What is Veterans Health Insurance (Tricare)?
By Rod Powers
Tricare is the military’s health insurance program, and it comes in four varieties: Tricare Prime, Tricare Extra, Tricare Standard, and Tricare for Life. Tricare, the military’s health insurance plan, covers everyone — active-duty members, retirees, and their families. However, retirees and their dependents have to chip in for the cost of coverage.
Veterans health insurance: Tricare Prime
The Tricare Prime option is very much like an HMO, or health maintenance organization. Like an HMO, you’re assigned to a primary care provider (PCP). This is usually, although not always, a military medical facility (on-base hospital or medical clinic). You receive most of your healthcare needs through the PCP. Like most HMOs, in order to receive care from a specialist you must first receive a referral from your PCP.
Tricare Prime requires you to enroll and pay an annual enrollment fee; plus you pay a small fee (called a cost-share in the military) each time you receive medical care. When you receive medical care under Tricare Prime, you don’t have to file a reimbursement claim. The provider automatically does this for you.
Tricare Prime is the most cost-effective Tricare option, but you generally have to live close to a military base to take advantage of it.
Veterans health insurance: Tricare Extra
The Tricare Extra program gives you more flexibility than Tricare Prime, but it can result in additional costs. If you’re eligible for Tricare benefits, you don’t need to enroll in advance to use Tricare Extra. You’re enrolled automatically the first time you use any benefits and present your military or dependent ID card as an insurance card to the provider.
Under this program, you can go to any Tricare network provider (TNP), present your military or dependent ID card, and receive medical care.
Under Tricare Extra, you pay an annual deductible. After the deductible is paid, Tricare pays 80 percent of the medical expenses, and you pay 20 percent of the authorized costs. TNPs have also agreed to do all the paperwork for you. Under Tricare Extra, you don’t have to file claims to be reimbursed.
Veterans health insurance: Tricare Standard
The Tricare Standard program gives you the greatest flexibility, but it costs the most. Under this program, you can see just about any medical provider you want. As with Tricare Extra, you pay an annual deductible. In addition to the deductible, you have to pay 25 percent of what Tricare says the medical service should cost.
If you want to find out what the Tricare allowable cost is for a particular medical procedure, visit the Tricare Costs page.
Medical providers under Tricare Standard can be broken into two groups:
Participating providers: Participating providers, although they’re not under contract as a TNP (Tricare network provider), have agreed to file claims for you, accept payment directly from Tricare, and accept the Tricare allowable charge, less any applicable cost-shares paid by you, as payment in full for their services.
There’s no national list of participating providers. You need to ask your provider if she participates in the Tricare program. The general rule is, if the provider fills out the claims paperwork for you, she’s a participating provider. If you have to fill out the claim form yourself, she’s a nonparticipating provider.
Nonparticipating providers: Nonparticipating providers have not agreed to accept the Tricare allowable charge for services or file your claims. Under the law, nonparticipating providers may charge up to 15 percent above the Tricare allowable charge for services (in addition to your regular cost-shares). This amount is your responsibility and isn’t shared by Tricare.
If you see a nonparticipating provider, you may have to pay the provider first and file a claim with Tricare for reimbursement. To file a claim, you need DD Form 2642, Patient’s Request for Medical Payment.
You don’t have to enroll in Tricare Standard. You’re enrolled automatically the first time you use any benefits and present your military or dependent ID card as an insurance card to the provider.
Be sure to check with the provider to see if she is a participating or nonparticipating provider. The doctor may decide to participate on a claim-by-claim basis. This means that for one type of service, the provider will participate (agree to accept the Tricare allowable charge and file claims on your behalf), but for another she won’t. Using a participating provider is your best option if you use Tricare Standard.
Veterans health insurance: Tricare for Life
Until a few years ago, when a retiree or retiree family member reached the age of 65, they were no longer eligible for Tricare. Instead, they were expected to receive medical care under the provisions of Medicare. This changed in 2001 with the introduction of Tricare for Life.
To remain eligible for Tricare benefits, you must enroll in Medicare Part B. This is the Medicare program where you pay monthly premiums in exchange for receiving medical care from authorized Medicare providers.
Under Tricare for Life, you receive your medical care from Medicare providers, but Tricare becomes a secondary insurer and picks up any costs that Medicare doesn’t cover. You pay no annual deductible or cost-share under this program.
What isn’t covered by veterans health insurance (Tricare)?
Tricare covers most inpatient and outpatient care that’s medically necessary and considered proven. However, there are special rules or limits on certain types of care, while other types of care aren’t covered at all. Some services or treatments require prior authorization.
A few examples of medical procedures that aren’t covered are:
Abortions (unless the mother’s life is at risk).
Condoms. However, other forms of birth control that require a prescription, such as birth control pills, are covered.
Cosmetic surgery or drugs used for cosmetic purposes (such as Botox). However, cosmetic surgery to correct a disfigurement, such as the result of an accident or burn, is covered.
Nonsurgical treatment for obesity or weight control.
Smoking cessation products and treatment.
Most dental work. (The military has a separate insurance program for dental care.) However, dental care that is medically necessary in the treatment of an otherwise covered medical (not dental) condition is covered.
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