Understanding TRICARE Prime

Most servicemembers agree that TRICARE is the most confusing military benefit. Choosing the right TRICARE Plan is a difficult and daunting task. The following information will explain the key factors you need to know to choose the best program for your family. These factors include:

Prime Features
The Point of Service Option
Prime Pros and Cons
TRICARE Cost Comparison
Helpful Hints

Note: All active duty servicemembers are automatically enrolled in TRICARE Prime and receive most of their care from military medical personnel. For active duty families, there is no enrollment fee for TRICARE Prime , however they must complete an enrollment form to select Prime as their coverage plan.

With TRICARE Prime, most health care will come from a military treatment facility (MTF), along with the TRICARE contracted Civilian Medical Providers called Preferred Provider Network (PPN).

Primary Care Manager
Your Primary Care Manager (or team of providers) will see you first for your health care needs. The Primary Care Manager:

• Provides and/or coordinates your care
• Maintains your health records
• Refers you to specialists, if necessary (To be covered, specialty care must be arranged and approved by your Primary Care Manager)

Care is usually provided in a military treatment facility, but civilian clinics may be used in some cases.

Point of Service (POS) Option
The POS Option under TRICARE Prime allows enrollees the freedom to seek and receive non-emergency health care services from any TRICARE authorized civilian provider, in or out of the TRICARE network, without requesting a referral from their Primary Care Manager (PCM) or the Health Care Finder (HCF). When Prime enrollees choose to use the POS option, all requirements applicable to TRICARE Standard apply except the requirement for a Nonavailability Statement (NAS).

However POS claims are subject to outpatient deductibles ($300 individual and $600 family), 50% cost-shares for outpatient and inpatient claims, and excess charges up 15% over the allowed amount. The 50% cost-share continues to be applied even after the Enrollment Year catastrophic cap has been met.

TRICARE Prime - Advantages

• No enrollment fee for active duty and families
• Small fee per visit to civilian providers, and no fee for active duty members
• No balance billing
• Guaranteed appointments (access standards)
• Primary care manager supervises and coordinates care
• Away-from-home emergency coverage
• Point-of-Service option
• Reduced catastrophic cap for retirees ($7,500 now decreased to $3,000)

TRICARE Prime - Disadvantages

• Enrollment fee for retirees and their families
• Provider choice limited
• Specialty care by referral only
• Not universally available

TRICARE Cost Comparison at a Glance
The following tables provide examples of cost-shares or copayments for families who use civilian providers and facilities under each of the three TRICARE options. The listed fees are subject to change.

Active Duty Family Members:

TRICARE Prime TRICARE Extra TRICARE Standard Annual Deductible None $150/individual or $300/family for E-5 & above; $50/$100 for E-4 & below $150/individual or $300/family for E-5 & above; $50/100 E-4 below Annual Enrollment Fee None None None Civilian Outpatient Visit No cost 15% of negotiated fee 20% of allowed charges for covered service Civilian Inpatient Admission No cost Greater of $25 or $13.90/day Greater of $25 or $13.90/day Civilian Inpatient Mental Health No cost $20/day $20/day Civilian Inpatient Skilled Nursing Facility Care $0 per diem charge per admission No separate co-payment/cost-share for separately billed professional charges $11/day ($25 minimum) Charge per admission $11/day ($25 minimum) Charge per admission

Retirees (under 65), Their Family Members, and Others

TRICARE Prime TRICARE Extra TRICARE Standard Annual Deductible None $150/individual or $300/family $150/individual or $300/family Annual Enrollment Fee $230/individual $460/family None None Civilian Copays 20% of negotiated fee 25% of allowed charges for covered service Outpatient Emergency Care Mental Health Visit $12  $30  $25    $17 (group visit) Civilian Inpatient Cost Share $11/day ($25 minimum) Charge per admission Lesser of $250/day or 25% of negotiated charges plus 20% of negotiated professional fees Lesser of $512/day or 25% of billed charges plus 25% of allowed professional fees Civilian Inpatient Skilled Nursing Facility Care $11/day ($25 minimum) charge per admission $250 per diem co-payment or 20% cost-share of total charges, whichever is less, institutional services, plus 20% cost-share of separately billed professional charges 25% cost-share of allowed charges for institutional services, plus 25% cost-share of allowable for separately billed professional charges. Civilian Inpatient Mental Health $40 per day 20% of institutional & negotiated professional fees Lesser of $169/day or 25% of allowable fees

SUMMARY -- Tricare Prime
Guaranteed access to timely medical care

• Priority for care at military hospitals and clinics
• Primary Care Manager provides and guides health care delivery
• Lowest cost for treatment among three options
• Requires enrollment for one year
• Retirees pay enrollment fee
• Very expensive to receive care outside Tricare Prime (Point-of-Service Option)
• Not available everywhere

Helpful Hints :

• Sponsors should ensure their family members have up-to-date uniformed services identification cards, and that they are properly enrolled in the Defense Enrollment Eligibility Reporting System (DEERS).*
• Beneficiaries may find that the closest MTF is outside their area. In that case they will be enrolled in TRICARE Prime Remote .
• Beneficiaries may be required to file their own claims when using TRICARE Standard . Beneficiaries may find more information about filing claims and download claims forms on the TRICARE Web site at www.tricare.osd.mil/claims/default.htm .
• Although TRICARE Standard beneficiaries have a lower priority for access to care in MTFs than TRICARE Prime enrollees, Standard beneficiaries may attempt to receive their care from an MTF. This will save money and paperwork.

*See also:
TRICARE Regional Managed Care Support Contractor Fact Sheet
Defense Enrollment Eligibility and Reporting System Fact Sheet

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