How Referrals and Specialty Care Will Work as New TRICARE Contracts Start in 2025

SFL Logo November 26, 2024

FALLS CHURCH, Va. – Health care delivery under new TRICARE contracts starts on Jan. 1, 2025. This change will affect you unless you have TRICARE For Life, the US Family Health Plan, or a TRICARE health plan overseas.

These new contracts will improve quality and access for beneficiaries in the United States. This includes enhancing referral management and access to specialty care.

“We’re excited about the improvements the new contracts will bring in 2025, especially if you get specialty care in the TRICARE civilian network,” said Tonya Utterback, referral management subject matter expert at the Defense Health Agency. “The regional contractors are putting systems in place to make sure your care continues without delays or interruption.”

How you get care won’t change for the rest of 2024. But you might have questions about what will happen in 2025—especially if you see specialty providers or have active referrals. Learn more about what to expect starting Jan. 1.

Getting referrals

A referral is when your primary care manager sends you to another provider to get necessary medical treatment they can’t provide. If you have TRICARE Prime, you need referrals for specialty care.

A pre-authorization is a more comprehensive review of medical services before you get care. Pre-authorizations are required for certain services.

Not sure when you need a referral or pre-authorization? Check out “Q&A: Getting and Using Referrals With TRICARE” on the TRICARE Newsroom.

Here’s how to get the referrals you need.

Through Dec. 31, 2024

If you live in the West Region:

If you live in the East Region:

  • You’ll keep getting referrals and pre-authorizations from Humana Military.

Beginning Jan. 1, 2025

If you live in the new West Region:

  • TriWest Healthcare Alliance will be your new regional contractor. You’ll get new referrals and pre-authorizations from TriWest.
  • TriWest will accept unexpired referrals and pre-authorizations from HNFS that were issued prior to Jan. 1, 2025. These will be valid through their expiration or June 30, 2025, whichever comes first.
  • TriWest will also accept valid referrals and pre-authorizations from Humana Military if you live in a state moving to the new West Region. These states are Arkansas, Illinois, Louisiana, Oklahoma, Texas, and Wisconsin. These will be valid through their expiration or June 30, 2025, whichever comes first.

Note: Do you or your child have referrals or authorizations through the Autism Care Demonstration?

  • TriWest will accept ACD referrals and pre-authorizations from HNFS that began prior to Jan. 1, 2025.
  • TriWest will also accept ACD referrals and pre-authorizations from Humana Military if you live in a state moving to the new West Region.
  • These will be valid through the date issued by the previous regional contractor.

If you live in the new East Region:

  • You’ll keep getting new referrals and pre-authorizations from Humana Military. 
  • Your existing referrals and pre-authorizations will remain valid. They’ll be valid until the approved expiration date.

The new contracts will allow for more efficient referral transfers between the East Region and West Region. This means your access to care will be smoother if you move between regions.

Getting specialty care

Do you see a specialist for ongoing care? Or do you expect you may see one in the future? The new contracts will enhance the process for finding network providers and scheduling first-time appointments with them.

Humana Military and TriWest will publish their network provider directories in November 2024. These directories will list provider subspecialties. (For example, they’ll note that an orthopedist specializes in hand surgery.) This will make it easier to find providers for the exact type of care you need. You’ll also be able to check if these providers offer telemedicine appointments.

You’ll be able to get help making that first appointment with a network specialist if you have TRICARE Select. To do so, reach out to your regional contractor and request help. They’ll work with the specialist’s office to find an appointment time that works for you.

You’ll hear more about any actions you may need to take in the coming weeks. For now, you should:

  • Check DEERS to confirm your information is current. This will help make sure you don’t miss important communications about your TRICARE benefit and upcoming changes.
  • Keep an eye on the Contract Transition FAQs. This page will be updated over the next few months. It has answers to commonly asked questions about the transition.
  • Sign up for email alerts from TRICARE. This will help you stay in the know about any updates.
  • Start getting ready for TRICARE Open Season. This year, it begins Nov. 11 and ends Dec. 10. Sign up for email alerts to learn more.

Want to learn more about the new TRICARE contracts? You can check out these articles on what you need to know and how the East and West Regions are changing.

Article Source: https://newsroom.tricare.mil/News/TRICARE-News/Article/3929333/learn-how-referrals-and-specialty-care-will-work-as-new-tricare-contracts-start