TRICARE, formerly known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), is a health care program of the United States Department of Defense Military Health System.[1] TRICARE provides civilian health benefits for military personnel, military retirees, and their dependents, including some members of the Reserve Component. The TRICARE program is managed by TRICARE Management Activity (TMA) under the authority of the Assistant Secretary of Defense (Health Affairs). TRICARE is the civilian care component of the Military Health System, although historically it also included health care delivered in the military medical treatment facilities.
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Historically, health care for military personnel and their dependents was provided in military medical facilities on a "space-available" basis. After World War II and the Korean War, access to care in military facilities became increasingly unavailable due to resource constraints and growing demands on the system. To address this problem, Congress passed the Dependents Medical Care Act of 1956 and the Military Medical Benefits Amendments of 1966. These acts allowed the Secretary of Defense to contract with civilian health care providers. This civilian health care program became known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) in 1966.[2]
In the late 1980s, because of escalating costs, paperwork demands, and general beneficiary dissatisfaction, DoD initiated a series of demonstration projects. Under a program known as the CHAMPUS Reform Initiative (CRI), a contractor provided both health care and administrative-related services, including claims processing. The CRI project was one of the first to introduce managed care features to the CHAMPUS program. Beneficiaries under CRI were offered three choices — a health maintenance organization-like option called CHAMPUS Prime that required enrollment and offered enhanced benefits and low-cost shares, a preferred provider organization-like option called CHAMPUS Extra that required use of network providers in exchange for lower cost shares, and the standard CHAMPUS option that continued the freedom of choice in selecting providers but required higher cost shares and deductibles.
Although DOD’s initial intent under CRI was to award three competitively bid contracts covering six states, only one bid, made by Foundation Health Corporation (now Health Net) covering California and Hawaii, was received. Foundation delivered services under this contract between August 1988 and January 1994.
In late 1993, in response to requirements in the DOD Appropriation Act for Fiscal Year 1994, the DoD announced plans for implementing a nationwide managed care program for the MHS that would be completely implemented by May 1997. Under this program, known as TRICARE, the United States was divided into 12 health care regions. An administrative organization, the lead agent, was designated for each region and coordinated the health care needs of all military treatment facilities in the region. Under TRICARE, seven managed care support contracts were awarded covering DOD’s 12 health care regions.[3]
Since then, TRICARE has undergone several restructuring initiatives, including re-alignment of contract regions, Base Realignment and Closure, and the addition of "TRICARE for Life" benefits in 2001 for those who are Medicare-eligible, and "TRICARE Reserve Select" in 2005.
TRICARE Standard provides a similar benefit to the original CHAMPUS program and is available to active duty personnel, retirees from the Active Component, retirees from the Reserve Component age 60 or older, and their eligible family members. Under TRICARE Standard, beneficiaries can use any civilian health care provider that is payable under TRICARE regulations. The beneficiary is responsible for payment of an annual deductible and coinsurance, and may be responsible for certain other out-of-pocket expenses. There is no enrollment fee for TRICARE Standard.
TRICARE Standard beneficiaries can elect to use the TRICARE Extra option by using a civilian health care provider from within the regional contractor's provider network. In this way, TRICARE Extra represents a preferred provider organization (PPO). When using TRICARE Extra, the beneficiary's coinsurance amount is reduced by at least five percentage points. There is no fee for use of the TRICARE Extra benefit other than the coinsurance.
TRICARE Prime is a health maintenance organization (HMO) style plan available to active duty personnel, retirees from the Active Component, retirees from the Reserve Component age 60 or older, and their eligible family members. Under TRICARE Prime, beneficiaries must choose a primary care physician and obtain referrals and authorizations for specialty care. In return for these restrictions, beneficiaries are responsible only for small copayments for each visit. There is an annual enrollment fee for TRICARE Prime for military retirees and their family members. There is no enrollment fee for active duty military and their family members.
US Family Health Plan, a TRICARE Prime-sponsored health plan option, is made available by nonprofit health care providers in the Northeast U.S., Southeast Texas/Southwest Louisiana, and the Puget Sound region of Washington state.
TRICARE Reserve Select is a premium-based health plan that active status qualified National Guard and Reserve members may purchase. The classification is sometimes referred to as TRICARE Reserve Component (RC). It requires a monthly premium and offers coverage similar to TRICARE Standard and Extra for the military member and eligible family members. It has a partial premium cost sharing arrangement with DoD similar to civilian private or public sector employer plans, although typically at a lower cost than civilian plans. The program coverage is available world wide to Selected Reserve (SELRES) members of both the Title 10 USC Federal Reserve Components (Army Reserve, Navy Reserve, Air Force Reserve, Marine Corps Reserve), Title 14 USC Federal Reserve Component (Coast Guard Reserve) and the Title 32 National Guard (Army National Guard and Air National Guard) in a drill pay (also known as "paid") status. As of February 2008, retired Reserve Component personnel under the age of 60, actively drilling Individual Ready Reserve (IRR) personnel in a non-paid status, or actively drilling Volunteer Training Unit (VTU) personnel in a non-paid status do not qualify for TRS. IRR and VTU members are eligible for reinstatement under TRS is they return to a SELRES status. Reserve Component personnel who are also Federal civil servants (to include Army Reserve Technicians and Air Reserve Technicians (ART) in the Army Reserve, Army National Guard, Air Force Reserve and Air National Guard) and eligible for the Federal Employee Health Benefit Program (FEHBP) are also excluded from TRS. Retired Reserve Component personnel and eligible dependent family members become eligible TRICARE Standard, TRICARE Extra or TRICARE Prime on the service member's 60th birthday in the same manner as Active Component retirees and their eligible dependensts are eligible immediately upon retirement from active service. Qualification questions should be referred to TRICARE.
TRICARE Reserve Retired is a premium-based health plan that qualified retired members of the National Guard and Reserve under the age of 60 may purchase for themselves and eligible family members. Established in 2008 and opened for enrollment in 2010, it is similar to TRICARE Reserve Select (TRS), but differs in that there is no premium cost-sharing with DoD as there is with TRS. As such, retired Reserve Component members who elect to purchase TRR must pay the full cost (100%) of the calculated premium plus an additional administrative fee. Although open to all eligible retired Reserve Component personnel under the age of 60, the program's principal focus is often perceived as being focused on recent Reserve Component retirees who are self-employed or otherwise ineligible for civilian employer provided/subsidized health insurance, especially those who were mobilized for full-time active duty service subsequent to 11 September 2001 in support of Operations ENDURING FREEDOM, IRAQI FREEDOM, NEW DAWN and/or NOBLE EAGLE. Retired Reserve Component personnel who elect to participate in TRR will exit TRR when the service member reaches age 60 and he/she and their eligible dependent family members become eligible for the same TRICARE Standard, TRICARE Extra or TRICARE Prime options as Active Component retirees and, in the case of TRICARE Prime, at the same cost as Active Component retirees. Qualification questions should be referred to TRICARE.
TRICARE for Life was first incorporated as part of the then 7 regional Managed Care Support Contracts of TRICARE in May 2001. The benefit was enacted by Congress in response to growing complaints from beneficiaries that as Medicare out of pocket costs increased a benefit was needed to pay these costs in lieu of TRICARE retirees being required to purchase Medicare Supplemental Coverage to pay for prescriptions, physician and hospital dispensed drugs, cost shares and deductibles. Before TRICARE for Life, TRICARE beneficiaries immediately lost TRICARE coverage upon attaining Medicare eiligibility. This included becoming Medicare eligible due to disability. TRICARE for Life is designed to pay patient liability after Medicare payments. There is no enrollment necessary for TRICARE for Life and to be eligible, you must be TRICARE and Medicare Eligible and have purchased Medicare Part B coverage. An exception to the requirement for Part B coverage exists when the beneficiary that is Medicare eligible is the spouse of an Active Duty Service Member. In some instances TRICARE for Life is primary payer when the services are normally a TRICARE benefit but not covered by Medicare. This includes drug charges, when Medicare benefit limits are attained and services performed outside the United States or in a Veterans Affairs facility where Medicare does not pay. TFL does not pay patient liability for services that are not a TRICARE benefit even though they may be paid by Medicare, such as chiropractic benefits. The policy limitations applying to TRICARE also apply to TFL and must therefore be deemed medically necessary and skilled care. Custodial care therefore is not covered. In 2004 the TRICARE for Life benefit was transferred from the individual regional TRICARE contractors. Medical claims are processed by the national TRICARE Dual Eligible Fiscal Intermediary Contractor (TDEFIC-Wisconsin Physicians Service Insurance Corporation). Pharmacy claims are processed by the TRICARE Pharmacy Contractor (Express Scripts) and Overseas TFL claims are processed by the TRICARE Overseas Program Contractor (as of September 2010 this will be International SOS using Wisconsin Physicians Service as their Fiscal Intermediary partner).
TRICARE Young Adult (TYA) is a premium-based health care plan available for purchase by qualified dependents who have aged out of TRICARE at age 21, or age 23 for full-time college students. Dependents are eligible if they are unmarried, not eligible for TRICARE coverage or their own employer-sponsored health care coverage, and as long as their sponsor remains TRICARE eligible. [4]
Eligible dependents have the option to purchase TRICARE Standard/Extra health coverage on a month-to-month basis. Purchased coverage includes medical and pharmacy benefits but does not include dental. A premium-based TRICARE Prime benefit will be available later in 2011.
The signing of the National Defense Authorization Act in January 2011 aligned TRICARE with the provisions of the 2010 Patient Protection and Affordable Care Act, and lead to the creation of TYA.New TRICARE Program Offers Coverage for Young Adults Under 26
Enrollment began May 1, 2011.
The ultimate responsible organization for administration of TRICARE is the U.S. Department of Defense Military Health System, which organized the TRICARE Management Activity (TMA). The TRICARE Management Activity contracts with several large health insurance corporations to provide claims processing, customer service and other administrative functions to the TRICARE program. Currently, there are three regional Managed Care Support Contractors (MCSCs), a Medicare/TRICARE Dual Eligible Fiscal Intermediary Contractor (TDEFIC), and a TRICARE Pharmacy contractor, who administers both Mail Order Pharmacy (TMOP) and Retail Pharmacy (TRRx) programs. In addition several administrative contractors provide quality management, auditing, and statistical services. TMA also oversees the TRICARE Dental Program (TDP), run by United Concordia, and TRICARE Retiree Dental Program (TRDP), run by Delta Dental.
In 2004, TRICARE Management Activity re-aligned the previous twelve regions into three large regions, known as TRICARE North, TRICARE South, and TRICARE West. Services in these regions are provided by:
All medical claims are processed by the following claims processing sub-contractors:
In 2009, the TRICARE Overseas Program contract consolidated the following:
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