TRICARE is the Defense Department's regional managed health care program for service
families. It consists of three options: TRICARE Prime, TRICARE Extra, and TRICARE
Standard. It is being implemented region-by-region throughout the country, and is expected
to be in place nationwide by mid-1998. Here's a brief description of each option:
TRICARE Prime
This is a voluntary enrollment option that's much like a civilian health maintenance
organization (HMO). If you live in an area where TRICARE Prime is offered, and you decide
to get your care through TRICARE Prime, you'll enroll for a year at a time. You'll
normally receive your care from within the Prime network of civilian and military
providers. Active-duty service members themselves will have automatic enrollment and will
choose, or be assigned to, a primary care manager. Their families--and all others who are
eligible--must take action if they want to enroll. Enrollment of newborns and newly
adopted children in TRICARE Prime is automatic if another family member is enrolled
(unless the sponsor specifies otherwise)--but the children must be registered in DEERS
(the Defense Enrollment Eligibility Reporting System) before their enrollment in TRICARE
Prime becomes effective.
Active-duty families won't have to pay an annual enrollment fee. All others will, but
there'll be no annual deductibles, and the patient's share of the costs for services under
Prime will be reduced. You won't have to file claims when using TRICARE Prime network
providers.
Covered services will be like those of TRICARE Standard (formerly called CHAMPUS), plus
additional preventive and primary care services. For example, physical screenings are
covered at no charge under TRICARE Prime, but are not covered under the other two health
care options, TRICARE Extra and TRICARE Standard.
You'll choose, or will be assigned, a "primary care manager" (PCM), from whom
you'll get most of your routine health care. Your PCM will manage all aspects of your
care, including referrals to specialists, with the help of the local health care finder
(HCF). Remember: Your PCM and HCF must arrange for a referral when required, before
you get specialized care.
As a TRICARE Prime enrollee, you also have what's called a "point-of-service"
(POS) option. This means that you can choose to get non-emergency services without
a referral from your primary care physician. However, if you decide to get care under the
POS option, there's an annual deductible of $300 for an individual or $600 for a family.
After the deductible is satisfied, your cost-share for POS care will be 50 percent of the
TRICARE allowable charge. You may also have to pay any additional charges by non-network
providers--up to 15 percent above the allowable charge. And, you may have to pay the
entire bill when you receive the services, then-- after a claim is filed-- wait for
reimbursement of the government's share of the costs.
TRICARE Extra
Under this option, you don't have to enroll, or pay an annual fee. You can seek care
from a provider who's part of the TRICARE network, and get a discount on services, and pay
reduced cost-shares (five percent below those of TRICARE Standard) in most cases. You
won't have to file any claims when using network providers. You will have to meet the
normal annual outpatient deductible ($50 for one person or $100 for a family, for
active-duty pay grades E-4 and below; or $150 for one person, and $300 for a family, for
all other eligible persons), as you would under TRICARE Standard. Call your contractor's
local health care finder for help in locating a provider who's part of the TRICARE Extra
network. Or, use the contractor's directory of providers (available at TRICARE service
centers). You can still use a military medical facility when space is available.
TRICARE Standard
This option is what you've come to know as CHAMPUS. The name change doesn't change the
benefits or how you use them. TRICARE Standard pays a share of the cost of covered health
services that you obtain from a non-network civilian health care provider. There's no
enrollment in TRICARE Standard. The annual deductibles, cost-shares and benefits are the
same as they were for CHAMPUS. Under this option, you have the most freedom to choose your
provider of care--but your costs will be higher than with the other two TRICARE options.
Also, you may have to file your own claim forms--and perhaps pay a little more for the
care (up to 15 percent more than the allowable charge), if the provider you choose doesn't
participate in TRICARE Standard. If the provider does participate, he or she agrees to
accept the TRICARE Standard allowable charge as the full fee for the care you receive, and
will file the claims for you.
To use TRICARE Standard, just pick a physician or other TRICARE-authorized provider of
care. Ask the provider if he or she participates in TRICARE Standard. Of course, you can
still use your nearby military hospital or clinic, if they have the capacity to provide
services to you.
No matter which of the three TRICARE options you decide to use, be sure you understand
the rules under which they operate. Get copies of any brochures, fact sheets or handbooks
that pertain to the option you select. You can usually obtain informational materials from
the health benefits adviser at the nearest military medical facility, or from the regional
TRICARE contractor's local TRICARE service center.
