Falls Church, VA, December 2, 2021 - TRICARE Open Season is your yearly opportunity to review your current benefits. It’s a time to make changes to your health plan based on your personal needs. Dec. 13 marks the end of open season, so it’s important to make your decisions now. But which plan will best meet your needs in the new year?
“Active duty service members must enroll in TRICARE Prime,” said Elan Green, chief of TRICARE Health Plan’s Member Benefits and Reimbursement Section at the Defense Health Agency. “However, eligible active duty family members may have a choice between TRICARE Prime and TRICARE Select. You can choose the health plan that better suits your family’s needs for the coming year.”
To learn more about the differences between your open season health plan options, here are some key facts about TRICARE Prime and TRICARE Select.
What type of health plans are these?
TRICARE Prime is your managed care option, like a health maintenance organization, or HMO. It usually features the use of military hospitals and clinics. It also greatly reduces out-of-pocket costs for authorized care provided outside military facilities by TRICARE-authorized network providers.
TRICARE Prime is only available in certain stateside areas, called Prime Services Areas, and overseas. You can search TRICARE plans to see if TRICARE Prime is an option where you live.
Other TRICARE Prime options include:
TRICARE Select is a self-managed care option, similar to a preferred provider organization, or PPO. It offers you the most freedom of choice. It’s available to most beneficiaries worldwide, including active duty family members (ADFMs), retirees, and retiree family members. In overseas locations, those who aren’t eligible to enroll in TRICARE Overseas Program (TOP) Prime, TOP Select is available.
How do you get care with each plan?
Under a TRICARE Prime option, you’ll get most of your routine care from a primary care manager (PCM). Your PCM could be: (1) a provider at a military hospital or clinic; (2) a civilian TRICARE network provider; or (3) a primary care provider under the US Family Health Plan. As described in the TRICARE Plans Overview, “Whether you receive care in the civilian sector or a military hospital or clinic will depend on your location and the capacity at nearby military facilities.”
The role of your PCM is to manage your care and refer you to specialists for care, when needed. When you need referrals or pre-authorizations, your PCM will work with your TRICARE regional contractor. If you’re an ADFM, retiree, or retiree family member, you can see a specialist without a referral under the point-of-service option. This will result in higher out-of-pocket costs.
With TRICARE Prime, your provider will file claims for you in most cases.
Under TRICARE Select, you aren’t required to have a PCM. You manage your own health care and can receive care from any provider. However, you can save money with TRICARE Select if you see a TRICARE-authorized network provider. When you receive care outside the established network of providers, you’ll have higher out-of-pocket costs. If you choose to see a provider who isn’t an authorized TRICARE provider, TRICARE won’t reimburse you.
If you need specialty care, you don’t need a referral or pre-authorization in most situations. However, you may have to pay for services up front and file your own claims for reimbursement.
What are the costs for each plan?
In general, TRICARE Prime offers lower out-of-pocket costs than TRICARE Select. Active duty service members (ADSMs) and ADFMs pay no enrollment fees. Retirees, their families, and others pay enrollment fees.
If you’re an ADSM or ADFM, you won’t pay out-of-pocket costs for TRICARE covered services if you see a TRICARE network provider in your region, and with the appropriate referral or pre-authorization. Retirees pay copayments or cost-shares for covered health care services from network providers in their enrolled region. When following your plan, out-of-pocket costs are limited to your catastrophic cap. Costs you pay under the point-of-service option don’t apply toward your catastrophic cap.
In general, TRICARE Select has higher out-of-pocket costs than TRICARE Prime. ADFMs have no yearly enrollment fees. For retirees, their families, and others, you may have enrollment fees based on when you or your military sponsor entered the uniformed services.
You pay a yearly deductible and per-visit copayments or cost-shares when following the rules of your plan. Your out-of-pocket costs are limited to your catastrophic cap. Non-participating, non-network providers can charge up to 15% above the TRICARE-allowable amount. TRICARE Select beneficiaries are responsible for this amount, plus your deductible and copayments or cost-shares.
Want to learn more about TRICARE Prime and TRICARE Select? Take advantage of the resources available on the TRICARE website to help you decide. If you’re unsure what TRICARE plans you may be eligible for, start with Find a TRICARE Plan. You can then review the health plan costs for 2022. You can also compare costs and compare health plans. Remember, open season ends Dec. 13, so don’t wait.