The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) is a comprehensive health care program managed by the Department of Defense (DoD) to provide medical services to eligible beneficiaries, including active-duty service members, retirees, and their families.
TRICARE is the modern name for the health care program serving uniformed service members, retirees, and their families. It encompasses multiple health care plans including TRICARE Prime, TRICARE Select, TRICARE for Life, and others, offering various options for beneficiaries to receive medical services.
Beneficiaries refer to individuals eligible to receive medical benefits under CHAMPUS/TRICARE. This includes active-duty service members, retirees, their dependents, and certain others designated by the Department of Defense.
Primary Care Manager (PCM)
A Primary Care Manager is a designated healthcare provider responsible for coordinating and managing the medical care of TRICARE beneficiaries enrolled in TRICARE Prime. PCMs serve as the first point of contact for non-emergency medical needs.
TRICARE Prime is a managed care option offering comprehensive health coverage to beneficiaries with assigned PCMs. It emphasizes preventive care and typically requires referrals and authorizations for specialty services.
TRICARE Select is a fee-for-service option that allows beneficiaries to seek care from any TRICARE-authorized provider without referrals. Beneficiaries pay cost shares for covered services.
TRICARE for Life provides Medicare-eligible beneficiaries with additional coverage beyond Medicare. It serves as supplemental coverage, covering Medicare deductibles, coinsurance, and other out-of-pocket costs.
A copayment is a fixed amount that beneficiaries pay out of pocket for covered medical services, typically at the time of service.
A deductible is the amount beneficiaries must pay for covered medical services before CHAMPUS/TRICARE begins to pay its share.
The out-of-pocket maximum is the maximum amount beneficiaries are required to pay for covered medical services during a benefit year. Once this limit is reached, CHAMPUS/TRICARE covers 100% of covered services for the remainder of the year.
Preauthorization is the process of obtaining approval from CHAMPUS/TRICARE before receiving certain medical services or treatments to ensure they are medically necessary and covered.
A network provider is a healthcare provider or facility that has a contract with CHAMPUS/TRICARE to provide medical services to beneficiaries at negotiated rates.
A referral is a recommendation from a PCM for a beneficiary to see a specialist or receive certain medical services. In TRICARE Prime, referrals are typically required for specialty care.
An appeal is a formal request for review of a decision made by CHAMPUS/TRICARE regarding coverage or payment for medical services. Beneficiaries have the right to appeal decisions they disagree with.
Medically necessary services or treatments are those deemed appropriate and essential for the diagnosis or treatment of a medical condition, as determined by CHAMPUS/TRICARE guidelines.