The TRICARE Health Plan includes:
Objectives
- Deliver more comprehensive primary care and integrated health services using advanced patient-centered medical home
- Coordinate care over time and across treatment settings to improve outcomes in the management of chronic illness, particularly for patients with complex medical and social problems.
- Match personnel, infrastructure and funding to current missions, future missions and population demand
- Establish more inter-service standards/metrics, and standardize processes to promote learning and continuous improvement.
- Create enhanced value in military medical markets using an integrated approach specified in five-year business performance plans.
- Align incentives with health and readiness outcomes to reward value creation
TRICARE Health Plan Functions
We deliver health care to 9.5 million TRICARE beneficiaries through an integrated network comprised of military hospitals and clinics and civilian providers, and ensure consistency of care in accordance with statute via policy and regulations, benefit determination, and benefit design.
The THP manages the TRICARE contracts in each region. This responsibility includes:
- Ensuring network quality and adequacy; resolves provider issues
- Monitoring customer satisfaction outcomes
- Managing customer service issues
- Coordinating appointing and referral management policies
- Addressing enrollment issues
- Contracting and fiscal management functions
- Establishing and coordinating regional marketing and education functions
- Overseeing contractor credentialing
- Developing TRICARE maximum allowable charge waiver packages
- Approving resource sharing agreements with the regional contractor and military treatment facilities (MTFs)
- Ensuring contract support for MTF optimization
- Approving Memorandum of Understanding with the regional contractors
- Serving as the award fee determination official for Health Care Services and Administration contracts
- Other delegated functions
THP supports MTF Directors in their delivery of health care services for MTF-enrolled beneficiaries, for the management of health care services for beneficiaries not enrolled to MTFs, supporting the MTF Directors in their efforts to optimize health care services in the MTFs, and other assistance as required to support both MTF and remote areas to meet regional strategic planning goals and the annual business plan objectives.
THP develops business plans to support all beneficiaries in each region, including non-MTF areas, remote areas, and those areas where the Service Surgeon Generals request THP Director support. Each individual business plan is integrated into a single, regional business plan that's submitted to the DHA Director each fiscal year.
Rates & Reimbursement
The Defense Health Agency offers this information as a reference. For the most accurate information or questions about rates, policies, etc., please contact your TRICARE regional contractor.
- Ambulatory Surgery Rates
- Anesthesia Rates
- Applied Behavioral Analysis Maximum Allowed Amounts
- Banked Milk Donor Rates
- Blend Rate Method for Radiology for Cancer and Children's Hospitals
- Bundled Codes
- CHAMPUS Maximum Allowable Charge Rates
- Childbirth Support Doula Services
- Diagnosis-Related Group Rates
- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
- Enteral and Oral Nutrition Products
- Foreign Rates
- Freestanding End-Stage Renal Disease Facility Reimbursement Rates
- Home Health Prospective Payment System
- Hospital Classifications
- Inpatient Procedures
- Laboratory Developed Tests
- Limits on Number of Services without Override Code
- Mental Health and Substance Use Disorder Facility List
- New Technology Add-on Payments
- No Government Pay Procedure Code List
- Outpatient Prospective Payment System
- Questionable Covered Services List
- State Vaccine Program
- TRICARE Allowable Charges
- TRICARE Dental Program Supplement
