In our previous lesson, we learned Medicare, Medicaid, Rail Road Medicare insurances, let's break down the Military insurances (forth part)
Military insurances are federally funded health benefit programs designed to provide care for active duty, veterans, retirees and their dependents. There are two main categories of Military Health System:
- Tricare
- CHAMPVA
Tricare
Tricare is a military health insurance program administrated by Defense Health Agency (DHA) under the department of defense, a part of the Military Health System. Tricare provides comprehensive healthcare coverage for Active duty (Uniform services), and retired service members of US defense forces, as well as their families and survivors, worldwide. Tricare older/former name was CHAMPUS (Civilian Health and Medical Program for Uniform Services). CHAMPUS was transitioned into TRICARE in the mid-1990s to modernize the military healthcare system and offer more plan options to service members and their families.
Tricare offers a variety of plans tailored to different needs and service types. The main plans includes:
- Tricare Prime
A managed care plan similar to HMO where beneficiaries / patient need referrals from their Primary Care Manager (PCM) for seeing specialist. There are further several options under Tricare Prime:
- TRICARE Prime – Standard plan for eligible beneficiaries
- TRICARE Prime Remote – For those in designated remote areas
- TRICARE Prime Overseas – For active duty members and families stationed abroad
- TRICARE Prime Remote Overseas – For those in remote overseas locations
- Tricare Select
Tricare select is similar to PPO where beneficiaries / patient can see any Tricare authorized provider without referrals. Out of network care may covered under higher cost. e.g.
- TRICARE Select Overseas – For those stationed abroad
- Tricare for Life (TFL)
This plan is designed for those who are eligibility for Medicare Part A and / or Part B. Tricare for Life (TFL) acts as a secondary payer to Medicare. It covers all the cost / PR made by Medicare.
- Premium Base Plans
These plans required monthly premiums and serve specific beneficiary groups. In this program, beneficiary have to pay yearly deductibles, cost share, and if see out of network provider, have to pay higher cost share and may have to file own health care claims. It comes with options:
- TRICARE Reserve Select – For eligible members of the Selected Reserve
- TRICARE Retired Reserve – For retired Reserve members under age 60
- Tricare Young Adult
Tricare Young Adult (TYA) is a health plan available to unmarried adult children of Active duty or retired service member who are no longer eligible for regular Tricare coverage. Typically regular Tricare coverage ends from age of 21 (or 23 if fully enrolled in college) to 26. TYA offers comprehensive medical and pharmacy benefits with two plan options:
- TYA Prime – Managed care with referrals and network restrictions (similar to Tricare Prime)
- TYA Select – Fee-for-service with greater provider flexibility (similar to Tricare Select)
- US Family Health Plan (USFHP)
Offered in specific U.S. regions, USFHP provides TRICARE Prime benefits through civilian provider networks.
- Other Tricare Programs
- TRICARE Dental Program – For eligible active duty family members and National Guard/Reserve members
- TRICARE Pharmacy Program – Covers prescription medications
- Continued Health Care Benefit Program (CHCBP) – Temporary coverage for those transitioning out of TRICARE
Eligibility Criteria
- Active Duty Members: Enroll in TRICARE Prime or TRICARE Prime Remote, depending on duty station.
- Family Members: May enroll in TRICARE Prime, TRICARE Select, USFHP (in specific areas), or TRICARE For Life (if Medicare-eligible).
- Retirees and Their Families: Options depend on age, Medicare status, and retirement classification.
- Adult Children (21–26): May enroll in TRICARE Young Adult.
Tricare Contractors:
The current TRICARE contractors are: Humana Military for the East Region, TriWest Healthcare Alliance for the West Region, and International SOS for overseas. These contractors manage healthcare services for TRICARE beneficiaries within their respective regions. Responsible for processing, paying claims and management Tricare specific rules codes and guides.
Tricare Insurance ID Pattern:
In Tricare, we call insurance ID a DOD (Department Of Defense) benefit number and DOD benefit number is 10 numeric digits found on the back of the Tricare card.
ID Structure
- First 9 digits: identify the sponsor (active duty, retiree, or deceased service member).
- 10th digit: identifies the beneficiary’s relationship to the sponsor:
- 0 = Sponsor (the service member or retiree)
- 1 = Spouse
- 2 and higher = Dependent children (order assigned by DEERS enrollment)
Is Tricare has 11 digits ID? (History)
Before 2011, TRICARE often used the sponsor’s SSN + a two-digit suffix (making it look like 11 digits).
After SSN removal for security reasons, the DBN (Department of Defense Benefit Number) became the official ID, always 10 digits.
CHAMPVA
CHAMPVA (Civilian Health and Medical Program of the Department of Veterans Affairs) is a VA health benefits program designed for the spouses, dependents, and survivors of Veterans who meet certain service-connected disability requirements.
How CHAMPVA Works?
When you enroll in CHAMPVA, the VA shares the cost of specific healthcare services and supplies with you. If you have other health insurance in addition to CHAMPVA, you may not have to pay as much out of pocket, or possibly nothing at all.
What CHAMPVA Covers
CHAMPVA covers a wide range of healthcare services and supplies, including:
- Family planning and maternity care
- Hospice care
- Inpatient care (hospital stays)
- Mental health services
- Outpatient care and procedures (like doctor visits and minor surgeries)
- Skilled nursing care (professional care such as medication management, wound care, and recovery support)
It also covers:
- Ambulance services
- Durable medical equipment (prescribed items to help with daily activities)
- Organ transplants
- Prescription medications
Vision and Dental Coverage
You can get these services at a reduced cost by enrolling in the VA Dental and Vision Insurance Program (VADIP).
Medicare and CHAMPVA
If you become eligible for Medicare (usually at age 65), you must enroll in Medicare Part A and Part B to keep or receive CHAMPVA benefits.
Primary vs. Secondary Insurance
- If you have Medicare or other health insurance as your primary coverage, CHAMPVA will act as your secondary insurance.
- If you have Medicaid, Indian Health Services, State Victims of Crime Compensation Programs, or a CHAMPVA supplemental policy, then CHAMPVA remains your primary insurance.
CHAMPVA Contractor:
The primary contractor responsible for processing CHAMPVA claims is the VHA Office of Integrated Veteran Care, specifically the CHAMPVA Claims team. They handle claim submissions, payment processing, and related inquiries.
CHAMPVA Insurance ID Pattern:
CHAMPVA ID is consist of 9 digit numbers only. It's usually matches the veteran’s VA claim number or Social Security Number (SSN).
- If the sponsor is still alive, it’s often their SSN.
- If the sponsor is deceased or had a VA claim number, that number is used.
Pattern for dependents
Dependents (spouse or child) share the same first 9 digits as the sponsor but have a two-digit suffix to identify the relationship.
Example format (fictional):
- Sponsor: Veteran John Doe — VA claim number 876543210
- Spouse’s CHAMPVA ID: 876543210-01
- Child’s CHAMPVA ID: 876543210-02 and vice versa.
The card may display the number without the dash, but the suffix still exists in VA’s system.
Note: If you are eligible for Tricare then you can't get CHAMPVA and vice versa
Frequently Asked Questions
Does CHAMPVA be secondary insurance?
Yes, CHAMPVA functions as a secondary payer (also known as the payer of last resort) to other health insurance, such as Original Medicare, Medicare Advantage plans, and other private health insurance, paying after those primary plans have paid their portion. CHAMPVA is the primary payer only in specific situations, such as when a beneficiary is enrolled in Medicaid, Indian Health Service, or a State Victims of Crime Compensation Program.
Does Tricare be secondary insurance?
Yes, TRICARE can be used as secondary insurance to cover out-of-pocket costs after another health insurance (OHI) plan has paid its share, but it is crucial to inform your TRICARE contractor and doctor about your OHI coverage to avoid claim denials. TRICARE is almost always the payer of last resort, meaning it pays after your primary insurance, such as an employer-sponsored plan or Medicare. TRICARE For Life (TFL) is specifically designed to be secondary to Medicare.
What is the timeframe for CHAMPVA & Tricare claim processing?
The standard processing time for CHAMPVA is somehow from 4 months to over 6 months, it depends on the circumstances and region. While Tricare processes the claim within the 30 days from the date of receiving.
What is the timely filling limit for CHAMPVA & Tricare?
The timely filing limit for Tricare is one year from the date of service (treatment day) for beneficiaries in the U.S. while three years for overseas beneficiaries. Similarly, CHAMPVA has one year from the date of service for beneficiaries in the U.S. while overseas has longer time to file a claim. But it is recommended to file a claim within 90 days from the date of service.
Does CHAMPVA makes PR 3 (Copay) as patient responsibility?
No, the term "PR 3" is not used in the CHAMPVA program. Instead of "PR 3," CHAMPVA has a 25% cost-share for covered services after you have met your annual deductible. CHAMPVA covers 75% of the allowable amount, and you are responsible for the remaining 25%.
Does Tricare makes PR 3 (Copay) as patient responsibility?
Tricare may or may not makes PR 3 as patient responsibility. It depends on plan and situation. Here is some key points to understand:
- Active-duty members under TRICARE Prime: no out-of-pocket costs.
- Retirees and their families: copayments apply.
- TRICARE Select and other premium-based plans: both active-duty families and retirees have cost-shares or copayments that vary by network status.
- Military pharmacies: no copayments for anyone...
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