Tricare for Military

Almost 10 million active-duty members of all military services, plus military retirees, and their families are covered by TRICARE, the military health system that provides benefits and options at a cost lower than most civilian health care plans with comparable benefits offerings.

What is TRICARE?

It might help to understand what TRICARE is if we first explain why it’s called TRICARE. Back in 1993 when the Department of Defense established TRICARE, it combined the medical programs of the Army, Air Force and Navy into one.

Now, as a part of the Pentagon’s Defense Health Agency, TRICARE provides health insurance managed by the government by combining the military’s health care resources with a network of civilian health care professionals. That means military hospitals and clinics work together with civilian contractors such as pharmacies and suppliers to provide health care benefits to the nation’s service members, veterans, retirees, and their dependents around the world.

It offers comprehensive health coverage, including prescription drugs, both at military care facilities and from a network of TRICARE civilian providers. If necessary, the program’s benefits can also be accessed through non-network providers as long as they are authorized by TRICARE.

TRICARE is available worldwide but is divided into three regions, each of which is managed by its own contractor. Nationally, there is TRICARE East (currently managed by Humana Military) and TRICARE West (currently managed by Healthnet Federal Services.) The Overseas region is managed by International SOS.

If you are on active duty, a TRICARE Prime plan is the only coverage available to you, and it comes with few costs. Other levels of military status offer options to carry private insurance or be covered through an employer along with a TRICARE plan, but in those cases TRICARE will only pay your costs after your other insurance has exhausted its benefits coverage.

There are two kinds of beneficiaries in TRICARE.

• Sponsors are covered active duty, retired and Guard/Reserves members of the military.
• Family members are the covered dependents of sponsors.

TRICARE splits its members into two groups depending on when the enlistment or appointment of the sponsor began. Group A members’ enlistment or appointment began before Jan. 1, 2018. Group B includes those whose enlistment or appointment began on or after Jan. 1, 2018. In some cases, enrollment fees and out-of-pocket costs are determined by which group a member is in.

Though active-duty service members must all be covered by a specific TRICARE Prime plan, TRICARE offers several other health care plan options for other eligible members of the military community and their families. Which plans are available and best for you depends on your sponsor status (active duty, separated from service, or retired), how you want to manage your health care, and, in some cases, where you live.

TRICARE Prime

TRICARE Prime is mandatory for all active-duty personnel who live or are stationed in a designated service area. It works like a health maintenance organization (HMO), in which each member has a primary care manager (PCM) and must go through that person for a referral to a specialist.

Here’s perhaps the best part: As long as the referral rules are followed, TRICARE Prime is provided to active-duty families at no charge. (Retired military covered under TRICARE Prime are charged an annual membership fee and are required to make fixed-dollar co-payments for a covered service or drug.)

And here’s another nice element to TRICARE Prime: The primary care manager files the claims for patients, alleviating much of the healthcare paperwork burden.

A couple of downsides: 1) Unlike civilian HMOs in which the member can choose his or her primary care physician, TRICARE Prime assigns the primary care manager to active-duty personnel. 2) In most cases, coverage under a TRICARE Prime plan means treatment must occur at a military facility rather than a civilian hospital. So, while it is the least expensive TRICARE coverage, Prime is also the most restrictive.

Even though active-duty service members are automatically covered by one of TRICARE Prime’s four different health plan options (including the standard coverage in a designated Prime service area), they still must choose one of the four plans and enroll in the program.

If the member doesn’t live in a Prime service area, the other TRICARE Prime options are:

• TRICARE Prime Remote. This plan services military members and their families on remote assignment. If the member lives and works more than 50 miles (or an hour’s drive) from the nearest Military Treatment Facility (MTF), Prime Remote offers health care through nearby civilian providers. It is available only in the U.S.
• TRICARE Prime Overseas. This plan offers the benefits of TRICARE Prime to eligible members of the military stationed outside the U.S. If the member needs a referral to a specialist, their primary care manager works through a contractor authorized by TRICARE to provide foreign services.
• TRICARE Prime Remote Overseas. As with the domestic Prime Remote coverage, this plan is for eligible members who aren’t near a Military Treatment Facility during their overseas assignment. As with Prime Overseas, a member’s primary care manager can make a specialist referral to a TRICARE-authorized foreign provider.

Each of the TRICARE Prime options also offers specialized plans tailored to young adults. The TRICARE Prime umbrella also includes a separate plan for family members of military personnel, called the U.S. Family Health Plan. We’ll get to both of those options a little later. 

For active-duty military, there are no enrollment or co-pay fees for any of the Prime plans, including remote and overseas, as long as the member receives care from his or her PCM or PCM-referred specialist.

TRICARE Select

Unlike the HMO model in TRICARE Prime, TRICARE Select operates like a preferred provider organization (PPO) in which program members can choose their own primary care manager or even elect not to designate a specific PCM.  Enrollees in TRICARE Select can also choose the specialists they wish to use rather than needing a specific referral from their primary care manager.

That might make TRICARE Select a better option for those who want more control over their healthcare plan (though that control will include the claim-filing paperwork when the patient sees a PCM or specialist who isn’t in the TRICARE network).

While TRICARE Prime is the only option available to active-duty members of the military, their family members — as well as retirees and veterans and their families — have the option of enrolling in TRICARE Select.

Depending on the sponsor’s military status, there are some higher out-of-pocket costs to TRICARE Select. Those can include co-pays for covered services, annual deductibles, cost-shares (a percentage of the provider’s regular fee), and  – for some eligible members – an annual enrollment fee. (The enrollment fee is waived for active-duty family members, medically retired retirees and their family members, and survivors of an active-duty sponsor or medically retired retiree.)

If you are eligible and don’t live in an area where TRICARE Prime is available, TRICARE Select might make sense as your health-care plan. You can also use TRICARE Select in conjunction with an employer-sponsored plan or other health insurance.

As with TRICARE Prime, TRICARE Select offers a plan for eligible members of the military and their families who live overseas. TRICARE Select Overseas operates with a slightly different cost system, the most significant of which is that a patient must pay up front for the service provided and then file a claim for reimbursement.

TRICARE Reserve Select

Available to Selected Reserve (members of a Ready Reserve unit, including National Guard), TRICARE Reserve Select offers the same services found in TRICARE Select, including the ability to choose  a primary care manager. A patient can see any TRICARE-authorized provider, including specialists, without a referral. It’s available around the world.

The out-of-pocket costs for co-pays, deductibles and cost-shares are similar to TRICARE Select. In addition, TRICARE Reserve Select charges its members a monthly premium. However, the cost for eligible members generally is still lower than under a civilian health-care plan with comparable benefits.

TRICARE Retired Reserve

Retired National Guard/Reserves and their families under the age of 60 are eligible for the TRICARE Retired Reserve plan, which is also available worldwide. It functions like TRICARE Reserve Select, though the out-of-pocket costs (co-pays, deductibles, cost-shares) are slightly higher and the monthly premiums can be substantially higher.

One of the reasons this plan might make sense for a Reserve retiree is that it is available immediately upon retirement, meaning you don’t have to wait until your retired pay kicks in at 60 to buy into the plan. In fact, TRICARE Retired Reserve stops its coverage when an enrollee turns 60 and becomes eligible for TRICARE Prime or TRICARE Select.

TRICARE U.S. Family Health Plan

This plan is an option under the TRICARE Prime umbrella that provides coverage to military families for routine doctor visits, specialty care, hospitalization, urgent care, prescriptions and more. Like other TRICARE Prime plans, it operates like an HMO in which each member has a primary care provider (PCP). But unlike Prime, which assigns a PCP to active-duty personnel, TRICARE U.S. Family Health Plan allows family members to choose a PCP from the system’s network of private doctors. Plus, all the care it provides comes from local not-for-profit civilian facilities rather than Military Treatment Facilities.

For family members of active-duty personnel, there is no enrollment fee and no out-of-pocket costs as long the care comes from a provider in the plan’s network.

Others in the military community are eligible to enroll in the U.S. Family Health Plan — including retired service members and their families, family members of Activated National Guard/Reserve, retired National Guard/Reserve members at age 60 and their families, and more – but they pay an annual enrollment fee and network co-payments.

The U.S. Family Health Care Plan isn’t available everywhere, though. It serves six regions of the country. If you don’t live in one of those designated areas, you can’t get access to it. 

TRICARE For Life

Available to Medicare-eligible military retirees and their dependents who have Medicare Part A and B, TRICARE For Life is a benefit program that pays medical expenses as a supplement to Medicare. It can also pay for some services not covered by Medicare for retirees, or when a member’s Medicare benefits have been used up.

If you have Medicare Part A and B and are otherwise eligible, you are automatically covered by TRICARE For Life without enrolling. However, you must continue to pay Medicare Part B premiums.

In the U.S. and U.S. territories, TRICARE For Life payments kick in after Medicare’s coverage limit has been reached. For members living overseas, TRICARE For Life is the first payer.

TRICARE Young Adult

A young person’s eligibility for TRICARE dependent coverage ends at age 21 or, if he or she is enrolled in college, 23. At that point, TRICARE Young Adult coverage is available to unmarried children of eligible sponsors until they turn 26, assuming they can’t enroll in a health plan through their job.

The plan provides comprehensive medical and pharmacy benefits on a cost scale determined by the sponsor’s military status, where the care is received, and whether the young adult enrolls in a TRICARE Prime plan or a TRICARE Select plan.

TRICARE Benefits

As we’ve outlined, there are numerous TRICARE health plan options from which to choose. Because each plan provides different coverage for different reasons, finding the right fit is important. Determining the most appropriate option for each individual is a function of the eligible sponsor’s status (active duty, separated from service, retired, overseas, or a member of the National Guard or Reserves) and several other factors.

By answering a series of questions at the Plan Finder on the TRICARE website, you’ll be able to determine your eligibility for specific plans.

Who you are and what plan you choose will determine how to book appointments, what requirements are needed for referrals and authorizations, and how much your out-of-pocket costs will be.

Remember, there are two types of beneficiaries: sponsors (active duty, retired and Guard/Reserve members) and family members (spouses and children registered in the Defense Enrollment Eligibility Reporting System, known as DEERS). But all TRICARE plans offer their beneficiaries comprehensive coverage that includes:

• Outpatient visits
• Hospitalization
• Preventive services
• Maternity care
• Reproductive health
• Immunizations
• Mental/behavioral health services
• Prescription drug coverage
• Special needs

Vision and dental coverage are available to eligible TRICARE beneficiaries through the Federal Employees Dental and Vision Insurance Program (FEDVIP), with 23 dental plans and 10 vision plan options.

In addition, some TRICARE beneficiaries can benefit from programs for specific health care needs, including:

• Smoking cessation
• Weight loss
• Cancer treatment
• Chiropractic care

Who is Eligible for TRICARE?

Although there are specific eligibility requirements for each plan, most members of the military community and their families can be covered under TRICARE’s options.

Active-duty members and their families in the Army, Navy, Air Force, Marines, Coast Guard, National Oceanic and Atmospheric Administration, and Public Health Service are eligible, as are National Guard/Reserve members and their families.

Retired service members and their families, and retired Reserve members and their families are eligible.

Medal of Honor recipients and their families are eligible. Survivors are eligible. Former spouses are eligible.

Unmarried biological, step- and adopted children of an eligible sponsor can be covered by TRICARE until they turn 21 (or 23 if they’re in college), and their eligibility can be extended beyond that age limit if they are severely disabled. After they turn 21 or 23, children can qualify for the TRICARE Young Adult plan.

TRICARE also has a plan available to cover dependent parents and parents-in-law of eligible sponsors who have been on active duty for more than 30 days. And Foreign Force members and their families can also receive health services through TRICARE, though their eligibility depends on the type of agreement their country has with the Department of Defense.

TRICARE Coverage for Dependents 

We’ve already told you that active-duty personnel can only enroll in one of the four TRICARE Prime options. Their dependents can also be covered under a Prime plan, but they might qualify for less-restrictive plans as well.

Whether you’re looking to maximize a military benefit for your child or a military benefit for your spouse, the right choice of a TRICARE plan is important.

For example, TRICARE Select, which allows a child or spouse of an active duty sponsor to see any authorized provider and choose the specialist of their choice, is the most flexible option. The U.S. Family Health Plan gives those family members who live in one of the six U.S. regions where it is available access to civilian health-care services such as routine doctor visits, hospitalization, and prescriptions.

In most cases, TRICARE Prime plans offer services only at military treatment facilities, so one of the other options might be more workable for dependents of a sponsor.

The basic comprehensive TRICARE benefit coverage provides several services and special programs for dependent children with special needs. And children whose sponsor died while on active duty can remain covered by TRICARE until they age out (at 21 or 23) or lose their eligibility through marriage or other reasons.

As we mentioned earlier, dependent parents and parents-in-law can also be covered by TRICARE.

How Much Does TRICARE Cost?

The cost of TRICARE varies from plan to plan, and specific expenses depend on the type and frequency of medical treatment needed, the status of the sponsor, the sponsor’s enlistment or appointment date (Group A or Group B) and other factors.

For a general cost comparison, though, here are a handful of plans that account for a range of ages of beneficiaries. In an effort to compare apples to apples, the costs in each case here are for an active-duty sponsor in Group B (those whose enlistment or appointment began on or after Jan. 1, 2018.)

TRICARE Prime:

• No enrollment fee
• No deductible
• No cost for outpatient visits, urgent care, emergency services, X-Rays, ambulance or any other healthcare service including mental health, maternity delivery, newborn care, skilled nursing and more. Active duty service members pay nothing out of pocket for any type of care. Their family members only pay for care when they use a pharmacy home delivery service or get care without a referral.

TRICARE Select:

   * No enrollment fee

   * Deductibles ranging from $56 to $168 for individuals, and from $112 to $336 for families.

   * No out-of-pocket costs for X-Rays, hospice care, immunizations, newborn care and other services.

   * Out-of-pocket costs ranging from $16 to $67 per visit or service for some health-care needs, such as outpatient visits, emergency services, ambulance, maternity delivery, mental health, hospitalization and skilled nursing.

TRICARE Young Adult Select:

• $265 per month enrollment fee/premium
• Deductibles ranging from $56 to $168 for individuals, and from $112 to $336 for families.
• Out-of-pocket costs are identical to TRICARE Select.

TRICARE FOR LIFE:

• No enrollment fee
• Deductibles ranging from $50 to $150 for individuals, and from $100 to $300 for families.
• No out-of-pocket costs for any type of health care if covered by both Medicare and TRICARE.

How to Enroll for TRICARE

You must be registered in DEERS to get TRICARE benefits. It’s what determines your eligibility status. Active-duty and retired service members are automatically registered in DEERS, but they are responsible for registering their family members for access to TRICARE.

Then it’s time to decide which option is right for you and enroll in a TRICARE plan.  You’ll need to download an application form, which you can do from this page on the TRICARE website.

If you’re new to active duty, you can only enroll in TRICARE Prime or TRICARE Prime Remote. If you’re a family member of someone new to active duty, you’ll be automatically enrolled in TRICARE Prime assuming you reside in a Prime Service Area. The effective date of your coverage is based on your eligibility in DEERS, and you’ll have 90 days from then to decide if you want to stay enrolled in Prime or switch to TRICARE Select coverage.

There are three ways to enroll in TRICARE Prime or TRICARE Select:

• Through the Beneficiary Web Enrollment (BWE) tool on milConnect.
• By mailing or faxing a TRICARE Select Enrollment Form.
• By phoning the appropriate regional TRICARE office.

If you live overseas, you can only enroll by phone, mail or in person at a Service Center.

You can use one of the three enrollment options listed above to  dis-enroll, as well.

Other plans (besides Prime and Select) may have slightly different enrollment procedures. Each is outlined here.

For anyone already enrolled in or eligible for TRICARE Prime or TRICARE select, TRICARE’s Open Season for enrollment and changes in coverage is in the fall. It runs from the Monday on the second full week in November to the Monday of the second full week in December. You can switch plans, enroll in a Prime or Select plan or – if you don’t do anything – stay in the plan you currently have during the Open Season.

However, at other times of the year, changes in TRICARE coverage can be made in response to significant life events such as marriage, the birth of a child, or retirement from active duty – as long as the enrollment changes are made within 90 days of the Qualifying Life Event.