Health Benefits

You are proud of your family member for serving our country. Our country works hard to take care of its service members in return.

In An Introduction to the DoD and VA System of Care, you learned about the DoD and VA medical treatment systems, TBI case management, and the Points of Contact (POCs) who can help you and your family member.. This article is about other medical treatment resources. These other resources can provide recovery and rehabilitation services for your family member. They also provide health benefits for eligible family members.

The Recovery Care Plan will be adjusted as your family member recovers and moves through the TBI Continuum of Care. The POC will help your family member transfer from one facility to the next. Use the information in this chapter to help you work with the POC to get the best care for your family member.

What is TRICARE and What Does it Cover?

For Active Duty, Activated National Guard, Reserve Components, Retirees, Families, and Survivors

TRICARE is a managed care program. TRICARE includes both direct care at military hospitals (MTFs) and purchased care (network care through Managed Care Contractors).

Each service member/veteran has different needs and is eligible for different services and benefits. This chapter provides basic information about TRICARE. It also lists Web sites and other references where you can find more information. Talk to your POC about your family’s health care needs. He or she can help you understand TRICARE and help you enroll, if needed.

TRICARE Services and Benefits

TRICARE serves active duty service members, National Guard and Reserve members, retirees, their families, survivors, and some former spouses.

TRICARE is a major component of the Military Health System. It brings together the health care resources of the Uniformed Services. It supplements military services with networks of civilian health care professionals, institutions, pharmacies, and suppliers. These may include community health and mental health centers.

TRICARE offers several health plan options to meet the needs of its members. TRICARE also offers two dental plans and several special programs. These programs include TRICARE for Life and TRICARE Pharmacy Options.

To find out what TRICARE services your service member/veteran and family members are eligible for, follow the steps below. Your POC can help you register in DEERS. Everyone must enroll in DEERS.

Important steps to receive and use TRICARE benefits:

STEP 1

• Register in DEERS and/or update DEERS information as necessary. DEERS is the Defense Enrollment Eligibility ReportingSystem (DEERS). It is a worldwide, computerized database of Uniformed Services members (sponsors), their family members, andothers who are eligible for military benefits.
• You must be registered correctly in DEERS to receive TRICARE benefits.
• DEERS contact information:
  • www.tricare.mil/deers
  • Toll-free: 1-800-538-9552.
• If your service member/veteran has any change in status — such as separation, retirement, or change of address--make sure his or her information gets updated in DEERS as soon as possible. If these updates are not done, your service member/veteran and family might have a break in eligibility. This means a break in health care coverage.
• Mistakes in the DEERS database can cause problems with TRICARE claims. It is critical to keep your DEERS information correct and up-to-date.
• To update your DEERS information:
  • Visit your local Uniformed Services personnel office or contact the Defense Manpower Data Center Support Office (DSO) at 1-800-538-9552 or https://milconnect.dmdc.osd.mil/milconnect/public/faq/DEERS.
  • Fax address changes to DEERS at 1-831-655-8317.
  • Mail the address change to the Defense Manpower Data Center Support Office, ATTN: COA, 400 Gigling Road, Seaside, CA 93955-6771.
  • Go online to TRICARE to update your information: http://www.tricare.mil/deers.
  • Keep copies of the update forms until you see the change is made.

STEP 2

Learn about TRICARE services and benefits.

• Take a look at the following Web sites to learn more about TRICARE: www.tricare.mil.
• With so many health care plans and programs, TRICARE can seem complicated. The more you know about your coverage, the better equipped you’ll be to get the care you need.
• TRICARE has three main choices for health care coverage:
  • TRICARE Prime - where military treatment facilities (MTFs) are the principal source of health care
  • TRICARE Extra - a Preferred Provider option with cost sharing
  • TRICARE Standard - a fee-for-service option (the original CHAMPUS program).
• TRICARE is available worldwide. It is managed in four separate regions. Three are in the United States. One is overseas.
  • The three regions in the United States include:
    • TRICARE North
    • TRICARE South
    • TRICARE West

STEP 3

Find out what services and benefits your service member/ veteran and family members are eligible for:

• Visit the TRICARE Web site “Plan Wizard” at http://www.tricare.mil/mybenefit.
• The “Plan Wizard” lets you and your service member/veteran enter specific information about military status, etc. Then it explains the services that he or she is eligible for.
• The Plan Wizard helps you understand which TRICARE options you and your family members may be eligible for. The military decides who is eligible for what. This information is reported to the Defense Enrollment Eligibility Reporting System (DEERS).

TRICARE Services and Benefits for National Guard and Reserve Members

TRICARE Reserve Select (TRS) is a health insurance plan that qualified National Guard and Reserve members may purchase when not on active duty. TRS requires a monthly premium. It offers coverage similar to TRICARE Standard and Extra.

Key features of TRS include:

• Available worldwide to most Selected Reserve members (and families) when not on active duty orders or covered under the Transitional Assistance Management Program
• Must qualify for and purchase TRS to participate
• Must pay monthly premiums. Failure to pay monthly premiums on time may result in disenrollment and an enrollment lockout
• Freedom to manage your own health care; no assigned primary care manager:
  • Visit any TRICARE-authorized provider or qualified host nation provider (if located overseas)
  • Pay fewer out-of-pocket costs when choosing a provider in the TRICARE network
  • Network providers not available overseas.
• No referrals are required, but some care may require prior authorization
• May have to pay for services when they are received and then seek reimbursement
• May have to submit health care claims
• May receive care in a military treatment facility (MTF) on a space available basis only
• Offers comprehensive health care coverage, including TRICARE’s prescription drug coverage.

Transitional Assistance Management Program (TAMP)

The Transitional Assistance Management Program (TAMP) offers transitional TRICARE coverage to certain separating active duty members and their eligible family members. Care is available for 180 days.

The four categories for TAMP are:

• Members involuntarily separated from active duty and their eligible family members
• National Guard and Reserve members separated from active duty after being called up or ordered in support of a contingency operation for an active duty period of more than 30 days and their family members
• Members separated from active duty after being involuntarily retained in support of a contingency operation and their family members
• Members separated from active duty following a voluntary agreement to stay on active duty for less than one year in support of a contingency mission and their family members.

Active duty sponsors and family members enrolled in TRICARE Prime who desire to continue their enrollment upon the sponsor’s separation from active duty status are required to re-enroll. To re-enroll in TRICARE Prime, the sponsor or family member must complete and submit a TRICARE Prime enrollment application.

Under TAMP, former active duty sponsors, former activated Reservists, and family members of both are not eligible to enroll or re-enroll in TRICARE Prime Remote or in TRICARE Prime Remote for Active Duty Family Members because both programs require the sponsor to be on active duty. Under TAMP, the sponsor is no longer on active duty but is treated as an active duty family member for benefits and cost sharing purposes.

TRICARE Prime Enrollment and Re-enrollment

Initial enrollment in TRICARE Prime occurs during the TAMP period. Family members whose applications are received through the 20th of the month are enrolled the first day of the next month. For example, if the application is received June 20, TRICARE Prime coverage for the family member begins July 1. If the application is received June 21, coverage for the family member begins August 1.

Continued Health Care Benefit Program (CHCBP)

The Continued Health Care Benefit Program (CHCBP) is a premium-based health care program administered by Humana Military Health Care Services, Inc. (Humana Military). CHCBP offers temporary transitional health coverage (18-36 months) after TRICARE eligibility ends. If you qualify, you can purchase CHCBP within 60 days of loss of eligibility for either regular TRICARE or Transitional Assistance Management Program (TAMP) coverage. CHCBP benefits are comparable to TRICARE Standard with the same benefits, providers, and program rules. The main difference is that you pay premiums to participate.

Who is Eligible?

Under certain situations, the following recipients may be eligible:

• Former active duty service members released from active duty (under other than adverse conditions) and their eligible family members. Coverage is limited to 18 months.
• Former spouses (not married again) who were eligible for TRICARE on the day before the date of the final decree of divorce, dissolution, or annulment. Coverage is usually limited to 36 months; however, some unremarried former spouses may continue coverage beyond 36 months if they meet certain criteria. Contact Humana Military for details.
• Children who cease to meet the requirements to be an eligible family member and were eligible for TRICARE on the day before ceasing to meet those requirements. Coverage is limited to 36 months.
• Certain unmarried children by adoption or legal custody. Coverage is limited to 36 months.

For more information about CHCBP, visit www.tricare.mil/chcbp or call 1-800-444-5445. Contact your POC or a Beneficiary Counseling and Assistance Coordinator (BCAC) to discuss your eligibility for this program.

TRICARE Military Medical Support Office (MMSO)

MMSO serves all three U.S. regions of TRICARE. It provides medical support and dental case management. It also coordinates civilian health care services outside the jurisdiction of a military treatment facility for TRICARE Prime Remote (TPR)-eligible active duty military and reserve component service members within the 50 United States and District of Columbia. For more information, access the following Web site: http://www.tricare.mil/tma/MMSO.

MMSO provides:

• Pre-authorization for civilian medical and dental care
• Authorizations for payment of civilian medical and dental bills
• Coordination of civilian health care services for remotely located service members
• Collaboration with unit representatives regarding Line-Of-Duty (LOD) cases.
• MMSO serves the following populations:
• Active Duty Service Members (ADSMs) enrolled in TRICARE Prime Remote (TPR)
• Non-enrolled ADSMs not managed by a military treatment facility (MTF)
• Reservists with Line of Duty (LOD) injuries or diseases (Reservists, National Guard)
• ADSMs receiving dental care outside the military dental treatment facilities (DTF), DTF-referred, or Remote Dental Program. TRICARE Fact Sheets The TRICARE Fact Sheets are designed for anyone who needs detailed information on many TRICARE topics, such as:
• Transitional Assistance Management Program
• TRICARE Appeals
• TRICARE Mail Order Pharmacy.

What Does the VA Health Care System Cover?

For Veterans

The VA operates the nation’s largest integrated health care system with more than 1,400 sites of care, including hospitals, community clinics, nursing homes, readjustment counseling centers, and various other facilities.

STEP 1 – Determine VA Eligibility

The number of veterans who can be enrolled in the health care program is determined by the amount of money Congress gives the VA each year. Since funds are limited, the VA set up priority groups to make sure that certain groups of veterans are able to be enrolled before others. Once you apply for enrollment, your eligibility will be verified. Based on your specific eligibility status, you will be assigned a priority group.

The priority groups range from 1-8 with 1 being the highest priority for enrollment. Some veterans may have to agree to pay a co-pay to be placed in certain priority groups.

• Basic Eligibility - If your service member served in the active military, naval, or air service and is separated under any condition other than dishonorable, he or she may qualify for VA health care benefits. If your service member is a member of the Reserves or National Guard who was called to active duty (other than for training only) by a federal order and completed the full period for which he or she was called or ordered to active duty, your service member may be eligible for VA health care.
• Minimum Duty Requirements - If your service member/veteran enlisted after September 7, 1980, or entered active duty after October 16, 1981, he or she must have served 24 continuous months or the full period for which he or she was called to active duty in order to be eligible. This minimum duty requirement may not apply to your service member/veteran if he or she was discharged for a disability incurred or aggravated in the line of duty.
• Service Disabled Veterans - If your service member/veteran is 50 percent or more disabled from service-connected conditions, unemployable due to service-connected conditions, or receiving care for a service-connected disability, he or she will receive priority in scheduling of hospital or outpatient medical appointments.

STEP 2 – Enroll for VA health care

• To apply for VA health care, your service member/veteran must complete VA Form 10-10EZ, Application for Health Benefits. The form can be obtained from any VA health care facility or regional benefits office, online at www.va.gov/health-care/how-to-apply, or by calling 1-877-222-VETS (8387).
• Many military treatment facilities have VA representatives on staff that can also help your service member/veteran with this request.

STEP 3 – Learn about VA Services and Benefits

VA provides health care and other benefits to OEF/OIF veterans returning from the armed services.

Here are some of the benefits VA provides:

• Five Years of Enhanced Health Care. Your service member/veteran is eligible to receive enhanced VA health care benefits for five years following his or her military separation date. Whether or not your family member chooses to use VA health care after separation, he or she must enroll with VA within five years to get health care benefits later on.
• Dental Benefits. He or she may be eligible for one-time dental care but must apply for a dental exam within 180 days of his or her separation date.
• OEF/OIF Program. Every VA Medical Center has a team standing ready to welcome OIF/OEF service members and help coordinate their care. Check the home page of your local VA Medical Center.
• Primary Health Care for Veterans. VA provides general and specialized health care services to meet the unique needs of veterans returning from combat deployments.
• Non-Health Benefits. Other benefits available from the Veterans Benefits Administration may include: financial benefits, home loans, vocational rehabilitation, education, and more. Access https://www.myhealth.va.gov/mhv-portal-web/other-va-benefits for information on these benefits.
• Benefits for Family Members. VA offers limited medical benefits for family members of eligible veterans. These include the following programs: Civilian Health and Medical Program of VA (CHAMPVA), caregiver support groups, counseling, and bereavement counseling.

Potential Co-Payments

Some veterans must make small co-payments for medical supplies and VA health care. Combat veterans are exempt from co-payments for the of any condition potentially related to their service in a theater of combat operations. However, they may be charged co-payments for treatment clearly unrelated to their military experience, as identified by their VA provider.

Conditions not to be considered potentially related to the veteran’s combat service include, but are not limited to:

• care for common colds
• injuries from accidents that happened after discharge from active duty
• disorders that existed before joining the military.

For more information regarding services available to returning active duty, National Guard, and Reserve service members of Operations Enduring Freedom and Iraqi Freedom, visit the Returning Service Members Web site at https://www.oefoif.va.gov/.

VA Personal Health Record – My HealtheVet

My HealtheVet offers veterans 24/7 Internet access to their personal VA health care information.

My HealtheVet provides access to the following:

• health information
• links to Federal and VA benefits, and other resources
• the veteran’s Personal Health Journal.

Future plans are to include scheduled appointments, co-pay balances, and key parts of the VA medical records.

You can record and track your veteran’s health information online in one location. You can print your veteran’s information on a doctor’s sheet. The online VA prescription refills allow you to order medications online and have them sent to your home.

Register for My HealtheVet at www.myhealth.va.gov/mhv-portal-web/home.

What Benefits and Services are Available for Veterans’ Families?

CHAMPVA - VA Civilian Care for Eligible Family Members

The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is a comprehensive health care program in which the VA shares the cost of covered health care services and supplies with eligible beneficiaries.

Due to the similarity between CHAMPVA and the Department of Defense (DoD) TRICARE program (sometimes referred to by its old name, CHAMPUS), the two are often mistaken for each other. CHAMPVA is a Department of Veterans Affairs program. TRICARE is a regionally managed health care program for active duty and retired members of the Uniformed Services, their families, and survivors. If you are a military retiree, or the spouse of a veteran who was killed in action, you are and will always be a TRICARE beneficiary. Check with your POC.

To be eligible for CHAMPVA, you cannot be eligible for TRICARE and you must be in one of these categories:

1. The spouse or child of a veteran who has been rated permanently and totally disabled for a service-connected disability by a VA regional office, or
2. The surviving spouse or child of a veteran who died from a VA-rated service-connected disability, or
3. The surviving spouse or child of a veteran who was at the time of death rated permanently and totally disabled from a service-connected disability, or
4. The surviving spouse or child of a military member who died in the line of duty, not due to misconduct (in most of these cases, these family members are eligible for TRICARE, not CHAMPVA).

For information on CHAMPVA and to apply, access the following Web site: www.va.gov/COMMUNITYCARE/programs/caregiver/index.asp.

Upon confirmation of eligibility, you will receive program material that specifically addresses covered and non-covered services and supplies in the form of a CHAMPVA handbook.

See more information included in Module 4: Navigating Services and Benefits.