TRICARE Maternity Care Options

(Note: The terms ‘pregnancy’, ‘maternity’, and ‘care before, during and after childbirth’ are used interchangeably to denote the period of time when a women first discovers she is pregnant through her six week postpartum and well baby checkup.)

Expectant mothers who are TRICARE beneficiaries have a variety of choices for receiving health care services before, during, and after childbirth. The scope of these services and their associated costs are related to beneficiary status, proximity to military treatment facility (MTF) services, and choice of TRICARE program and provider.

Active Duty Service Members (ADSMs)/ Spouses of ADSMs:

Active duty service members are expected to receive maternity services at their MTF when available. If the local MTF does not provide obstetric services, the service member’s primary care physician can refer her to a civilian provider. Some MTFs provide prenatal care and postpartum care and use a local civilian hospital for the actual childbirth experience.

ADSMs enrolled in TRICARE Prime Remote may deliver their baby at a local civilian hospital that has been approved by the Regional Contractor.

Voluntary Separation:

ADSMs who voluntarily separate from active duty while pregnant and spouses of ADSMs are not eligible for TRICARE upon separation. They may apply for transitional medical coverage under the Continued Health Care Benefit Program (CHCBP) within 60 days following loss of entitlement in the Military Health Care System. CHCBP is a premium-based health care program. Information on CHCBP can be found at http://tricare.osd.mil/chcbp/default.cfm. ADSMs who voluntarily separate because of pregnancy may request space-available maternity care in an MTF that has obstetric capability, however, no civilian maternity care will be provided under the TRICARE Program.

Involuntary Separation – Transitional Assistance Management Program:

ADSMs who are involuntarily separated from active duty while pregnant or the pregnant spouses of ADSMs who are involuntarily separated from active duty are eligible for health care benefits under the Transitional Assistance Management Program (TAMP). An involuntary separation is one other than one under adverse conditions. If the member desires to participate in TRICARE Prime during the TAMP period, she/he is required to re-enroll in the program for the 180 day TAMP period. Upon expiration of this benefit, these members may then enroll in the CHCBP.

TRICARE Prime Beneficiaries Enrolled to an MTF:

Family members of active duty and retirees enrolled in TRICARE Prime may obtain maternity services from the MTF where they are enrolled, if the services are available. The Military Health System has promoted Family-centered maternity care in order to provide Family-friendly and better coordinated MTF care for all TRICARE beneficiaries.

If TRICARE Prime enrollees opt to disenroll from Prime and choose a doctor or midwife under TRICARE Standard, there are several factors they should consider:

• With the exception of active duty Families with sponsors E-4 and below, those who voluntarily disenroll from TRICARE Prime will not be eligible to re-enroll in TRICARE Prime for a 12-month period from their date of disenrollment.
• The availability of civilian obstetricians or other maternity care providers should be explored before deciding whether MTF or civilian care is their best option. Due to escalating malpractice insurance costs, many civilian obstetricians have limited their practices to gynecology only; others may not accept TRICARE Standard.
• Local pediatrician availability should also be considered before deciding whether TRICARE Prime or TRICARE Standard is best.
• Most MTFs have the resources to take care of TRICARE Prime patients only. MTF care availability for those not enrolled to a MTF Primary Care Manager (PCM) varies from location to location, and by medical specialty within the MTF.

TRICARE Prime Point of Service:

TRICARE Prime enrollees who are pregnant may remain enrolled and use the TRICARE Prime Point-of-Service option to obtain their maternity care. This allows them to choose any TRICARE-authorized provider without a referral, rather than using the MTF or other TRICARE Prime network providers. However, those who choose the Point-of-Service option incur an annual $300/$600 individual/Family deductible and a 50 percent cost share. This means that TRICARE beneficiaries using the Point-of-Service option could pay more than $1,000 for active duty service members and Family members or $3,000 for retirees and retiree Family members out of pocket in a fiscal year, as the costs do not accrue toward their annual catastrophic cap limits.

Other TRICARE Prime Beneficiaries:

TRICARE Prime beneficiaries enrolled in civilian networks, and active duty Family members enrolled in TRICARE Prime Remote should work with their PCM to obtain referrals to appropriate specialty care services and discuss delivery options with their PCM. TRICARE regional contractors (North, South, and West) will process referrals which require authorizations and coordinate them for TRICARE Prime enrollees.

TRICARE Extra/TRICARE Standard Beneficiaries:

Beneficiaries using TRICARE Standard may choose any TRICARE Standard authorized provider for maternity care. TRICARE Standard users are subject to annual deductibles and incur cost-shares for each episode of care. Inpatient hospital costs vary, based on length of stay and sponsor status.

TRICARE Extra services may be used interchangeably with TRICARE Standard and can offer beneficiaries additional cost savings. Beneficiaries should inquire with their TRICARE Regional Contractor to determine whether TRICARE Extra providers are available in the area.

For more information beneficiaries should contact their TRICARE Service Center for assistance and questions. They may also check the TRICARE Web site at www.tricare.osd.mil.

TRICARE Beneficiary Maternity Costs
TRICARE Prime			TRICARE Standard/Extra
Type of Service or Fees	Active Duty Spouse or TRICARE-Eligible Daughter	Retiree or Retiree Spouse or TRICARE-Eligible Daughter	Active Duty Spouse or TRICARE-Eligible Daughter	Retiree, Retiree Spouse or TRICARE-Eligible Daughter
Annual Fiscal Year Deductible (applicable to outpatient services)	$0	$0	Applicable when beneficiary chooses to deliver at home or as an outpatient, with the exception of birthing center delivery. $50/individual or $100/ Family for E-4 and below. $150/individual or $300/ Family for E-5 and above.	Applicable when beneficiary chooses to deliver at home, in birthing center, or as an outpatient. $150/individual or $300/Family.
Global Maternity Care Fee (when beneficiary chooses to deliver in hospital as inpatient) -- includes prenatal care, inpatient professional services for delivery, and postnatal care	$0	$0	Standard: $0 1 Extra: $0	Standard: 25% 1 of allowable charges. Extra: 20% of the fee negotiated by TRICARE contractor.
Inpatient Professional Services for Newborn Care (that are not included in Global Maternity Fee such as services of pediatrician)	$0 for active duty; 100% for newborn if father is not an Active Duty or Retiree sponsor.	$11 per day; 100% for newborn if father is not an Active Duty or Retiree sponsor.	$0 as newborn is deemed enrolled in Prime for up to 60 days for cost-sharing purposes; 100% for newborn if father is not an Active Duty or Retiree sponsor.	Standard: 25% 1 of allowable charges unless the newborn is deemed enrolled in Prime. Extra: 20% of the fee negotiated by TRICARE contractor unless the newborn is deemed enrolled in Prime. 100% for newborn if father is not an Active Duty or Retiree sponsor.
Hospital Services for Inpatient Delivery	$0	$11 per day ($25 minimum charge) for admission.	$13.90 2 per day ($25 minimum charge) for admission.	Standard: $512 per day or 25% of billed charges whichever is less. Extra: $250 per day or 25% of TRICARE contractor negotiated charges whichever is less.
Newborn Cost-Share for Hospital Services	$0 for active duty spouse; 100% for newborn if father is not an Active Duty or Retiree sponsor.	$11 per day ($25 minimum charge) for each newborn inpatient day billed. 100% for newborn if father is not an Active Duty or Retiree sponsor.	$0 as newborn is deemed enrolled in Prime for up to 60 days for cost-sharing purposes. 100% for newborn if father is not an Active Duty or Retiree sponsor.	Standard: DRG HOSPITAL: Same newborn date of birth and date of admission: Unless the newborn is deemed enrolled in Prime, the cost-share will be the lower of the number of hospital days minus 3 multiplied by $512/dayday OR 25% of billed charges. Different newborn date of birth and date of admission: Unless the newborn is deemed enrolled in Prime, the cost-share will be the lower of hospital days for the newborn multiplied by $512/dayday OR 25% of billed charges. DRG EXEMPT HOSPITAL: 25% of allowed charges unless the newborn is deemed enrolled in Prime. Extra: Same newborn date of birth and date of admission: Unless the newborn is deemed enrolled in Prime, the cost-share will be the lower of the number of hospital days minus 3 multiplied by $250 OR 25% of TRICARE contractor negotiated charges. Different newborn date of birth and date of admission: Unless the newborn is deemed enrolled in Prime, the cost-share will be the lower of hospital days for the newborn multiplied by $250 OR 25% of TRICARE contractor negotiated charges. 100% for newborn if father is not an Active Duty or Retiree sponsor.
Professional Services Fee When Beneficiary Chooses to Deliver at Home or as an Outpatient	$0 for mother; 100% for newborn if father is not an Active Duty or Retiree sponsor.	$12 per visit for mother; 100% for newborn if father is not an Active Duty or Retiree sponsor.	Standard: 20%1 of the allowable charge for mom. $0 for newborn as the newborn is deemed enrolled in Prime for up to 60 days for cost-sharing purposes. Extra: 15% of the fee negotiated by TRICARE contractor for mom. $0 for newborn as the newborn is deemed enrolled in TRICARE Prime for up to 60 days.	Standard: 25% 1 of the allowable charge for mom. Unless the newborn is deemed enrolled in Prime, 25% of the allowable charge for services of the newborn’s provider if any. Extra: 20% of the fee negotiated by TRICARE contractor, for mom. Unless the newborn is deemed enrolled in Prime, 20% of the fee negotiated by TRICARE contractor for services of the newborn’s provider if any.
Prenatal Care, Outpatient Delivery, and Postnatal Care Provided by TRICARE Authorized Birthing Center (All Inclusive Rate) OR Maternity Care Ending in Childbirth in Hospital-Based Outpatient Birthing Room	$0	$25	$25	Standard: 25% of allowable charges. Birthing Center: Lesser of 25% of birthing center rate or 25% of billed charge. Hospital-Based Outpatient Birthing Room: 25% of billed charges. Extra: 20% of the fee negotiated by TRICARE contractor.

1. Non-participating provider may bill the beneficiary up to an additional 15% of TRICARE allowable charges.
2. This amount is updated each fiscal year.
3. Under the Point of Service Option, there is a 50% cost-share and an outpatient deductible of $300/individual and $600/Family.

Source: TRICARE Maternity Care Options