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 enrolling in TRICARE, families usually consider what best meets the needs of the entire family. The decision is more complex for a family member with specific medical requirements. What plan is right for their exceptional child? What specialty services are available? How far will I need to travel?

Location, Location, Location 

Not all TRICARE plans may be available in your new duty location. Do the research to see what is available for in-network providers through TRICARE Prime and TRICARE Select.

TRICARE Prime may be a fantastic option for military families with special needs located near a major military treatment facility (MTF) that has specialty departments, like a developmental pediatrician. TRICARE Prime is the most cost effective; however, it requires referrals from a primary care manager (PCM) for all specialty appointments.

TRICARE Select is often better for a medically complex child based on its flexibility. Referrals are not required for most specialty appointments, and you can access pharmacies out in town.

A Knowledgeable PCM/Pediatrician

Spend some time researching and interviewing pediatricians who have experience serving children with special needs. Do they have connections with the local pediatric hospital? Are they knowledgeable about early intervention/special education resources?

[RELATED: Coming Full Circle: How MOAA Works for This Military Family]

ECHO

Another benefit for some families in the Exceptional Family Member Program (EFMP) is the Extended Care Health Option (ECHO) Program. If eligible, you will be assigned a case manager who helps you procure services not normally covered through TRICARE, such as durable equipment, and respite and home health care.

The ECHO program is designed to mimic the benefits that a state Medicaid waiver provides, but Medicaid waivers are difficult to obtain for highly mobile families. With ECHO, there is a monthly copayment based on the active-duty servicemember’s rank. Plus, ECHO enrollment is required to access the Autism Care Demonstration Project, which offers Applied Behavior Analysis (ABA) therapy.

Non-Participating Providers 

There may be times your child with special needs requires a provider that does not accept TRICARE, especially if you are traveling. You can always self-pay in critical situations and ask for a “super bill” with the correct itemized coding. If you submit the claim to TRICARE within one year for reimbursement, with the right coding, TRICARE will reimburse at their rates.

[MOAA CHANGEMAKERS: Michelle Norman]

Supplemental Insurance 

MOAA offers supplemental insurance called MEDIPLUS for members enrolled in TRICARE Select. This valuable benefit will cover the copayments of appointments until your family meets the catastrophic cap set by TRICARE. Additionally, MEDIPLUS helps cover retail pharmacy copayments for prescriptions that are TRICARE-approved.

As a rule of thumb, TRICARE will be billed first, then a supplemental (secondary) insurance plan, and last is a Medicaid waiver plan. There may be times that a provider does not accept TRICARE and won’t provide services even if your child has a Medicaid waiver plan.

Be an Effective Advocate

Military caregivers should consider creating a medical binder to include their child’s medical records, visits, evaluations, referrals, medical power of attorney, TRICARE Explanation of Benefits, etc. The more organized you are, the easier it will be to advocate on your child’s behalf for medical care and eventually give them the tools to advocate for themselves one day.

Ensuring that your loved one with special needs has access to medical care may seem like a daunting task. TRICARE offers many health benefits for active duty families. You can switch plans during open season based on your family’s needs and current duty station.

With some research and fully understanding benefits, you will be armed with knowledge to make optimal medical care decisions for your family.