What troops need to know about Tricare in 2024

by Vern Evans

The 9.6 million Tricare beneficiaries can expect some important changes in the Department of Defense health care program within the next few years. New Tricare contracts are expected to be implemented starting on Jan. 1, 2025. The new contractor for the West Region is TriWest Healthcare Alliance. Humana Government Business, the incumbent contractor for Tricare’s East Region, will continue in that role.

When those contracts take effect, an additional 1.5 million beneficiaries will transfer to the West Region from six states in the East Region: Arkansas, Illinois, Louisiana, Oklahoma, Texas and Wisconsin. The West Region will cover 26 states.

Beneficiaries don’t need to take any action now; the contractors will notify beneficiaries of any action they need to take.

The new contracts will bring improvements for beneficiaries, according to defense health officials, such as more efficient health care referral transfers between the two regions; greater provider network flexibility; improved beneficiary choice; and enhanced telehealth appointments.

Meanwhile, after years of forcing some military beneficiaries to seek medical care in the Tricare private sector network, the Defense Department wants to attract patients back to military treatment facilities.

Citing problems that have led to “chronically understaffed military treatment facilities and dental treatment facilities,” Deputy Secretary of Defense Kathleen Hicks has directed sweeping changes to boost staffing at medical facilities and increase access to care for beneficiaries.

Hicks laid out a plan to grow the number of patients who receive care in a military treatment facility by 7% by the end of 2026, compared to the number of beneficiaries in December 2022. That would mean 3.3 million people would be using the MTFs in three years, according to Military Times calculations.

For example, officials are conducting a comprehensive review of all medical manpower and staffing; and plan to shuffle medical personnel to boost capacity at a few key locations by July 1.

Beneficiaries’ increased costs in 2024

Some military families saw a rise in their health care costs in 2024. Generally speaking, if a Tricare beneficiary paid out of pocket for Tricare before, those costs went up. Active duty service members don’t have any out-of-pocket costs.

For those who make co-payments for covered services such as primary care visits, specialty care outpatient visits and urgent care, the co-pays generally went up by $1 to $3 a visit. And those who pay annual enrollment fees also saw increases. Annual deductibles increased for some, too, which means the families will pay more out of pocket before Tricare kicks in.

Pharmacy costs also increased for Tricare beneficiaries who get their prescriptions filled at a retail pharmacy or through the mail-order program, as increases set by a 2018 law went into effect. There aren’t co-payments for prescriptions filled at military pharmacies.

Active duty members pay nothing for their covered medications through military pharmacies, retail pharmacies in the Tricare network and through the home delivery benefit. The military pharmacy is still the lowest cost option for all military beneficiaries, because there’s no cost for covered generic and brand-name drugs at these pharmacies.

A new Tricare Pharmacy Home Delivery policy continues from 2023: You must approve each refill when you’re enrolled in the automatic refill program, so that you only receive the prescriptions you need. Express Scripts, the administrator of the program, will let you know by phone, email or text, that you have a refill coming up. You’ll log in to your account to confirm you want it.

Tricare expanded the telehealth program during the pandemic to make it easier for military beneficiaries to get care. It now covers telehealth visits over the phone as a permanent benefit. While there was a temporary waiver on patient costs for telehealth during the pandemic, patients now pay cost-shares and co-pays. Telehealth costs are like costs for in-person care.

Tricare also covers the use of secure video conferencing to provide medically necessary services, allowing patients to connect with a provider using a computer or smartphone.

Who’s eligible?

Tricare offers 11 different options, with choices depending on the status of the military sponsor and the geographic location. It is open to active duty members; military retirees; National Guard and Reserve members; spouses and children registered in the Defense Enrollment Eligibility Reporting System; and certain others, including some former military spouses and survivors, as well as Medal of Honor recipients and their immediate families.

Those entering the military or changing status (e.g., from active duty to retired) should make sure they and their eligible family members are enrolled in the Tricare program of their choice. Those who don’t enroll may only receive care at a military clinic or hospital on a space-available basis; medical care by civilian providers would not be covered. The one-month open season begins on the Monday of the second full week in November. During that time, you can enroll in a new Tricare Prime or Tricare Select plan or change your enrollment. If you’re satisfied with your current Tricare health plan you don’t have to take action.

The law overhauling Tricare included a strict limitation on switching plans outside of open season. The exception to that rule is if there is a qualifying life event, such as the birth or adoption of a child, a move to a new duty station, marriage or retirement. Open season doesn’t apply to active duty members, who have full health coverage, or to retirees who are in Tricare for Life.

By law, Tricare beneficiaries fall into one of two categories:

  • Group A: Sponsors who entered the military before Jan. 1, 2018, and their dependents
  • Group B: Sponsors who entered the military on or after Jan 1, 2018, and their dependents

Those in Group A and Group B have different enrollment fees and out-of-pocket costs.

Families of active duty, National Guard and Reserve service members— as well as guardsmen and reservists who aren’t on active duty — are eligible for the Tricare Dental Program, which requires separate enrollment.

Most retirees and their family members are eligible for dental and vision coverage under the Federal Employees Dental and Vision Insurance Program, or FEDVIP, which is administered by the Office of Personnel Management and also requires separate enrollment.

What are the options?

Tricare offers two core health care options: Tricare Prime and Tricare Select.

All active duty members are required to enroll in Tricare Prime; they pay nothing out of pocket. Active duty families can also enroll in Tricare Prime without an enrollment fee. Prime beneficiaries are assigned a primary care manager, or PCM, at their local military treatment facility or, if one is not available, they can select a PCM within the Tricare Prime civilian network. Specialty care is provided on referral by the PCM, either to specialists at a military facility or a civilian provider.

Tricare Select is similar to a traditional fee-for-service health plan. Patients can see any authorized provider they choose, but must pay a deductible and co-pays for visits. Patients pay lower out-of-pocket costs when they receive care from a provider within the Tricare network.

All Tricare programs have a cap on how much a family pays out of pocket each fiscal year, depending on the sponsor’s status and the type of Tricare program used.

The plans

  • Tricare Prime: Similar to a health maintenance organization, Tricare Prime has lower out-of-pocket costs but requires enrollees to use network providers and coordinate care through a primary care manager — a doctor, nurse practitioner or medical team. It’s free to active duty members. Families enrolled in a Tricare Prime plan don’t have to pay enrollment fees or co-payments unless they use the point-of-service option or fill a prescription outside of a military pharmacy. Retirees must pay an annual enrollment fee (Group A retirees pay $363 for an individual or $726 for a family in 2024). Co-payments for medical visits are lower than other programs.
  • Tricare Prime Remote: Service members who live and work more than 50 miles or an hour’s drive from the nearest military treatment facility must enroll in Tricare Prime Remote. Family members are eligible if they live with an enrolled service member in a qualifying location, or they may use Tricare Select.
  • Tricare Prime Overseas: This is a managed-care option for active duty members and their command-sponsored family members in nonremote locations. They have assigned primary care managers at a military treatment facility who provide most care, and referrals for and coordination of specialty care. Tricare Prime Remote Overseas is a managed care option in designated remote overseas locations, with most care from an assigned primary care manager in the local provider network who provides referrals for specialty care. Activated National Guard and Reserve members and their families also may enroll in these options while the sponsor is on active duty; retirees and their families aren’t eligible.
  • Tricare Select: This is a preferred-provider plan — authorized doctors, hospitals and other providers are paid a Tricare-allowable charge for each service performed. Costs are higher for out-of-network providers, and certain procedures require pre-authorization. There is no enrollment fee for active duty families. Group A working-age retirees were required to start paying monthly enrollment fees in 2021. Co-pays vary by status and type of care: An in-network primary care outpatient visit costs Group A retirees and their families $36 in Tricare Select, for example, while Group A active duty family members pay $27. Group B active duty family members pay $18.
  • Tricare Reserve Select: Qualified Selected Reserve members can buy Tricare coverage when they are in drilling status — not while mobilized. The program offers coverage similar to Tricare Select.
  • Tricare Retired Reserve: “Gray area” National Guard and Reserve retirees who have accumulated enough service to qualify for military retirement benefits, but have not reached the age at which they can begin drawing those benefits (usually age 60) can purchase this insurance, which offers coverage similar to Tricare Select.
  • Tricare for Life: This wraparound program is for retirees and family members who are eligible for Tricare and Medicare. The provider files the claims with Medicare; Medicare pays its portion and then sends the claim to the Tricare for Life claims processor. Enrollees must enroll in Medicare Part A (free for those who paid Medicare taxes while working) and Part B (monthly premium required) to receive Tricare for Life.
  • Tricare Young Adult: Unmarried dependent children who do not have private health insurance through an employer may remain in Tricare until age 26 under a parent’s coverage via TYA Select or TYA Prime. Premiums are required for both.
  • U.S. Family Health Plan: Beneficiaries who live in one of six designated areas, can enroll in this as a Prime option. Those enrolled get all their care, including prescription drugs, from a primary care provider the beneficiary selects out of a network of private doctors affiliated with one of the not-for-profit health care systems in the plan. Beneficiaries don’t get care at military hospitals or clinics, or from Tricare network providers when enrolled in the U.S. Family Health Plan.

Action items

Beneficiaries must take action to enroll in a Tricare plan in order to be covered for civilian health care. Those who don’t enroll will only be able to get health care at a military clinic or hospital on a space-available basis.

To be eligible for any of the Tricare plans, beneficiaries must first be enrolled in the Defense Enrollment Eligibility Reporting System. Active duty members are automatically registered in DEERS when they join the military, but they must register eligible dependent family members. Service members should make sure the information is correct for their family members. Only military members can add or remove family members through the local ID card office.

Read more from the 2024 Pay and Benefits Guide here.

Karen has covered military families, quality of life and consumer issues for Military Times for more than 30 years, and is co-author of a chapter on media coverage of military families in the book “A Battle Plan for Supporting Military Families.” She previously worked for newspapers in Guam, Norfolk, Jacksonville, Fla., and Athens, Ga.

Read the full article here

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