TRICARE and You: Understanding the right of first refusal

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.

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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.

3 comments on “TRICARE and You: Understanding the right of first refusal”

  1. Currently I have both Tricare Standard and BCBS Federal for my spouse and I for all our medical needs. I’m about to retire from the Federal Government in a couple of years and am wondering do I really need to carry over my BCBS into retirement. My spouse has a counselor, psychiatrist, and is undergoing magnetic treatments through another neurologist. Currently I don’t pay anything out of pocket in deductibles, but hey the cost of coverage is going up when I turn 60 years old and after I’m retired. Who can I sit with and go over in English all my options to each of my individuals needs? BTW she’s on Medicare and collecting disability

  2. While I do understand the argument for ROFR, I of course don’t agree with the practice as currently written. In my experience, getting to the MTF was 2 hours each way, which put my family and myself in harms way and created added costs which could neither be reimbursed nor deducted from taxes, including transportation (wouldn’t meet % of AGI at tax time) and child care. This article doesn’t refer to a catchment zone, but one exists in my experience. In the case of my family, we actually choose to move to avoid a 4 hour round trip. I feel the government should provide shuttles and care locations if they are really going to make this ask of military families.

    An additional problem is continuity of care. When I started at the MTF with my health issue, I was able to see the same person for only 1 year before he was transferred. It is unacceptable to diminish the quality of my care because of the selection made in ROFR. I had a chance to build a lasting relationship with a provider that would have stayed in the area as long as I, but it was taken away.

    Lastly, the suggestion that someone switch to Tricare Standard is irresponsible. I feel confident that the great majority of people (including myself) do not understand the complete impact this decision would have on their financial health. If they are experiencing a significant health crisis and have been referred to a well recognized specialist, they will not have the mental capacity or space to sit down and weigh these pros and cons. It would be unduly stressful to ask them to do that. Should switching prove to be too costly for them, they are also locked from switching back for 1 year. It would be more acceptable if they had the option to see that particular provider under Tricare Standard.

    I do understand that this healthcare is provided at little to no costs for military families, and as such complaining about it can seem distasteful. However, I also know of all the sacrifices military families are making, and being able to fully enjoy the promised benefits doesn’t seem like a lot to ask.

    1. Jack,

      Thank you very much for voicing these concerns and experiences. We will ensure they are passed along.

      Very Respectfully,
      LT Katie Braynard
      Coast Guard Public Affairs

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