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Benefits Overview

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PLEASE READ: IMPORTANT INFORMATION ABOUT TRICARE FOR LIFE (TFL) COVERAGE AT A VETERANS AFFAIRS (VA) FACILITY...

August 8, 2013 - Beginning October 1st, 2013, when a TRICARE For Life (TFL) beneficiary receives care at a Department of Veterans Affairs (VA) facility for care not related to a service connected disability, TRICARE, by law, can only pay up to 20 percent of the TRICARE allowable charge. The beneficiary then has to pay the VA the remaining 80 percent Medicare would have paid had they used a Medicare certified provider.

WPS/ TRICARE For Life is sending a one time letter to any beneficiary that has had a claim processed by a VA through TFL since April 1st, 2012. The letters were mailed out this week. If you use your TRICARE benefit at a VA facility on or after October 1, 2013 you may have to pay the remaining balance after TRICARE pays its 20% of the TRICARE allowable charge. This is not a new Law, it is one both agencies (TRICARE & VA) recently realized wasn't being properly administered.

TRICARE and the VA recommend getting care for service connected disability at a VA. For all other care you should consider other options, including using a Medicare certified provider.

We thank you for your time and attention to this information and we look forward to serving you in the future. For your convenience, a copy of the letter that was sent out by postal mail is below for your review.

Copy of Letter

Dear TRICARE For Life Beneficiary:

In the past, when you visited a Department of Veterans Affairs (VA) facility for care not related to a service-connected disability, you may have paid very little out of pocket if you used your TRICARE benefit. Beginning October 1, 2013, this will change.

By law, TRICARE pays on any TRICARE For Life (TFL) claim only after Medicare and any other health insurance pay. Although VA facilities are TRICARE-authorized, they aren't Medicare-certified; the VA can't bill Medicare. This means that, under the law, TRICARE can pay only up to 20 percent of the TRICARE-allowable charge; you have to pay the VA the 80 percent Medicare would have paid if you used a Medicare-certified provider.

Although this isn't a new law, it's one both Agencies recently realized wasn't being appropriately followed.

TRICARE and the VA recommend getting care for your service-connected disability at a VA facility. For all of your other care, you should consider your options, including using a Medicare-certified provider. You may wish to talk to your VA facility about your VA options, including how VA claims are processed if you have other health insurance. Also, if you use your TRICARE benefit at a VA facility on or after 1 October, you may have to pay the remaining balance after TRICARE pays its 20 percent of the TRICARE-allowable charge.

The TFL contractor, WPS-TFL, can help with coverage details and explain how costs are covered. For more information about TFL call WPS-TFL at 866-773-0404 or visit www.TRICARE.mil/tfl. To find a TRICARE-authorized and Medicare-certified providers, visit www.TRICARE.mil/findaprovider.

Sincerely,

Mary Seiler
Vice President TRICARE Customer Service
Wisconsin Physicians Service

TRICARE Benefits Overview

The Civilian Health and Medical Program for the Uniformed Services (CHAMPUS) was the healthcare benefit program that preceded TRICARE. When the Department of Defense converted their healthcare benefit program to a managed care system, they also changed the name of their program to TRICARE. The new program is called TRICARE because beneficiaries have three healthcare coverage options.

TRICARE is a medical benefit program designed to pay for medical expenses for active duty military personnel and their families, and also for retired military personnel and their families. Although it appears to be an insurance program, it is actually a benefit program. It is a benefit offered to persons serving in the military as they pay no premiums for the coverage.

The following branches of the uniformed services are eligible for TRICARE benefits:

  • Army
  • Air Force
  • Marine Corps
  • Navy
  • Coast Guard
  • United States Public Health Service (USPHS)
  • National Oceanographic and Atmospheric Administration (NOAA)

In addition to covering many different branches of the uniformed services, TRICARE provides coverage for beneficiaries of many different statuses:

  • TRICARE automatically provides benefits for active duty sponsors, their spouse and children. Children of active duty sponsors can receive coverage up to age 21 or 23 (dependent on full-time student status).
  • TRICARE will provide benefits for sponsors retired from the military after a minimum of twenty years of service. Spouses and children of retired sponsors also are eligible for TRICARE benefits. Children of retired sponsors can receive coverage up to age 21 or 23 (dependent on full-time student status).
  • Guard and Reservists called to active duty for more than 30 days will become eligible for TRICARE coverage. The length of coverage is dependant on the amount of time they spend in active duty status. Family members of those in the Guard or Reserve called to active duty for more than 30 days will also become eligible for TRICARE benefits.
  • Foreign nationals, who are members of the North Atlantic Treaty Organization (NATO), which need and receive medical care in the United States, will also receive benefits from TRICARE.
  • Military personnel involuntarily discharged from service can apply for the Transitional Assistance Management Program (TAMP). Each branch of service determines eligibility for discharged personnel on a case by case basis.
  • The Continued Health Care Benefit Program (CHCBP) is a health care plan compliant with the Consolidated Omnibus Budget Reconciliation Act (COBRA). COBRA is a federal law that requires all employers to offer insurance coverage, at a cost, for employees who are leaving their place of employment. The United States Military complies with COBRA by offering the CHCBP plan.

The government tracks members of the uniformed services who can receive TRICARE benefits and share this information with agencies that process their claims by use of a system called the Defense Enrollment Eligibility Reporting System (DEERS). The Department of Defense maintains DEERS, however it is the sponsor's responsibility to make sure DEERS has correct and current information. Every claim that WPS processes for TRICARE queries DEERS to determine if the patient is eligible for TRICARE benefits. If the patient is not eligible, our system will automatically deny the claim. If they are eligible, the claim will continue processing.

There are three benefit plan options within TRICARE. They are Prime, Extra and Standard.

  • The Prime option works like a Health Maintenance Organization (HMO). The beneficiary must enroll in TRICARE Prime and pay a small enrollment fee. They must choose a Primary Care Manager (PCM) who they must see for all their health care needs. If the PCM is not qualified to handle a health care issue, they will refer the beneficiary to a Network specialist. Many services require a preauthorization for coverage. TRICARE Prime beneficiaries do not have to pay any yearly deductible, but they do have to pay a very low copay. This option is the most managed option, but it is also the option that has the smallest out of pocket cost for the beneficiaries.
  • The Extra option is like a Preferred Provider Organization (PPO). The beneficiary does not need to enroll in the Extra option, they become an Extra beneficiary by choosing a Network provider as their physician. If the Network provider is not qualified to handle a health care issue, they will refer the beneficiary to a specialist. Some services will require a preauthorization for coverage. Extra beneficiaries have to pay a yearly deductible and a 15% cost-share.
  • The Standard option is like an indemnity plan, this means the beneficiary can see any Network or non-Network provider they want to receive health care services. Referrals to specialists and preauthorizations for services are not required. Standard beneficiaries have to pay a yearly deductible and a 20% cost-share.

*** Prescriptions purchased within the 50 United States, Puerto Rico, the U.S. Virgin Islands, and Guam are processed by Express Scripts.

TRICARE started as an act of Congress, and Congress passes laws that govern the TRICARE program. Congress also appropriates the funds to the Department of Defense for the TRICARE program.