US Family Health Plan eNews 2023: Issue 3
Posted 08/11/23
For more of eNews Member Newsletter
IN THIS EDITION:
Understanding Referrals & The Point of Service (POS) Option
The US Family Health Plan is a managed care program with two benefit levels: Your TRICARE® Prime benefit and the Point-of-Service (POS) option.
When seeking specialty care, the benefit level you use is determined by the type of referral on file. Beginning October 1, 2023, providers are required to submit referrals to the Health Plan.
Your primary care provider (PCP) is the first line of defense when it comes to your health care. PCPs manage most of your routine health matters, though they will sometimes determine that a specialist would best handle a particular issue or health concern. In situations like this, they may refer you to another provider. Services or situations that do not require a referral include Urgent/Emergent Care, Routine Preventive Services, Office-Based Mental Health, or if you have other primary health insurance.
Receiving specialty care without a referral is considered a “self-referral” and will generally apply the Point-of-Service (POS) option, which has a higher member cost share.
A referral does not replace authorization or coverage requirements.
The Point-of-Service (POS) option allows you the flexibility to choose to see a TRICARE®-authorized provider without an approved referral. While this option can give you greater freedom, you should be sure you understand what your out-of-pocket costs will be before seeking care without a referral. You will incur higher cost shares if you choose to use the Point-of-Service (POS) option.
Seeing an In-Network Provider: Currently, the Health Plan does not require a pre-service referral submission if the rendering provider participates in the US Family Health Plan network. The referring provider must be billed on the specialist claim.
Seeing an Out-of-Network Provider: If you are referred to a non-participating provider, the referring provider must submit the referral request to the Health Plan for approval. If the referral is approved, your TRICARE® Prime Benefit will apply.
Contact your primary care provider to confirm you have referrals for the specialty care you plan to receive, even if you have seen that specialist before.
NOTE: Some referred services may also require AUTHORIZATION by the US Family Health Plan approving the services.
You can view the status of your Referrals and Authorizations on the Member Portal.
You can check if your provider participates in the network by searching the Online Provider Directory.
Learn more about Referrals and your Point-of-Service (POS) Option here.
National Immunization Awareness Month
Vaccines prevent serious diseases and save lives every day!
August was National Immunization Awareness Month, a yearly highlight of the importance of getting recommended vaccines at various life stages. Please take a moment this season to make sure you and your loved ones are up to date with recommended vaccines for the best protection against potentially life-threatening diseases.
Check out our convenient list of recommended vaccine schedules for children from birth through the teenage years. You can also visit the US Centers for Disease Control and Prevention (CDC) vaccine section where you’ll also find recommended vaccine schedules for adults and general information about immunizations, including which diseases vaccines protect against and vaccine safety.
Do you have kids heading to school? Make sure to check their school’s vaccination requirements to ensure your child is ready to safely start back to class.
Sore Throats—Antibiotics aren’t always the right treatment!
With sore throats, the cause will determine the treatment.
Did you know that most sore throats are caused by viruses and will generally improve within a week on their own. Antibiotic treatment is only effective when the sore throat is caused by bacteria (strep throat). The only way to determine if you have strep throat is by having a strep test performed. This test consists of a quick swab of the back of your throat to see if the bacteria is present.
Some reasons your doctor may suspect you have strep throat and not a sore throat caused by a virus or other reasons are:
- Fever
- Red and swollen tonsils, sometimes with streaks of pus
- Tiny red spots on roof of mouth
- Swollen lymph nodes in neck
- Sore throat that comes on very quickly
Using antibiotics to treat a sore throat that isn’t strep is not only ineffective, it also increases the risk of unnecessary side effects, or worse, creating more bacteria strains that are resistant to antibiotic treatment. One of these antibiotic-resistant strains is Clostridioides difficile (C.diff) which can cause severe diarrhea.
Talk to your health care provider about how to manage your symptoms if your sore throat is not strep throat and always take preventive measures to avoid getting any type of sore throat by washing your hands and avoiding sick people.
Mental Health Resources
Just a Click Away
We’ve recently updated our online Health and Wellness pages to help you learn about important health topics and take steps to protect your and your family’s best health:
- Mental Health and Martin's Point – learn about resources designed to support you and your family’s best mental health at every stage of life – from childhood, through adolescence, and to adulthood.
- US Family Health Plan and Suicide Prevention – Martin’s Point – if you or someone you know talks about suicide, self-harm, a mental health crisis, substance use crisis, or any other kind of emotional distress, get help right away.
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Low Back Pain: When (and When Not) to Image
Do you know what can keep you down longer than back pain? Unnecessary surgeries related to back pain.
Back pain is extremely common—roughly 75% of adults will experience low back pain in their lifetime. Similar to a sprained ankle, they often just require conservative treatment and time to feel better.Roughly 90-95% of back pains don’t require immediate imaging and will improve in a matter of weeks. Rushing to imaging can create more problems than it solves. Besides unnecessary exposure to radiation, it‘s not uncommon for abnormalities to be found during imaging that are harmless and not the cause of lower back pain. Unfortunately, these discoveries can lead to needless injections and/or surgeries which do nothing for the original complaint.
If you’re experiencing back pain, talk to your doctor about the best course of treatment. They can help you determine if imaging is necessary and, if so, what type of imaging is best for you.
Taking Control of Your Blood Pressure
Did you know that almost half of US adults have high blood pressure (above 130/80)? This common condition, also called hypertension, is considered a silent killer because, often, high blood pressure, itself, will lack any symptoms. Unfortunately, it can significantly raise the risk for heart attacks, strokes, and many other serious health conditions.
If you have high blood pressure, a first step in living a healthier life is taking steps to keep your blood pressure under control. This can start with understanding your risk factors for having this condition (some lifestyle-related risks can be controlled, but others like your own and your family’s medical history, your age, and your race cannot).
There are many things you can do to help manage your blood pressure, including making dietary changes, staying active, reducing stress, and more. There are also medications that act in different ways to help reduce your blood pressure.
If you know you have high blood pressure, talk with your doctor about the best ways for you to try to lower it and keep it under control. If you’re not sure if you have high blood pressure, make sure to get it checked soon and create a treatment plan with your doctor if it is too high.
Check out our Heart Health webpage to learn much more about the risk factors of high blood pressure, diagnosis/management, and common blood pressure medications used to treat this condition.
TRICARE® 2024 Prescription Copay Increases
For your planning purposes, we want to let you know that TRICARE will raise member prescription drug copays beginning January 1, 2024. These increases will affect all US Family Health Plan members except dependent survivors of active-duty service members (ADSMs), medically retired service members, and dependents of medically retired service members. These members will see no change in their prescription drug copays in 2024.
Here is a table of the new copays:
Please note that these are just the copay increases for prescription drugs. Other costs, such as deductibles and coinsurance, may also increase in 2024.
Don’t Risk Extra Costs: Get a Referral for Specialty Care
In most cases, if you receive specialty care without a referral from your PCP or other specialty provider, you will be subject to a higher cost share. By keeping your PCP at the center of your health care, referrals can ensure you receive appropriate care with the lowest cost share. Please note that a referral from your PCP or other referring physician does not imply or guarantee coverage or payment by the US Family Health Plan. For more information, visit https://martinspoint.org/pos. If you have questions about coverage, please call Member Services at 1-888-674-8734.
