Information for Health Care Workers of the Military Health System. Naval Medical Center Portsmouth

Information for Health

Care Workers of the

Military Health System

Naval Medical Center Portsmouth

TRICARE is the uniformed services health care program for active duty service members, active

duty family members, National Guard and Reserve

members and their family members, retirees and their

family members, survivors, and certain former spouses

worldwide

Topics

Affordable Care Act Tidewater MHS

TRICARE Regions TRICARE Eligibility

Military Treatment Facilities TRICARE

Other Programs and Benefits TRICARE and the VA

• _{TRICARE and the Affordable Care Act (ACA)}

• _{Beneficiaries covered by any TRICARE program – except}

line-of-duty care or direct care only – meet the minimum essential coverage (MEC) requirements of the ACA

• _{DEERS must be kept current for all TRICARE-eligible}

beneficiaries to ensure compliance under the ACA

• _{Veterans Affairs and the ACA}

• _{Veterans enrolled in VA health care programs meet the}

MEC requirements of the ACA

• _{Veteran’s family members enrolled in a VA health care}

program – such as CHAMPVA or the Spina Bifida program – meet the MEC requirements of the ACA

Hospital Corpsman Advancement

Question

 _Question

 If someone is not covered under regular TRICARE, but is eligible to purchase one of the TRICARE premium-based plans, will that eligibility alone be enough to meet the minimum essential coverage (MEC) requirement of the ACA?

 _Answer

 No. Individuals who are only eligible under TRICARE for one of the premium-based plans (such as TRICARE Reserve Select, TRICARE Retired Reserve, TRICARE Young Adult, or Continued Health Care Benefit Program), but who do not

purchase a plan, must find another coverage option, such as an employer-sponsored health care plan, to comply with the ACA. They will comply if they do purchase one of the plans.

McDonald Army Health Center Joint Base Langley-Eustis

576 Jefferson Avenue Newport News, Virginia

(757) 314-7500

Naval Medical Center Portsmouth Naval Support Activity 620 John Paul Jones Circle

Portsmouth, Virginia (757) 953-5000

USAF Hospital Langley Joint Base Langley-Eustis

77 Nealy Avenue Hampton, Virginia

Military Treatment Facilities in Tidewater Naval Medical Center Portsmouth (NMCP)

Branch Health Clinic (BHC), Dam Neck (1) BHC, JEB Little Creek (Boone Clinic) (2)

BHC, Naval Air Station Oceana (3) BHC, Naval Weapons Station Yorktown (4)

BHC, Norfolk Naval Shipyard (5)

BHC, Norfolk Naval Station (Sewell’s Point) (6) BHC, Northwest Annex (7)

TRICARE Prime Clinic (TPC) Chesapeake (8) TPC Virginia Beach (9)

McDonald Army Health Center (MCAHC)

Troop Medical Clinic 1 (10) Troop Medical Clinic 2 (10) JEB Fort Story Health Clinic (11)

USAF Hospital Langley (USAF)/633 MDG USCG Clinic Portsmouth, Yorktown and

TRICARE Regions and

Managed Care Support Contractors

TRICARE Regional Office North

www.tricare.mil/tronorth Health Net Federal Services

www.hnfs.com

(877) 874-2273

TRICARE Regional Office South

www.tricare.mil/trosouth Humana Military

www.humana-military.com

(800) 444-5445

TRICARE Regional Office West

www.tricare.mil/trowest

United Healthcare Military and Veterans

www.uhcmilitarywest.com

(877) 988-9378

TRICARE Overseas Program International SOS

www.tricare-overseas.com

Hospital Corpsman Advancement

Question

 _Question

 _{What is the role of the managed care}

support contractor (MCSC)?

 _Answer

 _{To provide health care services and}

support to augment the military health system for all TRICARE plan options except the U.S. Family Health Plan. In each region, they manage:

 _{Provider networks}

 _{Toll-free customer service call}

centers

 _{Enrollment, referral, authorization}

and claims processing

• _{TRICARE-eligible beneficiaries} • _{Sponsor/service member}

• _{Active duty or retired (including active, inactive or}

retired National Guard or Reserves)

• _{Medal of Honor recipient}

• _{Family members}

• _{Spouse/former (divorced) spouse} • _{Unmarried children}

• _{To age 21 (23 if a full-time college student)} • _{TRICARE Young Adult to age 26}

• _{Considerations for adult special needs children} • _{Survivors (spouse and children)}

• _{DEERS (Defense Enrollment Eligibility Reporting System) and}

ID cards

• _{Military personnel function}

• _{Verify and update when there is a change in status, duty}

station, address, phone or email; or when adding or removing a family member

• _{Rapids site (Personnel/ID card office) – (800) 538-9552}

• _{www.milconnect.dmdc.mil}

• _{Rapids site locater – www.dmdc.osd.mil} • _{Rapids site appointments –}

Hospital Corpsman Advancement

Question

 _{Question – True or False?}

 A beneficiary’s eligibility for TRICARE is determined by the Defense Health Agency.

 _Answer

 _{False. Eligibility determination}

is a military personnel function of each military service

component, and is coordinated through the Defense

Enrollment Eligibility Reporting System (DEERS).

• _{Newborns or newly adopted children}

• _{“Deemed” TRICARE Prime for the first 60 days (if another}

family member is covered under Prime)

• _{Claims processed following Prime guidelines, except:} • _{Referral and authorization requirements waived} • _{Point-of-service (POS) charges do not apply}

• _{To continue Prime after 60 days, must register in DEERS}

and enroll in Prime during the first 60 days

• _{If not, coverage reverts to TRICARE Extra/Standard on}

day 61

• _{If not registered in DEERS within the first year, TRICARE}

• _{Special situation – newborn of an unwed dependent}

daughter

• _{Not eligible for TRICARE unless the baby’s father is a}

service member, or the dependent daughter’s sponsor legally adopts the newborn, and registers the baby in DEERS

• _{For paternity issues, do testing as soon after birth as}

possible; this is not covered by TRICARE and is done at the patient’s expense

• _{Limited space-available care in an MTF may be available} • _{Secretary of the Navy Designee Program at NMCP}

• _{Special situation – married service members}

• _{If both parents of a child are service members, only one}

can be designated as the sponsor in DEERS

• _{If one spouse is retired and the other is on active duty,}

the family should register in DEERS under the active duty member to retain active duty preferences – lower costs and better MTF access-to-care

• _{If both are retired, the family should register in DEERS}

under one or the other to help control costs – one Prime family enrollment fee and one family catastrophic cap

• _{Special situation – terminal leave}

• _{Service members continue as active duty service}

members (ADSMs) while on terminal leave, until the actual separation or retirement date

• _{Remain in TRICARE Prime at final duty station} • _{If leaving the area of the final duty station}

• _{Seek care at any MTF, if available}

• _{Contact PCM for authorization before seeking any}

non-emergency care, including urgent care

• _{May be pre-authorized by the PCM to seek}

non-emergency care at a Veterans Affairs (VA) facility

• _{Family members can keep their current coverage, switch}

programs or, if in Prime, change their PCM

• _{Special situation – retirement}

• _{Regular retirement – service members and family}

members retain TRICARE eligibility after transitioning from active duty to retirement

• _{Medical retirement – service members with a service}

disability rating of at least 30% (not the same as a VA disability rating)

• _{Temporary Disability Retirement List (TDRL) – service}

member (SM) and family members (FM) retain TRICARE eligibility

• _{SM evaluated every 18 months, for up to 5 years,}

when a decision is made to retain on the TDRL, separate from service, return to duty, or move to the Permanent Disability Retirement List (PDRL)

• _{Special situation – Transitional Assistance Management}

Program (TAMP)

• _{Eligibility is determined by the separating ADSM’s service}

branch, and is processed through DEERS

• _{The separating ADSM and family members may be}

eligible for 180 days of TAMP if the service member:

• _{Is involuntarily separated under honorable conditions} • _{Separates following an involuntary retention, or}

voluntary agreement to stay on active duty for less than one year, in support of a contingency operation

• _{Receives a sole-survivorship discharge, or} • _{Agrees to join the Selected Reserves}

TRICARE Choices for Eligible Beneficiaries During TAMP

Prime/USFHP* Extra Standard

Annual Deductible None (unless Point-of-Service is used)

Sponsor E-1 to E-4: $50 individual/$100 family Sponsor E-5 and above: $150/$300

POS FY Outpatient

Deductible $300/$600 N/A

POS Co-pay 50% N/A

Civilian Provider

Office Visit Co-pay $0 15% 20%

Hospitalization $0 $17.80/day $17.80/day

Outpatient

Behavioral Health Co-pay

$0 15% 20%

Providers MTF or Network Network Non-Network

Balance Bill No Up to 15%

Catastrophic Cap $1,000/family

*TRICARE Prime or Uniformed Services Family Health Plan (USFHP). Prime is only available in Prime Service Areas (PSAs), and USFHP is only available in 6 geographic

Last day of active duty

Active Duty* TAMP CHCBP

TAMP begins (day 1) TAMP ends (day 180) CHCBP begins (day 181)

TAMP Eligible

TAMP Ineligible

time includes any period of terminal leave Active Duty* Last day of active duty CHCBP begins (day 1) CHCBP

TAMP Timeline

• _{Permanent eligibility criteria for special needs children}

• _{Unmarried and incapable of self-support because of a qualifying}

disability that existed before age 21 (or between age 21 and 23 if a full-time student)

• _{Child relies on the sponsor for over 50% of support (or was at the}

time of a sponsor’s death)

• _{Service points-of-contact and policy guidance}

• _{USA – Defense Financing and Accounting Office (DFAS) –}

Indianapolis; Army Regulation 600-8-14

• USAF – DFAS – Denver; Air Force Instruction 36-3026_IP

• USN – Navy Personnel Command – Millington; BUPERS Instruction 1750.10C

• USMC – Headquarters Marine Corps – Quantico; Marine Corps Order 5512.11D

• Applying for permanent eligibility

• Apply through DEERS at least 90 days before current ID card expires, with the following required supporting documentation:

• Physician’s written statement (dated within 90 days)

• If eligible, proof of Medicare A and B (not required for ADFMs)

• Birth certificate and parents’ marriage certificate

• Approved medical sufficiency statement/letter from an MTF

• Approved dependency determination (over 50%) from a uniformed service approval authority

• DD Form 1172, Application for Uniformed Services ID

Card-DEERS Enrollment and DD Form 137-5, Dependency Statement-Incapacitated Child Over Age 21

• Also required for an incapacitated student – a physician’s statement that the incapacitation occurred after age 21 and before age 23, and a letter from the school verifying the child was a full-time student when the incapacitation occurred

• _{Losing TRICARE eligibility}

• _{Situations where eligibility will be lost:}

• _{Sponsor – separate from active duty (not retiring); or}

end of TAMP

• _{Inactive or retired Guard or Reserve member}

(eligibility for other programs may apply)

• _{Spouse – divorce (some exceptions)}

• _{Former (divorced) spouse – remarriage or}

employer coverage

• _{Former (widowed) spouse – remarriage} • _{Children – age or marriage}

• _{Losing TRICARE eligibility}

• _{Health care options when eligibility for TRICARE is lost:} • _{Transitional Assistance Management Program (TAMP)}

– 180 days of ADFM coverage for certain separating service members and families

• _{Continued Health Care Benefit Program (CHCBP)} • _{Temporary (18 – 36 months) coverage}

comparable to TRICARE Standard and Extra, but does not include use of MTFs

• _{Quarterly premiums - $1,275/individual;}

$2,868/family

• _{Managed by Humana}

• _{Priorities for military treatment facility (MTF) access-to-care}

for primary and specialty appointments, and inpatient care

1) Active duty service members (ADSMs)

2) Active duty family members (ADFMs) in Prime 3) Retirees, family members and survivors in Prime 4) TRICARE Plus

5) ADFMs not in Prime (includes TRS enrollees)

6) Retirees, family members and survivors not in Prime

(includes TFL beneficiaries and TRR enrollees)

7) Others – space-available direct care only

• _{Ancillary services – usually available to all TRICARE-eligible}

beneficiaries on a walk-in basis

• _{TRICARE Programs} • _{Triple Options}

• _{Prime – managed care; enrollment required} • _{Mandatory for ADSMs; optional for others} • _{Related – Prime Remote, Overseas Prime and}

Prime Remote, and USFHP

• _{Extra – civilian preferred provider network}

• _{Standard – civilian fee-for-service non-network}

• _{TRICARE for Life (TFL) – Medicare wrap-around coverage} • _{TRICARE Reserve Select (TRS) and TRICARE Retired}

Reserve (TRR)

• _{TRICARE Plus – MTF-managed primary care program} • _{TRICARE Young Adult (TYA)}

TRICARE Program Eligibility Based on Status

Program

ADSM ADFM

Retirees and Retiree FMs

Medicare-Ineligible Medicare-Eligible Prime (U.S.) Mandatory

Option Option Option < age 65

USFHP No Option Option < age 65

Prime Remote, Overseas Prime/ Prime Remote With orders Option if command-sponsored No Extra and Standard No

Option Acts as Medicare

supplement for TFL

TFL Option if

Medicare-eligible _No

Medicare required to retain TRICARE

TRICARE Plus No Option if available

TYA Adult children < age 26 not otherwise eligible for TRICARE

TRS Option for Inactive Selected

Reserves and FMs No

TRR No Option for “Gray Area” Retired

TRICARE Triple Options

Prime/USFHP Extra Standard

Annual Retiree Enrollment Fee Single: $277.92 Family: $555.84 None Annual Deductible (FY)

None except Point-of-Service (POS)

E-4 and below ADFM: $50/$100

E-5 and above ADFM and Retiree/FM: $150/$300 POS Outpatient

Deductible (FY) $300/$600 N/A

POS Co-pay 50% N/A

Civilian Provider Visit Co-pay AD/ADFM: $0 Retiree/FM: $12 ADFM: 15% Retiree/FM: 20% ADFM: 20% Retiree/FM: 25% Hospitalization AD/ADFM: $0 Retiree/FM: $11/day ADFM: $17.80/day Retiree/FM: $250/day or 25% ADFM: $17.80/day Retiree/FM: $764/day or 25% Outpatient Behavioral Health Co-pay AD/ADFM: $0 Retiree/FM: $25 (individual) $17 (group) ADFM: 15% Retiree/FM: 20% ADFM: 20% Retiree/FM: 25%

Providers MTF or Network Network Non-Network

Balance Bill No Up to 15%

Hospital Corpsman Advancement

Question

 _Question

 _{Under which TRICARE option do}

non-active duty beneficiaries who are not enrolled in TRICARE Prime receive care from civilian TRICARE network providers?

 _Answer

 _{TRICARE Extra, which is similar to}

a civilian insurance preferred provider option (PPO). The network of civilian providers is maintained by the regional

managed care support contractor (Health Net Federal Services for the TRICARE North Region).

Hospital Corpsman Advancement

Question

 _Question

 _{Which TRICARE option for}

non-active duty beneficiaries is similar to a civilian

insurance fee-for-service program, and is available world-wide?

 _Answer

• TRICARE Prime – the managed care option that is available in Prime Service Areas (PSAs) (usually within 40 miles of an MTF or BRAC site)

• Mandatory coverage for ADSMs

• Optional coverage for ADFMs, retirees and retiree family members

• Not an option for retirees and retiree family members age 65 and older who have Medicare (also applies to the USFHP)

• TRICARE Prime Remote – for ADSMs assigned duty in remote locations in the U.S. (usually more than 50 miles from an MTF).

• Optional for ADFMs, family members of activated Guard and

Reserves, and certain surviving family members if certain criteria is met

• TRICARE Prime Overseas and TRICARE Prime Remote Overseas – for ADSMs assigned to overseas locations

• Optional for command-sponsored ADFMs

• U.S. Family Health Plan (USFHP) – option for ADFMs, retirees and retiree family members in six geographic locations in the U.S.

Hospital Corpsman Advancement

Question

 _Question

 _{An active duty service}

member assigned to

recruiting duty in a rural location in the U.S. more

than 50 miles from a military hospital or clinic is covered by which TRICARE program?

 _Answer

• TRICARE Prime Enrollment

• Coordinated by the regional contractor – Health Net for the North Region – (877) 874-2273

• Update when there is a change in status, duty station or address

• Reenlistment or retirement – new enrollment

• Moving between regions – portability

• Moving or changing PCMs within the same region – PCM change

• Split enrollment – family members in different regions

• New enrollments – 20th _{of the month rule}

• Medical Home provides patient and family-centered primary care

• Physician-led team of providers and support staff

• Improved quality, access and continuity; better communication and record-keeping; and wellness, healthy living and disease prevention

• PCM provides routine care and coordinates specialty and follow-up care, including urgent care, for chronic and acute illnesses

• _{TRICARE Prime Primary Care Manager (PCM) Assignment}

• _{ADSMs – assigned to designated MTF for their command,}

or duty station medical department

• _{ADFMs – priority assignment to MTF PCM, where}

available, or to civilian network PCM

• _{Retirees and family members – priority assignment to}

MTF PCM, where available, or to civilian network PCM

• _{Only available in Prime Service Areas (PSAs) in the}

U.S.

• _{Not eligible for Prime Remote, Overseas Prime or}

• TRICARE Prime Appointments and Access-to-Care (ATC)

• Emergency – immediately (911 or nearest ER)

• Urgent care – 24 hours, or less

• Routine care – 7 days, or less

• Specialty or wellness care – 28 days, or less

• Follow-up care – doctor’s discretion

• Drive-time/distance ATC standards

• PCM – 30 minutes (beneficiary can waive up to 100 miles)

• Specialty care – 60 minutes

• Primary care and specialty care appointments in Tidewater

• MTF appointments – Hampton Roads Appointment Center (HRAC)

• (866) 645-4584, or call the clinic directly

• _{TRICARE Prime Referrals and Authorizations}

• _{Required for most non-emergency care, including urgent}

and specialty care

• _{Exceptions – first 8 outpatient behavioral visits each}

fiscal year (does not apply to ADSMs) and some preventive services

• _{Specialty care offered first at an MTF}

• _{Referrals are for a specific time and number of visits} • _{Evaluate only/second opinion – one or two visits} • _{Evaluate and treat – for an episode of care}

• _{Unauthorized non-emergency care – point-of-service} • _{Beneficiaries with OHI (Medicare, employer plan) follow}

• _{TRICARE Prime Referral Process}

• _{MTF PCMs enter referral into MHS system}

• _{Civilian PCMs fax referral to Health Net at (888) 299-4181} • _{MTF specialty clinic reviews referrals – patient will be}

seen in the MTF if an appointment is available; if not, patient will be deferred to a civilian network provider

• _{Patient calls HRAC to check on referral status and}

schedule MTF appointment

• _{If deferred, patient will receive a letter from Health Net} • _{Patient may call Health Net for information and}

• _{TRICARE Prime Point-of-Service (POS)}

• _{Beneficiary financial liability for a larger percentage of}

costs for unauthorized non-emergency care

• _{Includes urgent care and most specialty care without}

a referral and authorization

• _{Does not apply to ADSMs}

• _{Outpatient deductible – $300/individual; $600/family} • _{Inpatient and outpatient cost-share – 50% of the}

TRICARE-allowable charge

• _{Possible additional 15% balance-billing for services}

received from non-network providers

• _{Beneficiary costs do not apply towards the catastrophic}

• _{Traveling with TRICARE Prime}

• _{If medical care is needed when traveling away from}

home, use an MTF, if available

• _{Emergencies – call 911 or go to the nearest ER} • _{Notify PCM within 24 hours}

• _{Coordinate all follow-up care with PCM}

• _{Urgent care – medically-necessary within 24 hours} • _{Coordinate with PCM}

• _{Call the Nurse Advice Line – (800) 874-2273} • _{Unauthorized urgent care is point-of-service} • _{Coordinate all follow-up care with PCM}

• _{TRICARE Prime Travel Benefit – for medically-necessary,}

non-emergency referrals to a specialist more than 100 miles from the patient’s PCM

• _{Does not apply to ADSMs as patients or non-medical}

attendants (NMA) – must have command travel orders

• _{MTF or TRICARE Regional Office (for patients with civilian}

PCMs) prior-authorization required in all cases

• _{Reimbursement for reasonable travel expenses for}

patient and one authorized NMA

• _{Meals, fuel, tolls, parking, lodging, transportation} • _{NMCP points-of-contact}

• _{Health Benefits – (757) 953-2610}

• _{TRICARE Claims – charges for health care services received}

from civilian providers

• _{Network providers (Prime and Extra) file the paperwork} • _{Beneficiary claim form for reimbursement – Patient’s}

Request for Medical Payment (DD Form 2642)

• _{Claims processors}

• _{North – Health Net (PGBA) – www.mytricare.com} • _{TFL and overseas – Wisconsin Physician Services}

(WPS) – www.tricare4u.com

• _{Beneficiaries with other health insurance (OHI) (i.e.,}

employer coverage or Medicare) should be familiar with coordinating benefits between the OHI and TRICARE

• _{With few exceptions (such as Medicaid), OHI is primary to}

• _{TRICARE Explanation of}

Benefits (EOB)

• _{Monthly summary}

statement (not a bill)

• _{Individual EOBs sent for}

denied claims or payment due to the beneficiary

• _{Available online at}

www.mytricare.com

• _{For assistance:}

• _{Provider’s billing office}

• _PGBA

• TRICARE Expense Item Terminology

• Balance billing

• Maximum 15% amount of the TRICARE Maximum Allowable Charge (TMAC) that beneficiaries may be charged for TRICARE-covered from non-network, non-participated civilian providers

• Catastrophic cap

• Maximum out-of-pocket expense in a fiscal year (FY) for which a family is financially liable for authorized TRICARE-covered

services

• Co-payment (co-pay)

• Fixed dollar amount beneficiaries pay for TRICARE-covered services

• Cost-share

• Fixed percentage amount of TMAC or negotiated rates that beneficiaries pay for TRICARE-covered services

• TRICARE Expense Item Terminology (continued)

• Deductible

• Fixed dollar amount beneficiaries pay each FY for TRICARE-covered services before TRICARE starts to pay

• Enrollment fee

• Annual amount retirees and retiree family members pay to be enrolled in TRICARE Prime or the Uniformed Services Family Health Plan (USFHP)

• Point-of-service (POS)

• A TRICARE Prime/USFHP option that allows non-active duty service member (ADSM) beneficiaries to obtain certain

TRICARE-covered services without referrals and/or prior authorization

• Premium

• Monthly or quarterly amount that beneficiaries pay for enrollment in certain TRICARE programs

• _{TRICARE Changes when Transitioning from Active Duty to}

Retirement include:

• _{Lower priority for access-to-care in an MTF} • _{Higher out-of-pocket costs}

• _{TRICARE Prime}

• _{Annual enrollment fee and civilian provider office}

visit co-pay

• _{Only available in Prime Service Areas (PSAs)} • _{Routine vision exam once every two years} • _{TRICARE Standard/Extra}

• _{Standard cost-share is 25%} • _{Extra cost-share is 20%}

• _{Other considerations when transitioning to retirement} • _{Fiscal year (FY) family catastrophic cap increases from}

$1,000 to $3,000

• _{Optional TRICARE dental coverage offered through Delta}

Dental (TRICARE Retiree Dental Program)

• _{Extended Care Health Option (ECHO) benefits are not}

available

• _{Beneficiaries with other health insurance (OHI), such as}

an employer health plan, must be familiar with the coordination of benefits

• _{Medicare-eligible beneficiaries entitled to premium-free}

Medicare Part A must purchase Medicare Part B to retain TRICARE coverage (TRICARE for Life)

Hospital Corpsman Advancement

Question

 Question – True or False?

 _{All retirees and their eligible}

family members may enroll in TRICARE Prime, regardless of their age or where they live.

 _Answer

 _{False. TRICARE Prime is only}

available to retirees and their family members in a Prime Service Area. TRICARE Prime is not an option for retirees and their family members age 65 and older with Medicare.

• _{Other TRICARE Programs}

and Benefits

• _{Applied Behavior}

Analysis (ABA)

• _{Cancer Clinical Trials} • _{Dental Programs}

• _{Disengagement}

• _{Extended Care Health}

Option (ECHO)

• _{Mental Health}

• _{National Guard and}

Reserves

• _{Nurse Advice Line}

• _{OB/Maternity Care}

• _Pharmacy

• _{Prevention/Wellness} • _{Prior Authorization} • _{TRICARE for Life (TFL)} • _{TRICARE Overseas}

Program (TOP)

• _{TRICARE Young Adult}

(TYA)

• _{Uniformed Services}

Family Health Plan (USFHP)

• _{Applied Behavior Analysis (ABA)}

• _{Comprehensive Autism Care Demonstration}

• _{Beneficiaries with an autism spectrum disorder (ASD)}

diagnosis

• _{Consolidated three previous programs into one} • _{TRICARE Basic Program}

• _{Autism Demonstration} • _{Autism Pilot}

• _{Expanded benefit with fewer requirements}

• _{Beneficiary cost depends on status and program} • _{All services require authorization from Health Net} • _{www.tricare.mil/plans/specialprograms/autism.aspx}

Beneficiary Costs (Co-Pays and Cost-Shares)

Direct ABA Services

(expenses count towards the catastrophic cap)

ADFMs enrolled in TRICARE Prime – $0 co-pay

ADFMs with TRICARE Standard/Extra – 15% cost-share in network (Extra); 20% out of network (Standard)

Retired family members (FMs) enrolled in TRICARE Prime – $12 co-pay per visit

Retired FMs with TRICARE Standard/Extra - 20% cost-share in network (Extra); 25% out of network (Standard)

FMs with TRICARE Reserve Select (TRS) – 15% cost-share in network (Extra); 20% out of network (Standard)

FMs with TRICARE Retired Reserve (TRR) – 20% cost-share in network (Extra); 25% out of network (Standard)

Reinforcement ABA Services (expenses do

not count towards the catastrophic cap)

ADFMs – monthly ECHO cost-share based on sponsor’s pay grade

• _{Cancer Clinical Trials}

• _{Department of Defense (DoD) partnership with the}

National Cancer Institute (NCI)

• _{Research studies for the prevention, diagnosis and}

treatment of cancers and other illnesses

• _{Open to all TRICARE beneficiaries; TRICARE shares the}

cost of evaluation and testing to determine participation eligibility, and medical care during the trial

• _{www.tricare.mil/Plans/SpecialPrograms/CancerClinicalTri}

als.aspx

• _{Active Duty Dental Program (ADDP) – for ADSMs} • _{Military dental treatment facility}

• _{Authorized civilian care coordinated by United Concordia}

– https://secure.addp-ucci.com/ddpddw/

• _{TRICARE Dental Program (TDP) – for ADFMs} • _{Optional, premium-based coverage}

• _{MetLife – https://mybenefits.metlife.com/tricare}

• _{TRICARE Retiree Dental Program (TRDP) – for retirees and}

retiree family members

• _{Optional, premium-based coverage}

• Does not apply to ADSMs

• Disengagement of an MTF patient to civilian medical care may be necessary when required medical services are beyond the MTF’s capability

• Alternative MTF sources should be considered first before disengaging a patient to civilian care

• Disengagement, or relinquishment of full responsibility for a patient by the MTF, is only for the episode of care for the medical reason for which the patient is being disengaged

• Patients to be disengaged should be counseled and advised of their rights and responsibilities, including eligibility for covered services and any potential financial liability

• Counseling must be documented

• Patients only entitled to MTF direct care (such as dependent parents, in-laws or siblings; or newborns of unwed dependent daughters) are not covered under TRICARE for any services received from civilian providers

Hospital Corpsman Advancement

Question

 _{Question – True or False?}

 _{Disengagement procedures must be}

followed when an active duty service member requires medical care that is beyond the capability of the MTF.

 _Answer

 _{False. Disengagement applies only}

to non-ADSMs who are sent to civilian providers for care that is beyond the MTF’s capability. The MTF will always maintain some level of responsibility for an ADSM whose care is transferred to a civilian

provider or facility; therefore, total relinquishment of responsibility for an ADSM cannot be accomplished.

• _{Extended Care Health Option (ECHO)}

• _{Supplements basic TRICARE benefits for ADFMs with}

qualifying physical or mental conditions

• _{Sponsor must be enrolled in the service-specific}

Exceptional Family Member Program (EFMP) before registering the family member in ECHO

• _{All services must be pre-authorized by Health Net} • _{Health Net ECHO case manager – (877) 874-2273}

• _{Tidewater area ECHO case manager – (800) 977-7531} • _{Fiscal year limit on benefits – $36,000/beneficiary}

• _{Monthly cost-share per family based on sponsor’s pay}

grade, and only applies in months benefits are used

ECHO Costs and Limits

• Monthly cost-share is per sponsor; not per ECHO beneficiary

• Cost-share is paid only if ECHO benefits are used during the month

• Fiscal year limit for what TRICARE will pay for

covered benefits per ECHO beneficiary is $36,000 (not including the ECHO Home Health Care Benefit)

• Unused benefit amounts are not transferable

between eligible family members Sponsor Pay Grade Monthly Cost Share Sponsor Pay Grade Monthly Cost Share

E-1 to E-5 $25 W-5, O-5 $65

E-6 $30 O-6 $75

E-7, O-1 $35 O-7 $100

E-8, O-2 $40 O-8 $150

E-9, W-1, W-2,

O-3 $45 O-9 $200

Hospital Corpsman Advancement

Question

 _Question

 What is required of a sponsor before family

members become eligible for ECHO benefits?

 _Answer

 The sponsor must be an

active duty service member and enrolled in the service-specific Exceptional Family Member Program (EFMP). Retiree family members are not entitled to ECHO

• _{Inpatient and outpatient mental health services available}

from:

• _{Psychiatrists and other physicians} • _{Clinical psychologists}

• _{Certified psychiatric nurse specialists} • _{Licensed clinical social workers}

• _{Certified marriage and family therapists} • _Counselors

• _{Non-ADSMs can self-refer for the first 8 outpatient visits}

each fiscal year

• _{Subsequent visits require authorization from Health Net} • _{www.tricare.mil/mentalhealth}

• _{National Guard and Reserve Components} • _{Air Force Reserve}

• _{Air National Guard} • _{Army National Guard} • _{Army Reserve}

• _{Coast Guard Reserve} • _{Marine Corps Reserve} • _{Navy Reserve}

• _{National Guard and Reserve Categories} • _{Ready Reserve}

• _{Inactive Army National Guard and Individual Ready}

Reserve

• _{Selected Reserve}

• _{Active Guard and Reserve}

• _{Individual Mobilization Augmentee (IMA)}

• _{Selected Reserve Units and Military Technicians} • _{Retired Reserve and Standby Reserve}

• National Guard and Reserve access to TRICARE programs based on status

• Activated for less than 30 days – line-of-duty care only

• Activated for more than 30 days – ADSM/ADFM benefits

• TRICARE Reserve Select (TRS) – inactive Selected Reserves and family members

• Voluntary, premium-based program

• ADFM TRICARE Standard/Extra benefits and costs

• www.tricare.mil/welcome/plans/TRS.aspx

• TRICARE Retired Reserve (TRR) – ‘gray area’ retirees (under age 60) and family members

• Voluntary, premium-based program

• Retiree TRICARE Standard/Extra benefits and costs

• www.tricare.mil/welcome/plans/TRR.aspx

Inactive Pre-activation (Mobilization) Active (Mobilized) Deactivation (Demobilization) Retired

Status

• _{Inactive status}

• _{Reserve member coverage} • _{Line-of-duty (LOD) care}

• _{TRICARE Reserve Select (TRS)} • _{Optional; premium-based}

• _{Selected Reserve members only} • _{TRICARE Dental Program (TDP)}

• _{Optional; premium-based} • _{Family member coverage}

• _{TRS – sponsor must be enrolled}

• _{TRICARE Young Adult (TYA) Standard – sponsor must}

be enrolled in TRS

• _{Pre-activation status}

• _{Early eligibility – up to 180 days before activation with}

delayed-effective-date orders for more than 30

consecutive days in support of a contingency operation

• _{Eligibility ends if orders are cancelled} • _{Reserve member coverage}

• _{TRICARE Prime}

• _{Active Duty Dental Program (ADDP)} • _{Family member coverage}

• _{TRICARE Prime}

• _{TRICARE Extra/Standard} • _{TYA Prime or Standard} • _TDP

• _{Active status}

• _{Activated for more than 30 consecutive days in support}

of a contingency operation

• _{Reserve member coverage*} • _{TRICARE Prime}

• _{Active Duty Dental Program (ADDP)} • _{Family member coverage}

• _{TRICARE Prime/USFHP}

• _{TRICARE Extra/Standard} • _{TYA Prime or Standard} • _TDP

* All medical and dental care for ADSMs, including activated National Guard and Reserves, is coordinated through the Military Health System

• _{De-activation status}

• _{Following activation for more than 30 consecutive days in}

support of a contingency operation

• _{Reserve member coverage – 180 days of Transitional}

Assistance Management Program (TAMP)

• _{TRICARE Prime/USFHP}

• _{TRICARE Extra/Standard}

• _ADDP

• _{Family member coverage}

• _{TRICARE Prime/USFHP}

• _{TRICARE Extra/Standard} • _{TYA Prime or Standard} • _TDP

• _{Retired status – ‘Gray Area’ retiree – under age 60} • _{Reserve member coverage}

• _{TRICARE Retired Reserve (TRR)}

• _{TRICARE Retiree Dental Program (TRDP)} • _{Family member coverage}

• _{TRR (sponsor must be enrolled)}

• _{TYA Standard (sponsor must be enrolled in TRR)}

• _{Retired status – regular retirement at age 60} • _{Reserve member coverage}

• _{TRICARE Prime/USFHP}

• _{TRICARE Extra/Standard}

• _{TRICARE for Life (TFL) – when eligible for Medicare}

• _TRDP

• _{Family member coverage}

• _{TRICARE Prime/USFHP}

• _{TRICARE Extra/Standard}

• _{TFL – when eligible for Medicare} • _{TYA Prime or Standard}

• _{Line-of-duty (LOD) care}

• _{For injuries or illnesses incurred or aggravated in the line}

of duty while on inactive duty training, or active duty orders for less than 30 days

• _{Includes injuries sustained while traveling under}

orders to and from a duty station

• _{LOD determination is made by the command or National}

Guard or Reserve unit

• _{Care provided at MTFs or coordinated by the Reserve and}

Service Member Support Office (R&SMSO)

• _{TRICARE Reserve Select (TRS)} • _Eligibility

• _{Inactive Selected Reservists and family members} • _{Not eligible for or enrolled in a Federal Employee}

Health Benefit Plan (FEHBP) (self or spouse)

• _Benefits

• _{TRICARE Extra/Standard (Standard overseas)}

• _{Monthly premiums}

• _{$50.75/member; $205.62/member and family}

• _{To qualify and purchase coverage – complete the online}

‘DMDC Reserve Component Purchased TRICARE Application (RCPTA)’

• _{TRICARE Retired Reserve (TRR)} • _Eligibility

• _{‘Gray area” retirees and family members}

• _{Not eligible for or enrolled in a Federal Employee}

Health Benefit Plan (FEHBP) (self or spouse)

• _Benefits

• _{TRICARE Extra/Standard (Standard overseas)}

• _{Monthly premiums}

• _{$390.89/member; $961.35/member and family}

• _{To qualify and purchase coverage – complete the online}

‘DMDC Reserve Component Purchased TRICARE Application (RCPTA)’

Hospital Corpsman Advancement

Question

 _Question

 _{At what age does a retired}

reservist become eligible for regular retiree TRICARE

benefits?

 _Answer

 _{At age 60. Eligible family}

members also become entitled to TRICARE at the same time as the sponsor.

• TRICARE for Life (TFL)

• For Medicare-eligible beneficiaries

• Most people at age 65; under age 65 with a disability

• Entitled to premium-free Medicare Part A and enrolled in Part B

• Exceptions – ADSMs and ADFMs not required to enroll in Part B until the sponsor retires

• Monthly Part B premium; no TFL enrollment fee

• TRICARE pays secondary to Medicare

• TRICARE Prime not an option for retiree and retiree family member TFL beneficiaries at age 65

• Medicare-eligible beneficiaries under age 65 may enroll in Prime, where available, and the enrollment fee is waived

• Claims and information – Wisconsin Physician Services

• Monthly TFL presentation at NMCP – 2nd _{Tuesday of each month}

• _{Primary care program at select MTFs} • _{Internal Medicine Clinic at NMCP}

• _{The MTF manages the program and controls enrollment,}

which is usually by invitation only

• _{Most enrollees are TFL-eligible, and are not eligible for}

TRICARE Prime

• _{No enrollment fee or other costs for care received in the MTF} • _{Access to primary care appointments and benefits is the}

same as for TRICARE Prime

• _{Access to specialty care appointments is not guaranteed, but}

may be offered on a space-available basis or for continuity of care

• _{TRICARE Nurse Advice Line (NAL)}

• _{For all TRICARE beneficiaries in the U.S., including Alaska}

and Hawaii (does not include USFHP enrollees)

• _{Answer health care questions and concerns}

• _{Advise on need for care – self, routine, urgent or}

emergent

• _{Communicate with MTF PCMs and schedule}

• _{TRICARE OB and Maternity Care in Tidewater}

• _{Most Prime patients in Tidewater will receive their OB}

and maternity care through Women’s Health at NMCP (953-4300), or USAF Hospital Langley (764-6994/6992)

• _{Includes ADSMs, ADFMs, retirees and retiree family}

members in Prime, with military or civilian PCMs

• _{Medically-necessary maternity care includes:}

• _{Prenatal care, including OB visits and}

medically-necessary ultrasounds

• _{Antepartum care for high risk pregnancies} • _{Hospitalization for labor and delivery}

TRICARE Prime

Service ADSM/ADFM Retirees, Retiree Family Members and all Others

Annual FY outpatient deductible $0 $0

Global maternity care fee* $0 $11/day ($25 minimum)

Inpatient professional services for

newborn care $0 $11/day ($25 minimum)

Newborn cost-share for hospital

services $0

• Newborn date of admission matches date of birth: $11/day ($25 minimum) applies to 4th and subsequent inpatient days

• Newborn admitted after date of birth: $11/day ($25 minimum) applies to all inpatient days

Professional services fee (if mother

delivers at home or as an outpatient) $0 $12/visit for mother

Authorized birthing center or

hospital-based outpatient birthing room $0 $25/day

TRICARE Prime Point-of-Service (unauthorized non-emergency care; does not apply to catastrophic cap or to ADSMs)

Annual FY outpatient deductible ADSM – N/A; All others – $300/individual or $600/family

Inpatient and outpatient cost-share ADSM – N/A; All others – 50% of TRICARE allowable charge

TRICARE Extra (Network) and Standard (Non-network) (does not apply to ADSMs) Annual FY outpatient deductible • ADFMs sponsor E-4 and below – $50/individual or $100/family _{• All others – $150/individual or $300/family} Global fee* cost share for ADFMs and

TRS

• $17.80/day ($25 minimum); No separate cost share for separately billed professional services

Global fee* cost share for all others • Extra: less of $250/day or 25% billed charges, plus 20% professional services _{• Standard: less of $764/day or 25% billed charges, plus 25% professional services} * After pregnancy is confirmed, most costs are grouped under one diagnosis code. The global fee covers prenatal, inpatient, delivery and postnatal care. Costs depend on beneficiary status, TRICARE program used, and provider (military or civilian).

• _{TRICARE pharmacy choices}

• _{MTF – www.tricare.mil/coveredservices/pharmacy.aspx} • _{Home delivery (mail order) and retail network in the U.S.}

– Express Scripts

• _{www.express-scripts.com/tricare} • _{(877) 363-1303}

• _{Retail non-network in the U.S.}

• _{Mail order overseas – prescriptions must be written by a}

U.S.-licensed physician

• _{Claims processed by Wisconsin Physician Services}

(WPS) – www.tricare4u.com

• _{Note – individuals enrolled in USFHP do not have access to}

Pharmacy Choices, Prescription Categories and Beneficiary Costs1

Pharmacy Tier 12 _{Tier 2 Tier 3}3

MTF (up to 90 days supply) No Cost Not Available4

Home Delivery/Mail Order5_{(up to 90 days) No Cost $16 $46}6

Retail Network (up to 30 days) $8 $20 $477

Retail Non-Network - TRICARE Prime (up to 30 days) 50% cost-share after POS deductible is met8

Retail Non-Network - ADFMs TRICARE Standard/Extra or

TRICARE Reserve Select (up to 30 days) Greater of $20 or 20% of the total cost

9 Greater of $47 or

20%9

Retail Non-Network - Non-ADFMs Standard/Extra, TFL,

or TRICARE Retired Reserve (up to 30 days) 25% of the total cost

9

1. ADSMs do not pay for any authorized prescription medications at any pharmacy. The annual deductible for all other beneficiaries does not apply to prescriptions filled through home delivery or a retail network pharmacy.

2. When available, prescriptions will be filled with generic formulary (Tier 1) medications. Brand name formulary (Tier 2) drugs with a generic equivalent will only be dispensed if medical necessity is requested and approved by Express Scripts. If

approved, the brand name co-pay will apply. If not approved, the beneficiary will be responsible for the entire cost of the medication.

3. Medications designated non-formulary (Tier 3) have been determined to be less clinically-effective or less cost-effective than other drugs in the same therapeutic class.

4. With limited exceptions, non-formulary medications are generally not available through anMTF pharmacy.

5. Beneficiaries with other health insurance (OHI) with a prescription benefit, including Medicare Part D, cannot use the home delivery program, unless a particular medicine is not covered by the OHI, or the OHI prescription benefit has been exhausted. 6. Non-formulary medications may be available through home delivery at the formulary co-pay if medical necessity is requested

and approved by Express Scripts.

7. The availability of most non-formulary medications through a retail pharmacy is very limited.

8. The TRICARE Prime annual point-of-service (POS) deductible for non-ADSMs is $300/individual and $600/family. 9. The TRICARE Standard/Extra annual deductible for active duty family members (ADFMs) of a sponsor E-4 and below is

Tidewater MTF Pharmacy Site Published e-RX Site Name NCPDP/NPI

Branch Health Clinic (BHC) Dam Neck DoD PORTS VA DAM NECK ePhcy 4845345 / 1396158168

BHC JEB Little Creek-Fort Story (Boone Clinic) DoD PORTS VA LITTLE CRK ePhcy 4845357 / 1205249075

BHC Naval Air Station Oceana DoD PORTS VA BHC OCEANA ePhcy 4845410 / 1578977666

BHC Norfolk Naval Station (Sewells Point Clinic) DoD PORTS VA BHC SEWELLS PT ePhcy 4845369 / 1205249059

BHC Naval Weapons Station Yorktown DoD PORTS VA BHC YORKTOWN ePhcy 4845460 / 1952717472

BHC Northwest DoD PORTS VA NORTHWEST NSG ePhcy 4845888 / 1548664949

Kenner Army Health Clinic, Fort Lee DoD FT LEE ePhcy 4845395 / 1417361866

McDonald Army Health Center (MCAHC) JEB Langley-Eustis DoD FT EUSTIS ePhcy 4845458 / 1861807703

Naval Medical Center Portsmouth (NMCP) DoD PORTS VA NMC ePhcy 4845371 / 1548673205

Scott Center Annex Norfolk Naval Shipyard Portsmouth DoD PORTS VA SCOTT CENTER ePhcy 4845838 / 1013319755

TRICARE Prime Clinic (TPC) Chesapeake DoD PORTS VA TPC CHESAPEAKE ePhcy 4845383 / 1508270950

TPC Virginia Beach DoD PORTS VA TPC VA BEACH ePhcy 4845408 / 1851704431

USAF Hospital Langley DoD LANGLEY ePhcy 4845523 / 1720494834

TRICARE Mail Order Pharmacy (Home Delivery) Express Scripts Home Delivery 2623735 / 1558443911

An electronic prescription (eRx) is a computer-generated prescription sent electronically from your health care provider directly to our pharmacy

• _{TFL Home Delivery Pharmacy Pilot Program} • _{For retirees and family members with TFL}

• _{Mandatory maintenance medication refills through home}

delivery – such as blood pressure, cholesterol or thyroid medications

• _{Exceptions and waivers}

• _{Prescriptions filled at an MTF pharmacy}

• _{Acute care meds (antibiotics, pain meds, etc.)} • _{Beneficiaries with OHI prescription coverage} • _{Program notifications by mail from Express Scripts}

• _{www.tricare.mil/tfl} • _{(877) 363-1303}

Hospital Corpsman Advancement

Question

 _Question

 _{Beneficiaries enrolled in}

what program do not have access to MTFs and TRICARE facilities, including pharmacy benefits, except in an emergency?  _Answer

Preventive Health Care and Wellness Services

ADFMs and TRS Retirees, FMs and TRR Prime1 Standard2

TRS Prime3

Standard2 TRR

Breast MRIs

Clinical Preventive Exams Colon Cancer Screenings Immunizations and Vaccines Mammograms

PAP Smears

Well-Child Care Visits

No copayment No cost-share No copayment No cost-share Cardiovascular Screenings Eye Exams4 Genetic Testing Infectious Disease Screenings School Physicals4 No copayment Network: 15% Non-network: 20% No copayment Network: 20% Non-network: 25%

1 Prime, Prime Remote, Overseas Prime, USFHP, Young Adult Prime 2 Standard/Extra, Young Adult Standard/Extra

3 Prime, USFHP, Young Adult Prime

• _{Prior authorization is required for all TRICARE-eligible}

beneficiaries when TRICARE is the primary payer for:

• _{Certain medications}

• _{Adjunctive (medically-necessary) dental} • _{Home health care and hospice}

• _{Non-emergency substance abuse or behavioral health}

admissions

• _{Outpatient behavioral health (after the 8}th _visit) • _{Skilled nursing facility care (after day 100 for TFL)} • _{Most organ transplants}

• _{ECHO (ADFM benefit only)}

• _{Prior authorization from TRICARE is generally not required}

• _{TRICARE Overseas Program (TOP)}

• _{Prime and Overseas Prime Remote are only for ADSMs}

and command-sponsored family members

• _{All others – TRICARE Standard} • _{Space-available MTF care}

• _{Most care from host nation providers} • _{To find a provider or get assistance}

• _{TOP Area Office or MTF} • _{U.S. Embassy or Consulate}

• _{TOP regional contractor – International SOS} • _{(888) 777-8343 (from the U.S. only)}

• _{TRICARE Young Adult (TYA) Program} • _{Eligibility requirements}

• _{Unmarried child of a TRICARE-eligible sponsor}

• _{At least 21 years of age (23 if a full-time student), but}

under age 26

• _{Not eligible for an employer health plan}

• _{National Guard and Reserve sponsors must be eligible}

for regular TRICARE or TAMP benefits, or must be eligible for and enrolled in either TRS or TRR

• _{Their children only eligible for TYA Standard/Extra} • _{Monthly premiums (January – December 2015)}

• _{Uniformed Services Family}

Health Plan (USFHP)

• _{Benefits and costs similar to}

TRICARE Prime

• _{6 geographic locations}

• _{Eligible beneficiaries same as}

TRICARE, except for ADSMs and TFL

• _{Except for emergencies,}

enrollees do not use TRICARE facilities

• _{www.usfhp.com}

• _{(800) 748-7347}

• Martin’s Point Health Care

• Brighton Marine Health Center

• Saint Vincent Catholic Medical Centers of New York

• Johns Hopkins Medicine

• CHRISTUS Health

• _{Eligibility – Veterans Affairs (VA)} • _{Eligibility – CHAMPVA}

• _{Dual Eligibility – TRICARE and VA} • _{VA Health Care Programs}

• _{VA Pharmacy}

• _{VA Health Care Facilities}

The Veterans Health Administration (VHA) is

the component of the Department of Veterans Affairs (VA) that oversees the delivery of health care

benefits to veterans, their dependents and survivors

• _{Eligible veterans}

• _{Service member discharged or separated from military}

service under conditions other than dishonorable

• _{Minimum duty requirements may apply to veterans}

who enlisted after 07 September 1980, or who entered active duty after 16 October 1981

• _{Reserve and National Guard member called to active}

duty (other than for training only) by federal order, and completed the full period of activation

• _{Dependents and survivors may be eligible for CHAMPVA} • _{For complete information about VA eligibility and health care}

• _{Enrollment into the VA health care system} • _{Most veterans apply for enrollment}

• _{www.1010ez.med.va.gov/sec/vha/1010ez/; (877)}

222-8387

• _{All applicants are assigned to one of eight priority groups}

based on a number of factors, including:

• _{VA disability rating, service history (dates and}

assignments)

• _{Employability, income and net worth}

• _{Priority (or sub-priority) group designation determines:} • _{Priority for access to care and co-pay requirement}

• _{Civilian Health and Medical Program of the Department of}

Veterans Affairs (CHAMPVA) eligibility

• _{Dependent spouse or child of a veteran having a}

service-connected total and permanent disability

• _{Non-TRICARE-eligible survivors of a veteran who died:} • _{From a VA-rated service-connected disability, or who}

was rated at the time of death by the VA as totally and permanently disabled, or

• _{In the line of duty, not due to misconduct}

• _{A surviving spouse under age 55 who remarries loses}

eligibility, but may re-establish it if the remarriage ends

• _{If spouse remarries after age 55, eligibility is not lost} • _{Medicare-eligibility requires Parts A and B to keep}

• _{Dual eligibility – TRICARE and the VA}

• _{Separating from active duty (not retirement)}

• _{TRICARE – certain service members and eligible}

family members may be entitled to 180 days of

temporary coverage under TAMP, but otherwise lose eligibility upon separation from active duty

• _{VA – veterans, with or without a VA disability rating}

for a service-connected condition, may apply for benefits after leaving active duty

• _{Dual eligibility – TRICARE and the VA (continued)}

• _{Retiring from active duty (including TDRL and PDRL)} • _{TRICARE – service members and eligible family}

members retain eligibility after transitioning from active duty to retirement

• _{VA – veterans, with or without a VA disability rating}

for a service-connected illness or injury, may apply for benefits after retirement

• _{CHAMPVA – retiree family members or survivors}

eligible for TRICARE are not eligible for CHAMPVA benefits

Dual Eligibility – Program Eligibility Based on Beneficiary Status

Program ADSM ADFM Separating SM Separating FM Retired SM

Retired FM

TRICARE Yes No Yes

TFL No Option if Medicare-_eligible No Required if Medicare-eligible

TRS No Option for inactive _{Selected Reserve} Option if sponsor is enrolled No

TRR No Option for retired Reserve < age 60 Option if sponsor is enrolled

TYA No Option if eligible No Option if _eligible

TAMP No For certain separating SMs, deactivating Reservists, and _FMs

If retirement is postponed by retention on AD for a contingency operation

CHCBP No Option when TRICARE eligibility ends No

VA No

Yes – must apply to meet requirements and access care

No

Yes – must apply to meet

requirements and access care

No

CHAMPVA No

If sponsor rated totally and permanently disabled, died from a VA-rated service-connected disability, or was rated totally and

permanently disabled at the time of death

• _{VA Health Care Programs for Veterans} • _{Outpatient and inpatient services}

• _{Primary, specialty and surgical care} • _{Diagnostic testing}

• _{Mental health and substance abuse treatment} • _{Prescription drugs (prescribed by a VA physician)} • _{Preventive services}

• _{Immunizations and health education programs} • _{Physicals and health care assessments}

• _{VA Health Care Programs for Families}

• _CHAMPVA

• _{www.va.gov/hac; (800) 733-8387} • _{Children of Women Vietnam Veterans}

• _{For birth children Vietnam women veterans}

determined by the VA to have one or more covered birth defects

• _{www.va.gov/hac/forbeneficiaries/cwvv}

• _{(888) 820-1756}

• _{Spina Bifida Health Care Benefits}

• _{For Vietnam and Korea veterans birth children in}

receipt of a VA award for spina bifida benefits

• _{VA pharmacies will only fill prescriptions written by VA}

physicians

• _{If a beneficiary, including someone who is dual-eligible,}

receives care at a VA facility for a VA-covered benefit, prescriptions should be filled at a VA pharmacy

• _{If a dual-eligible beneficiary receives care through TRICARE}

for a VA-rated service-connected condition, prescriptions should be filled through the TRICARE pharmacy program

Use of VA Health Care Facilities Based on Beneficiary Status

Beneficiary Status Use for TRICARE-Covered Services* Use for VA-Covered Services

ADSMs and Activated Guard and Reserves

Emergency care; urgent and routine care with a

referral and authorization N/A

ADSMs – Terminal Leave All services, with prior authorization N/A ADFMs; or ADSMs and

ADFMs during TAMP

TRICARE Prime (if TRICARE PCM) or TRICARE

Extra (if TRICARE network) N/A

Separated (not retired)

Service Member N/A

For service-connected disability or if veteran’s eligibility criteria is met

Separated (not retired)

Family Member N/A CHAMPVA, if eligible

Retired Service Member (not Medicare-eligible)

TRICARE Prime (if TRICARE PCM) or TRICARE Extra (if TRICARE network)

For service-connected disability or if veteran’s eligibility criteria is met

Retired Family Member (not Medicare-eligible)

TRICARE Prime (if TRICARE PCM) or TRICARE

Extra (if TRICARE network) N/A

Retired Service Member (Medicare-eligible/TFL)

Not Medicare-authorized; TRICARE pays 20%;

beneficiary pays 80% For service-connected disability

Retired Family Member (Medicare-eligible/TFL)

Not Medicare-authorized; TRICARE pays 20%;

beneficiary pays 80% N/A

* Most VA facilities participate as TRICARE network (Extra) providers, including all VA facilities in the TRICARE North Region. Some also participate in TRICARE Prime as primary care managers (PCMs). To find a participating facility or provider, go to the Health Net provider directory at www.hnfs.com.

• _Online

• _{TRICARE – www.tricare.mil} • _{Medicare – www.medicare.gov} • _{Social Security – www.ssa.gov}

• _{Reserve Affairs – www.defenselink.mil/ra} • _{Veterans Affairs – www.va.gov}

• _{Veterans Health Administration – www.va/gov/health} • _{NMCP – www.med.navy.mil/sites/NMCP2/}