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When it comes to health insurance, which is the smarter choice—coverage through your employer-sponsored plan or TRICARE?
If that question has you stumped, you’re not alone. The advantages of TRICARE, and the benefits available to you and your family, could hinge on whether you’ve been called to active service. And sometimes, the decision boils down to factors other than cost. How can you be sure your coverage won’t lapse if you switch from one plan to another? What happens if you deploy and your family lives far from a military installation with clinics and hospitals? Can your special-needs child continue seeing the same pediatrician if you move to TRICARE from a civilian provider?
Staff Sergeant Deundra Jones, readiness NCO for the 230th Signal Company, Tennessee National Guard, knows all too well the frustrations that can emerge with efforts to understand TRICARE. For five years, he managed TRICARE early eligibility benefits for the Tennessee Guard, helping units put benefits in place for Soldiers and their families before deployments.
He and his family have had to work out the kinks of TRICARE for themselves, too. Like many Guard families, their situation requires a specific type of coverage.
“I’m Active Guard Reserve,” Jones says. “My family is on TRICARE Prime Remote because we live more than 50 miles away from a military treatment facility. They see civilian doctors in the TRICARE network, and I don’t pay a premium for routine medical services.”
We asked Jones to help clarify the TRICARE system and how you fit within it. Here’s what you need to know:
TRICARE PLAN OPTIONS
Let’s start by looking at the different types of coverage available to you. Your eligibility for various plans depends on your service status within TRICARE—are you inactive, pre-activated/activated or deactivated?
If you’re inactive, you’re on Guard duty for 30 days or less for active service, AT or training, including weekend drills.
Coverage: TRICARE Reserve Select. It’s a premium-based healthcare plan that you may purchase for yourself and/or your family members. Monthly premiums, an annual deductible and cost-shares apply. You can receive care from any TRICARE-authorized provider (network or non-network), and at military hospitals or clinics on a space-available basis.
If you’re pre-activated/activated, you’ve been called or ordered to active service for more than 30 consecutive days in support of a contingency operation. Soldiers holding this status receive early eligibility for Active Duty health and dental benefits up to 180 days before active service begins.
Coverage: TRICARE Prime or TRICARE Prime Remote. These plans are similar to managed care options, available in specific geographic areas. The Remote plan is for families living more than 50 miles or one hour’s drive from a military installation with medical facilities. There are no premiums, no deductibles, fewer out-of-pocket costs, and (in most cases) no claims to file. You receive most care from a military hospital/clinic or civilian network primary care manager. Referrals and/or prior authorizations are required for specialty care.
If you’re deactivated, you’ve been released from a period of active service.
Coverage: Your healthcare options depend on whether or not you were activated in support of a contingency operation. If you were, you qualify for the Transitional Assistance Management Program (TAMP), which provides 180 days of transitional healthcare benefits to help service members and their families transition to civilian life. For more on TAMP, visit TRICARE.mil/tamp. If you weren’t activated in support of a contingency operation, you may qualify for TRICARE Reserve Select or the Continued Health Care Benefit Program (CHCBP). The CHCBP is a premium-based healthcare plan administered by Humana Military. Though not a TRICARE program, CHCBP offers continued health coverage for 18–36 months after TRICARE coverage ends. Learn more about CHCBP at TRICARE.mil/chcbp.
Just as TRICARE coverage is not the same for every Soldier, neither are the insurance-related issues that arise from deployments and other facets of service. Here are some questions common among Guard members:
My civilian employer offers health insurance. How do I determine if it’s a better deal than TRICARE Reserve Select (TRS) for my family and me?
The best way, Jones says, is to lay both plans beside each other, figure out which options apply to your family’s situation, and cross-compare for the best fit. To start, weigh your premium (the amount you pay for the plan each month) and your deductible (the amount you pay out of pocket before your insurer picks up expenses).
Let’s look at current TRS premiums and deductibles as an example:
The current monthly premiums (through Dec. 31, 2016) are $47.90 per individual member and $210.83 per family.
The current annual deductibles (through Dec. 31, 2016) for ranks E-4 and below are $50 per individual, and no more than $100 per family. For E-5s and above, deductibles are $150 per individual, and no more than $300 per family.
After that, you’ll pay a cost-share based on the type of provider you see (network vs. non-network). For a full list of those costs, see TRICARE.mil/costs/healthplancosts/trs/costshares_us.
Now compare this to your civilian employer’s plan. For example, you may see monthly premiums of $300 per individual and annual deductibles of $3,000, which would make TRS much more affordable.
But if the two plans’ costs are comparable, the next step is to ferret out other pros and cons. Drilling down into the differences between plans may require some research. Would you have to change doctors if you switched from your employer’s plan to TRS? If your child sees a specialist for a specific condition, that could be a significant consideration. Would you pay more for certain prescriptions under your employer’s plan? That’s another key point that could mean hundreds of dollars in the long run.
Does TRICARE offer a prescription plan for Guard Soldiers?
Yes. You’re eligible for TRICARE’s Pharmacy Program, administered by Express Scripts, when you’re enrolled in TRICARE Reserve Select, are on Active Duty orders, or are covered by TAMP. TRS subscribers pay monthly premiums and cost-shares.
Can I get dental insurance through TRICARE?
Yes. It’s a voluntary program for which you’ll pay monthly premiums and cost-shares, and you can enroll if you aren’t activated or covered by TAMP. Your family can enroll, too.
If you are activated or covered by TAMP, you get Active Duty dental benefits.
To enroll in the TRICARE Dental Program, go to TRICARE.mil/coveredservices/dental/tdp/enrollment.
How does my proximity to a major military base affect the kind of coverage I can get?
With TRICARE Reserve Select, you choose your own TRICARE-authorized providers.
But if your family is on TRICARE Prime Remote because you live more than 50 miles or one hour’s drive from a military hospital or clinic, you’ll get most care from your primary care manager (PCM). The PCM refers you to specialists for care he or she can’t provide, files claims for you, and works with the TRICARE contractor in your region for referrals and authorizations. If a network PCM is not available to you, then your family can select any TRICARE-authorized provider as your PCM.
If you’re within 50 miles of a military hospital or clinic, you will be served by that facility’s providers.
I’m about to deploy in support of a contingency operation. How do I switch from TRICARE Reserve Select to TRICARE Prime? And how do I ensure there’s no break in coverage during the transition?
In most states, Jones says, when a unit is alerted about a deployment, Soldiers' information is loaded into a personnel database that communicates with DEERS (Defense Enrollment Eligibility Reporting System). At that point, you qualify for TRICARE early eligibility benefits—the benefits you’ll have when you’re activated—for up to 180 days prior to mobilization.
When you reach your mobilization site, you’ll enroll in one of the TRICARE Prime plans: Prime, Prime Remote, Prime Overseas or Prime Remote Overseas. If you need specialty, urgent or inpatient care before you’re enrolled, try to get that care at a military hospital or clinic first. If you’re referred to a TRICARE network provider, you must receive authorization from your regional contractor.
For family members, TRICARE does not recommend enrolling in a Prime option during the pre-activation period, especially if your family members are already covered by another insurance plan. Instead, wait to make the switch until you have begun active service to ensure there’s no break in coverage.
Guard families have three options during pre-activation:
- Continue using your other insurance (like your civilian employer-sponsored plan), if you have it.
- Use TRICARE Standard and Extra, a fee-for-service plan available in the U.S. (TRICARE.mil/plans/healthplans/tse).
- Get care at a military hospital or clinic.
Medical claims for individuals covered under TRICARE early eligibility during the pre-activation period should be submitted for processing to TRICARE by the provider; however, Jones suggests keeping copies of healthcare receipts and explanations of benefits for care received during this time as a safeguard in case any issues arise related to payment for a particular claim.
Also note that it’s up to you to ensure your family members are correctly registered in DEERS. The database is the key to establishing TRICARE benefits eligibility, and mistakes in the system can lead to problems with claims processing. To verify the accuracy of your family members’ information in DEERS, or to update it, call 800-538-9552 or visit TRICARE.mil/deers.
Once you come off mobilization, you qualify for the Transitional Assistance Management Program (TAMP), which is also good for 180 days post-mobilization.
What if I’m called up suddenly and my spouse has to make changes to our family’s plan after I’m gone? How do they find out all they need to know and do?
Keep in mind that Guard units typically have ample notice before deployments—often as much as a year in advance. There will be plenty of time for your family to compare TRICARE Prime with your civilian employer’s insurance coverage.
If your unit is activated for State Active Duty in the event of a natural disaster or other emergency, then you may have very little notice. But this type of activation rarely exceeds 30 days. “During situations like this,” says Jones, “the majority of Citizen-Soldiers maintain medical coverage from their employers.”
Again, making sure your family members’ information is up-to-date in DEERS is critical. And although circumstances are rare in which a Guard spouse would need to make changes to TRICARE on their own, Jones strongly suggests that Soldiers and their spouses maintain a current power of attorney. This legally binding document authorizes your spouse to handle TRICARE enrollment and changes (among other legal matters) in your absence. “Without a power of attorney,” he says, “the Soldier would have to find time during his or her deployment to contact TRICARE and facilitate the enrollment of their spouse.”
If I switch my coverage from TRICARE Reserve Select to a Prime plan, can my family members and I continue to see the same doctors?
That depends on whether your doctors are in the TRICARE network, says Jones. If you have TRICARE Prime Remote and there are no network providers available in your remote location, then you and your family may be eligible to receive care from a non-network provider (with TRICARE authorization). If you have TRICARE Prime, you have two options:
- See a non-network provider if a) there are no network providers available, and b) your regional contractor approves the doctor.
- Use the point-of-service option and visit any TRICARE-authorized provider without a referral.
Be prepared to pay more out-of-pocket fees with the point-of-service option. Learn more about it at TRICARE.mil/costs/healthplancosts/primeoptions/pos.
How do I find doctors who accept my TRICARE plan?
TRICARE offers an online tool to help. Go to TRICARE.mil/finddoctor to search for network providers, non-network providers, military hospitals and clinics, and overseas providers.
To use the tool, you’ll need to know which TRICARE region you’re located in. For a breakdown, see TRICARE.mil/about/regions. That page also lists customer service numbers for each region (see "Quick References" below); for more help, call to have an operator look up a doctor in the system or answer other questions.
Keep in mind that you’ll pay less out of pocket with network providers. You’ll have to pay only your cost-share during the doctor visit, and your provider receives the balance due from TRICARE.
What happens if I’m injured or become severely ill while on Guard duty? How does this affect my family’s coverage?
You qualify for line of duty (LOD) care.
LOD determinations are used to establish, manage and authorize healthcare for any specific injury or illness that results in emergency or urgent care while a Soldier is serving on drill weekends or during AT.
If you’re on TRICARE Reserve Select, it has no bearing on your family’s coverage; family members continue to receive care under TRS. Your LOD care is separate from any other TRICARE coverage, including TRS and pre-activation benefits.
If you’re deployed, you will receive care at military treatment facilities in your deployment location, and your family will continue to receive the same coverage as an Active Duty family.
I’m enrolled in a Prime plan. What happens if I’m in an accident and end up at a nonmilitary hospital or other treatment facility?
For Prime plan subscribers, any emergency room treatment is covered, anywhere. Still, Jones recommends contacting TRICARE after the fact to verify that coverage.
I’m insured through my civilian employer. But if I’m deployed and switch to Prime, can I rejoin my employer’s plan when I return?
Yes. Under the Uniformed Services Employment and Reemployment Rights Act (USERRA), you and your family are entitled to reinstatement in your employer’s healthcare plan upon your return. Your employer’s insurance provider cannot impose a waiting period or withhold your coverage due to pre-existing conditions (other than a service-connected disability).
Keep in mind that you and your family members have 180 days of continued TRICARE coverage under post-mobilization benefits.
TRICARE North Region
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TRICARE South Region
TRICARE West Region
TRICARE Pharmacy Program
TRICARE Dental Program
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