TRICARE Standard

Regular Army: Active Duty

Benefit Fact Sheet

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Summary:

TRICARE Standard is the basic TRICARE health care program, offering comprehensive health care coverage for eligible Soldiers and Family members not enrolled in TRICARE Prime. Eligible persons registered in the Defense Enrollment Eligibility Reporting System (DEERS) are automatically covered by TRICARE Standard. TRICARE Standard is a fee-for-service option that gives beneficiaries the opportunity to see any TRICARE-authorized provider (doctor, nurse practitioner, lab, clinic, etc.). Standard offers the greatest flexibility in choosing a provider, but it also involves greater out-of-pocket expenses for the patient.

Eligibility:

Active duty Soldiers who are covered by TRICARE Prime are not eligible for TRICARE Standard. Dependent parents or parents-in-law are not eligible, though Family members may be eligible.

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.

Benefit Highlights:

TRICARE Standard offers greater flexibility by allowing TRICARE-eligible beneficiaries to choose any TRICARE-authorized provider. TRICARE-authorized providers are not required to participate in the TRICARE network; however, the regional contractor in that region must certify them as authorized providers. TRICARE Extra allows beneficiaries to choose hospitals and providers within the TRICARE network and receive discounted cost-shares, but not out of it.

TRICARE Standard allows beneficiaries to self-refer for specialty care. Beneficiaries who choose TRICARE Standard are not assigned a primary care manager, so in most cases, they are able to see specialists without prior authorization. Some outpatient procedures require prior authorization. Beneficiaries should contact their regional contractor for authorization assistance before seeking care. Beneficiaries or their providers must file claims before TRICARE Standard can pay its share of the bills.

TRICARE Standard does not cover all health care. The plan pays for only medically necessary care. For inpatient mental health care, preauthorization and continued stay authorization requirements apply to Residential Treatment Center care, partial hospitalization program care, and alcoholism detoxification and rehabilitation. TRICARE Standard beneficiaries living in an MTF catchment area must obtain a non-availability statement from their local MTF before being admitted as an inpatient for mental health services.

By law, when a TRICARE beneficiary has private health insurance (OHI), that insurer must be the first payer. TRICARE then becomes second payer for TRICARE covered services and may be the primary payer for services expenses not covered by the other health insurance but covered by TRICARE.

Costs for TRICARE Standard:

TRICARE Standard 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 Standard. 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 15% 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 Standard-covered services in any fiscal year. The catastrophic cap for Families of active duty service members is $1,000. All others have a catastrophic cap of $3,000. 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 15% that nonparticipating providers may charge above the TAC.

The chart below shows the costs beneficiaries may incur under TRICARE Standard.

 

Family Members of Active Duty Service Members

Retirees, Their Family Members and Others

Annual Deductible

$150 per individual or $300 per Family for E-5 and above; $50 per individual or $100 per Family for E-4 and below. $0 deductible for Family Members of National Guard and Reserve activated for more than 30 days

$150 per individual or $300 per Family

Cost Share(outpatient visits, emergency care, medical equipment, preventative services and mental health visits)

Network:15% of the negotiated rate

 

Non-Network:  20% of allowable charges after the annual deductible is met

Network:20% of the negotiated rate

 

Non-Network:  25% of allowable charges after the annual deductible is met

Hospitalization

$17.35 per day ($25 minimum charge)

 Network:  $250 per day or 25% of billed charges, whichever is less, plus 20% cost-share for separately billed services

Non-work: $744 per day or 25% of billed charges, whichever is less, plus 25% for separately billed services.

Civilian Inpatient Behavioral Health

Inpatient:  Greater of $20 per day or $25 per admission

Outpatient:  15% of the negotiated rate - Network /  20% of the allowable charge - Non-Network

Network:  20% of the negotiated rate

Non-Network:

High-volume hospital: 25% of the hospital-specific per diem.

Low-volume hospital: $218 per day or 25% of the billed charges, whichever is less

Ambulatory Surgery

$25

Network:  20% of negotiated rate

Non-Network: 25% after the annual deductible is met

Inpatient Skilled Nursing

$17.35 per day ($25 minimum charge)

Network:  $250 per day or 25% of billed charges, whichever is less, plus 20% cost-share for separately billed services

Non-Network:  $744 per day or 25% of billed charges, whichever is less, plus 25% for separately billed services.

Additional Information:

For more information, please visit the TRICARE Standard webpage maintained by the TRICARE Management Activity:
http://www.tricare.mil/Welcome/Plans/TSE.aspx

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

TRICARE Standard Handbook:
www.tricare.mil/~/media/Files/TRICARE/Publications/Handbooks/TSE_HBK.pdf

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

Document Review Date: 10 March 2014