Maternity Care: Important Information for Expectant Mothers

What is new with maternity care in the military?

You have the privilege of making a choice for your maternity care. Beneficiaries whose first prenatal visit occurs on or after December 28, 2003, have more choices for their prenatal care, labor and delivery, and post-natal care under TRICARE. In 2001, Congress passed a law that allows uniformed services beneficiaries with TRICARE Standard to choose a civilian provider for maternity care, even if they live close to a military hospital. Beneficiaries will no longer need permission (a non-availability statement) from their local military treatment facility (MTF) to choose a civilian provider.

What are my options with TRICARE?

There are two main options when choosing a TRICARE package. These are TRICARE Prime and TRICARE Standard. Each option has its own advantages and disadvantages.

What are the benefits of TRICARE Prime?

TRICARE Prime uses military providers and hospitals and a network of civilian providers and hospitals. There are no yearly deductibles, and co-payments for individual provider visits are almost always less than in TRICARE Standard. In most locations, if you have TRICARE Prime you may choose a primary care manager either from a MTF or a civilian health care facility. MTF commanders are authorized to enroll beneficiaries to their MTF before beneficiaries enroll with civilian primary care managers in the network. The primary care manager is usually a family physician, internist, pediatrician, or obstetrician/gynecologist. This provider takes care of routine, outpatient medical problems and check-ups. If in-hospital or specialty care is required, including maternity care, you must go to the MTF if the services are available there. In most
cases, expectant mothers with TRICARE Prime must have their prenatal care and deliver their babies in the MTF when the MTF has obstetrical care available.

The Military Health System is committed to providing outstanding, family-centered and safe maternity care for all of our patients. We are professional health care providers who understand the unique needs of our military families, especially in today's climate of increasing deployments.

So what has changed for TRICARE Standard patients seeking maternity care?

Under the new law, a woman whose first prenatal visit occurs on or after December 28, 2003, may choose a civilian doctor or midwife for her prenatal care and have her baby in a civilian hospital under TRICARE Standard. This is available even if she lives near an MTF where maternity care is delivered. Under the maternity benefit, TRICARE pays the expenses for prenatal care, labor and delivery, and post-natal care. However, there is a co-payment for maternity care. The amount varies based on your length of stay in the hospital and your sponsor's status as an active duty or retired member. The initial newborn care also is covered under this plan, if the newborn is a dependent of an active-duty member or a retiree. The attached table shows possible out-of-pocket costs under TRICARE Standard and for those enrolled in TRICARE Prime.

I have TRICARE Prime and live in an area where the MTF provides obstetrical services. Do I have to switch to TRICARE Standard to get civilian maternity care?

To receive civilian maternity care, you have two options: use the TRICARE Prime Point-of-Service option, or disenroll from TRICARE Prime and convert to TRICARE Standard. While civilian maternity care may seem attractive, there are disadvantages to pursuing these options.

If you choose the Point-of-Service option, you will incur significant charges. The TRICARE Prime Point-of-Service option allows TRICARE Prime enrollees to receive nonemergency, TRICARE-covered services from any TRICARE-authorized provider without a referral from their primary care manager or authorization from a health care finder. Using the TRICARE Prime Point-of-Service option is more costly to the enrollee, and Point-of-Service charges are not subject to the catastrophic cap, which means you could pay more than $1,000 or $3,000 out of pocket in a fiscal year. However, with the Point-of-Service option, you remain enrolled in Prime.

If you switch to TRICARE Standard, you will not be able to re-enroll in TRICARE Prime for a period of one year unless your sponsor is E-4 or below. During this time, if you need medical attention other than maternity care, you will be subject to out-of-pocket expenses, such as deductibles and co-payments. For example, if a pregnant woman covered by TRICARE Standard is in a motor vehicle accident, these charges will apply. In addition, if an infant over three days of age sustains an injury or illness, these charges apply.

Most MTFs have the resources to take care of TRICARE Prime patients only. If you have TRICARE Standard, you may be required to seek care outside the military, paying the required deductibles and co-payments. These fees may be expensive. Whether or not medical care is available to TRICARE Standard patients varies from location to location, and even for different medical specialties at the same MTF. This sometimes results in unexpected out-of-pocket expenses. Your TRICARE service center can help with any questions about your situation. For additional information you also may check the TRICARE Web site at www.TRICARE.osd.mil.

 

BENEFICIARY COSTS FOR MATERNITY-RELATED CARE
	Prime				Standard/Extra
Type of Service or Fees	Active Duty Spouse	Retiree or Retiree Spouse	Active Duty Daughter	Retiree Daughter	Active Duty Spouse	Retiree or Retiree Spouse	Active Duty Daughter	Retiree Daughter
Annual Fiscal Year Deductible (applicable to outpatient services)	$0	$0	$0	$0	Applicable when beneficiary chooses to deliver at home or as an outpatient, with the exception of birthing center delivery. $50/individual or $100/ family for E-4 and below. $150/individual or $300/ family for E-5 and above.	Applicable when beneficiary chooses to deliver at home, in birthing center, or as an outpatient. $150/individual or $300/family.	Applicable when beneficiary chooses to deliver at home or as an outpatient, with the exception of birthing center delivery. $50/individual or $100/family for E-4 and below. $150/individual or $300/ family for E-5 and above.	Retiree DaughterApplicable when beneficiary chooses to deliver at home, in birthing center, or as an outpatient. $150/individual or $300/family.
Global Maternity Care Fee (when beneficiary chooses to deliver in hospital as inpatient) -- includes prenatal care, inpatient professional services for delivery, and postnatal care	$0	$0	$0	$0	Standard: $0 1 Extra: $0	Standard: 25% 1 of allowable charges. Extra: 20% of the fee negotiated by TRICARE contractor.	Standard: $0 1 Extra: $0	Standard: 25% 1 of allowable charges. Extra: 20% of the fee negotiated by TRICARE contractor.
Inpatient Professional Services for Newborn Care (that are not included in Global Maternity Fee such as services of pediatrician)	$0	$0	100% for newborn unless father is Active Duty or Retiree	100% for newborn unless father is Active Duty or Retiree	$0 as newborn is deemed enrolled in Prime for up to 120 days for cost-sharing purposes	Standard: 25% 1 of allowable charges unless the newborn is deemed enrolled in Prime. Extra: 20% of the fee negotiated by TRICARE contractor unless the newborn is deemed enrolled in Prime.	100% for newborn unless father is Active Duty or Retiree	100% for newborn unless father is Active Duty or Retiree
Hospital Services for Inpatient Delivery	$0	$11 per day ($25 minimum charge) for admission	$0	$11 per day ($25 minimum charge) for admission	$13.32 2 per day ($25 minimum charge) for admission	Standard: $459 2 ($441 effective May 1, 04) per day or 25% of billed charges whichever is less. Extra: $250 per day or 25% of TRICARE contractor negotiated charges whichever is less.	$13.32 2 per day ($25 minimum charge) for admission	Standard: $459 2 ($441 effective May 1, 04) per day or 25% of billed charges whichever is less. Extra: $250 per day or 25% of TRICARE contractor negotiated charges whichever is less.
Newborn Cost-Share for Hospital Services	$0	Same newborn date of birth and date of mom’s admission: $11 per day ($25 minimum charge) applies to the 4th and subsequent days of the newborn’s inpatient stay. Different newborn date of birth and date of mom’s admission: $11 per day ($25 minimum charge) applies to all days of the newborn’s inpatient stay.	100% for newborn unless father is Active Duty or Retiree	100% for newborn unless father is Active Duty or Retiree	$0 as newborn is deemed enrolled in Prime for up to 120 days for cost-sharing purposes	Standard: DRG HOSPITAL: Same newborn date of birth and date of mom’s admission: Unless the newborn is deemed enrolled in Prime, the cost-share will be the lower of the number of hospital days minus 3 multiplied by $4592 ($441 effective May 1, 04) OR 25% of billed charges. Standard: DRG HOSPITAL: Same newborn date of birth and date of mom’s admission: Different newborn date of birth and date of mom’s admission: Unless the newborn is deemed enrolled in Prime, the cost-share will be the lower of hospital days for the newborn multiplied by $4592 ($441 effective May 1, 04) OR 25% of billed charges. DRG EXEMPT HOSPITAL: 25% of allowed charges unless the newborn is deemed enrolled in Prime. Extra: Same newborn date of birth and date of mom’s admission: Unless the newborn is deemed enrolled in Prime, the cost-share will be the lower of the number of hospital days minus 3 multiplied by $250 OR 25% of TRICARE contractor negotiated charges. Different newborn date of birth and date of mom’s admission: Unless the newborn is deemed enrolled in Prime, the cost-share will be the lower of hospital days for the newborn multiplied by $250 OR 25% of TRICARE contractor negotiated charges.	100% for newborn unless father is Active Duty or Retiree	100% for newborn unless father is Active Duty or Retiree
Professional Services Fee When Beneficiary Chooses to Deliver at Home or as an Outpatient	$0	$12 per visit	$0 for mom. 100% for newborn unless father is Active Duty or Retiree.	$12 per visit for mom. 100% for newborn unless father is Active Duty or Retiree.	Standard: 20%1 of the allowable charge for mom. $0 for newborn as the newborn is deemed enrolled in Prime for up to 120 days for cost-sharing purposes. Extra: 15% of the fee negotiated by TRICARE contractor for mom. $0 for newborn as the newborn is deemed enrolled in TRICARE Prime for up to 120 days.	Standard: 25%1 of the allowable charge for mom. Unless the newborn is deemed enrolled in Prime, 25%1 of the allowable charge for services of the newborn’s provider if any. Extra: 20% of the fee negotiated by TRICARE contractor, for mom. Unless the newborn is deemed enrolled in Prime, 20% of the fee negotiated by TRICARE contractor for services of the newborn’s provider if any.	Standard: 20%1 of the allowable charge for mom. 100% for newborn unless father is Active Duty or Retiree. Extra: 15% of the fee negotiated by TRICARE contractor for mom. 100% for newborn unless father is Active Duty or Retiree.	Standard: 25%1 of the allowable charge for mom. 100% for newborn unless father is Active Duty or Retiree. Extra: 20% of the fee negotiated by TRICARE contractor for mom. 100% for newborn unless father is Active Duty or Retiree.
Prenatal Care, Outpatient Delivery, and Postnatal Care Provided by TRICARE Authorized Birthing Center (All Inclusive Rate) OR Maternity Care Ending in Childbirth in Hospital-Based Outpatient Birthing Room	$0	$25	$0	$25	$25	Standard: 25% of allowable charges. Birthing Center: Lesser of 25% of birthing center rate or 25% of billed charge. Hospital-Based Outpatient Birthing Room: 25% of billed charges. Extra: 20% of the fee negotiated by TRICARE contractor.	$25	Standard: 25% of allowable charges. Birthing Center: Lesser of 25% of birthing center rate or 25% of billed charge. Hospital-Based Outpatient Birthing Room: 25% of billed charges. Extra: 20% of the fee negotiated by TRICARE contractor.

 

OTHER HEALTH CARE
	Prime				Standard/Extra
Type of Service or Fees	Active Duty Spouse	Retiree or Retiree Spouse	Active Duty Daughter	Retiree Daughter	Active Duty Spouse	Retiree or Retiree Spouse	Active Duty Daughter	Retiree Daughter
Annual Enrollment Fee (includes ALL health care under Prime	$0	$230/individual, $460/family	$0	$230/individual, $460/family	N/A	N/A	N/A	N/A
Annual Fiscal Year Deductible (Applicable to outpatient services)	N/A3	N/A3	N/A3	N/A3	$50/individual or $100/family for E-4 and below. $150/individual or $300/family for E-5 and above.	$150 per individual or $300 per family.	$50/individual or $100/family for E-4 and below. $150/individual or $300/family for E-5 and above.	$150 per individual or $300 per family.
MTF Hospital	$0	$13.322/day	$0	$13.322/day	$13.322/day	$13.322/day	$13.322/day	$13.322/day
MTF Outpatient	$0	$0	$0	$0	$0	$0	$0	$0
Civilian Inpatient (Network Hospital)	$0	$11/day ($25 minimum charge per admission).	$0	$11/day ($25 minimum charge per admission).	$13.322/day ($25 minimum charge per admission).	Lesser of $250/day or 20% of the fee negotiated by TRICARE contractor for institutional services, plus 20% of the professional fee.	$13.322/day ($25 minimum charge per admission).	Lesser of $250/day or 20% of the fee negotiated by TRICARE contractor for institutional services, plus 20% of the professional fee.
Civilian Outpatient (Network Provider)	$0	$12 outpatient $30 emergency care $25 mental health ($17 group)	$0	$12 outpatient $30 emergency care $25 mental health ($17 group)	15% of the fee negotiated by TRICARE contractor	20% of the fee negotiated by TRICARE contractor	15% of the fee negotiated by TRICARE contractor	20% of the fee negotiated by TRICARE contractor
Civilian Inpatient (Non- Network Hospital)	50% of the allowed charges under the Point-of Service- option.	50% of the allowed charges under the Point-of Service- option.	50% of the allowed charges under the Point-of Service- option.	50% of the allowed charges under the Point-of Service- option.	Greater of $25 or $13.322/day.	Lesser of $4592/day (441/day effective May 1, 04) or 25% of billed charges plus 25% of allowed professional fees.	Greater of $25 or $13.322/day.	Lesser of $4592/day (441/day effective May 1, 04) or 25% of billed charges plus 25% of allowed professional fees.
Civilian Outpatient (Non- Network Provider)	50% of the allowed charges under the Point of Service option3	50% of the allowed charges under the Point of Service option3	50% of the allowed charges under the Point-of Service option3	50% of the allowed charges under the Point of Service option3	20%1 of allowed charges for covered service	25%1 of allowed charges for covered service	20%1 of allowed charges for covered service	25%1 of allowed charges for covered service
Civilian Inpatient Mental Health (Network)	$0	$40/day	$0	$40/day	$20/day ($25 minimum charge)	20% of institutional fee negotiated by TRICARE contractor plus 20% of professional fee negotiated by TRICARE contractor	$20/day ($25 minimum charge)	20% of institutional fee negotiated by TRICARE contractor plus 20% of professional fee negotiated by TRICARE contractor
Civilian Inpatient Mental Health (Non- Network)	50% of the allowed charges under the Point of Service option	50% of the allowed charges under the Point of Service option	50% of the allowed charges under the Point of Service option	50% of the allowed charges under the Point of Service option	$20/day ($25 minimum charge)	High Volume Hospital: 25% of hospital specific per diem. Low Volume Hospital: Lesser of $1642/day or 25% of billed charge. Residential Treatment Center: 25% of the allowed amount. Partial Hospitalization: 25% of the allowable amount, plus 25% of allowable professional charges.	$20/day ($25 minimum charge)	High Volume Hospital: 25% of hospital specific per diem. Low Volume Hospital: Lesser of $1642/day or 25% of billed charge. Residential Treatment Center: 25% of the allowed amount. Partial Hospitalization: 25% of the allowable amount, plus 25% of allowable professional charges.
Civilian Inpatient Skilled Nursing Facility Care (Network)	$0	$11/day ($25 minimum charge per admission).	$0	$11/day ($25 minimum charge per admission).	$13.322/day ($25 minimum charge per admission).	Lesser of $250/day or 20% of the fee negotiated by TRICARE contractor for institutional services, plus 20% of the professional fee negotiated by TRICARE contractor.	$13.322/day ($25 minimum charge per admission).	Lesser of $250/day or 20% of the fee negotiated by TRICARE contractor for institutional services, plus 20% of the professional fee negotiated by TRICARE contractor.
Civilian Inpatient Skilled Nursing Facility Care (Non-Network)	50% of the allowed charges under the Point of Service option.	50% of the allowed charges under the Point of Service option.	50% of the allowed charges under the Point of Service option.	50% of the allowed charges under the Point of Service option.	$13.322/day ($25 minimum charge per admission).	25% of allowed charges for institutional services, plus 25%1 of allowable professional charges.	$13.322/day ($25 minimum charge per admission).	25% of allowed charges for institutional services, plus 25%1 of allowable professional charges.
Home Health Care (Network)	$0	$12/visit	$0	$12/visit	15% of the fee negotiated by TRICARE contractor	20% of the fee negotiated by TRICARE contractor	15% of the fee negotiated by TRICARE contractor	20% of the fee negotiated by TRICARE contractor
Home Health Care (Non- Network)	50% of the allowed charges under the Point of Service option3	50% of the allowed charges under the Point of Service option3	50% of the allowed charges under the Point of Service option3	50% of the allowed charges under the Point of Service option3	20%1 of the allowable charge	25%1 of the allowable charge	20%1 of the allowable charge	25%1 of the allowable charge
Ambulatory Surgery (Network)	$0	$25	$0	$25	$25	20% of the fee negotiated by TRICARE contractor	$25	20% of the fee negotiated by TRICARE contractor
Ambulatory Surgery (Non- Network)	50% of the allowed charges under the Point of Service option.	50% of the allowed charges under the Point of Service option.	50% of the allowed charges under the Point of Service option.	50% of the allowed charges under the Point of Service option.	$251	Lesser of 25% of group rate or 25% of billed charge1	$251	Lesser of 25% of group rate or 25% of billed charge1
Durable Medical Equipment (DME), Prosthetic Devices, and Medical Supplies	0% of the fee negotiated by TRICARE contractor	20% of the fee negotiated by TRICARE contractor	0% of the fee negotiated by TRICARE contractor	20% of the fee negotiated by TRICARE contractor	Standard: 20%1 of the allowable charge. Extra: 15% of the fee negotiated by TRICARE contractor.	Standard: 25%1 of the allowable charge. Extra: 20% of the fee negotiated by TRICARE contractor.	Standard: 20%1 of the allowable charge. Extra: 15% of the fee negotiated by TRICARE contractor.	Standard: 25%1 of the allowable charge. Extra: 15% of the fee negotiated by TRICARE contractor.
Ambulance Services	$0	$20 per occurrence	$0	$20 per occurrence	Standard: 20%1 of the allowable charge. Extra: 15% of the fee negotiated by TRICARE contractor.	Standard: 25%1 of the allowable charge. Extra: 20% of the fee negotiated by TRICARE contractor.	Standard: 20%1 of the allowable charge. Extra: 15% of the fee negotiated by TRICARE contractor.	Standard: 25%1 of the allowable charge. Extra: 20% of the fee negotiated by TRICARE contractor.
Laboratory X-Ray, and Ancillary Services	$0	$12 per visit. Note: No copay when provided and billed as clinical preventive services and no copay for specified CPT code ranges.	$0	$12 per visit. Note: No copay when provided and billed as clinical preventive services and no copay for specified CPT code ranges.	Standard: 20%1 of the allowable charge. Extra: 15% of the fee negotiated by TRICARE contractor.	Standard: 25%1 of the allowable charge. Extra: 20% of the fee negotiated by TRICARE contractor.	Standard: 20%1 of the allowable charge. Extra: 15% of the fee negotiated by TRICARE contractor.	Standard: 25%1 of the allowable charge. Extra: 20% of the fee negotiated by TRICARE contractor.
Clinical Preventive Services	$0	$0	$0	$0	Not covered	Not covered	Not covered	Not covered
Routine Pap Smears	$0	$0	$0	$0	Standard: 20%1 of the allowable charge. Extra: 15% of the fee negotiated by TRICARE contractor.	Standard: 25%1 of the allowable charge. Extra: 20% of the fee negotiated by TRICARE contractor.	Standard: 20%1 of the allowable charge. Extra: 15% of the fee negotiated by TRICARE contractor.	Standard: 25%1 of the allowable charge. Extra: 20% of the fee negotiated by TRICARE contractor.
MTF Pharmacy	$0	$0	$0	$0	$0	$0	$0	$0
TRICARE Retail Network Pharmacy	$3/generic $9/brand (30-day supply)	$3/generic $9/brand (30-day supply)	$3/generic $9/brand (30-day supply)	$3/generic $9/brand (30-day supply)	$3/generic $9/brand (30-day supply)	$3/generic $9/brand (30-day supply)	$3/generic $9/brand (30-day supply)	$3/generic $9/brand (30-day supply)
TRICARE Mail Order Pharmacy	$3/generic $9/brand (30-day supply)	$3/generic $9/brand (30-day supply)	$3/generic $9/brand (30-day supply)	$3/generic $9/brand (30-day supply)	$3/generic $9/brand (30-day supply)	$3/generic $9/brand (30-day supply)	$3/generic $9/brand (30-day supply)	$3/generic $9/brand (30-day supply)
Non-network Pharmacy4	50% of cost	50% of cost	50% of cost	50% of cost	> of $9 or 20% of cost	> of $9 or 20% of cost	> of $9 or 20% of cost	> of $9 or 20% of cost
Catastrophic Cap	$1000	$3000	$10005	$30005	$1000	$3000	$10005	$30005

Non-participating provider may bill the beneficiary up to an additional 15% of TRICARE allowable charges.

1. This amount is updated each fiscal year.
   
2. Under the Point of Service Option, there is an outpatient deductible of $300/individual and $600/family.
   
3. Non-network pharmacy use is subject to outpatient deductibles.
   
4. This does not include the cost of care for the newborn infant.

Click Here to read the (AAP) policy in reference to Family-Centered Care

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