What is the Catastrophic Cap for Tricare – Overview
Every person requires extensive medical checkups, weekly doctor visits, different diagnostic tests, and long hospital tests at some point in their life.
Eventually, you may reach your catastrophic cap to maintain your health. In this article, we will talk about the catastrophic cap for Tricare.
Catastrophic Cap and Tricare
A catastrophic cap is when you need to pay the maximum part of your bill from your own pocket for a covered service in a calendar year.
When a Tricare user reaches their catastrophic cap, Tricare often pays a part of that expense, which is called the Tricare allowed amount for the rest of the calendar year.
Tricare offers different amounts for different people depending on who they are. People who use Tricare Reserve Select or TRS receive $1000 per family yearly from Tricare. Tricare pays the same amount for all active-duty family members.
People from the retiree category receive the catastrophic cap of $3000 or $3500, depending on their beneficiary group.
The catastrophic cap applies to different covered services, including pharmacy copayments, annual deductibles, and other cost shares.
What Costs Do Count Towards Your Catastrophic Cap?
What is the Catastrophic Cap for Tricare – Pharmacy copayments
- The cost of healthcare services that are covered by Tricare
- Costs for outpatient and inpatient
- All pharmacy copayments
- All the deductibles
- Any other cost-shared charges depending on Tricare allowable charges, provider type, and locations
Where is the Catastrophic Cap Inapplicable?
Here are some situations where you can not apply the Catastrophic Cap.
- Services that Tricare does not cover
- Extended Care Health Option sponsor
- Beneficiary liabilities
- The Tricare prime point of service charges
- Any charges from the nonparticipating providers
- Enrolment fees for Tricare select and Tricare prime
- Monthly premiums for Tricare Retired Reserve (TRR), Tricare Reserve Select (TRS), Tricare Young Adult (TYA), and Continued Health Care Benefits Program (CHCBP)
What Are the two Beneficiary Groups?
There are two beneficiary groups; Group A and Group B. If you or your sponsor started the initial appointment or enlistment before January 1, 2018, you belong to Group A.
However, if you or your sponsor started the initial appointment or enlistment on or after January 1, 2018, you belong to Group B.
What Happens After You Reach Your Catastrophic Cap?
When you reach your Catastrophic Cap of a calendar year, you do not have to pay for the Tricare allowable charges for any covered healthcare services.
However, you need to pay for things that are not under the Catastrophic Cap protection, including point of service charges, amounts billed by nonparticipating providers, and payments of all noncovered services.
If you belong to group B and reach your catastrophic year and you have enrolled for TRR, TRS, TYA, or CHCBP, you do not have to pay for your covered services or supplies for the rest of the calendar year. However, you have to pay your monthly premiums.
If you have enrolled for Tricare Prime or Select benefits and you have reached your Catastrophic Cap, you do not have to pay your enrollment fees for the rest of the calendar year.
Catastrophic Cap for Tricare Prime in 2023
| Status | For Group A | For Group B |
|---|---|---|
| Anyone other than the active-duty family members | $3000 | $4262 |
| Medically retired service members and their families, Survivors of active duty deceased sponsor | $3000 | $4262 |
Catastrophic Cap for Tricare Select in 2023
| Status | Group A | Group B |
|---|---|---|
| Anyone other than the active-duty family members | $4028 | $4262 |
| Medically retired service members and their families, Survivors of active duty, deceased sponsor | $3000 | $4262 |
Catastrophic Cap for Tricare Prime and Tricare Select in 2023
| Status | Group A | Group B |
|---|---|---|
| Active duty family member | $1000 | $1217 |
Catastrophic Cap for Active Duty Members in 2023
| Status | Catastrophic Cap |
|---|---|
| Family members who are enrolled in Tricare Select Tricare Prime A combination of both Tricare Select and Tricare Prime | $1000 per family |
| Spouse who are enrolled in Tricare Prime Family members who are enrolled in Tricare Young Adult (TYA) | $1000 for Prime enrollees $1217 for Tricare Young Adult (TYA) enrollees The total family Catastrophic Cap is $1217 |
Catastrophic Cap for Retirees in 2023
| Status | Catastrophic Cap |
|---|---|
| Group A family members who are enrolled in Tricare Prime, Tricare Select, and a combination of both Tricare Select and Tricare Prime | $3000 per family for Prime enrollees $4028 per family for Select enrollees |
| Group A spouse and one child is enrolled in Tricare Select and another child is enrolled in Tricare Young Adult (TYA) | $4028 for Tricare Select enrollees $4262 for Tricare Young Adult (TYA) enrollees |
| Group B spouse and one child is enrolled in Tricare Select, and another child is enrolled in Tricare Young Adult (TYA) | $4262 per family |
Conclusion
Tricare Catastrophic Cap offers several benefits for military people and helps them receive the healthcare services they require. Tricare offers a specific amount when you reach your Catastrophic Cap depending on certain things.
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