Navigating Urgent Care as a Military Family

urgent-careMy family has fairly extensive experience with urgent care. We have been very fortunate to avoid major medical issues and emergencies, but, like most people with kids, we’ve had our share of strep throat, stomach viruses, and recurrent ear infections. In true Murphy’s Law fashion, these situations tend to crop up at the most inconvenient times.

When my daughter was a toddler, I could predict her ear infections with remarkable accuracy based on the federal holiday weekend schedule when our Military Treatment Facility (MTF) would be closed for 3-4 days straight. Many times, I was faced with a decision on where and when to seek care that did not fit the category of emergency, but seemed quite necessary to me.

When you or a family member need unexpected medical care, it can sometimes be difficult to know who to call or where to go. Urgent medical conditions are those that do not threaten life, limb, or eyesight, but need attention to prevent them from becoming a serious health risk. Your options differ based on whether you have TRICARE Prime or Standard but, in both cases, your primary care manager (PCM), family doctor, or pediatrician is your best place to start.

For TRICARE Prime Beneficiaries
If you reach your PCM but they cannot provide an appointment within 24 hours, you can request a referral to a local network urgent care clinic. You can find a network urgent care clinic by using the Find a Provider tool on your regional managed care support contractor’s website: HealthNet Federal Services in the North Region, Humana in the South Region, and UnitedHealthcare in the West Region or by calling the customer service line.

If you are unable to reach your PCM, call your managed care support contractor to discuss your options.

A TRICARE Prime beneficiary who uses an urgent care clinic without a referral is choosing the TRICARE Point of Service option which results in higher out of pocket costs. The Point of Service option has a $600 family deductible. This means that your family has to pay $600 out of pocket before TRICARE cost sharing begins. If your trip to urgent care is your family’s first time using the Point of Service option, the entire fee will be applied against the deductible and you will be responsible for paying the urgent care clinic out of pocket.

For TRICARE Standard Beneficiaries
TRICARE Standard does not require a referral for urgent care. If you reach your family doctor or pediatrician but they cannot provide an appointment – or – if you are unable to reach your regular doctor, you can find a network urgent care clinic using the same options listed above. Your usual deductible and cost shares will apply.

This spring, TRICARE plans to introduce a Nurse Advice Line that will give beneficiaries another option for getting an Urgent Care referral. We will release details on the Nurse Advice Line as soon as they are available to us.

What questions do you have about TRICARE? Let us know in the comment section below and we’ll do our best to answer them!

karen-rPosted by Karen Ruedisueli, Government Relations Deputy Director

8 responses to “Navigating Urgent Care as a Military Family

  1. Do you need a referral for urgent care with Tricare Reserve Select?

  2. Was prior military,honorably discharged, didn’t retire am I and mybwife eligible for tricare?

  3. daisy martinez

    I got sick and had to go to an urgent care clinic. I am currently out of state visiting family.I have tricare prime. I am worried for out of pocket bills. I was wondering if tricare will cover all the costs.

  4. Does TriCare Standard ever really cover Urgent Care? We have been to several Urgent Care facilities in the past when we needed to be seen after our primary physicians normal hours. Although we use “TriCare approved urgent care facilities, we seem towns up paying more than if we claim to be uninsured. Ex: My spouse falls and experiences severe wrist pain that does not subside after applying ice and taking a Motrin. It is after hours and we go to an “approved facility” Because we have TriCare Standard we are considered insured. They end up doing an X-ray and note a small fracture. Soon thereafter we learn that the facility was not reimbursed by TriCare. Since we are considered insured, the urgent care bills us $347.00. If we did not mention TriCare and stated that we are a self pay, the visit would have been $110.00 as a self payer plus $63.00 for the wrist X-ray. Total out of pocket is $173. 00 by not claiming TriCare. Another typical example: My spouse, who is a nurse, comes down with Strep throat. It is a weekend and she does not want to miss work on Monday; and of course, does not want to risk infecting her oncology patients. We go to urgent care on Friday night. Although the facility is supposedly an approved TriCare Urgent Care Facility, the visit ends up disapproved by TriCare. The facility bills us $282.00 for the visit. I end up getting Strep from my wife. I go to the same Urgent Care but claim no insurance. I pay $110.00 for the visit.
    I just don’t get it. Could you please explain?

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