Members of the Army, Navy, Air Force, Marine Corps, Coast Guard, Public Health Service, and National Oceanic and Atmospheric Administration and their families are eligible for TRICARE. Reserve and National Guard personnel become eligible when on active duty for more than thirty consecutive days or on retirement from reserve status at age sixty.
Providers who participate accept the TRICARE allowable charge as payment in full for services. Participating providers are required to file claims on behalf of patients. Participating providers may appeal a decision. Nonparticipating providers may not charge more than 115 percent of the allowable charge and may not appeal a claims decision. The patient pays the provider, and TRICARE pays its portion of the allowable charges directly to the patient.
A nonavailability statement (NAS) is used to certify that a military treatment facility (MTF) cannot provide care for a TRICARE Standard beneficiary.
TRICARE Standard is a fee-for-service plan in which medical expenses are shared between TRICARE and the beneficiary. Most enrollees pay annual deductibles and cost-share percentages. TRICARE Prime is a managed care plan. After enrolling in the plan, each individual is assigned a Primary Care Manager (PCM) who coordinates and manages that patient’s medical care. In addition to most of the benefits offered by TRICARE Standard, TRICARE Prime offers additional preventive care, including routine physical examinations. TRICARE Extra is also a managed care plan, but instead of services being provided primarily from military facilities, civilian facilities and physicians provide the majority of care. Individuals must receive health care services from a network of health care professionals.
Under the TRICARE for Life program, individuals age sixty-five and over who are eligible for both Medicare and TRICARE may continue to receive health care at military treatment facilities.
Individuals eligible for the CHAMPVA program include veterans who are totally and permanently disabled due to service-connected injuries, veterans who were totally and permanently disabled due to service-connected conditions at the time of death, and spouses or unmarried children of a veteran who is 100 percent disabled or who died as a result of a service-related disability in the line of duty. Under the CHAMPVA for Life program, CHAMPVA benefits are extended to individuals age sixty-five and over who are eligible for both Medicare and CHAMPVA.
