TRICARE for the Special Needs Family Member Carmen DeLeon-Dingman BSN, RN Nurse Consultant-Case

1. TRICARE for the Special Needs Family Member Carmen DeLeon-Dingman BSN, RN Nurse Consultant-Case Management Special Needs/Wounded Ill & Injured Support TRICARE Regional Office - South 1 Permanent Change of Station (PCS) Expiration of Time of Service (ETS)Permanent Change of Station (PCS) Expiration of Time of Service (ETS)

2. Today�s Agenda TRICARE Overview Extended Care Health Option (ECHO) Autism Demonstration Family Member Program Resources 2 During today�s briefing, I will present a TRICARE overview, the Exceptional Family Member Program and TRICARE�s Extended Care Health Option. I will also provide you with resources for additional information. During today�s briefing, I will present a TRICARE overview, the Exceptional Family Member Program and TRICARE�s Extended Care Health Option. I will also provide you with resources for additional information.

3. What is TRICARE? TRICARE is� � the health care program supporting active duty service members, National Guard and Reserve members, retirees, family members, survivors, and certain former spouses worldwide. � a network of military and civilian health care professionals working together to foster, protect, sustain, and restore health for those entrusted to their care. 3 TRICARE is the uniformed services health care program for active duty service members and their families, retired service members and their families, members of the National Guard and Reserve and their families, survivors, and others who are eligible. TRICARE provides an integrated health care delivery system by bringing together the health care resources of the Military Health System�such as military hospitals and clinics�and supplementing them with networks of civilian health care professionals, institutions, pharmacies, and suppliers. There are no preexisting-condition exclusions with TRICARE, which means you cannot be denied coverage by TRICARE because of a health condition that existed before you became a TRICARE beneficiary.TRICARE is the uniformed services health care program for active duty service members and their families, retired service members and their families, members of the National Guard and Reserve and their families, survivors, and others who are eligible. TRICARE provides an integrated health care delivery system by bringing together the health care resources of the Military Health System�such as military hospitals and clinics�and supplementing them with networks of civilian health care professionals, institutions, pharmacies, and suppliers. There are no preexisting-condition exclusions with TRICARE, which means you cannot be denied coverage by TRICARE because of a health condition that existed before you became a TRICARE beneficiary.

4. TRICARE Stateside Regions 4 TRICARE benefits are available wherever you live, but customer service contact information will change depending on your TRICARE region. There are three TRICARE regions in the United States. In the TRICARE North Region, your regional contractor will be Health Net Federal Services. In the TRICARE South Region, your regional contractor will be Humana Military Healthcare Services. In the TRICARE West Region, your regional contractor will be TriWest Healthcare Alliance. The regional contractor will help you with benefit questions, enrollment, and claims. Contact information for each region will be provided at the end of the presentation.TRICARE benefits are available wherever you live, but customer service contact information will change depending on your TRICARE region. There are three TRICARE regions in the United States. In the TRICARE North Region, your regional contractor will be Health Net Federal Services. In the TRICARE South Region, your regional contractor will be Humana Military Healthcare Services. In the TRICARE West Region, your regional contractor will be TriWest Healthcare Alliance. The regional contractor will help you with benefit questions, enrollment, and claims. Contact information for each region will be provided at the end of the presentation.

5. TRICARE Overseas Region 5 Overseas, there is one TRICARE region managed through three TRICARE Area Offices: TRICARE Latin America and Canada includes Canada, the Caribbean Basin, Central and South America, Puerto Rico, and the U.S. Virgin Islands. TRICARE Eurasia-Africa includes Africa, Europe, and the Middle East. TRICARE Pacific includes Australia, Guam, Japan, Korea, New Zealand, and Western Pacific remote countries. Note to presenter: On September 1, 2010, International SOS Assistance, Inc. will begin service as the TRICARE Overseas Program contractor for all areas outside of the 50 United States and the District of Columbia. Visit TRICARE.mil/overseas for program and enrollment information. Overseas, there is one TRICARE region managed through three TRICARE Area Offices: TRICARE Latin America and Canada includes Canada, the Caribbean Basin, Central and South America, Puerto Rico, and the U.S. Virgin Islands. TRICARE Eurasia-Africa includes Africa, Europe, and the Middle East. TRICARE Pacific includes Australia, Guam, Japan, Korea, New Zealand, and Western Pacific remote countries. Note to presenter: On September 1, 2010, International SOS Assistance, Inc. will begin service as the TRICARE Overseas Program contractor for all areas outside of the 50 United States and the District of Columbia. Visit TRICARE.mil/overseas for program and enrollment information.

6. Worldwide database of personnel information Service branch determines eligibility Uniformed services identification (ID) card-issuing facility: www.dmdc.osd.mil/rsl/owa/home Update your DEERS information: Online: www.tricare.mil/DEERS By Phone: 1-800-538-9552 Defense Enrollment Eligibility Reporting System (DEERS) 6 The Defense Enrollment Eligibility Reporting System, or DEERS, is a worldwide database of personnel information, including TRICARE eligibility. The sponsor�s service branch determines eligibility and enters the SMs status in DEERS. Keeping DEERS information current, especially the address, is critical to ensuring uninterrupted TRICARE coverage for the SM and their family. The Defense Enrollment Eligibility Reporting System, or DEERS, is a worldwide database of personnel information, including TRICARE eligibility. The sponsor�s service branch determines eligibility and enters the SMs status in DEERS. Keeping DEERS information current, especially the address, is critical to ensuring uninterrupted TRICARE coverage for the SM and their family.

7. Helps with the transition back to civilian life Programs available for those who are eligible: Transitional Assistance Management Program (TAMP) Continued Health Care Benefit Program (CHCBP) May be eligible for TRICARE Reserve Select (TRS) Active Duty coverage ends on the last day of active duty Service member may be eligible for VA benefits 7 The transition from military to civilian life can be challenging, so TRICARE provides transitional health care coverage to protect the beneficiary and the family between military and civilian health care coverage. If eligible, the service member may be entitled to: The Transitional Assistance Management Program, or TAMP, and/or The Continued Health Care Benefit Program, or CHCBP The service personnel branch determines eligibility for TAMP, and DEERS record will reflect eligibility status. If there are questions concerning eligibility, SM should contact command unit representative. If transitioning from the National Guard and Reserve, the beneficiary may be eligible for TRICARE Reserve Select (TRS) If the beneficiary is not eligible for TAMP and does not purchase TRS or CHCBP, TRICARE benefits end on the last day of active duty. The SM may also be eligible for VA benefits. The transition from military to civilian life can be challenging, so TRICARE provides transitional health care coverage to protect the beneficiary and the family between military and civilian health care coverage. If eligible, the service member may be entitled to: The Transitional Assistance Management Program, or TAMP, and/or The Continued Health Care Benefit Program, or CHCBP The service personnel branch determines eligibility for TAMP, and DEERS record will reflect eligibility status. If there are questions concerning eligibility, SM should contact command unit representative. If transitioning from the National Guard and Reserve, the beneficiary may be eligible for TRICARE Reserve Select (TRS) If the beneficiary is not eligible for TAMP and does not purchase TRS or CHCBP, TRICARE benefits end on the last day of active duty. The SM may also be eligible for VA benefits.

8. 8 Available if activated in support of a Contingency Operation TAMP provides 180 days of transitional health care benefits to help certain uniformed service members and their families transition to civilian life. If SM qualifies , the 180-day TAMP period begins the day after the SM separates from active duty. During TAMP, the SM and the family is covered as would the active duty member and family members. Must re-enroll in PRIME or will default to Standard. Depending on where the SM and the family live, will determine which option to choose TRICARE Prime or TRICARE Standard. There are no enrollment fees, but, if the SM chooses not to enroll in TRICARE Prime, the SM will be responsible for any applicable deductibles, cost-shares, and copayments for TRICARE Standard or Extra . Available if activated in support of a Contingency Operation TAMP provides 180 days of transitional health care benefits to help certain uniformed service members and their families transition to civilian life. If SM qualifies , the 180-day TAMP period begins the day after the SM separates from active duty. During TAMP, the SM and the family is covered as would the active duty member and family members. Must re-enroll in PRIME or will default to Standard. Depending on where the SM and the family live, will determine which option to choose TRICARE Prime or TRICARE Standard. There are no enrollment fees, but, if the SM chooses not to enroll in TRICARE Prime, the SM will be responsible for any applicable deductibles, cost-shares, and copayments for TRICARE Standard or Extra .

9. TRICARE Reserve Select Available for those in the Selected Reserve Excluded if eligible for the Federal Employees Health Benefit Plan Family members are eligible Available after TAMP ends Delivers TRICARE Standard or Extra coverage Has premium payments NOT eligible for ECHO benefits 9 Available to those in the Selected reserves If enrolled prior to activation must re-enroll, plan does not automatically resume Also part of the CHALLENGES! Can not begin until after TAMP (if eligible) Visit Guard and Reserve Web Portal to re-purchase planAvailable to those in the Selected reserves If enrolled prior to activation must re-enroll, plan does not automatically resume Also part of the CHALLENGES! Can not begin until after TAMP (if eligible) Visit Guard and Reserve Web Portal to re-purchase plan

10. Continued Health Care Benefit Program(CHCBP) Temporary, transitional health care coverage Available immediately after TRICARE coverage ends Similar to TRICARE Standard or Extra Has premium payments Enrollment must occur within 60 days after TRICARE or TAMP ends Available for up to 18 months after previous coverage ends 10 Once regular TRICARE eligibility ends, you may purchase temporary, transitional health care coverage under the Continued Health Care Benefit Program, or CHCBP. CHCBP is not a TRICARE program, but a Department of Defense program. �COBRA� like policy CHCBP is available immediately following the loss of TRICARE eligibility. CHCBP is similar to TRICARE Standard, but with premium payments. The program covers most care that is medically necessary, uses TRICARE-authorized providers, and follows most of the referral and authorization rules of TRICARE Standard. CHCBP is available for the sponsor and the family for 18 months after previous coverage ends, and coverage may be purchased in 90-day increments. Once regular TRICARE eligibility ends, you may purchase temporary, transitional health care coverage under the Continued Health Care Benefit Program, or CHCBP. CHCBP is not a TRICARE program, but a Department of Defense program. �COBRA� like policy CHCBP is available immediately following the loss of TRICARE eligibility. CHCBP is similar to TRICARE Standard, but with premium payments. The program covers most care that is medically necessary, uses TRICARE-authorized providers, and follows most of the referral and authorization rules of TRICARE Standard. CHCBP is available for the sponsor and the family for 18 months after previous coverage ends, and coverage may be purchased in 90-day increments.

11. Serving Those with Special Needs TRICARE�s basic benefit covers those with special needs Physical Therapy, Occupational Therapy, Speech Therapy Durable Medical Equipment Wheel chair and lift Behavioral Health Services Clinical Cancer Trials Hospice 11

12. Special Needs Resources Web Page http://www.tricare.mil/mybenefit/home/LifeEvents/SpecialNeeds/Resources 12

13. Special Needs Page http://www.tricare.mil/mybenefit/home/LifeEvents/SpecialNeeds 13

14. Programs for Family Members with Special Needs TRICARE TRICARE Prime TRICARE Standard Extended Health Care Option (ECHO) ECHO Case Management ECHO Home Health Care Enhanced Access to Autism Services 14

15. Extended Care Health Option(ECHO) ECHO is a TRICARE benefit as defined by: TITLE 32 NATIONAL DEFENSE CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE UNIFORMED SERVICES, 199.5 Supplements the TRICARE basic program Available ONLY to active duty family members (including activated Reservists & those on TAMP) 15 Reservist on �Delayed-Effective-Date Activation Orders� may qualify for active duty health benefits for up to 180 days before, if in support of a contingency operation like OIF/OEF. Contact Unit for when eligibility begins. Reservist on �Delayed-Effective-Date Activation Orders� may qualify for active duty health benefits for up to 180 days before, if in support of a contingency operation like OIF/OEF. Contact Unit for when eligibility begins.

16. ECHOBenefits Provides financial assistance to beneficiaries with qualifying conditions like; moderate to severe mental retardation, serious physical disability, physical or psychological condition that causes the beneficiary to be homebound or special education related to Autism diagnosis Government cost share is limited to $36,000/fiscal year for certain benefits available through ECHO 16 EHHC benefit is not subject to cap. Benefit cap is equivalent to what TRICARE would reimburse if the beneficiary was in a SNFEHHC benefit is not subject to cap. Benefit cap is equivalent to what TRICARE would reimburse if the beneficiary was in a SNF

17. ECHO Sponsor�s cost share based on pay grade regardless of the number of dependents enrolled ECHO benefit authorization required and must be obtained prior to receiving ECHO services Defense Enrollment Eligibility Reporting System (DEERS) will need to be updated and will be used to verified eligibility in ECHO 17

18. ECHO ECHO is a voluntary program requiring enrollment through the regional Managed Care Support Contractor (MCSC) Registration in ECHO requires a referral to the regional (MCSC) from the Primary Care Manager Contact the regional (MCSC) for additional information and assistance 18

19. ECHO Benefits Assistive services Durable equipment Expanded in-home medical services Medical and rehabilitative services In-home respite care services Training for assistive technology devices Institutional care Special education 19 Must have a qualifying condition/diagnosis ECHO provides benefits not available through the TRICARE Basic Program, such as coverage for assistive services, durable equipment, institutional care, and special education such as Applied Behavior Analysis (ABA) therapy. Contact MCSC for information on how to register Must have a qualifying condition/diagnosis ECHO provides benefits not available through the TRICARE Basic Program, such as coverage for assistive services, durable equipment, institutional care, and special education such as Applied Behavior Analysis (ABA) therapy. Contact MCSC for information on how to register

20. ECHO Home Health Care 20 ECHO Home Health Care, or EHHC, provides medically necessary skilled services to ECHO beneficiaries who are homebound and generally require more than 28 to 35 hours per week of home health services. Max hours based on location (RUG rate) EHHC Respite Care 8hrs/day, 5days/wk (40hrs/wk) ECHO Respite care 16hrs/month �Dinner & a Movie�, can ONLY be used if another ECHO benefit is used, can not be used if EHHC is being used EHHC benefits may include skilled nursing care; physical, occupational, or speech therapy; social services; training; medical supplies; and respite care. The patient's primary care manager or attending physician will determine if the patient is eligible for EHHC services and will develop a plan of care which will be reviewed by the physician, case manager and/or regional contractor every 90 days or when there is a change in the patient�s condition. Coverage for the EHHC benefit limited to the maximum amount TRICARE would pay per fiscal year if the beneficiary resided in a skilled nursing facility. � Limited to the 50 United States, District of Columbia, Puerto Rico, the US Virgin Islands and Guam.ECHO Home Health Care, or EHHC, provides medically necessary skilled services to ECHO beneficiaries who are homebound and generally require more than 28 to 35 hours per week of home health services. Max hours based on location (RUG rate) EHHC Respite Care 8hrs/day, 5days/wk (40hrs/wk) ECHO Respite care 16hrs/month �Dinner & a Movie�, can ONLY be used if another ECHO benefit is used, can not be used if EHHC is being used EHHC benefits may include skilled nursing care; physical, occupational, or speech therapy; social services; training; medical supplies; and respite care. The patient's primary care manager or attending physician will determine if the patient is eligible for EHHC services and will develop a plan of care which will be reviewed by the physician, case manager and/or regional contractor every 90 days or when there is a change in the patient�s condition. Coverage for the EHHC benefit limited to the maximum amount TRICARE would pay per fiscal year if the beneficiary resided in a skilled nursing facility. � Limited to the 50 United States, District of Columbia, Puerto Rico, the US Virgin Islands and Guam.

21. ECHO Home Health Benefits ECHO Home Health Care Not limited to part time or intermittent Capped by cost, not by hours Skilled Nursing Facility reimbursement rate Must be a Medicare certified agency EHHC Respite Care 8 hrs./day, 5 days per week Eligible beneficiary requires frequent interventions (requires training by medical personnel-but doesn�t have to be �skilled� interventions) �Sleep benefit� Contact the MCSC for more information 21 Limited to the 50 United States, District of Columbia, Puerto Rico, the US Virgin Islands and Guam. Beneficiary has to be homebound Limited to the 50 United States, District of Columbia, Puerto Rico, the US Virgin Islands and Guam. Beneficiary has to be homebound

22. ECHO Home Health Benefits (cont) ECHO Respite Care 16 hrs/month break for primary caregivers Can ONLY be used in a month when another ECHO benefit is being received �Dinner & a Movie� benefit Contact the MCSC for more information 22 The Respite benefit can not be used for pursuit of education, employment, deployment or siblings. Limited to the 50 United States, District of Columbia, Puerto Rico, the US Virgin Islands and Guam. Respite care also available through some Services EFMP The Respite benefit can not be used for pursuit of education, employment, deployment or siblings. Limited to the 50 United States, District of Columbia, Puerto Rico, the US Virgin Islands and Guam. Respite care also available through some Services EFMP

23. ECHO Web Page http://www.tricare.mil/mybenefit/home/LifeEvents/SpecialNeeds/ECHO/HomeHealthCare 23

24. ECHO Flyer 24

25. Enhanced Access to Autism Services 25 Treatments, therapies, and interventions, known as Educational Interventions for Autism Spectrum Disorders (EIA), have been known to reduce or eliminate specific problem behaviors and teach new skills to individuals with autism. These EIA services are not covered under TRICARE Basic Programs and are only partially covered through the Extended Care Health Option (ECHO).� Enhanced Access to Autism Services allows eligible beneficiaries to have access to a greater range of EIA services through an expanded network of educational intervention providers, including: EIA Supervisors, who are responsible for coordinating Behavioral Plans and Treatment Progress Reports, and EIA Tutors, who work one on one implementing the behavior plan designed and maintained by the EIA Supervisor.� Referral from a primary care manager or Autism Spectrum Disease specialist is required, and services count toward the ECHO $36,000 per fiscal year maximum.Treatments, therapies, and interventions, known as Educational Interventions for Autism Spectrum Disorders (EIA), have been known to reduce or eliminate specific problem behaviors and teach new skills to individuals with autism. These EIA services are not covered under TRICARE Basic Programs and are only partially covered through the Extended Care Health Option (ECHO).� Enhanced Access to Autism Services allows eligible beneficiaries to have access to a greater range of EIA services through an expanded network of educational intervention providers, including: EIA Supervisors, who are responsible for coordinating Behavioral Plans and Treatment Progress Reports, and EIA Tutors, who work one on one implementing the behavior plan designed and maintained by the EIA Supervisor.� Referral from a primary care manager or Autism Spectrum Disease specialist is required, and services count toward the ECHO $36,000 per fiscal year maximum.

26. Autism Demonstration Project DEMO will permit TRICARE reimbursement for Educational Intervention for those diagnosed with Autism Spectrum Disorders (ASD)* DEMO does not supersede medical management of beneficiary or eligibility for benefit under the ECHO program DEMO participation is voluntary and requires referral to MCSC from Primary Care Provider Child must be 18 months or older and have a ASD Diagnosis If AD Sponsor moves to another region, contact the MCSC as soon as possible to ensure a smooth transition of ECHO benefits at the new duty location Contact the MCSC for more information 26 *Autistic Disorder, Pervasive Development Disorder, Asperger�s Disorder and Childhood Disintegrative Disorder. *Autistic Disorder, Pervasive Development Disorder, Asperger�s Disorder and Childhood Disintegrative Disorder.

27. Exceptional Family Member Program Enrollment in EFMP required if available through branch of service EFMP enrollment will be waived if not available through branch of service Documentation needed (DD2792 & 2792-1) Contact the MCSC for more information 27

28. Family Member Program Key Functions Family support Medical Education Housing Assignment coordination Mandatory enrollment per Branch of Service Considers family member needs during assignment 28 The Exceptional Family Member Program has two key functions: family support assignment coordination For family support, EFMP coordinators work with military and civilian agencies to provide comprehensive and coordinated medical, educational, housing, and community support services for your family member. Respite care may be available From the assignment coordination aspect, the Exceptional Family Member Program ensures that the SM is assigned to locations where services exist to support the family member. All active duty service members are required to enroll in the EFMP per branch of service guidelines. Assigning you to locations that can support the needs of your family member is intended to help you concentrate on performing your duties for operational readiness and to maximize your quality of life. Reserve Component does not have the EFMP requirements The Exceptional Family Member Program has two key functions: family support assignment coordination For family support, EFMP coordinators work with military and civilian agencies to provide comprehensive and coordinated medical, educational, housing, and community support services for your family member. Respite care may be available From the assignment coordination aspect, the Exceptional Family Member Program ensures that the SM is assigned to locations where services exist to support the family member. All active duty service members are required to enroll in the EFMP per branch of service guidelines. Assigning you to locations that can support the needs of your family member is intended to help you concentrate on performing your duties for operational readiness and to maximize your quality of life. Reserve Component does not have the EFMP requirements

29. Key Players in Special Needs Coordination Family Primary Care Manager or Provider Primary Contact for care Managed Care Support Contractor (MCSC) Case Manager Medical Management Care Coordination & Collaboration ECHO Case Manager Collaboration & Communication Extension of Medical Management 29 Family must notify everyone involved of the potential move for the transition to as smooth as possible Essential that the family be on orders. Homebound beneficiaries may need transportation coordination that will need to be included on the orders and worked through the Command Making contact as soon as notification of PSC is essential in ensuring smooth transition to next duty station. Family must notify everyone involved of the potential move for the transition to as smooth as possible Essential that the family be on orders. Homebound beneficiaries may need transportation coordination that will need to be included on the orders and worked through the Command Making contact as soon as notification of PSC is essential in ensuring smooth transition to next duty station.

30. Key Players in Special Needs Coordination (Cont.) TRICARE Regional Office Nurse Consultant Liaison between MTF, beneficiary, MCSC and TMA Oversees contractual requirements of the MCSC TRICARE�Overseas TRICARE Area Office facilitates ECHO registration and assists with program information MTF Case Manager facilitates care coordination 30

31. Resources Contact information for regional/overseas program offices, find an MTF and TSC http://www.tricare.mil/contactus/ 31

32. TRICARE Regional Offices TRICARE Regional Office�South (210) 292�3207 www.tricare.mil/trosouth Nurse Consultant: Ms. DeLeon-Dingman TRICARE Regional Office�North (703) 588�1839 www.tricare.mil/tronorth Nurse Consultant: Ms. Bradish TRICARE Regional Office�West (619) 236�5356 www.tricare.mil/trowest Nurse Consultant: Ms. Wertz 32

33. TRICARE North RegionHealth Net Federal Services 1-877-TRICARE (1-877-874-2273) www.healthnetfederalservices.com TRICARE South Region Humana Military Healthcare Services 1-800-444-5445 www.humana-military.com TRICARE West Region TriWest Healthcare Alliance 1-888-TRIWEST (1-888-874-9378) www.triwest.com TRICARE Information and Assistance 33 Contact information for the MCSC and helpful websitesContact information for the MCSC and helpful websites

34. THANK YOU 34