When it comes to staying healthy, some years are better than others. Perhaps you or your family faced a bumpy road this year. There may have been extensive medical tests or procedures, lengthy hospital stays, or weekly doctor visits. You may have reached — or are close to reaching — your catastrophic cap. A catastrophic cap is the most you pay out of pocket for covered services each year. This protects you because it limits the amount of out-of-pocket expenses a family pays for TRICARE covered medical services.

Your catastrophic cap amount depends on who you are. For active duty family members or families using TRICARE Reserve Select (TRS), the cap is $1,000 per family, per year. Those in a retiree category have a catastrophic cap of either $3,000 or $3,500, depending on your beneficiary group: Group A If you or your sponsor’s initial enlistment or appointment occurred before January 1, 2018, you are in Group A. or Group B If you or your sponsor’s initial enlistment or appointment occurs on or after January 1, 2018, are in Group B.

The catastrophic cap applies to all covered services. This includes annual deductibles, pharmacy copayments, and other cost-shares based on TRICARE-allowable charges. The catastrophic cap doesn’t apply to:

Services not covered by TRICARE

Any amount that non-participating providers may charge above the TRICARE-allowable charge. The maximum amount TRICARE pays for each procedure or service. This is tied by law to Medicare’s allowable charges for services.

TRICARE Prime point-of-service charges

Enrollment fees for TRICARE Prime and TRICARE Select

Monthly premiums for TRS, TRICARE Retired Reserve or TRICARE Young Adult

What happens when you reach your catastrophic cap in a calendar year? You don’t pay any more of the TRICARE-allowable charge for covered services. But you’ll have to pay for services that don’t fall under the catastrophic cap protection. These include amounts billed by non-participating providers (up to 15 percent above the allowable charge), point-of-service charges, and all costs for non-covered services.

If you’re an active duty member who retires mid-year, don’t worry. The full deductible and cost-shares credited towards the previous family cap will be credited to the new cap.

Learn more about TRICARE costs or download the Costs and Fees Sheet on the TRICARE Publications page. You can also view and compare health plan costs using the new TRICARE Plan Comparison Tool. Take command of your health and understand your TRICARE benefit in 2018.

(0) comments

Welcome to the discussion.

Keep it Clean. Please avoid obscene, vulgar, lewd, racist or sexually-oriented language.
Don't Threaten. Threats of harming another person will not be tolerated.
Be Truthful. Don't knowingly lie about anyone or anything.
Be Nice. No racism, sexism or any sort of -ism that is degrading to another person.
Be Proactive. Use the 'Report' link on each comment to let us know of abusive posts.
Share with Us. We'd love to hear eyewitness accounts, the history behind an article.