§1075a Tricare Prime: Cost Sharing

Summary

Sets the fees and copays for people in TRICARE Prime. People covered by section 1074(a) (active-duty service members) pay nothing. Family members of service members and retirees who first joined the uniformed services on or after January 1, 2018, have specific enrollment fees, caps, and copays. People who first joined before January 1, 2018, follow the older TRICARE rules instead of those new amounts. For the post-2018 group, 2018 rates are: active-duty family members—$0 annual enrollment and a $1,000 annual catastrophic cap; retired beneficiaries—$350 individual/$700 family annual enrollment and a $3,500 catastrophic cap. Retiree copays include $20 for primary care, $30 for specialty outpatient visits, $60 ER, $30 urgent care, $60 ambulatory surgery, $40 ground ambulance, 20% of negotiated fee for durable medical equipment, $150 per inpatient admission, and $30 per day for skilled nursing. Dollar amounts are adjusted each year by the same percentage retired pay is increased under section 1401a, rounded down to the next dollar with fractions carried forward until $1 accumulates. Enrollment fees, deductibles, and caps apply by calendar year. The Secretary sets charges for services not listed. If a TRICARE Prime enrollee gets care without the required referral, they pay 50% of the allowed point-of-service charge. There is no cost-sharing for any approved contraceptive methods, contraceptive care (including insertion, removal, and follow-up), sterilization procedures, or counseling tied to those services when provided under TRICARE Prime. The Secretary may also 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 date of the enactment of the National Defense Authorization Act for Fiscal Year 2024.