What is Tricare and how does it benefit patients? A Guide to Medical Billing.

As a Medical Biller, the better you understand the medical insurance payment process, the better you can care for your patients. Your understanding of what a patient will owe and what will be covered can help them navigate the confusing world of medical insurance.

One area that is confusing for patients in your office is what Tricare benefits are available to assist with medical services.

The United States Military’s Health Insurance Plan, better known by the acronym TRICARE covers active-duty members, retirees, and their families. However, retirees and their dependents will often have to pay for the cost of coverage.

The Tricare program is available in four different programs:

1) Tricare Prime

The Tricare Prime program is very much like an health maintenance organization (HMO). In this way your patients are assigned to a Primary Care Provider (PCP). Like most HMOs, in order to receive care from a specialist your patients must first receive a referral from your office.

Tricare Prime requires patients to enroll and pay an annual fee, plus you pay a small co-pay fee (often called a ‘cost-share’ in the military) each time they receive medical care. Tricare Prime patients do not file a claim, but as a provider you do this on behalf of your patients.

2) Tricare Extra

The Tricare Extra program gives patients more flexibility, however it can result in additional costs. If a patient is eligible for Tricare benefits, they are enrolled automatically the first time they use any benefits, or present a military or dependent ID card to a Tricare Network Provider (TNP).

Under Tricare Extra, patients do pay an annual deductible. After the deductible is paid, Tricare pays 80 percent of the medical expenses, and the patient is responsible to pay 20 percent of the authorized costs.

3) Tricare Standard

The Tricare Standard program gives patients the greatest flexibility, however it costs the most. As with Tricare Extra, they pay an annual deductible. In addition to the deductible, they have to pay 25 percent of what Tricare says the medical service should cost. Under this program, a patient can see just about any medical provider they want.

4) Tricare for Life

In the past, when a retiree or retiree family member reached the age of 65, they were no longer eligible for Tricare. Instead, they were expected to receive medical care under the provisions of Medicare. This changed in 2001 with the introduction of Tricare for Life.

Under Tricare for Life, a patient will receive medical care from Medicare providers, but Tricare acts as a secondary insurer and picks up any costs that Medicare doesn’t cover. A patient will pay no annual deductible or cost-share under this program.