hi everyone and welcome to our video today we will be discussing tricare and the veterans health administration the vha so let's get started what is tricare tricare is the military's health coverage insurance program as a military person members are automatically entitled to the benefits that accompany tricare and are included under the coverage the program was implemented and is available to all seven service branches of the united states military those branches would include the navy the marine corps air force army coast guard public health service and the national oceanic and atmospheric administration to utilize and access the benefits of tricare it is essential that the member be enrolled and registered validly and efficiently in the defense enrollment eligibility reporting system which is otherwise referred to in the military vernacular by its simple acronym of deers after dutiful registration and deers the member is then deemed to be eligible to receive military military health care gains however it is not only military personnel that are covered under tricare it extends beyond them and provides medical coverage for the immediate family members of the military the beneficiaries of tricare are broadly split into two ways those serving or have served in military ranks previously are known as sponsors who sponsor their immediate families to come under the tricare umbrella the families therefore form the other type of major beneficiary of tricare while families are generally taken to be just the spouse and children tricare offers coverage for more than that what are the different types of tricare tricare comes in four varieties tricare prime tricare extra tricare standard and tricare for life tricare the military's health insurance plan covers everyone active duty members retirees and their families however retirees and their dependents have to chip in for the cost of coverage let's review tricare prime the tricare prime option is very much like an hmo or health maintenance organization like an hmo the member is assigned to a primary care provider otherwise known as a pcp this is usually although not always a military medical facility on a on a on base hospital or medical clinic there they will receive most of their health care needs through the pcp like most hmos in order to receive care from a specialist they must first receive a referral from their pcp tricare prime requires the member to enroll and pay an annual enrollment fee plus they are responsible for paying a small fee called a cost share in the military each time they receive medical care so they pay into a cost share which is similar to a co-pay for private insurance when the member receives medical care under tricare prime they do not have to file a reimbursement claim as the provider will automatically do this for them tricare prime is the most cost effective tricare option even though they generally have to live close to a military base to take advantage of it next let's take a look at tricare extra the tricare extra program gives the members more flexibility than tricare prime but it can result in additional cost if the member is eligible for tricare benefits they don't need to enroll in advance to use tricare extra they're enrolled automatically the first time they use any benefits and present their military or dependent id card as an insurance card to the provider under this program they can go to any tricare network provider so a tnp for tricare network provider and present their military or dependent id card and receive medical care under tricare extra the member would usually pay an annual deductible after the deductible is paid tricare pays 80 percent of the medical expenses and the member would pay 20 percent of the authorized costs tnps have also agreed to do all the paperwork for the member under tricare extra the member does not have to file a claim to be reimbursed thirdly we're going to take a look at tricare standard the tricare standard program gives the member the greatest flexibility but it costs the most under this program the member can see just about any medical provider they want as with tricare extra they pay an annual deductible and in addition to the deductible they have to pay 25 of what tricare says the medical service should cost okay um if a member wants to find out what the tricare allowable cost is for a particular medical procedure they would have to do they would have to research the actual procedure within the tricare cost plans um medical providers under tricare standard um can be broken into two groups so the first group would be participating providers um although they're not under contract like a tnp a tricare network provider have agreed to file claims for the member they accept payments directly from tricare and accept the tricare allowable charge less any applicable cost shares paid by the member as payment in full for their services there's no national list of participating providers this is this is more of a note um the member would need to ask the provider if he or she participates um in the tricare program the general rule is that if the provider fills out the claim paperwork for the member on they are a participating provider if the member has to fill out the claim form themselves then the provider is a non-participating provider which is the second group non-participating providers um non-participating providers do not agree basically do not agree to accept the tricare allowable charge for services or file the member's claims under the law non-participating providers can charge up to 15 percent above the tricare allowable charge for services in addition to the member's regular cost share that amount is the member's responsibility and is not shared by tricare um if the member sees a non-participating provider they might have to pay the provider first and then file a claim for with tricare um for reimbursement um they don't have to enroll in tricare standard um they're enrolled automatically the first time they use it or use any benefits as long as they present their military or dependent id card okay and lastly um there's tricare for life until a few years ago 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 actually changed back in 2001 with the introduction of tricare tricare for life so under tricare for life the member receives medical care from a medicare provider but tricare becomes a secondary insurance and picks up any cost that medicare doesn't cover um the member does not pay any annual deductible or do they have any cost sharing under this program services covered by tricare tricare is medical insurance meaning that it will only cover the medical aspects of a member's life this insurance will only benefit the member medically in case of any type of emergency or procedure that is required normally tricare benefits will depend upon and vary according to the type of plan that is in intended usage tricare covers hospitalization and outpatient visits as well as procedures involved in preventative care and maternity care immunizations as well as mental and behavioral health care are also included under the coverage program furthermore tricare covers most inpatient and outpatient care that is medically necessary and proven it also includes a yearly physical exam as well as any kind of surgery be it robotically assisted pre-existing conditions pharmaceutical prescriptions and other types of medical emergencies including but not limited to cosmetic surgery as a result of disfigurement due to burns and so on pharmacy services ensure that you that the member is provided with the prescription drugs they need when they need them in a timely and cost effective manner tricare covers most prescription drugs approved by the united states food and drug administration however it will not cover over-the-counter drugs services not covered by tricare tricare covers most inpatient and outpatient care that is medically necessary however there are special rules or limits on certain types of care while other types of care aren't covered at all some services or treatments require prior authorization under this plan a few examples of medical procedures that aren't covered are abortions unless the mother's life is at risk um certain types of birth control um the only type of birth control that is acceptable is a prescription type of birth control which would be something to the effect of birth control pills those would be covered um other procedures that would not be covered are cosmetic surgery or drug used for cosmetic purposes such as botox um non-surgical treatment for obesity or weight control smoking cessation products and treatment and most dental work is not covered um this is because the military has a separate insurance program for dental care however dental care that is medically necessary and the treatment of an otherwise covered medical condition and not dentaled um would be covered who qualifies for benefits when a military member is issued an id the id serves as a qualification method to prove that they are in fact enrolled in tricare um the basic qualifications are that the member is on active duty in the military members of the active drilling national guard or reserves that they are retired active duty members so active duty members can retire after performing at least 20 years of active duty service if they are retired from the national guard and reserve members who are receiving retired pay veterans who have received the medal of honor honorably discharge veterans who have been rated as a hundred percent disabled by the department of veterans affairs so the va due to a service related injury and dependence of those um listed here so dependents would include a veteran's spouse and a veteran's children surviving family members under certain conditions surviving family members of deceased military personnel are authorized to retain their id cards for coverage members who die during active duty while on active duty under orders that specified a period of duty of more than 30 days or members who died while any retired with pay status national guard and reserve members who died from an injury or illness that happened or was aggravated while on active duty for a period of 30 days or less national guard and reserve members who qualified for retirement and were receiving retirement pay national guard and reserve members who qualified for retirement but weren't receiving pay because they had not reached age 60. honorably discharged veterans rated by the va as a hundred percent disabled because of a service connected injury or disease and those on recipients of medals of honor family coverage under tricare typical family coverage under tricare include marital affiliates biological or adopted children sponsored dependent parents and parents in laws however instances and circumstances of family eligibility differ tricare eligible family members include marital partners so a wife and a husband and single unwed children of active duty service military affiliates marital dependence and unmarried offspring of retired uniformed service members military individuals who have been conferred the medal of honor and their immediate family members former spouses who have remained single and children who are yet single of deceased retired or active duty uniformed individuals marital dependents and unwed underage progeny of members of the reserves and national guard who are under order and command to serve in active duty for more than 30 days at a stretch or individuals in reserve and the national guard who are killed while serving in combat duty the wives and or husbands and their respective single as yet underage children of reservists and member of the national guard who are killed under any kind of circumstance or condition pertaining to active combat financially and functionally dependent parents and parent-in-laws can also be afforded care coverage under tricare under excruciating circumstances unwed single offspring who are under or have attained the age of 21. this also includes stepchildren who have been legally adopted by the military person in question tricare remains in place even if the spouse gets the verse i'm sorry divorced or remarried however if the stepchild was never adopted and if the marriage breaks down due to divorce tricare privileges will be revoked this does not mean that tricare coverage was not there whilst the stepchild's parents were married children over the age of 21 may be covered if they are excruciatingly handicapped or have disabilities that hinder proper functioning and if the condition was present before his or her 21st birthday children of military sponsors may also be covered under tricare until the age of 23 if they are still in school or an institute of higher learning on a full-time basis it also needs to be proven that the child in question is at least partially 50 percent responsible on his or her parent children who are lawfully placed in the guardianship of an active or retired service member the offspring of incumbent or past military service members who are illegitimate may also qualify as as legible candidates for tricare coverage but certain conditions may apply and consulting a health benefit advisor would definitely be helpful in addition some family individuals of incumbent servant members may be eligible for medical coverage if their military sponsor is under court ordered separation and is marital for spousal and child abuse spouses and children of the north atlantic treaty organization so members of nato nato and partners for peace pfp country ambassadors who are under official authority allowed to travel and stay with the nato and pfp country spokespersons they are eligible for outpatient benefits only as long as they are currently living in or temporarily staying in the united states of america other family members registered in the defense enrollment eligibility reporting system dears and lastly former marital partners of uniformed service members including active retired and former but they need to meet certain requirements these requirements are they must not remarry if they do so tricare privileges will be revoked in every case even though the new marriages are dissolved as a consequence of death or divorce they should not have an existing or additional health insurance plan such as that covered um such as a plan that's covered by an employer they should not have been married at all in the past to any of the nato or pfp nation members and lastly it is essential that the person has been married to the same member or former member for at least two decades what is the veterans health administration the vha the veterans health administration is the largest integrated health care system in the united states the executive in charge office of the under secretary for health directs this health care system with an annual budget of approximately 68 billion dollars overseeing the delivery of care to more than 9 million enrolled veterans they employ more than three hundred and twenty two thousand full-time health care professionals and support staff at a thousand two hundred and fifty five health care facilities including 170 va medical centers and 1074 outpatient sites of care of varying complexity including outpatient clinics bha is the nation's largest provider of graduate medical education and a major contributor to medical and scientific research more than 73 000 active volunteers a hundred and twenty seven thousand health profession trainees and approximately fifteen thousand affiliated medical factory um faculty are also an integral part of the vha community the vha's mission is quite simple to honor america's veterans by providing exceptional health care that improves their health and well-being services covered by the vha so certain things that would be covered under this type of coverage would be preventative care services like health exams including gender specific exams health education including nutrition education immunization against infectious diseases like the flu shot counseling on genetic diseases so diseases that run in the family they would also cover inpatient hospital services like surgeries medical treatments kidney dialysis acute care so um short term treatment for severe illnesses or injuries after a surgery um specialized care so that would be um care that would include organ transplants intensive care for mental and physical conditions and care for traumatic injuries they would also cover urgent and emergency care services um at certain va health facilities so urgent care for injuries and illnesses that need attention right away but that aren't life-threatening um at urgent care locations that are part of their contracted network okay so these can include care at va approved walk-in retail health clinics for minor illnesses like a sore throat or an earache or at an urgent care facility for more pressing but not life-threatening illnesses or injuries that require treatment like splinting casting or wound care they would also be covered for mental health services to treat certain issues like post-traumatic stress disorder so ptsd military sexual trauma mst depression and substance use problems um they would be covered to a certain degree for assisted living and home health care depending on the member's needs and income as well as space in the program prescriptions written or approved by a va doctor would also be covered they may cover services that that the members va primary care provider would state that is needed to support a particular treatment so ancillary services so these would be like tests used to diagnose health conditions including blood work x-rays ultrasounds therapy and rehabilitation services this would include physical therapy vision rehab and therapy for traumatic brain injury additional services would include prosthetic items audiology so care for hearing loss and radiation oncology for cancer care they would also cover routine eye exams and in some cases um they might offer coverage for eyeglasses or services for blind or low vision rehabilitation and in certain cases a member might be able to receive dental care as part of their va health benefits services not covered by the vha these services are not included in a member's va medical benefit package abortions and abortion counseling cosmetic surgery unless it's concluded that it's medically necessary so needed to prevent or treat a certain illness injury condition disease or symptom gender alteration so gender reassignment surgery not included health club or a spa membership medicines and medical devices that aren't approved by the food and drug administration although there are two special cases the first one is if the member is in an approved clinical trial or if the member is seriously ill and their va health care provider prescribes a new unapproved medicine because there are no other comparable treatment options called a compassionate use or expanded access exemption and lastly inpatient hospital or outpatient care if the member is a patient or an inmate in a non-va government agency institution if the agency must must provide the care service by law that would not be covered while reviewing the vha there are six glossary terms i would like to share please review the following slide care systems in many areas of the country several medical centers and clinics make work together to offer services to area veterans as a health care system in hcs in an effort to provide more efficient care by sharing services between medical centers healthcare systems allow vha to provide veterans easier access to advanced medical care closer to their homes so examples of health care systems include the va pittsburgh healthcare system which serves the pittsburgh area of pennsylvania and the va pugget sound healthcare system which services on the seattle and tacoma area of washington state the next term that i'd like to share with you guys is community-based outpatient clinic so these make access to healthcare easier um the vha utilizes community-based outpatient clinics otherwise referred to as cboc across the country these clinics provide the most common outpatient services including health and wellness visits without the hassle of visiting a larger medical center the vha continues to expand the network of cbocs to include more rural locations putting access to care closer to home another term um to review would be community living center so community living centers clcs are skilled nursing facilities often referred to as nursing homes veterans with chronic stable conditions such as dementia those requiring requiring rehabilitation or those who need comfort and care at the end of life are served within one of our community living centers um doma ciliary care or doma celeria are vha domicileries they provide a variety of care to veterans who suffer from a wide range of medical psychiatric vocational educational or social problems and illnesses in a safe secure homelike environment the next term is vet center vet centers provide readjustment counseling and outreach services to all veterans who served in any combat zone services are also available for family members dealing with military related issues the vha operates community-based vet centers in all 50 states the district of columbia in guam puerto rico and the u.s virgin islands and the last term is veterans integrated services network the united states is divided into 18 veterans integrated service networks or visms these are regional systems of care working together to better meet local health care needs and provides greater access to care hi everyone and thank you for listening into our video today i hope it was educational and that you were able to learn a little more about tricare and the vha thank you so much again and have a great day