How Tricare Changes when a Military
Sponsor Retires or Dies
When a military member retires from active service and begins drawing retired pay, one chapter in the member's life is ended and another begins. If the member has a family, their individual lives change as well, including their TRICARE cost shares.
When an active duty sponsor dies, surviving family members remain eligible for TRICARE benefits at the active duty dependent rates for a three-year period. At the end of the three-year period, TRICARE eligibility continues, but at the retiree dependent rates.
| |
Active Duty Service Member And Dependents |
Retired Service Member And Dependents |
| Enrollment in TRICARE Prime |
Active duty service members must be enrolled in TRICARE Prime. Dependents can choose which TRICARE option they prefer - TRICARE Prime, Extra or Standard |
Retired service members and their dependents can choose which TRICARE option they prefer - TRICARE Prime, Extra or Standard |
| TRICARE Prime |
- No enrollment fee for active duty service members or their family members
- No co-payments for any health care visit to a network or referred provider.
|
- Enrollment fees apply - $230 for individuals, $460 for families
- Co-payments ($12) required for outpatient visits to network providers
- Inpatient care - $11 per day, $25 minimum
- Inpatient mental health - $40 per day
|
| TRICARE Extra |
- Inpatient care - $12.72** per day or $25, whichever is more
- Outpatient care - 15% of the negotiated cost
|
- Inpatient care - $250 per day or 25% of hospitals billed charges, whatever is less, plus 20% of allowable charge for separately billed professional services.
- Outpatient care - 20% of the negotiated cost.
|
| TRICARE Standard* |
- Inpatient care - $12.72** per day or $25, whichever is more
- Outpatient care - 20% of allowable charges
- Annual outpatient deductible - $50 for individuals, $100 for families (E-1 - E-4), $150 for individuals, $300 for families (E-5 and above)
- Civilian inpatient mental health - $20 per day
|
- Inpatient care - $417** per day or 25% of hospitals billed charges, whichever is less, plus 25% of allowable charges for separately billed professional charges
- Outpatient care- 25% of allowable charges
- Annual outpatient deductible - $150 for individuals, $300 for families
- Civilian inpatient mental health - lesser of $159* per day or 25% of allowable fees
|
| Catastrophic Cap* |
$1,000 annually |
$3,000 annually |
| Eligible for Medicare (age, disability or end-stage renal disease (ESRD)) |
Active duty family members are not required to enroll in Medicare Part B to remain eligible for TRICARE |
Retired service members and their dependents must enroll in Medicare Part B to remain eligible for TRICARE. |
* The catastrophic cap is the annual upper limit. It applies only to the allowable charges for covered services. It applies to the enrollment year for TRICARE Prime enrollees and to the fiscal year for TRICARE Extra and Standard users.
**Rates are current for FY 2003; rates change every fiscal year.
Use of Military Treatment Facilities (MTFs):
If enrolled in TRICARE Prime at a particular MTF, retirees and their family members will have the same access standards as an active duty family. Retirees and their families who do not enroll in TRICARE Prime may continue to use MTFs as capactiy exists - if a particular facility can accommodate them.* A priority system has been established for access to health care in an MTF. Briefly, the priorities are as follows:
- Active-duty service members
- Active-duty family members who are enrolled in TRICARE Prime
- Retirees, their family members and survivors enrolled in TRICARE Prime
- Family members of active-duty service members who are NOT enrolled in TRICARE Prime (for the purpose of determining access priority, survivors of military sponsors who died on active duty who are NOT enrolled in TRICARE Prime are in this priority group)
- All other eligible persons, including retirees and their families who are NOT enrolled in TRICARE Prime
TRICARE Plus* is a MTF primary care enrollment program offered at selected MTFs. All beneficiaries eligible for care in MTFs (except those enrolled in TRICARE Prime, a civilian HMO, or Medicare HMO) may enroll in TRICARE Plus at an MTF if enrollment capacity exists.
Becoming Medicare-eligible:
Medicare eligibility usually begins on the first day of the month in which the beneficiary turns 65.* If the 65th birthday falls on the first day of the month, Medicare Part A eligibility begins on the first day of the preceding month. If the Medicare-eligible beneficiary purchases Medicare Part B, he or she will remain eligible for TRICARE through a program known as TRICARE For Life (TFL). With TFL, beneficiaries retain their eligibility for TRICARE Extra and Standard, but not Prime. TRICARE acts as a second payer to Medicare for services covered by both Medicare and TRICARE. When a retired sponsor reaches age 65 and becomes eligible for TFL, his or her spouse maintains regular TRICARE eligibility until he or she (spouse) becomes 65 years old.
Persons under age 65 who become entitled to Medicare Part A because of a disability or ESRD*, and who are enrolled in Medicare Part B, maintain their eligibility for TRICARE Prime, Extra or Standard. When they reach age 65, they will no longer be eligible for TRICARE Prime; they remain eligible for TRICARE Extra and Standard and become eligible for TFL. By law, TRICARE pays after Medicare for these eligible persons. Beneficiaries who become eligible for Medicare due to a disability or ESRD should report that eligibility to the nearest military personnel office, on or after the date of eligibility.
For more information, beneficiaries may contact a local health benefits adviser, beneficiary counseling and assistance coordinator or TRICARE service center or they may visit the TRICARE Web site at www.tricare.osd.mil .
*See also:
TRICARE: The Basics Fact Sheet
Choosing TRICARE Standard Fact Sheet
TRICARE For Life Fact Sheet
TRICARE Plus Fact Sheet
TRICARE and Medicare for Dual-Eligible Beneficiaries Under Age 65 Fact Sheet
Gold Star Wives of America, Inc. is a nonprofit national military widows service organization chartered by the United States Congress.
|
