It’s important to understand the financial implications of receiving care out of our network.
As a TRICARE Prime option, US Family Health Plan includes an out-of-network option that provides limited coverage for unauthorized, non-emergency, out-of-network services. (The federal government refers to this as a “point-of-service” option.)
In order for point-of-service coverage to apply, the care provided must be for a TRICARE-covered benefit. While this option does provide some coverage for unauthorized out-of-network care, you should be aware of the high out-of-pocket costs for which you will be responsible:
- Deductible (outpatient): $300 for individual, $600 for family per Plan year (January 1 through December 31)
- Cost share (outpatient): 50 percent of the TRICARE allowable charge, after annual deductible is met
- Cost share (inpatient): 50 percent of the TRICARE allowable charge
- Additional charges by out-of-network providers: Beneficiary is fully responsible. Up to 15 percent above the TRICARE allowable charge is permitted by law.
Out-of-pocket costs under the point-of-service option are not applied to the Plan’s catastrophic cap. This means that there is no cap on your out-of-pocket costs for unauthorized non-network care.
You may not ask your PCP to complete a referral after the services have been rendered in order to avoid the point- of- service deductible and coinsurance costs.
Frequently Asked Questions
I need to have knee replacement surgery. I’d like to see the surgeon who did my neighbor’s hip replacement, but he isn’t in the US Family Health Plan network. Can I still have my surgery with my neighbor’s doctor?
Yes, you can see this out-of-network provider, but the point-of-service deductible and coinsurance will apply. This could be very expensive.
I have a referral to an out-of-network provider that was authorized by my PCP and the Plan. Will I have to pay the point-of-service costs?
Since the out-of-network care has been authorized by the Plan, you will not have to pay the point-of-service costs.
I need to have a particular procedure that isn’t performed at any US Family Health Plan network hospital. Will I have to pay the point-of-service costs?
If the procedure is a covered procedure and is medically necessary, the Plan can authorize you to receive the care out of network at the authorized level of benefits. But your PCP will need to send a referral to the Plan for authorization. Without a Plan-authorized referral, point-of-service deductibles and coinsurance will apply.
I had an emergency while traveling out of state, and had to go to the emergency room. Will that care be subject to point-of-service costs?
No. Emergency care is covered by US Family Health Plan regardless of whether you see an in-network or out-of-network provider.
Are point-of-service deductibles and coinsurance applied to the catastrophic cap?
No, expenses incurred from unauthorized out-of-network care using the point-of-service option are not applied to your catastrophic cap.