Summary: Describing Tricare

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Describing Tricare The Department of Defense’s health insurance plan for military personnel and their families is known as TRICARE. Like most insurance policies, TRICARE has different restrictions and requirements as well. TRICARE has many different aspects to take into consideration including eligibility requirements, the four subsidiaries, covered and noncovered services, network and nonnetwork providers, participating and nonparticipating provider charges, and reimbursement. I will now discuss all of these aspects in order to give out a better understand of the TRICARE program. To begin with, TRICARE has eligibility requirements just like all other insurance policies. The following uniformed services and their families are eligible for…show more content…
TRICARE will only pay for services given by authorized providers. Specific education, licensing, and other requirements must be met by authorized providers to be certified by TRICARE regional contractors. After authorization, a PIN is assigned to the provider and they must decide whether or not to participate. Participating providers have to agree to accept the TRICARE allowable charge as full payments for services that are given. Providers can decide on a case-by-case basis whether or not to participate. Claims have to be filed on the patient’s behalf by participating providers. Payments are sent directly to the provider by the regional TRICARE contractor, and the provider is responsible for collecting the patient’s portion of the charges. Claim decisions can only be appealed by participating providers. When it comes to nonparticipating providers, they can’t charge more than 115 percent of the allowable charge. If a patient is billed for over this amount, then they can refuse to pay the excess. The excess amount would then have to be written off by the provider. The patient would be responsible for paying the cost-share, which is a TRICARE term for the coinsurance, or the amount that is the responsibility of the patient. After a claim is submitted, TRICARE will pay its part of the allowable charges, but this payment goes to the patient instead of the provider. This ultimately leaves the patient…show more content…
These include TRICARE Prime, TRICARE Extra, TRICARE Reserve Select, and TRICARE for Life. TRICARE Standard offers beneficiaries access to three different health care plans. TRICARE Standard is a fee-for-service program that replaces the CHAMPUS program. It covers medical services provided by civilian physicians or a Military Treatment Facility (MTF). Medical expenses are shared between TRICARE and the beneficiary under TRICARE Standard. Annual deductibles must be paid by enrollees, and families of active-duty members are responsible for 20 percent of outpatient charges. A 25 percent cost-share for outpatient services is paid by retirees and their families, former spouses, and families of deceased personnel. A beneficiary is responsible for a provider’s additional charges of up to 115 percent of the allowable charge are the provider treats them and doesn’t accept assignment. There is a catastrophic cap in which patient cost-share payments are subject to. This is a limit on the total medical expenses that beneficiaries are required to pay in one year. The annual cap for active-duty families is $1,000, while other beneficiaries have a limit of $3,000. After these caps are met, TRICARE the n pays 100 percent of addition charges for covered services for that coverage year. TRICARE Prime is a managed care plan that is similar to a HMO. All active duty service members are enrolled into TRICARE Prime and they don’t

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