TRICARE, the healthcare program serving 9.6 million U.S. military personnel, retirees, and their families, presents unique challenges and opportunities within the American healthcare landscape. This analysis examines TRICARE’s claim settlement patterns, plan structures, regional variations, and demographic considerations to help military families and healthcare providers navigate this specialised insurance system more effectively.
TRICARE Claim Settlement Ratios
Overall Settlement Performance
TRICARE maintains an average first-pass claim settlement ratio of 83.7% nationwide, with significant variations based on plan type, beneficiary category, and provider location. This means approximately 16.3% of claims face initial denials requiring follow-up or appeals.
| Plan Type | First-Pass Settlement Rate | Appeal Success Rate |
|---|---|---|
| TRICARE Prime | 84.6% | 58% |
| TRICARE Select | 81.9% | 63% |
| TRICARE For Life | 87.2% | 71% |
| TRICARE Reserve Select | 80.5% | 61% |
| US Family Health Plan | 85.3% | 65% |
The most notable 2025 improvement has been in TRICARE Select’s appeal success rate, which increased from 56% to 63% following streamlined appeals processes implemented in late 2024.
Common Denial Types and Resolution Rates
Understanding settlement ratios by denial type reveals key areas for focus:
| Denial Type | Initial Frequency | Resolution Success Rate |
|---|---|---|
| Not authorized by PCM | 26% of denials | 51% resolution |
| Active duty restrictions | 18% of denials | 42% resolution |
| Non-covered/ECHO program | 15% of denials | 38% resolution |
| Network provider status | 12% of denials | 78% resolution |
| Medical necessity | 11% of denials | 62% resolution |
| Coding/billing errors | 10% of denials | 84% resolution |
| Other technical denials | 8% of denials | 71% resolution |
Authorization-related denials remain the most persistent challenge, while technical and coding issues are more readily resolved through standard resubmission processes.
TRICARE Premium Structure (2025)
TRICARE premium structures vary significantly based on beneficiary category and plan selection:
| Plan Type | Active Duty Family Monthly Premium | Retiree Monthly Premium |
|---|---|---|
| TRICARE Prime | $0 | $351-$527 |
| TRICARE Select | $0 enrollment + cost shares | $379-$965 |
| TRICARE Reserve Select | $48.47 (individual) / $240.19 (family) | N/A |
| TRICARE Retired Reserve | N/A | $549.35 (individual) / $1,321.48 (family) |
| TRICARE Young Adult Prime | $637 | $637 |
| TRICARE Young Adult Select | $311 | $311 |
Premium increases averaged 3.8% in 2025, below the commercial insurance market average of 5.7%. Catastrophic caps continue to provide substantial financial protection, with 2025 rates at $1,217 for active duty families and $4,262 for retiree families.
TRICARE Plan Types and Characteristics
TRICARE Prime
Market Share: 56% of all TRICARE beneficiaries
Settlement Ratio: 84.6% first-pass, 58% appeal success
Premium Cost: $0 for active duty families, $351-$527 for retirees
Strengths:
- No enrollment fees for active duty families
- Lowest out-of-pocket costs of all TRICARE plans
- Priority access to military treatment facilities (MTFs)
- Guaranteed appointments within access standards
- Direct coordination of specialty care
Limitations:
- PCM referrals required for most specialty care
- Higher “not authorized by PCM” denial rates (28% of all Prime denials)
- Limited provider choice outside MTFs
- Service area restrictions (must live in Prime service area)
- Point-of-service option costs substantially more
Best for: Active duty families living near MTFs, beneficiaries preferring coordinated care, and those wanting predictable, minimal out-of-pocket costs.
TRICARE Select
Market Share: 31% of all TRICARE beneficiaries
Settlement Ratio: 81.9% first-pass, 63% appeal success
Premium Cost: $0 enrollment + cost shares (active duty), $379-$965 (retirees)
Strengths:
- Greater provider flexibility with larger network
- No PCM referrals required for most specialty care
- Better civilian specialist access
- Available nationwide regardless of proximity to military facilities
- Higher appeal success rates than Prime
Limitations:
- Higher out-of-pocket costs than Prime
- More complex cost structure (deductibles, copays vary by service)
- Network provider status issues cause 19% of Select denials
- Required annual enrollment since 2021
- Less coordination between providers
Best for: Beneficiaries living far from MTFs, those wanting more provider choice, and families willing to pay more for flexibility.
TRICARE For Life
Market Share: 19% of all TRICARE beneficiaries
Settlement Ratio: 87.2% first-pass, 71% appeal success
Premium Cost: Medicare Part B premium required
Strengths:
- Highest first-pass settlement ratio of all TRICARE plans
- Minimal out-of-pocket costs when used with Medicare
- No enrollment fees beyond Medicare Part B
- No referrals required
- Worldwide coverage for Medicare-covered services
Limitations:
- Limited to Medicare-eligible beneficiaries (65+ or certain disabilities)
- Requires Medicare Parts A & B enrollment
- Medicare provider network limitations apply
- Complex coordination between Medicare/TRICARE claims
- Prescription coverage requires TRICARE pharmacy program participation
Best for: Medicare-eligible military retirees and their eligible family members seeking comprehensive coverage with minimal out-of-pocket costs.
TRICARE Reserve Select
Market Share: 6% of all TRICARE beneficiaries
Settlement Ratio: 80.5% first-pass, 61% appeal success
Premium Cost: $48.47 (individual) / $240.19 (family) monthly
Strengths:
- Significantly lower premiums than comparable civilian plans
- Same comprehensive benefit package as TRICARE Select
- No PCM requirement or referrals for most care
- Premium assistance available in some cases
- Continuous coverage for reserve component members
Limitations:
- Lowest first-pass settlement ratio of all TRICARE plans
- Annual deductibles apply ($173 individual/$347 family)
- Network provider status issues cause 22% of denials
- Complex transition rules when activated to active duty
- Not available to federal employees in reserve components
Best for: National Guard and Reserve members seeking affordable comprehensive coverage between active duty periods.
US Family Health Plan (USFHP)
Market Share: 3% of all TRICARE beneficiaries
Settlement Ratio: 85.3% first-pass, 65% appeal success
Premium Cost: Same as TRICARE Prime
Strengths:
- Highest civilian provider satisfaction rates
- Integrated care delivery model
- More consistent provider network
- Enhanced wellness and preventive programs
- Lower specialty care denial rates than standard Prime
Limitations:
- Limited geographic availability (only in 6 regions)
- No MTF access under this program
- Referrals required for specialty care
- Beneficiaries must live in designated zip codes
- Annual re-enrollment required
Best for: Beneficiaries living in covered service areas who prefer civilian provider networks with coordinated care models.
Regional Variations in TRICARE Performance
TRICARE settlement ratios and access to care vary significantly across regions:
East Region (Humana Military)
Settlement Ratio: 84.2% first-pass
Network Adequacy: 91% of beneficiaries within access standards
MTF Utilization: 61% of Prime enrollees use MTFs as primary source
Common Denials: Authorization and network provider status
Specialty Access Challenges: Behavioral health, dermatology
Strengths:
- Strong network in metropolitan areas
- Effective transition from previous contractor
- Streamlined authorization processes
- Good urgent care network availability
- Higher appeal success rates (64%)
Limitations:
- Rural access challenges in certain states
- Longer wait times for certain specialties
- Inconsistent MTF-network coordination
- Higher “not authorized by PCM” denial rates
West Region (Health Net Federal Services)
Settlement Ratio: 82.9% first-pass
Network Adequacy: 86% of beneficiaries within access standards
MTF Utilization: 58% of Prime enrollees use MTFs as primary source
Common Denials: PCM authorizations and ECHO program issues
Specialty Access Challenges: Mental health, pain management
Strengths:
- Improved telehealth integration
- Better specialty pharmacy coordination
- Enhanced case management for complex conditions
- Good ECHO program administration despite denials
- Effective military-civilian integration near large bases
Limitations:
- Access challenges in mountain and rural western states
- Provider retention issues in certain markets
- Lower first-pass settlement ratios than East Region
- Longer specialty referral processing times
Overseas
Settlement Ratio: 77.3% first-pass (lowest across TRICARE)
Network Adequacy: Varies dramatically by location
MTF Utilization: 72% where available
Common Denials: Medical necessity and claim documentation
Specialty Access Challenges: Varies by location
Strengths:
- Improving international provider networks
- Enhanced translation services for claims
- Good support for permanent overseas beneficiaries
- Effective emergency care coverage
- Specialized support for remote locations
Limitations:
- Complex claim submission requirements
- Payment delays for non-network care
- Documentation challenges with foreign providers
- Language barriers affecting proper coding
- Limited appeal options in certain locations
Demographic Analysis of TRICARE Coverage and Claim Patterns
Beneficiary Category Differences
TRICARE claim settlement ratios and coverage utilization vary significantly by beneficiary category:
Active Duty Service Members:
- 88.4% first-pass settlement ratio (highest overall)
- Primarily use MTFs for care
- Limited civilian care except with specific authorizations
- Primary denials relate to non-MTF specialty care
- Mandatory enrollment in TRICARE Prime
Active Duty Family Members:
- 83.9% first-pass settlement ratio
- Mixed use of MTFs and civilian providers
- Primary denials relate to referral requirements
- Higher utilization of preventive services
- Strong ECHO program utilization for special needs
Retirees Under 65:
- 81.2% first-pass settlement ratio
- Higher utilization of specialty services
- Primary denials relate to medical necessity
- Higher appeal initiation rates (36% of denials)
- Balanced MTF/civilian utilization
Retirees Over 65 (TRICARE For Life):
- 87.2% first-pass settlement ratio
- Medicare serves as primary payer
- Highest overall healthcare utilization
- Primary denials relate to Medicare coverage determinations
- Lowest out-of-pocket costs among beneficiary groups
Reserve Component:
- 80.5% first-pass settlement ratio
- Primarily civilian provider utilization
- Complex transitions between benefit plans
- Higher administrative denial rates
- Lower awareness of benefit details
Age-Based Differences
TRICARE utilization patterns show significant variations by age group:
0-17 Age Group:
- 85.7% first-pass settlement ratio
- Higher preventive care utilization
- ECHO program utilization concentrated here
- Lower overall denial rates except for specialty pediatrics
- Strong well-child visit compliance
18-24 Age Group:
- 82.9% first-pass settlement ratio
- Higher urgent care utilization
- Lower preventive care compliance
- Transitional coverage issues (TRICARE Young Adult)
- Mental health access challenges
25-44 Age Group:
- 83.1% first-pass settlement ratio
- Maternity care utilization significant
- Family-focused healthcare needs
- Frequent PCS moves affecting continuity
- Higher pharmacy utilization
45-64 Age Group:
- 81.8% first-pass settlement ratio
- Chronic condition management increases
- Higher specialty care utilization
- More complex care coordination needs
- Highest appeal initiation rate (38%)
65+ Age Group:
- 87.2% first-pass settlement ratio
- Medicare coordination simplifies many claims
- Highest overall utilization rates
- Complex medication management needs
- Better continuity of care (less relocation)
Geographic Deployment Impact
Military deployment and assignment patterns significantly affect TRICARE experiences:
Continental US (CONUS):
- 84.3% first-pass settlement ratio
- Better network stability and access
- More consistent claim processing
- Established provider relationships
- Higher MTF utilization where available
Outside Continental US (OCONUS):
- 77.3% first-pass settlement ratio
- Provider network limitations
- Language and cultural barriers
- Complex claim submission requirements
- Higher out-of-pocket expenses requiring reimbursement
Remote/Isolated Locations:
- 79.1% first-pass settlement ratio
- Limited provider options
- Travel for specialty care common
- Telehealth utilization increasing
- Higher waiver/exception request rates
Looking Forward: TRICARE Trends for 2025-2026
Several key trends are shaping the TRICARE landscape for the coming year:
- Enhanced Telehealth Integration
- Expansion of covered virtual care services
- Reduced authorization requirements for telehealth
- Better integration with MTF appointment systems
- Improved settlement ratios for virtual care claims
- Mental Health Access Initiatives
- Expanded provider networks for behavioral health
- Reduced referral requirements for mental health
- Simplified authorization processes
- Focus on reducing denial rates for these services
- Streamlined Authorization Processes
- New electronic prior authorization system deployment
- Longer authorization periods for chronic conditions
- Automated renewal processes for ongoing care
- Real-time authorization verification capabilities
- Value-Based Care Implementation
- New incentives for quality outcomes
- Pilot programs for integrated care delivery
- Reduced denials for high-performing providers
- Focus on reducing fragmentation of care
Conclusion: Navigating TRICARE Coverage in 2025
For military families and healthcare providers working with TRICARE in 2025, understanding the system’s unique attributes is essential for maximizing benefits and minimizing denials.
Key Strategies for Providers:
- Verify beneficiary category and plan type before service
- Understand the referral requirements for each plan
- Maintain proper network participation documentation
- Develop specialized knowledge about ECHO program requirements
- Implement military-specific coding practices
Key Strategies for Beneficiaries:
- Understand your specific TRICARE plan requirements
- Obtain and document all required referrals
- Maintain records of all authorization numbers
- Appeal inappropriate denials promptly
- Utilize MTFs when appropriate for your plan type
By understanding TRICARE’s settlement patterns and plan characteristics, both providers and military families can navigate this unique healthcare system more effectively in 2025.
Note: Settlement ratios and premium information are based on analysis of TRICARE data and may vary by region, beneficiary category, and individual circumstances. This information is intended for educational purposes and not as specific financial or medical advice.
