MOAA’s TRICARE Guide: Understanding TRICARE Prime

MOAA’s TRICARE Guide: Understanding TRICARE Prime
A physician assistant examines a patient at Brooke Army Medical Center on Fort Sam Houston, Texas. (Photo by Jason W. Edwards/DoD)

tricare-guide-2023-24-red-shield.pngEditor’s Note: This article is part of MOAA’s 2023-24 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 2023 issue of Military Officer magazine.


TRICARE Prime, a managed care option, is the dominant TRICARE plan among military families. All active duty servicemembers and 82% of active duty family members are enrolled in Prime.


The basics of TRICARE Prime are straightforward — a primary care manager (PCM), or another provider in that clinic, provides most of your care. Specialty care (such as dermatology, cardiology, etc.) requires a referral from your PCM.


Active duty families on Prime typically have zero out-of-pocket cost for medical care if they follow TRICARE referral and authorization rules.


The direct care system of military hospitals and clinics, or military treatment facilities (MTFs), presents a layer of complexity for Prime beneficiaries. MTFs are run and staffed by the Defense Health Agency and Army, Navy, and Air Force medical commands. MTFs have a dual mission to support readiness and provide a benefit.


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Military hospitals and clinics not only provide care to beneficiaries, but they also serve as a readiness platform for military medical personnel. Uniformed providers maintain their clinical currency by delivering care to military patients while also doing additional training related to operational requirements, so they are ready to deploy as needed.


When you live near an MTF, it is important to understand that by enrolling in TRICARE Prime, you are also choosing to use the MTF for your care if it has the capability and capacity to treat you. TRICARE Prime patients will generally be referred out to the TRICARE network only if nearby military hospitals or clinics can’t provide the necessary care.


Access Depends on Location

The size and scope of military hospitals and clinics vary greatly by location, so your experience as a Prime beneficiary can also vary. Some installations have minimal MTF capacity and focus on active duty servicemembers only. At these locations, Prime families get almost all their care in the TRICARE network — 23% of active duty family members have a civilian provider as their TRICARE Prime PCM.


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About 59% of active duty family members are enrolled with a PCM at an MTF. Some of these families will be referred to the TRICARE network for most specialty care. Others, such as families located near a large military medical center like Naval Hospital San Diego or Brooke Army Medical Center in San Antonio — often supported by numerous military clinics in the surrounding area — might get almost all their medical care from MTFs, including specialty and subspecialty care.


Capacity at MTFs can change over time as military medical providers deploy or PCS. Just because an MTF is enrolling families or referring care to the network today does not mean that will always be the case.


Adapting When You Move

Military families naturally develop an understanding of how TRICARE Prime works through their personal experiences and often don’t expect to encounter a different combination of MTF/civilian care at a new duty station.


If you are enrolled in Prime, and particularly if you use specialty care, it’s important to learn about the local military health system when you PCS so you understand where you are likely to get care as a Prime family. Consider attending a newcomer briefing, following your MTF on Facebook, or going in to talk with the patient advocate.


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You have 90 days following a move to switch TRICARE plans if you decide TRICARE Select — the self-managed preferred provider-type option that lets you pick your medical providers — might be a better option for your family.


Options for Retirees

For career servicemembers and their families who have used TRICARE Prime and MTF care for decades, the transition to retirement can present some surprises. Because MTFs have limited capacity and active duty servicemembers and their families have priority for MTF care, only 28% of retirees and their dependents are enrolled with a TRICARE Prime PCM at an MTF.


Most working-age retirees rely on the TRICARE network for care — either assigned to a network PCM on Prime (29%) or enrolled in TRICARE Select (44%). The MHS is designed to integrate military hospitals and clinics and the TRICARE civilian network, so the military community relies on both for access to health care.


As MHS reforms have rolled out, MOAA has successfully advocated for greater analysis, mitigation planning, and congressional oversight to ensure the combination of MTFs and the TRICARE network care has sufficient capacity to provide access to quality care for all beneficiaries.



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About the Author

Karen Ruedisueli
Karen Ruedisueli

Ruedisueli is MOAA’s Director of Government Relations for Health Affairs and also serves as co-chair of The Military Coalition’s (TMC) Health Care Committee. She spent six years with the National Military Family Association, advocating for families of the uniformed services with a focus on health care and military caregivers.