TRICARE Extra

Army Reserve: Active Duty

Benefit Fact Sheet

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Summary:

TRICARE Extra is an option that allows TRICARE Standard beneficiaries to save money by making civilian doctors' appointments with doctors (nurse practitioners, labs, clinics, etc.) who are "participating" providers.

Beginning in January 2016, DFAS will provide IRS Form 1095-C to all U.S. military members, and IRS Form 1095-B to all Retirees, Annuitants, former Spouses and all other individuals having TRICARE coverage during all or any portion of tax year 2015. An IRS Form 1095 documents you (and your Family members, if applicable) have the minimum essential coverage. These forms will document the information that DFAS will provide to the IRS on yourself and your authorized Family members. The forms will be required to be reported with your 2015 federal tax return. DFAS will provide you with IRS Form 1095 series forms no later than Jan. 31, 2016.

Eligibility:

Reserve Soldiers on active duty are not eligible for TRICARE Extra. TRICARE Extra can be used by any TRICARE-eligible Family members, who are called on active or ordered to active duty for more than 30 consecutive days, and not otherwise enrolled in TRICARE Prime.

Family members - Spouses, survivors, and unmarried Children - have the choice of enrolling in TRICARE Prime or using TRICARE Standard and TRICARE Extra.

Family members - Spouses, survivors, and unmarried Children - who are properly registered in the Defense Enrollment Eligibility Reporting System (DEERS) are automatically covered by TRICARE Standard. Eligible beneficiaries do not need to enroll for Standard coverage, nor take any other action; if an individual is otherwise eligible for TRICARE health care coverage, they are automatically covered under TRICARE Standard.

A valid uniformed services ID card serves as proof of eligibility to receive health care coverage under TRICARE Standard. The ID card is, in effect, a form of insurance card, and beneficiaries should have it with them when seeking medical care as proof of eligibility.

The National Defense Authorization Act (NDAA) FY 2011 gave the DoD the authority to expand benefits to qualified dependents that lose TRICARE eligibility and are under the age of 26. Young adults can purchase TRICARE Young Adult and pay monthly premiums. Initially, only TRICARE Standard/Extra will be available. Once implemented, claims may be filed and premiums paid retroactively to January 1, 2011.

Benefit Highlights:

  • TRICARE Extra is an option for TRICARE Standard beneficiaries who want to save out-of-pocket expenses by making an appointment with a TRICARE Prime network provider (doctor, nurse practitioner, lab, etc.). Enrollment is not required. Coverage is automatic as long as your information is current in DEERS.
  • Costs also vary depending on your military status (active duty Family members vs. retirees, their Families and others). After you have met an annual deductible, you are responsible to pay a cost-share (or percentage).
  • The Extra option-user can expect that the network provider will file all claims forms for him or her. (The Standard beneficiary might have claims filed for him or her, but the non-network provider can decide to file on his or her behalf or not, on a case by case basis.)
  • When using the Extra option, the Standard beneficiary must meet the same requirements to satisfy a deductible and pay a cost share for treatment.
  • Under TRICARE Extra there is no Extra identification card because there is no enrollment. Your valid uniformed services ID card serves as proof of your eligibility to receive health care coverage from any TRICARE Prime provider.

Costs for TRICARE Extra:

TRICARE Extra requires that you satisfy a yearly deductible before TRICARE cost sharing begins, and beneficiaries are required to pay co-payments or cost shares for outpatient care, medications, and inpatient care. The deductible is based on the federal fiscal year.

There are no monthly premiums for TRICARE Extra. Beneficiaries are responsible for cost shares and deductibles for care that is covered under TRICARE Standard. Providers who participate in TRICARE will accept the TRICARE allowable charge (TAC) as the full fee for services they render. However, non-participating providers may charge up to 20% above the TAC for their services, and TRICARE Standard beneficiaries are financially responsible for these additional charges.

A "catastrophic cap" is the annual upper limit a Family will have to pay for TRICARE Extra covered services in any fiscal year. The catastrophic cap for Families of Army Reserve Service members is $1,000. The catastrophic cap applies only to allowable charges for covered services. The catastrophic cap does not apply to services that are not covered, POS charges, cost-share amounts, and the additional 20% that nonparticipating providers may charge above the TAC.

Annual Deductible for Guard/Reserve Members and Their Families:

  • Rank E4 and below: $50 per individual, but no more than $100 per Family
  • Rank E5 and above: $150 per individual, but no more than $300 per Family

Note: *You won't need to meet your annual outpatient deductible if the Guard/Reserve sponsor is activated for more than 30 days in support of a contingency operation.

The chart below shows the Cost Shares for National Guard/Reserve Members and Their Families:

Type of Care

Network Provider

Non-Network Provider

Ambulance

15% of negotiated fee

20% of allowable charge

Ambulatory Surgery (Same Day)

$25

$25

Behavioral Health (Inpatient)

$20 per day ($25 minimum charge)

$20 per day ($25 minimum charge)

Behavioral Health (Outpatient)

15% of negotiated fee

20% of allowable charge

Clinical Preventive Services

$0 for colorectal, breast, cervical and prostate cancer screenings; immunizations; and well-child visits for children under age 6.

For all other preventive services: 15% of negotiated fee

$0 for colorectal, breast, cervical and prostate cancer screenings; immunizations; and well-child visits for children under age 6.

For all other preventive services: 20% of allowable charge

DME, Prosthetic Devices, Medical Supplies

15% of negotiated fee

20% of allowable charge

Emergency Services

15% of negotiated fee

20% of allowable charge

Home Health Care

$0

$0

Hospice Care

$0

$0

Hospitalization (Inpatient Care)

$17.80 per day ($25 minimum charge)

$17.80 per day ($25 minimum charge)

Immunizations

$0

$0

Laboratory and X-ray

15% of negotiated fee

20% of allowable charge

Maternity (office visits and hospitalization for delivery planned in a hospital in an inpatient setting)

$17.80 per day ($25 minimum charge)

Note: This is one global fee for all of the maternity care and delivery.

$17.80 per day ($25 minimum charge)

Note: This is one global fee for all of the maternity care and delivery.

Maternity (office visits for delivery planning in a TRICARE-authorized birthing center)

$25

$25

Maternity (office visits for delivery planned at home or other setting)

15% of negotiated fee

20% of allowable charge

Newborn Care

The lower of the number of hospital days minus three multiplied by $17.80, or 25% of the total billed charges.

Note: If any Family member is enrolled in TRICARE Prime, the newborn is also covered by Prime for up to the first 60 days and costs are $0.

The lower of the number of hospital days minus three multiplied by $17.80, or 25% of the total billed charges.

Note: If any Family member is enrolled in TRICARE Prime, the newborn is also covered by Prime for up to the first 60 days and costs are $0

Outpatient Visit

15% of negotiated fee

20% of allowable charge

Skilled Nursing (Inpatient)

$17.80 per day ($25 minimum charge)

Only available in the U.S. and U.S. Territories.

$17.80 per day ($25 minimum charge)

Only available in the U.S. and U.S. Territories.

Additional Information:

For more information, please visit the TRICARE Extra webpage maintained by the TRICARE Management Activity:
http://www.tricare.mil/standardextra

For more information on TRICARE Young Adult eligibility:
http://www.tricare.mil/Plans/HealthPlans/TYA.aspx

TRICARE DEERS Information:
http://www.tricare.mil/DEERS

TRICARE Standard and Extra Fact Sheet:
http://www.tricare.mil/~/media/Files/TRICARE/Publications/FactSheets/TSE_FS.pdf

Document Review Date: 20 March 2015