Like any change, TRICARE may appear confusing at first glance. When taken a little at a time, however, the program is less overwhelming.

Understanding TRICARE is not as difficult as a permanent change of duty station. In fact understanding TRICARE comes down to finding answers to a few rather basic questions. The first, most basic question for which military family members must have an answer is, "Do I want to enroll in TRICARE Prime, or should I skip enrollment and use TRICARE Standard and Extra?" To answer that question, you will need to know how Prime works, as well as the available alternatives if you choose not to enroll. This TRICARE article gives you that information.

Getting down to the basics

TRICARE is the Department of Defense health plan for active duty personnel from all uniformed services, as well as CHAMPUS-eligible active duty family members, retirees, and retiree family members. TRICARE Prime, the only option that requires enrollment, is specifically linked to military medical facilities (MTFs). Most MTFs will be part of TRICARE Prime and will offer top priority to those who are enrolled in Prime. Because of this priority and what it means to the availability of appointments in military facilities, a second question is, "Do I want to use military or civilian clinics and hospitals?" While there may be some "space available care" in military facilities for those who are not enrolled in Prime, it will be very limited. Therefore, a decision to enroll in Prime is also a decision to use military facilities for the majority of your care; and, a decision not to enroll is a decision to primary use civilian facilities.

Managing your care

Basic question #3 is, "Who do I want coordinating my care, me or a health care provider? "TRICARE Prime is designed to provide patients with a Primary Care Manager; a health care provider who will help them manage their health care requirements, get necessary care in a timely manner, and limit out-of-pocket expenses. TRICARE Prime places importance on management, on prevention, and on a coordinated process to obtain necessary care. Once enrolled in Prime, you have a specific process to follow that ensures you get the care you need. You know where to turn every time you need medical care. Most importantly, necessary care must be provided according to specific standards.

Appointment for routine care - available within 7 days

Appointment for urgent care - available within 24 hours

Appointment for specialty care - available in the time determined by the provider

Appointment for wellness exams and check ups - available within 4 weeks

Emergency care - available 24 hours/day

Primary care - no more than 30-minute drive from home to clinic

Specialty care - no more than 60-minute drive from home to clinic

The intent of TRICARE Prime is to move away from "potluck providers" where a patient sees a different person at each visit. Once enrolled in Prime, patients are given a Primary Care Manager, the provider who they will see for most of their routine needs. Will this always be possible? Realistically, the answer is, "no." In a military setting, seeing the same provider every time is not always possible.

Temporary duty, deployments, military training and full booked schedules may preclude an appointment with a specific provider. To address the intent of TRICARE Prime, most military facilities have grouped their providers in teams. Therefore, while same day, urgent appointments may not be available with your Primary Care Manager, another team member should be available to make sure you receive the care you need.

Realistic expectations are important to deciding if TRICARE Prime is the best option for you, and to making TRICARE Prime work once you choose to enroll.

You're in the driver's seat

On the other hand, TRICARE Standard and TRICARE Extra let you do the coordinating. There is no enrollment. You determine your health care needs, as well as where and when you receive care. Whether you try for a space available appointment in a military clinic or choose civilian providers, it's your call. Both Standard and Extra use civilian providers and require that patients pay annual deductibles and co-payments. You can use these two options interchangeably.

TRICARE Standard, choosing authorized providers who are approved but are not part of the TRICARE Network, offers you the greatest flexibility in selecting your health care providers. When you choose to use a Network provider, you automatically switch to TRICARE Extra, the option that gives you flexibility and saves you a little money.

Military vs. Network

TRICARE is a partnership between military medical facilities and a civilian health care corporation. This partnership integrates military and civilian care into one military health program. In Region 1, the Department of Defense contracted with Sierra Military Health Services to administer the TRICARE program and to develop a network of civilian health care provider in support of military medical facilities.

Although the civilian network expands access to health care services, there is one basic difference - the cost of care. Military facilities, including medical centers, community hospitals, ambulatory care centers, and Family Health Centers, do not charge for outpatient visits. There are no fees for visits to health care providers, prescriptions, x-rays, lab tests or other outpatient services.

Civilian network providers charge for their services. The amount of the fee depends on the option you are using. If you are enrolled in TRICARE Prime, the co-payment is not a percentage of the "allowable cost" as with CHAMPUS today. Instead, the co-payment is a flat fee, determined by the rank and status of the sponsor.

Family members of active-duty personnel in the ranks of E-4 and below pay $6 per patient per visit to a civilian network provider. Family members of active duty personnel in the ranks of E-5 and above, as well as retirees and their family members pay $12 per patient visit. Active duty personnel who are referred to the civilian network do not pay a fee.

For those who choose not to enroll in TRICARE Prime, the civilian network of providers offers a way to save little money. If not enrolled in TRICARE Prime, you will always be responsible for a percentage of the cost of care. However, if you choose to use a network provider, you will still pay a percentage, but the percentage is 5% less than it is with TRICARE Standard.

Thus, another question is, "How much do I want to pay for my health care - a little - a percentage or a flat fee?"

Security when traveling

There is one very important rule when you are enrolled in TRICARE Prime - seek all care from your Primary Care Manager. Your answer to question, "Can I live by this rule?" is the key to making TRICARE Prime work, and to keeping a lock on your pocketbook.

But, what happens when you are away from home, you are sick, and you can not visit your Primary Care Manager? TRICARE Prime recognizes that people sometimes get sick while traveling. As an enrollee, you have a TRICARE Prime Enrollment Card to carry in your wallet. On the card is a toll-free number, linking you to a Health Care Finder and the authorization you must have before you get care. Health Care Finders are available to you 24-hours a day, and seven days a week. Receiving prior authorization for care means that your financial responsibility is limited to the $6 or $12 fee for an outpatient visit to a civilian network provider, or the flat fee for a visit to a civilian emergency room.

If you choose not to call for the required authorization before you get care, you will pay more than what CHAMPUS now requires (or TRICARE Standard or Extra)! The only exception to the requirements for prior authorization is in the case of a medical emergency (a threat to life, limb or eye-sight.) When emergency care is require, you are allowed to call for retroactive authorization, after receiving the necessary care.

If you are not enrolled in TRICARE Prime, you do not have to call for authorization for care when traveling. Wherever you are, you choose your civilian providers, make the appointment and pay your share of the costs. Supplemental insurance, an insurance plan to help cover your out-of-pocket expenses, can provide added security if you choose to use TRICARE Standard and TRICARE Extra.

Can we make this work?

Deciding whether to enroll in TRICARE Prime or to use TRICARE Standard and TRICARE Extra is personal decision. That decision is based on individual needs, and the cost of health care. Families do not always agree on what is most important when they seek medical care. With the TRICARE Program, military families can pick the option that best suits each family member's particular needs. An entire family is not locked into only one option. For example, the active duty sponsor is required to enroll in TRICARE Prime. His or her spouse may prefer using civilian providers and would be better off using TRICARE Standard or TRICARE Extra. However, the children, who regularly use military clinics for their care, should be enrolled in TRICARE Prime.

For each family member, determine your priorities, and make your best choice.