Coverage during international travel
November 30th, 2009 | TriCare Help | Posted by Military Times
Q. My husband and I have Tricare for Life. We plan a trip to Canada. Will Tricare for Life pay for emergency medical care we might need? Does it have a special plan for tourists? Do you know of any other plans?
Generally, only the Tricare Standard portion of Tricare for Life will cover you in Canada. I have heard that Medicare covers some limited emergency care in parts of Canada, but you’ll need to call Medicare for details. To the extent that is true, it would be a Tricare for Life benefit.
Before buying any “tourist” plans, read them carefully. If the plan does not agree to be primary payer, don’t buy it. Tricare will be unable to pay anything because of federal law requiring Tricare to always be last payer to any other insurance.
Tricare for Life is a U.S. government program, and U.S. law prevails in its operation, regardless of where the medical care is received.
If you can use Tricare only, be prepared for the likelihood that you will have to pay much of your Tricare $150 deductible when the claim is processed, along with a 25 percent Tricare cost share.
I believe the first commercial health insurance company to come up with an affordable, short-term Tricare supplement for travelers like you will make a killing.
Our doctor says he no longer belongs to Tricare
November 27th, 2009 | TriCare Help | Posted by Military Times
Q. Our doctor joined a group practice. Although he continues to see Medicare patients, the office manager said the practice does not belong to Tricare, and we have to pay full price for our medical care and file with Tricare ourselves.
I thought that if a provider accepts and bills Medicare, federal law requires him to also accept and bill Tricare. What are the facts?
That law applies only to institutional providers, such as hospitals. Individual providers, such as physicians, psychologists, private physical therapists and the like, are not bound by that law.
If the physician has severed his relationship with Tricare and is no longer a Tricare-authorized provider, Tricare cannot pay for any of his services regardless of who files the claim.
If he remains a Tricare-authorized provider but no longer participates in Tricare on the claims, you may use his services and file the claims yourself. In that case, he is no longer required to accept the amount Tricare allows as full payment for his services.
However, there is a law that limits the amount you may be charged for his services. It is a provision of the law governing Medicare called the Limiting Charge. In 1983, Congress made that law apply to Tricare as well as to Medicare.
The Limiting Charge allows a nonparticipating physician to charge a Medicare or a Tricare beneficiary up to, but not more than, 15 percent over the amount Tricare allows on a claim. Tricare will pay its usual amount directly to you. You will be responsible for paying the physician the amount Tricare allowed on the claim plus an additional 15 percent more than the amount allowed.
Your out-of-pocket expense for using such a physician, then, is your usual 25 percent cost share plus the 15 percent surcharge.
You might want to tell the office manager that Medicare and Tricare are required by law to use the same methodology and most of the same databases to calculate the amounts they allow on claims.
The amounts allowed by the two programs seldom differ by more than a few dollars. Tricare often allows slightly more than Medicare because of its younger, healthier beneficiary population.
What about vision coverage?
November 25th, 2009 | TriCare Help | Posted by Military Times
Q. I’m a retiree. Does Tricare have vision coverage?
Tricare may pay for medically necessary and appropriate medical and surgical services to treat injuries and diseases of the eye. It may cover one routine eye examination to measure the eyes for glasses for active duty family members only.
Tricare may not pay for eyeglasses or contact lenses except for two or three specific and uncommon eye conditions, and for one pair of spectacles or lenses following intraocular lens implant surgery.
Contact your Tricare Service Center for more information regarding coverage for spectacles or lenses if you believe you might qualify.
Tricare may not pay for vision training or eye exercises of any kind.
If Medicare denies my claim, will Tricare pay it?
November 24th, 2009 | TriCare Help | Posted by Military Times
Q. I have a supplement through an insurance company in case I have a claim denied by Medicare. In this case, the company will not honor my claim. Will Tricare pay the claim that Medicare denies? Could I use Tricare as a Medicare supplement?
Effective on October 1, 2001, Congress authorized Tricare beneficiaries who become entitled to Medicare and who are enrolled in Medicare Part A and Part B to use Tricare Standard as second payer to their Medicare coverage. That Tricare plan is called Tricare for Life.
TFL consists of full coverage under Medicare Parts A and B plus full coverage under Tricare Standard. The TFL beneficiary has two, full-coverage, stand-alone health insurance plans. The Tricare portion is free. Medicare is the primary plan. The beneficiary must seek all his medical care from Medicare providers who will file a Medicare claim for the services he provides.
When Medicare completes all its processing of the claim and pays its share to the provider, it will automatically forward the claim to Tricare as second payer. In the vast majority of claims, Tricare will pay whatever Medicare did not pay for every medical service that is covered by both Medicare and Tricare. When both Medicare and Tricare cover a service, Tricare acts as a free Medicare supplement. The Tricare deductible and cost share are waived, and the combined Medicare plus Tricare payments will pay the Medicare claim, and the provider’s bill, in full. The patient will pay nothing. The vast majority of TFL claims will be of that kind.
In response to your question, if Medicare denies payment on a portion of the claim — if it cannot pay for one or more of the services the patient received — the first thing to do is to file an appeal with Medicare. You will find instructions with the documents Medicare sent to you when it reported the charge was denied.
After all the appeal actions have been taken and resolved for or against your claim, Medicare will forward the claim to Tricare as usual, including the charges for the items Medicare did not pay and the report of the appeal actions.
If the particular item that was denied is for a service that is covered by Tricare, Tricare will process the claim for that particular item as the only insurance coverage for that item. In that case, all Tricare claims processing rules will apply including the Tricare deductible and cost share. That is, the claim for the service not covered by Medicare will be processed as if the patient did not have Medicare coverage — as if Tricare is his only health insurance. It will be processed in exactly the same way as your Tricare claims were processed before you became eligible for Medicare.
If the item is not covered by Tricare or Medicare, the patient must pay the entire charge for that item out of his own pocket.
Get my own coverage, or continue as a dependent?
November 23rd, 2009 | TriCare Help | Posted by Military Times
Q. I am a 60-year-old Army retiree. I have done nothing regarding Tricare or Medicare because my wife is still on active duty in the Army, which makes me a military dependent with Tricare Prime.
My question is, should I be doing something now? If not, when? Should I wait until my wife retires?
If you are entitled to receive retired pay, you are eligible for Tricare in your own right. But being an active-duty dependent is a better situation than having Tricare under your own Social Security number.
You have a smaller cost share, 20 percent instead of a regular retiree’s 25 percent, and your catastrophic cap is only $1,000, instead of $3,000 as it is for most retirees. It seems that you are in very good shape for your health care coverage.
When your wife retires, you and she should continue to keep your Tricare eligibility under only one of your SSNs. That keeps you with only one family catastrophic cap account, which is good.
I don’t think that you need to do anything until you get Medicare when you are 65. Between now and then, call DEERS at least once a year to make sure your registration is correct and up-to-date, and promptly report to DEERS any change in your status, such as an address change so your record is up-to-date at all times. The DEERS toll-free number is 1-800-538-9552.
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.