NMCP TRICARE TAP Brief 2008 by wsj58G


									     TRICARE –
 Your Military Health Plan

Transitioning from
  Active Duty to
Retirement - 2008

                             April 12
      Decision Process
 Where will you live?
 Will you be employed?

 How is your and your family’s health?

 What health plans are available?

 What are the costs of the different plans?

 Are you and your family insurable?

 Will you need supplemental insurance?

                                          April 12
             TRICARE Regions

Regional Contractors:
 TRICARE North (Health Net)
   1-877-TRICARE (1-877-874-2273)
 TRICARE South (Humana)
 TRICARE West (TriWest)
   1-888-TRIWEST (1-888-874-9378)   April 12
            TRICARE Eligibility
   Must show eligible in DEERS
   Active duty & retired sponsors
   Medal of Honor recipients
   Family members (spouse and children)
       Unmarried children to age 21; 23 if full-time student
       Incapacitated child (if determined physically or mentally
        disabled prior to age 21)
       Valid ID card required for all beneficiaries age 10 and older
   Certain survivors
   Certain former spouses
                                                                   April 12
         Defense Enrollment Eligibility
         Reporting System (DEERS)

   Defense Enrollment Eligibility Reporting
       Defense Manpower Data Center Support
        Office (DSO)
        • Phone: 1-800-538-9552
        • Fax: 1-831-655-8317
        • Mail: DSO (Attn: COA or TFL), 400 Gigling
          Road, Seaside, CA 93955-6771
        • Web: www.tricare.mil/DEERS

                                                      April 12
          Making Changes
          in DEERS
   Demographic changes (address, phone)
       Can be done in person; by phone, fax or mail; or
   To add or remove a family member
       Sponsor responsibility
       Personnel / ID Card Office
       Birth, death, adoption, marriage, divorce
       Documentation required
         • Certificates
         • Decrees
                                                      April 12
    DEERS – Unremarried
    Former Spouses

   Unremarried Former Spouses
     Former spouse’s SSN used to
      verify eligibility (20/20/20 rule)
     Not eligible if covered by an
      employer-sponsored health plan
     Personnel / ID Card Office
     Stepchildren eligibility

                                           April 12
            Accessing Care During
            Terminal Leave
   ADSM is still considered active duty
    during the terminal leave period and must
    access care under the Prime rules
       Access care through the nearest MTF
       Go to a civilian hospital-based emergency room
       Call back to PCM / Regional contractor to
        authorize urgent care through a civilian doctor or
        urgent care clinic
       Routine care from other than your PCM will not
        be authorized while on terminal leave
                                                        April 12
               How TRICARE Changes
               When You Retire
                               When on Active Duty                  Upon Retirement
                           TRICARE   Prime
                                                             TRICARE Prime
                           TRICARE   Prime Remote
TRICARE Options                                              TRICARE Extra
                           TRICARE   Extra*
                                                             TRICARE Standard
                           TRICARE   Standard*
                           No enrollment fees               Enrollment fees apply
                           No copayments                    Copayments apply in network
TRICARE Extra           15% cost-share                    20% cost-share
TRICARE Standard        20% cost-share                    25% cost-share

Catastrophic Cap        $1,000 annually                   $3,000 annually
                        ADSMs—1st priority
                                                          Priority depends on enrollment in
MTF Access              ADFMs—priority depends on
                                                          TRICARE Prime
                        enrollment in TRICARE Prime
                        Family members not required       Must purchase Medicare Part B
                        to purchase Medicare Part B       regardless of age

* ADSMs are not eligible for TRICARE Extra or TRICARE Standard; for ADFMs only        April 12
        Military Treatment
        Facilities – Access to Care
   Upon retirement, your access to services at an MTF
    will change to a lower priority
   You will have higher priority access to specialty
    care in an MTF if you enroll in TRICARE Prime
   If you choose to use TRICARE Extra or TRICARE
    Standard, you will continue to have access to care
    in an MTF on a space-available basis only
   Access to most ancillary services will continue
    (pharmacy, lab, x-ray, immunizations, emergency
                                                   April 12
            Military Treatment Facility
            – Priorities for Care
   Active duty service members
   Active duty family members enrolled in Prime *
   Retirees, their family members, and others
    enrolled in Prime
   Active duty family members NOT enrolled in
    TRICARE Prime
   Retirees, their family members, and others
    NOT enrolled in Prime
   All other eligible beneficiaries
* If spouse is still active duty, use status as Active Duty Family Member when
accessing medical care
                                                                        April 12
         Catastrophic Cap
   Annual (fiscal year) out-of-pocket
    expense for TRICARE-covered benefits
     Deductibles
     Co-payments

   Active duty families
       $1000/year
   Retiree and retiree families
       $3000/year
                                       April 12
 Prime
  Managed    Care Plan/HMO
 Extra
  PPO

 Standard
  Fee   for Service
                              April 12
         TRICARE Standard
   Fee-for-service option (old CHAMPUS)
   No enrollment required
   Seek care from any TRICARE-authorized
   Responsible for annual deductibles and cost-
    shares—highest out-of-pocket expense
   May have to pay up-front, then file claim for
   May seek care in an MTF on a space-available
    basis                                     April 12
           TRICARE Standard –
   Deductible
       $150 individual/$300 family per fiscal year
   Cost-shares after deductible has been met
       Outpatient care – 25% of TMAC (when using a
        non-participating provider, patient may be
        responsible for 15% above the TMAC)
       Inpatient Care – lesser of $535 per day or 25% of
        billed charges for facility bill, plus 25% of
        allowable professional fees
   Catastrophic Cap
       $3000 per fiscal year
                                                       April 12
     TRICARE Extra
 Preferred provider option (PPO)
 No enrollment required

 Seek care from any TRICARE network
 Responsible for annual deductibles and
  discounted cost-shares
 Providers required to file claims for you

 May seek care in an MTF on a space-
  available basis
                                          April 12
         TRICARE Extra – Costs
   Deductible
       $150 individual/$300 family annually
   Cost-shares after deductible has been met
       Outpatient care – 20% of negotiated rate
       Inpatient care – lesser of $250 per day or 25% of
        negotiated charges for facility bill, plus 20% of
        negotiated professional fees
   Catastrophic Cap
       $3000 per fiscal year
                                                      April 12
           TRICARE Standard &
           Extra – a Comparison
   Annual deductible
       Active duty E-4 and below: $50 individual/$100 for family
       Active duty E-5 and above: $150 individual/$300 for family
       Retirees and families: $150 individual/$300 for family
   Extra cost-shares (outpatient, after deductible)
       Active duty family members: 15% of negotiated rate
       Retirees and their family members: 20% of negotiated rate
       No balance-billing; claims filed for you
   Standard cost-shares (outpatient, after deductible)
       Active duty family members: 20% of TMAC
       Retirees and their family members: 25% of TMAC
       Can balance bill up to 15% more than TMAC; may have to file
        your own claims                                       April 12
         TRICARE Prime –
   Prime does not automatically carry over into retirement
   A new enrollment application must be completed for the
    Region where you will live to continue in TRICARE Prime
   Deadline for submission – 20th of each month
   Annual enrollment fees will apply
      $230/Individual; $460/Family
      Paid monthly, quarterly, or annually
         • Include the Enrollment Fee Allotment Authorization Letter with
           application if paying by allotment
   If your spouse is active duty, enroll in Prime as an Active
    Duty Family Member (ADFM)
   Former spouse, if eligible, considered own sponsor
      Separate enrollment fees apply
   Must select or be assigned a PCM                          April 12
          TRICARE Prime –
          Enrollment Types
   New Enrollment
       First time enrollment as a retiree
   PCM Change
       Changing PCMs within the same Region
   Portability
       Changing PCMs from one Region to another
   Split Enrollment
       When family members live and enroll in
        different Regions; enrollment fee paid in
        Region where the sponsor lives
                                                    April 12
            Primary Care Manager
   MTF or network provider
   Provides most of your primary care and
    coordinates specialty care when needed
   Knows your family medical history, lifestyle,
    and habits
   Helps you develop and carry out a personal
    health maintenance and improvement program
   Prevents and detects health problems through
    regular screenings and wellness education
       Retirees enrolled in Prime are entitled to one
        preventive vision check every two years at no cost
                                                       April 12
         TRICARE Prime –
   MTF Care
       Outpatient care at no cost
       Inpatient care at subsistence rate
   Civilian Care
       PCM/Specialty outpatient visit: $12 copayment
       Inpatient visit: $11 per day ($25 minimum)
       Emergency services: $30 copayment
       Behavioral health outpatient visit:
         • $25/individual
         • $17/group
       Behavioral health inpatient visit: $40 per day April 12
        TRICARE Prime – Point
        of Service (POS)
   Unauthorized, non-emergent care
     Retro-authorizations not granted
   Allows freedom of choice
   Outpatient fiscal year deductible:
       $300/individual
       $600/family
   Patient responsibility – 50% of TMAC
       Plus 15% more is possible for non-
        participating providers
   No upper limit to POS Catastrophic Cap
                                             April 12
       TRICARE Prime –
       Newborn Enrollment
   Conditional Enrollment –
     Newborns  are covered under
     TRICARE Prime for the first 60
     days after birth - as long as one
     additional family member is
     enrolled in Prime
                                     April 12
            Traveling with TRICARE
   Use MTF if near a military base
   All routine medical care should be taken care of
    before traveling, or delayed until after returning
       Including immunizations, routine exams, and
        medication refills
   For out-of-area acute or urgent care, the PCM or
    the Regional contractor should be contacted for an
    authorization before obtaining care
   For out-of-area emergency care, call 911 or go to
    the nearest hospital-based emergency room
    (military or civilian; Prudent Lay Person Rule)
                                                      April 12
      Access to Care when
      Living Overseas
 You and your eligible family members have
  access to MTF facilities overseas on a
  space-available basis
 You will not be eligible for enrollment in
  TRICARE Prime while living overseas, but
  will be covered for civilian health care
  under TRICARE Standard
 The same annual deductibles and cost-
  shares will apply as when using TRICARE
  Standard in the United States          April 12
            TRICARE and Other
            Health Insurance (OHI)
   TRICARE generally pays after all OHI plans except:
       Medicaid
       TRICARE supplements (which are used to pickup remaining
        cost shares after TRICARE has processed the claim)
   Referrals and prior authorization are not required for
    TRICARE-covered services (except for adjunctive dental
    and behavioral health care)
   However, any OHI referral and authorization
    requirements must be followed
   Submit claims to TRICARE (with copy of OHI’s EOB) for
    amounts not paid by OHI
   Use OHI with TRICARE Standard/Extra
       Not recommended with Prime
                                                             April 12
       Comparison of TRICARE
       Prime and OHI Premiums
         Plan                Annual Premiums
      (2008 Costs)          Individual Plan   Family Plan

TRICARE Prime                    $230.00         $460.00
Mail Handlers, Non-Postal        $533.00        $1271.14
Value Plan
Mail Handlers, Non-Postal        $878.80        $1991.60
Consumer Plan
Mail Handlers, Non-Postal       $1357.98        $2890.42
Standard Plan
                                                    April 12
        Claims Filing

   Who is responsible for filing claims?
     Network provider/participating provider
     Beneficiary
   Forms needed for filing claims
     TRICARE Claim Form (DD-2642)
     Full Itemized Statement (HCFA-1500)
     Statement of Personal Injury (DD-2527)
     OHI Explanation of Benefits (EOB)
     Prescriptions
                                            April 12
      Claims Assistance
 Contact the TRICARE contractor for your
  Region (North, South or West)
 Go online to www.myTRICARE.com
 Contact the HBA/BCAC office at the nearest
  military hospital or clinic
 Claims normally process within 21 to 30
  days of the date medical care was received;
  and you will receive an Explanation of
  Benefits (EOB) in the mail
                                         April 12
         TRICARE Pharmacy
   MTF Pharmacy
   TRICARE Mail Order Pharmacy (TMOP)
       Express Scripts – 1-866-DoD-TMOP (363-8667)
       www.express-scripts.com/TRICARE
   TRICARE Retail Network Pharmacy
       Express Scripts – 1-866-DoD-TRRx (363-8779)
       www.tricare.mil/pharmacy
   Non-network Retail Pharmacy

                                                  April 12
     TRICARE Pharmacy –
     Generic Drug Use Policy
 Generic versions of prescription drugs
  will be dispensed when available
 Medical necessity must be justified
  when specifically requesting brand
  name drugs over generic versions
 When generic equivalents do not exist,
  the brand name version will be
                                       April 12
                Pharmacy Costs
     Place of                 Formulary                   Formulary                 Non-formulary
                               Generic                   Brand Name                    (Tier 3)
     Service                   (Tier 1)                    (Tier 2)
Military Treatment
Facility (MTF)          $0                          $0                             N/A
(up to 90-day supply)
Mail Order (TMOP)
(up to 90-day supply)   $3                          $9                             $22
Retail Network
(TRRx)                  $3                          $9                             $22
(up to 30-day supply)
Retail Non-network      Non-Prime:
(up to 30-day supply)   $9 or 20%, whichever is greater, after deductible is met

                        50%, after POS deductible is met
          Other Health Insurance
          (OHI) and Pharmacy
   The MTF pharmacy can still be used, even if you have OHI
   If prescription drugs are covered by OHI:
      When using a retail pharmacy, OHI will be the primary payer,
        and TRICARE will be secondary
      Electronic coordination of benefits apply when using a
        network retail pharmacy (pharmacy files to both OHI and
      The Mail Order Pharmacy (TMOP) program cannot normally be
        used with OHI, unless you have reached the OHI benefit cap,
        or the prescribed drug is not covered by the OHI
      If using a non-network retail pharmacy, the pharmacy will
        generally file to OHI and you must submit a claim to TRICARE
   If prescription drugs are not covered by the OHI, or if you
    have reached the OHI benefit cap, you may use either the

    TMOP or retail pharmacy benefits
                                                              April 12
          TRICARE For Life
   Eligibility
       Medicare-eligible sponsors and family members,
        including retired guardsmen and reservists age
        65 and over, and widows and widowers
       Certain former spouses if eligible for TRICARE
        before age 65 (20/20/20 rule)
   Requires enrollment in Medicare Part B
   TFL coverage effective date
       First day of month eligible beneficiary turns 65
       DEERS and ID card must be updated
                                                           April 12
        TRICARE For Life
   Began October 1, 2001
   Claims filed automatically from Medicare to
    TRICARE (provider only needs to file to
       Claims processor is Wisconsin Physician
        Services (WPS) - www.tricare4u.com
   If OHI exists, Medicare will pay first, OHI
    second, and TRICARE will pay last.
   No enrollment fees (except for Medicare
    Part B monthly premiums)
   Space-available access at MTFs
       Primary and specialty care appointments
       Most ancillary services accessible        April 12
          TRICARE Plus
   MTF primary care enrollment program
   Offered at certain MTFs
   Limited enrollment capacity
   No enrollment fees
   All TRICARE-eligible beneficiaries (except those
    enrolled in Prime or have a civilian HMO plan) may
    seek enrollment in TRICARE Plus
   Offers only primary care – access to specialty care
    through the MTF is not guaranteed
   Enrollment in TRICARE Plus does not affect TFL
    benefits or other existing programs                April 12
   TRICARE Dental Program (TDP)
     For active duty family members, & National
      Guard & Reserve members & their families
     United Concordia is the contractor
   TRICARE Retiree Dental Program (TRDP)
     For retirees & their families, Medal of Honor
      recipients & their families, & certain
      survivors & former spouses
     Delta Dental Plan of California is the
                                               April 12
         Retiree Dental Program
         Premiums – Locally (2008)
Number of Enrollees   Monthly     Prepayment*
Single                   $32.33         $64.66
Two Person               $63.07        $126.14
Family (3 or more)      $105.48        $210.96

 * A prepayment of two month’s premiums is
             required to enroll.
                                           April 12
        TRICARE Assistance &
   Beneficiary Counseling & Assistance Coordinators/Health
    Benefit Advisors
      Located at NMCP and all clinics
      (757) 953-2610
   TRICARE Service Centers
      Health Net Federal Services
      1 (877) TRICARE (874-2273)
   TSC Locations
      Naval Medical Center Portsmouth
      Kenner Army Health Clinic
      Langley 1st Medical Group
      McDonald Army Community Health Clinic
   www.TRICARE.mil
                                                          April 12
             TRICARE Assistance &
             Information - BCACs
   Boone Branch Health Clinic,          Oceana Branch Health Clinic,
    NAB Little Creek                      NAS Oceana
        (757) 953-8183/8185                  (757) 953-3933 (Option 7)
   Kenner Army Health Clinic, Fort      Sewells Point Branch Health
    Lee                                   Clinic, Norfolk Naval Base
        (804) 734-9447                       (757) 953-8708
   Langley 1st Medical Group,           TRICARE Prime Clinic
    Langley AFB                           Chesapeake
        (757) 225-5111                       (757) 953-6382
   McDonald Army Community              TRICARE Prime Clinic Virginia
    Health Clinic, Fort Eustis            Beach
        (757) 314-7939                       (757) 953-6710/6711
   Naval Medical Center                 Yorktown Branch Health Clinic,
    Portsmouth                            Naval Weapons Station
        (757) 953-2610/2611                  (757) 953-8441
   Northwest Branch Health Clinic,      Yorktown Coast Guard Health
    NavComSta NW                          Clinic
                                                                           April 12
        (757) 421-8220                       (757) 856-2147
Thank You!

                April 12

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