Understanding Military Medical Benefits and TRICARE
Military medical care is now called TRICARE
Depending upon their status, active duty members, retired members, members of the Guard/Reserves, family members, and certain veterans receive free or government subsidized medical and dental care. For the most part, this care falls under an overall program known as TRICARE.
History of Military Medical Care Benefits
Prior to the 1980s, there were basically two ways for military personnel, retirees and family members to receive military health care. Military members received treatment at military medical facilities, and retirees and family members received free treatment (depending on availability of space) at military medical facilities, or they could use a program known as CHAMPUS (Civilian Health and Medical Program Uniformed Services) to receive government-subsidized medical care from civilian providers.
The idea of military medical care for the families of active-duty members of the uniformed services dates back to the late 1700s. In 1884, Congress directed that the “medical officers of the Army and contract surgeons shall whenever possible attend the families of the officers and soldiers free of charge.”
Changes to Benefits During World War II
There was very little change until World War II. Most draftees in that war were young men who had wives of childbearing age. The military medical care system, which was on a wartime footing, couldn't handle the large number of births, nor the care of very young children. In 1943, Congress authorized the Emergency Maternal and Infant Care Program (EMIC). EMIC provided for maternity care and the care of infants up to one year of age for wives and children of service members in the lower four pay grades.
It was administered by the “Children's Bureau,” through state health departments.
Changes During the Korean Conflict
The Korean conflict again strained the capabilities of the military health care system. On Dec. 7, 1956, the Dependents Medical Care Act was signed into law. The 1966 amendments to this act created what would be called CHAMPUS beginning in 1967. The law authorized ambulatory and psychiatric care for active-duty family members, effective Oct. 1, 1966. Retirees, their family members and certain surviving family members of deceased military sponsors were brought into the program on Jan. 1, 1967. The CHAMPUS budget for Fiscal Year 1967 was $106 million.
Records don't indicate how many claims were filed in FY 1967, but the total probably wasn't more than a few thousand.
Changes to Control Medical Costs and Improve Access
In the 1980s, the search for ways to improve access to top-quality medical care, while keeping costs under control, led to several CHAMPUS “demonstration” projects in various parts of the U.S. Foremost among these was the “CHAMPUS Reform Initiative” (CRI) in California and Hawaii.
Beginning in 1988, CRI offered service families a choice of ways in which they might use their military health care benefits. Five years of successful operation and high levels of patient satisfaction convinced Defense Department officials that they should extend and improve the concepts of CRI, as a uniform program nationwide. The new program, known as TRICARE, is now fully in place.
In FY 1996, the TRICARE/CHAMPUS budget was more than $3.5 billion, and more than 20 million claims were received. Today, nearly 5.5 million people are eligible for TRICARE benefits.
Types of TRICARE
When TRICARE was first instituted, there were only three types. Over the past few years, more TRICARE health plan options have been established. Visit the TRICARE website for complete details on all TRICARE plans:
- TRICARE Prime
- TRICARE Prime Remote
- TRICARE Prime Overseas
- TRICARE Prime Remote Overseas
- TRICARE Standard and Extra
- TRICARE Standard Overseas
- TRICARE For Life
- TRICARE Reserve Select
- TRICARE Retired Reserve
- TRICARE Young Adult
- US Family Health Plan
This option is similar to an HMO in concept. It requires that one specifically enroll in the program (active duty members are enrolled automatically). Individuals enrolled in TRICARE Prime are assigned to a primary care provider (PCP), which is usually the local military medical facility (base hospital).
In order to receive specialist care, enrollees must be referred by their PCP. Under this program, there is no enrollment fee or cost-sharing for active duty members and family members of active duty.
For retirees (under age 65) and family members of retirees (under age 65), there is an enrollment fee for TRICARE Prime that increases each year. One can get the forms to enroll in TRICARE Prime online.
A brand new option under TRICARE Prime is the Point of Service (POS) enrollment option. Normally under TRICARE Prime, you must be referred by the PCP in order to receive any reimbursement for medical care received from anyone other than the PCP. But, if you elect the POS option at time of enrollment, you can use TRICARE Prime and still use the TRICARE Standard or TRICARE Extra options described below.
TRICARE Standard and Extra
This program gives more flexibility than TRICARE Prime, but could result in addition costs. You do not need to enroll in advance to use TRICARE Extra. Under this program, you see any Authorized TRICARE Provider, present your ID Card and receive medical care.
The TRICARE Authorized Providers have a contract with the military to limit costs to designated amounts. Under TRICARE Extra, active duty family members pay an annual deducible (the year begins every October):
- Rank E4 and below pay $50 per individual, but no more than $100 per family
- Rank E5 and above pay $150 per individual, but no more than $300 per family
For retirees and retiree family members (under age 65), the program costs a little more, though the annual deductible is the same ($150.00 per individual or $300 per family. Visit the TRICARE Standard and Extra Costs webpage for all cost details.
Under TRICARE Extra, the medical provider fills out the TRICARE Claim Forms for you, and they receive direct payment from TRICARE for their portion. You simply pay them your portion of the costs.
TRICARE for Life
Until recently, when a retiree or retiree family member reached the age of 65, they were no longer eligible for TRICARE. Instead, they were expected to receive medical care under the provisions of Medicare. This changed in 2001 with the introduction of TRICARE for Life (TFL). Again, there is no need to enroll in advance (except one must be enrolled in Medicare Part B). Additionally, the only charges for this program are the monthly Medicare Part B premiums. Under this program, you see an authorized Medicare Provider and present your ID Card.
TRICARE then becomes the second payer and picks up any costs that Medicare doesn't cover.
Although Medicare doesn’t cover services provided outside of the continental United States, retirees residing in foreign countries can still take advantage of TFL because TRICARE becomes the primary source of health benefits for them.
Like those living in the United States, to be eligible overseas retirees must be enrolled in Medicare Part B. TRICARE for Life will provide the same level of coverage afforded retirees under 65 and they will be responsible for the same TRICARE cost shares and deductibles as the under 65 retirees. Since a great number of retirees living overseas did not enroll in Part B because Medicare didn’t cover medical care received in foreign countries, some of the military related organizations are pushing for a waiver of the Part B penalty which entails a 10 percent penalty for each year the individual was eligible for Part B but didn’t enroll.
However, there is currently nothing in the works that indicates such a waiver is coming.
Pharmacy Benefits with TRICARE
There are several ways to fill prescription medications through TRICARE:
You may have prescriptions filled (up to a 90-day supply for most medications) at a military treatment facility (MTF) pharmacy free of charge. Please be aware that not all medications are available at MTF pharmacies. Each facility is required to make available the medications listed in the basic core formally (BCF). The MTF, through their local Pharmacy & Therapeutics Committee, may add additional medications to their local formally based on the scope of care at that MTF.
TRICARE Mail Order Pharmacy (TMOP)
You can order medications online or through the mail. You can receive up to a 90 day supply (for most medications). Generic formulary costs are $0, while the brand name formulary is $20. Non-formulary cost is $49 unless you have a medical necessity.
You may receive up to a 30-day supply of prescription medication from a pharmacy within the TRICARE Pharmacy Network. The cost for generic formulary is $10, and the cost for brand name formulary is $24. Non-formulary is $50 unless you have medical necessity.
The costs for non-network pharmacies are based on where you are, who you are and in some cases, what plan you're using. You may need to pay up front and file a claim for reimbursement.
The costs will generally be higher, however, for non-active duty beneficiaries. Active duty service members will receive full reimbursement. For complete details and costs for beneficiaries, visit the TRICARE prescription costs web page.
Active Duty/Reserve Dental Care
Dental care for active duty, of course, is free through the Military Dental Clinic. TRICARE does, however, offer optional dental plans for family members of active duty and members of the Guard/Reserves and their family members. These programs require a monthly premium. The programs pay the total cost of some dental care, plus cost-share for other dental care. Current monthly premium rates are (2003):
- Active duty - One family member, $8.11 per month. Two or more family members, $20.27 per month.
- Selected Reserves - For the military member, $8.11 per month. For one family member, $20.27 per month. For more than one family member, $50.67 per month. For the military member and his/her family, $58.78 per month.
- Individual Ready Reserves (IRR) - For the military member, $20.27 per month. For one family member, $20.27 per month. For more than one family member, $50.67 per month. For the military member and his/her family, $70.94 per month.
TRICARE Dental Programs
TRICARE offers three different dental plans, each through a separate dental insurance contractor:
The premiums for the Retiree Dental Program depends upon where you live, and number of family members covered.
VA Medical Care
I run into folks all the time who think that any military retiree or any veteran can get free medical care from the Veterans Administration. Not true. To receive medical care from the VA, you must be a Veteran (over 180 days of military service), have an honorable discharge and have either a service-connected illness, injury or disability, or you must fall into a certain range of poverty.
More information about VA Medical Care is available on the VA's Web Site.