility. This continued coverage into Medicare eligibility applies only to people who already were enrolled in the USFHP as of October 1, People who enrolled after that date must switch to Medicare and TRICARE For Life upon attaining Medicare eligibility. Visit for additional details on the USFHP. TRICARE Pharmacy Benefits TRICARE patients have multiple options to meet their medication needs, including: Pharmacies at military hospitals and clinics, where medications are provided at no cost to beneficiaries. Retail pharmacies, which provide 30-day prescription fills and require beneficiary copays, and The TRICARE Home Delivery Program, which provides 90-day prescription, fills by mail at substantially lower copays than retail drug stores (no cost for generic drugs). Initial medication prescriptions should be filled in military or retail pharmacies. The Home Delivery program is for refills of longer-term maintenance medications. Beneficiaries who don t have regular access to military pharmacies should check out the Home Delivery system, which offers 67% or greater savings on refills compared to retail drug stores. This chart compares retail vs. Home Delivery copays for different kinds of drugs. Pharmacy Copayments for 2013* Military Pharmacy Retail Pharmacy Home Delivery (30-day supply) (90-day supply) Generic Drugs 0 $5 0 Brand-Name Drugs 0 $17 $13 Non-Formulary Drugs** 0 $44 $43

5 Notes: *Copays for retail and home delivery are subject to possible annual increases tied to the inflation rate. At current inflation rates, there would be no increase in the generic or brand-name drug copays for 2014, and the non-formulary rate will probably rise by $1 next year. **TRICARE declares certain drugs as non-formulary if they are no more effective than other available drugs for the same purpose but cost more for the military to buy. If your doctor prescribes a nonformulary drug, talk to him or her about substituting a generic or brand-name drug that s equally effective for you but has lower copay. If your doctor believes a non-formulary drug is medically necessary for you, the doctor can request that TRICARE grant a waiver to give you the drug at the regular, lower copay. Visit for additional details. Use the TRICARE Formulary Search Tool at to determine the point of delivery options available for your script and the copayment as well as any applicable Medical Necessity or Preauthorization Forms. Continuing Health Care Benefits Program (CHCBP) This program allows service members and family members who are losing TRICARE eligibility to buy a continuation of TRICARE-like coverage. People who can benefit from using CHCBP include service members who are separating (not retiring) from military service and their qualifying family members. Under the CHCBP, you can purchase coverage equivalent to TRICARE Standard for periods of 90 days at a time. Like Standard, CHCBP has a deductible of $150 (individual) or $300 (family) and a 25% copay for inpatient and outpatient services. It also includes TRICARE pharmacy coverage. But it s not cheap. Premiums for 2013 are: $1,138 per quarter for an individual $2,555 per quarter for a family CHCBP is not a permanent health insurance option. It s meant to provide temporary coverage for 18 months (service member) to 36 months (family member) until more permanent coverage is found. You must purchase the Continued Health Care Benefit Program (CHCBP) within 60 days of losing TRICARE eligibility or within 30 days of loss of TRICARE Reserve Select coverage. CHCBP coverage begins on the first day after the loss of TRICARE eligibility. For additional details, visit

6 The Transitional Assistance Management Program (TAMP) Upon separation from the service and after terminal leave is complete, the TAMP benefit provides for 180-days of premium-free transitional health care for the service and family members. Eligibility is determined by your service with the Defense Eligibility Reporting System (DEERS) documenting it in your record. You must have separated under honorable conditions from active duty or activation for National Guard or Reserve members under one of the following: Active duty involuntary separation, Active duty separation from involuntary retention (stop-loss) supporting a contingency operation, Active duty separation to a Selected Reserve component agreement without a break in service, National Guard or Reserve member separation after a contingency operation activation period of greater than 30 consecutive days, Sole survivorship discharge. You can use any of the below health plan options or choose to receive care at the Military Treatment Facilities (MTF S). Both TRICARE Prime options along with the US Family Health Plan (USFHP) option require enrollment. Go to for further information on the structure of each plan option. TRICARE Prime TRICARE Standard and Extra US Family Health Plan (USFHP) TRICARE Prime Overseas TRICARE Standard Overseas TRICARE Retiree Dental Program Military retirees and their family members and survivors are eligible to buy coverage under the TRICARE Retiree Dental Program. If you enroll within 120-days of retirement, the 12-month wait period for crowns, onlays, bridges, partial or full dentures and orthodontics is waived. The program is administered under a TRICARE contract with Delta Dental. See the fact sheet at for details on coverage, deductibles, etc. Premiums vary based on your location and the number of family members you want to cover. Visit to enter your ZIP code and see what your premium would be.

7 Description TRICARE PROGRAMS FOR ACTIVE DUTY MEMBERS AND FAMILY MEMBERS TRICARE PRIME TRICARE STANDARD TRICARE Prime is an HMO-style plan that uses a specific network of doctors. Under normal circumstances, it guarantees appointments with participating providers within specific time standards. In most cases, TRICARE Prime care is delivered through military hospitals or clinics. TRICARE Prime is the only option available to active duty members. Active duty family members are enrolled in Prime automatically unless they specifically request TRICARE Standard. Appointments to see specialists or doctors other than your primary care manager must be pre-approved in most cases. Family members may choose coverage under TRICARE Standard, a fee for service plan under which beneficiaries are free to find their own civilian doctors. Visits with other doctors, including specialists, do not require pre-approval in most cases. TRICARE Standard has an annual deductible and higher copays than TRICARE Prime. It may be difficult to find doctors who will accept new TRICARE patients in some areas, especially those not near military installations. Enrollment Fee Annual Outpatient Deductible Outpatient Visit Copay Inpatient Copay Catastrophic Cap (Maximum out-of-pocket payment for TRICAREallowed charges) There is a special program (called TRICARE Prime Remote) to provide Prime coverage for active duty family members who have been sent on military orders to locations without reasonable access to military facilities. E-1 to E-4: $50 individual/$100 family E-5+: $150 individual/$300 (family) 20% of TRICARE-allowed charges $17.35 per day ($25 minimum) $1,000 per family per year $1,000 per family per year

8 Description Enrollment Fee/Premium TRICARE PROGRAMS FOR RETIRED SERVICEMEMBERS AND FAMILY MEMBERS TRICARE PRIME TRICARE STANDARD TRICARE For Life TRICARE Prime is an HMO-style TRICARE Standard is a fee for plan that uses a specific service plan under which network of doctors. Under beneficiaries are free to find normal circumstances, it their own civilian doctors. guarantees appointments with participating providers within Visits with other doctors, specific time standards. Care including specialists, do not is delivered through military require pre-approval in most hospitals or clinics or through a cases. network of civilian providers. Appointments to see specialists or doctors other than your primary care manager must be preapproved in most cases. As of October 1, 2013, Prime is only available to retired members and families who live within 40 miles of a military hospital or clinic (some who were already on Prime before that date may apply to retain Prime if they live within 100 miles). $269/year (single) $539/year (family) (fee rises each year EXCEPT for medical (Chapter 61) retirees; ensure DEERS is aware of Chapter 61 status to avoid annual fee increases) It may be difficult to find doctors who will accept new TRICARE patients in some localities. TRICARE For Life (TFL) provides supplemental coverage for military retirees and family members who are eligible for Medicare. For Medicare-covered services, TFL pays all expenses not paid by Medicare. TFL applies to all military beneficiaries age 65 or older, and to retired members under age 65 who: a. Qualify for military retired pay, AND b. Have been deemed 100% disabled by Social Security. If the retiree is eligible for Medicare, but the spouse is not, the retiree is on TFL and the spouse is on Prime or Standard. Medicareeligibles can t decline Medicare/TFL and keep Standard or Prime. TFL has no enrollment fee, but requires enrollment in Medicare Part B, which has premiums of $100/mo or more per person, depending on income. Part B premiums rise each year. Annual Outpatient Deductible $150 individual $300 family Outpatient Visit $12 25% of TRICARE-allowed Copay charges Inpatient Copay $11 $698/day or 25% of charges, whichever is less Catastrophic Cap $3,000 per family per year $3,000 per family per year $3,000 per family per year (Maximum out-ofpocket payment for TRICAREallowed charges)

9 Description CHAMPVA COVERAGE FOR FAMILY MEMBERS OF QUALIFYING VETERANS CHAMPVA CHAMPVA is a fee for service plan under which the Department of Veterans Affairs provides coverage through civilian doctors for certain veterans family members. CHMPVA patients are free to find their own doctors. Visits with other doctors, including specialists, do not require pre-approval in most cases. It may be difficult to find doctors who will accept new CHAMPVA patients in some localities. Eligibility To be eligible for CHAMPVA, you cannot be eligible for TRICARE (the health care program for currently serving and retired military members and families) or other health insurance and you must be in one of these categories: 1. the spouse or child of a veteran who has been rated permanently and totally disabled for a service-connected disability by a VA regional office, or 2. a person officially designated under the VA Post 9/11 Caregiver program as the caregiver of a qualifying veteran, or 3. the surviving spouse or child of a veteran who died from a VA-rated service connected disability, or 4. the surviving spouse or child of a veteran who was at the time death rated permanently and totally disabled from a service connected disability. Enrollment Fee/Premium Annual Outpatient Deductible* Outpatient Visit Copay* Inpatient Copay* Impact of Medicare Eligibility* Catastrophic Cap (Maximum out-ofpocket payment for CHAMPVAallowed charges) (Note: If the beneficiary is eligible for Medicare, CHAMPVA eligibility is contingent on enrollment in Medicare Part B, which has a premium of $100/month or more, depending on income; See Impact of Medicare Eligibility below) $50 individual $100 family 25% of CHAMPVA-allowed charges 25% of CHAMPVA-allowed charges For a CHAMPVA-eligible person who is also eligible for Medicare and enrolled in Medicare Part A and Part B, CHAMPVA covers all costs that Medicare doesn t for Medicare-covered services. Beneficiaries in this category have no deductibles or copays for inpatient or outpatient Medicare-covered services. $3,000 per family per year

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