Originally Posted by dlm194
Ohhh!!! Wait a sec, I think I see where I'm in error. MarineWife ~ you are saying the provider can charge up to 15 or 20% more....So if a midwife normally charges $4000 but Tricare will only "allow" $2000, the midwife can only charge up to $400 more (20% of 2000).
It's not more than 15% above the TC allowable charge. So, that would mean if TC allows $1500 for a homebirth, which is what I've been quoted by everyone I've spoken with, and your provider is non-participating, the provider cannot charge you more than $225 extra. They don't have
to charge you that but they can if they choose. That's in addition to the deductible and cost-share, though.
Using the above example, if you are E-4 or below, that would be a $50 deductible plus a 20% cost-share, $300, plus the $225. The total out of pocket for you would be $575. If you are E-5 or above, the deductible is $150 so the total cost out of pocket for you would be $675.
That is all for a non-participating provider. A participating provider, whether in-network or out-of-network, cannot charge you anything more than your deductible plus cost-share. There would be no additional 15% cost above that. The total cost of that for E-4 or below would be either $275 if in-network (15% cost-share) or $350 if out-of-network (20% cost-share).
All of the above is if you use Standard or Extra.
The cost is different on Standard for a hospital vs. homebirth. With a hospital birth, you only have to pay the daily cost-share for the time you are in the hospital, which is $16.85/day with a minimum charge of $25. That covers all your prenatal care plus the birth. For a homebirth, you have to pay either 15% for an in-network provider or 20% for an out-of-network provider. That's after paying the $50 or $150 deductible. That is so messed up. A vaginal hospital birth costs thousands more than a homebirth but TC will pay for almost all of the hospital birth but only a percentage of a homebirth. WTH?!
It will be different with Prime. The POS option with Prime costs more than Standard because the deductible is $300 and the cost-share is 50%. However, if you get a referral or authorization or whatever TC calls it, you shouldn't have to pay the deductible or cost-share. I'm not sure about the 15% above the TC allowable charge. I don't know if TC would give a referral or authorization for a non-participating provider.
TC Remote should work the same way as Prime so you would need referrals and authorizations or you would be using the POS option.
I hope all of that makes sense. It can be very confusing. I didn't search for the TC allowable charges on the website.