TRICARE Standard Handbook Glossary

Accept TRICARE Standard assignment

See "Participate in TRICARE."

Allowable charge

The amount on which TRICARE Standard figures your cost-share for covered care. TRICARE Standard figures the allowable charge from all professional (non-institutional) providers' bills nationwide, with adjustments for specific localities, over the last year. The claims processor can tell a provider the allowable charge amount for specific services or procedures. Also known as the "CHAMPUS Maximum Allowable Charge" (CMAC).

Authorized provider

A doctor or other individual authorized provider of care, hospital or supplier who has applied to, and been approved by, TRICARE to provide medical care and supplies. Generally, that means the provider is licensed by the state, accredited by a national organization, or meets other standards of the medical community. If a provider is not authorized, TRICARE cannot help pay the bills. (See the "Where to Get Care" chapter for other providers.)

Balance billing

This is when a provider bills you for the rest of his or her charges (the "balance" of the charges), after your civilian health insurance plan or TRICARE has paid everything it's going to pay. Federal law says you aren't legally responsible for amounts in excess of 15 percent above the TRICARE allowable charge.

Capitation

A fixed amount of money that a managed-care plan gives to a doctor or hospital to care for a patient, no matter what the patient's care actually costs.

Catastrophic cap

A cost "cap" or upper limit has been placed on TRICARE Standard-covered medical bills in any fiscal year. The limit that an active-duty family will have to pay is $1,000; the limit for all other TRICARE Standard-eligible families is $7,500. (See the beginning of the "How Much Will It Cost?" chapter for more details about this cap on your medical expenses and for the limitations that apply.)

Claims processor

That's the contractor that handles the TRICARE claims for care received within a particular state or region. They're also called TRICARE contractors and "fiscal intermediaries" or FIs. They have toll-free phone numbers to handle your questions.

Co-payment

This is a fixed amount you'll pay when you're enrolled in TRICARE Prime and you visit the doctor for some type of medical care. Sometimes, the terms "co-payment" and "cost-share" (see below) are used interchangeably.

Cost-share

That's the percentage you pay-and the part TRICARE Standard pays-of the allowable charges for care on each claim. Your cost-share depends on your sponsor's status (active or retired) in the service. Your cost-share is paid in addition to the annual deductible for outpatient care and anything a non-participating provider charges above the allowable charge. The TRICARE Standard cost-share is the difference between the allowable charge and your cost-share.

Deductible

That's the amount you must pay on your bills each year toward your outpatient medical care, before TRICARE begins sharing the cost of medical care. That is, you pay your provider(s) the first $150 for an individual, or $300 for a family, worth of medical bills each fiscal year-from October 1 through September 30 (for the families of active duty members in pay grade E-4 and below, the deductible amounts are $50 for an individual and $100 for a family). The contractor keeps track of your deductible and subtracts it from your claims during the year. How much you've paid toward your deductible is spelled out on the Explanation of Benefits. The deductible is separate from, and in addition to, your cost-share.

DEERS

The Defense Enrollment Eligibility Reporting System. That's the computerized data bank which lists all active and retired military members, and should also include their dependents. Active and retired service members are listed automatically, but they must take action to list their dependents and report any changes to family members' status (marriage, divorce, birth of a child, adoption, etc.), and any changes to mailing addresses. TRICARE contractors check DEERS before processing claims to make sure patients are eligible for TRICARE benefits.

Diagnosis-Related Groups (DRGs)

DRGs are a way of paying civilian hospitals for inpatient care under TRICARE Standard. They're effective in 48 states, the District of Columbia and Puerto Rico. Only Maryland and New Jersey are exempt from the federal DRG payment system. Under DRGs, TRICARE Standard pays most hospitals a fixed rate for inpatient services, regardless of how much the care actually costs. The goal is to cut health care costs for both military families and the government. (See the "Inpatient Costs" section in the "How Much Will It Cost?" chapter for a more detailed explanation of DRGs.)

Explanation of Benefits (EOB)

A statement the TRICARE contractor sends you and the provider who participates in TRICARE Standard that shows who provided the care, the kind of covered service or supply received, the allowable charge and amount billed, the amount TRICARE Standard paid, how much of your deductible's been paid, and your cost-share. It also gives the reason for denying a claim. Sometimes also called the TRICARE Explanation of Benefits (TEOB).

Extra

See "TRICARE Extra."

Fiscal Intermediary (FI)

See "claims processor."

Health Benefits Adviser (HBA)

Persons at military hospitals or clinics who are there to help you get the medical care you need through the military and through TRICARE. Contact an HBA whenever you have any questions on obtaining medical care. But remember-while HBAs can give valuable advice and assistance, they can't guarantee coverage under TRICARE. Your TRICARE contractor must review each claim and make payment determinations in accordance with uniformed services eligibility rules and the TRICARE Standard regulation.

Health Care Finder (HCF)

These are health care professionals, generally registered nurses, who help you find needed care. They work with your Primary Care Manager (PCM) to locate the specialty care you may require. Health Care Finders are located at TRICARE Service Centers.

Health Maintenance Organization (See HMO)

A health plan to which you pay a fixed premium (and often, small user fees) for an assortment of medical services, usually including primary and preventive care. The HMOSee employs physicians, therapists, etc., to serve your medical needs.

Managed care

A concept under which an organization (like an HMO) delivers health care to enrolled members and controls costs by closely supervising and reviewing the delivery of care.

Medically (or psychologically) necessary

Medical (or psychological) services or supplies which are considered appropriate care and are generally accepted by qualified professionals to be reasonable and adequate for the diagnosis and treatment of illness, injury, pregnancy, mental disorders, or well-child care.

Military hospitals

We use it as shorthand for all uniformed service hospitals including the ten former Public Health Service hospitals. Also, the acronym "MTF" (military treatment facility) is sometimes used to refer to military hospitals. (See "Uniformed services hospitals.")

Nonavailability statement (NAS)

That's a certification from the uniformed service hospital that says it can't provide the care you need. If you live in certain ZIP codes around a military hospital, you must get a nonavailability statement before getting non-emergency inpatient care at a civilian hospital under TRICARE Standard. Don't forget-TRICARE does not determine eligibility, nor does it issue nonavailability statements. The statements must be entered electronically in the Defense Department's DEERS computer files by your nearby military medical facility. (See the "Nonavailability Statements" section of the "Where to Get Care" chapter for the exceptions to this rule.)

Other health insurance

If you have other health care coverage-besides TRICARE Standard or TRICARE Extra or Prime-for yourself and your family through an employer, an association or a private insurer; or if a student in the family has a health care plan obtained through his or her school-that's what TRICARE considers "other health insurance" (OHI). It may also be called "double coverage" or "coordination of benefits." It doesn't include TRICARE supplemental insurance. It also does not include Medicaid. (See the definition of TRICARE supplemental insurance later in this glossary.)

Participate in TRICARE

Health care providers who "participate" in TRICARE, also called "accepting assignment," agree to accept the TRICARE allowable charge (including your cost-share and deductible, if any) as the full fee for your care. Individual providers can participate on a case-by-case basis. They file the claim for you and receive the check, if any, from TRICARE. Hospitals that participate in Medicare must, by law, also participate in TRICARE Standard for inpatient care. For outpatient care, hospitals may or may not participate.

Participating provider

See "Participate in TRICARE."

Preferred Provider Organization (PPO)

A network of health care providers who provide services to patients at discounted rates or cost-shares.

Prime

See "TRICARE Prime."

Provider

A doctor, hospital or other person or place that delivers medical services and/or supplies.

Sponsor

The service person-either active-duty, retired or deceased, whose relationship to you (spouse, parent, etc.) makes you eligible for TRICARE.

TRICARE Prime

One of the three health care options under DOD's TRICARE managed health care program for military families. TRICARE Prime is the HMO-type option, under which you enroll for a year at a time, and agree to seek health care from the network of health care providers and institutions set up by the TRICARE contractor for the region in which you live. (See the "TRICARE Prime" section at the beginning of this book for more details about Prime, such as how this option works and how much it costs.)

TRICARE Extra

This is the second of the three health care options under DOD's TRICARE managed health care program. You don't have to enroll in Extra; you may use it on a case-by-case basis. You simply see a provider who's part of the TRICARE Extra network established by the local TRICARE contractor, and pay reduced cost-shares for your care. (See the "TRICARE Extra" section at the front of this book for more details about Extra.)

TRICARE Standard supplemental insurance

These are health benefit plans that are specifically designed to supplement TRICARE Standard benefits. They generally pay most or all of whatever's left after TRICARE Standard has paid its share of the cost of covered health care services and supplies. These plans are frequently available from military associations and other private organizations and firms. Such policies aren't necessarily just for retirees, but may be useful for other TRICARE-eligible families as well.

Uniformed services hospitals

This includes all military hospitals and former Public Health Service hospitals that are now called "uniformed services treatment facilities" (USTFs) in Baltimore; Boston; Seattle; Portland, Maine; Cleveland; Houston, Galveston, Port Arthur and Nassau Bay, Texas; and Staten Island, N.Y

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