Prime is similar to a health maintenance organization, which has lower out-of-pocket costs but requires enrollees to use network providers and coordinate care through a primary care manager – a doctor, nurse practitioner or medical team.
Prime requires enrollment. It's free for active-duty members and their families, but retirees must pay an annual enrollment fee. In fiscal 2013, those fees are $269.28 for an individual and $538.56 for a family.
Prime limits out-of-pocket expenses; it has no deductibles, and co-payments for health care visits are lower than for the other programs. Co-pays for outpatient civilian doctor visits are $12 for enrolled retirees and their family members. Active-duty family members don’t pay for civilian medical care if they follow the Prime rules. They do pay for civilian pharmacy services.
The catastrophic cap – the ceiling on how much a family must pay annually for Tricare-covered health care services – is $1,000 for active-duty families and $3,000 for retirees’ families.
A Tricare Prime option is available overseas for active-duty troops and their command-sponsored family members. Prime is not available to retirees or noncommand-sponsored families overseas.
Costs rise substantially if a Prime enrollee goes outside the Tricare network without authorization from the primary care provider using the point-of-service option. In such instances, deductibles are $300 for an individual or $600 for a family. After the deductible is met, Tricare will pay only 50 percent of what it establishes as the Tricare allowable charge.
TRICARE PRIME REMOTE
Service members who live and work more than 50 miles or an hour’s drive from the nearest military treatment facility must enroll in Tricare Prime Remote. Family members are eligible if they live with an enrolled service member in a qualifying location. Family members may opt for Prime Remote or choose Tricare Standard or Extra.
TRICARE PRIME REMOTE AND STANDARD OVERSEAS
The Tricare Overseas Program is managed by contractor International SOS Assistance and includes Prime, Prime Remote and Standard options. Tricare Prime Overseas is a managed-care option for active-duty members and their command-sponsored family members living in nonremote locations. They have assigned primary care managers at a military treatment facility who provide most care and refer for and coordinate specialty care.
Tricare Prime Remote Overseas is available in remote locations for active-duty personnel and their command-sponsored family members. Like Prime Overseas, those enrolled have an assigned primary care manager who provides most care.
Tricare Standard Overseas provides comprehensive coverage to active-duty family members, retirees and their families and all others who can’t enroll in Tricare Prime Overseas. Enrollment is not required and coverage is automatic as long as the beneficiary is in the Defense Enrollment Eligibility Reporting System. Beneficiaries receive care from host-nation providers. They may seek care at a military treatment facility on a space-available basis only. No referrals are needed for care but some services may require prior authorization. Beneficiaries may have to pay the provider in full when they get care and file for reimbursement.
Standard is modeled after a traditional fee-for-service health plan. Authorized doctors, hospitals and other providers are paid a Tricare allowable charge for each service performed.Individuals may use only Tricare authorized providers, and they pay more than under other Tricare plans. Certain procedures also require pre-authorization. For civilian doctor visits, cost shares are a percentage of the allowable charge. Retirees and other eligible beneficiaries pay 25 percent; active-duty family members pay 20 percent.
Standard patients must meet outpatient deductibles before the government shares costs. Deductibles, which depend on rank and family status, range from $50 to $150 for an individual and $100 to $300 for a family. The annual catastrophic cap on allowable charges is $1,000 for active-duty families and $3,000 for retirees.
Cost shares are waived for preventive screenings for colorectal, breast, cervical and prostate cancers as well as immunizations and well-child visits for children under 6 years of age.
The Pentagon’s proposed 2013 budget calls for new annual enrollment fees for working-age retirees and their families to use Standard or Extra – $70 for an individual and $140 for a family. At press time, the proposal was pending in Congress.
Extra is a preferred-provider option, a variation of Tricare Standard that allows Standard/non-Prime enrollees to lower their costs by using a Tricare network provider.
Extra does not require enrollment or charge premiums, but users must meet deductibles before government cost shares are covered. For paygrades E-4 and below, deductibles are $50 for an individual and $100 for a family; other active-duty members and retirees pay $150 for an individual and $300 for a family.
Users also must pay a portion of the costs associated with receiving care. For civilian doctor visits, active-duty families pay 15 percent of the allowable cost; retirees pay 20 percent.
TRICARE FOR LIFE
Medicare and Tricare play a role in health coverage for older retirees and their family members. Medicare Part A, which is free, covers hospitalization. Medicare Part B outpatient insurance, which requires monthly premiums, is necessary for retirees to be eligible for Tricare For Life.
Medicare-eligible beneficiaries who are entitled to Part A and purchase Medicare Part B use Tricare as a secondary payer under Tricare for Life. Those eligible for Medicare Part A who do not enroll in Part B lose Tricare eligibility, with one exception: Medicare-eligible active-duty family members are not required to purchase Part B until the sponsor retires.
Tricare For Life works as a wraparound supplement to Medicare only in the U.S. and its territories because Medicare does not cover health care abroad. Overseas, Medicare-eligible beneficiaries are covered by Tricare Standard if they have Medicare Part B insurance.
The Pentagon’s proposed 2013 budget calls for new enrollment fees for all Medicare-eligible beneficiaries except dependents of active-duty personnel. The annual fee would be based on military retirement income: $35 per individual for those making up to $22,589; $75 for those making between $22,590 and $45,178; and $115 for those making $45,179 and more.
TRICARE RESERVE SELECT
Selected reserve members can buy Tricare coverage when they are in drilling status –not mobilized– provided they are eligible for Tricare Reserve Select.
The program, which offers coverage similar to Tricare Standard and Extra, is available to drilling reservists who are not eligible for or enrolled in the Federal Employee Health Benefits program.
Monthly premiums in 2012 are $54.35 for an individual and $192.89 for family coverage. This includes medical, behavioral health and prescription drug benefits. For office visits, patients pay 15 percent of the allowable charge if the health care professional providing the service is in the Tricare network, 20 percent if not.
Annual deductibles apply to outpatient services. For paygrades E-4 and below, they are $50 for an individual and $100 for a family. For higher ranks, they are $150 for an individual and $300 for a family. The catastrophic cap is $1,000 a year.
Tricare Plus allows beneficiaries who are not in a civilian or Medicare HMO to enroll at a military clinic or hospital on a space-available basis for primary care only. They do not pay an enrollment fee and cannot be guaranteed specialty care, but they are seen according to the same access standards as Prime patients within military treatment facilities that offer Tricare Plus. Enrollment availability and capacity varies by clinic or hospital, so enrollment is not portable.
TRICARE RETIRED RESERVE
This program is for so-called “gray area” National Guard and reserve retirees who have accumulated enough service to qualify for military retirement benefits, but have not yet reached the age at which they can begin drawing those benefits (usually age 60).
Retired reservists can purchase TRR, which offers coverage similar to Tricare Standard, if they are under age 60 and are not eligible for or enrolled in the Federal Employee Health Benefits program.
For 2012, monthly premiums are $419.72 for an individual and $1,024.43 for a family.
TRICARE YOUNG ADULT
Unmarried dependent children who do not have private-sector health insurance through an employer may remain in Tricare until age 26 under a parent’s coverage as part of the Tricare Young Adult program, created to bring Tricare in line with the broader national health care reform law.
Two plans are offered in 2012: TYA Standard, with a monthly premium of $176, and TYA Prime, carrying a monthly premium of $201.
To qualify, a beneficiary must be an adult child of an eligible sponsor at least 21 and not older than 26, must not qualify for his own employee-sponsored health care coverage and must be unmarried.
UNIFORMED SERVICES FAMILY HEALTH PLAN
Some beneficiaries – including active-duty family members, retirees and their family members, can use an additional Tricare Prime option available through networks of community-based, not-for-profit health care systems in six areas of the U.S. through the Uniformed Services Family Health Plan. These facilities are “designated providers,” offering a range of coverage at little out-of-pocket cost.
Enrollment is required and can be on an individual or family basis. Participants must live within the designated provider’s area. USFHP enrollees must agree not to use other military or government health care facilities except for emergencies or if USFHP refers the patient to such a facility.
Active-duty service members cannot enroll in USFHP.
Under the 2012 Defense Authorization Act, USFHP is prohibited after Sept. 30, 2012, from accepting new members age 65 and older. Until then, persons of any age can enroll and remain for life. New members who join after the deadline must leave the plan when they turn 65.
Beneficiaries living in a USFHP location must choose either Tricare or USFHP. Eligible beneficiaries enrolled in Tricare Prime at a military facility or with a civilian Prime provider can withdraw at any time and enroll in the Prime program offered by USFHP, and vice versa.
If beneficiaries are transferred to an area without a USFHP facility, they can withdraw and resume using military facilities, Medicare or Tricare.
Unlike in Tricare, retirees over age 65 already in the plan or who enroll before Sept. 30, 2012, do not need to have Medicare Part B to participate in USFHP. However, the Defense Department highly encourages beneficiaries to enroll in Part B when they first become eligible, to avoid Part B premium surcharges if they later move away.
If beneficiaries do not enroll in Medicare Part B when first eligible, and want to do so later, they will pay (in addition to the normal Medicare Part B monthly premium) an annual 10 percent penalty for each year they were eligible to enroll but did not. In addition, they will be able to enroll in Medicare Part B only during the general enrollment period, Jan. 1-March 31 of each year, and Part B benefits/Tricare coverage will not become effective until July 1 of that year.
USFHP operating areas:
♦Maine, New Hampshire, Vermont, upstate and western New York and the northern tier of Pennsylvania: Martin’s Point Health Care, 888-241-4556
♦Maryland, Washington, D.C., and parts of Virginia, West Virginia, Pennsylvania and Delaware: Johns Hopkins Medicine, 800-808-7347
♦Massachusetts, Rhode Island, northern Connecticut: Brighton Marine Health Center, 800-818-8589
♦New York City, Long Island, southern Connecticut, New Jersey and Philadelphia and area suburbs: St. Vincent Catholic Medical Centers, 800-241-4848
♦Southeast Texas, southwest Louisiana: CHRISTUS Health, 800-678-7347
♦Puget Sound region of Washington state: Pacific Medical Centers, 888-958-7347