JKO TRICARE Fundamentals Course (TFC)

It is the premium-based plan for retired reservists who have not yet turned age 60

Which of the following BEST describes TRICARE Retired Reserve (TRR) coverage?

National Guard/Reserve members separating from a period of active service of more than 30 consecutive days in support of a contingency operation.

All of the following are eligible for the Transitional Assistance Management Program (TAMP) EXCEPT?

180 days

TAMP beneficiaries are eligible for __________of medical coverage?

Contact the adjudicating staff judge advocate

Beneficiaries should do all of the following to resolve claims EXCEPT

Active duty families

The Extended Care Health Option (ECHO) covers service and supplies beyond the basic TRICARE benefit for only?

Non-network pharmacies

Which of the following TRICARE Pharmacy Program options charges TRICARE Prime enrollees (except for active duty members) a 50 percent point-of-service cost-share?

Medicare Part B

Individuals may have to pay a late enrollment penalty if they don't sign up for which of the following when they first become eligible?

90 day

If a beneficiary is using Home Delivery, he or she receives a __________________ supply and three refills of most medications?

Have a service-related condition validated by a DoD physician

Former active duty members who are TAMP eligible may be eligible for Transitional Care for Service-Related Conditions (TCSRC) if they?

TRICARE-eligible beneficiaries, TRICARE-authorized providers, The spouse, parent, or legal guardian of a minor (under age 18) or an incompetent beneficiary - All of the above

Who may file a claim with TRICARE?

TRICARE Young Adult

Under which health plan do retirees, their eligible family members, or active duty family members NOT qualify to purchase vision coverage through the Federal Employees Dental and Vision Insurance Program (FEDVIP)

They are called to active service for more than 30 consecutive days in support of a federal contingency operation or preplanned mission and show as eligible in DEERS.

National Guard and Reserve members are eligible for the same health care benefits as active duty members when:

Federal Employees Dental and Vision Insurance Program

Which of the following is the voluntary dental option for retired members of the Uniformed Services and their eligible family members?

TRICARE For Life, TRICARE Reserve Select, TRICARE Prime - All of the above

TRICARE Plus is a primary care program offered at some military hospitals and clinics/enhanced multi-service markets for beneficiaries not enrolled in_____.

$0 a year

Active duty members and their family members pay __________ for TRICARE Prime enrollment.

Up to 15% above the TRICARE-allowable charge

When a beneficiary gets care from a non-network, non-participating provider, he or she may have to pay?

Optional for active duty family members in remote areas locations, stateside and overseas

TRICARE Prime Remote for Active Duty Family Members (TPRADFM) is?

$462

An individual retiree in Group B pays a _______ enrollment fee with TRICARE Select?

Part B

ADFMs who have Medicare Part A must sign up for _____________ before their sponsor's retirement date to avoid a break in TRICARE coverage?

They were pre-enrolled in TRICARE Prime

Newborn children of active duty family members are automatically covered under TRICARE Prime if?

Active duty members

Which of the following categories of beneficiaries isn't eligible for TRICARE Select?

Defense Health Agency, Great Lakes (DHA-GL)

The ____ reviews claims, approves payments, and determines the impact of a diagnosis on remote active duty members' fitness for duty.

catastrophic cap

The most a beneficiary pays out-of-pocket each calendar year for TRICARE- covered services or supplies is called?

TRICARE Reserve Select (TRS) and TRICARE Retired Reserve (TRR) offer the TRICARE ______ benefit to all covered individuals?

Covered for an injury incurred or aggravated in the line of duty

When on active service for 30 days or less, National Guard and Reserve members are?

How often may TRICARE Select enrollment fees, deductibles, cost-shares, and/or copayments change?

Each calendar year

If a beneficiary is declared ineligible for ECHO ________________________________.

The decision is not appealable

Newborn children of active duty family members are automatically covered under TRICARE Prime if

They live in a Prime Service Area

Which of the following categories of beneficiaries isn't eligible for TRICARE Select?

Active duty members

A civilian network provider:

Signs a contractual agreement with the regional contractor

If a beneficiary visits a non-network participating provider, the provider:

Accepts the TRICARE-allowable charge as payment in full

The most a beneficiary pays out-of-pocket each calendar year for TRICARE- covered services or supplies is called:

Catastrophic cap

What does direct care refer to

Care and pharmacy services only at a military hospital or clinic

Which of the following is a managed care option for active duty and eligible family members who live and work in designated remote ZIP codes?

TRICARE Prime Remote

Enrollees, whose sponsor initially enlisted or was commissioned before January 1, 2018, fall into which beneficiary category?

Group A

A beneficiary is considered in Group B if their sponsor enlisted or was commissioned:

On or after January 1, 2018

Which of the following options is direct-care only and therefore doesn't count as minimal essential coverage under the Affordable Care Act (ACA)?

TRICARE Plus with no other TRICARE eligibility

The ____________________________ reviews claims, approves payments, and determines the impact of a diagnosis on remote active duty members' fitness for duty.

Defense Health Agency, Great Lakes (DHA-GL)

National Guard and Reserve members are eligible for the same health care benefits as active duty members when:

They are called to active service for more than 30 consecutive days and show as eligible in DEERS

When on active service for 30 days or less, National Guard and Reserve members are:

Covered for an injury incurred or aggravated in the line of duty

TRICARE for Life (TFL) offers wrap-around medical coverage to TRICARE beneficiaries who have Medicare__________.

Part A and Part B

Individuals may have to pay a late enrollment penalty if they don't sign up for which of the following when they first become eligible?

Medicare Part B

An individual retiree in Group B pays a _______ enrollment fee with TRICARE Select.

$462

Delayed-effective-date active duty orders may be issued to National Guard and Reserve members who are:

Called to active service for more than 30 consecutive days in support of a contingency operation

When TRICARE Select enrollees receive care from non-authorized, non-network providers:

TRICARE will not pay their claims

The __________ option lets TRICARE Prime enrollees get non-emergency care from any TRICARE-authorized or overseas provider without a referral, but at higher cost.

Point of service

The ___________________________ is a voluntary, premium-based dental insurance plan that provides worldwide dental coverage to eligible, enrolled beneficiaries

TRICARE Dental Program (TDP)

Which of the following TRICARE Pharmacy Program options charges TRICARE Prime enrollees (except for active duty members) a 50 percent point-of-service cost-share?

Non-network pharmacies

If a beneficiary is using Home Delivery, he or she receives a __________________ supply and three refills of most medications.

Which of the following is the voluntary dental option for retired members of the Uniformed Services and their eligible family members?

Federal Employees Dental and Vision Insurance Program

TRICARE Young Adult

TRICARE Plus is a primary care program offered at some military hospitals and clinics/enhanced multi-service markets available to beneficiaries not enrolled in_____.

TRICARE Prime

Which online tool shows information about medications covered under the pharmacy benefit?

Formulary Search Tool

The Extended Care Health Option (ECHO) covers service and supplies beyond the basic TRICARE benefit for only:

Active duty families

When a beneficiary gets care from a non-network, non-participating provider, he or she may have to pay:

Up to 15% above the TRICARE-allowable charge

Active duty family members who have Medicare Part A must sign up for ____________________ before their sponsor's retirement date to avoid a break in TRICARE coverage.

Medicare Part B

When a beneficiary's health care services are covered by Medicare, TRICARE, and his or her OHI, TRICARE is the _____________ payer.

Last

Who may file a claim with TRICARE?

All of the above

Continued Health Care Benefit Program must be purchased within _____ days of when TRICARE eligibility ends.

TAMP beneficiaries are eligible for __________days of medical coverage.

180

TRICARE Prime Remote for Active Duty Family Members (TPRADFM) is:

Optional for active duty family members in remote areas locations, stateside and overseas

For TRICARE Prime Remote (TPR), active duty members and eligible Guard/Reserve members must be permanently assigned to and live more than 50 miles or more than a __________ drive time from a military hospital or clinic (based on ZIP code).

1 hour

Beneficiaries should do all of the following to resolve claims EXCEPT:

Contact the adjudicating staff judge advocate

Finish the statement below to correctly describe the Defense Enrollment Eligibility Reporting System (DEERS). DEERS is a centralized Department of Defense database that ______________________________.

Lists benefit and eligibility information for your uniformed service members and others, as deemed eligible by the DoD

TRICARE Reserve Select (TRS) and TRICARE Retired Reserve (TRR) members lose eligibility when the sponsor:

Becomes eligible for the Federal Employees Health Benefits (FEHB) program

All of the following are eligible for the Transitional Assistance Management Program (TAMP) EXCEPT:

Service members voluntarily separating from active duty under honorable conditions

Which of the following CAN'T be appealed?

The amount of the TRICARE-allowable charge

When can an enrollee change or enroll in a TRICARE Prime or TRICARE Select plan?

Both A and B

Which of the following are TRICARE Pharmacy Program options?

All of the above

The US Family Health Plan (USFHP) offers medical coverage with the same copaymemnts as what TRICARE option?

TRICARE Prime

Active duty members and their family members pay __________ for TRICARE Prime enrollment.

TRICARE Reserve Select (TRS) and TRICARE Retired Reserve (TRR) offer _____________ benefits to all covered individuals.

TRICARE Select or TOP Select

Which of the following BEST describes TRICARE Retired Reserve (TRR) coverage?

It is the premium-based plan for retired reservists who have not yet turned age 60

Former active duty members who are TAMP eligible may be eligible for Transitional Care for Service-Related Conditions (TCSRC) if they:

Have a service-related condition validated by a DoD physician

The ________________________________ authorizes civilian dental care for active duty members to ensure dental health and deployment readiness.

Active Duty Dental Program (ADDP)

Which of the following CAN'T be appealed?

The amount of the TRICARE-allowable charge

If a beneficiary visits a non-network participating provider, the provider:

Accepts the TRICARE-allowable charge as payment in full

When a beneficiary gets care from a non-network, non-participating provider, he or she may have to pay:

Up to 15% above the TRICARE-allowable charge

The most a beneficiary pays out-of-pocket each fiscal year for TRICARE-covered services or supplies is called

Catastrophic cap

What does direct care refer to?

Care and pharmacy services only at a military hospital or clinic

When can an enroll change, enroll in, or end their plan?

Both A and B

Which statement correctly describes the Defense Enrollment Eligibility Reporting System (DEERS)? DEERS is a centralized Department of Defense database that ______________________________.

Lists benefit and eligibility information for uniformed service members and others as deemed eligible by the DoD

Enrollees, whose sponsor initially enlisted, or was commissioned before January 1, 2018, fall into which beneficiary category?

Group A

A beneficiary is considered ?non-grandfathered? if their sponsor, enlisted or was commissioned:

On or after January 1, 2018

Newborn children of active duty family members are automatically covered under TRICARE Prime if:

They live in a Prime Service Area

How often may TRICARE Select costs change?

Both A and B

Which of the following categories of beneficiaries isn't eligible for TRICARE Select?

Active duty members

A non-active duty beneficiary in Group B pays a _______ enrollment fee with TRICARE Select.

$450

When Select enrollees receive care from non-authorized, non-network providers:

TRICARE will not pay their claims

The _______________________option lets TRICARE Prime enrollees get non-emergency care from any TRICARE-authorized or overseas provider without a referral, but at higher cost.

Point of service

Active duty members and their family members pay ____________________for TRICARE Prime enrollment.

$0.00 a year

The US Family Health Plan (USFHP) offers medical coverage with the same copays as what TRICARE option?

TRICARE Prime

Which of the following is a managed care option for active duty and eligible family members who live and work in designated remote ZIP codes?

TRICARE Prime Remote

TRICARE Prime Remote for Active Duty Family Members (TPRADFM) is:

Optional for active duty family members in remote areas locations, stateside and overseas

For TRICARE Prime Remote (TPR), active duty members and eligible Guard/Reserve members must be permanently assigned to and live more than 50 miles or more than a ___________ drive time from a military hospital or clinic (based on ZIP code).

1 hour

The _________________ reviews claims, approves payments, and determines the impact of a diagnosis on remote active duty members? fitness for duty.

The Defense Health Agency, Great Lakes (DHA-GL)

National Guard/Reserve members are eligible for the same health care benefits as active duty members when:

They are called to active service for more than 30 consecutive days and show as eligible in DEERS

When on active service for 30 days or less, National Guard/Reserve members are:

Covered for an injury incurred or aggravated in the line of duty

Delayed-effective-date active duty orders may be issued to National Guard/Reserve members who are:

Called to active service for more than 30 consecutive days in support of a contingency operation

TRICARE Reserve Select (TRS) and TRICARE Retired Reserve (TRR) offer the TRICARE ____________ benefit to all covered individuals.

Select or TOP Select

Which of the following BEST describes TRICARE Retired Reserve (TRR) coverage?

It is the premium-based plan for retired reservists who have not yet turned age 60

TRICARE Reserve Select (TRS) and TRICARE Retired Reserve (TRR) members lose eligibility when the sponsor:

Becomes eligible for the Federal Employees Health Benefits (FEHB) program

All of the following are eligible for the Transitional Assistance Management Program (TAMP) EXCEPT:

Service members voluntarily separating from active duty under honorable conditions.

Former active duty members who are TAMP eligible may be eligible for Transitional Care for Service-Related Conditions (TCSRC) if they:

Have a service-related condition validated by a DoD physician

Continued Health Care Benefit Program must be purchased within ____ days of when TRICARE eligibility ends.

TAMP beneficiaries are eligible for __________ of medical coverage.

180 days

Which of the following are TRICARE pharmacy program options?

All of the above

Which online tool shows information about medications covered under the pharmacy benefit?

Formulary Search Tool

Which of the following TRICARE pharmacy program options charges Prime enrollees (except for active duty members) a 50 percent point-of-service cost-share?

Non-network pharmacies

The _________________________ authorizes civilian dental care for active duty members to ensure dental health and deployment readiness.

Active Duty Dental Program (ADDP)

The _______________________ is a voluntary, premium-based dental insurance plan that provides worldwide dental coverage to eligible, enrolled beneficiaries.

TRICARE Dental Program (TDP)

If a beneficiary is using Home Delivery, he or she should get a __________ supply and three refills of most medications.

90 days

TRICARE Retiree Dental Program premiums are based on:

The enrollee's home zip code and number of family members enrolled

TRICARE Plus is a primary care program offered at some military hospitals and clinics/enhanced multi-service markets for beneficiaries not enrolled in _________________________.

TRICARE Prime

The Extended Care Health Option (ECHO) covers service and supplies beyond the basic TRICARE benefit for only:

Acitve duty families

If a beneficiary is declared ineligible for ECHO _________________________________________.

The decision is not appealable

Which of the following options is direct-care only and therefore doesn't count as minimal essential coverage under the Affordable Care Act (ACA)?

TRICARE Plus with no other TRICARE eligibility

TRICARE for Life (TFL) offers wrap-around medical coverage to TRICARE beneficiaries who have Medicare________________________.

Part A and Part B

Individuals may have to pay a late enrollment penalty if they don?t sign up for which of the following when they first become eligible?

Medicare Part B

ADFMs who have Medicare Part A must sign up for ____________________ before their sponsor?s retirement date to avoid a break in TRICARE coverage.

Part B

When a beneficiary?s health care services are covered by Medicare, TRICARE, and his or her OHI, TRICARE is the _______________ payer.

Last

Who may file a claim with TRICARE?

All of the Above

Beneficiaries should do all of the following to resolve claims EXCEPT:

Contact the adjudicating staff judge advocate

A civilian network provider:

Signs a contractual agreement with the regional contractor (

How long of a drive for routine or urgent care?

30 minutes

How long of a drive from specialty care?

60 min

There are two kinds of non-network providers. What are they?

Participating and non-participating

Which TRICARE program is like a Health Maintenance Organization (HMO)?

Prime

Which TRICARE plan is like a preferred provider option?

Select

Direct care refers to?

Care and pharmacy services at MTF

What does DEERS stand for?

Defense Enrollment Eligibility Reporting System

What is a prime service area?

PSA - A 40 mile radius of a MTF, Market or Base Realignment and Closure (BRAC) site. ADFMs are automatically enrolled in Prime inside a PSA.

TAMP?

Transitional Assistance Management Program

What is ECHO?

Extended Care Health Option

How long does the hospital have to accept a Right Of First Refusal (ROFR) for an urgent referral? Or routine referral?

90 mins; 2 business days

Referrals and authorizations do not carry over in three situations?

Regions, retiree or separations.

Prime Travel benefit kicks in if pt is referred to specialty care how far away?

100 miles one way from PCMs office determined by the Defense Table of Offical Distances

QLE event for moving starts the 90 day clock when?

Address is updated in DEERS

NEO

Non-combatant evacuation operations

PTs can make a PCM change in Milconect?

Yes

USFHP

The US Family Health Plan. It is a Prime option but it is not TRICARE.

What form is used to change enrollment, PCM change, etc.?

DD Form 2876

TRICARE Prime Remote is offered when active duty and eligible family members live how many miles away from MTF?

50 miles

What is the coast guards equivalent of an LOD?

NOE - notice of eligibility

LOD reimbursement pharmaceutical form?

DD form 2642

National Guard and Reserve members are eligible for the same health care benefits as active duty members when

They are called to active service for more than 30 consecutive days and show as eligible in DEERS

Individuals may have to pay a late enrollment penalty if they don't sign up for which of the following when they first become eligible?

Medicare Part B

Who may file a claim with TRICARE?

All of the above

TAMP beneficiaries are eligible for __________days of medical coverage.

180

Beneficiaries should do all of the following to resolve claims EXCEPT:

Contact the adjudicating staff judge advocate

Lists benefit and eligibility information for your uniformed service members and others, as deemed eligible by the DoD

Which of the following CAN'T be appealed?

The amount of the TRICARE-allowable charge

When can an enrollee change or enroll in a TRICARE Prime or TRICARE Select plan?

Both A and B (Following a Qualifying Life Event (QLE), During the annual fall open enrollment season)

The __________ option lets TRICARE Prime enrollees get non-emergency care from any TRICARE-authorized or overseas provider without a referral, but at higher cost.

Point of service

Which of the following BEST describes TRICARE Retired Reserve (TRR) coverage?

It is the premium-based plan for retired reservists who have not yet turned age 60

Former active duty members who are TAMP eligible may be eligible for Transitional Care for Service-Related Conditions (TCSRC) if they:

Have a service-related condition validated by a DoD physician

The ___________________________ is a voluntary, premium-based dental insurance plan that provides worldwide dental coverage to eligible, enrolled beneficiaries.

TRICARE Dental Program (TDP)

Which of the following TRICARE Pharmacy Program options charges TRICARE Prime enrollees (except for active duty members) a 50 percent point-of-service cost-share?

Non-network pharmacies

If a beneficiary is using Home Delivery, he or she receives a __________________ supply and three refills of most medications.

90 day

Which of the following is the voluntary dental option for retired members of the Uniformed Services and their eligible family members?

Federal Employees Dental and Vision Insurance Program

How often may TRICARE Select enrollment fees, deductibles, cost-shares, and/or copayments change?

Each calendar year

A beneficiary is considered in Group B if their sponsor enlisted or was commissioned:

On or after January 1, 2018

When on active service for 30 days or less, National Guard and Reserve members are:

Covered for an injury incurred or aggravated in the line of duty

Individuals may have to pay a late enrollment penalty if they don't sign up for which of the following when they first become eligible?

Medicare Part B

Active duty family members who have Medicare Part A must sign up for ____________________ before their sponsor's retirement date to avoid a break in TRICARE coverage.

Medicare Part B

Continued Health Care Benefit Program must be purchased within _____ days of when TRICARE eligibility ends.

1 hour

TRICARE Reserve Select (TRS) and TRICARE Retired Reserve (TRR) members lose eligibility when the sponsor:

Becomes eligible for the Federal Employees Health Benefits (FEHB) program

Which of the following are TRICARE Pharmacy Program options?

All of the above

When TRICARE Select enrollees receive care from non-authorized, non-network providers:

TRICARE will not pay their claims

Active duty members and their family members pay __________ for TRICARE Prime enrollment.

$0 a year

TRICARE Young Adult

The Extended Care Health Option (ECHO) covers service and supplies beyond the basic TRICARE benefit for only:

Active duty families

Which of the following categories of beneficiaries isn't eligible for TRICARE Select?

Active duty members

The most a beneficiary pays out-of-pocket each calendar year for TRICARE- covered services or supplies is called:

Catastrophic cap

A civilian network provider:

Signs a contractual agreement with the regional contractor

Newborn children of active duty family members are automatically covered under TRICARE Prime if:

They live in a Prime Service Area

Which of the following is a managed care option for active duty and eligible family members who live and work in designated remote ZIP codes?

TRICARE Prime Remote

The ____________________________ reviews claims, approves payments, and determines the impact of a diagnosis on remote active duty members' fitness for duty.

Defense Health Agency, Great Lakes (DHA-GL)

TRICARE for Life (TFL) offers wrap-around medical coverage to TRICARE beneficiaries who have Medicare__________.

Part A and Part B

TRICARE Prime Remote for Active Duty Family Members (TPRADFM) is:

Optional for active duty family members in remote areas locations, stateside and overseas

All of the following are eligible for the Transitional Assistance Management Program (TAMP) EXCEPT:

Service members voluntarily separating from active duty under honorable

TRICARE Reserve Select (TRS) and TRICARE Retired Reserve (TRR) offer _____________ benefits to all covered individuals.

TRICARE Select or TOP

________________ is a primary care program offered at some military hospitals or clinics. Enrollment is required, and approval is based on the military hospital or clinic commander's guidance. It's not available to TRICARE Prime enrollees.

TRICARE Plus

What does direct care refer to?

Care and pharmacy services only at a military hospital or clinic

If a beneficiary visits a non-network participating provider, the provider:

Accepts the TRICARE-allowable charge as payment in full

Newborn children of active duty family members are automatically covered under TRICARE Prime if

They live in a Prime Service Area

Enrollees, whose sponsor initially enlisted or was commissioned before January 1, 2018, fall into which beneficiary category?

Group A

Which of the following options is direct-care only and therefore doesn't count as minimal essential coverage under the Affordable Care Act (ACA)?

TRICARE Plus with no other TRICARE eligibility

National Guard and Reserve members are eligible for the same health care benefits as active duty members when:

are called to active service for more than 30 consecutive days and show as eligible in

When a beneficiary's health care services are covered by Medicare, TRICARE, and his or her OHI, TRICARE is the _____________ payer.

Last

TRICARE Prime Remote for Active Duty Family Members (TPRADFM) is:

Optional for active duty family members in remote areas locations, stateside and overseas

Which of the following CAN'T be appealed?

The amount of the TRICARE-allowable

An individual retiree in Group B pays an enrollment fee for TRICARE Select.

True

The US Family Health Plan (USFHP) offers medical coverage with the same copaymemnts as what TRICARE option?

TRICARE

Delayed-effective-date active duty orders may be issued to National Guard and Reserve members who are:

Called to active service for more than 30 consecutive days in support of a contingency operation

TRICARE Reserve Select (TRS) and TRICARE Retired Reserve (TRR) offer _____________ benefits to all covered individuals.

TRICARE Select or TOP

The ________________________________ authorizes civilian dental care for active duty members to ensure dental health and deployment readiness.

Active Duty Dental Program (ADDP)

TRICARE Plus

Which online tool shows information about medications covered under the pharmacy benefit?

Formulary Search Tool

If a beneficiary is declared ineligible for ECHO ________________________________.

The decision is not appealable

When a beneficiary gets care from a non-network, non-participating provider, he or she may have to pay:

Up to 15% above the TRICARE-allowable charge

Enrollees, whose sponsor initially enlisted or was commissioned before January 1, 2018, fall into which beneficiary category?

Group A

Managed care option is what type of TRICARE?

TRICARE Prime

- TRICARE Prime is a managed care option similar to a civilian health maintenance organization (HMO)

- Prime enrollees may receive care at an MTF or from a TRICARE network provider (Direct Care)

Preferred provider option is what type of TRICARE?

TRICARE Select

- Network care patients

Who is eligible for TRICARE Prime?

Active duty service members

Active duty family members; including Transitional Survivors

National Guard/Reserve members
-Activated on federal orders for more than 30 consecutive days

Family members of National Guard/Reserve members
-When sponsor is activated

Non-Active Duty Beneficiaries Under Age 65

What are the beneficiaries enrollment options?

Online

By phone

By mail

In Person

What is a referral?

A referral is the process of sending a patient to another professional provider (physician or psychologist) for consultation or a health care service that the referring provider believes is necessary, but is not prepared or qualified to provide.

What are the prime pLan features for Health Maintenance Organization (HMO)?

Assigned Primary Care Manager (PCM) (gatekeeper)

Lowest cost

Less choice

ATC standards

No copay at MTFs

Travel entitlement

Enrollment fee

What are the TRICARE Prime costs for the patient?

$0.00

Catastrophic Cap: $1,000 per family per fiscal year

TRICARE Point of Service option (POS):

Allows non-active duty TRICARE Prime enrollees to receive non-emergency care from any TRICARE-authorized provider without requesting a referral from their PCM

What are the charges associated Prime Point of Services (POS)?

Deductible per fiscal year for outpatient care only:
- Individual $300 & Family $600

Cost share for outpatient care:
-50%

Cost share for inpatient care
- 50%

Any additional charges by non-network providers
- Beneficiary is responsible

What are the POS Exceptions?

Emergency medical services

Preventive care services from a network provider

Behavioral health outpatient visits from a network provider

Primary Other Health Insurance (OHI) care (must have documentation that OHI processed the claim)

What is After Hours Care?

HA Policy 11-05: "All TRICARE Prime patients will have access to their PCM 24/7

Nurse Advice Line

Call 24/7

Answer your urgent care questions

Give you health care advice

Help you find a doctor

Schedule next-day appointments at military hospitals and clinics

What are the importants facts about Urgent Care for TRICARE Prime patients?

For TRICARE Prime, non-Active Duty only

No referral or prior authorization required (CONUS)

No PoS charges

Network copayments still apply

Who is eligible for TRICARE Select?

Active duty family members

Transitional Survivors/Survivors

Retirees and their family members

Medal of Honor recipients and their families

Family members of National Guard/Reserve members

TRICARE Select Enrollment Enrollment is required.

Enrollment is required. Fees are based on beneficiary category and group

TRICARE Select Military Treatment Facility Access:

Space available

Preferred Provider Organization (PPO) style healthcare plan

PPO means you use preferred providers within the "network" to receive a cost discount

Enrollment required

Annual Deductible

No claims to file for network providers

No referral needed

Space available access at MTFs

TRICARE Select PPO Plan Features:

Higher cost

More choice

Discount for using network providers

Deductible

Cost-sharing

Enrollment fee based on "Group"

How much does TRICARE Select pay when a patient sees a Specialty Non-network Provider (Outpatient)?

$150 deductible

20% of the remaining cost

25% of the remining cost (RTF)

Where can you find copay information?

www.tricare.mil

What are the compared features for TRICAREPrime vs. TRICARE Select?

TRICARE Prime: Low Cost & Low Choice

TRICARE Select: High Cost & High Choice

Authorized Providers

Authorized providers are individuals, institutions, organizations, or suppliers who are certified to provide benefits under TRICARE

Network Providers

Serve TRICARE beneficiaries through a contractual agreement with the regional contractor, which makes them a member of the TRICARE Prime network

Non-Network Providers

Have no contractual agreement with the regional contractor; however, they may still serve TRICARE beneficiaries

Participating Non-Network providers

Agree to serve TRICARE beneficiaries on a case-by-case basis

Agree to accept the TRICARE allowable charge as payment in full

Non-participating, non-network provider

Agree to serve TRICARE beneficiaries on a case-by-case basis

Do not accept the TRICARE allowable charge as payment in full

May charge beneficiary 15% above the TRICARE allowable charge (balance billing)

TRICARE Prime Remote

TPR is available to active duty service members who live and work greater than 50 miles from a military treatment facility (based on zip code) and greater than an hour drive from a military treatment facility

ex...... Recuriter

Who is eligible TRICARE Prime Remote?

Active duty service members

Active duty family members

Guard/Reserve members
- Activated on federal orders for more than 30 consecutive days

Guard/Reserve family members

Primary Care Managers

PCMs manage the enrollee's medical care by:

Providing routine and urgent medical care

Coordinating referrals for specialty care

Assisting with prior authorizations (when needed)

Maintaining medical health records

TRICARE Prime Remote Seeking Care:

Routine Care:

- TPR enrollees seek routine care from their PCM or TRICARE-authorized non-network provider

- No referrals are required

Specialty Care:

- Enrollees require a referral and authorization for any specialty care

- Regional contractors coordinate active duty service member referrals with the Service Point of Contact (SPOC) for review and fitness for duty determination

Urgent Care:

- Enrollees should seek urgent care from their PCM, TRICARE-authorized non-network provider or through their regional contractor

Emergency:

- Enrollees should seek care at the nearest emergency room

- No referrals are required

When are National Guard and Reserve and thier family eligibile for TRICARE Prime:

Duty more than 30 days

or

Duty more than 30 days in support of OCO

What is line of duty care for National Guard/Reserve members?

While on active duty orders for 30 days or less, National Guard/Reserve members are covered by their Service component for any injury, illness, or disease incurred or aggravated in the line of duty

- During this period, National Guard/Reserve family members are not eligible for TRICARE benefits

TRICARE Reserve Select

TRICARE Select is TRICARE's preferred provider option

TRS members may also seek care at military treatment facilities on a space-available basis

Enrollees must be registered in DEERS

When can you loose TRICARE Reserve Select?

Are called to active duty on federal orders for more than 30 consecutive days

Retire

Become eligible for (in their own right) or obtain coverage under a Federal Employee Health Benefit Program (FEHBP)

Fail to pay premiums

TRICARE Retired Reserve

Member-only: $ 431.35 per month

Cost Share Rates: 20%-25%

Premium-based health care plan

Retired reservists under age 60

Family members & survivors of retired reservists

Not eligible for FEHBP

What are the 2 TRICARE Transitional Benefits?

Transitional Care for Service-Related Conditions

Continued Health Care Benefit Program

Transitional Assistance Management Program

Provides 180 days of transitional health care coverage for certain members of the Uniformed Services who are separating from active duty and their eligible family members

TAMP Eligibility

Separating:

Active duty under honorable conditions

Involuntarily retained under Stop-Loss in support of a contingency operation

Voluntary agreement to stay on active duty for less than one year in support of a contingency operation

A National Guard/Reserve member separating from a period of active duty that was more than 30 consecutive days in support of a contingency operation

Continued Health Care Benefit Program (CHCBP)

Premium-based health care program that offers temporary transitional health coverage (up to 18 or 36 months) after TRICARE eligibility ends

CHCBP eligibilty

Eligible beneficiaries have up to 60 days after losing military healthcare (including 180 days of TAMP)

TRICARE Plus

MTF-based enrollment option for beneficiaries who are NOT enrolled in TRICARE Prime

MTF Commander may limit enrollment based on capability and capacity

Exceptional Family Member Program (EFMP)

Identifies family members with special medical and/or educational needs

Enrollment is mandatory upon identification of a family member with special needs

Enrollment helps ensure active duty service members get stationed where the family member's special needs can be met

Extended Care Health Option

Supplemental program to the basic TRICARE program

Provides an additional financial resource for an integrated set of services and supplies

Extended Care Health Option Qualifying Conditions

Moderate or severe mental retardation

Serious physical disability

Extraordinary physical or psychological condition

Diagnosis of a neuromuscular developmental condition

Multiple disabilities

ECHO Cost Shares

Based on rank:

$25 - $250

Computer/Electronic Accommodations Program (CAP)

The Federal government's funded reasonable accommodations program for employees with disabilities in the DoD and throughout the Federal government

Uniformed Services Family Health Plan

A TRICARE Prime option available through networks of community-based, not-for-profit health care systems in six areas of the United States

USFHP Eligibility

Active duty family members

Certain former active duty service members and their eligible family members

Uniformed services retirees and their eligible family members

Eligible unremarried former spouses

Medicare

A health insurance program for the following:

People age 65 or older

People under age 65 with certain disabilities

People (of any age) with end-stage renal disease or amyotrophic lateral sclerosis (commonly known as Lou Gehrig's disease)

People with Mesothelioma due to asbestos exposure in Troy and Libby, Montana

Medicare Part A: Hospital Insurance

Inpatient hospital care

Inpatient rehab

Skilled nursing facility
care (not custodial or
long-term care)

Medicare Part B: Medical Insurance

Helps cover physician services and outpatient hospital care

Medicare Part C: Medicare Advantage Plan

Provides all medically necessary Medicare covered services

Offers some extra benefits

Medicare Part D: Prescription Drug Coverage

Available through private insurance companies approved by the Centers for Medicare and Medicaid Services

TRICARE For Life (TFL)

Patient must be 65+

Medicare wrap-around coverage for beneficiaries who are eligible for Medicare

Must enroll in Medicare Part B (otherwise, no TRICARE enrollment required)

TRICARE Pharmacy Benefit

The TRICARE pharmacy benefit provides cost sharing for drugs and medicines that:

Are approved for marketing by the U.S. Food and Drug Administration

By U.S. law, require a physician's or other authorized professional provider prescription (acting within the scope of their license)

Are actually ordered and prescribed by an authorized provider in accordance with state and federal law

Direct Care (MTF) Pharmacy

Beneficiaries may have prescriptions filled (up to a 90-day supply for most medications) at a military treatment facility (MTF) pharmacy free of charge

Home Delivery

Prescriptions may be mailed to any address in the United States and its territories, including temporary and APO/FPO addresses

Beneficiaries may have prescriptions filled (up to a 90-day supply for most medications) via home delivery with minimal out-of-pocket costs

Retail Network Pharmacy Option

The network retail pharmacy option allows beneficiaries to fill prescriptions at civilian pharmacies throughout the United States, including U.S. territories

Retail Non-Network Pharmacy Option

A non-network retail pharmacy is a pharmacy that is not in the TRICARE pharmacy network

When using a non-network pharmacy, beneficiaries will have to pay the full price for medication and file a claim for reimbursement

Maintenance Medications

First two times the script is filled, TRICARE sends the patient a letter

Third time, patient pays 100% of script cost

Active Duty Dental Program

The Active Duty Dental Program (ADDP) provides private sector/civilian dental care for active duty service members (ADSMs) to ensure dental health and deployment readiness

Dental Treatment Facility (DTF) Referred Care:

DTF referred care authorizes the ADSM to receive care from a civilian dentist when the DTF is unable to provide the required care

Remote Active Duty Dental Care:

Remote Active Duty Dental Care is private sector/civilian dental coverage for remote ADSMs who reside and work (duty location) greater than 50 miles from a military DTF

Remote Dental Care

Remote Active Duty Service Members can coordinate their own routine dental care/procedures, as long as the treatment is less than $750 per procedure or appointment, or the cumulative total is less than $1500 within a consecutive 12-month period

TRICARE Dental Program

A voluntary, premium-based dental insurance plan administered and underwritten by the TDP contractor, United Concordia

TRICARE Dental Program Eligibility

Eligible active duty family members

Guard/Reserve members (not on active duty)

Guard/Reserve family members

TRICARE Overseas Program

The TOP is the DoD's health care program outside of the Continental United States (CONUS)

TRICARE Overseas Program covers 3 overseas areas:

TRICARE Latin America/Canada (TLAC)

TRICARE Eurasia-Africa

TRICARE Pacific

TOP Health Care Coverage Options:

TOP Prime

TOP Prime Remote

TOP Select

TOP TRICARE For Life (TOP TFL)

TOP Plus (MTF-based with limited availability)

TRICARE Active Duty Dental Program

TRICARE Dental Program

Enhanced Overseas TRICARE Retiree Dental Program

What is a claim?

Claims are filed to issue payment for services or supplies provided by civilian sources of medical care

Authorized providers may file claims:

An authorized provider is one approved under TRICARE for services or supplies provided to a beneficiary and receive payment directly from TRICARE

Beneficiaries may file claims:

Any TRICARE-eligible beneficiary

There are 2 major claims processing contractors for TRICARE:

Palmetto Government Benefits Administration (PGBA)
- CONUS claims

Wisconsin Physicians Service (WPS)
- OCONUS & all TFL claims

Filing Deadlines

Claims should be filed within one (1) year

Beneficiaries should file a claim as soon as possible after care

Beneficiaries may ask their civilian provider to file the claim

Resolving Claims Issues

Step 1

The first step a beneficiary should take to resolve claims issues is to call the regional contractor for assistance

Resolving Claims Issues

Step 2

The beneficiary may contact a Military Treatment Facility or TRICARE Regional Office Beneficiary Counseling and Assistance Coordinator (BCAC)

Resolving Claims Issues

Step 3

The beneficiaries may contact the TRICARE claims processing contractor

TRICARE is:

the health care program serving active duty service members, National Guard and Reserve members, retirees, their families, survivors and certain former spouses worldwide

TRICARE Eligibility

Active Duty Service Members (ADSM)

Active Duty Family Members (ADFM)

Retiree, Retiree family members (RFM)

Eligibility for TRICARE

Must be enrolled in Defense Enrollment Eligibilty Reporting System (DEERS)

What are the seven uniformed services determine TRICARE eligibility:

1. Army
2. Marine Corps
3. Navy
4. Air Force
5. Coast Guard
6. Public Health Service
7. National Oceanic and Atmospheric Administration (NOAA)

What is Defense Enrollment Eligibility Reporting System (DEERS)?

The central, online eligibility and enrollment data repository that contains personnel and health care benefit information for the DoD.

The following information can be found in DEERS:

Names

Mailing addresses and telephone numbers

Social Security Numbers

Dates of birth

Gender

Program information (e.g., program eligibility, enrollment in other health insurance)

What is the purpose of DEERS?

an established source to verify benefit and entitlement eligibility information for uniformed service members.

DEERS maintains information about :

TRICARE eligibility

TRICARE option coverage

Primary care manager (PCM) assignment

Catastrophic caps

Deductibles

Enrollment fee totals

Other health insurance (OHI).

Does DEERS determin eligibilty?

No

DEERS doesn't determine eligibility, it only reports it.

When to update DEERS:

Retiring or Separating

Marriage or Divorce

Having a baby

Moving to new location (address & phone number changes)

Become Medicare eligible

Death of a sponsor or family member

How to update DEERS:

MilConnect (www.dmdc.osd.mil/milconnect )

When will newborns be AUTO enrolled?

For 90 days after birth

When are Pre-adoptive and adopted children eligible for TRICARE?

When they have been properly registered in DEERS

Documents are required to register a child in DEERS:

Certificate of live birth

DD Form 1172, "Application for Uniformed Services Identification and Privilege Card"

- Pre-adoptive/adopted children: Legal forms, as specified by the sponsor's branch of Service, for pending/permanent adoptions

What are Transitional Survivors?

Family members (spouse and children) of the deceased sponsor

What is a Survivor?

Survivor" are spouses of the deceased sponsor

-The spouse is regarded as a "survivor" after the three year anniversary of the sponsor's death

-TRICARE pays survivor claims at the retiree family member payment rate

When does children under Transitional survivor status enrollment stop?

Ends at age 21 or age 23, if enrolled full-time in an institution of higher education and dependent on sponsor for 50% of financial support

What are the Special Eligibility Categories?

Family members of an active duty service member who was discharged as a result of a court-martial conviction

Abused or former spouses and dependent children of active duty

Spouses and children of representatives of NATO and Partners for Peace nations

Unremarried former spouses are no longer TRICARE eligible if they:

Remarry, even if the remarriage ends in death or divorce
They may gain TRICARE eligibility through a new spouse

Purchase and are covered by an employer-sponsored health plan

Were the former spouse of a NATO or Partners for Peace nation member

Title 10 states

Service members on active duty are "entitled to care"

Active duty dependents are "entitled to care" subject to space and capabilities

Retirees and their dependents "may be given care" subject to space and capabilities

Who has priority for enrollment & access within our MTFs?

Active duty members

Active duty dependents & survivors enrolled in Prime

Retirees, their dependents & survivors enrolled in Prime

Dependents & Retirees not enrolled in Prime

How do you verfiy eligibility?

Check ID

Validate DEERS/other
- DEERS Check Via CHCS