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.
Why were we billed for hospital stay?
November 3rd, 2009 | TriCare Help | Posted by Military Times
Q. My wife and I are enrolled in Medicare Part B. Medicare and Tricare for Life have been paying all the bills. Now she has received a bill from the hospital for emergency room treatment. The bill says Medicare and Tricare have paid their shares and we owe $153. Is there a logical explanation for this bill?
I have no way to gain access to your Tricare claims, so I couldn’t do more than speculate about the reason for the balance due. But, I can tell you how to get the information.
Write to Tricare Management Activity, 16401 E. Centretech Parkway, Aurora, CO 80011-9043. Explain the problem in detail. Because your wife was the adult patient, she must sign the letter (Privacy Act stuff). Include her full name and her Social Security number, your full name and SSN, home address, a daytime phone number for her, the name and address of the emergency room, and the date(s) of medical care.
Every time a health insurance plan processes a claim, it issues to the patient a full report of each action it took on each of the medical service charges submitted. On a hospital claim, there may be dozens, even hundreds, of them. Most plans call their report an Explanation of Benefits, or EOB. Medicare calls its report a Summary Notice.
Include with your letter to Tricare Management Activity a legible copy of each EOB and Summary Notice your wife received from Medicare and Tricare for all the charges related to her emergency room care. It is important that each charge submitted to Medicare should be reported on both the Medicare Summary Notice and the Tricare EOB. That is so TMA, in its search for an unpaid $153, can trace each charge to determine the way it was processed.
Is my wife covered by Medicare yet?
November 2nd, 2009 | TriCare Help | Posted by Military Times
Q. I retired from the Army in 2004, I’m now 57 and my wife just turned 60. When must my wife sign up for Medicare Part A or B?
The legal age for Medicare eligibility for most people is 65, unless they qualify for Social Security disability benefits before then. Social Security wants people to apply for Social Security and Medicare at least 90 days before the first day of the month when they will turn 65. At that time, your wife should apply for Social Security benefits, including Medicare parts A and B. To learn more, call Social Security at 1-800-772-1213.
You should also call the Defense Enrollment Eligibility Reporting Service (DEERS) Support Office at 1-800-538-9552 to ensure that you and your wife are properly registered in that database. Ask whether you and your wife are eligible for Tricare. As you are a uniformed service retiree, your wife should be eligible for Tricare Prime or Tricare Standard coverage now.
In the meantime, visit the Tricare web site and make a note of the contact information for your regional office. You can read overviews for Standard and Prime, as well. Tricare Standard is free; Tricare Prime costs $460 per year for a family of two people or more. Both plans can be used to supplement any other health insurance you have. Tricare Standard, however, is the recommended plan for people with other health insurance. It will pay all, or most, of the deductible and copayment from your other health insurance.