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In a lot of ways Tricare has 3 or 4 different programs, (depending on how you view them).

Active duty personnel are not really under Tricare. They are required to use base hospitals and clinics, (or in case of U.S Navy when deployed, the ship’s medical facilities). The only time that is not true is when the active duty personnel are stationed somewhere that is not close to a military medical facility, such as recruiting duty or on leave or transiting through an area where there is no military medical facilities.

In the above exceptions the active duty personnel are covered under Tricare Remote. This is a program where they are assigned to a private provider, or network, and coordinate their care through the contractor that Tricare contracted with for that purpose. In the US the contractors are split into several regions and they coordinate the medical care. Overseas, International SOS, (ISOS), is the contractor for all outside the continental US, (OCONUS), active duty medical care.

Active duty family members, (ADFM), are covered under Tricare. If they are residing within the area of a medical hospital, they normally will use the hospital staff and facilities for their care, but that will be coordinated with Tricare Prime which is basically a Preferred Provider Organization, (PPO), which is set-up and run by the regional contractor. The ADFM will be assigned to a Primary Physician who will then coordinate with the contractor and other Prime specialist for referral medical care. Prime has an annual premium which must be paid and there are minimum co-pays for some services.

All ADFM’s OCONUS must be on Tricare Prime and those in remote areas are on Tricare Prime Remote. Tricare Prime OCONUS requires the premium be paid but the co-pays are waived. Also, under the newest Tricare Prime OCONUS, all Tricare Prime is to be a cashless system. The foreign Prime providers are under contract with ISOS and the providers submit the full bill to ISOS through their sub-contractor Wisconsin Physician Services, (WPS, the claims processing contractor).

For AFDM’s that do not want to be on Tricare Prime, (stateside), they can use any Tricare certified provider under Tricare Standard. Tricare Standard requires a $150, (individual), or $300, (family), deductible annually and then they are required to pay 20% of the Tricare allowable amount, (called a Champus maximum allowable charges, CMAC). Many ADFM’s chose this option because they can use doctors that they like rather than the Prime assigned doctor.

Retirees in the US near a military hospital can use Tricare Prime if there are openings in the available slots, (I.E. if there are not enough ADFM’s signing up for the Prime).

Otherwise, retirees in the US are on Tricare Standard and pay the same deductibles as the ADFM’s but pay 25% of the CMAC for their medical care.

Finally, we get to the retirees OCONUS. No retirees OCONUS are allowed to be in Tricare Prime OCONUS. They must be on Tricare Standard. Most OCONUS areas, (Europe mostly), the providers will participate on claims, (but that is not an absolute), and will bill Tricare directly. The problem arises there when WPS pays less than billed due to WPS’s determination of non-medically necessary care or, because of the differences in medical terminology OCONUS and the US, WPS determines that the procedure is not the procedure billed. Then, after losing certain amounts of payments, the providers refuse to participate and require payment up front.

In the US if a provider accepts a Tricare patient they can not bill the patient for the difference of what they normally charge and what Tricare’s CMAC will pay, (balance billing). OCONUS, that law does not apply except for the contract that ISOS has with Prime providers. Thus OCONUS the patient may be required to pay the bill in full and files a claim with WPS for reimbursement. If the bill is from a country other than the Philippines and Panama, WPS pays the billed ammount, (except as I indicated above). But for the Philippines and Panama, Tricare has developed a CMAC for us. The Philippine CMAC is .52% of the average US CMAC. Panama’s is .60% of the average US CMAC.

Unfortunately, since they were established in 2008, there has been no increases in the CMAC other than the Medicare adjustment for US inflation, (annually, 1-3%), but the inflation in the Philippines has been 8-15%, (or more), for medical care annually. Along with that, there has been no adjustment for the fluctuation in the money exchange rate. When the exchange rate was 52 Pesos to a $ when the study was done for this CMAC, (2005), and is now 42 Pesos to a $, there is a loss of purchasing power, but no adjustment in the CMAC to reflect the true inflation and exchange rate.

The bottom line is, what was somewhat close to the actual cost of medical care in the Philippines, (based on the CMAC), now leaves the retirees paying more than the 25% co-pay mandated by law.

When the CMAC was announce, but before it went into effect, we were able to convince Tricare that ancillary cost, (x-rays, laboratory test, etc.), were higher here than in the US because most of the equipment comes from the US and/or Europe and the maintenance, training and repair parts also come from the US and/or Europe. We forced Tricare to do an independent study of the ancillary issue and got them to agree that those should be paid at the full Tricare Puerto Rico CMAC.

We also won on the issue of prescription medicines because most are also from the US or Europe, so they are paid mostly at billed charges.

I know I was long on this explanation, and may have a few minor points wrong, but I hope it gives a better idea of what Tricare is.

We live under numerous other rules that US retirees do not live under, but I will leave those issue for another day unless someone request a rundown on them.