TRICARE Fundamentals Course by yaofenji

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									                     TRICARE Fundamentals Course


                          Who We Are
                          & Our History




                           14Participant Guide




References

TPM 6010.54-M, August 1, 2002, C-19, March 3, 2005
TRICARE Fundamentals Course
14) Who We Are & Our History




  Explain the structure of the Military Health System
  Identify the TRICARE regions
  Define TRICARE and how it has evolved
  Explain the purpose of the National Defense Authorization Act (NDAA)




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1.0 The Military Health System (MHS)
The Military Health System is the interconnected and interdependent web of organizations that carry
out the Military Health Care Mission. This includes those employed by the Department of Defense to
deliver care on the battlefield, on ships, in the air and in Military Hospitals, and it includes our partners
in the TRICARE network who deliver care for Department of Defense (DoD) beneficiaries in civilian
hospitals and clinics throughout the world. Supporting health delivery are activities that meet the unique
needs of a military health system—training and education centers for physicians, nurses, technicians
and administrators; research and development centers around the globe; and experts who manage one
of the largest health plans in the world.

1.1 The Mission of the MHS:
To provide optimal Health Services in support of our nation’s military mission—anytime, anywhere.

1.2 The Vision of the MHS:
    The provider of premier care for our warriors and their families
    An integrated team ready to go in harm’s way to meet our nation’s challenges at home or abroad
    A leader in health education, training, research, and technology
    A bridge to peace through humanitarian support
    A nationally recognized leader in prevention and health promotion
    Our nation’s workplace of choice




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2.0 Organizational Structure of the Military Health System (MHS)

 SERVICES                             The President


  ARMY                                SecDef                           OSD
        SG
                                                                            ASD (HA)
  AIR FORCE

        SG                                                                    TMA

  NAVY                                                           Chairman, JCS

        SG                                            J1   J2     J3   J4    J5   J6   J7   J8

  USMC                                                          The Joint Staff


     SG – Surgeon General
     OSD – Office of Secretary of Defense
     ASD (HA) – Assistant Secretary of Defense (Health Affairs)
     SecDef – Secretary of Defense
     JCS – Joint Chief of Staff

3.0 TRICARE
TRICARE is the health care program serving active duty service members, retirees, their families,
survivors and certain former spouses worldwide. As a major component of the Military Health System,
TRICARE brings together the health care resources of the uniformed services and supplements them
with networks of civilian health care professionals, facilities, pharmacies and suppliers to provide
access to high-quality health care services, while maintaining the capability to support military
operations.

4.0 TRICARE Management Activity (TMA)
4.1 TMA Charter
The TRICARE Management Activity (TMA) was formally established under Department of Defense
Directive (DoDD) 5136.12 on May 31, 2001. TMA is a field activity of the Undersecretary of Defense
for Personnel and Readiness. Since February 1998, TMA leadership has managed the TRICARE
healthcare program for those entitled to DoD medical care.




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DoDD 5136.12 is the TMA Charter and solidifies TMA's mission, responsibilities, functions,
relationships, authorities, and organizational structure. DoDD 5136.1 and the Defense Federal
Acquisition Regulation Supplement (DFARS) references to the "Office of CHAMPUS" are now
understood to be "TRICARE Management Activity." As a chartered organization, TMA continues to
operate under the authority of the Assistant Secretary of Defense for Health Affairs.

4.2 TMA
    Executes health affairs (HA) policy and develops TMA policy
    Oversees TRICARE’s managed healthcare program for all uniformed services beneficiaries and
     their families worldwide
    Manages all financial matters of TRICARE

4.3 TRICARE Management Activity (TMA) organizational chart:




Notes:
    The Assistant Secretary of Defense for Health Affairs (ASD/HA):
       o Provides and maintains the readiness to provide healthcare services and support to
         members of the Uniformed Services healthcare services, and supports members of the
         Armed Forces during military operations.
       o The Department's healthcare mission provides healthcare services and support to members
         of the Armed Forces, their family members, and others entitled to DoD healthcare.




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      The TRICARE Regional Offices (TRO) and TRICARE Area Offices (TAO) report directly to the
       TMA Deputy Director.
      There are six major functional offices within each TRO/TAO:
         o Medical Office
         o Force Health Protection and Readiness
         o Financial Office
         o Information Office (information management, technology, and readiness)
         o Pharmaceutical Operations
         o Health Plan Operations Office (includes Communications and Customer Service)

4.4 TMA Communications and Customer Service (C&CS) organizational chart:


                                                    Director

     Administrative Staff


                            Public         Customer                  Beneficiary    Beneficiary
     Resources &
                            Affairs        Communications            Publications   Creative
     Strategic
                            Branch         Branch                    Office         Communications
     Planning                                                                       Branch
     Branch
                                      Staff            Customer
                                      Development      Service
                                      & Training       Branch
                                      Branch


4.4.1 Resources and Strategic Planning Branch
      The Resources and Strategic Planning Branch:
         o Conducts customer research and market analysis
         o Manages the TRICARE Beneficiary Delphi Council, a TMA-chartered worldwide group of
           approximately 250 volunteers representing all beneficiary categories serving as a sounding
           board for new C&CS communication concepts and products.




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4.4.2 Public Affairs Branch
    The Public Affairs Branch uses communications strategies to inform the media and beneficiary
     about TRICARE through:
       o News releases
       o Fact sheets
       o The Media Readiness Room: http://www.tricare.mil/pressroom/
       o The news media
       o Beneficiary associations
       o DoD and regional contractor communication professionals
       o The annual TRICARE Stakeholders Report
4.4.3 Customer Communications Branch (CCB)
    The Customer Communications Branch (CCB) is TMA’s liaison for TRO/TAO and MTF
     Beneficiary Counseling and Assistance Coordinators (BCACs) and Debt Collection Assistance
     Officers (DCAOs)
    CCB also:
       o Manages the Assistance Report Tool and the BCAC/DCAO Directory
       o Resolves beneficiary questions and concerns
       o Writes and updates the TRICARE Web site Frequently Asked Questions
       o Develops, delivers, and administers the TRICARE Fundamentals Courses
       o Communicates information regarding TRICARE programs and activities to medical, non-
         medical, line, and combatant personnel of all uniformed services, including Guard/Reserve
         members.
4.4.4 Beneficiary Publications Office
    The Beneficiary Publications Office:
       o Develops beneficiary and provider educational materials, such as the TRICARE program
         handbooks, brochures, beneficiary and provider briefings and flyers
       o Develops beneficiary (8 publications/year) and provider (12 publications/year) newsletters
         and bulletins
       o Coordinates printing and distribution of beneficiary and provider materials
       o Develops TRICARE Dental Program educational materials
       o Manages the TRICARE Smart Site: http://www.tricare.mil/tricaresmart/
       o Oversees development and review of TRICARE-related mailings in coordination with DMDC




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4.4.5 Beneficiary Creative Communications Branch
    The Beneficiary Creative Communications Branch:
       o Manages the TRICARE Web site: http://www.tricare.mil
       o Responds to Congressional inquiries

5.0 The TRICARE Continental United States (CONUS) Regions
TRICARE plan oversight is managed through three geographic health services regions. Each of the
regions has a regional contractor that administers and helps coordinate the health care services
available through military treatment facilities (MTFs) and a network of civilian hospitals and providers.




5.1 West Region
The West region is comprised of Alaska, Arizona, California, Colorado, Hawaii, Idaho, Iowa (except the
Rock Island Arsenal area), Kansas, Minnesota, Missouri (except the St. Louis area), Montana,
Nebraska, Nevada, New Mexico, North Dakota, Oregon, South Dakota, Texas (the southwestern
corner including El Paso only), Utah, Washington, and Wyoming.

5.2 North Region
The North region is comprised of Connecticut, Delaware, the District of Columbia, Illinois, Indiana,
Kentucky, Maine, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New York, North
Carolina, Ohio, Pennsylvania, Rhode Island, Vermont, Virginia, West Virginia, Wisconsin, and portions
of Tennessee (Ft. Campbell area), Iowa (Rock Island Arsenal area), and Missouri (St. Louis area).

5.3 South Region
The South region is comprised of Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi,
Oklahoma, South Carolina, Tennessee (except the Ft. Campbell area), and Texas (except the
southwestern corner including El Paso).


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6.0 TRICARE Regional Offices
Each of the three CONUS TRICARE regions is administered by a separate TRICARE Regional Office
(TRO): TRICARE Regional Office-North, TRICARE Regional Office-South, and TRICARE Regional
Office-West. The TROs are government entities that oversee the regional contractors to ensure they
fulfill their contractual responsibilities.


TRICARE Regional Office Organizational Chart
                              General organizational structure

                               Regional Director
                               Senior Executive Service (SES)
                               or General/Admiral (Flag)




IM/IT Operations     Business Ops             Program Ops        Clinical Ops       Contract Ops
CIO and Staff        Chief                    Chief              Chief              Chief
Information          Administration           Purchased Care     UM/QM/RM           Alternate
Assurance            Support                                                        Contracting Officer
                                              Access             Clinical Quality
                     Analysis and                                Mgmt               Staff
                                              Marketing and
                     Evaluation
                                              Education          Case Mgmt
                     Finance
                                              Health Benefits    Health Program
                                              Counseling         Analyst
                                              Customer Service
                                              Reps
                                              Enrollment and
                                              TSC
                                              USCG Liaison
                                              Training



6.1 Regional Director
Each TRO is led by a Regional Director, who reports to and operates under the TMA Deputy Director.
The TRO Director is the regional health plan manager and has visibility of both contract and direct care
assets, and coordinates with the Services to develop integrated health plans for regional military
treatment facilities. Specific responsibilities include:
     Management of the TRICARE contracts for all eligible MHS beneficiaries in the region. This
      responsibility includes:


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       o ensuring network quality and adequacy including provider issues
       o monitoring customer satisfaction outcomes
       o coordinating referral and authorization policies
       o managing enrollment activities
       o overseeing contractor credentialing
       o ensuring contract support for MTF optimization
       o other delegated functions
    Provision of the support to the military medical treatment facility (MTF) Commanders in their
     delivery of health care services to enrolled and non-enrolled beneficiaries; supporting the MTF
     Commanders in their efforts to optimize health care services in the MTFs;
    Develop business plans for non-MTF areas (e.g., BRAC sites), remote areas, and those areas in
     which a Service Surgeon General requests regional director support.
    Integration of MTF and remote business plans into a single, regional business plan for submission
     to TMA prior to the start of each fiscal year, and subsequent monitoring of performance against
     the business plans.
    Funding of regional initiatives to optimize and improve the delivery of health care, through
     dedicated resources and a disciplined and open business case planning/approval process.
     Opportunities for investment capital can be initiated by the Regional Director, a single MTF
     Commander or by a Senior Market Manager on behalf of the MTFs in a multiple service market.
    Chair of the TRICARE Regional Advisory Committee

6.2 Other Roles within the TRICARE Regional Office include the following:
    Medical Director (referrals, UM/QM/CM)
    Managed Care Director (networks, marketing, BCAC)
    Business or Finance Director (Resource Sharing/Support, Bid Price Adjustment analysis)
    Contracting Director (surveillance, deficiencies)
    Operations Director (TRICARE Prime Remote, Reserve component issues)
    Information Management Director (DEERS/DOES, ALHTA/CHCS)

6.3 Senior Market Manager
    Title applies to the MTF commander designated by the Surgeons General to be the market
     manager for each of the 13 multi-service markets. Multi-service markets are major military
     treatment facilities and their subordinates that form one unified health system.
    Collaborates in a process to develop consolidated business plans and jointly work resource issues
    Oversees the single integrated business plan that may include appointing services, resource
     sharing, optimization initiatives, and DoD/VA sharing opportunities
    Makes recommendations concerning short-term operational decisions

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7.0 The Role of the Regional Contractor
Each of the three CONUS regions has a regional contractor. The regional contractor’s role is to help
support and augment the services available at MTFs by developing a network of civilian hospitals and
providers to meet the healthcare needs of TRICARE beneficiaries and carrying out contractually
required administrative functions.

7.1 Regional Contractor Responsibilities
The regional contractors perform varied functions at the regional level, including the following:
    Establishing and maintaining the TRICARE Prime provider network
    Delivering customer service
    Operating beneficiary information lines
    Operating TRICARE Service Centers (TSC)
    Providing administrative support such as enrollment, disenrollment, and claims processing
    Providing communications and educational information to beneficiaries and providers
    Managing the referral and authorization function
    Maintaining quality and disease management programs.
    Performing utilization and medical review for referrals to the network according to best business
     process

7.2 Regional Contractor—West Region
The regional contractor for the West region is TriWest Healthcare Alliance.




      Toll-free Phone                  1-888-874-9378 (1-888-TRIWEST)

                                       www.triwest.com this redirects to
      Web site
                                       https://www.triwest.com/triwest/default.html

                                       West Region Claims, P.O. Box 77028,
      Claims Mailing Address
                                       Madison, WI 53707-7028

      Toll-free Phone for Claims       1-888-874-9378

      Claims Web site                  www.tricare4u.com

      TRO Web site                     www.tricare.mil/west/default.cfm



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7.3 Regional Contractor—North Region
The regional contractor for the North region is Health Net Federal Services, LLC.




      Toll-free Phone              1-877-874-2273 (1-877-TRICARE)

                                   www.healthnetfederalservices.com this is their HN corporate
      Web site                     page – refers to VA and other contracts.We typically link to:
                                   https://www.hnfs.net/bene/home

                                   Health Net Federal Services, LLC c/o PGBA, LLC/TRICARE
      Claims Mailing Address
                                   P.O. Box 870140, Surfside Beach, SC 29587-9740

      Toll-free Phone for Claims   1-800-930-2929

      Claims Web site              www.mytricare.com

      TRO Web site                 www.tricare.mil/north/default.cfm


7.4 Regional Contractor—South Region
The regional contractor for the South region is Humana Military Healthcare Services, Inc.




      Toll-free Phone              1-800-444-5445

      Web site                     www.humana-military.com

                                   TRICARE South Region, Claims Department
      Claims Mailing Address
                                   P.O. Box 7031, Camden, SC 29020-7031

      Toll-free Phone for Claims   1-800-403-3950

      Claims Web site              www.mytricare.com

      TRO Web site                 www.tricare.mil/south/default.cfm



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7.5 MTF Commander role as related to TRICARE
    Responsible for managing health care delivery for the active duty personnel and TRICARE
     beneficiaries who are seen within their MTF, with access to care higher for those enrolled in Prime
     with MTF PCM.
    May enter into a Resource Sharing Agreements or have providers refer patients to a network
     civilian provider if the MTF cannot or does not have capacity to provide the care to enrollees
     directly.
    Through a Memorandum of Understanding, coordinated by the Commander, the regional
     contractor and the TROs, sets priorities for assignment of MTF PCMs, enrollment activities,
     network development and adequacy, resource sharing arrangements, management of referrals
     and authorizations, educational outreach, and similar local initiatives.

7.6 Beneficiary Counseling and Assistance Coordinator (BCAC)
    Advocates for beneficiaries and provides assistance on TRICARE benefits
    Serves at each TRICARE Regional Office and MTF
    Works closely with the TMA/TRO/TAO staff, regional contractors, and claims processing staff
    Improves customer service and satisfaction, enhances beneficiary education, and reduces
     congressional inquiries from beneficiaries
    The BCAC directory is available on the TRICARE Web site– www.tricare.mil/BCACDirectory.htm
    An official listing of BCAC responsibilities can be found in DOD Instruction 6015.23 at
     http://www.dtic.mil/whs/directives/corres/pdf/601523p.pdf

7. 7 Debt Collection Assistance Officer (DCAO)
    Program directed by the Under Secretary of Defense (Personnel & Readiness)
    Serves at each TRICARE Regional Office and MTF
    Becomes involved when beneficiary notified of collection action
    Resolves TRICARE related debt collection cases using established policies and guidelines
    DCAO directory available on TRICARE Web site—http://www.tricare.mil/bcacdcao/
    Roles and responsibilities are outlined in the DCAO Training Guide:
     www.tricare.mil/1bcac3263827/1138/reference-guides.cfm

8.0 TRICARE Service Centers (TSCs)
TRICARE Service Centers are usually located with an MTF to serve beneficiaries and provide
information on and assistance with the TRICARE program. The TSCs are staffed by regional contractor
employees and are separate entities from MTF staff.




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8.1 TSCs Provide:
    Information about TRICARE Prime, Standard, and Extra
    Information on the Point of Service (POS) option
    Information on eligibility for the TRICARE Dental Programs
    TRICARE Prime enrollment and TRICARE Reserve Select enrollments
    Facility PCM selection
    Coordination of access to and referral for civilian specialty care
    Assistance with claim issues (when the regional contractor is responsible for the claim processing)
    TRICARE network providers and pharmacies lists

9.0 The TRICARE Overseas Regions
Outside the Continental United States (OCONUS) there are three separate overseas regions: Europe,
Pacific, and Latin America/Canada. The TRICARE Overseas regions operate in the same way as the
CONUS regions with a few exceptions:
    There are no contracted network providers overseas.
    TRICARE Area Offices (TAOs), rather than regional contractors, authorize care for beneficiaries.
    The Regional Deputy Director manages and administers the TRICARE Overseas Program.

9.1 TRICARE Area Offices
Like the TRICARE Regional Offices (TROs) within the CONUS regions, the three TRICARE Overseas
regions are each managed by a TAO.

9.2 TRICARE Area Offices (TAO):
    TAO Europe: Comprised of Europe, Africa, and the Middle East. (120 countries over 3 continents,
     and 11 time zones).
    TAO Pacific: Comprised of the Western Pacific/Far East, which includes China, Thailand, Korea,
     Australia, Japan, and so forth.
    TAO TRICARE Latin America/Canada (TLAC): Comprised of the Caribbean, Central and South
     America, and Canada.

9.3 TRICARE Area Office Directors
    Plan and deliver services to meet the healthcare needs within their area of responsibility, whether
     through the available MTFs, contracts, or local host nation providers.
    Offers many of the same services offered by a stateside regional contractor or TSC (e.g.
     enrollment assistance, claims processing assistance, benefit education).
    May contract directly for support services or include this requirement in existing TMA regional
     contracts (e.g. TSC staff, translation services).



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    Serves as a primary contact to the overseas claims processor, Wisconsin Physician Services
     (WPS), and TMA for issues relating to their areas of responsibility.

9.4 OCONUS MTF Commanders
    OCONUS MTF Commanders are responsible for providing and managing healthcare delivery for
     active duty personnel and TRICARE Overseas Program (TOP) Prime enrollees, as well as other
     Military Health System (MHS) beneficiaries who are eligible for care at MTFs on a space available
     basis.
    OCONUS MTF Commanders work directly with the TAO for network development, and local
     initiatives.

9.5 Claims Processor - Overseas
The Claims Processor for the all three overseas regions is Wisconsin Physicians Service (WPS).




       Toll-free Phone                               1-888-777-8343


       Claims Mailing Address                        WPS—Foreign Claims, P.O. Box 7985,
                                                     Madison, WI, USA 53707-7985
       TAO Pacific and TLAC

       Claims Mailing Address                        Active Duty:

       TAO Europe                                    WPS—Active Duty Claims Processing,
                                                     P.O. Box 7968, Madison, WI, USA 3707-7968
                                                     Active Duty family members:
                                                     WPS—Claims Processing, P.O. Box 8976,
                                                     Madison, WI, USA 53708-8976

                                                     1-608-301-2310
       Commercial Phone for Claims
       TAO Europe and Pacific

                                                     1-608-301-2311
       Commercial Phone for Claims TAO TLAC


       Web site TAO Europe                           www.europe.tricare.osd.mil/

       Web site TAO Pacific                          www.tricare.mil/pacific/tao-pacific.cfm

       Web site TAO TLAC                             www.tricare.mil/tlac/default.cfm



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10.0 MTFs’ Dual Mission
Military Treatment Facilities (MTFs) are responsible for providing both Force Health Protection and
Beneficiary Health Care.

         Force Health Protection (FHP)                       Beneficiary Health Care


                                                                                     Other health care
                                                                                       services not
                                  Individual                                          associated with
                                   Medical                                             FHP training
                                  Readiness
                                                   Health Care
                       Military-Unique
                       Training for the                that
                       Medical Force
                                                   Supports FHP
                                                                                        Clinical care
                                DNBI*
                              Prevention             Training                          not associated
                                                                                         with FHP
                                                                                           training




                                Both FHP and Beneficiary Health Care
 *Disease and Non-Battle Injury

10.1 Definition of Force Health Protection
―The medical portion of Force Protection. All measures taken by commanders, leaders, individual
Service members, and the Military Health System to promote, improve, conserve, or restore the mental
and physical well being of Service members across the range of military activities and operations.
These measures enable the fielding of a healthy and fit force, prevention of injuries and illness and
protection of the force from health hazards, and provision of excellent medical and rehabilitative care to
those who become sick or injured anywhere in the world. [1]‖




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11.0 Legislation
11.1 National Defense Authorization Act (NDAA)
    The NDAA is under the jurisdiction of the Senate and House Armed Services Committees.
    Under the NDAA, Title VII is Health Care.
    The NDAA provides statutory direction across all DoD programs by either establishing, changing,
     or eliminating programs and activities:
       o Example: Preauthorization elimination.
           -   In NDAA FY 2003, Section 701 prohibits TRICARE preauthorization requirement for
               inpatient mental health cases where Medicare has already authorized the care and
               Medicare is the primary payer.
           -   Requires advance authorization for a continuation of inpatient mental health services
               when Medicare coverage terminates.
           -   To implement this, it needs a regulation change.
       o Result of the NDAA: Preauthorization is no longer required.
    In DoD, a requirement could also be viewed as a new service which is:
       o Identified with an assessment of how much the new service will cost.
       o Presented to the legislative staffers to develop a bill that goes before Congress for funding.
    Changes to TRICARE benefits are presented from Congress through the annual NDAA process.
       o Although these changes are listed in the NDAA, the implementation dates are staggered due
         to several factors including waiting for the following:
           -   Public review/comment
           -   Funding
           -   Contract awards
           -   Policies to be written
           -   Contractor implementation
       o The staggered implementation dates allow for staffing of requirements through the TMA
         Directorates causing different dates between implementation and execution.
       o This fine-tuning is one of the reasons that make it appears that the TRICARE benefits
         program has had several changes.




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11.2 Key Points in the FY 2009 NDAA
 Section Explanation

 Benefit Enhancements
 701      One-Year Extension of Prohibition on Increases in Certain Health Care Costs for
          Members of the Uniformed Services
 702         Temporary Prohibition on Increase in Copayments under Retail Pharmacy System
             of Pharmacy Benefits Program
 704         Chiropractic Health Care for Members on Active Duty
 705         Requirement to Recalculate TRICARE Reserve Select Premiums Based on Actual
             Cost Data
 711         Waiver of Copayments for Preventative Services for Certain TRICARE Beneficiaries
 712         Military Health Risk Management Demonstration Project
 713         Smoking Cessation Program Under TRICARE
 714         Availability of Allowance to Assist Members of the Armed Forces and their
             Dependents Procure Preventive Health Care Services

11.3 Defense Appropriations Act (DAA)
      Provides funding or budget authority for authorized agencies, programs, and activities.
      Establishes spending levels for programs and activities.
      Under the Constitution, all appropriations must originate in the House of Representatives.
      Comes under the jurisdiction of the Senate and House Appropriations Committees.

11.4 Code of Federal Regulations (32 CFR) Part 199
      After the NDAA and Defense Appropriations Act become Public Law, Executive departments and
       agencies implement laws by publishing their rules in the Federal Register.
      The rules explain how the statutory mandate/statutory discretion will be implemented by DoD.
      Part 199 contains the regulations published in the Federal Register relating to the
       CHAMPUS/TRICARE program.

11.5 Title 10
      The U.S. Code is divided into 50 titles, and Title 10 dictates Armed Forces matters.
      Chapter 55 of Title 10 covers medical and dental care.
      When laws are enacted that affect military healthcare, they normally amend Title 10, Chapter 55.

11.6 Title 32
      U.S. Code title that covers the National Guard affairs


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12.0 Where it all began
Before 1884 Military Medical Care was for Military Members Only
    1775—Congress established a ―hospital‖ (actually a medical department) in Massachusetts with a
     Director-General (chief physician of the hospital), four surgeons, an apothecary (pharmacist), and
     nurses (usually wives or widows of military personnel) to care for military members.
    1818—Secretary of War John C. Calhoun established a permanent medical department.

Military Medical Care for Families
    1884—Congressional direction
       o ―Medical officers of the Army and contract surgeons shall, whenever possible, attend the
         families of the officers and soldiers free of charge‖
    1943—Congress authorizes Emergency Maternal and Infant Care Program (EMIC)
       o Provided maternity care and care of infants up to one year of age for wives and children of
         Service members in the lower four pay grades
       o Administered through state health departments
    1956—Dependents Medical Care Act
       o Amendments to this Act created what would be called CHAMPUS
    1966—Civilian Health and Medical Program for the Uniformed Services (CHAMPUS)
       o Authorized ambulatory and psychiatric care for active duty family members
    1967—Retirees, their family members, and certain surviving family members of deceased military
     sponsors were brought into the program

Healthcare under CHAMPUS
    1965 to 1993—CHAMPUS, the Civilian Health and Medical Program of the Uniformed Services
       o Served the military for over 30 years
       o A cost-sharing program used to provide inpatient and outpatient care for:
           -   Active duty family members from civilian sources when they were unable to get inpatient
               and outpatient care through a military hospital or clinic
           -   Family members of either deceased or retired personnel or retired military personnel and
               their family members under the age of 65
       o Space available care in MTF was available for all non-active duty.
       o Civilian care required:
           -   Annual deductible
           -   Cost share for every visit
           -   Non availability statements for inpatient care


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TRICARE Fundamentals Course
14) Who We Are & Our History

TRICARE is conceived
      1980s—CHAMPUS ―demonstration‖ projects
      1988—CHAMPUS Reform Initiative (CRI)
        o California and Hawaii
        o Offered family members a choice of ways in which they could use their military healthcare
          benefits
        o Five years of successful operation and high levels of patient satisfaction

TRICARE is Born
      1993—Department of Defense officials, along with Congress extend and improve the CRI
      The improved program is called TRICARE:
        o CHAMPUS becomes TRICARE Standard
        o Coverage, deductibles, cost shares, and claim-filing rules stayed the same.
        o Essentially the name just changed.
      With the switch to the TRICARE name, three options were implemented:
        o TRICARE Prime—basically the care received in MTFs
        o TRICARE Standard—same as CHAMPUS
        o TRICARE Extra—TRICARE Standard with a discount due to negotiated fees with providers
          in a network

13.0 TRICARE Evolution
1995
      Nurse advice lines toll-free worldwide
      Catastrophic cap reduced from $7,500 to $3,000 per year, non-active duty TRICARE Prime
       enrollees

1996
      TRICARE Web site www.tricare.osd.mil was launched.

1997
      TRICARE Prime enrollment portable across regions
      TRICARE Selected Reserve Dental Program
      National Mail Order Pharmacy




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TRICARE Fundamentals Course
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1998
      TRICARE Retiree Dental Program (TRDP)
      TRICARE Management Activity (TMA) established as a DoD field activity
      Stopped balance billing of TRICARE Prime enrollees by non-participating providers
      Limited balance billing by non-institutional providers
      The final TRICARE region (Northeast) was put in place

1999
      Automatic re-enrollment for TRICARE Prime enrollees
      TRICARE Prime Remote for active duty personnel

2000
      Designated Beneficiary Counseling & Assistance Coordinators (BCACs) at every Lead Agent and
       MTF
      Established Debt Collection Assistance Officer (DCAO) Program
      Catastrophic cap reduced from $7,500 to $3,000 per year, uniformed services retirees, their family
       members, and survivors using TRICARE Standard and TRICARE Extra

2001
      TRICARE Dental Program, combined TRICARE Family Member Dental Plan and TRICARE
       Selected Reserve Dental Program
      TRICARE Senior Pharmacy program was implemented
      Eliminated copays for active duty family members enrolled in TRICARE Prime
      TRICARE For Life – provides second payer to Medicare coverage to uniformed services retirees,
       their family members, and survivors who are age 65 years and over
      Chiropractic care benefit for active duty uniformed services members

2002
      TRICARE Transitional Healthcare Demonstration Project for 60 to 120 days for family members of
       active duty sponsors involuntarily separated from military service under honorable conditions or
       family members of Reserve component members separated after serving on active duty for more
       than 30 days in support of contingency operations
      TRICARE Prime Remote for active duty family members
      TRICARE Online (tricareonline.com) implemented with symptom checker, prescription checker,
       personal health journal, consumer health information, disease management tools, and online
       appointment scheduling with their assigned MTF PCM for TRICARE Prime and TRICARE Plus
       enrollees



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TRICARE Fundamentals Course
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      Awarded TRICARE Global Remote Overseas contract to International SOS Assistance, Inc., to
       standardize the benefit across all remote overseas regions

2003
      TRICARE Mail Order Pharmacy contract to Express Scripts, Inc.
      TRICARE implements patient privacy standards mandated under the Health Insurance Portability
       and Accountability Act of 1996 (HIPAA)
      First TRICARE Fundamentals Course taught
      TRICARE Retiree Dental Program contract to Delta Dental Plan of California
      TRICARE Global Remote Overseas contract begins

2004
      Automatic issuance of Certificates of Creditable Coverage for those who lose TRICARE eligibility
      Dual-eligible Claims Processing contract to Wisconsin Physician Services Insurance Corp.
      New contract to provide healthcare to active duty and their families started in Puerto Rico
      Healthcare Services and Support contracts to Health Net Federal Services Inc. (North),
      TriWest Healthcare Alliance Corporation (West), and Humana Military Healthcare Services
       (South)
      TRICARE Retail Pharmacy contract to Express Scripts, Inc.
      Transition to 3 stateside regions is completed

2005
      TRICARE Reserve Select begins
      Extended Care Health Option (ECHO) begins
      Permanent Uniformed Services ID cards for beneficiaries age 75 and over

2006
      Family members now have a 30-day period to submit a TRICARE Prime enrollment form.
      The opportunity to purchase TRICARE Reserve Select (TRS), in one of three premium tiers, was
       extended to all qualifying members of the National Guard and Reserves.
      Gastric bypass, gastric stapling or gastroplasty, including vertical banded gastroplasty is covered
       by TRICARE.

2007
      Authorized anesthesia and other costs for dental care for children and certain other patients.
      Expanded eligibility of Selected Reserve members under TRICARE program.
      Standardization of claims processing under TRICARE program and Medicare program.

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TRICARE Fundamentals Course
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      Enhanced mental health screening and services for members of the Armed Forces.

2008
      Extended prohibition on increases in certain health care costs for the uniformed services.
      Temporary prohibition on increase in copayments under retail pharmacy system of pharmacy
       benefits program.
      Inclusion of mental health care in definition of health care.
      Establishment of Joint Pathology Center.

14.0 TRICARE Figures for FY 2008
      9.2 million TRICARE Eligible Beneficiaries
        o 5.026 million TRICARE Prime Enrollees
        o 1.569 million TRICARE For Life
        o 167,000 TRICARE Plus
        o 96,000 US Family Health Plan
        o 57,000 TRICARE Reserve Select
        o 2.194 million Non-enrolled Users
        o 75,000 Age 65 & older (not TRICARE For Life)
      TRICARE Dental coverage
        o 1.704 million Active Duty
        o 1.794 million Active Duty Family Members
        o 1.043 million Retirees
      MHS Direct Care Facilities
        o 63 Military Hospitals
        o 413 Medical Clinics
        o 413 Dental Clinics
      133,500 MHS Personnel
        o 89,400 Military
        o 44,100 Civilian
      $42.178 billion FY07 Budget (Unified Medical Program)
        o $23.694 billion Defense Health Program
        o $368 million Medical Military Construction
        o $6.958 billion Medical Military Personnel
        o $11.158 billion Medicare Eligible Retiree Accrual Fund

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TRICARE Fundamentals Course
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Summary




  Explain the structure of the Military Health System
  Identify the TRICARE regions
  Define TRICARE and how it has evolved
  Explain the purpose of the National Defense Authorization Act (NDAA)




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TRICARE Fundamentals Course
14) Who We Are & Our History


Appendix
1. Roles and Responsibilities of Debt Collection Assistance Officers (DCAOs)
Refer to the Debt Collection Assistance Officer Implementation & Training Guide, at:
www.tricare.mil/1bcac3263827/1138/reference-guides.cfm

2. Roles and Responsibilities of Beneficiary Counseling and Assistance Coordinators (BCACs)
Refer to DODI Number 6015.23, dated 30 October, 2002, at:
www.tricare.mil/1bcac3263827/1138/reference-guides.cfm




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