Navigating the TRICARE maze: Prime vs. Standard

tricare-prime-vs-standardCo-pays.

Cost-shares.

In-network vs. out-of-network.

I’ll have a whole new vocabulary once I master the TRICARE maze!

For the past 9 years, I’ve used TRICARE Prime. I’ve seen doctors at Military Treatment Facilities (MTFs) and in town. I thought I scored big time when I was assigned a Primary Care Manager (PCM) out in town because the base was too full to take new patients. When we were stationed outside of Washington D.C., I navigated between multiple MTFs to get the care I needed.

It’s not a perfect system and there are some glitches. For example, accessing records between an Army hospital and a Navy hospital…let’s just say it doesn’t work as well as it should. The different systems don’t always “talk” to each other, which means you may need to hand-carry records, especially ultrasounds, MRIs, or other digital images between MTFs. And if you do see a civilian provider off the installation you’ll also need to carry records between providers.

With Prime, one thing I never had to worry about was cost. As long as I had referrals and pre-authorizations – I had minimal co-pays, if any at all. In fact, I had our first son while covered under Prime and don’t recall paying anything for my prenatal care, labor, delivery, or post-partum care. I attended child birth classes, met with a lactation consultant, took an infant CPR class, and even left the hospital with a bag full of goodies for our newborn.

Four years later, we are expecting our second and I decided to switch to TRICARE Standard. Why? Because when I got pregnant, I was recalled by the MTF, even though I live more than 30 miles from an MTF and was already seeing a civilian provider in town. And, unfortunately, the MTF I was recalled to doesn’t have the providers I need. I didn’t want to navigate appointments in opposite directions driving 30 miles one way to the MTF and 30 miles in the opposite direction to specialists.

I thought I understood the deductible, co-pays, and cost-shares under TRICARE Standard. Yet, maternity care has its own set of cost-shares, too. I’ve learned to keep copies of my Explanation of Benefits (EOBs) and any bills I receive directly from a provider. I call my regional contractor frequently to review claims and ask questions. I discovered my OB’s billing office isn’t an expert on TRICARE billing, and as a result, I was being overcharged. I had the same problem with overcharges for lab work, too.

And I discovered the hospital education benefits I enjoyed at the MTF with my first pregnancy aren’t covered. There is a fee to take a child birth refresher class or meet with a lactation consultant.

Our second baby is due in a few short weeks and overall I’m happy with the quality of care we are receiving under TRICARE Standard. I’ve learned I have a role to play in keeping costs down by asking questions about coverage, reviewing bills, reading the TRICARE website, and talking to my regional contractor to understand our benefit. TRICARE Standard has given me the flexibility to see the providers I prefer, but it comes at a cost.

What are your experiences with TRICARE Prime vs. TRICARE Standard? What would you recommend to other military families?

katie2Posted by Katie Savant, Government Relations Information Manager

One response to “Navigating the TRICARE maze: Prime vs. Standard

  1. Great post. I’m facing some of these issues as well..

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