Blue Cross/ Blue Shield/ TRICARE/ CHAMPVA (Pg. 70-73)

Blue Cross/Blue Shield (BCBS)

• BCBS operates as a not-for-profit private health insurance organization, offering plans for group coverage and individual purchases.
• Historically, Blue Cross focused on hospital benefits while Blue Shield provided physician benefits.
• Benefits vary geographically and include fee-for-service, managed care, and Medicare supplemental plans available nationwide.
• BCBS membership ID numbers consist of three letters for easy identification by medical office staff.

TRICARE/CHAMPVA

• TRICARE, a government program, provides healthcare benefits for active-duty servicemembers and their families.
• Eligibility includes active duty servicemembers, spouses, unmarried children (up to ages 21 or 23 if full-time students), children with disabilities, uniformed service retirees, and dependents of deceased service members.
• Benefits cover a portion of civilian healthcare costs with stipulations on deductibles and cost-sharing percentages; patients usually seek care from nearby military hospitals.
• Active-duty personnel typically receive care from military facilities, except in cases of unavailability, which requires a non-availability statement.
• TRICARE includes several plans:
  • TRICARE Prime: Functions like an HMO with assigned primary care physicians and a network of military health facilities.
  • TRICARE Select: Operates as a PPO offering more flexibility and control over specialist access without referrals, generally at a higher cost.
  • TRICARE for Life: Works alongside Medicare to provide secondary coverage for eligible beneficiaries after Medicare pays its share.

CHAMPVA

• The Civilian Health and Medical Program of the Department of Veterans Affairs provides care for veterans and dependents under specific conditions (total or permanent disability).
• CHAMPVA is a service benefit program, not a traditional insurance program; there are no contracts or premiums involved.
• Beneficiaries can receive care from civilian or military providers without requiring preauthorization.
• When combined with other insurance, CHAMPVA acts as the secondary payer.

Commercial Plans

• Approximately half of insured Americans obtain health insurance through private or commercial companies, primarily through employer-sponsored group policies.
• Private insurance companies also offer individual and self-insured plans, with notable companies like Aetna, United Health, Cigna, WellCare, Humana, and BCBS.
• Regulations about private health insurance typically vary by state.

Workers’ Compensation

• Workers' compensation provides wage replacement and medical benefits for employees injured during employment, sacrificing the right to sue for negligence.
• This system, known as “the compensation bargain,” is established as a contract between employee and employer.
• Benefits include wage replacements, medical reimbursements, and support for dependents of workers who are killed on the job.
• Administered at the state level with provisions for weekly compensation and vocational rehabilitation programs for those with job-related disabilities.
• Key aspects of workers’ compensation include:
  • Coverage for work-related injuries or illnesses without a deductible or copayment; employers cover all premiums.
  • All medical providers treating work-related injuries must accept payment in full and avoid billing patients.
• Temporary Disability (TD) benefits support those unable to perform job functions temporarily based on earnings.
• Permanent Disability (PD) benefits are for workers with lasting disabilities, structured for rehabilitation or monetary settlements once a case is evaluated for finality.