✏ Table of Content :
What is Tricare ?
TRICARE is a healthcare program in the United States that provides medical benefits and services to active-duty military personnel, military retirees, and their dependents. It is managed by the Defense Health Agency (DHA) and is one of the largest healthcare programs in the country.
The primary goal of TRICARE is to ensure that eligible beneficiaries have access to quality healthcare services, both in military treatment facilities (MTFs) and through civilian providers. TRICARE offers a range of healthcare options, including health insurance plans, prescription drug coverage, and dental and vision plans. The program provides coverage for a wide range of medical services, including doctor visits, hospital stays, preventive care, mental health services, and specialty care.
TRICARE offers various plans to accommodate the needs of different beneficiaries. These plans include TRICARE Prime, TRICARE Select, TRICARE Reserve Select, and TRICARE for Life. Each plan has its own features and eligibility requirements. There are also specific plans for members of the Reserve and National Guard, retired service members, and survivors of deceased service members.
TRICARE is separate from the healthcare coverage provided by the Department of Veterans Affairs (VA) for veterans. It is specifically designed for the active-duty military community and their eligible family members.
How Does the Tricare Work ?
TRICARE works as a comprehensive healthcare program that provides medical benefits and services to eligible members of the military community. Here's a general overview of how TRICARE works:
1) Eligibility:
TRICARE eligibility includes active-duty service members, military retirees, their dependents (spouse and children), and some members of the Reserve and National Guard. Eligibility can vary depending on factors such as military status, location, and specific TRICARE plan.
2) Plan Selection:
Once eligible, beneficiaries can choose from different TRICARE plans based on their needs and eligibility category. The main plans are TRICARE Prime and TRICARE Select, but there are additional plans available for specific circumstances.
3) Enrollment:
Beneficiaries need to enroll in TRICARE to access its benefits. Enrollment processes can vary depending on the eligibility category and the chosen TRICARE plan. Active-duty service members are typically automatically enrolled, while retirees and their dependents may need to take specific actions to enroll.
4) Primary Care Provider (PCP):
Under TRICARE Prime, beneficiaries are assigned a primary care provider (PCP) who manages their routine healthcare needs. The PCP serves as the main point of contact for medical care and coordinates referrals to specialists if needed. TRICARE Select allows beneficiaries to see any TRICARE-authorized provider without a referral.
5) Network Providers:
TRICARE has a network of healthcare providers, including hospitals, clinics, and individual practitioners. Depending on the plan, beneficiaries may be required to use network providers to receive the highest level of benefits and minimize out-of-pocket costs. Out-of-network care is also available under certain circumstances but may involve higher costs for the beneficiary.
6) Coverage and Costs:
TRICARE covers a wide range of medical services, including doctor visits, hospital stays, preventive care, mental health services, and specialty care. The level of coverage and associated costs depend on the specific TRICARE plan. Beneficiaries may have to pay deductibles, copayments, and/or coinsurance for certain services, but the costs are generally lower when using network providers.
7) Overseas Coverage:
TRICARE also provides coverage for eligible beneficiaries living overseas through the TRICARE Overseas Program (TOP). It offers similar benefits to stateside plans but with some differences in network providers and claim processes.
8) Claims and Reimbursements:
When receiving care, beneficiaries or their providers submit claims to TRICARE for reimbursement or payment. The claims process varies depending on the plan and location, but TRICARE provides instructions and resources to assist with filing claims.
Types of TRICARE Programs
TRICARE offers several different plans to meet the diverse needs of eligible beneficiaries. Here are the main types of TRICARE plans:
1) TRICARE Prime:
TRICARE Prime is a managed care option available in certain geographic regions. It emphasizes a primary care provider (PCP) who coordinates and manages your healthcare. Referrals from your PCP are typically required for specialty care. TRICARE Prime offers comprehensive coverage and generally has lower out-of-pocket costs compared to other plans.
2) TRICARE Select:
TRICARE Select is a fee-for-service option that allows you to see any TRICARE-authorized provider without a referral. You have the flexibility to choose your healthcare providers, including specialists, without primary care gatekeeping. TRICARE Select does not require enrollment but has higher out-of-pocket costs compared to TRICARE Prime.
3) TRICARE Reserve Select (TRS):
TRS is a premium-based plan available for qualified members of the Selected Reserve, including the National Guard and Reserve members. It offers comprehensive healthcare coverage similar to TRICARE Select, but with specific eligibility requirements and premium payments.
4) TRICARE Retired Reserve (TRR):
TRR is a premium-based plan for retired members of the Reserve and their eligible family members who are not yet eligible for Medicare. It provides healthcare coverage similar to TRICARE Select.
5) TRICARE For Life (TFL):
TFL is a Medicare-wraparound coverage available to TRICARE beneficiaries who are eligible for both TRICARE and Medicare. TFL acts as secondary insurance to Medicare and helps cover out-of-pocket costs such as deductibles, copayments, and coinsurance.
6) TRICARE Young Adult (TYA):
TYA is a premium-based plan for eligible adult children of uniformed service members. It offers medical and pharmacy benefits and is available for young adults who have aged out of their parents' TRICARE coverage.
7) TRICARE Dental Program (TDP):
TDP provides comprehensive dental coverage to eligible beneficiaries and their family members. It is a separate program with its own premiums and coverage options.
8) TRICARE Pharmacy Program:
TRICARE offers a pharmacy program that provides prescription drug coverage. Beneficiaries can obtain medications through military treatment facilities, network retail pharmacies, and mail-order services.
Who is Eligible for TRICARE ?
TRICARE eligibility encompasses different groups within the military community and it can be complex or may vary based on specific plans and circumstances. Here are the primary categories of individuals who are generally eligible for TRICARE:
1) Active Duty Service Members (ADSM):
This category includes members of the Army, Navy, Air Force, Marine Corps, Coast Guard, Space Force, and the Commissioned Corps of the Public Health Service and the National Oceanic and Atmospheric Administration. ADSMs are automatically eligible for TRICARE.
2) National Guard and Reserve Members:
Members of the National Guard and Reserve components who are on active duty orders for more than 30 days, as well as their eligible family members, may qualify for TRICARE coverage. There are specific programs available, such as TRICARE Reserve Select (TRS) and TRICARE Retired Reserve (TRR), depending on the member's status.
3) Retired Service Members:
Retired service members of the uniformed services and their eligible family members are generally eligible for TRICARE. Retired Reserve members become eligible at age 60, while those under the age of 60 may be eligible for TRICARE Reserve Select (TRS).
4) Family Members:
Spouses and unmarried children (including adopted and stepchildren) of eligible sponsors are eligible for TRICARE coverage. Certain criteria, such as age limits and dependency status, may apply to determine eligibility for specific TRICARE plans.
5) Survivors:
Surviving spouses and children of deceased service members may be eligible for TRICARE benefits under specific programs such as the TRICARE Survivors Benefit Plan (TSBP) or TRICARE Young Adult (TYA).
6) Others:
There are additional categories of individuals who may be eligible for TRICARE, including Medal of Honor recipients, certain former spouses, and others in unique circumstances. Eligibility in these cases may require meeting specific criteria outlined by TRICARE.
What Services are Covered by TRICARE ?
TRICARE covers a wide range of medical services to ensure comprehensive health care coverage for eligible beneficiaries. The specific services covered may vary depending on the TRICARE program and the beneficiary's status. However, here are some common services covered by TRICARE:
1) Doctor visits:
Routine check-ups, consultations, and examinations with primary care physicians and specialists.
2) Hospital stays:
Inpatient care, surgeries, and medically necessary treatments in both civilian and military hospitals.
3) Emergency care:
Treatment for life-threatening conditions or severe injuries in emergency rooms or urgent care centers.
4) Prescription medications:
Coverage for prescribed medications through military pharmacies, network pharmacies, or the TRICARE Mail Order Pharmacy program.
5) Preventive services:
Routine vaccinations, screenings, immunizations, and preventive care measures to maintain overall health.
6) Mental health care:
Diagnosis and treatment for mental health conditions, including counseling, therapy, and psychiatric services.
7) Maternity and childbirth services:
Prenatal care, labor and delivery, postpartum care, and coverage for necessary maternity-related treatments.
8) Rehabilitation services:
Physical therapy, occupational therapy, speech therapy, and other rehabilitative services.
9) Laboratory and diagnostic tests:
Coverage for lab tests, X-rays, MRIs, CT scans, and other diagnostic procedures.
10) Home health care:
Skilled nursing care, medical equipment, and other services provided at home for those who qualify.
11) Medical equipment and supplies:
Coverage for durable medical equipment, prosthetics, orthotics, and necessary supplies.
12) Ambulance services:
Emergency transportation via ambulance when medically necessary.
13) Dental care:
Dental services are provided through separate dental programs such as TRICARE Dental Program (TDP) or TRICARE Retiree Dental Program (TRDP).
How to Enroll in TRICARE ?
To enroll in TRICARE online, you can visit the TRICARE website (tricare.mil) and follow the enrollment instructions. The specific process may vary depending on your eligibility category and the TRICARE program you're enrolling in. Active-duty service members are typically automatically enrolled. Retirees and their dependents may need to take specific actions to enroll.
Here's a general overview of how to enroll in TRICARE:
1) Choose a TRICARE Plan:
Review the available TRICARE plans and select the one that best suits your needs. The main options are TRICARE Prime, TRICARE Select, and TRICARE For Life. There are also specialized plans for specific circumstances such as TRICARE Reserve Select (TRS) or TRICARE Young Adult (TYA).
2) Complete the Enrollment Process:
The enrollment process can vary depending on your eligibility category and the chosen TRICARE plan. Here are some common enrollment methods:
a) Online Enrollment:
Visit the Beneficiary Web Enrollment (BWE) portal on the TRICARE website and follow the instructions to complete your enrollment online. This method is available for certain categories of beneficiaries.
b) Phone Enrollment:
Contact the TRICARE Regional Office or the Defense Manpower Data Center Support Office to enroll over the phone. They will guide you through the process and help you complete the necessary paperwork.
c) Mail or Fax Enrollment:
Download the enrollment application form from the TRICARE website, complete it, and submit it via mail or fax to the appropriate TRICARE Regional Office or the Defense Manpower Data Center Support Office.
3) Provide Required Documentation:
Depending on your eligibility category, you may need to provide certain documents to support your enrollment, such as proof of military service, marriage certificates, or birth certificates for dependents. Be prepared to provide any requested documentation during the enrollment process.
4) Wait for Confirmation:
After submitting your enrollment application, you will receive confirmation of your enrollment and the effective date of your TRICARE coverage. It's important to keep a copy of this confirmation for your records.
If you need assistance or have specific questions during the enrollment process, contact the TRICARE Regional Office or the Defense Manpower Data Center Support Office. They can provide guidance and address any concerns you may have.
Remember that enrollment periods and requirements may change over time, so it's always recommended to refer to the official TRICARE website or contact the appropriate TRICARE office for the most up-to-date information on how to enroll in TRICARE.
TRICARE Benefits
TRICARE program offers a range of benefits and services. Here are some of the benefits of TRICARE:
1) Comprehensive Coverage:
TRICARE offers comprehensive coverage that includes a wide range of medical services, including preventive care, hospitalization, prescription medications, mental health services, and emergency care.
2) Choice of Providers:
TRICARE allows beneficiaries to choose from a network of civilian healthcare providers, including doctors, specialists, hospitals, and pharmacies. This flexibility enables beneficiaries to select the providers they prefer and access care in their local communities.
3) Worldwide Coverage:
TRICARE provides coverage both within the United States and overseas. This is particularly beneficial for military families stationed abroad, as they can access medical care at military treatment facilities or through TRICARE-authorized civilian providers.
4) Low Cost:
TRICARE offers competitive pricing and cost-sharing options, making healthcare more affordable for military families. Active duty service members generally receive care at no cost, while other beneficiaries have access to various cost-sharing options and low-cost premiums.
5) Access to Specialty Care:
TRICARE provides access to a wide range of specialty care services, including medical specialists, mental health professionals, and rehabilitation therapies. This ensures that beneficiaries can receive specialized care for specific health conditions or treatments.
6) Preventive Services:
TRICARE emphasizes preventive care, offering a range of preventive services such as screenings, immunizations, and wellness programs. These services help beneficiaries maintain good health, detect health issues early, and prevent the progression of certain conditions.
7) Dependents' Coverage:
TRICARE extends coverage to the dependents of military service members, including spouses and children. This ensures that family members have access to healthcare services, promoting the overall well-being of military families.
8) Continuity of Care:
TRICARE aims to provide seamless healthcare coverage, even during transitions such as relocation or deployment. It offers resources and programs to ensure beneficiaries can continue receiving necessary care and medications, regardless of their location.
9) Special Programs:
TRICARE offers additional programs to address specific healthcare needs, such as the Extended Care Health Option (ECHO) for beneficiaries with special needs, the TRICARE Dental Program for comprehensive dental coverage, and the TRICARE Pharmacy Program for prescription medications.
10) Telehealth Services:
TRICARE has expanded its telehealth services, allowing beneficiaries to receive medical care remotely. This is especially beneficial for individuals in remote locations, those with limited mobility, or those seeking non-emergency care without the need for in-person visits.
Contact TRICARE
To contact TRICARE, you can call their general inquiries line at 1-800-TRICARE (1-800-874-2273), or visit the TRICARE website for more specific contact information based on your location and situation.
Frequently Asked Questions
What is the catastrophic cap for TRICARE?
The catastrophic cap for TRICARE is the maximum amount of out-of-pocket expenses that eligible beneficiaries must pay for covered services within a fiscal year.
Does CVS take TRICARE?
Yes, CVS pharmacies are part of the TRICARE retail pharmacy network and accept TRICARE for prescription medication coverage.
Does TRICARE cover chiropractic?
Yes, TRICARE covers chiropractic services for active duty service members and retirees under certain circumstances and with specific limitations.
What does TRICARE not cover?
TRICARE does not cover cosmetic procedures or treatments that are not deemed medically necessary.
What is the difference between TRICARE Prime and TRICARE Select?
TRICARE Prime is a managed care option that provides comprehensive coverage with a primary care manager (PCM) overseeing your care. TRICARE Select is a fee-for-service option that offers more flexibility in choosing providers but requires beneficiaries to pay deductibles and copayments.
Does TRICARE cover dependents and family members?
Yes, TRICARE provides coverage for eligible dependents and family members of active duty service members and retirees. The specific eligibility and coverage depend on the beneficiary's status and the TRICARE program they are enrolled in.
Are there any costs associated with TRICARE?
Yes, TRICARE has costs associated with it, such as enrollment fees, annual deductibles, copayments, and cost shares. The amount you pay depends on the TRICARE program, your beneficiary category, and the type of care received.
Can I use TRICARE when I travel outside the United States?
Yes, TRICARE provides coverage both within and outside the United States. It provides coverage for eligible beneficiaries living overseas through the TRICARE Overseas Program (TOP). However, the coverage and rules may vary depending on your TRICARE program.
How can I find a TRICARE network provider?
TRICARE has a network of authorized providers that offer services at discounted rates. You can use the TRICARE website or call the TRICARE regional contractor to find a network provider near you. You can also choose non-network providers, but it may result in higher out-of-pocket costs.