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TRICARE Standard and Extra (Out-of-pocket) Costs


TRICARE is the health insurance program for the DoD providing health care benefits for a variety of civilian military personnel including active duty families, retirees, their families and members of the Reserves. TRICARE is managed under the direction of the DoD under an office called the TRICARE Management Activity (TMA).

TRICARE Standard and Extra is a fee-for-service plan that can be used by all non-active duty personnel. There is no need to enroll as long as you are current in the Defense Enrollment Eligibility Reporting System. You can visit any TRICARE authorized provider and can receive care from military facilities if they can accommodate you.

Like most civilian health insurance, TRICARE includes “Out-of-pocket costs” that must be paid by the policyholder for treatment. After out-of-pocket expenses are paid, TRICARE pays the rest.

TRICARE is divided into three different levels, TRICARE Standard, TRICARE Extra and TRICARE Prime. TRICARE Standard allows the policyholder to choose any civilian health care provider that meets TRICARE regulations. TRICARE Extra allows you to choose your health care from a Provider Network like a PPO. TRICARE Prime is basically a military HMO.

Out-of-pocket costs vary on whether you are using the Standard or the Extra option. Extra requires you to use doctors within the Provider Network so your out-of-pocket costs are lower than using TRICARE Standard, which allows you to see any authorized medical provider.

Out-of-pocket costs are also determined by whether you are an active duty family member versus anyone else eligible for TRICARE. Active duty family members (ADFM) pay much less.

TRICARE will only pay 15% above their standard rate for non-participating providers. The rest will be your responsibility and is excluded from out-of-pocket expenses. MAKE SURE you understand all the costs before using a non-participating provider.

TRICARE Out-of-pocket costs include:

  • Annual deductible + cost-share percentage of care and additional charges

TRICARE Extra comparison of Out-of-pocket costs (Taken from TRICARE 2010/2011, can change yearly).

ADFM E-4 and below:

  • $50, individual, $100 family deductible.
  • Most services: 15% cost-share for Extra, 20% cost-share for Standard after annual deductible is met.
  • $16.30 per day ($25.00 minimum) for Hospitalization.
  • Inpatient Behavioral Health, $20 per day ($25 minimum) for both Extra and Standard.
  • Inpatient Skilled Nursing: $16.30 per day ($25 minimum).

ADFM E-5 and above:

  • $150, individual, $300 family deductible.
  • Most services: 15% cost-share for Extra, 20% cost-share for Standard after annual deductible is met.
  • $16.30 per day ($25.00 minimum) for Hospitalization.
  • Inpatient Behavioral Health, $20 per day ($25 minimum) for both Extra and Standard.
  • Inpatient Skilled Nursing: $16.30 per day ($25 minimum).

Family members of National Guard and Reserve activated in support of Contingency Operation (OEF, OIF, Noble Eagle)

  • $0 deductible.
  • Most services: 15% cost-share for Extra, 20% cost-share for Standard after annual deductible is met.
  • $16.30 per day ($25.00 minimum) for Hospitalization.
  • Inpatient Behavioral Health, $20 per day ($25 minimum) for both Extra and Standard.
  • Inpatient Skilled Nursing: $16.30 per day ($25 minimum).

Retirees and everyone else:

  • $150 individual, $300 Family deductible.
  • Most services: 20% cost-share for Extra, 25% cost-share for Standard after annual deductible is met.
  • Hospitalization using Extra: $250 per day or 25% of the billed charges for institutional services, whichever is less, PLUS 20% cost-share for separately billed services.
  • Hospitalization using Standard: $535 per day or 25% of the billed charges for institutional services, whichever is less, PLUS 25% cost-share for separately billed services.
  • Inpatient Behavioral Health using Extra: 20% of the total charge, PLUS 20% cost-share for separately billed services
  • Inpatient Behavioral Health using Standard: High-volume Hospital: 25% of the hospital-specific per diem. Low-volume hospital: $197 per day or 25% of the billed charges, whichever is less.
  • Inpatient Skilled Nursing using Extra: $250 per day or 20% of billed charges for institutional services, whichever is less, PLUS 20% cost-share for separately billed services. Using Standard: 25% of allowed charges for institutional services, plus 25% cost-share for separately billed services.

This chart is included to give you a general idea of what your out-of-pocket costs might be. You should talk to TRICARE directly for specifics related to your situation.

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