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TRICARE Benefits Update
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TRICARE is committed to providing you with high-quality, affordable health care choices. One of the ways we honor this commitment is by offering valuable new benefits and keeping you informed about changes in your coverage. Listed below are some of the benefit updates for 2009.
Expanded Coverage for Autism Services
The Enhanced Access to Autism Services Demonstration Project went into effect on March 15, 2008. It expands coverage for active duty family members (ADFMs) diagnosed with autism by providing TRICARE reimbursement for Educational Interventions for Autism Spectrum Disorders services, such as applied behavior analysis, delivered by paraprofessional providers or qualified tutors. Under the program, autistic children are eligible for a greater range of existing evidence-based services.
To be eligible, military dependents must be at least 18 months old, enrolled in the Exceptional Family Member Program, registered for TRICARE Extended Care Health Option (ECHO) coverage and live in the 50 United States or the District of Columbia.
New Policy Adds Weight Loss Option
TRICARE now covers laparoscopic adjustable gastric banding (Lap-Band® surgery) for treatment of morbid obesity. This policy change is retroactive to February 1, 2007. If you’ve had Lap-Band surgery and you qualify under the new policy guidelines, you may submit a claim for reimbursement. If you submitted a claim and it was denied, you may appeal the denial.
You are eligible for Lap-Band surgery if you meet any one of the following conditions:
- Cholecystitis
- Diabetes
- Hypertension
- Hypothalamic disorder
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- Narcolepsy
- Pickwickian syndrome (or other severe respiratory disease)
- Severe arthritis of the weight-bearing joints
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- You have had an intestinal bypass or other surgery for obesity and, due to complications, require a second surgery.
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Cancer Clinical Trials Available to TRICARE Beneficiaries
As of April 1, 2008, TRICARE participation in cancer clinical trials is a permanent benefit. ADFMs, as well as TRICARE-eligible retirees and their families, may participate in National Cancer Institute-sponsored Phase II or Phase III cancer prevention or clinical treatment trials at approved facilities. For active duty service members, military treatment facilities fund certain approved cancer clinical trials.
This coverage was previously offered under the Department of Defense Cancer Prevention and Treatment Clinical Trials Demonstration, conducted from 1996 through March 2008. Beneficiaries with coverage under the demonstration project will retain their benefits.
Cancer trial participants who registered on or after April 1, 2008, should note the following:
- Cost-shares and deductibles will apply (if applicable).
- Prior authorization is required for all coverage.
- If TRICARE eligibility is lost during a trial, TRICARE will no longer reimburse the trial benefit.
Skilled Nursing Facility Care
TRICARE now requires network and non-network skilled nursing facilities (SNFs) to have a participation agreement in place in order for TRICARE to make a payment to such facilities, even if Medicare is making a payment.
As a result, for TRICARE- and Medicare-eligible beneficiaries, TRICARE can pay second for an SNF that participates in Medicare and has entered into a participation agreement with TRICARE. Once Medicare benefits have been exhausted, TRICARE may pay first to such SNFs.
Before being admitted to an SNF, it is important for you to know if the facility has a participation agreement on file with TRICARE. If there is no participation agreement, TRICARE will not cover any portion of the stay.
For more information on these benefit updates, visit TRICARE's web site or contact Humana Military.
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