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  • For Members & Patients

Point-of-Service Benefit

Referrals & Your Point-of-Service (POS) Option

The US Family Health Plan is a managed care program with two benefit levels:

  • Your TRICARE® Prime benefit level
  • The Point-of-Service (POS) option benefit level

When seeking specialty care, the benefit level you use is determined by the type of referral on file.


The US Family Health Plan Network

Members generally receive care and referrals from a contracted provider participating in the US Family Health Plan network—the doctors, health care providers, and hospitals who have agreed to take care of our members at negotiated rates. Seeing a provider who participates in the US Family Health Plan Network ensures you are receiving the highest quality of care from a broad network of clinicians who have passed our rigorous credentialing standards.


PCP-Managed Care

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.

Online Account Access
Access your Member Portal to find your benefits, check your claims and more. Log In/Register
Benefits and Plan Documents

Referrals

Most specialty services require a referral. Sometimes referrals are made for routine preventive care. Other times, referrals are made for a specific diagnosis and treatment. For instance, if you are experiencing ongoing foot pain, your PCP might refer you to a podiatrist or an orthopedist specializing in foot and ankle issues. Receiving specialty care without a health care provider’s referral is considered “self-referral” and claims for this care will generally apply your Point-of-Service (POS) option, which has a higher member cost share.
All prior authorization requirements apply, regardless of an approved referral. 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.


Your Point-of-Service (POS) Option

The Point-of-Service (POS) option allows you the flexibility to choose to see a TRICARE®-authorized provider without an approved referral. You will incur higher cost shares if you choose to use the Point-of-Service (POS) Option. 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 health care provider’s referral.

All prior authorization requirements apply when using the POS option.

Seeing an In-Network Provider: At this time, the Health Plan does not require a pre-service referral submission or approval, as long as the rendering provider participates in the US Family Health Plan network and indicates the referring provider on the claim


Seeing an Out-of-Network Provider

If you are referred to a provider who does not participate in the US Family Health Plan network, the referring provider must submit the referral request to the Plan for approval. If the referral is approved, your TRICARE® Prime benefit will apply.


When Services Are Not Available from an In-Network Provider

 If your referring provider feels it may be medically necessary for you to see a TRICARE®-authorized provider who does not participate in the US Family Health Plan network, they can submit a referral request to the Health Plan with supporting documentation. If the Health Plan approves the referral, services would be covered at the TRICARE® Prime benefit level.
During the determination process, the plan will review medical criteria and policies to determine which benefit level is appropriate. If it is determined that the referred services are available from a provider participating in the US Family Health Plan network, your referral request may be denied. You can still opt to use your Point-of-Service (POS) option for medically necessary covered benefits at a higher member cost share.


Point-of-Service (POS) Option Cost

When you use the Point-of-Service (POS) option to get care, you will pay a deductible of $300 per year for an individual or $600 per year for a family for covered services, and a cost share/coinsurance of 50% of the TRICARE® Maximum-Allowable Charge (TMAC).


Using POS Option with Out-of-Network Providers

When using your POS option with a TRICARE®-authorized provider who does not participate in the US Family Health Plan network, you may be subject to “balance billing.” You will be responsible for these costs, which may be amounts up to 115% of the TMAC.

The POS option only applies to TRICARE®-authorized providers. If the provider is not TRICARE® authorized, you will be responsible for the entire cost and no benefit level will apply.


Catastrophic Cap

 Any amounts paid for services received through the Point-of-Service (POS) 0ption are NOT applied to your maximum-out-of-pocket, or “catastrophic cap,” which means there is no maximum limit to these charges.


Prior-Authorization

 Prior authorization requirements still apply. A referral is a request for specialty care, not always a determination of medical necessity. A referral does not replace authorization or coverage requirements.