Demystifying the point-of-service option (East Region)

Medical bills can feel overwhelming. Unexpected charges can turn what feels like a routine visit into a financial burden. Understanding TRICARE’s point-of-service option can help you avoid a surprising charge. Otherwise, you could be responsible for point-of-service fees in situations where you weren’t expecting charges.

Point-of-service fees apply when a TRICARE Prime beneficiary receives nonemergency care from a provider without a referral from their primary care manager, or when they obtain preventive care, such as a colonoscopy or Pap test, from a non-network specialist. This doesn’t apply to active duty service members.

If you’re a TRICARE Prime beneficiary and receive care as described above, then you could be responsible for financial costs, as a PCM referral is required for all specialty careSpecialized medical/surgical diagnosis, treatment, or services a primary care provider isn’t qualified to provide.. So, as a beneficiary, here’s a helpful idea to keep in mind: “If a referral isn’t on file, then I’ll have a high deductible and cost-shareA percentage of the total cost of a covered health care service that you pay..”

With the point-of-service option, first, you must first meet a $300 deductible ($600 for a family). After reaching the deductible, you’ll pay for the services you receive (also called a cost-share). This charge will be 50% of the TRICARE-allowable chargeThe maximum amount TRICARE pays for each procedure or service.  This is tied by law to Medicare's allowable charges.. You can’t apply these costs towards your catastrophic cap.

You may be asking, “How do you know if an appointment could trigger the point-of-service option?” Here are some common situations.

Scenario #1:

You want to stay on top of your preventive care. You schedule a colonoscopy with a gastroenterologist that your friend said was a good doctor. You don’t ask your PCM for a referral. You have your test and—good news!—everything is clear. Bad news: Even though it was for preventive care, the doctor wasn’t in-network, and now you’re on the hook for point-of-service fees.

Result: While your benefit covers preventive services, you need a referral for the specialist. If during the referral process, a network provider isn’t available, TRICARE East may allow you to see a non-network provider. However, if you don’t follow the process, you’ll be responsible for point-of-service fees.

Solution: The easiest way to ensure you’re seeing a specialist who is a network provider is to obtain a referral through your PCM, as the referral process makes sure of the provider’s status.

Scenario #2:

You have a mole on your arm that looks suspicious. You find a dermatologist on the Find a Provider Tool and make sure they’re a network provider with TRICARE East. Then you call their office and make an appointment. You want to stay on top of your health concerns—no one wants skin cancer. However, you need a referral from your PCM for that appointment to be covered.

Result: You’d be responsible for the fees related to this appointment, per the point-of-service option, because you didn’t see your PCM first and get a specialty care referral.

Solution: Not getting a referral for specialty care can cause you to incur point-of-service fees. Get a referral for all specialty care.

Scenario #3:

Your PCM recommends seeing a specialist for a medical concern you have. They tell you they’ll make a referral on your behalf. You reach out to the specialist directly for an appointment. You think, “What’s the difference? I’m going to the specialist they recommended; I just don’t want to wait on the referral.”

Result: If you see the specialist before the referral is processed, you’ll use the point-of-service option and incur related fees.

Solution: To check the status of your referral, log in to the TRICARE East beneficiary portal. Check to see if a referral was submitted, and, if not, contact your PCM.

The best ways to protect yourself from added expenses:

• Always get a referral for specialty care to avoid point-of-service fees.
• Confirm your referral status through the beneficiary portal.

By following these guidelines, you can help safeguard your health and the impacts on your wallet.

Learn more about point-of-service.