AFSA CHAPTER 1056

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"VOICE OF THE ENLISTED SINCE 1961"

May 1999, Revision

TRICARE is a health care program for members of the uniformed services and their families, and survivors and retired members and their families. TRICARE brings together the health care resources of each of the military services and supplements them with networks of civilian health care professionals to provide better access and high quality service while maintaining the capability to support military operations. There are 11 TRICARE Regions in the U.S. plus TRICARE Europe, TRICARE Latin America and TRICARE Pacific. Each region has an assigned Lead Agent staff who are responsible for the military health system in that region. TRICARE Pacific is managed administratively by the Region 12 Lead Agent staff.

2. What will happen if I don't take any action to change my current health care plan?

If you are on active duty, you will be enrolled in the TRICARE Prime benefit. All other eligible persons deciding not to enroll in TRICARE Prime may still be eligible for care in military medical facilities on a space available basis and maintain TRICARE Standard eligibility (formally CHAMPUS). You may also participate in a new money-saving option called TRICARE Extra by choosing a physician in the Extra network.

3. How does TRICARE improve military readiness?

TRICARE increases flexibility of the Military Health System (MHS), which affords our military medical personnel the ability to maintain their personal readiness while assigned to a base hospital or clinic. This flexibility is demonstrated in the unprecedented collaboration among the military medical departments and in the partnerships we are building with civilian health care companies. These initiatives which include joint service sharing and strong public-private partnerships, contribute to the durability of the MHS.

4. Will the quality of care that I am currently receiving through the Military Treatment Facility (MTFs) improve with the TRICARE program?

The same high quality of care that you are receiving will continue and be enhanced because of improved access and continuity of care for enrolled members. TRICARE Prime also offers the additional benefit of wellness and prevention programs.

5. How can I find the location of my nearest TRICARE Service Center?

If your region has initiated TRICARE, you may inquire using your phone system's directory assistance operator, or call the nearest military hospital or clinic. Additionally, below are telephone numbers for each region, where you can call and get information about TRICARE and your health care benefits.

Region 1 Maine, New Hampshire, Vermont, Massachusetts, Connecticut, Rhode Island, Delaware, Maryland, New Jersey, New York, Pennsylvania, the District of Columbia, Northern Virginia, and the northeast corner of West Virginia Operational June 1, 1998 1-888-999-5195	Region 6 Oklahoma, Arkansas, western two thirds of Louisiana, Texas, excluding southwest corner. Operational November 1, 1995 1-800-406-2832	Region 12 (Pacific) Hawaii and Alaska Operational April 1, 1996 1-800-242-6788 Pacific and WESTPAC 1-888-777-8343
Region 2 North Carolina and most of Virginia. Operational May 1, 1998 1-800-931-9501	Central (Region 7/8) New Mexico, Arizona excluding Yuma, Nevada and southwest corner of Texas, including El Paso, Colorado, Utah, Wyoming, Montana, Idaho excluding northern Idaho, North Dakota, South Dakota, Nebraska, Kansas, Minnesota, Iowa and Missouri Operational April 1997 1-888-TRIWEST (874-9378)	Latin America Panama, Central America, South America 1-888-777-8343
Region 3 South Carolina, Georgia, and Florida excluding panhandle Operational July 1, 1996 1-800-444-5445	Region 9 Southern California and Yuma, Arizona Operational April 1, 1996 1-800-242-6788	Europe Europe, Africa, Middle East, Azores and Iceland Operational October 1996 1-888-777-8343
Region 4 Florida panhandle, Alabama, Mississippi, Tennessee and eastern third of Louisiana Operational July 1, 1996 1-800-444-5445	Region 10 Northern California Operational April 1, 1996 1-800-242-6788
Region 5 Michigan, Wisconsin, Illinois, Indiana, Ohio, Kentucky, and West Virginia excluding the northeast corner. Operational May 1, 1998 1-800-941-4501	Region 11 Washington, Oregon, and northern Idaho Operational March 1, 1995 1-800-404-0110

6. Who is eligible to participate in TRICARE?

All active duty members in the seven uniformed services: Army, Navy, Air Force, Marines, Coast Guard, National Oceanic and Atmospheric Administration (NOAA) and Public Health Service (PHS), as well as their CHAMPUS-eligible family members, CHAMPUS-eligible retired military, their family members and survivors as well as active duty family members and retirees and their family members who are under age 65, Medicare eligible because of a disability, and enrolled in Medicare Part B.

7. I am currently enrolled in the Uniformed Services Family Health Plan (USFHP). How does that program fit into TRICARE?

If you are enrolled in the USFHP, you cannot participate in TRICARE, and vice-versa, until your enrollment expires. The USFHP is responsible for the total health care needs of its member patients. With a referral from a Uniformed Services Treatment Facility, you may use the local MTF. (Note: The USFHP is a managed care program for nonactive duty Uniformed Services beneficiaries, CHAMPUS and Medicare eligibles, delivered by Uniformed Services Treatment Facilities, under contract to DoD to provide care for Title 10 beneficiaries.)

8. What are my health plan options available under TRICARE?

For eligible beneficiaries, the TRICARE program offers a triple-option health care plan.

TRICARE Prime is the managed care option offered by the Department of Defense. It integrates military and civilian health care into a single delivery system. Beneficiaries who choose this option agree to a one-year enrollment. Enrollees selecting this option choose a Primary Care Manager (PCM) (see question 32 for definition) to provide or arrange for their health care needs. The TRICARE Prime option offers additional wellness and preventive care services.

TRICARE Extra is similar to TRICARE Standard but offers discounts to patients when they use TRICARE network providers. This option allows beneficiaries to receive their care from civilian network providers at a reduced cost compared to TRICARE Standard. There are no claim forms to file -- just pay your reduced copay after satisfying the deductible. You may use a combination of the TRICARE Extra and Standard programs at any time, depending on whether you choose physicians inside or outside the network. There is no enrollment requirement for this program.

TRICARE Standard is a fee-for-service option that is the same as the standard CHAMPUS benefit. Beneficiaries using this option have the greatest choice of civilian physicians, but at a higher cost. The cost of having this choice includes a deductible, plus a percentage of subsequent charges, called copayments or copays. Enrollment is not a requirement to participate.

9. Which option is the best choice for me if I don't live close to an MTF?

If you are able to enroll in the TRICARE Prime program, this would be the most cost-efficient option for you. If there is not a Prime program serving your area, you can still save money by participating in the TRICARE Extra program by using a civilian network provider. TRICARE Service Centers (TSC) have lists of TRICARE Extra network physicians. If TRICARE Extra is not available in your area, you will have to utilize TRICARE Standard.

10. Which is the best of the three TRICARE options for a retiree who lives in two different parts of the country?

For a retiree with two residences, because of the new "Portability Rules" they will still have the triple option available and can choose the best option for themselves. The only change is that if they choose Prime they will be able to disenroll and reenroll twice in the same year as long as their second re-enrollment is in the original region. For those individuals desiring more flexibility they may want to elect to utilize either TRICARE Extra or Standard.

11. How do TRICARE Service Centers assist beneficiaries?

TRICARE Service Centers are staffed by health care professionals who are there to help beneficiaries get the service that they need. Such as:

Health Care Finders, who will make appointments and help find specialists when you need them. They also provide names of doctors participating in the TRICARE Extra network, and will help locate doctors who accept Medicare payments for services provided Medicare eligible beneficiaries age 65 and over.
Beneficiary Services Representatives, who will help explain the options available to you and assist in your choice of the program that suits you best. They can enroll you in TRICARE Prime, assist with the selection of a Primary Care Manager, and help resolve any billing problems.

TRICARE Service Centers also send beneficiaries TRICARE information packages describing the features of each of the TRICARE options and what alternatives are available for each beneficiary category.

12. How can I find out more information about the TRICARE program?

By visiting or calling your local TRICARE Service Center which is usually located near or within a MTF, or, the Health Benefits Advisor (HBA) at any MTF.

13. What is my priority for care in the MTF?

By law, priority for care at the MTF will be based on the following criteria:

Active duty personnel

Active duty family members enrolled in TRICARE Prime

Retirees, Survivors and their family members enrolled in Prime

Active duty family members not enrolled in Prime

Retirees, Survivors and their family members not enrolled in Prime

Non-enrolled persons eligible for military health care will be seen at military hospitals and clinics on a space-available basis.

14. If I have a grievance for services rendered under the TRICARE program, who can I contact?

Any grievance should be reported to the MTF Commander or Lead Agent. Generally, the regional Managed Care Support contractor will be responsible for grievances for services rendered by civilian network providers under the TRICARE program. Contact the nearest TRICARE Service Center for more information.

15. Is there a maximum that I may have to pay under the three TRICARE options?

Under TRICARE Standard and Extra, active duty family members can be responsible for up to $1,000 and retirees for up to $7,500 per year in total out-of-pocket costs for covered medical services. Under Prime, the maximum out-of-pocket expenditure per year for covered medical services is $1,000 for active duty family members and $3,000 for retirees and their families per enrollment year. Effective March 26, 1998 the catastrophic cap for the Prime Point-of-Service option will be lifted. Under the Point-of-Service option you pay 50 percent of the cost after a separate, somewhat higher deductible is met ($300 for single enrollment and $600 for family enrollment).

TRICARE PRIME

16. Should a family member covered by other comprehensive health insurance enroll in Prime?

If a family member has other comprehensive health care insurance, we do not encourage enrollment in TRICARE Prime. When other comprehensive health coverage is involved, TRICARE is automatically the secondary payer. It may be easier to coordinate benefits with other health insurance under TRICARE Extra and TRICARE Standard. Please check with your TRICARE Service Center for further guidance.

17. What guarantees do I have that, as a TRICARE Prime enrollee, I won't just end up on the phone, waiting to make an appointment at the hospital or clinic?

Like many aspects of TRICARE Prime, performance standards have been applied to the central appointments system, which is available at most locations. We have arranged for enough phone lines and people to answer them to avoid patients waiting for unreasonable periods of time. If additional capability is still required, we will provide it. However, you will likely find busy signals and long waits a thing of the past.

18. What should I do if I'm a Prime enrollee and get sick while traveling outside my region? What if the 800 number is busy and I can't make contact?

You should contact your Primary Care Manager for instructions in a non-emergency situation. Authorization for care can also be obtained from the Health Care Finders. For non-urgent or non-emergency care you must first obtain authorization. If you see a physician without authorization for a non-emergency problem, you will still be covered for some of the costs incurred under the Point-of-Service option. That option pays 50 percent of the cost after a separate, somewhat higher deductible is met ($300 for single enrollment and $600 for family enrollment).

Active Duty

19. I'm on active duty and stationed away from a military installation. What do I do for medical care, and do I have to pay?

Currently, as an active duty member, you are covered for your health care needs through supplemental care funds; under no circumstance will you be required to pay for any health care you may need. While not available currently, policy changes are being worked to provide TRICARE Prime from civilian PCM in the local area for Geographically Separated Units (GSU).

Enrollment

20. Does the enrollment fee for TRICARE Prime have to be paid all at once, or can it be paid in installments?

It is permissible to pay the Prime enrollment fee in quarterly installments. There is no additional administrative fee for quarterly payments.

21. How can I enroll in TRICARE Prime?

If you are on active duty you will be enrolled in TRICARE Prime automatically and assigned a Primary Care Manager. When Prime is fully implemented in your area, other categories of beneficiaries can enroll on a voluntary basis either by visiting or calling the local TRICARE Service Center and completing an enrollment application.

22. What is my priority for being offered enrollment in TRICARE Prime?

Priority for enrollment is: 1) active duty will be automatically enrolled and receive most of their care in the MTF; 2) active duty family members may voluntarily enroll and will be primarily accommodated within the MTF; 3) retirees and their family members and survivors may voluntarily enroll. If the MTF has reached capacity, everyone wishing to enroll in Prime will be referred to the network providers.

23. If I enroll in TRICARE Prime does that mean that my whole family has to enroll?

Not all family members are required to enroll in TRICARE Prime. Depending on your specific situation and needs, it may be best, for example, for a spouse to be in TRICARE Prime, and a student son or daughter, to use Extra or Standard. Contact your TRICARE Service Center for advice.

24. Is there a minimum enrollment period requirement for TRICARE Prime?

Enrollment is for a 12-month period under TRICARE Prime. At the end of this initial consecutive 12-month enrollment period, you must choose to continue your enrollment in Prime or choose another option that best suits your situation. If you disenroll early for nonpayment of fees, or you request disenrollment without a move, you will be eligible to re-enroll in 12 months.

25. If I choose to disenroll after I have enrolled in TRICARE Prime, what penalty is incurred? Can I get back into TRICARE Prime if I don't like the other options?

If the enrollment fee was paid in one payment, you will not receive a refund. Enrollment is for 12 months, unless you move from the area or lose eligibility; if you disenroll early you are eligible to re-enroll in 12 months.

26. Are there any deadlines or restrictions for enrolling in TRICARE Prime?

If implemented in your area, you may enroll in TRICARE Prime at any time. Please note that while enrollment for Prime is on a continuous basis, assignment to a Primary Care Manager in a military clinic, where treatment is free, is based on a first come, first served basis. However, Military Treatment Facility Commanders can determine whether your enrollment will be to a civilian Primary Care Manager or an MTF Primary Care Manager. Those enrolled to an MTF may be required to select a civilian Primary Care Manager at the time of re-enrollment because of changes in MTF capacity.

27. Can my son or daughter, who is away from home at college, enroll in TRICARE Prime at his college if the option is available there?

For active duty families your son or daughter may enroll in TRICARE Prime as an individual if the option is offered in his or her geographic area. Retiree's and their family members will have the option of split enrollments (enroll as a family in one region and pay one fee but be able to receive care for children in school in a different region) once all regions are up and fully functional.

28. In the near future, I might want my children, who will be leaving for college, to switch from Prime to Standard. What is the process for this?

Currently, when you enroll yourself or your family in Prime, there is a one-year commitment. If you know in advance that you will want to change programs, you will have the option not to re-enroll those persons at the end of the year. However, disenrollment is permissible for a move.

By not enrolling you will automatically be participating in TRICARE Standard.

Portability (Moving)

29. As a retiree enrolled in TRICARE Prime, does my enrollment transfer to the new region if I move?

As a retiree you will be allowed to disenroll and re-enroll twice during the same year. The caveat is that you re-enroll to the original region (i.e. disenroll in region 1 and enroll to region 3 then disenroll in 3 and re-enroll back to region 1). You will be covered for emergency care under Prime from your original region while in route to the next region.

30. If my family moves to a different region, are we (active duty) automatically assigned a new Primary Care Manager, or do we have to re-enroll?

Enrollment in TRICARE Prime entails the assignment of a Primary Care Manager, enrollment in DEERS, and communication with the member on what enrollment in the TRICARE program means. For active duty members, enrollment is automatic. For active duty family members, enrollment in TRICARE Prime is on a voluntary basis.

Currently, if you move to a different region, you will have up to 30 days at the new site to enroll. Your old region will cover you for care until you enroll at the new region. Enrolled members will start a new 12-month enrollment period.

31. If I'm a Prime enrollee and move to a region where TRICARE isn't implemented, what happens? What happens to the balance of my enrollment fee?

TRICARE should be implemented across the U.S. by mid 1998. However, if Prime is not available in the new region, you must disenroll from your old region after 30 days. You may seek care in a MTF, or use TRICARE Standard (CHAMPUS) for civilian health care and file a claim for reimbursement. For retirees, enrollment fees are not refundable. If you believe you will be transferred before your enrollment year is up, pay the fee in quarterly installments and stop paying when you leave.

Primary Care Providers

32. What is a Primary Care Manager (PCM)?

A PCM is a medical professional, or a team of providers, in a military hospital or clinic, or in a civilian network, who will assume primary responsibility for providing, arranging and coordinating an enrollee's total health care. A physician designated as a PCM could be one who practices in General or Family Practice, Internal Medicine, Pediatrics and OB/GYN. Nurse Practitioners and Physician's Assistants who are privileged to provide primary care services may be organized as part of the PCM team.

33. How can I get a listing of PCMs and other network providers?

A listing of network providers (Provider Directory) in your area is available at your local TRICARE Service Center.

34. If I select a civilian network PCM, can I still use a MTF for routine health care services?

No, enrollees choosing a civilian Primary Care Manager must be referred to the military treatment facility for specialty and inpatient care by that Primary Care Manager. An enrollee who has chosen a civilian Primary Care Manager may, however, return for pharmacy, laboratory, radiology and other ancillary care they may require.

35. If I am already confident that I need to see a specialist, do I need to contact my PCM before I go? What will happen if I don't?

For those enrolled in TRICARE Prime, it is always necessary to first consult your Primary Care Manager for specialty care. If it is necessary for you to see a specialist, your PCM will help make an appointment for you. If you see a specialist on your own, without prior approval from your PCM you will be participating in Prime's Point-of-Service option and will be responsible for 50 percent of the cost after the deductible ($300 for single enrollment and $600 for family enrollment) is met.

36. My PCM refuses to provide a referral for services I believe I need. What do I do?

The TRICARE Prime program has provisions for second opinions. If you feel that the diagnosis or treatment plan may not be correct, you can request that your Primary Care Manager refer you out for a second opinion. Additionally, if you are dissatisfied with your Primary Care Manager (PCM), you can request assignment to another PCM. If you are still not satisfied, you can file a complaint or grievance regarding the non-availability of service decision to the MTF Commander or Regional Lead Agent. Finally, you have the option of using the Point-of-Service option under Prime. A retroactive reimbursement may be an option through a successful appeal process.

Special Benefits

37. How do we obtain emergency care under TRICARE?

Any eligible beneficiary should access the nearest emergency room of any military or civilian hospital for true emergencies, regardless of which TRICARE option you use.

38. Does the copayment increase for the emergency room?

There are no out-of-pocket costs for any care received at a military hospital, including emergency room care. The out-of-pocket costs for care received at a civilian emergency room for families of E-4 and below enrolled in Prime is $10. For families of E-5 and above and retirees and their families, the copay for an emergency room visit is $30. This single payment, $10 or $30, includes all emergency room services provided in conjunction with the visit. For those who have chosen to remain in TRICARE Standard, or use the TRICARE Extra program, their regular deductibles and copayments apply.

39. What is a Health Evaluation and Risk Assessment?

It is a self-initiated questionnaire surveying many lifestyles and diet factors which will be reviewed and discussed with you by your primary care provider.

40. Is mental health and substance abuse recovery covered under TRICARE Prime?

Mental health and substance abuse treatments are covered under TRICARE Prime with a minimal copayment. The cost for outpatient visits will be $10 for E-4 and below and $20 for E-5 and above. Retirees will pay $25 per visit. The copayments are reduced for group visits. For inpatient care the costs are $20 per day for all active duty family members and $40 per day for retirees.

41. What is the function of the Nurse Advisor?

Nurse advisors are available in most regions, by phone, to provide advice and assistance that will enhance patient decision making about their health care. They are available 24 hours a day, 7 days a week, and can discuss treatment alternatives, symptoms, and illness prevention or can advise whether a situation warrants immediate medical attention. Any TRICARE-eligible person can use the service of the nurse advisor.

42. Does TRICARE Prime cover long-term care?

Prime will cover long-term health care to the extent that CHAMPUS does today, that is, noncustodial, skilled care. Please discuss specific care requirements with your local Health Benefits Advisor.

43. Will a pre-existing condition be a factor before being accepted into Prime?

No. Pre-existing conditions will not disqualify you from enrolling in Prime.

TRICARE EXTRA & TRICARE STANDARD

44. Is preventive care covered under Standard or Extra?

Preventive care is an added benefit under Prime. If the particular preventive service is a benefit included under the TRICARE Standard (CHAMPUS) benefits, you will be responsible for the deductible and copayment under Extra and Standard. See your Health Benefits Representative about specific preventive care under TRICARE Standard.

45. How do I switch from TRICARE Standard to Extra and vice-versa? Can I do this at any time?

As long as you are not enrolled in TRICARE Prime, you may switch between Standard and Extra at any time. You can switch by making the choice between any civilian doctor and a doctor within the Extra network.

46. If I am participating in TRICARE Standard, do I have to pay for medical care at a MTF?

There aren't any out-of-pocket costs for outpatient care received at an MTF. However, it is important to remember that TRICARE Prime enrollees will receive priority for care at that MTF before non-enrolled beneficiaries. You will be seen on a space-available-basis only.

47. I am participating in TRICARE Standard. Do I need to pay for my medical expenses up front, or will the doctor bill TRICARE directly?

Under TRICARE Standard, depending upon your provider, you may be required to pay for your share of the medical treatment up front. If you go to a doctor who participates in the Extra network, your out-of-pocket costs will be less than with Standard and you will not have to file claims.

PROGRAM FOR PERSONS WITH DISABILTIES

48. I have an eligible family member with special needs. How does TRICARE fit in with the Program for Persons with Disabilities (PFPWD), previously known as the Program for the Handicapped?

The PFPWD is a financial assistance program for active duty dependents with severe physical disabilities or with moderate to severe mental retardation who cannot get specialized training or care through public resources. Active duty family members can take advantage of both TRICARE and the PFPWD programs concurrently. The exception is that authorized services provided in conjunction with the PFPWD qualifying condition cannot be furnished under the basic program as long as the qualifying condition exists and there is a PFPWD benefit authorization outstanding.

The PFPWD is used concurrently with TRICARE Prime, Extra or Standard. Authorization for benefits under PFPWD does not affect your enrollment in TRICARE Prime. It does provide an additional financial option to explore when utilizing medical resources. When you are enrolled in TRICARE Prime, you are assigned a Primary Care Manager, who has the responsibility to authorize specialty care under the Prime program. Benefits not normally covered may be cost shared under the PFPWD.

Because of the cost associated with care for family members with special needs, most families will be encouraged to review all of the TRICARE options. Recognizing that the catastrophic cap under Extra and Standard is only $1,000, and all further cost are covered at 100% by the government, TRICARE Prime may not be your best option. Further, most State and Federal Agencies cover some of these specialty services at little or no additional cost. Check with your regional TRICARE Service Center to see which TRICARE option is the best for your particular family member. For personnel who are Medicare eligible due to a disability and are under the age of 65, they still retain their TRICARE eligibility (see questions 55 and 56 for more information).

NATIONAL MAIL ORDER PHARMACY

49. What is the National Mail Order Pharmacy Program (NMOP)?

The NMOP is DoD's new timesaving and inexpensive mail order service for maintenance prescriptions. Beneficiaries can receive free delivery to a home, temporary stateside address, or APO/FPO addresses.

50. Who is eligible for the NMOP?

At this time:

Active duty worldwide

CHAMPUS beneficiaries living in Alaska and Puerto Rico

All beneficiaries in the TRICARE Prime, Extra and Standard program except those in regions 1,2 and 5.

Uniformed services treatment facility enrollees

Overseas CHAMPUS beneficiaries with APO or FPO addresses

Base realignment and closure Medicare eligibles in TRICARE regions 1, 2, and 5.

Base realignment and closure Medicare eligibles at: Naval Air Station, Adak, AK; Naval Air Station, Alameda, CA; Naval Air Station, Treasure Island, CA; Sierra Army Depot, CA and Ft. Chaffee, AR

51. I currently have access to a mail order program under TRICARE Prime. Is the NMOP the same program?

No. It is an entirely different program that is not only region-wide, but also worldwide, under one contract with Merck-Medco Rx Services. Regarding current enrollees, the NMOP is only available to those enrolled in TRICARE Prime at an MTF. So, if you are enrolled at a MTF, and not through a Prime network, you are eligible to use the NMOP. Effective April 1, 1998 the NMOP will be available to all beneficiaries now covered by Managed Care Support contractors (both enrolled and non-enrolled beneficiaries). These beneficiaries will be phased in upon completion of negotiations with the MCS contractor currently responsible for their regional mail order benefit.

52. What medications are available through the NMOP?

The NMOP is for prescriptions that you take on a regular basis, such as medication to reduce blood pressure or treat asthma, diabetes, or any long-term health condition. It is not intended to be used for acute medications like antibiotics.

53. What if I have other health insurance with a prescription benefit?

Any beneficiary who is in one of the eligible groups for the NMOP, but has other health insurance with a pharmacy benefit will be required to use the other available pharmacy benefit coverage first.

54. How can I get more information about the NMOP?

If you are in one of the eligible beneficiary groups, see your local military treatment facility pharmacy for details, or call the Merck-Medco Member Services line at 1-800-903-4680. Outside the U.S., contact your long distance carrier for access. The TDD number for the hearing impaired is 1-800-759-1089. Both a short Program Registration Form and a Confidential Patient Profile Registration Form will need to be completed.

MEDICARE

55. I am disabled, under age 65. Can I enroll in TRICARE Prime?

Yes. Beneficiaries eligible for Medicare on the basis of disability or end stage renal disease that are: (1) under age 65, and (2) enrolled in Medicare Part B, are eligible to enroll in Prime and have the enrollment fee waived. However, when these beneficiaries reach age 65, they must receive their health care through Medicare.

56. I am under age 65 and have Medicare Part A and B due to end-stage renal disease. I am responsible for and pay the monthly Medicare Part B premium. If I enroll in TRICARE Prime, will I also be responsible for the enrollment fee or will it be waived?

DoD has instituted a new rule that allows them to waive the enrollment fee for all persons who fall into this very category.

57. Can Medicare eligibles, over 65, enroll in Prime?

In an effort to better serve the medical needs of all of our over 65 retirees, DoD has long supported a program that would allow dual-eligible beneficiaries to use their Medicare benefit at Military Treatment Facilities (MTFs). This program was previously referred to as Medicare Subvention. Congress recently passed legislation that allows DoD and the Health Care Financing Administration (HCFA-the government agency responsible for Medicare) to conduct a Medicare Subvention demonstration, called TRICARE Senior Prime, in selected areas.

Six project sites have been selected and enrollment may be an option for you if you reside in these areas. If you do not live near one of these demonstration sites, you can continue to seek care in an MTF on a space-available basis; acquire prescriptions through military pharmacies, as well as a retail and mail order pharmacy program if you reside in a Base Realignment and Closure (BRAC) area; and use the Health Care Finders to assist in finding physicians in the TRICARE Extra network who will accept Medicare.

58. How will TRICARE Senior Prime work?

TRICARE Senior Prime, DoD's Medicare Subvention program, will operate similar to a Medicare at-risk health maintenance organization (HMO), with the goal of becoming a fully participating Medicare HMO in the future. All care must be obtained either by or through your Primary Care Manager at the MTF.

59. How can I be part of the TRICARE Senior Prime demonstration program?

To be eligible to enroll in TRICARE Senior Prime, you must meet all of the following requirements:

Be age 65, or attain age 65 on or prior to the first day of health care delivery, dates to be announced.
Live in the geographic area covered by the demonstration program
Be eligible for Medicare and care in the MTF.
Received medical care in an MTF prior to July 1, 1997, or became eligible for Medicare after July 1, 1997
Be enrolled in Medicare Part B
Agree to access covered services only through the TRICARE Senior Prime program.

Even if you meet all of the eligibility requirements listed, you may not be enrolled in the demonstration if you:

- Have elected Medicare hospice coverage or have end-stage renal disease*
- Are under age 65 and eligible for Medicare because of a disability

* Exception: A beneficiary who is diagnosed with end-stage renal disease or who elects the Medicare Hospice benefit after enrollment in the project is eligible to remain in the program.

60. How can I obtain more information about the TRICARE Senior Prime demonstration Project?

If you live in one of the six geographic areas covered by the demonstration project, you will receive, in the mail, an information packet with more specific details about the project in your particular area, or call your local TRICARE Service Center.

RESERVE AND NATIONAL GUARD COMPONENTS

61. As a reservist when are my family members and I eligible for TRICARE?

As a reservist, you and your family members are eligible for TRICARE when you become activated and are issued orders sending you to active duty for a period of more than 30 consecutive days and when you retire from reserve status and are age 60.

62. As an activated reservist how will I receive my health care?

All activated reserve/guard members will be enrolled in TRICARE Prime and will receive all of their care in MTFs. If you are stationed in an area where there are no MTFs, you will receive your care from a civilian provider. Under no circumstance will you be responsible for any out-of-pocket costs.

63. Will my family members need to choose between the three TRICARE options?

This depends on the length of time for which your active duty orders have been issued. If you, the sponsor, have been issued orders for a period of more than 30 consecutive days, your eligible family members may choose to receive health care through the Military Health System (MHS). In the MHS your family member will have access to the benefits included in two TRICARE health plan options, TRICARE Standard (CHAMPUS), and, if available, TRICARE Extra. To help in the decision, an assessment of your family's health care needs and the health care delivery options for which they qualify will assist in them in choosing an option that best meets their health care and cost needs.

If your have been issued orders for 179 days or more, your family members have the option to enroll in a third TRICARE option, TRICARE Prime, if available in your area.

64. Am I eligible for health care in the MHS when I retire from the reserves/guard?

Upon becoming age 60 and completing the required service time, you and your eligible family members have the option to use TRICARE. Retired military personnel and their family members, aged 65 and older, are eligible to receive health care benefits under the Medicare system, and are not, at this time eligible for TRICARE. However, you are eligible for space-available-care at an MTF or clinic.

DENTAL

65. What is the TRICARE Selected Reserve Dental Program (TSRDP)?

In order to maintain dental readiness, the 1996 National Defense Authorization Act directed the establishment of the TSRDP for members of the Selected Reserve.

66. What sort of coverage do I get with the TSRDP?

Covered services include diagnostic, preventive, basic restorative, oral surgery and emergency services; items such as crowns, root canals, bridges and orthodontia are not covered.

67. Will the TSRDP cost me anything?

The monthly premium is $4.36. Enrollees must submit a prepayment of 4 months of premiums ($4.36 x 4 = $17.44) with their enrollment form. There are no copayments for diagnostic, preventive or emergency care services. Copayment responsibilities for restorative services for E1 through E-4 are 10%, for E-5s and above it is 20%. Copayment responsibilities for oral surgery services for E-1 through E4 is 30%, for E-5s and above it is 40%. The maximum annual benefit for all services is $1,000 of paid allowable charges per contract year. Modest annual changes to the premium levels are anticipated.

68. Who is eligible for the TSRDP?

Eligible Selected Reserve members who have at least one year of Selected Reserve service remaining who are located in the 50 United States, the District of Columbia, Puerto Rico, Guam and the US Virgin Islands. TSRDP is not available to reservists living in Europe, Asia, or areas outside those mentioned.

Unit Members. A member who is assigned to a national Guard or Reserve unit that is organized to perform Inactive Duty Training (drills/UTAs) and annual training as a minimum.

Individual Mobilization Augmentees (IMAs). IMAs are Reserve personnel assigned to Active component organizations. They also perform drills and annual training.

Training Pipeline Personnel. Selected Reserve enlisted members who have not yet completed initial active duty for training (IADT) and officers who are in training for professional categories or in undergraduate flying training.

Excluded: Active Guard/Reserve (AGR), and Selected Reserve members on extended active duty are not eligible to sign up for this program. Others not eligible: Reserve/ Guard family members, members of the Standby Reserve, Retired Reserve and Individual Ready Reserve.

69. How can I get more information about the TSRDP?

The contractor for the TSRDP, Humana Military Health Care Services has a toll free telephone number, 1-800-211-3614, which will be staffed Monday through Friday 0800-1800 E.S.T., to answer your questions.

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Last update: 9/2/1998

This site maintained by Roger Shaw and Charlie Broussard
Last updated 09/14/2001

General Information

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GENERAL INFORMATION

TRICARE PRIME

Active Duty

Enrollment

Portability (Moving)

Primary Care Providers

Special Benefits

TRICARE EXTRA & TRICARE STANDARD

PROGRAM FOR PERSONS WITH DISABILTIES

NATIONAL MAIL ORDER PHARMACY

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