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Understanding Military Medical Care

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Tricare Prime. This option is kind of like an HMO concept, and requires that one specifically enroll in the program (active duty members are enrolled automatically). Individuals enrolled in Tricare Prime are assigned to a Primary Care Provider (PCP), which is usually the local military medical facility (base hospital). In order to receive specialist care, they must be referred by their PCP. Under this program, there is no enrollment fee or cost-sharing for active duty members and family members of active duty. For retirees (under age 65) and family members of retirees (under age 65), there is an enrollment fee of $230 per year for a single individual, or $460 per year for a family. In addition to the annual enrollment fee, retirees and their family members pay a cost-share of $12.00 per outpatient visit, $30.00 per emergency care incident, $25.00 per mental health outpatient visit, $11.00 per day for inpatient care, and $40.00 per day for inpatient mental health care. There is a maximum $3,000 "catastrophic cap," that a retired family would have to pay each year.

One can get the forms to enroll in Tricare Prime online.

A brand new option under Tricare Prime is the Point of Service (POS) enrollment option. Normally, under Tricare Prime, one must be referred by the PCP in order to receive any reimbursement for medical care received from anyone other than the PCP. But, if one elects the POs option at time of enrollment, one can use Tricare Prime, and still use the Tricare Standard or Tricare Extra options described below.

Tricare Extra. This program gives more flexibility than Tricare Prime, but could result in addition costs. One does not need to enroll in advance to use Tricare Extra. Under this program, you see any Authorized Tricare Provider, present your ID Card, and receive medical care. The Tricare Authorized Providers have a contract with the military to limit costs to designated amounts. Under Tricare Extra, active duty family members pay an annual deducible (the "year" begins every October) of $150 (individual) or $300 (family). After the deducible is paid, Tricare pays 85 percent of the cost for the office visit, and you pay 15 percent. For inpatient care, active duty family members pay $11.45 per day. For inpatient mental health care, active duty family members pay $11.45 per day, or a total of $25.00, whichever is greater.

For retirees and retiree family members (under age 65), the program costs a little more. While the annual deducible is the same ($150.00 per individual or $300 per family), the cost-share is 20 percent per visit for outpatient care, the lesser of $401 per day, or 25 percent of the hospital bill and 20 percent of the professional fees for inpatient care; and 20 percent of the institutional charges, plus 20 percent of the professional fees for inpatient mental health care.

Under Tricare Extra, the medical provider fills out the Tricare Claim Forms for you, and they receive direct-payment from Tricare for their portion. You simply pay them your portion of the costs.

Tricare Standard. Tricare Standard is the closest to the old "CHAMPUS" program. This program gives the greatest flexibility, but costs the most. Under this program, you can see pretty much any medical provider you want. Again there is the $150.00/$300 annual deducible Under this program, for active duty family members, Tricare pays 80 percent of what it says the care should cost, and you pay 20 percent. If the medical provider charges more than what Tricare says it should cost, you have to pay the additional difference. For inpatient care, the rates are the same as for Tricare Extra.

For retirees and retiree family members (under age 65), again, it costs more. In addition to the annual deducible, you have to pay 25 percent of what Tricare says it should cost, plus anything extra that the medical provider charges (over the Tricare authorized cost).

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