Submit all claims separately; do not bundle multiple claims. Processors manage claims separately, if you send multiple claims in together, a problem with one claim will delay payment on all claims. Choosing the right TRICARE coverage plan for your family is difficult. Each of the three TRICARE options are designed to fit the needs of the individual beneficiary. Understanding the following factors will assist you in determining if TRICARE Standard is your best choice.
Why TRICARE Standard?
TRICARE Standard Features
The Cost – Copays and Deductibles
Getting Help and Hints
TRICARE Standard is the TRICARE option that provides the most flexibility to TRICARE-eligible beneficiaries. It is the fee-for-service option that gives beneficiaries the opportunities to see any TRICARE-authorized provider. TRICARE Standard is not available to active duty service members. Standard shares most of the costs of medically necessary care from civilian providers when military treatment facility (MTF) care is unavailable.
Reasons for Choosing TRICARE Standard:
Beneficiaries who are happy with the treatment they currently receive from a specific civilian provider that may not be in the TRICARE provider network often choose to use TRICARE Standard. Some beneficiaries, especially retirees under age 65 and their families, may live in areas where the TRICARE Prime network is not available, and TRICARE Standard may be their only option. Additionally, retired service members may have employer-sponsored health insurance. TRICARE Standard may be used as secondary coverage for these beneficiaries.
Standard’s Pros – Advantages
Broadest choice of providers
No enrollment fee
You may also use TRICARE Extra
Standard’s Cons – Disadvantages
No Primary Care Manager
Patient pays Deductible and Co-payment
Patient pays balance if bill exceeds allowable charge and provider is non-participating (up to 15% additional)
Beneficiaries may have to do their own paperwork and file their own claims
Important Note: The Point of Service annual deductible and cost-share amounts do not count toward your enrollment-year maximum out-ofpocket expense, but instead are credited to your fiscal year maximum. There is no limit to the amount of a patient’s responsibility under the POS option.
TRICARE Standard Features:
TRICARE Standard offers greater provider choice. Beneficiaries may choose any TRICARE-authorized provider. TRICARE-authorized providers are not required to participate in the TRICARE network; however, they must be certified as an authorized provider by the managed care support contractor (MCSC) in that region. Beneficiaries should contact their regional MCSC to find a TRICARE authorized provider.
TRICARE Standard allows beneficiaries to self-refer for specialty care. Beneficiaries who choose TRICARE Standard are not assigned a primary care manager, so, in most cases, they are able to see specialists without prior authorization. There are some outpatient procedures that require prior authorization. Beneficiaries should contact their regional contractor for authorization assistance before seeking care.
For inpatient mental health care, pre-authorization and continued stay authorization requirements apply to Residential Treatment Center care, partial hospitalization program care, and alcoholism detoxification and rehabilitation. All beneficiaries should contact TRICARE regional contractors regarding potential limits on length-of-stay at these facilities. TRICARE Standard beneficiaries living in an MTF catchment area must obtain a non-availability statement from their local MTF before being admitted as an inpatient for mental health services.
Costs for TRICARE Standard:
Beneficiaries are responsible for cost shares and deductibles for care that is covered under TRICARE Standard. Providers who participate in TRICARE will accept the TRICARE allowable charge (TAC) as the full fee for services they render. However, non-participating providers may charge up to 15 percent above the TAC for their services, and TRICARE Standard beneficiaries are financially responsible for these additional charges.
A “catastrophic cap” is the annual upper limit a family will have to pay for TRICARE Standard-covered services in any fiscal year. The catastrophic cap for families of active duty service members is $1,000. All others have a catastrophic cap of $3,000. The catastrophic cap applies only to allowable charges for covered services. The catastrophic cap does not apply to services that are not covered, or to the total amount of what nonparticipating providers may charge above the TAC.
Getting Help With TRICARE:
TRICARE Standard has specific rules, and beneficiaries choosing to use TRICARE Standard may need to contact the regional contractor call centers toll free number or a beneficiary counseling and assistance coordinator (BCAC) in their area for assistance. Customer service staff can answer specific questions about health care benefits, billing or claims as well as provide help navigating through the Military Health System. TRICARE Beneficiaries may locate a BCAC online.
Helpful Hints on TRICARE Standard:
Sponsors should ensure their family members have up-to-date uniformed services identification cards, and that they are properly enrolled in the Defense Enrollment Eligibility Reporting System (DEERS).* Note: This form can be found in the Important Forms Section
Beneficiaries may be required to file their own claims when using TRICARE Standard. Beneficiaries may find more information about filing claims and download claims forms on the TRICARE Web site.
Although TRICARE Standard beneficiaries have a lower priority for access to care in MTFs than TRICARE Prime enrollees, Standard beneficiaries may attempt to receive their care from an MTF. This will save them money and paperwork.
Beneficiaries will save money by seeking care from a TRICARE network provider. For more information see TRICARE Extra.
TRICARE suggests conducting business online whenever possible, calling during non-peak hours, and visiting TRICARE service centers for face-to-face assistance as ways to beat phone congestion.