Massachusetts military service members and veterans have seen major changes to their pay and benefits over the past year. Revisions to health care coverage are more complex, and may impact individual service members, veterans and their families in different ways.
What it is
Tricare is a health care program for almost 9.4 million beneficiaries that offers 11 different options, with choices depending on the status of the sponsor and the geographic location: Active-duty members; military retirees; National Guard and Reserve members; family members (spouses and children registered in the Defense Enrollment Eligibility Reporting System) and certain others, including some former military spouses and survivors, as well as Medal of Honor recipients and their immediate families.
Those entering the military on or after Jan. 1, or changing status (i.e., from active duty to retired) should make sure they and their eligible family members are enrolled in the Tricare program of their choice. Those who don’t enroll may only receive care at a military clinic or hospital on a space-available basis, and medical care by civilian providers wouldn’t be covered. The one-month open season begins on the Monday of the second full week in November and goes through the Monday of the second full week in December. During that time, you can enroll in a new Tricare Prime or Tricare Select plan; or change your enrollment. If you’re satisfied with your current Tricare health plan you don’t have to take action to stay enrolled.
Tricare offers two core options: Tricare Prime and Tricare Select. Select replaced Tricare Standard and Tricare Extra in 2018. All active-duty members are required to enroll in Tricare Prime; they pay nothing out of pocket. Active-duty families can enroll in Tricare Prime without an enrollment fee. Prime beneficiaries are assigned a primary care manager, or PCM, at their local military treatment facility or, if one is not available, they can select a PCM within the Tricare Prime network. Specialty care is provided on referral by the PCM, either to specialists at a military facility or a civilian provider.
Tricare Select is similar to a traditional fee-for-service health plan. Patients can see any authorized provider they choose, but must pay a deductible and co-pays for visits. Patients pay lower out-of-pocket costs when they receive care from a provider within the Tricare network.
All Tricare programs have a cap on how much a family pays out of pocket each fiscal year, depending on the sponsor’s status and the type of Tricare program used.
- Tricare Prime: Prime is similar to a health maintenance organization, which has lower out-of-pocket costs but requires enrollees to use network providers and coordinate care through a primary care manager – a doctor, nurse practitioner or medical team. It’s free to active-duty members and families; retirees must pay an annual enrollment fee ($300 for an individual, $600for a family in 2020). Those whose initial period of service began before Jan. 1, 2018 are grandfathered in to these rates. Co-payments for medical visits are lower than other programs, and there are no deductibles unless patients get care outside the network.
- Tricare Prime Remote: Service members who live and work more than 50 miles or an hour’s drive from the nearest military treatment facility must enroll in Tricare Prime Remote. Family members are eligible if they live with an enrolled service member in a qualifying location, or they may use Tricare Select.
- Tricare Prime Overseas/Prime Remote Overseas: Tricare Prime Overseas is a managed-care option for active-duty members and their command-sponsored family members living in nonremote locations. They have assigned primary care managers at a military treatment facility who provide most care and referrals for and coordination of specialty care. Tricare Prime Remote Overseas is a managed care option in designated remote overseas locations, with most care from an assigned primary care manager in the local provider network, who provides referrals for specialty care. Activated National Guard and Reserve members and their families also may enroll in these options while the sponsor is on active duty; retirees and their families aren’t eligible.
- Tricare Select: This is a preferred provider plan – authorized doctors, hospitals and other providers are paid a Tricare-allowable charge for each service performed. Costs are higher for out-of-network providers, and certain procedures require pre-authorization. There is no enrollment fee for active-duty families, or for retirees and their families and others whose period of service began before Jan. 1, 2018. Copays vary by status and type of care: An in-network primary care outpatient visit costs retirees and their families $29, for example, while some active-duty family members pay $21 and others – those whose sponsor entered the network on or after Jan. 1, 2018, pay $15.
- Tricare Reserve Select: Qualified Selected Reserve members can buy Tricare coverage when they are in drilling status – not mobilized. The program offers coverage similar to Tricare Select.
- Tricare Retired Reserve: “Gray area” National Guard and Reserve retirees who have accumulated enough service to qualify for military retirement benefits but have not reached the age at which they can begin drawing those benefits (usually age 60) can purchase this insurance, which offers coverage similar to Tricare Select.
- Tricare for Life: This wraparound program is for retirees and family members who are eligible for Tricare and Medicare. The provider files the claims with Medicare; Medicare pays its portion and then sends the claim to the Tricare for Life claims processor. Enrollees must enroll in Medicare Part A (free for those who paid Medicare taxes while working) and Part B (monthly premium required) to receive Tricare for Life.
- Tricare Young Adult: Unmarried dependent children who do not have private health insurance through an employer may remain in Tricare until age 26 under a parent’s coverage via TYA Select or TYA Prime. Premiums are required for both.
- US Family Health Plan: Beneficiaries who live in one of six designated areas, can enroll in this as a Prime option. Those enrolled get all their care, including prescription drugs, from a primary care provider the beneficiary selects, from a network of private doctors affiliated with one of the not-for-profit health care systems in the plan. Beneficiaries don’t get care at military hospitals or clinics, or from Tricare network providers when enrolled in the US Family Health Plan.
Beneficiaries must take action to enroll in a Tricare plan in order to be covered for civilian health care. Those who don’t enroll will only be able to get health care at a military clinic or hospital on a space available basis.
To be eligible for any of the Tricare plans, beneficiaries must first be enrolled in the Defense Enrollment Eligibility Reporting System. Active-duty members are automatically registered in DEERS when they join the military, but they must register eligible dependent family members. Service members should make sure the information is correct for their family members. Only military members can add or remove family members; this is done through the local ID card office.
Tricare changes: What you need to know
The military’s Tricare health program was overhauled a few years ago to include a strict limitation on switching between Tricare plans.
And for retirees, a new dental program, the Federal Employees Dental and Vision Insurance Program, or FEDVIP, has replaced the now-defunct Tricare Retiree Dental Program.
As of 2019, beneficiaries can’t switch between Tricare Prime and Tricare Select until the yearly open season starting each November, unless there’s some sort of qualifying life event, such as the birth of a baby, a move to a new duty station, marriage or retirement.
Amid Tricare’s bureaucratic reforms and changes in regions and contractors, beneficiaries are dealing with higher costs, and some have had difficulty finding local doctors and other medical providers who are in the Tricare network. Defense health officials have been closely monitoring the performance of the two Tricare contractors and are working to resolve the problems.
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