Tricare can be more confusing than you’d think, especially if you’re used to being treated at Medical Treatment Facilities (MTF) and you start seeing civilian providers. And it doesn’t help that the civilian providers often don’t know what’s going on, and sometimes the contractors (Humana in the East, Health Net Federal Services in the West) don’t know, either. That makes it even more important that YOU know exactly what’s going on. And sometimes that’s hard.
Seriously, I know. When we switched from Prime to Select in 2019, our providers couldn’t figure out what to do with us. It took weeks to get everything sorted.
Tricare is a great benefit, but sometimes it can be a little confusing. Prime vs. Select, co-pays vs. cost-shares, catastrophic caps and deductibles – who can keep track?
Thankfully, there are some resources that should make things a lot more clear. The first, and possibly most important resource is the 2021 Tricare Costs and Fees sheet. (This will open a PDF in another tab, so don’t do it on your phone if you don’t want it to download.) It’s only four pages, and the last page isn’t even about medical (it’s dental,) and it’s a pretty darn clear explanation.
How To Use This Tool
I recommend you print it out, and highlight the sections that apply to you. For example, if you’re Tricare Prime, you can cross out all the Tricare Select stuff. If you’re in group A ), just cross out all the group B stuff. If your sponsor is active duty, you can cross out all the retiree information. This should leave you with four basic groups of information: your enrollment fees, your deductible, your co-pays, and your catastrophic cap.
What’s This Group A and Group B Stuff?
With changes to Tricare in 2018, beneficiaries are sorted into two groups: those whose sponsor entered military service before 1 January 2018 (Group A), and those whose sponsor entered military service after 1 January 2018 (Group B). Just to be extra tricky, several groups who should be in Group A are actually put into Group B: Tricare Reserve Select, Tricare Retired Reserve, Continued Health Care Benefit Plan, and any family that has someone on Tricare Young Adult.
Enrollment Fees
Some Tricare options have enrollment fees. To me, this is a weird choice of the word enrollment fee, because I think enrollment fee implies a one-time fee to get enrolled in something. But in the case of Tricare, the enrollment fee is like a premium – you pay it for each month that you are enrolled in that plan – but it’s not a premium because premiums are different and apply to plans like Tricare Young Adult and Tricare Reserve Select. Enrollment fees are listed as an annual cost, but it can be deducted monthly from your retirement pay or you can pay quarterly, depending on your situation. (Be prepared to pay the first few months up front.)
In 2021, both Tricare Prime and Tricare Select will have enrollment fees for retirees.
Don’t confuse enrollment fees with premiums that are paid by groups such as Tricare Young Adult or Tricare Reserve Select. They seem the same, but they don’t count towards your catastrophic cap. And that’s important!
Deductibles
Tricare Select beneficiaries pay an annual deductible before Tricare cost-sharing begins. The deductible is based on status (currently serving or retiree), rank (for currently serving members), group (based upon initial date of military service or enrollment in Tricare Reserve Select, Tricare Retired Reserve, Tricare Young Adult, or the Continued Health Care Benefit Program), and even whether the provider is in-network or out-of-network. There are a lot of variables!
Co-payments or Cost-Shares
Many individuals pay copayments or cost-shares for services covered by Tricare. These amounts vary based upon your status, which Tricare you are using, whether the provider is in-network or out-of-network, and which group you are in.
Catastrophic Cap
The catastrophic cap is the most you’ll pay for covered care in a given calendar year. There are several catastrophic caps based on your status, group, Tricare eligibility type, and which Tricare plan you use. All eligible costs count towards your catastrophic cap EXCEPT premiums and Tricare Prime Point of Service options. Costs that do count towards your catastrophic cap include enrollment fees, deductibles, pharmacy costs, and co-payments and cost-shares for medical care.
Print out the 2021 Tricare Costs and Fees, then cross out the stuff that doesn’t apply to you, and you will understand Tricare a LOT more. Give it a try!
This is a great start for someone trying to understand the basics of Tricare. I wish you would do a TRICARE 102 post to include. Pharmacy & those copayment, the difference between a ‘in-network provider’, ‘non-network provider’, and ‘out of network provider’. Another big one is using the TRICARE manual, the 2015 Policy Manual in particular, as a reference guide for what Tricare covers and not put too much trust in what government contractors (I’m looking at you Humana) says.
Using the manuals is very important. My kids needed a special baby formula due to a cow milk allergy. Humana rep told me it wasn’t covered Policy Manual said it was covered. After I refered the representative to Tricare’s policy manual they agreed formula was covered.
Great feedback! I will work on that!
I think a lot of people get confused on how the maximum out of pocket cost (“MOOP”) works if you are using non-network providers. I looked at this recently and I think that even once you reach the MOOP, you can still end up paying up to 115% over the allowable charge with a non-network provider. I haven’t looked into how a non-network provider can be bound by any “cap” of 115% of Tricare’s allowable charge, so I’m not sure how that works either. I haven’t gotten into that situation with Tricare select yet, but it is something to consider, especially with so many providers switching to non-network recently. I am also not sure if a supplement would cover that additional amount. On the flip side, I do go to a few non-network providers, and I end up paying less than I do for my network provider co-pays.
I have a friend who handles the billing at a non-network provider office. According to her (so second hand) their office the office can charge 15% over the maximum allowable charge. Website linked below a search tool for the max allowable charge.
https://health.mil/Military-Health-Topics/Business-Support/Rates-and-Reimbursement/TRICARE-Allowable-Charges
Kate, as always you’ve done a great job making foundation for folks to get a handle on this!!!Thanks for all you do!!!
I have Tricare for Life. Why am I being billed for lab work?
MTF stands for Military Treatment Facility.
Do costs paid to a non-network provider count towards the catastrophic cap?
It depends whether you are on Select or Prime. Point-of-service costs on Prime do not count toward the catastrophic cap.