Military Health, Tricare programs - Military Times

Tricare Glossary

115 PERCENT RULE

Authorized health care providers who do not participate in Tricare still are limited in what they can charge military patients for services. Under federal law, authorized health care providers can charge no more than 15 percent above what Tricare allows to be charged.

For example, if Tricare Standard allows a maximum charge of $100 for a visit to an authorized specialist, the specialist cannot charge a Tricare Standard patient more than $115. The patient is responsible for the usual cost shares and deductible, and most also are responsible for the extra 15 percent charge.

Tricare pays the 15 percent for Tricare for Life users and for family members of reservists activated for more than 30 days.

Any patient billed more than 115 percent should show the provider the explanation of benefits or statement of how much Tricare will allow. If the provider does not correct the bill, the patient should contact the claims processor, who will ask the doctor to comply. If that fails, Tricare headquarters will contact the provider and ask for justification for the higher bill. Unless the higher bill can be justified, the doctor has 30 days to refund the excess charge or stop billing the patient. Health care providers who do not comply may lose their Tricare authorization.

Patients can waive this rule if they would like to stay with a particular doctor.

APPEAL

When Tricare denies a claim, a beneficiary may take further action. If Tricare says the claim was denied as not medically necessary, the beneficiary first should ask the managed care contractor to reconsider. The request must be made within 90 days of the date on the denial statement and include a letter explaining why the beneficiary thinks the care should be covered, along with a copy of the denial statement.

The contractor’s second decision is due 30 days from the time the letter is received. If coverage again is denied based on medical necessity, the beneficiary has 90 days to appeal to the Tricare National Quality Monitoring contractor, a group independent of the managed care contractor that reviews the case and issues a decision.

That decision is final if the amount in dispute is less than $300. If the disputed amount is $300 or more, subsequent appeals may be filed with the Tricare Management Activity, Aurora, Colo.

When a claim is denied based on policy interpretation, the beneficiary or provider may first ask the contractor to reconsider. The request must be made within 90 days. Rejected claims may be appealed to the Tricare Management Activity if the amount is at least $50. A subsequent appeal may be made to that office if the disputed amount is at least $300.

Ultimately, a Tricare user can file a lawsuit to try to have the claim paid after all other appeals have been exhausted.

AUTHORIZED PROVIDER

Military patients should ask civilian doctors not in a Tricare Prime or Extra network if they are authorized providers under Tricare Standard. Seeing an unauthorized provider will result in the denial of claims, even if the treatment is a type normally covered by the program.

CLAIMS

Tricare claims are handled by health insurance companies and claims adjustment firms under Defense Department contracts.

Families with private health insurance must submit claims to those companies first. When that insurer has paid, a claim then can be filed with the Tricare contractor for the state where the member lives.

Health care providers must file claims using HCFA Form 1500 (for individual providers) or UB-92 (for institutions) within 12 months of administering outpatient treatment or within 12 months of discharging someone from an inpatient facility.

DD Form 2642, for civilian outpatient treatment, can be obtained from many civilian hospitals, most military hospitals, a health benefits adviser or a Tricare contractor.

CONTACT INFORMATION

Anyone seeking more information about Tricare can contact a health benefits adviser or health care finder at the local base, or the Tricare contractor (claims processor) serving the area. Information also is online at http://www .tricare.mil.

DEDUCTIBLES

There is no deductible for inpatient treatment using Tricare at civilian hospitals.

Tricare Prime has no outpatient deductible if care is received at a military treatment facility or a civilian provider in the Prime network.

Under Prime’s Point-of-Service option, however, deductibles for outpatient care from providers not in the network are $300 for an individual and $600 for a family. After the Point-of-Service deductible is paid, Tricare will cover only 50 percent of the amount it allows to be charged.

Tricare Extra and Standard have annual deductibles for outpatient care. Deductibles are calculated by fiscal year, Oct. 1 to Sept. 30. With each new fiscal year, the deductible must be met again. An electronic system tracks how much each person or family has paid in co-payments and toward the annual deductible. Still, it’s a good idea to keep a copy of all medical bills.

People who buy prescription drugs at retail stores that are not part of the Tricare network also pay deductibles of $150 for an individual or $300 for a family. Enlisted members in paygrades E-4 and below pay lower deductibles: $50 for an individual, $100 for a family. Prime enrollees pay the point-of-service deductible.

Tricare waives the deductibles for family members of reservists who are called to active duty for more than 30 days.

DENTAL — INPATIENT

For dental care related to hospitalization, patients must get approval from the Tricare contractor for their area before receiving treatment. Send a statement from a doctor (if one is involved) about the condition, along with a statement from the dentist saying what care is needed, why and how much it will cost. Requests should be made at least 30 days before scheduled treatment.

HOSPICE CARE

Hospice care provides various kinds of home and inpatient care for terminally ill patients. Tricare offers a hospice benefit that gives patients with six months or less to live several episodes of care: two initial 90-day periods and an unlimited number of subsequent 60-day periods.

Patients revert to Tricare Standard coverage when not using hospice care. While enrolled in this program, patients waive entitlement to other Tricare reimbursement related to the terminal illness, except for services from an attending doctor.

The hospice benefit has no deductible.

INPATIENT

An inpatient is someone who is lodged and fed in a hospital or clinic while receiving treatment.

NONAVAILABILITY

In late 2003, Tricare eliminated a major hurdle for Standard and Extra patients needing inpatient medical care. Previously, they were required to first check with their local military facility to see if the care could be obtained there. If not, they were issued a nonavailability statement and could seek the care at a civilian facility. The 2003 change did away with that requirement and allowed beneficiaries to get inpatient care at civilian hospitals without getting prior approval from a military facility.

However, beneficiaries who use Standard or Extra and want to receive nonemergency inpatient mental health care at a civilian facility still must first check with the nearby military hospital to see if the care can be provided there. If it cannot, the hospital will issue the nonavailability statement allowing the patient to use a civilian facility.

If a patient receives inpatient mental health care without obtaining the nonavailability statement, Tricare won’t share the costs, unless there are extenuating circumstances that prevented someone from getting a nonavailability statement.

Patients do not need nonavailability statements if they have Medicare or another health insurance that pays first.

By law, a military hospital can ask the Defense Department to still allow it to require the nonavailability statements for specific medical treatments. But the military cannot require Standard and Extra patients to receive obstetric care at military hospitals and clinics. As a result, military hospitals have taken steps to improve their maternity care to attract customers.

Prime participants do not have to get nonavailability statements for any kind of care. People enrolled in Prime must consult their primary care manager to learn where they can be treated.

OTHER INSURANCE

People who have health coverage in addition to Tricare must file claims first with that plan, which is the primary payer.

Payment from the primary plan plus Tricare may cover 100 percent of the bill, even after applying the usual cost-sharing requirements. Tricare will not pay anything if coverage by the first payer exceeds Triage’s maximum allowable charge.

Tricare users eligible for Medicare are in a similar situation: Medicare must be used before Tricare will pay benefits.

Federal law establishes the order of payment. There are two exceptions:

å When the second coverage is Medicaid, Tricare pays first.

å When the patient’s other insurance is specifically designated as a Tricare supplemental plan, Tricare pays first.

Claims for job-related illnesses and injuries are paid by workers’ compensation programs and are not covered by Tricare Standard. When workers’ compensation is exhausted, Tricare benefits can be used.

Former spouses who normally are eligible for Tricare lose these benefits when they are covered by an employer-sponsored health plan.

OUTPATIENT

When patients are treated at a hospital or clinic but leave the same day, they are considered outpatients.

PARTICIPANT

A doctor who participates in Tricare accepts as full payment the amount Tricare allows for the particular service or supply. A doctor who does not participate is refusing to accept what Tricare allows as payment in full.

Doctors who are not in Tricare networks are free to decide when or if they will participate in Tricare Standard. The fact that doctors agree to accept Standard rates for one procedure does not obligate them to do so the next time a patient receives care.

Even if the doctor does participate, that does not mean a patient will get free care. The patient still must pay the deductible, co-payment or cost share and any service or supply not covered by Tricare.

PREAUTHORIZATION

Certain surgical, diagnostic and treatment procedures require preauthorization from the managed care contractor before care in order for Tricare to pay for it. Check with local contractors for details.

Medical specialists sometimes disagree on what care is necessary and appropriate. Often, it comes down to this: Tricare will pay if the patient or physician can prove the treatment is medically necessary.

PRIME SERVICE AREA

A prime service area (PSA) is an area that has been defined and mapped within proximity to military treatment facilities, installations affected by base realignment and closure, and other areas. Minimum government standards for military treatment facility PSAs and BRAC PSAs are geographically defined by ZIP codes that create a radius of about 40 miles from the treatment facility or BRAC installation.

Military treatment facility enrollment areas, which replace catchment areas, are areas within a 30-minute drive of a treatment facility. A commander may require Tricare Prime beneficiaries to enroll with the military treatment facility.

OTHER MEDICAL

AGENT ORANGE

Veterans who believe they have health problems stemming from exposure to herbicides during the Vietnam War can get free exams at VA hospitals and clinics.

Some veterans may be eligible to receive free follow-up inpatient health care if a physician determines their illness may be related to Agent Orange exposure.

A list of diseases that officials say merit compensation can be found at http:// www1.va.gov/agentorange/docs/aofact sheetaug01.doc.

Some of the diseases have a time limit for onset, starting the day the veteran left Vietnam. The veteran does not need to have been diagnosed within the time limit if a medical professional states the disease began within that limit.

Veterans should file disability claims with VA officials promptly. If the disease is recognized, benefits are retroactive to the date of filing. VA benefits are adjusted each Dec. 1. Currently, monthly payments range from $117 per month for single veterans rated 10 percent disabled to $2,527 per month for those rated 100 percent disabled. Rates increase based on the number of family members a veteran has.

Children of Agent Orange-affected veterans who suffer from spina bifida, a potentially disabling birth defect, may qualify for VA compensation. Severely disabled children can receive $1,585 per month; less disabled children can get $930 per month; mildly afflicted children can get $270 per month.

Children with certain birth defects born to female Vietnam veterans also are eligible for compensation ranging from $123 to $1,586 per month.

Contact: http://www.va.gov

AIDS

All prospective recruits, active-duty members and reservists are tested for the human immunodeficiency virus that causes AIDS. If an initial test is positive, it’s repeated to confirm the result.

Would-be recruits who test positive for HIV are rejected for service, but federal law bars the services from using information about HIV or AIDS revealed during medical exams as a basis for adverse personnel actions.

Active-duty members with evidence of HIV infection in their blood serum are referred for a medical evaluation to make sure they are fit to continue military service. A member declared physically fit for duty cannot be separated solely because of positive test results.

Infected individuals are examined every six to 12 months to see if they have contracted an AIDS-related illness. Service members infected with HIV cannot deploy overseas, although they can deploy to Puerto Rico.

Infected service members determined physically unfit for duty are medically retired or separated. Service members who are at or close to retirement age may retire with the pay and military medical benefits they have earned.

Military officials are required to notify individuals who are at risk of infection from a service member who tested positive for HIV. Among those notified are spouses, children (or their legal guardians) and any sex or drug partner in another military family, as long as they are beneficiaries of the military health care system.

ALCOHOL TREATMENT

The military offers inpatient or outpatient alcohol treatment at almost every installation.

Detoxification is required of service members diagnosed as being dependent on alcohol. Many facilities also offer special programs for spouses and teenage children.

Family members with alcohol problems may get outpatient counseling at military facilities. Inpatient treatment may be available at the nearest military facility.

For more information, contact your local commander or drug and alcohol representative.

DEERS

Access to military medical programs is controlled by the Defense Enrollment Eligibility Reporting System.

Active-duty members automatically are entered in DEERS when they join the service. Family members who qualify as dependents must be signed up. This includes newborns who must be enrolled before claims for their care can be processed under Tricare.

Enrollment means completing a short form available at personnel offices. Beneficiaries should keep addresses and other information current in their DEERS records. Sponsors are required by law to keep their addresses current in DEERS.

For address changes:

å Visit your local uniformed services ID card facility.

å Go to the Tricare Web site, http://www.tricare.mil/mybenefit/home/overview/Eligibility/DEERS, or the Defense Manpower Data Center Web site, https://www.dmdc.osd.mil/appj/address/index.jsp.

å Write to DSO, Attn: COA, 400 Gigling Road, Seaside, CA 93955-6771.

å Contact the DEERS Beneficiary Support Center, (800) 538-9552, fax (831) 655-8317, 9 a.m. to 6:30 p.m. EST, Monday through Friday.

Qualifying dependents under the DEERS system include:

å Spouses.

å Unmarried children under age 21.

å Unmarried children who are full-time students may be covered until they turn 23 years old or when they are no longer full-time students, whichever comes first.

å Unmarried children age 21 and older who were born with severe physical or mental handicaps or developed such handicaps while they were dependents, and whose condition makes them rely on their parents for at least half their support.

å Parents or parents-in-law who live in a residence provided or maintained by their active-duty son, son-in-law, daughter or daughter-in-law, and receive more than half of their financial support from the service member. They are not eligible for Tricare Prime, Standard, Extra or Tricare for Life. They can be seen only on a space-available basis at military hospitals or clinics, or may enroll in Tricare Plus.

å Children placed in a service member’s legal custody by a recognized adoption agency or court. The children must be under age 21, or 23 if they are in school or incapable of self-support because of a condition that began while they were dependents.

å Widows or widowers of active-duty members or retirees who have not remarried.

å Certain former spouses of service members or retirees who were married for at least 20 years to the same member and have not remarried.

Contact: For DEERS enrollment status, (800) 538-9552; Alaska and Hawaii, (800) 527-5602; California, (800) 334-4162. Be sure to have the sponsor’s Social Security number on hand.

FISHER HOUSE

The military and the nonprofit Fisher House Foundation provide some relief for active-duty and retiree families with a loved one who is seriously ill or critically injured, providing temporary lodging and support near military medical centers. These privately funded lodgings are known as Fisher Houses, after founders Zachary and Elizabeth Fisher, a civilian couple who wanted to help service members.

The network of lodgings was established in 1990. Thirty-eight Fisher Houses are located at VA medical centers and military installations in 15 states, the District of Columbia and Europe, serving more than 11,000 families per year. Five more Fisher Houses were in the works as of early 2008.

Families stay at any Fisher House for free.

A doctor or social worker at a military hospital can issue referrals for admission to a Fisher House.

Contact: 1401 Rockville Pike, Suite 600, Rockville, MD 20852; (888) 294-8560; http://www.fisherhouse.org

GULF WAR ILLNESS

More than 200,000 veterans have been seen in military or Department of Veterans Affairs medical facilities for care related to their service in the 1991 Persian Gulf War. Both the VA and the Defense Department are trying to keep track of sick Gulf War veterans and do research to help determine possible causes for their ilnesses. Federally funded research is ongoing on possible effects of low-level exposure to chemical warfare agents, depleted uranium or other toxic exposures.

Ill spouses and children of Persian Gulf War veterans also receive free health exams at VA centers.

Gulf War veterans and those who served in the current wars in Iraq and Afghanistan qualify for free VA care if the VA finds that their condition may have resulted from exposure to a toxic substance or environmental hazard. Veterans who have health concerns related to their Persian Gulf service should contact the nearest VA medical center.

Certain illnesses are presumed connected to service and are compensable as such. Persian Gulf War veterans with certain chronic but undiagnosed illnesses, or illnesses defined by a cluster of symptoms, such as chronic fatigue, irritable bowel syndrome or fibromyalgia, can be eligible for VA disability compensation. The condition must manifest during military service or by Dec. 31, 2011.

Persian Gulf veterans who develop amyotrophic lateral sclerosis, or Lou Gehrig’s disease, also can be compensated under a presumption that it is connected to service.

The VA publishes a periodic newsletter, the “Gulf War Review,” to update veterans on research and available benefits. The VA’s Web site has a Gulf War section at http://www1.va.gov/gulfwar.

That site has a link to VA’s Gulf War Handbook, outlining benefits and services for veterans of that conflict. A toll-free help line operated by the VA is available at (800) 749-8387. Specialists can be reached weekdays from 8 a.m. to 4 p.m. Central Time. Recorded messages provide information around the clock, seven days a week.

Contact: See the Pentagon’s Gulf War illnesses information Web site, http:// www.gulflink.osd.mil, and the VA’s Gulf War section at http://www1.va.gov/ gulfwar.

HERO MILES

The Fisher House Foundation runs a program that provides free airline tickets to military men and women who are undergoing treatment at a military or VA medical center incident to their service in Iraq or Afghanistan, and their families. Passengers from the general public donate their frequent flyer miles to the program. More information is at http://www .fisherhouse.org/programs/heroMiles .shtml.

ILLICIT DRUGS

Service members are tested for drugs when they join the military and then randomly throughout their careers.

The services use a two-step system to identify drug users: first, a screening test; then, if a sample tests positive, a more sensitive and specific test to confirm drug use. Urine specimens are given under direct observation to ensure there is no switching of specimens and that nothing is added to produce a false reading.

An active-duty member who tests positive for drugs may face court-martial or nonjudicial punishment, which can lead to an administrative or punitive discharge. Detoxification, if required, is provided in a military treatment facility. Longer-term rehabilitation and treatment will be offered through the Department of Veterans Affairs.

Outpatient counseling for family members with drug problems is available.

Service members have the right to have their urine specimen retested at their own expense by an independent lab. The specimen can be the same as that sent to the military lab. Retesting should be done as soon as possible.

LODGING

See Fisher House, previous page.

LONG-TERM CARE INSURANCE

Active-duty and retired service members, federal employees and retirees may purchase long-term care insurance for themselves and their families through the Office of Personnel Management’s Federal Long Term Care Insurance Program. The government does not share program costs, but because the insurance is offered at group rates, officials say premiums are, on average, 20 percent lower than the cost of coverage under other comparable programs. Some people, however, have been able to buy plans through commercial carriers at lower prices.

The program covers expenses associated with long-term care delivered in or outside the home, at adult day care centers, assisted-living facilities or nursing homes. Long-term care is not covered by many medical insurance plans, including Medicare and Tricare.

Federal employees can purchase the insurance for themselves, spouses, children and parents. Federal retirees can enroll only themselves and spouses.

The program does not have regular open enrollment seasons. However, certain categories of people are eligible to apply at any time. Applicants must answer health-related questions and may need to provide medical records or be interviewed.

Premiums are based on the enrollee’s age when coverage is purchased.

Contact: http://www.opm.gov/ insure/ltc

MALPRACTICE

A 1950 Supreme Court ruling known as the “Feres doctrine” forbids active-duty people from suing the government for medical malpractice or almost any other reason.

Active-duty members can be compensated in other ways for malpractice — retirement disability, for example. If they are severely injured by malpractice, they are entitled to certain Social Security and VA benefits.

A federal appeals court in early 2002 carved out an exception to the Feres doctrine, ruling that service members can sue the government if their privacy rights have been violated.

While active-duty members cannot sue the government for malpractice, family members and retirees can sue for personal injury compensation in cases of medical malpractice or other negligence by a government employee.

Administrative claims must be exhausted before an individual goes to court with a lawsuit, and many states place ceilings on the amount that can be paid in malpractice cases.

To file a claim, family members and retirees fill out a form at a base claims office, stating the basis for their belief that malpractice occurred and asking for a specific amount in damages.

A claim must be filed within two years of the alleged malpractice. Retirees can file only for malpractice that occurred after they retired. Most of the military’s legal powers in such cases are on the government’s side. Military lawyers can help an alleged malpractice victim file such claims but cannot officially represent the victim. Local lawyers for the military can settle claims for small amounts, but most malpractice claims are forwarded by base officials to their respective service’s main office.

The military has six months to review a claim. If a settlement offer is unsatisfactory, individuals can negotiate for more. If still unsatisfied, they can go to court. Also, if the military makes no offer within six months, individuals can sue.

In 1991, the Supreme Court ruled that military family members cannot sue service doctors overseas. However, in cases of medical care provided overseas, family members may file administrative claims for compensation.

In these cases, family members dissatisfied with a claims decision can appeal to the service secretary or judge advocate general, depending on the size of the claim. The decision in such an appeal is not subject to court review.

MEDICARE/SENIOR CARE

Most military retirees become eligible for Medicare health benefits when they turn 65. Some, however, qualify for Medicare much earlier because they have certain disabilities. In either case, Tricare will help pay the balance of medical bills after Medicare has paid its portion as long as he or she is enrolled in Medicare Part B.

(See Tricare for Life, Page 37.)

Other health programs for which military retirees may be eligible include:

å Tricare Plus. This program allows retirees to enroll for primary care services at a military treatment facility if the local commander determines there is room. It does not guarantee specialty care, however.

å Uniformed Services Family Health Plan. This Tricare Prime option is available to retirees through networks of community-based, not-for-profit health care systems in six areas of the U.S.

PRIVACY ACT

As a rule, the services must comply with federal laws regarding the confidentiality of medical records. Under the Privacy Act, patients have the right to see and obtain a copy of their health care record.

But if a physician believes the record would harm the patient, the patient will be asked to name another physician to whom a copy of the record can be sent and from whom the patient can obtain the record. If that physician declines to provide the record, the military must take affirmative action to deliver the record to the patient.

Health information concerning a patient may be used for that patient’s treatment and other purposes as permitted under the medical privacy rule that implements the Health Insurance Portability and Accountability Act (HIPAA). These permitted uses are outlined in the Tricare Management Activity Notice of Privacy Practices found at each medical and dental facility.

Commanders may access service members’ health information when such access is necessary to accomplish the military mission.

Additional patient rights under that rule are contained in the same privacy practices notice. These include the right to request amendments to medical records and to request certain restrictions on permitted uses and disclosures of their records.

The services maintain an accounting of the disclosure of health records to others. This notation usually is logged into a person’s medical file or an electronic medical disclosure tracking tool. This enables patients to learn who, outside the medical community, has seen their health care information.

Patients may request an accounting of disclosures from their local treatment facility to gain this knowledge. The HIPAA Privacy Officer at each facility can provide additional information on HIPAA.

TOBACCO

Since the early 1980s, the Defense Department’s tobacco-cessation crusade has succeeded in reducing the number of smokers and those who use smokeless tobacco (although the military’s latest worldwide health survey of active-duty members have shown a slight upturn in tobacco use during the wars in Iraq and Afghanistan). The campaign includes tobacco-cessation programs as well as education and counseling services.

At the Web site, http://www.ucanquit2 .org, tobacco users can develop a personalized plan for quitting, play games, listen to podcasts, connect to online cessation programs and chat with a trained cessation counselor, seven days a week from 8:30 a.m. to 2:30 a.m. Eastern time.

Tricare also has information, links and a list of some of the smoking-cessation programs offered by the services at http://www.tricare.mil/healthychoices/ default.cfm.

As a rule, Tricare will not pay for such services in the civilian community, or for prescription medications used to support smoking cessation, although defense officials intend to test these services in some areas of the country. Defense officials want to curb and reverse what has been an increase in tobacco use since the advent of the global war on terrorism.

UNIFORMED SERVICES FAMILY HEALTH PLAN

Military beneficiaries — including retirees, their dependents, others who are Tricare-eligible, and the dependents of active-duty members can take advantage of an additional Tricare Prime option available through networks of community-based, not-for-profit health care systems in six areas of the U.S. through the Uniformed Services Family Health Plan. These facilities are called “designated providers.”

Participants must live within the designated provider’s area to enroll in the plan, which provides a wide range of coverage at little out-of-pocket cost. Enrollment is required and can be on an individual or family basis.

In exchange, USFHP enrollees must agree not to use other military or government health care facilities unless it is an emergency or USFHP refers the patient to such a facility. Active-duty members cannot enroll in USFHP.

Beneficiaries must choose either Tricare or USFHP if they live in a USFHP location. Eligible beneficiaries enrolled in Tricare Prime who are patients at a military facility or with a civilian Prime provider can withdraw at any time and enroll in the Prime program offered by USFHP, and vice versa.

The program offers preventive services such as immunizations, physical examinations and prescription drug coverage. If beneficiaries are transferred to an area without a USFHP facility, they can withdraw from the plan and go back to using military facilities, Medicare or Tricare. Unlike in Tricare, retirees over age 65 do not need to have Medicare Part B in order to participate in the USFHP.

However, the Defense Department highly encourages beneficiaries to enroll in Part B when they first become eligible, to avoid Part B premium surcharges if they move away from a USFHP area.

If beneficiaries do not enroll in Medicare Part B when first eligible, and choose to do so later, they will pay (in addition to the normal Medicare Part B monthly premium) an annual 10 percent penalty for each year they were eligible to enroll in Medicare Part B but did not. In addition, they will only be able to enroll in Medicare Part B during the general enrollment period, Jan. 1-March 31 of each year, and Part B benefits/Tricare coverage will not become effective until July 1 of that year. Beneficiaries, other than active duty, are encouraged to enroll in Medicare Part B when first eligible.

The USFHP operates through six groups:

å Maine, New Hampshire, Vermont and Northeastern New York: Martin’s Point Health Care, (888) 241-4556.

å Maryland, Washington, D.C., and surrounding areas: Johns Hopkins Community Physicians, (800) 808-7347.

å Massachusetts and Rhode Island: Brighton Marine Health Center, (800) 818-8589.

å New York and New Jersey: St. Vincent Catholic Medical Centers, (800) 241-4848.

å Texas and Louisiana: CHRISTUS Health, (800) 678-7347.

å Washington: PacMed Clinics, (888) 958-7347.

Contact: http://www.usfhp.org

VETERANS’ BENEFITS

Most military retirees, as well as veterans who did not stay in the military for a full career, must apply for enrollment in the Department of Veterans Affairs health system to receive VA health care under the Uniform Benefits Package.

Enrollment applications can be obtained through the nearest VA care facility’s benefits office or by calling toll-free (877) 222-8387.

The following veterans are not required to enroll:

å Those with a service-connected disability rated by the VA at 50 percent or more.

å Those who have been out of service for less than a year after being discharged for a disability incurred or aggravated in the line of duty, but that VA has not yet rated.

å Those seeking care from the VA only for service-connected disabilities.

In order of priority for care are the following:

å Priority 1: Veterans with service-connected conditions rated 50 percent or more disabling or who have been determined by VA to be unemployable due to service-connected conditions.

å Priority 2: Veterans with service-connected conditions rated 30 percent to 40 percent or more disabling.

å Priority 3: Veterans who are former prisoners of war; have received the Purple Heart; have service-connected conditions rated 10 percent or 20 percent disabling; were discharged from active duty for a disability incurred or aggravated in the line of duty; and veterans who were injured as a result of VA treatment or participation in a VA vocational rehabilitation program.

å Priority 4: Veterans receiving aid and attendance or housebound benefits and veterans who have been determined by the VA to be catastrophically disabled.

å Priority 5: Veterans who are receiving VA pension benefits; eligible for Medicaid programs; or whose income and assets are below the established dollar thresholds.

å Priority 6: Veterans who have zero-percent service-connected conditions; but are receiving VA compensation, are seeking care only for disorders relating to Ionizing Radiation and Project 112/SHAD; are seeking care for Agent Orange exposure during service in Vietnam; are seeking care for Gulf War Illness or for conditions related to exposure to environmental contaminants during service in the Persian Gulf; served in World War I or the Mexican Border War; or served in combat in a war after the Gulf War or during a period of hostility after Nov. 11, 1998, for two years following discharge or release from the military.

å Priority 7: Nonservice-connected veterans and zero-percent noncompensable service-connected veterans with income exceeding the threshold for the VA means tests established by law, and below the Department of Housing and Urban Development’s geographic income limit, or with income below both the VA threshold and the HUD low-income limit, whose net worth plus income exceeds $80,000 and who agree to pay specified co-payments.

For more information on HUD geographic income limits, visit http://www .huduser.org/datasets/il/il07/index.html.

å An eighth category of veterans, created by Congress in 2002, comprises higher-income veterans who seek care for illnesses unrelated to military service. Veterans who agree to pay specified co-payments and whose income and net worth exceed both the VA means test threshold and HUD’s geographic means test threshold are in this category.

Veterans who fit the description of this category and were enrolled before Jan. 17, 2003, can remain in the VA’s health care system. Enrollment for other veterans in this category has been suspended because the VA cannot currently provide timely care to all veterans already enrolled in the system.

See the chart of VA income thresholds at http://www.va.gov/healtheligibility/ Library/pubs/VAIncomeThresholds.

The process of determining whether a veteran qualifies for free care based on income alone is called “eligibility assessment.”

To qualify in this manner, veterans must have an annual income of $28,429 or less and an annual income plus net worth of not more than $80,000, if they do not have dependents.

For veterans who are married, or single with a dependent family member, the maximum annual income to qualify for free care is $34,117; also, their annual income plus net worth must not exceed $80,000.

For each additional dependent child, the income ceiling rises by $1,909.

Income levels are adjusted annually on Jan. 1 by the same percentage by which the VA raises its pension benefits.

When determining a veteran’s means, the VA uses HUD’s geographic means test, which takes into consideration where the veteran lives; the cost of living varies by location.

Veterans who do not qualify for free or reduced care must agree to pay the VA a co-payment equal to what they would pay under Medicare — $1,024 for the first 90 days of inpatient hospital care during a 365-day period. This need not be 90 days in a row.

They also must pay $10 for each day in the hospital. A patient is charged half the Medicare co-payment for each subsequent 90 days spent in the hospital in the same 365-day span.

Veterans with incomes above the means test threshold but below the VA’s geographically based income thresholds have reduced co-payment obligations — they pay 20 percent of the full inpatient rate.

Veterans who are not considered needy and are not being treated for service-connected medical problems are not charged for preventive care visits, such as flu shots and laboratory tests. But they must pay for other office visits. Outpatient primary care costs $15 a visit and outpatient specialty visits cost $50.

Contact: For more information on eligibility, go to http://www.va.gov/health eligibility/eligibility.

The VA handbook “Federal Benefits for Veterans and Dependents,” can be found at http://www1.va.gov/opa/ vadocs/current_benefits.asp or contact VA at (877) 222-8387.

WOUNDED WARRIORS

For wounded service members and their families navigating the systems that provide their health care, the Defense Department and the military services have programs intended to provide help and support as they prepare to return to active duty or to civilian life. They are:

å Army Wounded Warrior Program: http://www.aw2.army.mil

å Marine for Life: http://www.m4l.usmc.mil

å Navy Safe Harbor Program: http://www.npc.navy.mil/command support/safeharbor

å Air Force Palace HART (Helping Airmen Recover Together) program, run by the Air Force Personnel Center’s Airmen, Family and Community Operations Branch.

å The Defense Department’s Military Severely Injured Center can provide assistance and connections to the services’ programs. Call toll-free (888) 774-1361; overseas: 0-800-888-0013, press “05” to make a toll-free call to the U.S., then enter (888) 774-1361.

Services are free. Regional counselor-advocates also are available at select military treatment facilities and VA hospitals. http://www.militaryhomefront .dod.mil/troops/injuredsupport

å Warriors Navigation and Assistance Program: Operated by Humana Military Healthcare Services for those in the Tricare South region, helping active-duty, Guard and Reserve members get information and access to high-quality health care, offering personal guidance and problem solving.

Contact: (888) 4GO-WNAP, or http://www.humana-military.com/ South/bene/warrior-assistance.htm

å Computer/Electronic Accommodations Program (CAP): Helps provide assisting technology to returning wounded service members with injuries that caused vision or hearing loss, dexterity impairments, including upper-extremity amputees, as well as communication and cognitive difficulties.

The program works with Pentagon and Department of Veterans Affairs officials to help in the reemployment process. If the service member stays on active duty or becomes a federal civilian worker, CAP can provide work-related accommodations to the federal agency free for internships and/or permanent employment.

Contact: http://www.tricare .mil/cap/wsm

å “A Handbook for Injured Service Members and Their Families” is designed to help wounded warriors and their families navigate the bureaucracy to get benefits they have earned.

The 149-page handbook was prepared free by a New York-based law firm for two nonprofit charities, the Wounded Warrior Project and the Intrepid Fallen Heroes Fund. It can be downloaded free at http://www.woundedwarrior project.org and http://www.fallen heroesfund.org.