DEFINITION: TRICARE is a federal program that shares the cost of hospital and medical care for dependents of those on active duty and of those retired from the Military Forces and their dependents, as well as some
former Military spouses.
DEFINITION: CHAMPVA is a federal program that shares the cost of hospital and medical care for dependents of those 100% disabled as the result of a service connected disability; and the dependents of those deceased
who were 100% disabled as the result of a service connected disability. Other rules for CHAMPVA are essentially the same as for TRICARE.
ELIGIBILITY: Basically the following are eligible for Champus benefits. TRICARE benefits end whenever the beneficiary become eligible for Medicare.
A) ACTIVE-DUTY FAMILY
1. Spouse
2. Former spouse provided specific criteria are met.
3. Children and stepchildren
To age 21 if unmarried.
To age 23 if full time student and unmarried
After 21 if disabled and unmarried with disability prior to age 21.
4. Active-duty sponsor is NOT eligible for benefits.
B) RETIRED OR DECEASED SPONSOR
Same as above except living retired Sponsor is eligible for benefits.
PROOF OF ELIGIBILITY: Valid Uniformed Services Identification and Privilege Card, DD Form 1173, or for retirees a gray colored DD Form 2 (Ret.). Expiration date is on the front of the card and the effective date is
on the back of it. TRICARE checks eligibility through the DEERS computer files
BASIC COVERAGE: Portion of costs of inpatient and outpatient services from any civilian health care providers, subject to conditions of the plan, based on a Cost-Share concept.
EXAMPLES OF CARE COVERED: Inpatient and outpatient care for medical or surgical conditions, inpatient and outpatient care for mental, nervous conditions, and chronic conditions. Beneficiaries who require
continuous inpatient care for more than 90 days for a chronic medical ( exclusive of mental disorder ) or surgical condition must have a plan for management of the condition approved by the appropriate TRICARE
claims processor. Inpatient or outpatient care for contagious conditions, maternity and infant care services of nurses, physical therapists etc., artificial limbs and eyes rental of durable equipment such as wheelchairs
hospital beds etc., routine physical examinations and inoculations when required for dependents of active duty members when traveling outside the United States as a result of the member's duty assignment,
family planning drugs administered at a civilian facility or physician ( drugs supplied by an inpatient facility are covered only if a prescription is needed or their issuance, except insulin ambulance when medically
needed. Authorization is needed for the services of optometrists, psychologists and dentists, except where dentistry is part of the necessary medical care.
EXAMPLES OF EXCLUSIONS: Physical examinations and immunizations except as above, well baby care after age two, prosthetic devices such as hearing aids and orthopedic foot wear, domiciliary or custodial
care, eye glasses for the correction of ordinary refractive error, sexual dysfunction or inadequacy counseling, obesity when obesity is the major condition treated, cosmetic surgery, some Christian Science services any
service or supply which is not necessary to diagnose and treat a mental or physical illness, injury, or body malfunction as diagnosed by a physician, dentist or clinical psychologist.
NONAVAILABILTY STATEMENT: DD Form 1251. Champus will not pay for non emergency inpatient care received at a civilian source by any beneficiary who lives within an approximate 30 to 60 mile radius zip
code catchment area of a Uniformed Services medical facility that provides inpatient care, unless that facility issues a nonavailability statement - does not apply to emergency inpatient care or care while away from the
home area on a trip. The Commander of a Uniformed Services hospital, which includes Public Health Service hospitals, may issue a nonavailability statement in the following cases: when maternity patient resides more
than 30 miles from a facility that can provide care, when transportation conditions impose unreasonable difficulties and costly conditions, when the required care is not available at the Uniformed Services hospital,
there is a conflict of opinion between civilian and military physicians as to the proper care or the course of treatment.
INPATIENT CARE: Spouses or children of active duty members pay $ 25.00 or $ 8.05 a day, whichever is greater. TRICARE is under the DRG payment system for hospitals for most admissions to acute care and
short-term hospitals, except for the State of Maryland.
COST CAP: TRICARE has a cap on the cost of covered care. It is $ 1,000 per fiscal year for active duty families and $ 10,000 per fiscal year for all others. The cap applies only to the amount required to meet annual
deductibles and cost-shares based on allowable charges. After the cap is reached the TRICARE claims processor will pay the full allowable charges for TRICARE covered care for the balance of the fiscal year.
OUTPATIENT CARE: A deductible must be paid in each fiscal year. The fiscal year is from October 1 through September 30. For one beneficiary the deductible is $ 50.00 per fiscal year. For a family of two or more
beneficiaries the deductible amount collectively is $ 100.00 per fiscal year. For spouses and children of members on active duty Champus pays 80% of the reasonable charges after the deductible. For other
beneficiaries Champus pays 75% of the reasonable charges after the deductible.
FILING DEADLINE: The deadline is the last day of the Calendar year following the Calendar year in which the services and supplies were provided.
AMBULANCE SERVICE: TRICARE may share the cost of ambulance service as an outpatient service under TRICARE rules. Taxis, medicabs and ambicabs do qualify as ambulances.
ASSIGNMENT: A provider who accepts the TRICARE assignment agrees to accept the TRICARE allowable charge as the full fee and can not charge the patient between the a greater charge and the allowable charge.
DUAL COVERAGE: When a TRICARE patient has another health plan, TRICARE always is the secondary payer. Medicaid is not considered double coverage, so in this instance TRICARE is the primary payer. Many have
TRICARE supplemental coverage. In this case TRICARE also is the primary payer.
CLAIMS PROCESSOR: A claims processing company, such as an insurance company, under contract with TRICARE to do so for TRICARE claims.
DEERS: Defence Department Enrollment Eligibility Reporting System.
ID CARDS: Cards issued by the Uniformed Services and the Veterans Administration showing a person is eligible for TRICARE and other benefits.
JUDGE ADVOCATE: The legal officer at a military base who is responsible for collecting TRICARE money in third party liability cases, such as in automobile accident cases.
