When military spouse Joelle Rabow Maletis searched for healthcare providers that would accept Tricare near her home in Mountain View, California, she didn’t find many options.
The nearest active-duty installation with medical services was nearly two hours away, and it was difficult to find some specialty services any closer.
“Even if you can get pre-authorization for care, there may not be anybody in the network,” Rabow Maletis said. “That’s certainly the case in the Bay Area.”
As a result, Rabow Maletis, a marriage and family therapist, decided to enroll in health insurance through her own employer, rather than use military health coverage. But that is not an option for service members, however, who are required to be on the military’s health insurance, or for most members of military families, who tend to rely solely on the service member’s income.
Navigating Tricare plans
Tricare is the healthcare program for active-duty troops and members of the National Guard and Reserve, as well as family members, survivors and military retirees. The program brings military hospitals and clinics together with a network of civilian healthcare professionals.
Tricare offers various plans with different eligibility criteria. Tricare Select, advertised as the most flexible, is a self-managed option available to most active-duty family members, as well as military retirees and their families.
Tricare Prime, the only option available for active-duty service members, operates like a health maintenance organization (HMO) and typically requires the use of military hospitals and clinics. The plan has lower out-of-pocket costs but is available only in “prime service areas,” where military hospitals and clinics are nearby.
With Tricare Prime, costs can rise a lot if an enrollee goes outside of the Tricare network without authorization.
If a medical service isn’t available through a military hospital or clinic, the cheapest option for Tricare Prime enrollees is to find an in-network civilian provider. Those providers collect payments directly from Tricare without enrollees needing to file claims.
Tricare is seamless if it’s used at military hospitals and clinics but becomes tricky if you’re seeking care outside of those facilities, said Jeffrey Quinlan, M.D., a Navy veteran and chairman of the Department of Family Medicine at the University of Iowa.
When going outside of the network, out-of-pocket costs depend heavily on the geographical location of Tricare users and the contracts that the military has negotiated with Tricare operators in those locations, Quinlan said.
“Sometimes there are a limited number of providers in a given area that might take Tricare,” Quinlan said. “[Tricare users] can see somebody who doesn’t take Tricare, but then their out-of-pocket costs are going to be higher. So, there are options, but they’re less financially appealing.”
When Tricare users go to healthcare providers who are out of the network, they’ll likely be forced to pay the full costs to providers and file claims with Tricare for partially reimbursed later. Providers have the legal right to charge 15% more than what Tricare allows, and that additional payment isn’t reimbursed, according to Tricare rules.
Seeking healthcare outside of military hospitals and clinics is expected to become more of an issue for service members — particularly women — in the next few years.
The Department of Defense (DOD) proposed a plan in 2019 to reduce the number of uniformed medical providers by 17,000 over time. Maureen Farrell, M.D., a Navy veteran and OB-GYN at Naval Medical Center San Diego (NMCSD), said that the Navy is focusing those cuts on obstetrics and pediatrics.
Debate on the proposal is ongoing in Congress.
“There’s this move to minimize the number of active-duty members you have as healthcare providers for less operationally relevant roles,” Farrell said. “Specifically, obstetrics and pediatrics are targeted by the Navy … I think it’s a real misstep.”
Resources for off-base care
Farrell has a 25-year history with the military health system as both a physician and a Tricare enrollee.
During her years of treating troops, she talked with many servicewomen who had no experience with navigating health coverage or advocating for themselves in a medical setting.
“A lot of our younger enlisted members are moving to a strange place and have never considered health insurance,” Farrell said. “They were either just covered with their parents, or in some cases, they didn’t have health insurance.”
For servicewomen looking for an advocate, Farrell suggested Accolade, a resource that helps Tricare Select enrollees understand their benefits and access care.
When service members sign up with Accolade, they’re assigned to a nurse manager who will communicate with them over phone, text and email to discuss any medical needs.
Farrell used the service after going to a nonmilitary provider to have her children’s wisdom teeth removed and struggling to get Tricare to accept the paperwork for reimbursement.
“A $1,500 dental bill hanging over your head could be a real source of stress,” Farrell said. “I was willing to ride it out because I knew it was covered, but for someone who may be less familiar, that could be really scary and anxiety-provoking.”
Farrell and Quinlan suggested the Tricare websites as starting points for servicewomen seeking to better understand their Tricare network. There are two sites: one for the eastern half of the United States and one for the west.
Rabow Maletis suggested using Military OneSource, a program funded by the DOD to help service members and their families figure out benefits.
Consultants with Military OneSource are available 24/7 to answer questions about Tricare as well as other issues, such as taxes, education and spouse unemployment.
“A lot of people are looking at Military OneSource to get care if they’re having a hard time navigating Tricare,” Rabow Maletis said. “I’ve been impressed with how quickly they help clients.”