Benefit Limits

Covered items that are limited in duration, frequency, number, or dollar amount. Benefit limits may also apply based on the patient’s age.

For example, TRICARE covers inpatient treatment for nervous/mental/emotional disorders and alcohol/drug addiction, but the benefit is limited. See this section for details. This is only an example. Other benefit limits exist. 

Calendar Year

January 1 through December 31.

CHAMPVA

Stands for Civilian Health and Medical Program of the Department of Veterans Affairs. It is similar to TRICARE, but it is specifically for spouses and children of disabled veterans.

Claim Forms

Standard forms used by providers to submit charges to TRICARE/CHAMPVA and/or the supplement insurance company.

Claim

A request for TRICARE/CHAMPVA and/or the insurance company to pay for a covered benefit.

Co-Payment or Co-Pay

The fixed portion of a health care charge, separate from the deductible, for which the patient is financially responsible. Usually represented as a flat dollar amount.

Corporate

Refers to the employer-group portion of the TRICARE Supplement business. 

Cost Share

The fixed portion of the charge, separate from the deductible, for which the patient is financially responsible. Usually represented as a percentage.

Deductible

The initial dollar-amount of health care charges received during the plan year for which TRICARE/CHAMPVA and/or the insurance company will not pay.

Covered charges are applied to the deductible until the deductible is satisfied. After the deductible is satisfied, TRICARE/CHAMPVA and/or the insurance company will pay their share of benefits for the remainder of the plan year.

Diagnosis Code (ICD-9 Code)

The alpha-numeric code submitted by the provider on the claim form to describe the injury, sickness, or reason for the medical service.

ICD-9 stands for international classification of disease, ninth revision clinical modification.

Daily Subsistence Fee

The portion of charges left behind by TRICARE when the patient uses a government hospital.

Direct Bill

The insurance administrator collects insurance premiums from every individual member/family participating in the plan. Direct bill can be accomplished via paper bills mailed to the member or by automatic EFT debits to a pre-authorized bank account.

Direct Bill Continuation

A provision allowing Corporate members to continue coverage after employment ends. The member makes arrangements with us to be direct billed (either paper bill or EFT).

Excess Charges

Charges billed above and beyond the TRICARE/CHAMPVA allowed amount. Non-participating providers may bill excess charges, but the excess charge is limited by law. We cover excess charges up to 15% over the allowed amount 

Exclusions

Items and services that are not covered.

Explanation of Benefits

A written summary issued by TRICARE/CHAMPVA or by the supplement plan to explain how a claim was processed. It includes the name of the patient, name of the provider, date of service, total amount billed, amount paid, and amount remaining as the patient’s responsibility to pay. It is not a bill.

Facility Charges

Charges made for use of a medical facility. Can be inpatient or outpatient. Includes but is not limited to same-day surgery operating room charges, inpatient hospital stays, emergency room charges, etc. These charges are billed separately from the professional charges.

Calendar Year

January 1 through December 31.

Grace Period

The period of time after the due date in which premium payments will still be accepted without coverage lapsing.

Group Bill / List Bill

Instead of collecting individual premiums from every member of a group, the insurance administrator receives lump-sum payments from the group as a whole.

HCFA 1500

A standard claim form used by providers to submit professional charges to TRICARE/CHAMPVA or to the supplement insurance company.

Inpatient Care

Overnight care including a charge for room and board. Includes but is not limited to hospital admission, skilled nursing facility, hospice facility, and residential behavioral health services. Bills from these facilities include charges for room and board, supplies, and general staffing. Separate bills will be issued for the physicians, anesthesiologists, radiologists and other professional services provided during the stay.

Insurance Carrier

The insurance company behind the policy. TRICARE/CHAMPVA supplement plans are carried by Hartford Life and Accident Insurance Company.

Lifetime Maximum

Some health insurance plans will stop paying benefits when the overall/total amount paid during the lifetime of the policy reaches a certain amount. Our TRICARE/CHAMPVA supplement plans do not have these maximums.

Medicare

A federal health benefit program for persons age 65 and older. Also available to younger persons with certain disabilities or end-stage renal disease.

Persons eligible for Medicare are usually ineligible for TRICARE supplement plans.

Open Enrollment Period (OEP) for TRICARE Supplement

For Corporate groups, the open enrollment period is set by the employer. This is a period of time each year when eligible, non-insured employees can enroll into the supplement plan.

Retail plans are available year round. There is no open enrollment period.

Outpatient Care

Medical services not associated with an inpatient stay in a facility. Includes but is not limited to emergency room visits, urgent care services, office visits, outpatient therapy, diagnostic tests, laboratory services, ambulance transportation, durable medical equipment purchase/rental, home health care services, and prescription medications.

Participating Providers

Providers who have signed contracts with TRICARE. These providers have agreed to file claims for the TRICARE members and to accept the TRICARE allowed amount as payment in full (no excess charges).

 Payroll Deduction

The process by which an employer group collects individual insurance premium payments from its employees by withholding the needed premium from their pay checks. The employer uses this money to pay a group/list bill for all participants in the plan.

Pre-Certs and Prior Authorizations

TRICARE requires certain services to be approved ahead of time. This approval is only needed from TRICARE – not also from the supplement plan.

Pre-Existing Conditions

An injury or sickness, diagnosed or undiagnosed, for which medical care is received prior to the effective date of the insurance coverage.

Retail plans define pre-existing conditions as being present during the six months prior to the effective date of coverage. See this section for more details.

Corporate plans do not have a pre-existing conditions limitation.

Pre-Existing Conditions Limitation

A period of time, after coverage has started, when pre-existing conditions are not covered.

Retail plans will not cover pre-existing conditions until the seventh month of the policy. See this section for more details.

Corporate plans do not have a pre-existing conditions limitation.

Primary / Secondary / Tertiary Insurance

When a person has more than one health insurance plan, one of them is primary and pays first. The secondary plan pays second (considers the charges left behind by the first plan). If there are three plans, one of the plans will be tertiary (considers the charges left behind after the primary and secondary plans have paid benefits).

Procedure Code (CPT Code)

The alpha-numeric code submitted by the provider on the claim form to describe the exact service, procedure, equipment, or supply for which charges are being made.

CPT stands for current procedural terminology.

Professional Fees / Charges

Charges billed by physicians and other medical professionals. Includes but is not limited to charges for office visits, surgeons, radiologists, anesthesiologists, and attending physicians.

Providers

A general term for persons, organizations, or entities providing medical services to patients (doctors, therapists, hospitals, pharmacies, laboratories, etc.).

Referrals

Some TRICARE plan options require the member to receive a referral from the primary care physician prior to seeing a specialist. While these referrals may be needed for TRICARE, they are not also needed for the supplement plan.

Retail

Refers to the association portion of the TRICARE/CHAMPVA Supplement business.

State Mandated Benefits

Insurance is mostly regulated by state law. Some states have passed laws mandating that certain benefits be included in insurance plans. Insurance companies must extend the mandated benefits to insured persons living in those states. Residents of other states may not have these benefits. See this section for more details.

Tax ID Number

A unique number (similar to a Social Security Number) assigned by the IRS to most businesses, non-profit organizations, and other entities (including hospitals and other medical providers) who have business bank accounts, hire employees or establish partnerships, and/or collect sales tax.

Third-Party Administrator (TPA)

An organization employed by an insurance company to perform specified functions on behalf of the insurance carrier.

Selman & Company is the TPA authorized to administer the TRICARE/CHAMPVA supplement plans written by Hartford Life and Accident Insurance Company

As the TPA, Selman & Company is responsible for client/group relations, broker services, marketing, enrollment, customer service, premium billing, claims processing, and record maintenance.

With our TRICARE/CHAMPVA Supplement, the carriers retain certain responsibilities such as writing the policies, setting/filing premium rates, legal compliance, financial solvency, and bearing the risk of financial loss/gain due to claims experience.

TRICARE

A Department of Defense health benefit program for the military community. There are several options/plans under the TRICARE program (see this section for more details).

TRICARE Supplement / CHAMPVA Supplement Plans

TRICARE and CHAMPVA participants may choose to purchase supplemental coverage to help pay the deductibles, co-payments, and cost shares left behind by TRICARE/CHAMPVA.

TRICARE Young Adults program (TYA)

A TRICARE program allowing children to continue TRICARE coverage beyond the normal age limit.

UB92

A standard claim form used by providers to submit facility charges to TRICARE or to the supplement insurance company.