New Name, New Costs. New TRICARE?

Civilian at MTF

It’s happening. Everyone stay calm.

On September 29, the Department of Defense (DoD) released the most detailed information to date on major changes for TRICARE users taking effect in 2018. These changes are supposed to simplify TRICARE, but may take some getting used to—especially for current TRICARE Standard users who go to civilian providers off base.

The good news for TRICARE Prime families who use Military Treatment Facilities (MTF) and clinics is that not much will change for you.

TRICARE Standard users, DoD’s newly released changes will affect you. Here’s how:

We now know the exact dollar amounts TRICARE Select users will pay for most services.

Your out-of-pocket cost is based on when your service member first joined the military. Everyone whose enlistment or appointment occurred before January 1, 2018 (i.e., everyone already in a uniform or retired) will be “grandfathered” in to TRICARE Standard’s existing cost shares, which we expected to stay the same.

The bad news is that this is NOT how DoD followed through. 

To make out-of-pocket costs more predictable, DoD made some changes to what grandfathered TRICARE Standard/Select families will pay out-of-pocket. Unlike Standard, where you pay a percentage of what the doctor charges, Select users will pay a fixed amount. DoD has set those fixed amounts for primary care, urgent care, specialty care, Emergency Room, and other types of visits.

This means some Select beneficiaries will end up paying more out-of-pocket than they would if they paid a percentage of the doctor’s fee, and some will pay less.

Here’s what that could look like for your family: under the current Standard cost shares, one active duty family member in Standard recently paid $66.30 for an ER visit that resulted in a hospital stay. On another ER visit for an acute issue, that family member only paid $28.86 and went home with some medicine. But under the new “grandfathered” cost shares, each time she visits the ER, her cost will be $87, no matter how severe the medical issue.

For military families on a budget or trying to get better care for their family by being on Standard, this could result in a much more expensive health care option.

Additionally, based on charts (TABLE 1: TRICARE Select and TRICARE Prime Cost Sharing for ADFMs for 2018, TABLE 2: TRICARE Select and TRICARE Prime Cost Sharing for Retiree Families for 2018) provided by the DoD, many currently serving military families in Select will likely pay more for health care costs than families whose military member will join the Uniformed Services after January 1, 2018.  

For example, the Emergency Room Visit copay for new active duty family members is $40 while grandfathered families will pay $87.

Right now, we still don’t know how these fixed cost-shares will affect things like maternity care, lab fees, and other specialty care, like physical therapy. But we’ve asked DoD leaders for more information on how they came up with the dollar amounts for each of these services.

Just like your high school algebra teacher, we’d like to see the “work” and not just the answer!

The take away?

We are sending our thoughts and suggestions to DoD to ensure these changes to TRICARE don’t cause undue stress for your family... but we need your help.

TRICARE Standard families, what did you pay out of pocket for your last pediatrician’s visit? Your last visit to a specialist? Your last trip to the ER? Give us your thoughts in the comments.

These new TRICARE changes can be a bit confusing, and we want to keep you in the loop with information that could affect you. Sign up for TRICARE email updates, and follow NMFA’s Facebook page for posts and articles about how TRICARE changes will affect your military family.

Posted September 29, 2017


From: Laura on: October 17, 2017
My son was just diagnosed with Epilepsy. We have been to the ER twice now because of his seizures. My husband is retired. We are on Tricare standard and I’m really not looking forward to the changes. We live about 6 hours from the closest base. If these changes take place,I don’t know how we will be able to afford my sons doctor visits. He sees his regular doctor and a neurologist. I cant even imagine the costs that we will have for the ER and ambulance service. This makes me so angry. My husband served 26 years and we can’t even get decent medical care half the time because no one wants to take Tricare insurance anymore. It Sucks!
From: Sam on: October 5, 2017
for PT I paid $16-24 per visit on Standard. My whole hospital stay with having both my kids only cost $35 each time. My obgyn is about $12 a visit if i have to pay anything at all. Past my deductible, i have never paid at the pesiatrician's office. Also i am getting injections in my back and that is done at an outpatient surgery center which is $25, if that changes to 15% that will cause a financial hardship making it so i will probably not be able to get them.
From: Katy on: October 4, 2017
Unless paying my deductible, I have NEVER paid $87 for an emergency room visit.... all this sounds crazy! How is being grandfathered in better?? First you change my dental, raise my RX copays and now my medical! This is irritating.
From: Volunteer - Alexandria, VA on: October 4, 2017
After I reached my deductible, I’ve been paying $27.55 for mental health therapy. I hope they do not increase these costs. We’re already paying for other mental health costs out-of-packet as a family because the military can’t be trusted not to hold that against my spouse. At times those costs have been $300-$600 a month and I firmly believe some of these health issues are related to combat deployments and military life. I think I paid about $15 to see a very good orthopaedic doctor. Honestly, I’d be fine with paying a bit more if I get good care. $25-$35 would still be very reasonable in my opinion but that’s because I’ve gotten insurance from my employer before and had a $2,500 high deductible plan with a HSA.
From: Monique on: October 4, 2017
I have my family on Tri-Care Prime. I am seen on base and for convenience my husband and daughter are seen off post. Each of his visits cost $12 and hers are $10. When she was ill I wanted to take her to an urgent care but was told that in order to avoid a costly bill, I had to take her to the ER. So based on this, 1) I am wasting the ERs time because my daughter is sick she does not have a broken bone and 2) I will end up with a pretty steep bill. This is ridiculous. I am not sure how this makes anything easier nor is this the "promise" that was made to me when I joined in 1990. Thank you for keeping us as up to date as you can on these changes
From: John J on: October 4, 2017
I switched from Tricare Prime to Standard due to our location. I pay $50-$100 for most of our medical bills. Our Urgent Care was $40.16 ER visit was $79.09 With a family of 4 we are 2/3rds through our $3000 catostrophic cap.
From: Emily Norton on: October 4, 2017
Why are there 2 groups of beneficiaries for active duty?
From: Jocelyn on: October 4, 2017
The changes mentioned above actively presents a hardship to military families. In my ADSM family, we have been both prime, and standard- without co pays and with co pays, respectively. A typical ER visit on standard is roughly $50, an office visit is roughly $30, and urgent care roughly $13. As a reminder- this is a cost share or co pay based on the tricare allowable rate for a particular visit; where the beneficiary pays a % of the allowable rate for the visit which the /office/clinic/hospital has agreed to charge Tricare for the service. Having beneficiaries switch to paying a fixed amount- across the board for all sub-types of visits is going to create a significant hardship! (1) financial negative impact; these "one size fits all" costs will be much higher per beneficiary/family and also including increased RX payments as well. (2) In order for beneficiaries to choose a potentially better fiscal and health care management option- beneficiaries may opt to stay tricare Prime- saving on co pays and cost shares. HOWEVER- many many many MTF's simply cannot accommodate the number of beneficiaries who choose prime as their health care option. The clinics/med groups are not equipped adequately, medical or admin personnel are inadequate for patient load/empanelment, and the Drs (even the contract/GS) are hard to come by. RX are typically backlogged in pharmacies because of inadequate projection of usage, and in general, the military has been working more... with less. Thats unfortunate, but it is the reality. (3) for tricare/MHS to incentivize beneficiaries to save costs and pick the tricare prime option- then the MHS/MTFs will need to ENSURE that there is appropriate staffing, supplies, facilities, etc to accommodate the higher percentage of beneficiaries they wish to serve. (4) if the above mentioned items are not adequately implemented- patient care will falter. (5) Access to care standards will not be met. (6) There will be a backlog of referrals for specialty care, diagnostics, etc. (7) the MTF's will fund higher percentages of beneficiaries who travel outside of the area of locale for medically necessary care/speciality care in order to meet the given right to access to care standards not otherwise met. Is the MHS aware of this? Is the legislature aware of this? ^ This relates only to the direct medical impacts and the extremely HIGH potential of failing to meet the minimum standards set for healthcare nationwide by AAAHC/HSI/Joint commission, and others. The indirect impacts affect local/retail pharmacy costs, express scripts, MTF pharmacy allowable, etc. Finally, the concept of "grandfathering" within the MHS delivery system is a novel idea and flawed in delivery. This issue- the grandfathering- needs to be thoroughly explored as it creates a higher margin of error in costs and utilization, and developing additional sub-sets of payees of beneficiaries. This can be simplified. KISS. This entire proposal needs reviewing, re-tooling, and absolutely requires input from beneficiaries directly. Perhaps per region. I'm always available.
From: Richard on: October 4, 2017
I took my daughter for her 18 month check up and my copay was $12 and I'm on tricare standard
From: Kristen on: October 3, 2017
I took my son in to the pediatrician today, Oct 3, 2017, for a strep culture and paid a $93 copay. Seems kind of high.
From: Amber on: October 3, 2017
My last pediatrician appt we paid $10.96 for out of pocket. My last specialist bill was $19.57, and our last ER total bill was $175 prior to hitting our cat cap of $1,000. I think it is absurd that folks who have been serving long er than new recruits are going to be stuck paying more. It should be the same across the ranks if you choose to use Tricare Standard(select).
From: Mark on: October 3, 2017
What, if any, are the changes to Tricare Reserve Select? And, are there separate tables for that plan?
From: Anonymous on: October 3, 2017
We had payed $25 on avg for physical therapy appts prior to meeting our catastrophic cap. Most of our pediatrician appts were either no cost or $20 depending on if my child received an immunization
From: Siti Connery on: October 3, 2017
Well seems like the government is draining every military veteran income just to cover the health care. My husband retired was in Er last month and we have to pay a co-pay of $500, $87 on lab and $41 on doctor visit.. We are not eligible for Prime as we live more than 40 miles of any military base
From: Amybeth Patten on: October 3, 2017
Just took my son to optometrist. Bill was $21.46. Last pediatrician visit was $35.00 for 2 kids with vaccines.
From: Mary on: October 3, 2017
I am Prime and my husband is Standard (he's retired and 100% disabled so he has the VA for primary medical). I am limited to one clinic for basic medical and the hospital (but I've lambasted Humana Military/TRICARE for that and they are supposedly working on it). To me, this is just one more way that Congress and the DoD is screwing over the military, especially retirees - people who completed their commitment and can't really fight back. Retirees were promised back in the 1990s that they would pay a fee, but that the fee wouldn't increase (these are people who enlisted under the promise of free medical for life if honorably retired); well that fee's been increased almost every year since then. And the supposed grandfathering to prevent price increases has now gone over the edge. Notice that the article said that for Prime users "not much will change". It's only going to get worse. It should be illegal for the DoD to make changes that have not been approved by Congress. And thank John McCain (the "hero") and Lindsay Graham (the military supporter) for voting to screw us over.
From: April on: October 3, 2017
My husband was severely wounded in Iraq in 2008. We currently pay a monthly payment of $19.16 (this is what a single member pays, but for those severely wounded, this is the rate a family pays, plus my husband has medicare so he is considered TriCare for Life) My question is...will this change? We already have thousands of dollars a year of out of pocket medical expenses for therapies or drugs not covered.
From: Jenny on: October 3, 2017
I've never paid anything out of pocket on Standard outside of the yearly deductible. I've only hit the max once. Our pediatricians did not charge a copay for Tricare Standard. BUT the reimbursement rate is much more than TRICARE Prime, which is based on Medicare rates. That would be my biggest concern...if they're lowering reimbursement rates for Standard because then they really will charge me more. My other question is if the maximum out of pocket per family is changing:
From: Amy on: October 3, 2017
Not sure how being grandfathered into a system would "penalize" that seems a bit backward. The last pediatrician appt after our deductible was a little over $20, last urgent care $60+. We are standard because of limited access and horrible quality of care at our last duty station, aside from all of the red tape to get treatment through Prime. Prior to that experience, we had no issues being on Prime.
From: Mary on: October 3, 2017
I’d love to know what the copay will be for allergy injections. I have not seen that anywhere. Right now it is less than $10. Once again Tricare is making changes without fully informing the beneficiaries.
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