Military Health: A Tour of Tricare

This article originally appeared on 28 March 2015.

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Tax time is upon us and the Affordable Care Act has once again raised its head. What does it mean for the military?  Not much, the military has TRICARE… right?

The Defense Health Agency closed all the walk-in service centers back in April for all CONUS bases but everything you need to know is available online at www.tricare.mil. The only real issue…insurance talk is a bit hard to understand and now the only one to talk to is on the phone.

So I am going to take a tour of TRICARE and let you know what you’ve got.

Active duty personnel are enrolled from the first day that they report to Basic. The only real issues for active duty are that you must obey the rules.  TRICARE works like an HMO for those who are enrolled in the Prime option.  There are two options– Prime and Standard.  Active Duty can only be Prime. Your family, spouse or children, can be Prime if enrolled, or remain on Standard. They both provide the same level of coverage.

The first and most important part is the Defense Enrollment Eligibility Report System (DEERS). DEERS is the gatekeeper. Every active duty service member should check their status and make sure their information is correct. Most problems with eligibility occur due to incorrect data. If you are not checking https://www.dmdc.osd.mil/milconnect regularly, you need too.

All active personnel are Prime but families all start out as Standard. Standard is the Fee for Service option in TRICARE. Basically a Standard eligible beneficiary can seek care at any facility that accepts TRICARE without the requirement for a referral or preapproval from the military. But they cannot make appointments to military hospitals except on space available situations. Military Emergency room visits and Pharmacy are still free.

Standard costs the patient money.  There is no enrollment fee for Standard or Prime for active duty or their families but Standard has some cost for use for the family. When a patient goes to an accepting provider, there is a one-time annual deductable that is either $50 dollars (E-4 and below) or $150 for (E-5 and above) for up to two family members.

Cutting to the chase is the Catastrophic Cap.  All active duty personnel have a Catastrophic Cap of $1000 per fiscal year. This cap protects the service member and family from out of pocket expenses for medical costs that exceed the $1000 limit.

I know I just confused you.  The first doctor visit will generate a bill and the family will have a deductable which is assessed from the bill.  Once the deductible has been met, then a percentage of the bill will be assessed. Beneficiaries on Standard will be assessed 20% of the bill until the Cap is met.  So if you have a bill for $1,000,000.00 you will only have a cost of no more than $1000.  And you will not have another bill for authorized care until the next 1 October.

It does not matter how many visits you have or how many family members have visits. Once the cap is reached for the fiscal year, TRICARE pays the bills entirely.

There is some confusion about the option called Extra. Extra is when someone using Standard receives care from a TRICARE network provider and they receive a discount for care.  The assessed charge is 15% and it is still part of the same $1000.

Prime status is the HMO option and requires enrollment for family members.  Prime is free to use but has rules. If a family is in the restricted zone of a military hospital, they will be assigned to that hospital for care. Waivers can be requested but mostly you will go where the military sends you.

Care under Prime requires preauthorization even for active duty. Patients can receive treatment at any emergency room but urgent and specialty care require preapproval.  There is only one exception; family members can seek Behavioral Health treatment for up to 8 self referred visits per fiscal year before they require a referral from their provider.

Using the Prime option, patients will be assigned to a primary care physician. Active duty personnel are assigned as directed by their unit and families are assigned by the military rules or by the TRICARE contractor that controls their area.

Under Prime status, patients need to seek all routine treatment at their assigned primary care providers.  Urgent care is provided by the military hospital unless preauthorized and emergency care can be provided by any emergency room.

If active duty or family members seek care outside of preauthorized channels, they can be liable for up to 50% of the bill, the service member can be held liable for the entire bill for their care if they go outside of channels. This is what is known as a point of service charge. The point of service charge is not covered by the Catastrophic Cap. If you break the rules the financial assessment can be up to 50% of the bill regardless of the size of the bill.

Some tips:

1. If you call for an ambulance, get in the ambulance. TRICARE will pay for an ambulance if you believe you need one. It is called layman’s rule. No beneficiary is required to know what their medical condition is, if they believe as the patient or parent that an ambulance is required, TRICARE will cover the bill so long as the patient is transported.
2. If you don’t accept transport, you can be assessed liability for the ambulance service charge.
3. TRICARE has a national Nurse Advice Line now, 800-TRICARE. 24/7 service and they can assist in getting urgent care referrals for beneficiaries who are traveling. Or call the regional contractor for your area.
4. Enrollment can be done by using the Beneficiary Web Enrollment option on www.tricare.mil or by calling the regional contractor.
5. Appointments can be made to military primary care providers using tricareonline.com.
6. Each of the regional contractors has a website that allows beneficiaries access to their referrals online and most importantly their claims information.
7. Make sure you are checking your Explanation of Benefits (EOB). TRICARE will notify you of your patient responsibility for any assessed charges submitted by providers. Do not pay a medical bill before you check with TRICARE to see if you actually owe a bill.
8. TRICARE has specific pricing and while providers may charge a higher amount, this does not mean that they will be paid that amount. Network providers know how much they will receive from TRICARE for fees.
9. If you receive a bill, check your EOB first to see what you may owe. You must address any bill you receive but addressing the bill does not mean paying it. If TRICARE does not assess any patient responsibility, you can use the EOB to refute the bill. If you need assistance call the claims at 800-403-3950. PGBA handles claims for all three TRICARE regions.
10. If there is a coding issue that results in no payment to the provider, you will need to contact the provider to submit the corrected claim.

TRICARE takes good care of the military and their families but you need to understand how to use the benefits you are provided.

FACT Sheets, which are references for specific items and fully prepared Power Point presentations are available at http://www.tricare.mil/Publications.aspx

While walk in services have been closed, units can still request beneficiary education briefings in most cases by coordinating with your local military hospital.