§1075a TRICARE Prime: cost sharing

Summary

Sets the rules for what people pay under TRICARE Prime. People covered by section 1074(a) pay nothing. For people who first joined the uniformed services on or after January 1, 2018 (and their dependents), the plan uses a 2018 cost table (and yearly updates) that makes most care free for active-duty family members and charges retirees specific amounts: enrollment $350 per individual / $700 per family; no annual deductible; annual catastrophic cap $1,000 for active-duty family members and $3,500 for retirees. Examples from the table for 2018: outpatient primary care $0 for active-duty family / $20 for retirees, specialty care $0 / $30, ER $0 / $60, urgent care $0 / $30, ambulatory surgery $0 / $60, ground ambulance $0 / $40, durable medical equipment $0 / 20% of negotiated fee for retirees, inpatient admission $0 / $150, skilled nursing/rehab $0 / $30 per day. These 2018 dollar amounts are adjusted each year by the same percentage retired pay increases get under section 1401a, rounded down to the next dollar with any fractions carried forward. Enrollment fees, deductibles, and catastrophic caps apply per calendar year. Costs for services not listed are set by the Secretary. People who joined before January 1, 2018 (and their dependents) follow the other rules in the law instead of the 2018 table. If a TRICARE Prime enrollee gets care without the required referral, they pay 50% of the allowed point-of-service charge. All FDA-approved contraceptives, related care (including insertion, removal, follow-up), sterilization, and counseling have no cost-sharing. The Secretary may waive cost-sharing for the first three outpatient mental health visits each year for active-duty family members; that waiver authority ends five years after the enactment date of the National Defense Authorization Act for Fiscal Year 2024.