Tricare Help: Demystifying cost shares and co-payments - Getting out, military health issues - Navy Times

Tricare Help: Demystifying cost shares and co-payments

Answering your questions on Tricare.

Q. What’s the difference between my Aetna co-payment and Tricare’s cost share? What do the different words mean?

A. They’re merely different words to describe the same concept.

When Tricare’s precursor, CHAMPUS, was created by Congress in 1966, the law talked about paying the costs of medical care. CHAMPUS had a share — a percentage — of the costs which it paid, and the beneficiary had his share of the costs.

The term “cost share” followed. It is the percentage of the claim — the share of the cost — for which the patient is responsible.

In the absence of a deductible, Tricare’s cost share plus your cost share equals the total amount allowed on the claim. You are responsible for paying only what Tricare does not pay on a claim on which the provider opts to participate in Tricare.

If the provider chooses not to participate on the claim, the patient is responsible for paying what Tricare does not.

In addition, the provider is allowed to charge the patient up to 15 percent more than the amount Tricare allows on that claim. Tricare can pay no part of that 15 percent surcharge; the patient is responsible.

Q. Our doctor got a letter from Tricare telling him that Tricare has revoked his authorized-provider status with the program. What can we do?

A. Nothing — except choose a new physician. If your doctor is no longer a Tricare-authorized provider, Tricare can no longer pay for any medical services he provides to Tricare beneficiaries.

Under federal law, any claims you file for medical services he renders to you after the effective date of the cancellation as an authorized provider must be denied.

Q. I’m a first sergeant with a deep frown line between my eyes that makes people think I’m angry. I asked my hospital for a Botox injection to help remove it and was told they can’t do it. A friend suggested that I could get it done under Tricare. True?

A. Active-duty personnel are not eligible for civilian medical care at government expense unless they are referred by their military hospital. In that case, it is the hospital, not Tricare, that pays the bill. If you filed a Tricare claim, it would be denied. Your service provides all your medical care.

The alternative is to pay yourself. Talk with your hospital’s commanding officer. The worst that can happen is that he says no.

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Write to Tricare Help, Times News Service, 6883 Commercial Drive, Springfield, VA 22159; or e-mail tricarehelp@militarytimes.com. In e-mail, include the word “Tricare” in the subject line and do not attach files. Get Tricare advice anytime at the Tricare Help blog.