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Medical Insurance -- Question & Answer Listing  
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Question / Answer

Question:
Are both TRICARE Prime and TRICARE Standard offered to military families OCONUS?

Answer:
The TRICARE Overseas Program is a dual-option benefit consisting of TRICARE Overseas Prime and TRICARE Overseas Standard. The Prime option offers enrollees clinical preventive services with no enrollment fees, co-payments or deductibles. Any care received that has not been referred by the primary care manager (PCM) or that is not an emergency may cost shares and deductibles. The TRICARE Overseas Program Standard option is identical to the CONUS TRICARE Standard option. Consult TRICARE’s website or your local TRICARE benefit representative for specifics on the overseas program.

Question:
Are families of active duty service member who lost their retirement eligibility because they were court martialed and separated still eligible for TRICARE?

Answer:
Families of active-duty service members who lost their retirement eligibility because they were court-martialed and separated for abuse, and spouses and children of NATO representatives under certain circumstances are eligible for TRICARE.

Question:
Are there any changes I need to be aware of when I reach the age of 65 if I am currently covered under the TRICARE system?

Answer:
Medicare takes over from TRICARE as the primary payer of health benefits for military retirees once they reach the age of 65.

Question:
Are there any discounts associated with using a provider who is part of the TRICARE Extra Network?

Answer:
If you seek care from a provider who is part of the TRICARE Extra Network, you get a discount on services and have reduced cost-shares.

Question:
Are there limits on the amount of costs a beneficiary is expected to pay under TRICARE?

Answer:
There are annual "caps," or limits, on what you'll have to pay for covered care in any government fiscal year (Oct. 1 through Sept. 30) under all three TRICARE options. Under TRICARE Prime, the cap for active-duty families is $1,000; for all others, it's $3,000 unless you get care on your own, without a referral from your TRICARE Prime PCM, and without an authorization from the health care finder (HCF). This is called using the "point-of-service" (POS) option. If you do this, there's no cap on your expenses in a fiscal year, and you'll be responsible for 50 percent cost-shares on all POS health care charges for the rest of your enrollment period, after you meet the POS deductible amount. The annual fiscal year cap on your expenses under TRICARE Extra and Standard is $1,000 for active-duty families, and $7,500 for all others. Note that the cap applies only to allowable charges for covered services. Charges for services that aren't covered, or the yearly accumulation of what non-participating providers of care may bill you above the allowable charges for the care you received, will not count toward the catastrophic cap.

Question:
Are TRICARE Prime enrollees eligible for reimbursement of travel expenses if referred to another health care provider?

Answer:
The TRICARE Prime travel entitlement is available to non-active duty TRICARE Prime enrollees and TRICARE Prime Remote family members (when implemented) when they are referred for specialty care more than 100 miles from the Primary Care Manager (PCM) location. Beneficiaries must have a valid referral and travel orders from a TRICARE representative at the military treatment facility (MTF) where they are enrolled or from the regional lead agent's office if their PCM is a TRICARE network provider.

Question:
As a TRICARE Prime enrollee overseas, will I only be cared for by military medical treatment facilities?

Answer:
Depending on the care required, you may be seen by both military and local civilian providers overseas.

Question:
Can a person enrolled in TRICARE Prime still be eligible to receive services under the Program for Persons with Disabilities (PFPWD)?

Answer:
Enrollment in TRICARE Prime does not affect a person’s eligibility to receive services through the PFPWD; however, all requirements of TRICARE Prime, such as using the Primary Care Manager (PCM) for specialty care referral, must also be met.

Question:
Can I appeal a decision made by a military treatment facility (MTF)?

Answer:
As a TRICARE beneficiary receiving care in an MTF, you have certain appeal rights. Check with the MTF's Beneficiary Counseling and Assistance Coordinator (BCAC) to find out their local appeals process. If it cannot be resolved at the MTF level, use your region's Lead Agent office.

Question:
Can I be both TRICARE and Medicare-eligible?

Answer:
To use TRICARE, Medicare-eligible beneficiaries regardless of their age must have Medicare Part A and be enrolled in Medicare Part B, unless they are active duty family members (ADFMs). Medicare-eligible ADFMs regardless of their age, must purchase Medicare Part B when their sponsor retirees to remain eligible for TRICARE coverage. ADFMs under age 65 who fail to purchase Medicare Part B at the time their sponsor retirees may incur Medicare penalty costs when they apply for Medicare Part B before they turn age 65.
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