Introduction to TRICARE

1. Introduction to TRICARE Presented by: Francine Forestell, Chief, TMA Customer Communications Division

2. What is TRICARE? • Health care program for 9.1 million beneficiaries • Integrated health care delivery system • Military treatment facilities (MTFs) • Civilian health care facilities • Affordable program options • Comprehensive coverage • Available worldwide

3. TRICARE Eligibility • Beneficiary categories • Sponsors (active duty, National Guard, Reserve or retired service members) • Family members (spouses and unmarried children) • Survivors, certain former spouses and others • Requirements • Registration in the Defense Enrollment Eligibility Reporting System (DEERS) • Valid Uniformed Services ID Card • Medicare Part B if dual-eligible, except for active duty family members

4. TRICARE Regions TRICARE Overseas 1-888-777-8343 www.tricare.mil/overseas

5. TRICARE Web site

6. Contact Information

7. Standard Fee for Service No enrollment req Any TRICARE-authorized provider Costs Active duty family member: 20% of allowable charge Retirees: 25% of allowable charge May have to file own claims Nonparticipating providers may charge up to 15% above allowable charge for services Extra Preferred Provider No enrollment req Any TRICARE network provider Costs Active duty family member: 15% of negotiated rate Retirees: 20% of negotiated rate Providers file claims Not responsible for additional charges for covered benefits TRICARE Options Prime/TP Remote • HMO • Enrollment req • Any TRICARE network provider • Outpatient co-payments • Active duty family member: $O • Retirees: $12 office visit • Providers file claims • Not responsible for additional charges for covered benefits • TRICARE Prime Remote: • Active Duty/AD Family Members; • Designated TPR ZIP code areas; • Family must reside with sponsor: Family must remain in same location if sponsor deployed

8. Standard No referrals Prior Authorization may be required MTF on space available basis Extra No referrals Prior Authorization may be required MTF on space available basis TRICARE Options Prime/TP Remote • Must have Referral and Authorization • Point of Service charges if no referral in place • MTF has “First Right of Refusal” • Access standards for emergency, routine, specialty care Standard/Extra are not available to active duty service members. BR400801BEN0504C

9. Prime/TPR Active Duty Member Referrals • Referrals required for specialty care • PCM or routine provider coordinates with regional contractor • Referrals approved for a length of time and number of visits • Service point of contact (SPOC) fitness-for-duty review required for active duty

10. Transitional Assistance Management Program • Guard or Reserve member activated for more than 30 consecutive days in support of a contingency operation • 180 days transitional health care • Eligible for TRICARE Prime, Standard, and Extra • Must re-enroll in Prime upon separation • Dental care at dental treatment facilities • Member and family Visit the Guard-Reserve Portal at https://www.dmdc.osd.mil/Guard-ReservePortal

11. TRICARE RESERVE SELECT • Premium-based health care plan a sponsor may purchase if he or she qualifies – must be a member of the Selected Reserve • Provides coverage similar to TRICARE Standard and Extra • Administered by the regional contractors • Enrollment required • Information at www.tricare.mil/reserve/reserveselect Visit the Guard-Reserve Portal at https://www.dmdc.osd.mil/Guard-ReservePortal

12. TRICARE For Life Medicare-TRICARE dual-eligible • Medicare wrap-around coverage for all TRICARE and Medicare dual-eligible Uniformed Services beneficiaries, regardless of age • Beneficiaries entitled to Medicare Part A are required by law to have Medicare Part B coverage to retain their TRICARE benefits • Exception: Active duty family members entitled to Medicare Part A are not required to purchase Medicare Part B coverage • No enrollment required • Any Medicare, TRICARE-authorized provider

13. Continued Health Care Benefit Program • Provides transitional benefits for a specified period of time (18-36 months) to: • Former service members and their families • Some unremarried former spouses • Emancipated children (living on their own) • Benefits available under CHCBP are similar to TRICARE Standard • Quarterly premium • $933 for individual • $1996 for family BR400801BEN0504C

14. Pharmacy Options and Costs * Non-formulary drugs are available at the formulary cost if medical necessity is established; www.tricare.mil/pharmacy

15. TRICARE Dental Options Separate benefit from TRICARE health care. Dental contractors administer the program.

16. TRICARE Behavioral Health Care Services BR412802BET0505W

17. In Conclusion… • Questions?

18. Behavioral Health Care Things to Remember • Must be under the care of a provider authorized to prescribe drugs if taking prescription medications for a behavioral health condition. • It is recommended that psychiatric medication management services be provided by a psychiatrist. • Most non-medical behavioral health providers (e.g., clinical psychologists, clinical social workers, marriage & family therapists, psychiatric nurse specialists) do not need a physician referral and supervision. • Pastoral and Mental Health Counselors do requirea physician referral and supervisionprior to being seen. • The provider is expected to consult/refer you to a physician for treatment of a condition that co-exists with your behavioral health condition. BR412802BET0505W

19. AUTHORIZED PROVIDER (TRICARE APPROVED) * NON-AUTHORIZED PROVIDER NETWORK PROVIDER (contract) NON-NETWORK PROVIDER (no contract) TRICARE CANNOT PAY SIGNS PRIME CONTRACTOR AGREEMENT PARTICIPATING (accepts assignment, i.e., TRICARE payment in full) NON-PARTICIPATING (does not accept assignment or TRICARE payment in full) ACCEPTS TRICARE NEGOTIATED PAYMENT PARTICIPATES ON CASE-BY-CASE BASIS MAY FILE CLAIM (if not, member must file) FILES CLAIM FOR MEMBER FILES CLAIM FOR MEMBER MAY BALANCE BILL UP TO 115% OF TRICARE ALLOWABLE CHARGE Note: * Beginning 1 September 2004, Medicare certified providers are considered TRICARE Authorized. MAY NOT BALANCE BILL To Find a Provider: http://www.tricare.mil/mybenefit/home/Medical/FindingAProvider Source: CFR 199.6 – Authorized Providers

20. Referrals and Authorizations • Referral: The act or instance of referring a beneficiary to another authorized provider for necessary medical or behavioral health care treatment. • Prior Authorization: A decision issued electronically or in writing that states TRICARE will cover services that have not yet been received. Failure to obtain a prior authorization when required will result in a denial of payment for those services. BR412802BET0505W