Will Mail Handlers plan plus Tricare be enough?
November 20th, 2009 | TriCare Help | Posted by Military Times
Q. My wife and I have long had Mail Handlers Standard but now are considering Mail Handlers Value. We also have Tricare. I am concerned that the Value policy and Tricare won’t be enough insurance. Can you provide any thoughts or sources of information?
I’m disadvantaged because I don’t know what benefits are provided under various plans available through the Federal Employees Health Benefits Program (FEHBP). I am aware that Mail Handlers is one of the better plans available for federal employees, but I don’t know how Mail Handlers Value differs from Mail Handlers Standard. I must leave that analysis and its applicability to your needs to you alone.
Let me talk briefly about what I do know.
I can tell you that Tricare Standard is a full service, stand-alone plan that, when it was created in 1966, was modeled after the FEHBP’s High Option Blue Cross and Blue Shield Plan. That plan was considered to be one of the best available in the nation at the time. Because of its generous and broad coverage, it was the most expensive plan available to federal employees. It is no longer available, perhaps for that reason.
Over the years, many beneficiaries have had Tricare Standard as their only health insurance. It’s greatest deficiency as one’s only coverage is its $150 deductible and 25 percent copayment (cost share). Tricare has always recommended a good Tricare supplement, when possible, for those enrolled only in Tricare Standard.
In my experience, and having corresponded with several thousand Tricare beneficiaries, I believe that when Tricare Standard is combined with a good Tricare supplement — or much better, with a good primary plan such as any of the FEHBP plans — beneficiaries find that most of their health care costs are paid in full or almost in full. The latter would be my choice for coverage.
That is particularly true because all Tricare beneficiaries are automatically eligible for, and are enrolled in, the free Tricare Pharmacy Program, which is one of the best prescription drug plans available. A Tricare beneficiary does not need any other pharmacy insurance.
Note: The Tricare Pharmacy Program has a new, combined information center at 1-877-363-1303, toll-free.
By federal law, Tricare is always last payer to all other health insurance plans. Whatever commercial plan you choose under the FEHBP, Tricare will serve as second payer, and it will usually pay most, often all, of what the primary FEHBP plan does not pay.
The FEHBP doesn’t offer any “junk” plans. Although they differ in the kinds and amounts of coverage, all the FEHBP plans are solid, legitimate plans. Tricare Standard is a good choice as your second payer for any plan under the FEHBP.
Thus, your decision must be based on your reading of the fine print in your two Mail Handlers plans, to decide which of the two provides more adequately for you and your family. With Tricare Standard as second payer, only the details of the two Mail Handlers plans and their application to your particular family needs to concern you
Tricare Prime, on the other hand, is in my opinion the plan of first choice as an individual’s or a family’s only coverage. But I do not recommend Tricare Prime for any beneficiary who has other health insurance. Tricare Prime functions as a Health Maintenance Organization, or HMO — a plan under which the beneficiary must receive all his care from providers who are under contract with the plan, and he usually pays a fixed fee which is the same for each doctor visit.
Because you may use only plan providers, an HMO limits your choice of physicians to those on a list of certain providers in one specific geographic locality. Because of those requirements under Tricare Prime, it is not a good choice to be second payer to any other health insurance. It has a potential for too many problems when benefits are coordinated between the two plans. That invites errors and, especially, misunderstandings.
Choosing an FEHB plan
November 13th, 2009 | TriCare Help | Posted by Military Times
Q. My husband is retired from the U.S. Army and currently carries the FEHB Standard Blue Cross & Blue Shield and Tricare Standard. The cost of the FEHB BCBS Standard has risen considerably; do you know which fee-for-service FEHB plan works best with Tricare Standard as a secondary insurance? We were thinking about going with the BCBS Basic, which is almost half of what I am paying now for the BCBS Standard.
Regardless of what other health insurance (OHI) you have, Tricare is always second (last) payer, by law. When Tricare Standard coordinates its benefits with their OHI, some beneficiaries have told me that it usually pays most, or sometimes all, of the OHI’s deductibles and copayments. I have the impression, however, that much depends on the quality of the OHI.
Retirees I worked with at the CHAMPUS Headquarters (CHAMPUS was Tricare’s precursor until 1995) in the 1980s chose the cheapest FEHBP plan available because of the way Tricare coordinated benefits.
Folks working in the (now) Tricare Headquarters’ Coordination of Benefits (COB) section have told me that unless they have in hand a copy of the OHI claim, they can’t predict the amount Tricare will pay as second payer. Coordination of benefits has become that complicated.
I have been writing Tricare Help since 1992, and I have responded to thousands of beneficiary inquiries about many things. But, I have never heard of anybody collecting the data and doing the calculations necessary for a comparative analysis of the kind you suggest.
Not to be interpreted as advice — because I don’t know — but the BCBS Basic might be a nice conservative trial to see how well Tricare Standard serves as second payer to a less expensive plan than BCBS Standard. If you are willing to gamble, you can always change back during Open Season the next year if it doesn’t work out well.
If you do it, you’ll have a story to tell me about it in 2011. In turn, I will have something to report to the next person who asks the same question.
Looking forward to coverage for gray-area retirees
November 11th, 2009 | TriCare Help | Posted by Military Times
Q. We were reading the Army Times and came across an article that mentioned Tricare for gray-area retirees. We are interested to know whether my husband will qualify for Tricare now, at age 58, and if so, what the cost will be. Also, could I be covered under his plan as well? The article stated that the Defense Department still must set premiums and enrollment rules. We would love to get some information on this, including what we have to do, the cost, and where to sign up.
Your question primarily concerns Tricare eligibility. Although it may seem strange, Tricare has no authority in the matter of Tricare eligibility. Only the services have the authority to make individual determinations about Tricare eligibility.
Before you do anything else, call the Defense Enrollment Eligibility Reporting System (DEERS), to determine whether you and your family are eligible for Tricare — what you are eligible for, and when. DEERS is an official computerized database of all DoD beneficiaries and the benefits to which each is entitled by law. DEERS’ toll-free number is 1-800-538-9552. Put that number in your Rolodex. You will very likely need it again.
Ask DEERS any questions you might have regarding eligibility. Find out what you must do to enroll in Tricare — to become registered in DEERS as eligible for the program.
There will be things regarding the Tricare Program itself, such as benefits and claims, that DEERS will be unable to answer. DEERS deals only with eligibility issues. I suggest you make a checklist before calling so you don’t forget anything, and keep notes of what you are told.
Then, after you have resolved all your questions with DEERS, get back to me so we can discuss any other questions.
My doctor says I still owe more
November 10th, 2009 | TriCare Help | Posted by Military Times
Q. My doctor’s bill was $267. I paid him the amount Tricare allowed, $173.82, plus an additional 15 percent. That should have paid his bill in full. Apparently, it didn’t. I am getting bills from them that say “Balance due: $67.10.”
I could pay him that amount, but I don’t think he is entitled to it. I explained to them that I had paid the amount Tricare allowed plus an additional 15 percent. That is what you have explained in your column. I showed them the Tricare Explanation of Benefits so they could see it themselves. They told me this rule applies only to Medicare patients, not to me. Is that right?
The only information I have is what you report in your question. Based on that information, it appears you have paid correctly.
The 15 percent rule is a provision of Medicare law called the Limiting Charge. It says that a nonparticipating provider may charge a Medicare beneficiary up to, but not more than, 15 percent over the amount Medicare approved on the claim.
Congress passed a law applying the Medicare Limiting Charge to Tricare claims beginning Oct. 1, 1993.
But you will never be able to persuade your doctor’s office that you and I are right, and they are wrong. Here’s what you need to do: Write a letter to your Tricare claims processing office at the same address where you submit claims. Explain the situation to them. Attach a copy of the EOB for that claim and copies of the bills you have received.
Tricare will contact the doctor’s office on your behalf and explain the law to them. In most cases, that will resolve the issue. If it doesn’t and the doctor’s office has really dug in its heels, send me another e-mail.
What if Tricare pays in error?
November 9th, 2009 | TriCare Help | Posted by Military Times
Q. Let’s say Tricare finds out after six months or a year that it paid a claim in error for a dependent. Will it ask for its payment to be returned? If so, who would be responsible for repaying Tricare — the provider or the patient?
If Tricare pays a claim in error, federal law requires it to recoup the money. It will ask the payee on the claim to refund the erroneous payment.
If the provider participated in Tricare on the claim and received payment directly from Tricare, the provider would be asked to refund the payment. If the provider did not participate on the claim, payment would have gone to the adult patient or the custodial parent of a minor child, who would be responsible for repaying Tricare.
When Tricare determines that a claim has been paid in error and requests a refund, it is because the claim was denied. Whoever is asked to return the payment — the adult patient on the claim, the custodial parent if the patient was a minor, or the participating provider — may, and should, file an appeal of the denied claim.
Tricare has only one concern and one responsibility: the return of the full amount of a payment made in error.
Will surgeries on pre-existing scar be covered?
November 8th, 2009 | TriCare Help | Posted by Military Times
Q. My young daughter was burned two years ago. She has had surgery two times for scar revision as she has grown, and will need at least two more operations as she gets older.
My family and I will get Tricare later this year when I am 60. Will my daughter’s subsequent surgeries be covered by Tricare, or will coverage be denied or limited because the scar is a pre-existing condition?
Tricare is not an insurance company; it is a federal health benefits program, similar in that respect to Medicare. Unlike many commercial health insurance plans, Tricare has no restrictions or limitations on the coverage of pre-existing conditions.
A potential problem, easily overcome, could be with the continuity of care if you want the later surgeries performed by the same surgeon who did the previous operations.
For Tricare to cover the surgery, the surgeon must be or become a Tricare-authorized provider. That is, he must apply to Tricare and submit the information required to establish that he is a properly trained and licensed physician in the state where he practices.
When Tricare approves his application, he will be authorized to receive payment for services rendered to Tricare beneficiaries. All insurance plans and companies require some form of provider authorization.
Apart from certain medical emergencies, Tricare may not pay for any services received from an unauthorized provider.
Could my new wife be turned away for pre-existing conditions?
November 7th, 2009 | TriCare Help | Posted by Military Times
Q. I’m a retired sailor. My lady friend and I plan to be married next month. She has had a health insurance policy through her job for almost 20 years, but its price keeps going up. We hope to cancel that policy and put her under my Tricare insurance and supplement, if that is possible. The problem is that she is diabetic, has bad arthritis, and has lost one breast to cancer, which runs in her family.
Will Tricare refuse to insure her because of her pre-existing medical conditions? Or, if Tricare will cover her, will it be limited in some way — especially if her cancer returns?
As soon as you are married, contact the Pass and ID Card Section at any uniformed service facility so your wife can apply for all the benefits to which she will be entitled, including Tricare. If there is no facility nearby, call the Defense Enrollment Eligibility Reporting System support office, toll-free, at (800) 538-9552, for instructions and advice about the best way for her to apply. Only the military services can register her in DEERS so she can use Tricare.
Tricare has no exclusions or limitations on coverage for pre-existing medical conditions. From her first day of eligibility, your wife’s Tricare coverage will be exactly the same as that of all other Tricare beneficiaries.
I am concerned, however, about your wife’s coverage by your Tricare supplement. Tricare is not a health insurance company or policy. It’s a federal health benefits program governed by federal law and regulation. Tricare supplements, however, are offered by commercial insurance companies. They’re not part of Tricare, and Tricare has no control over them. Each has its own rules.
I know little about Tricare supplements. Tricare Help is seldom asked about them, and my comments are limited to “read the fine print,” which is always good advice about any contract.
Most commercial health insurance policies have limitations on the coverage they provide for pre-existing medical conditions. Policies they write as supplements for primary plans, such as Medicare or Tricare, most likely will have similar provisions. The important details are in the fine print.
For example, a commercial insurer might exclude any coverage for cancer from your wife’s Tricare supplemental policy. Or it might limit its cancer exclusion to breast cancer because of her personal and family history of the disease.
A fairly common exclusion is that a new beneficiary must go for several months, sometimes a year or more, without needing treatment for a pre-existing condition in order for it to be covered. When that time has passed, and if the beneficiary has not needed medical care for the pre-existing condition, it will be covered as if it were not pre-existing.
That can be bad news for beneficiaries with chronic conditions such as diabetes or arthritis. How bad the news is could depend on the way the policy defines a “need” for medical care for the condition.
It might not balk at a diabetic’s routine needs for insulin, blood testing and related supplies, but if the beneficiary has had an acute diabetic episode requiring emergency care or hospitalization, she might be disqualified for coverage.
These are only illustrations of the kinds of restrictions commercial policies can put on their coverage of pre-existing conditions. Different policies may have different restrictions.
Check the fine print on your existing Tricare supplement and, perhaps, several others, to learn exactly how each supplement handles coverage of pre-existing conditions.
There is an unpleasant reality I must mention: If you were to die, your wife’s Tricare eligibility would not be affected. Unless she remarried, she would be eligible for Tricare for the rest of her life.
If the marriage ended in divorce, however, she would lose Tricare eligibility immediately.
If your wife were to cancel her present health insurance policy, and if your marriage were to end in divorce, she would find herself uninsured by Tricare and, because of her medical history, she probably would be uninsurable by any commercial insurer except at great cost.
Please note that if your wife is a federal employee, she can suspend — rather than cancel — her federal employees health insurance plan. That way, she could reinstate the coverage during open season in any year.
‘Authorized’ providers, ‘participating’ providers, and the 15 percent
November 6th, 2009 | TriCare Help | Posted by Military Times
Q. One of your recent columns implies that there is a difference between a Tricare-authorized provider and a Tricare-participating provider. I thought they meant the same thing. What is the difference, if any? What does the “15 percent” refer to?
A provider is any person or organization that provides services to another person or organization. Your phone company, for example, is a provider of telephone services.
There are many kinds of providers of health services. In addition to physicians and hospitals, they include self-employed nurse practitioners, physical and occupational therapists, nurses in private practice, clinical psychologists, medical supply and equipment vendors, and the like.
This discussion is limited to physicians. The participation rules apply to all Tricare-authorized providers.
For the safety of their beneficiaries and to prevent (or at least discourage) fraud, all health insurance companies require some form of provider registration or certification. Before they pay claims on behalf of beneficiaries, insurance companies must be certain that providers are fully qualified, licensed physicians in good standing in the states where they practice.
Tricare is no different. To become Tricare-authorized providers, physicians or other providers of health services must apply to Tricare, submit information to confirm their qualifications and be approved. They then can receive payment from Tricare for covered medical services provided to Tricare beneficiaries.
Except in certain medical emergencies, Tricare will not pay for any service a beneficiary receives from an unauthorized provider.
On every Tricare claim, an authorized provider can choose whether to participate. Tricare will allow, and pay, the same amount regardless of whether the provider participates. However, the beneficiary will be responsible for paying more when the provider does not participate.
If providers choose to participate on a claim, they will sign the participation agreement on the claim forms and file the claims on behalf of the beneficiaries. They agree to accept the amount Tricare allows on that claim as full payment for those services.
Tricare will pay its share directly to the participating providers. When the beneficiaries pay their part of the claim, the participating providers’ bills for the covered services will be paid in full.
A beneficiary is not responsible for paying more than the amount allowed for covered services on a participating claim, regardless of the amount billed.
If a provider chooses not to participate on a claim, Tricare will send its payment to the beneficiary, who is responsible for paying the nonparticipating provider as much as, but not more than, 15 percent over the amount allowed on the claim. Tricare will pay nothing toward that 15 percent surcharge.
It’s important to note the difference between the amount Tricare allows on a claim and the amount it pays. On most claims, that difference is the beneficiary’s deductible, if applicable, and cost share. If Tricare denies a charge, however, the amount the beneficiary is expected to pay may be more than those items.
When a Tricare claim, or a portion of a claim, is denied — it will say “$0.00” in the “Amount Allowed” column on the explanation of benefits — the beneficiary should file a written appeal within 90 days. The EOB always reports the reason a charge was denied. An appeal may change, or even remove, the amount a beneficiary is required to pay on denied charges.
Appeal instructions are on the back of every EOB. You cannot appeal by telephone. For further information about appeals, call your Tricare Service Center.
The federal law that limits the amount a Tricare beneficiary may be charged for covered services on a nonparticipating claim is a provision of Medicare law called the Limiting Charge. Physicians who see Medicare patients know about that law. Congress extended the law to include Tricare claims in 1993.
Regardless of whether a provider participates on a claim, if he demands payment in excess of the amount permitted by law, you should notify the Tricare claims processor immediately by mail. Include a copy of the original Tricare EOB and copies of the bills or letters that cite the balance due.
Does Tricare get a piece of car-crash settlement?
November 5th, 2009 | TriCare Help | Posted by Military Times
Q. My wife was hurt in a car accident. Tricare paid her medical bills, like it is supposed to. The other driver’s insurance has offered to settle with my wife, but our lawyer says Tricare wants her to use the settlement to repay what it spent on her medical bills. That is unfair. My wife is the one who got hurt, so it is her money. I already paid for Tricare with my military service. If it wants money, Tricare should go to the insurance company for it like we did. Is it legal for Tricare to get a free ride at my wife’s expense?
According to your letter, Tricare has already done for your wife all the things it is supposed to do. It has paid all of the claims for her medical care. If your wife has paid her cost shares and any deductibles on the claims, according to the Explanation of Benefits forms she has received from Tricare, she has no providers demanding payment. Her bills were paid in full.
Your question now concerns legal matters, and I am not a lawyer. While I can tell you what a law says, or you can read the law yourself; I am not qualified to interpret a law or to say how it applies to a given individual or situation.
This reply is based on what I learned when I worked for the Pentagon’s Office of Health Affairs and things I have read after that. You should take no action or make any decisions based on what I tell you — seek guidance from your lawyer. If he has questions, he can write to the Office of General Counsel, Tricare Management Activity, 16401 E. Centretech Parkway, Aurora, CO 80011-9043.
According to your letter, because the other driver caused the accident, he was responsible for paying for the resulting damages, including your wife’s medical bills. His insurance company became a third party in the case; on his behalf, it became liable for paying at least part of the costs of restoring your wife to the condition she was in before the accident — what lawyers refer to as “making her whole.” Whether it does is a legal matter and out of my purview.
Federal law requires Tricare to try to recover, from a liable third party, the reasonable costs of the medical care Tricare paid for.
That is a matter between Tricare and the insurance company; your wife is not involved in Tricare’s recovery efforts. Even if Tricare is unable to recover the full amount, your wife will not be held liable to pay any remaining amount.
In my experience, the amount due to Tricare under federal law will be withheld from the insurance settlement before any funds are released to your wife. Presumably, part of the settlement has never been hers alone. The amount remaining after Tricare recovers its part will be hers to keep.
Transferring eligibility when remarrying
November 4th, 2009 | TriCare Help | Posted by Military Times
Q. I’m a retired officer who is getting married next month. My bride-to-be has Tricare as the unremarried former spouse of another officer. I know she’ll lose that Tricare eligibility when she marries me. Will her previous status cause any problems or delays in putting her under my sponsorship for Tricare once we’re married?
Because of her previous marriage, your fiancée was indeed eligible to retain her Tricare eligibility after the divorce from her former husband. Her Tricare eligibility, however, was carried in the Defense Enrollment Eligibility Reporting System under her own Social Security number, not that of her former sponsor.
Handled properly with DEERS, that eligibility will end at midnight of the day before she marries you. She will become eligible for Tricare under your sponsorship and Social Security number one second later on the day she marries you.
For your bride to use Tricare, you will have to apply for a new ID card for her and ensure she is properly registered in DEERS. Contact the DEERS Support Office at (800) 538-9552.
The only problem I foresee might be with proper crediting of any Tricare deductible that has been withheld on her claims in the current fiscal year under her Social Security number.
For information on transferring deductible credits from one Social Security number to another for the same person, call or write to the Tricare Service Center for the Tricare region where you will live after the marriage.