TRICARE Program for Retirees
TRICARE is the health insurance program for military beneficiaries. Active duty servicemembers and their dependents are mostly exempt from TRICARE fees; however, this changes with a change in status (e.g., retired, National Guard/Reserve, TRICARE Young Adult). Coverage and fees can vary with regard to the TRICARE coverage elected and depend on whether:
(a) the military sponsor is on active duty or retired,
(b) the beneficiary is eligible for Medicare, or
(c) the beneficiary uses military or civilian facilities for health care and medications.
Why do I need health insurance?
TRICARE PROGRAMS FOR RETIRED SERVICEMEMBERS AND FAMILY MEMBERS
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Description (Note: If you have other health insurance, TRICARE is always the last payer.) |
TRICARE Prime is an HMO-style plan that uses a specific network of doctors. It guarantees appointments with participating providers within specific time standards. Care is delivered through military hospitals or clinics or through a network of civilian providers. Appointments to see specialists or doctors other than your primary care manager (PCM) require a referral from your PCM.
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TRICARE Standard is a fee-for-service plan under which beneficiaries are free to find their own civilian doctors. Visits with other doctors, including specialists, do not require PCM referrals in most cases. TRICARE Standard has an annual deductible of $150 a person or $300 a family and 20-percent cost shares for active duty or 25 percent for retirees. Those who use a network provider called TRICARE Extra get a 5-percent discount. |
TRICARE For Life (TFL) provides supplemental coverage for military retirees and family members who are eligible for Medicare. For Medicare-covered services, TFL pays all expenses Medicare doesn’t. TFL applies to all military beneficiaries age 65 or older and to retired servicemembers under age 65 who:
If the retiree is eligible for Medicare, but the spouse is not, the retiree is on TFL and the spouse is on Prime or Standard. Medicare-eligible beneficiaries cannot decline Medicare/TFL and keep Standard or Prime. |
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Enrollment Fee/Premium |
$273.84 a year (individual) |
None |
TFL has no enrollment fee but requires enrollment in Medicare Part B, which has premiums of $100 a month or more per person, depending on income. Part B premiums rise each year and are auto-deducted from Social Security. |
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Annual Outpatient Deductible |
None |
$150 an individual; |
None |
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Outpatient Visit Copayment |
$12 |
25-percent of TRICARE-allowed charges |
None |
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Inpatient Copayment |
$11 |
$744 a day or 25-percent of charges, whichever is less |
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Catastrophic Cap (Maximum out-of-pocket payment for TRICARE-allowed charges) |
$3,000 a family per year |
$3,000 a family per year |
$3,000 a family per year |
**See also U.S. Family Health Plan
Under current law, military disability retirees are exempt from annual increases in TRICARE Prime enrollment fees and pharmacy copayments that apply to non-disability retirees. Military disability retirees do not include all retirees who have a disability rating from the VA. They only include those who received a medical (Chapter 61) retirement from their branch of service. To ensure exemption from future annual fee increases, retirees in this category should contact DEERS to ensure their records reflect the medical/disability retirement as a Chapter 61 retiree.
TRICARE For Life (TFL) is for people who are eligible for Medicare.
That includes:
(a) all military beneficiaries who are age 65 or older and
(b) military retirees or dependents rated as 100-percent disabled by the Social Security Administration(not DoD or VA) at an earlier age for at least 24 consecutive months.
Once a person becomes eligible for Medicare, he or she must enroll in Medicare Part B to keep TRICARE coverage. Medicare Part B premiums are about $100 a month per person and are tied to a beneficiary’s adjusted gross income. Each January, Part B premiums are adjusted based on how much Medicare costs have risen.
Once enrolled in Part B, Medicare pays first at 80-percent cost for covered benefits. TFL pays the remaining 20percent for covered TRICARE benefits. Under TFL, the beneficiary files a claim with Medicare, and unless he or she has other health insurance, the Medicare claim automatically crosses over to TFL to pay the TRICARE cost-share.
When searching for a provider, ask whether he or she accepts Medicare, and let him or her know you have TRICARE for tests or procedures and facilities requiring TRICARE authorization.
Skilled nursing facility care is only covered when the beneficiary is expected to recover. Nursing homes are not covered by Medicare or TRICARE for long term care.
When you go to the doctor, present your Medicare card and military ID card. The provider only submits a claim to Medicare. The crossover of the claim to TFL is automatic.
As long as you use doctors and other TRICARE-authorized facilities that accept Medicare, you limit your out-of-pocket costs for doctor or hospital visits, except copayments for any medications you get from non-military pharmacies.
TFL falls under the same catastrophic cap as TRICARE plans under age 65. The maximum out-of pocket cost you will pay per family for TRICARE-covered benefits in any fiscal year (from October to September) is $3,000.
Automatic enrollment in Medicare Part B occurs following 24 months of SSDI unless coverage is declined. Declined Medicare Part B results in a lifetime penalty of 10-percent for every 12 months of failed enrollment. The exception is a TRICARE waiver while on active duty. Ensure enrollment in Medicare Part B and premium payment prior to retirement to avoid a lapse in coverage.
Retired Members: If Medicare eligibility because of a disability is established after retirement, you must enroll in Part B to retain health coverage under TRICARE. (For details on how the coverage works, read more about TRICARE For Life, under which TRICARE acts as second payer to Medicare).
Medicare and TRICARE benefits for SSDI-eligible members under age 65 are identical to those TFL-eligible members over age 65. This is known as dual-eligible, meaning beneficiaries are eligible for both TRICARE and Medicare under age 65.
No. The family member coverage and fees depend on the following:
(a) the military sponsor status (active duty or retired),
(b) the family member’s eligibility for Medicare, or
(c) geographic location. If he or she lives within a 40-mile radius of an MTF, he or she may enroll in TRICARE Prime. If not, by default, his or her option is TRICARE Standard.
See DoD’s TRICARE and Medicare Under-65 Fact Sheet for more on the effects of failing to enroll on time.
Information on TRICARE Pharmacy benefits