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How TRICARE Changes When a Military Sponsor
Retires or Dies

When a military member retires from active service and begins drawing retired pay, one chapter in the member’s life is ended and another begins. If the member has a family, their individual lives change as well, including their TRICARE cost shares.

When an active duty sponsor dies, surviving family members remain eligible for TRICARE benefits at the active duty dependent rates for a three-year period. At the end of the three-year period, TRICARE eligibility continues, but at the retiree dependent rates.

	Active Duty Service Member and Dependents	Retired Service Member and Dependents
Enrollment in TRICARE Prime	Active duty service members must be enrolled in TRICARE Prime. Dependents can choose which TRICARE option they prefer—TRICARE Prime, Extra or Standard	Retired service members and their dependents can choose which TRICARE option they prefer—TRICARE Prime, Extra or Standard based on the availability in their area.
TRICARE Prime	No enrollment fees for active duty service members or their family members No co-payments for any health care visit to a network or referred provider	Enrollment fees apply—$230 for individuals, $460 for families Co-payments ($12) required for outpatient visits to network providers Inpatient care—$11 per day, $25 minimum Inpatient mental health—$40 per day
TRICARE Extra	Inpatient care—$12.72** per day or $25, whichever is more Outpatient care—15% of the negotiated cost	Inpatient care—$250 per day or 25% of hospitals billed charges, whatever is less, plus 20% of allowable charge for separately billed professional services. Outpatient care—20% of the negotiated cost
TRICARE Standard*	Inpatient care—$12.72** per day or $25, whichever is more Outpatient care—20% of allowable charges Annual outpatient deductible—$50 for individuals, $100 for families (E-1 - E-4), $150 for individuals, $300 for families (E-5 and above) Civilian inpatient mental health—$20 per day	Inpatient care—$417** per day or 25% of hospital’s billed charges, whichever is less, plus 25% of allowable charge for separately billed professional charges Outpatient care—25% of allowable charges Annual outpatient deductible—$150 for individuals, $300 for families Civilian inpatient mental health—lesser of $159* per day or 25% of allowable fees plus 25% of allowable charge for separately billed professional fees.
Catastrophic Cap*	$1,000 annually	$3,000 annually
Eligible for Medicare (age, disability or end-stage renal disease (ESRD))	Active duty family members are not required to enroll in Medicare Part B to remain eligible for TRICARE.	Retired service members and their dependents MUST enroll in Medicare Part B to remain eligible for TRICARE.

*The catastrophic cap is the annual upper limit. It applies only to the allowable charges for covered service. The catastrophic cap applies to the enrollment year for TRICARE Prime enrollees and to the calendar year for TRICARE Extra and Standard user.
**Rates are current for FY 2003; rates change every fiscal year.

Use of Military Treatment Facilities (MTFs):
Retirees and their families who do not enroll in TRICARE Prime may continue to use MTFs as capacity exists—if a particular facility can accommodate them.* A priority system has been established for access to health care in an MTF. Briefly, the priorities are as follows:

Active-duty service members
Active-duty family members who are enrolled in TRICARE Prime
Retirees, their family members and survivors enrolled in TRICARE Prime
Family members of active-duty service members who are NOT enrolled in TRICARE Prime (for the purpose of determining access priority, survivors of military sponsors who died on active duty who are NOT enrolled in TRICARE Prime are in this priority group)
All other eligible persons, including retirees and their families who are NOT enrolled in TRICARE Prime
     TRICARE Plus* is a MTF primary care enrollment program offered at selected local MTFs. All beneficiaries eligible for care in MTFs (except those enrolled in TRICARE Prime, a civilian HMO, or Medicare HMO) may seek enrollment for primary care at an MTF where enrollment capacity exists.
Becoming Medicare-eligible:
     Medicare eligibility usually begins on the first day of the month in which the beneficiary turns 65.* If the 65th birthday falls on the first day of the month, Medicare Part A eligibility begins on the first day of the preceding month. If the Medicare-eligible beneficiary purchases Medicare Part B, he or she will remain eligible for TRICARE through a program known as TRICARE For Life (TFL)*. With TFL, beneficiaries retain their eligibility for TRICARE Extra and Standard, but not Prime. TRICARE acts as a second payer to Medicare for services covered by both Medicare and TRICARE. When a retired sponsor reaches age 65 and becomes eligible for TFL, his or her spouse maintains regular TRICARE eligibility until he or she (spouse) becomes 65 years old.
     Persons under age 65 who become entitled to Medicare Part A because of a disability or ESRD*, and who are enrolled in Medicare Part B, maintain their eligibility for TRICARE Prime, Extra or Standard. When they reach age 65, they will no longer be eligible for TRICARE Prime; they remain eligible for TRICARE Extra and Standard and become eligible for TFL. By law, TRICARE pays after Medicare for these eligible persons. Beneficiaries who become eligible for Medicare due to a disability or ESRD should report that eligibility to the nearest military personnel office, on or after the date of eligibility.
     For more information, beneficiaries may contact a local health benefits adviser, beneficiary counseling and assistance coordinator or TRICARE service center or they may visit the TRICARE Web site at www.tricare.osd.mil/.

*See also: TRICARE: The Basics Fact Sheet
                Choosing TRICARE Standard Fact Sheet
                TRICARE For Life Fact Sheet
                TRICARE Plus Fact Sheet
                TRICARE and Medicare for Dual-Eligible Beneficairies Under Age 65 Fact Sheet

Benefit Gains Have Turned TRICARE Reformers Toward Smoother Service
February 8, 2001

Military leaders and defense health officials locked arms two years ago to rescue a mismanaged and chronically under-funded military health care system, which was hurting morale and perhaps readiness.
The alliance between the Joint Chiefs and TRICARE officials has resulted in successes. For example, it was at least partially responsible for Congress approving last fall the biggest increase in military medical benefits in more than 30 years. The partnership had a bigger role in a recent sharp drop in complaints, from both patients and health care providers, over access to care and claim processing delays.
That alliance, senior defense officials said, is turning its attention now to a $1.4 billion health budget shortfall for the current year, and to reorganizing TRICARE networks and support contracts to reduce hassles for patients and improve efficiency.
Defense officials credit Army Gen. Henry ``Hugh'' Shelton, chairman of the Joint Chiefs, for keeping high-level attention on health care. He shifted the focus there in 1999 after helping to secure impressive military pay and retirement gains from the administration and Congress.
Shelton soon had plenty of company, not only four-star colleagues but military associations, which led the charge for health care reform for years, and a groundswell of individual retirees, angry over broken health care promises.
When Shelton's public and private advocacy for health benefit reform failed to win the support he wanted from the Clinton White House, particularly for disenfranchised elderly retirees, spouses and survivors, Congress took up the cause. Military leaders and TRICARE officials still sound surprised by the richness of benefit gains passed in 2000.
For active duty families, they include an end to co-payments, of $6 and $12 per doctor visit when enrolled in TRICARE Prime, the managed care program. This change will take effect April 28 but, in some regions, co-payments will continue to be collected for additional months. These patients later will be reimbursed for paying the co-pays.
On Oct. 1, TRICARE Prime remote benefits will be extended to the families of 80,000 service members assigned 50 miles or more from the nearest military base. Only service members themselves in remote areas have the fuller health benefit now.
About 1.4 million elderly beneficiaries will become eligible April 1 for the same of pharmacy drug options as younger retirees. On Oct. 1, when TRICARE for Life begins, military beneficiaries enrolled in Medicare Part B, will be able to use TRICARE as a second payer to Medicare. Many elderly will be able, in time, to drop medigap insurance plans.
Given the richness of the new benefits, defense officials sound satisfied that health promises to older retirees are being kept. ``Go out and look at benefits around the world and, I'll tell you what…this is a first-class benefit,'' said a senior official.
For almost two years, Defense health officials and representatives of the Joint Staff have worked together on easing irritants under TRICARE for patients and providers through better business practices. Officials announced, at the annual TRICARE conference last month, that the number of TRICARE claims delayed more than 60 days fell sharply, from more than 30,000 in December 1999 to less than 1000 a year later. The number of claims over that are more than 120 days old fell from 1493 in December 1999 to 18 a year later.
The Defense Department this year is required to conduct its second Quadrennial Defense Review, an intense effort to review strategy, determine proper force structure, and argue that enough dollars be earmarked in future budgets. One Defense official said Shelton sparked a kind of ``mini-QDR,'' but for military medicine two years ago. And it continues.
Besides adopting better business practices, Defense officials are moving to fully fund health care budgets, which were chronically under-funded during the Clinton years. The Defense Medical Oversight Committee has the lead.
DMOC was formed in the wake of complaints from the Joint Chiefs about TRICARE. Rudy de Leon, then under secretary of defense for personnel and readiness, believed military leaders needed to understand the true costs of health care while pressing for change. As a result, the service vice chiefs and under secretaries of each service are full participants in DMOC, with one of the vice chiefs serving as co-chair on a rotating basis.
DMOC currently is studying the structure of TRICARE and its regions, weighing organizational alternatives including whether a single contractors should handle all claims processing or all pharmacy networks across regions, so that users see more of a consistency of service and benefits no matter where assigned.
Another big concern is closing a $1.4 billion gap in the medical budget for this fiscal year. DMOC, said one senior official, ``has brought the medical funding issue to life like it's never been before.'' So when debating budgets, the service vice chiefs ``have already got the medical piece locked and cocked in their minds.''
For the DMOC, the Army vice chief is heading up a study on TRICARE organization, the Marine Corps is studying procurement strategy for the system, and the Air Force vice is looking at the strategic business plan.
``Are the contracts set up right within a region. Should we have one contract? Should we have 100,'' asked a Defense official. ``If they were in civilian health care delivery, how would they structure this system…We tried to structure it militarily, in the past. That may be totally wrong.''
``About the end of March,'' he added, ``the DMOC is supposed to have some plan for the road ahead.''
Comments and suggestions are welcomed. Write to Military Update, P.O. Box 231111, Centreville, Va. 20120-1111, or send e-mail to: milupdate@aol.com