This page details information about different costs that can pop up despite being covered by a TRICARE health care plan, such as co-payments. Financial costs are, of course, a common TRICARE Financial Concerns. Find out more about them, and also whether your costs will be reimbursed or not.
The Concept of Co-payment
Co-payments are a shared payment plan. In health care insurance services, co-payments occur where the insured person pays a certain amount of the total overall service charge for example for routine checkups or doctor consultations. Elsewhere, all other medical costs incurred are paid for by the medical coverage insurance. Like any other insurance plan, TRICARE is not an all-encompassing, comprehensive coverage plan. While most if not all medically necessary procedures are paid for by the coverage, some costs remain. These costs have to be borne personally by the beneficiaries. Co-payments are out of pocket costs and are unavoidable even while having an Insurance coverage plan like TRICARE in place.
When using TRICARE Extra and Standard, you will have to give co-payments based on the type of care you seek and also the type of service provider that you go to (network or non-network). Some examples of costs incurred under the TRICARE Extra plan include:
- For ambulances service, you must pay 15% of the negotiated service charges.
- For inpatient mental health charges, a total of $25 needs to be paid daily.
- For inpatient treatment while being admitted into the hospital, a minimum of $25 needs to paid daily.
- Similarly, for neonatal care, $25 is the minimum daily charge.
- Laboratory and X-Ray services charges are 15% of the overall service fees.
TRICARE Prime on the other hand had minimal cost sharing plans, as TRICARE Prime requires beneficiaries to seek care from the network services providers, thus, there are no co-payments that are required to be made, and so all services can be utilized without any charges.
Reimbursement is the monetary act of compensating someone for an expense. Under a health care insurance policy, claims are filed for any out of pocket expenses and if deemed necessary are reimbursed by the insurance coverage. It is essentially payback for money spent. Not every cost has to be reimbursed, those covered under the insurance are not reimbursed. Active Duty service members do not have to pay any out of pocket costs for pharmacy privileges. If and when any expenses are born personally, filing a claim will help in getting complete reimbursement. Pharmacy claims are filed with Express Scripts, which is the official partner of Tricare Pharmacy. If costs are incurred out of pocket for any service that is covered under the minimum essential coverage plan, reimbursement claims can be filed with your authorized network service provider.
In almost all instances, your service provider will file your medical claims on your behalf and you will in turn receive an explanation of benefits detailing what was paid and what needs to be paid. However, in some instances you will have to file your own claims including while in travel, if you seek care from a non-network service provider and when you are covered underTRICARE for life, which needs assistance from Medicare. If you do file your own claims, forms need to reach TRICARE within a year at best.
The sooner your claim is processed, you and your provider will be paid at the earliest possible convenience. Most claims are paid within thirty days. Reimbursement for TRICARE covered services is paid for the TRICARE allocated amount. This reimbursed amount does not include any co-payments, cost shares or deductibles.