Is TriCare Catastrophic Cap Legit? — The Bump
Military Families

Is TriCare Catastrophic Cap Legit?

TriCare doesn't cover provider in my area, so even though we have health insurance, we're basically paying out of pocket.  They said that once I hit the catastrophic cap, they'll cover everything from then on.  With a baby coming, it won't be hard to hit that, but is it the truth or will there be some loophole that will force us to pay more? My experience with TriCare has been less than stellar, so I'm just waiting for the other shoe to drop with them. 

Re: Is TriCare Catastrophic Cap Legit?

  • There are absolutely no Tricare providers in your area?  That just seems so hard to believe, but I guess it is possible. 

    I'm by no means an expert, but here's what I found online: "The catastrophic cap applies only to allowable charges for covered services. The catastrophic cap does not apply to services that are not covered, or to the total amount of what nonparticipating providers may charge above the TAC."

    It sounds like you could have to pay more than the catastrophic cap if your provider charges more than the Tricare allowable charges.  I think you need to call Tricare and discuss with your provider in detail their charges to get a good idea of how much you might owe.

    Hilary
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  • I would call them and really talk it out. My DD was born almost 4 months early and we didn't see a single bill. Her entire 112 day NICU stay was covered, as were all of her treatments and surgeries. My three day hospital stay was covered, as were my three separate ambulance rides. 

    I also think it's a little strange that there are no providers in your area. You called all of the OBs and checked the list provided by your PCM? 

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  • Are you SURE there are absolutely zero Tricare covered providers in your area? Are NG, Reserves, or AD family (maybe it doesn't matter)? I just find it odd that there isn't one single person. You may have to travel a short way to find a provider.

    As for TriCare being less then stellar, well, that is 100% the opposite for me. I realize not everyone has good experiences with them and I'm sorry if this seems to be what is happening for you.

  • NSLNSL member
    This makes absolutely no sense.  If no providers in your area take Tricare they also don't take any Medicare/Medicaid patients.  I find it VERY hard to believe there's no health care for anyone who falls into one of those three categories where you live.
  • You might have to switch from TriCare Prime to TriCare Standard. I've been dealing with my switch for months, I thought I had it figured out until I actually moved here. The closest Prime PCM to me is 110 miles away and closest MTF is 200+miles. I just had 2 appts today and a bunch of testing tomorrow since I am now high risk. I haven't had to pay anything as of yet, my OB just said they would bill me and my specialist said my co-pay was 0. I suggest you call TriCare, they have been helpful to us or check out the TriCare website and search for standard providers.
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  • We had standard when I had my 2nd son and I hated it!!! Granted it allowed me to go to a fantastic childrens hospital to deliver and I"m so thankful for that but all the bills and out of pocket expenses really ircked me.

    I think once you know Tricare really well and know your boundaries with them you'll get along just fine. Speak up!! That is my best advice, if you don't like something or don't agree with it, Tricare HAS to let you get a second opinion and pay for it.

     

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  • Thanks for the tips ladies!  I had called before just to find a gyno in my area and the closest person was about an hour and a half away. The same went with an OB.  I've already had to pay out of pocket with them, just for my annual, and when we called they brought up the catastrophic cap.  I'll just have to call them and go through every procedure and check up with them in detail. 
  • What tricare are you on prime,standard or remote?
  • imageRecene:
    Thanks for the tips ladies!  I had called before just to find a gyno in my area and the closest person was about an hour and a half away. The same went with an OB.  I've already had to pay out of pocket with them, just for my annual, and when we called they brought up the catastrophic cap.  I'll just have to call them and go through every procedure and check up with them in detail. 
    When I was PG with DD I had to drive an hour away but it was worth it. Sometimes it better to drive then to suffer the price. I had the best care and hospital stay.
  • imagestargazer224:
    imageRecene:
    Thanks for the tips ladies!  I had called before just to find a gyno in my area and the closest person was about an hour and a half away. The same went with an OB.  I've already had to pay out of pocket with them, just for my annual, and when we called they brought up the catastrophic cap.  I'll just have to call them and go through every procedure and check up with them in detail. 
    When I was PG with DD I had to drive an hour away but it was worth it. Sometimes it better to drive then to suffer the price. I had the best care and hospital stay.
    I would second this! When DH was careflighted after his injuries, we received a bill that said "Tricare may not cover this" -- they ended up covering it for other reasons but I would say do what you have to to see a tricare provider.
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