Healthcare in the Military: Standard vs. Prime/ Our Doctors


We have had many questions from both local friends and far away family as to the doctor’s we are seeing and care we are receiving through the military’s health insurance, Tricare. I am very happy to say that our experiences with both have been fantastic and are incredibly thankful for our team of doctors, and financial security which allows us to focus on caring for Walter – not how to finance it. Wally’s special care, hospital stay, and repair could add up to the hundreds of thousands of dollars. Not to worry – that is precisely why we have insurance, and why we’ve made the financial decisions we have chosen so as to ensure our security. Our out of pockets will be relatively minimal.

 

TRICARE PRIME

When I found out I was pregnant, I was on the Tricare “Prime” network. The option is essentially what I dub a military HMO. It directs your care by way of a Primary Care Manager, requires that your initial visits all be on base within the military network, and if necessary, refers you out to designated specialists. Honestly, just getting my pregnancy test was a bit of a hassle – between getting the appointment scheduled, showing up at the Navy Health Clinic, and following up after that, it all felt tedious and bureaucratic. To be fair, the facilities are exceptionally nice/clean, and the staff helpful and friendly. Personally I grew up on a PPO and am not particularly fond of the referral process HMO’s require. Prime does come with the clear benefit of zero out-of-pocket: no co-pays, no fees, so long as you follow the military’s referral process.

PROS: all covered services are covered at 100%, no co-pays, and most care is conveniently located on base.

CONS: You are not directing your own care and wait times between referrals can be frustratingly long – if you get the referral in the first place.

  

TRICARE STANDARD

However, as a working pregnant lady, time is truly gold, and choosing an OBGYN I could count on, I was comfortable with, and who was philosophically on the same page as me regarding care and delivery was important. I took a recommendation from a friend to find my OB, and have been THRILLED with my decision. (I’ll detail specifically about the practice later). Being on Standard allowed me to chose my OB, the hospital where I would deliver, and I can’t help but believe sped up the process with meeting the special doctors we now need for Wally.

In a matter of 24 hours after Walter’s initial anatomy scan, we had reviewed ultrasound findings with the OB, had an echocardiogram with our perinatologist, driven to DC Children’s hospital for an additional echocardiogram/fetal heart monitoring, opted to take part in a research study, and met with our fetal heart team: pediatric cardiologist, pediatric cardiothoracic surgeon, nurse coordinator, and social worker. Though at the point Walter’s ToF was confirmed we would have in all likelihood been referred out of the military network to DC Children’s Hospital – there is no way that paperwork and processing could have occurred in the timely manner it did for us when not waiting on a referral. Also, I can’t help but wonder whether Walter’s ToF would have been detected in the first place, as our OB’s sonographer has her experience in high risk pregnancies with a perinatologist’s office and knew exactly what to look for.

 Now here’s the great part: on Tricare Standard, maternity care is covered at 100% as well. All of these visits and specialists are covered by Tricare Standard without out-of-pocket cost shares from us. So really, there are few reasons to NOT be on Standard for maternity. Granted, any care that is not maternity while on standard will have a co-pay of 5% – 20% depending on whether the provider is part of the (Standard “Extra” network). Still, I don’t have a problem cost sharing in preventative care and including a little bit of an incentive structure to the care I receive. The most comforting aspect of the whole system is that deductible per person (before Tricare kicks in) is $150, and the per family deductible is $300. Even better is that the “catastrophic out-of-pocket cap” is $1000 – meaning that once our cost shares total a thousand dollars as a family, Tricare covers our care at 100%. That is definitely a price I am willing to pay for freedom of provider. Active Duty service members must remain on Prime. It makes sense from a logistical prospective (so their care can be overseen by command), and it does appear that active duty service members receive priority in scheduling and wait times (as they should).

 As for newborns, they are covered for the first 60 days of life by PRIME regardless of whether the mother is Standard or Prime. In Wally’s case, he will not be moved or have doctors changed because of this, and his initial hospital stay will be covered in full. I’m still unclear whether his surgery will fall under total wellness care (100%) or Standard, but either way, footing the bill with the catastrophic cap in place is something we can already set aside for our family’s medical needs. Knowing that the hospital stays and surgeries Wally will require will likely cost in the hundreds of thousands of dollars, we are incredibly humbled and grateful for the health insurance the Marines have provided us.

 PROS: choose your own provider and doctors (most around military bases accept Tricare), seek the doctors/specialists you choose without waiting on your PCM (Primary Care Manager) or paperwork for a referral to process.

  • Co-pays are 5% – 20% depending on the provider (Standard Extra, in preferred network will be less)
  • Per/person deductible: $150, Per/family deductible: $300
  • Max out of pocket per family per year is $1000 (Catastrophic Cap)
  • Maternity care is covered at 100%, with the exception of the Maternity hospital stay for delivery which is usually around $25/day
  • There is no additional cost to be on Standard from your Service Member’s paycheck

CONS: You will likely spend at least your deductible, and depending on your needs up to $1000/year

  • Currently, it appears that service members cannot set up HSA’s (Health Spending Accounts) which allow you to set aside sums of pre-tax dollars for the sole purpose of health care costs (such as that $1000 cap if you know you will likely hit it). Most private companies offer HSA’s so if a spouse works outside of the military he/she can set one up for this purpose. The issue is currently being considered by Congress, but…who knows
  • Once you “disenroll” from Prime, you cannot re-enroll for one year

Rx: I want to include that regardless of whether you are covered by Prime or Standard, most prescriptions taken to the Navy Health Clinic are covered at 100% (with super short walk-in wait time). Off base doctors can’t call in prescriptions to the Navy Health Clinic, so you just need to get the signed Rx in hand, take it to the window, and volai! – medicine!

________________________________

Our Doctors:

 OBGYN: Elite Women’s Health (located at Mary Washington Hospital)

  • Dr. Patel, Dr. Stadulis, Dr. Colon
  • All have been wonderful through this process, handle high risk pregnancies, and are readily available, timely, and informative. I never feel rushed at an appointment and they have outstanding bedside member.
  • They have repeatedly taken the extra steps to make sure the process is running smoothly for us, even calling at home to check and see “how we’re doing”

Perinatologist: Maternal Fetal Medicine (located at Stafford Hospital)

  • Dr. Dhillion is outstanding in all aspects. She has stayed after hours to meet with us, made and taken phone calls at 10 pm to set up specialist appointments, and been delightfully encouraging the entire time. She oversees all of Walter’s growth scans and gave us the initial ToF dx. She takes great care in her work, while not sugar coating the realities Walter’s condition. Definitely recommend for anyone needing to see a peri!

Fetal/Peds Cardiologist: DC Children’s Hospital Fetal Heart Team

  • Dr. Donofrio has been as equally outstanding as the rest: coming in on a day off to meet with us, spending time to explain options/procedures, and giving us confidence in Walter’s surgery. The entire team from the research staff to the nurses and social workers are extremely helpful and responsive.

Peds Cardio Thoracic Surgeon: Dr. David Jonas, DC Children’s

  • I have only met Dr. Jonas once and very briefly (because he is most often in surgery), but he too helped to explain the anticipated timing of Walter’s surgery, procedure, and outlook. He is, naturally, incredibly qualified and successful in his field, and we are looking forward to meeting with him again after Wally is born to truly detail the exact plan and procedure for Walter’s heart.
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2 thoughts on “Healthcare in the Military: Standard vs. Prime/ Our Doctors

  1. Great information. I hope that some other parents looking for answers for their babies with TofF will find your blog helpful. You know, as a Granny and your Mom, I love information. ❤ ❤ ❤

    Like

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