TRICARE
Benefits for Activated Reservists, National Guard and Their Family Members
Healthcare
& TRICARE
Families of activated reservists
and National Guard members become eligible for healthcare benefits under
TRICARE Standard or TRICARE Extra on the first day of the military sponsor's
active duty, if his or her orders are for a period of more than 30 consecutive
days of active duty, or if the orders are for an indefinite period.
TRICARE STANDARD
TRICARE Standard is the former CHAMPUS program with a new name. Benefits under TRICARE Standard are the same as they were for CHAMPUS.
For active-duty families, TRICARE Standard pays 80 percent of the TRICARE allowable charge for covered healthcare services that are obtained from authorized, non-network, civilian healthcare providers. Those who receive the care are legally responsible for the other 20 percent of the allowable charge, plus other charges billed by "non-participating" providers, up to the legal limit of 15 percent above the allowable charge. Providers who "participate" in TRICARE accept the TRICARE allowable charge as the full fee for the care they provide.
Persons who use TRICARE Standard or Extra pay annual deductibles for outpatient care of $150 for one person and $300 for a family (for active-duty military sponsors who are E-4 and below, the amounts are $50 for one person, and $100 for a family). TRICARE Extra features discounted cost-shares (15 percent of negotiated fees) when TRICARE network providers are used.
Families of Reserve and National Guard members who are called to
active duty for 179 days or more may enroll in TRICARE Prime, if they live
where Prime is available. Family members of reservists and National Guard
activated on indefinite orders cannot enroll in TRICARE Prime until the 179th
day of active duty. Until the 179th day, these families are eligible for the
TRICARE Standard and Extra options. TRICARE Prime enrollment will not be
retroactive. There are no enrollment fees for active-duty family members. But
enrollment forms must be completed, and military treatment facilities and/or
TRICARE Prime network providers must be used.
Enrollees do not have to pay for care at military treatment facilities, but they will be charged $12 copayments ($6 if the military sponsor is E-4 or below) when they use civilian network providers.
Since many Reserve families may have continuing relationships with providers who are not in the TRICARE networks, enrolling in TRICARE Prime (and thereby having to use only providers who are part of the TRICARE Prime network) may not be the best choice for these families. TRICARE Standard may work better for them.
Also, persons who are covered by other health insurance (such as a civilian employer's health plan) should be aware that TRICARE pays after those plans have made their payments for healthcare services. The only time TRICARE is not second payer is when Medicaid (a public assistance program) is involved, or if the patient has a healthcare insurance policy that is specifically designated as a TRICARE supplemental policy. In those cases, TRICARE pays before the other insurance.
TRICARE Standard users should ensure the provider from whom they seek health care has been certified by the regional TRICARE contractor as an authorized provider of care for TRICARE patients (check with the provider or with the regional TRICARE contractor). If they receive services from a provider who is not authorized, the cost of services, even though they might otherwise be covered by the program, will not be shared by the government.
TRICARE Dental Program (TDP)
Beginning February 1, 2001, Reservists and their family members are eligible for the TRICARE Dental Program, the same comprehensive, worldwide dental program that was previously available only to active duty family members. The TDP will be available to Reservists and family members in both the CONUS or “Continental United States” (the 50 United States, District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands) and the OCONUS or “outside the Continental United States” (all other areas) service areas.
Whether your goal is to maintain readiness for yourself or to provide affordable, quality dental coverage for your family, the TDP is dental plan for you.
Eligibility
The TDP is a voluntary program available worldwide to members of the Select Reserve and Individual Ready Reserve (IRR) and their eligible family members. Unlike the previous TRICARE Selected Reserve Dental Plan, the TDP allows you to select coverage for your family member in addition
DEFENSE ENROLLMENT ELIGIBILITY
REPORTING (DEERS)
Activated reservists and National Guard members should check with their Reserve centers or unit commanding officers to make sure that all information about them and their family members is current and accurate in the Defense Enrollment Eligibility Reporting System data base. Incorrect information can result in delayed claims processing, problems with the use of retail pharmacies and the National Mail Order Pharmacy benefit, and other difficulties. For information about DEERS enrollment, contact the DEERS Telephone Center from 6 a.m. to 5 p.m. Pacific Time, toll-free, at (800) 334-4162 (California only), (800) 527-5602 (Alaska and Hawaii only), or (800) 538-9552 (all other states).
If you're an activated reservist or National Guard member, you can get more information about your family's TRICARE Standard benefits from the TRICARE Standard Handbook. To get one, check with your nearest uniformed services hospital or clinic, or any TRICARE Service Center. Or, write to the TRICARE Management Activity, 16401 E. Centretech Pkwy., Aurora, CO 80011-9043.
ADDITIONAL INFORMATION
TRICARE regions have toll-free information lines. These numbers can be accessed from the TRICARE web site at http://www.TRICARE.OSD.MIL or you may reach them as indicated below: You can also get information from the.
TRICARE REGION
- Northeast (888) 999-5195
- Northwest (800) 404-0110
- Southeast (800) 444-5445
- Central States (888) 874-9378
- Heartland (800) 941-4501
- Southwest (800) 406-2832
- Gulf South (800) 444-5445
- Mid-Atlantic (800) 931-9501
- Northern Calif./Golden Gate/Southern Calif./Hawaii/Alaska (800) 242-6788
- Pacific/Puerto Rico/Latin America/Canada/Europe (888) 777-8343
Frequently Asked Questions
- As a reservist, when are my family members and I eligible for TRICARE?
As a reservist, you and your family members are eligible for TRICARE when you become activated and are issued orders sending you to active duty for a period of more than 30 consecutive days, and when you retire from Reserve status and are age 60.
- What are my health plan options available under TRICARE?
For eligible beneficiaries, the TRICARE program offers a triple-option healthcare plan.
TRICARE Prime is the managed care option offered by the Department of Defense. It integrates military and civilian health care into a single delivery system. Beneficiaries who choose this option agree to a one-year enrollment. Enrollees selecting this option choose a primary care manager to provide or arrange for their healthcare needs. The TRICARE Prime option offers additional wellness and preventive care services. There is no annual deductible when you are enrolled in Prime.
TRICARE Extra is similar to TRICARE Standard but offers discounts to patients when they use TRICARE network providers. This option allows beneficiaries to receive their care from civilian network providers at a reduced cost compared to TRICARE Standard. There are no claim forms to file; you just pay your reduced copay after satisfying the deductible. You may use a combination of the TRICARE Extra and Standard programs at any time, depending on whether you choose physicians inside or outside the network. There is no enrollment requirement for this program.
TRICARE Standard is a fee-for-service option that is the same as the standard CHAMPUS benefit. Beneficiaries using this option have the greatest choice of civilian physicians, but at a higher cost. The cost of having this choice includes a deductible, plus a percentage of subsequent charges, called copayments or copays. Enrollment is not a requirement to participate.
- Will my family members need to choose between the three TRICARE options?
This depends on the length of time for which your active duty orders have been issued.
If you, the sponsor, have been issued orders for a period of more than 30 consecutive days, your eligible family members may choose to receive health care through the Military Health System. In the Military Health System your family member will have access to the benefits included in two TRICARE health plan options, TRICARE Standard (CHAMPUS), and if available, TRICARE Extra. To help in the decision, an assessment of your family's healthcare needs and the healthcare delivery options for which they qualify will assist them in choosing an option that best meets their healthcare and cost needs.
If your have been issued orders for 179 days or more, your family members have the option to enroll in a third TRICARE option, TRICARE Prime, if available in your area. Family members of reservists and National Guard activated on indefinite orders cannot enroll in TRICARE Prime until the 179th day of active duty. Until the 179th day, these families are eligible for the TRICARE Standard and Extra options. TRICARE Prime enrollment will not be retroactive.
- Which option is the best choice for me if I don't live close to a military treatment facility?
If you were able to enroll in the TRICARE Prime program, this would be the most cost-efficient option for you. If there is not a Prime program serving your area, you can still save money by participating in the TRICARE Extra program by using a civilian network provider. TRICARE Service Centers have lists of TRICARE Extra network physicians. If TRICARE Extra is not available in your area, you will have to use TRICARE Standard.
- How can I enroll in TRICARE Prime?
If you are on active duty you will be enrolled in TRICARE Prime automatically and assigned a primary care manager. Other categories of beneficiaries can enroll on a voluntary basis either by visiting or calling the local TRICARE Service Center and completing an enrollment application.
- If I enroll in TRICARE Prime does that mean that my entire family must enroll?
Not all family members are required to enroll in TRICARE Prime. Depending on your specific situation and needs, it may be best, for example, for a spouse to be in TRICARE Prime, and a student son or daughter to use Extra or Standard. Contact your TRICARE Service Center for advice.
- Is there a minimum enrollment period requirement for TRICARE Prime?
Enrollment is for a 12-month period under TRICARE Prime. At the end of this initial consecutive 12-month enrollment period, you must choose to continue your enrollment in Prime or choose another option that best suits your situation. If you disenroll early for nonpayment of fees, or you request disenrollment without a move, you will be eligible to re-enroll in 12 months.
- If I choose to disenroll after I have enrolled in TRICARE Prime can I return to TRICARE Prime if I find the other options unsuitable?
Enrollment is for 12 months, unless you move from the area or lose eligibility; if you disenroll early you are eligible to re-enroll in 12 months.
- Are there any deadlines or restrictions for enrolling in TRICARE Prime?
If the sponsor is on orders
for 179 days or more, families are eligible for enrollment the first day of
activation. Please note that while enrollment for Prime is on a continuous
basis, assignment to a primary care manager in a military clinic, where
treatment is free, is based on a first come, first served basis. However,
military treatment facility commanders can determine whether your enrollment
will be to a civilian primary care manager or a military treatment facility
primary care manager. Those enrolled to a military treatment facility may be
required to select a civilian primary care manager at the time of re-enrollment
because of changes in military treatment facility capacity.
- If my family moves to a different region, are we automatically assigned a new primary care manager, or do we have to re-enroll?
Enrollment in TRICARE Prime entails the assignment of a primary care manager, enrollment in DEERS, and communication with the member on what enrollment in the TRICARE program means. For active duty members, enrollment is automatic. For active duty family members, enrollment in TRICARE Prime is on a voluntary basis.
Currently, if you move to a different region, you will have up to 30 days at the new site to enroll. Your old region will cover you for care until you enroll at the new region. Enrolled members will start a new 12-month enrollment period.
Dental care
- What is the TRICARE Selected Reserve Dental Program?
In order to maintain dental readiness, the 1996 National Defense Authorization Act directed the establishment of the TSRDP for members of the Selected Reserve.
- What sort of coverage do I get with the TSRDP?
Covered services include diagnostic, preventive, basic restorative, oral surgery and emergency services; items such as crowns, root canals, ridges and orthodontia are not covered.
- What will the TSRDP cost?
The monthly premium is $4.36. Enrollees must submit a prepayment of four months of premiums ($4.36 x 4 = $17.44) with their enrollment form. There are no copayments for diagnostic, preventive or emergency care services. Copayment responsibilities for restorative services for E1 through E-4 are 10 percent, for E-5s and above it is 20 percent. Copayment responsibilities for oral surgery services for E-1 through E4 is 30 percent, for E-5s and above it is 40 percent. The maximum annual benefit for all services is $1,000 of paid allowable charges per contract year. Modest annual changes to the premium levels are anticipated.
- Who is eligible for the TSRDP?
Eligible Selected Reserve members who have at least one year of Selected Reserve service remaining who are located in the 50 United States, the District of Columbia, Puerto Rico, Guam and the U.S. Virgin Islands. TSRDP is not available to reservists living in Europe, Asia or areas outside those mentioned.
Unit Members. A member who is assigned to a Reserve or National Guard unit that is organized to perform Inactive Duty Training (drills/UTAs) and annual training as a minimum.
Individual Mobilization Augmentees (IMAs). IMAs are Reserve personnel assigned to active component organizations. They also perform annual training.
Training Pipeline Personnel. Selected Reserve enlisted members who have not yet completed initial active duty for training (IADT) and officers who are in training for professional categories or in undergraduate flying training.
Excluded: Active Guard/Reserve (AGR) and Selected Reserve members on extended active duty are not eligible to sign up for this program. Others not eligible are Reserve/Guard family members, members of the Standby Reserve, Retired Reserve and Individual Ready Reserve.
- How can I get more information about the TSRDP?
The contractor for the TSRDP, Humana Military Health Care Services, has a toll free telephone number, (800) 211-3614, which will be staffed Monday through Friday 8 a.m. to 6 p.m. Eastern Standard Time to answer your questions.
Getting care
- As an activated reservist, how will I receive my health care?
All activated Reserve and National Guard members will be enrolled in TRICARE Prime and will receive all of their care in military treatment facilities. If you are stationed in an area where there are no military treatment facilities, you will receive your care from a civilian provider. Under no circumstance will you be responsible for any out-of-pocket costs.
- What should I do if I am a TRICARE Prime enrollee and get sick while traveling outside my region? What if the 800 number is busy and I can not make contact?
You should contact your primary care manager for instructions in a non-emergency situation. Authorization for care can also be obtained from the Health Care Finders. For non-emergency care you must first obtain authorization. If you see a physician without authorization for a non-emergency problem, you will still be covered for some of the costs incurred under the Point-of-Service option. That option pays 50 percent of the cost after a separate, somewhat higher deductible is met ($300 for single enrollment and $600 for family enrollment).
- How do my family and I obtain emergency care under TRICARE?
Any eligible beneficiary should access the nearest emergency room of any military or civilian hospital for true emergencies, regardless of which TRICARE option you use.
- Does the copayment increase for the emergency room?
There are no out-of-pocket costs for any care received at a military treatment facility, including emergency room care. The out-of-pocket costs for care received at a civilian emergency room for families of E-4 and below enrolled in Prime is $10. For families of E-5 and above and retirees and their families, the copay for an emergency room visit is $30. This single payment, $10 or $30, includes all emergency room services provided in conjunction with the visit. For those who have chosen to remain in TRICARE Standard, or use the TRICARE Extra program, their regular deductibles and copayments apply.
- What is my priority for being offered enrollment in TRICARE Prime?
Priority for enrollment is (1) active duty will be automatically enrolled and receive most of their care in the military treatment facility; (2) active-duty family members may voluntarily enroll and will be primarily accommodated within the military treatment facility; (3) retirees and their family members and survivors may voluntarily enroll. If the military treatment facility has reached capacity, everyone wishing to enroll in Prime will be referred to the network providers.
Mental health
- Are mental health and substance abuse recovery covered under TRICARE Prime?
Mental health and substance abuse treatments are covered under TRICARE Prime with a minimal copayment. The cost for outpatient visits will be $10 for E-4 and below and $20 for E-5 and above. Retirees will pay $25 per visit. The copayments are reduced for group visits. For inpatient care the costs are $20 per day for all active duty family members and $40 per day for retirees.
National Mail Order Pharmacy
- How can I obtain more information about the National Mail Order Pharmacy?
If you are in one of the eligible beneficiary groups, see your local military treatment facility pharmacy for details, or call the Merck-Medco Member Services line at (800) 903-4680. Outside the United States, contact your long distance carrier for access. The TDD number for the hearing impaired is (800) 759-1089. Both a short Program Registration Form and a Confidential Patient Profile Registration Form will need to be completed.
Other health insurance
- What if I have other health insurance? What does this mean to me?
If you have other health insurance in addition to your TRICARE Standard benefits, be aware that TRICARE Standard pays after all other plans you may have, except for Medicaid (a public assistance program) and certain insurance policies that are specifically designated as TRICARE supplements.
This means that if you have another health plan in addition to TRICARE Standard, the other plan must pay whatever it covers before TRICARE Standard will make any type of payment. You may have coverage for yourself and your family through an employer, an association or a private insurer. This also includes the medical portion of an auto insurance policy, or any coverage that students in the family may have through their schools.
- Should a family member covered by other comprehensive health insurance enroll in Prime?
If a family member has other comprehensive health insurance, we do not encourage enrollment in TRICARE Prime. When other comprehensive health coverage is involved, TRICARE is automatically the secondary payer. It may be easier to coordinate benefits with other health insurance under TRICARE Extra and TRICARE Standard. Please check with your TRICARE Service Center for further guidance.
- When will TRICARE pay and what will they pay?
When your other plan has paid, then TRICARE Standard will pay for covered outpatient services, within certain limits. Here are two examples of how the government determines its payment for your covered civilian health care (both examples assume that you have already satisfied your annual outpatient deductible):
First Example: If you go to a provider of care who participates in TRICARE Standard, the TRICARE contractors will pay the lesser of:
1. The amount of the provider's billed charges, minus the other health insurance's payment; or
2. The amount that TRICARE Standard would have paid if you didn't have any other primary health insurance.
Here's an illustration of this example: The participating doctor bills you $100, which is the same as the TRICARE Standard allowable charge for the care. Your other insurance pays $80, leaving $20 unpaid. Since you're a military retiree, the TRICARE Standard share of the doctor's bill would be $75 if you didn't have other insurance. Since you do have other insurance, TRICARE Standard will pay whichever amount, $75 or $20, is less. So, in this illustration, TRICARE Standard pays the $20 that your other insurance didn't cover.
Second Example: If you go to a non-participating provider, that is, one who does not accept the TRICARE Standard allowable charge as the full fee for the care provided and who may charge more for your care, the TRICARE contractors will pay the lesser of:
1. An amount up to 15 percent more than the TRICARE Standard allowable charge, minus the amount your other health insurance paid; or
2. The amount that TRICARE Standard would have paid if you didn't have any other health insurance.
Here's an illustration of this example: Although the allowable charge for the care is $100, the non-participating doctor bills you $150. Your other insurance pays $125 of that, leaving $25 unpaid. The TRICARE Standard share of the doctor's bill would be $75, that is, 75 percent of the allowable charge, if you didn't have other insurance. Since you do have other insurance, and it paid $125, TRICARE Standard will pay nothing.
Why? Because the TRICARE Standard payment for care received from a non-participating provider, when you have other insurance, is limited to 15 percent above the allowable charge (in this case, $115), minus the amount your other insurance paid (in this case, $125). Since the other insurance paid more than $115, TRICARE Standard won't pick up any of the rest of the charges.
- Am I responsible for other costs that my insurance or TRICARE did not pay?
You are responsible for any unpaid amounts the provider has not been paid for TRICARE-covered srvices, but only up to the legal limit of 15 percent above the allowable charge. In the second illustration (above), the non-participating provider has been paid more than 15 percent above the $100 allowable charge, so you would owe nothing. In this illustration, you would not be legally liable for more than $115 in medical bills.
You must, however, pay all charges for care that aren't covered by TRICARE Standard.
- What if I have other health coverage by a health maintenance organization, in addition to being enrolled in TRICARE Standard?
If you have other primary insurance from an HMO, it will be treated the same as any other type of health coverage. The primary health policy will have to pay before TRICARE does.
The HMO provider of care must meet TRICARE provider requirements. The services from the HMO must be medically necessary, and must be covered by TRICARE for payment to be made by TRICARE.
TRICARE will not pay for services you may have obtained through your HMO, but did not, because you went outside the HMO for the services.
If you do not get advance authorization from the HMO, you may end up paying the entire bill for the care. Also, any advance authorizations required by TRICARE must be obtained for the care. In other words, you or your provider may have to obtain advance authorizations from both your HMO and TRICARE in order for the care to be fully covered.
TRICARE will pay for TRICARE-covered services that the HMO certifies in writing that it would not have covered, even if the services had been obtained through the HMO.
TRICARE-eligible persons who also have medical coverage through an HMO may have TRICARE Standard cost-share expenses under the same rules as for other health plans that pay before TRICARE Standard.
Caution: Families who have a health maintenance organization as their other health insurance can't jump between the HMO and TRICARE Standard. All covered healthcare services must be obtained from the HMO.
- What if I have other health insurance with a prescription benefit?
Any beneficiary who is in one of the eligible groups for the National Mail Order Pharmacy, but has other health insurance with a pharmacy benefit, will be required to use the other available pharmacy benefit coverage first.
Primary Care Manager or Provider
- What are "authorized" providers of care under TRICARE? What are "participating" providers? And, what are "network" or "non-network" providers?
Many people, providers of care and patients alike, have questions about what an authorized provider is, and what it means to participate (or not participate) in TRICARE, or to join a TRICARE contractor's network of providers. Here are some answers:
Authorized providers: Becoming authorized means that a provider has been certified by the contractor as a legitimate provider of care in a particular medical field (having met specific educational, licensing and other requirements) and has been assigned a "provider number," which is on file with the contractor.
A provider of care who is not authorized under TRICARE might be someone like a chiropractor or an acupuncturist (classes of providers that aren't recognized by TRICARE because the care they provide is outside the scope of TRICARE's benefit structure).
Participating providers: A participating provider accepts the TRICARE allowable charge as the full fee for the care the patient receives. A participating provider files the claims for his or her TRICARE-eligible patients. The regional TRICARE contractor sends its portion of the payment for the patient's medical bills to the provider, and the patient pays his or her share of the costs to the provider.
Non-participating providers: A provider who is authorized, but who does not participate may still treat TRICARE-eligible patients, but he or she may charge more than the allowable charge for the care provided, up to the legal limit of 15 percent more than the allowable charge.
The TRICARE contractor will pay its portion of the allowable charges, as it would in the case of a participating provider, but the payment will go directly to the patient. The patient is then responsible for the entire bill, up to the legal limit.
Network and non-network providers: Providers who are authorized to give care to TRICARE-eligible patients may decide to apply (and be accepted by a TRICARE contractor) to become part of the contractor's healthcare provider network. The network is a group of providers who have signed agreements with the contractor to provide care to eligible persons, often at specific discounted rates, and to participate on all claims under the TRICARE Extra or TRICARE Prime health care options.
Non-network providers are authorized to provide care to TRICARE patients, but have decided not to join the contractor's TRICARE Extra or TRICARE Prime networks. Instead, they provide care under TRICARE Standard, and choose either to participate in Standard (accepting the allowable charge as their full fee and filing the claim for the patient) or to not participate (possibly charging more for the care, up to the legal limit).
- What is a primary care manager?
A primary care manager is a medical professional or a team of providers, in a military facility or in a civilian network, who will assume primary responsibility for providing, arranging and coordinating an enrollee's total health care. A physician designated as a primary care manager could be one who practices in General or Family Practice, Internal Medicine, Pediatrics or OB/GYN. Nurse practitioners and physician's assistants who are privileged to provide primary care services may be organized as part of the primary care manager team.
- Where do I obtain a listing of primary care managers and other network providers?
A listing of network providers (provider directory) in your area is available at your local TRICARE Service Center.
- If I select a civilian network primary care manager, can I still use a military treatment facility for routine healthcare services?
No, enrollees choosing a civilian primary care manager must be referred to the military treatment facility for specialty and inpatient care by that primary care manager. An enrollee who has chosen a civilian primary care manager may, however, return for pharmacy, laboratory, radiology and other ancillary care they may require.
- If I am already confident that I need to see a specialist, do I need to contact my primary care manager before I go? What will happen if I do not?
For those enrolled in TRICARE Prime, it is always necessary to first consult primary care manager for specialty care. If it is necessary for you to see a specialist, your primary care manager will help make an appointment for you. If you see a specialist on your own, without prior approval from your primary care manager, you will be participating in Prime's Point-of-Service option and will be responsible for 50 percent of the cost after the deductible ($300 for single enrollment and $600 for family enrollment) is met.
- My primary care manager refuses to provide a referral for services I believe I need. What do I do?
The TRICARE Prime program has provisions for second opinions. If you feel that the diagnosis or treatment plan may not be correct, you can request that your primary care manager refer you out for a second opinion. Additionally, if you are dissatisfied with your primary care manager, you can request assignment to another primary care manager. If you are still not satisfied, you can file a complaint or grievance regarding the non-availability of service decision to the military treatment facility commander or regional lead agent. Finally, you have the option of using the Point-of-Service option under Prime. A retroactive reimbursement may be an option through a successful appeal process.
Retirement
- Am I eligible for health care in the Military Health System when I retire from the Reserve/National Guard?
Upon becoming age 60 and completing the required service time, you and your eligible family members have the option to use TRICARE. Retired military personnel and their family members, age 65 and older, are eligible to receive healthcare benefits under the Medicare system, and are not, at this time eligible for TRICARE. However, you are eligible for space-available care at a military treatment facility or clinic.
Supplemental insurance
- What if I have TRICARE supplemental insurance?
Some people have an insurance policy that’s specifically designated as a TRICARE supplemental policy. Such a policy pays after TRICARE Prime, Extra or Standard have paid everything it will pay for your care. You must file your own claims with your supplemental policy. Be sure to attach copies of any required bills, receipts and Explanation of Benefits forms.
- Where can I find supplemental information on insurance companies or policies?
TRICARE supplemental insurance policies are offered by most military associations and by some private firms. They are designed to reimburse patients for the civilian medical care bills they must pay after TRICARE pays the government's share of the cost. Before you buy any supplement, carefully consider which plan is best suited to your individual needs.
- What rules do the supplemental insurance policies have concerning acceptance for preexisting conditions?
Each TRICARE supplemental policy has its own rules concerning acceptance for pre-existing conditions, eligibility requirements for the family, deductibles, mental health limitations, long-term illness, well-baby care, care provided to persons with disabilities, claims under the diagnosis-related group (DRG) payment system for inpatient hospital charges, and rules concerning allowable charges.
The associations, organizations and insurance companies offering supplemental insurance policies are in no way sponsored, recommended or endorsed by the Department of Defense or the TRICARE Management Activity. Neither DOD nor the TRICARE Management Activity promotes any specific policy for purchase, nor recommends retention or cancellation of any coverage you may have. The decision is strictly yours.
TRICARE Service Center
- How can I find the location of my nearest TRICARE Service Center?
All regions have initiated TRICARE; you may inquire using your phone system's directory assistance operator, or call the nearest military hospital or clinic. Additionally, below are telephone numbers for each region, where you can call and get information about TRICARE and your health care benefits.
Region
1 1-888-999-5195
Maine, New Hampshire, Vermont, Massachusetts, Connecticut, Rhode Island,
Delaware, Maryland, New Jersey, New York, Pennsylvania, the District of
Columbia, Northern Virginia, and the northeast corner of West Virginia
Operational June 1, 1998
Region
2 1-800-931-9501
North Carolina and most of Virginia
Operational May 1, 1998
Region
3 1-800-444-5445
South Carolina, Georgia, and Florida excluding panhandle
Operational July 1, 1996
Region
4 1-800-444-5445
Florida panhandle, Alabama, Mississippi, Tennessee and eastern third of
Louisiana
Operational July 1, 1996
Region
5 1-800-941-4501
Michigan, Wisconsin, Illinois, Indiana, Ohio, Kentucky, and West Virginia
excluding the northeast corner
Operational May 1, 1998
Region
6 1-800-406-2832
Oklahoma, Arkansas, western two thirds of Louisiana, Texas, excluding southwest
corner
Operational November 1, 1995
Central (Region
7/8) 1-888-TRIWEST (874-9378)
New Mexico, Arizona excluding Yuma, Nevada and southwest corner of Texas,
including El Paso, Colorado, Utah, Wyoming, Montana, Idaho excluding northern
Idaho, North Dakota, South Dakota, Nebraska, Kansas, Minnesota, Iowa and
Missouri
Operational April 1997
Region
9 1-800-242-6788
Southern California and Yuma, Arizona
Operational April 1, 1996
Region
10 1-800-242-6788
Northern California
Operational April 1, 1996
Region
11 1-800-404-0110
Washington, Oregon, and northern Idaho
Operational March 1, 1995
Region 12
(Pacific) 1-800-242-6788
Hawaii and Alaska
Operational April 1, 1996
Pacific and WESTPAC 1-888-777-8343
Latin
America 1-888-777-8343
Panama, Central America, South America
Europe 1-888-777-8343
Europe, Africa, Middle East, Azores and Iceland
Operational October 1996
- How do TRICARE Service Centers assist beneficiaries?
TRICARE Service Centers are staffed by healthcare professionals who are there to help beneficiaries get the service that they need. These professionals include:
Health Care Finders, who will make appointments and help find specialists when you need them. They also provide names of doctors participating in the TRICARE Extra network.
Beneficiary Services Representatives, who will help explain the options available to you and assist in your choice of the program that suits you best. They can enroll you in TRICARE Prime, assist with the selection of a primary care manager, and help resolve any billing problems.
TRICARE Service Centers also send beneficiaries TRICARE information packages describing the features of each of the TRICARE options and what alternatives are available for each beneficiary category.
- What is the function of the nurse advisor?
Nurse advisors are available in most regions, by phone, to provide advice and assistance that will enhance patient decision making about their health care. They are available 24 hours a day, seven days a week, and can discuss treatment alternatives, symptoms and illness prevention or can advise whether a situation warrants immediate medical attention. Any TRICARE-eligible person can use the service of the nurse advisor.
TRICARE Standard and Extra
- Will a pre-existing condition be a factor before being accepted by TRICARE?
No. Pre-existing conditions will not disqualify you from enrolling.
- Is preventive care covered under Standard or Extra?
If the particular preventive service is a benefit included under the TRICARE Standard (CHAMPUS) benefits, you will be responsible for the deductible and copayment under Extra and Standard. See your health benefits representative about specific preventive care under TRICARE Standard.
- How do I switch from TRICARE Standard to Extra and vice-versa? Can I do this at any time?
As long as you are not enrolled in TRICARE Prime, you may switch between Standard and Extra at any time. You can switch by making the choice between any civilian doctor and a doctor within the Extra network.
- If I am participating in TRICARE Standard am I required to pay for medical care at a military treatment facility?
There are not any out-of-pocket costs for outpatient care received at a military treatment facility. However, it is important to remember that TRICARE Prime enrollees will receive priority for care at that military treatment facility before non-enrolled beneficiaries. You will be seen on a space-available basis only.
- If I am participating in TRICARE Standard, will I be required to pay for my medical expenses up front, or will the doctor bill TRICARE directly?
Under TRICARE Standard, depending upon your provider, you may be required to pay for your share of the medical treatment up front. If you go to a doctor who participates in the Extra network, your out-of-pocket costs will be less than with Standard and you will not have to file claims.
Uniformed Services Employment and Reemployment Rights Act of 1994
- What is the Uniformed Services Employment and Reemployment Rights Act of 1994, and what does it have to do with my health care?
Congress provided clear protection for all members of the uniformed services (including non-career Reserve and National Guard members, as well as active duty personnel) in October 1994, with passage of the Uniformed Services Employment and Reemployment Rights Act, Chapter 43 of Title 38, U, S. Code. The Department of Labor is the enforcement authority for USERRA, and it processes all formal complaints of violations of the law. One major section of the law includes health plans.
Chapter 43 - Employment and Reemployment Rights of Members of the Uniformed Services; Subchapter II - Employment and Reemployment Rights and Limitations; Prohibitions
§ 4317. Health plans
(a) (1) In any case in which a person (or the person's dependents) has coverage under a health plan in connection with the person's position of employment, including a group health plan (as defined in section 607(1) of the Employee Retirement Income Security Act of 1974), and such person is absent from such position of employment by reason of service in the uniformed services, the plan shall provide that the person may elect to continue such coverage as provided in this subsection. The maximum period of coverage of a person and the person's dependents under such an election shall be the lesser of
(A) the 18-month period beginning on the date on which the person's absence begins; or
(B) the day after the date on which the person fails to apply for or return to a position of employment, as determined under section 4312(e).
(2) A person who elects to continue health-plan coverage under this paragraph may be required to pay not more than 102 percent of the full premium under the plan (determined in the same manner as the applicable premium under section 4980B(f)(4) of the Internal Revenue Code of 1986) associated with such coverage for the employer's other employees, except that in the case of a person who performs service in the uniformed services for less than 31 days, such person may not be required to pay more than the employee share, if any, for such coverage.
(3) In the case of a health plan that is a multiemployer plan, as defined in section 3(37) of the Employee Retirement Income Security Act of 1974, any liability under the plan for employer contributions and benefits arising under this paragraph shall be allocated -
(A) by the plan in such manner as the plan sponsor shall provide; or
(B) if the sponsor does not provide
(i) to the last employer employing the person before the period served by the person in the uniformed services, or
(ii) if such last employer is no longer functional, to the plan.
(b) (1) Except as provided in paragraph (2), in the case of a person whose coverage under a health plan was terminated by reason of service in the uniformed services, an exclusion or waiting period may not be imposed in connection with the reinstatement of such coverage upon reemployment under this chapter if an exclusion or waiting period would not have been imposed under a health plan had coverage of such person by such plan not been terminated as a result of such service. This paragraph applies to the person who is reemployed and to any individual who is covered by such plan by reason of the reinstatement of the coverage of such person.
(2) Paragraph (1) shall not apply to the coverage of any illness or injury determined by the Secretary of Veterans Affairs to have been incurred in, or aggravated during, performance of service in the uniformed services.
- What are the rules for entitlement to health insurance?
For absence of less than 30 days, benefits continue as if the employee has not been absent. For absence of 31 days or more, coverage stops unless the employee elects to pay for Consolidated Omnibus Budget Reconciliation Act (COBRA)-like coverage (for a period of up to 18 months). Health insurance must be reinstated the day an employee is reinstated with no waiting period.
- Does an employee accrue vacation or medical/sick days from the employer while on military leave of absence?
No. However, as in the previous question, an employer may choose to offer accrual of vacation or medical/sick days as an additional benefit. An employer is not required under the Uniformed Services Employment and Reemployment Rights Act to provide any paid benefit when an employee is not working at the work site.
- What are my options for my family and myself if I have a service-connected disability that requires treatment upon my release from active duty.
The National Defense Authorizations Act of Fiscal Year 2000 has authorized continuance on active duty for members of the Reserve components with the consent of that member to receive authorized medical care, to be medically evaluated for disability or other purposes. If you remain on active duty, your TRICARE benefits for your family will continue.
Maintained
by the U.S.
Army Medical Department.
Updated 18 October 2000
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Updated: 15 Dec 2000 |
TRICARE Prime Remote to Open for Family MembersBy Staff Sgt. Kathleen T. Rhem, USA WASHINGTON, Dec. 15, 2000 -- Families of active-duty service members serving in areas far from a military base and its medical facilities will be eligible soon for a new program designed to cut their healthcare costs. The fiscal 2001 defense authorization act provides for TRICARE Prime Remote for Family Members to begin Oct. 1, 2001. Active duty members in locations more than 50 miles from a military medical treatment facility have had TRICARE Prime Remote since Oct. 1, 1999. Their families, however, are covered under TRICARE Standard.
TRICARE Prime Remote is similar to civilian health maintenance organizations and preferred provider plans. Beneficiaries use participating healthcare providers and pay relatively low co-payments and no deductibles. Under TRICARE Standard, users can choose any provider, but they pay deductibles and higher co-payments. TRICARE Prime Remote for Family Members will affect the families of roughly 80,000 active duty service members, including recruiters, ROTC instructors and staff, and Training with Industry program participants. The new family member program will offer the same co-payment schedule as TRICARE Prime -- much lower than TRICARE Standard. Coast Guard Lt. Cmdr. Robert Styron, regional operations officer for the TRICARE Management Activity here, said the new program responds to families' complaints about being ordered to remote areas where TRICARE Standard is their only military healthcare option. He acknowledged healthcare can be fairly costly using TRICARE Standard. Families object because their medical care would be free if they were on a base or in a catchment area, Styron said. TRICARE officials are still ironing out enrollment details, but expect to publicize steps prior to Oct. 1. Styron stressed individuals can make the process easier when the time comes by ensuring their information in the Defense Eligibility Enrollment Reporting System is current and accurate. He said the legislation also includes a "waive charges" clause to provide some interim relief until TRICARE Prime Remote for Family Members debuts. Generally, TRICARE plans to waive most cost shares and deductibles incurred by eligible family members between Oct. 30, 2000, and Oct. 30, 2001. Styron said the clause isn't in effect yet because officials are still working out program details. In the meantime, he advised family members in remote areas to keep all their receipts for co-payments, cost shares and deductibles. "They may be able to be reimbursed when the details are worked out," he said. Related Site of Interest:
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AFRTS TV Report: "New TRICARE benefits in 2001" can
be viewed at 
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Updated: 30 Nov 2000 |
Budget Adds Major TRICARE Benefits for Active DutyBy Staff Sgt. Kathleen T. Rhem, USA WASHINGTON, Nov. 30, 2000 -- Active duty members and their families should look for major new benefits coming soon in DoD's TRICARE managed healthcare plan, a senior program official said. Air Force Col. Frank Cumberland, TRICARE Management Activity director of communications and customer service, said the most publicized TRICARE change in the defense budget signed Oct. 30 has been the opening up of benefits to Medicare-eligible retirees age 65 and older. The coming wave of change, however, won't overlook active duty members and families, he added. Some of the benefits being added to TRICARE within the next year include:
TRICARE and health affairs officials are still working out the details on these changes and will announce them when plans are complete, Cumberland said. TRICARE managers are also working to increase access to school physicals, eliminate the need for some nonavailability statements and some referrals for specialty care. Some of these issues may not come to pass before a new TRICARE contract is awarded, perhaps in 2003 or 2004, program officials advised. Dr. H. James Sears, executive director of the TRICARE Management Activity, called the changes outlined in this year's budget legislation "the biggest platter of benefit changes" since the mid-1960s. TRICARE, he said, is adding benefits and continues to lower beneficiaries' out-of- pocket costs and, in the process, taking the irritants out of the TRICARE program and improving accessibility." Sears added that people generally evaluate their healthcare system based on three factors:
"When you look at TRICARE, those are all slam dunks," Sears said. For more information, visit the TRICARE Web site at www.tricare.osd.mil.
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M
Foundation
(Northwest, Golden Gate, Southern California and Southwest Regions)
Sierra (Northeast Region)
TRIWEST (Central Region)
Anthem Alliance (Heartland and Mid-Atlantic
Regions)
Humana (Southwest and Gulfsouth
Regions)
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Pharmacy Home
Last Update: 11/01/2000
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Overview
of Pharmacy Benefits
TRICARE
offers several convenient ways for you to have prescriptions filled depending
on your family's specific needs: ·
First, you may have
prescriptions filled (up to a 90-day supply for most medications) at a military
treatment facility (MTF) pharmacy free of charge. Please be aware that
not all medications are available at MTF pharmacies. Each facility is
required to make available the medications listed in the basic core formulary (BCF). The MTF,
through their local Pharmacy & Therapeutics Committee, may add additional
medications to their local formulary based on the scope of care at that MTF. ·
Second, the National
Mail Order Pharmacy (NMOP) is available for prescriptions you take on a
regular basis. You can receive up to a 90-day supply (for most medications)
of your prescription through the mail by using the NMOP. Visit National Mail Order
Pharmacy for details. ·
Finally, prescription
medications that your doctor requires you to start taking immediately can be
obtained though a TRICARE retail network pharmacy for a small copay. For more
information on this option, associated costs and lists of retail network
pharmacies in your neighborhood, visit Retail Network
Pharmacies. Beneficiary Categories and Co-Pays
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TRICARE Prime Remote to Open for Family Members
By Staff Sgt. Kathleen T. Rhem, USA
American Forces Press Service
WASHINGTON, Dec. 15, 2000 -- Families of active-duty service members serving in areas far from a military base and its medical facilities will be eligible soon for a new program designed to cut their healthcare costs.
The fiscal 2001 defense authorization act provides for TRICARE Prime Remote for Family Members to begin Oct. 1, 2001. Active duty members in locations more than 50 miles from a military medical treatment facility have had TRICARE Prime Remote since Oct. 1, 1999. Their families, however, are covered under TRICARE Standard.
TRICARE Prime Remote is similar to civilian health maintenance organizations and preferred provider plans. Beneficiaries use participating healthcare providers and pay relatively low co-payments and no deductibles. Under TRICARE Standard, users can choose any provider, but they pay deductibles and higher co-payments.
TRICARE Prime Remote for Family Members will affect the families of roughly 80,000 active duty service members, including recruiters, ROTC instructors and staff, and Training with Industry program participants. The new family member program will offer the same co-payment schedule as TRICARE Prime -- much lower than TRICARE Standard.
Coast Guard Lt. Cmdr. Robert Styron, regional operations officer for the TRICARE Management Activity here, said the new program responds to families' complaints about being ordered to remote areas where TRICARE Standard is their only military healthcare option. He acknowledged healthcare can be fairly costly using TRICARE Standard.
Families object because their medical care would be free if they were on a base or in a catchment area, Styron said.
TRICARE officials are still ironing out enrollment details, but expect to publicize steps prior to Oct. 1. Styron stressed individuals can make the process easier when the time comes by ensuring their information in the Defense Eligibility Enrollment Reporting System is current and accurate.
He said the legislation also includes a "waive charges" clause to provide some interim relief until TRICARE Prime Remote for Family Members debuts. Generally, TRICARE plans to waive most cost shares and deductibles incurred by eligible family members between Oct. 30, 2000, and Oct. 30, 2001.
Styron said the clause isn't in effect yet because officials are still working out program details. In the meantime, he advised family members in remote areas to keep all their receipts for co-payments, cost shares and deductibles.
"They may be able to be reimbursed when the details are worked out," he said.
Related Site of Interest:
- TRICARE Web site
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