What Is the TRICARE Term for Coinsurance?

TRICARE is the healthcare program for uniformed service members, retirees, and their families. It integrates resources from the Military Health System with a civilian healthcare network to support the well-being of its beneficiaries. Understanding how healthcare costs are shared within this system is important for those who rely on its services.

TRICARE’s Approach to Cost-Sharing

TRICARE uses the term “cost-share” to refer to what commercial health insurance plans typically call “coinsurance.” A cost-share represents the percentage of the total allowable charge for covered services that a beneficiary pays after any applicable deductible has been met. This differs from a copayment, which is a fixed dollar amount paid for a specific service or prescription. For example, a copayment might be a set fee for a doctor’s visit, while a cost-share is a percentage of the overall bill for a procedure.

Cost-shares directly contribute to a beneficiary’s out-of-pocket expenses for healthcare services. While active duty service members generally have no cost-shares or copayments for covered services, other beneficiaries, including active duty family members and retirees, will incur these costs depending on their plan and the type of care received. This percentage-based payment structure applies across various TRICARE plans and services.

Calculating Your TRICARE Cost-Share

The specific cost-share amount a TRICARE beneficiary pays can vary based on several factors, including their TRICARE plan, the type of provider they see, the service received, and their beneficiary category. For instance, TRICARE Prime generally features lower out-of-pocket costs, often with copayments rather than cost-shares for in-network care, especially when care is obtained through a primary care manager. However, if TRICARE Prime beneficiaries use the point-of-service option for non-emergency care without a referral, they may incur a 50% cost-share after meeting a specific deductible.

TRICARE Select, which functions more like a Preferred Provider Organization (PPO), typically involves cost-shares for services after the annual deductible is satisfied. These cost-shares can differ based on whether the provider is in-network or out-of-network. Generally, using TRICARE-authorized network providers results in lower cost-shares compared to non-network providers. Non-network providers who are non-participating can charge up to 15% above the TRICARE-allowable charge, and beneficiaries are responsible for this additional amount.

The beneficiary’s status, such as active duty family member or retiree, also influences cost-share percentages. For example, active duty family members often have lower cost-shares than retirees and their families. Furthermore, whether a service member’s initial enlistment or appointment was before January 1, 2018 (Group A) or on or after this date (Group B) can impact cost-share amounts. Specific services, like inpatient care, outpatient visits, or prescription drugs, also have their own defined cost-share structures.

Additional TRICARE Out-of-Pocket Costs

Beyond cost-shares, beneficiaries may encounter other out-of-pocket expenses. Deductibles represent the amount a beneficiary must pay for covered services before TRICARE begins to share costs. For example, TRICARE Select plans typically have annual deductibles that vary by beneficiary group and sponsor rank, while TRICARE Prime usually has no deductible for in-network care. Once the deductible is met, cost-shares and copayments then apply to subsequent covered services.

The annual catastrophic cap serves as a financial safeguard, limiting the maximum amount a family will pay out-of-pocket for TRICARE-covered services in a fiscal year. Once this cap is reached, TRICARE pays 100% of the allowable charge for covered services for the remainder of the year. Deductibles, copayments, cost-shares, and enrollment fees generally count towards this catastrophic cap. However, certain costs, such as premiums for some plans and charges for non-covered services, do not apply toward the catastrophic cap.

Enrollment fees or premiums are another component of out-of-pocket costs for some TRICARE plans. For instance, retirees and their family members enrolled in TRICARE Prime or TRICARE Select may pay annual enrollment fees. Premium-based plans like TRICARE Reserve Select and TRICARE Young Adult require monthly or quarterly premiums. These fees are separate from deductibles and cost-shares but are part of the overall financial commitment for TRICARE coverage. For TRICARE For Life, beneficiaries must typically pay Medicare Part B premiums to maintain coverage.