The Department of Defense announced today a new, uniform health benefit option
for military families, retirees and their families which will significantly
reduce the cost of health care to beneficiaries and to the federal government.
Under this new health maintenance organization (HMO) option, TRICARE Prime, all
patients treated in military treatment facilities will continue to receive care
without having to share in the cost of the services provided.
This HMO option
establishes fees and copayments for care provided to beneficiaries in
participating civilian medical facilities which are, on the average,
significantly less than existing fees and copayments.
Family members of uniformed services personnel, and survivors and retired
members and their families will have the choice of three health care delivery
options, including the HMO option, when TRICARE is fully implemented in their
locations.
These new provisions will go into effect as the TRICARE managed
care support contracts are begun in each of the 12 TRICARE Regions across the
country.
The first Region (Region 11, which includes Washington and Oregon)
will offer the HMO option beginning in March 1995.
TRICARE is the DoD regional managed care program that brings together the
health care delivery systems of each of the military services, as well as the
Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), in a
cooperative and supportive effort to better serve military patients and to
better use the resources available to military medicine.
In addition to the
HMO option, TRICARE Prime, there are TRICARE Extra and TRICARE Standard.
TRICARE Prime is the voluntary enrollment option that offers patients the
advantages of managed health care, such as primary care managers, assistance in
making specialty appointments, and someone else to do their claims filing.
The
Prime option offers the scope of coverage available today under CHAMPUS, plus
additional preventive and primary care services.
For Prime enrollees, the new
cost sharing provisions do away with the usual standard CHAMPUS cost sharing.
Of particular note, families of active duty personnel will have no enrollment
fees.
CHAMPUS-eligible retirees who enroll in Prime will pay an enrollment
fee; but will pay only $11 per day for civilian inpatient care in comparison to
the $323 per day plus 25% of professional fees charge faced by those retirees
who use TRICARE Standard.
For Prime enrollees there will be copayments for
care received from civilian providers.
These copayments are significantly less
than the other two options and are detailed on the chart below.
CHAMPUS-eligible beneficiaries may elect to enroll in TRICARE Prime on an
annual basis.
The other two choices for health care delivery under TRICARE
are:
TRICARE Standard - This option is the same as the standard CHAMPUS
program.
TRICARE Extra - In the TRICARE Extra program, when a CHAMPUS-eligible
beneficiary uses a preferred network provider, he/she receives an out-of-pocket
discount and usually does not have to file any claim forms.
CHAMPUS
beneficiaries do not enroll in TRICARE Extra, but may participate in Extra on a
case-by-case basis just by using the network providers.
The uniform HMO benefit fee and copayment schedule follows:
E4 and Below E5 and Above Retirees and
Family Members Family Members Survivors and Their
Family Members
Annual Enrollment Fee $0 $0 $230/$460
Indiv/Family
Copayments for services
outside Military Treatment
Facilities
Outpatient Visits, Including $6 $12 $12
Separate Radiology or Lab
Services and Home Health
Visits
Emergency Room Visits $10 $30 $30
Mental Health Visits, $10 $20 $25
Individual
Mental Health Visits, Group $6 $12 $17
Ambulatory Surgery $25 $25 $25
Prescriptions $5 $5 $9
Ambulance Services $10 $15 $20
Durable medical equipment, 10 percent 15 percent 20 percent
Prostheses, Supplies
Inpatient Per Diem, General $11 $11 $11
Inpatient Per Diem, Mental $20 $20 $40
Health/Substance Use
Estimated Annual Savings per $170 $240 $100
Enrolled Family
