(Note: The terms 'pregnancy', 'maternity', and 'care before, during and after childbirth' are used interchangeably to denote the period of time when a women first discovers she is pregnant through her six week postpartum and well baby checkup.)
Expectant mothers who are TRICARE beneficiaries have a variety of choices for receiving health care services before, during, and after childbirth. The scope of these services and their associated costs are related to beneficiary status, proximity to military treatment facility (MTF) services, and choice of TRICARE program and provider. The following is a summary of these services:
Active duty service members are expected to receive maternity services at their MTF when available. If the local MTF does not provide obstetric services, the service member's primary care physician can refer her to a civilian provider. Some MTFs provide prenatal care and postpartum care and use a local civilian hospital for the actual childbirth experience.
ADSMs enrolled in TRICARE Prime Remote may deliver their baby at a local civilian hospital that has been approved by the Regional Contractor.
ADSMs who voluntarily separate from active duty while pregnant and spouses of ADSMs are not eligible for TRICARE upon separation. They may apply for transitional medical coverage under the Continued Health Care Benefit Program (CHCBP) within 60 days following loss of entitlement in the Military Health Care System. CHCBP is a premium-based health care program. Information on CHCBP can be found at http://tricare.osd.mil/chcbp/default.cfm. ADSMs who voluntarily separate because of pregnancy may request space-available maternity care in an MTF that has obstetric capability, however, no civilian maternity care will be provided under the TRICARE Program.
ADSMs who are involuntarily separated from active duty while pregnant or the pregnant spouses of ADSMs who are involuntarily separated from active duty are eligible for health care benefits under the Transitional Assistance Management Program (TAMP). An involuntary separation is one other than one under adverse conditions. If the member desires to participate in TRICARE Prime during the TAMP period, she/he is required to re-enroll in the program for the 180 day TAMP period. Upon expiration of this benefit, these members may then enroll in the CHCBP.
Family members of active duty and retirees enrolled in TRICARE Prime may obtain maternity services from the MTF where they are enrolled, if the services are available. The Military Health System has promoted family-centered maternity care in order to provide family-friendly and better coordinated MTF care for all TRICARE beneficiaries.
If TRICARE Prime enrollees opt to disenroll from Prime and choose a doctor or midwife under TRICARE Standard, there are several factors they should consider:
TRICARE Prime enrollees who are pregnant may remain enrolled and use the TRICARE Prime Point-of-Service option to obtain their maternity care. This allows them to choose any TRICARE-authorized provider without a referral, rather than using the MTF or other TRICARE Prime network providers. However, those who choose the Point-of-Service option incur an annual $300/$600 individual/family deductible and a 50 percent cost share. This means that TRICARE beneficiaries using the Point-of-Service option could pay more than $1,000 for active duty service members and family members or $3,000 for retirees and retiree family members out of pocket in a fiscal year, as the costs do not accrue toward their annual catastrophic cap limits.
TRICARE Prime beneficiaries enrolled in civilian networks, and active duty family members enrolled in TRICARE Prime Remote should work with their PCM to obtain referrals to appropriate specialty care services and discuss delivery options with their PCM. TRICARE regional contractors (North, South, and West) will process referrals which require authorizations and coordinate them for TRICARE Prime enrollees.
Beneficiaries using TRICARE Standard may choose any TRICARE Standard authorized provider for maternity care. TRICARE Standard users are subject to annual deductibles and incur cost-shares for each episode of care. Inpatient hospital costs vary, based on length of stay and sponsor status.
For more information beneficiaries should contact their TRICARE Service Center for assistance and questions. They may also check the TRICARE Website.
1. Non-participating provider may bill the beneficiary up to an additional 15% of TRICARE allowable charges.
2. This amount is updated each fiscal year.
3. Under the Point of Service Option, there is a 50% cost-share and an outpatient deductible of $300/individual and $600/family.
For general information about TRICARE, call the toll-free TRICARE information line for your region found at the TRICARE Contact Us web page.
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