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Show . ' May 14, 1998 SmisiuirairQce MppDemeirQltaD in Risingfiealth care costs;: cuts by Marty Kessler Standard Extra Prime Annual Deductible Active Duty E4 & Below Active Duty E5 & Above Retired $50 ind$100 fam $150 ind$300 fam $150 ind$300 fam Same as Standard Same as Standard Same as Standard $0 $0 $0 Annual Enrollment Fee Active Duty Retired $0 $0 $0 $0 $0 $2.50 ind$460 fam Expenses Beneficiary Services Director Rising health care costs combined with reductions in military medical facilities have many military beneficiaries asking if they should purchase supplemental health care insurance. TRICARE supplemental insurance acts as a secondary payer and is designed to help pay beneficiary cost snares or Costs of individual plans vary depending on the TRICARE option selected and the patient's benePrime, Extra or Standard active duty dependent, retiree or ficiary status retiree dependent. To determine if supplemental insurance is right, first examine some terms, what they mean and how they affect expenses and supplemental Civilian Provider y Office Visit Active Duty E4& below Active DulyE5& above Retired premiums. TRICARE Prime: A managed care plan modeled after civilian health maintenance organizations (HMOs). This is the least expensive plan for the consumer, resulting in the lowest supplemental insurance premiums for the consumer. TRICARE Standard: The old CHAMPUS program under a new name. This is the most expensive plan for the consumer, resulting in the highest risk for the insurance company and highest premiums. TRICARE Extra: A preferred provider plan that allows TRICARE Standard patients the flexibility to use providers in the Prime network at a reduced cost While this option is less expensive to the consumer than Standard, it is more expensive than Prime. Orga- nizations who offer supplemental insurance plans don't have plans specific to TRICARE Extra. Coverage falls under the same rates as TRICARE Standard. Other Health Insurance: A health insurance plan other than a TRICARE supplement offered through an employer, association, private insurance company or school. This plan is always considered the primary insurer and pays first with TRICARE acting as a sec- ondary payer. For the most part, these plans work well with TRICARE Standard or Extra, but aren't very effective when using Prime. In general, if you have other health insurance which is the primary payer, purchasing a supplement as a third payer may not be wise from a financial standpoint. Condition: A medical condition that existed prior to obtaining other health care insurance or a TRICARE supplemental plan. Each insurance plan has its own individual rules about accepting conditions. The plan can patients with either set coverage limitations or deny coverage entirely based on its underwriting requirements. This can be an important factor in choosing a supplemental insurance policy before a medical condition occurs. Point of Service: A TRICARE option for Prime g pre-existi- enrollees to obtain care through providers without prior authorization. This is a high-cos- t option with the patient paying at least 50 percent or in some cases, all of the costs. Some supplements will cover this option, although the premiums are high. Catastrophic Cap: The upper limit a patient is required to pay before the government starts paying 100 percent of the allowable charges. The result is obvious in this case the higher the cap, the higher non-netwo- After hours care policy for active duty military 20 of allowable charges 20 of allowable charges 25 of allowable charges 15 15 20 of negotiated fees of negotiated fees of negotiated fees $6 $12 $12 20 20 25 15 15 20 of negotiated fees of negotiated fees of negotiated fees $10 $30 $30 Civilian Provider y ER Visit et Pre-existin- military medical facilities create questions Active Duty E4 & below Active Duty E5 & above Retired Civilian Inpatient Active Duty Retired of allowable charges of allowable charges of allowable charges y Same as Standard $9.90dav; min $25 per adm lesser of $360day or 25 of hosp lesser of $250day or 25 hosp charge; plus 25 of prof fees charge; plus 20 prof fees Point of Service Active Duty & Retired Annual Catastrophic Cap Active Duty Retired NA Deductible of $300md; $600fam plus 50 of charges $l,000family Same as Standard Same as Standard $l,000family J'S Ins Costs . Spouse $60 $ 110 Child Active Duty Retired min $25 per adm $ 1 1day; min $25 per adm NA $7,500family Annual Est Supplemental $llday, RetSpouse Child $200-- $ $32-$9- ' 1 ' Same as Standard Same as Standard 5 1000 $3,000famity Spouse $32-- $ 100 Child RetSpouse Child $160-$40- $20-$8- $75-$50- 0 $60-$38- 0 the supplemental insurance premiums. Allowable Charges: The charges that CHAM-PUallows for each service rendered. These charges often are less than what the provider or facility bills. Balance Billing (Excess Charge): The act of providers for the rest of his or billing by her charges over and above the CHAMPUS allowable charge. Federal law states that patients are not legally responsible for most charges in excess of 15 percent above the CHAMPUS allowable charge. Most supplements will offer a second plan that pays excess or cost shares. The charges in addition to premium is higher with this type of plan. However, the plan can be particularly effective for the Standard beneficiary living in an area where providers do not accept the CHAMPUS allowable charge as full pay- Surprisingly, supplement costs for active duty beneficiaries who choose the TRICARE Prime option do not decrease dramatically from that of a Standard beneficiary. This is not the case when analyzing retiree supplement costs. Retirees and their dependents have a high catastrophic cap that makes them particularly vulnerable for inpatient charges under the TRICARE Standard Option. The end result for the retiree is higher premiums. Retiree supplement costs are also affected by beneficiary age and sex. Before considering the purchase of a supplemental policy, the beneficiary should carefully assess which plan is best suited for their individual needs. Each TRICARE supplemental policy has its own rules concerning eligibility requirements for the family, pre- The chart with this article provides a snapshot of expenses and supplemenbeneficiary tal insurance costs associated with each TRICARE program. Supplement costs vary greatly depending upon the plan, coverage offered, and the organization providing the insurance. The chart shows the risk for substantial expenses increases considerably when the beneficiary is a TRICARE Standard patient or is a TRICARE Prime patient who uses the point of service option. limitations, S co-pa- ment et Normal clinic hours are: Primary Care and the Flight Surgeon, Monday-Frida730 a.m.-4:3- 0 p.m. Family Practice sick call, Monday-Frida7:30-- 8 a.m. and 12:30-p.m.. Flight Medicine sick call, Monday-Thursda- y 7:30-- a.m. and 2 p.m.; Fria.m. and 2 p.m.. day 7:30 Urgent Care, Monday-Frida- y a.m.-- 8 p.m.; weekends and holidays 9 1 a.m.-noo- Active duty military are required to contact their primary care manager before seeking civilian medical care. The exception is if the patient requires emergency care. Emergency care is existing conditions, deductibles, mental health long-ter- illness, well-bab- y care, dis- ability coverage, inpatient claims and rules concerning allowable charges. To obtain a listing of TRICARE supplemental plans, stop by the TRICARE Service Center, Bldg. 545, across 0 and speak to from the base hospital, or call a beneficiary service representative. The list includes e each organization's name, phone number and address plus key questions to ask the organizations to help determine the best value for the money spent. defined as care necessary to avoid the loss of life, limb, or eyesight If a member was seen for an emergency, contact the TRICARE Service Center at and the payment process Ext will be started. Beginning June 1, members w ho care withreceive out prior authorization from their PCM will be responsible for the bill. Members may contact their PCM after The ambuhours by calling Ext lance staff will answer the call and connect the member with the PCM on call; average connection time to a PCM is two to three minutes. 728-260- toll-fre- The payment process is fairly streamlined for members who call and receive a PCM authorization. The base hospital has a system to ensure the authorization is recorded and the bill is paid. If an authorization is not obtained, the member must fill out additional paperwork that requires a signature from their comma'nder or a designated representative. Once the base hospital receives the bill and supporting medical documentation, the claim will be reviewed for payment consideration. For more information, call the TRICARE Service Center at Ext. |