TRICARE and You: Understanding the right of first refusal

Written by Lt. Andrew Taylor, Health, Safety and Work Life Service Center

Capt. Steve Mescher, the Integrated Support Command Miami Dentist, and Magnolia Egemen, the dental assistant, clean a patient's teeth during his examination at the ISC Miami clinic Wednesday, Oct. 8, 2008.  The clinic provides physical examinations, immunizations and clinical laboratory, pharmacy and referral services to other treatment facilities for specialty care.  U.S. Coast Guard photo by Petty Officer 3rd Class Barry Bena.

Capt. Steve Mescher, the Integrated Support Command Miami Dentist, and Magnolia Egemen, the dental assistant, clean a patient’s teeth during his examination at the ISC Miami clinic Wednesday, Oct. 8, 2008. The clinic provides physical examinations, immunizations and clinical laboratory, pharmacy and referral services to other treatment facilities for specialty care. U.S. Coast Guard photo by Petty Officer 3rd Class Barry Bena.

Navigating the referral process for specialty medical care can be challenging for service members and their families. One of the items that frequently causes confusion is when you have a referral you think will be provided in the civilian sector, or are receiving care from a civilian provider, and are then drawn into a military medical facility.

When you are enrolled as a TRICARE Prime beneficiary and seek specialty care or treatment, military treatment facilities must first be considered – if they have the services available. This means if the military hospital or clinic has the capability to provide specialty care, it may choose to treat you rather than refer you to a civilian network provider. Therefore, a military treatment facility may exercise “right of first refusal”, or ROFR, to provide your health care within the military treatment facility.

Who does ROFR affect?

ROFR applies to all TRICARE Prime beneficiaries, including active duty members, and Prime enrolled retirees and family members, seeking specialty care outside a military treatment facility.

Why does ROFR exist?

ROFR is cost-effective for both you and the TRICARE program. By using military treatment facilities, there is no added cost of involving civilian providers, and you avoid a copayment.

How does ROFR work?

Your healthcare provider sends referral requests for specialty care through the TRICARE system and local (within a calculated 60 minute travel time) military treatment facilities are given the opportunity to review and determine if they can provide the care. If a military treatment facility does not respond or indicates that it cannot provide the care, you will be referred out to a civilian provider.

What happens when a military hospital or clinic chooses to treat me, exercising its ROFR?

You will receive written notification of a military treatment facility’s acceptance and provided instructions for scheduling an appointment. The military treatment facility may also contact you directly.

What if I don’t want to be seen in a military treatment facility? Do I have a choice?

In most cases you don’t have a choice. The government is already paying for military facilities and providers, so if you are referred out to a civilian provider, it is paying twice.

What if I’m already seeing a civilian specialist for my medical care? Will I have to switch providers if I get a ROFR notice?

Likely you will, unless switching providers would harm you in some way.

Is there a way I can exercise more control over my options so I can see the providers I want?

Yes, you can switch your enrollment to TRICARE Standard. Military treatment facilities do not have ROFR for TRICARE Standard enrollees. To have this additional degree of choice, you will have a higher out of pocket costs as Standard requires higher copays.

You can find more information about the ROFR process here.

If you need assistance in navigating your healthcare benefit, you may call a Coast Guard Health Benefits Advisor (HBA) at 1-800-9HBAHBA.

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