A common question from working military spouses and military retirees is, “Should I take my employer’s health insurance, since I have Tricare?” It’s a smart question to ask, but you’ll need some details to find an answer.
Understanding How Tricare and Other Health Insurance Work Together
In Tricare language, any other health insurance is called OHI.
The most important thing to know is that Tricare always pays second to OHI except for Medicaid, Medicare, specifically designated Tricare supplements, and a couple of other very unique government programs like state run victim compensation programs and Indian Health Care. Your employer’s health coverage will pay first and then the balance will be submitted to Tricare.
Side note: Be sure you understand your Tricare options, either active duty or retired. I’ve talked to people who are willing to pay pretty significant premiums for OHI based upon misunderstandings of the Tricare system. Often, people will tell me that they don’t want to go get their care on base, or deal with referrals. Once I explain Tricare Select, they realize that maybe they don’t need OHI to get the flexibility they want.
How Much Are You Paying For Tricare?
First, you need to know how much you’re paying for Tricare. This article can help you figure it out, but the most important part is the catastrophic cap.
A catastrophic cap is the most you’ll pay for covered services in a year. For active-duty families, the 2022 catastrophic cap is $1,000 for sponsors who joined the military prior to 1 January 2018 (Group A) and $1,120 for sponsors who joined the military on or after 1 January 2018 (Group B.) For retiree families, the catastrophic cap depends on which plan you use and also your group.
2022 Tricare Retired Catastrophic Caps
| Group A (sponsor entered military before 1 Jan 2018) | Group B (sponsor entered military on or after 1 Jan 2018 |
|
|---|---|---|
| Tricare Prime | $3,000 | $3,921 |
| Tricare Select | $3,706 | $3,921 |
In many, many cases, just the premium on the other policy is more than the catastrophic cap on Tricare. If that is the case, you’ll have to figure out whether your other policy covers something that Tricare doesn’t cover, like chiropractic care.
How Much Healthcare Do You Use?
The catastrophic cap is important because it represents the most you’ll pay for covered care, but many families never get anywhere near their catastrophic cap. In that case, you may want to consider the ongoing costs.
Each combination of plans (active duty vs. retiree, Group A vs. Group B, and Prime vs. Select) has its own costs. As I mentioned before, this article is a good place to figure out the costs you will have for each plan. Some, like Tricare Prime for active duty family members who use a Military Treatment Facility, have nearly no out-of-pocket costs. Others plans may have an enrollment fee and/or ongoing co-pays for care.
If you think that you never use enough health insurance to meet your catastrophic cap, map out the health care that you do use in a year and figure out what it will cost you with and without OHI. Keep in mind that these are just estimates and you could have a very light health care year, or you could have an injury or illness that blows these estimates out of the water.
How Much Will Tricare Pay After Your Other Health Insurance?
The first step is to submit your claim to your OHI. It’s super-important to follow the rules of your OHI. If your OHI denies a claim for any reason, including a lack of referrals, Tricare will generally also deny the claim.
Once your claim is paid by your OHI, it is then forwarded to Tricare.
If the provider was a Tricare network provider, or a participating non-network provider (who accepts Tricare assignment), Tricare will pay the smaller dollar amount of these three calculations:
- billed amount minus the OHI payment, so no balance remaining
- amount TRICARE would have paid without OHI, little to no balance remaining
- amount beneficiary owes after the OHI paid (usually the OHI copayment or cost share), so no balance remaining
If the provider was a non-participating provider (does not accept Tricare assignment), Tricare will pay the smaller dollar amount of these three calculations.
- 115 percent of the allowed amount minus the OHI payment
- Amount TRICARE would have paid without OHI
- Amount beneficiary owes after the OHI paid (usually the OHI copayment or cost-share)
Non-participating providers may only bill a Tricare beneficiary up to 115% of the Tricare allowed amount. If the OHI paid more than 115% of the Tricare allowed amount, Tricare will not pay any remaining portion. Tricare considers the charge paid in full and the provider may not bill the beneficiary.
Prescription Coverage
Prescription coverage works pretty much the same way as health care coverage. Your OHI will pay first, and Tricare will pay second. Use a Tricare network pharmacy to keep your costs as low as possible, and inform the pharmacy staff of both insurance plans.
Beneficiaries with OHI are permitted to use military treatment facility pharmacies. They will need to provide their OHI information so that the Department of Defense can bill the OHI.
Tricare beneficiaries with OHI may not use Tricare Home Delivery (Express Scripts) unless:
-
- their OHI does not include pharmacy benefits
- the drug is not covered by the OHI
- or you have met your OHI’s benefit cap
What About Active Duty Members?
Active duty service members, including activated reservists and National Guard, can not use other health care as their primary coverage. As a general rule, they are only covered by Tricare. If an active duty service member wishes to use OHI, they need to work with their Tricare contractor first.
The Tricare Young Adult Twist
One situation in which carrying other health insurance may make sense is if you have one or more kids who are no longer eligible for regular Tricare coverage, but are not yet 26. If you are considering covering them under Tricare Young Adult, they would almost always be covered under your other health insurance, possibly at no additional charge. This could change the math entirely, particularly if you have multiple kids in that gap.
One Other Thing To Consider
There is one other thing to consider when deciding whether to use OHI with Tricare: What is your mental and emotional capacity for dealing with paperwork and other issues? In theory, OHI and Tricare are supposed to work together smoothly, and sometimes that works out. But sometimes it doesn’t. If you can’t stand dealing with insurance, or you don’t have time, you might want to stick with Tricare alone.
Every situation is different, and there’s no right answer for everyone. You have to consider the coverage and costs of your other health insurance, and the coverage and costs of Tricare, how they’ll work together, and your family’s medical needs. In many cases, Tricare beneficiaries find that there is no reason to pay for additional health insurance. Don’t make a decision without thoroughly understanding how it all works!
For more information about using Tricare with other health insurance, see the Tricare webpage on the topic.
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Thanks for the article, but I am having a hard time finding information on Tricare Select. I am in Group A. I am employed and have health insurance under my employer that also covers my wife. Now I understand that we will be required to pay a monthly premium starting in January for select. The only resource we use “on base” is the pharmacy. So I don’t believe we need select. But I just want to be sure. Can you shed any light on what select provides and if you already have health care coverage if you need it.
Hi Dale – the equation remains the same, just the numbers change a little bit. Tricare Select is outstanding stand-alone coverage and I’m surprised that your employer’s health insurance is a better offer. (It does happen, but it’s definitely an exception.) If you are using your employer health insurance, Tricare Select can help with deductibles, co-pays, and cost-shares of your employer coverage.
My husband is retired Army. He works for a company that has a $12K deductible insurance plan. Tricare is our secondary. We were told we had to use his company insurance if it was offered. So we do have a choice and we can cancel his employer benefits and only use Tricare?
Hi, I have the same question. Do we have to opt in for employer insurance if offered? Or is Tricare ok with us declining OHI…? Also retired military. Thank you!
I am wondering the same thing. Did you get an answer?
At this time, you are not required to accept other health insurance. That’s an idea that has been tossed around, and may happen at somepoint in the future. But not now.
Hi Kate, I’m retired military with 4 kids 12 and under. My wife works for Banner Healthcare and can get medical insurance through them. The cost will be around $500/month to cover my wife and 4 kids. My wife and I are confused as to whether or not to enroll in her medical insurance or should we stick to only Tricare? Please advise.
Hi George,
There’s no single right answer to that question. Your wife’s plan will cost you more, as the catastrophic cap on covered services is only $3000 (Prime) or $3500 (Select.) But that extra cost may be worth it, if it is hard to find providers in your area, or if her plan covers things that Tricare doesn’t cover (like chiropractic.)
Most people find that just Tricare works for their situation, but dig around a little to see if that would be true for you.
Good luck!
Hi Kate. Has this changed since November 2020? Are retires required to accept OHI from our employers if we have Tricare Prime for self and spouse? Where can I get more information?
Hi Sean,
Nothing substantial has changed, though I may need to see if there are any 2020 figures in this post. Retirees are not required to accept employer health insurance if they have access to Tricare.
What kind of information are you looking for? The Tricare website is pretty good. http://www.Tricare.mil
Thanks Kate for the great information …! I’m retired ANG and became “Tricare eligible” last February. I asked about making changes (Tricare and Anthem reps) but never got a solid answer and subsequently made no changes. (Wish I would have found you sooner!!) Turns out I should have been a little more assertive, because I could have saved a bunch on premiums alone over the past 9 – 10 months. During Open Enrollment this year I discovered that my employer offers a “Tricare Supplement” which, I’m learning will pick up what Tricare Select does not. Very reasonable rate it seems. Stay tuned … I’ll let you know mid-year or so, how things are going.
Thanks again for what you do!! Keep up the good work!
Bill! I am so glad that you found a good solution for you! Please keep me updated!
Bill,
How is your Tricare Supplement working for you? We are in a similar situation, looking for real-world feedback.
Thanks,
Debra
Debra – the Tricare Supplemental that I have is Selman and Company (SelmanCo) which is offered through my employer. I pay $122.30 / month and have a $200 family deductible … really good support and coverage has been as advertised.
Having had an “average health year” (knock on wood!!) By year’s end I will have saved roughly 15-20% over what I would have paid had I stayed with Anthem/Blue Cross.
One downside … the paperwork with TC-Select / SelmanCo is MUCH MORE tedious … I definitely need to stay on top of it!
Hope this helps!
My wife retires January 1, 2021, she is 62. We use her employer’s insurance plan, it is better than the ones my employer provides. I plan to retire June 30, 2021 as well, I am 61. We also have Tricare Select and I am in Group A. The health plans my employer provides for me are expensive and are not very good plans. My question is, “Does Tricare require me to enroll in one of my employer’s health plans to keep Tricare?” Can I just use Tricare and not enroll in one of the plans provided by my employer?
Tricare does not require you to enroll in an available employer health plan. You can just use Tricare.
Changes to this have been floated around for years, but there hasn’t been any significant attempt to make this a requirement for Tricare. Could it happen in the future? It could. But it isn’t the rule now, and I wouldn’t forsee that passing anytime in the near future. But definitely a good idea to belong to a military benefits organization like MOAA or TREA to keep up on these types of issues.
What rule prevents me for buying high quality private health insurance as an active duty member (United States Public Health Service under HHS not Armed Forces)? I cannot find anything written in law but am told by tricare not to. I assume that I have consumer rights. I cannot find any law that states I cannot buy private health insurance.
I am retired military and have OHI through my new employer starting 1 Jan. It is 100% paid for by my employer. I have notified Tricare that I have OHI. My employer plan has a $250 deductible and of course Tricare has $150. Do i need to meet BOTH before Tricare pays out? It seems like Tricare costs are already very reduced by the fact that the OHI would pay the bulk of any medical costs, but by having OHI, it looks like I am now having two deductibles to meet. I called Humana, they were not clear at all.
I’m in the same situation with 100% employee-paid coverage. My obvious goal is to avoid paying more out of pocket by using the “free” coverage…the secondary insurance treatment of copays and deductibles is confusing, should I be declining the free plan?
Tricky question. In theory, it would depend on the deductible and other out-of-pocket costs on your “free” coverage. But from everything I’ve seen and heard, there is a disconnect between how it is “supposed” to happen and how it actually happens. In good news, it seems like Tricare pays more than advertised, keeping actual costs lower than expected. Perhaps it is simply because if you ask 100 different times, you’ll get 100 different answers to how they work together. I was once on a conference call from someone who was representing Tricare on the call, and she clearly didn’t understand how it worked with 2nd insurance even though that was the purpose of her being on the call.
In good news, you’re going to have outstanding coverage either way. The bigger issue that I hear people complaining about is getting the bills coordinated, especially at pharmacies. This may not matter to you if you don’t seek a lot of care, or if you have the time and patience to slog through the occasional paperwork drill. But if you have higher medical needs or life is otherwise crazy, that might be a lot.
I wish I had a more clear answer for you. But there seems to be some aspect of “see what happens” to this process. It’s maddening but also what’s consistently reported to me.
Ditto. I’ve called Tricare multiple times and ask the same question and get a different answer every time. They always have to put me on hold to research it and it clearly don’t know what they are talking about. The last person I talked to recommended that I call the claims department rather than customer service Since they are the ones who actually process claims they should know how it works. She also mentioned that the way the medical service provider does the billing might make a difference as well. I haven’t had a chance to call the claims department yet. Tricare is already a big hassle! Averaging together all the answers I got and all the written Tricare guidance I can find, I believe Tricare will pay the deductible and copays of the primary health insurance as long as they are in the form of medical bills that were not paid by the primary and the claim was not denied because you didn’t follow the primary’s rules. I’m going to give it a shot and just cancel the employer coverage if it ends up costing me more than Tricare alone. I will post back with my experience.
Hello,
My son will ‘age out’ from my employer covered insurance, leaving myself and my daughter on this plan. The only reason I signed up for employer covered insurance was for my son to have health insurance. Since he is aging out, should I go back to TRICARE, where the cost is significantly less? Also, I am looking at future health cost when I get older. Is TRICARE a better option? The hospital I go to now under my employer plan seems to have better ‘bedside manner’ but it costs a lot more for copay and prescriptions.
That’s a very individual question, and depends on a lot of factors. How much is “significantly less,” and how does that amount fit in your budget? Does your employer policy cover any treatments that you use and are not covered by Tricare (such as chiropractic.) Is Tricare doing a good job as a second-payer after your employer plan, or has that been complicated or difficult? Are you seeing any doctors that you want to keep and who don’t take Tricare? Which Tricare are you using right now – Prime or Select? How is that going for you? Are you an active duty family member, or a retiree family member?
Every person will have a different answer to this question.
This is so informative–thank you very much. My employer heavily subsidizes their coverage offerings to the point that I can get one of the higher deductable plans at no premium cost to me so I’m trying to understand of I should decline it. The paperwork/hassle was a great point. The piece I’m not understanding is whether Tricare (select) would cover the costs over their deductable amount but under my employer insurance deductable amount. Thanks for any insight you can offer!
The private hospital/clinic in Merida Yucatan, Mexico will no longer accept Tricare. You can pay yourself and seek reimbursement, but Tricare was offering such low payments for reimbursement for medical care. They have stopped accepting and billing Tricare directly. (my understanding that for one person’s surgery, Tricare wanted to pay only $200 USD for surgeon fees. What is going on? The hospital was happy as they could be up to the last three or four months.
Hi
So I was diagnosed with breast cancer stage 4 in November 2019. Since than I have accumulated a deductible 3 times… 4500 x 3 =13500… not to mention lots in prescription co-pays and things that were just not covered under my husband’s ohi. The deductibles are currently killing me as it is. So now I am eligible to get tricare select and I think that maybe both insurances would be best thing for me. What are you thoughts.
Elizabeth, I’m sorry to hear of your situation. Are you paying for the other health insurance? Tricare Select has a catastrophic cap of $3500 per year (if your sponsor entered the military before 1 January 2018, slightly higher if they entered after that date.) You may find it cheaper and easier to have just Tricare. A quick spreadsheet should show you which way to go.
Best wishes for successful treatment!
Hi Kate
Thank you so much for the well wishes. I do appreciate that.
Yes my husband pays over 100 per week for his insurance. I am the veteran and I entered the military before 2018 and have now reached 60 years of age and qualify for tricare.
To boot my husband’s insurance is changing yet again on July 1st so I am thinking I will have yet another 4500 deductible under the new insurance. It seems to never stop.
Thank you for the reply
Elizabeth, I am reluctant to make any recommendations based upon the limited information you have shared, but I suspect Tricare would be much cheaper for both of you. There is an enrollment fee, but that amount is applied to your catastrophic cap.
Have you read through these articles? I hope that they make it easier to understand what Tricare pays for and how. https://www.katehorrell.com/tricare-costs-and-fees/
https://www.katehorrell.com/military-retiree-medical-tricare-prime-select-or-usfhp/
Let me know if you need any help comparing your options. Also keep in mind that you’ll switch to Tricare for Life in 5 more years.
Congratulations on reaching the age for retirement pay, and thank you for your service.
Kate
My husband is retired from the military and we currently have Tricare Prime. If my employer offers insurance do I have to take it as my primary insurance and Tricare Prime as my secondary? Or can I just keep Tricare Prime for my insurance?
You can keep Tricare as your primary insurance.
So my wife and I just got married and we are trying to navigate the insurance world. I am medically retired with VA coverage and honestly I use VA coverage the most since I went through an MEB and my issued are covered by the VA. My wife on the other hand has a High Deductible HSA plan for her and our daughter. We have heard that you cannot have an HSA plan alongside Tricare. We are not really sure what our next step is nor what is true, but we are trying to figure out the best option/s possible.
Any guidance would be greatly appreciated!
CC – It is correct that you can not have an HSA if you have Tricare coverage, but it is the opinion of at least one of the major military financial education organizations that if you don’t sign up for a Tricare plan, you are eligible to have an HSA.
You’ll have to consider the price of Tricare vs. the price of your wife’s plan plus the tax benefits of an HSA, especially if she is able to sock money away there. You probably won’t be able to predict with exactness but you should get close enough to be comfortable with whatever you decide.
Congratulations on your marriage!
I retired on 1 MAR of this year from a state job and also from the National Guard. I am carrying both OHI from my previous employer ($400 per month) and my wife and I are enrolled in Tricare Select ($25 per month).
Is there someone I can talk with to compare the plans or should I just draw it out and compare both plans. I live in a part of the state with great health care and have found a provider and hospital that accept Tricare. I had the OHI for over 35 years and can’t cut the cord! I feel like I’m wasting $4800 a year.
You can get professional help to compare the two plans, but I suspect you’re more than capable of doing it yourself. Be sure to consider premiums, deductibles, cost-shares and co-pays, and catastrophic caps. Because you say that you are paying $25/month for Tricare Select, I am thinking that you are receiving military retirement pay and on “regular” Tricare, not Tricare Retired Reserve. With that, you’re looking at a $3,706 catastrophic cap for 2022 (assuming you are Group A, entering the military before 1 January 2018.) Simply the premiums for your OHI exceed your Tricare catastrophic cap.
The other two things to consider are: does your OHI cover stuff that Tricare doesn’t cover, like chiropractic, and do you have any kids who are on your OHI who would require a premium payment for Tricare Young Adult.
You’ve got this, but if you don’t, I can recommend some people to help.
Happy Thanksgiving!
I am in Group A with Tricare Select. My wife is 63 and is paying over $600 a month for employer insurance. We want to drop the employer insurance but here in Maine very few providers accept Tricare. On the other hand almost all providers accept Medicare. (Her gastroenterologist accepts Medicare but not Tricare.) If we dropped the employer insurance and had to go to non-Tricare providers, would that be a financial problem? What if we had a Tricare supplement? (I am over 65, retired military.)
Have you looked into the out-of-network costs with Tricare Select? Often the cost different between in-network and out-of-network is minimal. Obviously every situation is different, but I don’t even ask if someone is in-network or out-of-network anymore, simply that they are “participating.” See if this helps: https://www.tricare.mil/FindDoctor/AllProviderDirectories/NonNetwork
If I have Tricare prime and I also take my employers OHI can I still been seen on base and other MTFs? I know they would bill the OHI but it would be “out of network” so would I be responsible for payment of deductible and whatever the OHI did not cover? Or do they submit a claim to the OHI and everything not covered is then covered by tricare prime? Or am I no longer eligible to be seen on base if I have OHI?