Tricare: Marketplace Insurance Or Not?

TRICARE is a health care program for active-duty and retired uniformed services members and their families. It is considered a qualified health coverage option under the Affordable Care Act, meaning that enrollees are considered covered under the health care law and do not need to make any changes. TRICARE's young adult coverage rules are different from the Affordable Care Act's version, and it is important to note that TRICARE policies and benefits are governed by public law and federal regulations, which are subject to change.

Tricare and the Affordable Care Act

The Affordable Care Act requires individuals to maintain basic health care coverage, termed minimum essential coverage. Failure to have minimum essential coverage may result in a fee for each month an individual is not covered.

Tricare offers several health plans that meet the minimum essential coverage requirements, including:

• Tricare Prime Remote
• Tricare Prime Overseas
• Tricare Prime Remote Overseas
• Tricare Select Overseas
• Tricare Reserve Select
• Tricare Retired Reserve
• US Family Health Plan
• Transitional Assistance Management Program (transitional)

If you are enrolled in one of the plans above, you have the minimum essential coverage mandated by the Affordable Care Act.

However, if you are only eligible for care at military hospitals and clinics (known as "direct care") and are not covered by another Tricare plan, you typically do not have minimum essential coverage. Examples of beneficiaries who are only eligible for direct care include dependent parents and parents-in-law, Guard/Reserve members receiving Line of Duty care Service, and Secretarial Designees.

It is important to note that Tricare policies and benefits are subject to change and are governed by public law and federal regulations. For the most up-to-date information, individuals should refer to the Tricare website, contact their Tricare regional contractor, or consult their local military hospital or clinic.

Tricare's young adult coverage rules

TRICARE Young Adult (TYA) is a plan that qualified adult children can purchase after eligibility for "regular" TRICARE coverage ends at age 21 (or 23 if enrolled in college). The plan provides comprehensive medical and pharmacy benefits.

Who can participate?

You may qualify to purchase TRICARE Young Adult if you're:

• An unmarried, adult child of an eligible sponsor. Eligible sponsors for TRICARE Young Adult include:
• Active-duty service members
• Retired service members
• Activated Guard and Reserve members
• Non-activated Guard and Reserve members using TRICARE Reserve Select
• Retired Guard and Reserve members using TRICARE Retired Reserve
• Unremarried former spouses registered in DEERS under their own Social Security number
• At least 21 years old but not yet 26 years old.
• If enrolled in a full course of study at an approved institution of higher learning and your sponsor provides more than 50% of your financial support, your eligibility may not begin until age 23 or upon graduation, whichever comes first.
• Not eligible to enrol in an employer-sponsored health plan based on your own employment.
• Not otherwise eligible for TRICARE coverage.

You may buy coverage at any time by submitting a completed TRICARE Young Adult Application with an initial two-month premium payment to your regional (stateside/overseas) contractor. After the initial payment, you must make ongoing monthly premium payments by electronic funds transfer or recurring debit/credit card payments.

Tricare Young Adult costs are based on three things:

• The option you choose when you enrol: Prime or Select.
• Your sponsor's military status.
• Where the care is received.

To participate, you're required to pay monthly premiums. Your plan option and sponsor's military status determine what you pay for covered services.

The TRICARE Young Adult-Prime Option works the same as TRICARE Prime. You'll have an assigned primary care manager (PCM) who provides most of your care:

• Military or network provider
• Refers you to specialists for care they can't provide
• Works with your regional contractor for authorization and to find a specialist in the network
• Files claims for you

The TRICARE Young Adult-Select Option works just like TRICARE Select:

• Visit any TRICARE-authorized Provider. An authorized provider is any individual, institution/organization, or supplier that is licensed by a state, accredited by a national organization, or meets other standards of the medical community, and is certified to provide benefits under TRICARE. There are two types of TRICARE-authorized providers: Network and Non-Network.
• If you see a network provider, you'll pay less out of pocket and the provider will file claims for you.
• You don’t need a referral for any type of care, but some services may require pre-authorization.

Tricare as primary or secondary payer

If you have health insurance other than Tricare, such as Medicare or an employer-sponsored health insurance programme, Tricare supplements do not qualify as "other health insurance". By law, Tricare pays after all other health insurance, except in the following cases:

• State Victims of Crime Compensation Programs
• Other Federal Government Programs identified by the Director, Defense Health Agency (e.g. Indian Health Service)
• Medicaid

In these cases, Tricare is the primary payer. If you have other health insurance, it is your primary coverage and pays your medical claims before Tricare. Tricare is considered secondary coverage. After your doctor, hospital, or pharmacy is paid by your other health insurance, they will file a claim with Tricare or send you a bill for any remaining costs. If you receive the bill, you should send it to Tricare.

If you have TRICARE for Life, Tricare becomes the second payer. If Tricare pays first and then discovers you had other health insurance, Tricare will take back any payments made and will only reprocess your claim after your other health insurance pays.

If you are an active-duty service member, you can use other health insurance under certain circumstances and when in compliance with DoD and Service regulations. However, there is no coordination of benefits with your OHI and Tricare, and you are responsible for all costs.

Tricare and other health insurance

If you are enrolled in Tricare or the Veterans Health Care Program, you are considered covered under the health care law. You don't need to make any changes. However, if you don't have veterans or other health coverage, you can use the Health Insurance Marketplace to enrol in a plan.

Tricare is a health care program for active-duty and retired uniformed service members and their families. Most Tricare health plan options already meet the requirements for minimum essential coverage. If you qualify for the following plans, you must purchase them to have minimum essential coverage: Tricare Reserve Select and Tricare Retired Reserve.

If you have any health insurance other than Tricare, it is called "other health insurance". This can be through your employer or a private insurance program. By law, Tricare pays after all other health insurance, except for State Victims of Crime Compensation Programs and other Federal Government Programs identified by the Director, Defense Health Agency (e.g. Indian Health Service). This means your other health insurance processes your claim first, and then you or your doctor files your claim with Tricare.

If your other plan doesn't cover the entire cost, file a claim with Tricare. If your other plan denies a claim for failure to follow their rules, Tricare may also deny your claim. It is important to keep your other health information updated and tell your Tricare contractors and doctors when you have other health insurance. If Tricare gets your claim before your other health insurance processes it, Tricare will deny it.

Tricare and tax returns

The Affordable Care Act (ACA), also known as Obamacare, requires that all Americans have qualifying health care coverage, called minimum essential coverage (MEC). If you do not have MEC for the entire year, you may have to pay a penalty for not having the required health care coverage. Most Tricare health coverage meets the requirements for MEC.

Tricare Coverage that Meets the Requirement of Minimum Essential Coverage:

• Uniformed Services Family Health Plan
• Tricare Young Adult
• Tricare Reserve Select
• Tricare Retired Reserve

Forms:

The Defense Finance and Accounting Service (DFAS) will issue 1095 tax forms to Tricare beneficiaries. There are two different forms:

• IRS Form 1095-B (for Military Retirees, Annuitants, and Former Spouses)
• IRS Form 1095-C (for Active Duty Military and Federal Civilian Employees)

These forms will be available through the online myPay account access system or by mail. You need to print or keep an electronic copy of these forms for your records, but you don't have to submit them with your income tax return.

Reporting Tricare on Your Tax Return:

When filing your taxes, you will need to indicate that you have health care coverage by checking the appropriate box on your income tax return form. The specific form and line number will depend on which form you are filing (1040EZ, 1040A, or 1040). If everyone claimed on your tax form was eligible for acceptable Tricare coverage for the entire tax year, you can simply check the box and continue.

However, if you or any family members were not covered by Tricare for the entire year, your reporting requirements may be different, and you should seek assistance from a tax professional or your base's Volunteer Income Tax Assistance (VITA) program.

Important Considerations:

• Tricare Plus, available to dependent parents of military members, does not meet the MEC requirements of the ACA.
• If you have dependent parents using Tricare Plus without other MEC, your tax situation may be more complicated.
• If your spouse and/or children don't have Tricare because you have not enrolled them in the Defense Enrollment Eligibility Reporting System (DEERS), you may need additional guidance.

Frequently asked questions