TRICARE
United States Department of Defense
PURPOSE
The mission of TRICARE is to provide quality health care for members of the Armed Forces, military families, and others entrusted to the Department of Defense’s care. It consists of three options: TRICARE Prime, TRICARE Extra, and TRICARE Standard. TRICARE Prime is a voluntary enrollment option that’s much like a civilian Health Maintenance Organization (HMO). TRICARE Extra is when you seek care from a provider who’s part of the TRICARE network and receives a discount on services, paying reduced cost-shares (five percent below those of TRICARE Standard) in most cases. TRICARE Standard (previously know as CHAMPUS) pays a share of the cost of covered health services that you obtain from a non-network civilian health care provider. There’s no enrollment in TRICARE Standard. The annual deductible, cost-shares and benefits are the same as they were for CHAMPUS. Under this option, you have more freedom to choose your provider of care—but your costs will be higher than with the other two TRICARE options.
FINANCIAL CRITERIA
See “Eligibility”.
CONTACT
TRICARE Service Centers
Region 6
(800) 406-2832
http://www.tricare.osd.mil
All Oklahoma TRICARE Service Centers are listed below:
301 N. 1st Ave.
Building 46
Altus AFB, OK 73523-5005
Reynolds Army Community Hospital
CDRUSAMEDDAC
4300 Thomas St.
Ft. Sill, OK 73503-6300
5700 Arnold St.
Building 5801
Tinker AFB, OK 73145-8102
527 Gott Road
Vance AFB, OK 73705-5105
ELIGIBILITY
• Eligible family members of active-duty service members.
• Military retirees and their eligible family members.
• Surviving eligible family members of deceased, active, or retired service members.
• Wards and pre-adoptive children.
• Some former spouses of active or retired service members who meet certain length-of-marriage rules and other requirements.
AT SERVICES PROVIDED/COVERED
• Assessments & Evaluations
• Information & Referral
• Case Management
• Locating Alternate Funding
• Advocacy/Other
AT DEVICES PROVIDED/COVERED
Aids for Hearing Impaired
Wheelchairs & Mobility Aids
Aids for Vision Impaired
Environmental Controls
Augmentative Communication
Seating & Positioning Equipment
Hospital Beds
Medical Supplies
Prosthetics & Orthotics
APPLICATION PROCESS
• In order to use TRICARE, you must be listed in the Defense Department’s DEERS (Defense Enrollment Eligibility Reporting System) computerized data base as being eligible for military health care benefits. This includes newborns, who must be enrolled in DEERS before claims for their care as TRICARE eligible patients can be processed. Generally, it is the sponsor’s responsibility to make sure that his or her family members are enrolled in DEERS through the nearest military personnel office. All military sponsors should ensure that the status of their families (marriage, divorce, new child, etc.) is current in the DEERS files so TRICARE claims can be processed quickly and accurately.
APPEALS PROCESS
1. Generally, there are three possible levels of review under TRICARE
Standard appeal procedures. The levels available in any particular case will be specified in the notice of your right to appeal a particular decision. The three levels include:
• Reconsideration conducted by TRICARE contractor responsible for the decision in a particular case;
• Formal review conducted by a contractor or by the TRICARE Service Office (TSO);
• Hearing administered by the TSO but conducted by an independent hearing officer
2. The appeals process varies depending on whether the denial involves a “medical necessity” determination, factual determination or a provider sanction. All initial and appeal determinations include a section which explains how, where, and by when to file the next level of appeal.
PIECES OF THE PUZZLE
• One TRICARE benefit option is the “Program for Persons with Disabilities.”
• The Program for Persons with Disabilities (PFPWD) is only for seriously disabled persons who are dependents of active-duty members.
• You must apply and get approval before TRICARE Standard can help pay the costs of care.
• You should check with your nearest Health Benefit Adviser (HBA) or TRICARE Service Center (TSC) before applying for benefits under the program.
• Sometimes not using PFPWD benefits for diagnostic and treatment services can save you money. The PFPWD benefits is generally limited to $1,000 per month. You may instead be able to get these services under the basic TRICARE Standard program, where you may have to pay only a maximum of $1,000 in a fiscal year (this is the “catastrophic cap” on expenses for active duty families).
• If you decide to use PFPWD for the needed services and your costs exceed the $1,000 monthly limit, those amounts in excess of the limit under PFPWD may not be cost-shared by TRICARE Standard under the basic program. Therefore, you should work very closely with your HBA or TSC when considering using these benefits.
• Enrollment in TRICARE Prime does not affect a person’s eligibility to receive services under PFPWD.
• Who Qualifies? The PFPWD serves people with two kinds of serious disabilities: persons who have moderate or severe mental retardation and those who have a significant physical disability.
• Public funds and facilities must be either unavailable or insufficient to meet the patient’s disability-related needs. In many communities, public funds are available for persons with disabilities. If so, you must first get assistance this way. Your HBA or TSC may be able to help you find out about help available in your community. If public help isn’t available or isn’t enough, TRICARE Standard helps pay for covered services. But you must include with your request for PFPWD benefits a letter from the proper public official saying why public help is unavailable or insufficient. If you do not know whom the right public official is, contact a HBA or your TSC.
NOTE: As with the rest of the TRICARE program, all providers of services or supplies/equipment must be authorized. Contact your HBA or TRICARE contractor for guidelines on the type of information required to establish the existence of a qualifying medical condition and to establish the need for the benefits required.
