FALLS CHURCH, Va. –
Have you ever received a medical bill that was higher or lower than you expected it to be? If so, you aren’t alone. Health care cost language can often be confusing, and it may not always be clear how much you need to pay for a particular heath service. The good news is that familiarizing yourself with cost terms
and how your TRICARE plan works
, can help you get the most out of your coverage and avoid surprises.
“Knowing which beneficiary group
you fall into is a good place to start,” said Mark Ellis, chief of the Policy and Programs Section of the TRICARE Health Plan at the Defense Health Agency. “Whether you’re in Group A or Group B is part of what determines your enrollment fees or premiums and any other per service out-of-pocket expenses you may have with your TRICARE plan.”
Here are some other common TRICARE cost terms to look out for the next time you need to see your doctor or pay your bill.
Are you a retiree or retiree family member who isn’t eligible for Medicare? If so, you may be required to pay an enrollment fee
—an annual amount—for your TRICARE coverage. This applies to TRICARE Prime
(including US Family Health Plan
) and TRICARE Select
. Active duty service members (ADSMS) and their family members have no enrollment fees.
Depending on your health plan, you may have a monthly or quarterly premium. This is the amount you pay to maintain your TRICARE coverage. Premiums apply to premium-based plans
, such as:
This is the maximum amount TRICARE will pay a doctor or other provider for a procedure, service, or equipment. This applies to all TRICARE plans. According to the TRICARE Choices in the United States Handbook
, “Nonparticipating non-network providers may charge up to 15% above the TRICARE-allowable amount.” Keep in mind, this doesn’t apply to your catastrophic cap, which we’ll touch on below.
The catastrophic cap
is the most you pay out of pocket each year for TRICARE covered services
. This includes costs, like enrollment fees, deductibles, copayments, and other cost-shares based on the TRICARE-allowable charge. Remember that not at all costs apply to the catastrophic cap. These exceptions include:
is the amount you pay before cost-sharing actually begins. It applies to these plans:
Remember, if you’re enrolled in a TRICARE Prime
plan, you have to meet your annual deductible when using the point-of-service option
. This option allows non-ADSMs to see a TRICARE-authorized provider other than their primary care manager for any nonemergency services without a referral.
is the percentage of the total cost of a covered health care service that you pay after your annual deductible is met (if a deductible applies to your plan). Sometimes you may have more than one cost-share, depending on the type of care you receive. An example of this would be if you see different doctors on the same day. Cost-shares aren’t applicable to ADSMs.
This is often mistaken for cost-share and vice-versa, but these two terms are different. The difference is that a copayment
is a fixed dollar amount (for example, $30) that you pay for a covered service or prescription, whereas a cost-share is the percentage of the total cost (for example, 25%). Copayments also depend on your TRICARE plan, beneficiary category, group, the type of service you receive, and whether the service is provided by a network provider.
Keep in mind, ADSMs don’t have any out-of-pocket costs. If you’re an active duty family member enrolled in a TRICARE Prime plan, you won’t have copayments unless you’re using the point-of-service option
or filling a prescription outside of a military pharmacy
Looking for more on this topic? Visit the TRICARE Cost Terms
page for definitions. The TRICARE Costs and Fees Sheet
and TRICARE Compare Cost Tool
are also helpful if you need to see specific dollar amounts. And, of course, your TRICARE contractor
is available if you have questions. By understanding cost terms, you can make informed health care decisions for you and your family.