Those who are eligible to apply for TRICARE health insurance coverage have a variety of choices to make, but among the most important decisions is whether to pick TRICARE Prime or TRICARE Select.
Active duty military members themselves do not have the ability to elect TRICARE Select over TRICARE Prime; this is reserved for family members only. Active duty military will be enrolled in TRICARE Prime and should expect to use the available military healthcare options on-base or nearby before being referred to a private or civilian care provider.
But for family members, the rules are different and depending on your needs and healthcare requirements, TRICARE Select may be the better choice.
A Brief Explanation of TRICARE Prime
TRICARE Prime is a comprehensive managed health care insurance plan that offers coverage for medical services that are deemed “medically necessary.” How does TRICARE define this? According to the official site, the requirement is that the medical care or a service is “appropriate, reasonable, and adequate for your condition and considered proven.”
The Role of the Primary Care Manager In TRICARE PRIME
If you elect to sign up for TRICARE Prime coverage, you will see a Primary Care Manager (PCM) that may or may not be a military medical care provider, or the equivalent in a civilian local network. Primary Care Managers are required to see you first before giving a referral to specialists as care or treatment requires. Your PCM works with a regional contractor for authorization of referrals.
If you elect care without being referred by the PCM you may be liable for more of the cost of treatment or other services depending on circumstances. This is especially true for military members who choose to get care without consulting the PCM-when military members skip the PCM, they may be required to pay the full amount for the services provided.
Referral Rules For Military Family Members
Family members should know that different rules apply; you should try to get a referral for most services that are not offered by the Primary Care Manager, but when on-base military care facility is not available, an in-network referral is the next step.
That said, you can go directly to care without a referral by using an option called Point of Service; family members who do so will be required to pay more out-of-pocket for the services.
Military members do not have the Point of Service option. Only military family members do.
Different Versions Of TRICARE Prime
There are several varieties of TRICARE Prime depending on the nature of your military service. They include:
- TRICARE Prime
- TRICARE Prime Remote
- TRICARE Prime Overseas
- TRICARE Prime Remote Overseas
A Brief Explanation of TRICARE Select
TRICARE Select is an option military family members (but not the active duty service member, where applicable) can choose when TRICARE Prime doesn’t quite meet the needs of the patient(s). TRICARE Select allows coverage for military members themselves when they meet the following criteria;
- Non-activated Guard/Reserve members and their families who qualify for care under the Transitional Assistance Management Program
- Retired Guard/Reserve members at age 60 and their families
- Surviving spouses and surviving dependents
- Medal of Honor recipients and their families
- Qualified former spouses
The list above should not be considered the full range of people who are eligible to use TRICARE Select. Others who are permitted to use it include:
- Active duty family members
- Retired service members and their families
- Family members of activated Guard and Reserve members
Using TRICARE Select
If you choose TRICARE Select, you are allowed to visit any TRICARE-eligible provider. You are not required to visit or get a referral from a primary care provider before doing so, which is a major difference between TRICARE Prime and TRICARE Select.
However, some patients may require prior authorization from a TRICARE regional contractor for some services, and it’s best to discuss these needs with a TRICARE rep in advance of the need when possible.
With TRICARE Select, you may choose between an in-network and non-network care provider. This decision will affect the amount of money you are required to pay for your care and may also determine whether you will be responsible for filing your own insurance claim paperwork or not.
TRICARE Select users use their military-issued ID rather than an insurance wallet card when getting treatment or other services from the healthcare provider.
What You Need To Know About Using TRICARE Select
TRICARE Select users may be charged an annual outpatient deductible. You may be required to participate in cost-sharing or be billed a percentage of the cost of care. One important factor to remember about TRICARE Select; using TRICARE Select and getting care from a network provider means you pay your costs, co-pays, or percentage of the cost at the time of your appointment for the services rendered.
When you are getting care from a non-network provider, this is quite different – you may be required to pay in full up front and apply to be reimbursed by TRICARE later on. This is a contingency that you should prepare for in advance; be sure to have funds saved to make your required advance payment so your care is not delayed.
Are You Right For TRICARE Select?
TRICARE Select is not always the right choice depending on circumstances. If you live in an area where TRICARE Prime cannot be used, TRICARE Select is a good second option. The same is true when you have other health coverage besides TRICARE such as Medicare, or employer-provided coverage.
TRICARE Select is a good option for those military family members and other eligible enrollees who need a care provider not in in the TRICARE network and don’t want to change their existing services.
Comparing TRICARE Prime And TRICARE Select
Under TRICARE Prime, the provider will file insurance claims for you in most cases.
Under Select, network providers may file claims for you, but when getting non-network care, you may be required to file your own claims.
Under Prime, there is “enhanced” vision coverage and preventive services. Most care will be offered by your PCM, and there are fewer out-of-pocket expenses. Under Select, you can receive care from any TRICARE-authorized provider; referrals not required, but some care may require prior authorization. You may be required to pay for services up front and seek reimbursement under TRICARE Select.
TRICARE Prime is managed care, TRICARE Select is described as a preferred provider network available to all non-active duty beneficiaries.
The TRICARE official site reminds that active duty service members pay nothing out-of-pocket for approved care. Active duty family members are required to pay for care when they use the TRICARE Prime plan and they get care without a referral, TRICARE Select, or when utilizing a network pharmacy or TRICARE Home Delivery.
Specific costs for TRICARE Select and TRICARE Prime will vary depending on a variety of factors, but you can use a cost comparison tool at the TRICARE official site.
Joe Wallace is a 13-year veteran of the United States Air Force and a former reporter for Air Force Television News
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