CHAMPUS, PPO and Medicare Health Insurance Program Information

Part 2, Chapter 8: CHAMPUS and Medical Savings Accounts Page 2

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In many ways, the traditional CHAMPUS system seems to follow the basic structure of the Medicare program (See Chapter 9). Individuals choose their own providers, and claims are processed by local plan administrators rather than by a single national processing center. Furthermore, CHAMPUS categorizes providers as either participating providers or nonparticipating providers, just as Medicare does.

Participating providers accept the CHAMPUS allowable amount, the amount that CHAMPUS has determined to be appropriate for a particular treatment or service. The individual is generally responsible for the deductible and the co-payment. Nonparticipating providers are permitted to charge up to 115% of the CHAMPUS allowable amount (15% above the allowable amount). In addition, both participating providers and nonparticipating providers generally file claims directly with local CHAMPUS plan administrators. That helps to reduce the burden for the consumer in regard to claim-filing, although it's still essential for individuals to keep accurate records of all medical bills and claims.

Participants in the traditional program also have a PPO (Preferred Provider Organization) option called Tri-Care Extra. The PPO option allows participants to consult a provider within the PPO network when they wish. Consulting a network provider may result in significant cost-savings. PPO participants can consult out-of-network providers, as well.

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