If Tricare pays less than Medicare, how does it work with TFL?
January 27th, 2010 | TriCare Help | Posted by Military Times
Q. I’ve read stories about Tricare and it seems less reliable than most commercial plans. It pays 5 percent less than Medicare does, so how will it help pay my Medicare claims under Tricare for Life?
Medicare and Tricare allow the same, or almost the same, amount for identical services because, by law, they must use the same, or almost the same, methods and databases to determine that amount.
Even when the amount allowed is the same, however, you are correct. Medicare pays 80 percent of the amount it approves or allows, whereas, for retirees, Tricare pays only 75 percent.
But Tricare’s allowance under Tricare for Life is seldom considered.
For Tricare for Life beneficiaries whose only health insurance is Medicare and Tricare Standard, and have no additional coverage from, say, a civilian job, Medicare is their primary health insurance, and Tricare Standard is secondary.
Tricare for Life beneficiaries must get all their civilian care from providers who will file a Medicare claim. On the vast majority of those claims, both Medicare and Tricare cover all the services on the initial Medicare claim. Tricare’s payment is determined by the amount Medicare pays, not by the amount Tricare allows.
When both programs cover every service on a claim, Medicare first pays 80 percent of the amount it allows on the charges after satisfaction of the Medicare deductible, if applicable, on that claim. Tricare pays the patient’s share — the Medicare deductible and copayment.
The patient owes the provider only what Medicare does not pay. When Tricare pays that amount, the Medicare claim and the provider’s bill are paid in full. The patient owes nothing more.
Therefore, on most TFL claims, Tricare’s allowable charge is not a factor.
Your transition to Tricare for Life
January 26th, 2010 | TriCare Help | Posted by Military Times
Q. I will be 65 this year and become eligible for Tricare for Life. My wife, daughter, and I have been under Tricare Prime for several years and it has met our health care needs in almost every respect.
But now, as soon as I get Tricare for Life, I will become ineligible for Tricare Prime and be switched to Tricare Standard against my will. Not only will I have the additional expense of Medicare Part B, but under Tricare Standard, we will start incurring deductibles and cost shares that we don’t have under Tricare Prime. Is there any way we can keep Prime when we get Tricare for Life?
Your loss of Tricare Prime eligibility and automatic transfer to Tricare Standard can’t be avoided — it’s part of the legal requirements for Tricare for Life.
Under Tricare for Life, Tricare Standard acts as a free Medicare supplement. You cannot choose to keep Tricare Prime.
Reading between the lines in your letter, however, leads me to believe you expect your transition to Tricare for Life and Tricare Standard to affect other members of your family. Not so.
Your transition to Tricare for Life and transfer from Prime to Standard will have no effect on your family’s Tricare Prime enrollment. You will be the only one affected.
Your daughter may continue under Tricare Prime until she loses Tricare eligibility at age 21 (age 23 if she is a full-time college student), or until she marries, whichever comes first.
Your wife may continue under Tricare Prime until she becomes entitled to Medicare and Tricare for Life at age 65. At that time, she’ll lose her Tricare Prime eligibility and transfer to Tricare Standard under the Tricare for Life program, just as you were.
Why does my doctor keep billing me?
January 25th, 2010 | TriCare Help | Posted by Military Times
Q. My doctor charged $268. Tricare allowed $192.50 and sent me a check for 75 percent, or $144.38. I paid the doctor $192.50 plus the 15 percent surcharge, for a total of $221.38. Now the doctor is demanding another $46.62, making the total the amount of his original bill, and says he’ll turn my account over to a collection agency if I don’t pay. It’s my understanding that federal law doesn’t allow him to do that. What should I do?
You are correct. The doctor may not charge you more than 15 percent over the amount Tricare allowed. If he sees Medicare patients, he is aware that the Limiting Charge law applies to Medicare claims; he needs to learn that it applies to Tricare claims also.
You should send a report to the Tricare office that processed your claim. The address is on the Tricare Explanation of Benefits form. Include a copy of the EOB and any “balance due” notices from the doctor. If the doctor persists, report him again.
It is unfortunate that the law will not allow Tricare to do more than write to the doctor and explain the federal law. Beyond that, all it can do is threaten to discontinue his status as a Tricare-authorized provider and threaten to cancel his ability to participate in other federal programs such as Medicare.
The doctor may be unaware of what his billing clerk is doing. You might consider writing or talking with him about it.
Who is required to accept Tricare?
January 22nd, 2010 | 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.
Didn’t you write 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 happens when I reach my Catastrophic Cap?
January 21st, 2010 | TriCare Help | Posted by Military Times
Q. How much is Tricare supposed to pay when my family has reached its $3,000 Catastrophic Cap? Someone said it won’t pay anything because that is all the cost shares that I am allowed to pay in a year.
Your friend is mistaken, but that particular mistake is one I haven’t heard before.
During each fiscal year, Tricare maintains a running total of all the deductible and cost share amounts your family has had to pay out of pocket (or that was paid by your Tricare supplement, if applicable).
As a retiree family, your Catastrophic Cap amount is $3,000, as you have assumed.
When your family members, combined, have paid $3,000 in deductibles and cost shares during a given fiscal year, Tricare will begin to pay 100 percent of the amount it allows on each claim. That is, you will not be charged any more cost shares or deductibles for the remainder of that fiscal year.
The government’s fiscal year runs from Oct. 1 of one year through Sept. 30 of the next year. At midnight on Sept. 30 every year, the amount accumulated in your family’s catastrophic cap account returns to zero and the accumulation of deductibles and cost shares your family pays begins anew.
Can I keep TFL after my divorce?
January 20th, 2010 | TriCare Help | Posted by Military Times
Q. My husband and I are divorcing after 16 years of marriage. He was in the military for 43 years, but I was only married to him from 1993 to 1996 when he retired. I am on Social Security disability and Tricare for Life. I went on this disability while being married to him. Will I be able to keep my Tricare for Life forever or for any time after the divorce?
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 the Defense Enrollment Eligibility Reporting System (DEERS) computer database, and to issue an appropriate uniformed service identification card.
Following your divorce from your military sponsor, you will be in a category referred to as a former spouse. In order to remain eligible for Tricare following your divorce, you will have to meet the eligibility criteria federal law requires for persons in that category. According to the information in your letter, above, I do not believe you would meet those criteria. I believe you will lose all rights to Tricare and to any medical care provided at government expense at midnight of the day the divorce is final.
For official confirmation of my statement and for official information and answers to all questions regarding Tricare eligibility, I urge you to contact DEERS, by calling its toll-free number, 1-800-538-9552, to discuss your personal and individual circumstances. Before you call, perhaps you would find it helpful to make a list of all your questions so you forget none of them and are prepared to make notes about your conversation with DEERS.
DEERS is a federal agency under the auspices of the US Department of Defense. DEERS is not related in any way to any program under the Social Security Administration, such as Medicare.
For official information concerning your rights to coverage by any Medicare program or plan, you should call the Social Security Administration, toll-free, at 1-800-772-1213.
The Tricare program called Tricare for Life consists of full coverage by Medicare Part A and Part B plus full coverage by Tricare Standard. To be eligible for Tricare for Life, you must be enrolled in Medicare Part A, and Medicare Part B, and Tricare Standard. The loss of either Medicare eligibility or of Tricare eligibility will cancel your eligibility for Tricare for Life.
Would father’s new wife get Tricare?
January 19th, 2010 | TriCare Help | Posted by Military Times
Q: My father-in-law has Tricare, as he was in the Air Force. He has been divorced for years. Our question is if he remarries, will his new wife be covered?
The gentleman’s new wife will become legally eligible for Tricare at the moment the officiating person pronounces them married. To use Tricare, however, the husband must enroll her through his uniformed service so she can be registered in DEERS and be issued a military identification card.
For instructions on registering his new wife, the service member should call the Defense Enrollment Eligibility Reporting System (DEERS), toll-free, at 800-538-9552.
If the lady is entitled to Medicare and is enrolled in Medicare Part B, he should tell DEERS so special instructions can be issued.
If the marriage ends in divorce, her Tricare eligibility will end at midnight of the day the divorce is final. If the marriage ends by the husband’s death, however, her Tricare eligibility will continue for the rest of her life unless she remarries. If she were to remarry, her Tricare eligibility under this husband’s sponsorship would end immediately. It can never be restored.
Will bariatric surgery be covered?
January 18th, 2010 | TriCare Help | Posted by Military Times
Q. My wife is advised to have bariatric surgery. Can Tricare Standard cover it?
Yes, certain stomach surgical procedures for weight loss are covered by Tricare for certain beneficiaries.
For the procedure to be covered for a particular patient, however, she must meet specific guidelines concerning her weight and associated medical conditions. Those guidelines are established by the federal regulation that governs Tricare. Federal regulations have the force and effect of law.
I suggest that your wife’s surgeon write to her Tricare Service Center. He or she should ask for a statement of exactly what is required by regulation for the surgery to be covered by Tricare for any particular patient.
The surgeon will have to decide whether your wife meets those medical criteria and whether the procedure he/she proposes is one of those authorized by regulation. If the regulation’s medical requirements are not met, the procedure cannot be covered. Thus the surgeon will know in advance whether to proceed with the proposed surgical intervention.
Meeting the regulatory requirements does not constitute preapproval and guarantee of coverage. It merely establishes the conditions under which coverage is possible.
Please note that, among the requirements for coverage, the physician must be a Tricare-authorized provider. That is, the physician must be registered with Tricare and be authorized to receive payment from Tricare for medical services rendered to its beneficiaries.
The registration process is simple, and the physician incurs no obligation with Tricare by becoming a Tricare-authorized provider. All health insurance plans require some form of physician registration and certification for the protection of both the patient and the insurer.
Is coverage retroactive?
January 15th, 2010 | TriCare Help | Posted by Military Times
Q. My fiancé is in the Air National Guard and uses Tricare. He tells me that when we get married, I will not only be covered under Tricare, but that Tricare will pay off my current medical bills that I am paying off from a surgery earlier this fall. Is that true?
Your fiancé is mistaken about Tricare’s payment for your past medical care. Your Tricare benefits will apply only to medical care you receive on and after the date you become eligible for Tricare.
I don’t understand your statement that your fiancé is able to use Tricare at this time. Reservists and Guards normally do not become eligible for Tricare until their 60th birthday. A new law may change that before the end of 2010 and make some of them eligible earlier, but that law is not in effect yet.
For official information regarding Tricare eligibility such as who is eligible and when eligibility begins, please call the Defense Enrollment Eligibility Reporting System, known as DEERS, toll-free, at 1-800-538-9552. DEERS is a federal agency under the Defense Department. It maintains a registy of all persons who are, or who may become, eligible for military benefits, including Tricare.
Covered by dad’s Tricare – and I’m pregnant
January 8th, 2010 | TriCare Help | Posted by Military Times
Q. My dad is retired and has Tricare Prime health insurance. I’m 20 years old and attending college, and I just found out I’m pregnant. Will the birth be covered under my parents’ insurance? And will the child be covered?
You need to call the Defense Enrollment Eligibility Reporting System (DEERS), toll-free, at 1-800-538-9552, to make sure your Dad properly enrolled you in Tricare, and you (because you are over 17 and an adult for Tricare legal purposes) have kept your military ID card and DEERS registration up-to-date.
If you are unmarried, Tricare eligibility will usually continue (by law) until midnight on the day before your 21st birthday. However, for as long as you are enrolled as a full-time student in good standing at an accredited university, your Tricare eligibility can be continued until midnight of the day before your 23rd birthday. Eligibility beyond age 21 is not automatic. You must make special arrangements. Ask DEERS for help.
So, first, call DEERS. If DEERS does not report that you are eligible for Tricare, ask what you need to do to re-establish your Tricare eligibility. While talking with DEERS, make sure all your other information is correct and up-to-date. Check the expiration date of your ID card. If it is within 90 days or so of expiring, ask DEERS how to renew it.
To use Tricare, your DEERS record and ID card both must be up-to-date. DEERS will help you with instructions for anything you need to do. Talk with DEERS about extending your eligibility after age 21. Get them to explain the matter of your full-time student status. Such as, if you drop out of school for a semester to have the baby, you will not be covered by Tricare during that time because you will not be a full-time student. Make sure you talk with DEERS about that situation and understand it thoroughly.
At any time when DEERS reports that you are eligible for Tricare, you are entitled to full Tricare benefits, including all maternity care. If DEERS says you are not eligible at any time, Tricare cannot pay for any medical care you get when DEERS does not say you are eligible.
You are eligible for Tricare because of your father’s military service. That benefit, however, does not extend to his grandchildren. The fact that you, the mother, are Tricare-eligible, does not make your baby eligible.
If the baby’s father is an active duty service member, or a military retiree, the baby can be made eligible, even if you are not married to him. Ask DEERS about it if that’s the case.
Be sure that you know what Tricare plan you are covered by. If you are enrolled in Tricare Standard, you may get care under Tricare anyplace in the world. If you are enrolled in Tricare Prime, you may use only certain doctors and hospitals. They are most likely only in the area where your father lives.
You have to make some decisions about where you will get all your maternity care and which Tricare plan to be enrolled in. If Tricare Prime is available where you live, you can have your Prime membership transferred, if that is the area where you will get your medical care.
You cannot easily get your prenatal care in one Prime service area and deliver in a different Prime service area. You can get your prenatal care in Prime area A and deliver in Prime area B only if you time it right and get your membership transferred in time. That is hard to do when you are in labor. Especially on a weekend or at 2 a.m. on Tuesday. Don’t count on being able to do it.
If you are enrolled in Tricare Prime, I suggest that you call your Tricare Prime Service Center and have a long talk with them to make sure you understand Tricare Prime’s rules about which providers you may use. You can incur a lot of unnecessary expense if you do not follow Prime’s rules exactly.
Also, changing doctors in mid-pregnancy may be a problem. It isn’t easy to find a doctor who will accept you as a new maternity patient after your first trimester.
I’m sure your Dad or Mom will want to be involved, and Dad will want to help you to resolve all your Tricare issues. Tricare, however, is not allowed to talk with him about your medical care unless you send Tricare a signed and dated letter with which you authorize them to talk with Dad and Mom (by name) or whomever you wish to authorize. Otherwise, Tricare cannot talk with another person about you. That is Privacy Act stuff. There is no getting around that law, not even for your Tricare sponsor.
If you have thought of having an abortion, Tricare is not allowed by federal law to cover it unless your life would be in danger if the pregnancy were to continue. That is a pretty powerful restriction and hard to prove.
You have a lot of things to learn and arrangements to make, and not a lot of time to do it, especially the decision about your maternity care doctor.