Published September 10, 2012
What is TRICARE?
Tricare is a health care program for active duty, their eligible family members, their survivors and eligible retired military personnel and their family members. Tricare is designed to: 1) improve timely access to health care 2) maintain a high quality of care 3) offer more services and a full range of specialists 4) give beneficiaries a choice of plans and providers and 5) control health care costs.
Who is eligible for TRICARE Prime?
Active duty members, their eligible family members and survivors (normally under age 65), eligible retirees and their family members (normally under age 65) and Reserve Component members and their families, if the RC member is activated for more than 30 consecutive days. Enrollment in Tricare Prime is mandatory for active duty members.
To ensure eligibility, your information in DEERS must be current. You may contact DEERS to verify your information by calling 1-800-538-9552. All eligible beneficiaries must additionally reside in a service area where Tricare Prime is offered.
Why Choose TRICARE Prime?
There are lots of good reasons to choose the TRICARE Prime plan:
Assignment to a primary care manager who provides and/or coordinates your care, maintains your health records and approves and refers you to specialists when medically necessary.
2) Focused, preventive medical care to help keep you healthy.
3) Coverage when traveling away from home.
4) Tricare Prime enrollment is free for active duty members and their families. Survivors, retirees and their family members have an annual Tricare Prime enrollment fee of $260 for a single enrollee or $520 for an entire family. Eligible retirees, survivors and their family members who enroll in the Tricare Prime plan should expect considerable savings and enhanced medical care over the TRICARE Extra and TRICARE Standard plans.
Where Can I Get Help With TRICARE?
You can receive assistance regarding the Tricare program at any Tricare Service Center. Each MTF is served by a TSC that is staffed with customer service representatives. The CSRs can explain the different TRICARE plan options, help beneficiaries choose the plan that suits them best, assist with completion of the enrollment application, assist with claims adjudication and locate civilian network or Tricare-certified providers. The TSC employees assist beneficiaries who use any of the three Tricare plans. The Laughlin TSC is located in the 47th Medical Group building.
Additional information about TRICARE can be found on the Tricare website at www.tricare.mil.
TRICARE Offers Options
Tricare includes three health care plans and two programs: Tricare Prime, Tricare Extra and Tricare Standard and the Tricare For Life and Tricare Plus Programs. The 47th Medical Group, as most other military treatment facilities, offers Tricare Prime. Beneficiaries who choose to use the Tricare Extra or Tricare Standard plans must seek their medical care with Tricare-authorized civilian providers.
If You Get A Bill By Mistake
For Tricare Prime beneficiaries, there are no claim forms, bills (except for co-payments) or balance-billing for services covered by Tricare. However, if you do get a bill by mistake, contact Tricare at 1-877-874-2273 to ensure that the claim was processed correctly. If you are still unable to resolve the issue, please come by Laughlin's TRICARE Service Center at the health benefits advisor at (830) 298-6350.
Reading The Explanation Of Benefits
After receiving care outside the 47th Medical Group, Tricare will send you an explanation of benefits. This document will reflect the care received, the amount billed, the amount paid by Tricare and any deductible or co-pay for which you may be responsible.
The most important column for beneficiaries to look at is the middle column titled "Beneficiary Liability Summary." This column will tell you if you have any deductibles, co-payments or cost shares. Pay special attention to the remarks section, as this section will explain how and why a service was paid or not. If you feel there is an error, please refer to the phone number on the Explanation of Benefits.
Point Of Service Option
POS is an option under Tricare Prime that allows enrollees the freedom to seek and receive non-emergent health care services from any Tricare authorized civilian provider, in or out of the network, without requesting a referral from their PCM or the health care finder. When Tricare Prime enrollees chooses to use the POS option, all requirements applicable to Tricare Standard apply, except the requirement for a non-availability statement.
POS claims are subject to outpatient deductibles ($300 individual and $600 family), 50 percent cost-shares for outpatient and inpatient claims, and excess charges up to 15 percent over the allowed amount. The 50 percent cost-share continues to apply even after the enrollment year catastrophic cap has been met.
The POS option can be a very expensive choice, but it is an option available to all Tricare Prime beneficiaries. If you do not follow the required steps for a referral, your visit into the network could bill as POS. In that case, you will be responsible for the deductibles and cost-shares outlined above.
Please note: Active duty personnel are not eligible to use the POS option. They must seek care only from their MTF PCM or they will be responsible for 100 percent of all billed charges.