TRICARE Eliminates Prime Co-Pays For Family Members - active-duty family members - Brief Article

All Hands, June, 2001

The 2001 National Defense Authorization Act (NDAA) contains great news for active-duty uniformed services members and their families. One new provision is the elimination of co-payments for active-duty family members (ADFM) enrolled in TRICARE Prime.

ADFMs enrolled in TRICARE Prime will no longer have to make co-payments for the care they receive from their civilian providers. Currently, ADFMs in pay grades E-1 to E4 and pay grades E-5 and above pay $6 and $12, respectively, for such visits. In addition, family members' $11 per day civilian inpatient charge is being eliminated, as is the $11.45 per day family member rate for enrollees admitted to a military treatment facility.

Legislation included in the 2001 NDAA, such as the elimination of co-payments, is giving recruiters something to cheer about. As an employee benefit, TRICARE is quickly becoming what military leaders hoped it would: The world's best health care for the world's best military.

ADFMs will still have to make pharmacy co-payments for the National Mail Order Pharmacy program and at network retail stores, but these charges are nominal. In addition, military treatment facilities continue to provide prescription drugs free of charge -- a huge cost saving available to all uniformed services beneficiaries.

To obtain the elimination of co-payments for care received from their civilian providers TRICARE Prime enrollees must follow certain TRICARE Prime rules.

For example, TRICARE Prime enrollees must normally obtain authorization from their primary care manager before seeking care from civilian providers. While they retain the right to seek civilian care without authorization from their primary care manager, the TRICARE Prime point-of-service charges will apply.

Family members who use the point-of-service option are responsible for paying the annual deductible of $300 per member or $600 per family, and 50 percent of the TRICARE allowable charge once the deductible is met. Family members also are responsible for any additional charges billed by the non-network provider, up to 15 percent above the TRICARE allowable charge (balance billing rule).

Members are encouraged to consult with a health benefits adviser (HBA) or beneficiary counseling and assistance coordinator (BCAC) prior to using the point-of-service option. The elimination of co-payments for ADFMs who see civilian providers is not only about cost. It's also about making the TRICARE benefit equal for those who see civilian versus military providers.

In response to feedback from beneficiaries, TRICARE Prime is being re-designed to take the irritants out of the program. Cost is a big concern for beneficiaries, and the elimination of co-payments for ADFMs enrolled in Prime is a plus for customer satisfaction.