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TRICARE Benefits and Eligibility

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TRICARE Benefits and Eligibility

The TRICARE program is an invaluable source of health insurance benefits for U.S. Armed Forces personnel, veterans and their dependents and spouses. Different types of health insurance plans are available to qualifying beneficiaries, depending on where they live. Additionally, TRICARE for life was introduced in May of 2001 to aid in paying patient liability after Medicare payments, once a participant becomes eligible for Medicare.

To qualify for TRICARE benefits, you must meet the program’s eligibility requirements. If you are interested in TRICARE insurance, it is worth taking the time to learn more about the program, the plans that may be available to you, qualifications, covered medical services and how to enroll in a plan. By doing so, you will be better prepared to submit an application for benefits and you will know what to expect if approved for insurance coverage.

What is TRICARE insurance?

The TRICARE program is a health insurance program for military personnel, veterans their dependents that provides comprehensive health care at an affordable cost. As of October 1, 2013, TRICARE is managed by the Defense Health Agency (DHA) with a mission to improve United States security by providing comprehensive health support and sustaining the health of those who have served and been entrusted into the department’s care.

TRICARE insurance offers numerous plan options that provide comprehensive coverage to beneficiaries, including:

  • Health plans.
  • Special programs.
  • Prescription drug coverage.
  • Dental plans.

TRICARE Copays and Costs

If approved for the TRICARE program, your health care costs will be based upon your profile and the health plan option that you have selected. For example, active duty service members are expected to pay nothing out-of-pocket for any type of care. However, active duty family members will only pay for care when using:

  • A Tricare prime plan and care is received without a referral.
  • TRICARE select.
  • A network pharmacy or TRICARE home delivery services.

TRICARE for Life will include costs if a service is covered by TRICARE but is not covered by Medicare.

In some cases, TRICARE beneficiaries may be expected to pay a portion of the cost of a health service or prescription drug, such as with a copayment or through another form of cost-share. Additionally, TRICARE pharmacy and dental costs are considered separate from health care costs and fees.

If you would like to save more money, you may be eligible for the TRICARE Prime program, depending on where you live. This plan offers far fewer out-of-pocket costs in comparison to any other TRICARE plan.

TRICARE Eligibility Requirements

It is important to understand who qualifies for TRICARE in order to determine whether or not you may be eligible for the program. The TRICARE program can only provide health insurance coverage to:

  • Uniformed service members and their families.
  • National Guard/Reserve members and their families.
  • Survivors.
  • Former spouses.
  • Medal of Honor recipients and their families.
  • Others registered in the Defense Enrollment Eligibility Reporting System (DEERS).

Available TRICARE benefits and plan options will vary depending on the category of care you qualify for.

A Review of TRICARE Plans

While TRICARE plans all provide comprehensive health insurance coverage, fees and availability may vary based upon the area you live in, as well as your eligibility category. If interested in TRICARE, you are strongly encouraged to learn more about each type of plan that may be available to you in order to make an informed selection.

TRICARE Prime

Under this plan, beneficiaries select a primary care physician and must obtain referrals and authorizations for specialty care medical services. Copayments are often lower in comparison to other plans and there is an annual enrollment fee for participants who are military retirees and their qualifying family members.

TRICARE Select

This TRICARE insurance plan offers the most freedom of choice in comparison to other plans as there is a preferred provider network available to all non-active duty beneficiaries. Referrals are not generally required, but some medical care and services may require prior authorization. With this plan, you pay for your medical services up front and then file a claim with TRICARE for reimbursement.

TRICARE Reserve Select

There is often a monthly premium, but coverage is similar to that of TRICARE Select. There is partial premium cost sharing, but the plan is still often lower than non-military based health insurance plans. This plan is only available for active status qualifying National Guard and Reserve members.

TRICARE Retired Reserve

Care is provided by any TRICARE-authorized provider, network or non-network. With this plan, referrals are not required, but some forms of medical care and services will require prior authorization. In some cases, medical services are covered right away while at other times beneficiaries may need to pay for services up front and then file a claim with TRICARE for reimbursement.

TRICARE for Life

TRICARE for Life first began in May of 2001. Before this plan was enacted, TRICARE beneficiaries would lose coverage if they became eligible for Medicare. This program is designed to pay patient liability after a Medicare payment, and provides additional coverage to qualifying beneficiaries with Medicare.

TRICARE Dental

TRICARE administers dental programs through United Concordia Dental and Delta Dental. Dental plans are separated into three different programs.

  • The Active Duty Dental program is for active duty service members.
  • The TRICARE Dental program is offered to the families of active duty service members.
  • The TRICARE retiree dental, also referred to as FEDVIP dental, is a voluntary dental insurance plan offered to qualifying retired service members and their families.

How to Apply for TRICARE

You may be able to apply for TRICARE or change your current plan after a Qualifying Life Event (QLE). When a QLE occurs, you will have a 90 day period to make any eligible enrollment change or to begin coverage. QLE are events such as:

  • A change in sponsor status that results in an ineligibility to continue existing coverage, such as activating or deactivating.
  • A change in family composition, such as marriage, divorce, the birth of a child or a death in the family.
  • A change of address.
  • Losing family member eligibility, such as after reaching a certain age.
  • Losing or gaining other health insurance.

Applying for TRICARE benefits can be done after updating your or your family member’s information in the Defense Enrollment Eligibility Reporting System following a QLE. Afterwards, you can apply on the TRICARE website, by mail or by phone.

Reviewing TRICARE Coverage Options

TRICARE benefits and covered services can vary, depending on the plan that you are enrolled in. However, generally, covered services include, but are not limited to:

  • Visits with a physician.
  • Preventative care, including vaccinations.
  • Well-child care.
  • Urgent care.
  • Lab work, x-rays and ultrasounds.
  • Cancer screening.
  • Prescription drug coverage.
  • Women’s health and pregnancy.

The TRICARE program does not generally cover services and supplies that are not deemed medically or psychologically necessary, including, but not limited to:

  • Acupuncture.
  • Cosmetic drugs.
  • Autopsy services.
  • Elective services.
  • Nursing homes.
  • Weight loss products.