A Active duty members, who are covered by 10 U. B Active duty family members, who are beneficiaries covered by 10 U. D Medicare eligible retirees and Medicare eligible retiree family members who are beneficiaries covered by 10 U. It generally features use of military treatment facilities and substantially reduced out-of-pocket costs for care provided outside MTFs.
Beneficiaries generally agree to use military treatment facilities and designated civilian provider networks and to follow certain managed care rules and procedures. It allows beneficiaries to use the TRICARE provider civilian network, with reduced out-of-pocket costs compared to care from non-network providers, as well as military treatment facilities where they exist and when space is available.
Any such law, or regulation pursuant to such law, is without any force or effect, and State or local governments have no legal authority to enforce them in relation to the TRICARE regional contracts. However, the Department of Defense may by contract establish legal obligations of the part of TRICARE contractors to conform with requirements similar or identical to requirements of State or local laws or regulations.
Such laws are laws relating to health insurance, prepaid health plans, or other health care delivery or financing methods, within the meaning of the statutes identified in paragraph a 7 i of this section.
Preemption, however, does not apply to taxes, fees, or other payments on net income or profit realized by such entities in the conduct of business relating to DoD health services contracts, if those taxes, fees or other payments are applicable to a broad range of business activity. For purposes of assessing the effect of Federal preemption of State and local taxes and fees in connection with DoD health and dental services contracts, interpretations shall be consistent with those applicable to the Federal Employees Health Benefits Program under 5 U.
TRICARE Prime is a managed care option that provides enhanced medical services to beneficiaries at reduced cost-sharing amounts for beneficiaries whose care is managed by a designated primary care manager and provided by an MTF or network provider. The TRICARE Select health care plan also provides enhanced program benefits to beneficiaries with access to a preferred-provider network with broad geographic availability within the United States at reduced out-of-pocket expenses.
Further, some rules and procedures are different for dependents of active duty members and retirees, dependents, and survivors.
Active duty members are required to enroll in Prime where it is offered. Active duty members shall have first priority for enrollment in Prime. Beneficiaries in the active duty family member category are eligible to enroll in Prime where offered or Select. B Attains 23 years of age or ceases to pursue a full-time course of study prior to attaining 23 years of age, if, at 21 years of age, the eligible surviving dependent is enrolled in a full-time course of study in a secondary school or in a full-time course of study in an institution of higher education approved by the Secretary of Defense and was, at the time of the sponsor 's death, in fact dependent on the member for over one-half of such dependent 's support.
All retirees, dependents of retirees, and survivors who are not eligible for Medicare Part A are eligible to enroll in Select. Additionally, retirees, dependents of retirees, and survivors who are not eligible for Medicare Part A based on age are also eligible to enroll in TRICARE Prime in locations where it is offered and where an MTF has, in the judgment of the Director , a significant number of health care providers, including specialty care providers, and sufficient capability to support the efficient operation of TRICARE Prime for projected retired beneficiary enrollees in that location.
All participants in Prime are eligible to receive care in military treatment facilities. Participants in Prime will be given priority for such care over other beneficiaries. Among the following beneficiary groups, access priority for care in military treatment facilities where TRICARE is implemented as follows:. A Active duty service members;.
For purposes of this paragraph d 1 , survivors of members who died while on active duty are considered as among dependents of active duty service members. Enrollment in Prime does not affect access priority for care in military treatment facilities for several miscellaneous beneficiary groups and special circumstances. Those include Secretarial designees, NATO and other foreign military personnel and dependents authorized care through international agreements, civilian employees under workers' compensation programs or under safety programs, members on the Temporary Disability Retired List for statutorily required periodic medical examinations , members of the reserve components not on active duty for covered medical services , military prisoners, active duty dependents unable to enroll in Prime and temporarily away from place of residence, and others as designated by the Assistant Secretary of Defense Health Affairs.
Additional exceptions to the normal Prime enrollment access priority rules may be granted for other categories of individuals, eligible for treatment in the MTF, whose access to care is necessary to provide an adequate clinical case mix to support graduate medical education programs or readiness-related medical skills sustainment activities, to the extent approved by the ASD HA.
Such additional services are authorized under 10 U. Other authority for such additional services includes section of the National Defense Authorization Act for Fiscal Year The specific set of such services shall be established by the Director and announced annually before the open season enrollment period. Standards for preventive care services shall be developed based on guidelines from the U.
Department of Health and Human Services. Such standards shall establish a specific schedule, including frequency or age specifications for services that may include, but are not limited to:.
The exact services offered shall be established under uniform standards established by the Director. Under the authority of 10 U. Such services must be provided by a TRICARE network provider and be medically necessary and appropriate in the context of the particular patient's treatment. The specific services designated for this purpose will be those the Director determines provide especially high value in terms of better health outcomes.
The specific services affected for any plan year will be announced by the Director prior to the open season enrollment period for that plan year. Any such other enhancements or changes must be approved by the Director based on uniform standards. Active duty family member status is for a period of 3 years from the date the active duty sponsor dies or until the surviving eligible dependent:.
A The family member 's active duty sponsor has been assigned permanent duty as a recruiter; as an instructor at an educational institution, an administrator of a program, or to provide administrative services in support of a program of instruction for the Reserve Officers' Training Corps; as a full-time adviser to a unit of a reserve component; or any other permanent duty designated by the Director that the Director determines is more than 50 miles, or approximately one hour driving time, from the nearest military treatment facility that is adequate to provide care.
B The family members and active duty sponsor , pursuant to the assignment of duty described in paragraph g 3 i A of this section, reside at a location designated by the Director , that the Director determines is more than 50 miles, or approximately one hour driving time, from the nearest military medical treatment facility adequate to provide care. C The family member , having resided together with the active duty sponsor while the sponsor served in an assignment described in paragraph g 3 i A of this section, continues to reside at the same location after the sponsor relocates without the family member pursuant to orders for a permanent change of duty station, and the orders do not authorize dependents to accompany the sponsor to the new duty station at the expense of the United States.
D For a 3 year period, the surviving spouse of a member who dies while on active duty for a period of more than 30 days whose death occurred on or after October 7, A The reserve component member has been ordered to active duty for a period of more than 30 days.
B The family member resides with the member. C The Director , determines the residence of the reserve component member is more than 50 miles, or approximately one hour driving time, from the nearest military medical treatment facility that is adequate to provide care.
The additional health care management requirements applicable to Prime enrollees under paragraph n of this section are applicable under TRICARE Prime Remote for Active Duty Family Members unless the Director determines they are infeasible because of the particular remote location. Enrollees will be given notice of the applicable management requirements in their remote location.
Under the TRICARE program , any military medical treatment facility MTF commander may establish resource sharing agreements with the applicable managed care support contractor for the purpose of providing for the sharing of resources between the two parties.
Internal resource sharing and external resource sharing agreements are authorized. Pursuant to an agreement between a military medical treatment facility and TRICARE managed care support contractor, quality assurance, utilization review, and preauthorization requirements and procedures applicable to health care services outside the military medical treatment facility may be made applicable, in whole or in part, to health care services inside the military medical treatment facility.
This paragraph k 2 describes the categories of health care services relevant to determining copayment amounts. These are outpatient visits and related services described in paragraph f 2 of this section. Beneficiaries shall not be required to pay any portion of the cost of these preventive services even if the beneficiary has not satisfied any applicable deductible for that year.
These are outpatient visits, not occurring in an ER or urgent care center, with the following provider specialties:. F Physician 's Assistant. This category applies to outpatient care provided by provider specialties other than those listed under primary care outpatient visits under paragraph k 2 ii of this section and not specifically included in one of the other categories of care e.
This category also includes partial hospitalization services, intensive outpatient treatment, and opioid treatment program services. This is for ground ambulance services. This is for facility-based outpatient ambulatory surgery services.
This category includes a residential treatment center , or substance use disorder rehabilitation facility residential treatment program.
Those programs include:. Tricare Prime is like a civilian health maintenance organization, or HMO. Users are assigned a primary care manager and must get referrals to access specialty care. User costs depend on military service status. For example, an active-duty family enrolled in Tricare Prime pays no fees so long as they follow referral rules, but retiree families do pay out of pocket. Learn more about Tricare Prime on Military.
Tricare Select is like a civilian preferred provider organization, or PPO. Users can select their own primary care manager and self-refer to specialists.
While some provider appointments, such as well-child visits, carry no fees, others do. How much users pay and whether they face an enrollment fee depends on their service status. Learn more about Tricare Select on Military. Tricare Reserve Select is a plan for traditional Guard and reservists and functions exactly like Tricare Select, with one significant difference: Users must pay a monthly premium.
Learn more about Tricare Reserve Select on Military. Tricare for Life is the name assigned by law for the program that provides supplemental health coverage for retirees and their spouses who are over age Confusion sometimes is caused when those leaving the military are told they will receive Tricare for life -- meaning Tricare as a lifetime benefit, as opposed to being assigned to the Tricare for Life plan. Learn more about Tricare for Life coverage on Military.
Tricare Young Adult is available in both Prime and Select versions and is available to military dependents who are full-time students between the ages of 23 and 25 or non-students between ages 21 and Tricare Young Adult users pay enrollment fees set by law. Doing the right thing has always been at the forefront of our decision making. We work hard to serve our customers, using our organization's four key cornerstones: honesty, accountability, transparency, and integrity, and we continue to explore new opportunities to support our customers in meaningful ways.
We built our California headquarters during this contract and established a trained, experienced and dedicated workforce many of whom continue to work for HNFS today. Managed care support contracts prove to be a successful venture for the government. HSI , the parent company of Health Net and QualMed, begin merger discussions to build market share and synergies to better serve customers into the future.
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