Hi Ray! and all my old friends from iRV2!
Sorry I haven't been around for the past year or so!
I had a bit of time and saw this here and thought that perhaps my in depth Tricare posts needed to be posted here as well.
Folks, there is no way to lay out Tricare differences for travelers in an easy three liner post. So avoid the below if you really don't need to make the decision between Prime or Standard while traveling.
The first part A is from 2003 but is still accurate to a great extent.
The second part B is from this year with all the current links to support my premises.
PART A. From 2003
(Below is PART B from 2006 with the current links to the information I outline in PART A.)
(Hate reading my long posts? Want the summary and none of the details? Skip down to part one, which is only 10 brief sentences, and then click on the one short link, read that, and you're done!)
Boy have things changed since I last took a look at Tricare! I have been threatening to research this for a few months now, and Dale was kind enough to email me that I was in error when I said retirees pay 20% cost shares. He was right, it is 25%. Guess I am a few years out of date on that one. And a lot more.
Now that we are no longer traveling on the road, I needed to see if there was any advantage to changing from Tricare Standard/Extra to Tricare Prime anyway. Boy have I gotten some info, for RVrs in particular, who are retirees, and traveling fulltimers, as well as snowbirds that stay at two locations a year. I'll use S/E in place of typing Standard/Extra (S/E) every time I refer to it.
Unfortunately this is a complex subject, and for you to get full use of this article, and nail down which Tricare program is really best for you, you will have to go to the links provided when you come across them. Otherwise you'll think I am giving my opinion instead of facts. The links are the latest up to date Tricare links. And they are fairly brief. More to the point I'll point you to the exact sentence/paragraph that backs up my statements, which makes it much less tedious. Then, if you are working with a budget, and want to do the math for yourselves, I'll provide all of the info, accurate as of today, to look at the real costs to you for each, and your liabilities for payments. For you to reach the right decision for you, you will have to take your last few years of medical costs, and plug them into the costs to you for Tricare Prime Vs S/E or Extra. Those details are in Part two.
But since there are many that just want the short and sweet bottom line, never go to links or hate reading my long detailed research results, I'll divide it into two parts.
I am going to make it simpler by assuming two traveling RVrs; one or both of which are retired military, not yet covered by Medicare part B. The reason for that is there are also deductibles and enrollment fees for singles most of which are about half the family rates for two people. So you singles can go to the links and plug in your actual numbers. For the most brevity, I'll stick to the family rates, which are what a couple would pay.
Part One:
You are Tricare eligible, traveling, and enjoying life. You don't want to go through all of this, even if it is lots easier than choosing a cell phone provider. Here it is. Tricare Standard/Extra (S/E) is your best choice. You can also read that statement in a short summary from the Tricare page. It specifically states that "Best choice for those who regularly travel for long periods of time or for those who have other health insurance." After you go to this link, and read it from Tricare, you are done. They say it, I agree. Get Tricare S/E.
Part Two:
Tricare Prime is an HMO. Plain and simple. Tricare standard is Champus.
From the Tricare website "What does the term TRICARE stand for? TRICARE stands for the triple option benefit plan available for military families: TRICARE Prime - Voluntary HMO option TRICARE Extra - PPO option - no enrollment or annual fees - provides discount cost-sharing rates. TRICARE Standard - Fee-for-service option (same as standard CHAMPUS) with its normal cost-share.
http://www.tricare.osd.mil/fraud/ click on FAQs, then click on "what is TriCare?"
HMOs have evolved to provide most care, not necessarily all care, in the least expensive way possible. Many hate HMOs, other appreciate them. Please don't post the politics of HMOs as this will not deal with those issues. Some HMOs are pretty bad; some are pretty good, most fall somewhere in the middle. Whether you hate them or love them, or fall somewhere in between, makes no difference. HMOs are here to stay; we will have to deal with them. This topic is about whether Tricare Prime or S/E will serve a retired full-time traveling RVr best.
An HMO is a group of administrative controllers that set maximum payments they will allow for each treatment, maximum hospital stays allowed, cost shares, etc. They are normally lower than the prevailing rate. They also exclude some treatments from any kind of coverage. In order to make money, which is an HMO's goal, as well as the goal of the providers and facility administrators, HMOs have to have recruited providers and facilities that are willing to accept lower payments from the HMO than they normally charge. For example, with no coverage, a person might have to pay $1000.00 for surgery and a two-night hospital stay. A person with an HMO will pay 20 or 25% of the total allowed by the HMO. The HMO may allow only $500.00, and one night in the hospital. If HMOs paid the top rate of $1000.00 your cost share at 20% would be $200.00. In this example they allowed $500.00, that hospital and its providers are part of the HMO, so they are bound to accept that payment as payment in full, so your cost share or co pay is only $100.00.
That begs the question of why a facility or provider will accept lower payments by becoming part of an HMO's network.
Doctors are also fighting some of the misleading statements given by HMOs by publicizing some little known facts such as end of year bonuses that reduce costs to the HMO along with care, that increase earnings, by sharing a pool of money saved amongst all of the facilities and providers in the HMO.
"Some physicians and nurses working for HMOs and insurance companies are getting bonuses for denying medical care or reimbursement to patients. Some physicians (gatekeepers) who work for HMOs get more money the more they deny emergency room care."
http://www.dranonymous.com/hmo_facts.html
Here another Doctor found Aetna to be deceptive in its practices and amazing in what they consider to be an emergency. Since we are talking Tricare here, why would I mention Aetna? Because they are/were one of the providers for one Tricare Region! Go here
http://www.hmohardball.com/ then click on HMO violators on the left menu, then scroll down and click on "click here to view HMO violators," then select Aetna. You'll find in that Aetna report that they do not consider a broken hip and emergency. When you are out of your region and Tricare Prime they will pay for emergency care. But is what you consider to be an emergency what they do?
There used to be 12 Tricare regions in the continental US, with as many different HMOs and PPOs acting as providers for each, which will be phased out by the new three regions and only three HMO providers:
Here is the "New" Tricare-only three regions and three providers." The transition begins on Sept. 1, 2003. The turnover of responsibility for services in the newly aligned Tricare North, South and West regions will be phased in, starting with areas in the West region on June 1, 2004, and will be completed by November 2004".
http://www.defenselink.mil/releases/...0821-0387.html
If you read that link you are wondering if that kind of deceptive phrasing is used in Tricare webpages and literature. Absolutely! Every sentence I have read about Prime when they comment on its advantages has been intentionally misleading, while stating truthful facts that hide the truth behind terminology that seems plain. I will show that if you just follow the links and explanations, tedious though they may be.
The next link below gives more detail on Prime. Pay attention to these statements: "Care is usually provided in a MTF, but civilian clinics may be used in some cases." MTF is a Military treatment facility. When traveling you may not be anywhere near one. And they restrict any treatment outside the system to HMO partners in your home region only. They go on the say "Prime also focuses on preventive and wellness care, and there's no annual deductible." I have to comment on that. They are wording it very cleverly, and hiding the truth. There is no "deductible" for retirees with prime. True! Instead they must pay an annual "enrollment fee" of $460.00 (family of two or more) every year, whether any health care is provided that year or not. With S/E, there is no enrollment fee at all, and the maximum per person deductible is $150.00, and no more than $300.00 (family of two or more) per year. Let's look at that a little closer. If you are S/E and nobody sees a doctor that year, there is no deductible to pay at all either. If only one family member sees a doctor, then they will pay up to, but no more than $150.00 deductible, for that year. The other family member is not charged! So it goes like this: No family member needs a doctor that year-Prime costs $460.00, S/E costs nothing. One family member needs service that year- Prime costs $460.00, S/E $150.00. Both family members or more need to see a doctor that year-Prime $460.00, S/E costs $300.00. I am only comparing the fees for both that must be paid before health care can proceed. Not any co pays or cost shares.
Tricare S/E and Extra are the same. The only difference is that they give you a 5% break when you are S/E, and choose to use a Prime provider. Think of it this way-you do not sign up for Extra, you sign up for Standard, and when you use the HMO providers you get an "EXTRA" 5% off your co-pay.
Note that the S/E and extra cost share for treatment at civilian hospitals is worded to make it sound like more than it is, the cost per day is $417 per day OR 25% cost share WHICHEVER IS LOWER!! lol! Remember that there is a $3k cap on cost shares paid per year for S/E but not with Prim e outside of your region, so that is the limit of liability, except for Prime when POS is used out of your region. Scroll down the Prime lists and see all of the co pays and cost shares listed, then when you look at S/E or extra, take an actual bill for an equivalent visit and you'll find that the charges are close enough in many of the charges as to be about the same, or even cheaper with S/E or Extra. Here is a webpage with all three compared. I have also heard folks say that S/E and extra folks will not get treatment, or long delayed treatment at Military Treatment Facilities (MTF.) Please read the
Now here are the reasons that a traveling Tricare RVr, except for a true snowbird who stays put, half a year, every year in the same two locations.
Prime portability is unlimited for active duty. Retirees are allowed two moves in any year from one region to another, provided the second move is back to their original region. In other words, you can only move once to another region, and back to the first, not to another region, then to a third.
So what happens if you are Prime, and out of your region and did not move to the new region? If you see a civilian health care provider and that provider is not a Tricare provider then Point of Service, or POS kicks in. You will have to pay an immediate deductible of $300 per person, $600.00 per family. Then you are liable for at least a 50% cost share!!! Why do I imply it may be more? Because Tricare limits their responsibility to 50% of THEIR allowable charge!!! Not the going rate where you find yourself needing care! So if the 50% Tricare "allows" and pays is only 25% of the local charges you incurred, you could be liable for 75% of the actual costs!
But that is not the worst part of getting stuck in a POS situation. Ready for this? There is no catastrophic cap on the deductible and cost shares under POS!!!! That's right! If your care results in $100k of expenses, you could find yourself liable for $50k or more, if Tricare allowable charges don't cover 50% of the billing charges!!
Your annual enrollment fee for Prime, which you pay whether you see a doctor in that year or not, is $460.00 for a family.
If you find yourself using POS, that does not apply to the $600.00 family deductible. You are billed for the deductible anyway, in addition to your already paid enrollment fee.
With S/E or extra, there is no annual enrollment fee for retirees! If you don't see a doctor that year, there is no deductible to pay either. Once you see a doctor you will pay no more than $150.00 per person deductible, or $300.00 for a family once each year.
Most doctor visits are under $50.00 for the visit alone excepting some areas and referrels to specialists. Here my Doc charges $30.00, my wife's Doc $35.00 for a visit. 25% of that is about 8-9 bucks.
Prime retirees pay a flat $12.00 per visit.
I can travel anywhere, see any Doc that I want, most of whom will accept will accept Tricare S/E. In fact, many of the local doctors here in the Shreveport area will not accept Tricare prime at all, and some of those WILL accept Tricare standard. I do not need pre approval or the referral of a Primary Care Manager like Prime requires.
Now let's recognize that all of the verbiage is geared to drawing as many of us into Prime as they can, and making deceptive statements has definitely been part of that!
Notice you have to search all over to find out it is an HMO managed system, or whenever they mention that Prime has an enrollment fee for retirees you have to search all over to find it.
So let's do a couple of scenarios to compare the two, and then you go ahead and plug in your own figures and/or projections.
All the below are for retirees, at family rates for two or more people. For doctor visits I'll use $40.00 as that is more than we pay here, and less than some and I think will provide a good average. I'll use the 20% Extra cost share when the Prime folks are also getting in region care from their PCM. In other words, you can't do Prime without Prime providers at all, or out of region so let's compare apples to apples.
I already did a scenario with no medical care for both people:
Prime=$460 S/E=$0.00
Now let's see how the difference might be with four visits to the doctor, and a $1000.00 day surgery, for only one person in the family. Only the first two visits were at the MTF or PCM office, the other two were to specialists, and the surgery was performed at a downtown hospital that accepts Prime.
Prime= 4Xdoctor visits @ $12.00 co pay = $48.00
1X Ambulatory surgery (same day) $25.00
$460.00 annual enrollment fee
Total =$533.00
S/E= 4Xdoctor Visits at $8.00 each (20% of 40) = $32.00
20% of the $850.00 day surgery = $170.00
Deductible $150.00
Total = $352.00
Now let's compute that same scenario for a Prime Family out of their region and it is a broken hip (As I've already shown above from one of the Tricare's past HMOs own words) which is NOT considered an emergency but instead only "urgent."
Prime annual enrollment fee for families = $460.00
Prime Family Deductible for POS = $600.00
4X doctor visits billed at $40.00 @ 50% cost share from POS=$80.00
1X Ambulatory surgery @ 50% POS cost share billed at $1000.00 minus deductible of $600.00=$200.00
Total = $1340.00
The only difference for someone on standard in this scenario is that they will pay a cost share of 25% Vs 20% when they are near a TriCare provider and can tap into the 5% reduction by using Extra. The deductibles etc remain the same.
4X doctor visits @25% of 40.00 ea. = $10.00ea. or 40.00 total
25% of ambulatory surgery of $1000.00 billed but after the $150 deductible leaving $850.00 = $212.50
$150.00 deductible
Total = $402.50
But wait! What if you have a few complications like I had this year with blood clots post surgery complication and the total bills go up past 30k dollars??
Read this carefully and understand it. Tricare Prime folks who have to use POS, are not protected by the catastrophic cap of $3000.00 when using POS. Tricare standard people are.
Do the math for your past history. Do scenarios for both having catastrophic medical bills out of region, and as S/E.
At the least, the new three region system now going into effect can make prime a consideration as you can limit your travels to one other region, transfer to it, then transfer back, for each year. But don't try to go to the third in the middle, as you will be POS everywhere else for the duration of the year.
OK. My decision as a stationary family now? I will stay with Tricare standard. I can choose the better physicians with no limitations, my max combined liability for both of us is only $3000.00, I can see a doctor without permission in most cases, and one I choose. I can use the Tricare providers and be Extra at 20% or not. Why?
Here in the Shreveport Bossier City Louisiana area, we have one of the highest concentrations of retired military in the country per capita. (Per capita is the important part of that) We have Barksdale AFB here but they dropped their hospital down to only clinic services, and few of those. So now, here, when my doc tried to refer me to his top three choices, we found that none of them accepted Tricare Prime, usually one of them accepted standard. With thousands of doctors in this area, if you call the Tricare office for approved Tricare providers, they have only three to five on average that they list for each specialty, of hundreds.
So folks, my intent here was to point out the propaganda in the verbiage you read even on the Tricare sites and books. And to let you know that if you have chronic serious and expensive illnesses, and need Prime, or that you now have an advantage with three large areas to travel in, and can plan one area each year, you can use portability to avoid any POS extremes.
But more to the point that when you run your own numbers, you may find that Tricare standard is not only cheaper for healthy persons, but also allows much more freedom in choosing your docs and care. When I needed treatment in Alaska, in Soldotna, with no military or Tricare providers anywhere near me. I just went to the doc in town, presented my ID card, got treated, and paid a 20 dollar cost share for a just under $100.00 dollar bill. No hassles, calls to a PCM for permission, no arguments about coverage after the fact, no worries!
For those who slogged through this, I think you have all you need to make your own decision based on your individual needs, travel plans, and health.
Hope that helped!
PART B. With current links to information from 2006
OK I got some time today, here are the current links and excerpts from the tricare websites.
Remember to evaluate all of this with your own needs and wants, and travel plans.
One size indeed does not fit all.
Prime facts for retirees moving around in brief.
There are many areas with no prime coverage. Make sure you know the coverage in the areas you travel to for Prime enrollees. Standard need not worry.
POS fact sheet for Prime enrollees
http://www.tricare.osd.mil/Factsheet...eet.cfm?id=183
http://www.tricare.osd.mil/tricarepr...mecompares.cfm
Moving around the country with Prime
http://www.tricare.osd.mil/tricareprime/transfer.cfm
This page explains catastrophic cap, and way down at the bottom is the explanation of Prime enrollees who go for POS. No cat cap, new enrollment fees, and 50% co-pays.
http://www.tricare.osd.mil/retirees/catcap.cfm
Go to the bottom of the page for this interesting bit of info:
If TRICARE Prime is not yet available in the area to which you're moving, you may disenroll from Prime before leaving your old location, or you may disenroll after you move to the new location. If you disenroll, you'll go back to coverage under TRICARE Standard. Active-duty military sponsors are covered for health care by their service branches.
If you wait to disenroll from TRICARE Prime until after you've completed your move, and then don't disenroll immediately, you'll have to pay higher costs under the "point-of-service" (POS) health care option if you seek non-emergency civilian care without an authorization before disenrolling from Prime.
Under POS, you pay an annual $300 deductible (for one person) or $600 (for a family), for inpatient or outpatient care, before TRICARE cost-sharing begins. When the deductible has been satisfied, TRICARE contractors will pay 50 percent of the allowable charges for covered care, instead of the 75-80 percent they'd pay under TRICARE Standard.
If you're a Prime enrollee, and you need emergency care while traveling, go to the nearest hospital's emergency room (you don't have to get prior authorization for emergency care). Be sure to report the emergency care episode to your PCM--or have someone else do it--within 24 hours of getting the care.
For other types of care, call the TRICARE contractor's health care information line for an assessment of your symptoms and recommendations for care. Or, you may call the health care finder (HCF) or your PCM at the region you're leaving, to get an authorization for civilian care, if necessary. Care that isn't urgent, such as a routine eye exam, won't normally be authorized. You should wait for this type of care until you transfer your TRICARE Prime enrollment to your new location.
That link is here:
http://www.tricare.osd.mil/news/1998/news98_01.htm
You can only transfer your region twice a year.
http://www.mytricare.com/internet/tr...ment&Expand=02
More links:
http://www.mytricare.com/internet/tr...f-PcktExpnss_2
This from the northern region FAQs on POS
The Point of Service option under TRICARE Prime allows enrollees the freedom to seek and receive non-emergent health care services from any TRICARE authorized civilian provider, in or out of the network, without requesting a referral from their Primary Care Manager (PCM) or the Health Care Finder (HCF). When Prime enrollees choose to use the POS option, all requirements applicable to TRICARE Standard apply except the requirement for a Nonavailability Statement (NAS). Point-of-Service claims are subject to outpatient deductibles ($300 individual and $600 family), 50% cost-shares for outpatient and inpatient claims, and excess charges up 15% over the allowed amount. The 50% cost-share continues to be applied even after the Enrollment Year catastrophic cap has been met.
Occasionally the Primary Care Manager (PCM) or other authorized provider refers a beneficiary to a non-network provider or fails to obtain required authorization, or a claim is processed under Point of Service when the beneficiary did not intentionally choose to use the option, and the claim is processed as Point of Service. Health Net may review the beneficiary's records to determine if appropriate authorization is on file; however, TRICARE regulations do not allow appeals on Point of Service determinations. If required authorization is not on file, our Customer Services Representatives are not authorized to adjust the claim.
Go to this page and click on FAQs in the left menu under "Getting Help." Then on the fAQs page, scroll down to "what is point of service and can it be reversed":
https://www.hnfs.net/bene/home/
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