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 the individual seeks care from a provider whose part of the TRICARE network and receives a discount on services, paying reduced cost-shares in most cases. TRICARE Standard pays a share of the cost of covered health services that can be obtained from a non-network civilian health care provider. There’s no enrollment in TRICARE Standard. Under this option, the individual has more freedom to choose a provider of care—but costs will be higher than with the other two TRICARE options.
CONTACT
TRICARE Humana Military Healthcare Services, Inc. (South Region)
(800) 445-5445
http://www.tricare.osd.mil
Oklahoma TRICARE Service Centers are listed below:
301 N 1st Ave
Building 46
Altus AFB, OK 73523-5005
4301 NW Wilson St
Reynolds Arm Community Hospital
Ft. Sill, OK 73503-6300
5700 Arnold St.
Building 5801, Rm E29A
Tinker AFB, OK 73145-8102
527 Gott Road
Vance AFB, OK 73705-5105
FINANCIAL CRITERIA
• See “ELIGIBILITY”
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
Prosthetics & Orthotics
Aids for Vision Impaired
Medical Supplies
Augmentative Communication
Seating/Positioning Equipment
Environmental Controls
Wheelchairs & Mobility Aids
Hospital Beds
APPLICATION PROCESS
• In order to use TRICARE, the individual 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, which 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); and
• 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
• The Extended Care Health Option (ECHO) is a supplemental program to the basic TRICARE program. ECHO provides financial assistance for an integrated set of services and supplies to eligible active duty family members (including family members of activated National Guard or Reserve members).
• There is no enrollment fee for ECHO, however family members must:
• have an ECHO-qualifying condition;
• enroll in the Exceptional Family Member Program (EFMP) as provided by the sponsor’s branch of service; and
• register in ECHO through ECHO case managers in each TRICARE region.
• Qualifying conditions include:
• moderate or severe mental retardation;
• a serious physical disability; and
• a physical or psychological condition that causes the beneficiary to be homebound.
• Extended Care Health Option (ECHO) benefits may include:
• medical and rehabilitative services;
• training to use assistive technology devices;
• special education;
• institutional care when a residential environment is required;
• transportation for institutionalized beneficiaries to receive authorized ECHO benefits;
• assistive services, such as those from a qualified interpreter or translator;
• durable equipment, including adaptation and maintenance;
• In-home medical services through ECHO Home Health Care (EHHC);
• In-home respite care services;
• ECHO respite care: 16 hours per month when receiving other authorized ECHO benefits;
• EHHC respite care: up to 40 hours per week (eight hours per day, five days per week) for those who qualify; and
• Educational Interventions for Autism Spectrum Disorders (EIA) services through the Enhanced Access to Autism Services Demonstration.
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