Tricare, formerly known as the Civilian Health and Medical Program of the
Uniformed Services, is a health care program of the United States Department
of Defense Military Health System. Tricare provides civilian health
benefits for military personnel, military retirees, and their dependents,
including some members of the Reserve Component. The Tricare program was
managed by Tricare Management Activity under the authority of the Assistant
Secretary of Defense. Tricare is the civilian care component of the Military
Health System, although historically it also included health care delivered in
the military medical treatment facilities.
On 1 October 2013 TMA disestablished and Tricare responsibility was transferred
to the Defense Health Agency which was established on the same day.
History Historically, health care for military
personnel and their dependents was provided in military medical facilities
as promised by the military, and through a referral system, by civilian medical
personnel where military physicians were not available in a certain specialty, or
overcrowding of a military medical facility occurred. After World War II
and the Korean War, access to care in military facilities became increasingly
unavailable due to resource constraints and growing demands on the system, and
"space-available basis" was first noted. To address this problem, Congress passed
the Dependents Medical Care Act of 1956 and the Military Medical Benefits
Amendments of 1966. These acts allowed the Secretary of Defense to contract
with civilian health care providers. This civilian health care program became
known as the Civilian Health and Medical Program of the Uniformed Services in
1966. In the late 1980s, because of escalating
costs, paperwork demands, and general beneficiary dissatisfaction, DoD
initiated a series of demonstration projects. Under a program known as the
CHAMPUS Reform Initiative, a contractor provided both health care and
administrative-related services, including claims processing. The CRI
project was one of the first to introduce managed care features to the
CHAMPUS program. Beneficiaries under CRI were offered three choices – a health
maintenance organization-like option called Tricare Prime that required
enrollment and offered enhanced benefits and low-cost shares, a preferred
provider organization-like option called Tricare Extra that required use of
network providers in exchange for lower cost shares, and the standard CHAMPUS
option that continued the freedom of choice in selecting providers but
required higher cost shares and deductibles known as Tricare Standard.
Although DOD’s initial intent under CRI was to award three competitively bid
contracts covering six states, only one bid, made by Foundation Health
Corporation covering California and Hawaii, was received. Foundation
delivered services under this contract between August 1988 and January 1994.
In late 1993, in response to requirements in the DOD Appropriation
Act for Fiscal Year 1994, the DoD announced plans for implementing a
nationwide managed care program for the MHS that would be completely implemented
by May 1997. Under this program, known as Tricare, the United States was
divided into 12 health care regions. An administrative organization, the lead
agent, was designated for each region and coordinated the health care needs of
all military treatment facilities in the region. Under Tricare, seven managed
care support contracts were awarded covering DOD’s 12 health care regions.
Since then, Tricare has undergone several restructuring initiatives,
including re-alignment of contract regions, Base Realignment and Closure,
and the addition of "Tricare for Life" benefits in 2001 for those who are
Medicare-eligible, and "Tricare Reserve Select" in 2005.
Tricare's options = Tricare Standard =
Tricare Standard provides a similar benefit to the original CHAMPUS program
and is available to retirees from the Active Component, retirees from the
Reserve Component age 60 or older, and their eligible family members. Under
Tricare Standard, beneficiaries can use any civilian health care provider that
is payable under Tricare regulations. The beneficiary is responsible for
payment of an annual deductible and coinsurance, and may be responsible for
certain other out-of-pocket expenses. There is no enrollment fee for Tricare
Standard. = Tricare Extra =
Tricare Standard beneficiaries can elect to use the Tricare Extra option by using
a civilian health care provider from within the regional contractor's
provider network. In this way, Tricare Extra represents a preferred provider
organization. When using Tricare Extra, the beneficiary's coinsurance amount is
reduced by at least five percentage points. There is no fee for use of the
Tricare Extra benefit other than the coinsurance.
= Tricare Prime = Tricare Prime is a health maintenance
organization style plan available to active duty personnel, retirees from the
Active Component, retirees from the Reserve Component age 60 or older, and
their eligible family members. Under Tricare Prime, beneficiaries must choose
a primary care physician and obtain referrals and authorizations for
specialty care. In return for these restrictions, beneficiaries are
responsible only for small copayments for each visit. There is an annual
enrollment fee for Tricare Prime for military retirees and their family
members. There is no enrollment fee for active duty military and their family
members. The majority of Tricare PRIME enrollees must exclusively use the MTF
to receive their care, as long as the MTF has capacity. If the MTF does not
have capacity, the commander of the MTF notifies the region's contractor and the
contractor's provider network is used to supplement the MTF's capacity. If the
MTF regains capacity, the MTF reserves the right to move the beneficiaries back
to receiving their care at the MTF in a process known as "recapture."
US Family Health Plan US Family Health Plan, a Tricare
Prime-sponsored health plan option, is made available by nonprofit health care
providers in the Northeast U.S., Southeast Texas/Southwest Louisiana, and
the Puget Sound region of Washington state.
= Tricare Reserve Select = Tricare Reserve Select is a
premium-based health plan that active status qualified National Guard and
Reserve members may purchase. The classification is sometimes referred to
as Tricare Reserve Component. It requires a monthly premium and offers
coverage similar to Tricare Standard and Extra for the military member and
eligible family members. It has a partial premium cost sharing arrangement
with DoD similar to civilian private or public sector employer plans, although
typically at a lower cost than civilian plans. The program coverage is available
world wide to Selected Reserve members of both the Title 10 USC Federal Reserve
Components, Title 14 USC Federal Reserve Component and the Title 32 National
Guard in a drill pay status. As of February 2008, retired Reserve Component
personnel under the age of 60, actively drilling Individual Ready Reserve
personnel in a non-paid status, or actively drilling Volunteer Training
Unit personnel in a non-paid status do not qualify for TRS. IRR and VTU members
are eligible for reinstatement under TRS is they return to a SELRES status.
Reserve Component personnel who are also Federal civil servants in the Army
Reserve, Army National Guard, Air Force Reserve and Air National Guard) and
eligible for the Federal Employee Health Benefit Program are also excluded from
TRS. Retired Reserve Component personnel and eligible dependent family members
become eligible Tricare Standard, Tricare Extra or Tricare Prime on the
service member's 60th birthday in the same manner as Active Component retirees
and their eligible dependents are eligible immediately upon retirement
from active service. Qualification questions should be referred to Tricare.
= Tricare Reserve Retired = Tricare Reserve Retired is a
premium-based health plan that qualified retired members of the National Guard
and Reserve under the age of 60 may purchase for themselves and eligible
family members. Established in 2008 and opened for enrollment in 2010, it is
similar to Tricare Reserve Select, but differs in that there is no premium
cost-sharing with DoD as there is with TRS. As such, retired Reserve Component
members who elect to purchase TRR must pay the full cost of the calculated
premium plus an additional administrative fee. Although open to all
eligible retired Reserve Component personnel under the age of 60, the
program's principal focus is often perceived as being focused on recent
Reserve Component retirees who are self-employed or otherwise ineligible
for civilian employer provided/subsidized health insurance,
especially those who were mobilized for full-time active duty service subsequent
to 11 September 2001 in support of Operations Enduring Freedom, Enduring
Freedom, Iraqi Freedom, New Dawn and/or Noble Eagle. Retired Reserve Component
personnel who elect to participate in TRR will exit TRR when the service
member reaches age 60 and he/she and their eligible dependent family members
become eligible for the same Tricare Standard, Tricare Extra or Tricare Prime
options as Active Component retirees and, in the case of Tricare Prime, at
the same cost as Active Component retirees. Qualification questions should
be referred to Tricare. = Tricare for Life =
Tricare for Life was first incorporated as part of the then-seven regional
Managed Care Support Contracts of Tricare in May 2001. The benefit was
enacted by Congress in response to growing complaints from beneficiaries
that as Medicare out of pocket costs increased a benefit was needed to pay
these costs in lieu of Tricare retirees being required to purchase Medicare
Supplemental Coverage to pay for prescriptions, physician and hospital
dispensed drugs, cost shares and deductibles. Before Tricare for Life,
Tricare beneficiaries immediately lost Tricare coverage upon attaining Medicare
eligibility. This included becoming Medicare eligible due to disability.
Tricare for Life is designed to pay patient liability after Medicare
payments. There is no enrollment necessary for Tricare for Life and to be
eligible, members must be Tricare and Medicare Eligible and have purchased
Medicare Part B coverage. An exception to the requirement for Part B coverage
exists when the beneficiary that is Medicare eligible is the spouse of an
Active Duty Service Member. In some instances Tricare for Life is primary
payer when the services are normally a Tricare benefit but not covered by
Medicare. This includes drug charges, when Medicare benefit limits are
attained and services performed outside the United States or in a Veterans
Affairs facility where Medicare does not pay. TFL does not pay patient liability
for services that are not a Tricare benefit even though they may be paid by
Medicare, such as chiropractic benefits. The policy limitations applying to
Tricare also apply to TFL and must therefore be deemed medically necessary
and skilled care. Custodial care therefore is not covered. In 2004 the
Tricare for Life benefit was transferred from the individual regional Tricare
contractors. Medical claims are processed by the national Tricare Dual
Eligible Fiscal Intermediary Contractor. Pharmacy claims are processed by the
Tricare Pharmacy Contractor and Overseas TFL claims are processed by the Tricare
Overseas Program Contractor. = Tricare Young Adult =
Tricare Young Adult is a premium-based health care plan available for purchase
by qualified dependents who have aged out of Tricare at age 21, or age 23 for
full-time college students. Dependents are eligible if they are unmarried, not
eligible for Tricare coverage or their own employer-sponsored health care
coverage, and as long as their sponsor remains Tricare eligible.
Eligible dependents have the option to purchase Tricare Standard/Extra health
coverage on a month-to-month basis. Purchased coverage includes medical and
pharmacy benefits but does not include dental. A premium-based Tricare Prime
benefit will be available later in 2011. The signing of the National Defense
Authorization Act in January 2011 aligned Tricare with the provisions of
the 2010 Patient Protection and Affordable Care Act, and lead to the
creation of TYA. Enrollment began May 1, 2011.
Program administration The ultimate responsible organization
for administration of Tricare is the U.S. Department of Defense Military
Health System, which organized the Tricare Management Activity. The Tricare
Management Activity contracts with several large health insurance
corporations to provide claims processing, customer service and other
administrative functions to the Tricare program.
= Basic structure = Currently, there are three regional
Managed Care Support Contractors, a Medicare/Tricare Dual Eligible Fiscal
Intermediary Contractor, and a Tricare Pharmacy contractor, who administers
both Mail Order Pharmacy and Retail Pharmacy programs. In addition several
administrative contractors provide quality management, auditing, and
statistical services. = Dental insurance =
TMA contracts and administers a couple of dental programs.
MetLife – as Tricare Dental Program Delta Dental – as Tricare Retiree Dental
Program = Health insurance =
In 2004, Tricare Management Activity re-aligned the previous twelve regions
into three large regions, known as Tricare North, Tricare South, and
Tricare West. Services in these regions are provided by:
North – Health Net Federal Services, LLC The North Region includes Connecticut,
Delaware, the District of Columbia, Illinois, Indiana, Kentucky, Maine,
Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New York, North
Carolina, Ohio, Pennsylvania, Rhode Island, Vermont, Virginia, West
Virginia, Wisconsin and portions of Iowa, Missouri and Tennessee.
South – Humana Military Healthcare Services, Inc. The South Region includes
Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, Oklahoma, South
Carolina, Tennessee and Texas. West – United Healthcare The West Region
includes Alaska, Arizona, California, Colorado, Hawaii, Idaho, Iowa, Kansas,
Minnesota, Missouri, Montana, Nebraska, Nevada, New Mexico, North Dakota,
Oregon, South Dakota, Texas, Utah, Washington and Wyoming.
All medical claims are processed by the following claims processing
sub-contractors: North, South and West – PGBA, LLC
Tricare Overseas claims – Wisconsin Physicians Service Insurance Corporation
In 2009, the Tricare Overseas Program contract consolidated the following:
Overseas enrollment Tricare Overseas claims processing
Three area Tricare Service Center contracts
Tricare Global Remote Overseas Tricare Puerto Rico Prime
In October 2009 International SOS Assistance, Inc. was awarded the
contract to provide comprehensive health care support services to the Department
of Defense Tricare Overseas Program. See also
Health insurance in the United States References
External links Official website
TRICARE @ Google+