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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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