Point of Service (POS) Option
What is the POS option?
Recently, the Department of Defense modified the TRICARE Prime benefit to add a Point of Service (POS) option. It provides limited coverage for unauthorized, out of network services for services that aren’t medical emergencies. Prior to this benefit enhancement, there was no coverage for unauthorized out of network care: now there is partial coverage. Care provided must be a covered benefit in order for POS coverage to apply.
What are the costs?
While this option provides some coverage for unauthorized out of network care, you should be aware of the high out-of-pocket costs:
|Deductible per Plan Year (1-Oct through 30-Sept) for outpatient care only||$300||$600|
|Cost Share for outpatient care||50% of TRICARE allowable charge, after annual deductible is met|
|Cost Share for inpatient care||50% of TRICARE allowable charge|
|Any additional charges by non-network providers||Member is responsible. Up to 15% above the TRICARE allowable charge is permitted by law|
Important: Out of pocket costs under the POS option are not applied to the catastrophic cap. This means there is no cap on your out of pocket costs for unauthorized non-network care.
Please note: there is no change to your costs (if any) for care provided in network, or for authorized out of network care. Likewise, there is no change to your costs (if any) for emergency care, regardless of whether the emergency care is provided in or out of network. The POS option applies only to non-emergency, unauthorized, out of network care; everything else remains unchanged.
FAQs about POS
Some frequently asked questions are listed below. If you have any additional questions, please contact Member Services at 1-800-818-8589.
What has changed?
The government recently modified our contract to add a Point of Service (POS) option to provide limited coverage for unauthorized services. Prior to this change, there was no coverage for unauthorized services. You may now choose to see out of network providers without Plan authorization, at a significant out-of-pocket cost. The service must be a TRICARE covered benefit. All other aspects of the plan remain the same.
When will the POS option become available?
The POS option is available now.
How does the POS option work—how can I use it?
If you receive authorization to see an out of network provider for covered health care services, you simply pay your usual copayment (if any). However, if you see an out of network provider for covered health care services without Plan authorization, you pay a deductible and coinsurance.
- A deductible is the amount you must pay out of pocket before any coverage is available for unauthorized benefits.
- Coinsurance is a percentage of the covered medical costs you are responsible for paying at the out-of-network level of benefits once the deductible has been met.
I don’t receive any care out of network. Are my costs changing?
No, POS costs would not apply: you costs for care provided in network are at the usual level of benefits.
I need to have knee replacement surgery, and would prefer to see the surgeon who did my neighbor’s hip replacement, but he is not in the US Family Health Plan network. Can I still have my surgery with this provider?
Yes, you can see this out of network provider, but the POS deductible and coinsurance will apply.
I have a referral to an out of network provider that was authorized by both my PCP and the Plan. Will I have to pay the POS costs?
No, since the out of network care is authorized by the Plan, your costs remain the same.
I need to have a particular procedure that is not performed at any in-network hospital. Will I have to pay the POS costs?
If the procedure is a covered procedure and is medically necessary, the Plan will authorize you to receive the care out of network at the authorized level of benefits. But you will need to have your PCP send a referral to the Plan for authorization. Without a Plan-authorized referral, POS deductibles and coinsurance will apply.
I had an emergency while traveling out of state, and had to go to the emergency room. Will that care be subject to the POS costs?
No. Emergency care is covered at the authorized level of benefits, regardless of whether you see an in-network or out of network provider.
Are the POS deductibles and coinsurance applied to the catastrophic cap?
No, expenses incurred from unauthorized out of network care using the point of service option do not apply toward your catastrophic cap.