Healthcare for Active Duty Healthcare for Active Duty Military Families…Military Families…

“Keeping it Safe Here” “Keeping it Safe Here”

Martin McCaffrey, MD, CAPT Martin McCaffrey, MD, CAPT USN (Ret)USN (Ret)

Military Ranking Military Ranking

http://www.defenselink.mil/specials/insignihttp://www.defenselink.mil/specials/insigniasas

What is TRICARE?What is TRICARE?Health care program for 9.2 million Health care program for 9.2 million beneficiaries beneficiaries – 120,000 births per year120,000 births per year

Integrated health care delivery systemIntegrated health care delivery system– Military treatment facilities (MTFs)Military treatment facilities (MTFs)– Civilian health care facilitiesCivilian health care facilities

Range of program options Range of program options Comprehensive coverageComprehensive coverageAvailable worldwideAvailable worldwide

TRICARE Eligibility TRICARE Eligibility Beneficiary categoriesBeneficiary categories– Sponsors (active duty, National Guard, Sponsors (active duty, National Guard,

Reserve or retired service members) Reserve or retired service members) – Family members (spouses and unmarried Family members (spouses and unmarried

children) children) – Survivors, certain former spouses and Survivors, certain former spouses and

othersothers

RequirementsRequirements– Registration in the Defense Enrollment Registration in the Defense Enrollment

Eligibility Reporting System (DEERS) Eligibility Reporting System (DEERS) – Valid Uniformed Services ID CardValid Uniformed Services ID Card

TricareTricare

StandardStandard– Basic, comprehensive coverageBasic, comprehensive coverage– No enrollment requiredNo enrollment required– Fee for service flexibilityFee for service flexibility– Deductible Deductible

ExtraExtra– Standard plus (access to Prime Network providers at TMA rates or Standard plus (access to Prime Network providers at TMA rates or

Other Providers) Other Providers)

PrimePrime– Required for AD membersRequired for AD members– Must Must activelyactively enroll enroll– Assumption is all primary care at MTFAssumption is all primary care at MTF– Referral/approval required for specialty care Referral/approval required for specialty care

http://www.tricare.milhttp://www.tricare.mil

Tricare North Contacts Tricare North Contacts

TRICARE StandardTRICARE StandardEnrollment not requiredEnrollment not requiredCare from non-network TRICARE-Care from non-network TRICARE-authorized providersauthorized providers– Provider may charge up to 15% above Provider may charge up to 15% above

TRICARE allowable charge TRICARE allowable charge – May have to submit your own health care May have to submit your own health care

claimsclaims

Referrals not required for specialty care Referrals not required for specialty care Some services may require prior Some services may require prior authorizationauthorizationMTF care on a space-available basis onlyMTF care on a space-available basis only

TRICARE Standard and Extra:TRICARE Standard and Extra:Active Duty FamiliesActive Duty Families

TRICARE OptionTRICARE Option TRICARE TRICARE StandardStandard TRICARE ExtraTRICARE Extra

Outpatient Outpatient DeductibleDeductibleAmount due each fiscal Amount due each fiscal year before cost-sharing year before cost-sharing begins.begins.

Sponsor rank E1-E4: Sponsor rank E1-E4: $50/indivdual or $100/family$50/indivdual or $100/family

Sponsor rank E5 & above: Sponsor rank E5 & above: $150/individual or $300/family$150/individual or $300/family

Outpatient Cost-Outpatient Cost-shareshare

20%*20%* 15% 15%

Inpatient CostsInpatient Costs $14.80/day ($25 minimum)$14.80/day ($25 minimum)

Inpatient Behavioral Inpatient Behavioral Health CareHealth Care

$20/day ($25 minimum)$20/day ($25 minimum)

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

TRICARE PrimeTRICARE PrimeEnrollment requiredEnrollment required– Portable: Easy to transfer when you movePortable: Easy to transfer when you move– Split enrollment:Split enrollment: Families can enroll together Families can enroll together

in different regionsin different regions

Access standards for careAccess standards for careMost care received from primary care Most care received from primary care manager manager Minimal out-of-pocket costsMinimal out-of-pocket costsNo claims to file (inNo claims to file (in most cases)most cases)

TRICARE Prime Costs:TRICARE Prime Costs:Active Duty FamiliesActive Duty Families

Enrollment Enrollment FeesFees

$0$0

Deductible*Deductible* $0$0

Outpatient Outpatient Costs*Costs*

$0$0

Inpatient Inpatient Costs*Costs*

$0$0

Emergency Emergency CareCare

$0$0

Catastrophic Catastrophic CapCap

$1,000 per family per fiscal $1,000 per family per fiscal yearyear

Pharmacy Options and CostsPharmacy Options and Costs

Type of Type of PharmacyPharmacy

FormularyFormularyNon-FormularyNon-Formulary

(Tier 3)(Tier 3)GenGen(Tier 1)(Tier 1)

BrandBrand(Tier 2)(Tier 2)

MTFMTF(up to 90-day (up to 90-day supply)supply)

$0$0 $0$0 N/AN/A

Mail orderMail order(up to 90-day (up to 90-day supply)supply)

$3$3 $9$9 $22*$22*

NetworkNetwork(up to 30-day supply)(up to 30-day supply)

$3$3 $9$9 $22*$22*

Non-Non-networknetwork(up to 30-day supply)(up to 30-day supply)

Prime/TPRADFM: POS fees Prime/TPRADFM: POS fees applyapplyAll Others: $9 or 20%, whichever All Others: $9 or 20%, whichever is more. Must meet deductible.is more. Must meet deductible.

Prime/TPRADFM: POS fees Prime/TPRADFM: POS fees applyapplyAll Others: $22 or 20%, All Others: $22 or 20%, whichever is more. Must meet whichever is more. Must meet deductible.deductible.

Other Tricare Notes Other Tricare Notes

TransportsTransports– Authorization to non-MTF usually requiredAuthorization to non-MTF usually required

Reimbursement for TravelReimbursement for Travel– Beyond 100 mile radius eligible for travel Beyond 100 mile radius eligible for travel

support (Non-medical attendant: NMA)support (Non-medical attendant: NMA)– Distance and allowances determined by TMADistance and allowances determined by TMA

Tricare Support Center (TSC) at every Tricare Support Center (TSC) at every basebaseTMA website (TMA website (www.tricare.milwww.tricare.mil))

Command ContactsCommand Contacts

Every military member belongs to a unit or Every military member belongs to a unit or commandcommand– Multiple commands or units on a given baseMultiple commands or units on a given baseEvery service member has an immediate NCO Every service member has an immediate NCO (E-5 above) or Officer(E-5 above) or Officer– Rank dependent Rank dependent – Supervisor name/contact critical for all military Supervisor name/contact critical for all military

families we care forfamilies we care for– Some proactive, some not, weekly contact helpful for Some proactive, some not, weekly contact helpful for

the familythe family

Conversations With CommandsConversations With Commands

Command has a missionCommand has a missionAD member’s deployAD member’s deployIn the perfect world, full family present for a In the perfect world, full family present for a difficult prenatal course, birth or NICU staydifficult prenatal course, birth or NICU stayMostMost families understand this may not always families understand this may not always be the casebe the case– Is AD member required back from a deployment?Is AD member required back from a deployment?– When can the AD member deploy next?When can the AD member deploy next?– AD Members generally want to deploy when it is AD Members generally want to deploy when it is

medically reasonable medically reasonable

Notification of Deployed Family Notification of Deployed Family MemberMember

Service member's CommandService member's CommandRed CrossRed Cross– Messages to service members 24/7/365Messages to service members 24/7/365– Service member’s full name, rank/rating, branch, social security Service member’s full name, rank/rating, branch, social security

number, military address and information about the deployed number, military address and information about the deployed unit and the home base unit (for deployed service members unit and the home base unit (for deployed service members only) only)

– Drs. name, diagnosis, prognosis, current condition, life Drs. name, diagnosis, prognosis, current condition, life expectancyexpectancy

– Recommend service member presence?Recommend service member presence?– 1-800-696-38731-800-696-3873

Command Family Support GroupsCommand Family Support Groups– Ombudsman (Navy, Army)Ombudsman (Navy, Army)– Key Volunteers (USMC)Key Volunteers (USMC)

Family Support Services (all services)Family Support Services (all services)– http://deploymentlink.osd.mil/deploy/familyhttp://deploymentlink.osd.mil/deploy/family

Preparing Families for DischargePreparing Families for Discharge

Compassionate reassignmentCompassionate reassignmentMay get bills after hospitalizationMay get bills after hospitalization– Don’t panicDon’t panic– Call Tricare Service Directory (TSC)Call Tricare Service Directory (TSC)– TSCs throughout regionsTSCs throughout regions– Staffed with customer service repsStaffed with customer service reps– TSC locator on Tricare website TSC locator on Tricare website

www.tricare.osd.milwww.tricare.osd.mil

InformationInformation– http://www.militaryonesource.comhttp://www.militaryonesource.com– http://www.tricare.mil/specialneedshttp://www.tricare.mil/specialneeds– http://www.stompproject.org/http://www.stompproject.org/– Consider contacting STOMP for inserviceConsider contacting STOMP for inservice

Must Do’s for Families as Must Do’s for Families as Discharge ApproachesDischarge Approaches

DEERS (Defense Enrollment Eligibility DEERS (Defense Enrollment Eligibility Reporting System) Reporting System)

Tricare Coverage (must enroll for Prime)Tricare Coverage (must enroll for Prime)

Exceptional Family Member ProgramExceptional Family Member Program

ECHO ProgramECHO Program

Exceptional Family Member Exceptional Family Member Program (EFMP)Program (EFMP)

Identifies family members with special medical and/or Identifies family members with special medical and/or educational needseducational needsEFMP enrollment is mandatory and required immediately EFMP enrollment is mandatory and required immediately upon identification of a family member with special upon identification of a family member with special needs.needs.Start this paperwork pre-discharge from NICUStart this paperwork pre-discharge from NICUDocuments the services they requireDocuments the services they requireConsiders those needs during the personnel assignment Considers those needs during the personnel assignment process (especially when approving family members for process (especially when approving family members for accompanied travel to overseas locations)accompanied travel to overseas locations)Involves the personnel and medical commands and the Involves the personnel and medical commands and the educational systemeducational system

ECHO ProgramECHO Program

A supplemental program to the TRICARE Basic A supplemental program to the TRICARE Basic ProgramProgramProvides eligible active duty family members Provides eligible active duty family members with additional financial resourceswith additional financial resourcesFocuses on integrated sets of services and Focuses on integrated sets of services and supplies designed to assist in the reduction of supplies designed to assist in the reduction of the disabling effects of the beneficiary’s the disabling effects of the beneficiary’s condition. condition. Pays up to $2500/month after co-pay metPays up to $2500/month after co-pay metUse public resources firstUse public resources first

ECHO DeductiblesECHO Deductibles

ECHO ProgramECHO Program

Qualifying conditions include:Qualifying conditions include:– Moderate to severe mental retardation Moderate to severe mental retardation – Serious disabilitySerious disability– An extraordinary physical or psychological An extraordinary physical or psychological

condition of such complexity that the condition of such complexity that the beneficiary is homeboundbeneficiary is homebound

Families must apply through the EFMP Families must apply through the EFMP officeoffice

ECHO ProgramECHO Program

Durable medical equipmentDurable medical equipmentTraining for assistive technologyTraining for assistive technologyAssistive communication devicesAssistive communication devices16 hours of respite care per month if receiving 16 hours of respite care per month if receiving another ECHO benefitanother ECHO benefitTraining to give home medsTraining to give home medsTransportation Transportation Institutional care when requiredInstitutional care when requiredMedical and rehab services, prosthesis, Medical and rehab services, prosthesis, orthopedic braces and appliancesorthopedic braces and appliances

ECHO ProgramECHO Program

Institutional care when requiredInstitutional care when required

Medical and rehab services, prosthesis, Medical and rehab services, prosthesis, orthopedic braces and appliancesorthopedic braces and appliances

ECHO Home Health CareECHO Home Health Care– In home health service needs not met under In home health service needs not met under

ECHOECHO

Maternity (Prenatal) BenefitMaternity (Prenatal) Benefit

In 2002, NDAA approved maternity benefit for In 2002, NDAA approved maternity benefit for Tricare Tricare standardstandard female enrollees female enrollees

Only non-AD eligibleOnly non-AD eligible

One time cost of $25 for ALL prenatal and One time cost of $25 for ALL prenatal and maternity costsmaternity costs

If father AD, infant eligible for Tricare Prime at If father AD, infant eligible for Tricare Prime at birthbirth

Mother not able to enroll (re) in Prime for 1 yearMother not able to enroll (re) in Prime for 1 year– Potentially risky if non-OB health issues develop Potentially risky if non-OB health issues develop

Maternity LeaveMaternity Leave

AD mothers receive six weeks maternity leaveAD mothers receive six weeks maternity leave– Not counted as regular leaveNot counted as regular leave

Discuss with Command plan to allow time at Discuss with Command plan to allow time at home, especially if infant admitted to the NICU home, especially if infant admitted to the NICU – Don’t consume all maternity leave during NICU stayDon’t consume all maternity leave during NICU stay– May need to consider returning to work during a long May need to consider returning to work during a long

NICU stayNICU stay

Variable approach by Command’s re extended Variable approach by Command’s re extended leave and TAD/TDY of AD Member to hospital leave and TAD/TDY of AD Member to hospital

Supporting the FamilySupporting the Family

Occasionally Command not supportiveOccasionally Command not supportiveFailure to generate Command support Failure to generate Command support – Service member has not informed us of full chain of Service member has not informed us of full chain of

command and other contact optionscommand and other contact options– We have not contacted the proper peopleWe have not contacted the proper people– The Command has significant problems with the The Command has significant problems with the

service memberservice member– Absolutely cannot spare the service personAbsolutely cannot spare the service person

Letter writing has great valueLetter writing has great valueRarely are commands unwilling to support Rarely are commands unwilling to support reasonable medical requestsreasonable medical requests

Who We AreWho We Are

Healthcare for Active Duty Military Healthcare for Active Duty Military Families…Families…

“Keeping it Safe Here”“Keeping it Safe Here”

Family Readiness = Force Readiness