2.4 TRICARE, CHAMPVA, VA
Key Takeaways
- TRICARE is the health program for active-duty service members, retirees, and their families; the main options are TRICARE Prime, TRICARE Select, and TRICARE For Life.
- Eligibility for TRICARE is verified through DEERS (Defense Enrollment Eligibility Reporting System); a claim for a beneficiary not in DEERS will be denied.
- TRICARE Prime is a managed-care option requiring a primary care manager; using non-network care without a referral triggers higher point-of-service charges.
- CHAMPVA covers eligible spouses and children of veterans who are permanently and totally disabled or deceased from a service-connected condition, and is not for active-duty dependents.
- VA health care includes direct care at VA facilities and Community Care, which authorizes treatment by non-VA providers when VA care is not accessible.
Military and Veteran Health Programs
Quick Answer: TRICARE covers active-duty members, retirees, and families, with Prime, Select, and For Life plans verified through DEERS. CHAMPVA covers dependents of permanently disabled or deceased veterans. VA health care serves veterans directly, plus Community Care from outside providers.
The CPB exam treats military and veteran programs as distinct payers with their own rules. A biller must not confuse TRICARE (the military health program) with CHAMPVA and VA care (administered by the Department of Veterans Affairs).
TRICARE Plan Options
| Plan | Best Description | Network Rule |
|---|---|---|
| TRICARE Prime | Managed-care, HMO-style option | Requires a Primary Care Manager (PCM) and referrals |
| TRICARE Select | Preferred-provider, fee-for-service option | No PCM; freedom to see TRICARE-authorized providers |
| TRICARE For Life | Wraparound coverage for those with Medicare Parts A and B | Acts as secondary to Medicare |
TRICARE For Life (TFL) is essential for Medicare-eligible beneficiaries: Medicare pays first, and TFL pays the remaining cost-sharing for services covered by both.
DEERS — The Eligibility Backbone
All TRICARE eligibility flows from the Defense Enrollment Eligibility Reporting System (DEERS). The sponsor (the service member or retiree) and their registered dependents must be current in DEERS. A claim for a person not enrolled in DEERS will be denied, so verifying DEERS status is a routine front-end task.
Point-of-Service Charges
Under TRICARE Prime, a beneficiary who seeks non-emergency care outside the network without a referral uses the point-of-service (POS) option and faces a separate POS deductible and higher coinsurance. Staying in network and following referral rules avoids those added costs.
CHAMPVA
The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) covers eligible spouses and children of veterans who are rated permanently and totally disabled from a service-connected condition, or who died from a service-connected condition. CHAMPVA is not TRICARE and is not for active-duty family members. When a beneficiary has both Medicare and CHAMPVA, CHAMPVA generally pays secondary to Medicare.
VA Health Care — Direct Care vs Community Care
Veterans themselves receive care through the VA health care system:
- Direct care is provided at VA medical centers and clinics.
- Community Care (formerly the Veterans Choice Program) authorizes a veteran to be treated by a non-VA community provider when VA care is not available, the wait or distance is excessive, or it is in the veteran's best medical interest.
Community Care claims require prior authorization from the VA; billing a community provider's services without that authorization leads to denial.
A biller submits a TRICARE claim, but the dependent is not listed in DEERS. What is the likely outcome?
Which program covers the spouse and children of a veteran who is permanently and totally disabled from a service-connected condition?