Important Information For Patients

For Tricare Patients

Are you enrolled in a TRICARE Prime plan? Then you have a primary care manager (PCM) to handle your basic primary health care services. But what if you need specialty treatment, like from a cardiologist to evaluate a possible heart problem or a dermatologist to check a mole that’s changed? In that case, your PCM needs to submit a referral for you to see a specialist.
 
Some TRICARE plans, including TRICARE Select, don’t require referrals for most health care services. However, if you’re enrolled in one of the following plans, you need a referral before you visit a specialist:

• TRICARE Prime

• TRICARE Prime Overseas

• TRICARE Prime Remote

• TRICARE Prime Remote Overseas

• TRICARE Young Adult Prime

• US Family Health Plan

 
“If you’re an active duty service member or active duty family member enrolled in a TRICARE Prime plan, you need a referral from your PCM to seek most specialty care,” said Tonya Utterback, referral and authorization expert with the TRICARE Health Plan at the Defense Health Agency. “Without a referral, you may not be able to make an appointment with a specialist, or TRICARE may not be able to pay for it.”
 
What else do you need to know about referrals? Here are a few helpful facts about the referrals to get you started.

•  How long is the referral process? Your PCM will send a referral request to your regional contractor, who’ll process the referral. It can take approximately three business days for your regional contractor to process your referral. It may take less time if your PCM determines your referral to be “clinically urgent” and marks it as such.

• How can you track your referral? You can view or check the status of your referral by logging into your account on your regional contractor’s website. If you aren’t already registered for secure services, you’ll need to register first, then sign in. You can also call your regional contractor’s automated phone service. If overseas, call your TRICARE Overseas Program Regional Call Center, or check the MyCare Overseas app.

• Where can you receive care? Your regional contractor may refer you to a military hospital or clinic or a TRICARE network provider. If a network provider isn’t available in your area, you may receive approval to see a non-network provider.

• Can you visit a specialist without a referral? With the point-of-service option, yes. The point-of-service option allows those enrolled in a TRICARE Prime plan to visit a specialist without an approved referral from their PCM. But you’ll be subject to point-of-service charges. As outlined in the TRICARE Costs and Fees 2022 Fact Sheet, a yearly deductible before cost-sharing ($300 for individual/$600 for family) will kick in under the point-of-service option. The point-of-service option isn’t available for active duty service members (ADSMs). ADSM civilian care must be via a PCM referral with the exception of emergency care.

• Is a pre-authorization the same as a referral? This is a little different than a referral, but still involves getting approval by your regional contractor. Sometimes, your TRICARE contractor must review a requested health care service or prescription drug to see if it’s medically necessary and a TRICARE covered benefit. This is called a pre-authorization. Some health care services require pre-authorization before you receive them, regardless of your TRICARE plan. These include adjunctive dental services, Applied Behavior Analysis, home health care, hospice care, and more. Without this approval, you could be responsible for the full cost. ADSMs need pre-authorizations for all inpatient and outpatient specialty services.

 
Once the referral process is complete, you’ll receive an electronic authorization letter. Schedule your appointment with the health care provider listed on that letter. The authorization has an expiration date, so don’t wait too long. Want to use another provider? Then contact your regional contractor:

• East Region: Humana Military

• West Region: Health Net Federal Services, LLC

• Overseas: Contact your TRICARE Overseas Program Regional Call Center

Open Enrollment for 2023

The 2023 Open Enrollment Period (OEP) starts Tuesday, Novermber 1, 2022 and ends on Sunday, January 15, 2023.

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I Missed My State’s Open Enrollment Deadline. Can I Still Get Healthcare Coverage?

If you missed the enrollment deadline in your state, it is still possible that you can qualify for a Special Enrollment Period (SEP) that will allow you to apply for health insurance. You can qualify for an SEP if you have experienced a qualifying life event. Qualifying life events can include:​

• The loss of health insurance through a job

• Household changes such as marriage, divorce, a death in the family, or having a baby

• A change in your home address

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See a list of qualifying life events. You have 60 days to enroll in a plan, if you qualify for an SEP. But, if you miss that 60-day window, you will have to wait until OEP to enroll in an individual health insurance policy for 2023.

If you missed the 2022 Open Enrollment Period in your state and you do not qualify for an SEP, you can apply for a short-term health insurance plan. Short-term health insurance coverage can be purchased outside of OEP for up to 364 days, and you can reapply for short-term coverage for up to 36 months in most states. Short-term health insurance plans might be a good, temporary fit for healthy people, as they will not cover pre-existing conditions like Affordable Care Act (ACA) plans.

If you do not qualify for an SEP and decide not to apply for a short-term health plan, you will have to wait until Open Enrollment 2023 begins in fall 2022.

HealthMarkets can help you determine whether you qualify for an SEP and find an individual health plan that meets your needs. Shop, compare, and enroll in a health plan online or call us at (800) 304-3414.