TRICARE service areas are being reorganized, which will cause many military retirees and dependents to lose access to TRICARE Prime on October 1, 2013. Retirees, their dependents, surviving dependents, and TRICARE Young Adult members who live more than 40 miles away from a military medical facility or base closure site may be required to change their health care from TRICARE Prime to TRICARE Standard.
These changes will not affect active duty military members or their families when they are stationed away from a local military treatment facility. This includes active duty members in remote assignments, education or training assignments, recruiting positions, and more.
Understanding the TRICARE Changes
Please note this will not affect every TRICARE Prime member, every retiree, or every dependent. According to TRICARE.mil, the Prime Service Area (PSA) changes will not affect the following classes of beneficiaries:
- Active duty service members and family enrolled in TRICARE Prime*
- Activated Guard/Reserve members and family enrolled in TRICARE Prime*
- Surviving spouses of deceased active duty service members enrolled in TRICARE Prime* (for the first three years after the sponsor’s death)
- Surviving children of deceased active duty service members enrolled in TRICARE Prime*
- Children of active duty service members using TRICARE Young Adult-Prime
- Beneficiaries who already use TRICARE Standard and Extra
- Beneficiaries using TRICARE Retired Reserve, TRICARE Reserve Select, TRICARE Young Adult-Standard or TRICARE For Life
Find out if you will be affected. TRICARE has a Zip Code tool to help you determine if your TRICARE Prime eligibility will lapse.
Comparing the TRICARE Plans
To understand the impact of these changes, it’s important to understand how TRICARE Prime and TRICARE Standard function. (Note: All figures apply to retirees and their dependents. Some numbers may vary depending on your status. Please visit the TRICARE website for more information.)
TRICARE Prime is a low cost health care program, which charges members a fixed annual enrollment fee each year, and a small co-pay each visit. The FY2013 enrollment fees for retirees are $269.28 for an individual, or $538.56 for a family. The co-pays for retirees and family members are $12 per visit. TRICARE Prime members are required to receive their health care from network providers.
TRICARE Standard is a fee for service health care program, which allows members to choose their own medical care providers. There is currently no annual fee, and certain preventive visits are available at no cost, including preventive care such as mammograms, vaccines, cancer screening, prostate examinations and routine check-ups. However, there are additional out of pocket expenses. For example, beneficiaries are required to pay 25% of the allowable charges out of pocket. There is an annual deductible of $150 per individual, or $300 per family (this is money that beneficiaries are required to pay before the insurance kicks in). The maximum out of pocket expense per family is $3,000.
Some TRICARE Prime members may be able to remain under Prime with waivers. TRICARE is allowing some service members to receive a waiver to remain under TRICARE Prime, even if they live outside of the 40 mile limit. To be eligible, the Prime members must live within a 100 miles of the nearest TRICARE Prime network and must sign an access waiver to waive the driving-distance limits imposed by TRICARE Prime (normally a 30 minute drive to their primary care provider). TRICARE officials have stated that any displaced PRIME members will be admitted into the network if they meet these conditions, regardless regardless of number of beneficiaries enrolled.
What is not changing. In some cases, TRICARE members will be able to keep their current medical providers, even if they are moving from TRICARE Prime to TRICARE Standard. If you are losing your TRICARE Prime eligibility, then contact your physician to see if they provide service for TRICARE Standard members (most will provide service for both policies).
Impact of TRICARE Changes
This cost cutting move is expected to affect approximately 175,000 TRICARE beneficiaries, and will save the TRICARE system between $45 and $55 million a year. There are pros and cons to each of the TRICARE programs, but ultimately, how you use your benefits will determine how much you are affected. How will this affect the average retiree? Let’s take a look at some of the numbers (current for FY2012):
Cost for Enrollment (note: current enrollment fees; there have been proposed changes to TRICARE enrollment fees, including the creation of an enrollment fee for TRICARE Standard members):
- Prime individual: $269.28
- Prime family: $538.56
- Standard individual: None
- Standard family: None
Cost for Deductibles:
- Prime individual: None
- Prime family: None
- Standard individual: $150
- Standard family: $300
- Prime individual: $12 per visit
- Prime family: $12 per visit
- Standard individual: 25% of the allowable charges, up to $3,000 annual family limit
- Standard family: 25% of the allowable charges, up to $3,000 annual family limit
Some preventive health examinations are also cost free under TRICARE Prime, so there is no $12 co-pay for certain annual exams and preventive screening.
How will this affect you? If you are someone who doesn’t visit the doctor frequently, or only visits for annual screenings, you may come out ahead under TRICARE Standard. If you have other health needs, you may end up spending less under TRICARE Prime. It’s important to note that the most you will pay out of pocket with TRICARE Standard is $3,000 per year, but you could spend significantly less, depending on your needs.