Active duty, National Guard, and retired service members—as well as their families and survivors—deserve the best access to healthcare. Many receive their benefits through TRICARE, a Department of Defense healthcare program. If an individual doesn’t qualify for TRICARE, they may be able to get health insurance through the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), which also covers the cost of healthcare services and supplies for family members. TRICARE and CHAMPVA provide their members with access to a nationwide network of providers, including Veterans Affairs medical facilities. This portability factor is important for members if they move or travel out of the state.
Some Medicaid members (family members or retired service members) are unaware that they are also eligible for these programs. This would expand their access to benefits and care, and Medicaid programs could realize savings opportunities. If eligible, TRICARE and/or CHAMPVA would become members’ primary insurance, meaning that qualifying medical claims must first be paid by TRICARE or CHAMPVA, before being paid by the state Medicaid program. This provides Medicaid cost avoidance, and the state may also have the opportunity to recover the cost of claims they paid or rebill claims to TRICARE or CHAMPVA for services that Medicaid provided.
Previously, the process to identify potential TRICARE and CHAMPVA beneficiaries used data available through the Department of Defense under an agreement with the Centers for Medicare and Medicaid Services. This agreement expired in 2017—leaving states in a quandary on how to find unreported TRICARE and CHAMPVA coverage or validate self-reported coverage.
Finding the Right Solutions
Beginning in 2023, ForHealth Consulting’s Medicare Enhancement Eligibility Program, in partnership with the Massachusetts Medicaid program (MassHealth), explored alternate data sources to identify, validate, and update TRICARE and CHAMPVA coverage in state systems. Working with MassHealth, we identified potentially eligible members through available Public Assistance Reporting Information System (PARIS) data and determined that coverage could be confirmed for members through a health insurance information exchange. PARIS provided the leads for potential TRICARE and CHAMPVA eligibility and the health insurance information exchange validated enrollment.
Through these efforts, we verified TRICARE coverage for over 2,000 members (52% of the identified population) and updated this information in Medicaid systems. Initial efforts have identified CHAMPVA coverage for 125 members (22% of the identified population). We also detected 950 new opportunities to recover historical Medicaid expenditures from TRICARE.
Outreach and Education are Critical to Our Success
After we analyze the data, we are sometimes left with cases where members could be eligible for, but are not accessing TRICARE or CHAMPVA coverage. Our next step is developing a member outreach and education program to contact and support members in understanding the benefits of enrolling in TRICARE and/or CHAMPVA.
Enrollment involves a complex set of rules where veterans must complete multiple forms and provide required verifications. This is a possible reason that people may not complete the application process, and families may not keep up with their insurance status, especially if their sponsor has passed away. Additionally, members may be unaware of opportunities for TRICARE and/or CHAMPVA coverage to be reopened with status changes such as marriage and divorce. Even children up to a certain age could still be covered.
Due to our efforts, MassHealth is estimated to save $9M annually because of the identified TRICARE and CHAMPVA coverage. Potential new opportunities for expenditure recovery could yield an additional $1.8 million.
What Makes Us Different?
ForHealth Consulting’s fully comprehensive program employs innovative identification strategies, using data from multiple sources in the most effective ways. Our team of experts compares federal data sources against state data, and queries clearinghouses to get a full picture of members who may qualify for TRICARE and/or CHAMPVA coverage.
Our in-house infrastructure captures as many Medicaid members as possible who may have TRICARE and/or CHAMPVA coverage. Many state Medicaid agencies may not have the resources to execute this complex level of data mining.
Finally, our unwavering commitment to education, customer service, and support for client organizations and members helps to secure the highest level of healthcare and service for veterans and their families.
Attending MESC 2024? Learn more about how we can help you and your members who qualify for TRICARE and/or CHAMPVA get the most healthcare options available to them while potentially saving your organization millions of dollars.