Insurance

When the US entered the war in 1917, President Wilson asked the Secretary of Treasury to appoint a committee of experts from the insurance, social services and medical community to recommend legislation that would meet the financial needs of servicemen and their dependents both during and after the war. The result was an extensive amendment to the War Risk Insurance Act, which included a provision for voluntary life insurance on the lives of servicemen.

The reason for the amendment is simple, like the property and casualty insurance companies who were unwilling to assume the risk of insuring ships and cargo during a war, the private life insurance companies were unwilling to underwrite the coverage for members of the service. While actuaries are extremely accurate in predicting deaths during peace-time, it is almost impossible to estimate how many deaths there will be during a war. To avoid taking on this type of high risk insurance companies have traditionally added what is referred to as a “war clause” to their contracts during war time periods.

As a result of the amendments to the War Risk Insurance Act, the government soon became the largest life insurer in the US. The response to the program was in many respects overwhelming. Although the coverage was optional, over 93% of those eligible took the coverage, and most of those took the maximum amount of $10,000. Through each succeeding war and major military conflict the government, through the VA, has continued to provide life insurance to members of the armed services while they were on active duty and after they were separated.

Today we have 6 different programs that cover veterans of WWI, WWII, the Korean war and certain groups of disabled veterans. Namely, United State Government Life Insurance, National Service Life Insurance, Veteran’s Special Life Insurance, Veteran’s Reopened Insurance, Service-Disabled Veterans Insurance and Veteran’s Mortgage Life Insurance.

Tricare: The Military’s Health Insurance
Medical care in necessary and beneficial in maintaining good health. A special group of veterans are authorized to participate in Tricare, the military’s version of healthcare insurance.

Tricare: Choosing a Plan
Tricare is the military’s health insurance program that covers everyone including active-duty members, retirees, and their families. However, retirees and their dependents much pay a portion of the cost of coverage; medical care is free for those who are still serving and their families. Because this is a book about veteran’s benefits, the information in this chapter is limited to what affect the veteran and the veteran’s family members— in other words, those no longer in the military.

For veterans and their authorized family members, Tricare has four options, depending on your needs:

  • Tricare Prime
  • Tricare Extr
  • Tricare Standard
  • Tricare for Life
  • Tricare Prime: An HMO by another name

The Tricare Prime option is very much like an HMO, or health maintenance organization. Like an HMO, you are assigned to a primary care provider (PCP). This is usually, although not always, a military medical facility (on-base hospital or medical clinic). You receive most of your healthcare needs through the PCP. Like most HMOs, in order to receive care from a specialist you must first receive a referral from your PCP.

Tricare Prime requires you to enroll and pay an annual enrollment fee; plus you pay a small fee (called a cost-share in the military) each time you receive medical care. When you receive medical care under Tricare Prime, you do not have to file a reimbursement claim. The provider automatically does this for you.

Tricare Prime is the most cost-effective Tricare option, but you generally have to live close to a military base to take advantage of it. However, many military retirees choose to live near a military base because of the on-base shopping discounts they receive.

To enroll in Tricare Prime, you must fill out some paperwork. Enrollment forms are available online at www.tricare.mil/mybenefit/Forms.do or at any military medical facility.

Tricare Extra: When an HMO Just Won’t Do
The Tricare Extra program allows more flexibility than Tricare Prime, but it can result in additional costs. If you are eligible for Tricare benefits, you do not need to enroll in advance to use Tricare Extra. You are enrolled automatically the first time you use any benefits and present your military or dependent ID card as an insurance card to the provider.

Under this program, you can go to any Tricare network provider (TNP), present your military or dependent ID card, and receive medical care. There are thousands of TNPs across the country. You can find a TNP close to you by visiting www.tricare.mil/mybenefit/home/Medical/FindingAProvider. The TNPs have a contract with the military to limit costs to designated amounts.

Under Tricare Extra, you pay an annual deductible. After the deductible is paid, Tricare pays 80 percent of the medical expenses, and you pay 20 percent of the authorized costs. TNPs have also agreed to do all the paperwork for you. Under Tricare Extra, you do not have to file claims to be reimbursed.

Tricare Standard: A Little More Cost Equals Much More Freedom
The Tricare Standard program gives you the greatest flexibility, but it costs the most. Under this program, you can see just about any medical provider you want. As with Tricare Extra, you pay an annual deductible. In addition to the deductible, you pay 25 percent of what Tricare says the medical service should cost.

If you want to find out what the Tricare allowable cost is for a particular medical procedure, use the search tool provided at www.tricare.mil/allowablecharges.

Medical Providers Under Tricare Standard Can Be Broken Into Two Groups:
Participating providers: Participating providers, although they are not under contract as a TNP (Tricare network provider), have agreed to file claims for you, accept payment directly from Tricare, and accept the Tricare allowable charge, less any applicable cost-shares paid by you, as payment in full for their services.

There is no national list of participating providers. You need to ask your provider if she participates in the Tricare program. The general rule is, if the provider fills out the claims paperwork for you, she’s a participating provider. If you have to fill out the claim form yourself, she’s a nonparticipating provider.

Nonparticipating providers: Nonparticipating providers have not agreed to accept the Tricare allowable charge for services or file your claims. Under the law, nonparticipating providers may charge up to 15 percent above the Tricare allowable charge for services (in addition to your regular cost-shares). This amount is your responsibility and is not shared by Tricare.

If you see a nonparticipating provider, you may have to pay the provider first and file a claim with Tricare for reimbursement. To file a claim, you need DD Form 2642, Patient’s Request for Medical Payment. The form is available online at www.tricare.mil/mybenefit/Download/Forms/dd2642.pdf, or you can call 303-676-3400 and ask to have a copy mailed to you.

Be sure to check with the provider to see if she is a participating or nonparticipating provider. The doctor may decide to participate on a claim-by-claim basis. This means that for one type of service, the provider will participate (agree to accept the Tricare allowable charge and file claims on your behalf), but for another she will not. Using a participating provider is your best option if you use Tricare Standard.

Tricare for Life: Medicare Plus Tricare Equals Free Care
Until a few years ago, when a retiree or retiree family member reached the age of 65, they were no longer eligible for Tricare. Instead, they were expected to receive medical care under the provisions of Medicare. This changed in 2001 with the introduction of Tricare for Life.

To remain eligible for Tricare benefits, you must enroll in Medicare Part B. This is the Medicare program where you pay monthly premiums ($96.40 in 2009) in exchange for receiving medical care from authorized Medicare providers.

Under Tricare for Life, you receive your medical care from Medicare providers, but Tricare becomes a secondary insurer and picks up any costs that Medicare doesn’t cover. You pay no annual deductible or cost-share under this program.

Checking Your Tricare Eligibility
More than 9.3 million people are eligible for Tricare. The lists here are limited to veterans who are no longer in the military and their family members.

As a veteran, you are eligible for Tricare benefits if you

  • Are a retired active-duty member.
  • Are retired from the reserves or National Guard and are age 60 or older.
  • Served in the military (for any length of time) and were awarded the Medal of Honor, our nation’s highest military award.

If you’re a spouse or dependent of a veteran, you are entitled to Tricare benefits if you are a spouse or child of an eligible veteran.

Children include:

  • Unmarried children under the age of 21
  • Those under the age of 23 if attending college and the parent(s) provide at least 50 percent of their support

A child may be covered beyond these limits if he is severely disabled and the condition existed prior to his 21st birthday, or if the condition occurred between the ages of 21 and 23 while the child was enrolled in college.

A surviving spouse of a military member who died on active duty. In this case, your Tricare benefits expire three years after the death of the active-duty member.

An ex-spouse of a military member or retiree, if — as of the date of the divorce — you were married to the member or veteran for at least 20 years, and the military member was in the military for at least 20 years of the marriage.

An ex-spouse of a military member or retiree, if — as of the date of the divorce — you were married to the member or veteran for at least 20 years, and your ex was in the military for at least 15 years, but less than 20 years, of the marriage. In this case, your Tricare benefits expire one year after the date of the divorce.

If you are a surviving spouse or a former spouse and you remarry, you lose your Tricare benefits. Unlike many veterans benefits, you do not regain Tricare if that subsequent marriage later ends.

Enrolling in DEERS
In addition to meeting the eligibility criteria outlined in the previous section, veterans and family members need to ensure they are enrolled in the Defense Enrollment Eligibility Reporting System (DEERS). This is the massive computer system that tracks military members, veterans, and family members who are eligible for military benefits.

If you are eligible for Tricare, you are probably already enrolled in DEERS, however it is important to make sure your information is up to date.  Mistakes or outdated information in the DEERS database can cause problems with Tricare claims.

You Can Verify and Update Your DEERS Information in Several Ways:

In person: To add or remove family members, or to change your mailing address, phone number, or e-mail address, visit a local ID card office. ID card offices are located on all military bases.

By phone: Call the Defense Manpower Data Center Support Office at 800-538-9552 to update your mailing address, e-mail address, and phone number. You cannot add or remove family members over the phone.

By fax: Fax any mailing address, e-mail address, or phone number changes to the Defense Manpower Data Center Support Office at 831-655-8317. To add or remove family members, fax supporting documentation (marriage certificate, birth certificate, divorce decree, or death certificate).

By mail: Mail changes to the Defense Manpower Data Center Support Office. You must also mail supporting documentation if you are adding or removing a family member. The address is Defense Manpower Data Center Support Office, Attn: COA, 400 Gigling Road, Seaside, CA 93955-6771.

Online: Visit the DEERS Web site at https://www.dmdc.osd.mil/appj/address/index.jsp, and follow the steps to update your mailing address, e-mail address, and phone numbers online. You cannot add or remove family members online. Getting Your Medication

Tricare eligible participants have a host of options for obtaining their medications. Depending on which option you select, your medications may be free or provided at the low cost of $3 per prescription, or may be more expensive.

The provider automatically files a reimbursement claim if your medications are obtained from a military pharmacy, Tricare network pharmacy, or the mail-order pharmacy.

If your medications are obtained from a non-network pharmacy, the pharmacy may not file a claim on your behalf. In that case, file your own claim for reimbursement using DD Form 2642, Patient’s Request for Medical Payment. The form is available online at www.tricare.mil/mybenefit/Download/Forms/dd2642.pdf, or you can call 303-676-3400 and ask to have a copy mailed to you.

Medication on Military Bases
Picking up your prescriptions from an on-base pharmacy is the best options if you live close to a military base. Prescriptions filled at these pharmacies are completely free.

However, your nearby on-base pharmacy may not stock all the medications you need. Whether it does depends on the size of the military base, and therefore on the size of the military medical facility that supports that base.

Military regulations require each on-base military pharmacy to stock medications that are on a list called the Basic Corps Formula (BCF) listing. Depending on the size of the military pharmacy, it may stock medications on the Extended Core Formula (ECF) list as well. To see a current listing of medications on both lists, visit www.pec.ha.osd.mil/BCF/BCFclass.htm.

Choosing Your Own Pharmacy
Prescriptions may also be filled at any civilian pharmacy. By using one of the 54,000 pharmacies in the Tricare network, your prescriptions will only cost you $3 per prescription or refill (up to a 30-day supply) for generic drugs and $9 for name-brand items.

You may choose to use a commercial pharmacy that is not a part of the Tricare network at the cost of paying more. Additionally you will most likely need to pay the full amount of your prescription upfront, and then file a claim with Tricare to be reimbursed. Tricare will reimburse you $9 or 20 percent of the authorized cost for the medication, whichever is greater.

If you’re enrolled in Tricare Prime and elect to use a commercial non-network pharmacy , there’s an annual deductible of $300 per person or $600 per family before you receive any reimbursement. If you use Tricare Extra or Tricare Standard for your medical needs and elect to use a non-network pharmacy, the annual deductible is part of the Tricare Extra or Standard annual deductible.

Mail-Order Pharmacy
Using the mail-order pharmacy is a convenient option if your medication is not urgent.

Prescriptions or refills  can be ordered by mail or online. Tricare’s mail-order pharmacy will send your medication directly to your door. Your cost-share is the same as using a Tricare network pharmacy–$3 for a generic drug and $9 for name-brand pharmaceuticals. However, by using the mail-order service you can receive a 90-day supply for the price of a 30-day supply.

Enroll in the mail-order pharmacy online at www.express-scripts.com/custom/dod/ben_message. You can also enroll by going to the Web site and printing out the mail-order registration form. Then mail it to Express Scripts Inc., P.O. Box 52150, Phoenix, AZ 85072; or fax it to 877-895-1900.

How Much Does All of This Cost?
Your costs under Tricare depend on which Tricare program you elect to participate in (see the “Tricare: Pick a Plan, any Plan” section). The following sections describes the approximate prices you can expect for each program.

Comparing Costs
Once you have determined Tricare is right for you, the next step is determining which plan is most cost effective for your circumstances. Table 5-1 shows you how the costs compare for Tricare Prime, Extra, and Standard. Because Tricare for Life works in conjunction with Medicare, the costs of that plan are addressed in the next section. (If you want to know how much you would pay for prescription drugs, see the “Getting Your Medication” section.) Note: The costs for services under Tricare Extra and Tricare Prime are what you pay after you have met your deductible.

Costs of Services Under Tricare for Life
Tricare for Life combines Medicare Part B benefits and Tricare benefits. Under this program, you pay a Medicare monthly Part B premium, which in 2009 is $96.40 per month. You must also pay the annual Tricare deductible, which is $150 per individual or $300 for a family, but you do not have to pay the Medicare annual deductible.

If you obtain your medical care from an authorized Medicare provider, Medicare covers a majority of the costs, and Tricare pays the remainder. The result is no additional cost to you. In effect, you are receiving complete and total healthcare coverage for the price of your monthly Medicare Part B payments and the annual Tricare deductible.

There may be instances where a medical service is covered by Medicare but not Tricare, or vice versa (although these situations are rare). In such cases, if the service is covered by Medicare but not Tricare, you pay the standard Medicare co-pays. If the treatment is authorized by Tricare but not Medicare, you pay the co-pays listed under Tricare Extra or Tricare Standard, depending on whether you’re receiving the treatment from a Tricare network provider.

Catastrophic Cap
The maximum amount that you have to pay out-of-pocket per fiscal year (October 1–September 30) for Tricare-covered medical services is called the catastrophic cap. The cap applies to all covered services: annual deductibles, pharmacy co-payments, inpatient and outpatient cost-shares, and other costs based on Tricare allowable charges.

After you meet the catastrophic cap, Tricare pays your portion of the Tricare allowable amount for all covered services for the rest of the fiscal year. This protects your finances in the event of long-term illness or injury.

Not Covered by Tricare
Tricare covers most inpatient and outpatient care that is medically necessary and considered proven. However, there are special rules or limits on certain types of care, while other types of care are not covered at all. Some services or treatments require prior authorization.

A few examples of medical procedures that are not covered are:

  • Abortions (unless the mother’s life is at risk).
  • Condoms. However, other forms of birth control that require a prescription, such as birth control pills, are covered.
  • Cosmetic surgery or drugs used for cosmetic purposes (such as Botox). However, cosmetic surgery to correct a disfigurement, such as the result of an accident or burn, is covered.
  • Nonsurgical treatment for obesity or weight control.
  • Smoking cessation products and treatment.
  • Most dental work. However, dental care that is medically necessary in the treatment of an otherwise covered medical (not dental) condition is covered.

Using Tricare Overseas
The only Tricare program that can be used in foreign countries (by eligible veterans and their family members) is Tricare Standard. Tricare Prime can be used overseas by current military members and their families, but Tricare Prime is not available overseas to others. Tricare Extra cannot be used in foreign countries because there are no Tricare network providers outside of the United States. You cannot use Tricare for Life in non-U.S. states and territories overseas because of Medicare restrictions.

Under Tricare Standard, the military pays 75 percent of the authorized cost. If the overseas provider charges more than what Tricare authorizes for the procedure, you have to pay the difference out of your own pocket.

If you’re age 65 or older, you must still enroll in Medicare Part B and pay the monthly Medicare premiums to use Tricare Standard overseas.

Dental Care
The Tricare Retiree Dental Program (TRDP) is a separate, voluntary coverage program available to eligible users of Tricare (see the “Checking Your Tricare Eligibility” section earlier in this chapter). Under this program, you pay a monthly premium in exchange for dental care benefits, which are managed by a company called Delta Dental.

If after you read the following sections you decide you want to enroll, go to www.trdp.org/pro/index.html. You can get more information about the dental program there. You can also enroll by calling 888-838-8737 between 6 a.m. and 6 p.m. (Pacific time) Monday through Friday.

Looking Into Vision Care
Veterans enrolled in Tricare Prime are allowed one comprehensive eye examination every two years. Veterans who use Tricare Standard, Tricare Extra, and Tricare for Life do not qualify for free or reduced-cost eye examinations.

Regardless of the plan, Tricare only pays for eyeglasses and contacts for the following conditions:

  • Infantile glaucoma
  • Keratoconus
  • Dry eyes
  • Irregularities in the shape of the eye
  • Loss of human lens function resulting from eye surgery or congenital absence

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