How Much Does Tricare Cover for Maternity Costs for HPSP Recipients?
If you are an HPSP recipient expecting a baby within your active duty window, it is important to know how much of the cost Tricare will cover.
The most important thing to understand is that as long as the wife has another insurance, Tricare will always be the secondary insurance. This means that your primary insurance will be billed first and then Tricare will be billed. The primary insurance will be billed normally, as if you have no other insurance. You will be required to pay the deductible to your primary insurance before they pay their portion. Your primary insurance will have an allowable amount that they’ve agreed upon with your hospital for maternity and delivery costs. They will pay a percentage of that amount based on your plan, after you’ve paid your deductible. Whatever is left after that, will be billed to Tricare, and they will pay the remainder of the bill, up to their allowable amount.
This is difficult to understand without real numbers so let’s create a scenario. Let’s assume your doctor bills for all services at the time of delivery. Let’s say the bill is $21,000. Your primary insurance, however, has agreed to pay $10,000. The hospital writes off $11,000 immediately due to the contract they have with your primary insurance. Your deductible is $2,000 which goes toward the $10,000 the insurance has agreed to pay. Now there is $8,000 left on the bill. Your insurance plan states that it will pay 90% after your deductible is met. 90% of $8,000 is $7,200. Out of the $10,000 owed to the doctor, the primary insurance has paid $7,200 and you have paid $2,000. There is still $800 left on the bill. A breakdown of all of these payments are then sent to Tricare. They make sure you met your deductible with the primary insurance and then decide how much, if any, they will pay toward the remaining amount. They will only pay up to a total of their allowable amount, which includes what has already been paid by the primary insurance. For example, if Tricare’s allowable amount is only $8,000 and your primary insurance has already paid $9,200 (between insurance and your deductible) then Tricare will not pay any more toward your bill. However, if Tricare’s allowable amount is $10,000 and your primary insurance has already paid $9,200 (between insurance and your deductible) then Tricare will pay the remaining $800. Whatever Tricare does not pick up, you will be responsible to pay, on top of your deductible, up to your yearly maximum. You will not be required by your primary insurance to pay more than your yearly maximum out of pocket.
If Tricare were the primary insurance during active duty (which is only possible if they are the only insurance) then things would be much simpler. Tricare would pay for everything, and all that would be expected of you is a couple hundred bucks. So why not just have your wife quit her job, get off her insurance, and only be on Tricare during your active duty window when she is expecting? Simply put, this is extremely risky and may not be beneficial. Tricare will only pay for services rendered during the active duty period. As many doctors bill for all services at the time of delivery, all of the prenatal appointments leading up to the delivery would be included in the total. Tricare would not pay for these prenatal appointments, however. If you’ve cancelled your other insurance, now you are stuck paying the bill for nine months of doctors’ visits leading up to the delivery. Also, it isn’t very easy to get on and off of insurances, so it isn’t wise to cancel your the expectant mother's primary insurance just to save a few hundred dollars.
The best thing to do is keep the expectant mother on her primary insurance, under a plan that saves you the most money for the year she’ll be delivering in between the deductible and the monthly premiums. When the baby is born during your active duty window, pay your deductible and hope that between your primary insurance and Tricare, most of the remaining costs are covered. It would not be wise to rely on just one insurance or the other.
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*This information is provided as a resource and should not be solely relied upon for information regarding insurance benefits as an HPSP recipient. Specific questions should be answered directly by the HPSP representative for your military branch.