TRICARE Open Season: Time to pick a plan

  • Published
  • 341st Missile Wing Public Affairs

The TRICARE Open Season is in full swing until Dec. 9. During this time, beneficiaries can enroll in or change their TRICARE plan.

Picking a health plan is an important and personal decision. If a member wants more flexibility in their choices of providers, a primary doctor to manage and coordinate overall care, there are some items to consider while comparing TRICARE Prime and TRICARE Select plans.

TRICARE Prime is similar to a health maintenance organization, or HMO plan. As described in the TRICARE Plans Overview, TRICARE Prime features the use of military hospitals, clinics and reduces out-of-pocket costs for authorized care outside military hospitals and clinics by TRICARE network providers.

Active-duty service members must enroll in TRICARE Prime. Depending on eligibility and where they live, eligible active-duty family members may have a choice between a TRICARE Prime plan and TRICARE Select.

TRICARE Prime is only available in certain stateside areas called Prime Service Areas. Entering a ZIP code into the TRICARE Plan Finder will show if TRICARE Prime is available in the area.

Getting Care with Prime
Most routine care will come from an assigned or selected primary care manager.

The PCM’s role is to manage care, file medical claims and refer a member to a specialist when needed. If specialty care is needed, the PCM will work with the TRICARE regional contractor for referrals and authorizations.

Active-duty family members, retirees or retiree family members won’t need a referral from a PCM under the point-of-service option. With POS, a member can get non-emergency health care from any TRICARE-authorized provider. Active-duty service members cannot use this option

Costs with Prime
As outlined in the ‘TRICARE Costs and Fees Sheet’, active-duty service members, family members and transitional survivors have no enrollment fees. Members will also pay no out-of-pocket costs for TRICARE-covered services as long as members see a TRICARE network provider in an enrolled TRICARE region with the appropriate referral or authorization.
Retirees, their families and others must pay an enrollment fee and any copayments for covered health care services from network providers in their enrolled TRICARE region. However, out-of-pocket costs are limited by the cap amount for that calendar year.

Since there’s no deductible, TRICARE Prime has the lowest out-of-pocket costs of all the TRICARE health plans.

TRICARE Select is available everywhere and is similar to a preferred-provider organization, or PPO plan, meaning a member isn’t assigned to a PCM.

Members can see any TRICARE-authorized provider per their choice, but with this flexibility in provider options comes additional out-of-pocket costs.

Described in the ‘TRICARE Plans Overview’, members can save money by using TRICARE network providers.

Getting Care with Select
Referrals aren’t needed for most health care services, but members may need pre-authorization from their regional contractor for some services. Network providers file claims for the TRICARE Select beneficiary. For non-network care, members may have to file their own claims.

Costs with Select
Active-duty family members don’t have a yearly enrollment fee. For retirees, their family members and others, there may have enrollment fees based on when the military sponsor initially joined the military.

Once enrolled, there is a yearly deductible for TRICARE–covered services. When the deductible is met, beneficiaries pay per-visit cost-shares or copayments for most services.

When following the rules of the plan, out-of-pocket costs are limited to the member’s yearly cap.

Visit Health Plans to learn more about TRICARE Prime and TRICARE Select in order to help make informed decisions about health. Plan features can be compared via the TRICARE Compare Plans tool. To enroll in or change TRICARE Prime or TRICARE Select plan, the most ideal time is during TRICARE Open Season.