Breaking Down Your TRICARE Options

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!!!

(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!!! 

The Military's Free Healthcare...Worth Every Penny

I've had my fair share of clinic visits from the small amount of time we've been apart of the Air Force. My family and friends know me as being somewhat accident-prone and by somewhat I mean highly accident-prone. So one big benefit of being in the military for us has been my ability to essentially see a doctor whenever I need to. I don't even want to imagine what our medical bill last year would have been if we weren't in the military. However, like many things involved with the military, getting the right kind of medical attention you need can be stressful at times. 

The idea for writing this post came to me on my most recent visit to my PCM (we will call him Dr. IdontListen) to get an opthamologist referral. It was my first time seeing Dr. IdontListen and I wanted to do a followup with him on some medical issues I had at our last base. After browsing Pinterest for 45 minutes in the waiting room, my name was finally called. I followed one of the nurses into a medical room, where I was asked a number of common, routine questions. I then proceeded to wait another 40 minutes until Dr. IdontListen finally made an appearance. I got a number of indications within the first few minutes of meeting him that this visit was not going to go well.

Indication #1: He was wearing blue jeans. A doctor wearing blue jeans is cool if you're in a 1980's movie staring Michael J. Fox, but in real life I would prefer a professional appearance from the person whose job it is to keep me alive.

Indication #2: Dr. IdontListen's first words walking in the door were, "so...are you a worrier?" Translation to me:"so...are you a hypochondriac?" That made me feel real comfortable.

Indication #3: Since we were off to such a great start, Dr. IdontListen decided there was no need for an examination, and he would just jump straight to prescribing drugs. With a smirk he tells me there is no need to take into consideration previous SPECIALISTS' recommendations or even LOOK at my eyes.  How can he possibly know what to give me...is he psychic? At this point, I'm thinking it might be a good idea to start looking for his diploma on the wall and make sure it doesn't read "Hogwarts School of Medicine."  

Indication #4: I went home and immediately called an opthamologist (aka. expert when it comes to eyes) who told me not to use the drops that were prescribed to me and that Dr. IdontListen is insane!!! 

So bottom line, my visit did not go well. I have spoken to a number of other people since my visit who have had Dr. IdontListen and have had similar issues with him...

If you are apart of Tricare PRIME (as I am), you may be assigned to a PCM that you don't particularly care for. It is important to know that you have options. 

1) For one, you can switch your PCM. Switching your PCM is typically a straightforward and pain-free process - you can switch at anytime, provided the new PCM is accepting new patients. 

• The easiest way is to call HUMANA at 1-800-444-5445 and speak to a representative so they can put in your request. 
• You can also change your PCM by completing a  TRICARE Prime Enrollment and PCM Change Form with the new PCM's name (once you've picked one out) and address. You only need to complete the portion of the form related to the PCM change. Mail the form to Health Net (their address is listed on the form) and the change will become effective once the application is received and processed by your regional contractor.  For more information, visit http://tricare.mil/mybenefit/home. 

2) If you would really prefer to see a doctor of your choosing, then consider participating in TRICARE Standard.

• TRICARE Standard provides the most flexibility to TRICARE-eligible beneficiaries. It gives beneficiaries the opportunity to see any civilian TRICARE-authorized provider. 
• There may be additional fees you will have to pay under TRICARE Standard (i.e. cost shares and deductibles) depending if the doctor you wish to see is in the authorized TRICARE network or not, but for some these fees are worth any additional cost. (TRICARE Prime vs. Standard will be explained in another post)

Lastly, I thought I would end this post with some helpful tips from (abc.com) for the next time you do see your PCM or any doctor. Some hints that I need to remember as well!!

• You are the Expert on You: trust your gut feeling - if something doesn't seem right, believe your instincts and speak up...it is your life that is on the line. 
• Be Organized: make a list of what is bothering you before you go so you can remember everything that needs to be addressed and then you can prioritize these issues with your doctor.
• Don't Go Alone: everybody needs a health buddy - it can be your spouse (if possible), a family member, a best friend...you just need another set of eyes and ears to help you plan and listen to your doctor. Studies show that up to 50% of patients forget what the doctor has told them the minute they walk out the door. Your health buddy can take notes, help you follow through on your doctor's advice and be another set of ears to remember any instructions! 
• Know Your Goal for Every Condition: don't passively accept medication (ooops!) not knowing the purpose or the goal the doctor is trying to achieve. Write down the target goal and measure your progress. Often, people are under or over or mistreated with medications.
• Follow Up on Tests Results: don't assume "no news is good news." Tests results can be easily misfiled, misplaced or even misread. You need a copy of every blood test result, X-ray report and pap test or EKG. Give your doctor a self-addressed stamped envelope and ask for a copy. You are legally entitled to any information in your file. 
• Carry Basic Medical Info With You at All Times: you need to plan for emergencies so you can ensure you get the proper care. When faced with an emergency (i.e. Hurricane Katrina, a car accident or acute illness while on the road) you should always have on you a form that lists your allergies, blood type, every pill you take and the dosage, immunizations and emergency contact. Click here for an emergency form you can fill out and carry with you. 

In the word's of my mother, "be an advocate for your own health." And...unless his name tag reads "Doogie Howser M.D," be suspicious of a Dr. that wears blue jeans ; )