TRICARE

TRICARE is the health care program the Department of Defense runs for members and former members of the uniformed services and their dependents. Title 10, section 1072(7) defines the "TRICARE program" as "the various programs carried out by the Secretary of Defense under this chapter and any other provision of law providing for the furnishing of medical and dental care and health benefits to members and former members of the uniformed services and their dependents," and then enumerates three health plan options: TRICARE Prime, TRICARE Select, and TRICARE For Life. The definition is worth noticing for its shape. TRICARE is constituted in law as an umbrella, in the same way Medicare is a set of parts rather than a single plan, so a question about "what TRICARE covers" almost always has to be answered for one of the options rather than for the program as a whole.

The all-capital spelling is not a style choice. Both the statute and the Defense Health Agency write TRICARE that way, and the agency notes that it is a registered trademark of the Department of Defense. It does not expand into anything, which is why it is treated here as the program's name rather than as an acronym.

The three current options are each defined separately in section 1072. TRICARE Prime, at 1072(14), is "the managed care option of the TRICARE program", meaning an assigned primary care manager, a network, and referrals for specialty care. TRICARE Select, at 1072(12), is "the self-managed, preferred-provider network option under the TRICARE program established by section 1075", and section 1075(a)(2) adds that beneficiaries in Select "will not have restrictions on the freedom of choice of the beneficiary with respect to health care providers". The trade between the two is the familiar one: Prime charges less and constrains where care is received; Select costs more per service and does not. Two further definitions at 1072(11) and (15), TRICARE Extra and TRICARE Standard, describe options made available before January 1, 2018 and are legacy vocabulary that still turns up in older material.

Section 1075(b)(1) sorts Select enrollees into cost-sharing categories, and the way it does so previews the program's most consequential rule. There is an "active-duty family member" category and a "retired" category, and the retired category is expressly defined to exclude "Medicare-eligible beneficiaries described in subsection (d)(2)" of section 1086. Those beneficiaries are not left out of coverage; they are the population TRICARE For Life exists for.

The Medicare interaction is the single most useful thing on this page. Section 1086(d)(1) states flatly that "A person who is entitled to hospital insurance benefits under part A of title XVIII of the Social Security Act is not eligible for health benefits under this section." Section 1086 is the provision that covers retirees and their families, so on its own that sentence would end TRICARE coverage the moment a retiree became entitled to Medicare Part A. Paragraph (d)(2) supplies the exception, and the exception is conditional: the prohibition does not apply to a person who "is enrolled in the supplementary medical insurance program under part B", with an additional requirement for people under 65 that their Part A entitlement arise through the disability or end-stage renal disease routes. Enrolling in Medicare Part B, and paying its premium, is therefore the price of keeping TRICARE as a Medicare-eligible retiree. This is exactly the decision the Medicare late enrollment penalty punishes people for getting wrong, and the two consequences compound: declining Part B both ends the TRICARE benefit under section 1086 and starts a penalty clock.

What TRICARE For Life then does is pay second. Section 1086(d)(3)(A) addresses care "for which payment may be made under medicare and a plan contracted for under subsection (a)", which is to say care both programs cover, and directs the plan to pick up the beneficiary's out-of-pocket cost after Medicare and any other third-party payers. Subparagraph (B) then caps that: the plan may not pay more for the care than "the total amount that would be paid under the plan if payment for that care were made solely under the plan". The practical reading is that where Medicare and TRICARE both cover a service, the beneficiary usually has little or nothing left to pay, and where only one of them covers it, the ordinary rules of that one program apply.

Two boundaries are worth drawing. TRICARE is not VA health care. TRICARE is a Department of Defense program under Title 10 for service members, retirees and their families; the Veterans Health Administration is a separate system under Title 38 for veterans, with its own eligibility rules and its own facilities. Some people qualify for both. And TRICARE is not Medicare: it does not replace Part A or Part B, and for a Medicare-eligible retiree it operates alongside them rather than instead of them.

Costs move. Enrollment fees, annual deductibles, catastrophic caps and pharmacy copays differ by plan option, by whether the sponsor's service began before or after January 1, 2018, and by whether the beneficiary is an active-duty family member or a retiree, and they are adjusted annually. The dollar figures written into section 1086(b) belong to the older structure and are not what a beneficiary pays today. Any specific amount should be read from the program's current published schedule at the time it matters.

1. Eligibility flows from the sponsor's status, whether that is active duty, retirement from a uniformed service, or a qualifying survivor relationship, and it is recorded in the Defense Enrollment Eligibility Reporting System.

2. The beneficiary chooses an option. Prime, with a primary care manager and referrals, or Select, with free choice of provider and higher cost-sharing.

3. Cost-sharing follows the beneficiary category. Active-duty families and retirees are separate categories in the statute and pay different amounts.

4. At Medicare eligibility the rules change. Entitlement to Medicare Part A ends eligibility under the retiree provision unless the beneficiary is also enrolled in Part B.

5. TRICARE For Life then pays second for care that both Medicare and TRICARE cover, subject to a ceiling equal to what TRICARE alone would have paid.

A hypothetical worked example of the second-payer arithmetic. Bernadette is a retired officer, 68, enrolled in Medicare Part B and covered by TRICARE For Life. With her annual Part B deductible already met for the year, she receives an outpatient service with a Medicare-approved amount of $1,000. Part B generally pays 80 percent of the approved amount, or $800, leaving $200 of coinsurance. Because the service is one both programs cover, section 1086(d)(3) directs TRICARE to pick up her remaining out-of-pocket cost, so the $200 is paid by the plan rather than by her, subject to the statutory ceiling that the plan never pays more than it would have paid had TRICARE been her only coverage.

Change one fact and the answer changes. Had Bernadette declined Part B, section 1086(d)(1) would have made her ineligible for TRICARE benefits under that section in the first place, so she would face the full $1,000 with only Part A behind her, plus a Part B late enrollment penalty whenever she eventually signed up.

Pros

• Coverage continues into retirement, which is rare. Most employer health coverage ends when employment does.
• The Prime option carries low out-of-pocket costs for beneficiaries who accept the network and the referral process.
• For Medicare-eligible retirees, the combination of Medicare and TRICARE For Life leaves very little cost-sharing on services both programs cover.
• Coverage extends to family members, not only the service member.
• Select gives beneficiaries who value provider choice a route to it without leaving the program.

Cons

• Keeping coverage after Medicare eligibility requires enrolling in Part B and paying its premium, which is a real and permanent cost that surprises people.
• Prime's network and referral requirements can be restrictive, particularly for families living far from a military treatment facility.
• Fees and cost-sharing differ by category and by the sponsor's entry date, so two retirees can face different numbers for the same care.
• The program's amounts are adjusted administratively, so a figure learned once goes stale.
• It is not VA health care, and assuming one covers what the other does is a common and costly mistake.