TRICARE Beneficiary Maternity Costs

TRICARE Prime

TRICARE Standard/Extra

Type of Service or Fees

Active Duty Spouse or TRICARE-Eligible Daughter

Retiree or Retiree Spouse or TRICARE-Eligible Daughter

Active Duty Spouse or TRICARE-Eligible Daughter

Retiree, Retiree Spouse or TRICARE-Eligible Daughter

Annual Fiscal Year Deductible
(applicable to
outpatient services)

$0

$0

Applicable when beneficiary chooses to deliver at home or as an outpatient, with the exception of birthing center delivery.

$50/individual or $100/ family for E-4 and below. $150/individual or $300/ family for E-5 and above.

Applicable when beneficiary chooses to deliver at home, in birthing center, or as an outpatient.

$150/individual or $300/family.

Global Maternity Care Fee (when beneficiary chooses to deliver in hospital as inpatient) -- includes prenatal care, inpatient professional services for delivery, and postnatal care

$0

$0

Standard:
$01

Extra:

Standard:
25% 1 of allowable charges.

Extra:
20% of the fee negotiated by TRICARE contractor.

Inpatient Professional Services for Newborn Care (that are not included in Global Maternity Fee such as services of pediatrician)

$0 for active duty; 100% for newborn if father is not an Active Duty or Retiree sponsor.

$11 per day; 100% for newborn if father is not an Active Duty or Retiree sponsor.

$0 as newborn is deemed enrolled in Prime for up to 60 days for cost-sharing purposes; 100% for newborn if father is not an Active Duty or Retiree sponsor.

Standard:
25% 1 of allowable charges unless the newborn is deemed enrolled in Prime.

Extra:
20% of the fee negotiated by TRICARE contractor unless the newborn is deemed enrolled in Prime.

100% for newborn if father is not an Active Duty or Retiree sponsor.

Hospital Services for Inpatient Delivery

$0

$11 per day ($25 minimum charge) for admission.

$13.90 2 per day ($25 minimum charge) for admission.

Standard:
$512/dayday per day or 25% of billed charges whichever is less.

Extra:
$250 per day or 25% of TRICARE contractor negotiated charges whichever is less.

Newborn Cost-Share for Hospital Services

$0 for active duty spouse; 100% for newborn if father is not an Active Duty or Retiree sponsor.

$11 per day ($25 minimum charge) for each newborn inpatient day billed.

 

100% for newborn if father is not an Active Duty or Retiree sponsor.

$0 as newborn is deemed enrolled in Prime for up to 60 days for cost-sharing purposes.

 

100% for newborn if father is not an Active Duty or Retiree sponsor.

Standard:
DRG HOSPITAL:
Same newborn date of birth and date of mom’s admission:
Unless the newborn is deemed enrolled in Prime, the cost-share will be the lower of the number of hospital days minus 3 multiplied by $512/dayday OR 25% of billed charges.

Standard:
DRG HOSPITAL:
Same newborn date of birth and date of mom’s admission:
Different newborn date of birth and date of mom’s admission: Unless the newborn is deemed enrolled in Prime, the cost-share will be the lower of hospital days for the newborn multiplied by $512/dayday OR 25% of billed charges.

DRG EXEMPT HOSPITAL: 25% of allowed charges unless the newborn is deemed enrolled in Prime.

Extra:
Same newborn date of birth and date of mom’s admission:
Unless the newborn is deemed enrolled in Prime, the cost-share will be the lower of the number of hospital days minus 3 multiplied by $250 OR 25% of TRICARE contractor negotiated charges.

Different newborn date of birth and date of mom’s admission:
Unless the newborn is deemed enrolled in Prime, the cost-share will be the lower of hospital days for the newborn multiplied by $250 OR 25% of TRICARE contractor negotiated charges.

100% for newborn if father is not an Active Duty or Retiree sponsor.

Professional Services Fee When Beneficiary Chooses to Deliver at Home or as an Outpatient

$0 for mother; 100% for newborn if father is not an Active Duty or Retiree sponsor.

$12 per visit for mother; 100% for newborn if father is not an Active Duty or Retiree sponsor.

Standard:
20%1 of the allowable charge for mom. $0 for newborn as the newborn is deemed enrolled in Prime for up to 60 days for cost-sharing purposes.

Extra:
15% of the fee negotiated by TRICARE contractor for mom. $0 for newborn as the newborn is deemed enrolled in TRICARE Prime for up to 60 days.

Standard: 25%1 of the allowable charge for mom.
Unless the newborn is deemed enrolled in Prime, 25% of the allowable charge for services of the newborn’s provider if any.

Extra: 20% of the fee negotiated by TRICARE contractor, for mom.
Unless the newborn is deemed enrolled in Prime, 20% of the fee negotiated by TRICARE contractor for services of the newborn’s provider if any.

Prenatal Care, Outpatient Delivery, and Postnatal Care Provided by TRICARE Authorized Birthing Center (All Inclusive Rate)

OR

Maternity Care Ending in Childbirth in Hospital-Based Outpatient Birthing Room

$0

$25

$25

Standard:
25% of allowable charges.

Birthing Center: Lesser of 25% of birthing center rate or 25% of billed charge.

Hospital-Based Outpatient Birthing Room:
25% of billed charges.

Extra:
20% of the fee negotiated by TRICARE contractor.