Without further delay, I will turn things over
to Dr. James Black. All right! Well, thank you and… and welcome everyone and I appreciate the opportunity
to speak to you today about the Preventive Care
Benefits under TRICARE. If we go to the next slide! We are now on Slide 2, titled
Disclaimer, which I will read. The appearance of hyperlinks
does not constitute endorsement by the Department of
Defense of this website or the information, products
or services contained therein.
For other than
authorized activities such as military
exchanges and Morale, Welfare and Recreation sites, the Department of Defense does not exercise any
editorial control over the information you
may find at these locations. Such links are
provided consistent with the stated purpose of this Department
of Defense-sponsored webinar. Next slide! We are on Slide 3,
titled Agenda, which shows what I will
be presenting today. I will give you a few
seconds to read that over. All right!
Move on to the next slide. We are now on Slide 4. I believe it's important
to understand exactly what Preventive Care
means under TRICARE. Fortunately for us, it is defined in the
Federal Regulations that governs TRICARE, specifically Code of
Federal Regulations 199.2, where Preventive Care
is defined as diagnostic or other medical procedures
not related directly to a specific illness, injury
or definitive set of symptoms, or obstetrical care, but rather performed as
periodic health screening, health assessment
or health maintenance. Next slide! We are now on Slide 5
titled TRICARE Prime Options. Now that we understand
what preventive care is, we will begin to explore
some of the specifics under the various
TRICARE health plans.
For TRICARE Prime, the first bullet lists the
plans under this option. The other four bullets on
the right give some details about… about
preventive care coverage, such as you can get
your preventive services from your primary care manager
or other network provider. There is no requirement for
referrals or authorization. There are no
out-of-pocket costs. It should be noted that for active duty service members, they always need a
referral or authorization to see a civilian provider
for any healthcare services, unless it is an
emergency situation. Next slide! Now Slide 6 we will begin discussing
the TRICARE Select Options. As on the previous slide,
the first bullet on the left lists the various plans
under this option. And as you can see on
the bullet on the right, that no referral is necessary and there are no
out-of-pocket costs if you use a network provider. Next slide! On Slide 7, there are some
aspects of preventive care under TRICARE Select
worth noting.
As we saw in the previous slide, there are no out-of-pocket costs if you use a network provider for all the covered
preventive services. If you go to a
non-network provider, there are some
preventive services you can get with no
out-of-pocket costs. These are the cancer screens… screenings listed there, immunizations and
well-child visits. For other covered
preventive services, there will be cost-shares, even if the service is obtained at the same time
as a no-cost service. For example, if you are seen
for colorectal cancer screening and another preventive
service is provided, then there will be a
cost-share for that service. Next slide! We are now on Slide 8. An important point that
should be emphasized is for TRICARE Prime
and Select health plans, a beneficiary isn't
required to pay any portion of the
cost of covered, TRICARE network
preventive services, even if the
beneficiary's deductible hasn't yet been fulfilled. Next slide! On Slide 9, for beneficiaries enrolled
in US Family Health Plan, you can get your
preventive services from your primary care manager
or TRICARE network provider.
Referrals and authorizations
are not required and there are no
out-of-pocket costs. For those under this plan,
if you want to learn more, please note the website
address provided. Next slide! We are now on Slide 10 and I will begin discussing some of the enhancements to
the preventive care benefit we have been able to achieve. Under the Patient Protection
and Affordable Care Act, there are a number of
preventive care services that were mandated by this law.
Since TRICARE is governed
under a separate set of laws, the requirements under
the Affordable Care Act did not apply to TRICARE. It was decided to see
what options there were that TRICARE could pursue
to reduce the disparity. As a result, TRICARE was able to add additional coverage
of preventive services that followed
the recommendations from the Department of Health
and Human Services' U.S. Preventive Services Task
Force and Health Resources and Services Administration. And the next slide lists
some of the enhancements. We are now on Slide 11, and on this slide
and the next three we will give examples of
some of the enhancements we were able to achieve. First, an annual
Health Promotion and Disease Prevention exam for all TRICARE Prime and TRICARE Select beneficiaries age 6 and older is covered. For colorectal cancer screening, FDA-approved DNA stool
testing is covered. An example of this test
would be CologuardTM that you may have seen advertised on TV. Also for colorectal
cancer screening, CT Colonography, also known
as virtual colonoscopy, is covered for
the criteria listed.
For those who may not be
familiar with this test, a CT scan is used to examine
the large intestine for cancerous polyps
instead of using the scope. Excuse me! Next slide! We should now be on Slide 12. The age restriction for clinical
breast exams was removed. If your provider ordered
the BRCA1 or BRCA2 gene test because you were at a high
risk for breast cancer, genetic counseling by a TRICARE
authorized provider is covered, with no cost-shares
or co-payments. Also, under the laboratory-
developed test demonstration, the BRCA1 and BRCA2 test can be attained with no
cost-share or copayments if coverage guidelines are met. Next slide! On Slide 13, the policy
language was revised so that the annual "well-woman" preventive office visits are covered with no
cost-share or copays for all female
beneficiaries under age 65 and did not have
to be associated with a cervical
cancer screening.
Since cervical cancer screening should be done at least
once every three years, there was confusion regarding
coverage of the annual "well woman" exam if a cervical
cancer screening was not due. This language will help
clear up that confusion. You can find more information
about Well Woman Exams at the website provided
at the bottom of the slide. Next slide! This is Slide 14. We did remove
the age restriction for physical examinations required in connection
with school enrollment, but sports physicals
are still excluded. We have made it clear in policy
that various counseling services such as for depression and
intimate partner violence and abuse are to be provided
at no additional costs. Also, Intensive
Behavioral Counseling is available for individuals who are at increased risk of
Sexually Transmitted Infections. Next slide! We are now on Slide 15.
Here are some
of the enhancements that were previously available, you know,
to TRICARE Prime at no cost, but now are also available
to Select at no cost, the one annual Prevention Exam
for beneficiaries 6 and older. The lung cancer screening using
low-dose computed tomography, also known as a CT scan. This is covered annually for those between
55 and 80 years of age with a 30-pack a year
history of smoking, which means one has smoked a pack of cigarette
a day for 30 years. Not currently smoking or
have quit within 15 years. There are some limitations such
as haven't smoked in 15 years, or have a condition
that limits life expectancy or unwilling to undergo
curative lung surgery. The reason for this
is one has a disease that is going to drastically
shorten their life, or for example,
one has lung cancer and for whatever reason elects
not to have curative surgery, then there is not much point in undergoing lung
cancer screening. Finally, a one time screening
for Abdominal Aortic Aneurysm by ultrasound for men age
65-75 who have ever smoked.
The U.S. Preventive
Services Task Force found that for women the current
evidence is insufficient to recommend this
screening at this time. Next Slide! Okay, we are now on Slide 16. As we all know, obesity is a problem not only
for the military health system but for the entire country. There are health consequences
as a result of being obese, such as high blood pressure,
type 2 diabetes, coronary heart disease, stroke,
osteoarthritis, among others. For beneficiaries who are obese, intensive behavioral interventions to promote weight
loss are covered. This benefit is
available for adults who have a BMI of 30 or higher. There are websites where you can calculate your BMI
using your height and weight and don't need to figure
out the metric system to calculate kilograms
per meter squared. For children and adolescents, their BMI value must be
greater than 95th percentile. What this means is after
the BMI is calculated it is expressed as a percentile which can be obtained
from either a graph or a percentile calculator.
These percentiles express
a child's BMI relative to other children in the US. Again, there are
websites available to assist in calculating
the BMI in percentile. As you can see, you know, the number of sessions
that are covered per year when provided by a TRICARE authorized provider. The last bullet gives some examples of the types
of interventions covered, such as guidance regarding
diet and activity and lifestyle changes. Again, using a network
provider is preferable. Next slide! On slide 17, we will end our briefing by focusing on Well-Child Services. Congress created a specific
preventive care benefit for this age group between
birth and up to age 6. But some of the
same provisions apply such as no referral or authorization is needed. For Prime beneficiaries, you can get this care from their
PCM or other network provider and there are no
out-of-pocket costs if using a network provider. This applies to both
Prime and Select. Next slide! So this Slide 18 will highlight
some of the covered services. TRICARE does follow
the guidelines of the American Academy
of Pediatrics and the Centers for
Disease Control and Prevention, commonly known as the CDC.
Specifically, TRICARE
covers routine newborn care and screenings
recommended by the AAP. TRICARE also covers vaccinations
as recommended by the CDC. To see what age-appropriate
vaccines the CDC recommends, their website is provided. For this growing and
developing population, physical exams and mental health and behavioral
assessments are covered. It should be noted these
recommended screenings by the AAP are also covered for
beneficiaries from age 6-21 during their annual
Health Promotion and Disease Prevention Exam. Next slide! Slide 19 continues the list of
some of the covered services. The Bright Futures mentioned there is the AAP's
recommendations for preventive health care that
includes various screenings such as for vision,
and hearing, physical, mental and behavioral development, along with physical
examinations and procedures such as certain blood tests. Next slide! On Slide 20 are some of the
other Well-Child Services. The website provided gives
a more detailed explanation and a list of covered services
under the Well-Child benefit.
Next slide! On Slide 21 is listed a
number of useful websites and also contact information
for our regional contractors. For the East Region,
it's Humana Military; for the West, Health Net Federal
Services and for overseas, the International
SOS Government. The contractors can assist
you in answering questions such as whether a provider
is network or non-network or if there are any
associated copays. Next slide! This completes my briefing. And again, thank you
for joining us today and it has been my pleasure
to present this information on preventive care to you.
Okay.
At this time I will read the questions
that have come in and Dr. Black and the other staff will
answer them, if able to. Okay.
The first question reads, does preventive care cover bone density test and vitamin D test? For osteoporosis,
I know that… that is covered. I don't believe, you know,
vitamin D, you know, checking your vitamin D
level is a covered benefit. Okay.
The next question reads, TRICARE only pays once a
year for vision screening and my doctor agrees
this is preventive care and I should be seen once a year
even if it is out-of-pocket. Let me see. There was no question. I am sorry, for
osteoporosis screening, it is covered for women
for osteoporosis whose fracture risk is
equal to or greater than that of a 60-year-old female who has no additional
risk factors. But, you know, the short
answer to the question is, yes, that is, you know,
one of the preventive services that is covered under TRICARE.
Dr. Black in regards
to the question that they just had about the
vision screening, for retirees, there is no TRICARE
benefit under Select, so as a result they do
have to pay out-of-pocket for their vision exam. Okay.
Thank you! Okay.
Thank you! And also… and Stan,
also just to add to that, under TRICARE Prime,
for those retirees who have it, they do get an eye
exam every two years, for diabetics,
it is annually, that can be…
it can be received, as long as it is medically…
as long as it is documented that they are diabetic, they can get that annually
under the Prime benefit.
Okay.
Thank you! The next question reads, I am currently TRICARE Select, on October 1 I turn 65 and will become eligible at
that time for TRICARE For Life. I understand that at the time there are specific Medicare programs I need to enroll in. Can you explain to me when I need to do this
and what Medicare program I need to enroll in to be
eligible for TRICARE for Life? Also, I would like to know how this will affect
my wife's medical coverage as she will be 58 in October.
When you turn 65…
three months before you turn 65, you should receive a
postcard informing you that you are eligible to
sign up for Medicare Part B. By law, you have to purchase it. You are entitled
to Medicare Part A, you must purchase Part B in order to maintain
your TRICARE eligibility. Once you do that and you
become TRICARE For Life, Medicare is now
your primary payer, TRICARE For Life is secondary. So you must follow
all Medicare rules on receiving all
medically necessary care in order for
TRICARE to cost-share on any claims for care received.
There are some benefits
that are covered by Medicare that may not be
covered by TRICARE and that also
applies vice versa, there are some services
that may be covered by TRICARE but are not covered by Medicare. So the biggest thing to remember is that once you become
TRICARE For Life, you must follow all
Medicare requirements. This is Francine, and just to answer the
first part of your question, Medicare Part A
is your entitlement to inpatient services,
hospitalization, etc. Medicare Part B is basically when you purchase that, then Medicare will cover outpatient services. There is a Medicare Part C, Medicare Advantage Programs
that you will pay a premium and normally then you
are getting the benefit, the Medicare basic benefit
with some other enhancements through a commercial carrier. And then there is
a Medicare Part D, which is Drug
Prescription Coverage, which is normally
associated with your having some type of purchased
Medicare coverage plan.
For TRICARE purposes…
for TRICARE purposes, the TRICARE Pharmacy Benefit
is considered by Medicare to meet the Part D requirement, so you aren't required
to purchase Medicare Part… you are not…
you are not required to have a Medicare
Part D Program. As Mr. Feller pointed out, you basically have
to be entitled to A and purchase B to
continue TRICARE. When you become
TRICARE for Life, your wife can continue based on if she is currently
Prime or Select, that will continue
until such a time as she becomes
Medicare eligible. But I would ask the
people asking questions, that really isn't
preventive care related, so on some of these
questions we may just say, once we get the
question and your email, we will go ahead
and respond that way.
So keep on track with the
preventive care, folks. -Thank you!
-Okay. Thank you! The next question reads, what is the status of
the FEDVIP start date? Okay, to make it short
and trying to be on track, open season enrollment for that will begin November 12
through December 10. You can go to
tricare.benefeds.com and that's where you
will find information and we will be putting more information out about that. Thanks!
Next question please! Okay.
The next question reads, I obtained a
mammogram on 1/29/18 and TRICARE paid the cost
of filing of the 100%, but says that the cost
of reading the film by the radiologist
is not paid at 100%. Why would you get a mammogram and not be… be able
to get the results? How is this possible? I am a spouse of a retired
Army in the East Region in the Select Program. Under clinical
preventive services the mammogram itself
is covered at 0%. If the providers…
If the
provider is requiring you to come back for an office
visit for the reading of that, normally that is supposed
to be considered part of it, but if you were… if you sought
the preventive care service without a referral from your PCM or just went and
got it independently, then yes, somebody does have
to interpret that result, and so that would be
the radiologist billing for his or her basic services, if you sought that
mammogram independently. Okay. I am sorry, go ahead. Does someone else want
to add something or? No, that was me
over-speaking myself. Oh, okay, no problem. Next question reads, why aren't travel vaccines
considered preventive care and paid by TRICARE? I believe if you are on,
you know, orders to PCS, you know, travel vaccines are…
are covered but, you know, if you are electing to take a
vacation overseas and there are, you know, specific, you know,
vaccinations required, then, you know,
that's not, you know, necessarily considered a
preventive benefit for at least you know… you know,
for the purposes of TRICARE. This is an elective decision
to pursue your vacation in this particular location.
And for those that
are within the catchment of a Military
Treatment Facility, you could check with the
immunization clinic at that MTF to see if they carry
that immunization and if they will
administer it to you. Okay, thank you! Next question,
does TRICARE have any plans to cover nutrition
for help for diabetes? Does TRICARE have any plans to cover nutrition
help for diabetes? -Well, I am trying to…
-Go ahead Dr. Black. Well, I am trying to…
you know, when they say nutrition help, are… are they, you know,
specifically talking about, you know, you know, providing
specific, you know, foods, you know, for the beneficiary, like, you know,
you know, you know, would it be sugar free
or those types of things, if that's the case, then I am not aware of anything that TRICARE is looking
at regarding that.
I mean, TRICARE does cover
medically necessary foods, you know, in particular situations, you know, that… you know, like for individuals who have cystic fibrosis
and have a difficulty with, you know, malabsorption,
they are not able to absorb, you know, certain
nutrients, etc., then, you know, TRICARE can cover for medically necessary foods, but for… for diabetic foods, then, you know,
that is not covered and I am not aware of any…
any move to change that. Okay, thank you! Next question reads,
I have TRICARE Select, do I need to wait a full 365
days between annual well visits, what is the time I must
wait and not be charged? You know, Francine,
maybe you can help out. I think there's…
there's sort of a 30 days kind of administrative
grace period if… you know, if you…
not exactly… you know, if you get there
little… you know, maybe at 11 months, it would still be covered,
is that correct? Yes, Dr.
Black, you are correct, that there is… you can then go up to 30 days
before and 30 days after, again, it's probably
a little bit better to go after if you can, but sometimes people are traveling out of the area and they would want to get
that before they travel or whatever they may
be doing and so yes. I will just call your
contractor to confirm that before you seek services. Okay. Next question reads, how is HP and DP exams different
than an annual physical? You know, an annual physical, you know, can sort
of be the same thing.
I mean it's…
it's a preventive service, so if an annual physical, you are going in and, you know, you are talking with
your provider, you know, and let's say that,
you know, your provider, you know, counsels you
about, you know, diet or… or those types of things,
I mean I think, you know, in my mind they are…
they are somewhat, you know, synonymous
but, you know, for TRICARE to kind of really,
you know, define, you know, what this particular
visit is for, you know, sort of has the… the longer, you know, name for it, but I think, you know, that, you
know, in general terminology, going in for your annual routine physical examination would be, you know, considered
a… a preventive… annual preventive visit. For clarification on that, which is not exactly the same
because it depends upon what kind of procedural
code the provider uses. Oftentimes when they are
doing a physical exam, if they determine that maybe you need a EKG to rule out something or other because now they are ruling out medical conditions, whereas the health
promotion and prevention really covers a lot of the preventing screening that Dr.
Black
referred to today. So if you are going to go in and have your cholesterol
level checked and your blood pressure checked and they are going to go ahead and maybe give you
an immunization while you are there, that is the health
promotion prevention, and there are certain
codes that depending upon how the provider submits
the claim will determine whether or not they are billing for a health promotion
and prevention visit or if they are billing
for a physical exam. Usually you aren't
going to the doctor for any particular condition when you are seeking
preventive services, you are merely
seeking the services, and most of that screening can
be done in a provider's office.
Correct, yes, yeah,
thank you Francine, you are exactly right. Okay. Next question reads,
will TRICARE cover the new shingles vaccine
called Shingrix? It is much more effective than
previous shingles vaccine; also as of last week I was told that TRICARE was
not covering this vaccine? Yeah, this is Calvin. The… the vaccine Shingrix is
now a TRICARE covered benefit, the requirement is now age 50 for that particular one versus the Zostavax, which is age 60. So, just… the requirements
are for, you know, other than the age, the Shingrix is now
a covered vaccine. And what he is alluding to is if you get it in
the provider's office, only recently have
certain retail pharmacies made it available, so you need to check to see if there is a
participating provider… I mean a participating
pharmacy in your area. Not all pharmacies
have to give it. They basically… when they sign
up to be part of the network, they will make
that determination, whether or not they
are going to offer it.
It will be paid if you get
it in a provider's office and then it now would be paid if you go to one of the participating pharmacy. And this is Jim, you know, and… and the
reason TRICARE covers it is because recently the…
the CDC, you know, made that one of
the… the recommended vaccines, and so once CDC made that… made that recommendation then,
you know, per TRICARE policy, you know,
TRICARE could cover it. Okay.
Next question reads, Patient First is a network
provider for TRICARE providers, yet when I went
to get immunization such as flu,
shingles and pneumonia, they wanted to
charge me a copay. Also, where can I get
a virtual colonoscopy; my PCM only does scope? I am not sure we cover
virtual colonoscopies yet. And CareFirst, you
basically went to get… where they… I know
they are subcontracted under one of the
regional contractors, so I can't address as to why
they would be charging a copay. Were they part of
the pharmacy setup or were they part of like a mini-clinic that you
could drop in at or something? Yeah, so if you can…
If you
can get that question to us so we can validate on that, because if they are
a network provider, then they should…
and there is a requirement to receive those
services without a copay and they are trying
to charge them, we will have to… we will
have to check with the… have the region check with the
contractor to find out exactly how that's… why that is. So if that's one question,
you can forward… you can forward
to us afterwards, we will send a response on that. Okay. Next question,
prior to January 1, 2018 an annual physical
was covered at a 100%, even if done at a
non-network provider; we didn't know this had changed when we went in for our regular doctor on January 11th. We did find out
there was a problem when we received a
bill for service and lab work, it would
have been really nice had we been informed
of these changes prior to the changes
being implemented, two to three months after the
fact is not a good practice. Okay, I thought there
was a question in there, but, sorry about that, it
was just a comment.
And… let's see, next question
is the well-woman office visit with
a PCM or OB/GYN? An OB/GYN is considered as
a primary care manager for – for women. Okay, next question. My PCM – let me see, my PCM never heard of an annual health promotion
disease prevention covered once a year. Since retired for 17
years, I have never had this, where do I find
out more about this? I am sorry, go
ahead, Dr. Black. Well, I was just
going to say, you know, the websites
that were listed, you know, at the end
of the briefing, you know – you know can provide
you more information but, you know, I defer to my, you know, other experts
in the room there, they have additional thoughts.
No, that's exactly what I
was getting ready to say, the websites that are
provided for you to get more information as you should
get all of your information on your benefits is
located on tricare.mil. So, I would ask that you
refer to that website where all information pertaining to your
healthcare benefit. And the provider
themselves can actually contact provider relations with
the regional contractor and ask for
clarification on what sorts of things
clinically would be considered associated with
that visit.
An just FYI to those who
may be on the phone and not in the platform,
currently on the screen showing other resources that
has all the TRICARE websites and the regional
contractors' information, so as Dr. Black and the
staff mentioned, you can look at those… you can
look at that fly to get websites and phone numbers. Next question! How do we get information
on the BMI reduction program? Well, I think the response
was sort of be the same as – as for the last
question, you know that, you know the website — websites
there, you know, provide, you know, sort of
a more, you know, detailed explanation of
the – you know, of the benefits
that are covered.
Any other thoughts from our folks in the room? Well, I think it's a question
of again your provider, if they are thinking
of you qualifying for weight loss surgery,
you have to meet those requirements associated
with it, and so, as a result, where you can get
that counseling and how TRICARE
could pay for it, should be addressed
with the provider and with the
regional contractor from the beneficiary
perspective. Because in order perspective
to have the claim you are going to have to prove
you meet the requirements for the counseling in order
to get the weight loss – meet the weight
loss criteria. Oh wait! I am sorry Dr. Black, can they seek that
independently? I apologize, I
just misspoke. Under preventive care, when they
are seeing a provider then and wanting to get
the counseling as referenced under
preventive care service, look up, is there a
particular CPT code or something
associated with that or a typical any
primary care provider? Well, right. I mean, I think, you know
that, you know that, you know, if you do, you know,
meet the criteria then, you know, they can
have the, you know, the behavioral health
counseling, and again, who – who provides that, you
know, can I think vary.
You know, there are, you
know, some authorized providers that, you
know, this is, you know, important part of their…
their practice that they have, you know, that they do. So, you know, I think
again it's, you know, you know, it's going
to your PCM first and seeing if you
meet the criteria and then, you know,
if – if it's a, you know,
counseling is something that you would wish to
pursue, then the – you know, then the, you know,
I think the contractor can assist in making
that happen. I would also say it
would be very wise in this particular instance
to make sure that you seek services from a
network provider because they will be held
accountable to meeting the requirements of TRICARE, making sure that you
meet the BMI, you know, qualifications,
making sure the limit is the 12 to
26 visits in a year. So oftentimes, advocate
that you really seek type — these type of services
from network providers.
Yeah, I guess that's
probably the one thing just to really hammer
home is that using a network provider is
always the preferred, you know, course of action. Okay, thank you! Next question, is
diabetic foot care considered preventive care? Well, the, you know… you know, for diabetics
you will certainly do a foot exam is, you
know, standard practice. It's standard of care,
and so, if you are – if you are going in for that,
you know, particular, you know, service
then, you know, I would consider that,
you know preventive care. Okay, is skin cancer
screening visits covered under TRICARE Select? Yes, I mean, you know,
skin cancer, you know, screening is covered and again with
TRICARE Select, if use a network provider
then there should be no, you know, no cost
shares or copays. Next question! Is there an age limit from
starting age to end age for HPV test? Is it also covered
as a screening and do the providers still
need to have the patient sign a waiver? Let me see, I
will have to, you know, actually go to the to the policy, so, you know,
HPV (Human Papillomavirus), you know, DNA
testing is covered as a cervical cancer
screening only when performed in conjunction
with a Pap smear and only for women
aged 30 and older.
I do not see anything
regarding a waiver. Okay, next question! Is there a benefit for
routine dermatology screening? Well, as mentioned
previously and again, I will try to see if I can
see the, so skin cancer, so examination of the skin
should be performed for individuals with a family or personal history
of skin cancer, increased occupational or
recreation exposure to sunlight or clinical evidence
of precursor lesions. But again, I
would say that, you know, if you are going in for your annual exam that, you know, again is probably
just a standard practice by your provider that, you know, doing a, you know,
a skin check is kind of a, you know, part of the
normal preventive exam, but you know,
certainly for those that may be at
increased risk or in occupations that where they work outside a lot, et cetera, that you know, it will be specifically
covered for that. This is Francine. Again as a reminder, there
is a difference between screening versus going in
and if they determined that you might have
some type of growth that needs to be biopsied
or anything like that, that takes it out of the realm of preventive screening and actually gets it into more of the medical
treatment category.
So, be aware of
that as well. Okay, next question! What websites tell
specific details on what services are covered as
a preventive service? Yeah, when you go to tricare.mil
at the top of the page, you will see something
that says What's Covered. You can click on that
and in that box, there is a section in there, where you can actually
type-in exactly what you are looking for
to see if it is covered. It will come up showing
you if it is a covered benefit or there is any language in
there pertaining to that, it will show you
what it is, it will show you the
coverage limitations of it, and it may also
require you to get some additional
information on it. But, go to the tricare.mil
page, go under What's Covered and that's where
you could quickly find a lot of the things that
you are looking for. We can't put in all the details
that might be in our manual and what the actual policy
and the operational and any exclusions and
any certain criteria, because otherwise
that whole section would be as big
as our manuals, which you really wouldn't want
to have to look through that.
What's covered is really
a lot of the basic, a lot of the more common, a lot of the things
that oftentimes people are looking for. So if you see it and
there might be there are certain
restrictions back then when you would call your regional contractor. And under the new
contracts there is, if a provider or yourself would
have any question about whether or not something
would be covered under TRICARE they can ask for
a preauthorization review and at that point the
contractor can determine based on the information
provided by the provider, the diagnostic codes,
the procedural codes, the tests, the whatever to
determine what of that visit would likely be
covered under TRICARE.
TRICARE can't guarantee
payment though until that actual claim comes in and
based on what's on that claim determines what
services are or aren't covered. Okay. Thank you! Is glaucoma an existing
condition to receive a once a year paid eye
doctor visit under TRICARE Prime Retiree, or
is it just diabetes? Well, with glaucoma, again, you have a diagnosed condition, so each time
you would go in for any type of your
vision check or whatever then that would, you know, from more in
the medical benefit not a a preventive benefit.
I mean everyone, you know,
can get, you know, the, you know, the covered, you
know, preventive vision visit, you know, whether
you have, you know, diabetes or glaucoma
or whether, you can still get that visit, but any additional visits, you know, would — would be
under the medical benefit and would have a,
you know, possible, you know, copays, et cetera. Okay. If you are still working
and have health insurance through work, where does
TRICARE fall within this? If you are a working individual
with Other Health Insurance or OHI from your…
your civilian job or whatever, that is
your primary insurance, TRICARE is always
second payer.
Right! So unless… yeah, unless
you are a recipient of Medicaid then
TRICARE pays first. So what you must do is,
you must provide that Other Health Insurance
information to the regional contractor, because again, that pays first. Once they pay they should, if their [Inaudible]
established with TRICARE, once your other health
insurance pays, it should be forwarded to
TRICARE to pay on if there is anything
for TRICARE to pay on. You know, for any reason
it is discovered that you have Other Health Insurance
and it was never reported, and TRICARE has been
paying as primary, now the government has a
responsibility to go back and recoup any monies
that was paid and then, you know, that would take… take it to a whole
another situation. So, please, be sure to report
that Other Health Insurance to your contractor, and as well as as
well as pharmacy. Okay. Next question reads,
how long does it take for a physician to be accepted
as a TRICARE provider? My physician applied
in early January and has heard nothing back nor
will any of the area reps return her calls
or e-mails? It's contingent on a
number of factors.
Right now as you know
during this transition there have been another… a number of new providers
coming into the network, so we really can't. There is no set timeline,
there is no government requirement that
it has to be done. It's making ensure
the appropriate documentation and sites, the contractor has to go and validate that information. And so, during this
transition time, the volume of being able
to certify providers or make sure that
they are authorized, Board-certified et cetera, maybe taking a little
bit longer than usual. Okay. Next question! I am a spouse with
TRICARE Select and have never
used my insurance. I scheduled a visit with a
new primary care provider requesting a wellness
appointment. I was informed. I will likely have to
schedule a follow-up for the wellness exam since
this is my first visit. With the first appointment
require a copay, if so how much is the copay
for outpatient appointments? Go ahead, Dr.
Black. Well, I was just going to say
that, you know, if you go in, and if you
need to come back, you know to, you know,
complete, you know the, you know whatever
preventive services or… or evaluations that need
to be done, then that would, you know, it's my understanding
that would not incur, you know, any kind of
copay or cost-share. Is that correct, Francine? Well, the first one is
considered as an office visit because you are
establishing yourself as a new patient with
that individual. So, that one, yes, you
would have a copay and I am looking for the cost
information right now. But the second one when
you go in and actually have the the health visit done, that one would not have an
associated cost with it. But as soon as I find the
cost information, I will. But, you know, with
that, you know that, you know second visit, if they had to come back
for additional visits, you know for that, you know
for preventive services, you know the no copay
would still apply.
Is that correct? If it was strictly for any type
of preventive service care, yes. Right! Okay. Was this, did…
was that Select? Okay, hold on a minute. And it was a Retiree -Let's see.
-Next question is. I am a spouse with
TRICARE Select. I have never used
my insurance. Doesn't say if… it
doesn't indicate. If people go to – if they
go to tricare.mil/cost, they will be able to look
up that information based on if they are Active
Duty or Retiree, if they are Group A or Group B and if they are
Prime or Select. So, just being able
to answer about from that information we would
assume it's a Retiree, if they never used
their health benefits in the civilian sector.
So, clinical
preventive services, but for a regular
outpatient visit I am sorry, for the
regular outpatient visit they would for routine care. I am going to – this
is sub position and the people want to go in
and check it themselves then. Yeah, she said my husband
is in the Reserves. Her husband is
in the Reserves. Then you are using
the Select, visit if he is enrolled if… if you have never used
it, it could be, you have to be enrolled
in the TRICARE program called TRICARE alert —
Reserve Select. When your sponsor isn't in
an Active Duty status and as a Group A under Select, primary care visits are $28, specialty care $41. You use a network provider
but you do have to be enrolled in TRICARE
Reserve Select if you are an inactive guard
reserve family member.
This is James, so if they are
going in for the first time, this will probably coded as
a new patient evaluation, you know, versus a
preventive care benefit. So, yes, that first, you,
know visit would have a, you know, would not
be the same thing as a preventive care visit. And that's assuming you
are using a network provider, and under Select you can
either use network providers or if you use a
non-network provider, outpatient visits are 25%
of the TRICARE allowable charge. So that can vary
depending upon where you are located
in the country. Okay, next… oh, go ahead. That's all. Okay. Next question reads,
my daughter was born with a condition that
require genetic testing, her doctor recommended
that my husband and I also receive testing in order to get
a better read on the situation as a whole. This recommendation would
fall under preventative care as it would… as it
would screen for things that we wouldn't be
able to see otherwise. However, TRICARE deemed
this family planning and would not allow for us
to go through with his recommendation without
paying for it first without paying for it ourselves? Yes, and that's correct.
You know, there is
a couple things. One, you know that, you
know, TRICARE only covers lab tests that
are FDA-approved. There is a number of tests
and maybe you remember, in the briefing,
talking about the laboratory-developed test
demonstration, and this is where, you know, the FDA, you know, has used their enforcement discretion, they don't do safety and efficacy evaluation of these
laboratory developed tests, you know, which many of
them are genetic tests. So, to that standpoint you
know that TRICARE doesn't cover them, but a
demonstration was started and so, since the FDA is
not evaluating these tests that the Defense Health Agency
is evaluating the tests for you know, for safety
and efficacy. And the tests that is
currently covered, you know, again and you
can go to tricare.mil or you know talk with your contractor which gives, you know a list of these laboratory developed tests and most of them
are genetic tests, you know, that are covered
under the demonstration.
Now again, you know,
TRICARE, you know, covers healthcare services
that are used to diagnose and treat, and is necessary
for the medical management of that condition. You know, screening
to see if, you know, if you have a particular genetic mutation, you know, is not really considered medical care and as far as the
preventive side, that you know, unless it's, you know, it's been evaluated
by the Defense Health Agency, it's something
that, you know, can be covered under
this demonstration and it's not covered under the
preventive care benefit either. Okay, thank you! We have — next
question reads, we have TRICARE
Standard Retired Army, do we have to do anything or are we automatically
transferred to TRICARE or East Humana, we live
in North Carolina? Okay, so you no longer are
TRICARE Standard as of January 1 of this year. If you were TRICARE Standard
prior to December 31, 2017 you're automatically
converted to TRICARE Select, which was effective
January 1. So, the first thing you
need to do is check DEERS to make sure you show as
TRICARE Select in DEERS and all your
information is correct. There was nothing you had
to do as long as you are not trying to go from
TRICARE Select to TRICARE Prime.
So you should
be good to go. And yes, the East region is
your original contractor, you can also call them to
validate that you are Select. Okay, next question! This is a – I guess referring
to a previous question for the Other
Health Insurance, TRICARE and Medicare, is that the order for payment
when I have all three? When you are working,
your employer is first, Medicare is second,
TRICARE is third, and in that instance, you would
have to manually submit claims to TRICARE because
Medicare only interfaces with one other
insurance plan. When you retire, if you
continue to keep you commercial then it is Medicare first, commercial second,
TRICARE third. Okay, thank you! Next question reads oh go ahead. Stan, just to clear about
something on that too. Regardless of if you are still
working at age 65 or older, and Medicare tells you, you do not have to purchase
Part B until you retire.
For TRICARE purposes, to
maintain your TRICARE eligibility you must still
purchase Medicare Part B. If you want TRICARE. If you want
TRICARE, correct. Okay, next question, is
hormone replacement therapy considered
preventative for women? No. Okay, next question, and
probably our last question since we are up on
the top of the hour. Will there be a difference in any amount of
preventive eye care when TRICARE goes to FEDVIP, I cannot find out if I'm
still going to be covered for the same amount
of preventive eye under TRICARE Prime Retiree and
why would I get vision coverage.
If I were to give preventative
eye care under FEDVIP, would I lose my
preventative eye care under TRICARE
Prime Retiree? Okay, so under TRICARE
Prime as a retiree, as we said before,
as we said before, you get an eye exam every two
years if you're diabetic, you can get it every year. Once the FEDVIP
becomes available, you still maintain your
TRICARE vision benefit; however, what the FEDVIP, one of
the four plans they will offer, they would now… you would
now have the ability to you may have the ability now
under one of those plans to have eye glass
coverage as well as contact lens coverage. That is not a benefit
under TRICARE. So, you do not have to
purchase one of the plans offered under the
FEDVIP provision, that is strictly your
decision, but again, it will give you a little more of a benefit especially when it comes to eye glasses and the coverage
for contact lenses. And for those retirees
that don't currently have a vision benefit under
TRICARE, they now would and when you have a vision
benefit, it would be…
It may possibly be when you
are researching those plans, it's beyond just
the screening that we currently cover
under preventive services. And this is Jim.
I think also that depending on the plan, you know that some of the, you know, the laser surgeries
that TRICARE doesn't cover, you know, might be available
under these plans too. Okay, well I would like to
thank — Stan, research – research is going to be
the biggest thing that beneficiaries have to do when the FEDVIP
becomes available, is to go to that site, they are going to have to
review the available plans and make a determination what works
best for them and whether they choose to
purchase a vision plan or not? And this is Jim. And I am a retiree
and I've already, you know, gone to the website
and started looking around, so I would encourage
others to do the same.
The more you know and
the sooner you know it, I think the better off will
be once the, you know the you know the
open season starts and you know start have
to make a decision. Okay, I would like to
thank Dr. James Black for sharing his invaluable
experience and expertise. I would also like to give a
special thanks to Francine and Calvin for
answering the questions. I would also like to thank our
attendees for attending and participating in
today's webinar. And if you find yourself
having questions after the webinar is over or if you were unable to… or if we were unable to answer
your questions today, please contact your
regional contractor.
Also many of the answers
to questions related to the TRICARE benefit can
be found on the TRICARE website at
http://www.tricare.mil. This concludes
today's webinar on 'Understanding your TRICARE
Preventive Care Benefits.' Thank you all and
have a great day!.
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