Editor’s Note: This article is part of MOAA’s 2020-21 TRICARE Guide, brought to you by MOAA Insurance Plans, administered by Mercer Consumer. A version of the guide appeared in the November 2020 issue of Military Officer magazine.
These frequently asked questions and our answers will explain significant health care changes you need to know as you transition into retirement.
Because TRICARE costs and policies may be subject to change, be sure to check TRICARE.mil for official up-to-date information on your health care benefit. Click the question below to go straight to the answer, or scroll down to see the entire Q-and-A.
- What steps must I complete when transitioning from active duty to retiree?
- What are my TRICARE Prime options?
- What are some common complaints about TRICARE Prime?
- What is the US Family Health Plan (USFHP)?
- What is a Qualifying Life Event (QLE)?
- What are my TRICARE Select options?
- How do I find a physician who accepts TRICARE?
- Can spouses sign up for different programs?
- What is the catastrophic cap, and does it change in retirement?
- What are Group A and Group B designations?
- I’m going to live overseas. Am I covered?
- When do my children “age out” of TRICARE?
- After “aging out” of TRICARE, are there any other options if my children don’t have an employer-provided health care program? (Updated Nov. 6)
- I’m under TRICARE Prime. What if I don’t want to wait months for a referral?
- How does my pharmacy benefit change in retirement?
- My employer offers a Health Savings Account (HSA). Can I participate?
- What happens to a servicemember’s TRICARE coverage during terminal leave?
- What happens to the family members’ TRICARE coverage during terminal leave?
Q. What steps must I complete when transitioning from active duty to retiree?
A. Once you’ve decided which TRICARE program works best for your family and your status has been updated to “retired” in the Defense Enrollment Eligibility Reporting System (DEERS), you’ll need to contact the specific contractor that manages the program in your locale. You can enroll online, via telephone or through U.S. mail. You can pay monthly or quarterly, or pay the full annual amount up front.
Visit TRICARE.mil to sign up for email alerts to be notified when details are released on the process for retirees to pay the TRICARE Select enrollment fee. To avoid a break in TRICARE coverage, you must enroll in a TRICARE plan within 90 days of your retirement date.
Q. What are my TRICARE Prime options?
A. If you live within acceptable distances (typically a 30-minute drive) from a military treatment facility (MTF), you must still check with the contractor to see if that specific MTF is accepting new retirees and families. Each MTF has a limit on the number of retirees and families they can accept.
If denied at one MTF, the contractor will tell you if another MTF in your area is accepting new retirees and families. At the next open season, or “qualifying life event” (QLE), you can ask if the preferred MTF will allow enrollment.
In many metropolitan areas, TRICARE contracts with major medical providers to offer a civilian care Prime option. This option will be more expensive than enrollment at an MTF, as you will incur co-pays for medical services.
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Q. What are some common complaints about TRICARE Prime?
A. The complaint most often heard is the lack of flexibility and the time it can take to be seen by specialists. All care must be coordinated through your primary care manager (PCM). If you need a referral, you must first see your PCM. A referral can take time to process, and even if an MTF specialist is available, you can sometimes wait months before an appointment can be scheduled.
Q. What is the US Family Health Plan (USFHP)?
A. USFHP is an additional TRICARE Prime option available through networks of community-based, not-for-profit health care systems in six areas of the U.S. Visit www.usfhp.com for location details and contact information for the networks, which cover New England, New Jersey, and much of New York; the metro areas and extended suburbs of New York City, Philadelphia, Baltimore, and Washington, D.C.; southwest Louisiana and portions of Southeast Texas; and the Puget Sound area of Washington state.
As with TRICARE Prime, you will be assigned a primary care provider (PCP), instead of a PCM, to provide referrals within the system.
Enrollment in USFHP prohibits access to military hospitals or the TRICARE network other than that plan’s network of providers. Enrollment fees and co-pays are the same as Prime, with no annual deductible.
The most commented-on drawback of this program is that those enrolled in USFHP who live near an MTF pharmacy cannot access the free pharmacy program.
Q. What is a Qualifying Life Event (QLE)?
A. A QLE allows you to make changes to your TRICARE benefits outside of the “open season.” For example, while serving, your family was TRICARE Prime, and after retirement, your family decides to switch to TRICARE Select.
QLEs also include events such as a move, birth of a child, marriage, divorce, and death.
TRICARE’s annual open season runs from the second Monday in November to the second Monday in December. Your retirement also allows you to change TRICARE coverage if desired.
Q. What are my TRICARE Select options?
A. TRICARE Select is the most flexible TRICARE program. The trick is to make sure you find medical care providers that accept TRICARE.
TRICARE Select will begin charging an enrollment fee for military retirees beginning in 2021: $150 for individuals and $300 for families per year. TRICARE Select also has an annual deductible. For individuals, the first $150 in medical charges must be picked up by the retiree. Families have a $300 annual deductible.
Deductibles have always counted against the catastrophic cap. Beginning in 2021, so will enrollment fees. TRICARE Select co-pays are higher than TRICARE Prime co-pays.
Q. How do I find a physician who accepts TRICARE?
A. TRICARE’s FindDoctor page and each contractor (Humana Military, Health Net, International SOS) provide search engines to locate medical providers in your area.
Q. Can spouses sign up for different programs?
A. Yes. For example, the retiree may prefer to be seen at an MTF and therefore enroll in TRICARE Prime. The spouse may prefer greater flexibility and choose to enroll in TRICARE Select. Each spouse will be charged at the individual rate versus the family rate.
Q. What is the catastrophic cap, and does it change in retirement?
A. The catastrophic cap (CC) is the most you will pay out of pocket for covered services each year before TRICARE picks up all additional covered costs. The CC increases from $1,000 to $3,000 in retirement. The CC for retirees on Select increases to $3,500 in 2021 and will increase by COLA each year thereafter.
The CC is reset every calendar year, and the amount amassed on active duty during a retirement year rolls into the retirement CC. TRICARE Prime enrollment fees do count against the CC.
Q. What are Group A and Group B designations?
A. Group designations determine which fee structure for enrollment, deductible, co-pay, and catastrophic cap each beneficiary must pay. All servicemembers and their families who entered service prior to Jan. 1, 2018, fall under Group A. Those entering on or after Jan. 1, 2018, are in Group B.
Use TRICARE’s Compare Cost Tool to see the costs of Group A vs. Group B, as well as Prime vs. Select enrollment, deductible, co-pay, and the catastrophic cap costs/limits.
Q. I’m going to live overseas. Am I covered?
A. Yes. TRICARE Select Overseas (TSO) is available for retirees and their dependents living overseas. There is a TRICARE Prime Overseas, but that is restricted to active duty and their families. For 2020, TSO has the same annual enrollment fees as TRICARE Prime. The deductibles of TRICARE Select and the enrollment fees do not count against the catastrophic cap.
Beginning in 2021, the TSO enrollment fee will be the same as TRICARE Select ($150 individual/$300 family) and the enrollment fees will count against the 2021 $3,500 catastrophic cap.
To find a provider, you can use the medical provider search engine at www.internationalsos.com. MOAA also recommends that you check with the embassy or consulate for where American military expats get medical care.
Q. When do my children “age out” of TRICARE?
A. TRICARE eligibility for dependent children ends on their 21st birthday — or their 23rd birthday if they are still enrolled in school.
Q. After “aging out” of TRICARE, are there any other options if my children don’t have an employer-provided health care program?
A. Yes. TRICARE Young Adult (TYA) Prime or Select is available for military children who have aged out of TRICARE. They remain eligible for TYA until their 26th birthday and if they remain unmarried.
TYA Prime works the same as TRICARE Prime: You must reside in a Prime service area or a MTF must have room for enrollment. TYA Prime premiums are $376 per month for 2020, increasing to $459 per month in 2021.
TYA Select premiums are $228 per month for 2020 and increase to $257 in 2021. TYA Prime and Select catastrophic cap, deductibles (Select only), and co-pays follow the Group B cost schedules.
When a young adult ages out of TYA, he or she is eligible to purchase the TRICARE Continued Health Care Benefit Program for up to 36 months.
Q. I’m under TRICARE Prime. What if I don’t want to wait months for a referral?
A. Under TRICARE Prime, you will incur point-of-service charges for any specialty care you receive without a referral. You should do your best to find a specialist who accepts TRICARE to reduce costs. You will incur a deductible ($300 individual/$600 family) that will not apply to your catastrophic cap. After the deductible is reached, you can expect co-pays that are typically 50% of the allowable TRICARE fee.
Q. How does my pharmacy benefit change in retirement?
A. For the retiring servicemember, the change is that you’ll now have a co-pay when filling prescriptions via commercial pharmacies or home delivery through Express Scripts.
Dependents’ coverage does not change; they have co-pays for commercial pharmacy and Express Scripts and free prescriptions through the MTF system.
Q. My employer offers a Health Savings Account (HSA). Can I participate?
A. To be eligible for an HSA, you must be covered under a high deductible health plan and have no other health coverage (except what is permitted under “other health coverage,” or OHC, as defined by the IRS). TRICARE does not qualify as OHC.
Therefore, a retiree enrolled in any TRICARE program cannot participate in an employer’s HSA program. Disenrollment from TRICARE would allow the retiree to participate in the employer’s HSA.
Q. What happens to a servicemember’s TRICARE coverage during terminal leave?
A. A retiring servicemember remains enrolled in TRICARE Prime at their last duty station until the date of retirement.
They can get medical care from any military hospital or clinic, but there are limitations and/or pre-authorizations required for non-urgent care. They can also get care at VA medical facilities with a referral/pre-authorization.
If retiring servicemembers believe they may need routine medical care during terminal leave, or if they are planning to leave the area of their last duty station during terminal leave, they should consult with the TRICARE referral office at their MTF or the Defense Health Agency – Great Lakes at (888) 647-6676.
Please note: Your medical providers will likely not understand the requirements for getting care during terminal leave.
Q. What happens to the family members’ TRICARE coverage during terminal leave?
A. A family remains covered by their TRICARE plan until the date of retirement. If they are enrolled to an MTF, they will stay enrolled with their current providers until the retirement date — unless there is another reason for a PCM change, such as a provider PCS.
If the family relocates during terminal leave, this is considered a qualifying life event. The family can switch TRICARE plans or remain with their current plan and enroll with a TRICARE Prime PCM at their new location if necessary.
They do not need to update to retiree TRICARE coverage until the retirement date.