In-network vs out-of-network rehab: what it means for your TRICARE bill

Network status is one of the most misunderstood parts of TRICARE coverage. Many people assume that if a facility accepts TRICARE, the cost-sharing will be the same regardless of where they go. It is not. Whether a facility has a contract with TriWest , the TRICARE regional contractor for San Antonio , determines both what you pay and whether the facility can bill you for charges above TRICARE’s allowable rate.

What in-network and out-of-network actually mean

To accept TRICARE at all, a facility must hold a TRICARE certification from the Department of Defense. This is a separate credential from being in-network. Every TRICARE-covered facility is certified , but not every certified facility has a network contract with TriWest.

In-network means the facility has signed a contract with TriWest agreeing to accept TRICARE’s allowable charge as payment in full. The facility cannot bill you for the difference between their actual charge and TRICARE’s allowable rate. You pay your plan’s cost-sharing , a co-pay or percentage of the allowable charge , and the facility accepts that as payment complete.

Out-of-network means the facility is TRICARE-certified but has no rate contract with TriWest. TRICARE still pays , but it pays a lower percentage of a lower base rate. And the facility is not prohibited from billing you for the difference between what TRICARE pays and what they actually charge. This is called balance billing, and it is legal for out-of-network providers.

The balance billing problem explained

Balance billing is the single largest source of unexpected treatment costs for TRICARE beneficiaries who choose out-of-network facilities. Here is a concrete example of how it works.

Suppose an out-of-network residential facility charges $900 per day. TRICARE’s allowable charge for that level of care and market is $500 per day. TRICARE Select pays 50 percent of the allowable charge, so TRICARE pays $250 per day. The remaining $650 per day is your potential responsibility , $250 from your cost-sharing portion of the allowable charge, plus $400 in balance billing from the facility’s charge above the allowable rate. For a 28-day residential stay, that could be $18,200 in balance billing alone, on top of your TRICARE cost-sharing.

The annual out-of-pocket cap does not cover balance billing. The $3,500 catastrophic cap for TRICARE Select applies only to your cost-sharing on TRICARE’s allowable charge. The balance billed amount above the allowable charge sits outside the cap entirely.

This is not a hypothetical , it is one of the most common financial complaints from military families who chose a facility without verifying network status first.

TRICARE Prime: even stricter about network

For TRICARE Prime beneficiaries (active-duty and their families enrolled in Prime), going out of network without a referral authorization triggers the point-of-service option , a separate set of cost-sharing rules that are significantly worse than the standard in-network rates.

Under the point-of-service option, you pay 50 percent of TRICARE’s allowable charge with a separate $300 individual deductible that does not apply to your regular Prime deductible (which is $0). There is no annual cap on point-of-service cost-sharing. In addition, the facility can still balance bill you for amounts above the allowable charge.

For TRICARE Prime beneficiaries, the practical rule is simple: always get a referral from your PCM before seeking civilian care, and verify that the referred facility is in-network before admission. Your PCM referral should direct you to an in-network facility, but it is still worth verifying independently.

How to verify network status before admission

When out-of-network may be the only option

In some cases, the specific level of care or specialized program you need may not be available at an in-network facility in San Antonio. In those situations, going out of network may be clinically necessary.

If you believe an out-of-network facility is the only appropriate clinical option, contact TriWest before admission and explain the clinical situation. In some cases, TriWest can issue a single-case agreement , a temporary in-network arrangement between TRICARE and an out-of-network facility for a specific episode of care. Single-case agreements are not guaranteed, but they are worth requesting when the clinical justification is clear and there is no in-network equivalent available.

If a single-case agreement is not possible and you proceed with an out-of-network facility, negotiate directly with the facility on balance billing. Some facilities will agree to waive balance billing for TRICARE beneficiaries in exchange for prompt payment, particularly if you or your advocate can explain TRICARE’s payment process clearly.

What this means for San Antonio specifically

San Antonio falls under the TRICARE West region, managed by TriWest Healthcare Alliance. The network of substance use treatment providers under TriWest in the San Antonio area includes multiple facilities across levels of care , residential, PHP, and IOP. The military treatment facilities at Fort Sam Houston and Lackland AFB are always in-network (they are part of the Military Health System).

Our treatment centers directory lists facilities in the San Antonio area that work with TRICARE beneficiaries. Network status is noted for each facility as reported to us, but always verify directly with TriWest before admission. Network contracts change and directories can lag behind current status.