What about health care reform?
September 29th, 2009 | TriCare Help | Posted by Military Times
Q. Isn’t it true that Medicare Part B requirements come before Tricare’s, and that medical procedures received under Medicare must be approved before Tricare takes action (with certain exceptions)? And wouldn’t reducing the standard cost of procedures under Medicare cause more competent physicians — those who charge more than the standard rate — to not accept Medicare patients and therefore reduce the number and quality of physicians available to military retirees under Tricare? These are not rhetorical questions; they reflect my skepticism regarding the total truth from those trying desperately to sell a program with far too many hidden costs and benefits.
When a uniformed service retiree, retiree family member, or a survivor of a deceased active duty or retired member becomes entitled to Medicare, that program becomes his primary health “insurance.” He becomes, in effect, a Medicare beneficiary first; Tricare Standard becomes second payer to his Medicare claims.
Under the law governing Medicare, the retiree must seek all civilian care from Medicare-authorized providers only. The Medicare provider will file an ordinary Medicare claim for the services he provides to the TFL beneficiary just as he would for any other Medicare patient.
If you are familiar with the rules governing TFL under federal law, you know that when both Medicare and Tricare cover all the medical services on the Medicare claim, Tricare will pay whatever Medicare does not pay, up to the amount Medicare approved on each charge. There is no Tricare deductible or Tricare cost share applied to the Tricare portion of the TFL claim. Thus, the Medicare claim, and the provider’s bill, are paid in full. The TFL beneficiary has no out-of-pocket costs for that claim.
For a number of years, certain factions have attempted every year to decrease the amounts Medicare may approve on claims, thus reducing the total amount Medicare may pay. If Congress were to allow those reductions, it could have the effect of reducing the number of providers who will continue to provide services to Medicare beneficiaries. That could have the effect of Medicare’s being considered a failed program in need of being replaced by private industry.
I understand your questions and concerns, but long-time readers of Tricare Help know that, since I started the print column in 1992, I have consistently endeavored to keep it free of personal opinions or other political disputes. If I did, the column would quickly become just another forum for debate, and it would lose its original nature of helping beneficiaries to better understand their medical benefits. I explain Tricare only as it is, not what it should or might become.
Therefore, I will not comment on my personal opinion or my feelings about attempts to compromise the value of the Medicare program for all its beneficiaries, civilian as well as military.
It is worth noting, however, that the President is on public record of saying that there is nothing his proposed health care reform program that will damage or reduce Medicare coverage in any way. Note also that Medicare, like Tricare, is governed by federal laws that only Congress, not the president, has power and authority to change. The President himself lacks the power to add or remove even a comma from the law as enacted or amended by Congress.
My unit disbanded. Where should I go with Tricare questions?
September 29th, 2009 | TriCare Help | Posted by Military Times
Q. I am an Air Force reservist and am going to be 60 end of October. In a recent Tricare Help article it was stated I would have to contact my reserve component and tell them I wanted to apply for benefits for myself and family. But my unit has been disband and move to a other part of the country. What do I do now?
Here’s a good rule of thumb: Any question that concerns Tricare eligibility can always be addressed to the DEERS Support Office, toll-free, at 1-800-538-9552. That’s where you need to go for help with your question.
Eligibility issues are all DEERS deals with. DEERS cannot tell you anything about the Tricare program, benefits, or claims. But, DEERS can tell you the phone number to call to get official information about those things.
How can I find out if Dad is eligible?
September 25th, 2009 | TriCare Help | Posted by Military Times
Q. My father retired from the Navy reserves with previous active duty after 24 years. When he retired he was informed by the Navy that he was enrolled in Tricare and that he just needed to take his retired ID card to the VA for health care. He is retiring in three years from his civilian job, and they pay 70 percent of his health care costs. He won’t be eligible for Medicare Part B for another year after he retires from the civilian world.
Does he have Tricare? Can he get it if he doesn’t? Can Tricare be a secondary carrier to pick up the 30% his employer doesn’t pay?
Tricare is a federal health benefits program similar in that respect to Medicare. Eligibility is established by federal law for certain categories of people, including immediate family members of active duty uniformed service personnel, uniformed service retirees, some retiree family members, and survivors of deceased active duty and retired personnel.
Only the uniformed services may determine whether a given individual meets the legal criteria for Tricare eligibility, register an eligible person in the Defense Enrollment Eligibility Reporting System (DEERS) database, and issue an appropriate uniformed service identification card. Please contact DEERS, toll-free, at 1-800-538-9552. to inquire about your father’s Tricare eligibility. You may be unable to get the information due to Privacy Act restrictions, however. If you have a problem, ask DEERS how to resolve it.
DEERS is a federal agency and part of the Defense Department. All information in the DEERS database is protected by the Privacy Act. DEERS deals with Tricare eligibility only. It is unable to provide information about Tricare benefits or claims.
Tricare and medical services received from the Department of Veterans Affairs (VA) are totally unrelated, however. Although both are programs under auspices of the U.S. government, they were created and are governed by totally different laws. If the VA beneficiary is charged for any services received from that agency, Tricare cannot pay for it unless the VA facility has a special arrangement with Tricare, which few do.
By federal law, Tricare is always last payer to all other health insurance (OHI), medical programs such as an HMO, or medical payments such as one might receive as the result of auto accident insurance, or proceeds from a slip-and-fall injury, and the like.
If your father is eligible for Tricare, so is his wife and any unmarried children under age 21, or under age 23 if the child is a full-time student at an accredited college or trade school. If your father is divorced, his former wife may be eligible for Tricare. Ask DEERS for more information in that case.
Your father (and other eligible family members) must file claims for health care with his OHI first. When the OHI completes all processing and issues the patient an Explanation of Benefits (EOB – the final report a health insurance plan issues regarding all its actions on the charges on a claim), the patient may file a Tricare claim for any unpaid balance.
As second payer, Tricare will usually pay part, or often all, of the OHI’s deductibles and copayments. Tricare will issue the patient an EOB when it completes processing. The EOB will report the amounts Tricare paid of the remainder after the OHI paid its maximum. If any amount is still due to the provider of care, the Tricare EOB will report that amount.
Here is how to file a claim with Tricare as second payer to OHI.
1. Complete an official Tricare claim form DD2642. Tricare’s web site can help you with claim filing and give you contact information for the patient’s Regional Tricare Office. The patient should keep a permanent record of that information.
2. Attach a photocopy of each of the itemized bills that were sent to the OHI. An itemized bill is the paper that lists each of the medical services the patient received and the charge for each service. A “balance due” bill cannot be used in place of an itemized bill.
Either the patient or the provider may file the claim, but the patient must sign the claim form. A claim for a hospital’s services must be filed by the hospital. Please note that the bills for a physician, surgeon, radiologist, pathologist, anesthesiologist, etc. are not “hospital services,” although the care was received while the patient was in the hospital. Such people are called individual providers and will bill separately for their services.
A hospital bill includes services and supplies provided by the hospital, and payment should go to the hospital. They include such things as room and board; special diets; general nursing services; use of the emergency room, operating room, recovery room or intensive care unit; use of the hospital’s imaging services and personnel (such as an X-ray or MRI); use of the hospital’s laboratory services and personnel; drugs; gases; blood; and delivery equipment such as tubing or needles.
3. Attach a copy of the OHI’s EOB(s) that reports its actions taken with each of the charges on the itemized bill.
4. Make a copy of each document for your records.
5. Send the packet to the appropriate Tricare claims processing office.
Note: Check the copy of each document submitted to be certain it is legible, including all words and numbers on the bills and EOBs. Complete the Tricare claim form carefully. Uncle Sam likes things neat and easy to read; it minimizes errors, thus saving time.
Allow Tricare at least four weeks, door to door, for processing. Respond promptly to any requests for additional information. If a Tricare claim is denied, the reason will be stated on its EOB. If a denial reason mentions DEERS or eligibility, call DEERS immediately at 1-800-538-9552.
If the reason for denial of a claim cannot be resolved quickly, say, by telephone, the patient has 90 days in which to file an appeal. The appeal must:
- be in writing
- report the specific matter in dispute
- contain a copy of the Tricare EOB reporting the denial
- and be signed by the adult patient.
It should be sent to the address of the claims processing office that issued the EOB reporting the denial.
Mixed messages on cancer treatment
September 25th, 2009 | TriCare Help | Posted by Military Times
Q. I have been diagnosed with prostate cancer and I am considering High Intensity Focused Ultrasound as my treatment option. I will be traveling outside the U.S. for this treatment since it is not approved here. My insurance is Medicare and Tricare For Life. Medicare will not cover anything outside the U.S., and initially Tricare has told me they will not cover it. However, I have spoken with several people who have Tricare who say they have been reimbursed for this procedure. How I should proceed?
First of all, I can give you only unofficial advice on this matter, since I have no official relationship with Tricare or the Defense Department. Neither I nor my published works should be considered as representing or speaking on behalf of Tricare.
You should contact your Tricare claims processing contractor to ask for an opinion about whether the procedure can be covered by Tricare, but I don’t know whether one will be forthcoming. I think that for Tricare to say the procedure will be covered could be considered to be a prior authorization, which Tricare is not allowed to provide unless a prior authorization for a procedure is required.
Failing a reply you consider adequate from the Tricare claims processor, I recommend that you write to the Tricare Management Activity, 16401 E. Centretech Parkway, Aurora, CO 80011-9043. (The Tricare Management Activity is a federal agency under auspices of the Office of the Assistant Secretary of Defense for Health Affairs. It is charged with certain management and/or directive functions regarding operation of the Tricare program.)
If you decide to have the procedure you describe, and if payment of your claim is denied, I believe your only initial option in that case would be to file an appeal of the denial of your claim. Of course, filing an appeal is no guarantee that an adverse determination will be reversed.
Tricare Standard: Where do I begin?
September 23rd, 2009 | TriCare Help | Posted by Military Times
Q. I retired from the Air Force in 1995 and since early 1996 have been employed by the U.S. Postal Service and have always had FEHBP health coverage. Now thanks to your columns I understand I can also enroll in Tricare Standard and possibly have my co-payments and deductibles covered by Tricare. Great! How and where do I go about enrolling in Tricare Standard? Must I let my medical care providers know that I have a primary insurance (FEHBP) as well as secondary (Tricare Standard)? Will my primary insurer send the bill for the co-pay to Tricare? If not, do I submit the co-pay and/or deductible to Tricare myself?
As you have discovered, not knowing about all your retirement benefits can be costly. I say this not to chide you, but to remind others uniformed service retirees to be alert regarding their rights and those of their eligible family members. To learn more about their eligibility, they should call DEERS.
Your service probably registered you in DEERS as being eligible for Tricare when you retired. It was your responsibility to register your family members. DEERS registration reports the benefits a person is entitled to, including Tricare.
I suggest you call the DEERS Support Office, toll-free, at 1-800-538-9552, to verify your registration and to ensure that it is up to date. Ask DEERS to confirm your Tricare eligibility and to provide instructions and help to register your eligible family members.
You should tell your health care providers that you have health insurance as a postal employee and that Tricare is your secondary coverage.
Unlike the situation of a person whose only coverge is Tricare for Life (Medicare plus Tricare Standard), Tricare cannot accept a claim as second payer from your employer’s insurance plan. You must file that claim yourself.
To do that, download a official Tricare Claim Form DD2642. The Tricare web site can also give you the claims filing address for your residential area and other claims filing information, including a number to call for help.
Here’s how to file a claim with Tricare as second (or third) payer:
- Complete a Tricare Claim Form DD2642.
- Attach copies of the same itemized bills as were sent to your other health insurance. Please note: The requirement is for an itemized bill that lists each medical service you received and the charge for that service. A “balance due” bill will not serve.
- Attach a copy of the other plan’s Explanation of Benefits, which reports the way it processed each of the charges on the itemized bill.
- Make copies of all documents for your records.
- Send the packet to the Tricare claims processing contractor for your residential area.
Does my wife need Part B?
September 22nd, 2009 | TriCare Help | Posted by Military Times
Q. I am 75-year old Navy retiree enrolled in Tricare for Life and Medicare Part B. My wife is 61 years old, does not have a job, and is enrolled in Tricare Prime. Is she required to enroll in Medicare Part B?
Here is what federal law requires: If a retiree, retiree family member, or a survivor of an active duty or retired member becomes eligible for Medicare at any age, federal law requires him or her to enroll in Medicare Part B. If a person who is required to be enrolled in Part B does not enroll, he or she will immediately lose Tricare eligibility until Medicare Part B enrollment becomes effective and his or her DEERS record is corrected.
Note, below, when Part B enrollment is required for your wife and when it is not required.
Regardless of her age, if your wife is eligible for Medicare now, she is required to be enrolled in Part B.
If your wife is not eligible for Medicare now, she is not required to be enrolled in Part B.
When your wife gets Medicare, probably when she is 65, she must enroll in Part B, but not until she gets Medicare.
If your wife has Medicare now, or if she receives Social Security disability benefits now, write to me again. We will need to talk about it.
I’m already on Medicare Part A
September 15th, 2009 | TriCare Help | Posted by Military Times
Q. I turn 60 in February. I have been disabled for the last 10 years and am on Medicare Part A. I didn’t have to accept a penalty for not signing up for Part B because my wife works and I use her insurance. Do I have to sign up for Part B to receive any Tricare benefits? My wife retires in March and we will still be covered by her policy until she becomes eligible for Medicare.
The following information is unofficial. For official information about avoiding the late enrollment penalty for Part B, call Social Security at 1-800-772-1213. For official information about getting Tricare when you are 60, call DEERS at 1-800-538-9552.
Both Medicare and Tricare have laws about when a person must enroll in Medicare Part B. The Tricare law is going to affect you first when you turn 60. Then, the Medicare law will affect you when your wife retires. Either way, you are going to have to be enrolled in Medicare early next year. Here’s why.
The law that governs Tricare says that a retiree who has Medicare is required to be enrolled in Part B. Although you are not 65, you got Medicare early due to your disability. That means you must have Part B up and running in order for you to get Tricare when you are 60 next February.
Because you will be a retiree with Medicare at age 60, you must be enrolled in Part B for your Tricare eligibility to go into effect. You will begin your Tricare eligibility by being enrolled in Tricare for Life.
If you did not have Medicare already, your Tricare eligibility would begin on your 60th birthday Because you have Medicare, however, you have to be enrolled in Medicare Part B before your Tricare eligibility can start.
You need to contact Social Security in October and enroll in Medicare Part B. Arrange with Social Security for your Part B to become effective on the first day of February because that is the month when you will be 60 years old. Your Medicare Part B must be in effect when you turn 60 because you cannot get Tricare without it.
You can hold off one more month enrolling in Part B because you wife is still employed by the company that provides her and your health insurance. But, as soon as she retires, the grace period for you to enroll in Part B without penalty will start to run. And you can’t get Tricare until you are enrolled in Part B due to your already having Medicare.
You will save yourself a lot of needless administrative hassles by starting your Part B and Tricare on the first of February as I suggested above. The longest you can hold off enrolling in Part B will be the grace period between the date of your wife’s retirement and the end of the grace period for enrolling in Part B without penalty. That will be two or three months at most, and during that time, you will not have Tricare.
You cannot get Tricare and Tricare for Life until you are enrolled in Medicare Part B.
Can I still get care at military treatment facilities?
September 11th, 2009 | TriCare Help | Posted by Military Times
Q. I will soon be transitioned to Tricare for Life. With the fact that my primary insurance will be Medicare and secondary will be Tricare Standard, will I be eligible to use a local military treatment facility? I live in San Antonio and we have some of the finest military hospitals and clinics in the world within 15 miles of my home and I have received fantastic service from them.
When you become entitled to Medicare, enroll in Part B, and your DEERS record is updated, you will be eligible for Tricare for Life (TFL). By law, you will lose your Tricare Prime eligibility, but the rest of your family will not be affected in any way by your transition to Tricare for Life.
With your loss of Tricare Prime, you will no longer have the priority access to military treatment facility (or MTF for short) care you and your family have now. Theirs will continue under Tricare Prime, but your primary health insurance will be Medicare. You must seek all your civilian medical care from Medicare providers.
It’s not too early to begin searching for one. When you call for an initial appointment, ask whether the doctor is accepting new Medicare patients. Many do not, so that’s why you may need some lead time, unless you are sure you can get MTF care.
The Medicare provider will file a Medicare claim for the services he provides to you. Medicare will process the claim, pay its share directly to the doctor, and automatically forward the claim to Tricare Standard as second payer. Tricare also will send its payment directly to the doctor. You will learn more about how it all works when you get your Tricare for Life Handbook (see below).
Now, let’s talk about your continued ability to get free care at MTFs.
Tricare has nothing to do with military regulations concerning MTF management or decisions about a retiree’s access to MTF care. You need to call the Patient Administration Office at each of the MTFs near your home. Discuss with them your situation about Medicare entitlement, Tricare for Life, and your loss of Tricare Prime eligibility. Each MTF’s Commanding Officer has sole authority to determine whether you can continue to get care at the facility. The situation may differ from one MTF to another and is dependent on the availability of space, personnel, and the facility’s technical capacity to provide the kinds of care you need.
For more information about Tricare for Life, call your Regional Tricare Office, Humana Military Healthcare Services, toll-free, at 1-800-444-5445, and ask them to send you a free Tricare for Life Handbook. You can also download one here.
And be sure to study Tricare’s official web site, which will help you use the program more efficiently. The overview is the best place to start.
Am I too old to apply?
September 11th, 2009 | TriCare Help | Posted by Military Times
Q. I already have Medicare A & B. Can I apply for Tricare at age 76?
There are no age restrictions, at either end of life, for Tricare eligibility.
Tricare eligibility is established by federal law for designated categories of persons. Tricare, however, does not have the authority to make individual eligibility determinations. Only the uniformed services have the authority to determine whether a given individual meets the legal criteria for Tricare eligibility, to register an eligible person in DEERS, and to issue an appropriate uniformed service identification card.
For information about your Tricare and Tricare for Life (TFL) eligibility, please contact the Defense Enrollment Eligibility Reporting System, better known by its acronym, DEERS, toll-free, at 1-800-538-9552.
DEERS is a computerized database that lists all Defense Department beneficiaries and the benefits to which each person is entitled. DEERS is a federal agency and part of the Defense Department. All inquiries are confidential and information in the database is protected by the federal Privacy Act of 1974.
DEERS personnel will need to know your full name, date of birth, Social Security number and, if applicable, your date(s) of military service, if any. If you did not serve in the uniformed services, or if you are not entitled to receive retired or equivalent pay from the uniformed services, DEERS will have other questions regarding the presumed basis for your Tricare eligibility. If that involves a family member, you will also need that person’s full name and Social Security number. Again, all DEERS inquiries are confidential.
What if my doctor says he takes Medicare, but not Tricare?
September 11th, 2009 | TriCare Help | Posted by Military Times
Q. I have Tricare For Life. If I go to a doctor who accepts Medicare but does not accept Tricare is that something that I need to be concerned about? I understand that Medicare will automatically forward a claim to Tricare.
The only thing the doctor cares about is whether he gets all the money that is due to him.
Here’s the way it works. This is all explained in your Tricare for Life Handbook. Call your Tricare Service Center and ask for a free TFL Handbook, or download one here.
As a Tricare for Life beneficiary, you know that you have complete coverage by Medicare Part A and Part B plus complete coverage by Tricare Standard. You know, also, that you must seek all your civilian medical care from Medicare providers.
The doctor will submit a Medicare claim for the services he provides to you. Medicare will process the claim and pay its share to the doctor directly. That will usually be 80 percent of the amount the doctor billed on the claim unless there is a Medicare deductible involved. If there is a deductible, Medicare will subtract it from the amount it approves and pay the doctor 80 percent of the remainder.
Then it will forward the claim to Tricare automatically. Tricare will process the claim and for every service on the Medicare claim that is also covered by Tricare, Tricare will pay the doctor whatever Medicare did not pay for those items. That will usually be your Medicare copayment and your Medicare deductible if applicable on that particular Medicare claim.
On the vast majority of your Medicare claims, both Medicare and Tricare will cover all the services you received. When that happens, which is almost always, Tricare will pay whatever Medicare did not pay, up to the amount Medicare approved. That payment by Tricare will complete payment of the Medicare claim and the doctor’s bill. Both you and the doctor will be happy. He doesn’t care where the money comes from as long as he gets it.
Now the bad news. Sometimes you get a particular medical service from a Medicare doctor that Medicare does not cover, but Tricare does. Medicare will deny payment for that particular item and forward the claim to Tricare with that item unpaid. Tricare will be your only “insurance” for that particular item. As Medicare paid nothing, and because Tricare is your only health insurance for that item, all Tricare claims processing rules must be applied (by law) when it processes the claim for that item which Medicare did not cover. That means when Tricare processes the charge for that item, it must (by law) apply your Tricare deductible and 25 percent cost share to the amount Tricare allows for that item. On that claim, you may have to pay some of the cost of that item Medicare did not cover.