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The Department of Defense operates one of the nation's largest health care systems. Nearly 8.3 million individuals are eligible to receive care through the Military Health Services System (MHSS).
Since the end of the Cold War, the U.S. military has dealt with new challenges to its organization and mission. Fewer men and women are on active duty. Along with fewer combat forces, there have been reductions in support forces, including physicians and other medical professionals. In fact, the number of doctors, nurses and medical technicians in military service has declined as much as 50 percent in some locations.
The Base Realignment and Closure Commission (BRAC) recommended closing a number of installations that were no longer needed for a smaller military force. As a result of this and other downsizing efforts, 35 percent of the military hospitals that existed in the U.S. in 1987 have closed or will be closed by 1997. Yet, the total number of people seeking health care through the MHSS has dropped far less - by only 9 percent.
Another shift in support requirements has occurred over the last few decades. In the early 1950s, military retirees and their families comprised only 8 percent of those eligible for care in the military health care system. Today, retirees - who often require more medical care than their active duty counterparts - make up more than 50 percent of those eligible for care. But as hospitals were closed, health care for many retirees became less accessible, with appointments at military hospitals and clinics more and more difficult to obtain.
Simply stated, the demand for health care began to exceed the systems capacity to deliver it. Two more factors led to changes in the MHSS - the rising cost of health care and the continuing requirement to maintain a trained and ready medical corps to support our troops, in peace or combat.
Costs for medical care are rising in both the civilian and military communities due to many complex factors. Some of the major causes are:
While providing health care during peacetime is an important mission, the number one priority of the MHSS is to support emergency operations. A new approach was needed to meet peacetime demands for health care while preserving the capability within the active duty medical corps to deploy and support military men and women on operational missions.
Responding to the Health Care Challenge
In response to the challenge of maintaining medical combat readiness while providing the best health care for all eligible personnel, the Department of Defense introduced TRICARE. TRICARE is a regionally managed health care program for active duty and retired members of the uniformed services, their families, and survivors. TRICARE brings together the health care resources of the Army, Navy and Air Force and supplements them with networks of civilian health care professionals to provide better access and high quality service while maintaining the capability to support military operations. TRICARE is being implemented throughout the U.S., Europe and the Pacific as a way to:
A Phased Approach
TRICARE will be managed by a senior military health care officer, called the Lead Agent, in each of 14 geographical regions in the U.S., Europe and the Pacific. Because of its size and complexity, the program is being phased in a region at a time over a two to three year period. Region 11, made up of the states of Washington and Oregon, was the first region to implement TRICARE. The program began operation in March 1995, and is managed by the Lead Agent for Region 11, located at Madigan Army Medical Center at Fort Lewis, Washington. Implementation is scheduled to be completed in the United States by the end of 1997.
Eligibility for TRICARE
TRICARE is the health benefits program for all seven of the uniformed services. All active duty members and their families, retirees and their families, and survivors who are not eligible for Medicare may participate in at least one of the three TRICARE options. Additionally, those individuals under 65 who are eligible for Medicare because of disability or end-stage kidney disease may also participate. Congress is considering the Department of Defense's proposal to bill Medicare for health care that military hospitals provide to those 65 and older. The new source of money would expand availability of care in military hospitals and clinics for this group. Meanwhile, many of the features of TRICARE, such as use of the TRICARE Service Centers, are available to all MHSS beneficiaries. And, Medicare-eligible retirees may still seek care at Military Treatment Facilities (MTFs) on a space-available basis. But, to ensure good continuity of care, and not be subject to the uncertainty of space-available care, Medicare-eligible retirees are advised to enroll in Medicare Part B so they will always have access to health care.
HEALTH CARE PROGRAMS
One of the central features of TRICARE is the choice of health care plans it offers. While all active duty men and women are automatically enrolled in an option called TRICARE Prime, other eligible individuals may choose among TRICARE Prime, TRICARE Standard, and TRICARE Extra. The options are specifically designed to fit individual preferences and lifestyles, and ensure efficient use of military health care resources.
TRICARE Prime
The TRICARE Prime option provides the most comprehensive health care benefits at the lowest cost of the three TRICARE options. Those wishing to take advantage of TRICARE Prime must enroll so that adequate professional staffing and resources are available in both military and supporting civilian facilities.
Chief among the many features of TRICARE Prime is guaranteed access to care in a timely manner at military treatment facilities or our civilian provider network. Priority for treatment in military hospitals and clinics will be given to participants enrolled in TRICARE Prime. Furthermore, care will be provided according to strict time standards.
Another key feature of TRICARE Prime is that all who enroll will be assigned a Primary Care Manager. A Primary Care Manager is a health care professional or medical team who patients see first for their health care needs. Primary Care Managers will be supported by military and civilian medical specialists to whom patients will be referred if they need specialty care.
Who Is Eligible?
All active duty military personnel are eligible and are automatically enrolled in TRICARE Prime at their nearest Military Treatment Facility (MTF). Family members of active duty sponsors, retirees and their family members under 65 may also enroll in TRICARE Prime.
Why Select It?
This option is best for families and retirees who want guaranteed access to the most benefits, and who live close to a military hospital or civilian TRICARE Prime network. First priority for care at military hospitals and clinics will be given to those enrolled in TRICARE Prime with a Primary Care Manager at that facility.
How Much Does It Cost?
While benefits are the same, the cost for services received under TRICARE Prime differs for active duty families and retired military and their families. The source of care may also affect the cost. With TRICARE Prime, coverage begins immediately, as there is no annual deductible that must be paid before benefits begin.
TRICARE Prime requires an annual enrollment fee for retired military members and their families who select this health care option. The fee is $230 per 12-month enrollment period for an individual beneficiary, or $460 per family. TRICARE Prime members may make their enrollment payment all at once, or in quarterly payments.
There is no TRICARE Prime annual enrollment fee for active duty personnel or their families.
Outpatient visits to military hospitals and clinics for Prime enrollees require no additional payment beyond the annual enrollment fee for retired beneficiaries. Visits to civilian Primary Care Managers or specialists outside an MTF require a $12 payment for each visit for all enrolled active duty family members whose sponsors are E-5 and above, and for all retired military and their family members and survivors. Enrolled family members of active duty personnel grade E-4 and below pay $6 per civilian network care visit.
Inpatient care required by Prime enrollees will often be provided at a nearby military hospital. This is true regardless of whether your Primary Care Manager is located at a military hospital or clinic, or is part of the supporting civilian health care network or facility. Inpatient care at a military hospital costs $9.90 per day.
Family members of active duty personnel enrolled in TRICARE Prime who are assigned inpatient care at a civilian hospital must pay $11.00 per day, or a minimum fee of $25.
One of TRICARE Prime's major features is the cost of civilian inpatient care for enrolled retired military and their families. The fee will normally be $11 per day, and that fee is guaranteed through 1998. Only in exceptional circumstances when a TRICARE Prime network hospital requires independent hospital services will the cost exceed that amount. Retirees should check with their TRICARE Service Center to ensure they understand their - and the hospital's - payment responsibilities.
Primary Care Managers
Primary Care Managers are the single point-of-contact for non-emergency health care for enrollees in TRICARE Prime. Depending on the enrollees' status, locale, and availability of medical professionals, they may select a Primary Care Manager at a nearby military hospital or clinic; or they may request a civilian professional who is a member of the contracted Prime network in a nearby community.
In some cases, the Lead Agent may direct your assignment to a military Primary Care Manager at an MTF if there is unused capacity; or you may be assigned a civilian Primary Care Manager if MTF capacity is exceeded. In most cases, however, the choice will be yours.
Primary Care Managers may be family practitioners, pediatricians, or other medical professionals, or they may be a team of doctors who will work together to provide continuity of health care.
Primary Care Managers will provide and coordinate care, maintain health records, and recommend preventive and wellness services. He or she will also arrange for specialists or for hospital admission, when necessary.
Receiving Care In TRICARE Prime
Eligible beneficiaries enrolled in TRICARE Prime will receive all their non-emergency care from their Primary Care Manager. While enrolled in TRICARE Prime, they will no longer be eligible for TRICARE Extra or TRICARE Standard.
If Prime enrollees need specialty care, their Primary Care Manager will refer them. In many cases, this care will be available through a military hospital. If the care needed is not available at a military hospital, their Primary Care Manager will authorize them to receive care from a civilian specialist.
It is very important to remember that in order to receive coverage for specialty care (military or civilian), it must be arranged and approved by your Primary Care Manager.
Guaranteed Access to Care
All beneficiaries enrolled in TRICARE Prime are guaranteed access to care. That care will be provided in military treatment facilities, or at a civilian network office or clinic, depending on where you select or are assigned a Primary Care Manager. That access to your Primary Care Manager will be available according to strict time standards.
If you are sick, you will be seen within one day. For less urgent care, such as a recurring backache, you will be given an appointment to see a health professional within one week. For routine requirements, such as for a diagnostic test or exam, you will be seen within four weeks.
You should not be required to travel more than 30 minutes to see your Primary Care Manager.
Focus on Preventive Care
With an emphasis on keeping families healthy, TRICARE Prime includes a variety of preventive and wellness services at no additional charge. Examples of such services include: eye exams, immunizations, hearing screenings, mammography, pap smears, prostate exams and other cancer-prevention and early diagnosis exams.
Priority Appointment Scheduling
Under TRICARE Prime, obtaining appointments is made easier. Many phone lines are installed so you receive quick, priority access to care in a hassle-free manner. When you enroll, you will receive information on how to make appointments.
Out-of-Area Care
If you should need non-emergency medical care while you're away from home, it will be covered, providing you obtain prior approval from your Primary Care Manager using a special toll-free telephone number. Care authorization is required for all routine medical care received out of the area or at another facility.
Enrolled beneficiaries who seek non-emergency care without prior approval will automatically be using what is called the TRICARE Point-of-Service option. This option requires payment of an annual deductible of $300 for an individual enrollee or $600 per family, plus 50 percent or more of visit or treatment fees.
Beneficiaries enrolled in TRICARE Prime who require emergency care should seek that care at the nearest civilian or military treatment facility.
How To Enroll In TRICARE Prime
All active duty personnel are automatically enrolled in TRICARE Prime. All others must complete an application. They may contact their TRICARE Service Center for assistance. Enrollment is for a 12-month period. At the end of that time, all still eligible will be asked whether they wish to continue enrollment for another year, or switch to TRICARE Standard or TRICARE Extra, which do not require enrollment.
Summary - TRICARE Prime
TRICARE Standard
TRICARE Standard is the new name for the health care option currently known as CHAMPUS. With TRICARE Standard, eligible beneficiaries may choose any physician they want for health care, and the government will pay a percentage of the cost. This option permits the most flexibility, but may be the most expensive, particularly if the physician's charges are higher than the allowable amounts. The potential costs of TRICARE Standard will be discussed later.
Who Is Eligible?
All persons eligible for military health care, except active duty and most Medicare-eligible beneficiaries, may use TRICARE Standard. There is no enrollment required. Simply select a physician who applies for government reimbursement in accordance with the terms of the program. Beneficiaries should check with their TRICARE Service Center to determine if they need a nonavailability statement, which may be required for civilian inpatient care and certain outpatient procedures.
Why Select It?
This option offers the greatest flexibility in choosing health care professionals. It is chosen most often by individuals and families who have established relationships they wish to maintain with civilian physicians. Often this happens when there is no nearby MTF. TRICARE Standard is also chosen by those who travel frequently or have summer or winter homes away from their primary residence. Additionally, it may be used by beneficiaries who have other health insurance, where TRICARE Standard is the second payer.
How Much Does It Cost?
With TRICARE Standard, the government shares the costs of health care. Beneficiaries are required to pay an initial amount of the charges for care, called a deductible. The deductible depends on the rank of the military sponsor. Once this amount has been paid, the government then will pay or reimburse a percentage of the cost for health care.
Annual deductible under TRICARE Standard and Extra
E-4 and below $50 for one person
$100 for two or more
E-5 and above $150 for one person
$300 for two or more
TRICARE Standard will pay 80 percent of the approved or allowable cost for outpatient health care, for active duty families, after the annual deductible has been paid. For retirees and their families, the rate is 75 percent.
However, the total cost for health care is subject to certain rules. Only those charges that do not exceed the allowable rate for treatment will be considered. Medical charges that exceed the rate set by the government, up to 15 percent more, will be the beneficiary's responsibility.
Here's an example of the cost computation for outpatient care with TRICARE Standard:
1. You are a family member of an active duty service member, E-5 or above. You visit your civilian physician because you have a swollen finger. Your physician examines your finger and has it x-rayed. The total bill for your doctor's treatment is $225.
2. Next, your physician submits the claim to the TRICARE claims processor. Several weeks thereafter, you receive a bill from the physician for $65. Why $65?
3. The claims processor determined that all of your care was covered by TRICARE Standard. However, the allowable charge for the care was $200. Since your sponsor is active duty, and you have already paid the annual family deductible, TRICARE paid 80 percent of the allowable charge of $200, or $160. You must pay the $65 difference between the $225 charged by the physician, and the $160 paid by TRICARE.
Inpatient care costs differ significantly under TRICARE Standard for families of active duty personnel and retired persons. With prior authorization for inpatient care at a civilian hospital, active duty family members pay $9.90 per day or a $25 minimum fee.
Retiree inpatient costs are much higher. The daily cost for inpatient care at a civilian hospital is $360 per day, or 25 percent of the charges, whichever is less. Also, retirees and their families must pay 25 percent of the cost for any separately-billed physician and professional fees, which can amount to an additional several hundred dollars per day.
Military retirees, active duty members and their families may seek care in a military hospital or clinic before receiving care from civilian sources. Such care, when available, currently costs $9.90 per day. However, first priority for care in military facilities will be given to those enrolled in TRICARE Prime.
These terms - both for outpatient and inpatient care - are the same as under CHAMPUS. They have not been changed with the implementation of TRICARE.
Summary - TRICARE Standard
TRICARE Extra
Costs for health care can be lowered, as compared to TRICARE Standard, by selecting a doctor or medical specialist from a network of civilian health care professionals who participate in the TRICARE Extra program. These carefully-chosen doctors and specialists have agreed to charge an approved rate for medical treatment and procedures.
Who Is Eligible?
All persons eligible for military health care, except active duty and most Medicare-eligible beneficiaries, may use TRICARE Extra. Like TRICARE Standard, there is no enrollment required for TRICARE Extra. Beneficiaries simply use the physicians and specialists in the Extra network.
Why Select It?
TRICARE Extra offers choices of civilian physicians and specialists from a network of health care providers. It is chosen by individuals and families whose regular physician is a member of the network. It is also the preferred option of those who live too far away from a military hospital for convenient access, but who wish to reduce the cost of health care as compared to TRICARE Standard.
How Much Does It Cost?
As with TRICARE Standard, the government shares the costs of health care. For using this network of preferred physicians and specialists, the government will pay an additional 5 percent of medical costs incurred. This savings applies equally for active duty families and retirees, raising the government's cost share to 85 percent and 80 percent, respectively.
Health care providers participating in the Extra network also agree to charge government-approved rates, so there will be no additional charges over and above that allowable rate, as there can be when using TRICARE Standard.
Another advantage of TRICARE Extra is that participating doctors will always file claims for the patient. With TRICARE Standard, some eligible beneficiaries may occasionally have to pay for health care first and then apply for reimbursement. With TRICARE Extra, the participating physician is paid directly by the government, requiring the patient to pay only the cost share amount at time of treatment. Beneficiaries not only save money with TRICARE Extra; they also save the time and trouble of filling out paperwork and filing claims!
The deductible for TRICARE Extra - that initial amount of the fees that must be paid before TRICARE payment begins - is the same as for TRICARE Standard.
When active duty family members seek inpatient care from medical professionals and facilities in the Extra network, their costs will be $9.90 per day, or a $25 minimum charge. Inpatient care costs for retired military personnel and their families using Extra are $250 per day, or 25% of daily hospital costs, whichever is less a saving over TRICARE Standard.
All eligible personnel can also use a combination of health care professionals: some who are part of the Extra network, and some who are not. Since there is no formal enrollment in either TRICARE Standard or TRICARE Extra, beneficiaries are free to switch back and forth among providers as they prefer.
As with TRICARE Standard, you may still seek care in a military hospital or clinic on a space-available basis.
How Do I Find a Physician Who Participates?
The Health Care Finder in your local TRICARE Service Center has a listing of physicians and specialists who have agreed to participate in TRICARE Extra.
Summary - TRICARE Extra
ADDITIONAL BENEFITS AND SERVICES
Emergency Care
Anyone, regardless of the health care option they participate in, should seek treatment at the nearest emergency room - military or civilian - if care is needed to safeguard life, limb or eyesight, or for serious injury such as a broken bone.
TRICARE Service Center
Each region is served by one or more TRICARE Service Centers. These facilities are there to help beneficiaries get the health care that they need, and are staffed by health care professionals. All persons eligible for military health care, including those now using Medicare, can receive assistance from the TRICARE Service Center. Here's what a typical TRICARE Service Center includes.
Beneficiary Services Representative
These health care professionals, usually nurses or physicians' assistants, will help explain the health care options available to you and assist in your choice of the program that suits you best. Beneficiary Services Representatives can help you enroll in TRICARE Prime and assist with the selection of a Primary Care Manager. They can also help with claims paperwork.
Health Care Finder
In addition to making appointments, Health Care Finders will help you find the care that you need. They coordinate with your Primary Care Manager to help locate your specialty care. They will also assist in finding physicians and specialists who will accept TRICARE Standard payment for service, thus avoiding additional charges from doctors' fees that are above the approved amount. Health Care Finders will provide a list of doctors participating in the TRICARE Extra network, and they will help locate doctors who accept Medicare payments for service.
Nurse Advisor
Many people have health care questions they want answered by a health care professional. In most regions, all beneficiaries will be able to call a nurse advisor at any time - 24 hours a day, seven days a week - for advice and assistance. You may want to discuss treatment alternatives, or discuss symptoms to determine whether your child should see a doctor. It's the weekend, and you've hurt your ankle. Or perhaps you have a medical procedure decision to make and want to talk privately about it with another person. The nurse advisor can help you. You can also talk to a nurse advisor about preventing illnesses and improving your family's health.
Getting Prescriptions Filled
All persons eligible for TRICARE, as well as those retirees now on Medicare, currently may take prescriptions to any military pharmacy and have them filled, free of charge. Bear in mind that this opportunity is limited to medications carried by the MTF.
A network of civilian pharmacies has been established as part of both the TRICARE Prime and the TRICARE Extra options. TRICARE Prime enrollees must adhere to program guidelines regarding prescriptions. For those not enrolled in TRICARE Prime, savings are still available by using pharmacies in the TRICARE Extra network. Medicare eligibles who have lost the pharmacy benefit due to a base realignment and closure action may also participate in the civilian pharmacy benefit. Check with your TRICARE Service Center for details.
A mail order pharmacy service is also provided under TRICARE. Active duty family members pay $4 per 90-day supply, and non-Medicare eligible retirees and families pay $8 per 90-day supply. Medicare eligible beneficiaries affected by a base realignment and closure action may also participate in the mail order pharmacy service. The cost is the same as for non-Medicare eligible retirees. Contact your TRICARE Service Center for details on this convenient service.
Catastrophic Cap
To protect all beneficiaries from devastating financial loss due to serious illness or long-term treatment, the government sets limits over which TRICARE eligible personnel will not have to pay. This is called your Catastrophic Cap Benefit.
For active duty family members, the maximum family liability is $1,000 for deductibles and cost-shares based on allowable charges for basic program services and supplies received in a fiscal year (October 1 - September 30).
For retirees and their family members and survivors, the fiscal year cap is $7,500. However, for retirees and family members enrolled in TRICARE Prime, the catastrophic cap is lowered to $3,000 per 12-month enrollment period.
After the maximum dollar limit is reached, TRICARE beneficiaries will not pay any additional cost-share or deductible for allowable health care services received during the remainder of the fiscal/enrollment year.
A Word To Retirees And Their Families
For some retirees under age 65 and their families who have been receiving space-available medical care at a nearby MTF, paying an enrollment fee under TRICARE Prime for guaranteed continued care at that facility may seem unwarranted.
The Department of Defense did extensive research into health care costs for military medical system beneficiaries. On average, retirees were spending more than $900 per year for health care. Since many retirees were receiving free care at military facilities, that meant that those who were unable to get access, or who were affected by the closure of a nearby facility, were actually paying much more.
TRICARE Prime was created to improve access to quality care for all retirees and to lower costs on the average. The result will be better access to quality care and lower health care costs across the board for all members of the retiree community enrolled in Prime, with the enrollment fees used to help offset the costs of civilian care.
Care Upon Reaching Age 65
Retired military personnel, their families and survivors age 65 and older are eligible to receive health care benefits under the Medicare system, and are not eligible for TRICARE.
For several years, the department has supported legislation that would authorize Medicare to pay DoD for health care provided to otherwise eligible military retirees and their families. Favorable resolution of this issue would expand availability of care in military hospitals and clinics for those former members and their families 65 and older.
Pending resolution of this issue, which is called subvention, Medicare eligible military retirees and their families may seek space-available care at military hospitals and clinics; and they are invited to use the TRICARE Service Center to find physicians who accept Medicare patients, as well as for other assistance and services.
However, military retirees and their family members should strongly consider enrolling in Medicare Part B upon reaching age 65, to ensure continued access to health care.
TRICARE SUMMARY
The medical mission of the Department of Defense is to provide medical services and support to the armed forces during military operations, and to provide medical services and support to members of the armed forces, their family members, and others entitled to military medical care. Preparedness to provide needed support is an integral part of the department's mission.
TRICARE is designed to meet the department's medical mission and includes provisions for supplementing military treatment facilities with resources and health care professionals from civilian medical organizations.
TRICARE permits a high rate of medical unit readiness to support military forces and, for beneficiaries, offers timely access to care, assured high quality care, controlled health care costs for patients and taxpayers alike, and choices of health care options to meet individual needs. The three health care options are:
Review these options and decide which best fits your current lifestyle. TRICARE Prime provides the most comprehensive benefits and guarantees access to care through a Primary Care Manager. The Prime option requires enrollment. TRICARE Prime enrollment forms are available from the TRICARE Service Center, if TRICARE has been implemented in your area. Active duty personnel are automatically enrolled.
TRICARE Standard and TRICARE Extra do not require enrollment. Simply select your physician and the government will participate as previously described.
Further Questions?
Contact your regional TRICARE Service Center or nearest military hospital or clinic.
TRICARE OPTIONS
Features-at-a-Glance
Note: The chart below provides a look at some of the features and benefits of the TRICARE options. It is by no means a complete listing. It is merely intended to summarize the information contained in this brochure so that you can begin to see the differences and evaluate the plan that will best meet your needs and the needs of your family. Before making your final decision, it is important that you fully understand the TRICARE program. If at any time you have questions, please call the TRICARE Service Center in your area.
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STANDARD | EXTRA | PRIME |
| Deductibles | Yes; the same as TRICARE Extra. | Yes; the same as TRICARE Standard. | None if care is received at an MTF or from civilian network. |
| Cost shares or co-payments | Yes; highest of all options. | Yes; but 5% lower than TRICARE Standard. | None for care in MTF; nominal for civilian network care. |
| Enrollment fees | None. | None. | None for active duty families; yes for retirees and their families. |
| Out-of-pocket costs | Highest of all options. | Lower than TRICARE Standard. | None for care in MTF; nominal (and far less than Standard and Extra) for civilian network care. |
| Access to civilian doctors and hospitals | Greatest flexibility to choose a doctor and medical facility. | Choice limited to network of civilian doctors. | All care is provided through assigned Primary Care Manager. Needed care not available at an MTF will be referred to civilian network. |
| Paperwork - filing claims for reimbursement | Sometimes. | None. | None. |
| Preventive test/exams | With applicable deductibles and co-pays. | With applicable deductibles and co-pays. | Recommended as part of primary care and included free of charge. |
| Primary care managers | No. | No. | Yes; key feature of this option. |
Information supplied by: Department of Defense, Health Affairs TRICARE Marketing
Office, 5111 Leesburg Pike, Suite 403
Falls Church, VA 22041.
Last update: 2/13/1997
provided compliments of:
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