Health Care Happenings

Welcome back for Part II of What’s Up Doc” where you get to diagnosis a condition I give you and I’ll let you know the answer the following week.

          Last week’s symptom:  Fatigue or trouble breathing plus chest pain or tightness and/or palpitations?

          You’re Diagnoses:

•  Probably coronary or other heart disease
•  Pleurisy (inflammation, possibly viral, of the lung surface) – maybe  following an upper respiratory infection
• Possible cardiac insufficiency due to a previous heart or pulmonary infection, untreated or badly treated
•  COPD

        The Answer:              The Doctor Says: Stress or panic attack
        But It Could Be:         Heart attack or heart disease

NICE JOB to everyone who responded.

Now, for Symptom #2: Numbness on one side, headaches, dizziness, suddenly blurred vision, lack of balance or muscle coordination, and/or slurred speech.

Your Diagnosis Is: ???????

How about we continue again next week?
Check back here next Wednesday for the answer!

Some reporters and bloggers have called for Americans to have the same health care benefits as Members of Congress. Implied is the belief that Members of Congress have extraordinarily generous health care benefits. Do they really? How do military health care benefits stack up against thiers?

Members of Congress are eligible to choose from a number of health plans offered to federal employees under the umbrella of the Federal Employee Health Benefits Program (FEHBP). These plans are administered by the Office of Personnel Management. The important thing to realize is that these are the same plans available to any federal civilian employee, not just to Members of Congress.

Here are some facts about FEHBP:
• FEHBP is available to federal employees, retirees and survivors, including Members of Congress and their staffs;
• All FEHBP plan participants pay premiums for their care, and are subject to deductibles and copayments;
• Like most employer-sponsored health plans, FEHBP plans are subsidized by the employer. In the case of Congress, it is the federal government who pays for subsidy, thorough taxes. Keep in mind that Tricare is financed the same way;
• Depending on the plan selected, the participant’s share of medical expenses is usually about 25% of charges;
• FEHBP plans can be available to federal retirees in retirement, so long as the federal annuitant was enrolled in a FEHB plan for five years prior to retirement (or enrolled during the entire period of service if employment was less than five years);
• FEHBP can also covers spouses and family members of federal retirees, so long as the retiree also enrolls in the Federal Survivor Benefit Plan (no survivor’s annuity election = no health care coverage for the retiree’s spouse).

If you want to read some of the particulars about FEHBP plans, click on this link: http://www.opm.gov/insure/health/

The bottom line: FEHBP offers good benefits to federal employees and retirees. So does the military. Are FEHBP benefits superior to Tricare? In my view, no. The systems are different, but each tries to meet the needs of their beneficiaries.

Now, Members of Congress are also among the civilian officials of government who are authorized to use military direct care at MTFs. Again, same as us! (Some conditions and charges may apply to their care). That’s a pretty strong testament to the quality of military direct care. Don’t be surprised if you bump into an official sometime, especially in the National Capital Area.

The combination of direct care, Tricare for military members and retirees under age 65, or Medicare and Tricare for Life for those over age 65 or otherwise eligible, is powerful. So be careful what you wish for; with all it bumps and warts, the military health system is second to none. Let’s protect it!

The more you research this topic, the more you realize you don’t know…and the more you realize that nobody else knows, either.

When it comes to possible impacts on military and VA care, there are a couple of key definitions — what constitutes “acceptable coverage” and what constitutes a “qualifying employer-provided plan.”

The “acceptable coverage” issue is pretty straightforward.  If you don’t have acceptable coverage, you may be subject to paying a tax.  In all of the various bills, military and VA care is deemed as acceptable coverage, so that’s not an issue for our community.

The impact of being in or out of the “qualifying employer-provided plan” seems to depend on who you’re suspicious of.  Rep. Joe Wilson’s (R-SC) amendment (adopted unanimously by the Education and Labor Committee) would exempt TRICARE from that definition.  As explained to us, the concern was that at some point in the future, a commision provided for under the bill could dictate coverage provisions that might be contrary to military needs.

I accept that concern as well-intended, and that it might be entirely right.  But I might also pose a scenario where the commission might dictate certain minimum coverage (e.g. equal treatment for mental health care with other health care) that DoD might not want to comply with.  In that scenario, it could be to servicemembers’ disadvantage to be considered as exempt from “qualifying employer-provided coverage” requirements.

In short, there’s no end to scenarios over which we could wring our collective hands, and it’s just not possible at this point to identify and protect against every way that the military and veterans community might conceivably be disadvantaged in the future by this or that national health reform provision.

So I take at face value the expressed intentions of both Republican and Democratic leaders who have assured us they don’t intend to disadvantage our community.

But I’m also not sure that they or anyone else can predict whether the bill language they intend to protect us will actually do that under any given future scenario.

Our best course, in my view, is to try to keep a clear perspective in evaluating each issue, try to avoid letting our individual political biases from objectively evaluating each new piece of information, and recognize that no matter what happens now, there will be future threats that we can’t anticipate that we’ll need to respond to when (not if) they occur.

I thought over the next couple of weeks I’d test readers’ medical knowledge—“Do you know more than your doctor?”

Well, let’s see how much you know.

Each week I’ll give you a symptom and you let me know what you think the doctor might say is wrong with you. Then, the following week, I’ll let you know what my medical source says the doctor will likely say you have and what the condition could be.

Here we go!

     Your Symptom:   Fatigue or trouble breathing plus chest pain or  tightness and/or palpitations?

     Your Diagnosis is: ______???______

Check back next Wednesday for the answer!

We’ve been working with the staff of Sen. Frank Lautenberg (D-NJ) on an amendment that would express the sense of Congress that:

Military health care is a primary offset to the adverse conditions of military service,

Military people deserve a package of care consistent with their extraordinary service and sacrifice,

Past proposals for large TRICARE fee hikes haven’t taken that into account, and 

The Defense Department should be looking at other ways to reduce health costs that don’t disadvantage military beneficiaries.

It’s uncertain whether there will be a separate vote on the amendment.  We’re hopeful that the leaders of the Armed Services Committees (both Republican and Democrat) will agree to include it in a so-called “managers’ package” composed of multiple initiatives on which the leaders agree.

Hopefully, it will be resolved this week.  Stay tuned.

[Late Update:  The Senate included the Lautenberg amendment in its version of the FY2010 Defense Authorization Bill Thursday evening (Jul 23).]

Ever wondered how TRICARE Prime processes claims for emergency beneficiary care received while traveling outside of the Prime Service Area (PSA)?   Read below to get an account of one such claim.

Several weeks ago, I blogged about my college age son’s visit to the ER while traveling as a TRICARE Prime beneficiary in the post entitled Have TRICARE – Will Travel. I thought an accounting of the subsequent sequence of events might prove informative for some – so here goes.

It all started in the ER when my son provided his insurance information to receive care. He thought his part was finished. Much to his surprise, the provider billed him directly!

The provider’s billing statement gave him the option of providing TRICARE’s information as the insurer and responsible party for payment, which he did. And again, he thought he was done.

Not so fast – TRICARE processed the claim and sent my son a check for 115% of the TRICARE Maximum Allowable Charge (TMAC) because the ER was a non-network provider and did not accept assignment. The attached TRICARE Explanation of Benefits (EOB) went on to say if he had not already paid the provider to use the attached check to reimburse them for services rendered. Being an astute young man he noted the amount TRICARE paid was less than half the amount of the bill he received and wanted to know who exactly was to pay the remainder.

This provided one of those teachable moments. I mentioned he may want to look over the EOB. After reviewing the information, he indicated the EOB listed $0.00 for deductible, copayment, and cost share under the Beneficiary Liability Summary; but, it was not intuitively obvious how the remainder of the bill was to be paid.

Thinking perhaps he had overlooked something, I quickly scanned the EOB and from his viewpoint could readily see the confusion. It did not clearly state that the TMAC amount satisfied the claim. I knew this – but how would he know?

We took it one step further and called the TRICARE claims contractor number at the bottom of the EOB. They confirmed the TMAC amount paid the claim in full. Furthermore, they informed him the provider was prohibited, by law, from balance billing him for the remainder of the amount – case closed!

I wonder how many others have encountered a similar situation…