TRICARE for providers: A guide to military health insurance
Following this year's Memorial Day, we're taking a look at an aspect of healthcare that’s little recognized among the broader American public: TRICARE
Healthcare is a top issue for voters in election after election. Health insurance is one of the more valuable assets available to ensure long-term security. And many people know someone who receives healthcare paid for by Medicaid or Medicare programs.
TRICARE, meanwhile, hides in plain sight as another way care is administered in the United States—specifically for military personnel.
What is TRICARE?
TRICARE is a health program offering comprehensive coverage to uniformed service members, retirees, and their families around the world. Civilian health benefits covered under TRICARE include health plans, special programs, prescriptions, dental plans.
The history of TRICARE
The military began offering service families a choice for how they use their health benefits in 1988, according to The Balance. After finding the program to be a success the Department of Defense announced its intention to extend the program into a nationwide initiative in 1993.
In the subsequent years, the DoD refined the program from its initial shape—the CHAMPUS Reform Initiative—into the program used by service members today: TRICARE.
TRICARE divided the U.S. into numerous healthcare regions. The health needs of each region are managed by an administrative organization. Plan members are offered a number of choices under TRICARE, some of which loosely align with plans you’d find in the private marketplace.
What TRICARE covers
Is TRICARE something your practice should be concerned with? It depends on whether your practice specialty is covered. So, what does TRICARE cover?
TRICARE resembles plenty of other plans on the market in terms of the range of services covered. For example, primary care ranging from office visits to telemedicine to blood pressure screenings are all covered. Additionally, myriad hospital care and surgery procedures are included under the plan’s coverage.
Some specialty offerings are also paid for throughTRICARE. Here are some of the more frequently visited specialties and more information on whether TRICARE covers them:
Does TRICARE cover vision?
It depends. TRICARE covers certain services for some plan members at specific locations.
For example, eye exam coverage depends on age, TRICARE plan and status—active duty, active duty family, guard or reserve member, or the family of a guard or reserve member.
In addition, TRICARE only directly covers frames and contacts for active duty service members. All other TRICARE members may be eligible for coverage through FEDVIP.
Anyone curious about what vision care TRICARE does and does not cover should review the covered services search page.
Does TRICARE cover chiropractic care?
For the most part, TRICARE coverage does not include chiropractic care. However, there are exceptions for active duty service members.
Active duty service members, and National Guard and Reserve members, can receive chiropractic care through the Chiropractic Health Care Program at designated military hospitals and clinics.
Does TRICARE cover physical therapy?
TRICARE benefits include physical therapy as long as the treatment was prescribed by a qualified provider and offered by a licensed physical therapist or occupational therapist.
Does TRICARE cover substance abuse treatment?
In many cases, TRICARE does cover substance abuse treatment. For example, plans may cover inpatient services, intensive outpatient programs, opioid treatment, office-based opioid programs, withdrawal symptom management, residential substance use disorder treatment and more.
There are plenty of other benefits offered through TRICARE’s plans. You can review the covered services search to learn what other benefits are offered under the program’s plans.
How to become a TRICARE provider
The steps to becoming a participating TRICARE provider depend on your practice location. You should fill out the application for your region in order to be certified. From there you can either join the TRICARE network or be a non-network provider.
TRICARE used to be divided into three regions: north, south and west. However, it has since been realigned into two regions.
TRICARE East covers everything east of the Mississippi River, in addition to Oklahoma, Arkansas, Louisiana and most of Texas.
Providers can find applications to become TRICARE East-certified here. In order to join the TRICARE East network or be a non-network provider you must get certified.
If you choose to also become a participating TRICARE provider you can apply to join the network here. Otherwise, after certification you can provide care to plan members as a non-network provider.
TRICARE West covers most of the states west of the Mississippi River excluding those mentioned above. It also includes slivers of West Texas.
Providers can find contact information to connect with their TRICARE West credentialing department here.
Applications to be a network provider can be found here and must be mailed to the appropriate location.
Network and non-network TRICARE providers
When you’re certified with TRICARE you can either join the network or become a non-participating provider.
Like regular payer plans, when you join the TRICARE network after certification you get access to portals for verifying benefits eligibility, filing claims, viewing the status of your claims and more.
In order to access TRICARE’s eligibility verification and claims filing portals you’ll have to acquiesce to a fee schedule.
Once you’re a part of the network for your region billing will function in much the same way it does with other contracted insurers. The patients will pay what they owe in out-of-pocket costs. Afterward, your practice files the claim through an online portal and is later reimbursed.
TRICARE also works with non-network providers. Your practice can either be a participating or non-participating non-network provider. Either way, TRICARE will still have to certify your practice.
As a participating provider you can still file claims on behalf of your patient. Patients will pay just what they owe out-of-pocket and your practice will be reimbursed.
As a non-participating provider you will not have access to the same claim filing portal. Instead, non-participating providers typically have patients file claims. Additionally, as a non-participating provider you may charge up to 15 percent above the TRICARE-allowable charge.
Typically, patients will pay non-particpating providers the full cost of the care at the point of service. From there the payer will send the reimbursement directly to the patient.
Is becoming a TRICARE provider right for your practice?
Hopefully you learned something about TRICARE since you started reading. Is becoming a certified provider right for your practice? Well, that’s for you to decide.
What is the military presence like in your community? Is there a way you can build this care into your practice brand? Would you like to give back to our country’s military service members?
If becoming a TRICARE provider is something you'd like to pursue apply to get certified! From there you can decide whether joining your regional TRICARE network or not makes sense for your practice.