Editor’s Note: This article is part of MOAA’s 2022-23 TRICARE Guide, brought to you by MOAA Insurance Plans, administered by Association Member Benefits Advisors (AMBA). A version of the guide appeared in the November 2022 issue of Military Officer magazine.
When you transition into military retirement, you will need to navigate substantial changes in health care. Here is a look at what’s ahead for you:
Note: Because TRICARE costs and policies may be subject to change, be sure to check TRICARE.mil for official up-to-date information on your health care benefit.
- What steps must I complete when transitioning from active duty to retiree?
- What are my TRICARE Prime options?
- What are some common complaints about TRICARE Prime?
- What is the US Family Health Plan (USFHP)?
- What is a Qualifying Life Event (QLE)?
- What are my TRICARE Select options?
- How do I find a physician who accepts TRICARE?
- Can spouses sign up for different programs?
- What is the catastrophic cap, and does it change in retirement?
- What are Group A and Group B designations?
- I’m going to live overseas. Am I covered?
- When do my children “age out” of TRICARE?
- After “aging out” of TRICARE, are there any other options if my children don’t have an employer-provided health care program?
- I’m under TRICARE Prime. What if I don’t want to wait months for a referral?
- How does my pharmacy benefit change in retirement?
- My employer offers a Health Savings Account (HSA). Can I participate?
- What happens to a servicemember’s TRICARE coverage during terminal leave?
- What happens to the family members’ TRICARE coverage during terminal leave?
What steps must I complete when transitioning from active duty to retiree?
- Choose the TRICARE program that works best for your family.
- Watch for your status to be updated to “retired” in the Defense Enrollment Eligibility Reporting System (DEERS).
- Within 90 days of retirement date, enroll in a TRICARE plan so your coverage is seamless.
- Contact the specific contractor that manages the program in your area. Enroll online, via telephone, or through U.S. mail.
- Spouses may sign up for different plans. They will be charged at the individual rate for their plan versus the family rate.
What are my TRICARE Prime options?
- Military treatment facility (MTF): Check with the contractor to see if an MTF near you (typically a 30-minute drive) is accepting new retirees and families. Check on the status of your preferred MTF at the next open season, or “qualifying life event” (QLE).
- Civilian care: TRICARE contracts with medical providers to offer this option in many metro areas. It will cost more than enrollment at an MTF, with copays for medical services.
- Specialty care: You will pay point-of-service charges unless you have a referral. Try to find a provider who accepts TRICARE to reduce costs. The deductible will not apply to your catastrophic cap.
What are some common complaints about TRICARE Prime?
The complaint most often heard is the lack of flexibility and the time it can take to be seen by specialists. All care must be coordinated through your primary care manager (PCM). If you need a referral, you must first see your PCM. A referral can take time to process, and even if an MTF specialist is available, you can sometimes wait months before an appointment can be scheduled.
What is the US Family Health Plan (USFHP)?
USFHP is an additional TRICARE Prime option available through networks of community-based, not-for-profit health care systems in six areas of the U.S. Visit www.usfhp.com for location details and contact information for the networks, which cover New England, New Jersey, and much of New York; the metro areas and extended suburbs of New York City, Philadelphia, Baltimore, and Washington, D.C.; southwest Louisiana and portions of Southeast Texas; and the Puget Sound area of Washington state.
As with TRICARE Prime, you will be assigned a primary care provider (PCP), instead of a PCM, to provide referrals within the system.
Enrollment in USFHP prohibits access to military hospitals or the TRICARE network other than that plan’s network of providers. Enrollment fees and co-pays are the same as Prime, with no annual deductible.
The most commented-on drawback of this program is that those enrolled in USFHP who live near an MTF pharmacy cannot access the free pharmacy program.
What is a Qualifying Life Event (QLE)?
A QLE allows you to make changes to your TRICARE benefits outside of the “open season.” For example, while serving, your family was TRICARE Prime, and after retirement, your family decides to switch to TRICARE Select.
QLEs also include events such as a move, birth of a child, marriage, divorce, and death.
TRICARE’s annual open season runs from the second Monday in November to the second Monday in December. Your retirement also allows you to change TRICARE coverage if desired.
What are my TRICARE Select options?
This is the most flexible TRICARE program. You don’t need a primary care manager, and you manage your own care. You will need to find medical care providers who accept TRICARE. Copays are higher than for TRICARE Prime. Select charges an annual enrollment fee for military retirees, to be changed based on Cost of Living Adjustment (COLA). It is $158 for individuals and $317 for families for 2022. The fees and deductibles count against the catastrophic cap.
How do I find a physician who accepts TRICARE?
TRICARE’s FindDoctor page and each contractor (Humana Military, Health Net, International SOS) provide search engines to locate medical providers in your area.
Can spouses sign up for different programs?
Yes. For example, the retiree may prefer to be seen at an MTF and therefore enroll in TRICARE Prime. The spouse may prefer greater flexibility and choose to enroll in TRICARE Select. Each spouse will be charged at the individual rate versus the family rate.
What is the catastrophic cap, and does it change in retirement?
The catastrophic cap (CC) is the most you pay out of pocket for covered services each year before TRICARE picks up all additional covered costs. The amount amassed on active duty during a retirement year rolls into the retirement CC. The CC for Prime has increased from $1,000 on active duty to $3,000 for retirees. The CC for Select is now COLA adjusted each year, and in 2022, it was increased to $3,706 from its 2021 level of $3,500. TRICARE Prime and Select enrollment fees count against the CC.
What are Group A and Group B designations?
These determine the fee structure you pay for enrollment, deductible, copay, and catastrophic cap. Group A: All servicemembers and their families who entered service prior to Jan. 1, 2018. Group B: Those entering on or after Jan. 1, 2018.
Use TRICARE’s Compare Cost Tool to see the costs of Group A vs. Group B, as well as Prime vs. Select enrollment, deductible, co-pay, and the catastrophic cap costs/limits.
I’m going to live overseas. Am I covered?
Yes. TRICARE Select Overseas (TSO) is available for retirees and their dependents living overseas. (TRICARE Prime Overseas is only for active duty and their families.) The TSO enrollment fee is the same as TRICARE Select ($158 individual/$317 family). Enrollment fees will count against the $3,706 catastrophic cap.
To find a provider, you can use the medical provider search engine at www.internationalsos.com. MOAA also recommends that you check with the embassy or consulate for where American military expats get medical care.
When do my children “age out” of TRICARE?
TRICARE eligibility for dependent children ends on their 21st birthday — or their 23rd birthday if they are still enrolled in school.
After “aging out” of TRICARE, are there any other options if my children don’t have an employer-provided health care program?
Yes. TRICARE Young Adult (TYA) Prime or Select is available for military children who have aged out of TRICARE. They remain eligible for TYA until their 26th birthday and if they remain unmarried.
TYA Prime works the same as TRICARE Prime: You must reside in a Prime service area or a MTF must have room for enrollment.
When a young adult ages out of TYA, he or she is eligible to purchase the TRICARE Continued Health Care Benefit Program for up to 36 months.
I’m under TRICARE Prime. What if I don’t want to wait months for a referral?
Under TRICARE Prime, you will incur point-of-service charges for any specialty care you receive without a referral. You should do your best to find a specialist who accepts TRICARE to reduce costs. You will incur a deductible ($300 individual/$600 family) that will not apply to your catastrophic cap. After the deductible is reached, you can expect co-pays that are typically 50% of the allowable TRICARE fee.
How does my pharmacy benefit change in retirement?
Military retirees and dependents now have a copay for prescriptions from commercial pharmacies or home delivery through Express Scripts. Prescriptions are free in the MTF system.
My employer offers a Health Savings Account (HSA). Can I participate?
To be eligible for an HSA, you must be covered under a high deductible health plan and have no other health coverage (except what is permitted under “other health coverage,” or OHC, as defined by the IRS). TRICARE does not qualify as OHC.
Therefore, a retiree enrolled in any TRICARE program cannot participate in an employer’s HSA program. Disenrollment from TRICARE would allow the retiree to participate in the employer’s HSA.
What happens to a servicemember’s TRICARE coverage during terminal leave?
A retiring servicemember remains enrolled in TRICARE Prime at their last duty station until the date of retirement. Here’s where they can get care:
- Any military hospital or clinic, but there are limitations and/or pre-authorizations required for non-urgent care.
- VA medical facilities with a referral/pre-authorization.
- For routine medical care during terminal leave, or if you plan to leave the area of the last duty station at that time, consult with the TRICARE referral office at your MTF or the Defense Health Agency-Great Lakes at (888) 647-6676.
What happens to the family members’ TRICARE coverage during terminal leave?
Military families are covered by their TRICARE plan until the date of retirement. If the family is enrolled in an MTF, they will stay enrolled with their current providers until the retirement date unless there is another reason to change their primary care manager, such as a PCS move.
Family relocation during terminal leave is a QLE. The family can switch TRICARE plans or remain with their current plan and enroll with a TRICARE Prime PCM at their new location. The family will not need to update to their retiree TRICARE coverage until the retirement date.
If the family relocates during terminal leave, this is considered a qualifying life event. The family can switch TRICARE plans or remain with their current plan and enroll with a TRICARE Prime PCM at their new location if necessary.
They do not need to update to retiree TRICARE coverage until the retirement date.
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