Category Archives: TRICARE

Storming the Hill Since 1969! #WayBackWednesday

It’s the 1990s, and our Association is making waves on Capitol Hill. During this decade, we released an innovative health care plan for military families, which included recommendations that were later incorporated into TRICARE.

Twenty years later, we are still on the forefront of TRICARE issues, including those controversial topics that your military family needs answers to. Not finding the answers you need? Leave us a comment and let us know how we can help!

Sydney-testifying

Navigating the TRICARE maze: Prime vs. Standard

tricare-prime-vs-standardCo-pays.

Cost-shares.

In-network vs. out-of-network.

I’ll have a whole new vocabulary once I master the TRICARE maze!

For the past 9 years, I’ve used TRICARE Prime. I’ve seen doctors at Military Treatment Facilities (MTFs) and in town. I thought I scored big time when I was assigned a Primary Care Manager (PCM) out in town because the base was too full to take new patients. When we were stationed outside of Washington D.C., I navigated between multiple MTFs to get the care I needed.

It’s not a perfect system and there are some glitches. For example, accessing records between an Army hospital and a Navy hospital…let’s just say it doesn’t work as well as it should. The different systems don’t always “talk” to each other, which means you may need to hand-carry records, especially ultrasounds, MRIs, or other digital images between MTFs. And if you do see a civilian provider off the installation you’ll also need to carry records between providers.

With Prime, one thing I never had to worry about was cost. As long as I had referrals and pre-authorizations – I had minimal co-pays, if any at all. In fact, I had our first son while covered under Prime and don’t recall paying anything for my prenatal care, labor, delivery, or post-partum care. I attended child birth classes, met with a lactation consultant, took an infant CPR class, and even left the hospital with a bag full of goodies for our newborn.

Four years later, we are expecting our second and I decided to switch to TRICARE Standard. Why? Because when I got pregnant, I was recalled by the MTF, even though I live more than 30 miles from an MTF and was already seeing a civilian provider in town. And, unfortunately, the MTF I was recalled to doesn’t have the providers I need. I didn’t want to navigate appointments in opposite directions driving 30 miles one way to the MTF and 30 miles in the opposite direction to specialists.

I thought I understood the deductible, co-pays, and cost-shares under TRICARE Standard. Yet, maternity care has its own set of cost-shares, too. I’ve learned to keep copies of my Explanation of Benefits (EOBs) and any bills I receive directly from a provider. I call my regional contractor frequently to review claims and ask questions. I discovered my OB’s billing office isn’t an expert on TRICARE billing, and as a result, I was being overcharged. I had the same problem with overcharges for lab work, too.

And I discovered the hospital education benefits I enjoyed at the MTF with my first pregnancy aren’t covered. There is a fee to take a child birth refresher class or meet with a lactation consultant.

Our second baby is due in a few short weeks and overall I’m happy with the quality of care we are receiving under TRICARE Standard. I’ve learned I have a role to play in keeping costs down by asking questions about coverage, reviewing bills, reading the TRICARE website, and talking to my regional contractor to understand our benefit. TRICARE Standard has given me the flexibility to see the providers I prefer, but it comes at a cost.

What are your experiences with TRICARE Prime vs. TRICARE Standard? What would you recommend to other military families?

katie2Posted by Katie Savant, Government Relations Information Manager

Middle of the Night Hero – The Nurse Advice Line

mom-with-sick-babyNew mom. Husband is out of town. 4 month-old with a raging fever and barky cough. It’s 3:00 A.M. Oh, and there’s a blizzard dumping buckets of snow.

I haven’t heard this cough before and it sounds like he’s having trouble breathing. Why does my husband have to be gone when I’m in the middle of a crisis? I don’t want to risk our lives taking our infant-son to the emergency room in this weather. So, what should I do?

Medical Advice Is Only a Phone Call Away
Thankfully, the Nurse Advice Line was up and running that night my son came down with pneumonia. And, the good news is that the Nurse Advice Line is back. Stateside military families, including those in Alaska and Hawaii, can call 1.800.TRICARE (874.2273) 27/4 and reach a licensed nurse. This was a godsend when my son was an infant. The nurse was able to ask me questions about my son’s condition. She also offered some at-home remedies to help sooth his symptoms and scheduled an appointment for me the very next morning.

I was very thankful to have a medical professional to call in the middle of the night. Her tips helped calm my son (and his nervous momma, too) and I was able to safely make it to my son’s pediatrician’s office in the morning when the roads were cleared.

Who Can Use the Nurse Advice Line?
The Nurse Advice Line is available to all TRICARE beneficiaries including Prime, Network Prime, Standard, TRICARE for Life, TRICARE Reserve Select, TRICARE Retired Reserve, TRICARE Young Adult. And if you use Prime and are enrolled at a Military Treatment Facility – the nurse can help you schedule an appointment. Score!

But do you still need a referral from your Primary Care Manager?  Find out here.

Do you think your military family will use the Nurse Advice Line?

KatiePosted by Katie Savant, Government Relations Information Manager

Navigating Urgent Care as a Military Family

urgent-careMy family has fairly extensive experience with urgent care. We have been very fortunate to avoid major medical issues and emergencies, but, like most people with kids, we’ve had our share of strep throat, stomach viruses, and recurrent ear infections. In true Murphy’s Law fashion, these situations tend to crop up at the most inconvenient times.

When my daughter was a toddler, I could predict her ear infections with remarkable accuracy based on the federal holiday weekend schedule when our Military Treatment Facility (MTF) would be closed for 3-4 days straight. Many times, I was faced with a decision on where and when to seek care that did not fit the category of emergency, but seemed quite necessary to me.

When you or a family member need unexpected medical care, it can sometimes be difficult to know who to call or where to go. Urgent medical conditions are those that do not threaten life, limb, or eyesight, but need attention to prevent them from becoming a serious health risk. Your options differ based on whether you have TRICARE Prime or Standard but, in both cases, your primary care manager (PCM), family doctor, or pediatrician is your best place to start.

For TRICARE Prime Beneficiaries
If you reach your PCM but they cannot provide an appointment within 24 hours, you can request a referral to a local network urgent care clinic. You can find a network urgent care clinic by using the Find a Provider tool on your regional managed care support contractor’s website: HealthNet Federal Services in the North Region, Humana in the South Region, and UnitedHealthcare in the West Region or by calling the customer service line.

If you are unable to reach your PCM, call your managed care support contractor to discuss your options.

A TRICARE Prime beneficiary who uses an urgent care clinic without a referral is choosing the TRICARE Point of Service option which results in higher out of pocket costs. The Point of Service option has a $600 family deductible. This means that your family has to pay $600 out of pocket before TRICARE cost sharing begins. If your trip to urgent care is your family’s first time using the Point of Service option, the entire fee will be applied against the deductible and you will be responsible for paying the urgent care clinic out of pocket.

For TRICARE Standard Beneficiaries
TRICARE Standard does not require a referral for urgent care. If you reach your family doctor or pediatrician but they cannot provide an appointment – or – if you are unable to reach your regular doctor, you can find a network urgent care clinic using the same options listed above. Your usual deductible and cost shares will apply.

This spring, TRICARE plans to introduce a Nurse Advice Line that will give beneficiaries another option for getting an Urgent Care referral. We will release details on the Nurse Advice Line as soon as they are available to us.

What questions do you have about TRICARE? Let us know in the comment section below and we’ll do our best to answer them!

karen-rPosted by Karen Ruedisueli, Government Relations Deputy Director

FAQ Series: Affordable Care Act and TRICARE – Dental, Vision, Breast Pumps

tricare-patientWith the roll-out of the Affordable Care Act (ACA), many TRICARE beneficiaries have questions about specific ACA provisions and whether those provisions will impact TRICARE. Specifically, military families have contacted us with questions about dental, pediatric vision coverage, and breast pumps for new moms.

General Information
The ACA defines “10 essential health benefits.” All insurance plans sold to individuals and small businesses (e.g., those sold on the exchanges) will have to cover items and services in the “10 essential health benefits” categories. Self-insured employers (large employers such as Apple, Home Depot, Yahoo, etc. who choose to pay claims from their own money vs. purchase a typical insurance policy for their employees) are exempt from the essential benefit requirement. More than half of Americans who have health insurance provided by their employers are in self-insured health benefit plans. Additionally, most large employer plans already cover most of the 10 broad essential benefits categories.

The ACA also requires most health plans to cover preventative services at no cost to the patient.

The ACA requires dental coverage for children. How does this compare to TRICARE?
Pediatric dental coverage is one of the ACA’s “10 essential health benefits.” The ACA gives states wide latitude to decide what specific “essential benefits” insurers must offer in their policies. According to the American Dental Association, most states will require plans to provide an adequate array of dental services (Utah is the only state to offer only preventative services).

TRICARE offers three dental programs for service members and military families: the TRICARE Dental Program, the TRICARE Retiree Dental Program, and the TRICARE Active Duty Dental Program. The dental programs offer coverage to active duty service members and their families, Guard and Reserve members (activated or not) and their families, retirees and their families, and surviving spouses and their children. TRICARE’s dental programs already cover children and the services included in the ACA mandated pediatric dental plans.

The ACA requires pediatric vision coverage. How does this compare to TRICARE?
Pediatric vision coverage is one of the “10 essential health benefits” the ACA requires. However, there is limited information on the healthcare.gov website regarding vision benefit specifics. According to the American Academy of Ophthalmology, individual and small group health insurance plans (such as those sold on the exchanges) will be required to include full coverage of childhood comprehensive eye exams and glasses or contact lenses for vision correction.

TRICARE offers coverage for routine eye exams for both children and adults. They will also cover treatment for medical conditions of the eye. TRICARE does not, however, cover contact lenses or eyeglasses for vision correction except under very limited circumstances. Visit the TRICARE website to read their Vision Benefits Fact Sheet (located on the right side of the page under “Related Downloads”) for details.

The ACA requires insurance plans to cover breast pump rental or provide breast pumps for new moms. How does this compare to TRICARE?
The ACA requires most health plans to cover preventative health services specifically for women, including breastfeeding comprehensive support and counseling. As part of breastfeeding support, the ACA requires insurers to cover breast pumps. However, plans that are grandfathered are exempt from this requirement.

TRICARE will only cover a breast pump if the baby is premature and meets certain criteria.

Will TRICARE’s coverage change to include these additional benefits the ACA requires?
TRICARE operates completely independently of the ACA which is concerned only with commercial insurers. Since TRICARE is not a health insurance policy or company, but a federal health benefits program, it is not subject to the laws that govern the insurance industry either at the federal or state level. As such, TRICARE is not required to adhere to the provisions in the ACA.

This does not mean that TRICARE will never change policy to enhance coverage. For example, to bring TRICARE in line with the ACA provision extending parents’ health insurance to their children up to age 26, the FY11 National Defense Authorization Act gave the Defense Department the authority to extend TRICARE coverage to young adults. Something similar would be required to provide pediatric vision and breast pump coverage to TRICARE beneficiaries, but no legislation or policy changes regarding these benefits have been introduced to date.

Do you have additional questions about how the ACA provisions impact TRICARE? Post a comment or send us an email at info@militaryfamily.org.

Posted by Karen Ruedisueli and Katie Savant, Government Relations Department

Preparing to Return to Civilian Life: A spouse’s perspective

crossroads-sign2With small budgets and shifting priorities, the mission for the U.S. military is changing. An estimated 123,900 service members will leave the Services within the next five years. Some folks signed up for one tour and only intended to stay in for that enlistment. Others joined knowing they wanted to make this a career. Regardless of the reasons for separating from the military, a significant number of current service members will not make the military a career.

When I read articles about downsizing, I immediately think about how this would impact our family; specifically what happens to our pay and benefits. Any entitlement to pay and benefits after your service member leaves the service will depend on the circumstances of separation.

For example, if the service member retires; he or she is eligible for retirement benefits. Unfortunately, most folks who are separating due to the drawdown are not eligible for retirement benefits. If you fall into the later category, here are some tips to help you prepare for life outside the gates:

Pay: This is a big one. You and your service member will need to decide how you will earn an income. It may be helpful to consider the following:

  • Your taxable and nontaxable income (i.e. allowances such as a housing allowance (BAH) are not taxable)
  • Your current and estimated expenses (i.e. if you are living on the installation now and will move back to your home town, check out the local rental rates, property values, utility costs, etc.)
  • The cost of living in your projected job market
  • Your estimated income needed to meet or exceed your current standard of living

Health Care: Health care is the largest non-monetary part of the service member’s benefit package. While the service member may be eligible for service-connect health care for life through the Department of Veterans Affairs (VA), your family generally loses coverage once the service member separates from the Service.

You may be able to receive health care coverage in the individual market, a health care exchange, or through an employer’s plan. Your family may be eligible to participate in TRICARE’s Transitional Assistance Management Program for 180 days of premium-free transitional health care benefits after regular TRICARE benefits end. After this coverage ends, your family may be eligible for the Continued Health Care Benefit Program (CHCBP).

CHCBP is a premium-based program offering temporary transitional heath coverage from 18-36 months after TRICARE eligibility ends. A family premium for 2013 is $2,555 per quarter.

Life Insurance: Whether you are separating from military service or retiring, you will need to decide what to do with your Servicemembers’ Group Life Insurance (SGLI) coverage. SGLI stays with you for an additional 120 days after you leave the service, and then it stops for good. You need to decide to either take Veterans’ Group Life Insurance (VGLI) or get your own individual life insurance.

For those who sustained injury or have chronic conditions, it is imperative to look at whether or not outside insurers will cover you. You can convert to VGLI in the specified time period without proof of good health. After that time period, you will have to prove you are in good health.

Keep in mind that Family Servicemember’s Group Life Insurance (FSGLI) provides coverage for your spouse and children. It may be converted to an individual policy, but not to VGLI. Companies listed on the VA website will convert spouse health coverage without proof of good health during a specified time period.

Ancillary benefits: Ancillary benefits may include the Commissary, Exchange, reduced child care fees, or discounts in your local community – all part of the overall military lifestyle and some elements of the military compensation package.

In most cases, you will not be able to continue to access these privileges; however, some communities may provide benefits for veterans. It is recommended you ask each establishment to determine what type of documentation you need to show if you are eligible to participate. You may find there is another type of discount, such as a community membership, for folks who live in a specific neighborhood, which is available to you instead of a military discount.

This is the first of a blog series discussing transition from military life to civilian life. What other transition topics would you like to see? Leave a comment below!

KatiePosted by Katie Savant, Government Relations Information Manager

Navigating the Healthcare Crossroad: Active Duty to Reserves

crossroads-ad-to-reservesRecently, my spouse separated from active duty and transitioned to the Reserves. Healthcare was a major concern for us. While he was on terminal leave, we were eligible for TRICARE Prime, but we had to change service regions and find new doctors for any non-urgent treatment.

We were unsure about what would happen upon his separation date.

He had an assignment to a Reserve unit that processed him in the day after he separated from active duty, preventing a break in service. This made us eligible for the Transition Assistance Management Program (TAMP).

TAMP provides continuation of TRICARE coverage for 180 days.
We applied for TAMP through the Defense Enrollment Eligibility Reporting System (DEERS). If your dependents are not enrolled in TRICARE Prime upon separation, you will have to submit a new enrollment. This means there will be a waiting period before benefits can begin.

In the meantime, you will have TRICARE Standard coverage. If you were previously enrolled in TRICARE Prime, you can have your TRICARE Prime enrollment backdated to the last day of active duty service. It is important to submit a DD Form 2876 to your regional or local TRICARE office, because it cannot be backdated through web enrollment.

As a Reserve family, we are enrolled in TRICARE Dental and pay premiums. When called to active duty, my husband’s premium is suspended until his activation period is over, and he is covered under TRICARE Active Duty Dental Program. Dependents will continue to pay premiums for dental coverage during the activation.

Whenever we had questions, calling TRICARE or Military OneSource usually resolved things, but there were some paperwork headaches. The websites are pretty thorough and easy to navigate, even when we felt overwhelmed by all of the new changes.

Have you or your service member made this transition? Share your tips for transitioning from active duty to reserves in the comments below! 

brookePosted by Brooke Goldberg, Government Relations Deputy Director