1. I got a letter that says I can t be Prime because of where I live. It says my Prime Service Area is going away. Why is this happening?

Transcription

1 1. I gt a letter that says I can t be Prime because f where I live. It says my Prime Service Area is ging away. Why is this happening? Under the new TRICARE reginal cntracts that began in 2007, the gvernment nly required Prime Service Areas arund military treatment facilities and in areas where installatins clsed due t base realignment and clsure. The gvernment didn t require the cntractr t keep ther existing Prime Service Areas since it increases the csts f administering the TRICARE benefit. Thugh the Prime ptin may n lnger be available where yu live, yu can get care under TRICARE Standard r TRICARE Extra. 2. Since my Prime Service Area is ging away, can yu tell me the difference between TRICARE Prime and TRICARE Standard? TRICARE Prime is a managed care ptin. Prime enrllees get rutine and urgent care frm a primary care manager (chsen r assigned). Enrllees must have referrals and authrizatins in place befre getting specialty care. TRICARE Prime is mstly centered arund military/unifrmed service clinics and hspitals and base realignment and clsure sites. Prime has always been limited t certain lcatins. Prime enrllees, ther than active duty and active duty family members, must pay an annual enrllment fee. Prime enrllees pay cpayments and ccasinal cst shares fr inpatient and utpatient services. When Prime enrllees seek specialty care withut a prper referral and authrizatin, they pay a deductible* and a 50% cst share under the Pint f Service ptin. TRICARE Standard is a fee-fr-service, pen chice ptin that's available wrldwide. Beneficiaries may get services frm any TRICARE-authrized r verseas certified hst natin prvider and nly a few select services require prir authrizatin. Standard beneficiaries pay n enrllment fees. Standard beneficiaries pay a yearly deductible* and cst shares fr inpatient and utpatient services. When a Standard beneficiary uses a cntracted, netwrk prvider, the cst share is reduced by 5% under TRICARE Extra. Fr cst infrmatin, visit The TRICARE Pharmacy benefit is the same under Prime and Standard. *Deductible the amunt yu pay ut f pcket befre TRICARE starts sharing the csts. Fiscal year (1 Octber thrugh 30 September) deductibles depend n the rank f the spnsr: E1-E4 $50 Individual $150 Family E5 and Abve $150 Individual $300 Family 3. My Prime Service Area is ging away. Des TRICARE Standard cst me mre r less than Prime? It depends n hw ften yu get health care services and the type f care yu receive. Under TRICARE Standard, yu dn t pay until yu actually get health care and like TRICARE Prime, there are n ut-f-pcket csts fr mst preventive care (mammgrams, prstate exams, vaccinatins, etc.).

2 Yu have t pay an annual fiscal year (1 Octber thrugh 30 September) deductible and cst shares fr cvered services. Yur catastrphic cap* is the same under bth Prime and Standard: $1,000 fr active duty family members $3,000 fr all ther TRICARE eligible beneficiaries. (TRICARE cvers active duty csts fr TRICARE-cvered services.) *Catastrphic cap the mst yu pay ut f pcket fr cvered services in a fiscal year (1 Octber thrugh 30 September). 4. I paid my annual TRICARE Prime enrllment fee thrugh September 30, D I get anything back if I disenrll befre Octber 1, 2013 when my Prime Service Area ges away? N. Enrllment fees aren t refundable. 5. I made an extra quarterly payment when I paid my Prime enrllment fee. The cntractr says I have Prime thrugh December, 30, D I get anything back when my Prime Service Area ges away n September 30, 2013? Yu nly get back the amunt that cvers yur Prime enrllment past Octber 1, Since yur extra payment cvers yu thrugh December 30, 2013, yu will nly get back that extra quarterly payment (Octber 1 thrugh 30 December 2013). 6. I m an active duty service member. My family and I are enrlled in Prime. I was tld my Prime Service Area is ging away. I thught I had t be TRICARE Prime n matter what. What happens nw? Yu and yur family remain cvered under a Prime ptin. Since yu live greater than 50 miles frm a military treatment facility, yu cntinue under TRICARE Prime Remte. Yur family is grandfathered in Prime. Yu r yur family lse Prime-ptin cverage in yur current lcatin if yu mve (permanent changes f statin (PCS) fr yu r utside the current PSA ZIP cdes fr yur family), yu retire, r yu r yur family members lse TRICARE eligibility. Remember, under Prime, if yu r yur family gets specialty services withut a referral and authrizatin, yu're respnsible fr all csts and yur family pays pint f service csts. 7. I live in a Prime Service Area that is ging away. My daughter is paying fr TRICARE Yung Adult Prime, but in a different lcatin that isn t ging away. Can she still be Prime even if I can t? Yes, as lng as she lives in a Prime Service area, she can still buy TRICARE Yung Adult-Prime cverage. 8. Are the Prime Service Areas ging away because f the cntract change frm TriWest t United Healthcare? N, this change isn't due t change in the West regin cntractr. 9. What are my health care ptins when my Prime Service Area ges away? If yu're:

3 1. An active duty service member: Yur benefits dn t change. TRICARE will autmatically transfer yu t TRICARE Prime Remte, if eligible, r grandfather yu in Prime until yu mve ut f the area, yu retire, r yu lse TRICARE eligibility. 2. An active duty family member: Yur benefits dn t change. If yu dn t live with yur spnsr r quality fr TRICARE Prime Remte fr Active Duty Family Members, yu're grandfathered and remain TRICARE Prime until yu mve ut f the area, yur spnsr retires r yu lse TRICARE eligibility. 3. If yu're ther than an active duty service member r active duty family member, yur basic ptins are: Use TRICARE Standard, the basic TRICARE benefit under the law. Depending n hw clse yu're t a military treatment facility r civilian netwrk prvider, yu may be able t enrll in a different Prime Service Area if yu waive the 30-minute drive time (military treatment facility r civilian netwrk prvider access based n enrllment guidelines and if accepting new enrllees). Nte: By signing n yur enrllment frm that yu agree t the waive the drive time, yu're agreeing t drive mre than 30 minutes fr rutine and urgent care and ne hur fr specialty care and fllw Prime referral and authrizatin requirements. Purchase emplyer-spnsred r ther type f cmmercial health care cverage (based n yur r a family member s emplyment). TRICARE Standard serves as secnd payer t ther health insurance and wuld likely cver a lt f yur ut-fpcket csts. Yu need t find ut if the ther plan has a specific windw fr when yu have t enrll. 10. I have Medicare (Parts A&B) and was enrlled in TRICARE Prime. Nw that my Prime Service Area is ging way, what d I d abut health care? If yu're an active duty family member, yu'll remain enrlled in Prime until yu mve, yur spnsr retires, r yu lse TRICARE eligibility. If yu re ther than an active duty family member, when yu get disenrlled n September 30, 2013, yu re cvered under TRICARE fr Life. If yu are under age 65, yu can enrll in a different Prime Service Area if yu agree t waive the drive time fr rutine and specialty care; t avid a break in cverage yu wuld need t request re-enrllment befre September 20th. Under TRICARE fr Life, Medicare is yur primary health plan yu have t fllw their rules and use Medicare-certified prviders. TRICARE becmes secnd payer and cvers a lt f yur ut-fpcket csts. T learn mre abut TRICARE Fr Life click here r call the TRICARE fr Life cntractr at Fr mre abut Medicare visit Hw are Prime Service Areas determined?

4 Prime Service Areas are defined by ZIP cdes that fall within r intersect a 40-mile radius frm a military treatment facility r base realignment and clsure lcatin. 12. Will I have a break in my TRICARE cverage when my Prime Service Area ges away? N, there's n break in health care cverage if yu are ging frm TRICARE Prime t TRICARE Standard. If yu are TRICARE Yung Adult - Prime and yur spnsr is: Active duty: Yu will be grandfathered under TRICARE Yung Adult-Prime as lng as yu live in the same Prime Service Area and yur spnsr remains n active duty. Other than active duty: Yu will be disenrlled frm TRICARE Yung Adult Prime effective Octber 1, If yu want t keep TRICARE cverage under TRICARE Yung Adult Standard - yu have t submit a new applicatin by September (fr an Octber 1 start date) t avid a break in TRICARE cverage. 13. D I need t d anything when my Prime Service Area ges away and I'm cvered under TRICARE Standard? The nly thing yu may need t d is find ut if the prviders yu were seeing under Prime will still see yu under TRICARE Standard. If they can t, yu may want t learn mre abut lcal prviders and find ut wh can best meet yur health care needs. 14. D I need t d anything when I lse TRICARE Yung Adult-Prime due t my Prime Service Area ging away? Yu must set up a new electrnic premium payment t buy TRICARE Yung Adult-Standard. T avid a break in cverage, yu have t send in a new TRICARE Yung Adult applicatin and set up a new premium payment within 30 days f the end f yur TRICARE Yung Adult-Prime perid (n later than September, 2013). If yu dn t want TRICARE Yung Adult-Standard, yu shuld cntact the reginal cntractr t disenrll frm TRICARE Yung Adult-Prime. 15. I ve paid mnthly TRICARE Yung Adult-Prime premium. D I get anything back if I dn't want t cntinue TRICARE Yung Adult-Prime since my Prime Service Area is ging away? Yes, yu get back the prtin f yur premium fr the days yu paid past yur end/terminatin date (e.g., if yu paid fr ne mnth and disenrll n day 10, yu get back the amunt that wuld cver the remaining 20/21 days). Yu have t cntact yur reginal cntractr and let them knw what date yu want yur cverage t end. 16. If I want t make the drive, can I waive the 30-minute drive time and enrll in Prime in anther Prime Service Area? Yu can. Yu have t cmplete a new enrllment/tya-prime applicatin. Nte n yur enrllment frm yu're willing t drive further and fllw Prime rules fr specialty care; yu may nt qualify fr Prime based n yur lcatin and the lcatin and availability f military r civilian primary care managers in the ther Prime Service Area. Yu shuld submit a new enrllment frm t the reginal cntractr befre the 20th f September fr a 1 Octber start date. Enrllment frms are fund at:

5 17. Where can I get a list f TRICARE Standard prviders since my Prime Service Area is ging away? TRICARE desn t maintain a list f TRICARE-authrized, nn-netwrk prviders wh see TRICARE Standard beneficiaries. The reginal cntractr may knw which prviders in a lcal area filed claims with TRICARE. Remember, if yu're able t get care frm a netwrk prvider, yu're using the Extra benefit and get a 5% discunt in yur cst share. Yu need t call lcal prvider ffices t find ut if they can see yu under TRICARE Standard. Yur lcal hspital may als be able t help yu find TRICARE-authrized prviders. Fr general help in finding a dctr/prvider, visit: Find a Dctr Nte: Medicare certified prviders are cnsidered t be TRICARE authrized. 18. I m a retiree and was tld I can t stay in Prime after Octber 1, 2013 even if I waive the drive time and want t enrll t a different Prime Service Area. Why is that? It culd be because yu live mre than 100 miles frm any civilian primary care manager in that ther Prime Service Area netwrk. If this is the case, yu can t cntinue Prime enrllment and yur enrllment ends n September 30, If yu dn t think this applies t yu, cntact yur reginal cntractr. 19. I transferred my Prime enrllment t a different Prime Service Area and agreed t waive the drive times. What happens t me Octber 1, 2012 when the Prime Service area where I live ges away? Yu shuld be able t remain with yur new primary care manager after Octber 1, 2013 as lng as yu stay enrlled t a primary care manager in a Prime Service Area, yur primary care manager is within 100 miles f where yu live, and yu submitted an enrllment frm that shws yu agree t waive the drive times fr primary and specialty care.