TRICARE
MANAGEMENT ACTIVITYby A. Maureen Hanna
TRICARE
MANAGEMENT ACTIVITY
by A. Maureen Hanna
The TRICARE Management Activity is accountable for quality health care for members of the Armed Forces, military families, and others entrusted to the Department of Defenses' care. TRICARE is the Defense Department's regional managed health care program for service families. It contains three options: TRICARE Prime, TRICARE Extra, and TRICARE Standard.
TRICARE Prime - This is a voluntary enrollment option. If you live in an area where TRICARE prime is offered, and you decide to get your care through TRICARE prime, you'll enroll for a year at a time. You receive your care from within the prime network of civilian and military providers. Active duty service members have auto enrollment and will either choose or be assigned to a primary care manager. Their families must take action if they want to enroll. Children must be registered in DEERS (the Defense Enrollment Eligibility Reporting System) before their enrollment becomes effective.
There is no annual enrollment fee for active duty families. There is no annual deducible or share of cost (unless not active duty).
The primary care manager (PCM) is where they get most of their routine health care. The PCM manages all aspects of care, including referrals to specialists (which must be done before they get specialized care).
There is a point-of-service (POS) option that allows them to get non-emergency services without referral from the primary care physician. For this there is an annual deductible of $300 (individual) or $600 (family). After the deductible is satisfied, the cost share is 50% of the TRICARE allowable charge. Non-network providers can charge an additional, up to 15%, above the allowable charge.
TRICARE Extra - There is no enrollment or annual fee. Individual can seek care from a provider who's part of the TRICARE network and get a discount on services. Outpatient deductible is $50 (for one person) or $100 (family) for active duty grades E-4 and below, or $150 (for one person) or $300 (family) for all other eligible persons.
TRICARE Standard - This is the option that was formerly known as CHAMPUS. TRICARE Standard pays a share of cost of covered health services that you obtain from a non-network civilian health care provider.
There is no enrollment. The annual deductibles, cost-shares and benefits are the same as they were for CHAMPUS.
The "Civilian Health and Medical Program of the Uniformed Services" - is a cost sharing program for military families, retirees and their families, some former spouses, and survivors of deceased military members. The uniformed services include Army, Navy, Air Force, Marine Corps, Coast Guard, Public Health Service and National Oceanic and Atmospheric Administration.
Champus shares the cost of most medical services from civilian providers when beneficiaries can't get care from a military hospital or clinic. Types of services available vary by facility. The hospitals serve active-duty members first.
You should check with the claims processor for each state and verify types of coverage and types of care provided.
Durable Medical Equipment
TRICARE Standard patients may rent, lease/ purchase
or simply purchase durable medical equipment if the following
criteria are met:
The allowable charge must exceed $100.
It must be medically necessary in treating a covered illness or
injury.
It must improve the function of a malformed, diseased or injured
body part or retard further deterioration of the patient's physical
condition.
It must be person-specific and be provided on a one-at-a-time
basis only.
It must be primarily and customarily used to serve a medical purpose.
DME is not covered if used primarily for transportation, comfort
or convenience. Wheelchairs do qualify as DME since they provide
mobility and retard deterioration. Cart-like vehicles may also
qualify.
It must withstand repeated use.
It must be other than eyeglasses, contact lenses, hearing aids
or other communication devices and must be other than exercise
equipment, spas, whirlpools, hot tubs, swimming pools or similar
items.
It cannot be beyond the medically appropriate level of performance
and quality required under the circumstances. Luxury or deluxe
items do not qualify. Special fitting of equipment to accommodate
a particular disability, e.g., a one-armed wheelchair, is covered.
It is not for a patient in a facility that provides or can provide
the equipment.
It is not available from a local uniformed service medical facility,
should one be in the area. A letter from the uniformed service
facility must accompany the claim when the patient's address is
within the ZIP code zone.
Under TRICARE Standard, DME may be purchased, rented or leased
by the month, depending on the cost and period of medical necessity.
The contractor will determine the most cost-advantageous position
for the government. Patients may request cost sharing over a one-
to six-month period.
Note: TRICARE rules exclude air conditioners, humidifiers,
dehumidifiers and purifiers (including electronic air filters),
regardless of the patient's diagnosis. The denial of these items
is not appealable.
TRICARE will share the cost of repair of DME that is already owned
by a patient, subject to the following criteria:
Repairs are limited to those required to make the equipment serviceable.
The physician must state that the equipment continues to be medically
necessary.
The repair cost must be less than the rental or lease/purchase
of a new unit.
The need for repair must not be due to willful or malicious conduct
on the part of the patient.
The attending physician must send a signed and dated statement
with the claim for repair including:
Patient's diagnosis
Nature of the repair required
Estimated length of medical necessity for the equipment
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