Law 6842-01  Winter 2011
American Health Care Law
Professor Vernellia R. Randall
The University of Dayton School of Law

 

Understanding Military Health

Home
Unit 01 Organization                                               x
Unit 02 Access                                              x
Unit 03 Quality                                              x
Unit 04 Reform                                              x
Syllabus                                              x
Lesson Outline                                              x


 

Other Syllabi 
AIDS
American Health Care Law
Bioterrorism 
Tobacco

Violence and Public Health
 
Favorite Poetry
Invictus
The Bridge Poem
Still I Rise
No Struggle No Progress
 
Related Websites
Race and Racism
Gender and the Law
Legal Education
Personal Homepage
 

 

Depending upon their status, active duty members, retired members, members of the Guard/Reserves, family members, and certain veterans receive free or government subsidized medical and dental care. For the most part, this care falls under an overall program known as "Tricare." While the Tricare system may appear to be complicated at first glance, it's really not all that hard to understand.

 

History

 

Prior to the 1980s, there were basically two ways for military personnel, retirees, and family members to receive military health care. Military members received treatment at military medical facilities, and retirees and family members received free treatment (space available) at military medical facilities, or could use a program known as CHAMPUS (Civilian Health and Medical Program Uniformed Services) to receive government-substidized medical care from civilian providers.

The idea of military medical care for the families of active-duty members of the uniformed services dates back to the late 1700s. In 1884, Congress directed that the “medical officers of the Army and contract surgeons shall whenever possible attend the families of the officers and soldiers free of charge.” There was very little change until World War II. Most draftees in that war were young men who had wives of childbearing age. The military medical care system, which was on a wartime footing, couldn't handle the large number of births, nor the care of very young children. In 1943, Congress authorized the Emergency Maternal and Infant Care Program (EMIC). EMIC provided for maternity care and the care of infants up to one year of age for wives and children of service members in the lower four pay grades. It was administered by the “Children's Bureau,” through state health departments.

The Korean conflict again strained the capabilities of the military health care system. On Dec. 7, 1956, the Dependents Medical Care Act was signed into law. The 1966 amendments to this act created what would be called CHAMPUS beginning in 1967. The law authorized ambulatory and psychiatric care for active-duty family members, effective Oct. 1, 1966. Retirees, their family members, and certain surviving family members of deceased military sponsors were brought into the program on Jan. 1, 1967. The CHAMPUS budget for Fiscal Year 1967 was $106 million. Records don't indicate how many claims were filed in FY 1967, but the total probably wasn't more than a few thousand. In FY 1996, the TRICARE/CHAMPUS budget was more than $3.5 billion, and more than 20 million claims were received. Today, nearly 5.5 million people are eligible for TRICARE benefits.

In the 1980s, the search for ways to improve access to top-quality medical care, while keeping costs under control, led to several CHAMPUS “demonstration” projects in various parts of the U.S. Foremost among these was the “CHAMPUS Reform Initiative” (CRI), in California and Hawaii. Beginning in 1988, CRI offered service families a choice of ways in which they might use their military health care benefits. Five years of successful operation and high levels of patient satisfaction convinced Defense Department officials that they should extend and improve the concepts of CRI, as a uniform program nationwide. The new program, known as TRICARE, is now fully in place.

 

Types of Tricare

 

When Tricare was first instituted, there were only three types: Tricare Prime, Tricare Standard, and Tricare Extra. Over the past few years, more Tricare options have been established.

Tricare Prime. This option is kind of like an HMO concept, and requires that one specifically enroll in the program (active duty members are enrolled automatically). Individuals enrolled in Tricare Prime are assigned to a Primary Care Provider (PCP), which is usually the local military medical facility (base hospital). In order to receive specialist care, they must be referred by their PCP. Under this program, there is no enrollment fee or cost-sharing for active duty members and family members of active duty. For retirees (under age 65) and family members of retirees (under age 65), there is an enrollment fee of $230 per year for a single individual, or $460 per year for a family. In addition to the annual enrollment fee, retirees and their family members pay a cost-share of $12.00 per outpatient visit, $30.00 per emergency care incident, $25.00 per mental health outpatient visit, $11.00 per day for inpatient care, and $40.00 per day for inpatient mental health care. There is a maximum $3,000 "catastrophic cap," that a retired family would have to pay each year.

One can get the forms to enroll in Tricare Prime online.

A brand new option under Tricare Prime is the Point of Service (POS) enrollment option. Normally, under Tricare Prime, one must be referred by the PCP in order to receive any reimbursement for medical care received from anyone other than the PCP. But, if one elects the POs option at time of enrollment, one can use Tricare Prime, and still use the Tricare Standard or Tricare Extra options described below.

Tricare Extra. This program gives more flexibility than Tricare Prime, but could result in addition costs. One does not need to enroll in advance to use Tricare Extra. Under this program, you see any Authorized Tricare Provider, present your ID Card, and receive medical care. The Tricare Authorized Providers have a contract with the military to limit costs to designated amounts. Under Tricare Extra, active duty family members pay an annual deducible (the "year" begins every October) of $150 (individual) or $300 (family). After the deducible is paid, Tricare pays 85 percent of the cost for the office visit, and you pay 15 percent. For inpatient care, active duty family members pay $11.45 per day. For inpatient mental health care, active duty family members pay $11.45 per day, or a total of $25.00, whichever is greater.

For retirees and retiree family members (under age 65), the program costs a little more. While the annual deducible is the same ($150.00 per individual or $300 per family), the cost-share is 20 percent per visit for outpatient care, the lesser of $401 per day, or 25 percent of the hospital bill and 20 percent of the professional fees for inpatient care; and 20 percent of the institutional charges, plus 20 percent of the professional fees for inpatient mental health care.

Under Tricare Extra, the medical provider fills out the Tricare Claim Forms for you, and they receive direct-payment from Tricare for their portion. You simply pay them your portion of the costs.

Tricare Standard. Tricare Standard is the closest to the old "CHAMPUS" program. This program gives the greatest flexibility, but costs the most. Under this program, you can see pretty much any medical provider you want. Again there is the $150.00/$300 annual deducible Under this program, for active duty family members, Tricare pays 80 percent of what it says the care should cost, and you pay 20 percent. If the medical provider charges more than what Tricare says it should cost, you have to pay the additional difference. For inpatient care, the rates are the same as for Tricare Extra.

For retirees and retiree family members (under age 65), again, it costs more. In addition to the annual deducible, you have to pay 25 percent of what Tricare says it should cost, plus anything extra that the medical provider charges (over the Tricare authorized cost).

For inpatient care, retirees and retiree family members pay the lesser of $401 per day, or 15 percent of the hospital bill and 25 percent of the professional fees; and the lesser of $149.00 per day or 25 percent of the institutional charges, plus 25 percent of the professional fees for inpatient mental health care.

A special note here. Under Tricare Extra, while you are normally responsible for paying anything over the Tricare authorized costs, if the medical provider fills out the claim forms for you (as many of them do) and receives direct payment from Tricare (vs. you filling out the claim forms yourself and being reimbursed by Tricare), the medical provider AGREES not to charge more than the Tricare Allowable Amount. This is true unless you sign a separate agreement with the medical provider which obligates you to pay the additional amounts. This is a little-known provision of the Tricare Standard Program. If the provider attempts to charge you more than the authorized amount (as happened to me recently), then you can contact your nearest Tricare Service Center and they will help arbitrate the dispute with the medical provider.

Guard and Reserve. Members of the Guard and Reserve (and their dependents) can use any of the above Tricare Options anytime the member is called to active duty for more than 30 days. Use of Tricare Prime is free, as it is with active duty family members. Health coverage is also provided up to 90 days prior to activation for servicemembers who receive a 'delayed-effective-date' order. The coverage lasts until 180 days following their activation. After that 180 day "transition" period, following activation, Guard and Reserve members can purchase special Health Care Coverage under the Tricare Reserve Select program, if they were activated for a contingency operation for 90 days or more.

Tricare for Life. Until recently, 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 this year (2001) with the introduction of "Tricare for Life." Again, there is no need to enroll in advance (except one must be enrolled in Medicare Part B). Additionally, the only charges for this program are the monthly Medicare Part B Premiums ($54.00 per month in 2002). Under this program, you see an authorized Medicare Provider and present your ID Card. Tricare then becomes the "second payer," and picks up any costs that Medicare doesn't cover.

Although Medicare doesn’t cover services provided outside of the continental United States, retirees residing in foreign countries can still take advantage of TFL because Tricare becomes the primary source of health benefits for them. Like those living in the United States, to be eligible overseas retirees must be enrolled in Medicare Part B. Tricare for Life will provide the same level of coverage afforded retirees under 65 and they will be responsible for the same Tricare cost shares and deductibles as the under 65 retirees. Since a great number of retirees living overseas did not enroll in Part B because Medicare didn’t cover medical care received in foreign countries, some of the military related organizations are pushing for a waiver of the Part B penalty which entails a 10 percent penalty for each year the individual was eligible for Part B but didn’t enroll. However, there is currently nothing in the works that indicates such a waiver is coming.

Tricare Plus. This is a brand new program, currently undergoing development. Basically, it will allow individuals to use Tricare Extra and Tricare for Life benefits at military medical facilities. Not all military medical facilities will offer this this option. Local commanders will determine whether or not they have the resources. Individuals will be required to enroll in the program at a participating medical facility, then must receive their primary care at that facility. There are no enrollment fees for this program. 

Pharmacy

 

There are basically three ways to receive medications through Tricare:

Military Pharmacies. First, you may have prescriptions filled (up to a 90-day supply for most medications) at a military treatment facility (MTF) pharmacy free of charge. Please be aware that not all medications are available at MTF pharmacies. Each facility is required to make available the medications listed in the basic core formally (BCF). The MTF, through their local Pharmacy & Therapeutics Committee, may add additional medications to their local formally based on the scope of care at that MTF.

Tricare Mail Order Pharmacy (TMOP). You can order medications online or through the mail. You can receive up to a 90 day supply (for most medications). The cost is $3.00 per prescription/refill for generic drugs and $9.00 per prescription/refill for name-brand drugs.

You can get your medications through any civilian pharmacy. If the pharmacy is part of the Tricare Pharmacy Network, the cost is the same as the Mail Order Pharmacy. If your pharmacy is not part of the Network, Tricare will reimburse you $9 or 20% of total cost (whichever is greater). For users of Tricare Prime who use a commercial non-network pharmacy (why would you?) there is an annual deducible of $300 per person or $600 per family. For users of Tricare Standard who elect to use a non-network pharmacy, the annual deducible is part of the Tricare Standard annual deducible.

Effective 1 April 2001, retirees/family members over the age of 65 are also eligible for the above pharmacy benefits, but -- like Tricare for Life -- they must be enrolled in Medicare, Part B to participate. Cost-share is the same as shown above.

 

Active Duty/Reserve Dental Care

 

Dental Care for active duty, of course, is free through the Military Dental Clinic. Tricare does, however, offer optional dental plans for family members of active duty, and members of the Guard/Reserves and their family members. These programs require a monthly premium. The programs pay the total cost of some dental care, plus cost-share for other dental care. Current monthly premium rates are (2003):

  • Active duty - One family member, $8.11 per month. Two or more family members, $20.27 per month.
  • Selected Reserves - For the military member, $8.11 per month. For one family member, $20.27 per month. For more than one family member, $50.67 per month. For the military member and his/her family, $58.78 per month.
  • Individual Ready Reserves (IRR) - For the military member, $20.27 per month. For one family member, $20.27 per month. For more than one family member, $50.67 per month. For the military member and his/her family, $70.94 per month.

 

Retiree Dental Program

 

In addition to dental programs for family members and Guard/Reserve, Tricare offers a separate dental program for military retirees and retiree family members. The premiums for this program depends upon where you live, and number of family members covered. Like the other program, the Retiree Program covers 100 percent of some costs, with cost-share for other costs.

You can also enroll online for this program.

 

VA Medical Care

 

I run into folks all the time who think that any military retiree or any veteran can get free medical care from the Veterans Administration. Not true. To receive medical care from the VA, one must be a Veteran (over 180 days of military service), one must have an honorable discharge, and one must either have a service-connected illness, injury or disability, or one must fall into a certain range of poverty. More information about VA Medical Care is available on the VA's Web Site.

 

 
 
Lessons - Unit 01
01 Health and Illness                                               x
02 Assuring Public Health                                              x
03 Organization                                              x
04 Structuring the System                                              x
05 Tax Exemption                                              x
06 Professionall Relationships                                              x
07 Antitrust I                                              x
08 Antitrust II                                              x

 


 

 

 

Related Pages:
Home ] Up ] Understanding Indian Sovereignty ] Legal Basis for Health Services to Indians ] [ Understanding Military Health ]
Subsequent Pages:
Home ] Up ]
Previous Pages:
Home ] 01: Health,  Illness and Sickness in the United States ] 02: Assuring the Public's Health ] 03: Organization and Structure ] 04:  Organization and Structure II ] 05: Tax-exempt Health Care Organizations ] 06: Professional Relationships ] 07: Antitrust in Health Care Part I ] 08: Antitrust in Health Care - Part II ]
Back Home Up

 


Last Updated:
 12/05/2010

You are visitor number:
Hit Counter
since September 2001

Always Under Construction!

Always Under Construction!

 

Contact Information:
Professor Vernellia R. Randall
Institute on Race, Health Care and the Law
The University of Dayton School of Law
300 College Park 
Dayton, OH 45469-2772
Email: randall@udayton.edu

 

 

Copyright @ 1994. Vernellia R. Randall 
All Rights Reserved