Understanding TRICARE medical benefits is a difficult task at best. 

Surveys document that most service members and their families are confused by TRICARE. 

"I was active duty for eight years," commented Rebecca Zimmerman, "and I never understood what it was all about."

What follows is a general primer designed to help active duty soldiers, retirees and their dependents understand the medical benefits of TRICARE. 

The first fact to remember is TRICARE is an enormous and complex health care system.  That said, it is also an understandable system.

Simply put, it is a managed health care program for active duty, activated guard and reserves, retired members of the uniformed services, and their families and survivors.  TRICARE brings together the health care resources of the Department of Defense and supplements them with networks of civilian health care professionals in order to provide access and quality service.

So far, so good?

Now, this managed health care program provides three options for beneficiaries aged 0 to 64 - TRICARE Prime, TRICARE Extra and TRICARE Standard.  Two additional offerings for those 65 and older may be available through your local military hospital - TRICARE for Life and TRICARE Plus.

TRICARE Prime

All active duty service members are automatically enrolled in this plan and receive their primary care at a Military Treatment Facility, or MTF.  Family members can choose to be enrolled in TRICARE Prime also; however, they may choose Standard or Extra.

The plan is free for families of active duty soldiers.  TRICARE-contracted civilian medical providers, otherwise known as network providers, augment care within the MTFs.

Retirees and their family members aged 0 to 64 pay an annual enrollment fee of $465.

Advantages: No enrollment fee for active duty soldiers and their family members; small fee per visit to civilian providers; no balance billing; guaranteed appointments (based on access standards); and away-from-home emergency coverage.

Disadvantages: There is an enrollment fee for retirees and their families (shop around); specialty care is by referral only.

TRICARE Extra

TRICARE Extra is not available to active duty soldiers or overseas.

Like TRICARE Standard, users don't have to enroll or pay an annual fee but must satisfy an annual deductible for outpatient care.  In this program, users receive care from a TRICARE Extra network provider.

Advantages: Co-payment is 5 percent less than TRICARE Standard; there is no balance billing, no enrollment fee, no deductible when using the retail pharmacy network, and no forms to file.  Users can also use TRICARE Standard.

Disadvantages: No primary care manger; provider choice is limited; patient pays deductible and co-payment.

TRICARE Standard

TRICARE Standard is not available to active duty service members.  It is a highly flexible, fee-for-service option that gives beneficiaries the chance to see any TRICARE authorized provider. The plan shares most of the costs of medically necessary care from civilian providers when MTF care is unavailable.

Advantages: Broad choice of medical providers; widely available; no enrollment fee, and you can also use TRICARE Extra.

Disadvantages: No primary care manager; patient pays deductible and co-payment; patient pays balance if bill exceeds allowable charge; and beneficiaries may have to do their own paperwork and file their own claims.

TRICARE Plus

This plan is for patients 65 years of age and older, and it exists at the discretion of the commander of the medical facility.  All beneficiaries eligible for care in MTFs can seek enrollment for primary care at MTFs where enrollment capacity exists. 

Note this - where "enrollment capacity exists."

As an accompanying article points out, the Madigan Army Medical Center, or MAMC, is quickly approaching its maximum service capacity of 100,000 according to Lt. Col. Pete Lehning, chief of managed care at the facility.

"We're in the process of shifting some of our TRICARE Plus applicants to medical network providers in order to continue to provide medical care to our soldiers and their families," he said. 

A key point to remember is Madigan officials have been directed to do what it takes for the time being to keep this program alive at the facility.

Advantages: No enrollment fees; the beneficiary's primary care manager is at the MTF, not off post in the civilian provider network.

Disadvantages: This plan is not available at all MTFs; it exists at the commander's discretion; it is a primary care access program, not a health plan, so it has no affect on civilian provider care; it does not guarantee access to specialty care at the MTF where an individual is enrolled.

TRICARE for Life

All Americans who turn 65 are enrolled in Medicare Part A.  TRICARE for Life is for all Medicare beneficiaries who enroll in Medicare Part B.  TRICARE for Life acts as the secondary insurance, covering the gaps that arise in Medicare payouts.

For more information about these programs, how they apply to you, and how to sign up for them, contact MAMC's TRICARE Service Center at (253) 968-3491.