MILITARY INSURANCE - TRICARE AND THE VETERANS HEALTH ADMINISTRATION (VA)

TRICARE

 

TRICARE is the Department of Defense’s health care program for members of the uniformed services—Army, Navy, Air Force, Marine Corps, Coast Guard, Public Health Service, and the National Oceanic and Atmospheric Administration—their families and survivors. TRICARE also offers health care programs for retired service members, including TRICARE Pharmacy and TRICARE for Life.  It is a set of regionally managed health plans available worldwide and managed regionally in six separate TRICARE regions—TRICARE North, TRICARE South, TRICARE West, TRICARE Europe, TRICARE Pacific, and TRICARE Latin America/Canada—jointly by the TRICARE Management Activity (TMA), TRICARE Regional Offices, and private contractors.

While most active military patients are treated within the military health facilities, most home infusion providers may treat non-active military, dependents, retired military, etc. covered by the principal TRICARE plans:

*See deductibles and co-pay comparisons.

**Active duty service men and women are limited to enrollment in TRICARE Prime.  The uniformed service directly provides their care through Military Treatment Facilities (MTFs) but may authorize network civilian providers to provide care if the MTF cannot perform the service. Home infusion providers treat active military patients under such authorizations.

***Formerly called Champus, however TRICARE should not be confused with CHAMPVA which is still an active program managed by the VA’s Health Administration Center (HAC). An individual who is eligible for TRICARE is not eligible for CHAMPVA.

Click here for descriptions of all TRICARE health plans and other related information.  Read about eligibility and dual-eligibilty.  Find out where to file paper claims.  Obtain a June 25, 2009 Department of Defense slide presentation explaining many aspects of the program.

Contractors by Regions and Programs:

Note:  Big Changes coming in 2017!

Reduction of Three TRICARE Regions to Two

There are currently three TRICARE regions in the United States: North, South, and West. The new regional contracts reduce the number of regions to two. Moving to two regions standardizes how you get your benefit.

  • East Region (merges current North and South Regions)
  • West Region (same as the current West Region)

Visit the TRICARE New Regional Contracts in 2017 website for details.

 

CMAC Fee Schedules.  The CHAMPUS National Pricing System (CMAC System) is one of a set of fee schedules used for establishing TRICARE payment.  TRICARE provides CMAC look up tools:

Program Manuals.  Download them from the link as published by TMA.

NHIA Advocacy Program with TRICARE:

NHIA Writes to Defense Health Agency (DHA) on Misinterpretation of Cures Act (May 16, 2018)

NHIA Seeks Appropriate Reimbursement for Home Infusion Drugs in Health Net-Administered TRICARE Regions(December 12, 2017)

Questions and Answers from Express Scripts, Inc. Pertaining to Home Infusion and the TPharm Program – a result from NHIA’s expressing concerns  (Jun 13, 2012)

TRICARE Policy for Infusion Drug Therapy Delivered in The Home – effective January 31, 2012, implementation is underway by the TRICARE contractors. Related is its Pharmacy Benefits Program policy. NHIA has concerns and plans to communicate to the program administrators. (Feb 24, 2012)

TRICARE Issues Policy:  Processing And Payment Of Home Infusion Claims – view the policy which was effective 11/9/09 but is no longer included in the program’s policy manual.  (Updated Feb 24, 2012; original post Nov 16, 2009)

TRICARE to Fix Claim Denials Called to Its Attention by NHIA (Aug 19, 2009)

TRICARE Meets with Home Infusion Therapy Providers (Jul 18, 2008)

 

Veterans Health Administration (VA)

 

The Veterans Health Administration is home to the United States’ largest integrated health care system consisting of 152 medical centers, nearly 1,400 community-based outpatient clinics, community living centers, Vet Centers and Domiciliaries. Together these health care facilities and the more than 53,000 independent licensed health care practitioners who work within them provide comprehensive care to more than 8.3 million Veterans each year.  Click here to learn more about the VA program.