TRICARE PRIME

TRICARE Prime is a Health Maintenance Organization (HMO) medical plan. HMOs provide guaranteed access to health care by assigning you to a specific facility for your care. HMOs use primary care managers to manage your health care needs and determine access to specialists.

By enrolling in TRICARE Prime, you agree to coordinate your health care needs through a primary care manager (PCM). Enrollees receive care through a military treatment facility (MTF) or through an assigned Prime-designated network of civilian providers.

If you're on active duty, you must enroll in TRICARE Prime. All others can choose to enroll in TRICARE Prime or TRICARE Select.

TRICARE Prime offers fewer out-of-pocket costs than TRICARE Select but less freedom of choice for providers.

When you enroll in TRICARE Prime, you should expect to drive no more than 30 minutes to your PCM for primary care and 60 minutes for specialty care. Retirees have to sign a waiver of the drive time standards when they enroll if they want to select a military or network PCM that’s outside of the 30-minute drive time standard or a specialist outside the 60-minute drive.

If you have other health insurance in addition to TRICARE, such as Medicare or an employer-sponsored health insurance, TRICARE Prime is probably not a good choice for you. Enroll in Tricare Select instead.

TRICARE Prime Eligibility

• Active duty servicemembers and their families,
• retired service members and their families (until you become eligible for TRICARE For Life),
• Guard/Reserve members and their families activated to active duty service for more than 30 days in a row,
• non-activated Guard/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,
• survivors,
• Medal of Honor recipients and their families, and
• qualified former spouses.

TRICARE Prime Costs

Costs are different for Group A and Group B members. Group A are members who entered the service prior to 2018. Group B is members who entered the service in 2018 and after.

Prime enrollment for active duty service members and their families has no enrollment fee or co-payments.

Retirees must enroll to use TRICARE Prime and pay the annual enrollment fee and the co-pays.

Annual enrollment fees are found here for each group/program. The Prime annual fee is adjusted each year based on the retired pay COLA.

In 2021, outpatient visits require a $21 co-pay for primary care and $31 for specialty care. Here is the full list of co-payment amounts by service.

The catastrophic cap, which is the maximum annual out of pocket cost, for active duty families is $1,000. In 2021, for retirees and their families it is $3,000/$3,703 (Group A/Group B). Costs you incur that contribute to the catastrophic cap include annual enrollment fees, deductibles (if applicable), pharmacy copayments and other copays and cost shares based on TRICARE-allowable charges.

The cap does not apply to:

• services not covered by TRICARE,
• any amount non-participating providers charge above the Tricare maximum allowable charge.
• TRICARE Prime Point of Service charges, nor
• monthly premiums for TRICARE Reserve Select, Tricare Retired Reserve, or Tricare Young Adult.

NOTE: The Prime Point-of-Service Option. If you have TRICARE Prime and choose to go outside your assigned PCM, you will pay dearly. This is known as the Point of Service option, and it is not an effective option. We suggest that if you will not follow the rules of Prime by going where you are assigned, you are better served by enrolling in TRICARE Select.

TRICARE Point-of-Service Option costs are here.

Positives

• No enrollment fee for active duty and families.
• Guaranteed access — you are assigned a medical facility.
• Managed health care.
• Assistance from primary care manager.

Negatives

• Requires a copayment.
• Annual enrollment fee for retirees.
• Limited options when choosing a provider.
• Mandatory referral for specialty care.
• Not available everywhere.
• The Point-of-Service Option.

Enrollment

TRICARE Prime requires enrollment in the Defense Enrollment and Eligibility Reporting System (DEERS) and reoccurring annual enrollment during the Open Season in November and December. If you are enrolled in Prime during the year, no additional enrollment action is necessary during future Open Season periods as it is assumed you will automatically continue in the Prime plan until you choose otherwise.

If you want to switch TRICARE plans, Prime to Select or vice versa, this must be done during the Open Season period unless you require TRICARE enrollment due to a “qualifying life event.” This would be a death, marriage, divorce, loss of another health care plan, etc. See TRICARE for the complete list.

You can choose to drop from all TRICARE plans if you prefer to use a different health care plan. We suggest you always enroll in a TRICARE plan as a backup. TRICARE Select works as a backup because there are no costs if you don’t use Select because of another plan.

Enroll at your ID card office or base hospital or online during the Open Season window.

Notify DEERS, of any changes in personal information, including address, marital status, and other health insurance.

Maintain an up-to-date Uniformed Services Identification Card. You can locate your nearest ID card issuing facility by viewing the DoD RAPIDS Site Locator online.

If you have questions about your TRICARE eligibility or coverage, please email beninfo@moaa.org or call the Member Service Center at (800) 234-6622 and ask to speak to a benefits counselor.

MEDIPLUS® TRICARE Supplement Insurance

To help reduce your unexpected out-of-pocket expenses, MOAA sponsors the MEDIPLUS® TRICARE Supplement Insurance Plans that help cover cost-shares not fully reimbursed by TRICARE for covered doctor visits, hospital stays, surgeries, prescription drug cost-shares and excess charges (up to 15% above the TRICARE allowed amount), once any applicable TRICARE and MEDIPLUS deductibles have been met.

MEDIPLUS has you covered:

• Pays cost-shares and co-pays
• Pays excess charges (up to 15% above the TRICARE allowed amount)
• Affordable members-only group rates
• Guaranteed acceptance for eligible MOAA members and their families – you’re covered immediately for all new health conditions. Any current injuries or illnesses are subject to the Pre-Existing Conditions Limitation and are covered after six months.

For more information on the MOAA MEDIPLUS TRICARE Supplement Plans, call 1-800-247-2192, e-mail moaa.service@mercer.com, or visit www.moaainsurance.com.

TRICARE Select

TRICARE Select (previously named TRICARE Standard) is a preferred provider organization (PPO) health plan. A PPO provides the greatest choice in health care providers in exchange for some extra costs. Unlike a health maintenance organization (HMO) like TRICARE Prime, a PPO does not assign you to a specific health care facility or doctors.

TRICARE Select allows you to go to any doctor, hospital, or clinic that accepts TRICARE Select insurance. There is no primary care manager; you are responsible for your own care management.

TRICARE covers services that are medically necessary — meaning appropriate, reasonable, and adequate for your condition and through proven, accepted procedures. In other words, services considered experimental or new age that are not commonly accepted practices are not covered. If you have questions, review TRICARE’s covered services.

Specialist referrals are not needed as long as services are necessary and follow accepted medical procedures.

It is to your advantage to use TRICARE network doctors. Find doctors online.

TRICARE Select Enrollment

TRICARE Select requires enrollment in the Defense Enrollment Eligibility Reporting System (DEERS) and reoccurring annual enrollment during the open season in November and December. If you are enrolled in Select during the year, no additional enrollment action is necessary during future open seasons as it is assumed you automatically will continue in the Select plan until you choose otherwise.

If you want to switch TRICARE plans — Select to Prime or vice versa — this must be done during the open season period unless you require TRICARE enrollment due to a qualifying life event. These include a death, marriage, divorce, loss of another health care plan, etcetera. View the complete list of qualifying life events.

You can choose to drop from all TRICARE plans if you prefer to use a different health care plan. We suggest you always enroll in a TRICARE plan as a backup. TRICARE Select works as a backup because there are no costs if you don’t use Select because of another plan.

Eligible Beneficiaries

Those eligible for TRICARE Select coverage include:

• active duty family members,
• retired servicemembers and their families,
• family members of activated National Guard/Reserve members ordered to active duty service for more than 30 days in a row,
• nonactivated National Guard/Reserve members and their families who qualify for care under the Transitional Assistance Management Program,
• retired National Guard/Reserve members at age 60 and their families,
• survivors,
• Medal of Honor recipients and their families, and
• qualified former spouses (see https://tricare.mil/Plans/Eligibility/FormerSpouses).

TRICARE Select Costs

ANNUAL FEE

There is no enrollment fee associated with TRICARE Select in 2020. However, there is an annual deductible and coinsurance costs. An annual enrollment fee will start in January 2021. The fee will be $150 for individuals and $300 for families (Group A), and will be in addition to deductibles and copayments. The fee will be deducted from retiree pay by the pay agencies (DFAS, USCG) on a monthly basis.

FEES BASED ON MILITARY STATUS AND GROUP

Separate fees apply to members who entered military service prior to 2018 (Group A fees) and those who entered military service in 2018 or after (Group B fees).

• Active duty Group A costs: The annual deductible for active duty ranks E-4 and below is $50 per individual and $100 per family. The annual deductible for active duty ranks E-5 and above is $150 per individual and $300 per family. Learn more. In 2021, active duty family members pay a $22 copayment for network primary care visits and a $34 copayment for specialty visits. A non-network visit is 20 percent of TRICARE allowable charges. Learn more.
• Retiree Group A costs: Retiree annual deductibles are $150 for individuals and $300 for families. Learn more. In 2021, retirees pay a flat copayment fee of $30 for primary in-network care and $46 for specialty in-network care. Out of network, you pay a 25 percent of TRICARE allowable charges. These copayments are after your deductible has been met. Learn more.
• Active duty Group B costs: Visit TRICARE’s website.
• Retiree Group B costs: Visit TRICARE’s website.

HOW COPAYMENTS WORK

If a practitioner accepts TRICARE, they accept the TRICARE payment amount for their services. Copayments stated as either the fixed-fee for in-network or the percentage for out-of-network, based on the TRICARE approved amount, not the retail amount charged by the service provider. For example (Retiree/Group A): A doctor charges $1,000 retail price for a primary care medical service and bills TRICARE Select. TRICARE states they pay $400 (illustration only) for the procedure, and the doctor who accepts TRICARE payment rates accepts the $400 for the service. Your copayment is the $30 fixed fee. If the doctor was non-network but still accepted you for treatment, your copayment would be 25 percent, meaning you would pay $100 of the bill and TRICARE pays $300.

CATASTROPHIC CAP

The catastrophic cap represents your maximum annual out-of-pocket expense before TRICARE pays in full. It includes all covered out-of-pocket expenses. For active duty families, the catastrophic cap is $1,000/$1,058 (Group A/Group B) per year. Starting in 2021 the retiree catastrophic cap will increase to $3,500 and increase by the annual COLA amount thereafter. Visit TRICARE's website for pricing for Group A and B copayment costs.

Positives

• Greatest choice of providers in the community
• Manage your own health care
• Control your costs based on usage

Negatives

• No primary care physician; managed care
• Higher out-of-pocket expenses
• Deductible/copayments paid by beneficiary
• If the provider does not file the claim, the beneficiary must file a claim for payments to providers; you might have to pay costs up front until reimbursed by claim

Keys to Continuing Eligibility

Notify DEERS of any changes in personal information, including address, marital status, other health insurance, etcetera. You can notify them online.

Maintain an up-to-date uniformed services identification card. You can locate your nearest ID card issuing facility through the DoD RAPIDS Site Locator.

MEDIPLUS® TRICARE Supplement Insurance

To help reduce your unexpected out-of-pocket expenses, MOAA sponsors the MEDIPLUS® TRICARE Supplement Insurance Plans that help cover cost-shares not fully reimbursed by TRICARE for covered doctor visits, hospital stays, surgeries, prescription drug cost-shares and excess charges (up to 15% above the TRICARE allowed amount), once any applicable TRICARE and MEDIPLUS deductibles have been met.

MEDIPLUS has you covered:

• Pays cost-shares and co-pays
• Pays excess charges (up to 15% above the TRICARE allowed amount)
• Affordable members-only group rates
• Guaranteed acceptance for eligible MOAA members and their families – you’re covered immediately for all new health conditions. Any current injuries or illnesses are subject to the Pre-Existing Conditions Limitation and are covered after six months.

For more information on the MOAA MEDIPLUS TRICARE Supplement Plans, call 1-800-247-2192, e-mail moaa.service@mercer.com, or visit www.moaainsurance.com.

TRICARE RESERVE SELECT AND RETIRED RESERVE

TRICARE Reserve Select and TRICARE Retired Reserve are premium-based health care plans available to eligible National Guard and Reserve members and their families. They operate similarly to TRICARE Select, which operates like a commercial preferred provider organization (PPO) health plan.

TRICARE Reserve Select (TRS)

WHO IS ELIGIBLE?

Members of the Selected Reserve (and their families) who meet the following qualifications:

• Not on active duty orders
• Not covered under the Transitional Assistance Management Program
• Not eligible for or enrolled in the Federal Employees Health Benefits (FEHB) program

Additionally, members in the Individual Ready Reserve, including Navy Reserve voluntary training units, do not qualify to purchase TRS.

If you lose coverage under another TRICARE health plan and qualify for TRS, you may purchase TRS with no break in coverage. Submit your completed TRS request form with an enclosed premium payment postmarked no later than 60 days after the loss of the TRICARE coverage. TRS coverage begins on the day after the loss of your other TRICARE coverage.

WHAT ARE THE COSTS?

• In 2021, the TRS enrollment premium will be $47.20 (individual)/$238.99 (family) per month. Annual deductibles will be $52/$105 (individual/family) for E-4 and below, and $158/$317 (individual/family) for E-5 and above. The annual catastrophic cap is $1,058. Primary/specialty care copayments will be $15/$26 per visit. Visit TRICARE’s website for more detailed pricing.

ENROLLMENT AND GENERAL INFORMATION

Visit the TRS website for complete details.

TRICARE Retired Reserve (TRR)

TRR is a comprehensive, premium-based health plan for members entering the gray zone and prior to reaching age 60. It works similarly to TRICARE Select as a PPO.

WHO IS ELIGIBLE FOR TRR?

• Retired reserve component members qualified for nonregular retirement.
  • Under age 60.
  • Not eligible for or enrolled in the FEHB program.
• Family members of qualified retired reserve members.
• Survivors of retired reserve members if:
  • the sponsor was covered by TRICARE Retired Reserve at death.
  • immediate family members of the deceased sponsor (spouses cannot have remarried).
  • TRR coverage is in place before sponsor turned 60.
  • survivor coverage is not affected by FEHB eligibility.

WHAT ARE THE COSTS?

• In 2021, the TRR enrollment premium will be $484.83 (individual)/$1,165.01 (family) per month, annual deductible $158/$317 (individual/family), and annual catastrophic cap $3,703. Primary/specialty care copayments will be $26/$42 per visit. Visit TRICARE’s website for more detailed pricing.

ENROLLMENT AND GENERAL INFORMATION

Visit the TRR website for complete details.

MEDIPLUS® TRICARE Reserve Select and TRICARE Retired Reserve Supplement Insurance

To help reduce your unexpected out-of-pocket expenses, MOAA sponsors the MEDIPLUS® TRICARE Reserve Select Supplement Insurance Plan and the MEDIPLUS TRICARE Retired Reserve Supplement Plan. Combined with your TRICARE Reserve Select or TRICARE Retired Reserve coverage, these supplemental insurance plans help cover cost-shares not fully reimbursed by TRICARE for covered doctor visits, hospital stays, surgeries, prescription drug cost-shares and excess charges (up to 15% above the TRICARE allowed amount), once any applicable TRICARE and MEDIPLUS deductibles have been met.

MEDIPLUS has you covered:

• Pays cost-shares and co-pays
• Pays excess charges (up to 15% above the TRICARE allowed amount)
• Affordable members-only group rates
• Guaranteed acceptance for eligible MOAA members and their families – you’re covered immediately for all new health conditions. Any current injuries or illnesses are subject to the Pre-Existing Conditions Limitation and are covered after six months.

For more information on the MEDIPLUS TRICARE Reserve Select Supplement or the MEDIPLUS TRICARE Retired Reserve Supplement, call 1-800-247-2192, e-mail moaa.service@mercer.com, or visit www.moaainsurance.com.