Chapter 12: Tricare Services
Updated On: 5/29/2013 10:19:29 AM
Introduction to Tricare
Oceanside, 1st Floor, C Wing
Hours: Weekdays, 7:30 a.m.-4:30 p.m.
Tricare Prime and Tripler Tricare Plus patients have 24-hour access to their providers through their primary care clinic phone numbers. This may help you avoid unnecessary ER visits and keeps your doctors aware of your needs.
Tricare is the Department of Defense’s (DoD) military healthcare program. The Tricare program today is worldwide, including Europe, Latin America and Pacific Regions. Hawaii is part of Tricare West along with many other western states.
Tricare includes healthcare provided by both military clinics and hospitals, and care provided through the civilian healthcare program formerly known as CHAMPUS. Tricare is now available in every DoD healthcare region.
The Purpose of Tricare is Three-fold:
Improve access to medical care
Provide healthcare of the highest quality
Deliver healthcare in the most efficient and cost-effective manner
Military members and families eligible for healthcare through DoD have three options from which to choose their health insurance coverage:
Other Tricare options discussed in this chapter are for persons eligible for Medicare.
The preferred healthcare insurance option for many military members and families is enrollment in Tricare Prime, DoD’s Health Maintenance Organization (HMO). Under Tricare Prime, first-time active-duty families are assigned a military Primary Care Manager (PCM). Retirees and their families can select either a military PCM or a civilian network provider.
Primary Care Manager’s Role
The PCM serves as the medical manager for all healthcare needs, including preventive healthcare, care during illnesses, and referrals to specialists when needed. Since your PCM manages your healthcare needs, he or she will always be the first point of contact when you need healthcare.
If your PCM cannot meet a specific healthcare need, he or she will refer you to the appropriate specialty physician. The specialist will notify your PCM of his or her findings so that your PCM can continue to manage your care. True emergency care may be an exception, and in such situations, you should go immediately to the nearest emergency room.
Other Prime Advantages
Other Advantages of Tricare Prime Include:
Free preventive healthcare benefits
Priority appointments to non-emergent healthcare
Lowest out-of-pocket cost shares of any of the Tricare options
Under Tricare Prime, active-duty family members receive healthcare at no charge, while non-active duty family members pay a nominal fee for authorized care with a provider outside of a Military Treatment Facility (MTF). Outpatient care in the MTF is at no charge. The Tricare Prime HMO offers the most comprehensive healthcare benefit, but it does have some restrictions. Please stop by one of our Tricare Service Centers to learn more about Tricare Prime, or call toll-free, (888) 874-9378.
Through Tricare Standard, you can seek care from any civilian healthcare provider, although some restrictions do apply. However, you are responsible for annual deductibles and cost-share amounts. A deductible is the cost of healthcare you are fully responsible for, before you can receive benefits through Tricare.
Once you have met your deductible, your Tricare benefits begin to help pay for your healthcare costs. At the beginning of each fiscal year (Oct. 1), you start a new deductible.
A “cost share” is the cost of healthcare you are responsible for. It is dependent upon your sponsor’s military status and pay grade. Your cost-share is usually based on a percentage of the Champus allowable charge. This option works best if you have other health insurance.
To be eligible for Tricare Standard benefits, you do not need to enroll in any program. You must simply be eligible for Champus.
As a Tricare Extra beneficiary, you can save money by selecting a physician who is a Tricare Network Provider (civilian provider). Whenever you visit a Tricare Network Provider, your cost share is decreased by five percent. Tricare Extra is easy to use. You don’t need to sign up for anything. Simply select a Tricare Network Provider. However, you are still responsible for your annual deductible.
Tricare For Life (TFL)
Tricare For Life (TFL) means additional benefits for beneficiaries who are 65 or older and enrolled in Medicare Part B. Patients gain access to TFL as long as they are uniformed services beneficiaries who are Medicare-eligible and have purchased Medicare Part B.
TFL, as a Health Insurance Carrier:
Acts as secondary payer to Medicare
Files claims automatically unless there is other health insurance (OHI)
Requires no monthly premium (except the cost of Medicare Part B)
Tricare Plus (T-Plus)
Separate and distinct from Tricare for Life or TFL is Tricare Plus, in which Tricare-eligible individuals and families choose to receive their primary care at a local Military Treatment Facility (MTF).
The following “Age In” patient category has priority in Tricare Plus if the patient meets the following criteria:
Have been enrolled in Tricare Prime for the two years immediately preceding their 65th birthday and who are assigned to the MTF primary care provider for the past two years as a Tricare Prime beneficiary.
Enrolled in Medicare Part B at age 65. Please note that Tricare Plus enrollment is based on an MTF’s capacity to continue to meet Tricare Prime appointment standards. Therefore, not everyone eligible for Tricare Plus can be enrolled in the MTF Program. Tricare Plus is not portable to other MTFs.
Your Next Step
Remember, any outpatient care you receive in a military clinic or hospital is at no cost to you. Whenever you receive care from civilian providers in Hawaii, your Tricare Program is there to help cover the cost of care.
It’s important for you to understand and decide which Tricare Program choice is right for you.
Our Tricare Service Center staff is prepared to help you understand the Tricare program and select the most appropriate
program. They can also help you select a Tricare Network Provider, choose a PCM, enroll in Tricare Prime and help explain your Tricare bills or claims.
Guide to Triaging Your Healthcare
When the issue is not pressing, you have a number of options available to access healthcare information and assistance. Learn how to triage your healthcare.
General Healthcare Information
When you are looking for general healthcare information and want to educate yourself or learn more about a healthcare issue that affects your family, Tricare has many options including 24/7 general information:
Visit Tricare Online at www.tricareonline.com . Go to “General Health Information” for many options.
Call toll-free, (888) 874-9378 to access a medical audio library.
Advice and Consultation
When you need more in-depth advice or consultation on a current health care problem:
Contact your Tricare Primary Care Manager (PCM) or provider.
Establish a relationship with your primary provider. To find a Tricare provider, call (888) 874-9378 or go to www.triwest.com to Tricare Resources.
ALWAYS CALL 911 first if you think it is an emergency. It is always wise to know in advance where to go in an acute or emergency situation. If you do not already have an established relationship with a primary care provider, use the healthcare finder service to locate a provider in advance of an emergency and:
Find out about the nearest emergency room and ambulance service
Learn about your avenues for seeking urgent care
Obtain the number to make an appointment with your PCM
Tricare Online (TOL) is the first central effort to develop an enterprise-wide resource for all DoD patients, providers and managers. To access TOL, log on to www.tricareonline.com. The web-based program improves the communication and education of healthcare services and information. It also provides secure links to other websites that provide valuable information.
TOL provides easier access to appointments, medication refills, referrals, enrollment, healthcare information and communication with patient providers.
The website’s educational benefits include:
A drug interaction checker
Tricare benefits explanations
A “condition checker” that explains different conditions that affect the body
A wellness information page that offers information about a variety of healthy lifestyle topics
A health calculator
Online primary care appointments to military PCMs
Web-based pharmacy refills, appointment reminders, prescription renewal requests