The Supplemental Health Care Program (SHCP) is designed to expand your healthcare options by providing coverage for services from civilian doctors. This program may be available to you if your duty assignment is within 50 miles of a military hospital or clinic, offering an important supplement to your TRICARE benefits.
Who is Eligible for SHCP?
Eligibility for the SHCP is determined by your affiliation and current status. You may be eligible if you belong to one of the following categories:
- Active duty service members, ensuring continuous access to necessary healthcare services.
- National Guard and Reserve members on active duty, extending coverage during periods of service.
- National Guard and Reserve members authorized for Line of Duty care, providing support for duty-related injuries or illnesses.
- Beneficiaries on the Temporary Disability Retirement List who require periodic physical examinations, maintaining necessary health evaluations.
- Medically retired former members of the armed services enrolled in the Federal Recovery Coordination Program, supporting ongoing healthcare needs.
- Eligible foreign military personnel (for outpatient care only), facilitating access to outpatient services within the program.
- National Oceanic and Atmospheric Administration personnel, U.S. Public Health Service personnel, and Reserve Officer Training Core students, cadets, and midshipmen, broadening access to diverse groups of uniformed personnel and trainees.
- Any non-TRICARE eligible person who receives approval from a military hospital or clinic to receive civilian services under SHCP, allowing for exceptions based on specific needs and approvals.
- Medicare beneficiaries are generally not eligible for SHCP, with a specific exception:
- Inpatient Medicare beneficiaries at a military hospital or clinic who require civilian diagnostic services that are not available within the military facility, ensuring access to all necessary diagnostic procedures even when civilian resources are required.
What Healthcare Services are Covered by SHCP?
The SHCP offers comprehensive coverage for a wide range of healthcare needs.
- SHCP covers virtually any health care service, provided that the care is authorized either through a referral from a military hospital or clinic or directly authorized by your military Service Point-of-Contact (SPOC). This ensures that necessary care is accessible when referred or authorized.
- For all covered services, Active Duty Service Members (ADSMs) benefit from not having to pay cost-shares, copayments, or annual deductibles, minimizing out-of-pocket expenses for healthcare.
- Your designated SPOC plays a crucial role by acting as a liaison, facilitating communication and coordination between the ADSM, civilian healthcare professionals, and claims processors throughout the healthcare process. This streamlined approach helps ensure smooth and efficient access to care and claims processing.
Understanding the SHCP Authorization Process
To access care through the SHCP, it’s important to understand the authorization process.
- The process begins with the civilian healthcare provider submitting a service request for review. This initiates the formal authorization process.
- Each request undergoes a thorough review to ensure that the requested services are not excluded by TRICARE guidelines and are in alignment with established coverage criteria. This step is crucial for determining coverage eligibility.
- Based on the review findings, requests are either approved or denied. Decisions are made strictly based on TRICARE guidelines and coverage policies.
- In cases where a denial letter is issued for non-covered services, the letter will include instructions on how to apply for a waiver from the DHA (Defense Health Agency). This waiver process provides a pathway to potentially overturn denials in specific circumstances.
Last Updated: 12/2/2024
