Point of Service Benefit

The US Family Health Plan is a TRICARE Prime plan – which means it is a network-based HMO type plan. Members generally receive health care from one of our contracted network providers – the doctors, health care providers, and hospitals who have agreed to take care of our members. Recently, however, TRICARE introduced the Point-of-Service benefit, which allows for more flexibility in seeing out-of-network providers.

Please read the information below before you decide to use the point of service option.

While this benefit can give you greater freedom, you should be sure you understand what your out of pocket costs will be before you use this option.  You may also want to call Member Services to talk through your options before you seek care from out-of-network providers.

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Q:

What is the point-of-service (POS) benefit?

A:

The point-of-service feature gives you the option, at an additional cost, to receive non-emergency health care services from any TRICARE-authorized provider without a referral from your Primary Care Provider. We still strongly encourage you to have your Primary Care Provider give you a referral, as your PCP knows your health the best and can help you choose the best specialist for your care.

Q:

What will it cost?

A:

When you use the point-of-service option to get care outside of the US Family Health Plan network, you will pay a deductible of $300 per year for an individual or $600 per year for a family for outpatient services, and a cost share for inpatient and outpatient services of 50% of the TRICARE allowable charge. In addition, you may be subject to “balance billing” by the provider. Any services received through the point-of-service benefit are NOT applied to your “catastrophic cap,” which means there is no maximum limit to these charges. If the provider you want to see does not participate with Medicare or TRICARE, you might be responsible for the entire bill.

Q:

This sounds expensive. Why would I want to do this?

A:

Some members desire to seek health care outside of our network, without getting a referral from their Primary Care Provider. This option provides some coverage for them to do so.

Q:

Do I still need prior authorization from the US Family Health Plan for services when I use the point-of-service option?

A:

You may. Some health care services, such as knee replacement surgery, require authorization by Martin’s Point in order to be covered. When in doubt, you should always call Member Services to check.

Q:

When doesn’t POS apply?

A:

The POS does not apply to:
• Newborns and adopted children during the first 60 days after birth or adoption
• Emergency care
• Clinical preventive care received from a network provider
• The first eight outpatient behavioral health care visits to a network provider per fiscal year (October 1–September 30)
• Radiology
• Pathology
• Anesthesiology while inpatient
• If you have other health insurance
• Care being sought is not TRICARE benefit or is determined not to be medically necessary

Additionally Zostavax vaccine, non-emergent ambulance, diagnostic services, dialysis, diagnostic drugs, and sleep studies are not subject to POS.

This is not a comprehensive list; depending on billing, there may be other services that may or may not be covered under your POS benefit. 

Q:

What if I have specific questions?

A:

Please call Member Services at 1-888-674-8734 to discuss specific questions you may have about the point-of-service option.