Trying to figure out TRICARE can be at times like playing Sudoku...on the hardest level...blindfolded.
Ok, ok it may not be that bad, but there is an endless amount of information out there about TRICARE and most of it is rather confusing. To help make this information a little more accessible, I outlined some general information about your three TRICARE health care options below (Prime, Standard and Extra). So grab some coffee and continue reading!!!
Ok, ok it may not be that bad, but there is an endless amount of information out there about TRICARE and most of it is rather confusing. To help make this information a little more accessible, I outlined some general information about your three TRICARE health care options below (Prime, Standard and Extra). So grab some coffee and continue reading!!!
(1) TRICARE Prime
- Care is typically provided at a military treatment facility (MTF)...basically a fancy way of saying the clinic on base...or at a contracted Civilian Medical Provider called Preferred Provider Network (PPN)...another fancy way of saying a doctor's office OFF base.
- It is the lowest cost out of all three TRICARE options
- Active duty family members pay NO enrollment fee for Prime, but you must complete an enrollment form and select Prime as your coverage plan
- You will be assigned a Primary Care Manager (PCM) who you will see first for your health care needs. He/She is responsible for coordinating your care, maintaing your health records and referring you to civilian doctors or specialists if necessary.
Advantages
- There is no enrollment fee for active duty and families
- Small fee per visit to civilian providers and no fee for active duty members
- No balance billing (a term used to describe when a provider bills a beneficiary for the difference between billed charges and the TRICARE allowable charge after TRICARE has paid everything it's going to pay) So basically, if you see a participating provider and they bill you for additional charges, you DO NOT have to pay them under Prime.
- Guaranteed appointments
- Primary care manager supervises and coordinates care
- Away-from-home emergency coverage
Disadvantages
- Enrollment fee for retirees and their families ($260 for an individual and $520 for families)
- Limited provider choice
- Speciality care by referral only
- Not available everywhere
(2) TRICARE Standard
- Provides the most flexibility out of all of the TRICARE options
- Can see any TRICARE-authorized provider
- You can call your managed care support contractor (MCSC) to find an authorized TRICARE provider. Providers who participate in TRICARE will accept the TRICARE allowable charge (TAC) as the full fee for services rendered. However, non-participating providers may charge up to 15% above the TAC for their services, and YOU would be responsible for the difference.
- Most of the costs of medically necessary care from civilian providers when an MTF is not available will be covered by TRICARE
- Beneficiaries often select Standard if they are happy with their current doctor and he/she is NOT in the TRICARE provider network - it allows them to keep their doctor, while reducing the cost of the visit
Advantages
- Broadest choice of providers
- Widely available
- No enrollment fee
- You may also use TRICARE Extra
Disadvantages
- No Primary Care Manager
- Patient pays deductible and co-payment
- Patient pays balance if bill exceeds allowable charge and the provider selected is non-participating in the TRICARE network (up to 15% additional)
- Nonavailability statement (NAS) may be required for civilian inpatient care areas surrounding MTFs
- A non availability statement (NAS) is needed when an MTF cannot provide the inpatient care you need and you must ask your MTF for one before you get inpatient care from a civilian source. Be sure to check with your MTF every time you need inpatient care - even if they couldn't provide the care you needed the last time you check, their staffing levels or capabilities may have changed and they may be able to care for you now. Also, the NAS is valid for hospital admission that occurs within 30 calendar days after the NAS is issued.
- Beneficiaries may have to do their own paperwork and file their own claims
(3) TRICARE Extra
- You can choose any doctor in the TRICARE Extra network
- Less expensive than TRICARE Standard
- You do NOT have to enroll or pay an annual fee
- You DO have to satisfy an annual deductible for outpatient care (just as you do in TRICARE Standard)
- Ability to seek care in a military hospital, but you are considered "low priority"
- When you receive care, you get a discount on cost sharing and you can use TRICARE Extra on a case-by-case basis, just by using network providers
Advantages
- Co-payment is 5% less than TRICARE Standard
- No balance billing
- No enrollment fee
- No deductible when using retail pharmacy network
- No forms to file
- You may also use TRICARE Standard
Disadvantages:
- No Primary Care Manager
- Provider choice is limited
- Patient pays deductible and co-payment
- Non availability statement may be required for civilian inpatient care for areas surrounding Military Treatment Facilities.
- Not available overseas or to active duty
TRICARE Cost Comparison Between Prime, Extra and Standard:
The following tables provide examples of cost-shares or co-payments for families who use civilian providers and facilities under each of the three TRICARE options. The listed fees are subject to change.
Active Duty Family Members:
TRICARE Prime | TRICARE Extra | TRICARE Standard | |
Annual Deductible | None | $150/individual or $300/family for E-5 & above; $50/$100 for E-4 & below | $150/individual or $300/family for E-5 & above;$50/100 E-4 below |
Annual Enrollment Fee | None | None | None |
Civilian Outpatient Visit | No cost | 15% of negotiated fee | 20% of allowed charges for covered service |
Civilian Inpatient Admission | No cost | Greater of $25 or $13.90/day | Greater of $25 or $13.90/day |
Civilian Inpatient Mental Health | No cost | $20/day | $20/day |
Civilian Inpatient Skilled Nursing Facility Care | $0 per diem charge per admission No separate co-payment/cost-share for separately billed professional charges | $11/day ($25 minimum) Charge per admission | $11/day ($25 minimum) Charge per admission |
*New enrollment fees effective on Oct. 1, 2011 for new enrollees
Helpful Hints:
- Sponsors (aka your spouses) should ensure their family members have up-to-date uniformed services identification cards, and that they are properly enrolled in the Defense Enrollment Eligibility Reporting System (DEERS).
- Beneficiaries may find that the closest MTF is outside their area. In that case they will be enrolled in TRICARE Prime Remote.
- Beneficiaries may be required to file their own claims when using TRICARE Standard. Beneficiaries may find more information about filing claims and download claims forms on the TRICARE Website.
- Although TRICARE Standard beneficiaries have a lower priority for access to care in MTFs than TRICARE Prime enrollees, Standard beneficiaries may attempt to receive their care from an MTF. This will save money and paperwork.
For more information, visit the TRICARE Website .
I hoped this post helped clarify your TRICARE options and will make your selection process a little easier. Best of luck!!!