, formerly known as the Civilian Health and Medical Program of the Uniformed Services
), is the managed care
component of the United States Department of Defense Military Health System
. TRICARE provides civilian health benefits
for military personnel
, military retirees, and their dependents
, including some members of the Reserve Component
. The TRICARE program is managed by TRICARE Management Activity (TMA) under the authority of the Assistant Secretary of Defense (Health Affairs)
. TRICARE is the civilian care component of the Military Health System although historically, it also included health care delivered in the military medical treatment facilities.
Historically, health care for military personnel and dependents was provided in military medical facilities on a "space-available" basis. After World War II and the Korean War, access to care in military facilities became increasingly unavailable. To address this problem, Congress passed the Dependents Medical Care Act of 1956 and the Military Medical Benefits Amendments of 1966. These acts allowed the Secretary of Defense to contract with civilian health care providers. This civilian health care program became known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS).
In the late 1980s, because of escalating costs, claims paperwork demands and general beneficiary dissatisfaction, DOD initiated a series of demonstration projects. Under a program known as the CHAMPUS Reform Initiative (CRI), a contractor provided both health care and administrative-related services, including claims processing. The CRI project was one of the first to introduce managed care features to the CHAMPUS program. Beneficiaries under CRI were offered three choices — a health maintenance organization-like option called CHAMPUS Prime that required enrollment and offered enhanced benefits and low-cost shares, a preferred provider organization-like option called CHAMPUS Extra that required use of network providers in exchange for lower cost shares, and the standard CHAMPUS option that continued the freedom of choice in selecting providers and higher cost shares and deductibles.
Although DOD’s initial intent under CRI was to award three competitively bid contracts covering six states, only one bid, made by Foundation Health Corporation (now Health Net) covering California and Hawaii, was received. Foundation delivered services under this contract between August 1988 and January 1994.
In late 1993, in response to requirements in the DOD Appropriation Act for Fiscal Year 1994, the DOD announced plans for implementing a nationwide managed care program for the MHS that would be completely implemented by May 1997. Under this program, known as TRICARE, the United States was divided into 12 health care regions. An administrative organization, the lead agent, was designated for each region and coordinated the health care needs of all military treatment facilities in the region. Under TRICARE, seven managed care support contracts were awarded covering DOD’s 12 health care regions.
Since then, TRICARE has undergone several restructuring initiatives, including re-alignment of contract regions, Base Realignment and Closure, and the addition of "TRICARE for Life" benefits in 2001 for those who are Medicare-eligible, and "TRICARE Reserve Select" in 2005.
TRICARE Standard provides a similar benefit to the original CHAMPUS program. Under TRICARE Standard, beneficiaries can use any civilian health care provider
that is payable under TRICARE regulations. The beneficiary is responsible for payment of an annual deductible
, and may be responsible for certain other out-of-pocket expenses
. There is no enrollment fee for TRICARE Standard.
TRICARE Standard beneficiaries can elect to use the TRICARE Extra option by using a civilian health care provider from within the regional contractor's provider network. In this way, TRICARE Extra represents a preferred provider organization
(PPO). When using TRICARE Extra, the beneficiary's coinsurance amount is reduced by at least five percentage points. There is no fee for use of the TRICARE Extra benefit other than the coinsurance.
TRICARE Prime is a health maintenance organization
(HMO) style plan. Under TRICARE Prime, beneficiaries must choose a primary care physician
and obtain referrals
and authorizations for specialty care
. In return for these restrictions, beneficiaries are responsible only for small copayments
for each visit. There is an annual enrollment fee for TRICARE Prime for military retirees and their family members. There is no enrollment fee for active duty military and their family members.
US Family Health Plan
US Family Health Plan, a TRICARE Prime-sponsored health plan option, is made available by nonprofit health care providers in the Northeast U.S., Southeast Texas/Southwest Louisiana, and the Puget Sound region of Washington state.
TRICARE Reserve Select [TRS]
TRICARE Reserve Select is a premium-based health plan that qualified National Guard and Reserve members may purchase. The classification is sometimes referred to as TRICARE Reserve Component (RC). It requires a monthly premium and offers coverage similar to TRICARE Standard and Extra. The program coverage is available world wide to Selected Reserve (SELRES) members in a paid status. As of February 2008 retired, IRR, TRS or VTU members do not qualify. Qualification questions should be referred to TRICARE.
The ultimate responsible organization for administration of TRICARE is the U.S. Department of Defense Military Health System
, which organized the TRICARE Management Activity
(TMA). The TRICARE Management Activity contracts with several large health insurance corporations to provide claims processing, customer service and other administrative functions to the TRICARE program. Currently, there are three regional Managed Care Support Contractors (MCSCs), a Medicare/TRICARE Dual Eligible Fiscal Intermediary Contractor (TDEFIC), and a TRICARE Pharmacy contractor, who administers both Mail Order Pharmacy (TMOP) and Retail Pharmacy (TRRx) programs. In addition several administrative contractors provide quality management, auditing and statistical services. TMA also oversees the TRICARE Dental Program (TDP) and TRICARE Retiree Dental Program (TRDP) which are run by Delta Dental
In 2004, TRICARE Management Activity re-aligned the previous twelve regions into three large regions, known as TRICARE North
, TRICARE South
, and TRICARE West
. Services in these regions are provided by:
All medical claims are processed by the following claims processing sub-contractors:
- TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC) - Wisconsin Physicians Service
- TRICARE Mail Order Pharmacy (TMOP), TRICARE Retail Pharmacy (TRRx), TRICARE Pharmacy Services (TPharm) (beginning in 2009) - Express Scripts, Inc.