Wanna Ditch the MTF – Is TRICARE Standard for You?

Pharmacy

We often hear from active duty families who are dissatisfied with their Military Treatment Facility (MTF) and considering a switch to TRICARE Standard. They may be frustrated with the lack of appointment availability or the complicated referral process that leads to delays in care.  Even though families are frustrated, they hesitate to make the switch to Standard fearing the unknown – particularly the potential out-of-pocket costs with TRICARE Standard.

TRICARE Standard Costs – What Can I Expect?

If you are an active duty family considering a switch to Standard, here are three points you should know about costs:

Deductible

What is a deductible? This is the amount you owe for covered health care services before TRICARE begins to pay. TRICARE’s annual deductible is applied each fiscal year from October 1 – September 31.

You can move one family member to Standard or you can switch the entire family over. Your deductible will also vary based on your sponsor’s rank:

    • If your sponsor is an E5 or above, and just one personin your family is TRICARE Standard, you will have a $150 annual deductible. If you move the entire family to Standard, your annual family deductible will be $300.
    • If your sponsor is an E4 or below, your deductible is $50 for an individual or $100 for the entire family.

Having a deductible means each October 1, you need to be prepared to pay the first $50-300 of your medical expenses out-of-pocket before TRICARE kicks in for the year.

Cost Shares

What is a cost share? This is the share of covered health care expenses you will pay out of your own pocket.

After you satisfy your deductible for the year, TRICARE starts to pay a large percentage of costs for covered health care services. For most doctor visits, you will pay 15% of the charges for each visit to TRICARE Network providers and 20% to Non-Network providers. Detailed cost shares can be found on TRICARE’s website.

Because you pay a percent of the medical care costs, the dollar amount of your cost share will depend on the type of appointment. For example,your out-of-pocket costs for a typical doctor appointment will be less than your costs for a sophisticated medical test or procedure.You will also pay less to see a network provider versus a non-network provider. Not only is the percentage you pay smaller (15% for network vs. 20% for non-network), TRICARE network providers have agreed to accept a discounted rate for TRICARE patients. It may be helpful to ask the cost of the procedure before the appointment to estimate your out-of-pocket expenses.

Catastrophic Cap

What is a catastrophic cap? The catastrophic cap is the maximum amount you will pay out-of-pocket per fiscal year.

This is one of the best parts about TRICARE because it limits your financial risk. For active duty families, TRICARE Standard currently has an annual catastrophic cap of $1,000.  That is the maximum your family will pay out-of-pocket during the fiscal year (October 1 – September 31).Once you’ve paid $1,000 out-of-pocket, all other medical care is at $0 for the rest of the fiscal year.

Most of your out-of-pocket costs will be applied to the catastrophic cap including your deductible, cost shares, and prescription co-pays. However, there are a couple exceptions. The cap does not apply to non-covered services. For instance, if you choose to get chiropractic care –a non-covered service – your chiropractic expenses will not go toward the catastrophic cap. Additionally, if you use non-network providers, the amount they charge you above the maximum allowable TRICARE charge will not count toward the cap. 

Some families (particularly those with complex medical issues), hit the cap really early in the year. Other families never hit the cap, but it’s nice to know there is a limit to what you might pay out-of-pocket.

A few other points to consider before you switch to TRICARE Standard...

Finding Medical Providers

Before switching to Standard, please consider looking for potential doctors by using one of TRICARE’s Find a Provider tools. You might want to start by asking your civilian neighbors for recommendations and then check to see if those providers are part of the TRICARE network. 

Please keep in mind once you switch to Standard, you may not be able to use the MTF for care. MTFs will only see Standard patients on a space available basis so you may not be eligible for their immunization fairs, back to school clinics, or other services. We rarely hear complaints about this as your TRICARE providers will offer similar services, but it is something to consider.

What if I have buyer’s remorse with TRICARE Standard?

Most families seem very satisfied once they switch from TRICARE Prime to Standard. However, if you miss Prime you can re-enroll after one year on Standard. If you PCS before that year is up, you will be eligible for Prime at your new duty station.

Yet Another Option (for some military families) – US Family Health Plan

The US Family Health Plan (USFHP) is part of the military health system. USFHP offers the full range of TRICARE Prime benefits (including minimal out-of-pocket costs) with an emphasis on wellness.  USFHP has very high satisfaction ratings from military families.  The catch? USFHP is only available in certain areas of the country. 

Has your family switched from TRICARE Prime to TRICARE Standard? Why or why not?

Posted March 8, 2016

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