What To Know Before Getting Care With Your TRICARE Plan

FALLS CHURCH, Va. – Did you or a family member recently enroll in a TRICARE health plan or change plans? Now is a good time to review how your plan works.

“Knowing what to do before and after you get care is key to making the most of your TRICARE plan,” said Zelly Zim, a senior analyst with TRICARE Policy and Programs at the Defense Health Agency. “Understanding your plan, TRICARE covered services, and costs will help you and your family prepare for your health care needs in the year ahead.”

Here are some key things to do and know before getting care.

1. Know which plan you’re enrolled in
Different TRICARE plans have different rules and out-of-pocket costs for getting care, as detailed in the TRICARE Plans Overview Fact Sheet. That’s why it’s important to know which TRICARE plan you’re enrolled in.

If you aren’t sure which plan you have, there are two ways to check. You can log in to the Defense Enrollment Eligibility Reporting System (DEERS) through milConnect or call your regional contractor.

Don’t forget to update DEERS whenever you have a change in your sponsor’s status, get married or divorced, have a baby, move, become eligible for Medicare, or if your sponsor or family member dies. These are Qualifying Life Events (QLEs), which may open a period where you can make changes to your plan.

Remember to keep your contact information (address, email address, and phone number) updated in DEERS and with your regional contractor.

2. Know where you can get care
Knowing where you can get care with your plan is one way to avoid unexpected costs.

You may be able to get care at a military hospital or clinic. This depends on your plan, location, and beneficiary category. You have priority at military hospitals and clinics if you’re an active duty service member (ADSM) or you have a TRICARE Prime plan. (This doesn’t include the US Family Health Plan.)

You may also be able to get care from TRICARE-authorized civilian providers. Use the provider directories to search for TRICARE-authorized providers near you. Civilian providers may be either network or non-network:
• Network providers have signed an agreement with a TRICARE contractor to follow TRICARE’s policies and procedures. If you see a network provider, you’ll only pay your in-network copayment or cost-share.
• Non-network providers haven’t signed an agreement with a TRICARE contractor. There are two types of non-network providers: participating and non-participating. Non-participating providers are typically the most expensive provider option.

Your plan determines if you need a referral or pre-authorization to see these providers. ADSMs and other TRICARE Prime beneficiaries need referrals for any care their primary care manager (PCM) does not provide. In these cases, your PCM will refer you to another provider or specialist.

Beneficiaries enrolled in all other TRICARE plans only need referrals or pre-authorizations for certain services.

3. Find what TRICARE covers
TRICARE covers care that’s medically necessary and considered proven. This includes preventive care and mental health and substance use disorder care. You can use the TRICARE Covered Services tool to see if a health service or supply is covered or not.

4. Review your out-of-pocket costs
Your health care costs may include deductibles, copayments, and cost-shares. These costs depend on your plan, your sponsor, where you get care, and the type of care you get.

Knowing your plan’s out-of-pocket costs up front can help you choose providers with lower costs and avoid unexpected costs. If you don’t follow your plan’s rules for getting care, you may end up paying more out-of-pocket.

TRICARE Prime beneficiaries can also use the point-of-service option. This lets you see any TRICARE-authorized provider without a referral. With this option, you’ll pay more out-of-pocket. The point-of-service option doesn’t apply to ADSMs.

To learn more about costs for covered services, use the TRICARE Compare Costs tool or check out the TRICARE Costs and Fees Fact Sheet.

5. Know how to file claims
Usually, your provider will file your claims for you. But if you get care while traveling, or from a non-participating provider, you may need to file your own claim.

It’s best to file your claim as soon as possible. File within one year of the date of service if you’re in the U.S. or U.S. territory, or within three years of the date of service if overseas. TRICARE claims processors process most claims within 30 days.

When submitting a claim, keep a copy of all paperwork for your records. If your claim is denied or you need help, contact your regional contractor.

TRICARE is here to support your family’s wellness and help you make the most of your benefits. To learn more about how to get care with your plan, visit Getting Care. If you have questions, call your regional contractor.

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