TRICARE - OTHER
DENTAL — ACTIVE DUTY AND RESERVE
Active-duty members receive their dental care through the military, managed by United Concordia. In 2012, the Defense Department expanded the dental benefit for demobilizing National Guard and reserve personnel to give them the same benefits up to 180 days after returning from deployment. In May 2012, the Tricare Dental program contract will transition to Metropolitan Life, promising lower co-payments and increasing the annual maximum benefit and lifetime orthodontia maximum. Participation is voluntary, and costs vary.
Benefits. As of May 1, the annual maximum benefit is $1,300. Certain preventive and diagnostic services do not count against the enrollee’s annual maximum. The lifetime orthodontia maximum as of May 1 is $1,750. There is no deductible.
Covered services include diagnostic and preventive care, sealants, fillings, endodontics, periodontics, prosthodontics (crowns, dentures and bridges), orthodontics and maximum coverage of up to $1,200 for emergency services. Also covered are associated costs specifically for beneficiaries with developmental, physical or mental disabilities and children age 5 and under, as well as coverage for diabetes-related dental issues.
If an active-duty, Selected Reserve or Individual Ready Reserve member dies on active duty, benefits continue for enrolled adult survivors for three years, with no premiums required. Benefits for enrolled surviving children continue for three years or until they reach age 21 (age 23 if a full-time student), whichever is longer.
Cost. Family members of active-duty, Selected Reserve and IRR (Special Mobilization Category) members, and family members of reservists on active duty for more than 30 days have their premiums cost-shared — the enrollee pays 40 percent of the monthly premium and the government pays 60 percent. IRR members (other than Special Mobilization Category) and family members of IRR and Selected Reserve members not on active duty are responsible for 100 percent of the monthly premium.
As of May 1, monthly premiums for active-duty family members are $10.30 for one family member (excluding the sponsor) and $30.89 for more than one family member (excluding the sponsor).
Selected Reserve and IRR personnel and their family members each have four levels of monthly premiums, depending on exactly who enrolls. The program has a civilian provider network. Enrollees can seek care outside the network, but may incur additional costs.
Enrollment. Enrollment is voluntary and requires at least a 12-month service commitment (active duty, reserve or combination). Exceptions are made for reservists with fewer than 12 months left in service who are called to active duty for certain contingencies. Members who live within the continental U.S. and are transferred outside it don’t have to re-enroll.
Overseas. Family members are seen in most military clinics overseas regardless of their enrollment in Tricare. Those enrolled in the dental program outside the continental U.S. are eligible for the same benefits, but policies and procedures vary depending on location and service provided.
For care from host-nation dentists, dental plan members who do not live in a remote area must get a statement of nonavailability and a referral form and use dentists on the provider list. Those in remote areas outside the U.S. without a fixed dental facility may get routine dental care without referral but will need a form for orthodontic care.
DENTAL — RETIREES
Military retirees and their families can purchase coverage under the Tricare Retiree Dental Program. In addition to those entitled to retired pay, those eligible include “gray area” reservists who qualify for, but are not yet receiving, retired pay because they are younger than 60; spouses and eligible children of enrolled members and certain nonenrolled members; Medal of Honor recipients and eligible family members; eligible children of deceased members; and deceased members’ spouses who have not remarried.
The plan, administered by Delta Dental of California, has a network of more than 100,000 civilian dentists. It provides dental coverage under “Basic” and “Enhanced” plans to enrollees in the 50 states, the District of Columbia, all U.S. territories and Canada.
Enrollees also may receive care from Delta Dental Premier dentists. They are not in the network but will not charge more than the fees they have agreed to with Delta Dental. Enrollees will be responsible for co-payments and deductibles, as applicable, plus any difference between the agreed-upon fees and the TRDP allowable fee.
Enrollees can use other licensed dentists, but may pay more and may have to file claims themselves.
Benefits. The Enhanced TRDP annual maximum is $1,200 per enrollee per benefit year for most covered services. Deductibles are $50 per person per benefit year, up to a cap of $150 per family. Diagnostic and most preventive services are excluded from maximums and deductibles.
Initial covered services include diagnostic, preventive and restorative treatments, sealants, endodontics, periodontics, prosthodontics, orthodontics, oral surgery, general anesthesia, dental accident coverage and emergency services. Some additional services are available after the first 12 months of enrollment, unless a beneficiary enrolls in the enhanced plan within 720 days of retirement; then services are covered immediately. These include crowns, onlays, bridges, partial and full dentures, orthodontics and dental implants.
Cost. Premiums, based on five pricing regions and the enrollee’s ZIP code, are adjusted each May 1 and are automatically deducted from retirement pay. Retirees can find the specific premium rates for their ZIP code online at www.trdp.org/pro/premiumSrch.html.
Enrollment. Enrollment is voluntary and requires an initial enrollment for 12 months, with an option to continue on a month-to-month basis. Enrollment requires two months of premiums due with a completed application.
Contact: www.trdp.org. For other information, call Delta Dental at 888-838-8737.
DISABLED FAMILY MEMBERS
The Defense and Veterans Affairs departments have programs for military family members with disabilities.
The Extended Care Health Option is a Tricare program that supplements whatever Tricare plan a military family may be using. ECHO pays for care not otherwise available to active-duty family members with mental disabilities or serious physical disabilities or who are homebound because of a severe, complex physical or psychological condition in the 50 states, the District of Columbia, Puerto Rico, Guam and the U.S. Virgin Islands. This includes qualified family members of activated reserve component members.
Coverage includes medical and rehabilitative care, special education, training in assistive technology devices, durable equipment, respite care and other services. Also provided is up to 16 hours per month of respite care for beneficiaries.
The maximum government cost-share is $36,000 per fiscal year for all services except home health care. The maximum cost-share for all other ECHO benefits combined is $2,500 per month. Monthly cost shares for covered services are based on paygrade, ranging from $25 for E-1s through E-5s to $250 for O-10s.
Since 2008, Tricare’s Autism Services Demonstration program has allowed diagnosed beneficiaries to receive applied behavioral analysis intervention. The program, available in 50 states and the District of Columbia, falls under ECHO, and co-pays and caps apply.
Disabled veterans and certain dependents also may qualify for VA programs.
HOME HEALTH CARE
The Extended Care Health Option has a subsidiary program called ECHO Home Health Care that includes coverage of medical equipment, supplies, certain therapies and nursing care to homebound patients whose conditions make home visits necessary.
The program covers skilled nursing from a registered, licensed or vocational nurse under direct supervision of a registered nurse; physical therapy from a licensed physical therapist, and speech pathology from a licensed speech therapist.
There are certification or licensure requirements for other professional disciplines providing home health services. In the case of skilled nursing services, coverage can be extended when:
♦The services are ordered by, and included in, the treatment plan established by the physician.
♦The services require the skills of a registered nurse under the supervision of another nurse or a physician.
♦Detailed nursing notes are kept for skilled nursing services.
Tricare permits home care for up to eight hours a day, five days a week, under its respite care benefit for active-duty members. Home health aide and medical social work services can be provided under the hospice benefit.
EHHC coverage is capped on an annual basis. The cap is limited to the maximum fiscal-year amount Tricare would pay if the beneficiary resided in a skilled nursing facility. This amount is based on the beneficiary’s geographic location.
Tricare covers, at no cost, age-appropriate doses of all vaccines recommended by the Centers for Disease Control and Prevention. Vaccines for active-duty family members who are accompanying sponsors under orders to an overseas duty station also are covered. Through the Tricare Pharmacy Program’s expanded vaccine initiative, certain vaccines are available at some network pharmacies for no co-payment.
Contact: For a complete list of covered vaccines, go to: www.tricare.mil/mybenefit/home/Prescriptions/Medications/Vaccines To locate a participating pharmacy, go to: http://www.express-scripts.com/TRICARE/pharmacy or call 877-363-1301.
Each military service has psychiatrists, psychiatric nurse practitioners, psychologists and social workers to help those with mental health and emotional issues. Therapy programs at military installations range from individual, marriage and group counseling to Al-Anon for relatives of alcoholics. Tricare beneficiaries not on active duty also are eligible for civilian outpatient mental health treatment. Prime patients may receive up to eight visits of outpatient mental health care without authorization if they use network providers.
Professionals whose services are covered by Tricare include psychiatrists, psychologists, psychiatric and clinical social workers, certified marriage and family therapists and approved mental health counselors. But the mental health provider must be authorized under Tricare, or services will not be covered.
Inpatient mental health treatment in a civilian facility must be pre-authorized by a Tricare regional managed care support contractor, except in an emergency. Military hospitals normally do not provide inpatient psychiatric care for family members, although they may in an emergency.
Tricare For Life beneficiaries should follow Medicare and Tricare procedures when seeking mental health services – follow Medicare first and Tricare second. Tricare patients who need intensive mental health care but not 24-hour hospitalization are eligible for psychological partial hospitalization at participating facilities; they are treated in the hospital during the day, but go home at night.
Tricare has a Behavioral Health Provider Locator and Appointment Assistance Service center for active-duty members and families enrolled in Prime or Prime Remote, and Tricare Overseas Prime enrollees temporarily in the U.S.
Contact: West Region, 888-874-9378; North Region, 877-874-2273; and South Region, 800-700-8646. More information on Tricare’s mental health benefits is at http://tricare.mil/mybenefit/home/MentalHealthAndBehavior
Telemental Health: Each Tricare region offers secure audiovisual conferencing for behavioral health services through an established network of sites as well as offsite providers who can treat, refer and evaluate Tricare beneficiaries for mental health services, including psychotherapy and medication management.
Contact: North Region, 877-874-2273; South Region, 800-700-8646; West Region, 888-874-9378. For a list of toll-free overseas contact information, go to www.tricare-overseas.com; for more information on Tricare mental health benefits, go to www.tricare.mil/mentalhealthAfterdeployment.org.
Afterdeployment.org Tricare offers a free resource for service members returning from deployment and their families. The site provides strategy and educational materials that address combat stress and triggers; conflict at work; reconnecting with family and friends; depression, anger and sleep problems; substance abuse; stress management; spiritual guidance; living with physical injuries; and more.
Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. This 24-hour outreach center provides information and referrals to service members, veterans, their families and others with questions about mental health and TBI. Center staff is available around the clock, 365 days a year, to deal with everything from routine requests for information to questions about symptoms a caller may be experiencing, to helping people find appropriate health care resources. The service is offered via telephone, online chat and email.
inTransition. This Defense Department program offers service members in mental health treatment a bridge of support between health care providers when they transfer to a new location or leave service.
The service member is assigned a “transition support coach” – a licensed behavioral health clinician specially trained in understanding today’s military culture. Coaches can offer information on how to successfully change care providers, assist with referrals, provide crisis intervention and supply other information on local resources. They also can help service members transition their mental health care from the military system to the VA health care system.
Contact: www.health.mil/intransition ; 800-424-7877 (in the U.S.); 800-424-4685 (outside the U.S.); individuals outside the U.S. also may call collect 314-387-4700.
Military beneficiaries can get prescription drugs free at military clinic or hospital pharmacies. For a co-payment of $5 for a generic and $12 for a brand name, they can get a 30-day supply at participating Tricare retail stores. They can get a 90-day supply of the same drugs through the Tricare Pharmacy Home Delivery Program for a co-payment of $9 for brand-name pharmaceuticals; there is no co-payment for generics.
A third tier of coverage charges $25 for some brand-name drugs not on the Defense Department’s pharmacy formulary. Defense officials in recent years have been moving more brand-name drugs to this pricing tier to encourage beneficiaries to use generics, which helps hold down Defense Department costs.
Beneficiaries cannot use Tricare home delivery if they have another pharmacy benefit plan, unless the medication is not covered under the other plan or the dollar limit of the other plan is exhausted.
Beneficiaries can have their prescriptions filled at a pharmacy not in the Tricare network, but they pay 20 percent of the retail cost of the drug, or $12, whichever is greater. They also pay annual deductibles. Lower enlisted paygrades – E-4 and below – not in Prime are charged a $50 deductible for an individual and $100 for a family. Everyone else not in Prime pays $150 for an individual or $300 for a family.
Prime enrollees who use pharmacies outside the network also pay deductibles of $300 per person or $600 for a family, and have a 50 percent co-pay for the drugs.
Most retirees 65 or older must have Medicare Part B to use Tricare’s retail and home delivery pharmacy programs. Only retirees and dependents who turned 65 before April 1, 2001, are not required to carry Part B to use pharmacy benefits. But Part B is needed for medical benefits.
The Pentagon’s proposed 2013 budget calls for increases in co-payments for brand names at retail stores and by mail order: $26 for a 30-day supply at a Tricare network pharmacy and $26 for a 90-day supply through mail order. Medications not listed on the Tricare formulary would cost $51 through mail order and be extremely limited at retail outlets. Medications through military clinics and pharmacies would remain free. At press time, the proposal was pending in Congress.
Contact: 877-363-1303; www.tricare.mil/pharmacy
Tricare’s formulary can be searched at http://pec.ha.osd.mil/formulary_search.php.
Supplemental insurance plans cover expenses that remain after Tricare pays its share of covered benefits. Usually offered by military associations through private insurance companies, these plans pay a specified amount of an individual’s share of Tricare costs. Normally, they don’t pay for things Tricare does not cover.
TRANSITIONAL HEALTH CARE
The Transitional Assistance Management Program provides 180 days of transitional health care and dental benefits to help eligible troops and families transition to civilian life. This includes those involuntarily separating from active duty under honorable conditions; reserve component members separating from active duty of more than 30 consecutive days in support of a contingency operation; separating from active duty following involuntary retention (stop-loss) in support of a contingency operation; and separating from active duty following a voluntary agreement to stay on active duty for less than one year in support of a contingency operation.
There are no enrollment fees for TAMP coverage. For those who qualify, the 180-day period begins the day after separation from active duty. Service members and families are covered under Tricare Standard and Tricare Extra. Those living overseas get the same coverage under Tricare Overseas Standard. Service members and their families are covered as an active-duty family member, and all rules for that beneficiary category apply to them.
During the TAMP period, service members may choose to enroll in Tricare Prime and Tricare Overseas Prime, where those options are available. Once beneficiaries lose TAMP coverage, they may apply for temporary, transitional health care coverage under the Continued Health Care Benefit Program (www.tricare.mil/mybenefit/home/overview/SpecialPrograms/CHCBP ). Those eligible must enroll in CHCBP within 60 days of loss of TAMP benefits, and pay monthly premiums for continuous health care benefits similar to Tricare Standard. Current quarterly premiums are $988 for an individual and $2,213 for a family.
Coverage is limited to either 18 or 36 months in 90-day increments.