The Department of Defense health care program known as Tricare provides civilian health benefits to military personnel, military retirees, and their dependents. In the past, healthcare for military personnel and their dependents was provided in military medical facilities, and by referral to civilian medical personnel only when military physicians were not available in a certain specialty, or there was an issue with overcrowding at the military facilities. Active duty military personnel have always had priority at military medical facilities, but with the growth of standing military forces access to care in military facilities became increasingly unavailable to military retirees and the dependents of both active duty military and retirees.
With the growing demands on the system, there were great constraints, and it became an issue that greatly needed to be addressed. 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 (CHAMPUS) in 1966.
Going Back to the Late 1980s
In the late 1980s, because of escalating costs, paperwork demands, and beneficiary dissatisfaction, the Department of Defense initiated a series of demonstration projects. Under a program known as the CHAMPUS Reform Initiative (CRI), a contractor provided both healthcare 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 the use of network providers — in exchange for lower-cost shares, and
- A standard option that continued the freedom of choice in selecting providers but required higher cost shares and deductibles known as Tricare Standard.
Since then, Tricare has undergone several restructuring initiatives, including re-alignment of contracted regions, and the addition of Tricare for Life benefits in 2001 for those who are Medicare-eligible, and Tricare Reserve Select in 2005.
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No Enrollment Fee for Tricare Standard
Tricare Standard provides similar benefits as the original CHAMPUS program. It’s a Fee-For-Service plan that is available to all non-active duty beneficiaries 60 or older and their eligible family members. It offers the most freedom in the choice of providers, and it has the highest satisfaction rate among users. There’s no enrollment fee for Tricare Standard, and you can get care from any Tricare authorized provider in-network or non-network. Referrals aren’t required, however, some care may need prior authorization. While there’s no enrollment fee for Tricare Standard, the beneficiary is responsible for the annual payment of a deductible and coinsurance. This program meets and/or exceeds the requirements for Minimum Essential Coverage under the Affordable Care Act.
You Must Have Original Medicare to be a Tricare For Life Member
There’s no enrollment necessary in Tricare For Life, but members must be Tricare and Medicare Eligible, and having Medicare Part A and Part B are a requirement. An exception to the requirement for Part B coverage exists when the beneficiary that’s Medicare-eligible is the spouse of an Active Duty Service Member. There is minimal out of pocket expense, aside from Medicare Part B premiums, and in most cases, there are no claims to file. Unlike with Tricare Standard, Tricare for Life requires that you make your appointments with in-network authorized providers. Furthermore, there’s no annual deductible with Tricare for Life for services that are covered by Medicare and Tricare. Medicare will pay its portion and automatically forward the claim electronically to TRICARE for processing. When it comes to the maximum that is paid out of pocket for both plans, they are both dependent on the sponsor’s military status, and they’re both about the same. You can get needed care from military clinics and hospitals, but only on a space-available basis.
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