Military families will see more consistency in their out-of-pocket costs as the reformed Tricare benefit takes effect Jan. 1, but some family advocates question whether those costs will go up.

Part of the confusion comes from the plan to “grandfather” troops and working-age retirees into the new fee system, allowing them to keep the current payment plan. Grandfathering usually allows a lower payment rate to continue for a changing fee system, but in this instance, according to a chart provided by the Defense Health Agency, those already enrolled will pay more in co-pays than those entering service Jan. 1 or later.

Some examples:

  • A family member of a service member now in uniform would pay $27 for a primary care outpatient visit to a network provider. A family member of a service member who joins up Jan. 1 or later would pay $15.
  • Specialty care visits would mean a $34 co-pay for those grandfathered in. New family members would pay $25.
  • Working-age retirees would pay $35 for an in-network primary care visit. Future retirees (entering service Jan. 1 or later) will pay $25.

The co-payments for the grandfathered group are an average of what the beneficiaries now pay, DHA spokesman Kevin Dwyer said, while the co-payments for those coming in to the military next year were set by law in the 2017 National Defense Authorization Act.

The chart’s revelations triggered “disbelief” from the National Military Family Association, executive director Joyce Raezer said, that those in service would pay more in co-pays than incoming service members.

“That was not the expectation,” said Raezer, who also noted that her specialty-visit co-pay under her new Tricare plan would go up. NFMA is not opposed to co-pays, she said, but the advocacy group is concerned military families may face rising medical costs.

There is a proposal being considered in the Senate to remove the grandfathering requirement. If so, everyone would pay the same out-of-pocket costs.

TRICARE’S NEW LOOK

As of Jan. 1, Tricare Standard and Tricare Extra will be replaced by a single plan dubbed Tricare Select. It’s a preferred provider organization, or PPO, plan that doesn’t require a referral and allows patients to choose any Tricare-authorized provider for services covered by Tricare.

Tricare Prime active duty family enrollees, as before, have no co-pays. The Tricare for Life health care plan for retirees age 65 and older is not affected by these reforms. All current beneficiaries will be automatically enrolled in their respective plans.

Rather than paying a percentage of the total cost of care as they do under Tricare Standard and Extra, Tricare Select patients will pay a fixed dollar amount, said Navy Vice Adm. Raquel Bono, the DHA director, in a media conference call. Tricare Select beneficiaries also will receive access to no-cost preventive services from network providers, as are now available to those in Tricare Prime.

The “simplicity and predictability” of the setup will help patients and providers, Bono said. Officials set the new figure by taking a simple average of what beneficiaries pay now, she said.

Families who are currently in Tricare Prime will be automatically re-enrolled in Prime on Jan. 1; those who are in Tricare Standard or Extra will be automatically enrolled in Select. But there will be flexibility that first year, Bono said, with people allowed “to move in and out of those plans as they develop an understanding of what works best for them.”

‘A LOT OF UNANSWERED QUESTIONS’

NMFA’s Raezer said not all the reform details have been made clear. One major concern is obstetric care, “because there’s a whole pricing arrangement” for that service, she said. “There are a lot of unanswered questions,” she said.

Another concern comes from how and when beneficiaries can change their plans. Bono said the new system will include an annual open enrollment period, with the first one coming from November to December 2018 to set up coverage beginning Jan. 1, 2019.

Outside that window, beneficiaries can’t change plans unless there’s a “qualifying life event,” which would cover marriage, divorce, the birth of a child and other similar happenings.

Family advocates have pushed for a broader definition of a qualifying life event, such as pregnancy, Raezer said.

“Military families have told us there are reasons why people make a choice, sometimes suddenly, to leave military treatment facilities and seek care elsewhere,” she said. “Right now, they are. There are folks who say ‘I am willing to accept the higher costs that come with Tricare Standard to get an appointment when I need it, get a doctor who’s listening to me, get the care I need.’ ”

Raezer said this annual enrollment shouldn’t be compared to civilian federal government health care, where beneficiaries make choices between the plans.

“That’s not Tricare. … Basically, for our folks, the choice is, do I want all my care in a military hospital or clinic, or don’t I?” she said.

Circumstances also often change for military families, said Karen Ruedisueli, deputy director of government relations for NMFA. “

Our families might be perfectly happy with their Tricare Prime MTF care at one installation, move to the next installation and assume they’ll get the same level of access and quality, and find a completely different scenario there.”