TriCare Program Options
Beneficiaries may choose any TriCare certified civilian provider to provide medical care. After an annual deductible is met, you pay a percentage of the total charges for any medical care you receive. Providers who do not accept the TriCare assignment may bill you for charges over the Standard allowable rates. If you or one of your family members frequently travels outside the Prime service area you may receive covered services from out-of-area, non-TriCare providers at TriCare Standard levels. Also, if you have other health or supplemental insurance (such as Medicaid), Standard may be the right choice for you. There are no enrollment fees or forms to complete.
For most families whose children are eligible for Medicaid or have Medicaid waivers (look under "Financial Issues" link for "Definition for Medicaid Waivers") TriCare Standard is an easy program to use. Beneficiaries are able to skip the extra time and distance traveling to see PCM's on Base/Post and go directly to their treatment sites. Most providers, if contracted, will generally handle TriCare and then Medicaid billing. Out of pocket costs are minimal if not zero. Remember any out of pocket medical expenses may be tax deductible.
Note: After spending a full year trying to work with the Prime program at their local AF Base, Linda switched both Madison and the rest of the family over to TriCare Standard. She was able to maintain better continuity of care using the same providers. No staff PCS (Permanent Change of Station) in the middle of treatment and having to start over with a new PCM. Time and gas money saved has off set the small amount spent out of pocket by the family. Madison's expenses generally meet the annual deductibles very quickly and are paid in full first by TriCare and then Medicaid. Providers in this area submit their own claims.
TriCare Extra is similar to a civilian health plan known as a Preferred Provider Organization (PPO). By using providers in the TriCare network, you pay 5 % less than TriCare Standard cost shares, after the annual deductible is met. TriCare network providers accept the negotiated fee for services. A list of providers is in the TriCare Provider Directory. There are no enrollment fees or forms to complete.
TriCare Prime is a managed care program patterned after civilian HMO's. Unique to the Prime option are:
Primary Care Manager (PCM). A PCM is your first contact for all medical needs, guides your care and refers you to specialists if needed. Each enrollee has a PCM to help manage his/her health care. A PCM can be an individual contracted provider (family practice physician, pediatrician or internist), a military treatment facility (MTF) physician or a team of physicians within the MTF. The MTF Commander may direct your assignment to a military PCM (if available), or you may choose a civilian network PCM-listed provider, if allowable in your area.
For AD families there are low or no enrollment fees, less out-of-pocket expense than Standard or Extra with no claims to file. Prime enrollment is for one year with an annual re-enrollment. However, there is enrollment portability designed to provide a seamless transition during TDY or PCS to another region that works well for AD members. This option generally does not impact Reserve and National Guard members who do not PCS when on active duty orders. Medical benefits through the Prime program ARE available to members during relocation. For other Prime benefits contact your TriCare POC for manuals and other information.
Note: Linda utilized the Prime program at her local AF Base for a full year. During that time there were several PCS staff changes, which meant PCM changes every few months. It became difficult to manage Madison's long-term medical needs when the MTF PCM was an OB/GYN with little experience in dealing with long-term debilitating physical conditions and diseases. After "starting over" orienting a new PCM to Madison and her medical needs every few months, the extra time and office visits these orientations entailed, and several differences of opinion regarding on-going courses of treatment it became clear that a physician specializing in pediatric, long-term care and rehabilitation was required. There were no physicians trained in this specialty available at the MTF. A change to the Standard Option with a Civilian, non-MTF related specialized physician was made and life at the Jorgensen household became MUCH easier!
As with any insurance program be sure to contact your TriCare representative and request all current program information.. Ask questions, find out what is and is not available in your area then make the best-educated decision you can. How you manage your family and their health care is up to you.
It is also important to keep TriCare updated on family moves and PCS changes. A Summer 2006 update from TriCare suggests,"TRICARE users can avoid setbacks and ensure seamless health care transfer when changing duty stations by meeting with a TRICARE representative prior to leaving their current duty station. A TRICARE Service Center representative can answer questions about transferring enrollment, program benefits and procedures for health care while in transit. TRICARE is divided into six regions around the world. Members need to ensure that their coverage gets transferred to the correct region to which they are moving. To complete transfer of TRICARE coverage, members should check-in with a TRICARE representative at their new duty station".