What is TRICARE/CHAMPUS Insurance?
CHAMPUS stands for Civil Health and Medical Program of the Uniformed Services. It is a government-funded health program that provides medical care for military members and their dependents. Military dependents can remain on CHAMPUS until they reach age 65, then they are eligible to switch to Medicare. CHAMPUS is a lot like Medicare, in which the government contracts through private parties that provide health care to participants in the program. Through the years, CHAMPUS has changed names and is now known as the TRICARE program.
There are several programs under the CHAMPUS / TRICARE systems. They include a fee-for-service option, a monthly fee option, a discounted price option, and a Medicare supplement entitlement program.
- The original CHAMPUS program is now TRICARE standard. With the standard program, participants can choose to pay a fee each time they require medical attention, as opposed to paying a monthly insurance payment.
- TRICARE Prime is a healthcare plan that has a set monthly fee. Members are required to use designated healthcare providers within the CHAMPUS health care network.
- TRICARE Extra is a program where members can shop through the TRICARE network in search of the lowest priced healthcare options.
- TRICARE for Life is an additional supplemental health insurance offered to members who are eligible for Medicare.
Read below to find out more about TRICARE/CHAMPUS insurance eligibility.
Determining eligibility requirements for CHAMPUS insurance
TRICARE insurance is available to active service men and woman, retired military personnel, and their dependent family members or survivors. Certain former spouses may also qualify for TRICARE.
Service men and women from all branches of the military are eligible for coverage under TRICARE insurance. However, veterans who qualify for the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) are ineligible for TRICARE.
TRICARE eligible family members
Eligible family members include
- The husband or wife of an active or retired service member
- Children age 21 or younger who are not married
- Children older than age 21 who are severely disabled
- Unmarried children up to age 23 who are attending school
- Medicare eligible members sixty-five or older
To qualify, all members must be listed in the Defense Enrollment Eligibility Reporting System (DEERS). DEERS is a worldwide database ran by the National Department of Defense.
TRICARE extended family eligibility
Extended family eligibility includes stepchildren 21 years and younger who are not married, and unmarried stepchildren 23 years or under who are furthering their education.
Adopted children or those placed in the care of an active or retired service member also qualify under the same requirements of the service member’s biological children.
Ineligible family members
Certain family members are ineligible for TRICARE benefits. They include the service member’s parents or their spouse’s parents, and ex-service members who qualify for CHAMPVA.
Spouses and stepchildren lose eligibility in the event of divorce. TRICARE/CHAMPUS coverage automatically terminates on the same day the divorce decree is final. However, if the service member adopted his or her stepchildren, they retain their eligibility.
This is not a complete list of eligible and ineligible members. National representatives of North Atlantic Treaty Organization (NATO) and Partners for Peace (PFP) nations and their families may qualify for limited TRICARE benefits. Abused spouses and certain former spouses may retain eligibility for CHAMPUS/TRICARE if they meet specific requirements. A military lawyer can help you determine your current eligibility status.
Applying for TRICARE/CHAMPUS insurance
Applying for a TRICARE insurance plan is fairly simple. Follow these steps to find a plan that suits your needs.
- Search the TRICARE insurance plan finder to find a plan that fits your needs.
- Save your searches to compare plans.
- Confirm that your information is correct in DEERS.
- Determine whether you live in a Prime Service Area (PCA).
- Choose a primary care manager (PCM).
If you wish to apply for TRICARE Prime, consider the following information to assist you in choosing a PCM. You must choose a military PCM if you live within 30 minutes of a military clinic or hospital. However, if you live more than 30 minutes but less than 100 miles from a military PCM provider, you may choose either a military or civilian PCM. Military hospital PCMs must have availability, capacity, and be willing to accept you as a patient.
TRICARE Prime Fee exclusions
Every member must pay fees for Prime insurance unless they are on active duty, the family of an active military service member, a survivor transitioning back from active duty, or a member 65 or younger who qualifies for Medicare Parts A and B. Eligible Medicare recipients can have enrollment fees waived and their payments reimbursed.
TRICARE/CHAMPUS insurance plans
There are several CHAMPUS insurance plans available.
- TRICARE Prime is for retired and active duty service members and their families. There is no deductible. Beneficiaries choose a PCM, but may also opt for point-of-service medical services that do not go through their PCM.
- TRICARE Prime Remote, Overseas, and Remote Overseas provide insurance options for service members who do not live near a US PCA. Prime Remote grants civilian benefits to service members with a permanent duty assignment 50 or more miles from a Military Treatment Facility (MTF). Prime Overseas and Prime Remote Overseas offer Prime benefits to active duty members who are stationed outside the United States.
- TRICARE Dental provides coverage for routine oral care. Eligible dependents of active duty service personnel may enroll through United Concordia. Military retirees and their dependents may enroll in the TRICARE Retiree Dental Program (TRDP) via Delta Dental.
- TRICARE Standard and Extra gives beneficiaries more flexibility in choosing a doctor. Beneficiaries do not have to pay an annual enrollment fee or select a PCM. Each person pays a cost-share per visit rather than a copay. Enrollment in TRICARE Extra is automatic; simply use a TRICARE network doctor to pay a lower cost-share percentage per visit. TRICARE Standard Overseas provides the same benefits outside of the US, minus the Extra program.
- TRICARE for Life (TFL) is a Medicare supplement for military retirees and their dependents. Participants must be age 65 or older and enrolled in Medicare part B. There are no premiums or enrollment fees for TFL.
There are other premium-based TRICARE options for active and retired members of the Selected Reserve and their families. There are also premium-based plans available for young adult dependents who have aged out of TRICARE but are ineligible for other forms of healthcare coverage.
How CHAMPUS insurance and Medicare work together
CHAMPUS – TRICARE members who wish to remain on a CHAMPUS insurance plan while using Medicare must be enrolled in Medicare Parts A and B. In addition to these requirements, these members must also be enrolled in a Medicare prescription plan.
The only exclusions from enrolling in Medicare part B is if you are on active duty, a family member of an active duty service member, or if you already have a TRICARE Reserve, Retired Reserve, Tricare for Young Adults, or a United States Family Care Plan.
Understanding the difference between CHAMPUS and CHAMPVA
TRICARE/CHAMPUS is a health assistance program designed to provide healthcare to active and inactive service members and their families. TRICARE’s healthcare programs are available to members and families of the United States Army, Navy, Air Force, and Marines. TRICARE/CHAMPUS also covers the Atmospheric Administration and Public Health Service Agencies.
CHAMPVA helps supplement the costs of medical care for veterans. Veteran Affairs pays the portion of veteran’s medical bills that is not covered by CHAMPUS. Most services take place through civilian healthcare providers. However, some VA locations may also provide care when it does not interfere with the veteran’s current treatment plan.
Finding a TRICARE/CHAMPUS provider
A provider directory on TRICARE website lists the doctors, hospitals, and clinics that are in the approved provider network. The directory also gives a full list of providers in each state and region. You can also call TRICARE headquarters or download the TRICARE service provider app.