Decisions... Decisions...

Michele Allen
MilitaryByOwner Advertising, Inc. 

Healthcare options are a hot topic in almost any public arena these days. Regardless of shifts in healthcare for the civilian world, military members have three basics choices in choosing healthcare plans for their families. Active Duty servicemen and women must be enrolled in TRICARE Prime, but should carefully consider the choice between Prime, Standard and Extra for their dependants.

How does TRICARE Prime measure up in this challenge? All dependants of active duty servicemen are eligible for TRICARE Prime, but enrollment is not automatic, the proper forms must be submitted through DEERS. The primary benefit to selecting Prime is that there are virtually no fees for the active duty dependant. There are no enrollment fees, deductibles, or costs when you are seen by a TRICARE Prime provider with referral. If keeping costs low is your primary objective, then PRIME is your best option. This cost-free healthcare does come at a price, not so easily recordable on your check ledger. 

Although Prime enrollees will have priority at all Military Treatments Facilities, care is managed through a Primary Care Manager. The Primary Care Manager sees the patient first for all non-emergency health care needs. The Primary Care manager determines and refers you to specialists. Emergency care must also be confirmed by the Primary Care Manager in order for coverage of the treatment to be ensured. Primary Care Managers must first refer patients to Military Facility Specialists. An inability to provide care, or care within 90 days would induce Prime managers to refer the patient to a TRICARE civilian provider. 

With Prime, the Point of Service Option does allow enrollees the freedom to seek and receive non-emergency healthcare services from TRICARE authorized civilian providers without a referral from their PCM.   With the Point of Service Option, claims are subject to outpatient deductibles ($300 individual, $600 family), 50% cost share for outpatient and inpatient claims and excess charges up 15% over the catastrophic allowed amount. The 50% cost share continues to be applied even after the Enrollment Year Catastrophic cap has been met. 

Retirees and their dependants have the option to retain Prime enrollment, but must pay enrollment fees ($260 individual and $520 family) and some cost shares for inpatient care. In the opposite corner of the healthcare decision stands TRICARE Standard, ready to present its case. What TRICARE Prime lacks in freedom and flexibility, Standard enrollees will have it in droves! With Standard, enrollees are not required to coordinate or have care approved through a Primary Care Manager. TRICARE Standard offers greater provider choice. Beneficiaries may choose any TRICARE-authorized provider. TRICARE-authorized providers are not required to participate in the TRICARE network; however, they must be certified as an authorized provider by the managed care support contractor (MCSC) in that region. Beneficiaries should contact their regional MCSC to find a TRICARE authorized provider.

The drawback to Standard for some is that the patient pays deductible and co-payment of 20% of allowable charges for active duty dependants and 25% for retirees and their dependants.   Additionally, non-participating providers may charge up to 15 percent above the TAC for their services, and TRICARE Standard beneficiaries are financially responsible for these additional charges. Beneficiaries may be required to file their own claims when using TRICARE Standard.

A third choice available to family members is TRICARE Extra.   Extra offers a wider choice of health care providers and facilities than Prime, and also can keep costs lower than Standard.  Patients enrolled in extra may obtain care without referral from a TRICARE network provider, rather than a TRICARE authorized provider to ensure that they pay a discounted cost share of 20%.   Although this limits the provider choices from the Standard plan, the costs are less and care is not managed by a Primary Care Manager. 

Many choose a supplemental private insurance that can be obtained through USAA or other providers to help to defer the costs of choosing the Standard or Extra Option. 

Another option for dependants is the TRICARE Young Adult Program that helps to keep young adults transitioning to their own insurance covered.   TRICARE Young Adult is an option for unmarried, adult children who have "aged out" of regular TRICARE coverage.  Dependant on the package the young adult chooses, Prime or Standard, a monthly premium is required.   Additional costs, provider limits and referrals align with the plan that is selected with enrollment. 

There are so many things to consider when choosing your plan, be sure to evaluate the needs versus costs for your family. And that’s not the end of the decision making; Pharmaceutical Options are the next thing to think about. For a brief overview of these options click here.