TRICARE provides high-quality health care to almost 10 million active duty service members, retirees, and their families. Its costs are expected to rise as a result of fewer deaths but more injuries in war, retirees living longer and using more services, and the Affordable Care Act’s minimum essential coverage (MEC) requirement. Currently, TRICARE offers a wide range of options: HMO-type managed care plans that coordinate all care through a primary care manager or provider with relatively low out-of-pocket costs; PPO-type plans that allow enrollees to choose from a wide network of authorized providers at a lower cost than an HMO plan; and a supplemental Medicare Part D plan called TRICARE for Life, available only to those eligible for Medicare.
Enrollment and monthly fees vary by plan type and sponsor status but are generally less expensive than a comparable civilian plan. Those fees include an enrollment fee, copays, and deductibles. TRICARE Standard is a traditional fee-for-service program that does not limit choice of care providers or require beneficiaries to select a PCM. Its annual deductible and cost share are based on the service member’s status and pay grade. Doctors who participate in TRICARE agree to accept as full payment the amount that TRICARE allows for a particular service or supply. Those who do not participate are free to refuse to treat TRICARE patients.
How Do I Qualify for TRICARE?
TRICARE eligibility is based on military branch, family status, and the type of health care coverage plan. The TRICARE website offers several tools to help determine eligibility, including the TRICARE Eligibility Checker and the TRICARE Comparison Tool. TRICARE coverage includes preventative services, mental health care, pharmacy and dental services, drug benefits, and specialty programs. TRICARE also provides health care coverage in some overseas locations.
Depending on the TRICARE plan, active-duty members may not have any out-of-pocket charges or claims to file when seeing their PCM at MTFs. Retirees and their family members typically pay copays when visiting a non-military provider, have annual deductibles to meet, and cost share rules to follow. In some cases, the TRICARE plan you choose can affect your military retirement pay and spousal benefit.
If you have other health care coverage through an employer or the health insurance marketplace, TRICARE is secondary and will cover only medical services that are not covered by your other health coverage. It’s important that you keep your information up-to-date in the Defense Enrollment Eligibility Reporting System (DEERS) to avoid any gaps in coverage.
If you are a retired service member, you can enroll in premium-free TRICARE Standard or TRICARE For Life. All other beneficiaries must buy access to Medicare Part B. This helps you meet the Affordable Care Act (ACA) requirement of having minimum essential coverage and may help you avoid paying a penalty fee.
TRICARE For Life
TRICARE for Life is the name of the Medicare-wraparound option available to TRICARE beneficiaries who are also eligible for Medicare. TRICARE For Life (TFL) offers the same health care coverage as Medicare, but without cost-sharing and with an automatic Medicare Part D drug benefit enrollment. It includes prescription drug coverage through a mail-order system (TRICARE Pharmacy Home Delivery), on-base pharmacies, and a network of retail pharmacists. The TFL handbook has detailed information on coverage and costsPDF.
Generally speaking, TRICARE for Life is the last payer when someone is covered by both Medicare and TRICARE. Generally, a provider will bill Medicare first, and then TRICARE for Life will pay its share. This minimizes out-of-pocket expenses for a beneficiary and reduces paperwork. However, there are some exceptions.
Medicare pays first for services received outside of the United States and its territories (American Samoa, Guam, Northern Mariana Islands, Puerto Rico, U.S. Virgin Islands). When this happens, a provider must submit the claim to Medicare. Medicare will then process the claim and forward it to TRICARE for Life.
To ensure the most accurate billing, TRICARE for Life requires that beneficiaries take both their military ID and Medicare card to providers when seeking medical care. This is to verify that the TRICARE for Life benefits are being used. It is also recommended that beneficiaries always have a copy of their DEERS record on them.
What’s my TRICARE plan?
TRICARE combines the military health system with a network of civilian health care professionals, hospitals, clinics, and pharmacies to foster, protect, sustain, and restore the health of service members, their families, survivors, and retirees worldwide. TRICARE provides comprehensive medical, dental, and pharmacy coverage with relatively low out-of-pocket costs compared to many civilian health plans.
The TRICARE program has both HMO (managed care) plan options, such as TRICARE Prime and Select Overseas, and PPO options, including TRICARE Reserve Select and TRICARE Young Adult. In addition, TRICARE offers an alternative health insurance program called TRICARE Supplemental Insurance (TSI). TSI is similar to traditional private supplemental insurance that is purchased by individuals and sold through brokers.
Beneficiary costs vary by the type of TRICARE health plan selected and the beneficiary group, such as active-duty service members or retirees and their dependents. For example, the annual deductibles that TRICARE Standard and Select enrollees pay for non-emergency care are $300 per individual or $600 per family, respectively. TRICARE Prime enrollees who use the POS option have the freedom to visit any authorized network provider for covered services without a referral from their PCM, although TRICARE Standard rules still apply, such as cost-sharing.
When TRICARE beneficiaries choose to visit a civilian provider outside the TRICARE network, they pay a higher cost-share for the service and typically have to submit a claim to be reimbursed by TRICARE. The TRICARE Compare Cost tool allows you to compare costs for each TRICARE plan option.