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TriCare

(Note: The below article is from the Aug 97 edition of Navy "All Hands" Magazine. While it is written with Navy personnel in mind, for the most part, the information is applicable for members of all of the services.


Health care is provided to Sailors and their families as a benefit of being a member of the Armed Forces. DOD operates one of the nation’s largest health care systems. Nearly 8.3 million individuals are eligible to receive care at its many hospitals and clinics. These hospitals and clinics consistently receive high rankings by the Joint Commission on Accreditation of Health Care Organizations, which examines both military and non-military medical facilities.

While few argue that the care received at military medical treatment facilities is anything but excellent, getting in to see a health care professional has become a problem. As a result of right-sizing, 35 percent of the military hospitals that existed in the United States in 1987 are closed today. The number of doctors, nurses and medical technicians in military service has declined along with the number of other service members.

Despite this, the total number of people seeking health care through the military’s health care system has dropped only slightly.

To ensure all members of the Armed Forces and their families have access to quality, low-cost health care, DOD introduced TRICARE, which brings together the health care resources of the Army, Navy and Air Force, and supplements them with networks of civilian health care professionals.

Under TRICARE, almost all active-duty Sailors — enlisted or officers — will see little change in the way they receive health care. But many family members will find they have health care choices and services they didn’t have before, and getting in to see a doctor is much quicker.

What Is TRICARE?

TRICARE is a health care plan for Sailors and their families.

Starting up a whole new way to deliver health care is an enormous undertaking. To make it easier, DOD has divided up the world into 14 different regions. TRICARE is being phased in around the world with different start dates for each region.

TRICARE’s major difference from the military health care provided in the past is choice. Family members are offered three options for health care - TRICARE Prime, TRICARE Standard and TRICARE Extra.

While Sailors will be enrolled in TRICARE Prime, family members may choose a different option depending on such factors as where they live, health status and preference of health care providers. Here’s a brief description of the three choices.

TRICARE Prime

TRICARE Prime provides the most comprehensive health care benefit at potentially the lowest cost of the three TRICARE choices.

Principal among the many features of TRICARE Prime is guaranteed timely access to care at military treatment facilities (MTFs) or in civilian health care facilities. Sailors and their families enrolled in Prime have priority for treatment in military hospitals and clinics.

Another key feature of TRICARE Prime is that all who enroll will be assigned a Primary Care Manager (PCM). A PCM is a health care professional or medical team that patients see first for their health care needs. PCMs take care of most enrollees’ health care needs, referring patients to a military or civilian medical specialist if specialty care is needed.

Another advantage of Prime is its focus on preventive care. Health care providers not only treat individuals with injuries and diseases, but provide information and care to help keep Sailors and their families healthy.

Why Select TRICARE Prime?

If you’re a Sailor, you will be automatically enrolled in TRICARE Prime. TRICARE Prime is best for families who want guaranteed access to the most health care benefits and who live close to an MTF or civilian health care providers who participate in TRICARE Prime. First priority for care at MTFs will be given to Sailors and their families enrolled in TRICARE Prime and whose PCM is at that facility.

TRICARE Prime
  • Guaranteed access to timely health care
  • Priority care at military hospitals and clinics
  • Primary Care Managers provide and guide health care
  • Focuses on preventive care
  • Lowest cost for treatment among three options
  • Family members enroll for one year at a time
  • Enrollment required
  • Very expensive to receive care outside TRICARE Prime
  • Not available in some locations away from military bases
  • Services may vary slightly from region to region

How Much Does It Cost?

Where you get your care - whether at an MTF or with a civilian who is participating in TRICARE Prime - will affect the cost. There is no cost for family members if they receive care at a military hospital or clinic. Visits to civilian PCMs or specialists not at the MTF cost $12 per visit for family members whose sponsor is E-5 and above. Family members whose sponsor is E-4 and below pay $6 for a civilian visit.

Sailors and family members who must spend the night in a hospital will pay about $10 a night for a stay in a military hospital, and only $11 a night, with a minimum charge of $25, for a stay in a civilian hospital. These fees are called co-pays.

How to Enroll in TRICARE Prime

As mentioned earlier, Sailors are automatically enrolled in TRICARE Prime. They may have to fill out a short form to assist with record keeping, but the only other action they need to take is to find out who their PCM is before they need care.

For most Sailors, their PCM is the health care provider at their nearest military clinic (sick call), the independent duty corpsman or medical officer aboard their ship, or their squadron’s flight surgeon.

Family members who choose Prime must fill out an application to enroll. Enrollment lasts for one year, and then may be renewed.

New family members — a newborn or adopted child — are automatically covered under TRICARE Prime for 120 days after their birth or adoption. After that, they must be enrolled to continue enjoying Prime’s services.

Information about enrollment and enrollment forms are available at TRICARE Service Centers, which are located near MTFs and other areas with large military populations.

An Important Note For TRICARE Prime Enrollees

TRICARE Prime enrollees who decide to seek care from other than their PCM or the medical specialists participating in Prime without getting authorization from the TRICARE Service Center will find that health care can be very expensive Ñ even more expensive than TRICARE Standard.

TRICARE Prime enrollees can not participate in TRICARE Extra or Standard.

TRICARE Standard

TRICARE Standard used to be called CHAMPUS. With TRICARE Standard, family members may choose any doctor or health care facility they want for health care, and the government will reimburse part of the cost. So while it offers great flexibility, it may be the most expensive choice.

TRICARE Standard
  • Greatest flexibility in choosing health care providers
  • Most convenient when traveling away from home
  • Potentially most expensive option
  • No enrollment required
  • Can seek space-available care in military hospitals and clinics, but at lower priority than TRICARE Prime enrollees
  • Available everywhere

Why Select TRICARE Standard?

This option offers the biggest choice of health care professionals. Some of the reasons family members choose Standard are because their regular civilian doctor has decided not to participate in TRICARE Prime; they travel frequently; they live very far from a MTF; they are away at school; or they have other health insurance.

How Much Does It Cost?

With TRICARE Standard, the government shares health care costs. Beneficiaries are required to pay an annual deductible, which is the amount family members pay each year on their medical bills before Standard starts sharing the cost. For E-4 and below, the deductible is $50 for one person or $100 for two or more family members. For E-5 and above, the deductible is $150 for one person and $300 for two or more family members.

Once the deductible is reached, the government will pay 80 percent of the costs - providing it doesn’t exceed the amount the government says it should cost.

A Word of Caution for Standard Users

If the health care provider chosen charges more than the government is allowing, the family member is responsible for not only 80 percent of the charges, but also up to 15 percent over the “allowable” amount.

Usually, overnight hospital care will be provided at the nearest MTF. The exceptions to using a MTF include: it’s full and there’s no space available; special authorization for care at a civilian hospital has been approved; or a life threatening emergency required immediate admittance to a civilian hospital.

For civilian in-hospital care, family members pay about $10 a day, or a minimum of $25, whichever is more. Cost for in-hospital care at the MTF is about $10 a day.

TRICARE Extra

A third choice available to family members is TRICARE Extra.

Extra offers a wider choice of health care providers and facilities than Prime, and also can keep costs lower than Standard.

TRICARE has made arrangements with many doctors and other health care providers, as well as health care facilities, to charge what the government will allow for treatment, and also give patients a 5 percent discount over TRICARE Standard. These health care providers and facilities are sometimes called “preferred providers.”

TRICARE Extra
  • Can choose any doctor in the TRICARE Extra network
  • Can use health care providers not in the Extra network, but at Standard rates
  • Less expensive than TRICARE Standard
  • Still may be expensive
  • More widely available than TRICARE Prime
  • No enrollment required
  • Can seek space-available care in military hospital and clinics, but at lower priority than TRICARE Prime enrollees

Why Select TRICARE Extra?

It is chosen most often by family members whose regular doctor participates in TRICARE Extra. Family members may choose Extra when they live too far away from an MTF for it to be convenient, but want to reduce health care costs as compared to TRICARE Standard.

How Much Does It Cost?

Just like with TRICARE Standard, the government shares the cost of health care. The government pays 85 percent of outpatient visit charges — which is 5 percent more than the 80 percent TRICARE Standard participants are reimbursed — when doctors and specialists who participate in Extra are used. Also, doctors and specialists who participate in Extra have agreed to charge government-approved rates, so there are no additional charges over the 15 percent. That’s not always the case with Standard.

An overnight hospital stay under Extra costs the same as Standard.

Another benefit of Extra is that family members can switch back and forth between health care providers who participate in Extra and those who don’t. Since there is no enrollment in either Standard or Extra, you can use an Extra-participating doctor for one type of care, and a non-participating one for another type of care without any penalty.

Just like with Standard, you must pay the deductible. It’s the same as Standard’s.

And, just like with Standard, family members can still seek care in a MTF on a space-available basis.

Who is Eligible for TRICARE?

All active-duty Sailors, their spouses and their unmarried children under 21 are eligible for TRICARE. Also, children who are full- time college students under 23 and most severely disabled unmarried children, no matter what their age, are eligible.

Also, the spouses and unmarried children of Reservists who are ordered to active duty for more than 30 days or die on active duty are eligible. Contact your local TRICARE Service Center for more details on eligibility.

Health Benefit Advisors

Health Benefits Advisors (HBA) are the experts on military health care and health care services and choices available to Sailors and their families. Every MTF has at least one HBA and they are also available at TRICARE Service Centers. To talk to an HBA, call the TRICARE toll-free information number for your region to find the one closest to you, or if TRICARE isn’t in operation for your region, call your local MTF.

TRICARE Service Centers

There’s a TRICARE Service Center near most MTFs and at other locations where there is a large military population. These centers are staffed with TRICARE service representatives who can assist Navy families choose the TRICARE option that’s best for their needs.

Other assistance the center provides includes:
  • TRICARE Prime enrollment
  • Primary Care Manager selection
  • Medical appointments scheduling
  • Health care benefit information
  • Pharmacy mail-in and retail service information
  • Finding doctors and specialists who accept TRICARE Standard payments
  • Finding doctors, specialists, pharmacies and facilities that participate in TRICARE Extra
  • Issuance of Non-Availability Statements when MTFs are full
  • Claims paperwork completion and submission

Nurse Advisors

Nurse advisors are another exceptional health care benefit for Navy families. In most parts of the country, a registered nurse is available to answer health care questions 24 hours a day, seven days a week. Nurse advisors can also provide information on what to do when urgent care is needed away from home.

Remember, in a medical emergency - one that threatens life, limb or eyesight - go to the nearest emergency room immediately.

Prescriptions

Prescriptions can be filled free of charge for Sailors and their families at any military pharmacy whether it’s prescribed by a civilian or military health care provider - if the military pharmacy carries the prescribed medication. Other ways to get prescriptions filled include a mail service pharmacy and a civilian retail service pharmacy. The cost for medication ordered in this way depends on whether family members are enrolled in Prime, or participate in Standard or Extra.

Catastrophic Cap

To protect Navy families from devastating financial loss due to serious illness or long-term treatment, a limit has been set on how much families will ever have to pay for medical costs. This is called a catastrophic cap.

The maximum liability for Sailors and their families is $1,000 for deductibles, co-pays and other fees paid in a year.

If retirement is in the near future ...

The military health care benefit, TRICARE eligibility, and TRICARE costs are different for retired Sailors and their families than for active-duty Sailors and their families. Soon-to-be retired Sailors and their families should contact their nearest TRICARE Service Center for information.

Dental care for Sailors and their families

Sailors get free dental care at military dental clinics while they are on active duty. Dental care for family members is provided on a space-available basis in most clinics.

Since dental clinics are not always in convenient locations for families, and appointments for dental care for family members are becoming more and more limited, DOD set up the TRICARE Family Member Dental Plan (TFMDP). It offers low-cost dental care for Sailors’ families by using civilian dentists.

Enrollment in TFMDP is voluntary, but it is a good way for Navy families to control dental costs and ensure access to dental care when needed. The cost for TFMDP is shared by the government and the family member. Sailors pay a modest monthly fee by payroll deduction to enroll. Cost for a single enrollment is $7.46. A family enrollment for more than one person is $19.09

TRICARE Family Member Dental Plan
  • Guaranteed access to dental care with a civilian dentist
  • Comprehensive dental coverage, similar to civilian dental plans
  • No deductibles
  • United Concordia pays $1,000 annual maximum per family member for non-orthodontics services
  • United Concordia pays $1,200 lifetime maximum per family member for orthodontics
  • Choice of dentists; you save more money when you choose a participating United Concordia dentist
  • Free pre-treatment estimates of dental services
  • One mailing and processing center with electronic claims submission available

While this monthly fee provides examinations and cleanings for no additional fee, other dental services require a co-pay or cost share. For example, 80 percent of the cost of a filling is paid for by the government. Family members are responsible for the remaining 20 percent.

Usually, enrollment is for a minimum of 24 months. Sailors fill out DD Form 2494 or 2494-1 at their Personnel Support Detachment (PSD) to start their payroll deduction and enroll. TFMDP is administered for DOD by United Concordia Companies, Inc. For more information about TFMDP contact United Concordia’s customer service toll free at 1-800-866-8499.

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