Military family members who are eligible for Tricare health insurance coverage have a variety of choices to make. One of the most important decisions is which plan to pick: Tricare Prime or Tricare Select.
Active-duty service members do not have that choice. They will be enrolled in Tricare Prime and should expect to use the available military health care options on-base or nearby before being referred to a private or civilian care provider. Family members can elect Tricare Prime or Tricare Select.
Depending on your needs and health care requirements, Tricare Select may be the better option.
A Brief Explanation of Tricare Prime
Tricare Prime is a comprehensive health care insurance plan offering coverage for medical services deemed medically necessary. The requirement — according to the Tricare website — is that the medical care or service is “appropriate, reasonable, and adequate for your condition and considered proven.”
The Role of the Primary Care Manager in Tricare Prime
If you elect to sign up for Tricare Prime coverage, you will see a primary care manager (PCM), who may or may not be a military medical care provider, or the equivalent in a civilian local network. You must see your primary care manager first before they can refer you to specialists as care or treatment requires. Your PCM works with a regional contractor for authorization of referrals.
If you elect to receive care without a referral from the PCM, you may be more liable for the cost of treatment or other services, depending on the circumstances. This is especially true for military members. When service members skip the PCM, they may have to pay the full amount for the services provided.
Referral Rules for Military Family Members
Different rules apply to family members. Try to get a referral for services that the primary care manager does not offer. If an on-base military care facility is not available, an in-network referral is the next step.
You may go directly to care without a referral by using an option called point-of-service; however, family members who do so will pay more out-of-pocket for the services.
Service members do not have the point-of-service option. It is only for military family members.
Different Versions of Tricare Prime
There are several varieties of Tricare Prime, depending on the nature of your military service. They include:
- Tricare Prime
- Tricare Prime Remote
- Tricare Prime Overseas
- Tricare Prime Remote Overseas
A Brief Explanation of Tricare Select
Tricare Select is an option family members of active-duty service members can choose when Tricare Prime doesn’t quite meet their needs. According to the Tricare website, the following are also eligible for Tricare Select:
- Retired service members and their families
- Family members of activated Guard and reserve members
- Non-activated Guard and reserve members and their families who qualify for care under the Transitional Assistance Management Program
- Retired Guard/Reserve members at age 60 and their families
- Surviving spouses and surviving dependents
- Medal of Honor recipients and their families
- Qualified former spouses
Using Tricare Select
If you choose Tricare Select, you can visit any Tricare-eligible provider. Unlike with Tricare Prime, you do not need to visit a primary care provider or get a referral from one before doing so.
However, some patients may require prior authorization from a Tricare regional contractor for some services, and it’s best to discuss these needs with a Tricare rep in advance of the need when possible.
With Tricare Select, you may choose between an in-network and non-network care provider. This decision will affect how much you will pay for your care and may also determine whether you will be responsible for filing your own insurance claim paperwork or not.
Tricare Select users use their military-issued ID rather than an insurance wallet card when getting treatment or other services from the health care provider.
What You Need to Know About Using Tricare Select
Tricare Select users may pay an annual outpatient deductible. You may also participate in cost-sharing or pay a percentage of the cost of care. Note: When you use Tricare Select and get care from a network provider, you pay your costs, co-pays or percentage of the cost at the time of your appointment for the services rendered.
When you receive care from a non-network provider, this is quite different. You may be required to pay in full up-front and apply to be reimbursed by Tricare later on. You should prepare for this contingency in advance; be sure to have funds saved to make your required advance payment so your care is not delayed.
Are You Right for Tricare Select?
Tricare Select is not always the best option. If you live in an area where you cannot use Tricare Prime, Tricare Select is a good second option. The same is true when you have other health coverage besides Tricare, such as Medicare or employer-provided coverage.
Tricare Select is also a good option for those military family members and other eligible enrollees who need care providers who are not in the Tricare network and don’t want to change their existing services.
Comparing Tricare Prime and Tricare Select
Under Tricare Prime, in most cases, the provider will file insurance claims for you.
Under Tricare Select, network providers may file claims for you, but when you access non-network care, you may need to file your own claims.
Under Prime, there is “enhanced” vision coverage and preventive services. Your PCM will offer most of your care, and there are fewer out-of-pocket expenses. Under Select, you can receive care from any Tricare-authorized provider; referrals are not required, but you may need prior authorization for some care. You may need to pay for services up-front and seek reimbursement under Tricare Select.
Tricare Prime is managed care, and Tricare Select is described as a preferred-provider network available to all non-active-duty beneficiaries.
According to the Tricare official site, active-duty service members pay nothing out-of-pocket for approved care. Active-duty family members pay for care under Tricare Prime when they get care without a referral, when they use Tricare Select or when they use a network pharmacy or Tricare home delivery.
Specific costs for Tricare Select and Tricare Prime vary depending on a variety of factors, but you can use a cost-comparison tool at the Tricare official site.
Joe Wallace is a 13-year veteran of the United States Air Force and a former reporter for Air Force Television News.
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