TRICARE and CHAMPVA (Civilian Health and Medical

50.4 - TRICARE and CHAMPVA (Civilian Health and Medical Program of Veterans Administration) (Rev. 1, 10-01-03) A3-3153.3.D, HO-260.3.F 1. General TRICARE and CHAMPVA are similar programs administered by the Department of Defense, except that the Veterans Administration determines the eligibility of persons seeking to establish entitlement to CHAMPVA coverage. TRICARE provides benefits for health care services furnished by civilian providers, physicians, and suppliers to retired members of the Uniformed Services and to spouses and children of active duty, retired, and deceased members. The term “Uniformed Services” includes the Army, Navy, Air Force, Marine Corps, Coast Guard, and the Commissioned Corps of the U.S. Public Health Service and of the National Oceanic and Atmospheric Administration. CHAMPVA provides similar benefits for spouses and children of veterans who are entitled to VA permanent and total disability benefits and to widows and children of veterans who died of service-connected disabilities. The governmental entity exclusion does not preclude Medicare payment for items or services furnished to a beneficiary who is also eligible for TRICARE/CHAMPVA benefit payments for the same services. Medicare is the primary payer for such items and services, and TRICARE/CHAMPVA is a supplementary payer. (See subsection 3, below.) 2. Effect of Medicare Eligibility on TRICARE/CHAMPVA Entitlement TRICARE/CHAMPVA beneficiaries, other than dependents of active duty members, lose their entitlement to TRICARE/CHAMPVA if they qualify for Medicare Part A on any basis and do not enroll in Medicare Part B (effective October 1, 2001). NOTE: TRICARE beneficiaries that turned age 65 prior to April 1, 2001 are not required to purchase Medicare Part B in order to retain their TRICARE Pharmacy benefits. However, all TRICARE individuals entitled to Medicare Part A must be enrolled in Medicare Part B to receive the rest of their TRICARE benefit. Individuals who are eligible for Medicare Part B benefits only, do not lose their entitlement to TRICARE/CHAMPVA benefits. If a Medicare beneficiary, who has lost entitlement to CHAMPVA upon becoming entitled to Part A of Medicare, thereafter exhausts any Part A benefits, the individual can again be entitled to CHAMPVA. Once the individual re-attains CHAMPVA benefits, the individual will not lose them by virtue of later again becoming eligible for Medicare Part A benefits. There is no similar provision for TRICARE which enables an individual to re-attain TRICARE eligibility after exhausting Medicare Part A benefits. A/B MACs (A) and (B) will direct questions concerning this provision to the CHAMPVA Center. 3. Medicare-TRICARE/CHAMPVA Relationship If a TRICARE/CHAMPVA beneficiary also has Medicare coverage, TRICARE/ CHAMPVA reduces its liability in all cases by the amount payable by Medicare, i.e., Medicare is the primary payer and TRICARE/CHAMPVA supplements Medicare by paying the Medicare deductible and coinsurance amounts and portions of the bill not covered by Medicare. Thus, dually entitled individuals may be reimbursed up to 100 percent of expenses for items and services covered by both programs. TRICARE/CHAMPVA has established policies and procedures which provide for (a) the identification of claimants who have coverage under both TRICARE/CHAMPVA and Medicare and (b) the detection of duplicate payments under both programs. If TRICARE/CHAMPVA inadvertently pays amounts which duplicate Medicare payments for the same items or services, TRICARE/CHAMPVA will take steps to recover the incorrect TRICARE/CHAMPVA payments.