Well it’s official!
Your sponsor (AD spouse) has you registered in DEERS, you have your military identification with the super flattering photo and now you can now take part in military benefits. In some ways, this is really exciting! But it can also be a very confusing and frustrating process. Mostly because of TRICARE.
TRICARE…TRICARE…TRICARE…
There are a lot of benefits available to military members and their families. One of the most commonly known AND most often utilized is TRICARE: the military’s medical benefits. If you are like me, you may have a love/hate relationship with TRICARE. It isn’t always user friendly and changes frequently, which sometimes causes more headaches than not. But don’t worry! I am going to summarize everything for you, highlight the most important point, hopefully answer the most common questions and give you the information to help make your decision. Plus give you peace of mind in your selection!
There are SEVERAL options, depending on your situation. Plans include TRICARE Prime, TRICARE Prime Remote, TRICARE Select, TRICARE Retired Reserve, TRICARE Reserve Select, TRICARE Young Adult, TRICARE for Life and US Family Health Plan. The plan you are enrolled in will depend greatly on your family’s status in the military and where you live.
Active Duty service members are automatically enrolled under TRICARE Prime and pay nothing out-of-pocket for any type of care. Although there is a lot to cover with each of the different plans, the majority of active duty military families use either TRICARE Prime or TRICARE Select. So those will be the ones I cover for now. Don’t worry, I have lots to cover over this series. So here comes Part 1!
Open Season
First point I want to make is about Open Season. As of the end of 2018, TRICARE Open Season is the annual period when you can enroll in or change your health plan for the next year. It will occur each fall, beginning on the Monday of the second full week in November to the Monday of the second full week in December. There are two main things you can do during Open Season:
- Enroll in a new TRICARE Prime or TRICARE Select plan
- Change the specifics of your enrollment (e.g., from individual to family)
If you are happy with your current TRICARE health plan, you do not have to do a thing! If you are not already in a plan and do not enroll during Open Season, you will only be able to get care at a military hospital or clinic, and only if space is available.
Making Enrollment Changes Outside of Open Season
Outside of TRICARE Open Season, you can enroll in or change enrollment to TRICARE Prime or TRICARE Select if you have a Qualifying Life Event (QLE). These are usually related to military service (activating, deactivating, retirement, injury, moving, etc) or a change in your home and family life (marriage, divorced, new child, having grown children, death in family, etc). If you aren’t sure if you have had a QLC, make sure to go check out the full list HERE.
These changes may mean different TRICARE options are available to you. Any TRICARE QLE opens a 90-day period for you to make eligible enrollment changes and all family members are able to make enrollment changes, even if only one has a QLC.
Groupings
TRICARE now has enrollment benefits and costs based on two things: What plan you are enrolled into and WHEN you enrolled. Depending on the when, you land in either Group A or Group B. These groups affect your enrollment fee and out of pocket expenses.
Group A refers to active-duty members and their families who have been in before Jan. 1, 2018. Group B includes those who joined the military (and their families) after Jan. 1, 2018.
Remember what group you are in! This is important, I promise.
Now for the break downs. I could basically write a BOOK about TRICARE and all the details. In fact, I am pretty sure there are books out there just about this….isn’t there? However, I don’t want to bore you with all that mumbo jumbo. So instead, I will lay it out simply with the main points you need to know.
TRICARE PRIME
Main Points:
- A managed care option offering the most affordable and comprehensive coverage.
- Prime is offered in specific areas in the United States. This is due to care being provided primarily in military hospitals and clinics with active duty military or network providers.
- Enrollment is required (See Open Season Schedule above)
- Enrollment fees are $0 for both Group A and B.
- Most care received from your assigned primary care manager (PCM): Military or network provider
- Refers you to specialists if he/she can’t provide the care
- Urgent Care visits fully covered: Must be treated at a military hospital or clinic.
- Fewer out-of-pocket costs (no annual deductible)
- No co-pays unless Out-of-Network/Non-Network.
- Minimal Prescription Fees
- Catastrophic Cap: Group A: $1000, Group B: $1028
- No claims to file (in most cases)
- Once you have enrolled you can download a TRICARE wallet card to take to your appointments but you must also show your military ID as proof of coverage.
Now that wasn’t too bad, now was it? There are a couple things I want you to take note of with Prime. Although there are no out-of-pocket expenses for in-network care, Prime is a managed-care option. This results in required referrals, you will not always be able to choose your provider, and usually slightly longer wait times for appointments (especially for specialists).
TRICARE Select (Previously Standard)
Main Points:
- TRICARE Select is a self-managed, preferred-provider option for eligible beneficiaries not enrolled in TRICARE Prime.
- Enrollment required (See Open Season schedule above)
- No enrollment fee for Group A or Group B.
- Beneficiaries may receive enhanced TRICARE Select benefits from any TRICARE-authorized provider without a referral.
- Lower out-of-pocket costs for in-network providers verses out-of-network providers
- Although no referral is necessary, prior authorization may be required.
- Urgent Care visits require co-pay when treated at any TRICARE authorized in-network clinic. No limits on visits.
- Annual Deductible: Slightly different for Group A and Group B (See Co-Pay and Cost-Share Sheet)
- Pay Fixed Fee per service instead of percentage: Slightly different for Group A and Group B (See Co-Pay and Cost-Share Sheet).
- Catastrophic Cap: Group A: $1000, Group B: $1028 (notice it is the same whether you are Select or Prime)
- You will not receive a TRICARE wallet card when using TRICARE Select. All you need is your military ID as proof of coverage. (This is something that many providers do not understand. I can’t even tell you how many times I have been asked for my TRICARE Wallet card as a Select beneficiary)
Here is the summary for you: You may choose our own provider under Select. There are lower costs out-of-pocket if they are in-network, verses non-network, although there is a low co-pay for most medical services. You do not need a referral for a specialists, but make sure that you have authorization from TRICARE ahead of time (this isn’t difficult, but your provider will need to do the necessary paperwork and it may take a few days).
Which one should you choose??
As I mentioned before, due to resent TRICARE updates (end of 2018), no changes can be made to your TRICARE benefit enrollment until the next Open Season (unless there is a Qualifying Life Change). So if you missed the opportunity to make changes, I would recommend taking the time prior to the next Open Season to really do your research on the pros and cons for your specific family and your family situation.
What is most important to you? Do you want to manage your own care? Do you need specialists for your family members and do not want to wait for referrals? Are you able to pay the out-of-pocket co-pays required? Then Select may by the route for you!
On the the hand, if you do not want to pay out-of-pocket, are able to get care at a military medical facility and/or do not have a need for many specialists then Prime may be the best fit for you!
Whatever you choose, make sure you stay informed! Knowledge is power when it comes to our healthcare. And be sure to stay tune and sign up to know when the next in the series is available!
