Tricare Help

What happens once my family reaches its Catastrophic Cap?

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How much is Tricare supposed to pay when my family has reached its $3,000 Catastrophic Cap? My friend said it won’t pay anything because that is all the cost shares that I am allowed to pay in a year.

Your friend is mistaken. During each fiscal year, Tricare maintains a running total of all the deductible and cost share amounts your family has had to pay out-of-pocket – or that was paid by your Tricare supplement, if applicable.

As a retiree family, your Catastrophic Cap amount is $3,000 as you have assumed.

When your family members, combined, have paid $3,000 in deductibles and cost shares during a given fiscal year, Tricare will begin to pay 100 percent of the amount it allows on each claim. That is, you will not be charged any more cost shares or deductibles for the remainder of that fiscal year.

The government’s fiscal year runs from October 1 of one year through September 30 of the next year. At midnight on September 30 every year, the amount accumulated in your family’s Catastrophic Cap account is returned to zero and the accumulation of deductibles and cost shares your family pays begins anew.

How do we decide between Tricare Prime and FEHBP?

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My husband is retiring from the military and now is eligible for the Federal Employee Health Benefits Program through his new job. He has minimal health issues, but I have a history of cancer and other problems. Should we enroll in FEHBP or use Tricare Prime? The premiums alone for FEHBP equal or exceed Tricare’s yearly $3,000 catastrophic cap. If we had both, could the FEHBP deductibles, copayments and premiums count toward Tricare’s catastrophic cap?

I cannot tell you exactly what you “ought” to do regarding your health insurance coverage; nobody can make that decision except you and your husband. But I can give you as much information as possible about Tricare to help you make that decision.

Tricare Prime functions as a Health Maintenance Organization (HMO). Tricare Prime providers (called network providers) are under contract with Tricare to provide the services mandated by law and regulation to beneficiaries enrolled in Prime.

They have privately negotiated with Tricare the fees they will charge for each of their services, but that’s between Tricare and the provider only. All the patient must be concerned about is the flat rate of $12 he or she must pay per office visit, or the flat rate of $11 per day for hospital stays.

Prime is not available everywhere. It is usually found within a 40- 50-mile radius of a military treatment facility. Tricare beneficiaries enrolled in Prime have priority access, right after active-duty family members, to free care at the MTF.

As with commercial HMOs, you must seek all care, except bona fide medical emergency care, from providers in your local network.

If you take a trip, clear it first with Tricare Prime, because on the road, “routine” care will not be covered inexpensively. There are considerable penalties ($300 deductible, 50 percent cost share) on claims for unauthorized care by non-network providers.

People have exactly the same problems with commercial HMOs under the FEHBP. Personally, I like HMO care except for the limited choice of providers, and the inconvenience if one travels. They are most like military sick call. The big ones have everything — labs, etc. under one roof, plus centralized record-keeping, central appointments, and the like. Big civilian HMOs may even own their own hospital. And their low cost is a big factor.

Like many things in life, it’s a trade-off. Study assiduously; know before you buy. You can download a free Tricare Prime handbook here.

FEHBP deductibles and cost shares do not count for your Tricare catastrophic cap, however. Only Tricare’s deductibles and cost shares count.

How does my catastrophic cap work?

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Q. I understand that when I reach the catastrophic cap of $3,000, Tricare will pay my medical bills in full for a year. How will I know when I reach that capped amount?

The catastrophic cap doesn’t work quite that way.

Tricare maintains a running total record of all deductible and cost share amounts a family pays during a given fiscal year. That total is reported on each Tricare explanation of benefits for every family member.
When the total reaches $3,000, Tricare will pay 100 percent of the amount it allows on every family member’s claims for the remainder of that fiscal year.

That is, for the remainder of that fiscal year, Tricare will not withhold any deductibles or cost shares from the amount it allows on each family members’ claims. It will pay in full the amount it allows, not the amount of the bill.

But it will apply this rule only to claims received through Sept. 30 of that year.

The fiscal year runs from Oct. 1 through Sept. 30. At midnight on Sept. 30 each year, the amount in the family’s catastrophic cap account reverts to zero, and the amount in the cap account begins to accumulate again with the first claim for services received in the new fiscal year.

When TFL beneficiaries travel overseas

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Q. I understand that Tricare for Life members are covered only by Tricare Standard when traveling outside the U.S. Are any short-term Tricare supplemental policies available to cover the difference between Tricare’s payments and total charges while traveling?

Yours is a question frequently asked. Unfortunately, I know of no such short-term supplemental policy.
I have decried the absence of such policies for years in this column. Their continued absence from the offerings of all insurers must indicate some universal obstacle of which I’m unaware — I doubt the insurance industry would otherwise ignore such a potential money-maker.

Short of buying a “regular” Tricare supplement, your only protection against costs beyond the amount Tricare pays is your $3,000 catastrophic cap.

If you consider buying a regular supplement, read the fine print carefully before you buy to be certain the supplement will meet all your needs outside the U.S.

What happens when I reach my Catastrophic Cap?

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Q. How much is Tricare supposed to pay when my family has reached its $3,000 Catastrophic Cap? Someone said it won’t pay anything because that is all the cost shares that I am allowed to pay in a year.

Your friend is mistaken, but that particular mistake is one I haven’t heard before.

During each fiscal year, Tricare maintains a running total of all the deductible and cost share amounts your family has had to pay out of pocket (or that was paid by your Tricare supplement, if applicable).

As a retiree family, your Catastrophic Cap amount is $3,000, as you have assumed.

When your family members, combined, have paid $3,000 in deductibles and cost shares during a given fiscal year, Tricare will begin to pay 100 percent of the amount it allows on each claim. That is, you will not be charged any more cost shares or deductibles for the remainder of that fiscal year.

The government’s fiscal year runs from Oct. 1 of one year through Sept. 30 of the next year. At midnight on Sept. 30 every year, the amount accumulated in your family’s catastrophic cap account returns to zero and the accumulation of deductibles and cost shares your family pays begins anew.

Get my own coverage, or continue as a dependent?

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Q. I am a 60-year-old Army retiree. I have done nothing regarding Tricare or Medicare because my wife is still on active duty in the Army, which makes me a military dependent with Tricare Prime.

My question is, should I be doing something now? If not, when? Should I wait until my wife retires?

If you are entitled to receive retired pay, you are eligible for Tricare in your own right. But being an active-duty dependent is a better situation than having Tricare under your own Social Security number.

You have a smaller cost share, 20 percent instead of a regular retiree’s 25 percent, and your catastrophic cap is only $1,000, instead of $3,000 as it is for most retirees.  It seems that you are in very good shape for your health care coverage.

When your wife retires, you and she should continue to keep your Tricare eligibility under only one of your SSNs.  That keeps you with only one family catastrophic cap account, which is good.

I don’t think that you need to do anything until you get Medicare when you are 65.  Between now and then, call DEERS at least once a year to make sure your registration is correct and up-to-date, and promptly report to DEERS any change in your status, such as an address change so your record is up-to-date at all times.  The DEERS toll-free number is 1-800-538-9552.