The TRICARE point-of-service (POS) option adds a measure of flexibility to the health care benefit of TRICARE Prime and TRICARE Prime Remote (TPR) for Active Duty Family Members; however, such flexibility comes at an additional cost. Simply put, POS allows Prime and TPR beneficiaries to choose to receive TRICARE-covered non-emergency services outside of the TRICARE Prime network of providers without a referral from their Primary Care Manager (PCM) or an authorization from TriWest Healthcare Alliance by paying an additional deductible and cost-share.
Typically, the POS option is used for a one-time visit to a non-network provider without a preauthorization. POS cost-sharing applies for those beneficiaries who receive urgent or specialty care without either a referral from their PCM or an authorization from TriWest; when they receive routine care while traveling; or when electing to have prescriptions filled at a non-network civilian pharmacy. Using the POS option results in higher out-of-pocket costs for beneficiaries.
When utilizing the POS option, TRICARE Prime and TPR beneficiaries are responsible for an annual deductible (for outpatient care) of $300 for an individual and $600 for a family. After the deductible is satisfied, the cost-share is 50 percent of the TRICARE allowable charge (the cost-share applies to both inpatient and outpatient services). Any additional charges by non-network providers also become the beneficiary's responsibility: up to 15 percent above the allowable charge, as permitted by law. Deductibles and POS cost-sharing may also apply to services received from a TRICARE Prime network provider if the care is not pre-authorized.
For example, if a beneficiary's annual deductible has been met and the visit costs and the TRICARE allowable charge is $500, the beneficiary must pay the fifty percent (50%) of the remaining POS charge, or $250. Additionally, POS costs are NOT applied towards the annual catastrophic cap. So, as you can see, using this option can be very expensive.
Beneficiaries should make every effort to avoid expensive POS charges by contacting their PCM for a referral before seeking care. TriWest will notify both the provider and the beneficiary when authorization is given.
The POS option does not apply to emergency situations. Beneficiaries in an emergency situation should immediately go or be taken to the nearest emergency care facility. The POS option also does not apply to TRICARE Standard beneficiaries. Active duty service members (ADSMs) are also not eligible to use the POS option. ADSMs who visit a civilian provider without a referral from their military treatment facility or the Military Medical Support Office, Great Lakes Illinois, will be denied payment of claims. In those cases, the ADSM will be required to pay all costs and will not be reimbursed by the government.
More information on POS and other TRICARE benefit information can be found at www.tricare.mil or www.triwest.com.
Posted 08/10/2005