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									     TRICARE
Your Military Health Plan


 New Parents Seminar

           Version 2
         November 2005




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Covered Maternity Care
• TRICARE covers maternity care, which includes
  prenatal care, delivery, and postpartum care

• If TRICARE eligibility ends during the pregnancy,
  TRICARE does not cover any remaining maternity
  care, unless the family qualifies for the
  Transitional Assistance Management Program
  (TAMP) or has enrolled in the Continued Health
  Care Benefits Program (CHCBP)




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Eligible Beneficiary Categories
• Expectant mothers
  – Active duty and retired service members
  – Active duty and retired family members
     • Spouse
     • Dependent daughter
• Newborns
  – Newborn claims are billed separately from
    claims for expectant mothers
  – Dependent daughter’s newborn is covered
    under TRICARE if the father of the baby is an
    active duty or retired service member




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Defense Enrollment Eligibility
Reporting System (DEERS)
• Sponsor must register newborn in DEERS
   – Obtain a copy of your child’s birth certificate or certificate
      of live birth
• Newborn is covered under TRICARE Prime for the first 60
  days after birth
   – At least one family member is enrolled in TRICARE Prime
      or TRICARE Prime Remote
   – Fill out enrollment application and enroll in DEERS to
      ensure continuous TRICARE Prime Coverage
• After 60 days, newborn claims will process as TRICARE
  Standard if not enrolled in DEERS and formally enrolled in
  TRICARE Prime
• Eligibility for TRICARE Standard ends 365 days after birth for
  newborns who are not properly registered in DEERS




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Updating DEERS Information
• Visit an ID card issuing facility; locate one near you at
  www.dmdc.osd.mil/rsl
• Call 1-800-538-9552
• Mail changes to:
   Defense Manpower Data Center Support Office
   Attn: COA
   400 Gigling Road
   Seaside, CA 93955-6771

• Make address changes online at:
  www.tricare.osd.mil/DEERSAddress




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Maternity Health Care Choices—
Military Treatment Facilities (MTFs)
• Offers family-centered care for the least
  out-of-pocket costs to beneficiaries—overall
  the best value
• TRICARE Prime enrollees have priority access
  to care
• Beneficiaries using TRICARE Extra or TRICARE
  Standard may seek care at the MTF if space is
  available, but are not required to use the MTF
  for maternity care




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MTFs—Family-Centered Care
• Offers families standardized services starting with the
  first obstetric visit and continuing after the birth
  of the child
• Respect for your emotional well-being, privacy, and
  personal preferences
• Empowerment through honoring your family’s personal
  and cultural beliefs
• Choices in treatment
• Flexibility to welcome fathers, significant others, and
  siblings to be a part of your childbirth experience




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MTFs—Family-Centered Care
• Improved continuity of providers for prenatal care
• Careful, seamless coordination between
  facilities if you need to transfer
• Personalized pain management
• Individualized birth plans
• Improved access to first trimester appointments
• Private postpartum rooms
• Lactation education and support




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Maternity Health Care Choices—
Civilian Facilities
• TRICARE Prime beneficiaries may be able to
  seek care from TRICARE network if MTF
  cannot provide services

• TRICARE Extra beneficiaries seek care from
  TRICARE network providers

• TRICARE Standard beneficiaries seek care
  from any TRICARE-authorized provider




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TRICARE Prime
• In most cases, expectant mothers enrolled in TRICARE
  Prime will have their prenatal care and deliveries in
  an MTF

• No annual deductibles
• No enrollment fees for active duty family members;
  retirees and family members pay $230/individual or
  $460/family
• Copayments are less under TRICARE Prime
• Newborns are deemed TRICARE Prime enrollees if at
  least one family member is enrolled in TRICARE Prime




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TRICARE Prime Costs—
Active Duty Family Members
This chart depicts maternity costs for the mother

  Type of Service         Active Duty Spouse Active Duty Daughter
 Maternity Care—
 Prenatal, inpatient
 admission and                   $0                   $0
 professional services,
 and postnatal care
 Professional Fee
 when Delivering at
                                 $0                   $0
 Home or as an
 Outpatient




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TRICARE Prime Costs—
Active Duty Family Members
This chart depicts maternity costs for the newborn

 Type of Service      Active Duty Spouse    Active Duty Daughter
                                           You are responsible for 100%
 Inpatient
                                           of the fees unless the father of
 Professional Fees            $0
                                           the baby is active duty or
 for Newborn Care
                                           retired
                                           You are responsible for 100%
 Newborn Cost-
                                           of the fees unless the father of
 Share for Hospital           $0
                                           the baby is active duty or
 Services
                                           retired
 Professional Fee                          You are responsible for 100%
 when Delivering                           of the fees unless the father of
                              $0
 at Home or as an                          the baby is active duty or
 Outpatient                                retired




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TRICARE Prime Costs—
Retirees and their Family Members
This chart depicts maternity costs for the mother

 Type of Service Retiree or Retiree Spouse                    Retiree Daughter
                                                            $11 per day ($25
 Maternity Care—       $11 per day ($25 minimum             minimum charge) for
 Prenatal, inpatient   charge) for inpatient admission      inpatient admission
 admission and
 professional
 services, and         No separate copayment for            No separate copayment
 postnatal care        professional services for delivery   for professional services
                                                            for delivery
 Professional Fee
 when Delivering
                       $12 per visit                        $12 per visit
 at Home or as an
 Outpatient




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TRICARE Prime Costs—
Retirees and their Family Members
This chart depicts maternity costs for the newborn
 Type of Service        Retiree or Retiree Spouse                     Retiree Daughter
 Inpatient                                                         You are responsible for 100%
 Professional Fees                                                 of the fees unless the father
                                         $0
 for Newborn                                                       of the baby is active duty or
 Care                                                              retired
                     Same newborn date of birth and date of
                     mom’s admission: $11 per day ($25 minimum
                     charge) applies to the 4th and subsequent     You are responsible for 100%
 Newborn Cost-
                     days of newborn inpatient admission           of the fees unless the father
 Share for
                     Different newborn date of birth and date of   of the baby is active duty or
 Hospital Services   mom’s admission: $11 per day ($25 minimum     retired
                     charge) applies to all days of newborn’s
                     inpatient stay
 Professional Fee                                                  You are responsible for 100%
 when Delivering                                                   of the fees unless the father
                                    $12 per visit
 at Home or as an                                                  of the baby is active duty or
 Outpatient                                                        retired




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TRICARE Prime Maternity
Referrals and Authorizations
• Must obtain a referral from the primary care
  manager (PCM) for civilian maternity care
• Authorization includes prenatal and postnatal
  care, including a six-week follow-up visit
• The referral does not include conditions
  not related to pregnancy (i.e., a sprained
  ankle, ear infection)




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Additional Maternity Authorizations
• For other specialty care or more than 16
  office visits
   – This includes perinatal, genetic, special testing
     procedures, and high-risk pregnancies

• If the admission is not authorized, you will
  be responsible for TRICARE Prime
  point-of-service (POS) charges




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Maternity Care—
Point-of-Service Option
• Maternity care from a network provider without
  obtaining a referral: POS option
• Responsible for annual deductible
   – $300 for an individual
   – $600 for a family
• Out-of-pocket cost-shares
   – 50% of the TRICARE allowable charge
• Responsible for any additional charges from non-
  network providers, up to 15% above the TRICARE
  allowable charge




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Should you Disenroll from
TRICARE Prime?
• It’s your decision, but before you do…
   – Check for available TRICARE network or
     authorized obstetricians
   – Check for available TRICARE network or
     authorized pediatricians for your newborn
   – Consider the increased costs not only for
     maternity care, but also for other health
     care




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Converting to TRICARE Extra or
TRICARE Standard
• Must disenroll from TRICARE Prime
• Subject to a one-year lockout from TRICARE
  Prime
   – Does not apply to families whose sponsor is
     E-4 or below
• Patients needing medical attention, other than
  maternity care, will be subject to TRICARE Extra
  or TRICARE Standard cost-shares and deductibles
• Care at MTF on a space-available basis—no
  guaranteed access to care at the MTF




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Maternity Expenses—TRICARE
Extra and TRICARE Standard
• Prenatal care, labor and delivery, and
  postnatal care with a civilian provider
   – Beneficiaries are responsible for annual
     deductibles and cost-shares

• The amount of the cost-share varies based
  on the length of stay in the hospital and the
  medical needs of the mother and baby




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TRICARE Extra
• Seek maternity care from TRICARE network
  providers
• Annual deductibles apply when you choose
  to deliver at home or as an outpatient
   – Active duty family members
     • E1-E4: $50/individual and $100/family
     • E5 and above: $150/individual and
       $300/family
  – Retiree/Retiree family members
     • $150/individual
     • $300/family




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TRICARE Extra Costs—
Active Duty Family Members
This chart depicts maternity costs for the mother
   Type of Service            Active Duty Spouse           Active Duty Daughter

                             $25 minimum charge per
                                                          $25 minimum charge per each
                             each inpatient admission
                                                          inpatient admission OR the
Maternity Care—              OR the amount that
                                                          amount that would have been
Prenatal, inpatient          would have been charged
                                                          charged as an inpatient at an
admission and                as an inpatient at an MTF,
                                                          MTF, whichever is greater
professional services, and   whichever is greater
                                                          No separate cost-share for
postnatal care               No separate cost-share for
                                                          professional services for
                             professional services for
                                                          delivery
                             delivery

Professional Fee when
Delivering at Home or        15% of negotiated fee        15% of negotiated fee
as an Outpatient




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TRICARE Extra Costs—
Active Duty Family Members
This chart depicts maternity costs for the newborn

  Type of Service       Active Duty Spouse      Active Duty Daughter
                                                You are responsible for
Inpatient               $0 because newborn is
                                                100% of the fees unless the
Professional Fees for   deemed TRICARE Prime
                                                father of the baby is active
Newborn Care            for first 60 days
                                                duty or retired
                                                You are responsible for
                        $0 because newborn is
Newborn Cost-Share                              100% of the fees unless the
                        deemed TRICARE Prime
for Hospital Services                           father of the baby is active
                        for first 60 days
                                                duty or retired
Professional Fee                                You are responsible for
                        $0 because newborn is
when Delivering at                              100% of the fees unless the
                        deemed TRICARE Prime
Home or as an                                   father of the baby is active
                        for first 60 days
Outpatient                                      duty or retired




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TRICARE Extra Costs—
Retiree or Retiree Family Member
This chart depicts maternity costs for the mother

 Type of Service      Retiree or Retiree Spouse              Retiree Daughter
                                                           $250 per day or 25% of
Maternity Care—       $250 per day or 25% of the           the negotiated charges for
Prenatal, inpatient   negotiated charges for inpatient     inpatient admission,
admission and         admission, whichever is less,        whichever is less, PLUS
professional          PLUS 20% of the negotiated fee       20% of the negotiated fee
services, and         for separately billed professional   for separately billed
postnatal care        charges for delivery                 professional charges for
                                                           delivery
Professional Fee
when Delivering
                      20% of negotiated fee                20% of negotiated fee
at Home or as an
Outpatient




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TRICARE Extra Costs—
Retiree or Retiree Family Member
This chart depicts maternity costs for the newborn
Type of Service         Retiree or Retiree Spouse                         Retiree Daughter
Inpatient                                                            You are responsible for 100%
Professional Fees                                                    of the fees unless the father of
                    20% of negotiated fee*
for Newborn                                                          the baby is active duty or
Care                                                                 retired
                    Same newborn date of birth and date of mom’s
                    admission: The number of hospital days minus
                    3 multiplied by $250 OR 25% of the negotiated    You are responsible for 100%
Newborn Cost-
                    fees, whichever is less*                         of the fees unless the father of
Share for
                    Different newborn date of birth and date of      the baby is active duty or
Hospital Services   mom’s admission: The number of hospital days     retired
                    for the newborn multiplied by $250 OR 25% of
                    the negotiated fees, whichever is less*
Professional Fee                                                     You are responsible for 100%
when Delivering     20% of negotiated fee*                           of the fees unless the father of
at Home or as an                                                     the baby is active duty or
Outpatient                                                           retired




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                *This cost-share does not apply if the newborn is deemed enrolled in TRICARE
                Prime because at least one family member is enrolled in TRICARE Prime. The
                newborn costs would be the same as for other retiree family members enrolled   25
                in TRICARE Prime.
TRICARE Standard
• Seek care from any TRICARE-authorized provider
• Annual deductibles apply when you choose to
  deliver at home or as an outpatient
   – Active duty family member
       • E1-E4: $50/individual and $100/family
       • E5 and above: $150/individual and
         $300/family
   – Retiree/Retiree family member
       • $150/individual
       • $300/family




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TRICARE Standard Costs—
Active Duty Family Members
This chart depicts maternity costs for the mother
 Type of Service           Active Duty Spouse           Active Duty Daughter
                         $25 minimum charge per         $25 minimum charge per
                         each inpatient admission OR    each inpatient admission OR
Maternity Care—          the amount that would have     the amount that would have
Prenatal, inpatient      been charged as an inpatient   been charged as an inpatient
admission and            at an MTF, whichever is        at an MTF, whichever is
professional services,   greater                        greater
and postnatal care       No separate cost-share for     No separate cost-share for
                         professional services for      professional services for
                         delivery                       delivery
Professional Fee
when Delivering at
                   20% of the allowable charge          20% of the allowable charge
Home or as an
Outpatient




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TRICARE Standard Costs—
Active Duty Family Members
This chart depicts maternity costs for the newborn

  Type of Service       Active Duty Spouse          Active Duty Daughter
Inpatient             $0 because newborn is       You are responsible for 100% of
Professional Fees for considered TRICARE          the fees unless the father of the
Newborn Care          Prime for first 60 days     baby is active duty or retired
                        $0 because newborn is     You are responsible for 100% of
Newborn Cost-Share
                        considered TRICARE        the fees unless the father of the
for Hospital Services
                        Prime for first 60 days   baby is active duty or retired
Professional Fee
                        $0 because newborn is     You are responsible for 100% of
when Delivering at
                        considered TRICARE        the fees unless the father of the
Home or as an
                        Prime for first 60 days   baby is active duty or retired
Outpatient




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TRICARE Standard Costs—
Retiree or Retiree Family Member
This chart depicts maternity costs for the mother

     Type of
                      Retiree or Retiree Spouse                Retiree Daughter
     Service
Maternity Care—       $535 per day or 25% of billed         $535 per day or 25% of billed
Prenatal, inpatient   charges, whichever is less for the    charges, whichever is less for
admission and         inpatient admission PLUS              the inpatient admission PLUS
professional          25% of the allowable charges for      25% of the allowable charges
services, and         separately billed professional fees   for separately billed
postnatal care        for delivery                          professional fees for delivery

Professional Fee
when Delivering
                      25% of the allowable charges          25% of the allowable charges
at Home or as
an Outpatient




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TRICARE Standard Costs—
Retiree or Retiree Family Member
This chart depicts maternity costs for the newborn
Type of Service             Retiree or Retiree Spouse                         Retiree Daughter
Inpatient                                                                You are responsible for 100% of
Professional Fees      25% of the allowable charges*                     the fees unless the father of the
for Newborn Care                                                         baby is active duty or retired.
                       Same newborn date of birth and date of mom’s
                       admission: The number of hospital days minus 3
                       and multiplied by $535 OR 25% of the billed
Newborn Cost-                                                            You are responsible for 100% of
                       charges, whichever is less*
Share for Hospital                                                       the fees unless the father of the
                       Different newborn date of birth and date of
Services               mom’s admission: The number of hospital days      baby is active duty or retired.
                       multiplied by $535 OR 25% of the billed
                       charges, whichever is less*
Professional Fee
                                                                         You are responsible for 100% of
when Delivering
                       25% of the allowable charges*                     the fees unless the father of the
at Home or as an
                                                                         baby is active duty or retired.
Outpatient




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                    *This cost-share does not apply if the newborn is deemed enrolled in TRICARE
                    Prime because at least one family member is enrolled in TRICARE Prime. The
                    newborn costs would be the same as for other retiree family members enrolled
                    in TRICARE Prime.                                                              30
Well-Baby and Well-Child Care
• TRICARE offers well-baby and well-child care for
  newborns up to age 6
• Available to all TRICARE beneficiaries
• TRICARE Prime continues to offer the best value
  to you
   – No copayments
   – Enhanced vision benefit
   – Priority access to care

• Deductibles and cost-shares apply when using
  TRICARE Extra and TRICARE Standard




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If Your Sponsor is Mobilized
• The other parent or guardian should be prepared to
  show power of attorney to register newborn in DEERS

• Some expectant mothers may elect to return to
  their families while their sponsor is mobilized
  and/or deployed

• These beneficiaries must follow certain guidelines to
  ensure that their claims are paid and that
  point-of-service (POS) charges are not incurred

• This refers to moves within and outside of your
  current region




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TRICARE Regional Contractors
• TRICARE North Region
  – Health Net Federal Services, Inc.
  – www.healthnetfederalservices.com
  – 1-877-TRICARE (1-877-874-2273)

• TRICARE South Region
  – Humana Military Healthcare Services, Inc.
  – www.humana-military.com
  – 1-800-444-5445

• TRICARE West Region
  – TriWest Healthcare Alliance
  – www.triwest.com
  – 1-888-TRIWEST (1-888-874-9378)




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Thank You!
• TRICARE offers a comprehensive maternity benefit for
  you and your newborn

• From preventive health services to better coordination
  with our civilian system and lower out-of-pocket costs
  for families, we have designed and fully implemented
  a strong, more uniform benefit

• Wherever we maintain medical capability and
  capacity, whether through military or civilian services,
  our goal is a world-class health benefit that serves the
  needs of our members




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TRICARE Product Feedback

Please provide feedback on this presentation at:

http://www.tricare.osd.mil/evaluations/presentations




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